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Nurses in North Dakota are pushing back on a new “high-risk” policy that will allow healthcare workers with asymptomatic cases of the virus to work in COVID-19 units at hospitals and nursing homes to help alleviate critical staffing shortages.
Governor Doug Burgum announced the change at a news conference on November 9, just as the state reported the highest rate of COVID-19 cases and deaths per capita in the nation during the previous week. The entire region, including South Dakota, Iowa, Minnesota, Montana, and Wisconsin, is experiencing a rise in cases.
The policy falls under the auspices of guidance outlined by the Centers for Disease Control and Prevention’s (CDC’s) Crisis Capacity Strategies to Mitigate Staffing Shortages, which allows healthcare workers with suspected or confirmed COVID-19 to resume work under certain circumstances. The announcement was met almost immediately with pushback from the North Dakota Nurses Association (NDNA).
In its statement, the NDNA objected to the policy, and emphasized that all other public health measures that could reduce the demand on the healthcare system should be implemented first, including a mandate to wear masks in public settings, social distancing, and good hand hygiene.
The NDNA gave its own news conference on November 20 to discuss the policy as well as the need for the public to step up and support mitigation strategies. Tessa Johnson, MSN, RN, president of the NDNA, said that nurses who are positive for the virus should not be working. “A nurse who is asymptomatic is still ill, and his or her body needs to recuperate,” she said. “And they should not be working in a high-risk and potentially deadly environment.”
Johnson pointed out that working instead of resting could cause nurses to become sicker and have poor outcomes. “Nurses should be at home and following the CDC guidelines that apply to everybody else,” Johnson said, adding that they should remain in isolation for a specific period of time and monitor their symptoms.
North Dakota was slow to initiate strategies aimed at mitigating the virus after cases began to spike. While some have now been implemented, Johnson pointed out that they were implemented too late. “Because of our failure to respond to the threat of COVID-19 with real evidence-based strategies, at the state level, we are now desperately trying to play catch-up and finding ourselves in a true crisis,” she said. “For weeks, we have led not only the nation but the world in hospitalizations and deaths per capita.”
Burgum has said he believes there will be little risk for viral spread if infected healthcare workers are only caring for patients in the COVID-19 units, and that these workers are already wearing protective gear.
However, Kelly Michelson, MD, MPH, a professor of pediatrics and director of the Center for Bioethics and Medical Humanities at Northwestern University’s Feinberg School of Medicine in Chicago, Illinois, believes the policy is problematic. “The risk of asking people to go to work when they are COVID-19 positive is a risk to the other providers as well as to the nurses themselves,” she told Medscape Medical News. “We now know that the way COVID spreads in hospital settings is from one care provider to another, rather than getting it from patients. When they go to break rooms and take their masks off, where they can’t distance, this is how it’s spreading, and this is going to make it worse.”
Michelson emphasized that putting COVID-19-positive nurses to work should be among the last resorts, and instead, appropriate public health measures should be implemented. “Hospitals have an obligation to provide a safe environment for their staff, and there is a real need for regional and national collaboration,” she said.
A Perfect Storm
Early in the pandemic, North Dakota had relied on testing, contact tracing, and isolation to control the pandemic, and the state still remains one of the nation’s leaders in testing per capita. Residents listened to public health experts and followed recommendations, such as staying away from large social gatherings and staying home when contact tracers told them they may have been exposed. Schools and certain businesses had also closed in mid-March.
The majority of cases were confined to an area near Fargo, and as the spread began to be contained across the state, the lockdown was gradually lifted in May. With few cases going into summer, residents were more lax about public health measures.
The rate of infections started to spike in late July, after Fourth of July gatherings. At least 30 North Dakota cases were reportedly traced to the Sturgis motorcycle rally in August, which was a hotbed of viral spread. Students were also returning to school, and neighboring states were also seeing cases climb.
Cases continued to spike to more than 1000 per day, until North Dakota became the leading state in per capita COVID-19 cases and deaths. But even then, a mask mandate didn’t come until 8 months into the pandemic. More than 60,000 state residents have tested positive, which extrapolates to about one of every 13 residents.
Rachel Heintz, RN, an emergency room nurse in Bismarck, explained that by May, they were seeing few COVID-19 patients. “We asked the administration what the plan is, what is the strategy, and how can we prepare for the next surge,” she told Medscape Medical News. “We tried and tried but got absolutely no response. We were basically told that this wasn’t something we needed to talk about, and we weren’t even able to have a conversation about it.
“So now fast forward to November, and we are in full crisis mode, and this shouldn’t be a surprise,” she said.
The hospital now has a surge plan but Heintz pointed out that the nurses were not involved in the plan, which would have helped maximize its capacity and strengths. “So we find ourselves in the position we’re in now,” she said.
Staffing shortages are becoming increasingly problematic across the country as the pandemic surges, but some of the shortages existed before COVID-19. Heintz explained that her center had cut 290 full-time positions, primarily ancillary staff.
“We have had bare-boned staff for years, and we have almost no ancillary staff,” she said. “All of the tasks and all of the burdens are falling on the shoulders of the nurses.”
During the NDNA press briefing, one intensive care unit nurse sent in a comment that she had just quit her job and was becoming a traveler, “because the hospital wasn’t listening.”
Another nurse commented that “no one wants to see that your loved one died because there wasn’t a nurse…they gave us no support, won’t approve paid time off if you get COVID. Everyone is leaving because they won’t change, I had to leave for my own mental health.”
One wrote that even travelers aren’t staying. “Travelers are breaking contracts that pay $8000 a week because the patient ratios are not safe.”
Another nurse commented that she “hated to be leaving at a time like this, but I have to leave because I caused preventable harm to someone.”
Johnson noted that North Dakota has been fighting a nursing shortage for years, and that many new nurses are deciding to move to other states.
“Sadly, some legislators and people are urging the governor to reverse the mandates that have been initiated to help mitigate the spread,” Johnson said. “We need our governor to listen to nurses in making these decisions. We have so much at stake and nurses must be involved.”
No other states have issued a policy change that would allow COVID-19-positive healthcare workers to care for patients. Johnson said that several hospital systems have said they will not be doing that. “My understanding is that it came from long-term care and that many are in dire need, and nurses are concerned that they may be asked and fear saying no,” she said. “They don’t want to be put in that position, so we would rather it just not be an option.”
According to the journal The BMJ, Belgium also plans to allow infected healthcare workers to work. The country has been severely affected and now has the second-highest rate in Europe after the Czech Republic. Belgium’s public health advisory agency, Sciensano, has guidelines to allow asymptomatic COVID-19-positive doctors and nurses to work, noting that such personnel can only be asked to work in “very exceptional cases,” and only with patients in COVID-19 units.
Some relief is coming to North Dakota, with the arrival of 60 US Air Force nurses. The nurses will be divided up into multiple specialty teams to care for patients in at least six hospitals in four cities.
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