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Voices from the front lines: How nurses feel about Ebola

Dr. Kent Brantly is congratulated by Emory University Hospital nurses and staff as he is discharged after receiving treatment for Ebola.

Dr. Kent Brantly is congratulated by Emory University Hospital nurses and staff as he is discharged in August after receiving treatment for Ebola. Photo credit: Samaritan’s Purse

When the first Ebola patient to be treated in the United States was headed for Emory University Hospital this past summer, two of the hospital’s nurses canceled their vacations to be there.

That’s how registered nurse Barbara Ribner described the dedication of the Emory nurses who deal with Ebola. Her husband, Dr. Bruce Ribner, is the medical director of the Serious Communicable Diseases Unit, which has successfully cared for four patients with Ebola.

Nurses are on the front lines of treating such deadly diseases, and have been in the forefront of the news surrounding Ebola in the U.S. Two nurses in Texas contracted the disease from a Liberian man who eventually died, and an American nurse returning from West Africa was subject to a controversial quarantine in New Jersey and Maine.

GHN talked to several Georgia nurses — some who work at Emory and some who work elsewhere — about caring for Ebola patients. The viral disease, originally identified in West Africa in the 1970s, has killed more than 5,000 people there this year, and for the first time has turned up in a few places outside Africa.

Emory nurses who cared for the Ebola patients discussed the complexity of the medical procedures at a recent conference. And at the same time, they said it was rewarding beyond their expectations.

“It’s a different feeling, because there’s this barrier between you [the nurse] and the patient,” said one nurse who preferred not to be identified. “You cannot touch your patient” to support them or help them understand that the staff is doing everything possible, the nurse said.

President Obama hugs Dallas nurse Nina Pham after she underwent successful treatment for Ebola.

President Obama hugs Dallas nurse Nina Pham after she underwent successful treatment for Ebola.

People with Ebola symptoms are contagious, and the sicker they are, the more risk of contagion they pose to others.

There is no “one size fits all,” explained another infectious disease trained Emory nurse who preferred to remain anonymous. Putting on the personal protective gear took 38 steps, while removing it took 50. These highly specialized nurses counted each step while another trained nurse watched every move.

Day after day and week after week, they could not make a misstep even once during this demanding process.

“Not everyone who went through our rigorous training passed,” said one of the nurses. Each nurse working with Ebola patients had to be 100 percent detail-oriented by following the highly complex procedures every time one of them entered or left the patient’s room.

The fear came not from getting the infectious disease, explained one Emory nurse, but “we were more afraid of giving the virus to someone else.” And for that reason, each nurse was fastidious about every procedure.

The nursing education coordinator for Emory Healthcare, Kelly Shelby, said that depending on when they started nursing, “nurses were probably frightened by other types of infectious diseases as well.” For some it might have been polio, while others feared SARS and AIDS.


Taking the danger seriously


“I think there is fear [of Ebola] because it’s a scary disease,” said Lorine Spencer, a nurse and a  CDC public health adviser. Fear of the unknown is a problem.

CDC workers and prepare to enter an Ebola treatment unit in West Africa.

CDC workers and Doctors Without Borders personnel  prepare to enter an Ebola treatment unit in West Africa.

“We are getting evidence-based, accurate information out there,” Spencer said. “We continue to learn from those that have been to West Africa to treat patients and returned safely.”

Rebecca Wheeler, an RN and past president of the Georgia Nurses Association, told GHN that “we [nurses] must seek out the latest information and evidence-based practices to respond to any emergency or infectious disease outbreak.”

Communication, training and equipment are critical. The U.S. is not accustomed to managing Ebola, so information and strategies will evolve as more experience with the disease is gained, said Wheeler.

Valdosta nurse Jody Leonard added, “The public has a much greater risk of dying from influenza [than from Ebola], so please, just get your flu shot.” When discussing the Ebola problem with family members, Leonard reminded them that the risk of contracting Ebola in the U.S. is extremely low. Not so for the flu.


Fear and uncertainty



The scientific information about Ebola has not changed. Experts have long known that infected people are not contagious until they have developed symptoms. That means the disease, though it poses a serious risk to people who care for ill patients, is not easily spread in casual settings.

But public fears about the disease have waxed and waned, reaching a peak last month after several Ebola diagnoses in the United States in quick succession.

Dr. Kent Brantly appears with Emory physicians, nurses and staff as he speaks to the media.

Dr. Kent Brantly appears with Emory physicians, nurses and staff as he speaks to the media.

Americans are both divided and uncertain about the threat posed by the illness, according to a recent Washington Post article. A Washington Post-ABC poll showed that just 24 percent of Republicans believed the federal government was doing all it could reasonably do to stop the disease. In contrast, 50 percent of Democrats believed the government was doing enough. But even 50 percent is not a ringing vote of confidence.

“The key is for the front line [health care providers] to have accurate information from reliable sources like the CDC. But they also need training and appropriate equipment,” said Wheeler.

Nurses and other members of health care teams need to speak up when they feel they are getting the things they need, and they must be listened to, Wheeler said.

In early October, National Nurses United stepped up the call for U.S. hospitals to immediately upgrade emergency preparations for Ebola. NNU is calling for all hospitals to immediately implement a full emergency preparedness plan for Ebola or other disease outbreaks.

Georgia health officials have not yet revealed the hospitals that are being prepared to treat Ebola patients. But infectious disease training remains ongoing for nurses and other medical professionals, as it has for years.


Quarantining nurses: Is it realistic?


October was a scary month of Ebola headlines. Thomas Eric Duncan, recently arrived from Liberia, died of the disease in a Dallas hospital. Then two nurses who had treated him were found to be infected with the virus. Then a New York doctor who had recently treated Ebola patients in Africa was diagnosed with the disease, amid media reports that he had roamed all over the Big Apple just before falling ill.

All three of those health care professionals were successfully treated — one at Emory — and all fully recovered. But officials around the country began to talk about not just isolating Ebola patients, but quarantining people who might have the disease.

When nurse Kaci Hickox returned to the United States in October after treating Ebola patients in Sierra Leone, she was placed in quarantine by New Jersey and then by Maine.

Hickox, insisting she did not have Ebola, objected to the quarantines. In Maine, she took the matter to court. A judged ruled there were insufficient grounds for quarantine, saying Hickox should simply submit to direct active monitoring. She did, and eventually was confirmed as not infected with the virus.

An Ebola isolation tent in Newark, N.J., for Kaci Hickox

An Ebola isolation tent in Newark, N.J., set up for Kaci Hickox

After the court fight, Hickox said, “We’ll only win this battle as we continue this discussion, as we gain a better collective understanding about Ebola and public health, and as we overcome fear . . .”

The American Nurses Association opposes the mandatory quarantine of health care professionals who return to the United States from the Ebola-ravaged areas of West Africa.

On Oct. 27, Gov. Nathan Deal announced that Georgia plans to increase Ebola monitoring for all people arriving from affected countries. His directive also included the possibility of quarantines, but none have been implemented.

An open letter to Georgia’s nurses (co-authored by Public Health chief Dr. Brenda Fitzgerald and Carole Jakeway, a Public Health Department official), called for vigilance in recognizing early symptoms of Ebola. “As nurses, this is the type of situation we have been trained for,” the letter reads, while discussing the potential for anxiety and stress among Georgia’s nursing personnel.

Nurses are a good source of information about this potentially deadly disease, said Texas Nurses Association Executive Director Cindy Zolnierek.

“Also, I have advice for a concerned public: Talk to a nurse. Very likely, you have nurses in your own family or as friends,’’ she said in a statement.

“Nurses are a great resource for information and a calm voice of reason. We hope you care for nurses as much as they work to care for you.”


Judi Kanne, a registered nurse and freelance writer, combines her nursing and journalism backgrounds to write about public health. She lives in Atlanta.


Public health nurses: Vital to Georgia, but all too few

Lorri Tanner, county nurse manager at the Walton County Health Department, hopes the state can lower its job vacancy rate for public health nurses.

Lorri Tanner, county nurse manager at the Walton County Health Department, hopes the state can lower its job vacancy rate for public health nurses.

Lorri Tanner arrived at work the Friday before Memorial Day with thoughts of a long weekend on her mind, but by the time she had settled into her office at the Walton County Health Department, her plans had drastically changed.

Tanner, a registered nurse and the county nurse manager, was informed of a potential case of active tuberculosis. If it was confirmed, she would need to address it immediately. Walton County has had fewer than five TB cases in the past two years.

Emergencies like this are not unusual the Friday before a holiday, Tanner said, recalling with wry amusement how ill-timed crises at work often derail her personal plans.

Each new case of TB is a serious issue. It must be reported to the local health department. A public health nurse interviews the patient to identify recent contacts. The nurse then coordinates and monitors the treatment of the patient and evaluates anyone who has come in contact with the individual.

TB cases are just one of the many responsibilities of a public health nurse.

“Public health nurses combine the science of nursing with public health,” said Patricia Miller, who is a registered nurse and an associate professor at R. H. Daniel School of Nursing at Piedmont College in Demorest. “They’re really the backbone of health promotion and prevention of illness.”

Miller was a public health nurse in Georgia for 15 years before she began teaching.

“In public health, we are always trying to prevent, treat and educate,” she said.

The many issues that public health nurses deal with, Miller said, include disaster response, immunizations, infectious diseases, family planning, sexually transmitted diseases, women’s and child health services, and stroke and heart attack prevention. Their work affects entire communities, not just the individuals who use local health department clinics.

But public health nurses like Tanner are in severely short supply, according a report released by the Georgia Department of Public Health (DPH).

Georgia currently has 1,400 public health nurses, said Carole Jakeway, chief nurse and director of the division of district and county operations at DPH. Nearly 20 percent of public health nurse positions are vacant, she said.

“It’s a high number for a vacancy rate and a low number of nurses,” Miller said.


Some alarming figures

Georgia’s population has grown by 1.5 million in the past decade, but the public health nursing workforce has shrunk. From 2003 to 2011, Georgia has lost an estimated 392 such nurses, about 22 percent, due to high turnover rates, lack of funding and non-competitive salaries.

The American Public Health Association calls for one public health nurse (RN) for every 5,000 people, according to DPH. By this standard, Georgia is more than 500 nurses short.

“Even though there are just 1,400 of us, we are the backbone of public health,” said Debra Adams, district nursing and clinical director of the Valdosta-based South Health District.

The South district, like most of the 18 public health districts, has a hard time recruiting nurses and a hard time keeping them. “Our turnover rate is in the double digits,” Adams said.

One reason for the shortage is DPH’s inability to fill the vacancies left by retiring nurses. The low salary keeps many qualified nurses from applying.

“We have lost a lot of seasoned public health nurses, so we are really in the process of trying to get a whole new crop in, and to be able to do that you need [to do] to be competitive in the marketplace,” said Susan Kristal, nurse manager for Barrow County.

Although the pay scale varies based on county, the average entry-level salary for a public health nurse was $31,474 in 2002. That was raised in 2008 to the current $36,770, Jakeway said.

“Right now we’re OK, but from time to time, we do have nurses leave, and most of the time it’s because of the low pay,” said Marcia Massengill, county nurse manager in Clarke County. “Then when we attempt to recruit, it has been very difficult to compete with the salaries offered by private practices and hospitals; we can’t even compare to those salaries.”

DPH estimates the salary to be as much as $25,000 below the market level.

The average starting salary for a new nurse in the private sector was $61,000 in 2006. By June 2012, that had risen to $65,837, Jakeway said.

Because of the low pay, the state is seeing mostly recent graduates and inexperienced nurses applying for the open positions, Massengill said.

“Experienced, seasoned public health workers are very valuable because this is not your typical nursing job,” said Kristal, who has worked in public heath for nearly 12 years. “[Public health nurses] have to have some experience and some seasoning to know how to handle the different things that come up, because every day is a new challenge.”


Work that requires special skills

Experience is particularly important because of the responsibilities involved. Registered nurses in public health often have to diagnose and treat patients without a physician.

“We’re asking a brand new nurse to do complete exams and be independent almost to a nurse practitioner level, and they just graduated,” said Massengill, who has worked in public health for 29 years.

It takes a great deal of time and money to train the new recruits to work independently, and this makes them even more qualified for jobs in the private sector. Many times, after at least nine months of on-the-job training, recent hires leave public health nursing for less stressful and higher-paying jobs — contributing to the high turnover rate.

“It has an impact all the way throughout the state,” said Kristal.

With the shortage of nurses and funding, some clinics have had to cut their hours. Clarke County’s Teen Matters clinic is one of them.

The full-time youth clinic opened in 1995. To provide services to more patients, a part-time Teen Matters clinic was added a few years ago while the older clinic maintained its full-time schedule. Teen clinics provide contraception and education to sexually active teens.

“With budget cuts in the last year, both clinics are now part time, which is particularly frustrating because we have a very high teen pregnancy rate here in Clarke County,” said Massengill.

Georgia has one of the highest teen childbearing rates, estimated at more than 14,000 in 2010. Teenage births cost Georgia taxpayers at least $465 million in 2008, according to data released by the National Campaign to Prevent Teen and Unplanned Pregnancy. Most costs are associated with negative consequences for the children of teen mothers, such as public health care, child welfare, incarceration and lost tax revenue.

In the face of mounting vacancies, some nurses are doubling up on their duties.

“Our primary TB nurse left recently and took a higher-paying job,” said Tanner, who as county nurse manager directs the Walton County Health Department, the West Walton Health Center and the Adolescent Center for Education Services. “I oversee our county TB program so when a nurse leaves, I am the one who fills in the gaps to make sure services are provided.”

The overall shortage of nurses limits the number of patients the clinic can see, said Adams of the South district.

Jakeway agrees that the nurse shortage affects all Georgians, and says that with less staffing at the local level, the nurses have to regroup and set priorities to make sure patients are served.


Will new status help?

Some, however, are hopeful that since Public Health became an independent state agency in 2011, plans that have existed for years to make public health nursing a more competitive field will finally move forward.

This is a top priority for DPH’s commissioner, Dr. Brenda Fitzgerald.

“We want to make sure we have very qualified people in these positions,” Fitzgerald said.

Yet DPH, like other state agencies, faces a 3 percent budget cut this fiscal year and in fiscal 2014.

Georgia is looking to implement a new nursing workforce development plan, according to Jakeway. The plan is intended to address recruitment and retention issues, create a competitive salary structure and develop a progressive career track. It remains to be seen, however, if the state budget will accommodate the plan.

“We are working to make sure the plans we have will fit with the state’s budget,” Fitzgerald said. “We are being very conservative and the government is being conservative, so we are moving forward but with reason and thought.”

Jakeway, who has worked in Georgia public health since 1989, is optimistic. “We are in the best position ever in all my years here,” she said.

Others are still concerned with how the state will fund the many programs that aid countless Georgians and the increase needed in salaries to compete with the private sector to hire more experienced nurses.

“There’s still that perception of the health department as ‘the clinic where the poor people go,’ and that’s not altogether true. We’re seeing people from all different walks of life,” said Massengill. “But bottom line is, I don’t know where the funding is going to come from.”

But many nurses, including Massengill and Tanner, remain fairly upbeat about the future.

“I’m hoping that with [Public Health] being its own department, there will be more concentration on what the needs of the community are,” said Tanner.


This article is the latest in a series developed by the Public Health News Bureau, a project funded by Healthcare Georgia Foundation. The bureau is staffed by graduate students from the Health and Medical Journalism Graduate Program of the University of Georgia’s Grady College of Journalism and Mass Communication. 


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