Nurses all over the country have been giving vaccinations for the COVID-19 virus. As more and more settings are offering the virus, there are a number of risks that nurses need to be aware of before going to work and assisting with vaccine distribution.
Jennifer Flynn, CPHRM, Risk Manager, Nurses Service Organization (NSO), agreed to answer our questions about what nurses need to be aware of when they’re going to give COVID-19 vaccinations.
Overall, what do nurse need to be aware of in general?
When assisting with a vaccination program, whether through your employer or volunteering, nurses need to ensure that vaccines are administered in appropriate settings with adequate patient safety and monitoring procedures. Nurses may require additional training to participate in administering vaccines. In general, nurses will want to educate themselves on vaccine specifics, as well as other considerations including but not limited to, contraindications for administration, potential adverse reactions, dosing requirements, storage and handling requirements, documentation requirements, administration requirements such as mixing with diluent, appropriate needle size and anatomic administration sites, and post-vaccination monitoring requirements. Providers will also want to be prepared for responding to adverse events, such as anaphylaxis.
What is informed consent and informed refusal? Why do nurses need to be aware of them? If someone refuses, what should they do?
Simply put, informed consent is a two-part process: the discussion and the documentation of that discussion. From a liability perspective, it helps to manage patient expectations—it can reduce the possibility of a misunderstanding. And, it can strengthen one’s legal defense in the event of a claim.
In order for patients to give informed consent, the verbal discussion allows the provider to explain the risks of the proposed treatment, benefits, and alternatives. In order to gage the patient’s understanding, they should have the opportunity to ask questions before any written consent is obtained.
The signed informed consent form should be placed in the patient’s health care information record.
Persistent failure to heed medical advice can lead to less than desirable results for the patient, as well as potential liability exposure for providers. Health care providers can counter this risk by adopting a standardized refusal-to-consent form, which serves to confirm in writing that the provider fully disclosed to the patient the risks of forgoing the proposed test, treatment, or procedure. By signing the form, patients acknowledge that they have discussed the proposed course of care with their practitioner and understand that failure to follow medical recommendations can have serious or even life-threatening consequences. The completed refusal-to-consent form should be placed in the health care information record.
Prior to administering the vaccine, nurses should participate as witness or be aware that the facility has performed the informed consent process that it has been properly documented. Ensure the patient received the manufacturer’s fact sheet, inform the patient of the FDA’s Emergency Use Authorization status of the vaccine, known and potential benefits and risks, option to accept or refuse the vaccine and the risks associated with refusal, any available alternatives, obtain the patient’s written informed consent and document the content of the discussion, materials provided to the patient, and the signed consent form in the patient’s health care record.
Why do they need to have adequate documentation when giving the vaccine? Does this differ is they’re doing this vaccination directly for their employer (say a hospital or rehab center/nursing home) or doing the work for a vaccine center?
A carefully documented record may prove invaluable in defending against allegations of negligence. When assisting with a vaccination program, whether through your employer or volunteering, documentation for administering vaccines should include the date and time of administration, vaccine administered, dosage and lot number, route and site of administration, and post-vaccination monitoring information.
As a reminder, the health care record is a legal document and is an essential tool to understand:
The patient’s medical event. Document thoroughly including treatment decisions made, actions taken, the corresponding rationale and information given to the patient.
The nurse’s actions. Good recordkeeping involves accurately conveying what was heard, seen and thought, what treatment was performed, why that treatment was necessary, and what future care was required—based solely on written documentation. Include patterns of noncompliance.
What the patient stated
What steps were taken to resolve or relieve the situation
Whether the patient responded favorably to those steps
The patient’s condition and mode of leaving following the appointment
The follow-up or referral instructions provided to the patient
If the record is deficient, the nurse’s credibility is weakened.
Because complete and accurate health care records are such an essential risk management measure, nurses should maintain proper documentation practices and follow their facility’s policies and procedures governing documentation.
Maintaining a consistent, professional patient health information record is essential to providing quality patient care, ensuring consistent communication among all professionals caring for the patient, and establishing the basis for an effective defense should litigation arise.
What are some tips for mitigating risk of malpractice?
Know and comply with your state scope of practice requirements, nurse practice act, and facility policies, procedures, and protocols. Follow documentation standards established by nurse professional organizations and comply with your employer’s standards. Maintain clinical competencies aligned with the relevant patient population and healthcare specialty. Develop, maintain, and practice professional written and spoken communication skills. Emphasize ongoing patient assessment and monitoring.
Can you give me some general education and infection control best practices that nurses should know?
When assisting with a vaccination program, whether through your employer or volunteering, the location should permit physical distancing between individuals who are in line to receive the vaccine in conformity with CDC guidelines. Patient appointments should be designated appointment times. Consider the creation of dedicated vaccination areas or specified hours for those at higher or severe risk associated with COVID-19. Implement strategies to manage patient flow, and limit crowding or long lines by using unidirectional signage. Limit the overall number of individuals permitted in vaccination or monitoring areas.
Anything else that is important for nurses to know?
I think it is also important for nurses to know “Do’s and “Don’ts” of what to do if they have received a legal summons/paperwork or State Board of Nursing complaint.
Contact your Risk Manager, your employer, and your insurance carrier immediately!
Secure and sequester the file to prevent alteration—Do not add or delete any information in the patient’s chart!
Comply with all investigations.
Give copies of records to patients when they request them.
Try to resolve legal/regulatory situations on your own (without legal or Risk Management guidance).
Call patient to discuss a legal/regulatory matter without talking to your attorney first.
Talk to anyone about the case other than your Risk Manager, your employer, your insurance carrier, and your attorney.
Oftentimes, nurses don’t take care of themselves like they should. While they focus on taking care of others, their self-care falls by the wayside. Especially during COVID-19 and the pandemic, they’ve put everyone else first.
Imani Wilform, MHC-LP, with Empower Your Mind Therapy, took time to answer our questions and give self-care tips on what nurses can do to make sure that they are making time for self-care. Our interview, which follows, has been edited for length and clarity.
Dealing with COVID-19 and the pandemic has been tough on everyone, but especially difficult on frontline workers such as nurses. Why should nurses be sure to practice self-care now?
As much as nurses care for everyone else, it’s crucial to pay attention to your own needs too. By its own true definition, self-care is about taking intentional care yourself: your mind, your body, your environment, and your spirit.
If we don’t practice self-care, we can become burned out, resentful, angry, and may even start feeling depressed. This also lowers your immune system and can make you feel tired and low. If you’re not feeling your best, how can you manage caring for others?
What are some things that nurses can do to be sure to remember self-care and to fit it into their busy days?
While the occasional self-indulgence like a spa day or getaway can be a great way to express some gratitude to yourself and all you accomplish, self-care is about more than an occasional treat. An intentionally cultivated daily self-care routine can make a huge difference in our lives and allow us to be balanced & more restored.
Today, ask yourself:
How do I typically take care of myself day to day?
Do I take time to regularly assess and address my needs?
How is that impacting both my mental and physical health?
I really want you to think about how (or if) you set aside time each day to take care of yourself. Do you have time to sit back and assess your needs? Do you listen to your body when it tells you that you need a break? When you’re mentally strained, do you have a routine that helps you rest and rejuvenate?
Is there anything they can do at work on a break or at home?
There are a lot of little things that are self-care, but aren’t exciting or Instagram-able. You can do these quickly:
Write down your to do list for the week to stop the constant nagging in your head.
Set a time to be done with screens before bed.
Make a meal plan that gets you excited to eat 3 meals a day.
Take a look at your calendar: are you overbooked, need a fun outing to look forward to, need to make a doctor’s appointment?
Call a friend to catch up.
Spend time outside.
What are absolute must-dos regarding self-care?
Assess your true needs: when we’re talking about daily self-care we’re talking mainly about wellness (mental & physical). For a week, keep a log of your physical and mental expressions of stress or strain. Are you tired? Do you have frequent headaches? Look at what comes up for you and come up with small, incremental steps to take action. Maybe you have constant headaches because you’re dehydrated. Start carrying a water bottle, set some reminders on your phone to actually drink from it.
Take a critical look at your routine: What is taking up your time on a daily basis? Often times we fall so behind on creating an actual daily routine that serves us that we end up playing perpetual catch up. Finding the right way to balance what you need day to day will help ease stress and keep you feeling more balanced and in control.
Prioritize rest: if you have to put it in your schedule or “to do” list to make sure you get time to rest and recharge then do it. Maybe it’s yoga, reading, taking a bath. Rest and rejuvenation should be a priority in your daily routine. Set aside small chunks of time each day where you stop the machine, ignore “productivity” and let yourself rest.
What would you say to a nurse who says s/he doesn’t have time for self-care because too much is going on?
Self-care can be something quick and small to help yourself with your own mental and physical well-being. As a nurse, it’s important to remember that you are just as important as your patients and family. Others rely on you, so rely on yourself too. Even if it’s a quick walk around the block during lunchtime or outsourcing personal to-dos to another family member—such as creating a shopping list or picking up a birthday gift for someone—try to take some time for yourself. Also remember that self-care shouldn’t create more pressure. If it’s too much to take time every day, start with setting aside some time once a month to check in with yourself.
Unfortunately, some issues or diseases are more prone to affect people in certain communities—case in point, colorectal cancer has been known to disproportionately affect the Black community as compared with white communities. In fact, according to the American Cancer Society, Black people are up to 20% more likely to get colorectal cancer and are also about 40% more likely to die from it.
We interviewed Phyllis Morgan, PhD, FNP-BC, CNE, FAANP, academic coordinator for Walden University’s MSN-FNP program, as she has conducted research on colorectal cancer in men as well as Black men and women’s health issues, including disparity in health and health care.
Phyllis Morgan, PhD, FNP-BC, CNE, FAANP
Why does colorectal cancer disproportionately affect the Black community?
There are several reasons why colorectal cancer disproportionately affects the Black community. First, there is a general lack of knowledge about screening for colorectal cancer, which contributes to inadequate prevention and screening behaviors. There are also various fears that come into play, such as fear of cancer and of a cancer diagnosis, and fatalistic views about cancer.
A recent study showed that in Black Americans, the right side of the colon ages much faster than the left side, which could contribute to this population’s increased risk for colorectal cancer, particularly on the right side of the colon, and at a younger age.
Other factors may include delayed treatment and the fact that Black individuals have a higher incidence of obesity and more often consume a high fat, low fiber diet, which increases risk.
Why are Black people who get colorectal cancer about 40% more likely to die of it than other groups?
In addition to factors such as inadequate prevention and screening behaviors as well as delayed treatment, racial inequities in care also contribute to the fact that Black people who get colorectal cancer are more likely to die of it than other groups. There is a widespread lack of access to care for many people in this population, and some have no health insurance or inadequate health insurance for treatment.
Additionally, lifestyle factors such as diet and exercise can contribute to this.
What are the challenges facing the Black community regarding colorectal cancer?
Some challenges facing the Black community regarding colorectal cancer include inequities in health care, lack of access to quality care, and a lack of adequate resources to educate about the importance of colorectal cancer screening. It is crucial that we increase screening by providing better education for the Black community regarding screening and the importance of polyps being removed from the colon.
Additionally, we need more diverse health care providers, so patients can have providers who look like them and with whom they can connect and relate. Black health care providers can play an important role in helping patients to understand the seriousness of colorectal cancer in their community.
What can nurses do in order to get people in minority communities to go for tests, pay attention to symptoms, etc.?
First, nurses can help by providing more colorectal cancer resources for their communities. In addition, culturally appropriate educational programs and community or faith-based educational programs can be helpful in encouraging people in minority communities to undergo screening.
As an African American woman and advanced practice nurse, I have participated in many projects and studies to identify ways to increase awareness, prevention, and treatment of health issues that impact the Black community. Specifically, I worked on a community and faith-based education program to increase awareness of prostate cancer among Black men, which resulted in an increase in participants’ general knowledge of prostate cancer and treatment by over 40%. I have also implemented successful community and faith-based education programs in North Carolina and Virginia to help educate Black people about colorectal cancer and increase screening behaviors. These types of programs are proven to make a difference.
Nurses can play a vital role in helping community and faith-based organizations develop and execute programs to address health disparities. It’s critically important for research to be conducted, especially in developing culturally appropriate models for diverse communities, so more contributions toward reducing health disparities can be made available to effect positive social change.
Last but not least, Walden University and the National League for Nursing are excited to launch the Institute for Social Determinants of Health and Social Change, where nurse educators and inter-professional colleagues will play an instrumental role in achieving health equity across various demographics. The institute is designed to cultivate these health care professionals into leaders who address the impact of structural racism, socioeconomic status, environment, education, adequate housing, and food insecurity on health and well-being.
In minority communities, there have been a number of challenges with people not wanting to receive a vaccine for COVID. While we’ve already talked with someone about what is going on in the Black community, we also wanted to check in with the Hispanic community as well.
Norma Cuellar, PhD, RN, FAAN, is President of the National Association of Hispanic Nurses as well as the editor-in-chief of the Journal of Transcultural Nursing. She took the time to answer our questions about this.
Why are Hispanic communities not being vaccinated as the same rate as white people?
There are many reasons. One is the social determinants of health, like a lack of access to health care providers or lack of culturally congruent health care. The second is trust. Underrepresented or underserved communities often look skeptically on the health care system because of historic inequities. This leads to fears of adverse health outcomes, including side effects of the vaccine.
Regarding the vaccine, what are the challenges facing the Hispanic community?
A major issue is confidentiality, particularly as it relates to immigration status. Also, language barriers can be a significant roadblock, so there needs to be more communication in Spanish to help reach people that are otherwise left behind.
Are people in the Hispanic community hesitant to receive the vaccine to prevent COVID-19? Why or why not?
There is a spectrum of receiving a vaccine: from yes to no, and then the middle. Vaccine hesitation is in the middle. It does not mean that the vaccine will not be taken but that the vaccine is not going to be taken for today. How can we move the “hesitation” into “action” or vaccination?
There are a variety of reasons that Latinos have vaccine hesitation. The lack of trust of the federal government plays a major role in their decision. They fear having information about them will put a red flag and immigration may be notified. They are concerned about increased deportations.
They get their information from their peers and doubt the messages that have been sent out about COVID-19 that have not been consistent. They do not know who to trust, and do not have anyone they trust to go to. They need a PSA that is culturally congruent to the Latino community.
In addition, for the past four years, they have been intimidated through propaganda. They fear the stigma of being Latino, referred to as “rapists” and “drug dealers” in the last four years. They stay away from dealing with authorities, avoiding confrontations, and conflict. They are concerned about being visible, aware of the increase of hate crimes in our country.
Like the Tuskegee study, Latinos know about the abuse of minorities who have been treated unethically in research studies and believe it could be repeated with the new vaccination that has not been fully tested. With few Latinos participating in NIH research funding, they are unaware of the benefits of learning more about improving health outcomes through legitimate research engagement. They want to see Latino role models who take the injection before they do.
If they are hesitant about receiving it, what information can nurses give to them to help alleviate their fears?
We need to forge new community partnerships and work with people that are trusted by their peers. We need to communicate directly with people who are hesitant and educate them on this. For the Latino community, we also need to relay information in Spanish.
How can nurses who work in Hispanic communities working to build trust in the communities that they serve? How are you building that trust?
Though not specifically vaccine-related, the All of Us Research Program is working actively with partner organizations to build trust in communities and help educate people about the importance of research. The National Association of Hispanic Nurses is just one of those proud partners. We go wherever we can reach the community, as many times as it takes, and partner with other Latino organizations to build trust with the community. Compassion is essential, and we believe that one-on-one engagement will help close the gap on these inequities.
How can more research like the NIH All of Us Research Program help to prevent health disparities like this in the future?
The All of Us Research program allows Latinos not to be subjects in a research study but to be participants in the program. Through community-based partnerships, we are educating our Latino communities about research and the program. We want them to see that they can trust us and see that the community partners are in this with them. Through All of Us, we encourage all minorities to participate in our program because it impacts generations to come. Increasing self-awareness by Latino leaders in our organization will show that we lead by example and that we have faith in these programs. We must develop trust and protect Latinos from everything they fear (deportation, notification of immigration status, lack of safety in research studies). Consistent messaging of health prevention measures in Spanish must be available.
Patricia Cummings, BSN, RN, had an experience that most other nurses don’t get. She gave the COVID-19 vaccine to Vice President Kamala Harris and her husband, Second Gentleman Doug Emhoff. Cummings, a student in Walden University’s Master of Science in Nursing program and clinical nurse manager at United Medical Center says that it was a phenomenal experience, but also acknowledges how the Black community is facing challenges with people receiving the shot.
“My experience of being able to inoculate Vice President Kamala Harris and her husband was truly humbling and exciting. I feel honored that I was given an opportunity to be a part of history, as Vice President Harris is the first woman and the first African American and Asian American person to be appointed to that role. It is certainly one of the greatest highlights of my nursing career thus far,” says Cummings.
But she says that, initially, even she, a nurse, was hesitant about getting vaccinated. “I wanted to conduct my own research on the scientific background of the vaccine as well as speak with colleagues who are experts in the fields of infectious diseases and epidemiology. After reviewing the results of the clinical trials and the vaccine production process, I was convinced about the efficacy and safety of the vaccine, and hence decided to take it,” Cummings explains. “As the mother of two children, we have had to make several adjustments in our socialization, schooling, and other activities. I desire to return to a level of normalcy in my personal life, and I understand that getting vaccinated is presently the only viable solution to avoid contracting and spreading the virus. I am also saddened at the hundreds of thousands of lives lost as a result of the virus and am anxious to seeing the pandemic come to an end.”
Cummings says that one of the biggest challenges facing the Black community is having access to the virus. “Until recently, the vaccine was only accessible at a few hospitals and clinics that are typically far and inaccessible. Additionally, the registration process has been arduous and often requires one to be computer literate, as many sites require registration via the internet,” she says.
However, this isn’t the only reason why BIPOC are hesitant to get vaccinated. History has scared many people. “Hesitancy in the BIPOC population is primarily attributed to their distrust in the U.S. health care system. Historical events such as the Tuskegee Experiment, in which Black men were deceived regarding treatment for syphilis, have had lasting effects on the BIPOC community,” says Cummings. “Additionally, many have expressed skepticism about the short timeframe in which the vaccine was created and the fact that, at first, the only available vaccines required two doses.”
Cummings suggests that nurses can help alleviate patients’ fears because they’ve tended to be seen as people whom the BIPOC can trust as providing information. “Nurses should therefore provide factual information about the efficacy and safety of the vaccine based on their understanding of the clinical trials, as well as the vaccination process thus far,” she says. “Additionally, they should promote vaccination as a part of primary prevention, health, and wellness.”
Building trust in the community she serves is something that Cummings works on regularly. “As a student at Walden pursuing my MSN in the Nurse Executive program, I have learned the importance that the role of a leader as a change agent plays in influencing others to make beneficial choices. I have therefore chosen to put significant effort into sharing information about the vaccine’s efficacy and safety in hopes of building trust in my community,” says Cummings. “I also share my own vaccination experience and am transparent about my initial hesitancy. Additionally, I participate in community events that afford me a voice to safely share information and answer questions in real time.”
Another problem, though, faces certain minority communities—not speaking the same language. “One challenge that I believe exists among Hispanics and other non-English speaking populations is a language barrier. I have not seen adequate advertising and information provided in languages other than English. I believe that it is imperative that vaccine information is presented in a manner that is comprehensible to all people,” says Cummings. “It is important to add that I am passionate about health promotion and wellness. I believe that all people should be able to make informed decisions. My goal is not to strong-arm anyone into accepting the vaccine, but merely to provide them with truthful information and my own experiences in hopes that they make wise choices.”