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Where There’s a Will, There’s Wellness

Penn Nursing Rethinks Mental Health in the Age of COVID-19.

By early July the flow of COVID-19 cases slowed to a trickle in Northern New Jersey. Penn Nursing alumna Cedar Wang, MSN, RN, GNP-BC, CHSE, at Holy Name Medical Center in Teaneck, New Jersey, watched in relief. She says, “Things have changed drastically in how much better prepared we are and how much more we know about the disease. The pressure has been lessened as far as that goes.”

But the emotional and psychic residue of working the front lines is not gone. Hundreds of patients have died from COVID-19 at her hospital. Nurses who jumped into crisis management without time to think are now feeling the weight of the endeavor. The isolation, exhaustion, and ethical uncertainties they compartmentalized in the spring are roaring back in difficult, individualized ways.

Like the virus itself, the mental toll of the pandemic is evolving. “It was a very numb experience. Almost like I couldn’t feel. Now I would characterize the feeling that I went through as surreal, even movie-like,” Wang says. “As things have started to open up and we’ve been with extended family in the backyard, people want to talk to me about COVID. But that’s not what I want to talk about.”

Organic support groups have popped up at Holy Name, in addition to weekly virtual resiliency rounds facilitated by a psychiatric nurse practitioner. The point of resiliency rounds is to invite hospital staff to share stories of perseverance and to provide a safe space for professionals to cope with stress and trauma.

“People don’t really understand what it’s been like,” Wang says. “We’re trained to take care of individual patients. Now we’re taking care of a whole population.”

Nurses have not yet seen the end of the crisis. In some parts of the country, those in the profession are experiencing the day-to-day stress that Wang once faced, depending on infection rates in their area. In other parts of the country, nurses are waiting for adequate workplace protections and personal protective equipment while bracing for a second wave. In New Jersey and elsewhere, there’s moral distress in the semblance of a return to normal: Nurses ending self-quarantine, seeing their spouses again, and taking a weekend off, while fully knowing the pandemic is far from over.

In this climate, Penn Nursing has accelerated improvements of its own mental health support systems, not only for current frontline workers but for the future of the profession. A new digital platform launched during the pandemic gives nurses and other employees at Penn Medicine quick access to appointments for mental health. That digital platform, COBALT, a joint venture between Penn Medicine and United Health Group, also provides current students with opportunities to expose themselves to teletherapy while getting clinical hours. Elsewhere at the school, the pandemic has also emboldened researchers to look harder at the ethical and moral dimensions of the nursing field.

“Nurses are the most trusted professional group in the country, and one of the largest professional groups in the country. But we also have to care for them,” says Connie M. Ulrich, PhD, RN, FAAN, a bioethicist and the Lillian S. Brunner Chair in Medical and Surgical Nursing at Penn Nursing. “I am very worried for our clinicians and how we move forward from this pandemic.”

Illustrated by Hokyoung Kim

“The country has been thinking about nurses as being brave and selfless, and I agree. But at the end of the day, mental health is an invisible illness.”

Allison Gelfarb, a Penn Nursing senior, was supposed to be in Hong Kong during spring semester, taking a course on the cultural contexts of caring for seniors. But at the start of the year, anti-government protests flared up in Hong Kong. Then concerns over a novel virus arose. When the course was cancelled, Gelfarb stayed stateside to pursue an independent study on the mental health effects of COVID-19 instead. “I think everyone knows nursing is a stressful profession, but this has been different,” she says.

Gelfarb, who studied academic literature published about previous pandemics—like the SARS outbreak of the early 2000s—underestimated how many stressors existed for nurses in a moment like this. There were the anecdotes of nurses living in hotels or basements to isolate, of course, but also the stress that accrued from working outside their specialties. “A lot of nurses were displaced from the populations they were used to working with. Labor and delivery nurses who are working on respiratory patients,” she says.

But it wasn’t until Gelfarb began externing at a psychiatric hospital in the suburbs of New York City that she says the independent study “really hit home.” One day this summer, a nurse was admitted to her floor with suicidal ideations. “It’s one thing to read about it and research, but another to see it in front of your eyes,” Gelfarb says. “The country has been thinking about nurses as being brave and selfless, and I agree. But at the end of the day, mental health is an invisible illness.”

The stereotype of nurses as unfailingly selfless, altruistic, and compassionate people often belies their own wellness needs. The American Nurses Foundation published a survey in July that reported half of nurses continue to feel overwhelmed by the pandemic; roughly three out of four say they have trouble sleeping, and nearly 30 percent are experiencing depression. Perhaps most troublingly, the survey of 10,000 nurses also revealed that a mere three percent cite their employers’ mental health programs as being a helpful resource during the COVID-19 pandemic.

Surveys like these drove a conversation within Penn Nursing about how best to pull together as a community to help address the mounting psychological demands for practitioners. There was another void that had to be filled, too: Students whose semester got interrupted by the virus still had unfulfilled clinical hours needed for degree completion. The cancellation of in-person residencies presented an uncanny opportunity.

“When COVID hit and Penn was shut down, the [nursing] track directors were talking to our partners in the health system about how we could think creatively,” says Susan Renz, PhD, DNP, GNP-BC, Penn Nursing’s Primary Care Program Director and Practice Associate Professor. “Our students so desperately wanted to help out.”

The development of COBALT was already underway. When it launched in April, under the umbrella of Penn Medicine’s employee assistance program, COBALT was a 24-7 resource for all workers in the hospital network, from physicians to secretaries to janitorial staff. It offers virtual support, live groups, and access to expert content around coping with stress, ranging from anxiety to trauma from experiencing racism. The site is designed to lower barriers to get help by allowing staff to navigate the site anonymously. COBALT provides in-house referrals to prescribers of psychiatric medicine.

In its first 90 days, COBALT had more than 10,000 unique users, including almost 1,000 employees who booked mental health appointments through the platform.

“But this was also an opportunity to meet the needs of our teaching departments and simultaneously meet the needs of the health system,” says Renz.

Renz and colleagues on the Penn Nursing faculty hatched the idea to have students on behavioral health and psychiatric tracks involved with COBALT. Starved of clinical hours, students have signed up to offer their own time slots—right alongside experienced mental health practitioners in the field—for hospital workers entering the platform, whether they’re looking for a needs assessment or some guidance.

“I love this model,” says Kate Hanselman, MSN, MSC, RN, a soon-to-be psychiatric nurse practitioner and recent masters program graduate. “So much of our education by necessity has to do with medication management. But with COBALT, we’re only really here to talk about therapeutic intervention and coping skills development. We’re only doing coaching, therapy, counseling type stuff.”

Hanselman worried that COVID-19 would throw her studies off track. “There were weeks and weeks of wondering how we’re going to graduate remotely on time,” she says. But COBALT has also given Hanselman a real-life test of her skills.

“Not only is this useful for my practice, it’s hugely helpful for health care workers struggling with a multitude of new, massive stressors who need that support,” Hanselman says.

Illustrated by Hokyoung Kim

“We must continue to discuss the connection between mental health and the moral obligations of the job.”

The pandemic is also identifying deficits on the curricular front in the nursing field. “23 percent of nurses report receiving no ethics education or training,” says Dr. Ulrich, citing a study in The American Journal of Bioethics. “Thinking broadly, we must continue to discuss the connection between mental health and the moral obligations of the job.”

Ulrich has published multiple papers this year on the ways in which nurses are unsupported in dealing with the ethical and moral dilemmas found on the front lines of a pandemic. Often, nurses are presented with conflicting opinions about how to approach their work in a crisis. For example, the 2015 American Nurses Association (ANA) Code of Ethics states that the primary responsibility of nurses is to the people (or community) receiving care. But the publication simultaneously upholds a responsibility for nurses to protect their own health and safety. Those two imperatives can’t always co-exist, Ulrich notes in one paper.

What’s worse is that many nurses are at the whim of hospital administrators who they don’t trust to have their best interests in mind, particularly with the allocation of resources. An ANA survey published in April noted that 58 percent of nurses were “extremely concerned” for their personal safety on the job, while 50 percent said their workplace didn’t provide adequate training for how to administer basic crisis response services like the COVID-19 test.

“We’re already facing a chaotic situation. Some nurses fear retaliation for skipping a shift. Some have already resigned,” says Ulrich. “Some of my earlier work stresses the importance of an ethical climate and belief in the mission of the organization in order for nurses to do their best job. Staff have to trust their organizations are doing all they can to protect them, and COVID has shown that’s not always happening.”

Ulrich hopes that one of the lasting effects of the pandemic will be getting nurses a seat at the table when policies are crafted around crisis care. And she hopes that more health systems do what Penn Medicine has done with COBALT. “Seeing friends get hospitalized, not having PPE, managing their grief—these all require support if nurses are going to stay in their positions over the long term.”

If there’s one silver lining to COVID-19, it’s been the world’s celebration of medical professionals as true heroes. It’s been the reminder of life’s preciousness and the integral role that nurses play in protecting it for everyone else. But for the nurses who look back on this moment years from now, how will COVID-19 be remembered?

“This year has definitely made me realize again why I became a nurse in the first place,” says Cedar Wang. “I watched some of my colleagues struggle with what they were being called to do, but I never felt reluctant or hesitant to go to work. This has given me greater resolve for the future. I’m a little bit more confident and secure in my decision-making.”

For many nurses, 2020 will go down in history as a time when their mental health was stretched thin. But it could also be a turning point for the profession, creating stronger and more competent practitioners who’ll be on the frontlines of the next crisis.

“COVID has reaffirmed my choice to become a nurse in a bunch of ways,” says Allison Gelfarb. For one, the short-term outlook for the economy isn’t optimistic for recent grads, but health care is expected to be an exception. “I have job security because mental health is going to be an issue, now more than ever. I’ll be working with people in an area where there will be a high level of need.”

Incidentally, Wang’s daughter has decided to enroll at Penn Nursing, a decision she came to during the pandemic. “It made her realize she wants to do a noble profession,” Wang says. “Society has a need for nurses, and strong nurses at that.”

Barriers Be Gone: Nurse-led Solutions in Teletherapy

When the pandemic stifled New York City in March, the demand for mental health services skyrocketed. “I was getting bombarded from friends and colleagues and nursing home staff for mental health referrals,” says Brighid Gannon DNP PMHNP-BC GNu’13. “The narrative I kept hearing was psychiatrists and therapists are not responding to phone calls or email, or their practices were full.”

Within a couple weeks, Gannon—who owns Ivy Psychiatry, a psychiatric consulting business for nursing homes across the state—heard about a solution being conceptualized by Dr. Pritma Dhillon-Chattha. Gannon had befriended Dhillon-Chattha years earlier when the two completed their Doctorate of Nursing Practice degrees at Yale. “We decided that there was a time-sensitive need in New York for a nurse-driven online psychiatry and therapy office,” Gannon says.

By mid-May Gannon and Dhillon-Chattha launched Lavender, an online practice that’s grown more than 400 percent by client volume over the course of the spring and summer. “It doesn’t seem like that’s going to slow down,” Gannon says. “People are being asked to tolerate a level of uncertainty that is just not feasible right now.”

Lavender provides expert-level teletherapy and medication management with the ease and convenience of a personal concierge. It has a streamlined website designed to be welcoming and responsive, reducing the risk of retraumatization by providing a positive user experience. New inquiries are answered by phone, email, and text on the same day they’re received. Then, clients are able to book medication and therapy appointments with psychiatric nurse practitioners on demand. Lavender gives the option of variable session lengths, allowing clients to purchase quick 20-minute check-ins with providers or meet for longer sessions, depending on the client’s mental health needs at any given time.

Lavender was able to launch so quickly in part because Gannon already had a provider team: 15 psychiatric nurse practitioners at Ivy Psychiatry. “What’s exciting about Lavender using psych NPs exclusively is that we can provide both therapy and medication management,” says Gannon. “There isn’t that siloed care that happens when you have a therapist and a psychiatrist doing two different things. Plus, there’s also really good cost savings for people, and cost savings are important now.” Gannon says that Lavender services are 30 percent less than the average provider in New York City.

While the platform is friendly to Millennials, it also supports home bound older adults with its Senior Care Concierge Program. Lavender accepts multiple forms of insurance, including Medicare.

For Gannon, Lavender’s early success demonstrates a long-term opportunity for reducing barriers to access within mental health services. “One of the positive things that’s happened in COVID is that health care was forced to modernize quickly. Providers and patients who were slow to adapt before are now using telehealth, increasing access to care,” she says.

But the platform is not only a boon for clients; it’s showcasing potential new career paths for nurses. “Nurses have never really been able to participate in the gig economy. I’m finding now with telehealth, a lot of nurses are able to pick up these side gigs, make a little extra money, and maybe have a more flexible life,” says Gannon.

Lavender, Gannon believes, is just one way to accomplish that. “I would love to see more nurses in entrepreneurship, starting their own businesses,” she says. “And I’m always happy to mentor and support them along the way.”