Nurses play a key role in applying lessons learned from the COVID-19 pandemic and mitigating the impacts caused by social determinants of health, according to the keynote speakers at the 2021 Maryland Action Coalition (MDAC) Virtual Leadership Summit, hosted by the University of Maryland School of Nursing (UMSON). The theme of the annual conference: “Meeting Challenges Head On: Maryland Nurses Respond.”

Keynote speakers Brian C. Castrucci and Susan Hassmiller.

"We’ve all lived through a year and a half of COVID. And people always ask, ‘Why is COVID so much worse in the United States than it is elsewhere?’ I suggest that COVID was the match, and we provided a whole lot of kindling for it with our decisions,” Brian C. Castrucci, DrPH, MA, president and chief executive officer of the de Beaumont Foundation, said in his keynote address, “Skills and Perspectives that Nurses Need to Lead a Post-Pandemic Public Health Renaissance.” 

“There are policy decisions that we’ve made over the past at least two decades, if not past 400 years, that really impacted how COVID played out in the United States,” said Castrucci, whose parents were emergency room nurses.

MDAC strives to improve health care by implementing recommendations set forth in the landmark report, The Future of Nursing: Leading Change, Advancing Health, released in 2010 by the Institute of Medicine (IOM) and the Robert Wood Johnson Foundation. The report addressed the challenges facing the nursing profession, in particular the need to prepare the nursing workforce to provide excellent care to an increasingly diverse and aging population, within a rapidly changing health care system. MDAC was formed in 2011 in response to the report.

“But what’s killing us, what’s causing our ill health is nothing that can be really determined and treated inside a clinic,” Castrucci continued. “We know that social determinants of health are what’s really challenging populations now. But our response has been to buy more and bigger buckets to bail out the boat. We’re not fixing the hole.”

Most of the nation’s COVID-19 deaths could have been prevented, he asserted, because they had more to do with the social determinants of health than the virus itself.

“The reason so many people died was not because of COVID. It’s because of decisions that we made five, 10, 100 years ago that for the first time for everyone in America were front and center,” he said. “COVID has made it really hard to ignore things. And we were super good at that in America.”

His biggest fear? “Once everyone’s vaccinated, and we’re all at the beach, and we’re all living our lives again, that we will just go back to the way things were,” he said. “COVID is like Mother Nature sending us a warning shot.”

He likened it to the bypass surgery patient who asks a nurse for a cigarette before he is even out of the hospital.

“Are we going to be the bypass patient who smokes? Or the bypass patient who eats well and exercises? I’m too concerned that America is already reaching for a pack of [Marlboro] Reds.”

In kicking off the conference, Jane M. Kirschling, PhD, RN, FAAN, the Bill and Joanne Conway Dean of the University of Maryland School of Nursing, referred to a report recently released by the National Academy of Medicine (NAM), The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity, which showed a need to reduce health disparities and tackle issues of structural racism.

“Of course, these are not new challenges,” said Kirschling, MDAC co-chair. “But for many of us, they have been brought into sharper focus and given greater urgency as a result of the clearly disparate impact of the COVID-19 pandemic on certain populations and the ongoing discussions about the impact of structural racism following the events of last spring.”

Another outcome of the COVID-19 pandemic? “The incredible toll that it has taken on nurses throughout the country,” Kirschling said. “Many of us are learning more about the level of moral distress experienced by nurses on the front lines of care delivery. New thinking is emerging on how we can better and more fully support nursing at all levels.”

Castrucci said that too often, health care professionals think they are addressing social determinants of health when in fact they are addressing the social needs of an individual patient.

To illustrate his point, he relayed his encounter with a community health worker who told him she was “working on the social determinants of health.”

She was assigned a patient, Mr. Johnson, a diabetic who was not compliant with his medication and was a frequent visitor to the emergency room. Figuring that Mr. Johnson was lonely, the community health worker began to take him on walks and to weekly bowling outings. He is now taking his medication properly and avoiding expensive hospital stays.

The woman told Castrucci she was addressing social determinants of health. She wasn’t, he said.

“I was like, ‘No, you have addressed the social needs of one particular human being, which is laudatory, but will not solve the problems that we have,’ ” he said. “Because there are thousands upon thousands of Mr. Johnsons, and we don’t have the resources to give each of them a person to go bowling with them.”

It is critical to the future of nursing that the terms be used correctly, he emphasized.

“Social determinants are those things working at that community and policy level, while social needs are those things that are impacting a patient’s health but are outside the realm of the clinic. Those two things are different, and they’re equally important, and they need to be addressed that way. But right now, health care is focusing mostly on social needs.”

Where to begin on the many lessons that can be learned from COVID-19? Communication is a good place to start, Castrucci said.

“For me, much of COVID-19 stands as a monument to really poor public health communication,” he said. “We needed to couch things from the start as we don’t know everything there is to know yet, but as we know more, we’re going to share.’”

Initial stay-at-home orders were framed as lockdowns, instantly drawing up negative connotations of prisons and active shooter drills at schools. “We never found a way to talk about Americans’ shared anxiety. And this is our challenge,” he said.

Nurses play a critical role in educating the vaccine-concerned, a phrase Castrucci prefers over vaccine-hesitant, he added, noting a recent Kaiser Family Foundation poll showed that nurses and other health care professionals are viewed as trusted sources of information.

Nurses were always quick to respond, from the pandemic’s early days to today.

“Nurses were there to get our backs throughout this entire pandemic, in the community, in the hospital, in the clinic, at the mass vax sites, and I don’t think our society has done much at all to get your back, and that is something that we have to reckon with,” Castrucci said.

The afternoon session featured an endnote presentation by Susan Hassmiller, PhD, RN, FAAN, senior adviser for nursing, Robert Wood Johnson Foundation, who since January 2019 has served as a key member of the leadership team for NAM’s recent report. It was her first presentation on the report to an action coalition.

“Achieving health equity is the most salient issue of our time,” Hassmiller said. “And I believe this is nursing’s time to help lead this change.” She reinforced that structural inequities lead to poorer health and increased stress, putting people of color at higher risk for many health conditions, including COVID-19.

Given that the report covers a time period beginning in 2020 but was released in May 2021, Hassmiller acknowledged that the only way for the report to be relevant was to delay its release, to recognize lessons learned from the pandemic and the ever-growing call for racial justice.

“This report is being released during a critical time in our nation’s history and in nursing,” she said. “We need policy reform to unleash our potential.

“You have been such a key part of our efforts to strengthen education and advanced practice and promote nursing leadership and increase workforce diversity,” she told a virtual audience of nurses from throughout the state. “We have built the capacity of this workforce to expand high-quality care to more Americans. The new report builds on the gains that we’ve made and seeks to leverage this capacity to advance health equity.”

Hassmiller outlined four key takeaways and related recommendations, out of nine major areas and 54 recommendations that the report addresses:

• Takeaway 1: Permanently remove practice barriers. Recommendation: All organizations should enable all nurses to practice to the full extent of their education by removing regulatory, private, and public payment limitations and restrictive policies and practices.
• Takeaway 2: Value nurses’ contributions. Recommendation: Payers and public health agencies should establish sustainable, flexible payment mechanisms to support nurses in health care and public health, including school nurses, in advancing health equity.
• Takeaway 3: Prepare nurses to tackle health equity. Recommendation: Nursing schools need to integrate content about drivers of health, health inequities, and population health concepts through the entire curriculum and expand community learning opportunities to encourage nurses to work with other health and non-health colleagues.
• Takeaway 4: Fully support nurses. Recommendation: Nursing education programs, employers, nursing leaders, licensing boards, and nursing organizations should initiate the implementation of structures, systems, and evidence-based interventions to promote nurses’ health and well-being immediately. The report recommends this should happen by the end of the year.

Hassmiller’s presentation was followed by a poster session that featured 20 live presentations and Q&A via a chat box. Another 31 entries were added to the MDAC website. The virtual summit ended with closing remarks from Patricia Travis, PhD, RN, CCRP, senior associate director, clinical trials, Johns Hopkins Medicine, and co-chair of MDAC. She bestowed the Best Poster Award on Patty Palmer, MSN, lead author with Vanessa Fahie, PhD, assistant professor, UMSON, for “An Assessment of the 2020 Health Care Summer College and Workforce Development Institute.” Travis also conducted an online poll, asking “What should the state of Maryland focus on as a priority from The Future of Nursing 2020-2030 report?” The option “Prepare nurses to tackle and understand health equity” led the audience response, with 33 percent of votes out of four possible options.

Katie Wunderlich, MPP, executive director, Health Services Cost Review Commission (HSCRC), also presented on “Maryland’s Experience and Progress in Implementing Value-Based Healthcare Reform.” HSCRC is an independent state agency responsible for regulating the quality and costs of hospital services to ensure all Marylanders have access to high-quality health care.

Before kicking off her presentation, Wunderlich expressed gratitude to those nurses who endured the pandemic from the front lines.

“I really want to extend a very heartfelt thank you to all the nurses out there. I know your work and dedication over the last 16 months has been a huge undertaking,” she said. “You have absolutely been on the front lines of this pandemic. And those of us who do not serve in a clinical capacity can’t fully appreciate how that is, to be on the front lines. I know it’s taken a toll on your families, on your health, and on your mental health.”

For more details about the summit and to view abstracts and posters, visit www.nursing.umaryland.edu/MDAC/.