Washington State recorded the first coronavirus disease 2019 (COVID-19) deaths in the early days of the pandemic. Hitting particularly close to home for the associate degree nursing community, Associate Degree Nursing (ADN) students and faculty in Kirkland, WA had been conducting clinical in the local long-term care facility at the center of the state's outbreak. Organization for Associate Degree Nursing (OADN) had the opportunity to speak with leaders from the Washington State Nursing Care Quality Assurance Commission (NCQAC) at the onset of the COVID-19 pandemic. The following interview was conducted on March 17, 2020 with Paula Meyer MSN, RN, FRE Executive Director of the NCQAC, and Gerianne Babbo Ed.D., MN, RN, the Commission's Director for Nursing Education.
BH: For TELN's global readership who might not be familiar, can you give us an overview of the NCQACs role in Washington State?
PM: The NCQAC functions as the board of nursing for Washington, with a fifteen-member, governor-appointed board overseeing over 140,000 nurses in the state. Specifically, the NCQAC protects the public's health and safety by regulating the competency and quality of licensed practical nurses, registered nurses, advanced registered nurse practitioners, and nursing technicians. The purpose of the NCQAC includes establishing, monitoring and enforcing licensing, consistent standards of practice, continuing competency mechanisms, and discipline.
BH: How does the COVID-19 epidemic differ from other public health concerns the Commission has addressed?
PM: Our role in a public health crisis is typically one of preparation. We plan for continuity in a disaster, continuing needs around licensing, for example. However, the COVID-19 situation is much more intense and widespread than a typical natural disaster. When the first case of COVID-19 in the United States was diagnosed here in Washington, Governor Inslee's administration and the Department of Health, which includes the NCQAC, moved to a heightened state of communication and alignment. It is so important in a public health crisis that these agencies speak with one voice and that the public is properly informed.
BH: Before we pivot to what the NCQAC is doing to support nursing education programs, can you speak to what the Commission is doing to support the nursing workforce at large during this crisis?
PM: The Governor's broad emergency authority allows the NCQAC and other agencies to adjust regulatory environments that can support population health in a crisis. While the goal to assure safe, quality nursing care for the public remains the same, the Commission is taking a number of steps to support the workforce and the frontline nurses caring for our ill and vulnerable population. First, emergency interim permits will be made available to nursing students, including LPNs, RNs, and ARNPs, who have graduated from a nursing program but are not yet able to take their national licensing exam. Students and their schools must certify certain information, including a registration date for licensing examination, before NCQAC licensing staff can issue an emergency interim permit allowing the applicant to work as a nurse during the declared emergency. When testing is available again, nurse applicants are required to take the national exam to complete the process for permanent licensing.
Additionally, under the Governor's current emergency proclamation order, nurses from Washington or other states with no prior disciplinary history may apply to work in Washington without further licensing requirements.
BH: You mentioned temporary licensing accommodations for nursing students who have graduated, what about students who haven't graduated?
PM: Current nursing students who have not graduated can work up to their level of education either as certified nursing assistants (CNAs) or nursing assistants. The Commission is working with nursing assistant programs to deliver learning outcomes with the shift towards online education and closure of clinical sites. If these programs provide federally-required content first, students may apply and work as nursing assistants-registered under the supervision of an LPN or RN while they complete the class.
BH: What about registered nursing students who may have delayed graduation due to the crisis?
PM: Most clinical sites are closed consequent to the emergency proclamation and widespread school closures. Nursing students who have yet to complete clinical experiences are encouraged to apply and register as nursing technicians. Many registered nursing students in Washington are already CNAs due to individual programs’ requirements, although that is not a statewide policy. Moreover, though, nursing students can be of support–and in turn, they will see nurses as role models from whom they learn compassion from and the care that requires a gentle touch.
GB: We mustn't forget that students are resilient, eager learners with expansive knowledge of safe nursing care. Despite the current situation, many student learning outcomes can continue to be met didactically, through virtual simulation, and clinical modalities that observe social distancing, like telehealth. It's also important to see this crisis as a learning opportunity for students. Even though students are not in clinical rotations with COVID-19 patients, students can benefit immensely from a re-emphasis of infection control theory and skills which lie at the heart of their curriculum and origins of nursing, itself.
BH: Can you talk about some of the challenges programs are currently facing with the COVID-19 pandemic?
GB: From the onset of the crisis, our goal at the NCQAC has been to deliver valid and rapid information to the nursing programs. Sixteen nursing students were in clinical at rotations at Life Care Center of Kirkland at the time of the facility's outbreak, the first in the nation. As the epidemic in Washington spread, many clinical sites were closing, particularly in densely populated urban areas. Eventually, all colleges across the state closed their campuses and moved to online instruction. In some cases, in-person simulation and skill labs have also ceased, unless proper precautions and strict social distancing can be assured. Nursing programs are now looking at the possibility that current terms and education may need to be expanded.
BH: How're nursing education programs navigating these challenges?
GB: WA state nursing programs are highly innovative and responsive to meeting student needs. Collaboration is key. Unlike many states, our deans and directors of all education levels meet jointly and often. Currently, schools are sharing simulation strategies and distance learning plans. They are developing best practices to ensure students’ at-home testing fosters self-monitoring and upholds academic integrity, or simply delaying testing in some cases. What's important is that these changes be made to benefit student learning under these very unique circumstances.
BH: How does the Commission support these program adjustments and innovations?
GB: First, under the Washington Administrative Code, up to 50% of the registered nursing student's clinical education can be delivered through high-quality, approved simulation. While the research support simulation to this level, Washington is only one of sixteen states that supports the 50% level. Programs are also encouraged to explore virtual simulation options. While these virtual options may not have psychomotor components, research shows that debriefing is actual the most critical component for student learning across high fidelity, low fidelity, human and virtual simulation. As simulation and other program changes require the Commission's approval, we have expanded our approval process's capacity to expedite reviews and get the programs feedback on proposed changes in a very short period of time.
Washington State also has specific guidance written into the state's code designed to encourage innovation projects or program approach for approved nursing education programs. Innovations proposed under these rules must maintain standards, protect the public, and be evaluated. We are encouraging the programs to utilize this mechanism as they navigate their current challenges. One example was a program that sought for preceptors and students to meet virtually. Not only does this change maintain student learning outcomes, but it also supports crucial social distancing.
BH: How might this epidemic force changes in nursing education that endure once COVID-19 is resolved?
GB: The exciting use of virtual reality in simulation has been a growing trend, but the current situation is accelerating its use and emerging position in nursing education. Virtual simulation scenarios that are high-risk/low-frequency may become more common. Additionally, many changes to learning infrastructure such as distance learning will probably see more utilization moving forward, along with better theoretical content online.
BH: When it comes to COVID-19, what else is the NCQAC doing to support the needs of Washingtonians?
PM: We're working with the National Council of State Boards of Nursing's advocacy staff to prevent loss of student financial aid that could result from a disruption in the course of study. On the practice side, we're working with our colleagues in labor organizations to make sure nurses are educated about COVID-19 patient assignments and the duties incurred upon assignment acceptance. We're also encouraging school nurses to volunteer or seek employment in patient care as school systems are closed. Additionally, discipline hearings have been postponed so that our attention can stay focused on the pandemic response and nursing staff suffer minimal disruption. The Commission is also giving renewed attention to the LPN workforce and looking to academic progression opportunities that could be offered to them, so that they may potentially supplement the existing workforce as RNs.
BH: By the time this interview prints in July 2020, we'll hopefully have flattened the curve and be recovering from the severe onset of this pandemic. What message do you have for TELN's readers for a future epidemic or other disasters in their community?
PM: Together, we can remind our families and communities about the strength of our nursing workforce during infectious disease emergencies other disasters. We should also go out and make new friends. These are the relationships that will support our resilience to confront future challenges.