Kiersten Henry of the American Association of Critical-Care Nurses: In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System

An Interview With Luke Kervin

…Increase access to mental healthcare, with an emphasis on decreasing the stigma of seeking such healthcare. Throughout the COVID-19 pandemic, there have been marked increases in reported symptoms of anxiety and/or depressive disorder among adults. The pandemic has also increased the risk of anxiety and suicidal thoughts among essential workers, including those in healthcare.

The COVID-19 pandemic is teaching us many things. One of the sectors that the pandemic puts a spotlight on is the healthcare industry. The pandemic shows the resilience of the U.S. healthcare system, but it also points out some important areas in need of improvement.

In our interview series called “In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System,” we are interviewing doctors, hospital administrators, nursing home administrators and healthcare leaders who can share lessons they are learning from the pandemic about how we can improve the U.S. healthcare system.

As a part of this series, I had the pleasure to interview Kiersten Henry, from the American Association of Critical-Care Nurses (AACN).

She has 23 years of experience in the nursing profession, including 15 years of experience as a nurse practitioner in the intensive care unit (ICU) at a Maryland hospital. She has worked in a variety of roles and environments, including at the bedside providing care to critically ill patients and their families; at the front lines of disaster response during natural disasters and the COVID-19 pandemic; and in the AACN boardroom as a national leader in critical care nursing. She has worked to ensure equitable access to care at the federal level on COVID-19 therapeutics allocation and distribution nationwide.

Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us about your background and what brought you to this specific career path?

I grew up the daughter of a registered nurse who worked in an emergency department. As with many other families of healthcare providers, our dinner table conversations often centered around what she had seen at work that day. Each summer, she would take her two weeks of vacation to be the camp nurse at a very rustic summer camp on Maryland’s Chesapeake Bay that my sister and I attended. I got to see firsthand her ability to balance compassion with competent care and to think quickly in unusual situations. It was at camp that I met several counselors who were emergency medical technicians (EMTs). I asked to see the EMT textbook and decided if I could handle the graphic medical pictures in the book, that was a good start. I went on to volunteer in the emergency department and became a volunteer firefighter/EMT when I finished high school. It was through a nursing school practicum that I found a love for the intensive care unit (ICU). I have been a registered nurse and then an acute care nurse practitioner in the ICU my entire career. I continue to fuel my passion for prehospital care and austere medicine through my work as a disaster medicine responder and camp nurse at the summer camp where it all began.

Can you share the most interesting story that happened to you since you began your career?

As a disaster medicine responder, I have been to a variety of unusual environments and set up patient care clinics in unexpected places, such as the mayor’s office in a mountain town in Puerto Rico after hurricanes Irma and Maria.

One of the most impactful and interesting things in my role working in a hospital occurred when a patient’s family expressed their gratitude for my care in their loved one’s obituary. This was a patient in whom I had diagnosed a pulmonary embolism (blood clot in the lung). He could be ornery, per his family’s description, and I found a way to connect with him, which helped him decide to cooperate more with the healthcare team. Several years later, he was back in the hospital just prior to Christmas, and I helped his family ensure he was comfortable and surrounded by loved ones as he died from a terminal illness. His obituary read in part “in lieu of flowers, memorial contributions may be made in honor of Kiersten Henry’s dedicated friendship and care.” He died 11 years ago, and his obituary still hangs above my desk to remind me that little things sometimes have the biggest impact.

Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?

The transition from RN to nurse practitioner requires even an experienced bedside nurse to go from expert to novice in their new role. While this isn’t related to a mistake, I still laugh at the fact that as a new graduate NP 15 years ago, I would spend great amounts of time checking and double-checking how much potassium to give a patient with low potassium (and the difference in dosing is nearly insignificant). As an RN, I had gone to countless physicians when my patients needed potassium and asked, “Mr. Jones has a low potassium; can you please order X dose of potassium?” What had seemed so minor became such a major stressor when I was the individual signing the order.

Can you please give us your favorite “Life Lesson Quote”? Can you share how it was relevant to you in your life?

I first heard this quote by Theodore Roosevelt in a talk by Brené Brown. It resonated then, but several years later, I was making a shadow box for my grandfather as he was placed on hospice and I found a laminated copy of the same quote in his wallet. He was a kind and hardworking man, as well as a World War II veteran, and finding that the same quote had also motivated him moved me greatly.

“The Man in the Arena. It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at the best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who neither know victory nor defeat.”

This quote became even more meaningful as we continue to battle COVID-19 in the hospital. Our teams show up day after day, despite many defeats, each time bringing all they have to the care of their patients. They dare greatly in the face of the unknown and with the weight of relentless tragedy.

Are you working on any exciting new projects now? How do you think that will help people?

I had the opportunity to spend the past three years as a director on the national board of the American Association of Critical-Care Nurses, the world’s largest specialty nursing association. We have been able to support acute and critical care interdisciplinary teams with educational materials throughout the pandemic, in addition to ongoing work to support Healthy Work Environments and pre-pandemic initiatives. We also provided an online course, and countless other resources, for our healthcare teams at no cost for rapid training and refreshing skills on the management of acutely and critically ill patients with COVID-19.

I have also had the opportunity to work nationally on clinical education and implementation of COVID-19 therapeutics, which is an ever-changing landscape. As new products are introduced, our hope grows for more lives saved.

How would you define an “excellent healthcare provider”?

Skilled and compassionate. The AACN Healthy Work Environment Standards include some of the components that I believe define an excellent healthcare provider. These include Authentic Leadership, which requires vulnerability and transparency; Skilled Communication, with colleagues and patients and their families; Meaningful Recognition (I often refer to this as my “leadership love language,” as I believe the smallest verbal recognition can change the course of someone’s day); and True Collaboration. To provide highly reliable care, a provider must be collaborative rather than hierarchical.

Ok, thank you for that. Let’s now jump to the main focus of our interview. The COVID-19 pandemic has put intense pressure on the American healthcare system. Some healthcare systems were at a complete loss as to how to handle this crisis. Can you share with our readers a few examples of where we’ve seen the U.S. healthcare system struggle? How do you think we can correct these specific issues moving forward?

Some of the biggest challenges we have seen during the pandemic include misinformation, disparities in access to care in underserved communities, lack of available resources (staff, space and equipment) to care for acutely and critically ill patients, and challenges in disseminating best practices and “lessons learned” from areas such as New York City, which saw the first waves of patients with COVID-19.

Moving forward, the healthcare system would benefit by continuing to have sources of information that are regularly updated with best practices for management of communicable diseases such as COVID-19, and forums for clinicians across the country and across acute care settings (critical access hospitals to tertiary care centers) to share their lessons learned in real time. Continuing to address longstanding health disparities and the mistrust some communities have in the U.S. healthcare system is another significant focus that will improve access and timeliness of care. Additionally, utilizing regional resources to ensure areas with a shortage of resources have the support they need during times of critical surge.

Of course, the story was not entirely negative. Healthcare professionals are true heroes on the front lines of the crisis. The COVID-19 vaccines are saving millions of lives. Can you share a few ways our healthcare system really did well? If you can, please share a story or example.

At a systems level, health systems and localities began to look at acute and critical care bed availability across facilities. This led to load-levelling where patients were moved from overcrowded facilities to those with capacity for more patients. Traditionally, patients are regularly transferred from community hospitals to tertiary care centers for specialty care, but the inverse almost never happens. With the needs created by the pandemic, community hospitals in some areas began to accept transfer patients from taxed tertiary care centers. This was a significant change in practice and evidence of systems-level thinking, which allowed for rapid assessment and adjustment of resource allocation.

Our critical care nurses, physicians, respiratory therapists, nurse practitioners, and physician assistants have long had a strong sense of interdisciplinary teamwork. The experience with COVID-19 has cemented this teamwork, but also expanded the size of our team and relationships with colleagues we did not previously know well.

Our teams shifted from encouraging open family visitation (an evidence-based practice in regular times) to becoming the human connection between our patients and their families. We got to know family members through long phone conversations and learned about our ventilated patients from their loved ones. We made posters for our patients with pictures from their families and held the hands of dying patients when their families couldn’t be there. When we knew a patient was going to be placed on a ventilator but was still awake, we would make every effort to have them call their family prior to receiving sedation, providing them with what was often one last phone call.

From the perspective of an ICU provider, COVID-19 required us to be incredibly flexible in our care delivery and to innovate at every turn to improve care. We used technology in new ways to supplement hands-on care and compassion to support acutely and critically ill patients. Not only did our staff become experts in proning therapy (placing patients on their stomach to improve oxygen levels), they constantly refreshed their knowledge of new modalities of care shown to be promising in addressing COVID-19 infection.

Prior to the pandemic, the World Health Organization had already designated 2020 as the Year of the Nurse and the Midwife. Nurses have truly reconnected with our Florence Nightingale roots in the face of therapeutic uncertainties, providing compassion, turning patients who were delirious toward the window to get them more sunlight, and shaving patients who had been in the hospital for weeks. So very often, the best prescription we could write was compassion, and we saw that across the country, countless times.

In our facility, as we faced our first COVID-19 death in the ICU, I relayed a lecture I had listened to at a disaster medicine conference. A Public Health Service officer spoke about team well-being during the Ebola response in Liberia, when their facility’s patient mortality rate was approximately 50%. In their facility, the team created a mural to honor and memorialize their patients. With each patient death or discharge, a symbol was painted on the mural for that patient. After hearing the story, our ICU team sprang into action. The following day, one of our providers used their artistic talent to create our own mural with a large tree at its center. For each patient who survived their ICU stay and was discharged from the hospital, a flower was painted at the base of the tree. For every patient death, a star was painted in the sky. This allowed our team a moment to pause and honor each patient, and has helped to tell our pandemic story. We each remember the stars and flowers we painted and the patients they represent. It developed into a beautiful coping strategy no one could have expected. These actions were replicated in so many ways across the country. Even as healthcare workers face uncertainty and the risk of illness, they show up day after day to care for patients, whatever that looks like on each given day.

Here is the primary question of our discussion. As a healthcare leader, can you share five changes to help improve the overall U.S. healthcare system? Please share a story or example for each.

• Engage the nursing profession early and often in healthcare policy and decision-making, at the national, local and facility level. Nurses comprise the largest portion of the healthcare workforce. For 19 years, the Gallup poll has ranked nursing as the most trusted profession. Despite this, “The Woodhull Study on Nursing and the Media” (published initially in 1998 and then revisited in 2018) demonstrated that nurses are quoted as a source of information in articles regarding healthcare only 2% of the time. The COVID-19 pandemic shows the far-reaching role of nurses in the healthcare system, and the voices of the nursing profession should be heard in regard to recommendations for improving the healthcare system.
• Encourage intentional, thoughtful interdisciplinary collaboration between healthcare training programs (schools of medicine, social work, nursing, respiratory therapy, etc.) to ensure high reliability care and collaboration as students become practicing healthcare providers. This collaboration should include training on conflict resolution, the role of team members in promoting a Healthy Work Environment, strategies for interdisciplinary support during stressful patient care situations, and effective communication with colleagues and customers. For example, I teach a guest lecture to advanced practice nursing students on “The Role of the Advanced Practice Registered Nurse (APRN) in Promoting a Healthy Work Environment.” While many APRNs are not in supervisory positions, they are seen as leaders by members of the interdisciplinary team. Their role in coordinating and facilitating patient care highlights them as role models and requires professional behavior consistent with such a position.
• Increase access to mental healthcare, with an emphasis on decreasing the stigma of seeking such healthcare. Throughout the COVID-19 pandemic, there have been marked increases in reported symptoms of anxiety and/or depressive disorder among adults. The pandemic has also increased the risk of anxiety and suicidal thoughts among essential workers, including those in healthcare. As a camp nurse at a sleepaway camp, I have seen the impact of reintegration into a large peer group on children and young adults who have been isolated during the pandemic. For those with social anxiety, this environment can further exacerbate anxiety after months without potentially stressful social interactions. Even for those who are ecstatic about a return to a “normal” summer, there is an adjustment to group norms and interactions with authority figures.
• Improve health equity and access to healthcare. The pandemic has highlighted the discrepancies in access to care and trusting the medical community across ethnic and economic groups. We continue to see this with vaccination efforts and COVID-19 therapeutics. Engaging members of underserved communities to help advocate within their communities and identify barriers is an essential component of improving equity.
• Improve information sharing across transitions of care. Despite advances in so many areas of technology, the U.S. healthcare system is lacking a medical record that follows a patient across care settings, jurisdictions or even providers. This leads to repetitive testing, and inadequate medication reconciliation and assessment of patient problems, and increases the risk for misdiagnosis or loss of a patient to follow-up. Creating a universal record that includes inpatient and outpatient information would facilitate more efficient care and reduce the risk of errors created during patient handoffs.

Let’s zoom in on this issue a bit deeper. How do you think we can address the problem of clinician/provider shortages?

Both diversity and access to healthcare education could be increased by offering programs that allow students to obtain education in their chosen healthcare field, funded by a healthcare institution or system, with a commitment to work in that facility for a predetermined number of years after completing a course of study. This idea would help eliminate student debt and incentivize individuals to enter the healthcare field.

Increasing the number of high schools that offer medical career programs is an additional approach. These programs allow students to become certified nursing assistants, while shadowing healthcare professionals in a variety of settings. It enables students to explore potential career paths and receive mentoring from providers in their field of interest. While my high school did not have such a program, the opportunity to become an emergency medical technician and volunteer in the emergency department, mentored by exceptional nurses, solidified my desire to attend nursing school.

How do you think we can address the issue of diversity among healthcare professionals?

Increasing access to healthcare education and decreasing the burden of student debt would help improve diversity in healthcare. Developing mentorship programs that begin in high school and continue through a professional education program would enhance social and academic support for students of all backgrounds, particularly those in underserved areas. Truly increasing diversity and inclusion in healthcare involves ongoing dialogue regarding institutional racism and opportunities for improving equity across healthcare providers.

How do you think we can address the issue of clinician/provider burnout?

Burnout and resilience have come to the forefront of healthcare provider wellness discussions during the COVID-19 pandemic. The American Nurses Foundation surveyed the mental health and wellness of over 12,000 nurses in December 2020. About 72% of respondents reported feeling exhausted in the past 14 days, and only 23% felt resilient. Of the top five positive coping mechanisms identified by respondents, the only work-related strategy was talking with colleagues. Others included time with family and friends, leisure and entertainment, exercise, spending time in nature and having a safe space to live (even if isolated from family). Only 5% found employee assistance programs or counseling services to be helpful.

This survey highlights the fact that nurses (and likely many other healthcare providers) are more comfortable debriefing with trusted colleagues than seeking formal support resources provided by their organizations. Resilience is a continuum rather than a fixed state, and encouraging healthcare providers to engage in activities that decrease stress is an essential component to decrease burnout. Many of us feel guilty when we take time away from work, but making time for ourselves and other acts of self-care are often the very things we need to do to provide optimal care to our patients and decrease compassion fatigue. Encouraging huddles post-shift, or after a challenging patient care situation (such as a cardiac arrest), allows healthcare providers to process the case with trusted peers and potentially lightens the mental and emotional load they carry home with them after each shift.

What concrete steps would have to be done to actually manifest all of the changes you mentioned? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

1. Individuals — We have seen people and communities who have stepped up during the pandemic to become “vaccine hunters” and get community members with language barriers or technology challenges scheduled for COVID-19 vaccinations. If these same people could assist underserved individuals in navigating the healthcare system, it would improve access to care and the health and well-being of so many.
2. Corporations — Corporations can sponsor students entering healthcare professions who otherwise might not have the resources for the required educational programs. A company could also partner with community groups and nonprofit organizations and provide them with volunteers to help support access to healthcare in an underserved community. This support could involve getting individuals to healthcare appointments, helping with scheduling or providing a support person during a challenging healthcare journey. Organization involved in health and wellness can also offer services to support healthcare provider well-being, as we saw with some free services offered online during the pandemic’s initial surge.
3. Communities — Communities, whether geographic or social, can work together to support students and underserved populations in all of the ways outlined for individuals and corporations. In addition, community leaders can help identify individuals who can mentor other members of the community, whether through a decision about a potential healthcare career, or supporting them through the vaccination process or a challenging healthcare journey.
4. Leaders — As a servant leader in the healthcare field, I believe leaders should be focused on supporting their teams or their constituents to achieve an optimal state of well-being. Leaders outside the healthcare system should support their teams in finding ways to bring equity to underserved communities. Healthcare leaders must focus on the well-being of their teams and addressing the compassion fatigue associated with the pandemic in ways that are helpful and meaningful to team members.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most people, what would that be? You never know what your idea can trigger.)

I will begin this idea with a story that exemplifies the power of something that may seem small but I believe demonstrates the root of healthcare system dysfunction. Over the Christmas holiday, I cared for a patient with COVID-19 who teetered on the brink of requiring a ventilator for over a week. At the time of his admission, I was introduced to his wife by a colleague who thought I might be able to support her. She and her husband are both members of a minority community. In conversation with her, I found out that she was also COVID-19 positive, in a high-risk group and had mild symptoms. She had been offered monoclonal antibody treatment but declined because she was focused on her husband. I spoke with her and explained that the research shows the antibodies would likely keep her out of the hospital and enable her to focus on caring for her husband. I arranged the appointment for her (in a neighboring town) and ensured she made it there. Her symptoms improved the next day, and she was able to focus on her husband, who was critically ill. I didn’t work any magic. I just explained to her in a compelling way why she needed to take time for herself to get this treatment and helped her navigate the process.

If every individual with the privilege of time and resources, as well as an understanding of how to navigate the healthcare system, could donate time to help individuals in an underserved community obtain healthcare screenings, appointments or even prescriptions, we could improve access and reduce disparity. This process would involve engaging leaders in those communities to build trust and confidence, but imagine what could happen if every person experiencing healthcare challenges had someone to help them navigate the barriers of making appointments or getting transportation. Similar to healthcare providers who mentor a high school student pursuing a medical career, to share their knowledge and provide moral support along the way. We can choose to look the other way, or in the words of Theodore Roosevelt we can “strive to actually do the deeds.” I, for one, would prefer to be in the arena.

How can our readers further follow your work online?

I’m on Twitter as @KierstenHenry, and I encourage your readers to explore the AACN website at AACN.org, including blogs, newsletters, nurse profiles and a multitude of evidence-based clinical practice resources and research.

Thank you so much for these insights! This interview was very inspirational and we wish you continued success in your great work.