UPDATED: July 8, 2020
Download the FAQ: MNA COVID-19 FAQ
Minnesota Governor Tim Walz issued an executive order suspended many collective bargaining rights for public employees. Is there any consideration of future executive orders that may have detrimental impact on healthcare workers?
FREQUENTLY ASKED QUESTIONS
Can a nurse refuse an assignment to a COVID-19 patient?
- You cannot refuse to work, but you and only you are responsible for the nursing care you deliver by virtue of the MN Nurse Practice Act.
- Under the Minnesota Nurse Practice Act, you have a right to refuse based on your ability to provide safe care, acuity, patient load, training, etc.
- There are different analyses about the likelihood of a healthcare worker transmitting the virus from one patient to another due to inappropriate PPE. We are seeking guidance from the state Boards of Nursing in Minnesota, North Dakota and Wisconsin but as of this writing (3/23/20) we haven’t received a response. This is an unprecedented emergency and we are not currently advising nurses to refuse an assignment based on a diagnosis only, but recommend nurses use their best professional judgment.
- You cannot refuse simply based on a diagnosis.
- If you are in an at-risk category, every hospital is treating the issue of modified assignments differently. Please seek out your facility’s policies about the issue.
- There is different advice on whether a nurse can refuse an assignment if they think the assignment is unsafe for them (for example, if the nurse has no PPE). We are seeking guidance from the state Boards of Nursing in Minnesota, North Dakota and Wisconsin but as of this writing (3/24/20) we haven’t received a response. This is an unprecedented emergency and we are not currently advising nurses to refuse an assignment based on a diagnosis only, but recommend nurses use their best professional judgment.
- IOWA: Can a nurse refuse an assignment to a COVID-19 patient?
- A nurse may refuse an unsafe assignment prior to accepting an assignment if she/he determines in her/his professional judgment the assignment is unsafe. If a nurse accepts an assignment then determines, in her/his professional judgment, the assignment is unsafe then she/he cannot refuse without transferring the assignment to another nurse. The nurse should seek out the hospital’s policy.
- The nurse should discuss the unsafe assignment with a manager. If an unsatisfactory answer is provided by the manager, go up the chain of command.
- If a nurse has malpractice insurance, call the insurance provider for their advice in these circumstances.
Why can’t we get appropriate PPE?
- There is a nationwide shortage of N95 masks and other PPE that would allow nurses airborne precautions when treating a confirmed or suspected COVID-19 patient.
- On March 23, Governor Walz signed Executive Order 20-16 directing all non-hospital entities to conduct an inventory of their PPE, ventilators, respirators, and anesthesia machines, report the result to the state, and either donate such equipment to a local coordinating entity or preserve it. On Saturday, March 21 Governor Walz directed the National Guard to transport PPE from storage at Camp Ripley to the Minnesota Department of Health (MDH).
- The President announced that he is engaging executive authority authorized under Title I of the Defense Production Act of 1950 by deeming “health and medical resources needed to respond to the spread of COVID-19, including personal protective equipment and ventilators,” meet the scarcity and national defense criteria under the Defense Production Act.
- However, according to NNU, the big thing to note is that the executive order doesn’t actually increase production of tests, PPE, or ventilators unlike some of the news coverage implies. The EO has to do with allocation of materials, facilities, and services related to COVID-19 response not production. We are working to find more information on this executive authority.
- We may receive PPE from the national strategic stockpile in the near future. But there are not currently enough PPEs to satisfy demand nationwide.
What are the best rules/guidelines around use and reuse of N95s?*
- Due to this unique virus that has already spread throughout our communities, all RNs working with potential and positive COVID-19 patients working in a hospital and all visiting nurses should be wearing surgical grade N95 masks with a face shield. If we are to stop the rapid spread of the virus this step needs to be taken now. It will do no one any good if in three weeks we have saved N95 masks but 40% of the RNs are ill and cannot care for patients.
- The best practice should be to use a new N95 with each patient encounter. If this is not possible, extended use and reusing N95s may need to be implemented.
STEPS IN ORDER OF BEST PRACTICE:
1. Individual/ single-use N95
2. Nurses carrying for multiple patients- all with positive and/or potential COVID-19: keep N95 on (use face shield over N95)- wipe/clean face shield between patients
3. If face shield not available- and reusing N95- cover N95 with surgical face mask between patients to protect integrity of N95 (to collect droplets, etc). Nurse should be wearing goggles, also.
4. Nurse carrying for multiple patients–not all COVID-19; store N95 in paper bag when not in use; continue to use face shield- wiping between patients. Really scrupulous donning and doffing procedures.
5. Surgical masks with face shield- wiping face shield between patients; use N95 for aerosolizing procedures (nebulization, CPR, intubation, etc.)
- Decontaminating N95s: In light of the shortage of personal protective equipment (PPE) in the United States, it is important to look for ways to best utilize our supply of protective items such as masks. Unfortunately, when we are asked if decontaminating N95s is a good idea, our short answer is “No!”None of the decontamination methods listed in NNU Respirator Reuse Fact Sheet are BOTH SAFE and EFFECTIVE. They should not be done. For a decontamination process to be deemed acceptable it must meet ALL the following criteria:
- it must not harm the wearer—the cleaning solution or product must not introduce hazardous substances to the provider,
- it must not decrease the efficacy of the product, and
- it must remove the contaminate (i.e. kill the pathogen).
Using Bleach to clean it, zapping it with UV light, or microwaving your mask will not work. Cleaning with ethylene oxide is not acceptable as this is a known carcinogen. Decontaminating with vaporized hydrogen peroxide is unacceptable as this is hazardous to inhale and utilizing ionizing radiation can severely damage the filter media.
The best practice is: Use and discard. When N95 are in short supply, instead of re-using or “decontaminating” them, employers should turn to PPE designed to be reusable and decontaminated safely, including powered air-purifying respirators (PAPRs) and elastomeric respirators.
Remember, on an airplane, you put on your own mask first, before helping others put theirs on. You MUST be protected appropriately before caring for others.
Why can’t people get tested?
- On 3/17, The Minnesota Department of Health (MDH) announced that due to a national shortage of COVID-19 laboratory testing materials, there will be adjustments to the testing criteria to focus on the highest priority specimens, including hospitalized patients, health care workers, and those in congregate living settings such as long-term care. Providers should inform all patients with undiagnosed fever and/or acute respiratory symptoms (cough, shortness of breath), even those not able to be tested, that they should self-quarantine for 7 days after illness onset, or 72 hours after resolution of fever (without taking fever-reducing medications), and improvement of respiratory symptoms, whichever is longer. Patients should seek care if their symptoms become severe.
Where do employees go for a test?
- Ask your employer’s occupational health department. There is a national shortage of test kit supplies and testing reagents needed in labs, so there will continue to be problems with tests for the foreseeable future.
With cancellation of elective surgeries, can OR nurses be forced to work in other areas?*
- We must look at this in the context of being a once-in-a-lifetime, unprecedented public health emergency. We should always observe contractual language, the Nurse Practice Act, and common sense as they all require that RNs be floated with an orientation to other units and not be assigned tasks for which they are not qualified and trained. That said, this is an all hands-on deck crisis. We have been very critical of the few hospitals in the state that have proposed to layoff RNs, given the state-mandated cessation of all non-urgent medical procedures. We have been pointing to the critical need of the hospitals to staff up and not down during the crisis.
If I get sick or have to self-quarantine, do I have to use my earned sick time/PTO?
- MNA believes that employers should pay RNs for time spent in quarantine or out sick due to COVID-19. No healthcare worker should have to use their earned sick time or PTO to keep themselves whole during the COVID-19 emergency. Please speak to your MNA Chairs or Labor Relations Specialist if your employer requires you to use your own benefit time.
If I test positive for COVID-19 and I self-quarantine, what criteria do I need to meet to go back to work?*
- Currently, once tested positive and quarantined, two negative test results need to be recorded before a nurse can return to work. The CDC’s current criteria for return to work can be found here.
Are stricter quarantine measures being discussed? What other public health measures should we push authorities to take?
- Minnesota: Governor Tim Walz issued Executive Order 20-20 ordering all Minnesotans, beginning Friday, March 27 at 11:59 p.m. through Friday, April 10, at 5:00 p.m., to limit movements outside of their homes beyond essential needs. Minnesotans may leave their homes to pick up essential items such as groceries or food, prescriptions, and gas, to relocate for safety reasons, or go to work if their job is deemed essential in a sector. For more information: https://mn.gov/governor/covid-19/faq.jsp
- Wisconsin: Governor Tony Evers issued Executive Order #12, “Safer at Home,” taking effect on Wednesday, March 25 at 8:00 a.m. until April 24 at 8:00 a.m., prohibiting non-essential travel. Like Minnesota, Wisconsin’s order allows people to buy groceries, seek healthcare and care for family members. There are also exceptions for people who work in essential sectors like healthcare, critical infrastructure and grocery stores.
- North Dakota: Governor Doug Burgum issued Executive Order 2020-06 on March 20, ordering the closure of all bars and restaurants to on-site sales; and the closure of recreational facilities, health clubs, theaters, and entertainment venues, through Monday, April 6, 2020.
Can my employer mandate me to work overtime?
- According to Minnesota statute, “a nurse may be scheduled for duty or required to continue on duty for more than one normal work period in an emergency.” https://www.revisor.mn.gov/statutes/cite/181.275
What precautions should a nurse take during aerosolizing procedures?
- “Extra care should be taken while aerosol-generating procedures. Non-invasive ventilation, high flow oxygen therapy, intubation/extubation, nebulization, open suctioning of airway secretions, bronchoscopy, induction of sputum, bag and mask ventilation, cardiopulmonary resuscitation, etc. have the potential to generate aerosols in high quantity. During such procedures, the use of a respirator, like N95 respirator, has been advised in preference to a facemask.” Source: COVID-19 in intensive care. Some necessary steps for health care workers. Malhorta, Gupta, Ish and Ish, 2020.
Can I be disciplined for the way I provide care in a crisis?
- We reached out to state Boards of Nursing in Minnesota, WI, IA and North Dakota to seek guidance:
- The Minnesota Board of Nursing told us : “The Board has not discussed so there is no position statement at this time.”
- The North Dakota Board of Nursing is closed until further notice. As of March 20, we emailed them and are waiting for a response
- The Wisconsin Board of Nursing meets once a month, does not have a practice specialist in-house and will not answer practice questions over the phone. As of March 20, we are waiting for a response to our email.
- The Iowa Board of Nursing referred us to the COVID Hotline where there was no answer.
Below is advice gathered from our interpretation of the Minnesota Nurse Practice Act.
The MN Nurse Practice Act explains the conditions and violations of the nurse practice act and what jurisdiction the board has to discipline you. Of interest, at this time, in this crisis, are:
- Clause (5) Failure to or inability to perform professional or practical nursing as defined in section 148.171, subdivision 14 or 15, with reasonable skill and safety, including failure of a registered nurse to supervise or a licensed practical nurse to monitor adequately the performance of acts by any person working at the nurse’s direction. This means that you may be asked to delegate to people you don’t know, haven’t met or are unfamiliar with their skill and competency level. Please confirm and realize you are responsible for tasks you delegate.
- (8) Delegating or accepting the delegation of a nursing function or a prescribed health care function when the delegation or acceptance could reasonably be expected to result in unsafe or ineffective patient care. This means be vigilant about only accepting to do delegated tasks you can deliver safely. Do you have the proper equipment, training and education to deliver it safely?
- (9) Actual or potential inability to practice nursing with reasonable skill and safety to patients by reason of illness, use of alcohol, drugs, chemicals, or any other material, or as a result of any mental or physical condition. If you are too sick or too tired to work safely, do not work.
- (16) Improper management of patient records, including failure to maintain adequate patient records, to comply with a patient’s request made pursuant to sections 144.291 to 144.298, or to furnish a patient record or report required by law. Make sure you take the time necessary to document. Even at the risk of incidental overtime, it’s more important to document properly than not take the extra time to document and risk missing documenting something critical Especially when there is so much unknown. Policies and information are changing shift to shift sometimes hour to hour.
Rumors are flying about the national guard and other extreme staffing measures. Is there more info about extreme staffing measures that may be possible?
- The Governor does have the ability to call up the National Guard and has asked for the authority to do that under a Department of Defense rule. He has not yet exercised that authority. In a press conference from 3/19/2020 he stated that if they did that, it would be for things like transporting patients from hospital to hospitals (or other facility if needed), providing food and other supplies for those that are quarantined; and perhaps helping to provide security at correction facilities, etc.
Minnesota Governor Tim Walz issued an executive order suspended many collective bargaining rights for public employees. Is there any consideration of future executive orders that may have detrimental impact on healthcare workers?
Walz suspended some collective bargaining rights only for state employees. His Executive Order states the following:
- “I also have concluded that to protect the health and safety of Minnesotans and minimize the impact of the peacetime emergency on government operations, state agencies require the flexibility to hire staff, schedule, assign, and reassign employees without adherence to existing limitations in collective bargaining agreements, memoranda of understanding, compensation plans, statutes, administrative rules, administrative procedures, and policies that present barriers to the needs of state agencies to efficiently and effectively mobilize and deploy their workforce during this peacetime emergency. When circumstances allow, Minnesota Management and Budget will work in partnership with the labor unions affected by any adjustments to the provisions of collective bargaining agreements or memoranda of understanding.”
How do we deal with issues around cleanliness of hospitals? I am not seeing an increase in overall cleaning (surfaces, door handles, etc.).*
- Increased cleaning of high-touch surface areas is a critical issue. It should be brought to the attention of the administration via the CNO, but also via direct communication with the head of your hospital’s Environmental Services (housekeeping) department. This issue is an excellent example of the great importance of having your elected MNA representatives participate in daily huddles, meetings, conference calls, etc. with your CNOs and other directors. We recommend this as a best practice at every hospital during this crisis. We also recommend that MNA members call upon their specific unit managers and directors to conduct unit-based huddles to discuss exactly these types of issues once during every shift. Contact your MNA Chair(s) or Labor Relations Specialist if you need support to push for these meetings.
Do I need to get an antibody test?
- As the country looks at ways of fighting COVID-19, antibody testing is gaining traction as a method to “reopen our country.” Frontline health care workers are slated to be among the first to be tested for SARS-CoV-2 antibodies. However, antibody testing requires further analysis and discussion before it is fully implemented. Before one gets an antibody test, it is important to remember:
- Antibody testing is not the same as establishing immunity. At this point, we do not know enough about SARS-CoV-2 to determine how long immunity lasts.
- There is a lack of oversight of antibody tests. The U.S. Food and Drug Administration (FDA) does not require review and approval for new SARS-CoV-2 serological tests, including tests for antibodies. Additionally, test results may not be reliable. There are reports of some antibody testing with less than 50% reliability.
- Misuse of antibody tests may have dangerous ramifications for containing spread of SARS-CoV-2. Using antibody tests to indicate immunity status may lead to unsafely returning workers to work because they are considered “immune.”
- Targeting health care workers for antibody testing raises ethical concerns. Health care employers must not use antibody testing to remove or downgrade protections for nurses and other health care workers.
- The use of any form of “immunity documentation” to determine return-to-work or lifting of stay-at home orders would further deepen racial and economic disparities in the United States.
What are Elastomeric Masks?
Elastomeric masks are NIOSH-certified, reusable half- or full-face respirators. They are made to be reused with exchangeable cartridges or filters. These filter cartridges are designated with a letter that identifies the cartridge’s ability to remove oils and oily mists in the air (N= No oil present, R= Somewhat resistant to oil, and P= Strongly resistant/Oil-proof) as well and a number- 95, 99, or 100—that designates the filter’s efficiency. In healthcare, where oil in the breathing air is not likely to be present, a filter with an N designation is most commonly used. However, as there is little practical difference in particle filtration efficacy and in breathing resistance between using an N filter and a more oil-resistant filter, R and P filters are also acceptable for use in health care.
A few key pieces to note about elastomeric masks:
- One MUST be fit tested prior to using an elastomeric mask and must be trained on how to perform user seal checks.
- Employers must have a clear plan in place for cleaning, disinfecting, and maintaining elastomeric respirators. OSHA’s Respiratory Protection Standard requires that employers have a written respiratory protection program (29 CFR Section 1910.134) that include procedures such as how the elastomerics will be cleaned/disinfected between patients, how they will be safely stored between uses, and how they will be thoroughly cleaned and disinfected per OSHA’s requirements [1910.134 App B2]. The employer is responsible for creating these procedures and must consult with the manufacturer for information about chemical compatibility, cleaning protocols, etc.
- The employers must also include in their protocols how often the filters will be changed. This decision should be made with input from the filters’ manufacturers. At a minimum, filters are recommended to be changed when they become soiled/damaged/grossly contaminated, if they become wet, when the expiration date has been reached, and/or when breathing becomes difficult, but they may need to be changed more often than that depending on the manufacturer’s information, the usage, work setting, etc.
- The employer needs to have in place screening, exposure surveillance programs, and widespread testing for healthcare workers. This is particularly relevant if the elastomeric mask has an exhalation valve present. Exhalation valves on elastomerics and other respirators allow for the outflow of air to relieve some of the pressure when breathing, and as such may represent a risk to patients if the nurse is an asymptomatic carrier of COVID-19.
QUESTIONS FOR YOUR EMPLOYER
Ask your hospital administration these questions:
1. What is the hospital’s plan to notify healthcare workers about a known or suspected case of COVID-19 in the facility? What is the plan to notify healthcare workers who have been exposed to COVID-19?
2. Has the hospital called for airborne precautions when healthcare workers care for a patient with a possible or confirmed case of COVID-19?
- The World Health Organization recommends only droplet and contact precautions, which neglects the precautionary principle, which states that we should not wait until we know for certain that something is harmful before we take action to protect people’s health. This is a new virus whose transmission pathway is unknown. Furthermore, at least fourteen healthcare workers have been infected with 2019-nCoV in China. Under the precautionary principle hospitals should implement airborne precautions in addition to contact and droplet precautions, for all patients with possible or known COVID-19 infections.
3. How many negative pressure rooms does the hospital have? What is the current supply of PPE? How much PPE is available for us? What are your plans if it’s not enough? Can’t we at least get scrubs and showers?
- Nurses demand the highest level of protection, including functioning negative pressure rooms and personal protective equipment for nurses providing care to possible and confirmed COVID-19 cases. Employers must ensure negative pressure rooms remain functional at all times during use. Highest level of PPE must include PAPR (powered air-purifying respirator), coveralls meeting ASTM (American Standard for Testing and Materials) standard, gloves, temporary scrubs, and other protections.
4. What is the hospital’s plan to educate healthcare workers on the virus, protective gear, donning and doffing, and other protocols related to COVID-19?
5. What is the hospital’s plan for a surge in suspected or confirmed COVID-19 patients? What are the plans to isolate, cohort and provide safe staffing?
6. What is the hospital’s plan for nurses who have been exposed to COVID-19?
- Any nurse/health care worker who is exposed to COVID-19 should be placed on precautionary leave for at least 14 days and will maintain pay and other benefits during the full length of that leave.
Please report any COVID-19 related incidents at your facility with MNA’s COVID-19 Incident Report. MNA staff and leaders will use this information to triage problems in the facilities.
The Minnesota Department of Health COVID-19 Hotline is 651-201-3920. More MDH resources are available here: https://www.health.state.mn.us/diseases/coronavirus/index.html
If you have workplace safety or health questions or concerns, contact MNOSHA Compliance at 651-284-5050 or firstname.lastname@example.org. More MNOSHA resources are available here: https://dli.mn.gov/business/workplace-safety-and-health/mnosha-compliance-novel-coronavirus-covid-19
- Department of Health: 608-266-1865
- Appleton Area Office (920) 734-4521
- Eau Claire Area Office (715) 832-9019
- Madison Area Office (608) 733-2822
- Milwaukee Area Office (414) 297-3315
- Department of Health: (515) 281-7689
- OSHA: 515-725-5621 or email@example.com
- North Dakota
- Department of Health: (701) 328-2270
- OSHA: 701-250-4521
AFTER CALLING ANY OF THESE AGENCIES, FOLLOW UP BY CALLING OR EMAILING YOUR LABOR REP WITH THE CONCERN YOU REPORTED.
As we continue to push the Minnesota Hospital Association and Mayo to meet to work on real solutions and to have a consistent approach, please continue to report concerns through our COVID-19 incident reporting form here: www.covid19form.com
NNU also has extensive amounts of information about the virus, health and safety issues, and demands on employers here: https://www.nationalnursesunited.org/covid-19 .
MNA’s COVID-19 page is here: https://mnnurses.org/resources/coronavirus/ Both pages are being updated regularly. Please refer members to these resources as well.
*(information courtesy of the Massachusetts Nurses Association https://www.massnurses.org/health-and-safety/current-topics/covid-19)