Quarterly publication direct mailed to approximately 10,000 RNs and LPNs in Ohio Volume 13 | Number 2 | April 2020 and delivered electronically via email to 260,000+ RNs and LPNs in Ohio

Legislative Update What’s inside this issue? ONA Members Get CE for FREE! Pages 4-5 Page 18

COVID–19 ONA Response

Last week the Ohio Nurses Association held a special town hall for nurses across the state regarding the COVID-19 crisis.

Please visit https://ohnurses.org/coronavirus/ for the most up to date information.

CALL TO ACTION

Jessica Dzubak MSN, RN against serious diseases such as COVID-19. Medical working. Drastic measures are being taken across grade masks and respirators, such as N-95, are the state to conserve and even re-use this necessary There is no question that these are unprecedented essential to protecting our nurses and healthcare equipment as Ohio braces itself for more COVID-19 times. Nurses and other healthcare providers are colleagues against the spread of disease. cases each and every day. overwhelmed with gratitude at the outpouring of We understand times are hard and the challenges love and support from their communities. In times we face now are frequently likened to war. But now What You Can Do of crisis, the support and appreciation shown by our more than ever we must continue to fight for the As ONA member and advocate Rick Lucas said in communities means everything. safest available equipment and reserve things like a recent national interview on CNN, if you want to help It is no secret that hospitals and other care homemade masks as an absolute last resort. nurses during this difficult time, “put down your sewing institutions are experiencing a massive shortage We know COVID-19 is now community-spread, machine and call your elected official.” of personal protective equipment (PPE), including meaning it is transmitted via the air and surface Campaigns from our national partners, American gowns, gloves, eye protection, masks and respirators. contact regardless of travel history. Homemade masks Federation of Teachers (AFT) and American Nurses This poses a significant threat to both healthcare can serve as a barrier for community members who Association (ANA) urge President Trump to enact the providers and their patients. This equipment is the have to go out to the grocery store or the pharmacy. Defense Production Act now. only barrier protecting those on the frontlines from Our healthcare providers, who are exposed to not only Each day we waste is one more day our nurses are contracting contagious diseases such as COVID-19. COVID-19 but other dangerous diseases, need the full without the needed equipment to keep themselves, One of the ways the community has stepped up to support and protection of medical grade equipment. and their communities, safe. assist healthcare providers has been to begin crafting Personal protective equipment should not be homemade face masks. While this is an incredibly considered a luxury for healthcare providers, yet these kind gesture, homemade masks are largely ineffective are the conditions in which our nurses are currently

Non-Profit Org. Inside this Issue U.S. Postage Paid Princeton, MN Permit No. 14 Ohio Nurses Association Events...... 2 Ohio Nurses Mourn the Passing of current resident or Ask Nurse Jesse...... 3 Representative Don Manning...... 13 Message from ONF Chair ...... 3 Climate Change Part 2...... 14 Legislative Update...... 4-5 CE4Nurses: Same Name, More Value . . . . . 18 Climate Change Part 1 ...... 6 Unbelievable Heroism...... 18 ONA Member Benefits...... 19 Page 2 Ohio Nurse April 2020 OHIO NURSE OHIO NURSES ASSOCIATION The official publication of the Ohio Nurses Foundation 15th Annual Nursing Professional 3760 Ridge Mill Drive Events 2020 Development Conference Hilliard, OH 43026 September 11, 2020 (614) 237-5414 Nursing Professional Development Location: The Quest, Columbus, OH Certification Prep Course Web site: www.ohionursesfoundation.org May 21-22, 2020 Labor Institute Articles appearing in the Ohio Nurse are Location: OCLC Conference Center, Dublin, OH September 13-14, 2020 presented for informational purposes only and Salt Fork Lodge, Cambridge, OH are not intended as legal or medical advice Nurses Choice Luncheon and should not be used in lieu of such advice. April 24, 2020 For specific legal advice, readers should Blackwell Inn and Conference Center, contact their legal counsel. Visit Columbus,ONA’s OH event websiteProvider for updates Updates Retired Nurses Conferenceon upcoming events. April 17, 2020 June 2 and 3, 2020 Franciscan Health, Indianapolis, IN Location: The Quest, Columbus, OH May 20, 2020 ONA Summer Celebration Location: OCLC Conference Center, Dublin, OH https://ohnurses.org/onaevents/ 2020-2022 Ohio Nurses Foundation July 15, 2020 Board of Directors Location: ONA Headquarters, Hilliard, OH September 10, 2020 Location: The Quest, Columbus, OH CHAIRPERSON: Susan Stocker VICE PRESIDENT: Shelly Malberti National Nurses Week 2020 ONLINE convenience, May 6 – 12, 2020 TREASURER: Annie Bowan QUALITY education SECRETARY: Joyce Powell To Register, go to www.ohnurses.org DIRECTORS: and click on Events Paula Anderson Nancy McManus Please note: all dates and locations are subject to change Gina Severino Barbara Welch CEO / PRESIDENT: We offer over 30 continuing education Lisa Ochs programs for health professionals The Ohio Nurse is published quarterly in From anticoagulation therapy to wound January, April, July, and October. management. Designated contact hours for pharmacology for APRNs! Learn your way with Address Changes: The Ohio Nurse obtains its live, independent study, online interactive, mailing list from the Ohio Board of Nursing. Send and hybrid programs. address changes to the Ohio Board of Nursing: 17 South High Street, Suite 400 Education in Your Own Time and Place Columbus, OH 43215 http://www.usi.edu/health/center-for-health- 614-466-3947 professions-lifelong-learning/certificate-programs/ www.nursing.ohio.gov 877-874-4584 For advertising rates and information, please In support of improving patient care, the University of contact Arthur L. Davis Publishing Agency, Inc., Southern Indiana Center for Health Professions Lifelong Learning is jointly accredited by the Accreditation 517 Washington Street, PO Box 216, Cedar Falls, Council for Continuing Medical Education (ACCME), the Iowa 50613, (800) 626-4081, [email protected]. Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to ONF and the Arthur L. Davis Publishing Agency, provide continuing education for the healthcare team. Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.

Acceptance of advertising does not imply endorsement or approval by the Ohio Nurses Foundation of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this Foundation disapproves of the product or its use. ONF and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect views of the staff, board, or membership of ONF. April 2020 Ohio Nurse Page 3 ASK NURSE JESSE MESSAGE FROM ONF CHAIR

I had already written my message for this issue but decided to save it for a later edition so I could send some thoughts regarding the COVID 19 pandemic. As I think about the situation we find ourselves in right now, I vacillate between denial and feeling overwhelmed. I’m a college administrator so my days have been filled with making sure students are getting what they need remotely and trying to find solutions for our Nursing and Allied Health students to complete their required clinical hours so they can graduate on time and get out into the workforce. I’d characterize the challenges I’m facing right now as a dilemma that with some creativity Susan Stocker, RN and cooperation, will work out. But for those of you who ONF Chair are on the frontlines of patient care, it’s a totally different reality. You are putting your lives and your family’s lives on the line every day to care for others. I think the word “hero” is over-used. Heroes are noted for courageous acts; someone endowed with great strength or ability; a person who, in the face of danger, combats adversity. Staff nurses are heroes everyday they go to work. But under the current conditions, you are super-heroes. I know you are being asked to carry on under extraordinary circumstances. As you know, ONF is Submitted Question: funding research on Moral Injury. Unfortunately, I fear we will have many, many Can an LPN stage pressure ulcers? stories of how the system has failed us. I recently announced that we are cancelling the Nurses Choice Awards luncheon. This is the year we probably needed to celebrate more than any Answer: other. We will plan an extra special celebration for next spring. In the meantime, According to the Ohio Board of Nursing: we will need to celebrate remotely. To those of you on the front lines, I can’t “The response to your question depends upon what is meant by thank you enough. Take care. Be well. “staging the wound.” Section 4723.01(F), ORC defines the practice of nursing as a LPN and includes “providing to individuals and groups nursing care requiring the application of basic knowledge of the biological, physical, behavioral, social, and nursing sciences at the direction of a licensed physician, dentist, podiatrist, optometrist, chiropractor, or registered nurse.” Chapter 4723-4, OAC, addresses the LPN’s role in the ANA COVID-19 Workplace Survey nursing process that includes the collection of objective and subjective The COVID-19 pandemic puts nurses on the front line, and data relevant to the client’s health status. preparedness is critical to preventing community spread. ANA An LPN may collect patient data that includes the LPN’s observation, is launching a workplace survey to gather and broadcast the measurement and comparative analysis of a wound to a staging chart, and perspectives and needs of nurses. The data from this survey will documenting the observation, measurements and comparative analysis. be aggregated and posted on ANA’s website to shine a light on the RN. The scope of practice for a RN is located in Section 4723.01(B), needs of those providing care. ORC. The scope of practice for a RN may include assessing health status for purposes of providing nursing care. When a RN “stages” a pressure Take the survey at ulcer it may be a part of the overall nursing assessment of the client for https://ana.co1.qualtrics.com/jfe/form/SV_4OpLErvMKgd6tud. purposes of providing nursing care, e.g., determining the nursing care that will be necessary pertaining to the client with a wound. Section 4723.151(A), ORC, prohibits a nurse from making a medical diagnosis, and from engaging in the practice of medicine or surgery. Under the RN scope of practice, defined by statute in Section 4723.01(B), ORC, a RN Nursing Continuing Education may identify a nursing problem, and certainly may describe a wound DIABETES EDUCATION PROGRAM including various tissue exposure, and may compare a wound to specific charts or graphs that identify types of wounds, and a RN may report a Do your patients/clients understand and effectively apply diabetes diagnosis determined by a qualified health care provider. However, a self-management skills? How good are you at managing hospitalized RN cannot him/herself independently determine and report a medical patients? Enhance your patient teaching and management strategies, and diagnosis. optimize patient outcomes with this professional development course. Therefore, whether a nurse, RN or LPN, may stage a wound, depends on what is meant by “stage a wound” and how it equates to a medical diagnosis and/or how it is documented and reported.” Register Today! 4 Thursdays: Be sure to follow your institutional policy on wound assessment and csuohio.edu/nursing/CE October 29 - November 29, 2020 documentation. CSU Main Campus Cleveland, OH For more information on RN and LPN Scope of Practice, visit: Tuition: $695 • https://nursing.ohio.gov/wp-content/uploads/2020/02/RN-LPN-Scope-of- 216.687.3867 | [email protected] Practice-2019.pdf • http://codes.ohio.gov/orc/4723.01 24 Contact Hours Awarded to RNs • https://nursing.ohio.gov/practice-resources/practice-rn-lpn/ Approved by the Commission on Dietetic Registration for 24 CPEUs • http://nursing.ohio.gov/wp-content/uploads/2019/10/10.8.19-RN-LPN- Cleveland State University is approved as a provider of continuing nursing education by Ohio Nurses Association, an FAQs-2019.pdf accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. (OBN-001-91)

For more information on best practices in wound assessment: • http://www.internationalguideline.com/static/pdfs/Quick_Reference_Guide- 29Dec2019.pdf Have a question for Nurse Jesse? Visit ohnurses.org/asknursejesse

Text ASPIRE to 89743 to apply Contact Hilary at (317) 587-0500 or email [email protected] Page 4 Ohio Nurse April 2020 LEGISLATIVE UPDATE

Tiffany Bukoffsky, MHA, BSN, RN • Creation of the Nursing Education Assistance • Elimination of smoking in public places as Loan Program. (1990) part of a coalition with other health care and The World Health Organization (WHO) has environmental interest groups. (2006) designated 2020 as the International Year of the • Recognition of advanced practice nurses— Nurse and the Midwife to not only celebrate the nurse practitioners, clinical nurse specialists, • Establishment of staffing standards in 200th birth anniversary of Florence Nightingale, certified registered nurse anesthetists, and accordance with ANA principles. (2008) but to “celebrate the world’s 22 million nurses and certified nurse midwives. (1996) 2 million midwives who make up half of the global • Defeated efforts to limit the rights of public health workforce – providing vital health care • Needle stick safety legislation. (1999) employees (including nurses) to bargain everywhere, as they have been doing for centuries” collectively. (2013) (WHO, 2020). Additionally, on January 6th, 2020, Gallup announced that nurses continue to rank • Prescriptive authority for nurse practitioners, highest in honesty and ethics for the 18th year in a clinical nurse specialists, and nurse-midwives. • Authority for nurses in pronouncement of death row by 85% of Americans. (2000) in certain circumstances. (2013) The profession of nursing has come a long way since the days of Florence Nightingale and • Creation of the Nursing Education Grant • Enhancement of the penalty for assaulting we have paved the way to become a powerful Program. (2003) nurses or other health care workers in voice for the patients we serve, at the bedside, hospitals. (2013) on committees in our place of employment, at the • Preservation of the role of registered nurses Statehouse and beyond. With a powerful voice and when the creation of alternative providers was • Authority for APRNs to hold admission public trust comes incredible responsibility that proposed by various state agencies. (2003, privileges. (2013) should not be taken lightly. Registered nurses in 2005, 2007, 2009, 2012—Ongoing) Ohio have a long-standing tradition of making an • Supported and applauded Governor Kasich’s impact on legislation in our state. The Ohio Nurses • Establishment of a no-interest loan through the expansion of the Medicaid program to extend Association (ONA) was formed in 1904 “to secure Bureau of Workers’ Compensation to facilitate eligibility up to the 138% FPL. (2013) legislation for the advancement of the nursing the purchase of lift assist equipment (ceiling profession in Ohio,” including legislative campaigns lifts) in long-term care and acute care facilities. for nursing registration and improved standards of • Minimized limits on the prescribing of schedule The American Nurses Association provided II controlled substances. (2014) education for professional nurses. ONA with an award for advocacy around safe ONA was instrumental in the implementation of lift devices. (2005) the Nurse Practice Act that was accomplished on • Authority for APRNs with prescriptive authority April 27, 1915. This key piece of legislation formed to delegate medication administration to trained the Nurses’ Examining Committee, now known • When the General Assembly created individuals in certain settings. (2015) as the Ohio Board of Nursing. Since then, we medication aides for long-term care and have actively engaged in the Ohio policy-making assisted living facilities, ONA made certain • Removal of language in the state budget process and have changed the face of professional these individuals would be required to meet that would have given unlicensed assistive nursing in our state. Below is a compilation of stringent education expectations and be personnel a scope of practice without ONA’s legislative successes over the last three governed by the Board of Nursing. (2005 & education, training, and licensure. (2015) decades: 2007)

Year of the Nurse & Midwife

Honoring our past… Appreciating our present… Transforming our future

To show our appreciation for all you do, register during Nurses Week to receive a FREE online CE module from the Fuld Institute for EBP taught by EBP expert Dr. Lynn Gallagher-Ford!

Learn more at: go.osu.edu/ebponlinemodules

Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare April 2020 Ohio Nurse Page 5 LEGISLATIVE UPDATE

• Tightened up language in the state budget that campaigns using social media, patch-through phone • Explore legislative language that would end created community paramedics, but provides calling, and making connections with legislators the use of on-call being used as mandatory restrictions to only work within a paramedic through email since 2015. ONA also launched the overtime scope of practice. (2015) Ohio Nurses’ Action Center in 2018, which houses all of ONA’s campaigns in one location. To-date, over Now is the golden opportunity to be involved in • Creation of an Ohio nursing license plate that 2,300 advocates have signed up to be a part of the policy-making because this small moment in time provides scholarships for nursing students and Action Center and almost 10,000 connections have within our profession is fleeting and we need YOU grant funding for nurse researchers through the been made with legislators, letting them know what to help us achieve success! If you would like to Ohio Nurses Foundation. (2016) nurses care about most. keep up-to-date with ONA’s grassroots efforts at In 2016, ONA revitalized the Legislative the Statehouse, please visit the Ohio Nurses’ Action • Requested a line item veto in state budget from Ambassador program. Through this program Center at: https://p2a.co/s4KjTLl. Governor Kasich on any language that would ONA has held 7 Advocacy Academies and to- If you would like to attend ONA’s next Advocacy impede the ability for people to gain access to date has provided education to over 90 Legislative Academy, visit ONA’s event page to keep an eye on Medicaid through the 2013 expansion. (2017) Ambassadors who now help carry ONA’s message to upcoming dates and locations: www.ohnurses.org/ our state legislators. nc__upcomingevents. Going forward, ONA will continue to be the • Preservation of an independent Board of leading voice for professional nursing in Ohio. If Nursing rather than having an umbrella agency we could take a glimpse into the future of what take on the regulation of nurses. (2017) professional nursing will look like in our state, it might include some of the following: • Update to the 2008 staffing law that requires hospitals to submit nursing services staffing • Working with the Governor’s office and the plans to the Ohio Department of Health by Ohio Department of Health to secure statewide March 1 of even-numbered years, whereas a hospital licensure Career Opportunities copy of these plans become public record and may be requested through ODH. (2017) You’ve Been Waiting For! • Stronger staffing language to existing law that provides safe, quality patient care • Protecting the “nurse” title from the use of Now Hiring: other professions, like registered veterinary Northeast Ohio Correctional Center, Youngstown technicians. (2017 – Ongoing) • Stronger workplace violence language to existing law that provides a safe working LPN, FT & PRN environment for nurses • Eliminated the unsafe practice of nurse mandatory overtime. (2017 – Ongoing) New Licensed Graduates Welcome! • Enhanced and modernized language that Competitive Salary Over the last five years, ONA has been allows APRNs to work to their full scope of exceptionally busy, with the grassroots presence at education, training, and certification an all-time high. ONA staff have continued to use Apply online at jobs.corecivic.com Phone2Action, a grassroots platform to push all • Explore legislative language that would require employers to provide rest and meal breaks CoreCivic is a Drug Free Workplace & EOE - M/F/Vets/Disabled. Page 6 Ohio Nurse April 2020 Climate Change Part 1: Impact on Health

Bobbi Spring, MS, RN, ANP-BC, CCRN, CEN in affected populations.” (EPA, 2006, p.5). The health as well as our physical health. It has been Centers for Disease Control and Prevention’s [CDC] found to impact the ability of students to learn and Climate change has had a devastating effect National Center for Environmental Health [NCEH] perform well on tests, especially students who are on our environment, including weather, air quality, notes that over 600 people annually die from extreme minorities or economically disadvantaged as they water quality and survivability of many, many heat in the U.S. (2019) While Ohio has had its share are more likely to live in homes and attend schools species, including animals, marine life, plants, of hotter days, for now we have been mostly spared without air conditioning. (Union of Concerned insects, and birds. Even the microscopic tardigrades, the extreme heat experienced in other parts of the Scientists, 2018). The risks of interpersonal and also known as water bears and considered the country such as the Southeast and Great Plains collective violence are increased by heat, both hardiest organisms on our planet, surviving extreme regions. These areas have experienced both the directly and indirectly. Evidence from a variety temperatures, years of dehydration, and even a largest magnitude and most widespread increases of sources (laboratory and field experiments, trip to outer space in a vacuum, may not be able to in heat wave days per year. (Smith, Zaitchik & correlational studies and review of violent crimes) withstand the combined effects of climate change Gohlke, 2013). The Centers for Disease Control demonstrates a correlation between elevated (the combination of chronic dehydration, higher and Prevention [CDC] note predictions that extreme temperatures and higher rates of aggression and temperatures and increased levels of ultraviolet (UV) heat events (EHE) will happen more often, with the violence directly. Areas of the world that have radiation. (Giovannini et al., 2018). What does this number of days with temperatures reaching 100°F higher average temperatures often have higher mean for our own species of Homo sapiens? Humans or more increasing dramatically across the United violent crime rates. Over time, during hot years, have always been dependent on our environments, States by the end of the century. (n.d.) hot seasons, hot months, and hot days, higher including climate and weather. The frequency, Ohioans have, so far, experienced less violence rates have been noted. (Bushman, 2013). severity, duration, and location of weather as well as weather extremes than other parts of the country. Anderson, Bushman and Groom (1997) concluded climate related events such as rising temperatures, Nevertheless, we still face the same heat-related decades ago “that the magnitude of the heat effect heavy rains, droughts, and severe weather events health concerns, especially for persons who work is sufficient to include increases in serious and have all been brought on by climate change. Areas outdoors or have breathing conditions. People who deadly assault as yet additional entries in the long that already have extreme weather events, such are more likely to be impacted by heat include those list of the negative consequences of global warming.” as droughts or hurricanes, will see more frequent who are elderly, very young, disabled, poor, living (p.1222). Excessive heat can lead to decreased and intense events. Some areas may experience alone and/or those with cardiac and pulmonary health sources of food and water as well as unbearable previously unknown climate-related health threats, conditions, such as asthma, COPD or heart disease, living conditions. Entire groups of people may need such as tropical pathogens expanding their regions which can be exacerbated by higher temperatures. to relocate to more habitable areas, also known as of infection as cooler areas, especially water, are (CDC, NCEH, Environmental Health Tracking ecomigration. Ecomigration and the competition warming and warm seasons are lasting longer. Branch, 2017). High temperatures raise the levels for resources in newer habitats could lead to (Balbus, et al., 2016). Essentially, climate change of ozone and other pollutants in the air exacerbating racial, ethnic, cultural conflicts, resulting indirectly is impacting our health by “first, by changing the cardiovascular and respiratory disease. Extreme in increased violence and even war. (Plante & severity or frequency of health problems that are heat raises pollen and other airborne allergen levels, Anderson, 2017). already affected by climate or weather factors; and which in turn trigger asthma. Asthma affects around Excessive heat can contribute to drought. second, by creating unprecedented or unanticipated 300 million people worldwide and temperature Prolonged drought is a leading environmental health problems or health threats in places where increases are expected to increase the rates of determinant of premature mortality, related to lack they have not previously occurred.” (Balbus, et al., this condition. (World Health Organization (WHO), of hygiene and sanitation, as well as reduced crop 2016, p. 25). Climate change has already brought 2018). Fungal spores, which also can cause allergic yields, food insecurity, and malnutrition. The number on a number of health issues, and potential health and asthmatic reactions (both in and out of doors), of severe droughts has increased worldwide, with concerns. How climate change will continue to effect as well as respiratory infections, will likely become some areas such as Brazil having a yearlong drought the earth is largely dependent on the degree of our more frequent as carbon dioxide and temperatures in 2018. (Watts et al., 2019). In the US, as example, action, or inaction, which is taken to address these increase. (Staudt, Glick, Mizejewski & Inkley, 2010). California experienced a five year drought (2012- escalating concerns. Respiratory and cardiac concerns are compounded 2016) for which a statewide drought emergency One of the most notable impacts of climate change by the fact that air pollution is getting worse. Watts was declared. (California Department of Water has been steadily increasing temperatures worldwide, et al. (2019) found that CO2 emissions rose by Resources, n.d.). However, drought can develop in also referred to as global warming. The past five 2.8% in 2018, which is the largest increase since all regions of the continent with devastating effects. years have been the warmest years in the modern 2010 in the US. People who live in areas with high “Since 1980, major droughts and heat waves within record, with 2018 being the fourth warmest since air pollution (primarily urban) or who don’t have air the U.S. alone have resulted in costs exceeding 100 1880. (NASA & California Institute of Technology, conditioning (especially those living on higher floor billion dollars, easily becoming one of the most costly 2019). While most of the hottest inhabited areas of levels) and people who work outdoors (such as in weather-related disasters on the continent during that the earth are located in the Middle East and northern construction and agriculture) are also at risk when time.” (NOAA, National Centers for Environmental Africa, the USA’s own Death Valley (extending temperatures are elevated. (CDC, National Center Information, n.d., para. 3). In 2019, despite being the from California to Nevada) comes in at number 8. for Environmental Health, 2017). However, all people, second wettest year on record, drought of varying (Gammon, 2011). The Environmental Protection can be affected by heat stress that may lead to heat degrees and length was experienced throughout Agency (EPA) (2006) defines Excessive Heat Events exhaustion and heat stroke. Young children are the US, including Alaska and Hawaii, with the state (EHE) as conditions where summertime weather is especially vulnerable to excessive heat concerns of of Washington being dry for the entire year. (NOAA, substantially hotter and/or more humid than average dehydration, electrolyte imbalance, fever, respiratory National Centers for Environmental Information, for a location at that time of year. “EHE conditions disease, and kidney disease. (Watts et al., 2019) 2020). Despite the heavy precipitation in the earlier can increase the incidence of mortality and morbidity Extreme heat can affect our mental and emotional part of 2019 causing agricultural damage in several April 2020 Ohio Nurse Page 7 counties, Ohio, primarily southwestern parts of state, away. (CDC, National Center for Environmental traumatic injuries would not be unexpected. Receding experienced flash drought in September and October. Health, 2019). Firefighters are at high risk of floodwaters can leave behind silt, mud and debris, “Droughts are caused by a lack of precipitation inhalation of wildfire smoke particles. (Finlay et al., both on land and in the waters of the affected area. over an extended period of time. In contrast, a flash 2012). Smoke inhalation is the leading cause of death The debris can be hazardous, containing sharp drought is preceded not just by a lack of rain, but also from fires. Immediate damage can be created by any objects, pesticides, fuel, dead creatures (animals, very high temperatures and/or lots of sunny days. combination of thermal injury of the upper airways, birds, etc.) and untreated sewage. Potentially Even if the dry period is not especially severe, the irritation or chemical injury to the airways from soot, dangerous mold can rapidly develop and overtake latter two can suck moisture from the ground quickly.” asphyxiation, and toxicity from carbon monoxide (CO) water-soaked debris and structures. Residents of (DiLiberto, 2019, para. 3). Fortunately, this occurred and other gases, including cyanide. (Lafferty et al., flooded areas may be left without power and/or during harvest season, so further agricultural 2018). Smoke exposure has been associated with clean drinking water, which can lead to outbreaks impact was minimized. (DiLiberto, 2019) although hundreds of thousands of deaths annually, based of waterborne diseases, such as typhoid, hepatitis long periods of high temperatures and associated on an assessment of the global health risks from A, and cholera. (Nunez, 2019). Healthcare access droughts contribute to dry conditions that can drive landscape fire smoke. Exposure leads to increased can be impacted by power outages, facilities wildfires. (CDC, National Center for Environmental rates of emergency department visits and admissions destruction and/or sudden increase in usage which Health, 2019). for respiratory and cardiovascular concerns, as can overwhelm providers and resources, physical Wildfires are started by humans (directly or well as outpatient medical visit for exacerbations of access impediments such as damaged roadways and indirectly) or lightening. While the recent massive asthma, bronchitis, chest pain, COPD and respiratory contaminated resources from hospital flooding. The Australian bushfires were created by humans, infections. (CDC, National Center for Environmental flooding, along with the silt and debris, can destroy but was exacerbated by climate change induced Health, 2019). food sources such as gardens and farms, killing and/ combination of record drought and record heat Climate change has affected our weather in or contaminating both plants and livestock. Access to turning the area’s vegetation into excellent fuel for other ways than extreme heat. One is an increase groceries and other food sources may be significantly fires. (Majkut & Zobel, 2020). Since September 2019, in precipitation across most of the US, with impacted. People living in the area can also be left fires have killed 28 people, destroyed 2,000 homes rainfalls becoming heavier and more frequent. The without safe shelter as their residences will likely be and scorched an area twice the size of Maryland occurrence of very heavy precipitation events has contaminated and need to be demolished. It can take (Brown, 2020). The World Wildlife Fund in Australia been above average since 1991 and increasing in weeks, months and even years to rebuild and the estimates that 1.25 billion animals may have been the past two decades, most notably in the Northeast, area to recover. Surviving a flood takes a mental toll killed directly or indirectly from fires that have Midwest, and upper Great Lakes regions. This has as well. Jackson and Devadason (2019) found mental scorched Australia, and expected to increase as loss led to an increase in flooding events, especially in health impacts from flooding, primarily post-traumatic of vegetation can contribute to eventual starvation of the Midwest and Northeast. (Melillo, Richmond, & stress disorders (PTSD), along with depression and the creatures that have survived. The loss of critical Yohe, 2014). While coastal flooding happens more anxiety, may be long-term, affecting every aspect of habitat will likely hasten the extinction of already often, floods are also increasing occurring away from the person’s life. This psychological distress can also threatened wildlife such as the dunnart, the glossy coastlines. In the past ten years, of the ten states impact physical illness experienced following floods. black cockatoo and even koalas. The full extent of the with the most flooding disasters, eight of those were “Periods of excessive precipitation and periods damage may not be known for years, even decades. inland. (Lam, 2018). This means that more areas of of drought influence both the availability and quality (Rice, 2020). the country than ever are vulnerable to flooding. In of water and have been linked to the transmission Veraverbeke et al. found that lightning ignitions of August, 2019, 16 Ohio counties were designated as of water and food borne disease. Poor health fires have increased since 1975, a record number primary natural disaster areas by the Agriculture status leads to increased susceptibility to both of lightning ignitions and exceptionally high levels of Secretary. This designation was related to flooding microbiological and chemical food hazards and burning occurring near the northern boreal forest and increased precipitation in the preceding months associated diseases.” (Jaykus et al., 2009, p.31). treeline in 2014 and 2015 (2017). Lightening occurs which led to significant agricultural losses. This Furthermore, extreme weather events can result in more frequently in hot weather and lighting strikes allowed farmers to apply for U.S. Department of the forced evacuation of refugees into close quarters. are expected to increase by 12% for every Celsius Agriculture (USDA) Farm Service Agency (FSA) This frequently results in extreme stress, malnutrition, degree increase in temperature. (Romps et al., emergency loans to help offset the negative and limited access to medical care, all of which 2014). Warmer temperatures trigger earlier springs economic impacts (U.S. USDA. FSA, 2019). contribute to increased susceptibility and severity of and longer warm seasons, extending the time frame In the last 10 years, that annual average of flood disease. An example of this is the norovirus outbreak for wildfire season. Early springs can mean early related deaths increased to 95 as compared to an following the 2005 Hurricane Rita forced evacuation snowmelts. Snowmelt is a significant source of average of 86 for the 30 years previously. Since of people living in the Louisiana-Texas border to freshwater for many high-latitude or mountainous 2015, this average has increased to more than 100 Reliant Park. During investigation of the outbreak regions. Melting too early can mean that water may deaths. (Lam, 2018). With the increases in heavy it was found that there were at least three different dry up before it gets cold again and lead to possible rainfall, this trend is expected to continue. The norovirus strains circulating suggesting multiple drought, which can increase the risk for wildfires. majority of these deaths occur while driving, either sources of infection. Contributing to the outbreak The massive wildfires in Alberta Canada in 2016 from drowning or trauma. (National Oceanic and were, crowded conditions leading to frequent, close correlated with the lowest area of spring time snow Atmospheric Administration, 2020). According to the personal contact, insufficient sanitation, and lack of cover in the Northern Hemisphere in the past 50 Federal Emergency Management Agency (FEMA) adequate toilet and hand-washing facilities. While the years. (Harvey, 2017). As well as the impact on six inches of water is enough to effect the control of infection was contained and treated, without fatalities, water supplies, wildfires have both direct and indirect most passenger cars, a foot of water can carry them consider the same scenario in an underdeveloped effects on humans (as well as other lifeforms). Finlay away and two feet of rushing water can carry away nation lacking our resources. The impact would et al. found that burn exposure can come from four most other vehicles including sport utility vehicles be more severe due to extended evacuation and different pathways. These are direct exposure to the (SUV’s) and pick-ups. (2004). Additional impact from relocation time, more over-crowding, with decreased flames and high heat, direct or indirect exposure flooding include contamination of freshwater supplies, access to health care limiting treatment and to smoke from burning or smoldering materials, increased risk of water-borne diseases, creation of enforcement of infection control measures. Deaths exposure to soil contaminated by the chemical breeding grounds for disease-carrying insects such would very likely occur, especially among the very products of burning vegetation and wood, and as mosquitoes, damage to homes, disruption of the young. (Jaykus et al., 2009). water contamination, caused by particulate matter supply of medical and health services as well as Flooding, including extreme and erratic rain deposition directly on water sources or leaching into injuries and near-drownings with resultant respiratory events, can flush parasites that resist chlorination into the groundwater. Ash debris from the Californian infections (WHO, 2018). water treatment and distribution systems, resulting wildfires of 2007 was found to contain high levels of Coastal areas are densely populated: more than in waterborne outbreaks. (Semenza et al., 2012). heavy metals such as arsenic, cadmium, copper, 8.6 million Americans live in areas susceptible to Outbreaks following extreme water-related weather and lead. After the 2002 Lithuanian fires there was a coastal flooding and more than $1 trillion worth of events, heavy rainfall and flooding being the most significant increase in heavy metal (copper, lead and property and structures are close to current sea level. common, were usually the result of the drinking- zinc) levels in the rivers surrounding the area. (2012). It is predicted that by the year 2050, the majority of water supply contamination, even in industrialized The consequences of burns to the body range US coastal areas are likely to have 30 or more days areas with water treatment plants. The treatment from mild, first degree burns to more severe third of flooding each year. (Bradford, n.d.) As compared to plant may be overwhelmed leading to cross- degree burns and even death. Severe burns, that inland freshwater flooding, coastal flooding is caused contamination between sewage and drinking-water affect multiple tissue layers, can have long term by salinized seawater. Heavy coastal development, pipes (more likely in older water infrastructures), sequela of loss of certain physical abilities, including with impacts from human activity and pollution, has sewage overflow, or bypass into local waterway. loss of limb(s), disfigurement, loss of mobility, reduced the ability of natural systems to adapt to The most commonly reported pathogens in these scarring, and recurrent infections because of climate changes. Rising sea levels, precipitated outbreaks overall were Vibrio (cholera) and Leptospira decreased ability to fight infection by burned skin. by storms or otherwise, can erode and overwhelm (Leptospirosis). Campylobacter (campylobacteriosis) Burns may even penetrate deep enough to cause coastal ecosystems, including destroying wetlands. and Cryptosporidium (crypto) were more commonly muscle and/or tissue damage, potentially affecting Declining wetlands means there is no longer a associated with treatment plant water contamination, every system of the body. Pain, during the injury natural buffer to prevent flooding. This allows rising while Cryptosporidium and Norovirus, along with and in recovery, is a very significant effect of burns. sea levels to effect the salinity of ground water which Vibrio and Leptospira were more often seen in Burns also have emotional impact, and survivors can may make it undrinkable. Rising waters, especially if environmental exposures after flooding. (Cann, et al., experience depression, nightmares, or flashbacks enhanced by storms and hurricanes, can also push 2013). from the traumatizing event. PTSD is common. If salt water further upstream, harming aquatic plants, While most often found in other parts of the world, there are losses, whether of significant others (friends fishes and animals that cannot tolerate increased both cholera and leptospirosis have still presented and family, even pets) and/or home and possessions, salinity. Mid-Atlantic estuaries have already been in the US. Cholera cases have steadily increased from the fire, grief can add to the emotional impact of found to be more salty, threatening flora and fauna worldwide since 2005, especially in Africa, Southeast a burn. (Johns Hopkins Medicine, n.d.) that are sensitive to salinity. (EPA, 2020). Asia, and Haiti. The gastrointestinal symptoms The smoke from wildfires contains particulate The risk of death aside, flooding has other of cholera can range from mild to severe and are matter, carbon monoxide, nitrogen oxides, and implications for health. People can be injured by treatable with antibiotics. The fatality rate of those various volatile organic compounds that are battering in fast flowing water, either by objects with severe cholera symptoms ranges from 25- precursors to ozone creation. This smoke can traveling in the water or by being pushed into significantly reduce air quality, both in the immediate obstacles along shore or debris jams. Broken bones, area of the fire and in areas downwind, even miles sprains, lacerations and/or contusions and other Climate Change Part 1 continued on page 8 Page 8 Ohio Nurse April 2020 Climate Change Part 1 continued from page 7 tropical cyclones/hurricanes, are now developing in the state, snowfall has not been impacted as much a warmer, moister environment. Due to this, storms due to lake effects. “Lake effect snow across the 50% without treatment. (CDC, NCEZID, Division are producing heavier precipitation during the event, Great Lakes occurs as a result of cold air rushing of Foodborne, Waterborne, and Environmental even if total precipitation in an area is decreasing. over relatively warm-and ice free-lake waters. Cold Diseases (DFWED), 2018). As with cholera, Storms in general have increased in strength and air that travels over water for a long enough distance leptospirosis is more common in tropical areas. It has frequency around the world, especially in winter will not only warm enough to begin to rise but also a range of symptoms and can occur in two phases. months. The most significant increases have been grab enough moisture from the lakes to begin to form The first phase symptoms can include fever, jaundice, with hurricanes occurring in the Atlantic, which are clouds and eventually snow.” (DiLiberto, 2017, para. gastrointestinal symptoms, myalgias and rash. If the expected to increase as hurricane season becomes 3). This lake affect could lead to heavier snowfall at second phase occurs it is more severe and can lead longer with each decade. (Climate Communication, present but over time and continued warming, even to meningitis, kidney or liver failure. It is also treated 2011). Flooding by tropical cyclones is also expected here precipitation would more likely be rain than with antibiotics although full recovery can take weeks to increase as a result of accelerating sea-level rise. snow. (DiLiberto, 2017). Decreased snowfall also to months in cases impacted by the second phase. (Woodruff, Irish & Camargo, 2013). has an economic impact. Winter sports and tourism Of concern is that this disease can live in soil and Immediate impacts to humans are death, traumatic brings an estimated $12.2 billion dollar value to the water for weeks to months, after excretion in the urine injury, loss of homes and infrastructures, followed U.S. economy. (Burakowski & Magnusson, 2012). by infected animals, who may not be symptomatic. by concerns associated with concurrent flooding Without snow, people can lose their jobs, healthcare Pets and livestock can be affected as well as rodents or storm surge. Storm surges are abnormal rises in benefits and homes. and wild animals. While still not common, the rate of seawater level created during a storm or hurricane Primarily occurring in the northern hemisphere, diagnosis in pets has increased in the past several which are then pushed onto the shoreline. (National as compared to seasonal ground freezing, when years. Although there is a risk of transmission from Ocean Service, n.d.c.) Economically, hurricanes a thick layer of soil stays permanently frozen for a pet to human, people are more likely to incur the are devastating. “Eight of the 10 costliest hurricanes minimum of two years in a row it is called permafrost. infection from contaminated water. (CDC, NCEZID, on record in the United States have occurred since Permafrost can range from a few feet to hundreds DFWED, 2019). 2004. Damage estimates are still being tallied for of feet deep. While some permafrost may have only Campylobacter, Cryptosporidium and 2017 hurricanes Harvey and Irma. Hurricanes Katrina existed for several years, some areas of it, mostly in Norovirus infections are seen in the US. In fact, (2005) and Sandy (2012) cost $125 billion and $65 Siberia and known as relic permafrost has existed Cryptosporidium, a microscopic parasite, is a leading billion respectively. Hurricanes Andrew (1992) and Ike since the Pleistocene period (1.8 million to 10,000 cause of waterborne disease in humans in the U.S. It (2008) cost $27 billion each.” (Center for Climate and years ago). (National Snow and Ice Data Center is chlorine tolerant which makes eradication difficult. Energy Solutions, n.d., para. 11). (NSIDC), n.d.). Permafrost is estimated to cover Crypto causes gastrointestinal symptoms that are Conversely, despite warmer temperatures, the approximately 20% of the Earth’s land surface, usually resolved by hydration and without treatment frequency of extreme snowstorms, primarily in including most of Alaska, about half of Russia in people with healthy immune systems. For those the eastern two-thirds of the continental U.S. has and Canada, and likely all of Antarctica. (Rivkina, who are immunocompromised, especially persons increased over the last 100 years, with twice as Friedman, McKay, & Gilichinsky, 2000). Permafrost with HIV, it is a challenge to treat effectively and they many occurring in the past fifty years as the prior is important in that it affects how much moisture is may not be cured. (CDC, NCEZID, DFWED, 2019). fifty. Approximately twice as many extreme U.S. present in an area. Permafrost areas can include Campylobacteriosis is the most common bacterial snowstorms occurred in the latter half of the 20th wetlands. Melting snow, summer rains, and melting cause of diarrheal illness in the United States, century than the first. Warming ocean waters, ground ice on the land surface cannot get through estimated to affect 1.5 million people yearly. It causes especially in the Atlantic, impact the severity of permafrost, which acts like a waterproof barrier. gastrointestinal symptoms, including bloody diarrhea, eastern U.S. snowstorms as they contribute high Ponds, lakes, and marshes are common in the and be transmitted from infected animals to humans. amounts of moisture flowing into these storms summer which is important to local flora and fauna In addition to contaminated water, it can also be which can lead to greater storm intensity. Unusually as well people living in the area. Many regions with acquired by ingestion of raw or undercooked meat, warm Atlantic ocean surface temperatures were permafrost get very little rain and snowfall and most often poultry. It is usually treated by hydration. felt to be a major contributor to the snowstorm without the barrier effect, water would either soak For people who are immunocompromised, or healthy that covered Washington, D.C. with 17.8 inches in or run off the land, resulting in a very dry area persons on rare occasion, may need antibiotics to of snow in February 2010. This storm, nicknamed (NSIDC, n.d.) combat sepsis or the complications of associated “snowmaggedon” was the fourth highest total snowfall Climate change is contributing to permafrost irritable bowel syndrome, Guillain-Barré syndrome or recorded for the area at that time. (NOAA, NESDIS, melt. There is now ten percent less frozen ground, arthritis. (CDC, NCEZID, DFWED, 2019). Although NCEI, n.d.). While snow storms are increasing, approximately two million square miles or an area associated with contaminated water, Noroviruses actually snowfall is not. The EPA (2016) has noted about two-thirds the size of the continental United are the leading cause of foodborne illness in the U.S. an average decrease of 0.19% annual snowfall. States, in the Northern Hemisphere than in the early and easily transmitted. Infected persons present with Catalano, Loikith and Aragon found evidence of 1900s. (NSIDC, n.d.). This leads to other concerns in gastrointestinal symptoms and there is no treatment decreasing snowfall in northwestern U.S. (Oregon, addition to local moisture effects. Melting permafrost but hydration. Norovirus infections are instrumental Washington and Idaho) especially at low to mid- has led to soil erosion along coastal areas and in 56,000 to 71,000 hospitalizations and 570 to 800 elevation areas such as the Cascades Mountains. in other waterways, lakes and rivers in Alaska, deaths yearly, primarily of young children and the They predict that by the end of the century, more than homes and livelihoods for people living on the elderly. The economic impact of norovirus is high, half of Northwest precipitation will fall as rain instead coast. Both physical structures (houses, buildings) costing the U.S. approximately $2 billion annually, of snow. (2019). Snow cover, an important source and infrastructure (pipelines, roads, railroads and mostly due to lost productivity and healthcare for replenishing water supplies in many areas, has plane landing strips) have begun to shift as formerly expenses. (CDC, National Center for Immunization decreased at a rate of about 3,300 square miles per frozen ground thaws and becomes unstable. Injuries, and Respiratory Diseases, Division of Viral Diseases, year in North America between 1972 and 2015. The impaired transportation leading lack of access for 2019). time frame snow cover remains has decreased by healthcare and goods, and loss of shelter are some Climate change means that all storms, including two weeks since 1972, due to earlier spring warming. related health concerns affecting native Alaskans thunderstorms, rainstorms, snow storms, and (EPA, 2016.). In Ohio, especially northern parts of in particular. (Brenner, 2018). Inadequate housing

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D’Costa et al. dengue is likely as its Aedes mosquito vector is very hospitalization, respiratory infections, skin infections (2011) found that 3000 year old microbial DNA, sensitive to climate conditions and expanded its and diarrhea caused by bacterial, viral and parasitic collected from Beringian permafrost, was genetically habitat. “Dengue is the most common vector-borne pathogens, especially among children. (Parkinson & resistant to B-lactam, tetracycline and glycopeptide viral disease in the world, causing an estimated 50 to Evengård, 2009). antibiotics. The researchers concluded that “antibiotic 100 million infections globally each year and 25,000 Melting permafrost can exacerbate climate resistance is a natural phenomenon that predates the deaths. In the tropics and subtropics, it is a leading warming. Normal decay processes for plants and modern selective pressure of clinical antibiotic use.” cause of illness and death. The incidence of dengue animals releases greenhouse gases, primarily (D’Costa et al., 2011, p. 457). has jumped sharply in recent decades as the disease methane and carbon dioxide. However, freezing Because permafrost prevents deep burials, has spread into new geographic regions. While still stops the decay process, trapping local lifeforms in human bodies, including those dying hundreds of rare in the United States, the frequency of dengue death, some for millennia, such as wooly mammoths. years ago that may have been infected with ancient infection is on the rise and is largely associated with Yedoma, a Pleistocene-age type of permafrost found diseases, have the potential to surface. In 1918, a travel to regions in which dengue is circulating, but in Siberia, contains a significant amount of ancient Spanish flu epidemic hit Alaska. Those succumbing some cases have been acquired locally.” (Baylor organic material that when melted is considered to to the disease were often buried in mass graves, College of Medicine (BCOM), n.d.a., para. 29). In a significant source of atmospheric methane. As preserved by the permafrost. Scientists took tissue fact, “dengue fever is the most rapidly spreading permafrost melts all the frozen organic matter quickly samples from the burial sites in 1951 and preserved vector-borne disease, with a thirtyfold increase in begins to decay. The faster it melts, the faster large them. In 2005, other researchers were able to global incidence that is largely attributable to climate amounts of greenhouse gases are released into the reconstruct the almost 90 year old virus – after change.” (United Nations Environment Programme, atmosphere. (NSIDC, n.d.). being buried for 33 years and sitting in the lab for 2019, para 3.) A further concern of permafrost melting is another 54 – which begs concerns for the hardiness The risk of developing malaria is increased due potential emergence of disease from previously of the organism. (Taubenberger, Hultin & Morens, to climate change as warmer weather allows for dormant pathogens, nicknamed “zombie diseases.” 2007). Researchers in Siberia in 2004 found frozen extended periods of transmission by the Anopheles Bacteria and viruses can remain alive and dormant mummies, approximately 300 years old, one with mosquito. At present, malaria kills over 400,000 in freezing temperatures. Pikuta et al. (2005) isolated traces of variola (smallpox) DNA in her tissues. people every year, primarily young children (age five Carnobacterium pleistocenium, bacteria that had (Reardon, 2014). In 2016, twenty-three people were and under) living in Africa. (WHO, 2018) been frozen in an Alaskan pond for approximately infected with anthrax in the Yamal Peninsula, Siberia Warming temperatures can affect the density and 32,000 years. There were no apparent ill effects as after prolonged warm summer. One child died as distribution of animal hosts and mosquito vectors the microbes began swimming around once the ice a result. It was later determined that epidemic of as well as shift in the geographical range of disease melted. Legendre et al. (2015) were able to revive infected reindeer, who had died 75 years earlier and caused by these agents, resulting in increased rates two 30,000-year-old Siberian viruses that infected been frozen in the permafrost, had been exposed of related illnesses. For example, the West Nile virus, amoebas after verifying they would not affect animals and thawed from the warm temperatures, releasing transmitted by the culex mosquito, originated in the or humans. However, the researchers noted that “the the anthrax into the environment. This re-energized warm climates of Africa, West Asian and the Middle fact that two different viruses retain their infectivity in anthrax then infected reindeer and people in the East. It entered the USA in 1999, likely through prehistorical permafrost layers should be of concern region. It is suspected that there are more locales infected birds which are the main reservoir for the in a context of global warming” (Legendre et al., with long dead, infected animals, or humans, which virus, creating a large outbreak. Culex mosquitoes 2015, p. 1) and further stated “our finding that two may be exposed in the future. (Jackson-Ricketts, are found worldwide in tropical and temperate different viruses infecting the same host could be 2017). regions, (BCOM, n.d.a.) however the mosquito and revived from a single permafrost sample, definitely In warmer parts of the world, climate change the infection have both found as far north as northern suggests that prehistory “live” viruses are not a rare also affects diseases, especially those that are Manitoba, Canada. Infected birds and humans have occurrence…. we cannot rule out that distant viruses water-borne or vector-borne. Climatic changes are also been detected as far north as Novosibirsk, of ancient Siberian human (or animal) populations lengthening the transmission seasons of vector- could reemerge as arctic permafrost layers melt and/ borne diseases as well as altering the geographic Climate Change Part 1 continued on page 10 Page 10 Ohio Nurse April 2020

Climate Change Part 1 continued from page 9 The number of counties where the blacklegged and central Asia, notably in Sweden and Russia. tick, responsible for most cases of Lyme disease, (WHO, 2018). Russia. (WHO, 2018). It is now considered the babesiosis, and anaplasmosis in the US, has Agriculture is especially sensitive to the impact of leading cause of mosquito-borne disease in the been found have more than doubled over the past climate variability and change. Rural communities continental United States. (CDC, National Center for twenty years. (CDC, 2019). The number of counties that rely primarily on agriculture are the most Emerging and Zoonotic Infectious Diseases, 2019). considered high-risk for Lyme disease, mainly in the vulnerable, however, we will all be affected over Zika, the most recent mosquito-borne virus northeastern and upper midwestern areas of the time as climate change poses a major threat to identified, has spread geographically from Brazil in United States, have increased by more than 300% food security. Millions of square miles of productive 2015 to regions that provide favorable habitats for between 1993 and 2012. (CDC, 2019). Lyme disease agricultural lands in all areas of the world are being the transmitting Aedes aegypti mosquitoes, areas is now considered the most common vector-borne degraded or destroyed by the climate linked effects that are expanding due to climate change. Zika disease in the United States, up from number six in of increased desertification, drought and floods. This has now been spread to the United States by local 2015. (CDC, NCEZID, DVBD, 2019). leads to rapidly increasing direct adverse impacts on mosquitoes. The potential range for these mosquitoes Although still most prevalent in the northeast, Lyme the livelihoods and food security to those in some is estimated to extend as far north as southern Ohio, disease has now been reported in all 50 states with of the world’s most vulnerable ecosystems, often in although no disease has been reported except for a large increase from 2016-2017. Pennsylvania had underdeveloped countries. People directly dependent in the states of Florida and Texas. (BCOM, n.d.a). the most Lyme disease cases in 2017 and notable on the forest ecosystems, usually extremely poor, are The zika infection produces mild to no symptoms increases were seen in Ohio (Quest Diagnostics, at most risk from climate change influences. (Food in humans. However, it can cause devastating 2018). Early Lyme disease symptoms may be and Agriculture Organization of the United Nations neurological effects on developing fetuses of mild to non-existent and some of those infected (FAO), 2011). pregnant women, including a large number of babies may not even know they’ve been bitten. With the Our food supply, whether agricultural or fisheries, born with microcephaly and lifetime developmental development of chronic Lyme disease (CLD), weeks is very dependent on the climate. In the US, the disorders (BCOM, n.d.a). to years after the initial infection, more systemic and length of frost-free growing seasons has been Another tropical disease that has spread into debilitating symptoms appear. (LymeDisease.org, increasing since the 1980s, most noticeably in the new areas due, in part, to changing climate is n.d.).An IGeneX survey found that it took longer than western states, and predicted to continue to lengthen. chikungunya. Chikungunya disease is caused by three years for 45% of CLD patients to be correctly (Melillo, Richmond, & Yohe, 2014.) This effect on the chikungunya virus, a “relative” of the dengue diagnosed and 24% saw more than 10 doctors before the ecosystems and agriculture may have benefits fever, and is transmitted by the tiger mosquito. that diagnosis, 36% spent more than $10,000 on out for some crops, depending on a crop’s optimal Rarely fatal, symptoms include fever, exhaustion, of pocket medical costs, and 65% were forced to quit temperature for growth and reproduction, but can and severe bone chikungunya pain. Until recently it a job or cut back on their hours due to their symptoms be detrimental for others. If temperatures exceeds was confined to tropical regions around the Indian (2019). Johnson, Wilcox, Mankoff and Stricker (2014) a crop’s optimal level and/or sufficient water and Ocean. In 2007 there was a chikungunya outbreak found that 72% of CLD patients surveyed had a worse nutrients are not available, yield increases may be in Ravenna, Italy affecting more than 100 people. By quality of life than those with other chronic illnesses reduced or reversed. (EPA, 2016). Crops can also be 2014, outbreaks had occurred in Europe, Asia, Africa, such as diabetes, multiple sclerosis and congestive harmed and yields reduced by extreme events, such and the Americas (Caribbean and Central and South heart failure. as floods and droughts. Droughts, in combination with America). The virus was found in the United States in While not as common, and usually without long higher temperatures for longer periods leads to drier 2014, and so far local transmission of the virus has lasting sequela, Rocky Mountain spotted fever, soil as well as affect water availability. Irrigation may been limited to Florida and Texas (BCOM, n.d.b.). spread by the dog tick, is much more deadly. It not be possible if it reduces water supplies needed for Mosquitoes aren’t the only vector affected by is often fatal from multisystem organ failure if not other basic needs such as drinking, especially when climate change. Milder winters and earlier spring treated within five days of symptoms and there were the supply is already stressed by drought. (EPA, onsets have enabled the rate of tick-borne diseases 21 deaths among the 360+ cases reported between 2016). to increase. Since the mid-1980s, Sweden has 2003 and 2016. It too is increasing in range and found Climate change has been affected, in part, by experienced an increase in tick-borne encephalitis in most states, although more common in North increasing carbon dioxide (CO2) levels. CO2 is (TBE) from the Ixodes ricinus tick that carries Carolina, Oklahoma, Arkansas, Tennessee, Missouri considered to be a greenhouse gas, or one that the virus. Climate change projections predict a and parts of Arizona. (CDC, NCEZID, DVBD, 2019). absorbs heat and warms our atmosphere. It is also northward shift in the range of Ixodes scapularis tick, The Asian longhorned tick was reported for the more abundant and stays in the atmosphere much responsible for Lyme disease, through Northeastern first time in the US in 2017 and research is ongoing to longer than the other greenhouse gases: methane Canada. (WHO, 2018). find out more about it. While no concerning infections and nitrous oxide. (Lindsey, 2019). The elevated Of the approximately 650,000 vector-borne have been reported with this tick in the US, they CO2 levels in our air can affect the nutritional quality diseases reported between 2004 and 2016, 77% have been known to cause illness in countries in the of plants. For example, the protein and nitrogen were tick-borne. Reported cases of tick-borne eastern hemisphere. The females can reproduce content in alfalfa and soybean plants, which are disease have doubled in this time frame, with Lyme without mating and are prolific. Thousands of ticks food sources for grazing livestock, are decreased by disease being most frequently reported at 82%. can be found at one time on an animal or person. CO2. This in turn affects the growth and health of the Cases of spotted fever rickettsioses, babesiosis, There is potential for significant blood loss of the animals. (EPA, 2016). When grown in elevated levels and anaplasmosis/ehrlichiosis also increased. infested creature. (CDC, NCEZID, DVBD, 2019). of atmospheric CO2 C3 grains and legumes have (Rosenberg, et al., 2018). Warmer temperatures, especially warm winters, lower concentrations of zinc and iron. This can lead The geographic range of some ticks that spread have promoted rodent host population irruptions to zinc and iron deficiencies, already considered a infections continue to increase, in part due to which led to major increases in the prevalence of “old significant global public health problem, in the people climate change. The lone star tick, which transmits world” Hantavirus infections, causing hemorrhagic who depend on these plants are major food sources. the pathogens that cause ehrlichiosis, tularemia, fever with renal syndrome [HFRS] (as compared to (Myers, et al., 2014). and Heartland virus disease, is continuing to move hantavirus pulmonary syndrome [HPS] seen in the Approximately 85% of all plant species are C3 from its original territory in the southeastern United “new world” Americas). In the past few decades, plants, or those which solely use the Calvin cycle in States into the northern and mid-western states. these outbreaks have been seen in Northern Europe their photosynthesis process, which is also inefficient

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galencollege.edu/careers April 2020 Ohio Nurse Page 11 in energy use as it is suppressed by oxygen. C3 source has not yet been determined). (U.S. Food stress and indirectly from reduced quality of their plants include the cereal grains such as wheat, & Drug Administration [FDA], 2019). Escherichia food supply. Heat stress can make animals more rice, barley and oats. Most trees and grasses are coli bacteria has many strains, including those that susceptible to disease, as well as decrease fertility C3 plants. Other significant C3 plants are peanuts, are part of human intestinal flora. The strain that and milk production. Parasites and pathogens flourish cotton, sugar beets, tobacco, spinach and soybeans. usually contaminates food and water (Shiga toxin- in warm, damper climates and treatment for them In hot dry conditions, this photosynthetic inefficiency producing E. coli [STEC]) causing gastrointestinal can increase the risk of medications and pesticides (photorespiration) is increased and the plant struggles symptoms, especially diarrhea, and fever. It is treated entering the food chain. With increases of detrimental to simply exist, rather than thrive. (Moore, Clark, by hydration. 5-10% of people infected with by strain CO2 effects on the quality of plants, animals need to Stern, & Vodopich, 1995). “Under current atmospheric develop hemolytic uremic syndrome (HUS), which eat more to obtain the same nutritional benefits as conditions, potential photosynthesis in C3 plants is requires hospitalization. While most recover, some when plants aren’t affected. (EPA, 2016). Poor quality suppressed by oxygen as much as 40%. The extent may have permanent renal damage or even die. food intake affects the protein quality of the animals of that suppression increases under stress conditions (CDC, NCEZID, DFWED, 2020). consuming it. People who consume poor quality such as drought, high light, and high temperatures. Higher temperatures, wetter climates, and plant and/or animal products do not gain the same As global temperatures rise, C3 plants will struggle to increased CO2 levels also contribute to the nutrition benefits as from higher quality food. Over survive—and since we’re reliant on them, so will we.” proliferation of many weeds, pests, and fungi, which time, this can contribute to malnutrition. However, (Hirst, 2019, para. 7). are only expected to increase. Mycotoxins which efforts to address the well-being of animals may Elevated temperatures can also speed up the are produced by certain fungi (molds) on crops, can also be problematic. For example, the “increased replication cycles of foodborne microorganisms, cause both acute toxic effects and chronic health use of indoor animal husbandry to counteract while extended summer seasons can increase the problems (including cancer) in both humans and heat stress may elevate the potential for animal- number of opportunities for deficiencies in food livestock. (WHO, Department of Food Safety and to-animal transmission of zoonotic pathogens.” handling. (Semenza, 2012). Rapidly increasing Zoonoses, 2018, p. 1). The use of pesticides, and the (Lake & Barker, 2018). The high risk of emerging climate change is a profound threat to public health subsequent residues in food, is expected to increase zoonoses (infections transmitted between animals and society. Historically, climate has constrained to combat the rise in weeds, insects and mold. and humans), persistence of pathogens, and changes the range of many infectious diseases and weather “Currently, U.S. farmers spend more than $11 billion in vector-borne diseases and parasites in animals, timing and intensity of outbreaks. Climate change per year to fight weeds, which compete with crops for may lead to the increased use of veterinary drugs, manifesting primarily in extreme weather events and light, water, and nutrients.” (EPA, 2016, para 7). with the potential of increased residue levels of these global warming, has contributed to the expansion in Allergenic plants will proliferate as well. Longer drugs in foods of animal origin. Among other acute the geographic range and seasonality of disease, growing seasons and warmer weather promote and chronic risks to humans, these drug residuals along with increased outbreaks. (Epstein, 2001). larger ragweed plants that produce more pollen much in food have been directly linked to an increase in Some food-borne illnesses may be the result of later into the fall. Springtime allergies to tree pollens antimicrobial resistance in both human and animal contaminated water. Climate change has led to begin sooner in the year and warmer temperatures pathogens. ((WHO, Department of Food Safety and altered patterns of flooding of cropland, introducing can enable the habitat expansion of highly allergenic Zoonoses, 2018) pathogens from the floodwaters into the soil. tree species, such as oaks and hickories. Poison ivy U.S. fishermen catch or harvest five million metric These pathogens can be spread from the plants also grows faster and is more toxic as urushiol, the tons of fish and shellfish each year, with fisheries grown in the soil if they are eaten raw. This risk plant’s allergenic substance, becomes more when contributing more than $1.55 billion to the economy is increased by the wellness trend of eating fresh carbon dioxide levels are higher. (Staudt et al., 2010). annually, as of 2012. (EPA, 2016). Climate change fruit and vegetables. As example, the high risk of Farmers, gardeners and others who work outside may worsen the stressors of overfishing and water contamination from Hurricane Irma related flooding in plant filled environments are at risk for asthma pollution already impacting fisheries in particular in 2017, caused the US Food and Drug Administration and allergy-related respiratory disorders or allergic as temperatures increase. Earth’s waters are to warn against the consumption of fresh produce dermatitis. Additional, stinging insects that may trigger becoming warmer. Cheng et al. found that that the that had been in contact with flood water. (Lake & allergic reactions in susceptible persons, even to the world’s oceans have been the warmest on record Barker, 2018). In areas affected by drought, likely point of anaphylaxis, are extending their ranges into for past ten years, with 2019 being the warmest in affected by climate change, the need for irrigation northern areas where they have not been a problem recorded human history. (2020). Our oceans act as water for crops may lead to the use of contaminated before. (Barnes, 2018) huge solar collectors and 90% of the warming that water from poor quality sources. Even without Plants that require pollination (of which many are has happened on Earth over the past 50 years has drought, water quality may be poor, especially in food sources) have been impacted as pollinators occurred in the ocean. This excess heat is stored underdeveloped nations. Disinfection methods are are on the decline. Without pollination, our plant and accumulating, contributing to ocean warming. not highly effective on fresh produce, which is often food sources may be greatly decreased, potentially However, most of this heat has yet to be released, as eaten raw. Several outbreaks have been associated leading to food scarcity and famine. Soroye, it eventually will, contributing to yet more warming. with irrigation water contamination, including that of Newbold and Kerr (2020) found that the increasing (Dahlman & Lindsey, 2018). a multistate Salmonella outbreak in 2008, affecting frequency of unusually hot days is increasing local These warming waters threaten marine an estimated 1500 people, linked to peppers from a bumblebee extinction rates across North America ecosystems and human livelihoods. For example, Mexican grower. (Mody et al. 2011). Salmonella is a and Europe. Butterflies, another group of pollinators, warmer waters jeopardize the health of corals, and bacteria that caused diarrheal infections, usually as have also been affected by climate change, primarily in turn, the communities of marine life that depend the result of eating contaminated food. In the U.S. it in their migration patterns, usually northward or upon them for shelter and food. Corals have a causes approximately 1.35 million infections, 26,500 elevation range shifts as well as earlier migration. symbiotic relationship with zooxanthellae algae. hospitalizations, and 420 deaths annually. (CDC, Unfortunately, earlier migration may align with later Water temperatures that are too high stress the coral, NCEZID, DFWED, 2020). Along with Salmonella, springtime growth of caterpillar food plants, leaving causing them to expel the algae living in them and E. coli has frequently contributed to raw food them without sufficient food sources. (Caldas, 2012). turning white, which is known as bleaching. Coral can infection outbreaks, most notably affecting Romaine “Americans consume more than 36 million metric recover from bleaching if the waters temperatures lettuce, including that in 2018 from contaminated tons of meat and poultry annually.” (EPA, 2016, water supply (note: the most recent E.coli outbreak para 9). Livestock are at risk, both directly from heat Climate Change Part 1 continued on page 12 Page 12 Ohio Nurse April 2020 Climate Change Part 1 continued from page 11 HABs produce toxins that can kill fish, animals, birds 2015) although no emergency was declared. HABs and even humans, although people are more likely continue affect our waters, with NOAA noting that drop quickly, but it does increase their mortality risk. to become ill. Some HABs overwhelm the water by the 2019 Lake Erie HAB covered an area larger than The U.S. lost half of its coral reefs in the Caribbean sheer volume. When they eventually die their decay the city of Houston, Texas and considered it a health in 2005 due to a massive bleaching event. Satellite deoxygenates the water as well as covering water threat. (NESDIS, 2019) data collected over the 20 years prior to the event dwelling creatures, clogging fish gills and smothering In coastal waters, “red tide” HABs are caused demonstrated that thermal stress in that one year them. (NOAA, 2016). This leads to creation of dead Karenia brevis, which also produces potent was greater than the previous 20 years combined. zones in the water, where there isn’t enough oxygen neurotoxins, leading to the widespread deaths of (National Ocean Service, n.d.b.) Ultimately, people for aquatic life to survive. Dead zones are usually fish, turtles, birds, and marine mammals. Red tides who depend upon marine fisheries for food and jobs triggered by heavy nutrient pollution. The largest occur most often in southwest Florida waters but have may face negative impacts from the climate change dead zone in the United States occurs every summer extended throughout the Gulf region at times. Red effects on our oceans. as Mississippi River Basin nutrient pollution spills tide toxins can be suspended in the air near beaches Ocean acidification, caused by CO2 dissolving in into the Gulf of Mexico, resulting in a zone that is triggering human respiratory illness. They can the ocean to create carbonic acid, is another effect of approximately 6,500 square miles. (EPA, 2017). also accumulate in shellfish and cause Neurotoxic climate change. Some marine life pull calcium from Harmful algal blooms are usually the result of toxin Shellfish Poisoning in humans who eat them, so the water to help build their shells and skeletons. releasing cyanobacteria algae, leading to blue-green affected states closely monitor shellfish and may (Lindsey, 2019) Rising seawater acidity interferes discolored and malodorous water. Cyanobacteria close harvesting for a period of time to protect public with this ability. Bednarsek et al. (2020) found a 10% blooms are common in the Great Lakes, especially health. (National Ocean Service, n.d.a.). During red increase in the dissolution of carbon dioxide into ocean in Lake Erie, as it is the shallowest of the lakes, tide, the costs of hospital visits for respiratory illness water over the last two decades due to increased and more easily warmed. Invasive aquatic zebra alone in Sarasota County Florida were as high as $4 atmospheric CO2. This acidification is more intense or quagga mussels, now present in Lake Erie also million dollars and an average of $22 million dollars near shorelines, effecting coastal sea life. The authors contribute to the growth of HABs because they are lost during red tide events annually, including found that Dungeness crab (Metacarcinus magister) filter/eat harmless green algae rather than the medical expenses and lost work days. (Florida Dept. larvae had severe carapace dissolution, from inability cyanobacteria, which then can multiply. Agricultural of Health, n.d.) to utilize calcium and increased acidity. This negatively run-off is more prevalent in the western basin of Lake As noted earlier in this paper, climate change has affects the growth and metabolism of the crabs and Erie where the problem is worse. (NESDIS, 2019). In mental and emotional impacts along with physical also makes them more vulnerable to predators. As 2014, routine testing found Toledo’s (Lucas County, ones, both acute and chronic. The American Dungeness crabs are considered to be popular and Ohio) water supply (derived from Lake Erie as are Psychiatric Association (APA) identifies climate valuable fishery commodities (providing up $200 many other communities in Ohio) was contaminated change as a mental health threat, noting that those million in annual revenue) decline in this population by Microcystin toxin released from Cyanobacteria with mental health disorders are disproportionately will have a major impact, as a food source and blooms. Microcystin can cause diarrhea, vomiting, impacted. (Ursano, Morganstein & Cooper, 2017). economically. Similar effects in crustaceans and other and liver damage in people and animals. A state Elevated levels of anxiety, depression and post- calcifying invertebrates were also noted (2020). of emergency was declared by the governor and traumatic stress disorders are associated with Algae are a normal part of both marine and “Do Not Drink” water advisories were posted. The extreme weather events (EWE). Disaster related freshwater ecology. When algae grow out of water was cleared after two days. In follow up by the losses, including those of home, employment, social control it is known as algal blooms. Algal blooms CDC, it was found that even though most Toledoans supports or those associated with ecomigration are usually recurring, notably in warmer months. were aware of it, half of the households interviewed can promote depression and anxiety. Increases in Factors leading to algal blooms include warmer reported using or drinking the contaminated water in aggressive behavior, domestic violence, suicide waters and extreme weather events, both linked to some way during the advisory, primarily for hygiene rates and mental health related emergency room climate change. Another significant factor is excess uses like bathing, handwashing, and brushing teeth. admissions have correlations with EWEs, especially nutrients, specifically phosphorus and nitrogen, from While some people and a few animals had minor extreme heat. While mental health services needs lawn and agricultural run-off. When these blooms symptoms, no major effects occurred. (CDC, 2018). increase in the aftermath of climate-related disasters, have negative effects, they are called harmful algal The following year, first time on record, the Ohio River there can be disruptions or decreases in the blooms (HABs). Depending on the type of algae, developed a 650-mile long bloom of Microcystis from availability or accessibility of services used (APA, HABs can have differing ecological impact. Some Huntington, West Virginia to Cincinnati. (Ohio EPA, n.d.). Some populations are especially vulnerable April 2020 Ohio Nurse Page 13 to impacts on their mental health. Those at risk include children, the elderly, the chronically ill, the mentally ill, the physically impaired, and women, those who are pregnant and post-partum women in Ohio Nurses Mourn the Passing of particular. Those with lower socioeconomic status, minorities, migrants, refugees and the homeless are also disproportionately impacted. Survivors aren’t Nursing’s Legislator of the Year the only ones affected by climate change events. First responders to climate-related natural disasters have been found to experience much higher rates of adverse psychological effects, including PTSD and Representative Don Manning depression, and may be in as much need as those they help (Ursano, Morganstein & Cooper, n.d). The Ohio Nurses Association help us solve the problems, like 48% of Americans feel that our mental health (ONA) is deeply saddened unsafe staffing, that plague our has already been impacted by climate change. to hear of the passing of daily lives. He wanted to do his (APA, 2019). The number of Americans who are Representative Don Manning, part in making our profession very worried about global warming has more than ONA’s Legislator of the Year better – for his fiancé, for his tripled since 2011 (Leiserowitz et al., 2018). Many and sponsor of House Bill 144. daughter and for the over people have a strong sense of loss, helplessness, “Recently, Ohio nurses lost 200,000 nurses in Ohio. and frustration due to their inability to make a true ally for our profession. Representative Manning often a difference in stopping climate change. This Representative Manning said superheroes don’t wear constant sense of fear of environmental doom is championed House Bill 144 capes, they wear scrubs and what the APA calls eco-anxiety. (Clayton, Manning, to end nursing mandatory badges. In October last year, we Krygsman & Speiser, 2017). Eco-anxiety is not overtime in Ohio. His respect were proud to honor him with the same as a clinical anxiety disorder and not and admiration for nurses came the Ohio Nurses Association considered a medical condition per the DSM5. While easily; his fiancé a nurse and Legislator of the Year Award,” environmental fears can worsen or trigger pre- his daughter in nursing school, stated Deborah Arms, PhD, RN, existing mental health problems, it may actually be he was a natural advocate for ONA president. an appropriate response to the climate crisis (Nuget, this legislation. His powerful “Beyond his advocacy, 2019). Eco-anxiety has wide range of expression testimonies helped to pass the Representative Manning was a from daily episodes of grief and despair, panic bill out of the house last year great man whom we were proud attacks, guilt and hopelessness to decisions not and into senate committee to call a friend. Representative to have children based on beliefs that it would be earlier this month. He Manning has left an indelible unethical due to future quality of life on our planet. enthusiastically advocated for nurses because he mark on our association. Our hearts are heavy and are (Arcanjo, 2018). Eco-anxiety is apparent in members believed in the pillars of our profession and wanted to with his family during this difficult time,” continued Arms. of Alaskan and Canadian Inuit nation. In studies by the APA, environmental warming negatively impacted their cold weather habitats and their wellbeing. Unable to pursue normal, and culturally significant, land-based activities, many turned to drugs and alcohol to fill that empty time. Loss of traditions built on centuries of cold climate living led to a loss in cultural identity and feelings of low self- worth (Arcanjo, 2018). The United Nations acknowledges that we all have basic human rights, including the relationship between a safe and healthy environment and the enjoyment of these rights. It is also recognized that climate change infringes on our human rights. The right to exist is universally considered a basic human right. Yet 150,000 deaths annually (and rising along with temperatures) are attributed to the effects of climate change. The rights to good health, food security, unpolluted air, clean and sufficient quantities of water, as well as proper sanitation have also been violated via effects of the climate crisis. The right to a safe place to live has been challenged directly (environmental) and indirectly (relocation and conflict) by climate change (United Nations Environment Programme, 2019). “The right to a healthy environment is recognized in law by at least 155 Member States. The failure of states to take adequate steps to address climate change may constitute a violation of the right to a healthy environment” (United Nations Environment Programme, 2019, para. 6). The United States has been a charter member since 1945 and one of the To access electronic copies of the five permanent members of the UN Security Council Ohio Nurse, please visit (Kiprop, 2019). However, in June 2018, the U.S. withdrew from United Nations Human Rights Council http://www.nursingald.com/publications (Dwyer, 2018). How this will affect the human rights of our citizens, including those of a having a safe, clean, healthy and sustainable environment for now and future generations, remains to be seen. And do we have enough to rectify the damages already done as well as prevent further escalation of climate change? Originally created in 1947 to symbolize nuclear threats to humanity and the planet, the Doomsday Clock has also possible catastrophic disruptions from climate change in its hand-setting deliberations since 2007. Reaching midnight signifies the potential end of the world, or in the case of climate change, the point of no return in potential recovery with the planet destined to become uninhabitable in the future. While the clock hands have been moved back and forth several times since its creation, the hands have steadily moved closer to 12: from 6 minutes to midnight in 2010 to 100 seconds to midnight in 2020. (Bulletin of the Atomic Scientists, 2020.). Tick, tick, tick…

References available upon request Page 14 Ohio Nurse April 2020 Climate Change Part 2: What Can Nurses Do to Adapt to and Mitigate Climate Change, Increase Resilience and Improve Health? Lucinda Cave, MSN, RN, NPD-BC of Practice, with the addition of Standard 17: The of increased molds and allergens, nurses could registered nurse practices in an environmentally address many patient questions and concerns. DEAR HEALTH LEADERS safe and healthy manner (ANA, 2015, p. 84). Among Patients may ask why their respiratory conditions Climate change is the greatest public health the competencies included under this standard are getting worse, or why the allergy season seems threat of our time, disrupting large global systems are: (a) assesses the environment to identify risk longer. Nurses could explain any climate change and altering the physical and social landscape in factors, (b) reduces environmental health risks to aspects. Nurses can encourage patients to monitor communities. We need meaningful and immediate self, colleagues, and health care consumers, and air quality closely (EPA, 2020) and follow prescribed solutions. Health professionals like you are trusted (c) communicates information about environmental treatment plans. The EPA has worked with school messengers who can build visible leadership health risks and exposure reduction strategies (ANA, nurses on a program for children to learn how to on climate, clean energy, and energy efficiency 2015, p. 84). monitor and communicate air quality near their solutions. You can leverage the growing awareness Nurses definitely belong in the fight against schools. School nurses can click the link: https:// of climate change impacts to engage your patients, climate change! airnow.gov/index.cfm?action=flag_program.index peers, community, and policymakers, and can then access slides and a webinar recording about motivate them to act on equitable climate solutions 2. Our Patients (and Learners) the program (EPA, 2018). (ecoAmerica and Climate for Health, 2019, p. 3). Depending on the practice role, nurses may have Nurses not only have a tremendous opportunity plenty of opportunity to speak directly to patients Vector-Borne Illness to mitigate climate change, by doing so they can about how climate change affects their health. This In assessing patients, it is important for nurses positively impact human health. The following would be especially important for patients at greatest to understand the climate-related infectious outlines six ways (“the six Ps”) how nurses can do risk – the elderly, those with chronic diseases, health threats common to their areas, and also to this: pregnant mothers, children and infants. It is beyond anticipate those which might be moving in due to 1. our Past and Profession the scope of this article to go into detail about entire the expanded territories and increased reproductive 2. our Patients and learners nursing care for the various conditions, but rather cycles of ticks, mosquitoes and water-borne agents 3. our Practice climate-related discussion ideas will be presented (American Public Health Association [APHA], 4. our Personal habits here. 2015). Nurses may need to assess for diseases 5. our Politics and Resilience new to their areas such as Zika, West Nile, or 6. our Partnerships. Extreme Heat Lyme disease, as well as reinforce information In late spring, throughout the summer, and into about avoiding mosquitoes, ticks, and water-borne 1. Our Past and Profession early fall when heat waves occur more frequently, it pathogens. Florence Nightingale cared for soldiers in the is important to address climate adaptation strategies. Similarly, nurses may need to explain how Crimea and founded modern nursing, and she also The elderly, pregnant mothers, and those with climate change increases a patient’s risk of made a great impact on the public health challenges chronic diseases need to understand that due to developing food and water-borne illness (CDC, of her day. She wrote articles and letters, met with climate change, heat waves are longer, hotter, 2019). European royalty, politicians, and military officers, and occur more frequently. Zalon (2019) adapted to fight tirelessly for clean air, water, food, and some strategies for preventing heatstroke from The Mental Health housing. She called for better conditions for those National Institute on Aging: Part 1 has already outlined ways that climate at greatest risk – the poor, the hungry, women and 1. Stay out of the sun. change impacts mental health. While caring for children. Miss Nightingale had a keen understanding 2. Remain in a cool place, preferably air- all patients, nurses can assess, care for and of environmental practices, and she harshly criticized conditioned. acknowledge climate-related mental health issues. the British for causing floods and famine in India 3. Drink fluids but avoid caffeine and alcohol. This would be particularly important for the most through deforestation practices (Beck & Dossey, 4. Shower, bathe, or sponge with cool water. vulnerable populations, or for those who have 2019). By channeling the same vision and energy of 5. Lie down or rest in a cool place. experienced climate-related trauma. Nurses can our founder, nurses today can hope to make similar 6. Keep blinds and shades drawn during hot times address concerns and make appropriate referrals advances against the health impacts of climate of the day. for mental health services (Connerton & Wooten, change. 7. Spend time during mid-day in a place with air- 2019). More recently, in 2008, the ANA House of conditioning (movie theater, mall, library, senior Any patient could express some of the more Delegates passed a Climate Change Resolution center) gradual climate-related mental health issues such urging nurses and member organizations to 8. Avoid crowds. as solastalgia (sense of loss related to change advocate for change on individual and policy levels. 9. Limit outdoor exercise during heat waves. in a place) or ecoanxiety (fear, anger, powerless Furthermore, the resolution supports initiatives by emotions related to climate change). Nurses can the healthcare industry to decrease its contribution to It may not be enough to simply present patients acknowledge that these feelings are real; people global warming (ANA, 2008). with these suggestions. Nurses may need to provide do feel a sense of loss when their environment has Nurses can derive additional support from the anticipatory guidance for patients to help them been altered due to climate change (Silver & Grek- 2015 edition of the ANA Scope and Standards through the worst climate-induced heat waves. Do Martin, 2015) and some people have a very deep they have access to air-conditioning? What can they sense of powerlessness over contributing to, yet do if they lose power? Do they need transportation to being unable to stop climate change (Moser, 2013). get to cool places? Do they have a friend, relative, or neighbor who can reliably check on them, especially Our Learners during the hottest weather? Some nurses may not have access to patients, Even patients who would not be considered but teach in nursing schools, or provide nursing at risk, but who work or spend a good deal of time professional development instead. Nurse Wittenberg’s 4-Year BSN & 12-18 month BSN-completion outdoors could have a ‘climate talk’ with a nurse. Do educators can use this opportunity to educate programs are designed to meet today’s nursing they know the signs and symptoms of overheating? and engage more nurses and future nurses on student’s goals. What are their plans for rest, water, and shade? the relationships between climate and health. At a recent table discussion during the Alliance of Whether you want to double major or be a student-athlete, Air Quality/Respiratory Health Nurses for Healthy Environment (ANHE) Nursing Wittenberg’s BSN program is committed to your success. As Part 1 indicated, climate change has a great Summit on Environmental Health (2019) nurse For more information contact: [email protected] deal of impact on respiratory health. From ground educators pointed out that they had not received level ozone pollution, to wildfire smoke, to effects this information in their own preparation programs

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Apply for a VISA® card today! Competitive Benefits Package 981 Wooster Rd. Millersburg OH 44654 Visit us at ohiohealthcarefcu.com April 2020 Ohio Nurse Page 15 and were looking for resources they could use to lessened mandatory disposal of unused supplies EcoAmerica and Climate for Health have teamed up educate their own students. One (free!) resource when patients were discharged. Because a nurse to produce the online resource, Moving Forward: A which was identified is the online text Environmental led the team, and worked with other nurses, it was Guide for Health Professionals to Build Momentum Health in Nursing written and edited by nurses who easier to integrate the carbon (and cost!) saving on Climate Action, which has ideas for the practice are involved with the ANHE Education Work Group plans into the hospital workflow. setting as well as in the community (Rehr & (Leffers et al., 2017). (Link: https://envirn.org/e- Another strategy to reduce carbon emissions Perkowitz, 2019). textbook/) Unit VI is particularly devoted to Climate suggested by Rehr and Perkowitz (2019) is to take a Change. Work has already begun on a second baseline institution audit of energy costs and usage, 4. Personal Habits edition, with anticipated online availability to begin then initiate energy savings plans. Money saved From the moment we wake up, to the moment we Spring, 2020. from energy reduction can then be applied towards go back to sleep, there are hundreds of personal ANHE, together with the group Healthcare more expensive emission-reducing plans such as choices nurses can make to be part of the climate without Harm launched the Nurses Climate installing solar panels and purchasing electric or solution. Rehr and Perkowitz (2019) emphasized that Challenge in 2017 with the goal of educating 50,000 hybrid vehicle fleets. healthcare providers can be leaders and role models health care professionals about the connection Sheldon (2019) reviewed seven years of literature for others in making personal choices for better between climate change and health (Cook, 2017). relating to ambulance carbon emissions and found health and a safer world. The internet abounds with As of February 11, 2020, Nurse Climate Champions that on the average, each ambulance trip produces energy-saving and carbon-saving ideas, and nurses have educated a total of 13,701 (ANHE, 2020). 31.3 Kg CO2. Much of that comes from engine idling are probably aware of most of them. Here are a few Encouragement, details, and directions for nurses which maintains lighting, communication equipment, which were cited at a recent Climate Ambassadors to join in this effort can be found on the ANHE refrigeration for medications, life support systems, Training session because they combine good health website. as well as vehicle heating and cooling. Ambulance practices with practices that are good for the planet idling and CO2 emissions can be reduced by (Healthcare without Harm & Physicians for Social 3. Our Practice installing on-board battery-powered auxiliary power Responsibility, 2019). The U.S. healthcare sector contributes about units (APUs). Drivers plug in the APU to charge 10% of all U.S. greenhouse gases, and the while parked at the hospital. Some ambulances Transportation estimated mortality burden from air pollution have solar panels installed on the rooftops to Efficient transportation is one of the most effective is roughly equivalent to mortality from medical provide additional power (U.S. Department of ways to mitigate climate change because it is errors (Salas et al., 2018). However, healthcare Energy, 2015). currently one of the greatest sources of pollution. And organizations are also beginning to reduce their Health Care Without Harm (2017) has created there are multiple solutions: public transit; electric carbon footprints, and nurses are assuming an online playbook for hospitals, outlining ways cars, buses, scooters, and bikes; car-pooling; ride important roles in these endeavors. healthcare facilities can work towards becoming and bike sharing; and active transportation. Active carbon neutral through: (a) Healthier Food, (b) transportation (riding a bike or walking) not only Sources of Emissions Leaner Energy, (c) Purchasing, (d) Less waste, reduces carbon emissions but helps to combat The greatest share of emissions from (e) Resilience, and (f) Transportation. Each page obesity and the risks for developing chronic conditions healthcare (71%) comes from the supply chain provides ideas, and names of hospitals which have such as diabetes and cardiovascular disease. – the production, transport, use, and disposal of already made significant progress in that area. Just as ambulances can decrease carbon goods and services (Health Care Without Harm, Nurses could use this resource, for example, to emissions by reducing idling time, drivers of personal 2019). Many patient supplies, especially single- determine when it would be more carbon-neutral to vehicles can do the same. Researchers estimate that use disposables, are made of plastic which is a purchase single-use disposable patient items, or to personal vehicles generate around 30 million tons of non-renewable petroleum product. Other sources clean and sterilize reusables. In general, in water- CO2 every year just from idling (U. S. Department of come from direct emissions – i.e., air exchange, enriched areas (like Ohio) it is more carbon-neutral Energy, 2015). Idling a car for more than 10 seconds anesthesia gases (17%) and indirect emissions for to use reusables (Bole, 2020). The Healthcare uses more fuel, costs more money, and produces electricity, transportation, heating and cooling. Plastics Recycling Council (HPRC) provides a more emissions than stopping and restarting the toolkit for hospitals who wish to begin a recycling engine. This is especially true in drive-through lines Nurse involvement initiative through its HospiCycle program (HPRC, or while waiting to collect passengers. People can Nurses have been involved in healthcare facility n.d.). “Waste reduction is a ‘gateway drug’ to reduce CO2 emissions by avoiding drive-through climate change efforts by recycling waste, adding sustainability,” claimed Schenk (2019). vegetable-based entrées to patient food selections, To encourage active transportation and reduce Climate Change Part 2 continued on page 16 sourcing more food locally, reducing energy usage, carbon emissions from drive-alone commutes, exchanging single-patient use items for reusables, one popular hospital program is ‘Pay not to Park’. preparing the facility for climate emergencies, Instead of having to pay for parking, employees initiating employee transportation options, and receive money not to park if they walk, bike, NOW HIRING planting trees and hospital rooftop gardens (Health carpool, or take public transportation. One hospital Registered Nurses - ALL AREAS including Care Without Harm, 2017). in Wyoming reduced its drive-alone commute rate PERIOPERATIVE and EMERGENCY Because nurses make up the greatest from 60% to 42% during a trial during the summer We are currently recruiting RNs in Lexington, KY in all areas component of the healthcare workforce, and their months (Practice Greenhealth, 2019). of UK Chandler, UK Good Samaritan and Kentucky Children’s decisions have a huge impact on how patient Hospital, all part of the University of Kentucky HealthCare system. products are used, nurses can greatly affect the Additional Resources BENEFITS INCLUDE: carbon footprint of a healthcare facility. Wolford My Green Doctor is a website (Mygreendoctor. • Education opportunities • Nurse residency program (2019) leads a sustainability team at a large hospital org) that has a plethora of resources for healthcare • Tuition benefits • Nursing professional advancement program • Comprehensive benefits package including and described one way the team reduced wastage employees of smaller healthcare settings, retirement plans with 200% match by changing supply distribution and reducing the such as clinics, and Practice Greenhealth number of supplies placed in patient rooms. This (Practicegreenhealth.org) provides additional ideas. APPLY NOW: UKJOBS.UKY.EDU Page 16 Ohio Nurse April 2020 Climate Change Part 2 continued from page 15 emission from livestock production (Public Health nationwide (Solar Energy Industries Association, Institute/Center for Climate Change and Health, 2019). The Union of Concerned Scientists (2017) lines altogether (thereby avoiding processed fast- 2016). Beef is one of the least efficient foods to estimated that switching entirely from coal to solar food as well). Some schools have become very produce when looking at “feed input to food output.” power could save 52,000 premature deaths a year. sensitive to parents idling their cars while waiting Beef production uses more land and freshwater to pick up their children because the emissions are and generates more greenhouse gas emissions per Wind Power more concentrated near the ground – the air that unit of protein than any other commonly consumed Wind power is one of America’s most competitive children are most likely breathing (U.S. Department food (Ranganathan et al., 2016). Beef only makes and fastest growing energy industries. of Energy, 2015). up 3% of the calories we eat but is the leading Currently, enough wind power is generated Air travel contributes about 12% of all driver of deforestation globally (Union of Concerned across the U.S. to serve about 30 million American transportation greenhouse gas (GHG) emissions Scientists, 2016). homes. However, wind energy represents just about and 3% of the total for U.S. (EPA, 2017). It is clear 1% of power generation in Ohio (American Wind that reducing air travel lessens emissions. Another Home Energy Energy Association, 2018). way to make a helpful impact is to purchase Improve energy efficiency at home by installing One added health benefit of wind and solar- carbon offsets when flying to ‘make up’ for the programmable technology, air sealing and generated power is that neither require water to flight emissions. Carbon offsets are contributions caulking, weather stripping, insulating attics, operate, so they do not pollute water resources, to programs which reclaim carbon (tree-planting walls, foundations, and crawl spaces, and or compete with other water needs. Coal mining for example) or help to make climate-vulnerable purchasing energy star appliances. Home energy and natural gas drilling have been found to pollute areas more resilient to catastrophes like drought, improvements bring additional benefits besides drinking water sources, and the extraction of natural flooding, and storms. Some airlines now even have reduced carbon emissions. They save money gas by hydraulic fracturing (fracking) requires large carbon offset purchase links direct from their ticket and improve indoor air quality (International amounts of water. In addition, all thermal power purchase sites. Energy Agency, 2019). Additional home energy plants, including those powered by coal, gas and recommendations include washing clothes in cold oil, use water for cooling (Union of Concerned Food Management water and line drying when possible. Dryer use Scientists, 2017). Reducing food waste and food waste diversion accounts for six to seven percent of U.S. residential (converting organic food waste to compost) can CO2 emissions. 5. Politics and Resilience lessen food insecurity and climate pollution at the Converting to LED light bulbs can cut electricity All of the above suggestions are ways individual same time. 40% of all food produced in the U.S. use by 85% compared to incandescent light bulbs, nurses and small groups can work to reduce carbon is wasted (Gunders, 2012) releasing methane, a and by 40% compared to fluorescent lights (Romm, footprint and reverse effects of climate change. greenhouse gas more powerful than carbon dioxide 2016). However, greater impact can be realized through (EPA, 2019, 04/11). Most uneaten food ends up in working with others at the local, state, national and landfills where it rots. Organic matter makes up 16% Solar Power even international levels. Through political action, of U.S. methane emissions. Food saved by reducing Some individuals might consider converting to nurses can pursue viable solutions that benefit our losses by just 15% could feed more than 25 million renewable forms of energy like solar and wind. Over climate, our communities, our health and wellbeing. Americans every year (Gunders, 2012). 6000 households installed solar panels each week Nurses can attend candidate forums to find out Eating more fruits and vegetables, and less in 2018. Solar prices have dropped more than 70% where political candidates stand on climate issues red and processed meat reduces the risk of heart in the past decade, leading the industry to expand at all levels of government – the priorities, the disease and cancer, while also reducing methane into new markets and deploy thousands of systems proposed actions and ways of paying for them. It

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Nome, Alaska | www.nortonsoundhealth.org April 2020 Ohio Nurse Page 17 follows that nurses can support those candidates a community become more resilient - able to source of public polling data about climate. whose plans would be healthiest for all and withstand and recover from climate emergencies encourage other voters. Nurses can also become when they happen. Rehr and Perkowitz (2019) Other Health-Related Partners involved in planning and implementing various suggested five steps to build a community’s • American Public Health Association climate-related programs and projects supported by resilience: • Climate for Health the government and private institutions. • National Environmental Health Association 1. Forecast Climate Impacts and Assess One area of involvement nurses have embraced • Physicians for Social Responsibility Vulnerabilities. Know what type of climate is urban greening - planting trees, parks, gardens, emergencies a locale is most likely to be agriculture, forests, and other green and natural exposed to and understand the medical Sources for information spaces in urban areas (Ciotta, 2019). There are and social vulnerabilities of the populations • Lancet Countdown www.lancetcountdown.org many health, climate, and economic benefits involved. In Ohio, we would most likely be (You can download the yearly reports for free, of urban greening, especially in low income dealing with heat waves, powerful storms, and but you may have to establish an account. communities which have been disproportionately flooding. Accounts are free, though.) affected by climate change. Planting trees reduces • U.S. Global Change Research Program the effect of heat islands, the additional warming 2. Project the Disease Burden. Using projected www.globalchange.gov caused by heat reflected from large swathes of data, determine the potential outcomes • The World Health Organization concrete. Surfaces shaded by trees and plants may pending anticipated losses of resources https://www.who.int/health-topics/climate- be 20-40 degrees F cooler than unshaded surfaces. - power, communications, transportation, change#tab=tab_1 Accessible parks have also been associated supplies. • The Intergovernmental Panel on Climate with greater physical activity, relaxation, social 3. Assess Public Health Interventions. Change. https://www.ipcc.ch/ interactions, and improved the quality of life in Develop emergency plans and inform the • United States Environmental Protection communities, especially in low-income communities public about them. Agency (EPA) www.epa.gov of color. Vegetation also has been associated • National Oceanic and Atmospheric with reduction in traffic noise, reduction in crime 4. Develop and Implement a Climate Administration (NOAA) www.noaa.gov and increases in property value. Planting trees Adaptation Plan. Make sure needed around buildings provides shade and decreases air equipment such as generators are safely References available upon request conditioning costs by 20% (Public Health Institute/ stored, yet accessible when needed. Center for Climate Change and Health, 2016). 5. Evaluate Impact and Improve. Discuss Restoring wild nature and ecosystem balance, benefits and obstacles after an actual reforesting and afforesting, are strategies that emergency and modify the plan if needed. most align with health (Nature Conservancy, 2018). Griscom et al., (2017) found that natural climate 6. Partnerships solutions, such as planting trees and fostering No nurse could single-handedly overcome all of vegetation could provide cost-effective ways to help the geophysical, health, and political challenges reach the Paris Climate Agreement goal of holding posed by climate change. Which is why having global warming to below 2 . Hearty trees and partnerships with other nurses, other health vegetation clean the air of CO2, as well as ozone, professionals, scientists, non-profits, professional nitrogen dioxide and particulate matter. In addition, organizations, and government agencies can be vegetation improves water filtration, flood buffering, helpful and reassuring. There are many available, soil health, biodiversity and enhanced climate each with a different aim or focus. The following resilience. list of helpful groups or ‘partners’ is not exhaustive Some nurses may accept opportunities to work but can guide a nurse who is interested in helping with city governments and task forces to accomplish others to adapt to and mitigate climate change, climate-related goals. Numerous cities have made increase resilience and improve health. public commitments to cut carbon and address climate change through organized initiatives, or by Professional Nursing Organizations establishing their own Climate Action Plans. So far, ONA has an Environmental and Community over 150 cities, more than 10 counties, and seven Health Caucus, which any ONA member can states have announced targets of 100% clean join. Members meet (usually by phone or email) to energy through the Sierra Club’s ‘Ready for 100’ share information and gather support about their plan. In Ohio, both Cleveland and Cincinnati have environmental interests. ONA members can join on the signed on. Cleveland has pledged to achieve 100% Communities page in the ONA Members Only content clean energy by 2050, and Cincinnati committed to on the website. accomplish a 100% transition by 2035 (Sierra Club, Alliance of Nurses for Healthy Environments n.d.). (ANHE) is a great resource for finding out about environmental health information and news that Resilience affects nurses. Membership is free. ANHE provides Nurses have worked with local and state health CNE webinars and has special interest groups. departments to anticipate and prepare for climate- Website is www.envirn.org. related emergencies in their communities (Rehr Healthcare without Harm and EcoAmerica & Perkowitz, 2019). Together, with other health are actually two partners, which both house lots officials, their planning and preparations can make of climate information to share. EcoAmerica is a

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Openings are available in the Emergency Department at Lake A TRULY REMARKABLE PLACE TO WORK West. Our Beachwood facility has openings in Peri-Ops. Sign-On Bonuses Available! Lake Health offers free, secure and convenient parking; an aggressive pay structure, tuition reimbursement and continuing As a member of our team you’ll have access to: education funding programs, a generous and comprehensive benefits package for all eligible positions, which includes medical, • State-of-the-art facilities dental, vision, pension, paid time off. Lake Health has been a • Excellent continuing education resources Northcoast 99 winner 16 years in a row. • Competitive salary and benefits • Tuition assistance • Childcare discounts and more! Qualified candidates who demonstrate a commitment to excellence Apply online at: may apply online at mountcarmelhealth.com/ www.lakehealth.org/careers. careers Page 18 Ohio Nurse April 2020 CE4NURSES: SAME NAME, MORE VALUE ONA Members Get CE for Free!

As professional development practitioners, we Not only are we introducing a new system to What Other Benefits Come with an ONA talk a lot about the importance of nurses maintaining improve your learning experience, we are proud to Membership? their professional development through quality announce that all ONA Members will have access • 50% off your first year of membership continuing nursing education. Staying current and to a full library of FREE continuing education! Gone • Discounted membership for retired RNs closing your professional practice gaps are key are the days of coupon codes and special links. • Great networking with other like-minded to maintaining competence in nursing practice. ONA Members will be able to sign-on and access professionals Engaging in meaningful continuing education education for free and on demand (*some exceptions • Discounts on registration to live conferences activities will broaden your knowledge and expertise, apply). and events as well as help you meet the standards of being This means that ONA Members get even more • Membership to American Nurses Association a professional nurse. The ANA Code of Ethics value added to their membership and will have the (ANA) and your district Provision 5.5 implores nurses to demonstrate a freedom to choose educational activities any time, no • Volunteer Opportunities, including groups on commitment to lifelong learning. Now, ONA has more links or coupon codes! environmental issues, health policy, continuing made it even easier to access the content you need, The new LMS is scheduled to launch in the education and more when you need it. beginning of April 2020. Our website link will stay the • Access to ONAConnect, an exclusive The Ohio Nurses Association is excited to same (www.ce4nurses.org) and we are working hard discussion board connecting nurses from announce that we are rolling out a new learning to make the transition as smooth as possible. across the state management system (LMS). This system will Anyone can utilize our new CE4Nurses site to • Be a part of legislative advocacy efforts make our popular continuing education website, access great continuing education webinars, articles • Up to a $140 savings on certification through CE4Nurses.org, even more user-friendly and and more. If having on-demand access to the ONA ANCC engaging. Learners will have the ability to store their library of CE for FREE isn’t enough to persuade • Free Publications, including: CE certificates, access online learning on-demand, you to become a member, you can still access and  Subscription to the Ohio Nurses Review – a and have access to even more quality CE activities, purchase most courses for only $18.00. Because $15 value including a variety of courses meeting the Category Ohio requires RNs to have at least 24 contact hours  Subscription to the American Nurse – a $20 A (Nursing Law and Rules) requirement for re- of continuing education every two years, this ONA value licensure. member benefit can save you over $430!  Online access to the OJIN – the Online Journal of Issues in Nursing  Email newsletters, such as Member Updates UNBELIEVABLE HEROISM

Brittany Turner, MSN, RN responses aside, in order to serve the greater good, fulfil the call, and practice their passion to help The country, rather the world, is experiencing those in need; nurses are acting with unbelievable something unlike anything we have encountered heroism. during most of our lifetimes. ‘Pandemic, illness, Heroism comes at a price. The most obvious precautions, PPE, emergency, virus, mortality, is the risk to physical health through increased shortages, isolation, distancing’ — all of these risk of exposure. But there is also the mental and are words floating in seemingly every news article emotional strain that comes along with placing and communication that comes flooding across oneself in the path of probable harm. our social media, emails, and TV stations. It is The National Center for Posttraumatic Stress understandable that the inherent response to this Disorder has recommendations for healthcare situation be anxiety, fear, panic, and uncertainty. workers during this time. The highlights are: However, one group exceedingly casts these natural • Fight stress through preparedness. Every nurse should demand that the organization they work for is doing everything possible in addressing preparedness, education, employee needs, and employee safety; take steps so that you feel prepared in your work and home.

• Address stress regularly and take care during working shifts. Taking time for reflection, rest, refreshment/food, self- monitoring, and refocusing can help manage stress and create opportunities to identify needed self-care.

• Prepare for the aftermath. Stress will continue to linger, even after the worst of COVID-19 passes. Be prepared with a plan on how to cope, reenergize, focus, and move forward in healthy ways. Know your resources, such as employee assistance programs or mental health services in your area. Acknowledging how this pandemic has affected your emotional or mental well-being is not weakness. The mental health impact is expected. While the world considers you a hero, we are all still human.

As nurses are not the only frontline health workers serving with bravery in the face of a pandemic, we recognize physicians, practitioners, respiratory therapists, radiology, nursing assistants, chaplains, EMT/paramedics, as well as those who serve in non-direct patient care roles that enable healthcare to keep going. We are all in this together. To those serving with unbelievable and undeniable heroism, THANK YOU. April 2020 Ohio Nurse Page 19

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