Transcript: Unwritten, Episode 4

Patricia Macalalag: Hi everyone! Thank you for joining us here today. Welcome to Episode 4 of Pearson Unwritten, a series of chats featuring author and student perspectives on the pandemic. As you all know, today’s discussion will center on women’s health.

I would like to get us started with some quick introductions. I am Patricia Macalalag, a third year Physiological Science major and Global Health minor at UCLA, as well as the Pearson Campus Ambassador. I am joined today by Laura Howe, the Vice President of Innovation and Communications for Pearson, who will be moderating our live training session. So get your questions ready. Drop them in the chat box below and we will get to them in about 15 minutes.

I would also like to give a warm welcome to Dr. Michele Davidson, a dual certified Psychiatric Mental Health Nurse Practitioner and Certified Nurse Midwife. She also holds a PhD in Nursing Administration and Health Care Policy from George Mason University.

Dr. Davidson currently works with women and men of all ages with various mental health issues, including pregnant and postpartum women. In 2012 her book, “A Nurse’s Guide to Women’s Mental Health” won an American Journal of Nursing Book Award.

I want to begin each of these conversations by turning it over to our author expert for a two minute hot take on the most important thing people should know right now about what is happening in our COVID-changed world.

So Dr. Davidson, please give us your hot take.

Dr. Michele Davidson: Thank you so much Patricia! We are in a new world with COVID-19. There are so many changes for so many people. This starts with anywhere from children to our pregnant women. We know that women -- 3.7 million women annually that deliver in the United States and we know that these women are facing unknown outcomes because we just don’t know a lot about COVID-19.

We look at our working age, our young adults, our middle age adults in our workforce, they are facing mandatory employment provisions as well as facing unemployment of an unknown duration.

We are also looking at parents who are struggling working from home. They are really striving to maintain work, childcare, homeschooling and the hardships that come -- that we are all facing from staying at home.

We know a large number of Americans are facing mental hardships with unknown duration.

Seniors in high school and college are at a time where we have cultural norms that aren’t going to be met and we have people facing a great deal of sadness and grief and disappointment over that.

We also have our college students who would have flown the nest and now are finding themselves having to come back and that can introduce a lot of stressors as well.

Extroverts we have seen in our practice are really struggling with social isolation. And overall most people don’t really like to embrace change. So there is so much change and when you have change, that’s unknown, with an unknown duration, with unknown outcomes we know this has a huge impact on mental health. I think we are going to see mental health on the forefront for a long time to come.

Patricia Macalalag: All right! Thank you Dr. Davidson! Let’s get right into some questions about parenthood, pregnancy and mental health during the pandemic. So other than coping with obvious issues like social distancing, how does the pandemic change the experience of expectant mothers? Have those changes added to the stress and anxiety that many expectant moms already feel?

Dr. Michele Davidson: Well, I think expectant moms are really facing an unknown at this point. We know in general ideally moms start prenatal care in the first trimester, 77% will be United States, undergo prenatal care. We know that’s being pushed back.

We also know the average number of visits is 14 visits during a pregnancy and we know that as many as 50% of these visits may be eliminated or done by telemedicine.

Pregnant women are now taking a lot more accountability for their health care. Not only are they having to do their education piece, not in classes, but a lot of online, but they are now needing to monitor a lot of things on their own, such as their blood pressure, perhaps urine dips, monitoring contractions at home, monitoring their blood sugars. There are a lot of women who aren’t getting their routine sonograms, so we may see this going out of practice because of safety provisions.

So this creates -- anytime you have an unknown or a change in routine like everyone, it creates a lot of anxiety. So we are seeing an increase in anxiety, increase in mood disorders. We know those things are more common in women, women with PTSD and some of those disorders, panic disorders, the anxiety disorder umbrella, with increased cases in pregnant women because of this unknown environment that we are in right now.

Patricia Macalalag: And as a follow up question, how then do we see this ultimately affects the health and wellbeing of children?

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Dr. Michele Davidson: Well, interestingly we don’t know what the outcomes will be in children who are in utero right now. There are limited studies on infants that have been born to mothers don’t seem to have any birth defects. We do know that when transmission does occur, it seems to be occurring after delivery with the contact of an infected mother.

But if you look at our older children, even our newborns and our toddlers, our school age children, we know that children sense when their parents are stressed and anxious and children don’t have the verbal abilities, even our teenagers, to really verbalize that. So we might see more behavior problems, more tantrums, more meltdowns, difficulty sleeping. We might see toddlers more clingy to parents.

Anyone who has a child knows as soon as you pick up the telephone, your child is right there in your face. So our moms trying to work from home are really trying to counterbalance that. So we do see these types of behaviors in children. So we want to give them age appropriate information, be honest with them, but not give any dooming comments like we have no idea how long this will last. We want to be encouraging. You know, they are doing a great job, how proud we are.

And think of activities that we can do at home to kind of help children thrive. So getting outdoors, riding bikes, these are great for kids. They can do a contest with their friends. And I can’t stress enough keeping in contact with friends, classmates, whether it be texting, Zoom calls, TikTok, FaceTime, all those things are really important regardless of age.

Patricia Macalalag: That’s very interesting. Very good point! So my third question for you is, are you seeing or hearing about any mental health affects in health care providers who are on the front lines of this pandemic?

Dr. Michele Davidson: We are seeing a lot of issues with the frontline workers. We know that 91% of our nurses, for example, are women. 77% of our teachers are females. So really when you look at those two professions, you are looking at women being responsible for the homeschooling movement, learning technology very quickly. We are looking at nurses that are striving to find appropriate protective equipment. Some are isolating themselves from family to prevent transmission to children and at-risk family members. So we see a lot more anxiety. We are seeing panic attacks. We are seeing mood disorders. And we are treating those through telemedicine and telepsychiatry, not only with medications, with therapies, with coping strategies, and encouraging self-care measures.

Patricia Macalalag: I definitely think this pandemic will have long-lasting effects on our society and the world in general. In those events like 9/11 in which the way we traveled changed forever, what are some of the changes in health care that you think will stay with us long after this pandemic ends? Do you anticipate any permanent transformations of health care system or delivery?

Dr. Michele Davidson: I do think we are going to see changes. I think we are going to see long-term health issues that are going to be common in our frontline workers. That being said, you know that when we had the 9/11 incident that there was a lot of PTSD in those frontline workers and a lot of anxiety, they needed a lot of therapy, some needed medication management so I think we are going to see that.

But on the positive side, I hope we see a better coordination with emergency services and awareness of just how many supplies and resources and positive protective equipment we need.

I think there is going to be a big push for policy reinvention. We know, decades have shown us the importance of the public health departments, of public health planning, of the CDC and the importance of epidemiology and disease tracking, those things haven’t always been on the forefront and have been so important in not having a public health crisis. So I think those things are all hopefully going to be really a push to really fund those and things like that.

I also hope we are going to see an ongoing appreciation for not only nurses, but our health care essential workers, whether it be our housekeeping individuals, our dietary aides, our radiology, the people who are discharging patients. So I hope that the movement will continue to show appreciation for those individuals.

The other change we have seen is how effective telemedicine and teletherapy and telemetry can be in the home setting and so I hope that we see a continuation of that, because it does bridge barriers as far as people with limited transportation resources, people in rural areas, geographic isolation, we are seeing that there is more availability for those.

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We are also seeing some states relaxing legislation guidelines for nurse practitioners and for nurses, so if there would ever be a push to nationalize, which is a big, big step to overcome, but if there could ever be a national licensure so that practice could be expanded to bring

those people that are medically underserved services. I think that would be something that we could really look out in the future.

Patricia Macalalag: Right! Okay. So I think we have time for one more question and this is actually something I am very interested in because it’s something I am learning about. So you are currently in private practice for psychiatry, how have you and your patients found the transition to teletherapy and telemedicine, what kind of advantages and disadvantages do you see from the shift?

Dr. Michele Davidson: Well, we have about 35% of our practice with telemedicine, so we were really fortunate that we were already engaged with telemedicine, but I can tell you some patients are uncomfortable with it. Some patients have to be concerned about privacy and some patients just aren’t technologically savvy to engage in it.

But I think some of the wonderful things we have seen is we see people in their own environment, in their home environment. I have met so many children, spouses, mothers and that really impacts patient’s surroundings, their environment. You can put back on those cues and understand why when we are telling someone they need self-care that they don’t have a minute because they have got four children climbing on top of them.

So it’s really given us another assessment piece. It’s been accessible for more people, people who can’t drive, people who have agoraphobia, that don’t leave their homes, aren’t driving, it’s really opened up appointments and availability for them. So there have been some really positives come out of this.

Patricia Macalalag: Thank you Dr. Davidson! All right! So we do want to take some questions and I will send it over to Laura for some questions.

Laura Howe: Yeah. So speaking of self-care Dr. Davidson, one of the things that I think has been sort of a recurring theme in some of the questions that we are getting is really around how you can support other people. And there was one question in particular that I thought was a really compelling question from someone who is struggling to balance everything that’s happening and wants to know how they can take care of others and what’s the best way to take care of others when you yourself are actually struggling with everything that’s happening around you.

Dr. Michele Davidson: So that’s a great question. I think one of the things we have to remember is before we can nourish other people, we have to nurture ourselves. So, doing self-care for yourself might be a hot shower alone with the door locked. It might be not answering the phone for half an hour.

When you are thinking about other people, human contact is really important. We know that with prisoners of war, one of the ways they torture them is no human contact. So reaching out to folks, whether it be through Zoom, a lot of people are organizing Zoom birthday parties, Zoom cocktail hours, Zoom classes, TikTok, FaceTime, even if it’s a text message. A lot of children don’t have the skill of writing letters, so pen pal programs are great ways to engage. Kids love getting letters. Sending letters to grandma and grandpa, reaching out to cousins they might not see very often. So those are ways.

Making a nice meal for a neighbor, leaving it on the porch, making cookies. We see neighborhood parties where people are just in their own driveway, but they are waiving to neighbors and engaging with a safe social distance and mask on. So those are all ways to keep in contact.

There are people who are sewing masks and getting those away or charging a minimal fee for those. Those are great ways where you feel like you are giving back.

Also drop things off to the local fire station; I know we do that a lot. We take donuts to the firefighters about once a week, just to know that they are being thought of. Making cards, all those ways of keeping in contact as best we can really help nurture and care for others.

Laura Howe: That’s great, and super important, too. Good advice! So this is an interesting question that someone wrote in around the comment you made about pregnant women and doing the home self-monitoring, so interest in how pregnant women are actually getting the equipment to do the self-monitoring at home, were they having to buy it, do they have providers that are giving it to them? So how are you -- how are people getting a hold of that and how are they doing kind of being able to do that self-assessment at home?

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Dr. Michele Davidson: Well, I think that really varies with your geographic area and the resources in your area. There are certainly some offices that maybe loaning out blood pressure cuffs or things like that, and a lot of patients are having to buy their own materials, and that really comes, you know, it’s really challenging, people on limited financial resources, there may be layoff from jobs and things like that.

So hopefully, just like the schools are prioritizing, who gets laptops in some areas to do school assignments, hopefully medical facilities are trying to look at who has the most need for the service; certainly our high-risk women with possible preeclampsia. A clampsia risk would be someone you want to have those blood pressure cuffs given to them before someone who was at low risk early on in the pregnancy.

Laura Howe: Great so another interesting question. So, I hear that babies are being separated from new moms in the hospital sometimes, how does the -- things like breastfeeding, infant-bonding and some of those very earliest moments she would have with an infant.

Dr. Michelle Davidson: Sure. So in some parts of the country where we have huge COVID numbers, we are seeing that separation. Certainly if mom is infected, we are seeing mandatory separation where mom would be separated from the baby for at least 72 hours after she had her last fever. But, you know, if dad is not infected, it can be dad being at the nursery, dad doing skin-to-skin contact on his chest. Mom pumping, we know that it is not transmitted in breast milk. So mom could be pumping, giving the baby bottles.

So I think it is very case by case basis. Surely as a nurse midwife, we always want to get that baby with mom as soon as possible. I always deliver the baby at the chest if there is no contraindications, and start that one-on-one bonding kind of with that family. So I think it’s important that we do look at the risk-benefit ratio, and each provider will do that separately.

Laura Howe: Great. In all of the episodes that we have had, one of the questions has been sort of a consistent theme throughout the episodes is really around how faculty members can help their students? There is some kind of, there is very particular things that the college students are going through right now, especially they are missing milestones, right? So what can faculty do to be able to support college students at this time?

Dr. Michele Davidson: So I think faculty really can have a really strong hold in supporting students, by reaching out to students one on one, whether that be by a phone call or an email.

I think it’s really -- nursing professors and healthcare scientists, a lot of times do know their students well, so if you know that a student cares for her mother, sending email in that regard, be really personal in your emails. Are you still working at Norfolk General Hospital? How is that going? Do you have enough positive, protective equipment at the nursing home where you work? You know, how are things there? So personalized, reaching out is really important.

I think if we can get individuals to make phone calls, I know the college students aren’t ones for phone calls as much with this generation, but you can text them and say hey, and talk to them and just touch base for a few minutes.

So I think that personal attention and that caring, really conveys caring, empathy that they are really supported. I think to resume class calls, even if it’s ungraded, then it’s just an opportunity for face-to-face contact. We know that some of our international students, when the universities close down, they don’t have an opportunity to go home. They could be a single student in the whole floor of the dorm and they are very isolated, they might only see students when they go to the dining hall and they are served as separated.

So for Zoom calls, for those kinds of individuals, these are really important ways to do that. So, reaching out by email, making contest, making videos. I have seen making silly videos. There is a Push Comedy Theater or -- it’s local to me but it’s a national contest and you can enter that contest and make funny videos, and just humor is a great tool. We know that laughter is the best medicine, and I think that’s true in these times as well.

Laura Howe: That’s great, so some more questions coming in. A lot of them coming in now. This is kind of an interesting and a very specific one. Do you think we’re maybe pushed nationally for more nurse practitioner autonomy due to the pandemic and are you aware of any efforts in that area?

Dr. Michele Davidson: I am not aware of national guidelines at this point. I am aware that some states have stated that nurse practitioners and physicians from other states can practice in their State temporarily. I am also aware that, for example, in Virginia our five-year independence policy was taken down to two years during the epidemics so you could practice independently in a State that usually has governing of physicians for five years.

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So I am hoping that some of those relaxed standards that have shown positive outcomes that we look at that data and can really -- we’re going to have to do a push politically and really be our own advocates to get these policies to stick and to expand this policy, but I think one of the silver linings in this is, this is a great opportunity to take the examples of how we have had more independence and use that to affect better autonomy from nurse practitioners and nurses.

Laura Howe: Great. So another question that came in sort of pivoting back to mental health issues, do you think given the situation with COVID-19 that this will lead long-term mental health issues for people even after the effect?

Dr. Michele Davidson: I think that individuals -- 25% of our population has a mental health issue, which is one in four in our population. So anytime we have a significant stressor whether

it be a death in the family, a pandemic, an earthquake, a hurricane, we know that there are lasting effects from that, we have seen that in the data for a century -- for decades. So we want to make sure that providing that right support to encourage self-care, healthy coping mechanisms, we want to encourage people to get out, to not be just locked in their house, so say social distance whether it’s going for walks, whether it’s being in their backyard doing some gardening, talking over the fence to neighbors, engaging in some activity every day, whether it be even mild physical exercise and activity, healthy eating. We want to make sure our people with substance abuse… We are seeing a lot of people with substance abuse that are losing their coping skills whether it’s going to AA meetings, or seeing their sponsor regularly, we are seeing an increased incidence in them starting to drink and not remaining sober.

So those are going to be issues we are going to need to address, and I think we are all navigating unchartered waters as we make provisions for patients and try to provide support. I know I do a lot more emails, I have a call list, so somebody trying to make visits less frequent for people who aren’t working but they need to support, so I will do a phone call, I will do an email, and just say, hey, I am just checking in how are you doing. So I think those are a lot of measures that we need to take to deal with what is going to be more long term issues from the COVID-19 pandemic.

Laura Howe: Okay, so our next question is from Erin who is a nursing student at SUNY Canton, so shoutout to SUNY Canton. So she’s -- but she works as an LPN at a nursing home on the dementia unit. “My residents are having a hard time coping with isolation from their loved ones, are there nursing interventions that could help decrease their anxiety?”

Dr. Michele Davidson: So that’s a great question. I am going to share with you my son, who’s 12-years-old with cerebral palsy has started a pen pal program for residents on a dementia unit in a nursing home. So he adopted the nursing home and got his classmates to send in letters and cards and pictures to them. We have also seen where people have had family members come outside the windows, and you know, have signs or hot coffee, a cup of coffee with grandma and a cup of coffee with the college student who’s now suddenly found themselves at home, and it’s a great therapeutic effect.

Of course with the dementia patients we want to make sure that -- because they have a little bit of impairment, it’s not to make them more distressed, but there are creative ways we can do that. I think providing a lot of support. I know they are trying to minimize groups that have them sitting far apart maintaining some normalcy in their routine, that’s very important for people who have impairment in memory. So, continuing to mingle at a distance.

Sharing stories, story time, maybe they want to talk about when they were young and went through a hard time and how they have come out of it, so that might be therapeutic for them. So those are great ways that we can engage them, and as you are very limited with staff but checking in on them, positive reinforcement, all those things are really important for that population.

Laura Howe: Great. We have got time for a couple of more questions, so this is another one that came in. What are you seeing, are you seeing anything in the healthcare field during the pandemic that has actually surprised you?

Dr. Michele Davidson: In nursing when I was a Midwife for 17 years I got to a point, I used to say, maybe nothing will surprise me but something always surprises me. So I am always pleasantly surprised or surprised in some ways. I am seeing a huge amount of primary care infused into our practice because a lot of the offices are not open or they are open for emergencies when people can’t get appointments.

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So I have probably in the last month treated more UTIs, vaginitis, done birth control prescriptions, done family counseling, taught abstinence, and done a lot of teaching for GYN issues. Luckily, I am dual certified so I can prescribe in those fields comfortably, but I have seen a lot of that. I have seen people concerned about blood pressures and asking, hey, is this blood pressure okay? And we have really triaged, I have actually diagnosed two cases of COVID just from seeing someone on the screen and said, no, you got to go in and then they have come back COVID positive.

So I think we are seeing so much primary care. We are seeing a lot more collaboration between therapists and the MPEs where we are calling our therapists that are working with clients and saying, hey, I prescribed this, how do you think they are doing? So, a lot more of that collaboration, which is a nice surprise.

So those things are surprising. The degree of extroverts that are having a very difficult time and the degree of introverts, it’s surprising that are just, hey, I am fine, I talk to coworkers and I am doing great. So that was a little bit interesting to see where the extroverts and introverts would fall.

Laura Howe: That is -- that is fascinating. So I think we have got time for one more question and this is the question: when we look back on the pandemic, so 6, 12 months from now, what do you think the biggest lessons are going to be that the healthcare community will have learned?

Dr. Michele Davidson: Well, I hope that we learned how important all the essential staff members are, whether it be our support staff as well. I hope society as a whole and medical providers in the healthcare system realizes how valuable our care team is and that is really not our rock-stars, our actresses and our sports figures, that really are important and they impact our life, it’s healthcare in the essential employees.

I am hoping that we learn how important it is to have a public health service and the CDC that is well-funded, that stays diligent with tracking these kind of things. I hope we see that and these can have a greater role and greater autonomy, and not only delivering as good of care but I can always say better care because we are spending more time with patients.

So I think those are some of the things that I hope that we will see. I was really actively doing some mental health things during 9/11 and I remember how patriotic we were and how we had such heartfelt things for those emergency workers. So I hope that rally continues and I hope the nursing students take away from this how valuable nurses are and how nurses change lives every day.

Laura Howe: And that is a terrific message for us to end on. So I am going to turn it back over to Patricia to wrap this up.

Patricia Macalalag: Thanks Laura and thank you so much for your time, Dr. Davidson. I would also like to thank everyone who joined us today. I hope this conversation was just insightful for you as it was for me. Please stay safe and take care.