Life in the pandemic: Some reflections on nursing in the context of COVID‐19

In the unparalleled and extraordinary public health emergency in which we find ourselves, across the world nurses stand as we always do—at the front line. Nurses everywhere are staffing our clinics, hospital wards and units—in some situations, literally working until they drop, and in some regions, they are doing so while dealing with a lack of essential items. Indeed, we see reports that nurses in many parts of the world are grappling with shortages of much-needed supplies including personal protective equipments such as masks, gloves and gowns, yet are actively embracing the challenges presented by COVID-19. As we contemplate the ramifications of this rapidly moving global pandemic, it is clear that the need for nurses has never been greater. In responding to this dire and unprecedented health crisis, as nurses, we are doing what we have been educated and prepared to do. As nurses, we have the knowledge and skills to deliver the care needed in all phases of the illness trajectory, and in reassuring, informing and supporting people within communities who are frightened, worried and wanting to stay well. As we have seen throughout history, nurses are well able to think outside the box, and develop creative and innovative solutions to all manner of problems, conundrums and challenges. However, there remains much about this current situation that is new and frightening. For one is the speed of the spread of COVID-19. In the fight against COVID-19, we are working against the clock. The trajectory of this situation is such that in some areas, infection rates are doubling every 24 hr or so, and this is leading to increasing community anxiety manifesting in various ways including panic buying and hoarding of essential supplies. It is clear that this health crisis will not affect everyone in the same way. The very strong public health message is to stay home, and stay safe within that home, in the assumption that everyone has a home that is safe, and within which they have some autonomy. There is some speculation as to whether rates of domestic violence might increase at this time as a result of the extraordinary strain that families face. Poverty is also an issue. It is well known and accepted that those who are homeless and impoverished have many less options when faced with health problems, and the challenges faced by these people will be much greater in this time of pandemic (Tsai & Wilson, 2020). Similarly, people who are captive or imprisoned for any reason, such as in corrections or refugee environments and other similar settings, are particularly vulnerable (Iacobucci, 2020). Older adults are high users of services across primary, secondary and tertiary healthcare settings. Many in this group live with multiple health and social issues that increase their vulnerability, now further exacerbated by the need for social distancing. Older people are known to be at greater risk of calamitous outcomes associated with COVID-19, and this dire picture is likely to be exacerbated because of the potential for rationing of care based on age, simply because there are not enough ventilators and other life-saving equipments to meet demand. The risk to older people is greater than to others, and in many countries, limitations on older people activities are in place in attempts to reduce risk of exposure. In several countries, restrictions on visiting nursing homes are in place and people over 70 years of age asked to reduce outings and remain indoors as much as possible to decrease contact with others and reduce the risk of contracting the virus. While necessary, this could put older people at risk of loneliness, isolation and exacerbation of existing problems, and so it is very important that we all look out for older people in our neighbourhoods and provide support, assistance and safe social interaction as required. Nurses are at the forefront in institutional settings such as nursing homes and prisons, with homeless people, and other hard to reach populations and are grappling with the effects of low health literacy, rapidity of change and health information, and a lack of resources to ensure that all know and understand what is required to keep them safe. It is so important that we all support these vulnerable populations and the nurses working within them by advocating for resources including adequate safe accommodation for all. We know from our colleagues that despite being actively engaged in this fight against COVID-19, in a way that few other professions are, and despite appearing calm and professional; like everyone else, many nurses are also experiencing fear of the unknown and concern for what lies ahead, for themselves, their patients, colleagues and their own families and friends. In addition to being nurses, we are also parents, siblings, friends and partners with all of the worries and concerns shared by most people—providing for and protecting ourselves and our families, and so in addition to caring for patients, the well-being of our own families weighs heavily on us as nurses at this time. The global nature of this crisis means that while all countries are engaged in the battle against COVID-19, some have been in the fight for longer and so there is the opportunity to learn from other countries. Indeed, in watching the unfolding horror particularly in Italy, we see just what can (and will) happen in the event that measures such as social distancing, hand hygiene and quarantine are not fully embraced by all in our communities. Earlier this year, Hong Kong was one of the first places in the world affected by the COVID-19 virus, evoking unwanted memories of the SARS outbreak of 2003 (Smith, Ng, & Ho Cheung Li, 2020). Despite initial fears, the spread of the virus appeared to have been effectively controlled over the last two months through the use of stringent measures, including practice of good personal hygiene, avoidance of group gatherings and implementation of social isolation measures. Indeed, by the beginning of March 2020 some public services in Hong Kong had started to resume normal activity and many people were returning to the workplace. In some part, these successes were due to the excellence of the clinical nursing workforce. We saw some stability in other countries in the same region including Singapore and Taiwan. There was hope that the corner had been turned in the fight against COVID-19; however, this has turned out not to be the case. Very recently, Hong Kong and several other South-East Asian countries have started to face the second wave of imported coronavirus infections, with the total number of cases in Hong Kong doubling during this period. The vast majority of these new cases have involved people flying to South-East Asia from abroad, especially students returning from North America and Europe, where COVID-19 infection has been escalating. Singapore and Taiwan, which had each taken comfort from seeing new infections taper off in recent weeks, have also seen surges of COVID-19 cases amongst arrivals in recent days. Health officials from these densely populated countries are now struggling to contain the new cases to avoid any new community outbreaks. A similar picture emerged in mainland China. After some sustained and marked reductions in the spread of the virus, China's National Health Commission have recently announced that all new reported cases were imported from overseas. Despite many people fully recovering from COVID-19 infection in China, there has been some concern that a new subset of patients affected by the virus may be emerging. There are reports that a handful of the many thousands of people declared cured after treatment have been readmitted to hospitals because their symptoms have returned. At the time of writing, this worrying feature of COVID-19 infection is only beginning to receive attention by the medical community, but clearly requires close consideration in the ongoing global fight against COVID-19. Across the world, there are concerns that nursing's capacity to provide care will be stretched by the increased workload and by the number of front-line nurses that are expected to be affected by COVID-19. In Australia, authorities are considering various mechanisms such as fast-tracking return to registration of qualified nurses who may be recently retired and allowing limited registration to people who may be suitable such as internationally qualified nurses. In the United Kingdom, there has also been a call for recently retired nurses to return to practice. Other planned strategies include establishing a COVID-19 temporary register for nurses who have left the register within the past three years, who will be able to opt into this register. Registered nurses not currently working clinically will be encouraged to consider working within clinical practice, and undergraduate nursing students will be able to opt to undertake the final six months of their programme as a clinical placement. Part of the COVID-19 temporary register is to include a specific student element for those in the final six months of their preregistration programme and will include details of specific conditions to ensure appropriate safeguards are in place. The fine details are still in development, and there may need to be further measures in what is a continually changing situation. In considering introducing new cadres of nurses, there are also issues around risk, retraining, refreshing and renewing knowledge. While there are some aspects of nursing that may not have changed too much over the years, health is generally a rapidly evolving field and particularly in the current situation. In contemplating returning to direct care giving roles, many retired nurses or others contemplating re-entry may have legitimate concerns about the real contribution that they could make in the current crises, particularly when considering direct care delivery and technological advancements in practice. It will be necessary to consider carefully any possible risk for nurses returning from retirement, and the potential ways these nurses could meaningfully contribute. This may be in working in quieter areas to free up current staff, and working in roles supporting front-line nurses. Either way, it will be crucial to have adequate learning and resourcing available to support these new cadres of nurses. However, as we identify innovative ways to provide a nursing workforce during this time of urgency, it is important that whatever we implement is safe and appropriate for staff and for patients. Patient safety is paramount and integral to nursing practice. Nurses generally become nurses because of the desire to help people regain and maintain optimal health, and here, we have a situation where there may be very few options to help those who are seriously ill because of COVID-19. This inability to save lives will take its toll on those at the front line, both physically and emotionally. As nurses, we know death. We have seen loss of life, and we have borne witness to the pain and the suffering of the dying and the grief of those left behind. For nurses, particularly in environments where the focus is on life preserving, such as emergency departments and intensive care units, death can represent failure, and so is therefore a source of stress and distress for the medical and nursing teams in these settings. We are now in a situation where nurses everywhere are bracing for what really is a tsunami of death. Our colleagues in China and Italy have and are leading the way, and we have seen reports and first-hand accounts of the distress and exhaustion of our Chinese and Italian colleagues who have been (and are) faced with large-scale death on a daily basis. All aspects of nursing activity are affected by this pandemic, and healthcare facilities have responded to nursing education student clinical needs in a variety of ways. Some have restricted student presence in their organisations, while others welcome healthy students. Academic nurses have also been quick to modify in the light of the crisis caused by COVID-19 and many have very quickly moved to online course delivery, including strategising to ensure reasonable student engagement, and making appropriate changes to examination procedures. There is also the need to recognise that many nurses currently enrolled in post-graduate courses may now have their current studies jeopardised because of cancellation of study leave or other pre-existing work patterns that can now no longer be guaranteed. Nurse educators and administrators are tasked with ensuring that students meet academic requirements while recognising the current pressures faced by health services and the need for nurses to be able to simultaneously meet the demands on them as nurses, students, parents, siblings, partners and the myriad of other roles that each nurse has to manage in their daily lives. The way this crisis has unfolded has meant that we have all sorts of new challenges in seeking to meet the health needs of our populations. For example, we have situations of cruise ships left sailing from port-to-port unable to dock; others inadvertently offloading passengers who are ill and contagious into communities, with health services left to set about tracing crew, passengers and those with whom they have been into contact. We have to prepare for the potential ramifications if COVID-19 takes hold in very vulnerable populations, such as prisons where it will be very hard to contain because of the proximity of people. There is also the aftermath to consider. Of critical importance will be nurses’ responses to the increased anxiety and mental health needs of the population as well as within the nursing community. These are very difficult times, and the scale of the challenges is unprecedented. Every single one of us has a role to play in supporting and advocating for the health of our communities, and in supporting nurses everywhere. Nurses are the backbone of health systems around the world, and this has never been more apparent than now. Amidst all the uncertainty about the virus and how long it might take before life begins to return to normal, there can be no doubt that nursing and the provision of health care will come out the other side of this pandemic stronger and better prepared to face future challenges. We write these “reflections” in the moment, as the impacts of the pandemic unfold around us daily. We are all living it right now. When it is over, we look back and reflect upon it and with the benefit of hindsight, might make normative judgements regarding what we ought to have done and what might have been best at a certain time. Right now, we all need to be kind to each other (and ourselves) as we grapple with new ways of living and working. We want to thank nurses everywhere for their tireless efforts in this unparalleled health emergency.