Keywords
Key points
- •COVID-19 had a major influence on nursing highlighting the indispensable role played by nurses.
- •The chaos of the pandemic resulted in real physical and emotional risks to nurses.
- •Challenges of moral distress, fear for self and family, and work impact were common.
- •In the face of all these challenges, nurses demonstrated extraordinary resilience, leadership, and innovation.
- •Nursing emerged from the pandemic with visible leadership in the field of health.
Introduction
There has always been a recognition for the need of a strong nursing workforce in history. After the end of World War II, President Truman in the Associated Press, 1946, February 28, stated that nurses are “one of the most important groups of health workers in the country.”
1
More than 70 years later, in 2020, the Year of the Nurse, with more than 5 million cases of COVID-19 recorded around the world, “nurses were standing firm against the onslaught of the virus and have saved many thousands of lives” (ICN President, 2020).2
Toward the end of 2019, our world changed due to the COVID-19 pandemic, and our lives, both personally and professionally, were irrevocably altered. Although hailed as heroes,
3
nurses were faced with finding new ways of living and new ways of working while navigating this changed landscape. For nurses across the globe, numerous new challenges emerged but so too has there been the emergence of a resilient workforce with new learning and ways of doing.COVID-19 has done a great deal to globally highlight the indispensable role played by nurses within the health-care system and has served to assist to address the invisibility of nurses, despite their limited voice in the national and regional responses to the COVID-19 pandemic.
4
Nurses have always been the backbone of the workforce, doing phenomenal and unbelievable work daily as they save lives, prevent complications, and prevent suffering, often unnoticed.1
Nurses’ stories from all corners of the world need to be written and exposed to the world because nurses have a plethora of wisdom to get out there. Through the chaos, COVID-19 has provided an opportunity to “tell these stories.”“Unpacking” the chaos of the pandemic
During the last 50 years, health-care workers, and specifically nurses, have encountered numerous risks from HIV/AIDS, SARS, swine flu, and Ebola.
5
Although COVID-19 was thought not to be as deadly as HIV/AIDS or the swine flu, the insufficient understanding of the virus at the start of the pandemic, its pathophysiology, mode of transmission, susceptibility profile, and contagious nature along with failures in the supply chains for personal protective equipment (PPE) meant that health-care workers were asked to take on substantial but uncertain risk.5
Challenges Related to Physical and Emotional Risks of COVID-19
These uncertain risks have had a large impact on the nursing workforce. It has been reported that the health workforce had a 7 times higher risk of severe COVID-19 infection compared with other workers.
6
The World Health Organization estimated that a possible 115,500 health-care workers have died from COVID-19 in the period between January 2020 to May 2021,7
although the real impact has remained unknown.8
The uncertainty and the real risk faced by nurses on a daily basis resulted in high levels of COVID-19 fear related to infection and safety concerns for themselves and their families,9
as well as work burnout with emotional exhaustion, depression,9
and possible posttraumatic stress. In a study conducted in South Africa, nearly half of the nurses included in the study were extremely concerned about family members and their own personal health10
with 3 in 5 nurses concerned about passing the infection on to family members.10
Qualitative stories globally from nurses also identified themes such as the shock of the virus, staff sacrifice and dedication, as well as collateral damage ranging from personal health concerns to the long-term impact on, and the care of, discharged patients and a hierarchy of power and inequality within the health-care system.11
Moral Distress and Ethical Challenges
One of the hidden challenges faced by nurses during the pandemic was the moral distress experienced in scenarios such as witnessing and participating in the triaging of resources and equipment to those who were seen as having a better chance of survival; watching patients dying alone without their family or loved ones due to visitor restrictions and social isolation policies; experiencing the cumulative loss of high number of patient deaths; suffering from physical exhaustion due to a heavy workload, schedule changes and shifting roles; experiencing anxieties about limited medical supplies, equipment, hospital beds, and PPE; and struggling with worry about their own health and possible exposure of their families while balancing professional obligation.
12
,13
Although for nurses from low-to-middle-income countries, having to make very difficult patient-management decisions according to the availability of resources is often a daily occurrence, for many in other higher income countries, this was a new reality never previously experienced. Nurses also faced several ethical challenges14
due to the conflicting professional values and unpalatable and complex ethical issues in practice.15
Nurses were placed in situations where the professional values of protecting the public from harm and a duty to provide care were in conflict with obligations to protect own health and the health of families15
all the while addressing equity of care issues in terms of triaging care, and patients not expected to survive but still needing care with the fair allocation of resources.12
Faced with the potential reality that patients will suffer, clinically deteriorate, or die, many health-care professionals found it extremely difficult to make or implement a decision to deny or delay treatment given their own human response, their professional socialization, and their profession’s expectations and norms about saving lives, relieving suffering, and not abandoning patients.15
Challenges of COVID Stigma
Another challenge experienced in many countries by nurses and other health-care professionals was that of COVID-19 stigma. In Malawi, nurses were not allowed to use public transport and were insulted in the street and evicted from rented apartments,
16
and a nurse from Mexico was sprayed with bleach.17
A study in Italy found that nurses experienced “stigma in the working environment” such as avoiding closeness with others, and “stigma in everyday life” with strong feelings of isolation because people avoided contact.18
In May 2020, a community of advocates from 13 medical and humanitarian organizations issued a declaration condemning more than 200 incidents of COVID-19–related attacks on health-care professionals and health facilities during the ongoing pandemic.16
This was happening at the same time as public displays of affection such as “clapping for hospital workers”3
(Box 1). This concern regarding the stigma for nurses associated with working in COVID-19 was highlighted by the International Council of Nurses, which called on governments internationally to stop attacks on nurses.19
Box 1
Some of the challenges experienced by nurses during COVID-19
- Fear for self and family
- •Dealing with a new unknown pandemic
- •Constant fear due to caring for patients not yet tested
- •Fear of infection from patients and work colleagues
- •Increased susceptibility to major health issues due to preexisting health issues
- •Fear of transmission to family and loved ones
- •Physical exhaustion
- •Resulting psychological stress, burnout, and traumatic stress disorder (PTSD)
- •
- Work challenges
- •Excessive job stress and constant high work pressure
- •Constantly changing workplace policies and procedures
- •Role and task shifting, for example, having to work in role not trained for
- •Large crowds of patients entering the workplace with COVID-19 and needing further space and resources
- •Trying to do more without additional resources, often in an already high-pressure low-resourced environment (especially problematic in Low- and Middle-income Countries [LMIC])
- •Working a busy shift in full PPE (if available)—impact on skin and added difficulties in communication and establishing rapport with patients
- •Having to deal with a lot of emotions from patients and their families
- •Not allowing visitors and or families to be present, often resulting in conflict
- •
- Ethical and Moral challenges
- •Modification of admission criteria and triaging resources
- •Withdrawing treatment due to resource constraints
- •Facilitating final goodbye’s with families excluded from the bedside
- •Shortages of isolation rooms and equipment
- •Feeling underprepared to function within the allocated role
- •
- Community challenges
- •Managing expectations of community members
- •Stigma toward health-care workers
- •COVID-19 conspiracy theories
- •
Facing Challenges with Resilience
However, amid this chaos and challenges, nurses have demonstrated extraordinary resilience. COVID-19 forced nurses to come up with new ways to manage and respond to the pandemic: to be quick to act appropriately, to be alert to changes that are needed, and to be receptive and adaptable to change. During the pandemic, many retired nurses returned to the workforce to assist as needed, undertaking further training to work in contact-tracing, COVID-testing stations, testing work, and in specialized units such as intensive care units (ICUs) and emergency departments.
20
Nurses working with COVID-19 patients were reported to have significantly greater resilience than other nurses
21
and front-line nurses experienced both positive and negative impacts of COVID-19, with the positive impact reported as increased empathy, compassion, and enhanced confidence in their professional skills.22
In a study in China, 96.8% of the nurses expressed their frontline work willingness, and 60.6% reported a sense of personal accomplishment working during COVID-19.9
Research has indicated that nurses tended to adopt positive strategies in the face of the psychological impact of the pandemic.23
This is in support with what Bonano24
in 2004 suggested, namely that understanding what you are doing, having a meaningful purpose and a strong belief system helped people become more resilient in stressful situations.25
“Showing stubborn hope,”26
moral courage, stamina and resilience, nurses continued to work on the front lines of the pandemic, once again holding the historic center of the recognition, prevention, care and control of infectious diseases from the time of Florence Nightingale.15
Out of the chaos, nurses as leaders emerge
However, in this chaos, we found the emergence of stories of innovation and successes in nursing care. Drawing inspiration from a Xhosa word used in South Africa—zenzele—which refers to the need to do things on your own without relying on others to do it for you, the COVID-19 pandemic has seen nurses across the globe taking up the initiative. They have recognized the need, realized there is nothing in place to assist and have thus risen to the challenge to provide a solution. These solutions have been in the form of innovative practices, communication and support strategies to assist the communities they serve.
Nurse Innovations in Clinical Practice
The pandemic caused a great many challenges in the clinical area thereby providing the impetus and forcing organizations, and specifically nurses, to think creatively and to be a valuable contributor to the multidisciplinary health-care team.
27
Nurses have a rich tradition of being recognized as the “hackers of the hospital,” that is, working creatively to solve issues of patient care, customizing medical equipment, and making new devices to ensure patient comfort and safety.28
,29
There are numerous examples of this from across the world and include something as simple as a photograph attached to a nurses gown (Table 1), an inflated nonsterile glove nestled in the hand of a sedated and ventilated patient, to the “Real talk Real time” virtual tool (see Table 1). COVID-19 also changed the way in which nurses at the bedside could practice. Nurses worked to find simple and cost effective practical solutions to many of these challenges, see “Isopouch” and “Code Cards” (see Table 1), while still providing support and high-quality care within the tight constraints of isolation and working effectively, despite increasing numbers of patients, by improving bedside handover as patient numbers surged (see Table 1).Table 1Some examples of COVID-19 nurse innovations from around the world
| Innovation | Description of Its Application in the Clinical Area |
|---|---|
| Own photograph on the front of your gown | Masks and face shields hide the face and facial expressions of the nurse. Photographs of the nurse’s face with their first name was attached and displayed to the front of their gown for patients to be able to see who was taking care of them |
| “Real Talk Real Time” | This virtual rounding tool has been able to provide comfort to family members by allowing them to be face-to-face with their loved one’s nurses or doctors in the ICU. Unlike other video chat offerings, using the Webex platform ensured it was secure and able to be accessed on multiple devices by various age groups. https://nursing.jnj.com/nursing-news-events/nurses-leading-innovation/meet-10-nurses-pioneering-innovative-covid-19-solutions |
| “Code Cards” with most commonly coded medications and procedures | These communication cards are used in isolation rooms, where they are held up to the glass to get important messages to the rest of the team (about required medication) during a resuscitation, thereby keeping the staff safe. https://nursing.jnj.com/nursing-news-events/nurses-leading-innovation/meet-10-nurses-pioneering-innovative-covid-19-solutions |
| IsoPouch (Isolation Pouch) | This was created by a nurse who realized the need for an inexpensive disposable pouch that she could fill with all the supplies she needed to care for her isolated patients, and which she could then throw away with her gown and other PPE once finished 30 |
| Handover Redesign Team | Nurse leaders and clinical nurses redesigned the bedside handover, and this was carried out in order to improve nursing practice implementation and handover processes that addressed nursing concerns and prioritized their needs 31 |
| “Hand of God”—water-filled nonsterile glove | This is placed in the hand of an intubated and ventilated patient, allowing them the feeling that someone is nearby, with them, holding their hand. This was in response to COVID-19 social distancing rules that families were not allowed at the bedside |
Digital innovation has always been present in the clinical areas and well used by the bedside nurse, however, possibly not to its full potential. COVID-19 challenged that
32
and resulted in numerous innovations in the clinical setting. The global pandemic accelerated the pace of this technological innovation across the entire world with, for example, mobile apps being used for monitoring quarantine in Sierra Leone and South Africa, information-providing drones in place in Rwanda,33
and using social media such as WhatsApp for support, information, and communication.Andersen, H. 2020. Insights From Africa’s Covid-19 Response: Tech Innovations. Available at: https://institute.global/advisory/insights-africas-covid-19-response-tech-innovations Accessed December 10, 2020.
Innovation is about using one’s own knowledge and skills to change old ways of thinking and practicing and to develop new improved ways of working.
34
This can be an extremely challenging task, and it is essential to be very purposive about the way in which we are educating nurses and to ensure we are adequately preparing them for success in the fourth industrial revolution. An additional problem is, however, that nurse innovations such as these often remain “hidden” because they do not spread beyond the area in which they were developed. This is for a variety of reasons including the limited dissemination of such products in written articles. This is especially true for lower income countries such as those in Africa, where many young scientists face numerous challenges converting their research into publications.35
Gomez-Marquez and Young (2016) argue that, “It is time to not only acknowledge nurses’ creativity and ingenuity, but celebrate and nurture it.”28
In order for innovation to thrive however, it needs a supportive environment. It is also important to reflect on the question, “What are we doing to nurture and support nurse innovation?”Communication Innovations
Communication became a central concern during the COVID-19 pandemic due to social distancing policies, the use of full PPE, and the novelty of the disease. This was particularly true regarding the ways in which nurses interacted with patients’ families, with significant restrictions on visiting and face-to-face consultations.
36
Nurses found new ways to communicate effectively with patients, family, and colleagues, by adapting to virtual consultations.20
WhatsApp collaboration groups with staff members and in ICUs by linking families with video iPad sessions to see their loved ones. This was evident in ICUs in the National Health Service (United Kingdom), where interactions with families were handled with video calling used in 63 (47%) of the ICUs and 39 (29%) ICUs had developed a dedicated family communication team.36
In South Africa, provincial departments of health established collaborative learning environments—#Colabs—as a learning space. This served to provide a space in which to share experiences, insights, and ideas that then translated to improvements in different clinical settings, including supporting staff. These #Colabs also played a valuable role in providing professional recognition for innovations in practices.37
These included “daily walkabouts” by nurse leadership to ask frontline staff every day “what matters to you” and then to act daily with “just do it” quick fixes to address identified challenges. “Daily huddles” were virtual daily get-togethers, which served to establish 2-way communication through WhatsApp to broadcast rapidly changing polices, actions, and successes of frontline worker stories.37
Innovations for support and fostering resilience
During the pandemic, nurse leaders contributed to many original solutions that limited the spread of disease and aided the pandemic response while supporting rapid changes across health systems in keeping with changing local and national policies, emerging data trends, scientific discoveries, and surge capacity requirements.
38
The resilience of staff to swiftly adapt to this new, uncertain landscape of nursing and patient care was essential and leadership needed to continue to work toward engaging nurses at the bedside to ensure best practices and resilient nurses.31
Leadership through a crisis is essential for the protective effect of nurses’ emotional well-being and learning from the pandemic about the impact of leadership in a crisis is important to facilitate recovery and lessen the impact in further outbreaks.39
Nurse leadership stepped up to create working environments that not only supports individual resilience but also organizational resilience. Nursing practice is conducted within an environment influenced and shaped by leaders, and recognizing the limits of individual resilience and a nurse’s capacity to manage chronic levels of physical, emotional, and moral distress is essential. Nursing leadership promoted strategies to enhance organizational resilience during and beyond the pandemic by creating an environment of trust and psychological safety, supporting nurse empowerment, and nurturing communication structures.40
To foster and preserve organizational resilience, leaders have to identify the challenges, ensure that workplace structures and processes are in place, and if they are not, they needed to advocate for them40
and consider employing different leadership styles to support nurse’s well-being.39
The emergence of visible nurse leadership
The COVID-19 pandemic thus brought with it many examples of complete disorder and confusion for individuals, communities, societies, and the world at large, and although nursing has risen to the challenge, suffered a great deal along the way, the pandemic has also provided great opportunities for the profession. COVID-19 has exposed the truth about nursing more than any organized campaign could have possibly done. It brought to light nursing’s indispensable role as the backbone of the health-care system and has highlighted their professionalism, not only as frontline care providers but also as health-care leaders and policy experts. It has provided an unprecedented opportunity for the general public to witness firsthand the vital role that nurses play.
20
The question for nursing now is whether to continue in our roles as implementers of policies that are handed to us or to use our size and influence for representation in places where decision-making that affects our practice, welfare, and profession are being discussed.20
Nursing leadership needs to be visible and must play an active role in multidisciplinary and interprofessional collaborative decision-making. Nurses have unique health-care expertise, and it is vital that they have a voice not only in high-level decision-making about the response and planning for the COVID-19 pandemic but also in future health crises.
4
Nurse leaders need to be adaptive and strategic while demonstrating concern regarding the well-being of the nursing workforce.41
Summary
COVID-19 is nothing like we ever could have anticipated, and it has irrevocably changed the world as we know it. This includes the nursing profession and has resulted in fundamental changes to the way in which nurses work. Nurses have been thrust into this challenging situation and have been called on to play a large and extremely important role in the management of this pandemic while still struggling for meaningful recognition as professionals on the frontline of the pandemic. It is also important that the leadership, the innovations, and resilience stories are shared and made visible through publication and professional recognition of the pivotal role of nurses in health. This is an opportunity to highlight to the world the value of nursing, the contribution of nursing, to increase the visibility of nursing and the phenomenal work that nurses do. So “let’s not waste a good disaster.”
Clinics care points
Disclosure
The authors have nothing to disclose.
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Article info
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Published online: December 08, 2022
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