YEAR OF THE NURSE GAINS NEW MEANING

Interviews conducted by Lisa Dubois and Anahita Modaresi in May 2020 have been edited for space and clarity.

Year of Nurse gains new meaning during the pandemic

The World Health Organization (WHO) designated 2020 as the "Year of the Nurse & Midwife" well before the COVID-19 pandemic disrupted our lives. As days and weeks turned into months, the important role that nurses have in difficult health care crises like these become so pronounced and valued. But how fitting that the designation is today. No one would have predicted the same year Florence Nightingale would have celebrated her 200th birthday; we would also witness a health care crisis like none other in modern times. Nightingale's pioneering efforts more than 167 years ago led to health care reforms and models used today. She established standards for sanitation, identified the value of data to inform care, and decreased mortality associated with preventable diseases - all of which are foundational to limiting the spread of disease. All were important then and just as important today as we address the many health challenges of the COVID-19 pandemic. These unprecedented times have challenged many nurses, especially those serving on the front lines. Countless nurses have sacrificed their own mental and physical health, as well as time with their family, and sadly, some have lost their lives while putting others before themselves. Nurses understand there’s an element of danger to their job, especially when dealing with a virus that scientists are still trying to figure out. In the pages that follow, you will read about two nurses who served on the front lines in New York City in March and April 2020. Both are graduates of the college, but who are at different points in their nursing careers. Caroline Wright, a 2018 BSN graduate, is a critical care nurse in Charleston and felt the calling to take her skills to where they could be best used at the time. Catherine Durham is a 2012 DNP graduate with 21 years of nursing experience. She is the assistant dean of the DNP program and a captain in the U.S. Navy Reserves. Both nurses are heroes, as are the countless others who have and continue to rise to the occasion by serving and caring for others during times of adversity.

In their own words...

In April, Caroline Wright, BSN ‘18, an ICU nurse at MUSC Health, volunteered to serve in the COVID-19 unit of Long Island Jewish Medical Center, New Hyde Park, NY, the U.S. epicenter of the pandemic at the time. Wright describes the importance of teamwork and the need to improvise, given limited resources in health care crisis situations. Wright notes the important role she took on for ICU patients during this time – that of support as a surrogate family member, because loved ones could not be present during the final moments of life. Her view from the frontlines is heartbreaking and unfiltered. Yet, she feels valued and believes she has skills to do what others can't.

When you first walked into the Long Island Jewish Medical Center, were you prepared for what you saw?

You know, I wasn't prepared for the reality of the situation. I had this idea in my head but when I walked into that unit, I was in complete shock. At the time, at MUSC Health, we had two COVID positive patients in the entire hospital. When I arrived in New York, I walked into this big room with over 60 COVID positive patients. The beds were on top of one another and just a foot or two apart. Patients were on ventilators and all alone. No family members were present. Some patients were on 9 or 10 drips at a time. I was in shock. I will honestly never forget that moment. I knew it was going to be bad, but I had no idea. It was overwhelming, and to think that was just one unit. The rest of the hospital was converted into multiple other makeshift COVID ICUs. It took creativity, as they converted areas like the PACU and the cath lab into an ICU to meet the demand of so many who were so ill. It was so insane. I had no idea and honestly, if people saw what I witnessed every day while I was there, they would not be leaving their homes or worried about wearing a mask.

What was the difference between your ICU experience in Charleston and your experience in a COVID unit in NYC?

Everything I learned went out the window because it was a completely different situation. You had to adjust and be flexible. The management was different than how you would typically manage an ICU patient. I couldn’t get caught up on things which we typically focused on, such as charting. Of course, we charted the important vitals, but the hospital management knew our priority was the patient. Also, there were a lot of new medications and I was not used to administering them. Since I was a new employee, I was constantly asking people questions about how things are done. I'd ask, "What's the protocol for this and that?" The response usually sounded like, “Well, it used to be this, but now just do your best.” Many hospital policies had to be modified or changed just to allow us more time at the bedside with the patient.

How was the management of the patient is different?

Since I was in a COVID unit, all the patients had respiratory issues, so the way we managed them was different. For example, we would lay patients on their stomach to help improve oxygenation. These patients also required a lot more sedation than typical ICU patients. Normally, we would have a patient on one or two sedation meds. These COVID

patients were on four or five, making it difficult to get them off of the drips. Weaning them off the vents was extremely hard.

What do you think would be helpful in terms of training nurses?

Teaching flexibility. In New York, we didn't have all the resources and supplies that were needed or that I was accustomed to using. I learned to make do with what I had and repurpose things. I learned how to stretch things beyond its typical usage and to use my best judgment and assess the situation. Physicians stressed that, too. Physicians really valued our opinions because they knew that we spent the most time with the patients. They encouraged us to speak up when we saw something unusual or if any major changes were needed for our patients. The role of the nurse was different. I felt the physicians really valued us.

Did you have any moments when you thought this is why I do this?

I was starting to question all this. These patients were the sickest of the sick and unfortunately the success rate with taking patients off a ventilator and extubating them was not very high. Many ended up being re-intubated, so we didn't get to see a lot of the positive side for those we cared for. Patients don't get discharged from the ICU. Before that happens, the patient goes to a step-down unit, consequently the ICU nurses do not see a lot of positive outcomes. However, I had a mother who had just given birth. She was COVID positive and intubated, so I was prepared for things to end tragically. Two weeks later, we took the tube out and the mom survived. It was phenomenal. Later, she was able to FaceTime with her baby. I can't imagine what she went through - to give birth and be away from her baby. It was pretty amazing. We tried to keep these moments fresh in our memories to help us push through and visualize the happy endings.

Was your nursing training helpful? What could have helped you prepare for this?

I don’t know how you can really prepare for something like this during a pandemic, but one thing that stood out for me was the teamwork. Maybe that could be strengthened back home? I'm usually someone who tries to do everything myself, but in these types of situations you really have to use the resources you’ve been given, and support from others. For example, as I was gowned up and in an isolation room, I couldn't go in and out, so I had to reach out for help. I made signs of what was needed that could be read through the window by another nurse who was charting outside the ICU. Nurses from other areas in the hospital served as resource nurses. It worked great because trained nurses could innovate. They would draw all of our labs, turn our patients and do many of direct nursing care functions to support us. It was a huge relief to have that assistance and support. They were all very well qualified and trained and were so amazing about jumping in and knowing what needed to be done and doing it. Another thing we did was prone patients (turn face down). They used PACU nurses to create a proning team so when the physician wanted a patient proned you would call and a group of five PACU nurses would arrive. Just having those type of resources to eliminate some of the stress was huge. The things we learned in textbooks can only take you so far in these difficult events. I had to apply the basic principles we learned in order to problem solve and figure out a different solution. It wasn’t only what I learned in nursing school that had to be adjusted, but even things I learned as an ICU nurse, I had to do differently. But what remained constant was reaching back to the basics of what I learned in school like the principles of ABC airway breathing circulation. The basics don’t change. This is what we train for. This is that moment. It's a once-in-a-lifetime thing. Everything we read about in the textbook combined with basic skills we are able to adapt and put to good use.

“ I am used to times in the ICU before COVID where loved ones gather and share a beautiful, bittersweet moment. Here death is cold, lonely and tragic so I held their hands and told them they are loved."

Under military orders, Cathy Durham, DNP '12, APRN, FNP-C, arrived in New York on March 6 to meet her team of 121 nurses from around the United States who were deployed to New York City, the coronavirus U.S. epicenter at that time. Three days prior, Durham was tagged to provide a leadership role on a mission to bring help and hope to thousands of New Yorkers. Durham is a Captain in the U.S. Navy Reserves and a senior nurse executive for Operational Health Support Unit Jacksonville that encompasses 133 reserve nurses from South Carolina, Georgia, Florida, and Puerto Rico. She joined the team in NYC to provide senior nurse leadership for a group of nurses mobilized from all over the United States. Military leadership felt medical assistance was critically needed in 11 hospitals across the city swamped with COVID positive patients. Durham and her team answered their call to duty.

What was your reaction when you first arrived in New York and realized the severity of the situation?

Before I was deployed, I remember thinking 40,000 ventilators was an overreaction because we live in the United States. How could this be necessary? We were all a little wary because we didn't know what the situation was going to look like. Sure, we saw images on television, but was it really out of control? The first hospital we went to was Bellevue, the oldest hospital in the U.S. It was full of incredibly sick patients. They had expanded their ICU services, but they weren't bursting at the seams. It wasn't hemorrhaging. They were busy, and they just needed a few more nurses. The second site we went to was Elmhurst Hospital. I was with two physicians and another nurse to perform a needs assessment. From our first encounter with the hospital's nursing supervisor, we knew things were different there. In my 25-year career, I've never seen that many patients in an emergency department and they were all COVID positive. The gurneys were three deep against the walls and into the hallways. As a nurse, I'm used to providing comfort for sick patients, yet I found it challenging to convey empathy with only my eyes because the N95 mask covered half my face. I could see the look of fear in their eyes. Their panic-stricken eyes were so hard to see. My physician colleague said that the patients' faces reminded him of photos of prisoners in concentration camps during World War II. The faces in that emergency department will never leave my mind and my heart. When the four of us walked out of the hospital, we didn't speak. We were still digesting what we saw. When we returned to the command center, we had a decision to make about which providers to send to these hospitals. There's a risk of sending our team members into a COVID hospital, but we were really honest with them and managed their expectations. Our nurses and physicians handled this situation with such grace. A month later, Elmhurst was no longer hemorrhaging and almost back to baseline in regard to their numbers. Elmhurst has an incredible staff. They smiled when they met us and engaged in conversation. Even though they had to compartmentalize their stress, they were very thoughtful in our discussions. All of the hospitals I worked in had an incredibly resilient group of people. Some of the Elmurst staff got emotional when we first walked inside in uniform. A few days later, when we went back to check-in, the CEO pulled us aside to tell us he had received lots of emails from staff. He said the thing that resonated most for him was the messages like, "when we saw the people in uniform coming in, it was the first day that we felt safe." That was pretty humbling.

What was your role while in NYC?

For the first five days, along with my physician counterpart, I was to call hospitals and create a needs assessment. From the Department of Health and Human Services (HHS), we knew which hospitals had the highest volume of ventilated patients and the greatest need. We told the chief nursing officers and chief medical officers that we were ready to embed a team into their hospital system if they needed us. We performed needs assessments at five hospitals within 48 hours. One thing we looked for was adequate staffing. For example, one site did not want any med-surg nurses because they had too many. But they were in dire need of ICU nurses and critical care nurses because their ventilated patients had grown by 400% in two days. We were able to get them the type of nurses they needed from our pool. Another site had the right mix of nursing

personnel and was open to taking more med-surg nurses. We also implemented a team nursing model where we paired an ICU nurse with an OR nurse. The pair could take three patients instead of just two. The OR nurse also operated as a "runner" to get supplies for the ICU nurse. At each site, we tried to match and leverage our assets as best we could. We managed expectations and understood what each hospital needed. We continued with site visits and checked back at sites where we embedded our people to see how they were doing. By the end of April, we had 217 nurses and physicians embedded in seven sites. As a senior nurse executive, when I wasn't doing administrative duties at the command center in a hotel, I rotated to a different clinical site every two days. I worked the bedside in ICUs with one of the nurses on my team. I haven't been an ICU nurse in 21 years, so many things changed, but I was there to serve the ICU nurse. If they needed something, I was going to get it. At the bedside, there's an opportunity to mentor and counsel. Very few ICU patients in the hardest hit hospitals are being discharged so some days were notably hard, and it was important to me to offer support to those nurses.

What made this situation more difficult than other highpressured situations you've encountered?

The racial and economic health disparities in this country were evident in the patient population that I saw in New York. Many of the patients needed to work to provide for their families, which prevented them from coming into the hospital until they were really sick. Also, many of the patients didn't have primary care providers that were managing their symptoms early on. Another hard thing had to do with the patient's family since they were not able to come inside the hospital. Families were not able to see how rapidly their loved one was declining. This made it very tough to have conversations with family members about end-oflife care. Family members were and still are having to make tough decisions about life-saving measures very quickly. We used tablets to help engage family members via FaceTime so that they could see their loved ones, work with the health care team to make decisions on their health, and at times be with them in their last moments, but it was hard for both the families and the staff. We had some psychiatric mental health providers on our team to help both patient families, patients and staff and augment the native hospital resources.

As a nurse educator and someone who was on the frontlines, what do you think is a critical need in nursing education?

From an educational standpoint, a critical need is to incorporate more public health into our education. Take a look at how nurses engage in public health aspects and how we can manage that. During this emergency, both physician and nurse were asked to work on teams outside their comfort zone. It was important to

Dr. Cathy Durham (left) with College of Nursing alumna, Sadie Treleven, BSN, R.N., at Harlem Hospital in May 2020.

create systems to support that work such as team nursing and to support people working outside their specialty. One team member stated, “we have two jobs here; be kind and be flexible” and that phase was repeated many times. If all health care professionals, nurses, in particular, could go back to our foundational roots and think about how you assess a patient. What are the basic principles of pathophysiology? Then we can come from a place of being flexible and kind to each other and work as a team to address the patient's needs and put aside what we think is our assigned role. We're all health care providers on the same side. I think we need to frame our education around that understanding. I know there were some legal questions around this line of thinking. Am I going to be sued if I have to be a med-surg nurse because I'm really an OR nurse? Am I going to be sued for working outside of my scope of practice? I'm one nurse to 15 patients. It's supposed to be one to eight, so I'm not going to be able to do all these things that I was told to do. We have to educate students on what it means to respond in an emergency and the ethical requirements. The American Nursing Association and the American Medical Association have statements on the ethical responsibilities in an emergency and a pandemic. So, we need to emphasize these ethical responsibilities in our education. Being a nurse in a pandemic begins with understanding the public health aspect, but also knowing how to be a team player. We may not need a labor and delivery nurse during a viral pandemic, but you're still trained as a nurse, so let's leverage your skills and educational preparation and maximize them in this pandemic setting. This was an incredible experience, and I was really proud to be there. I'm proud to be in nursing. I'm humbled by being part of a profession that is adaptable and is incredibly resilient. I will forever be grateful to have witnessed the many nurses I worked with who possess these attributes. I think if you don't look at this as glass-halffull and take the wins from it, you lose out.