A Tribute to Frontline Health Care Professionals During the COVID-19 Pandemic

COVID-19 has become a household name. The irony of a global pandemic during the year of the nurse and the midwife has not been lost on me. Awareness of the nursing profession has catapulted to global attention, an unexpected consequence of the pandemic. Cleanliness of the environment and good handwashing, first introduced by Florence Nightingale, have been on the forefront of everyone’s minds from health care professionals to the general public. Nursing, especially in acute and critical care settings, has garnered an overwhelming volume of free press during the pandemic, both from mainstream and social media. I hope we can capitalize on this momentum for nursing as a profession. Some of you may feel exhausted by this idea and others may be energized by the opportunities that lie ahead to enhance our profession.

As nurses, we often struggle to communicate to our friends, family, and the public what we do. During the pandemic, we have allowed reporters to shadow critical care nurses and other frontline health care professionals, observing what we do in real time. Emergency departments (EDs) and intensive care units (ICUs) have entered living rooms all over the world during the daily news. Portable devices permit many people to be only a click away from real-time updates on health care–related issues. The world has watched as nurses have struggled under the demands of the pandemic and provided lifesaving interventions; the world has seen and heard how much you care. People have heard your cries for help to ensure safe working conditions; many of you have been asked to do what no health care worker should be asked to do—work without adequate personal protective equipment (PPE). People also have watched many of you work extended hours without food or drink, unwilling to remove your N95 respirators and risk contamination, or be forced to reuse disposable masks because of the global PPE shortage. People have seen how you empathized with patients and their families who were separated during critical illness. The world has watched how you have coped with multiple deaths on 1 shift—more deaths than we could ever have imagined possible in the modern world. People also have watched how you have kept up your spirits, how you have persevered, and how you have returned to work each day, exhausted, scared, and ready to save more lives and provide supportive care.

To put this editorial into perspective, COVID-19 statistics at the time of writing are summarized below. Many of you have already experienced a surge of COVID-19 positive patients in your workplace and some may be waiting for a possible rebound—the calm before the anticipated storm. Global cases of COVID-19 have exceeded 3.6 million and continue to rise; global deaths have reached 251 586; US cases 1 209 587, and US deaths 69 468.¹  At this time, a high volume of health care workers have also tested positive for COVID-19. The more fortunate have been quarantined or experienced mild illness; the less fortunate have become critically ill, and hundreds have died.²  Please take a moment of silence to show respect and gratitude for these dedicated professionals.

Stress from this pandemic has been felt globally. We have heard many emotions expressed by health care providers, including fear, anger, frustration, exhaustion, sadness, guilt, pride, determination, and joy. Many of you have made personal sacrifices to isolate yourselves from your families and your loved ones to prevent virus transmission to or from them. Many, including my sister who is an ICU charge nurse, have envisioned their own mortality, making time to update loved ones about their end-of-life wishes and their will. It may be too early to fully understand the impact this pandemic has had on each of you and your families. Frontline health professionals have been juggling the same demands as all other families, such as partners working from home, the financial impact of changes in their partners’ employment status, children requiring full-time care and home schooling, coursework for academic degrees, the needs of sick family members, watching people in our community carry on as if nothing has changed, and uncertainty about life in general, yet frontline critical care professionals continued to do what they know best—show up to save lives.

During this crisis, nurses have redesigned models of care, such as how and where patients are triaged, use of support teams outside of isolation rooms, and education and integration of acute care nurses in the ICU setting and ventilator weaning units. You have been faced with situations you had never imagined before, such as ventilating 2 patients with acute lung failure using 1 ventilator.³  You have demonstrated your creativity and adaptability during periods of intense stress. Conservation efforts for PPE have led to creative storage solutions for N95 respirators. Underlying all this constant change has been uncertainty. Is it safe to reuse masks? Can masks be cleansed and reused? How many times can a mask be reused and remain effective? Can homemade masks worn over an N95 respirator extend the life of the N95 respirator? Will standard medical/surgical masks provide adequate protection during nonaerosolized procedures? Above all, can you keep your patients, yourself, your families, and your colleagues safe?

Another unexpected consequence of the pandemic has been the lack of patient- and family-centered care, one of our professional principles to provide holistic care. Out of necessity, hospitals have restricted visitation to reduce the spread of the virus. Numerous health care professionals and family members have expressed the sadness they experienced when patients were physically separated from their loved ones. Many health care workers have been brought to tears when yet another patient has died without his or her loved ones being present. Nurses, who are known for ingenuity, have used technology such as video calls to facilitate patient and family communication. As we move forward, how do we reconcile this gap in our ability to provide patient- and family-centered care during a pandemic while keeping the community and ourselves safe from virus transmission?

Many ethical questions have been raised during the pandemic, creating moral distress for frontline health professionals.⁴  Decision-making about which nurses should care for COVID-19 patients is more complex than usual. Should a nurse over the age of 60 or a nurse with comorbid health conditions be assigned to these patients? Should a nurse who has young children be assigned? Should a pregnant nurse be assigned? Are the lives of any nurses more or less important than the lives of other nurses? Are any team members more likely to breach isolation procedures and put the team at risk? If so, should that nurse not be assigned to a COVID-19 patient? Concerns about adequate PPE have led to nurses questioning their obligation to provide care for COVID-19 patients or even remain in their nursing role in this increasingly complex and potentially dangerous work environment.⁵  The American Nurses Association’s position statement on risk and responsibility states that nurses must assess personal risk on an individual basis and “accepting personal risk exceeding the limits of duty is not morally obligatory; it is a moral option.”^6(p3) The American Nurses Association’s bill of rights states that nurses have the right to work in a safe environment.⁷  Nurses must weigh any ethical and moral issues along with legal obligations posed by their state and institution.^8,9 

As resources have become scarcer during the pandemic, decisions around which patients should receive ICU care or which patients could share 1 ventilator may have become part of nurses’ reality. Triage of patients, typically limited to the ED, has extended to the ICU. Nurses had to engage their moral courage as they wrestled with issues that created conflict with their core values and ethical obligations.¹⁰ 

As we go to press, many countries have relaxed lock-down restrictions and are anxiously watching for a COVID-19 rebound. Data projections for the United States (assuming current social distancing until infections are controlled) indicated that by June 1, 2020, the United States would have fewer than 9000 COVID-19 patients in ICUs and fewer than 28 000 COVID-19 patients requiring hospitalization.¹¹  Globally, we should be past our most difficult months of the health-related portion of the pandemic, yet the effects from this crisis will be ongoing. Our health care system and frontline professionals have been challenged in ways we never imagined possible.

We are fortunate to work with so many dedicated health care professionals. I want to offer my heartfelt thank you to our frontline health care professionals in acute and critical care. Thank you for saving us, thank you for holding the hands of our loved ones who died without us by their sides, thank you for continuing to be there when we needed you, and thank you for caring!