RNs at the forefront
Nurses are being rightfully hailed for their steadfast commitment to patient care in the era of COVID-19. But the pandemic is far from the first time nurses have served on the front lines — and it won’t be the last. (Eventually look for nurses providing patient care in space.)
Here are just some of the health care frontiers where nurses have made their mark:
The coronavirus is contagious and dangerous, for sure — but the Ebola virus is far more lethal. In the 2014-2016 West Africa Ebola epidemic, the average death rate was 50% among those who contracted the virus.
As Ebola raged through the continent, a small number of patients came to three unique U.S. facilities to receive specialized care. The Nebraska Biocontainment Unit, at the Global Center for Health Security at University of Nebraska Medical Center, was among those select U.S. sites. Kathleen Boulter, nurse manager of the unit, was waiting on the airport tarmac as the flight transporting their first Ebola patient arrived.
In 2005, when the biocontainment unit opened, “It was new, it was exciting,” Boulter says. “At that time, the big fear was a bioterrorism event. It hadn’t been that long since the (2001) anthrax attacks in Washington and Florida. The idea of being prepared was something I wanted to be a part of.”
Ebola is spread by contact with blood or other body fluids of an infected person, or of someone who has recently died of the disease. Wearing adequate protective personal equipment is imperative.
“Keeping myself away from a single Ebola virus takes a lot more PPE,” Boulter says. “I want to wear PPE that is fluid-impermeable — I don’t want fluids to be able to carry it through the PPE back to my skin, where I may have micro-cuts. A little scratch on your arm might not seem dangerous to you, but if you’re around Ebola virus, it is.”
The Nebraska biocontainment unit holds 10 negative-pressure rooms, with air being pulled back from the outside hallway and nursing station back into the room, keeping lethal organisms from escaping. One thing for which Boulter is grateful: “I’m really thankful viruses don’t have wings and can’t fly.”
When taking care of Ebola patients, nurses’ speech was muffled by their masks, and they also contended with noisy powered air purifying respirators, or PAPRs, worn by staff to protect them from breathing in contaminated respiratory secretions. It’s difficult to hear or project your voice outward, Boulter says. “But we managed, met the challenge and worked through it.” Patients told nurses they recognized them by their eyes.
“It was great to be able to put all our training, everything that we had planned for, into action,” Boulter says. But it didn’t immediately occur to her that her team was giving groundbreaking care. Since then, they’ve provided training throughout the hospital and to multiple facilities on safe care for patients with emerging infectious diseases.
“Front line?” she says. “It wasn’t really until we got home that first night that we saw it was all over the news. That was definitely eye-opening: Wow, people are watching us. And it wasn’t just America, it was all over the world.”
Although the organization is called Doctors Without Borders, nurses are essential team members. Humanitarian instincts compel nurses to leave behind their families and comforts of home to take on missions in communities facing devastating infectious conditions.
Chagas, leishmaniasis and schistosomiasis are among the neglected tropical diseases that Doctors Without Borders teams treat in their humanitarian work across the globe.
And then there’s HIV/AIDS. “We were really on the front lines in the beginnings of the HIV epidemic and worked hard throughout the last three-and-a-half decades on it,” says Patricia Carrick, a family nurse practitioner and vice president of Doctors Without Borders/Medecins Sans Frontieres-USA. Early on, few people survived AIDS or the devastating side effects of medications then used to treat it.
Today, safe, effective medication means that HIV is a chronic condition, not a death sentence. Now the issue is access. “Especially in recent years, we’re working with new models of care,” Carrick says. “It’s trying to get care to people who are very remote, who have few options for communication, who have long distances to care centers. So we’re trying to shift care to communities and expert patients.”
Carrick, who currently practices in Dillon, Montana, has done a series of assignments for MSF overseas. Taking care of patients and residing in relatively rudimentary surroundings isn’t a problem, she says wryly: “Well, I’m a humanitarian and I’m also a camper.”
Of her dedication to helping others, “It’s not heroic — it’s daily life,” Carrick says. “The only way we can do our work with any success at all is because of our local colleagues. If you dumped me in the middle of Sierra Leone in the middle of an Ebola epidemic and I did not have colleagues from Sierra Leone who understand everything about what’s going on, who could help me interpret language and culture and the setting, and bring their own clinical skills to bear and understand the particularities of that community, you could have no impact whatsoever.”
The world will always need the humanitarian care these nurses provide. As Carrick says: “It’s one epidemic to the next.”
The military automatically comes to mind when it comes to frontline nurses. Military nurses serve with all major branches including the U.S. Army, Navy, Air Force and Coast Guard.
In the Revolutionary War, women served informally as nurses. Civil War nurses serving on battlefields and in hospitals include Clara Barton and Harriet Tubman. The rich history of military nurses also encompasses service in the Spanish-American War, World War I and World War II, the Korean War, Vietnam War and Gulf Wars.
“Nurses have served in just about any war,” says Col. Nan Park, a public health liaison officer at the Emergency Operations Center at Blanchfield Army Community Hospital in Fort Campbell, Kentucky. Park is a Desert Storm veteran with more than 30 years of nursing experience.
“We had WW II nurses in Corregidor in POW camps,” Park says. “We’ve had nurses assisting with some of the research and activities related to Ebola in past outbreaks. You’ll find military nurses — and Army nurses in particular — just about anywhere there is a fight. And it doesn’t have to be a military fight. They’re in the front lines of almost all medicine.”
Army nurses and medics are trained on how to give care “in just about any conditions,” Park says. Work conditions range “from the most equipped facility like you would see anywhere here in the United States to bare bones in a tent with whatever you carry in.”
These nurses care for any ill or injured patient who walks through the facility door — or tent flaps — for any medical or trauma-related reason, Park says. “Nurses are an integral part of the team that would be on the front lines.”
Military nurses face dangers of potentially being exposed to every infectious diseases in their environment, Park says. “And then, nurses in combat are exposed to any and all of what you would expect from combat.”
What does it take to thrive as a military nurse? “You’ve got to be willing to accept whatever circumstances you’re going to get thrown in,” Park says. “You’ll find that most nurses are there because they want to make a difference.”
It’s a mixed environment for transgender health care. Gender-affirming surgery and medical transition options are increasingly available and covered by insurance. Yet a number of states are pushing laws to ban gender-affirming care for trans kids. Groups like GLMA: Health Professionals Advancing LGBTQ Equality (previously known as the Gay & Lesbian Medical Association) are pushing back for all-inclusive, comprehensive care for every patient.
Health professionals can give all patients more effective, welcoming care by becoming more aware, says Jessica Landry, coordinator of the family nurse practitioner program and an assistant professor of clinical nursing at Louisiana State University Health Sciences Center School of Nursing in New Orleans.
To that end, Landry developed the Advocacy Program, a type of interactive training for health care providers to communicate with and provide culturally sensitive care to lesbian, gay, bisexual, transgender, questioning and intersex patients.
Before developing the program, Landry interviewed nurses, doctors, physician assistants and other involved in direct patient care, asking if they thought they could benefit from some sort of sensitivity training for LGBTQI patients. “Every last one of them said no, they treat everybody the same,” she says. “Really, what they’re trying to say is: I treat everybody with respect. I treat everybody with dignity.”
But that’s not enough, Landry tells hospital administrators when pitching her program. “If your staff knows nothing about somebody’s values, nothing about their lifestyle, they might think they’re being respectful — yet they’re not being perceived that way by the individual patients.” Her message is: “Step away from ‘I treat everybody the same’ and recognize where gaps in knowledge and gaps in care exist — and how do we close those gaps? Usually, bringing people together with education is great way to do that.”
Sexual assault survivor care
Before the advent of sexual assault nurse examiners, or SANEs, assault victims often faced a cold, clinical experience in the emergency room. Also known as forensic nurses, these specially trained RNs humanize health care for sexual and domestic assault survivors, while providing expert evidence collection and testimony to strengthen prosecution of perpetrators.
“A forensic nurse is that intersection between health care and the law, whenever there’s a patient with an interpersonal violence issue” says Sandra Sanchez, director of the Harris Health System forensic nursing program in Houston and a long-time forensic nurse. “We provide sensitive and compassionate care, recognizing that it’s not just the physical trauma but the emotional trauma.”
Through that trauma-informed care, “We’re able to mitigate some of the psychological effects,” Sanchez says. “And then we also take care of the medical-legal needs of the patient by doing thorough documentation of their history and their injuries, and if it’s necessary, we’ll also collect evidence.”
When Sanchez started ER nursing in 1995, there were few SANE nurses. For most sexual assault patients back then, the experience “was not a very good one,” she says. Survivors usually spent a long time in the common waiting room. Once they did get back into the exam room, “It was just very clinical — getting the tasks done but not really addressing the patient’s psychological needs.”
Evidence collection wasn’t ideal, either. With minimal training for ER staff, chain-of-custody issues and often less-than-thorough documentation, Sanchez says, “There was always a chance that evidence could be thrown out.” In 2002, Sanchez jumped at the opportunity to take a SANE training course.
Testifying in court was nerve-wracking at first. “Your heart’s beating out of your chest,” Sanchez says. But after testifying in more than 50 cases, she’s confident in her corroborating documentation and her ability to educate the jury about the examination process.
Research suggests SANE nurses may help patients get better results in court. And prosecutors surveyed responded that SANE programs contribute to superior documentation, thoroughness of the physical examination, and better identification of injuries, quality of relationships with patients, professionalism, skill in trial preparation and testifying and credibility with jurors.
The response to the SANE process from assault survivors is heartening. “You can see patients transform throughout the process of examination, from being anxious and not knowing what to expect,” Sanchez says. “We explain that we don’t have do the entire exam if they don’t want to, that they can stop the exam at any time, that they can do parts of the exams. So, from the beginning, once they realize they have choices and we’re giving the power back to them, they immediately start to relax and you can see a change in their demeanor.”
Initially, “the sexual assault victim automatically thinks that they’re not going to be believed,” Sanchez says. “And that’s the first and foremost thing we do — we start by believing.”
Nurses have always fought for civil rights, says Ernest Grant, president of the American Nurses Association. Now, he says, the difference is that many nurses proclaim their profession as they protest against social injustice.
“In the past, nurses have battled for it but mostly more as citizens — as a member of the community, not necessarily identifying themselves as being a member of a health care profession or a nurse,” Grant says. “But now they’re out there on the front lines, wearing scrubs. Last year, at about this time, at George Floyd’s death, people were actually out in scrubs and marching.”
Nurses are speaking out against violence and racism directed against Asian Americans and Pacific Islanders. They’re sending letters to the editor of major newspapers, and posting on Facebook, personal blogs and other social media, Grant notes. “They’re talking about not only their own stories — about how they’ve been affected or what may have been said to them — but also what they’ve been doing about it and calling on others to be social justice activists as well.”
In his own career, and as the first male nurse, and only the third Black nurse, to serve as ANA president, Grant has surmounted hurdles of his own. “Being an African American male, and also 6-foot-6, size-15 shoes, in a female-dominated profession, there are a lot of barriers you have to overcome,” he says. “Especially living in the South.”
Patient care iniquity is an important issue. “It’s about standing up when you see wrong being done against people of color,” Grant says, citing studies comparing the difference in urgency, medical workups and treatments applied when a Black man comes to the emergency room with heart attack symptoms versus the ER experience for a white man with identical symptoms.
Or it’s addressing instances of adequate pain medication being offered with more hesitation and resistance when a Black man is seeking relief, Grant says. “Sometimes, as nurses, we challenge physicians or challenge policy as to why is this person being treated differently?”
For nearly two decades, public surveys have consistently ranked nurses as the No. 1 most trusted professionals, Grant notes. “You don’t earn that trust for that amount of time without doing something right,” he says. “Our code of ethics requires us to treat everyone equally regardless of race, creed, sexual orientation or any other identifiers,” he says. “When we see injustice being done for one, we take it as injustice being done for all.”
Nurses — like other health care providers — have put their lives on line during the COVID-19 pandemic. To this day, nurses continue to provide diligent care in the face of onslaughts of infected patients, overflowing ERs and makeshift new hospital units, too often working while under-protected with inadequate PPE.
In myriad and diverse sites — nursing homes, intensive care units, transport helicopters, homeless shelters and more — nurses battling COVID-19 press forward with their ongoing role of serving on the front lines.
Nurses on every front line
Nurses have historically served — and continue to serve — on health care front lines including:
— LGBT health.
— Sexual assault survivor care.
— Social justice.
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