From fear to fortitude: Using the power within the nursing profession to fight COVID-19

Abstract

Communicating is essential. The communication chain within units and facilities must be kept strong. Good communication will help staff take responsibility for one another; knowing your work family is looking out for you can offer strength. Respecting each other encourages speaking up to create a platform for shared decision-making and problem-solving. Such shared responsibility will yield the best solutions because the whole is stronger together than individuals alone. Speaking up also is a way to offer immediate feedback if mistakes are observed so that errors are corrected. And when, not if, mistakes are made, staff need to be able to communicate these without fear of retribution.

Fear is defined as “an unpleasant often strong emotion caused by anticipation or awareness of danger.” (Merriam-Webster Dictionary) Synonyms for fear include dread, fright, and alarm (Merriam-Webster Dictionary). Fortitude, by contrast, is defined as “strength of mind that enables a person to encounter danger or bear pain or adversity with courage.” (Merriam-Webster Dictionary) Synonyms for fortitude include grit, intestinal fortitude, and spunk (Merriam-Webster Dictionary).

As the coronavirus disease, COVID-19, caused by the virus, SARS-CoV-2, spreads across the globe, fear spreads with it—fear for self, family, patients, co-workers; fear for our profession, country, world. That is not entirely unlike the fear that spread when the Serious Communicable Diseases Unit (SCDU) at Emory University Hospital (EUH) was activated in 2014 to care for people with Ebola Virus Disease (EVD; Jennings, Yeager, Feistritzer, Gullatte, & Martyn, 2018).

We acknowledge there are notable differences in the two situations. The EVD experience at EUH involved (a) a single unit designed to care for people with communicable diseases, (b) a small staff who were prepared by a biosafety trainer, (c) an abundance of resources, and (d) few patients. By contrast, the COVID-19 experience involves many hospitals across the nation as well as nontraditional settings—including military field hospitals, Navy hospital ships, and convention centers—that have been added to expand bed capacity. It involves a huge number of staff who are on the frontlines possibly without the benefit of a dedicated biosafety trainer. And there is no question but that resources—from personal protective equipment and ventilators to sufficient staff —are in short supply as the number of patients swells.

Still, COVID-19 affords the opportunity to optimize our circumstances and “bring out the ‘best’ in us all and not the ‘worst’” (Hayter, 2015, p. 9). The best in nursing is experienced during difficult times as exemplified by military and civilian nurses who respond to disasters such as Hurricane Katrina. The best in nursing was experienced in the SCDU where nurses viewed it as a once-in-a-lifetime experience that was life changing. And the best of nursing will shine as nurses and other health care workers grapple with these unprecedented circumstances in the United States that are more sweeping in scope than a hurricane or EVD.

As nurses working in an academic setting, we ache for our frontline colleagues as we watch from the sidelines. Our ability to provide support (or personal protective equipment) is limited, but we can share what we believe are important ways frontline workers can operationalize existing best practices to deal with the uncertainty that coincides with fear. Fear can be a source of motivation. These motivating ideas originated in the work of the SCDU at EHC. As the staff “feared for our lives,” (Jennings et al., 2018, p.1169), they enacted the principles of high reliability (Weick & Sutcliffe, 2007). These ideas have relevance for health care groups facing other dangerous situations (Jennings et al., 2018)—and COVID-19 qualifies as one of these. The five principles, paraphrased in the following, served as effective interventions to eliminate failures and breakdowns in the SCDU (Jennings et al., 2018). Yes, the supply chain is broken. Yet these are principles we can apply to keep one another safe.

Communicating is essential. The communication chain within units and facilities must be kept strong. Good communication will help staff take responsibility for one another; knowing your work family is looking out for you can offer strength. Respecting each other encourages speaking up to create a platform for shared decision-making and problem-solving. Such shared responsibility will yield the best solutions because the whole is stronger together than individuals alone. Speaking up also is a way to offer immediate feedback if mistakes are observed so that errors are corrected. And when, not if, mistakes are made, staff need to be able to communicate these without fear of retribution. The mistake is likely pointing to processes or procedures that need improvement.

Collaborating is essential. Working in a dangerous situation is enhanced when people work together. We know from the classic study by (Knaus, Draper, Wagner,and Zimmerman 1986) that desired critical care outcomes were more the product of nurse/physician relationships than treatment regimens. Here too, respecting one another will support leveraging the knowledge and expertise of all frontline staff to optimize everyone's unique skill sets and achieve the best outcomes possible. The power hierarchy common in health care must give way to an egalitarian structure where everyone's skills are respected—everyone meaning housekeeping, respiratory therapy, patient care technicians, everyone. A physician who has never managed a patient on a ventilator must have the wisdom to rely on the experienced critical care nurse. And the experienced critical care nurse must be willing to coach and guide those nurses pulled into the fray of critical care when they usually practice elsewhere.

Listening to frontline workers is essential. These individuals have firsthand knowledge of the issues and what is happening with patient care. When fear is spreading in the environment, leaders are especially challenged to listen and make changes as information becomes available. Rigidity must be set aside and flexibility must be embraced. Rapid adjustments are not about making snap judgments, but rather relying on calm and wise responses to determine which processes are not working, realizing the chain reactions that result from changes.

Recovering from failures quickly is essential. Resilience is about bending and not breaking. In this time of great demand, we must not perseverate over failures. That is sometimes the way in health care because of our penchant for perfection. Good enough is not typically acceptable. Now we must realize that perfection must give way to accepting we did our very best in trying times.

The fifth principle, attending to signals of developing problems, has passed us by. We oversimplified the nature of COVID-19 and the resources that might be required. We can, however, remain more attentive to future signals.

High reliability principles will not fix the broken supply chain, they will not be an antidote for the people who die alone, they will not expand staffing with the right numbers of health care workers with the right skills. They will, however, help us use resources we do have at hand to face the fear and danger with fortitude, bringing out the very best in nursing. Nurses of the United States will stand by their patients, their coworkers, and one another. Writer and artist Mary Anne Radmacher wrote, “Courage doesn't always roar. Sometimes courage Is the quiet voice at the end of the day, saying, ‘I will try again tomorrow.’” Nurses’ fortitude and courage will bring out the best in everyone.