In light of Florence Nightingale’s recent 200th birthday, it’s hard not to wonder—how would our founder of modern nursing be responding to the Coronavirus pandemic? Known as the “Lady With The Lamp,” Nightingale was noted for wandering the wards of the hospital at night carrying a lamp, providing support to soldiers during the Crimean War. Advocating for basic standards of care, Nightingale believed in the importance of good hygiene and adequate nutrition but also helped improve the emotional health of soldiers by writing letters home for them. It’s easy to imagine her at the bedsides of dying COVID-19 patients, charged with the painful work of helping family members say goodbye to their loved ones over FaceTime. A natural problem-solver, we can venture to guess that Nightingale would be a leader in transforming today’s trends in how to manage the well-being of American citizens and guiding our decisions on economic closures. Nightingale faced many odds during her lifetime, but ultimately became known as a social reformer, statistician, and founder of what we know of as modern nursing today.
“God spoke to me and called me to His service. What form this service was to take, the voice did not say.”
Nightingale’s parents initially disproved of her decision to become a nurse, expecting her to marry and raise a family at a young age. In fact, she had many marriage proposals but refused them all. Nightingale had other plans and, as a teenager, believed she received a calling from God to help the poor and the sick. Nursing was not a respected profession during her time and when Nightingale arrived at the British camp during the Crimean War, doctors did not initially welcome her. However, under her leadership, Nightingale’s group of nurses transformed the conditions of the hospital and brought the death rate down from 40 to 2 percent. Like many nurses today who are rapidly becoming infected with COVID-19 from working conditions, Nightingale fell ill shortly after arriving to Crimea with brucellosis, otherwise known as “Crimean fever.” With no active treatment for the disease, Nightingale suffered its persisting effects for almost 25 years, which frequently confined her to bed due to chronic pain.
After returning home from the war, Nightingale knew there needed to be health reform for the British Army. Having kept meticulous notes on the causes of illness and death during her time at Barrack Hospital, a commission was established based on Nightingale’s statistical findings to reform military medical systems. Nightingale had a knack for analyzing data and with the help of Dr. William Farr developed the first pie charts, calling them coxcombes. These charts helped illustrate her statistical findings in an accessible way and in 1860, Nightingale became the first woman elected Fellow to the Statistical Society. As a token of gratitude for her war efforts, a fund was set up that Nightingale used to institute the Nightingale Training School in London, which opened in 1860. The school offered a formal nursing education and made nursing a respectable option for women who desired work outside of the home. Although ill and bedridden for much of her later life, Nightingale wrote almost 200 books, pamphlets, and reports over the course of her career on hospital, sanitation, and statistics and provided advice on health care issues to colleagues across the globe.
“I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results.”
Florence Nightingale was a pioneer of nursing, leadership, and education and someone who certainly would not sit around and wait for things to blow over without taking action herself. In today’s times, one can easily imagine her as anyone from the charge nurse of an intensive care unit to an ANA president consulting with the White House team. One thing we know for certain is Nightingale would first and foremost be a patient advocate. She would not stand for a shortage of ventilators or medication for patients. If we learn nothing else from Florence Nightingale, we must remember that it is not enough just to care for our patients. We must be their voice when they cannot be heard and use actions to bring results.
Florence Nightingale, Nursing, and Health Care Today
This in-depth analysis of Nightingale's legacy goes beyond established scholarship to examine her lesser known–and arguably even more important–writings beyond Notes on Nursing. It introduces readers to the "real" Florence Nightingale who pioneered evidence-based health care, campaigned for hospital safety, promoted economic opportunities for women, and mentored two generations of nursing leaders.
While so many businesses are shut down and people are staying at home, there’s one thing that will keep happening no matter what—women are still having babies and need access to safe maternity care during the COVID-19 pandemic.
In this dangerous and uncertain time, we wanted to know what’s going on in labor and delivery (L&D)—at least from one nurse’s perspective.
Morgan Michalowski, CNM, WHNP-BC, IBCLC, RN, who works at a large urban, educational and research medical facility in Chicago, Illinois took time to answer our questions regarding the state of L&D.
What are hospitals currently doing (or should do) to keep their maternity/L&D patients safe right now?
Hospital-wide we have a visitor restriction in place, but in L&D we allow one support person to be with the mother. We are universally testing anyone admitted to the hospital for COVID and, in L&D specifically, utilize rapid point-of-care testing. It takes just a few minutes to determine if she is COVID positive.
Hospital workers in L&D wear N95s with a surgical mask over it when in contact with any patient, even if they are not COVID positive.
How are things different in the midst of COVID-19? Is someone still allowed to bewith the mother during labor/delivery?
The first two months, March and April, were a whirlwind. From creating new policies to providing high-quality care to figuring out how to promote bonding when NICU restrictions limit parental access, it was a steep learning curve for all.
We do allow one support person with a mother during labor, delivery, and postpartum. That visitor has to stay at the hospital with the mother through discharge. This seems to be working fine for the moment. We have had patients express interest in leaving the hospital as soon as possible, so they can be home with the rest of their family. Our team has been accommodating those requests. One of the biggest hurdles was figuring out how to support mothers if they’re separated from their baby due to a NICU admission. Most NICUs don’t allow any visitors, which is really tough on a lot of families. We coordinate video calls and check-ins so they feel connected to their baby, but it’s not the same.
What changes have occurred during COVID-19 that you think should be permanent either for the near future or forever?
One strategy in responding to COVID has been to expand the scope of practice for Nurse Practitioners and Midwives, which is having a positive and meaningful impact on care. I hope more states allow for this and continue this practice post-COVID.
Universal testing for COVID will become standard of care, in the same way that TB tests are required prior to starting school or a new job.
What’s happening with the newborns to keep them safe?
Healthy term newborns born to mothers without COVID room in with their mother until discharge. If mom and baby are low-risk, we try and discharge them within 24 hours. During that time, mom and her support person are required to wear masks.
If a mom is COVID positive, her baby goes to NICU until discharge.
Is everyone involved—mother, guest, child—getting tested?
We are currently only testing the mother, no one else. If mom is COVID positive, the NICU handles the care and testing of the baby.
Have the guidelines changed for when Mom and child are released?
No. While we try and discharge clients as quickly as possible, making sure they’re safe with adequate follow-up care is of the utmost importance. If a mom and baby are low-risk with a vaginal delivery, we discharge around 24 hours. If she’s low-risk, but had a c-section, discharge is around 72 hours.
Regarding post-natal care: are moms/newborns getting home nurse visits if
necessary? Is any other treatment happening or have some things moved to
Most postpartum visits can be handled through telehealth. We do see them in person for the six-week postpartum visit. We do not send anyone to the house.
Is there any other information that is important for our readers to know?
I think it’s important for readers to know that hospital workers are doing their very best to keep you, your loved ones, and themselves safe. Some of the restrictions—and the implication those restrictions have on the laboring mother—might not make sense or feel supportive. Every woman deserves to give birth with support and care in a safe environment. We are doing our best to make sure she gets all three.
What are the key methods that nurses and doctors use to prevent burnout? This question was at the heart of a recent study published in Critical Care Nurse, the clinical practice journal of the American Association of Critical-Care Nurses, “Self-care Strategies to Combat Burnout Among Pediatric Critical Care Nurses and Physicians.” This face to face study, conducted among a group of 20 nurses and physicians in pediatric intensive care and intermediate care units, explores six different strategies to help mitigate burnout
One: Maintain Awareness of the Meaning of Your Work
Calling to mind the higher purposes and meaning of the work you do
can be a very effective weapon for fighting burnout. Comments from
nurses in the study included:
“Caring, for me, is the heart. Doing things out of our heart adds meanings and values to what we do.”
“I love being a nurse because I have the privilege to come in and care for someone’s child, mother, brother, or sister and touch people’s lives.”
“Taking care of others makes me feel that I am doing something meaningful. I am involving myself in something for the greater good.”
The authors of the study say, “Finding ways to remember one’s sense of purpose might help refresh or renew one’s commitment to caring and overcome exhaustion.”
Two: Connect With Sources of Support
The risk of burnout can be assuaged by emotional and moral support. Such support can come not only from family and spirituality but also from maintaining your awareness of the progress patients are making. Among the responses from study participants were remarks such as:
“It motivates me at work that I am able to help patients and families feel better.”
“I want to feel that I did the best that I could for patients and families at work. When I do, I feel happy and energized.”
“My family is my buffer and energy source.”
“I feel that I work for a higher being. My spiritual belief and value give me energy.”
However, the authors sound a note of caution about becoming overly dependent on patients’ progress as a source of support, calling this “a vulnerable side. If health care professionals tie their happiness to patients’ positive progression, they could be at high risk for burnout.”
Three: Foster Trustful, Fulfilling Work Relationships
Forming and sustaining positive relationships with co-workers and
leadership can provide you with a lasting and valuable source of
support against burnout. Responses on this subject included:
“I love the people I work with. We help one another. My coworkers make work fun.”
“Nurse managers’ willingness to reach out makes a difference on a unit. Their availability on the unit created the bonding between nurses and nurse leaders.”
“Senior physicians’ support is very important.”
Such remarks made it clear that participants keenly felt the beneficial effects of working with a trusted, supportive, and caring team headed by good leaders.
Four: Train Yourself to Take a Positive Approach
Nurses and doctors stressed the role of positivity in avoiding
emotional and physical burnout. A number noted that dwelling upon
events such as patient deaths or seeking out their own shortcomings
tended to drain their energy and exacerbate stress and anxiety.
Taking a more optimistic approach, they found, often went a long way
toward relieving such symptoms:
“I started to focus on the bright side of my work. Doing so helped me relieve my stress and boost my energy.”
“While some days were demanding and emotionally distressing, I found a way to position myself to face the challenges by seeing the good in the overall picture. I keep a gratitude journal to count my blessings.”
“Recognizing my contributions to the lives of others and having a positive attitude help me face the high demand of my job.”
Five: Practice Emotional Hygiene
For most of those participating in the study, practicing emotional
hygiene strengthened their protective shield against burnout.
Emotional hygiene includes a variety of measures such as keeping a
proper work/life balance, relaxing in the company of family and
friends, attention to prayer or spirituality, and getting sufficient
sleep and exercise. Nurses in the study mentioned the aspects of
emotional hygiene they found most useful, including:
“To set boundaries and maintain a work-life balance.”
“I make sure that I have a good rest after work.”
“Practicing mindfulness helps me reduce stress.”
Six: Recognize and Appreciate Your Own Uniqueness
The sixth tool in the anti-burnout toolkit, say the authors, is “the
recognition of one’s unique self,” which facilitates finding
one’s “inner strength and power during difficult times.” Among
the responses on this topic were the following comments:
“Each of us is a unique contributor.”
“Even though I am a new nurse, my coworkers make me feel that I am an important member of the team, which helped me build confidence in myself.”
“Health care is like a team sport in which each one of us has a unique position [to play].”
own unique contributions, along with those of each member of the
team, the authors suggest, helps to “create a nurturing environment
that fostered individuals’ growth and ability to provide
high-quality patient care. Thus, strengths-based self-care could be
an effective strategy for collaborating in a team environment and
fighting symptoms of burnout.”
All of these
measures help practitioners keep pace with the intense demands that
confront clinicians in their work. In assessing their findings, the
authors conclude that “without adequate self-care strategies,
health care professionals are at risk for secondary trauma, burnout,
and compassion fatigue. Having a loving and caring heart and being
compassionate toward oneself is key to being able to care effectively
Nursing is a stressful profession even during normal times, but nursing during a pandemic takes an exponential toll on your mental health (and as stress weakens immune response, this exacerbates the threats to your physical safety). Even before the tragic suicide of New York ED doctor Lorna Breen, experts had been sounding the alarm about the psychological impact of working on the COVID-19 front lines.
You’re probably aware of the study published in the Journal of the American Medical Association (JAMA) that focused on the mental health of front line healthcare workers in Wuhan. The key finding was that clinicians —particularly nurses—who worked during the crisis suffered from unusual levels of depression, anxiety, insomnia, and distress. And in the US, as psychiatrist Jessica Gold observed in StatNews, “Underneath it, many health care workers are barely keeping it together. They are anxious and they are afraid. They aren’t sleeping and they find themselves crying more than usual…”
It is understandable that in the current situation you may be struggling with fears for your patients, for your loved ones, and for yourself. Such fears can be fueled by overwork (or underwork and financial worries, for many nurses), inadequate PPE, lockdowns making it impossible to go out and blow off steam with friends, isolation, and a host of other stressors. At such a time it is more important than ever to take care of yourself. As the AMA recently stated, “Attending to your mental health and psychosocial well-being while caring for patients is as important as managing your physical health.” But what can you do to protect your mind as well as your body?
A good first step is to firmly resolve to take action to protect and maintain your mental health on a daily basis. To support your efforts, here are some tools that may help you keep your head straight during a crazy time:
During this unprecedented time when COVID-19 is affecting everyone in some way, one of the biggest worries that health care workers and lay people are focusing on is how medical centers and hospitals are keeping patients and their workers safe.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, is Chief Nurse of Health Learning, Research and Practice, Wolters Kluwer. In addition, Dabrow Woods is also a critical care nurse practitioner at a large health system in the Philadelphia area, and Adjunct Faculty for Nursing and Health Professions a private research university with its main campus in Philadelphia, PA. She took time to answer our questions about what hospitals and medical centers are doing to keep patients and health care workers safe.
What are hospitals currently doing (or should do) to keep patients and their workers safe right now?
To ensure the safety of all clinical staff and patients, many hospitals have restricted visitors entirely to prevent COVID-19 from unknowingly entering the building. This measure is also helping sustain the availability of personal protective equipment (PPE) for hospital staff, which otherwise would need to be shared with patient visitors, amid a national shortage.
Hospitals have also established screening measures for staff entering the building for their shifts. As soon as they walk-in, employees have their temperature taken and are encouraged to disclose if they are or have been experiencing any symptoms related to COVID-19—such as dry cough and fever.
Upon entry into the hospital, all staff members must then don a mask and wear it while they are in the building. When with patients, staff must properly use personal protective equipment (PPE) based on the patient’s infection control precautions. In addition, hospitals have established hotlines for staff to call if they think they have been exposed. The hotline, which is typically monitored by an infectious disease specialist, assesses whether the health care professional is at a low, medium, or high risk and determines the appropriate response measures for the hospital and for the individual employee.
How bad is the current situation right now in health care facilities?
The current situation is very serious, especially in areas with large outbreaks. New York, Massachusetts, California, and Louisiana are just a few examples of states that are reporting widespread transmission to the CDC. These areas are critical zones that are experiencing a shortage of PPE and other equipment such as ventilators, with facilities reaching capacity while trying to accommodate a growing surge in infected patients.
To address this situation, some facilities have set up triage tents outside of the property’s main entrance for screening, as well as have begun utilizing a single ventilator, in some under-supplied areas, to ventilate two patients of similar size and lung capacity. Hospitals have also begun implementing alternative staffing models, such as fast-tracking training for staff that are outside of critical care expertise, but can provide a helping hand—including many fourth-year medical students, nurses from other areas, and recently retired nurses and physicians (who have also been asked to rejoin the workforce).
It is important to note that the impact of COVID-19 and the required safety measures have also created a unique and unfortunate situation where many patients are made to die without their loved ones by their side. As health care professionals, we do our best to provide comfort, holding the hand of our patients, and making sure they are not alone at the end.
What are nurses doing to keep everyone safe? How are they coping?
To keep everyone safe, nurses are following strict safety protocols and working as a team, now more than ever. Collectively, the mentality is “Let’s do this.” We’re at war with this virus, and to effectively fight it requires putting aside emotions and working together to focus on our patients and what we can do for each patient in the moment.
To cope, we have the support of our fellow nurses and other care team members, as well as the option of utilizing employee assistance programs and social workers, who offer a great resource and comfort in times of struggle. We have also found tremendous support within our communities. Hospital staff has been so busy, and some haven’t even had the time to pack a meal or make it down to the cafeteria to eat, so when community members drop off food at the hospital entrance, it is an amazing act of generosity and one that is deeply appreciated.
What are some steps that are recommended to keep everyone safe?
The CDC issued a Comprehensive Hospital Preparedness Checklist to help hospitals assess and improve their preparedness for responding to COVID-19, but an essential step to keeping everyone safe is encouraging non-health care workers to just stay home. The best way to prevent illness and reduce the transmission of COVID-19 is to not leave your home, except to buy food and/or receive medical care.
What resources are out there that nurses can utilize in their health care facilities?
Nurses need to have the latest evidence-based clinical decision support content at their fingertips, so they are taking the proper precautions in caring for COVID-19 patients. The CDC and WHO are consistently updating contact precautions as well as droplet and airborne precautions, and hospitals should ensure that point-of-care tools and evidence-based resources are readily available for frontline clinicians.
What are some things that nurses should never be doing in these kinds of situations?
During this crisis, nurses should never neglect their own care. If they don’t care for themselves, they will not be able to care for others. While nurses often run towards adversity, it is important to stop and put on protective gear before we put ourselves in harm’s way, regardless of the situation. We are at war with this virus, and therefore we need to wear the proper protective gear when going into battle. There is never an emergency that is too great to forego PPE.
Is there any other information that is important for our readers to know about keeping patients and workers safe?
I think it is important for your readers to know that we will get through this, one patient at a time. Resilience is vital for situations like this one. If we look at what we can do for our patients, not what we can’t do for them, we can reframe our perspective to think not of the of the patients we lost, but rather the many we saved.
How do you replenish and nourish your spirit in these unheard-of times when extreme stress is the norm?
At one hospital network located in the pandemic’s epicenter, you could nourish the spirit by accessing a brief podcast or video, or spending a few moments in a quiet room. At another hospital, you might search for meaning by consulting with a spiritual director.
“The COVID-19 crisis represents a real departure in terms of the emotional and spiritual stress on frontline personnel, especially nurses,” says Reverend David Cotton, Regional Director of Spiritual Care Services at Hackensack Meridian Health, a multihospital system serving New Jersey. Just as the system provides PPE, Reverend Cotton notes, health care providers’ emotional and spiritual needs must be cared for – “PPE for their spirit,” he says.
Hackensack’s new Spiritual Care Program provides guidance and support in areas such as grief; fear; hope; faith and inner peace; and meditation, gratitude, and purpose. Health care providers can access various resources including brief videos and podcasts hosted by clergy; inspirational writing; an email to make prayer requests; and a quiet room in each hospital. Professionals who are involved with the program include hospital chaplains, community clergy, and members of integrative and behavioral health teams.
Addressing Grief and Fear
Videos and podcasts on fear and grief, says Rev. Cotton, are among the most highly used resources by frontline staff. “Grief because they’re dealing with a whole new level of grief in the traditional sense, but also grief in the sense of loss. We’ve lost our rhythm of life. They’ve lost the way they usually do business as a nurse for 10 years or 20 years or two years. Nursing is different these days.” And fear because, for one thing, nurses may fear that they will take the virus home to their families.
Also popular are quiet rooms in each hospital, which have low lighting and soft music. “Those quiet, meditative prayer spaces are a great stress reducer and reliever,” he says. Visitors to the spaces can read scripture, pick up a religious article, or write a prayer request on a note, which chaplains will then pray over.
At Bridgeport Hospital, Bridgeport, Connecticut, a hospital of Yale New Haven Health, nurses can access a program to help them deepen their spiritual sense through the Murphy Center for Ignatian Spirituality of Fairfield University. They can take advantage of four free therapy sessions from the hospital, but then can access a spiritual director from the Murphy Center, available at no charge, according to Marcy Haley, Assistant Director at Murphy Center. No prior religious experience or background is needed. This program may extend to other hospitals that have a relationship with the Murphy Center, notes Haley.
In addition, the Center is working with Fairfield University’s Egan School of Nursing and Health Studies to develop a class on spirituality and palliative care, as well as offering pastoral support for all undergraduate and graduate nursing students, many of whom are working on the front lines.
Trauma, says Haley, has “a way of humbling all of us, and how we put those pieces back together is a spiritual journey as much as it is a physical and emotional journey.”