In the Fight

When pandemics hit, nurses are at the forefront

By Jenny Price

Illustrations by Jackapan Pairin

During the Crimean War in the 1850s, Florence Nightingale saved the lives of hospitalized British soldiers in danger of contracting and perishing from infectious diseases by deploying a powerful weapon we use today: basic hygiene.

A lesson from the earliest days of nursing has carried forward to one of the most powerful messages to fighting COVID-19. When the history of pandemics is written, nurses always play a central role, most visibly on the front lines at the bedsides of patients. But through their expertise in epidemiology and public health, they also improve care, give people tools to protect themselves, and help policymakers understand why some can’t always take those steps.

When we do it best you don’t even know we’re there

When someone tests positive for a communicable disease, the best way to prevent it from spreading is to chase down every contact they’ve had while contagious. That work is typically done by public health nurses, says Pam McGranahan, MS’04, DNP’12, a clinical associate professor and director of the Doctor of Nursing Practice program.

Public health nurses focus on what’s known as the three C’s: case finding, contact tracing, and containment of community spread. Earlier in her career, McGranahan did that job, which included going to a local high school to inform teenagers they’d contracted a sexually transmitted disease, ensure they had access to treatment, and determine who else they could have passed it on to. This case finding effort is especially critical in a pandemic, when the consequences of community spread can be fatal.

“These same strategies have been key to controlling other life-threatening pandemics for which we don’t have a vaccine, like TB and HIV,” McGranahan says. “Nurses in the community have been essential to the success of those efforts.” More than 150 years ago, the reality of contracting communicable diseases that we rarely see today was very different, she says. In rural Jackson County, Wisconsin, an 1870s smallpox cemetery holds 10 graves, several from one family. About two miles down the road are the graves of a family who all died from diphtheria. Before vaccines were developed for those diseases, public health nurses educated people about how they spread and how to protect themselves, McGranahan says.

Public health nurses also quarantined households and did home visits to keep sick people from going into the community and built on those relationships to organize and implement mass immunization clinics, ensuring that people didn’t die from diseases that have killed millions, she says. “Nurses were how we got on top of that,” she says.

“The trick with public health is that, when we do it best, you don’t even know we’re there.” —Pam McGranahan

“The trick with public health is that, when we do it best, you don’t even know we’re there,” she says. “You go to the movies and you don’t worry that you know you’ve just caught measles. And you don’t ever dream that you could lose a child to diphtheria.”

If we really do our job as leaders, we’re thinking ahead

As COVID-19 cases were on the rise in the spring, clinical professor and interim associate dean for academic affairs Barbara Pinekenstein ’73, DNP, was interviewing candidates for fall admission to the School of Nursing, many of whom were already working as nursing assistants in hospitals or long-term care. “I was so inspired,” she says. “They are stepping up in a really challenging time and are really clear about the importance of nursing and providing care.”

Pinekenstein started her career in direct patient care — first as a staff nurse, then as a clinical nurse specialist. She later spent two decades as a chief nursing officer and vice president for clinical informatics, including implementing electronic health records and other innovative technology. She has seen firsthand the leadership, teamwork, and critical thinking skills that nurses bring to emergency situations. The School works to instill those values in their students through active learning and case-based emergency scenarios so they go into the field knowing how to set priorities and make decisions in fast-paced environments, she says.

“The nurse is the one person who’s at the bedside 24 hours a day when somebody’s hospitalized.” Barbara Pinekenstein

“The nurse is the one person who’s at the bedside 24 hours a day when somebody’s hospitalized,” she says. “A critical part is to coordinate that patient’s care both while they’re in the hospital setting and when they go home.”

The School’s curriculum focuses on ensuring future nurses are able to adapt, be resilient, gather the right information, communicate in a crisis, and collaborate with patients and their families, she says. “If we really do our job as leaders, we’re thinking ahead and we’re being proactive in designing responses to scenarios before they occur,” she says.

Pinekenstein says leading during a crisis causes both emotional and physical fatigue due to longer hours, significant stress, and uncertainty. Strategies for mitigating fatigue that work well outside of a crisis — including rest breaks, self-care, clear communication, and contingency planning — are even more important when we’re in the middle of one.
“With this pandemic, it is a marathon, not a sprint,” she says.

A nursing heart and a medical mind

Meghann Martin, DNP’15, is part detective and part caregiver in her role as a nurse practitioner at University Hospital monitoring, diagnosing, and treating infectious disease in patients with HIV, tuberculosis, viral infections, and other conditions. Some have COVID-19 and some do not.

A self-proclaimed “microbiology nerd,” Martin worked as a nurse at the William S. Middleton Memorial Veterans Hospital in Madison before enrolling in the School of Nursing to earn her DNP with a focus on infectious disease. “I like bugs,” she says.
Her days have become more challenging as she works to determine if respiratory failure in her COVID patients is strictly from the virus or from another organism that’s also infecting them. “They need lots of imaging, they need a lot of hands-on attention,” Martin says. “So it becomes much more complicated and they have a higher risk of mortality.”

It also means a renewed focus on effective and compassionate communication with patients who don’t have COVID-19 yet but worry about contracting the virus while in the hospital. “The constant anxiety that is swelling in the hospital, that makes it different and a little scarier,” she says. “We wear face masks and shields for every patient. And you’re trying to make sure that patients understand that this is for their protection, not that we’re afraid of them.”

It also means providing strong support for her colleagues, including giving her cell phone number to residents in her service to call and talk through questions.

“We have a lot of fear and anxiety within the medical community during these types of pandemics,” she says. “With a new respiratory failure, the first thing you think of is, ‘Oh, my gosh, now they have COVID.’ But it’s on us to communicate with teams and say, ‘We still need to look for the typical things that happen to hospitalized patients.’”

Martin says she learned her effective and collegial communication skills through her experience at the VA and in her graduate studies at the UW. “I think that my nursing background in the DNP program really did prepare me to still have a nursing heart and a medical mind. The anxiety and the fear is so real, it’s palpable.”

Ask ‘Why?’ a lot

Carrie Bennett, MS’03, DNP, was early in her career when the H1N1 pandemic hit in 2009. “I don’t think I fully realized nor appreciated the preparatory and response work being done,” she says.

As a certified clinical nurse specialist (CNS), she’s played a role in supporting and promoting workflow changes for nursing staff at UnityPoint Health-Meriter Hospital. Bennett, a lead member for the Adult/Gerontology Clinical Nurse Specialist DNP cohort, maintains a clinical practice focused on complex elderly patients who were still being admitted to the hospital in the spring during the COVID-19 pandemic.

“The core function of the CNS in this climate isn’t much different,” Bennett says. “We’re constantly juggling multiple priorities and adding new or changing priorities as the climate around us changes.”

Bennett also supervises the Hospital Elder Life Program (HELP), through which more than 60 volunteers provide support to elderly patients to help minimize hospital-acquired delirium and functional decline. When coronavirus pandemic restrictions meant volunteers could not come to the hospital, she found ways to redeploy staff to provide the support patients needed. “CNSs tend to have a big-picture view of situations, ask ‘Why?’ a lot, and have a sound understanding of how to carry out quality improvement work, so because of that we find ourselves starting and joining multiple teams and workgroups,” she says.

Bennett was recently pulled into one hospital working group developing a plan for patients to virtually communicate with their families. Her HELP team had navigated that process prior to the pandemic to help elderly patients who occasionally need to hear and see their loved ones when anxious and/or delirious. “I had learnings I could share, as well as a pretty well-ironed out process that could be replicated to support all patients in need of virtually connecting to their loved ones,” she says.

We have to understand the context in which people are living their lives

Pandemics can teach us a lot about existing social disparities and how health and wealth inequities affect transmission and outcomes, says Megan Zuelsdorff, PhD, an epidemiologist and assistant professor in the School of Nursing.

“Risk exposures don’t occur randomly for most people. Usually, advantage or disadvantage in one area will be compounded by advantage or disadvantage in another part of your life.” —Megan Zuelsdorff

Zuelsdorff studies the social-biological pathways and mechanisms that underlie cognitive health disparities later in life, and is focused on the ways that various social structural factors influence health. “Risk exposures don’t occur randomly for most people,” she says. “Usually, advantage or disadvantage in one area will be compounded by advantage or disadvantage in another part of your life.”

In a pandemic, social conditions shape the risks people experience as well as their health outcomes, she says, noting the higher prevalence of COVID-19 cases and deaths experienced by African Americans. That includes “everything that we come into contact with, the things that we have to do versus the things we can change, and the protective resources that we have in place.”

When the Centers for Disease Control and Prevention first released social distancing guidelines after cases surfaced in the United States, she says, it sounded as if you needed a three-bedroom home with a master bathroom to isolate a family member with the virus from other people in their household. “That’s not a reality for a lot of people,” she says.
Zuelsdorff says epidemiologists and public health experts can look to maps and big data as well as community health providers and qualitative data to identify socio-behavioral phenomena and barriers that explain why some people may not follow social distancing or other guidelines. “If we want people to be able to follow these kinds of very general guidelines that we set out, we have to understand the context in which people are living their lives and adapt the messaging,” she says.

And although she doesn’t have a nursing background, her social epidemiology work fits squarely within the School’s focus on centering patients and their care within not only their families, but also their larger support networks and lives as a whole, she says.
“Nurses place care planning into a patient’s life, imagine what that’s going to look like, and imagine what the difficulties are going to be and what the facilitators might be as well,” she says. “So I find that my colleagues are already 10 steps ahead of me a lot of times.”

This will bring nursing to the forefront and show people what we really do

Amber Statz ’16 had been working as a nurse at Massachusetts General Hospital for just one year when the neurology intensive care unit she works in was designated to care for COVID-19 patients. Prior to the outbreak, she already knew how to care for patients on ventilators, including people who had experienced strokes and spinal cord injuries.
The difference now is that doctors rarely go into the rooms of COVID-19 positive patients to limit their exposure and that to other patients they see, she says. “I think this will bring nursing to the forefront and show people what we really do and the autonomy that we have,” she says. “We’re with the patients the most and our assessments are so vital to the team in making their decisions about care.”

There’s a lot to keep track of. Statz must keep her eyes on the patient and the monitor while simultaneously keeping track of the numbers and data coming in. “It’s happening all at the same time. Eventually it all kicks in.”

“We’ve been trying to reach out to our patients’ [families] at least once a day, calling them with updates, encouraging them to call whenever, letting them know that we’re there for their patient” —Amber Statz ’16

Through it all, Statz and her fellow nurses keep patients top of mind with the photos and personal details shared by family members displayed on poster boards in their rooms. “We’ve been trying to reach out to our patients’ [families] at least once a day, calling them with updates, encouraging them to call whenever, letting them know that we’re there for their patient.”

She’s staying mentally healthy by reaching out to other people on her unit for support, as well as walking her dog and reading on her days off to escape reality a bit. “It feels unreal,” she says. “Sometimes you wake up and you think it’s a dream, but it’s real.” But Statz says there’s nowhere else she wants to be. “I am young and healthy,” she says. “I should be out there on the front lines helping these people because I can do that right now.”