HealthManagement, Volume 20 - Issue 5, 2020

Nurses Are Not Soldiers

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Sabine is a staff nurse who has had COVID-19 patients in her ward, got infected herself and started a campaign for personal protective equipment delivery. But she doesn’t want to be called a ‘hero.’ In early June, she talked to HealthManagement.org about her COVID-19 experience and how the pandemic has made her question everything, even her calling.




Going Through Disease

I work in an acute hospital setting in Bristol, England, in a ‘holding bay.’ These ‘holding wards’ are for surgical and medical patients who have to either go to rehabilitation units or be relocated home. When COVID-19 came, nothing was really sorted within the management. So we were holding on to these patients while the whole system needed to be rearranged for COVID-19 needs.


Unfortunately, in the UK we started with the testing quite late. We were a ward with 19 patients and out of these 19, in the week of Easter we swabbed seven who had presented symptoms – cough, fever. We got the results on Good Friday, and out of seven patients we had five positive. And that was it. By that time we, as nurses, had already been exposed to those patients. In the UK we work 12 hours during the day and 13 hours in the night. This meant that in three days I had 36 hours of exposure, so my viral load was pretty high. I had difficulty breathing by then, and some nurses started off sick with others following over the Easter weekend. When I got back after the break, I was the only one left from my shift – this had never happened before. This also meant that there was a lot of work, so I spent another 24 hours in the ward, without proper PPE. By that time I had nearly 60 hours of exposure, and the next day I knew I was infected. Even without the symptoms beginning, it would’ve been a very big surprise if I hadn’t caught it. Imagine going into a bushfire without the right equipment and then asking yourself – why am I burning?


When the incubation time is over and the symptoms start, you first feel lethargic, then the fever kicks in two days later with dry cough, which then develops into productive cough. Later you lose your sense of smell and taste, and have headaches so strong that you can’t think.

I had all the ‘classic’ symptoms at the ‘classic’ time. To be swabbed, I had to go to an outreach team, which was based at a football stadium on the outskirts of the city. The timing of the test is very significant. Up to May, you could only swab between the second and the fifth day after the symptoms show. On any other day the test result would be negative even if you are positive. This is also something COVID-19-specific as with other tests, eg for staphylococcus aureus, the timeframe does not matter. With COVID-19 there were only 72 hours during symptom presentation to get valid test results. I was swabbed on day 5, and the result was positive, as I knew it would be. My infection and the infections of other colleagues of our ward were so unnecessary in so many ways – if only we had had the right equipment!


It took me seven weeks to recover. The first three weeks were absolutely horrendous. Luckily, I could stay at home, but there were three critical days. If after those I hadn’t gone on a plateau, I would’ve been hospitalised. Even though I had a ‘mild version’ of the disease, it was still a shocker. It’s nothing like having the flu because that is over within 7-10 days. You never have the experience of three weeks. And here you not only have these but also another four weeks to get rid of the lethargy.


Afterwards I wrote a report stating that it was unacceptable as in England we have to fill in an incident form. I imagine readers in Germany, for example, may blame the management, but that’s just part of the problem. For example, in other European countries in acute sector they were arguing whether we need to wear FFP3 masks when dealing with non-ventilated COVID-19 patients. The answer is, of course, you always have to wear an FFP3 mask, if you have COVID-19 patients – not just for aerosol-generating treatment. There must be international guidelines on COVID-19 that we all have to follow. Another point is that we got the patients’ results back on Good Friday, which is obviously not the best day for any action. Healthcare systems should be aware that we are very inefficient on bank holidays and weekends.


I have been in the nursing profession for 26 years and never come across anything like this. When you realise that you can actually die, it makes you question everything. Why have I signed up for this? Shall I give up now? What happens if we get the second peak and the third peak? Will we have COVID-30 in ten years from now? All this is very frightening. It does something to you – whether you want it or not.


Incredible Solidarity

I am originally from Germany, and people in the UK are very different from those in my home country. They are very emotional, believe it or not. So when in mid-March the government declared a war on COVID-19, there was solidarity that gave me goosebumps. That was the reason why I decided to increase my hours. Normally I work 25% of the quota, but under such circumstances becoming a full-time nurse again was unquestionable.

The government called on everyone who could help. If you had not worked as a nurse for 10 years, that is normally a no-go in this country. But then they wanted everyone – please come back, we will fast-track your training, and so on. And I said – all right, let’s do this!


It was absolutely incredible how I got sucked into this. Yes, we are one nation, yes, we want to save the National Health System (NHS) – and the NHS for British people is more important than the Queen, or maybe just as important – and that means a lot. No other European nation is so proud of their healthcare system than the British. No other European country celebrates its health system during the Olympic Games like the British society did in 2012 in London. So if the NHS is in a crisis, the whole nation is mourning.


I have never experienced anything like this in my home country. When I moved to the UK 17 years ago, I became a different nurse. Here, if you are in the nursing profession, you are in some ways a god. When people hear you’re a nurse they can’t thank you enough. So in some ways you feel very rewarded and appreciated by the British society. This is where the ‘heroes’ started, with all that weekly clapping and the church bells. Well, as a German, our history is not exactly good on the heroes’ side, so I am not supporting the ‘heroic’ wording of this. A hero in my books is always about the army, but us nurses are not an army. We did not sign up with our lives, when we became nurses... where a soldier might go to war and be killed…


In this new normal, a thing as simple as a hug cannot be taken for granted anymore. Still, people look out for each other. I signed up to our community network to help those who are chronically ill or high-risk patients. In my house there are four parties, and since the lockdown Friday is our baking day – we bake for each other. And we are not the only ones, everybody does little things for each other. A young woman is playing harp in a park nearby – we are only 20 spectators, but she cannot give concerts so she’s playing for us. Things like this are everywhere, and this is what the British are, after going through two world wars. Stiff upper lip and this attitude of ‘we hold together, we will make it.’ And we will get through this, of course! But what would be the price?


Then there is Germany where the outbreak was less – not little but less – than in other European countries. My colleagues there, very good friends whom I have known for 30 years, had to listen to people saying, “Oh, it wasn’t that bad.” These colleagues are working in the endoscopy department. They are at higher risk so they wear FFP3 masks and are fully dressed in protective clothes. And trust me, nobody ever has to wear this whole ‘space suit’ to work 8-10-hour shifts under such pressure. Nobody has to have even a glimpse inside of what we had to go through. So it is absolutely impertinent to say something like this. In the UK nobody would ever dare to say to a nurse, ”Oh, it wasn’t that hard, love, was it?” It would be unthinkable!


Fight for Basic Things

In this pandemic, the UK so far has had the worst outcome among European countries. We are still in a kind of a lockdown, still having 500-800 deaths per day with a population of 66 million. This is a true failure.


Now we are 10 weeks into the lockdown, and one would expect that by now, the country would be able to produce as much PPE as possible and not buy it from China or India. But this is not what the numbers show us! I am well aware that per day we have to use thousands of thousands of masks, gloves, etc. Nevertheless, it is unthinkable that in 2020 certain areas in the UK, especially those with the highest infection numbers, are not supplied with PPE. The number of COVID-19 patients are going down in the acute sector, but they are still very high in the community setting and care homes. For some reason, the government doesn’t see that these two areas are a priority now. There are thousands of companies in the UK, but the authorities have been unable to stimulate basic equipment manufacturing. And we are not talking about, say, ventilators, which are sophisticated machines (most of them here come from Germany). We are talking about masks, gloves and aprons. Basic things. In my view, this incapability to facilitate the production is a clear failure of the government.


When the outbreak started in Europe, in Italy, the BBC was showing all those intense pictures of what nurses, doctors and midwives had to go through without basic PPE. That really got into my head. Then the UK was hit, and I had my own first-hand COVID-19 experience. Later, pictures of our colleagues in New York started coming in. Putting these three examples – of Italy, New York and my own – into perspective, I thought, I can’t just sit here doing nothing. This was the start of my campaign (Box 1). There are, of course, millions of campaigns around. But as a nurse, or a midwife, or a healthcare professional, you act on behalf of all colleagues, and you feel the power of many behind you.

What I aim to achieve with my campaign is, obviously, starting the PPE production to cover the needs. This would also be a foundation for the future because with any pandemic there will be a second peak, or even a third one as was the case with influenza. According to reports, the second peak could be worse, but we are still in the first peak and have already been hit really hard. If we cannot control this, there would be hundreds of nurses and midwives and doctors dying because of the lack of PPE and testing and tracing. As I say in my campaign, we are not soldiers. As a healthcare professional, I don’t want to die because I did not have the right personal protection equipment. This is horrendous and unacceptable.


Another goal is that governments, not only in the UK but globally, realise they have failed. Of course, nurses working in Germany or Austria’s acute sector can probably say they have a government that looks after them. Nevertheless, nursing and medicine and midwifery is not just the acute sector. Even in these two countries, the home care and the community service have also been neglected in certain respect.


As such, no country in this world can say, “We are on top of our healthcare professionals, we have looked after them as much as we could.” There were countries that acted early on into the pandemic. But others, such as the UK or Sweden, started very late with the lockdown. I was wondering, why we have the World Health Organization, which is supposed to set standards for certain things. In turn, this makes you wonder what happens if we ever have this again. We don’t know yet if COVID-19 has mutated into COVID-20 or COVID-21, and this is very worrying.


All these questions compromised my own belief of being a nurse. Nursing is not just a profession, it’s my calling. We all have views about how we want to live. So if one day our beliefs and our systems are failing us, then I have a huge problem seeing what my colleagues have died for. Such thoughts could literally make me cry. We have signed up to save lives and to be there for human beings, but when we need help with basic equipment, the government says, “Well, actually 80% of PPE production is in China.” And you think – well, that’s not an answer. Why can we build hospitals in one day, but not produce enough of basic PPE? Why don’t we support each other? And what about international solidarity? When I send my campaign letter to my colleagues, even the ones who think they are safe, I always call for international solidarity among healthcare professionals. I know that Germany, for example, helped Italy, but why didn’t other European countries, who did not have large numbers, help our neighbours in Italy?


When people get my letter, many appreciate it but ask what they should do with it. My advice is always, just use it to bombard the Ministry of Health in your country, send it over and over again, help to spread the message. The important aspect here is that in many countries nursing is still a kind of obedient profession, nurses do as they are told to and would not think of taking any action. Also, not all nurses have had first-hand experience with COVID-19 patients, so they may not fully realise the scale of the problems. But my letter actually comes from somebody they know, and this ensures some trust in them. They realise that the disease is dangerous, that they have to take care, that it can hit anybody.


The best response so far has obviously been in the UK. The letter has gone to the Prime Minister, to the Minister of Health, to our local member of parliament, and obviously to our union, the Royal College of Nurses (RCN). I must say our union is very strong and they do tremendously good work. The RCN president actually took the time to respond to me – and we are 650,000 nurses and midwives here, and nearly 450,000 members in the union. She said it was a great letter and they were going to discuss it and see how they could act on it. I see this as a success. In general, it’s satisfying that nurses, midwives and doctors took my campaign – which is for their benefit as well – farther and farther. My letter has gone out as far as South Korea, Japan, Germany, Austria, Switzerland, Italy, Spain, Croatia, Finland, Estonia, Ireland and the U.S. This does not mean, of course, that issues with PPE have been resolved, but it is still better than doing nothing. So many nurses in Italy, the UK, the U.S. have died, so we can’t just sit and watch the world go by.


New Worrying Phenomenon

When you sign up to be a nurse and do your training, you know that one day you will be looking after a highly infectious patient, and you hope you’ll have the proper support, be it equipment, a designated ward or anything else.


But as a result of the pandemic, there is an emerging phenomenon of anxiety issues, the post-traumatic stress disorder (PTSD) among healthcare professionals working with highly infectious patients. The COVID-19 experience has hit us so hard that PTSD is appearing on an unprecedented scale. I believe this is one matter that the governments around the world should look into. ‘Being a hero’ and ‘going to a war’ is now part of a profession that has never had these kind of thoughts before. PTSD is pretty much anchored in our professional group.


Thankfully, mental health support services are being rolled out here and there. This problem has been openly discussed on BBC, with healthcare professionals coming up and saying, “I’m anxious to go to work” – even if they have the equipment. As I said, the NHS has a duty of care to the nation, so the mental health sector is looking into this. We already have programmes for PTSD booked for the army, and now we will try to apply them to the COVID-19 outbreak.


Personally, I do not feel anxious to return to work. I have been ill, of course, but not going back is out of the question. Moreover, I should go to a COVID-19 ward because for the time being I have certain immunity, even though I don’t know yet whether I can be re-infected. After all, this is my profession. When I was very ill, I questioned everything. But then I would think – no, I am a nurse and I love nursing. I have my colleagues to support, my patients to care for. And as I said, my story is just one of many. It’s a tiny drop in the ocean, but tiny drops make a big ocean and a big ocean makes big waves – that’s how I see it, metaphorically. 





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