By Patricia D’Antonio, PhD, RN, FAAN, Ware Professor of Nursing and director of the Barbara Bates Center for the Study of the History of Nursing, University of Pennsylvania School of Nursing, Philadelphia.
The lessons of the past.
As we struggle to make sense of unfolding data, announcements, and public health directives about the current coronavirus pandemic, appreciating the lessons from past pandemics can help us understand the effectiveness and challenges related to quarantines and social isolation, as well as the need for reliable and timely communications.
In times of public health uncertainty, nurses and nursing care have played a critical role in saving lives and relieving suffering. We now know a great deal about the role of nursing during the 1918 influenza pandemic. Some lessons need heeding now.
Historian Nancy Bristow’s American Pandemic (New York: Oxford University Press, 2012) presents the historical facts clearly. For example, public health officials’ 1918 prohibitions on public gatherings, the sharing of such (then) new personal items as toothbrushes, and school attendance and religious services met acceptance as well as resistance.
In 1918, supportive care saved lives.
During the 1918 pandemic, medical science struggled with public perceptions of the limits of its ability to respond. There were no tests or cures at the time, and flu vaccines only arrived later. However, the supportive care provided by nurses saved lives.
In 1918, as today, it is the critical, too often unrecognized clinical work that helps people withstand the onslaught of a strange infection and mobilize their own immunological responses. Supportive care is the provision of appropriate hydration, nutrition, fever control, rest, ventilation, and emotional support.
The tools of supportive care have changed in many ways since 1918. Hydration from frequent sips of water now comes from IV lines, nutrition support has moved from broths and porridges to carefully calibrated parenteral feedings, and fresh air comes not from the outside but from negative pressure isolation rooms that both provide filtered air to the patient and prevent the spread of infections to others.
But other things remain the same. Supportive care is now, as in 1918, highly skilled care. It’s not just the necessary technical know-how but also the complex hour-by-hour assessment of the supportive care’s efficacy and the possible need for recalibrations in that care.
Supportive care is collaborative, intensive, ‘precarious.’
Supportive care is intensive, time-consuming care that involves the input and collaboration of multiple members of the health care team. This care is also quite precarious. My own work on early 20th century nursing care—a time when health care professionals were only beginning to understand the implications of bacteria in their medical and surgical care—shows the limits and unpredictability of carefully constructed protocols when applied to care for real patients (American Nursing, Baltimore: Johns Hopkins Press, 2010).
Nurses, for example, received careful instructions about maintaining a “clean hand” for working directly with a patient and a “dirty hand” for transferring something used with or by that patient to an outside environment. This worked—until a patient sneezed, or coughed, or the nurse tripped with an armful of “dirty” laundry. In supportive care, nurses need to go slowly and carefully, and this takes more time.
Supportive care was also courageous care.
A fundamental transformation of health care occurred not only when it moved out of the home and into hospitals in the early 20th century, but when nurses responded to the call to provide care not just to family members at home but to strangers in hospitals. These strangers often had newly identified infectious diseases that could also infect nurses—and sometimes kill them. We know that the new coronavirus has infected nurses and other health care workers here, and in China there have been deaths.
Supportive care today remains courageous.
Listening to nurses’ urgent concerns today.
So we need to listen and respond to nurses’ calls—for more protective equipment, for more time to give care, for more staffing, and for more acknowledgments of their concerns. Nurses need to do for themselves before they can care for their patients. As airline safety announcements remind us, you must first look to securing your own oxygen masks before those of your children or fellow flyers.
Right now, joining nurses’ supportive care efforts to that offered by their health care colleagues can heal patients. And listening to nurses’ concerns can save them and their colleagues.