COVID-19 has claimed the lives of an estimated 3600 United States (US) healthcare workers (HCWs) between mid-March 2020 and April 7, 2021.1 It is not surprising that the highest percentage (30%) of these COVID-19-related deaths comprises nurses.1 While these numbers represent a small percentage of the 723 205 total number of COVID-19-related deaths (as of this writing) in the US,2 these dedicated nurses all succumbed while tirelessly working on the front lines. In fact, the majority of HCW deaths occurred early in the pandemic among those working in nursing homes, residential facilities, hospice, and other community health sites.1 Lack of personal protective equipment (PPE) and the conflicting information on how the virus was transmitted likely impacted infection rates to those at the bedside. This did not deter nurses and other HCWs from continuing to show up and provide care to the sick and dying despite grave personal risks to themselves and family members for contracting this deadly virus. COVID-19 quickly became a modern-day battlefield. The unwavering duty to provide care on the front line has been commendable and deserving of the utmost respect and recognition. This column is dedicated to these courageous frontline nurses who now join the ranks of many likeminded wartime nursing heroes who perished while in voluntary service to others.
INTERNATIONAL YEAR OF THE NURSE AND MIDWIFE
In 2019, the World Health Organization (WHO) in collaboration with the International Confederation of Midwives (ICM), Nursing Now, and the United Nations Population Fund (UNFPA) declared 2020 as the International Year of the Nurse and Midwife.3 Intended to coincide with the 200th birthday of Florence Nightingale, the aim was to provide a yearlong effort to celebrate the work of nurses and midwives, highlight the challenging conditions they often face, and advocate for increased investments in the nursing and midwifery workforce.3 Around the globe, nursing and midwifery organizations began planning celebratory events to honor both nurses and midwives.
Unforeseen was the rapid escalation of the COVID-19 pandemic early in 2020, essentially placing a firm halt on all travel and social activities. Quarantine became a household word, and HCWs around the globe began to face exponential increases in critically ill and dying patients, compounded by a critical shortage of PPE. As the numbers of sick and dying grew, so too did the stories of courage and fortitude of nurses and other HCWs facing horrific working conditions. What was not widely reported, however, were the numbers of HCWs who had contracted and subsequently died of COVID-19.4 Discrepancies in the total number of HCW deaths from COVID-19 have since been attributed to underreporting in the early months of the pandemic.4
The sobering irony of these events was how the pandemic highlighted the vital importance of skilled nurses at the bedside. The media quickly picked up on this, posting pictures of exhausted nurses wearing PPE that had to be reused for weeks due to the shortage of N95 masks, face shields, and other protective equipment. Because of visitor restrictions, individual stories of nurses caring for dying patients also began to emerge. The most poignant of these narratives were of nurses using personal mobile devices to connect family members with dying loved ones as they took their last breaths. Bearing witness day after day at the bedside to a multitude of dying patients was a surreal reality, and nurses quickly became the unsung heroes of this crisis. The WHO's intended International Year of the Nurse and Midwife celebrations evolved into numerous public service announcements, posters, accolades, and tributes thanking nurses and other HCWs.
Unfortunately, this long-overdue recognition of nursing's impact and value in the healthcare world has come at great cost to the physical and emotional well-being of frontline nurses. As COVID-19 cases rose, hospital inpatient areas were quickly converted to intensive care units (ICUs) to accommodate the rising numbers of critically ill patients. Long work hours, lack of PPE, and isolation from families became the norm for nurses working in these and other facilities. Unlike the known dangers facing military service members during wartime, nurses did not enter the healthcare workforce thinking they were in danger of dying from a work-related exposure. They did not receive intense battlefield training or learn how to set up a mobile ICU and, along with the rest of the healthcare team, were largely unprepared to fight this invisible enemy. Granted, a pandemic is not wartime, nor does it begin to underscore the sacrifices of military service members defending their countries. What the world's nurses and other HCWs have faced because of dedication and service to others during this pandemic, however, has been no less tragic.
A DISTINGUISHED HISTORY OF SERVICE
Throughout history, nurses have been on the front lines during wartime conflicts caring for wounded and dying soldiers. Seen as the founder of modern nursing, Florence Nightingale is probably the most recognized of these protagonists. Historical accounts of her service to injured, sick, and dying soldiers during the Crimean War have been passed down for generations. When Nightingale arrived at the British field hospital in Turkey, the overcrowded and unsanitary conditions were appalling.5,6 Along with a team of nurses, Nightingale was able to improve conditions and reduce mortality rates. These actions led her to a lifelong commitment to improving hospitals and care provision, especially in the care of the military.5,6 Her writings have laid a solid foundation for modern nursing practice, and to this day she is revered as a true pioneer.6
In the many wartime conflicts that followed the Crimean War, nurses around the world have continued Nightingale's legacy of compassionate service to injured and dying soldiers. Many of these courageous women followed their husbands into battle dressed as men to provide care and support.5,7 During the Civil War, nurses were finally acknowledged as an official part of the US Army and carried on many of Nightingale's doctrines. They too worked in overcrowded, makeshift hospitals with critical shortages of supplies and staff. After the war was over, they were the first women to be eligible for federal pensions for active-duty service.7 Many famous women served during the Civil War including nurse Clara Barton, the founder of the Red Cross, and activist Dorothea Dix, best known for reforming healthcare of the mentally ill.7
The US Army Nurse Corps became an official entity of the US Army after the start of World War I and by the end of the first year, more than 21 000 nurses volunteered for active duty.5,7 Nurses served in base hospitals, transport ships, mobile units, evacuation hospitals, and ambulance trains. Although many were on the front lines of conflict, most of the 400 nurses who died during this war succumbed to influenza.7 Likewise, during World War II, military nurses were more likely to die from exposure to illness than from combat-related injuries.7 By 1945, more than 59 000 US nurses had served in the military during the war and 1600 were decorated for meritorious service and courage under fire.5
While the Korean War brought nurses closer to frontline combat zones as part of Mobile Army Surgical Hospitals, or MASH units, none lost their lives during this 3-year conflict.5,7 Thousands of nurses served in the Vietnam War, all of whom volunteered to serve despite the war's unpopularity.5 Even with the high number of casualties, only 8 nurses were killed in action during the Vietnam War.5 They are venerated among the 58 281 service members whose names are inscribed on the Vietnam Veterans Memorial in Washington, District of Columbia. During the more recent Persian Gulf War and the conflicts in Iraq and Afghanistan, nurses have been deployed in record numbers to care for injured soldiers.7 Like their resilient predecessors, they have faced both challenging environmental work conditions and a shifting political and health policy landscape. The commitment to service and care has, nonetheless, been unwavering and unyielding.
DISCUSSION
This brief review of nursing's history of service in the military is a reminder that while present circumstances may have changed, one fact remains clear: nurses are highly skilled and fundamental to the healthcare team, regardless of the frontline challenge. Equally important is prioritizing the provision of adequate resources (training and supplies) to prepare and protect nurses from whatever risks they may face now and in the future. The COVID-19 pandemic has brought these and other critical issues into sharp focus. Never again will someone choose to be a nurse without an implicit understanding of the risks involved.
As nursing and other healthcare professions begin to recover from the devastating effects of the pandemic, one question remains: Can the current wave of gratitude and public attention provide nurses with a more realistic and sustained voice of agency? Now more than ever, nurses have an opportunity to showcase what they actually do and change the narratives of the past to a new reality of contemporary nursing practice.8,9 Present-day nurses have thus achieved a long overdue level of respect and support from the public. Seen as trusted, competent professionals, they are essential contributors to improved patient outcomes and safety.8 From a health policy perspective, nurse leaders will be better prepared to address the chronic underfunding of nursing education and advocate for competitive, equitable salaries and improved working conditions.9
In closing, let us never forget the work-related deaths of so many nurses and other HCWs from COVID-19. Similar to military nurses who perished during wartime service, these COVID-19 warriors deserve the utmost recognition for their service and sacrifice. Organizations such as the Guardian are attempting to identify and honor every HCW who died of COVID-19, especially those who succumbed during the early months of the pandemic.1 As International Nurses Day approaches on May 12, 2022, let it be seen not just as a celebration but as a day of remembrance for nursing colleagues and other members of the healthcare team whose lives were tragically lost while providing care and support to those infected with COVID-19.
-Linda A. Hunter, EdD, CNM, FACNM
Associate Clinical Professor
Department of Midwifery
Alpert Medical School of Brown University
Women and Infants Hospital
Providence, RI
References