1. White, Kenneth R. PhD, AGACNP, ACHPN, FACHE, FAAN
  2. Begun, James W. PhD
  3. Vicenzi, Angela E. EdD, RN


Understanding a bewildering crisis like a pandemic as 'normal' may be empowering.


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Nurses are responsible for taking care of patients and themselves during both "normal" times and "abnormal" times that can be scary, painful, and overwhelming. The COVID-19 pandemic has been one such time. Nurses on the front lines have been faced with unsafe working conditions, job loss, family separation, extraordinary stress and fatigue, and constant exposure to the devastating consequences of COVID-19.


We recommend one evidence-based, scientific perspective to aid in "keeping calm and carrying on" in abnormal times-complexity science, the multidisciplinary study of complex systems. Systems are complex when their units are highly interdependent, heterogeneous, and dynamic. Complexity science conveys that events like the COVID-19 pandemic and its sequelae are understandable, and in a sense, normal. This perspective, while it may not lead to control, may contribute to greater calm and may generate energy to search for positive steps and opportunities for innovation. Here, we identify three principles of complexity science relevant to the COVID-19 outbreak and its challenges to the nursing profession.


Small changes, big effects. Small changes in complex systems can have large and unpredictable effects. The microscopic virus that causes COVID-19 likely traveled from a bat to a human, initiating monumental changes across the globe. Importantly, none of the changes are inevitable, as they are influenced by the actions of those of us in the system.


Implication: Nurses can be active early in the response to abnormal events. Systemic responses take on a direction early on, and if nurses don't participate, the responses may be molded by others. Even small contributions such as educating patients on prevention can make a huge difference. Responses to a pandemic should be tailored to local conditions because localities are diverse in cultural, social, demographic, and political characteristics.


Order emerges from disorder. Death and disease due to COVID-19 initially appeared almost at random. But the deeper structure of order is being discovered as it emerges. For example, demographic characteristics like age and social determinants like income have implications for disease spread. Some patterns are easy to see, but more complex patterns require research. Comparisons between states or cities, for example, often do not account for key differences that explain COVID-19 rates. The discovery of patterns is critical to reducing the perception that chaos and confusion will persist forever.


Implication: Nurses can support and contribute to the evidence base that identifies patterns and will inform pandemic response policy going forward. Scientific research on the effectiveness of personal protective equipment, for example, is vital to the future of nursing. Nurse researchers are positioned to be among those leading the discoveries of new patterns and effective pandemic responses.


Diverse connections strengthen adaptation. In complex systems adapting to abnormal events, accurate information flow from the sites of the events makes systemic responses more valid. The infectious disease surveillance system, for example, is inadequate in many countries, including ours. Complexity science teaches that effective responses by policy makers depend on listening to those on the front lines and communication with diverse participants increases the likelihood of effective response.


Implication: Local COVID-19 response teams would benefit from including nurses with diverse perspectives-including infection prevention, management, supply chain, and acute and critical care. Effective response requires community health workers, as well as critical care and advanced practice nurses, to stem the spread, all in communication with appropriate agencies, organizational leaders, and media outlets. It is important that nurses have a seat at the table and advocate for prominent roles in agencies, on commissions, on pandemic response teams, and in media coverage.


Complexity science is not a panacea for crises like COVID-19. But realizing that abnormal times are actually "normal" and an opportunity for nurses to shape the future can energize nurses to promote their expertise. The observations, interventions, and leadership of nurses, often directed toward patients and families, can also influence foundations, government, and regulatory bodies shaping policies at the national and international levels.