Thoughts for Nurses on Coronavirus (COVID-19)

2024 Update: This post was written originally in March 2020 and cited many references from the CDC’s website and other sources that are no longer working or active. We have removed those links. A lot has changed since the original publication of this article. However, for posterity’s sake, we are maintaining it as it was originally written.

With everything that’s been evolving rapidly around the world, I wanted to reach out specifically to offer my support and thoughts for nurses on coronavirus.

Taking care of patients is already a pretty heavy burden, but then when you add on a pandemic, a workforce of people who are on the front lines, who also have their own health and livelihood to consider, with constant updates – one more terrifying than the next, it can get overwhelming pretty quickly.

As members of the most trusted profession, how we conduct ourselves and what we share with others (both online and in person) carries weight. Therefore, we do have a responsibility to consider how what we say may influence and impact others, while we simultaneously caring for ourselves and processing it all.

Facts about the Coronavirus

In December of 2019, cases of pneumonia with unknown etiology were identified in Wuhan, China. It has since spread across the globe, with cases now in every continent except Antarctica.

As of when I am writing this, the vast majority of those who are infected have mild symptoms that include dry cough, sore throat, and fever. Conversely, the majority of patients who end up in the ICU because of this have underlying comorbidities involving neuro, cardiac, endocrine, and other body systems. As a nurse, this absolutely makes sense. Naturally, if you already have COPD, heart failure, diabetes, etc. and adding on this additional insult will make a quick recovery more challenging and has proven fatal for some.

While numbers are constantly changing, the current reported mortality rate is 3.4%. Compare that to a 9.6% for SARS and 34.4% for Middle East respiratory syndrome (MERS).

(Source for all of the above is this article.)

If you remember back to 2002 with Influenza A/H1N1/”swine flu”, the total number of cases in the United States was estimated to be 59,000,000. Approximately 265,000 were hospitalized (so 0.05%), and 12,000 died (source).

Essentially, this is a novel virus strain (meaning we were previously unaware of until it first surfaced in December 2019). But, coronaviruses are actually a pretty large family of viruses that are one of the causes of the common cold, which we were previously well aware of (source). If you’ve got a microbiology textbook, you might see corona-viruses listed under “common cold”, as they’ve been identified as such back in the 1960’s (source).

So, why are we freaking out about a common cold?

That’s a good question; the higher mortality rate, how quickly it has spread, how little we know about this specific strain, the limited capabilities of our health care system to accommodate it, as well as the impact of constant updates on social media and regular media have on our perspective are all factors. We already feel the heat of tight staffing and needing hospital beds, and this can be a game changer.

Practically speaking… in an abundance of caution, proactive steps are being taken to lessen the likelihood the virus spreads further. If the virus spread, it would stretch our extremely over-stressed health care system. And if you’re a nurse, you’re keenly aware of how tight things are already with staffing. We don’t want to add even more on top of the existing challenging health care climate.

We also don’t know this strain well, and the unknown in medicine isn’t great. Patients can decompensate quickly, and require a lot of medical resources (vent, meds, CVC, art line, proning). We want to prevent as many people from getting to that ICU-level of care as possible. We’re already taking care of the typical flu patients every year, so adding on this has the potential to stretch us far beyond our capabilities.

Think about the grocery stores right now… how people have overwhelmed that system entirely and now if you wanted to go get something, even just 1 roll of toilet paper, you can’t. Imagine that happening to the health care system, and people who come in normally with things like strokes, heart attacks, from car accidents, etc. won’t be able to get the same resources as the system is overwhelmed with COVID-19 patients.

Also, let’s just toss in that there is a lot of unknown. And what do we commonly feel when faced with the unknown? Fear.

When you’re scared, what do you try to do? Control the situation.

Well, as nurses we know there’s not a whole lot other than supportive care that you can do for a virus. Therefore, there is little control to be had… add on constantly checking social media and news outlets, unprecedented closures of schools, events, and services… and we’ve got entire populations of people who go from being nervous to becoming completely panicked.

But, what can we do? So many of us feel so helpless right now, and therefore are doing some things we normally wouldn’t. The tough thing is, there’s isn’t one single thing that’s going to be a fool-proof protection from this. But, there are some things that can set us all up for success.

Ideally, we prevent contracting it ourselves and passing it along to others. However, we shouldn’t just stay away from people and hope that doesn’t happen – after all, many of you are at the bedside actively working with patients who already have it. Therefore, we also need to get our bodies/immune systems in game-day shape should we contract the illness.

Taking really poor care of ourselves, or sitting back and just hoping not to get it, expecting our bodies to successfully and quickly fight off pathogens with little impact on our lives is kind of like  signing up for a marathon but sitting on the couch, eating Doritos, drinking Mountain Dew, and watching Pandemic on Netflix on repeat for weeks until race day. People who run marathons know that it’s not just physical training to actually cross the finish line and not injure yourself, it’s also mental training as well to be able to stay motivated and keep their head in the race.

Therefore, as a fellow nurse and human I encourage you to gear up physically and mentally for the marathon. We need to get our bodies and minds ready for the coming weeks. It’s challenging because it’s not one single thing that we can do or buy that will instantly protect us, rather a multitude of things we can do and ways we can shift our thinking that together will make a collective difference.

And let’s say what we are all thinking: It is really really hard as a human being to take care of another human who contracted the disease you’re scared of getting yourself, try to save their life and take care of them, only to have them ultimately die or suffer severe complications.

That’s traumatic. That’s hard.

Dealing with those really complex emotions is really tough. I see you, I hear you, I’m with you.

Let’s get through this together – because we will.

We got through H1N1, West Nile, Ebola, SARS, Zika, and more – and we will get through this together.

I believe that structure is crucial in not only creating a physical and mental success plan, but consistently implementing it as well.

“Structure is essential in building anything that thrives.” 

– Dr. Henry Cloud

Our goal isn’t just to struggle through this and get to the other side of it, but to thrive through the adversity.

We can do this.

You can do this.

Even if going to work is scary, or if you feel overwhelmed with trying to get your childcare situated, or if you’re nervous about your parents, or stretched to the max financially – you can do this. Let’s get a plan of action to set ourselves up for success and take actionable steps each day to work through this.

Below are some evidence-based ideas of how to begin building your structure and thrive through this as the outstanding, supportive, and amazing nurses you are.

Optimize your physical readiness

Let’s go through ways that you can set your physical body up for success in preventing the spread as well as handling it should you contract the illness. During this time of feeling very out of control, these are things you can take proactive steps to be able to have some control.

Here is a resource that I really like that provides awesome information and is from the Institute of Functional Medicine. It dives into even more specifics on things you can do, and covers additional topics on natural ways you can support your immune system in addition to lifestyle adjustments.

Get adequate rest

I know you’ve seen this everywhere, but adequate rest is crucial for your immune system to function properly. The way (it is thought) to do so is to better enable your T-cells (a type of white blood cells) to fight off infection.

When you rest, your stress hormone levels are naturally lower (things like adrenaline, epinephrine, norepinephrine).  When these levels are lower, T-cells can better adhere to and therefore destroy pathogens – like viruses. The ability of your T-cells to adhere to these pathogens is crucial in killing it. Therefore, our T-cells are part of our immune system and to better enable them to fight infection, we must rest. This is one of the reasons why the CDC recommends rest for people who are sick with colds and flus (remember, COVID-19 is a strain of the common cold).

Here’s a great article that summarizes it, and here is the original study explaining it. I also really like this article explaining how the immune system and sleep are deeply interconnected. While this is a blog article, it does have ample credible citations to support it.

What getting adequate rest practically looks like:

• Being unapologetic about an early bedtime (hello, 2100 – you’re my favorite bedtime)
• Not answering every single email, DM, tweet, or text right away – putting your phone on silent as you rest so it’s not continually interrupted
• Not guilting/shaming yourself into completing your to-do list before you allow yourself to go to bed
• Not pressing yourself into a state where you have to “earn” your rest by getting a lot done first
• Giving your brain and body time to gear down for rest… this means transitioning to less screen time, warm lighting, a dark and cool room, etc. about 30-60 minutes before you actually want to fall asleep
• Not starting an interesting show or podcast right before your bedtime transition – you don’t want your brain getting geared up, you want it calming down. If you have to listen to something (no shame there, I do every night!), select something predictable, familiar, and comforting (coughTheOfficecoughcough).
• Crafting your sleep environment to be as relaxing and comfortable as you can – maybe you like light light music, some calming scents like lavender, a pre-bedtime shower or bath, or maybe a 20 minute bedtime yoga routine.

Stay hydrated, eat nutritious foods, breathe fresh air, get sunlight

When we get sick, we tend to feel bad quickly and don’t want to push fluids like we should. If you’re continually well-hydrated, if you do get sick – you’re not already trying to overcome fluid deficits.

We all know the problems with fluid volume deficits… decreased cardiac output, electrolyte disturbances, confusion (or changes in mood), dry mucous membranes, vital sign changes, etc. And therefore, we know the importance of proactively preventing it because otherwise we’re going to be dealing with complications. Don’t give yourself the complications! Keep yourself well hydrated each day… this enables your kidneys to clear out waste products efficiently and maintain optimal cellular health (source).

Make sure you’re staying hydrated. Now, we can’t start IV fluids on ourselves – but we can be proactive in making sure we’re staying hydrated.

Also, make sure you’re eating well. They don’t need to be gourmet meals, but trying to eat fresh and simple foods can go such a long way. Before you spend 6 hours researching different vitamin routines and brands, consider adding those brightly colored fruits and veggies first as research suggests this does a better job of supporting our immune systems than supplements (source).

Make sure you’re getting fresh air. Since we’ve got to be inside so much, make a conscious effort to get outside. Getting fresh air in our lungs is good for both the body and mind. This is especially helpful if you are in close quarters with others who may be under the weather and the air is being recirculated. Getting outside, even for just a short walk, can boost your immune system and morale. It does because volatile organic compounds with antibacterial properties called phytoncides are released by trees are thought to increase the immune system functionality and response (source, source).

Get some sunlight. Vitamin D has shown to have a major impact on the immune system and overall health, and many of us are deficient in it (source). In fact, decreased Vitamin D levels are associated with an increased susceptibility of infection (source).

What this can look like practically:

• Having a water bottle you ensure you drink a certain amount of daily to keep track and increase your likelihood of staying accountable
• Adding some foods that have high water content to your routine (watermelon, strawberries, oranges, cucumbers, etc.) Here’s a great list of more options. This doesn’t have to be a complete dietary overhaul and stressor, but consider buying some of these and substituting them as snacks, sides with meals, or choose recipes for meals that include some of them.
• Switching out one of your normal non-water drinks (your afternoon coffee or soda) to a glass of water
• Chugging a glass instead of slowly sipping so ensure you get it all down
• Jazzing up your water a bit to make it a bit less boring. Here’s an article with some great ideas.
• Making sure you’re also taking in other electrolytes and not just water; we don’t want to mess up our sodium and potassium and create a fluid volume excess. Broth would be a great thing to drink if you’re already sick, or adding a little salt, lemon, or maple syrup even to your water.
• Taking a walk outside or drive to a walking trail to get some time in nature; purposefully making sure to take good deep breaths
• Get about 10-30 minutes of sunlight (without SPF) around noon (source) on your days off
• Eating lunch outside or taking a short walk outside on your break

Cleanliness

As a society, we pretty much know we need to wash our hands but we’re kind of terrible at it. It’s estimated that 95% of us don’t wash our hands effectively (cue the Jim Carey, Liar Liar vomit face). The stats are pretty gross, but sadly not surprising. While most people actually do try to wash their hands (between 64-75% of women and 30-51% of men), again, only 5% actually did it in a manner that actually removed germs.

Man, humanity. You nasty.

Now, we all learned the proper way to wash your hands on the first day of nursing school. My professor actually took us into the bathroom and showed us how we were supposed to do it. That’s when I learned the whole count to 20/sing the ABC’s thing to make sure I did it long enough.

You’ve got to wash your hands with soap for about 20 seconds to physically remove the bacteria. We can’t just rinse with water as hot as Mordor and think we’re good to go; it’s about manually removing it with the friction and bubbles.

I’m not going to lie, I am a little happy knowing the rest of the general public may feel the burn of dry, cracked, and bleeding knuckles that nurses often get in winter months from washing their hands so much…. and that sting of hand sanitizer on the cracked knuckles that pierces your soul… followed by the soothing comfort of a thick coat of lotion (only to be washed off 6 minutes later).

Also, just keep your environment clean. Make sure you use clean towels, bedding, and dishes. So, if you’re sick, get a new glass every time you grab more water. Don’t re-use the same glass for three days. Clean your phone. Clean your counters.

Practical cleanliness tips:

• Wash hands (WITH SOAP, PEOPLE) while singing a song or verse that lasts about 20 seconds. Some options are Happy Birthday (whole song), Stayin’ Alive by the Bee Gees (chorus), Never Gonna Give You Up (chorus), Row Row Your Boat (whole song), This Land is Your Land (chorus), etc.
• Soap doesn’t need to be antibacterial to be sufficient. We don’t want to overdo that anyway, so just regular soap is a wonderfully wise selection.
• Switching out hand towels in bathrooms to paper towels, or making sure you switch the hand towel out daily.
• Cough into the crook of your shoulder instead of your hands.
• Changing your sheets (in particular pillow cases where all of your snot, drool, and gunk collects) often.
• Clean your kitchen counters, and other surfaces that are touched often, daily or more frequently if they get visibly dirty. Please don’t wipe a dirty rag everywhere, but use a paper towel or clean cloth to wipe down surfaces with your favorite cleaning agent. If you don’t have cleaning agents, lemon is a natural cleaner that you can use along with water.
• Clean your phone!
• Don’t share drinks, food, eating utensils.
• Take a hot shower right after a shift
• Make sure you take your scrubs off before you touch your stuff at home (take them off in the garage or right at the door and immediately shower)
• Teach your kids to properly wash their hands and cough
• Even though you might just be lounging at home and not seeing different people, change your clothes daily (this also can help bring a sense of normalcy during an isolating and possibly depressing time)

Prepare your home

With all of the school closures, adjusted work hours, restaurant/bar closures, etc. you may want to make sure you’ve got essentials on hand in the event you do get sick and can’t get out to get things and delivery options are minimal, expensive, or take way too long.

Think about what you would need to have on-hand to get through a week or two without physically going to the store. Please, don’t stock up for the apocalypse. There are a lot of people out there trying to get a reasonable amount of things for their home, but can’t because one person bought 75 packages of toilet paper and every single ounce of meat. Buy what’s reasonable to have for you. Please don’t try to have an arsenal of toilet paper somehow thinking that’s going to keep you from getting ill.

While you may not have your top favorite meals and may need to stray from your routine in terms of meal prep, it is better than going without entirely. I’m not going to talk specifics here because everyone’s lives are so different, but don’t forget about things like pet food, medication supply, baby formula and diapers, toothpaste, etc.

Maintaining your normal

After you’ve prepared your home and are taking care of yourself the best way you are able to at this time, try to get back to whatever sense of normalcy you can. When we think/talk about COVID-19 constantly, it just adds fuel to the fire.

Be intentional about plugging into your normal interests, day-to-day activities, and life. Look for innovative ways to adjust your daily routine during this time. Maybe get some spring cleaning done, watch that show you’ve been meaning to catch, read that book, take that online course, do that home-yoga video series, start that garden, paint that room, or whatever has been on your to-do list.

Protect your mental space

Now that we’ve talked about some physical ways to optimize yourself practically, let’s dive into the often overlooked but incredibly necessary proactive mental measures we should take and reminders to maintain perspective.

This is like the mental training for running a marathon, which is just as necessary as the physical training.

Setting mental boundaries and pausing before reacting

You may find yourself obsessively checking news outlets, refreshing Twitter/Instagram/Facebook feeds, or constantly interrupted by push notifications with high-alert words like “quarantine,” “outbreak,” “death toll,” “survivor,” “unrepresented,” etc. You may also find yourself chatting with people who cannot stop talking about this topic.

When you’ve done all you can to practically prepare yourself and your home for something like this, continuing to read up on details and things that aren’t really going to change things isn’t helpful. It actually becomes harmful.

Just because something is published or you receive a notification about it doesn’t mean it’s actionable or necessary. New organizations and social media create notifications to spur you to go to their app, open it, and stay on it as long as possible. It is up to us to control the time we spend on it and guard our mental and emotional well-being.

If you’ve already taken the necessary practical precautions, continuing to dissect this information is just going to increase your fear, the feeling of a lack of control, and your anxiety more. If you’re reading things and noticing feelings of anxiety, fear, stress, or even panic – pause.

Take some deep breaths. Try to reframe your initial reaction with objectivity and identify / and give words to your body’s physical response to reading the distressing information. Simply acknowledging how you’re physically feeling and identifying the emotions you’re experiencing can significantly calm your stress response and enable you to choose a response rather than having an immediate reaction. Acknowledging that something is scary can take the sting out of it and put us in a better state of mind to decide whether or not to take action.

Once we’ve taken deep breaths and calmed the stress response, then ask yourself if this new information is actionable or helpful. If so, decide the new action you need to take, the questions you need to ask, and move forward.

Practical ways to set boundaries around this topic:

• Only checking the news during pre-determined times of the day (for example, before and after work)
• Turning off push notifications for news apps and social media
• Considering deleting social media off your phone and only looking at it during specific times of day on your laptop or desktop (I’ve actually done this myself)
• Not looking to other people’s reactions to gauge your own – just because someone else is fearful does not mean you need to be fearful to be a good parent, nurse, spouse, or family member
• Changing the topic when people keep bringing it up, or exit the conversation

How to pull ourselves out of fear

Whenever you take action, I encourage you to do that from a place of peace in knowing this is the right step – not fear, pushing you.

Don’t be pushed by your fears, be led by your conscious and intentional decisions that align with the person you desire to be.

Something can be frightening or unnerving, but we don’t want to make decisions out of that place. To pull yourself out of a place of fear, I recommend you using a practice called self-compassion. It is simple, free, easy – and no one has to know you’re doing it. 

It is evidence-based and has shown to elicit positive neurobiological changes when utilized, particularly by nurses and others who regularly experience vicarious trauma, like war veterans.

How to practice self-compassion

These are all steps you walk through mentally. Again, no one has to know you’re doing this. These are internal self-talking points that you consciously choose to tell yourself.

First, acknowledge the situation.

That is as simple as:

• “Wow, this is really scary. I feel scared.”
• “This is a really tough situation.”
• “I feel really overwhelmed right now.”
• “I’m so scared.”

Next, remember that everyone has tough moments. The fact that you’re experiencing a tough moment doesn’t mean that something is wrong with you, it means that you’re human. These challenging experiences should not alienate us into inadequacy, rather bring us together because to experience them is to be human. When we feel connection, we feel safe.

(Side note: During this time where we are having to practice social isolation to prevent disease transmission, try your best to stay connected with your tribe in innovative and fun ways like “Who can find the oldest thing in your medicine cabinet… or a virtual book club… or a virtual watch party… etc.)

Now, I should say that it is really difficult to remember this in the midst of negative emotions and fears. Actively remind yourself of this. I practice self compassion often, and it can be really challenging in the midst of big emotions to remember that other people have experiences like this too. It sounds so simple, but it’s very powerful.

Also, do not do that thing (that we all do) and compare our experience to someone else’s, and assume that because someone else has it tougher that our feelings then don’t matter… that we just have to tough it out ourselves.  Your feelings and experience do matter. It doesn’t need to fit a certain threshold to be considered “bad enough” to give yourself support.

Taking care of sick and dying patients isn’t just tough for the patient – it’s tough for the nurse too. Just because you signed up to be a nurse doesn’t remove that entirely human side of you. This is tough! We’re allowed to say to ourselves, “Yes, it is really hard for my patient to have Coronavirus, be on a vent, completely uncertain what will happen – but it’s also really hard to be here taking care of him as well”.

Vicarious trauma is not the cost of caring. It is not your burden to bear silently, pretending taking care of very sick people isn’t hard simply because you’re not the one in the bed.

The way you can reframe this is simply telling yourself;

• “Everyone has tough moments.”
• “Discomfort is a normal part of life.”
• “Having feelings of inadequacy/fear/discomfort/etc is a normal part of life.”
• “Struggling is part of being human. We all struggle and have imperfect experiences.”

Finally, we need to balance this all out with some warmth. We need to extend the same compassion we extend to our patients back to ourselves.

Imagine the words you would say to a little loved one who has come to you scared, hurting, sad, disappointed – what would you say to comfort them? Say those same words to yourself.

This can sound like:

• “It’s okay. You’re going to be okay. You will get through this.”
• “I’m right here. I’m safe. I’m okay.”
• “You’re safe. You’re going to get through this. You will be okay.”
• “May I be kind to myself. May I give myself the compassion I need.”

Let’s put it all together into what we call a self-compassion break. 

Here are some examples:

EXAMPLE 1

1. This is a tough moment
2. Tough moments are a part of life
3. May I give myself the compassion I need

EXAMPLE 2

1. That was really scary. I feel scared.
2. These moments are a normal part of life. Everyone feels scared at times.
3. I am doing all that is within my power and control. I’m going to get through this. I am safe.

EXAMPLE 3

1. This is a really uncomfortable moment. I feel overwhelmed.
2. Struggling is a part of the human experience. We all have imperfect experiences.
3. It’s okay. I’m okay. I’ve got this. I will get through this.

To summarize

Things are uncertain and scary right now. You are not alone, nurses. We are all here for one another as we weather this storm. We will get through this, like we’ve gotten through so, so much before.

Create a framework to set yourself and your loved ones up for success.

Rest, get hydrated, eat well, keep yourself clean. Get some time in nature… breathe in some fresh air, enjoy some sunlight. These are all powerful, practical things that can significantly improve our immune response.

Unapologetically protect your mental space. While it might feel uncomfortable in the moment to cut your colleague off who is going on another tangent that’s going to make you feel worried all day – remember that moment of discomfort is better than the worry you may carry all day and the resentment you’ll feel towards them for (probably unknowingly) continuing to entice your fears. Be bold to protect your mental wellness.

Reframe fear. Move from a place of peace.

Be wise about what you post online. As a nurse, know that your words carry weight. You have the power to instill calm and peace, as well as to increase fear. Choose your words wisely.

It’s a lot to ask someone to go into a normal day of work and care for the very thing the news is constantly telling them to be terrified of… to tell them to do it well… to work extra hours… and to take care of themselves so they don’t contract it themselves…

To quote Dumbledore from Harry Potter, “Once again, I must ask too much of you”.

Know that this is asking a lot of you… that this is really hard… and it can be scary.

I see you, I feel you, I hear you. Command the space and grace you need as a human and a nurse. You are absolutely worthy of it.

References

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Resources

• 7 Ways to Make Water Taste Better
• ‘Forest Bathing’ Really May Be Good for Your Health
• How Sleep Affects the Immune System
• Boosting Immunity: Functional Medicine Tips on Prevention & Optimizing Immune Function During the COVID-19 (Coronoavirus) Outbreak 
• Yoga Before Sleep: Complete Guide to Bedtime Yoga For Better Sleep
• 10 Clever Ways to Clean With Lemon
• Self-Compassion
• Nurses and Secondary Trauma
• How to Safely Get Vitamin D from Sunlight
• CDC Coronavirus Fact Sheet
• World Health Organization – Coronavirus Updates
• CDC – Coronavirus Updates 
• American Nurses Association – Coronavirus Updates
• American Association of the College of Nurses – Coronavirus Updates