In her excellent editorial, “Rising from the ashes: affirming the spirit of courage,
community resilience, compassion and caring,” Professor Alison Kitson raised several
pertinent issues around caring in and for the world that we live in, set against the
devastation caused by the Australian bushfires (Kitson, 2020). Whilst watching the
horrendous television footage of the Australian disaster unfolding at the beginning
of the year, another news item was beginning to gain momentum, the emergence of an
unknown coronavirus disease in Mainland China. Once more, we witnessed dreadful humanitarian
images that looked like footage from a science fiction movie, sick people being heralded
into makeshift camps by individuals in protective suits. However, once again it was
not a movie, it was very real.
Living in Hong Kong, the emergence COVID‐19 immediately drew parallels with the 2003
severe acute respiratory syndrome (SARS) outbreak, which brought devastation to the
region. The profound impact that SARS had upon the people of Hong Kong can still be
clearly seen seventeen years later; people habitually wearing protective facemasks,
communally touched surfaces in public places being regularly disinfected, antibacterial
hand gel dispensers located throughout all shopping centres, and public toilets that
are amongst the cleanest in the world. The intent to prevent another SARS‐like infection
in Hong Kong is clear for all to see; however, that all changed at the end of last
year with the emergence of novel coronavirus in Mainland China, Quickly, cases were
confirmed in Hong Kong and the fear of another pandemic lead rapidly to a pandemic
of fear. People were panic buying, prices were rising, and supermarket shelves were
very quickly stripped of essential food items and basic cleansing products. It was
impossible to turn on the television without being told about the importance wearing
surgical masks, how to wear surgical masks, the surgical masks celebrities were wearing
and the danger of wearing “fake” surgical masks. Interestingly, limited attention
was being given to the effectiveness of wearing a surgical facemask in the face of
viral infection. Surgical masks were, and still are, in very short supply and retail
prices have increased sharply. One enduring television image of recent weeks has been
the sight of older people standing in line overnight in cold weather to get a small
package of surgical masks hoping to protect themselves from the virus. Perhaps, all
of these activities mask the truly important public health message that good personal
hygiene and effective handwashing is the most effective way to curb the spread of
the virus. As clinical nurses, we all know that engaging in these actions will outweigh
the benefits of wearing any surgical mask.
SARS generated a lot of very influential nursing research, particularly in the field
of infection control nursing. The Journal of Clinical Nursing published several significant
papers that highlighted the emotional impact of caring at the time of SARS and dealt
with some of the other lessons that could be learnt from the outbreak, in terms of
evaluating systems of care delivery and use of nursing care models (Watson, 2009).
It was hoped that research generated during this period would help the international
nursing community be in a better position to deal more effectively with any subsequent
viral outbreaks. With the emergence of COVID‐19, that was about to be tested. Would
healthcare managers and hospital administrators understand what is really needed to
support nursing practice and ensure the provision of high quality of care? Would they
deliver this time?
It was clear that amidst a worsening humanitarian crisis in Wuhan and the surrounding
regions of China that uncertainty was rife. Despite widespread efforts in the Chinese
mainland to combat the control and spread of COVID‐19, including the very quick construction
of purpose‐built hospitals; at the time of writing, many large cities remain in complete
“lock down,” with an ongoing massive quarantine of over 50 million people. COVID‐19
was about to show no respect for geographical borders and to test whether the world
was ready to deal effectively with a health risk of such high magnitude.
Reflecting on this situation at the beginning of the year, it was possible to see
that there were parallels in relation to issues of caring, compassion, courage and
resilience between the struggle with the COVID‐19 and those of the Australian disaster,
as outlined by Alison Kitson (2020). This editorial sets out to examine some of these
issues that are closely associated with the nursing profession.
Historically, nurses have always played an important role in infection prevention,
infection control, isolation, containment and public health, as initially advocated
by Florence Nightingale. Providing these aspects of care at this capricious time,
our clinical nursing colleagues in China and around the world are working under enormous
pressure to battle this life‐threatening viral infection. Worryingly, it is clear
that many of these nurses and healthcare professionals are not only fighting the virus,
they are also fighting the humanitarian crisis with limited protective supplies, putting
their own lives on the line.
Howard Catton (ICN CEO) commended the courage and compassion that has been shown by
Chinese nurses, stressing the importance of them having access to the correct safety
equipment and clothing at this time. However, there have been numerous reports of
shortages of even the basic personal protective equipment, such as masks and protective
suits (ICN, 2020). It has even been reported that in some rural Chinese hospitals,
clinical staff have resorted to wearing their raincoats and using plastic bags as
a source of protection (Buckley, Wee, & Qin, 2020). World Health Organization Director‐General
Mr Tedros hailed healthcare workers as “the glue that holds the health system and
the outbreak response together” (WHO, 2020). Indeed, the WHO provides very comprehensive
guidelines for the protection of front‐line healthcare workers when faced with such
an epidemic. The question is how can nurses adhere to such guidance when they are
starved of even the most basic personal protective equipment? How adhesive can “the
glue” be in the face of such adversity?
One third of all fatalities during the 2003 SARS outbreak in China were healthcare
professionals (Hung, 2003); at the time of writing, COVID‐19 has already accounted
for the lives of eight healthcare professionals (Griffiths, 2020). Healthcare‐associated
amplification of transmission of emerging viral infections is always a concern; surely,
lessons should have been learnt about the importance of occupational protection during
previous epidemics, including the Middle East respiratory syndrome (MERS) outbreak
in 2012. Clearly, some lessons have not been learnt, as clinical nurses in China who
are battling the virus are working around the clock and some are not eating food so
as to avoid the need for toilet breaks (Thiagarajan, 2020). Nursing staff need to
change their protective gear if they take a toilet break; therefore, some have resorted
to wearing diapers and there are even stories of nurses shaving their heads to reduce
spread of infection and to allow them to be able to change their protective gear more
quickly (Farber, 2020). Stories of nursing courage and compassion are bounteous; however,
the narrative of Nurse Yao, captured by the BBC, is one which is particularly touching.
Her day‐to‐day job was in a fever clinic, she decided not to celebrate Chinese Lunar
New Year with her family and chose to volunteer to work in a hospital in the epicentre
of the virus. In a moving narrative, she expressed her strong devotion to care for
those with the virus, reporting long working shifts “at the end of the shift, when
we take off our suits, we find our clothes are completely wet with sweat” and exhaustion
“nursing staff would collapse at the end of their shift and they were too tired to
walk home.” Despite working in such adversity, Nurse Yao chose to highlight the positive
aspects of her work with her nursing colleagues “the virus brings us all together,
it unites us.” (BBC, 2020a).
The word resilience is used a lot these days, and it has become something of a buzzword
in nursing, leading to criticism from within and out with our profession. However,
if we view resilience as “the ability of an individual to withstand adversity” (Jackson,
Firtko, & Edenborough, 2007 p3), then Nurse Yao embodies what it is to have resilience
in nursing.
During the last few weeks, there have been unprecedented levels of misinformation,
conspiracy theories, fake news and rumours related to COVID‐19, these can only be
counterproductive in the fight against the current epidemic.
Perhaps, this is the first major disease outbreak that poses a global threat in the
age of social media. Accounts vary, but it is clear that social media and sensationalist
reporting of the outbreak have generated panic and mistrust in the general public,
not only diverting attention away from the response to outbreak but also impeding
the activities of already stretched healthcare professionals. Hopefully, we and the
general public can gain some reassurance because the WHO are using their Information
Network for Epidemics platform to track for false information in numerous languages
and are working with social media providers, including Facebook, Twitter and Weibo
(a Chinese blog platform) to help filter out such misinformation. Conceivably, COVID‐19
will provide an opportunity to put into practice some of the lessons we learn from
studies of social media during this outbreak, specifically in relation to the dynamics
of online heroisation and blame. However, it does remain difficult to know what to
believe with the current media coverage of COVID‐19.
Remarkably, the WHO have deemed it necessary to circulate a statement indicating several
measures, that have been touted online and in social media, which are not effective
in the treatment of COVID‐19 including taking excessive vitamin C, smoking (yes seriously!),
wearing multiple surgical masks and self‐medicating with antibiotics. The WHO also
provides “Open WHO,” which offers free and reliable health‐related information to
the world. In China, medical advertisers have not missed the opportunity to capitalise
on the outbreak of COVID‐19, reporting that one traditional Chinese herbal remedy
may be effective in the prevention and treatment of the COVID‐19 (Heymann & Shindo,
2020). This remedy has now sold out across China, despite the fact that there is presently
very limited evidence to support the claims; indeed due to the nature of the illness,
it may actually produce counterproductive effects. It is also somewhat ironic that
the most likely crossover of the virus took place at a wet market, selling the very
foods and remedies that are used in traditional health practices to promote immunity
and longevity. The scientific community certainly needs more high‐quality rigorous
research into the issues surrounding the combined use of Western and Chinese medicine
in the prevention and treatment of disease.
As well as stories of courage and strength, times of crisis have been known to bring
out the darker side of human nature. Historically, the response to new diseases and
other catastrophic events have been known to evoke feelings of mistrust, hatred, fear
and outright racism. It has been shocking to hear the nature and the extent of anti‐Chinese
racism and stereotyping that has been reported around the world (BBC, 2020c). From
“coronavirus student parties” to the outright ban of people of Chinese ethnicity from
many restaurants, it would appear once again that the fear of pandemic has further
stoked a pandemic of fear. Healthcare professionals have not been exempt from such
expression of hatred and racism, the BBC reported one Filipino cardiac nurse in England
being asked to “stop spreading the virus” whilst on public transportation (BBC, 2020b).
Such levels of xenophobia and racial profiling are utterly abhorrent and have no place
in a modern civilised society.
Unfortunately, racism in the face of humanitarian disasters has a much longer history
than that of the current COVID‐19 outbreak. Human catastrophes are not just the result
of natural phenomenon; they are linked to political, social and economic factors that
create vulnerability to risk. Any response to a major disease outbreak is always deeply
political. Racist fear mongering and pointing the finger of blame towards Chinese
and Asian nationals may have contributed to the development of the current disaster.
Several nurses and doctors have lost their lives to COVID‐19, including Dr Li Wenliang
who was one of the first medical doctors to express concern about the emergence of
a new SARS‐like illness in the Hubei province (Green, 2020).
Another important lesson that should have been learnt from previous experience, such
as the SARS outbreak, is the need for appropriate psychological support for the healthcare
professionals. Clinical nurses, especially those working in hospitals providing front‐line
care for those with COVID‐19, are not only vulnerable to a higher risk of infection
but also mental health problems. The Journal of Clinical Nursing reported increased
levels of post‐traumatic stress disorders, anxiety and depression in nurses after
the SARS outbreak (Thompson, Lopez, Lee, & Twinn, 2004). They may experience fears
of contagion and spreading the virus to others, including loved ones. We cannot ignore
the need for timely psychological support and care specialised for those affected,
psychiatric treatments and appropriate mental health services need to be provided.
COVID‐19 presents a vast public health challenge, not only to China, but also around
the world. As outlined in this editorial, it has already posed many challenges to
our profession and international research community. It was only through high‐quality
nursing research that some of the questions raised by the SARS outbreak were answered
and lessons were learned. In some ways, COVID‐19 may act as a wake‐up call to the
world to revisit those lessons and to re‐examine public health priorities. We live
in a very different world from that of 2003, it is a constantly changing and very
unpredictable world. Hopefully, this outbreak will provide scope and impetus for nurse
researchers to address some of the key questions that have been thrown up by the current
epidemic and we need to do this in a collaborative way and from an international perspective.
We, as nurse researchers, should be mindful of the benefits of conducting this research
with healthcare colleagues in related professions to further develop the knowledge
base of the international scientific community. Despite extensive efforts, there also
needs to be more international collaboration amongst government, health agencies and
key stakeholders to ensure the response to the outbreak is optimised and to ensure
timely dissemination of accurate information. There should not be a disconnection
between those communicating the information and those requiring it, importantly the
internet and social media should not become the clearing house for vital health‐related
information for the general public.
Presently, outbreaks of COVID‐19 have been declared in at least thirty countries,
most markedly in Italy, Iran and South Korea (BBC, 2020d). The latter, which was badly
affected by MERS outbreak in 2012, is now on its highest alert. The WHO has warned
the world to brace itself in preparation for a pandemic (BBC, 2020e).
As nurses, we possess invaluable information on how to deal effectively with public
health issues, as Professor Kitson urged we should not be afraid to speak out on those
issues. At this time of great uncertainty, the voice of the nursing profession needs
to be heard by the world. Not only in the battle against COVID‐19, but also in preparation
for the next major health challenge. Globally, public health depends upon it.