The value of nurses in times of COVID: a Public Health perspective

On 31 December 2019, as we entered what was to be the International Year of the Nurse and the Midwife, we did not consider the looming threat already upon us.¹ This was the start of a global challenge driven by a virus that has called into question not only our entire, carefully constructed healthcare structure, but also our economic, social, family, political and even religious structures. This has brought about a change in the lifestyles of all humanity, which forces us to avoid the social relationships that so characterise and unite us as human beings, regardless of place of birth, race, social status, economic position, age or sex.

On 11 March 2020, the World Health Organisation declared COVID-19 a pandemic.²

By that time, people had already been bombarded with recommendations, instructions, and standards that we as health professionals disseminated. There was also a great amount of news, uncertainty, concern, fear, and compromised needs that clashed with our lifestyles. Soon, with the help of the media, we as health professionals had flooded every corner of society with terms, hitherto exclusive to the health disciplines, such as the difference between a suspected, probable, confirmed or ruled out case; when to determine close contact and when it is not of great relevance; the meaning of isolation and quarantine; the difference between cleaning and disinfection; the usefulness of PCR, serological, rapid and antigen tests and how their results are interpreted. Thus, terms such as “cumulative incidence”, “positivity rates”, mortality, and fatality have been gradually incorporated into our vocabulary, and how to differentiate between cumulative and non-cumulative cases.³

We also learned and “unlearned” about surgical masks, FFP2 or FFP3, and taught people how to make good use of them. We included safe distances, and we saw how a meter and a half is a huge distance when it stops you getting close to the people you love, but a very short one if it prevents you from infecting them. Finally, we now see how hand washing is the cornerstone in preventing the spread of SARS-CoV-2, an activity recommended and carried out by nurses from a century ago to prevent infection in the people under our care.

Health professionals have been able to reinvent the health system to respond to this social and health emergency, and it has been nurses in every hospital, health centre and care home who have led the implementation of all procedures and pathways with kindness and absolute dedication. Nurses have known how to innovate to ensure all the professional care required by people with COVID-19 and their families, who have experienced with anguish the problems associated with COVID-19 in their loved ones without being able to be by their side. Despite the constant changes in protocols, nurses have managed the changes in every unit, making the difficult easy, and once again, being by the side of the people who need our care, our support, and our accompaniment until the final goodbye.

To ensure the well-being of people free from the threat of SARS-CoV-2, states have invested an enormous amount of resources to re-establish health, economic and social structures, and to normalise a new way of living by finding a balance between the rights of individuals and safeguarding the health of the entire population.⁴

We are learning more about the virus every day. Although we still have relatively little scientific evidence, we know more about its mechanisms of transmission, the immune system response, the behaviour of the virus in different settings in terms of temperature, relative humidity, overcrowding, indoors or outdoors, ventilation with or without a filter, etc. According to the data available to date and the repeatedly observed pattern, 80% of identified cases present in a mild or moderate form, 15% require hospital admission and 5% require intensive surveillance.⁵ The most frequent symptoms include fever, cough, and a feeling of respiratory distress, although the infection has also been observed to present with a huge variety of symptoms similar to other respiratory diseases. We also know that, as yet, there is no drug treatment or vaccine capable of halting transmission of the disease, however we do know the measures that are more or less effective in preventing it, and how to protect ourselves against it.⁶

In short, we have had to take surveillance, prevention, and control measures while learning about the virus, which has made it exceedingly difficult to manage this global public health crisis.

However, even as we are immersed in this difficulty, we know that we have procedures backed by sufficient scientific evidence that, without a doubt, contribute to mitigating the effects of this pandemic.⁷ I am referring to health promotion and protection, to disease prevention and to the tools that guarantee its application such as health education⁸ and community intervention.

Nurses bring quality and warmth to restoring and maintaining people's health. Their competence and vision offer so much that cannot be replaced by any other profession. Yet we must go a step further so that all nurses incorporate health education with all the science that supports it in each and every one of the areas in which we work.

As an example of this approach, the Outbreak Containment Plan proposed by the Directorate General for Public Health and Participation of the Balearic Islands, based on the COVID-19 Early Detection, Surveillance and Control Strategy and published and regularly updated by the Ministry of Health,⁹ includes three strategic lines, in each of which nurses play a key role as an integral part of a multi-professional team.

The first strategic line establishes the process of detecting Sars-Cov-2 by means of diagnostic tests that detect active infection. It establishes the basic principles of proportionality and equity to ensure those who require tests receive them. It must fundamentally target the early detection of cases with transmission capacity and prioritise this over other strategies. This is why active infection testing is carried out on an individual basis of suspicious cases and their close contacts. We also refer to extended testing when we undertake periodic screening, selecting groups of vulnerable populations such as those in care homes and care home workers. In these cases, specific populations are tested after prior assessment when transmission at community level indicates certain patterns of infection such as in particular age groups, or those who have visited the same place in a specific period where outbreaks have been identified.

The second line sets out how cases and their contacts should be reported and isolated promptly. The place of isolation of choice is the home, if the person's state of health allows it, and this requires prior assessment to ensure that it meets the optimal conditions for effective case isolation and contact quarantine.¹⁰ When the person's home does not meet the appropriate conditions, there are two alternatives according to identified needs, the first is to provide assistance, and the second to ensure isolation in places that are equipped such as hotels or other facilities that can ensure appropriate isolation and quarantine.

The third line includes actions required to contain the outbreak efficiently. It covers everything from general preventive and protective measures, such as safety distances and the correct use of masks, to specific measures established for each area of exposure based on contingency plans drawn up with each of the agents involved. Contingency plans have been established in hospitals, social and health areas, prisons, areas of education, labour, irregular migration, transport, culture, sports and community.

The community setting includes a community intervention plan to contain outbreaks through a social structure created via community platforms and identifies measures to restrict capacity and limit movements established according to a prior risk assessment. The risk assessment includes epidemiological indicators such as cumulative incidence at 7 and 14 days, health indicators such as hospital and primary care pressure and, finally, social indicators such as population density or economic indicators such as average income. The plan could not be implemented without multi-professional teams from each area of exposure.

The experience of nurses in the community after so many years of primary and community care, provides integrality and focuses on the welfare of people taking existing resources into account. Moreover, nurses with our background and training, are able to identify the needs of people at home and in the community accurately and quickly and, therefore, play a key role in training these teams so that outbreaks can be controlled in all areas of the population.

It is time for public health and primary care¹¹ to work as a single team to provide health in all policies,¹² and in this sense have the capacity to influence people to improve and protect their health in all the areas where they work, education, family, social, cultural, sports, etc., making use of community intervention¹³ and involving all community agents. It is time for nurses to act as true leaders in these areas, not just for the sake of it, but because we are the most qualified professionals to do so. We have the knowledge and we have acquired sufficient skills through practicing them for years as highlighted by our attitude.