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Nurses on the front lines during pandemics

By: Jackie L. Hoskins, BSN, RN, CCRN; Shirley Ambutas, DNP, APN, CCRN-K, CCNS; Vera Clinton, DNP, APN, ACNS-BC; Barbara Gulczynski, DNP, APRN-BC, CCRN-CMC; and Janice Phillips, PhD, RN, CENP, FAAN

An annotated bibliography.

Editor’s note: This article has undergone peer review.

Key Points

  • Infectious disease outbreaks are an emerging global threat.
  • Nurses are one of the most invaluable assets during any infectious disease outbreak.
  • Nurses in all settings must have the appropriate access to personal protective equipment (PPE) as one of the most important means to protect themselves and mitigate further spread of any infectious disease outbreak.

This article provides an annotated bibliography on frontline nurses providing care during pandemics. The authors are all actively engaged in guiding and analyzing patient care, educating interdisciplinary team members on personal protective equipment (PPE), establishing evidence-based protocols, or supporting frontline nurses during the current COVID-19 pandemic.


On March 11, 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic. The escalating number of cases and deaths attributed to this deadly virus called for an all-hands-on-deck approach to providing care to some of the world’s sickest patients affected by the disease. Although nurses in some parts of the world have experience caring for patients and communities during previous infectious disease outbreaks (e.g., severe acute respiratory syndrome [SARS], H1N1, Ebola), not since 1918 have nurses in the United States had to serve during a pandemic of such magnitude as the COVID-19 pandemic.

As always, nurses around the globe are stepping up to provide lifesaving care to our sickest patients. They’re providing direct patient care, leading preparedness and response operations, and working with society at large to mitigate the deadly impact of this infectious disease outbreak. The heroic contributions and challenges of nurses throughout history during times of pandemics are relevant for nurses serving in this current one.

The aim of this annotated bibliography is to provide a brief synopsis of the various nursing issues, challenges, and contributions of nurses who have served during previous infectious disease pandemics. We conducted a search for research articles using the databases PUBMED, CINAHL, and Embase. Search terms included nursing, pandemics, infectious disease outbreaks, and disaster preparedness

The following is a sampling of published articles and is not meant to be an exhaustive review of the literature. Articles were selected because of their relevance to nursing practice and their ability to provide a variety of perspectives related to the nursing workforce, disaster preparedness, and professional nursing issues during previous pandemics. They are divided into categories.

Historical nursing perspectives

Robinson KR. The role of nursing in the influenza epidemic of 1918-1919. Nurs Forum. 1990;25(2):19-26.

The author examined the historical role of nursing during the influenza pandemic of 1918-1919. Three waves of the disease occurred in less than 12 months. The first wave occurred in the spring of 1918 and was mild, resulting in a low death rate.

The second wave spread from France to England and then to Spain, killing as many as 8 million people; it was labeled the Spanish flu. The second wave hit the United States in the fall of 1918. During this wave, about half of the deaths worldwide occurred among those 20 to 40 years old. In the last 4 months of 1918, 380,996 deaths were reported in the United States. The third wave in the United States occurred in early 1919 and was considered less severe.

During this pandemic, members of the visiting nursing services rapidly mobilized in the midst of a severe nursing shortage to create an emergency council that made home visits and taught the principles of good sanitation and disease prevention. Nurses serving in rural areas demonstrated much ingenuity, such as using hot bricks instead of hot water bottles and melting snow to bathe patients when caring for the sick during home visits. Nurses’ resilience, ingenuity, heroism, and keen mobilization skills earned them the reputation of being heroines in the fight against the deadly influenza virus.

The author concluded that nurses were instrumental in mobilizing large groups of people and were front and center in teaching personal hygiene and home sanitation to families. Nurses’ contributions during this time brought visibility and recognition for the Visiting Nurse Service of New York, providing testament to nurses’ invaluable role during the influenza pandemic of 1918-1919.

Keeling AW. “When the city is a great field hospital:” The influenza pandemic of 1918 and the New York City nursing response. J Clin Nurs. 2009;18(19):2732-8.

The author used a social history framework to analyze nurses’ role in responding to the second wave of the influenza pandemic in the fall of 1918 in New York City. The author highlighted the work of the Henry Street Visiting Nurse Service and the Nurses’ Emergency Council under the leadership of Lillian Wald, who was the director of the Henry Street Visiting Nurse Service and chair of the Nurses’ Emergency Council.

The New York City nurses provided care to thousands of patients with minimal federal support. They relied on local community agencies to establish makeshift hospitals and soup kitchens. The Henry Street Visiting Nurse Service, along with many social agencies and Red Cross volunteers, visited patients in their homes and provided nursing care. The immediate combined efforts of a previously established network of nursing and other social organizations, along with the American Red Cross and the United States Public Health Service, were instrumental in getting nursing care to those affected by the influenza virus. The author concluded that if a pandemic were to occur in 2009, when the article was published, immediate cooperation and collaboration would be essential at the local, state, and federal level.

Pandemic preparedness

Tiwari A, Tarrant M, Yuen KH, et al. Preparedness for influenza pandemic in Hong Kong nursing units. J Nurs Scholarsh. 2006;38(4):308-13.

In 2005, the WHO updated its pandemic plan in anticipation of a future pandemic. Building on this anticipatory guidance, the authors presented a three-phase preparedness plan for use during an influenza pandemic in the context of nursing services on two hospital units and university-based schools of nursing in Hong Kong.

The three phases of this preparedness plan comprised pre-event, event, and post-event. The pre-event phase focuses on staff training, communication, surveillance, infection control, and influenza vaccination. Once a pandemic outbreak occurs, the event phase goes into effect. This requires strong leadership, an effective communication system, ongoing surveillance with recommended infection control measures, strong capacity management, and support to staff and students as needed. The post-event phase focuses on restoring core functions. This phase requires ongoing diligence to prevent a reoccurrence of an outbreak and post-event support for staff and students. During this phase, nurses are actively engaged in restoring the delivery of patient care services.

Continuous monitoring of any organizational plans during a pandemic is of vital importance, a role that all nurses can take part in. The authors concluded that the proposed plan could serve as a framework for establishing a plan of action and was not to be used as a contingency plan during an infectious disease outbreak.

McMullan C, Brown GD, O’Sullivan D. Preparing to respond: Irish nurses’ perception of preparedness for an influenza pandemic. Int Emerg Nurs. 2016;26:3-7.

The authors examined the perspectives of nurses involved in planning for an influenza pandemic at an acute care hospital in Ireland. Ninety-one nurses completed an adapted survey that explored

  • personal and professional concerns
  • perceived impact on personal and professional life
  • preparedness for an influenza pandemic.

Respondents expressed a major concern regarding becoming infected from the influenza virus or infecting others, such as families, friends, and colleagues. Most respondents (78%) noted that others would be concerned for the nurses’ own health, highlighting the need to educate all stakeholders during a pandemic. Although 90% of respondents reported the potential for an increased workload, 86% expressed fears of inadequate staffing. Despite these challenges, 90% of respondents saw it as their job to care for patients during a pandemic.

The authors underscored the importance of addressing the fears and concerns of frontline workers as a means to help improve the work environment and support the delivery of effective care to communities. 

Professional nursing issues

Wood PJ. Managing boundaries between professional and lay nursing following the influenza pandemic, 1918-1919: Insights for professional resilience today? J Clin Nurs. 2017;26(5-6):805-12.

Applying an historical research lens to the 1918-1919 pandemic in New Zealand, the author used findings from official reports, newspaper articles, articles published in the country’s professional nursing journal, and descriptions outlined in the memoir of the country’s chief nursing officer, Hester Maclean, to describe tensions between professional and lay nurses.

During the pandemic, RNs worked alongside lay volunteers in public and emergency

hospitals throughout the country. After the pandemic, the country needed to ensure there would be enough community capacity to care for the sick in their homes and emergency hospitals. Maclean fought to maintain the distinction between professional nurses and lay volunteers. The call to train lay volunteers to provide nursing care suggested a second line of nursing that had the potential to blur boundaries between the two groups. Nurses demonstrated resilience despite these tensions and readily shared their knowledge and expertise to train lay volunteers.

The author emphasized that Maclean helped guard professional boundaries by maintaining control over community instruction in nursing and helping to build community lay nursing capacity by showing how professional and lay nursing could be effectively managed.

SARS pandemic

Shiao J, Koh D, Lo LH, et al. Factors predicting nurses’ consideration of leaving their job during the SARS outbreak. Nurs Ethics. 2007;14(1):5-17.

Using survey methods, the researchers explored factors predicting nurses’ considerations of leaving their job during the SARS pandemic in Taiwan in early 2003. Findings from 753 respondents revealed that nurses with more seniority and more work tenure were less likely to contemplate leaving their jobs. Nurses with previous experiences caring for patients with SARS also were less likely to consider leaving their job during an outbreak.

Predictors such as increased workload, shorter work tenure, fear of infection, perceived futility fatality of SARS, and fear of social isolation were identified as important factors shaping a nurse’s decision to leave his or her job during the pandemic. And although 10% of nurses in Taiwan considered leaving their job, concerns regarding the lack of an adequate supply of PPE may have been fueled by the lack of labor laws with a specific focus on protecting employees against infectious agents.

Researchers emphasized the importance of creating a more positive environment for nursing practice during a pandemic.

H1N1 pandemic

Corley A, Hammond NE, Fraser JF. The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: A phenomenological study. Int J Nurs Stud. 2010;47(5):577-85.

Using phenomenology methods, the authors examined the experiences of 34 nursing and medical staff caring for patients in an Australian intensive care unit (ICU) during the height of the 2009 H1N1 pandemic. Questionnaires and focus groups were used to capture the lived experience of staff working during this pandemic. Findings identified eight themes: wearing of PPE, infection control procedures, fear of contracting and transmitting the disease, adequate staffing levels within the ICU, new roles for staff, morale levels, education regarding extracorporeal membrane oxygenation (ECMO), and the challenges of patient care.

Researchers identified recommendations for future pandemic planning, including

  • appointing a dedicated infection control representative and a pandemic coordinator to enhance communication and overall management during times of crisis
  • maintaining effective communication channels
  • ensuring an PPE adequate supply
  • educating staff about advanced therapies
  • preparing staff to care for large volumes of severely ill patients.

Although not generalizable, these findings provided valuable insights when planning for future pandemics.

Dezzani-Martin S, Brown L, Reid M. Predictors of nurses’ intentions to work during the 2009 influenza A (H1N1) pandemic. Am J Nurs. 2013;113(12):24-31.

The authors examined the predictors of nurses’ intentions to work during the 2009 influenza A pandemic. Researchers sent questionnaires to a random sample of 1,200 nurses registered with the Maine State Board of Nursing. The questionnaire included demographic questions and 23 items assessing willingness and ability to work.

Of the 735 respondents, 90% expressed an initial intent to work during a pandemic. Respondents were significantly more willing to work during the influenza pandemic if provided adequate PPE. The opportunity to receive double pay or room and board were negative predictors of willingness to work. Other negative predictors associated with willingness to work included fear of developing flulike symptoms or infecting family members at risk for illness or death.

The authors acknowledged a lack of diversity among respondents, as most were white, female, and non-Hispanic working in a rural area. Although the 2009 flu pandemic was considered mild, as the threat of the disease increased, respondents were less willing to work. Discussion with managers after the pandemic ended included the need for enough N95 masks and other PPE to help ensure safety of patients, nurses, and nurses’ families. Nurses would be more willing to work during a pandemic if PPE issues were resolved.

Findings from this study underscored what employers must do to ensure an adequate nursing workforce during a crisis of this magnitude.

Honey M, Wang WY. New Zealand nurses perceptions of caring for patients with influenza A (H1N1). Nurs Crit Care. 2013;18(2):63-9.

The authors examined the perceptions of highly specialized nurses who provided ECMO therapy to patients infected with the H1N1 virus in New Zealand in 2009. The study used a two-phase mixed method study design (focus groups and questionnaire). During Phase 1, five nurses attended focus group discussions to share their views, challenges, and issues when caring for these patients. The researchers used focus group findings to inform Phase 2. Eighteen of the 25 eligible nurses completed the survey, constituting a 72% response.

Findings from both the survey and focus group revealed six challenges associated with providing care to ECMO patients during the pandemic. The three leading challenges were caring for high-acuity patients, wearing gowns and masks for 12-hour shifts, and feeling overworked and tired. Other challenges included fear of the unknown, working in an isolated environment, and fear of being infected.

Despite these challenges, nurses felt positive about caring for patients with H1N1 and felt that the experience of doing so advanced their skill set and level of job satisfaction. The authors offered recommendations for consideration during future pandemics, including the need for education on ECMO therapy for all providers and not just nurses.

Nurses on the front lines during a pandemic caring for ECMO patients should be recognized for their contributions during high-stress scenarios. These nurses could benefit from receiving support through strong interprofessional collaboration and communication as well as counseling services.

Zapata LB, Ruch-Ross HS, Williams JL, et al. Postpartum and neonatal nursing care during the 2009 H1N1 influenza pandemic. Nurs Womens Health. 2013;17(4):284-93.

Researchers surveyed members of the Association of Women’s Health, Obstetric and Neonatal Nurses to elicit data from nurses who planned and provided direct care to women during the early postpartum period and who provided neonatal care during the 2009 influenza A H1N1 pandemic. Participants (12,612) were initially sent an online survey to identify nurse demographics and hospital policies and procedures as well as to evaluate the Centers for Disease Control and Prevention (CDC) guidelines for this vulnerable patient population. Hospital administrators, educators, and/or nurse managers were not eligible to participate. In all, 2,641 nurses were deemed eligible to participate and subsequently completed the survey.

Most respondents (75%) rated CDC guidance on infection control as being very helpful, but 2% did not rely on the CDC guidance when providing care to this population. Participants indicated that hospital administration struggled with practices surrounding family-centered care, such as visitor restrictions and supporting new mothers who wanted to breastfeed their newborn during quarantine.

Researchers shared several lessons learned for use during future pandemics when providing care to antepartum, intrapartum, and postpartum patients and newborns. Ongoing continuing education and collaborative grand rounds are critical to enhancing clinical practice during public health emergencies.

Avian influenza H5N1

Ben Natan M, Zilberstein S, Alaev D. Willingness of future nursing workforce to report for duty during an avian influenza pandemic. Res Theory Nurs Pract. 2015;29(4):266-75.

Using Bandura’s Self-Efficacy framework (1997), researchers examined the self-efficacy and the perceptions of nursing students’ concerns for readiness to work during an Avian influenza pandemic while attending three academic nursing schools located in central Israel. A six-part, self-report questionnaire included questions related to sociodemographics and training, perceived self-efficacy, personal and family safety, perceived working conditions, willingness to report to work, and knowledge of nursing practice. Two hundred nursing students completed the self-administered paper questionnaire.

Results showed that half of the students were highly willing to report to work, with male Arab Muslim students scoring the highest on perceived self-efficacy. Findings revealed an association between students’ willingness to work during an influenza pandemic and financial incentives (76%), availability of PPE (69%), and convenient transportation. Conversely, female Jewish nursing students were less willing to work during the Avian influenza pandemic. The researchers recommended follow-up research after student nurse graduation.

Middle East Respiratory Syndrome (MERS)

Lee L, Kang SJ. Factors influencing nurses’ intention to care for patients with emerging infectious diseases: Application of the theory of planned behavior. Nurs Health Sci. 2020;22(1):82-90.

Using the Theory of Planned Behavior as a framework, researchers in this cross-sectional study examined Korean nurses’ intentions to care for patients with emerging infectious disease (EID) after the 2015 MERS epidemic in South Korea. Data were collected via an online questionnaire assessing beliefs about caring for patients with EID, perceived difficulty when caring for patients with EID, attitudes toward providing such care, perceived social pressure, perceived self-efficacy, and willingness to care for patients with EID.

Perceived behavioral control (high degree of confidence or self-efficacy), followed by attitude toward the behavior (the more positive, the more willing), were the two strongest predictors of a nurse’s intention to care for patients with EID. More men compared to women expressed an intention to care for this population.

The authors concluded that the Theory of Planned Behavior is a useful model for predicting nurses’ intentions to care for patients with EID.

Nursing implications

This brief synopsis of the literature underscores the invaluable role that nurses throughout history have played during infectious disease outbreaks. As history repeats itself, the findings from this review underscore a number of implications for nursing today as we navigate the COVID-19 pandemic.

PPE. Factors such as perceptions of risk and the availability of PPE were predictors associated with frontline nurses’ willingness and ability to work during previous pandemics. A major concern for nurses serving on the front lines during COVID-19 is the fear of being infected or infecting others.

In the midst of the current pandemic, nurses across the United States have expressed outrage regarding the lack of PPE. Numerous nursing organizations along with others have petitioned the federal government to find an immediate solution to this supply shortage so that nurses can be well protected now and into the future in the event of another infectious disease outbreak. To address this issue, nurses across the country are protesting and advocating on behalf of themselves and other nurses.

Public health nurses. Discussions highlighting public health nurses’ role during previous pandemics resonate with what is needed today to help mitigate the adverse outcomes associated with COVID-19. In separate articles, Keeling and Robinson described public health nurses’ invaluable role during previous pandemics, a contribution that deserves more recognition.

Public health nurses have traditionally used public health principles to help keep people safe throughout history, and today is no different. However, more effort is needed to enhance public health nurses’ visibility and recognition across the country. In recent years and in certain segments of the country, limited funding has been available to support a robust team of public health nurses. The current pandemic, similar to past pandemics, underscores the need for health promotion and preventive efforts in diverse settings, a job uniquely suited for public health nurses.

Skills. As noted throughout a number of articles, strong leadership, good communication, and interprofessional collaboration are essential skills that need to be fully operationalized during times of crisis. Nursing must continue to prepare its workforce in becoming proficient in demonstrating the use of these skills, which are even more important as we move to more electronic and digital communication platforms.

Research. As our global society continues to move forward to address the current COVID-19 pandemic, ongoing nursing research is needed. Research of this nature, particularly in the United States, is in its infancy. Now more than ever, capturing the experiences and support needs of all nurses serving on the front lines during any disease outbreak is a critical step in valuing and protecting one of our most valuable assets during times of crisis: Nurses.

The authors work at Rush University Medical Center in Chicago, Illinois. Jackie L. Hoskins is president of professional nursing staff, Shirley Ambutas is a clinical nurse specialist, Vera Clinton is a clinical nurse specialist, Barbara Gulczynski is an advanced practice nurse in the medical ICU (and an assistant professor at Rush University College of Nursing), and Janice Phillips is director of nursing research and health equity.


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