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"Dear Nurses, each of you is a gift, and we are forever in your debt."

The past 19 months has seen the onslaught of a pandemic unmatched in severity for at least a century. Now, as we dare to hope that return to normal life might be in sight, we do so cautiously, understanding that the SARS-CoV-2 virus is unlike anything we’ve seen before and it’s far too early to predict the end of the story. Everyone at every level of our healthcare delivery system stepped up to the challenge of caring for the victims of this virus. But as is always the case, it has been the nurses who made certain that there was always someone at the bedside and that no victim would be left alone.  This has been true since the beginning of nursing as we have come to recognize it.

There is fairly good evidence to support the notion that the nursing profession as we know it today had its beginning with Florence Nightingale. At first glance, Nightingale would have been an unlikely candidate to set that example. She was born into a very wealthy family, and given her affluent station, most people would find it inconceivable that she would do anything other than marry a suitable aristocrat and host elaborate dinners throughout the remainder of her adult life. To the contrary, at the age of 17, she refused a marriage proposal from just such a gentleman and made it clear over her parents’ strenuous objection, that aristocratic marriage did not comport with her ambition to minister to the sick. Seven years later she would enroll in a nursing school in Germany. Not long after completing her training, she returned to London and found a job at a Middlesex hospital. She quickly made a name for herself during a cholera outbreak when her attention to cleanliness and sanitation was so profoundly successful that it became a hallmark throughout the remainder of her career.

Arguably, Nightingale’s most well-known service occurred when she was persuaded by the British Secretary of War to take control a hospital for care of the British wounded in the Crimean War. She embraced the opportunity and travelled to Scutari, near present day Istanbul with 38 nurses that she had personally trained along with 15 Catholic nuns. They expected to find a hospital for wounded British soldiers. What she saw did not resemble a hospital. Instead, she found thousands of wounded soldiers, most of whom were dying, not from their wounds, but from the complications of infection fostered by poor sanitation, malnutrition, and neglect. No doubt it was through her aristocratic connections that she was able to persuade the British government to finance the building of a proper, well-equipped, well-ventilated hospital in addition to providing for effective sanitation and nutrition for the wounded. But what she is most remembered for (along with her tiny group of nurses) is a constant presence at the bedside which ensured cleanliness, vigilance against pressure ulcers, and perhaps most of all, the assurance that someone cared. It was because of that constant presence, day and night, that she became known as “the lady with lamp”.

It could be plausibly argued that the nursing effort during the Crimean War was responsible for reducing mortality rate of the wounded from 42% to 2% by focusing on sanitation, nutrition, and bedside care. Physicians, on the other hand, were very skilled at describing and predicting the natural history of disease. But in those years, they had very few tools to affect outcomes.

A lot has changed in the 168 years since Florence Nightingale arrived at Scutari. The science that supports medical practice has advanced far beyond what anyone would have imagined in the 19th century. And the discipline of bedside nursing has advanced right alongside the science. The 21st century nurse is highly knowledgeable in bedside diagnosis, physical examination, pharmacology, microbiology, emergency medicine, orthopedics, cardiology…the list goes on and on and on. The expansion of the nursing role into areas of clinical intervention has in turn changed the way nurses are trained. No longer is bedside training enough. Nurses have become profoundly capable clinicians, and this has led to a reimagining of what nursing education should look like. Another striking change is the number of men in nursing. In 1970, about 2% of nurses were men. That number is 12.7% as of April 2021. What has not changed is the unique capacity of the nurse to connect with the patient in a way that science cannot entirely explain.

One would think that finding such an important place in the healing arts would create an abundance of women and men who want to be nurses. That turns out to be true. Currently, about a third of applicants for baccalaureate nursing programs are turned down. The tragedy is that what these eager young people expect from a nursing career often turns out to be a disappointment of massive proportions.  Data from a study in 2018 indicate that over 400,000 nurses left the profession in that year alone.  Of that number, about one third cited burnout as their reason for leaving. The study was published in the March 2021 edition of JAMA Open Network. Preliminary data acquired over the past 12 months seems to predict that numbers of nurses leaving the profession will be even higher. The COVID pandemic and our handling of it has become the proverbial last straw for many talented, brilliant, and capable nurses.

Despite these discouraging statistics, I’d like to offer some words of encouragement. First, I want to acknowledge those of you who have found the courage and the resolve to remain in your profession in the face of these challenges. Those of us who have benefitted and will benefit from your skill and your diligence will be eternally grateful. Each of you is a gift, and we are forever in your debt. And finally, those of us who remain must dedicate ourselves to see and acknowledge those things that make healthcare a difficult profession. And having done that, we must re-dedicate ourselves to bring this honorable calling back to its rightful place…a place of honor and a place where we feel honored to serve.

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Randy Cook, MD, FACS

Physician, Coach, Podcast Host, Lifelong Learner

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