Our New Normal: Back to the Basics and Creating Our Future

At the beginning of January 2021, 218 countries and territories have reported 80 316 555 cases of coronavirus disease 2019 (COVID-19), with 1 770 695 deaths worldwide and more than 357 000 deaths in the United States.¹  As of this writing, the end of the pandemic is not within sight—in the United States, there are hundreds of thousands of positive COVID-19 diagnoses and several thousand deaths weekly. Colder weather is here, bringing flu season and more sheltering inside, potentially driving COVID-19 cases to even higher rates.

The COVID-19 pandemic has affected every aspect of our lives, and I, for one, am looking forward to getting “back to normal.” However, getting back to normal may not have an obvious timeline. What will go back to normal? How will we book and attend concerts and plays? When will restaurants across the country fully reopen? Will gyms operate the same way? What businesses, small or large, will survive this prolonged pandemic? Our old ways and behaviors are probably permanently altered. Public health experts suggest that even when a vaccine is approved, and the process of distributing vaccinations to millions finally occurs, wearing masks and social distancing will still play an important role in slowing transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

The postpandemic return to normal we are all longing for might feel more like an incremental crawl. There is no clear criterion at this point to officially end the pandemic. As Regina Rini²  reminded us, “You can’t negotiate with a virus.” We will be lucky to get a cease-fire. When this pandemic ends, we will be in a postpandemic new normal that may last years. As critical care nurses, we will continue to do what we always do: adapt.

Critical care nurses have found ways to keep SARS-CoV-2 from entering their homes after long shifts by implementing creative decontamination routines at their front door or designating “plague areas” for all work clothes and shoes. Nurses have found alternative living arrangements, including repurposed campers in hospital parking lots, and others have sent families away to temporarily live with relatives.³  After working one-on-one with COVID-19 patients, some health care workers have slept away from home. They have turned to hotel rooms, their cars, and elsewhere to keep their families safe.⁴  When the outbreak started filling hospitals, hotels opened their doors—in limited capacity and with reduced or no cost—to nurses and other providers who treated patients.

Critical care nurses have found creative ways to extend use of personal protective equipment (PPE), such as N95 masks and face shields, shift after shift during critical shortages to maintain their frontline defense against SARS-CoV-2 transmission. In turn, critical care nurses, nursing organizations such as National Nurses United, and others have protested and battled to address the shortages to get PPE in the hands of those who need it the most.^5–7 

New pandemic phrases have hijacked our everyday conversations, such as flatten the curve, social distancing, transmission rates, and asymptomatic spreaders. Our boot camp–style learning of this new lexicon has had an immediate effect on everyday life. We have radically changed virtually everything: how we commute, work, shop, manage our health, socialize, educate our children, and consider the care of older family members. All these changes were in the name of flattening the curve.

The pandemic has also reinforced some of the basic tenets we learned early in our professional careers, including timeless concepts such as handwashing, communication skills both within the team and to patients and family members, and maintaining resilience. These practices are now more important than they ever have been in recent memory. Hand hygiene should be at the top of the priority list. Hand sanitation is an essential, not optional, method of infection prevention. Since Semmelweis first reported the benefit of hand hygiene in the mid-19th century,⁸  hand hygiene has been, and should remain, the cornerstone of all interventions for preventing health care–associated infections. Use of either alcohol- based sanitizing solutions or soap and water has been found to notably reduce respiratory viruses, Staphylococcus aureus, gastrointestinal infection, and other outbreaks in health care settings. By extension, proper hand hygiene will limit any possible contact transmission of SARS-CoV-2. Although handwashing has always been a cornerstone of nursing practice, the reinforcement of hand hygiene among the public via health messages and media has raised awareness to new heights.

Another back-to-basics tenet we must maintain is how we interact with our patients, especially after a COVID-19 diagnosis, and their families. All health care institutions have implemented policies to address the volume of COVID-19 patients admitted to hospitals, including some of the strictest, most unprecedented visitation policies we have seen in decades. Because these visitation policy changes heighten the already challenging communication practices, we must renew our efforts to (1) maintain constant open engagement with patients and family members, (2) use remote or telehealth options (eg, FaceTime, Skype, Zoom) when possible, and (3) practice early recognition of the barriers that may erode good communication. For example, in hospitals where a designated family member was invited to join rounds, smart use of technology has lent a voice to both members of the health care team and caregivers who are no longer at the bedside.⁹ 

Early in the COVID-19 pandemic, the risks to both health care institutions and communities were high, solid epidemiological information was lacking, and, at least initially, PPE access was scarce. The initial weeks and months after a new health care community threat has been identified are often chaotic, with only initial epidemiological information to guide immediate decision-making. Understandably, it is difficult to make accurate hospital policy choices during these challenging conditions, and many COVID-19–related policies will change multiple times as new information is released. Constant policy changes are difficult for the nursing staff, hospital staff, patients, and visitors. Many patients were already afraid to enter a hospital, and now COVID-19 has more than likely terrified them with the prospect of a visit. Clear and consistent communication around policy can help manage patient expectations, and, most importantly, facilitate trust.

It is common to feel weighed down by the things in life we cannot control, such as the dynamic changes taking place in our critical care and other inpatient units as the COVID-19 census rises and falls. Although we have dedicated our careers to adapt to anything thrown in our way, fatigue from continuous social distancing, changing regional or community quarantine procedures, and limited contact with many family members and friends can erode our resilience if we are not careful. However, we can control the steps we take after an unexpected change and develop a plan to address it. Setting goals, prioritizing, and using checklists can reenergize us. Checklists allow us to direct our energy to where it is most needed at that moment, which can help distract and reorient us away from the things we cannot control to focus on what actually needs to get done. Being optimistic is important, and it does not mean we are being unrealistic. Always think “however this” in a tough situation; for example, “the situation isn’t great; however, this is what I can do about it.” Johns Hopkins School of Medicine¹⁰  and the University of California-Davis¹¹  provide the following guidance to maintain resilience in the face of the COVID-19 pandemic:

• Make a commitment to keep yourself and others safe by washing your hands, maintaining social distance, and wearing a mask in public.

• Practice COVID-19 safety precautions daily until they become habits.

• Keep safety supplies like extra face masks and small bottles of hand sanitizer with at least 60% alcohol easily accessible to encourage use.

• Involve children in keeping families consistent. Children help remind other family members to maintain physical distance, wear a mask, and keep their hands clean.

• Exercise! Exercising is one of the best ways to cope with stress and remain resilient. Engage in an activity like walking to encourage the release of endorphins, which can aid in relaxation.

• Communicate your frustrations with COVID-19 to a family member or friend.

• Practice constructive thinking, knowing you cannot change the current state of the pandemic, but you can change the way you think about it.

A silver lining for health care organizations, especially those that easily transitioned to pandemic clinical operations, is that we now have examples, or “lessons learned,” of how organizations were disrupted and a better idea of how future preparations can decrease the damage from the next threat. What can we reasonably demand of our institutions? What role will critical care nurses have in planning for future pandemics and other contingencies that disrupt health care delivery? These questions will not go away, so we need to realize they are more relevant than they ever were in our prepandemic world. A room full of newly certified ventilators and PPE will not do the trick. As nurses, it is incumbent upon us to be a part of the continual process of planning for the “worst.” It should be a prime directive for health care organizations and hospitals to update their health care continuity/contingency plan after the pandemic, and nurses should ask to have a seat at the table. Examples of business continuity plans are available at Ready.Gov (www.ready.gov). To borrow from military contingency planning, we need to know the strengths and weakness of the infectious enemy. We need to know what weapons worked the best for our institutions and what weapons, or “countermeasures,” we will need to obtain, create, and deploy to finally beat this foe and be ready for the next one. Our new normal demands it.