Xinjuan Wu, Na Guo, Na Zhou, and Shuyang Zhang tell the story of Chinese nurses in the area most affected by covid-19
Healthcare workers around the world are on the front lines of dealing with covid-19. Nurses in particular have been key members of professional healthcare teams trying to save lives. This was demonstrated in Hubei, China where nurses played a crucial role in controlling the pandemic.
China adopted a whole-of-government and whole-of-society approach to prevent thousands of new infections, as reported by the WHO-China Joint Commission.  China’s public health efforts included testing, quarantine, contact tracing, social distancing, travel restrictions, and educating the public on prevention.  Hospital-based medical measures focused on treating infected patients and reducing deaths in Hubei, the epicenter of the pandemic, and containing the spread of infections in other parts of the country.  Multi-professional teams led by doctors and nurses formed the frontline of defence against this highly contagious infection.
Nurses played a key role in this holistic approach. China had about 4.1 million registered nurses, including nearly 200,000 registered nurses in Hubei by the end of 2018.  This is slightly more than the number of licensed doctors (3.6 million, including licensed doctors and assistant doctors).  By 29 February 2020, 28,600 nurses nationwide, including over 5,500 intensive care nurses,  volunteered to support their nursing colleagues in Hubei. Nurses made up 68% of the external medical aid volunteers who supported healthcare practices in Hubei.  The speed in assembling the medical aid teams was unprecedented. In many hospitals, volunteers were enlisted, and supplies collected within 24 hours. Nurses stayed on duty and were away from their family, even during the Chinese New Year holidays. When they arrived at Hubei, generally the medical team from one province or one hospital would quickly take charge of one ward with 30 to 50 beds. This rapid mobilization demonstrated the commitment and professionalism of Chinese nurses.
The nursing teams provided different nursing care according to patients’ degree of illness. In Hubei, infected patients with mild to moderate symptoms were treated in “Fang Cang” shelter hospitals,  where nurses played the primary role in symptom management, disease progression monitoring, nutrition and exercise advice, psychological support and health education. According to WHO-China Joint Commission’s national data on February 2020, 13.8% of laboratory confirmed covid-19 patients had severe symptoms and 6.1% were critically ill (experiencing respiratory failure, septic shock, and/or multiple organ failure). 
Qualified critical care skills were vital for treating severe and critically ill patients. The more critically ill the patient was, the closer nurses cooperated with doctors in providing life support treatments, such as artificial airway management, prone position ventilation care, continuous renal replacement therapy (CRRT), and Extracorporeal Membrane Oxygenation (ECMO). The more rigorous monitoring conducted by nurses, the less complications patients would have, such as ventilator associated pneumonia, catheter related bloodstream infection, pressure ulcer and deep vein thrombosis. As the people who spend the most time with patients, nurses share responsibilities with doctors. “I want to express my highest gratitude and respect to all the nurses who have been working with us. Without them, we wouldn’t have achieved so much, especially in treating the critical patients,” said Dr. Wei Cao, a member of the external medical aid team from Peking Union Medical College Hospital (PUMCH). 
Nurses protected all medical team members by leading the provision of rigorous infection control training and making sure infection control policies were strictly adhered to. Senior nurses were the main trainers and the designated staff in every infection buffer zone to ensure personal protective equipment (PPE) was put on and taken off properly. Nurses also developed specific rules to prevent health care workers from spreading the infection to the community. Remarkably, none of the external medical aid team members got infected with covid-19 virus. 
Nurses needed special training to work under such challenging conditions. They had to wear full protective gears, such as goggles, several layers of gloves and gowns. It would be very difficult to implement any basic nursing operations with this full protective equipment even for the most skillful ICU nurses. Pre-service and constant simulation trainings were invaluable in preparing them to adjust quickly and deliver quality nursing care for treating critically ill patients.
And finally, teamwork among nurses, with other health professionals and with logistical support teams was essential. Shorter shifts with adequate rest breaks,  psychological support from team members, and adequate medical and life supplies were applied to boost morale and prevent exhaustion.
Crisis sparks reflections on longer-term nursing education to prepare nurses for similar public health emergencies in the future. Essential is training on infection control and intensive care mostly in postgraduate training for newly graduated nurses. This has now been initiated in a newly launched nurse residency project of The China Consortium of Elite Teaching Hospitals. [9,10]
Xinjuan Wu, nursing director of Peking Union Medical College Hospital, President of Chinese Nursing Association, and member of the national medical aid team from PUMCH.
Na Guo, deputy nursing director of Peking Union Medical College Hospital.
Na Zhou, program officer of China Medical Board, an advocator and ally of nurses.
Shuyang Zhang, Vice President of Peking Union Medical College Hospital, team leader of the national medical aid team from PUMCH.
Competing interests: None declared
Acknowledgement: Yanming Ding & Jili Zheng shared their knowledge and experiences of nurses in Hubei. Lincoln Chen & Wenkai Li advised conceptualization and writing of the manuscript. Jingjing Shang & Zhen Li edited the manuscript and helped with literature research.
Please see Chinese translation
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