key: cord-0896351-55ikumii authors: Anders, Robert L. title: What can we learn from U.S. military nursing and COVID‐19? date: 2020-10-24 journal: Nurs Inq DOI: 10.1111/nin.12384 sha: 20d7b8b7d0ba83da397498f468e9d565b4324c56 doc_id: 896351 cord_uid: 55ikumii nan Nurses have a history of working in dangerous situations since their origins. In the beginning, nurses were primarily men serving the injured during the Crusades, where they not only participated in battles but also cared for the sick and wounded. The modern nursing movement began with Florence Nightingale, a woman of privilege, who recognized the need to create an organizational structure that would provide a safe, clean, and compassionate environment for those that were wounded and sick. Nursing's roots in military environments offer valuable lessons for working in the era of the COVID pandemic. Although nurses have been on the frontline caring for the wounded and sick throughout history, nurses typically have been sheltered from the intense combat environment, and thus, few have been killed. Given the magnitude of World War II, it is important to note that only 201 USA military nurses died (US Army Center of Military History, 2003) . The military has created a system in which its nurses are shielded from exposure to combat (Berry-Cabán et al., 2018) . The same cannot be said for civilian healthcare organizations where the inability to protect working nurses has led to a death toll from COVID-19 that now exceeds that of the number of nurses who died in WW II (Babb et al., 2020) . The military plans extensively for war with a focus on the means to achieve their mission. Through war games and other simulations, strategic plans are developed to manage care for the sick and wounded. Comprehensive planning includes assuring adequate facilities, equipment, supplies, and healthcare personal are available to meet the projected need. Perhaps most important is the planning to protect military healthcare assets. Without adequate healthcare, many of the wounded will die. During the COVID pandemic, these basic strategic planning procedures were not adequately addressed by the civilian agencies responsible for providing adequate supplies, equipment, and personnel. The importance of strategic planning seemed to be ignored by U.S. Federal agencies; this lack of a strategic plan created an ethical and moral issue that has led to countless deaths (Berlinger et al., 2020). The military uses a variety of strategies to create an overall framework designed to protect their healthcare professionals. These strategies involve activities that are structural, psychological, and training related. Bottom-line strategic planning is critical if the mission to 'conserve the fighting strength' is going to be met. In the case of a pandemic, while the agencies responsible for planning include both government and civilian sectors, the need to plan to meet the mission of providing healthcare while protecting healthcare assets is similar. Some examples from successful military planning are useful to illustrate steps that could be taken during a pandemic. In WW II, nurses were trained as one unit and were sent overseas as a group and, for the most part, they stayed with one unit until the end of the war. In Vietnam, Afghanistan, and Iraq, the nurses typically deployed individually and thus did not have the benefit of a cohesive unit for support. The use of travel nurses to support local hospital staffing during the COVID pandemic is similar. Travel nurses, who are typically placed in an unfamiliar environment, away from family, friends, and nursing colleagues to care for critically ill COVID-19 patients, might benefit from a more cohesive support group. Except for WW II, most military deployments were for 6 months to 1 year. The shorter experience is thought to help reduce the stress of being in a combat situation for a more extended period. The travel nurse example is similar, with most having contracts of around 3 months, thereby having a shorter exposure to the high stress of caring for COVID-19 patients. The shorter assignment, like those used in the military, does seem an appropriate avenue to help minimize prolonged stress and fatigue. However, permanent staff caring for COVID-19 patients are not afforded this shortened experience. Consideration in planning for mobilization of permanent staff should be given to limit nursing duty times to ensure safety of the nurses from contamination and to reduce stress. The military ensures during deployments of a year of more that nurses have time to leave the practice setting for respite from the stress of the hospital. The takeaway message is to plan for the deployment of nursing staffing, provide adequate orientation time, and ensure there is sufficient time and support to prepare nurses to care for critically ill COVID-19 patients. Lastly, providing time away, if only a long weekend, to leave the weight of caring for COVID-19 patients can help with stress management. Although PTSD is not a new phenomenon, the thought that military nurses during WW II could have PTSD was discounted. The prevailing thought was that PTSD could only occur in combat situations (Lucchesi, 2019) . The Vietnam War revealed how prevalent PTSD was among nurses. Experts in mental health now agree that PTSD can affect both military and civilian nurses. At some point in their careers, as many as 28 percent of nurses experience PTSD (Brownlow et al., 2018) . The military has significant support systems for individuals who have or may develop PTSD (Miao, Chen, Wei, Tao, & Lu, 2018) . The impact of PTSD in civilian nurses caring for patients is expected to be as significant, if not more so, as it has been for military nurses (Chiappini et al., 2020) . There is an ethical and moral obligation to provide for the mental health needs of the nurses caring for COVID-19 patients (Menon & Padhy, 2020) . Military nurses attend numerous training exercises, all designed to prepare the nurses for combat. In the summer of 1970, as a young Army Lieutenant, I attended a 'boot camp' for new nurses. In addition to learning about the Army, we went to a special training area to learn about conditions in Vietnam. We were led into a simulated Vietnamese village where we were ambushed and had to learn on the spot how to care for the wounded. Mass casualty exercises helped to prepare us for combat nursing. A national strategic plan on how to prepare nurses and others to care for COVID-19 was largely missing. Each hospital, with limited guidance from the U.S. Centers for Disease Control, was expected to create its own protocol (Cortez, Tozzi, & Bloomberg, 2020) . Often conflicting information provided by Federal agencies was changed to accommodate political perspectives. Another moral and ethical issue thus was created as Federal agencies charged with protecting the public often based their responses on political perspectives (Anderson, 2020) . The chain of command is a foundational concept in the military. Every military member is required to know their respective chain of command. The concept means there is a definitive hierarchy of individuals responsible for achieving the mission from the first-line supervision to the commanding general or admiral. The command and control specifically identify the accountability of each supervisor and team member. Using a well-defined accountability structure fosters the successful completion of the mission. In the COVID-19 response, the command and control function, at least in the United States, was missing. There was no national leadership to direct the overall management of the COVID-19 response. The lack of leadership meant local and state agencies had to 'fend' for themselves, creating competition to obtained needed personal protective equipment (PPE), ventilators, other supplies, and medications. The lack of leadership combined with no national planning created a moral and ethical failure resulting in needless deaths (Berlinger et al., 2020) . The Hastings Center, an international leader in bioethics, published an ethical framework for healthcare institutions and guidelines for institutional ethics services responding to the coronavirus pandemic (Berlinger et al., 2020) (see Table 1 ). The first of the three ethical principles is to prepare for uncertainty. The COVID pandemic, caused by a novel virus about which little was known, implies that institutions, nurses, and other healthcare workers must plan and prepare for uncertainty as best they can. The lack of Federal government preparedness and limited availability of resources added to the uncertainty for healthcare providers as well as the public. The lack of national leadership was particularly apparent in Italy, Brazil, and the United States (Castro, 2020; Rucker et al., 2020) . The failure of the Federal government to plan for the pandemic is akin to the above example of the military not preparing its healthcare resources for use in combat. This lack of planning thus created a moral and ethical dilemma resulting in the needless deaths of citizens, including nurses (Why wan't it, 2020). 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