It has been 10 years since severe acute respiratory syndrome (SARS) crept into Canada and paralyzed Toronto. No one was prepared–Hospitals were caught unaware, health care professionals struggled to make sense of a deadly virus that initially looked and felt like the common cold and flu. Through this, nursing programs tried to balance effects of the outbreak on school and clinical attendance with student needs and concerns.
During these turbulent months, forty-four people would lose their lives, including three health care workers. The University of Toronto, Faculty of Nursing wrestled with how best to keep students safe. The nursing community was in the front-line of this outbreak, putting them at great risk and facing great stigma as the public responded to the mystery of SARS with understandable fear. With these obstacles in mind, faculty continued teaching and created their blueprints for how to educate during a crisis.
Ensuring each student would complete their year was a primary focus, but the Faculty also had to lay the foundations for future emergency preparedness response in the process. The former Chair, Undergraduate Nursing program shares her thoughts on what kept the program going, and how the lessons of SARS has impacted curriculum.
“We learned quickly that communication is critical at a time like this,” says Geraldine (Jody) Macdonald former Chair, Undergraduate Nursing program during the SARS crisis and current Senior Lecturer with the Faculty. “Faculty, students, the university, health care providers, the city and the province – everyone does really need to be on the same page.”
For nursing students, the Faculty’s September 2002 decision to implement WebCT, an online learning application, provided the means to complete educational models in a virtual environment. Replacing the clinical setting with a virtual one opened up a number of clinical teaching possibilities, while keeping students safe from the potential of SARS cross-contamination. This foray into e-learning also proved to be an essential tool in communicating with students and continuing with schooling. Just a few short weeks after the first wave of SARS, Macdonald received the call that all students were to be pulled from clinical practice. WebCT functioned as a temporary substitute for clinical placements. Students now had the chance to continue learning despite having their seven-week or 12- week placements cut short by the crisis.
“The call came on March 27, 2003 — the day after the province of Ontario declared SARS a public health emergency,” says Macdonald. “Every undergraduate nursing student had to be pulled from their clinical settings because of the SARS outbreak. Without concrete information on what this virus was, we had no idea when, or if, they would be able to go back. In the second wave of SARS, we had a reversal. Students were back in the clinical setting but removed from the classroom. We used our on-line system to support classroom learning for this time period. ”
This meant it was imperative for faculty to stay on top of the daily, and sometimes hourly, SARS information that was coming from the media, Toronto Public Health and the Ministry of Health and Long-Term Care. How courses and clinical placements would continue hinged on information from these sources. Pre-dating social media, hi-speed Internet and in some cases, email altogether, communicating clearly and effectively with students was a challenge. In response, the faculty created a SARS management committee. Organized by then-Associate Dean, Academic Programs and Current Vice-Provost at U of T Edith Hillan, Macdonald and others managed the flow of constant, frequently contradictory information, and how best to relay it to students.
“We had the great fortune to have Betty Burcher join our faculty six months before SARS hit,” says Macdonald. “Her years managing people and information at Toronto Public Health meant she knew the key players, knew how to think through the information we were receiving, and helped guide our SARS committee. Tracking undergraduate and graduate student attendance to manage potential exposure was one critical measure Betty suggested, and the committee implemented, to keep our students safe.”
The committee met daily to gather and disseminate information, in order to make decisions based on the SARS updates. Managing student fears and concerns about potentially losing their year while trying to teach the program was a delicate balance for the faculty. Add to that overwhelming feelings of uncertainty, the stigma surrounding nurses and their families, and the faculty were left feeling exhausted – alongside anyone working in health care during the crisis.
“Some of the toughest calls we had to make were to students saying they were pulled from clinical placements, and having to tell other students they were at risk of infection and would have to enter a 10-day quarantine,” says Macdonald. “Despite all of this, the students were able to complete their education and graduate that year. That speaks volumes about the dedication and commitment of the students who come to this program and their faculty.”
These results showed the fortitude of students enrolled in the program and the lengths to which the faculty went to support them. The success of integrating online learning, maintaining informed communications, and being flexible and innovative strengthened the Faculty of Nursing’s resilience and ability to support student learning during this time of emergency.
“We include SARS in the undergraduate curriculum, but it was so long ago that it’s not really meaningful to the students; something like H1N1 is more current to them,” says Macdonald. “While SARS was a huge stressor for faculty, numerous catastrophic events have happened throughout the world in the last decade that captures the interest of our students, and SARS can get lost in the shuffle.”
The history of SARS and the lessons learned are reflected in new additions to the nursing curriculum, such as the emergency preparedness seminars and simulations taught in the undergraduate Primary Health Care Course. Nursing ethics is also addressed to educate students on the choices nurses must make when there is an emergency, such as SARS, that puts their lives in potential danger.
“We recognize the importance of hand-washing, using properly-fitted N-95 masks and infection control screening processes that have become a permanent fixture since SARS but we also want students to think beyond the physical,” says Macdonald. “It’s not easy keeping students safe in these uncertain circumstances. There is always something on the horizon. Our future nurses need to learn how to use personal protective equipment to keep themselves safe when they are putting themselves in harm’s way. They also need to reflect upon what role they are prepared to take in times of emergency.”
Macdonald recognizes the amount of learning that came from SARS. Nurses were stretched to the limit, resources were scarce and had the outbreak entered a third wave, there was no back-up plan or surge capacity to support nurses already exhausted from working 14-16 hour days for roughly four months. This on top of the emotional and psychological toll SARS took.
“SARS brought us way too close to having no surge capacity for nurses,” says Macdonald. “The health system had to make changes to address the likelihood that something like this can, and likely will, happen again and nurses need support in every way possible during emergencies.”
In the aftermath of SARS, hard questions were asked and changes were made to health care systems. Nursing students entering clinical placements now are equipped with access to better personal protective equipment and other emergency resources, as are all nurses in health care settings. Leslie Vincent, who was Senior VP Patient Care and Chief Nursing Executive at Mt. Sinai Hospital during the SARS crisis, remembers all too well the limitations the hospital faced at this time.
“No one was prepared at the provincial or the hospital level,” says Vincent, who was the only nursing member on the provincial Expert Panel on SARS. “At the beginning, we didn’t know how sick people would get or how exactly SARS was spread. Not having a full understanding of the mechanism of how SARS was spread created an extra element of fear.”
Mt. Sinai, like many hospitals, had to implement infection control precautions, organize a SARS unit while still maintaining a working hospital, and provide new precautions, such as N-95 masks, to staff when stockpiles were low and shortages were worldwide. SARS was a wake-up call for the health care system, and made the city and the province take stock of what was needed to provide in an emergency response.
“Anyone who went through SARS knew something similar could happen again and it became imperative to make the system as safe as possible,” says Vincent, who is now the Executive Director, Centre for Professional Development at Bloomberg Nursing. “We now have plans in place to handle an actual pandemic, significant investment was made to public health infrastructure, infection control screening became mandatory and more effective, and supplies are stockpiled to avoid shortages.”
These changes and investments are now part of the everyday clinical experience for nursing students. The events of SARS may not resonate as closely for current nurses but for those who worked during the SARS crisis, sometimes just looking at an N-95 mask can bring back memories of what was, and indeed what could have been during 2003. Their dedication to patient care, continuing to work in potentially life-threatening conditions and ensuring that future nurses have the appropriate resources has changed health care in Canada for the better.