Courage doesn't mean being unafraid. Rather, it is fortitude and selflessness that move some people beyond their own concerns to do what must be done.

In the battle against Covid-19, there are many heroes, from cashiers and delivery drivers, who keep essential supplies flowing, to sanitation workers and first responders. In the hands-on battle against the disease, Alabama nurses are working shifts of 12 hours or more to save lives.

Brookwood Baptist Medical Center charge nurse Chrissie Yunke, RN, Princeton Baptist Medical Center nurse Lea Heard, RN, UAB charge nurse Toni Beam, RN, and unit nurse Jordan Oldacre, RN, are part of the legion of nurses who care for Covid-19 patients in Birmingham.

What motivates a nurse to don PPE and walk into a unit where one of the most contagious viruses in over a century is waiting?

"As a nurse who has experienced Covid within my family, I felt more than ready to head to the Covid floor," Yunke said. "Nurses do not draw back. We step up where we are needed."

When word came that Beam's unit was one of two along with two ICU units designated to care for Covid-19 patients at UAB, one of the first steps in her preparations was to plan for the safety of her team.

"Several of our nurses were pregnant. We don't have data on how the virus might affect pregnant women or their babies. The safest plan was to move pregnant nurses to other duties and recruit more nurses from other units to be ready when the virus made its way here," Beam said, who herself is pregnant. She chose to stay on to support her team.

"Fortunately, our infectious disease department, epidemiologists and supply team began watching the epidemic developing in China early and started preparing. So far, our PPEs and supplies have been adequate. They haven't always been the same brand we usually use, but they do the job."

When the first Covid -19 patients began arriving at Birmingham hospitals, there were surprises from opposite ends of the spectrum. Some were surprised by how very sick patients could quickly become compared to the usual progression of other illnesses. Others were surprised by the many people who tested positive for the virus but were either asymptomatic or had only a few mild symptoms. Nurses tend to agree that the biggest surprise was how quickly respiratory status can change.

Yunke said, "One hour their O2 saturation would be in the 90's with no shortness of breath, and the next it would be in the 70's and we would be sending them to a critical unit."

Oldacre saw the same pattern. "Many patients with no previous history of respiratory disease would go from being 92 to 100 percent on room air to requiring two to three liters of oxygen. "

Heard was surprised by the age of patients who developed respiratory difficulties. "I have seen many younger patients, ages 20 to 50, get intubated and have a much harder time getting extubated than normal."

Patients presented with varying symptoms, the most common being a persistent, nonproductive cough, fever, and shortness of breath. Some had muscle aches and pains, headache, loss of taste and smell, and extreme fatigue.

Since there were no medications specifically approved for treating the virus, nursing plans were primarily geared to treating the symptoms, giving oxygen and keeping close watch for any sudden declines in oxygen saturation.

"Each of our nurses usually provides most of the care for three patients," Beam said. "To minimize the risk of spreading the virus, they are also taking on additional roles such as physical therapy and occupational therapy. If they need assistance or have to deal with a crisis, our float nurse and charge nurse step in to help."

As visits from family and friends aren't possible for an extended period, nurses become the patient's primary emotional support and advocate.

"The nurse becomes the voice of the patient" Heard said. "By arranging digital visits for the patient and family using the iPad helps them feel more connected and informed."

Yunke said, "Communication with the family is key so that their loved ones have a thorough understanding of their daily status. I personally experienced this with my mother-in-law who has Covid in Michigan. We are thankful the nurses kept us updated. "

Working behind a mask also makes it more difficult for nurses to communicate the support that patients need. "The patients have a hard time identifying their nurses with all the PPE," Yunke said. "It's hard to show you're smiling under a mask, so you make certain your compassion is conveyed through your actions."

Long hours of working in a high stress situation are also difficult for nurses.

Oldacre said, "Caring for your own mental health has to be a priority. Most patients feel a loss of control and anxiety about what their diagnoses means for them, so they need their nurse to be as calm as possible. Having a good relationship with your coworkers and strengthening that support system is one of the best ways of dealing with the stress. Exercise has had a huge impact on keeping a positive outlook and helping me maintain work-life balance. I also find creative outlets like painting and reading helpful."

Strong community support is also helping to make nursing during a pandemic easier.

"The meals businesses, civic groups and churches bring us are very much appreciated," Beam said. "Some days, we are so busy we hardly have time to eat or buy food. We're also getting discounts on things like nursing shoes. It's not so much the discount itself as seeing that people appreciate our work that is encouraging."

Nurses are also spouses, parents and roommates. How do they manage the transition from hospital to home and keep the risks of working with the virus away from loved ones?

Yunke said, "It breaks my heart when I walk in and have to avoid a hug from my daughter or husband, but I do what is needed for their safety. I change into my personal scrubs at the hospital. Once I arrive home, I remove my clothing and shoes at the backdoor, put my clothes in a bag, and then straight into the washing machine."

Oldacre said, "I live with another Covid nurse. We leave our work shoes outside, change out of our scrubs immediately, place them in the washer, and frequently disinfect surfaces. I visit my parents on occasion, wear a mask and keep appropriate distance, but I have chosen not to visit my grandparents. I have coworkers with families who change clothes before leaving work, sanitize their car with wipes, and sleep separately from their husbands."

Although social distancing and masks are helping to slow the rate of spread, with each step Alabama takes toward reopening, there is the potential for increases in the number of new patients who need care. Vaccines are still some time away and there is a strong threat of a second wave emerging in the fall or winter. The pandemic is likely to be with us for a while, but eventually we will see light at the end of the tunnel. Five years from now, how will nurses look back at this time?

Oldacre said, "I hope I'm proud of the small contribution I made during a national crisis. I hope that I gave my patients a little extra comfort. I try to remind people that they can still enjoy life and find humor in small things. It's the most effective strategy I have found when dealing with hard times."

Heard said, "Everyone came together as a team to help each other get through this. Everybody worked together - from the hospital administration to the doctors and all the way down to the housekeeping. We are all in this together."