Improvement of the Barrier Nursing Course: A Universal Tactical Principle for Infection Control

Henry Schwanebeck^a, Dorothea Wiemer^a

^a Division of Tropical Medicine and Infectious Diseases, Department of Internal Medicine, Bundeswehr Hospital Hamburg, Branch at Bernhard Nocht Institute for Tropical Medicine

Summary

Preparing for scenarios involving highly pathogenic pathogens and clinically significant infectious disease patterns now requires robust, well-thought-out and, above all, standardised approaches. The newly designed, multi-site ‘Barrier Nursing’ course, as a competence-based training programme (KOA), defines infection control not merely as a hygiene measure for everyday clinical practice, but as a modular, tactical principle that can be applied in almost any situation. Through close civil-military cooperation and a focus on a practically trainable model for spatial separation, medical and nursing staff at all levels of qualification are empowered to act safely, routinely and in a standardised manner throughout the entire rescue chain. The following article presents the strategic orientation, methodology and content structure of this training format for the medical service.

Keywords: infection control; training; barrier nursing; highly infectious diseases; medical service; tactical principle

Introduction

The Strategic Dimension of Infection Control

Modern military medicine operates in a complex, often unpredictable and dynamic environment. During overseas deployments, humanitarian aid missions or in the context of national and alliance defence, medical personnel are increasingly confronted with situations that require rapid adaptation. These include local outbreaks of infectious diseases, natural disasters with destroyed infrastructure, and asymmetric threats. The ‘Barrier Nursing’ course fills a crucial gap in the preparation of medical personnel for the professional handling of outbreak situations and the management of severe infectious diseases. It is designed in line with competence-based training (CBT). Rather than relying predominantly on lecture-based teaching, the focus is on action-oriented, independent learning with a strong practical focus, to prepare soldiers optimally for real or unexpected operational scenarios. The structural and operational added value of this course is evident in three interlinked areas:

1. Building a strong foundation through civil-military cooperation
   Standardised processes and a common technical vocabulary ensure that cooperation between the military medical service and civilian actors is optimised in the long term
2. Direct applicability in routine domestic operations
   The comprehensive basic hygiene practices trained in the course are an essential tool for reducing the spread of multi-resistant pathogens (MREs) and nosocomial infections in everyday hospital practice.
3. Ensuring tactical operational readiness Staff are empowered to apply the concepts they have learnt safely and without delay, even in critical outbreak and conflict scenarios under adverse conditions.

The Foundation:
Civil-Military Synergies

The first key benefit – strengthening crossorganisational cooperation – forms the backbone of the entire course. Crisis situations in recent events have clearly demonstrated that outbreaks of infection do not stop at the interfaces between military facilities and the civilian healthcare system. To ensure the highest level of specialist expertise, the course therefore brings together the knowledge of highly specialised partners.

This close cooperation involves the Department of Infectious Diseases and Tropical Medicine at the Bundeswehr Hospital (BwKrhs) Hamburg at the Bernhard Nocht Institute, the STAKOB Centre of the University Medical Centre Hamburg-Eppendorf (UKE), and the Hamburg Professionl Fire Brigade. STAKOB stands for the “Permanent Working Group of Competence and Treatment Centres for Diseases Caused by Highly Pathogenic Agents”, an expert network at the Robert Koch Institute. This setup ensures that expertise is widely disseminated and passed on to staffl throughout the entire civilmilitary rescue chain. Friction losses that could arise during the handover of infectious patients betweencivilian rescue services and military facilities are reduced to a minimum through joint training and identical checklists.

Fig. 2: Example of Airlock Management (Image rights: (A) D. Wiemer, (B) BwKrhs Hamburg)

Daily Application:
Methodology and Safe Routine Operations

Building on this civil-military network, the course focuses intensively on methodology, which underpins the second added value – the transfer of knowledge into day-to-day routine operations. Practical skills are deliberately taught in very small groups. This high level of supervision enables instructors to correct errors immediately, calmly and precisely. This type of support reduces reservations about dealing with infectious patients and systematically transforms initial uncertainty into a professional, everyday routine.

Various pathogens serve as representative, tactical case studies. Participants learn to gain a thorough understanding of specific routes of transmission and to translate this into appropriate protective measures. Those who internalise during the course how, for example, the norovirus is isolated as a model for smear and contact infections will apply these principles far more consistently during outbreaks on a regular nursing ward. Influenza and Covid-19, in turn, serve as examples of respiratory transmission via droplets and aerosols, which significantly heightens general awareness of essential basic hygiene in daily patient contact and protects staff in both civilian and military hospital settings.

Fig. 3: Personal Protective Equipment is available in various types, adapted to the hazard situation (Image rights: (A) BwKrhs Hamburg, (B) H. Schwanebeck)

The Tactical Core:
The Barrier Model for Ensuring Readiness

Once basic hygiene and an understanding of pathogens have been consolidated, the course focuses on the third added value: the immediate ability to act and operational readiness in extreme situations. To this end, the training philosophy is streamlined to a clear tactical objective, namely the establishment and maintenance of reliable barriers against a pathogen.

This concept is based on three pillars.

Fig. 4: Checklists and the Buddy System are essential, safety-relevant instruments. (Image rights: D. Wiemer)

The Spatial Barrier (Spatial Separation/Zoning Model)

The course teaches the strict separation into the clean area (green), the airlock (yellow) and the contaminated area (red). Personnel must not only be able to manage this spatial organisation within permanent buildings, but also be able to set it up improvised in a field hospital or in temporary accommodation.

The Physical Barrier (Personal Protective Equipment)

This concerns the correct use of personal protective equipment (PPE). This is not applied across the board, but is always precisely adapted to the risk situation identified in advance, in order to avoid over- or underprotection.

The Methodical Barrier (Processes)

the best equipment fails when human error occurs. Therefore, the mandatory use of checklists and the two-person principle (buddy principle) is required for all safety-critical procedures. A partner supervises the highly critical process of removing contaminated PPE step by step, as the wearer’s field of vision is usually severely restricted.

This barrier concept can be seamlessly applied at all levels of medical services. In the pre-hospital setting and in the ambulance service (Role 1/2), the focus is on tactical hygiene under immense time pressure. Here, the self-protection of the personnel deployed plays a paramount role in ensuring their own safety whilst consistently preventing the spread of contamination at the scene of the emergency. At the level of medical regiments (Role 2/3), the focus shifts to the field-based implementation of spatial separation under full protective conditions. Finally, in permanent hospitals (Role 3/4), the complex clinical isolation of patients, including a well-thought-out negative pressure and airlock management system, is implemented.

Fig. 5: Complex training in full protection at the patient’s bedside (Image rights: H. Schwanebeck)

Step-by-Step Development:
From Basics to Advanced Training

To consolidate these skills and cater effectively for the broad target audience, the curriculum is structured in a step-by-step manner. To begin with, participants – ranging from medical soldiers to experienced medical officers – learn the absolute basics: hand hygiene, surface disinfection and the donning of standard protective equipment. Here, everyone gains valuable routines tailored to their individual level of knowledge. As the course progresses, the groups practise working in full protective gear, combined with critical supporting processes such as the management of infectious waste or the handling of the deceased in accordance with the guidelines of the Robert Koch Institute.

Conclusion

The COT course “Barrier Nursing” is an important and sensible measure in medical and nursing operational training. It translates infectious threats into a robust, tangible, and tactically applicable principle. By consistently imparting clear, methodical, physical, and spatial barriers, the course empowers all medical personnel to confront infection hazards with professional routine and high self-protection. This protects the individual soldier, ensures patient care domestically, and ultimately maintains the operational capability of the entire force.

Key Statements

• TheCOT ‘Barrier Nursing’ course teaches a modular, tactical approach to infection control that is universally applicable and practical.
• Through civil-military cooperation, medical and nursing staff are effectively prepared for and trained in outbreak and crisis scenarios.
• The course methodology is based on smallgroup training, which minimises errors, reduces reservations and establishes a professional routine for day-to-day practice.
• The barrier model comprises spatial, physical and methodological protective measures that can be flexibly implemented at all levels of the emergency services.
• The step-by-step curriculum promotes teamwork and personal responsibility and enhances operational capability and staff protection in every area of operation.

Manuscript Data

Citation

Schwanebeck H, Wiemer D. Advancement of the Barrier Nursing Course: A Universal Tactical Principle for Infection Control. WMM 2026;(9E):6.

DOI: https://doi.org/10.48701/opus4-960

For the Authors

Lieutenant Colonel (MC) Dr. Dorothea Wiemer

Division of Tropical Medicine and Infectious Diseases

Department of Internal Medicine

Bundeswehr Hospital Hamburg

Branch at Bernhard Nocht Institute for Tropical Medicine

Bernhard-Nocht-Str. 74, 20359 Hamburg

E-Mail: dorotheafranziskawiemer@bundeswehr.org