How Nurse Leaders Fixed 4 Areas Reshaped BY COVID-19

Nursing won't be the same again because of the coronavirus. Here's how nurses responded to the never-seen-before crisis to care for patients and make the profession stronger. 

This article appears in the September/October 2020 edition of HealthLeaders magazine.

Mary McGinn, BSN, RN, senior administrative director, patient logistics at Northwell Health's Lenox Hill Hospital on Manhattan's Upper East Side, has been through her fair share of catastrophes. In 2001, the veteran nurse was a month into a brand-new position managing patient throughput at St. Vincent's Hospital, the closest trauma center to the World Trade Center, when the 9/11 terrorist attacks occurred.

A decade later at Lenox Hill, she was part of the LHH emergency management team in its implementation of the hospital's response to Hurricane Sandy. There, she played a key role in the ED during the triaging and immediate placement of nearly a hundred patients from New York University Langone Medical Center after its backup generator failed and the hospital had to be evacuated.

But the COVID-19 pandemic is like nothing McGinn has experienced in her 45-year nursing career.

"I remember walking down the hall with someone, and he turned to me and said, 'You've probably seen it all.' I said, 'No, I don't think that I can say that after this,' " she recalls. "This is like what you see on a TV show, or you read in a book, and then you're living it. For me, this is probably the closest we have ever been to a war in what it's done to us and to our psyche."

The pandemic has put extreme strain on the United States and its people, particularly those in healthcare. COVID-19 has especially challenged the nursing profession to its limit, as some hospitals and health systems have had to endure a lack of personal protective equipment (PPE), an influx of patients, and sudden reassignment to different nursing units and roles.

But nurses are working through these challenges with support and innovation so they can continue to care for patients. In these pages, nurse leaders from around the country, including McGinn, discuss the integral roles nurses are playing as the profession is reshaped by the pandemic.

McGinn notes how multiple physicians have commented to her that nurses always responded to patient needs, even during the height of COVID-19. "When the call bell went off, they went in [patient rooms]. They ran to it. They didn't run away from it," McGinn says. "There's no replacing the bedside nurse. There's no replacing what they did during this time and the value of what they did. The education and training it requires to be a nurse today equals the skill set required of other members of the clinical team."

Though nurse leaders express concern about nurses' mental health and emotional trauma related to the crisis, they also have a sense of pride in the innovation and creativity RNs have shown.

Below are four areas where the pandemic has changed the nursing profession, and what nurse leaders are doing about them within this new environment.  

1. Nurses' mental health

Nursing burnout, compassion fatigue, and moral distress have been perpetual issues in nursing for at least the past decade. But nurse leaders like Tari Dilks, RN, DNP, APRN, PMHNP-BC, FAANP, president of the American Psychiatric Nurses Association and professor at McNeese State University in Lake Charles, Louisiana, are concerned that the scale, intensity, and pervasiveness of the COVID-19 pandemic will intensify these issues.

In addition to workplace stress, nurses are dealing with pandemic-induced stressors at home, including school closures, spousal job losses, and the fear of COVID-19 infecting their families, Dilks points out. Thus, nurses' well-being and mental health can no longer be overlooked.

"It's going to be incumbent upon their employers to make sure that mental health needs are being met," she says. "If we can figure out those things that help nurses be resilient … we're going to be in a much better place emotionally."

Peer support is one of many strategies that Penn Medicine Princeton Health in Plainsboro, New Jersey, has implemented to care for nurses' mental health, says Sheila Kempf, PhD, RN, NEA-BC, the organization's chief nursing officer.

For example, staff were trained to recognize the signs of being at high risk for emotional distress, such as verbalizing specific thoughts or emotions, and when peers should be referred to the Employee Assistance Program (EAP). The hospital also contracted a trauma clinical psychologist to talk with staff and run support groups with the EAP and the Ministries department.

"In the very beginning, when no one really knew what the [COVID-19] treatments were, it was overwhelming. But you didn't have time to stop and think about it," Kempf says about the nurses' experience. "By about June, it all started to sink in: what they went through, what they witnessed."

During the spring surge in COVID-19 cases, the 231-bed hospital had over 30 patients on ventilators with a census of around 80 COVID-19 patients a day. Typically, the hospital operates a 12-bed ICU.

To offer additional support during the crisis, the hospital's nurse advisory council formed a wellness committee. The group put together "code lavender" kits to promote self-care among the entire hospital staff. The kits included stress balls, chocolates, tea bags, cards with motivational sayings, and lavender essential oil. The team assembled about 3,000 kits and distributed them to all hospital employees.

"They went department by department and gave them out, which I thought was phenomenal," Kempf says.

The organization also began holding "clap outs," where staff gathered to clap and cheer for patients with COVID-19 who had been on a ventilator and were being discharged. In addition, for all COVID-19 patients being discharged, they played the song "Here Comes the Sun" over the loudspeaker. The intent was to celebrate patients' recovery and to show staff that their hard work was paying off, Kempf says. She estimates that song has been played about 500 times.

Yet, despite these recent efforts, Kempf says healthcare leaders should view nurses' mental health and well-being as a long-term issue.

"Even now, I'll say something to a staff nurse, and they'll start crying. It still happens," she says. "[Nurses] witnessed private conversations between husband and wife, sons and daughters, where they were saying goodbye [to loved ones]. I think that's where the crux of the emotional distress and PTSD is coming from because they witnessed things they should not." In addition, the staff was worried about bringing the coronavirus home to their own families. One of the local hotels provided free rooms to staff who either had to quarantine or could not go home due to a high-risk family member.

2. Patient throughput

As the senior administrative director, patient logistics, Lenox Hill's McGinn is responsible for the overall patient flow strategy, including the internal movements of all admitted patients from numerous portals of entry, the transitions of care within the hospital, and the facilitation and timely acceptance of external patient transfer requests.

McGinn says she believes patient safety, outcomes, and experience are all driven by the patient being in the right place at the right time. She also says nursing experience is extremely valuable in the role that she holds. Patient throughput, while operational in nature, really is a bridge between the clinical and ancillary departments of a hospital.

McGinn says she needed to utilize her previous experience, current skills, and numerous tools from her toolbox, including the enterprise TeleTracking system, when Lenox Hill's surge plan was developed with senior leadership and its ICU capacity grew from 48 beds to 123 beds. The expansion was accomplished by converting all the step-down units to ICU units, and physically moving the outpatient infusion center to Lenox Hill's ambulatory Manhattan Eye/Ear/Throat (MEETH) location, which added another 24-bed flexible-acuity unit.

"We knew we were going to need a lot of vacant beds to handle the surge volume. There are only two ways of getting beds that I know of: discharging patients, and by reclaiming and standing up closed units that were repurposed over the years. However, at some point, you finally run out of real estate, and you have to figure out what else from your surge plan you can implement," she says.

Having the support and resources of the Northwell Health system, McGinn says Lenox Hill was able to create and open a 35-bed nursing unit in the same building as the stand-alone Lenox Hill Greenwich Village ED. This was accomplished by utilizing the ambulatory PACU space of a closed surgical site. The unit's population was composed of patients who were clinically ready for discharge, but for various nonclinical reasons—such as needing a required number of negative COVID-19 tests—were screened and selected by a transition-in-care team who clinically approved the patients for lateral transfer after patient and family consent.

The unit was staffed with redeployed advanced practice clinicians, Greenwich Village team members, and a Northwell Health physician who volunteered to be the physician in charge. The transfer process was facilitated by the patient throughput team in collaboration with both the sending and receiving clinical teams to an off-main-campus nursing unit site. The Northwell Health IT team built the unit during surge planning, and the movement of these patients from one location to another was possible because of the technology platform that was in place.

In addition to discharging and relocating patients, McGinn says she was very concerned for the "load-balanced transfers" Lenox Hill admitted from several of their sister hospitals that were at the center of the epidemic.

"The last thing I wanted was for the nurses and the physicians who were already working their tails off to be running from rapid response to rapid response because we were transferring patients that were too acute to be at their level of care," she says.

McGinn called a meeting with the Lenox Hill ED leadership and advocated for triaging incoming patients through the ED, similar to what had been done during Hurricane Sandy, and the group agreed.

"I believe by transferring patients in this way, we prevented numerous rapid responses from occurring on the units," McGinn says.

One of the accomplishments Lenox Hill Hospital achieved throughout the COVID-19 surge was the timely movement of all patients to their beds, including ICU patients. There were "no boarding" issues in the ED, "which was a testament to everyone who worked tirelessly throughout this period," according to McGinn.

"We were able to get people out of the ED and up into a bed quickly. We had the ability to get them up to where the appropriate care was," she says.

The fact that McGinn is part of the emergency management team highlights the value of patient logistics.

"I go to those meetings and I participate, and I think, 'It really shows the level that people believe that throughput is valuable, and they need to have us at the table with them,' " she says.

Going forward, says McGinn, the patient throughput group will continue some of the duties it took on during the crisis.

For example, after consulting with teammates in epidemiology, the patient logistics team updated information to indicate when patients are being tested for COVID-19, whether a patient tests positive for COVID-19, and whether the patient was intubated.

"We are now taking that on permanently for all indicators," McGinn says. "That's a change in process. The throughput coordinators are utilizing Microsoft Teams®, having partnered with the epidemiology team, so they're constantly chatting with each other about who's a rule-out COVID low suspicion, high suspicion precautions, or who has a 'banner' from a previous admission. They have a clinical conversation, the outcome of the conversation is relayed, the banners are changed, and attributes in the system are removed if needed. This ensures that patients are going to the correct location the first time, thus reducing nursing handoffs."

This work will continue as McGinn's team continues to partner with the clinical teams, patient care management, and the ancillary department testing teams to identify, prioritize, and transport anticipated discharge-ready patients who require one last test before leaving.

"Those are things that we're doing to help facilitate earlier discharges," McGinn says.

 3. Teamwork

In recent years, many in the healthcare industry have called for an increase in interprofessional education and teamwork and a breakdown of traditional professional siloes. Nurses, and other healthcare workers, dealing with the COVID-19 crisis helped break down those siloes through necessity.

Natalia Cineas, DNP, RN, NEA-BC, senior vice president and system chief nurse executive at NYC Health + Hospitals in New York, says tackling the pandemic calls for teamwork both inside and outside the nursing profession.

"It's changed the whole notion of what 'type' of nurse you are. The whole specialty aspect went out the door," she says. "During COVID, if you were an ambulatory nurse, you would help [with] inpatient care. If you were with the Department of Defense—Army, Navy, Air Force—they came to help inpatient. If you were a Department of Education nurse, like a school nurse, you came, and you helped. I think it changed the whole notion of, 'That's that type of nurse, or they work over there.' I think it's solidified the fact that we're all one profession. Although you have to socially distance, we've become closer than we've ever been."

Sophia L. Thomas, DNP, APRN, FNP-BC, PPCNP-BC, FNAP, FAANP, president of the American Association of Nurse Practitioners, and a family and pediatric nurse practitioner (NP) at the Daughters of Charity Health System in Kenner, Louisiana, echoes this sentiment.

"One commonality I've found in all my conversations is an unprecedented sense of comradery and unity among all healthcare providers, which has been nice to see," she says. "Another one that's been welcomed is the increased level of incredible innovation and cooperation among the providers throughout the COVID response."

For example, NPs went to help in New York when Governor Andrew Cuomo signed an executive order that allowed them to practice without a collaborative practice agreement.

"We immediately had 4,000 nurse practitioners go for temporary assignments in New York, and as they care for patients, they share critical information about the virus. The information sharing has allowed NPs in all the types of care settings to better respond to COVID cases, whether they experienced an uptick or not," Thomas says.

4. Care delivery

The COVID-19 pandemic has created an environment that calls for new ways of delivering care. This has led to a great deal of innovation from both bedside nurses and nursing leadership. At Penn Medicine Princeton Health, in an effort to preserve PPE and provide good patient care, nurses created new care models in record time, Kempf says.

"In the beginning, the nurse performed all patient-related tasks because it was about preserving PPE and providing good care. For every patient on the med-surg floors who needed respiratory treatments, the nurses completed the treatments. They provided all the dietary and environmental services tasks," she says.

But following COVID-19's initial appearance, the nurses at Penn Medicine Princeton Health redesigned the nursing model to include an "inside" nurse within the patient room and an "outside" nurse or "runner" outside the patient room.

"We had runners in the hallways that did two functions. One was to make sure PPE was correctly donned. And, if an inside nurse needed something, [he or she] could communicate with the outside nurses and get what [was] needed. We could put medications, supplies, food in the [nurse] server from the outside so that [the inside nurse] could pick it up on the inside [of the room]," Kempf explains. "We designed this inside-outside model of care with staff within the first three days on our COVID unit. We went up there, we talked to staff and the educators and the leaders, and they just designed this entirely different model of care."

Additionally, in the ICU, IV pumps were placed outside of patient rooms for the outside nurses to manage.

"The nurses created a system where they had dual bar coding. The patient had the bracelet ID on, and a duplicate label with the patient's name was placed on each pump. The inside nurse could barcode the patient, and the nurse outside barcoded the med and then hooked it up," she says.

The organization also invested in headsets that could be worn under PPE, allowing inside and outside nurses to safely communicate with each other.

Kempf's nursing directors also took on new roles, each becoming an expert in a specific area.

"One was the PPE expert. She researched any PPE that had been donated to confirm that the CDC guidelines were met. She took face shields to Princeton University, and they printed them for us on the 3D printer when we couldn't get them from the company," Kempf says. "Another person became the labor deployment expert, checking credentials and education required for their new role. Someone else was the statistical person because we had to report everything to the state."

Kempf hopes this spirit of innovation continues in nursing long term.

"I think we will all look at things differently in terms of innovation and thinking out of the box. Crisis breeds creativity, and working under these kinds of conditions, I think a lot of nurses were surprised at what they could come up with. We have to give them the methodology for innovation and allow them to do it. We need to reward and recognize the staff who think outside of the box. I think it will have a good positive effect for the future," she says.