Over the past several months, we have seen, heard, and read stories about nurses on the frontline providing incredible care—sometimes under exceedingly strenuous conditions—to people who had tested positive for the coronavirus (COVID-19). They were applauded as they, and other health care providers, changed shifts. They were called heroes and they were exhausted. Some of those nurses were likely already experts in critical care and organizational employees. Others transitioned from different areas in the organization or into the organization itself. Behind the scenes was another set of heroes—those nurses responsible for the development of nurses, especially in crisis. They were our nursing professional development educators.
To create this editorial, I spoke with six individuals—four representing three hospitals across the United States, and two representing residency programs. Each had a distinct message of something they did that was specific to their organization, and each spoke to the quick, dramatic response they were making to prepare as many nurses as possible to fill and backfill the organizational demands. They, too, are heroes in helping us respond to the crisis we continue to experience.
Perhaps the most dramatic stories come from the New York City area because it was affected early and intensely. Dr. Launette Woolforde, Vice President Nursing Education and Professional Development at Northwell Health, identified the impact of educators for more than 17,000 nurses across more than 750 clinics and 23 hospitals. Orientation was accelerated for new nurse graduates (NGs). Centralized orientation was reduced by a day by compressing the amount of time devoted to the electronic medical record (EMR). Only 1 day was not virtual because it was reserved for demonstration of competency. NGs were assigned to the intensive care unit (ICU), regardless of where they planned to work in the future. In teams, they worked with a more experienced nurse so that two to three nurses were caring for three to four patients.
The remaining orientees were stratified based on experience, and their total orientation was shortened. Using a self-assessment tool, experienced nurses were able to complete the usual 6-day orientation in 3 days, with 1 day being in-person, 1 being virtual, and 1 focusing on the EMR. Throughout this time, the NPD educators leveraged YouTube, Zoom™, and the organization's learning management system, where all in-person content was made available virtually. If no videos existed on YouTube or a commercial site, the organization created them.
To capitalize on an available workforce, the NPD educators created a nurse refresher program for nurses who had not been engaged in direct care recently. Additionally, the clinics, in general, were closed so those nurses assumed in-patient care services. The focus was on key skills required in caring for the patient population.
The number of patients with COVID-19 quickly overtook the ICU, so other units were converted to care for these people. The organization contracted for the services of more than 600 travel nurses, and a cohort of nurses came from Intermountain Healthcare, Utah, and the University of Rochester New York. They all had the same access to the learning materials.
Northwell's fellowship program was expanded to support the regularly anticipated number of fellows and new graduates who may have had their capstone experience disrupted. Their clinical experiences focus on patients in the general units until they can transition to where they might normally work.
One outstanding example of sensitivity to the intensity of the situation is the fact that the organization is factoring in time for recovery before expecting new graduates to demonstrate competence. To maintain a competent, nonclinical workforce, NPD educators created a catalog of courses to align with essential competencies because this resource will be available all year. As a result, nurses will be able to transition rapidly to meet future demands.
Two clinically focused residency programs also adjusted their offerings to assist with the pandemic. Versant offered an online, competency-based program (Competency Validation for Clinical Practice) for health care workers with limited or noncurrent clinical experiences to gain the knowledge and skills needed to provide safe, standardized nursing care.
Vizient, which works with many of the hospitals in the New York City area, created content on topics vital to today's needs (e.g., infections, resiliency, and reflection). Issues on health equity, death, and dying are also covered, while the new nurses are supported by in-person or remote communication with program leads.
On the other coast, Ellen Carlos, Nursing Education and Practice Specialist at Legacy Emanuel Medical Center in Portland, Oregon, capitalized on her Doctor of Nursing Practice project related to security infrastructure. Little did she know, her idea of using portable video cameras to serve as sitters for patients who needed such services could expand to support care for patients with a diagnosis of COVID-19. The need to create additional services for the anticipated patient surge allowed the organization to convert a medical–surgical unit into a safe environment for the care of such patients. This unit had been closed due to a planned remodel. The cameras—originally intended for the sitter services—were quickly moved to the unit, and the technology staff worked diligently to activate these cameras to serve as a benefit to nurses in providing care in a time when personal protective equipment (PPE) was so limited. As a result, nurses and patients could talk with each other and nurses could see the patient and the devices they were monitoring.
They also created a program for nurses in the perioperative area—readily available because elective surgeries were canceled—to serve as the backup staff for nurses in medical–surgical areas. As with Northwell, Legacy Emanuel Medical Center used a team nursing approach. Key among the content areas were some medical–surgical procedures not used in perioperative nursing and how to use the EMR. This program was accomplished in 8 hours, with 4 hours of didactic learning and use of a checklist and 4 hours of shadowing in a unit. Administering medications was also a challenge because the types of medications administered in the perioperative area is narrow in perspective to the variety found in the typical medical–surgical unit. A major benefit of having to respond to this crisis is the organization's redevelopment of their disaster plan. Now, more detail is included to allow for a smooth transition to whatever the care demands might be in a disaster.
Although many non-direct care nurses were not deployed elsewhere, the NPD staff went to the emergency response centers to serve as lead screeners, safety officers, and reassignment nurses. They were there to serve and simultaneously they learned more about how to develop programs to transition nurses quickly in a crisis.
Down south in Atlanta, Georgia, Dr. Stephanie Bennett, Director, Patient and Family Centered Care and Patient Education, and Dr. Tim Cunningham, Vice President, Practice & Innovation at Emory Healthcare reported on NPD initiatives involving more than 7,000 nurses, in addition to other health care workers across the metro Atlanta area. Leveraging Emory's shared governance processes, teams developed and tested an ICU surge care delivery model, designed to address staffing and patient safety issues during the COVID-19 pandemic. The team also developed resources, such as skills checklists and daily task-based worksheets. The model and resources fostered nursing collaboration needed to transition from primary to team-based care, with experienced ICU nurses serving as team leaders. For example, during pilot testing, staff who normally did not work in the ICU used the model and resources to partner with an experienced nurse. Staff with less experience typically assisted with activities such as performing assessments and retrieving medications and supplies. During normal operations, clinicians in Emory's ICU (eICU), which included certified critical care nurses and an ICU intensivist, performed virtual patient and data monitoring in most units. Use of Emory's eICU technology during the COVID-19 pandemic in those units allowed redeployed nurses to rely on in-room audio and video support from subject matter experts to maintain patient safety.
Because of the transition of staff within the hospital, the medical–surgical units experienced a different shortage of staff. As a result, the NPD educators created and implemented intensive medical–surgical review courses to allow nurses from specialties, such as perioperative and clinic areas, to assume care for patients in the medical–surgical units. Additionally, a strategic partnership with Children's Hospital of Atlanta enabled pediatric nurses to deploy to Emory's adult patient care units, such as the ICU. In this instance, NPD leaders partnered with members of the Human Resources team to develop a rapid onboarding process, so staff could quickly deploy to the ICU.
Across the Emory system, the usual 2-day central orientation became a 1-day event. As needed, videos and virtual training were implemented to augment in-person education and training. The NPD educators were strategic and intentional in scheduling small, frequent classes to adhere to social distancing recommendations. Furthermore, the need to conserve PPE drove NPD educators' decisions about limiting educational activities and removing students from clinical experiences. The decision to halt student presence also related to the rules about limiting family presence.
Each of these organizations did something different. However, every effort was directed toward the ability to pivot from what was business-as-usual, to a new normal of critically ill patients suffering from something none of us understood. Hats off to educators worldwide who helped transition thousands of nurses from various roles and patient populations to a new role of frontline nurse hero.
We salute you!
Patricia S. Yoder-Wise, RN, EdD, NEA-BC, ANEF, FAONL, FAAN