Last week I published the first in a series of blogs focused on nursing in the midst of a crisis and why it is truly a team sport. I also highlighted that the value of our role and the job we do remains the same, both during and in the absence of crisis. This week I would like to share some of my learnings from my experience.
Walking into Uncertainty
Truthfully, I wasn’t sure what to expect when I signed up to work in this hospital. It’s been over three years since I worked in direct patient care. I’ve been in Nursing Leadership since late 2016. My office was in the middle of an ICU or PCU, but my direct patient care was limited. I was frequently involved in clinical emergencies and provided CPR, assisted nurses with hanging blood products and giving bed baths to patients when we were short-staffed or just when I had some time to be out on the floor. It was important to me that I was physically present with my team, demonstrating to them that I could “walk the walk,” so that they knew they could come to me with any issue, and that I would have a real understanding of their work.
All that being said, it had been over three years since I had to manage a patient assignment for a full 12-hour shift from start to finish, stay on top of my task list, reprioritize when a patient deteriorated, help out my pod-mates when they needed it, redirect a disoriented patient, communicate with a diverse clinical team about high stakes issues… and remember to take bio breaks and eat something at some point. Oh right, and complete all my documentation.
I was relieved that the clinical care came right back to me and it truly felt like “riding a bike.” I was not shocked or surprised by how sick these patients were or by the way they were clinically presenting. I had read so much about what people were seeing in hospitals across the world and I think I knew what to expect — to an extent. The rapid decline, intubation, and proning, were all things I had seen and done and could picture. So, the level of acuity, while extreme, was what I expected.
The unit in which I previously practiced as a bedside nurse (24 beds) was run by pulmonary critical care physicians. On any given day there were two to four people who were as acutely sick and unstable as the COVID patients seem to be at their sickest. So, the really high acuity presentation of the COVID patients in acute respiratory distress syndrome (ARDS) was familiar to me. I’m accustomed to caring for these types of patients. What was shocking was the volume of patients, and how many of them became critically ill very quickly.
The hospital where I worked during COVID had a 20-bed general ICU. It’s usually a mix of medical and surgical patients. When I was there, it was all COVID patients, and about 75% of the patients were in full-blown ARDS. And, as you can imagine, that volume of highly acute sick patients looks very, very different for healthcare workers. Working in a unit where it feels like everyone is running around trying to stabilize multiple extremely sick patients constantly, with no ebb and flow of the pace, was very intense. I left every day feeling a mixture of guilt and relief that my time there was limited. I can’t imagine being a fulltime ICU nurse right now — not knowing when the surge would peak, wondering if today’s slightly lower census would mean that things were really on a downward trend, and when my life and practice might return to normal.
I arrived on April 28th, about the time the volume of hospitalized COVID patients peaked where I live. The 20-bed ICU had overflowed to a post-procedure area, as well as the dialysis unit. Typically, ICU patients require a 2:1, patient to nurse ratio because of the intense level of care. Often, patients are so unstable as to require 1:1 nursing. This was also the case for some of the highly acute COVID patients.
Creating Flexible Teams
This hospital is very small and has limited resources in terms of critical care nurses. They don’t have a huge float pool. They don’t have multiple ICUs with different specialties like a surgical ICU with lower volumes so they can float staff to the ICU with COVID patients to balance things out. They don’t have any of those reserves. In order to staff the additional beds, as well as support the increased acuity, nurses were pulled from many different areas to create a team – medical-surgical nurses, and interventional radiology, cardiac cath lab, PACU nurses – to work in the ICU. They divided the 20 beds into three teams each shift, plus one team each for the overflow areas. Then they would pair a couple of critical care nurses with a med-surg or procedural nurse or an NP who had remote ICU experience. Together, the team would figure out how to manage 5 to 8 beds.
Nurses were pulled from the neighboring cancer center ICUs. I worked with nurses who were in pre-admission testing and hadn’t ever been in the ICU, and ones who ordinarily worked in the cardiac cath lab. There were nurses pulled from med-surg areas to support the critical care trained nurses and additional physicians from anesthesia departments across the health system. One whole medical-surgical/oncology unit was shut down and all those patients transferred to the other units to conserve staff. I know from experience the amount of coordination required to execute these operational shifts is staggering.
So right away I knew that this organization’s leadership had come together to assess the situation and figure out how to flex to their staff’s needs using the resources available to them. It was a dynamic process, where a few times a day the charge nurse of the ICU and the NM discussed where there were open beds (if any) and whether anyone was likely to leave. The NM was coordinating with other hospital leaders to decide the plan for each day — sometimes each shift. Sometimes we would shuffle patients around — moving one or two more stable patients to the ICU satellite areas to free up spaces for patients who might come in overnight either from the ED, a sub-acute facility or as an emergent transfer from the floor in distress.
I was so impressed by these nurses and their professionalism and willingness to adopt the team-based nursing model. I would arrive in the morning and I would see that I was on team A with two critical care nurses and one med-surg nurse, and a tech. We would have eight patients and while taking the report from the nightshift team that was leaving, we would have to discuss how to divide up those patients. This is not how nurses are used to operating.
Getting Comfortable Being Uncomfortable
Typically the night shift charge nurse has divided up the patients based on acuity and geography and the plan for the day and you arrive and are given your assignment. Here the nurses would arrive and right off the bat have to collaborate “in the moment,” knowing very little about the patient load and how we were going to divide work for the day. Most of the people there on any given day did normally work together, which was another interesting piece of the dynamic. Generally, everyone was so supportive of one another and extremely helpful. People did not dwell on fear, or lament about unfairness — we had work to do and we got it done. People were coming in, rolling up their sleeves, and saying, “Okay, what do we have here? How are we going to do this?”
What felt different was a real willingness to be “comfortable being uncomfortable” – to choose to move past the discomfort of the unfamiliar – whether it was clinical care, staffing models, or coworkers. We all had to go in and put egos aside and not worry about asking questions. When something was unfamiliar or a procedure was being done differently than I was used to, I learned to be open rather than critical. In these moments, I had to just say, “Okay, this is what I’m normally used to doing. What do you guys do? What materials do you have for this?” It was very humbling, and also incredibly rewarding.
There was not once when I felt like someone wouldn’t be able to help me out or know what to do. That was the best part of working with this group. There were some scary times. I was working with a group of people in one of the overflow areas and there were just buckets of supplies. You hope you can find what you need. But often you couldn’t. There were also times when someone had a question and we didn’t know the answer because we were in unfamiliar territory. But we would figure it out. I am definitely not used to those conditions – what some people are calling “crisis standards of care.” I assume none of these nurses were either. Everyone just rose to the occasion.
Nurses are known for being innovative and basing our practice on evidence. However, we also can be creatures of comfort. We like our home units — hate floating. We need to develop trust in our coworkers — it’s really hard to be new on a unit with people that have been working together for years. And, we rely heavily on protocols — safety is always a top concern. During COVID, people knew there was no other option but to be flexible. Everyone had to balance their own work with the teams’ work.
It made time management more challenging than usual. But, it was a much more flexible, dynamic way of doing things. We had a med-surg nurse act as a resource so that we could delegate tasks to them like medication administration, giving blood products, that were within their scope. I wasn’t used to delegating that much to another RN. It really shook up the normal staff relationships most nurses and nursing assistants are accustomed to.
Each day when I left, people would say, “Hey, it was great working with you today,” knowing we might never see one another again. I’m an agency nurse and I’m only there for a couple of weeks. Many of the people were being pulled from another area and this was just a one-off for them. They’re never going to see me again. At the end of the shift, we all thanked each other for the help, which is pretty typical in my experience when someone’s had a rough day — except in this case every single day was incredibly tough. Everyone was just so grateful for another set of hands, and someone willing to work really, really hard with the team.
There are so many healthcare workers who have flexed to meet the need by learning to manage ventilators and brushing up on pharmacology that they don’t frequently use and wondering if and when they will ever get to return to their normal unit, team, and specialty. Their entire professional lives have been turned upside down in a way that the rest of us can’t imagine. In so many ways this is not what they signed up for, and yet they’re gracefully and skillfully meeting the need. A lot has been discussed about the financial impact of COVID on hospitals and health systems, and the trauma many are experiencing in caring for and losing so many patients.
But we also need to acknowledge the role of this uncertainty and upheaval on burnout in healthcare workers. Workers need to be able to trust in their leaders. They must trust that their leaders are constantly reassessing the situation and pivoting accordingly, whether that is measures to conserve PPE so that supplies last or creative ways of shifting staffing models so that there are enough hands to do the work.
Healthcare workers have so many reasons to experience burnout in general, especially due to this pandemic, but we know that when trust erodes between workers and their leaders, they are at much higher risk for burnout. We must move beyond just “self-care” as a way of addressing burnout and focus on strategic ways to strengthen leader-staff relationships and trust. And that’s what I will discuss in my next blog post.