Finishing the marathon: Hospital CNOs offer advice to colleagues amid pandemic

Hospitals and health systems in the U.S. are balancing clinical and workforce priorities as they experience the effects of the COVID-19 pandemic and plan for what's next.

Executives have adjusted their strategies and operations to ensure patients receive quality care and that employees are supported mentally and emotionally. Here, nursing leaders from hospitals and health systems in some of the states hardest hit by the public health crisis share their top priorities and advice for colleagues preparing for a surge of COVID-19 patients.

Editor's note: Responses were lightly edited for length and clarity.

Debra Burke, RN, DNP, senior vice president for patient care and chief nurse at Massachusetts General Hospital (Boston): After two months of seeing steady increases in COVID patient volume, we are now in a plateau phase. Staff have faced this challenge with compassion, a can-do attitude and a determination to make a difference. 

But the work is hard, intensive and often very emotionally taxing. So now my top priority is to help staff to keep their energy up since this has been a long, difficult journey with their patients. An array of resources is available to promote coping skills, so keen attention needs to be paid to encouraging staff to utilize them to build their resilience.  

We also need to remain vigilant with protecting ourselves from being infected with the virus. I worry about our staff's own health. 

In some ways, this feels like the last mile of a marathon. Staff are just tired and want to sit down. We need to keep up spirits to maintain energy to finish this marathon.

Key advice: Bring key leaders together who can review data on what a surge might look like and create plans for the worst-case scenario. What will patient care needs be? How many ICU beds will be needed? What personal protective equipment, supplies and equipment are required? Training needs?  Decisions are patient- and data-driven. 

Then it is key to suspend the way you do things now and decide how you will meet patient care needs in a very different environment. New care-delivery models are needed. 

Shift all outpatient care to virtual care as soon as possible. Many ambulatory staff will need to move out of their current roles at some point and participate in inpatient care. 

Key leaders need to be able to make informed decisions quicker than they did in the past but be willing to re-look at their decisions, and course, correct if needed. There is no time to process all decisions for long periods of time. Also, it is important to recognize that not everyone has the skills for leading emergency preparedness. Suspend the impression that the top leaders in the organization need to lead the day-to-day business. Choose those leaders with the right skill sets to advance this work.

Natalia Cineas, DNP, RN, senior vice president, system chief nurse executive, NYC Health + Hospitals (New York City): Emotional support programs for our nurses are extremely important right now, as everyone is stepping back and realizing the full extent of the loss of life and the high cost of human suffering caused by the COVID-19 crisis. Our nurses have been on the front lines of this battle, and we want to make sure that we support them emotionally at this trying time. 

New York City Health + Hospitals has implemented a number of emotional support and wellness programs to help our nurses heal and address these heartbreaking experiences. These include the following: 

Helping Healers Heal Peer Support Champions, leadership, behavioral health and ancillary support volunteers are making wellness rounds at all facilities to actively engage employees working in areas heavily impacted by COVID-19. 

  • All New York City Health + Hospitals facilities have designated special spaces for staff to get relief from their patient care duties.
  • The Employee Assistance Program is currently offering online seminars and a telehealth option to assist front-line staff during the COVID-19 crisis. 
  • A new hotline, managed by NYC Health + Hospitals' Office of Behavioral Health, will connect staff to services and mental health counselors.
  • We are planning a memorial service at some future date to mourn those we have lost to this disease. 

This year's National Nurses Week — celebrated annually May 6 to 12 — takes on a special meaning, as it is being marked during the global pandemic. Now, more than ever, it is vital that we recognize and celebrate our nurses as heroes during Nurses Week, and also commemorate 2020's "Year of the Nurse and Midwife," designated by the World Health Organization. The final day of this year's Nurses Week also celebrates the 200th anniversary of the birth of nursing pioneer Florence Nightingale.

New York City Health + Hospitals has organized numerous activities throughout its facilities to recognize and celebrate our nurses during Nurses Week, including morning and evening "Clap For Nurses" events; special signage, flags, banners, posters and staff gifts; spotlighted social media and internal newsletter posts; and meal and treat deliveries throughout the week. 

It is important to embrace the now and recognize that we are part of history in the making. Our Harlem facility, for instance, is showcasing nurses who are working to address this crisis as part of its atrium museum, recognizing the work that these healthcare heroes are doing today that will be part of our history tomorrow. 

Moving forward, training, education and infection control are all top priorities. Systemwide, NYC Health + Hospitals has developed multidisciplinary teams to maximize our staff deployment and maintain readiness at our facilities for both COVID-19 and non-COVID-19 patients, as regular activities and normal patient volumes begin to resume. We are cross-training nurses to handle activities related to the special needs of many COVID-19 patients, including expanding our hemodialysis and peritoneal dialysis, as well as respiratory therapy. We also are focusing on our educational efforts for nursing students and our innovative nurse residency program, which is helping prepare new nurses for the challenges that lie ahead. 

Key advice: One of the most important steps that we took in the early days of the COVID-19 crisis was the development of our Virtual Deployment Team. The Office of Patient-Centered Care partnered with human resources, the enterprise service desk and the department of occupational health services to create a fast-track credentialing program and develop a virtual orientation and educational program for all new staff. These efforts reduced the typical onboarding process for new nursing staff from the traditional four-week time frame down to just two days. Existing nursing orientation procedures and materials were converted to online training, and an external web portal was created to allow off-premises access. Additionally, specialized COVID-19 educational materials were developed, and more than 7,000 nurses completed this training during the initial three-week crisis period.

To address our staffing needs, we reached out to a broad spectrum of nursing agencies, local colleges and universities, volunteer organizations and recently retired nurses to develop a database of potential nurses and nursing specialists — including respiratory therapists, hemodialysis nurses, critical care and medical/surgical nurses — for recruitment and deployment during the crisis.

We hired more than 4,000 agency nurses across all areas of our system and partnered with New York City's Department of Health and Mental Hygiene and Department of Education to redeploy more than 200 school nurses to our facilities. We recruited more than 400 nursing students and educators from local colleges and universities to assist with telehealth, and contacted 250 recently retired nurses, three of whom returned to work. We received invaluable support from the U.S. Department of Defense, deploying nurses and medics from the Army, Air Force and Navy service branches as leaders and educators throughout our system. These additional nurses and volunteers were deployed at our acute, ambulatory, post-acute and temporary facilities. More than 50 specialties were represented in the additional nursing staff, including the medical/surgical, ICU, ED, Critical Care and Cardiac divisions. In addition, redeployment of nursing staff was expedited by the chief nursing officers at each facility on an as-needed basis. 

Just as the theme for this year's Nurses Week — "Nurses: A Voice to Lead — Nursing the World to Health," suggests, we currently are soliciting feedback and listening to the voices of our nurses as we prepare for a potential resurgence in New York City and the surrounding communities to ensure readiness.

Terry Dentoni, RN, MSN, chief nursing officer of Zuckerberg San Francisco General Hospital and Trauma Center: My top priorities are obtaining and maintaining an adequate supply of PPE; maintaining a high standard of both patient and staff safety; establishing and maintaining an efficient flow for both COVID and non-COVID patients; and communication with staff and patients.

Key advice: My advice is to make decisions related to staffing and patient movement based on data:

  • Create levels of activation based upon census and acuity of patients to ensure staffing and PPE allocation
  • Create units that care exclusively for COVID patients 
  • Meet with the nursing directors daily to keep problems from becoming global issues
  •  Engage closely and cooperatively with union partners in regular meetings to go over PPE, patient and workflows, and other issues. Doing this has really decreased issues.

Anna Kiger, RN, chief nurse officer of Sutter Health (Sacramento, Calif.): Our priority will always be enhancing access to high-quality care. Sutter Health is prepared to use the breadth of our integrated network to increase critical care capacity to support COVID-19 patients if needed. At the same time, hospital emergency departments across our system are open and providing care beyond the pandemic. Our teams are trained and equipped to care for patients while protecting them along with staff. It's important for those who need emergency care to not delay it.

Sutter Health is also taking a phased approach to gradually broaden our clinical services in the locations where local guidance and public health orders allow us to do so. This safety-first approach helps us support patient needs while allowing us to continually monitor personal protective equipment and testing capability to ensure we can provide care safely and remain prepared for a surge should the number of COVID-19 patients begin to increase again. We are confident that we can broaden our clinical services and still maintain surge readiness.

Key advice: In a time where there are still unknowns, I suggest that our colleagues hold on to what they know is true: their unwavering commitment to patients and to each other. This feels especially meaningful as we celebrate Year of the Nurse/National Nurses Month and National Hospital Week. Our training and experience will help us rise to this challenge. Our teamwork and the compassion we show toward each other will always carry us and support us.

Linda Knodel, MSN, senior vice president and chief nurse executive of Kaiser Permanente (Oakland,Calif.): Right now, providing a safe environment for our nurses, clinicians, staff and patients — everyone in our medical centers — is a top priority. We are all concerned about COVID-19, and through this crisis, Kaiser Permanente has treated thousands of infected coronavirus cases. Ensuring that we follow public health guidance on how to keep everyone safe is critical. As more has been learned about this virus, our policies and practices have evolved.

Part of keeping people safe is to ensure we have adequate PPE. We are all limited by global shortages. It is reality, but whenever we find ways to keep our staff safe — even psychologically safe — we come together to address a solution.

We are aggressively working to secure additional personal protective equipment and other critical supplies to safeguard our front-line employees in our medical centers in accordance with the latest Centers for Disease Control and Prevention and World Health Organization guidelines, as well as guidance from our own infectious disease experts for clinical quality and safety. We recently secured more than 1.5 million extra scrubs for all our front-line staff. Within a three-week period, we worked across our continent to source and purchase as well as contract with vendors to increase our supply for our staff. 

We are deeply grateful to our medical teams, staff and employees who are expertly and compassionately caring for and protecting our members, patients, communities and each other.

Key advice: Taking care of yourself is key. One of our regional leadership teams put together a schedule so that leaders were available to staff around the clock while also allowing everyone a break. Allowing time to recoup is important for resiliency — and we all need to be resilient now. 

Being nimble is also key. At Kaiser Permanente, we have established a command center with leaders from all parts of our organization who function like a well-oiled machine with the ability to pivot.  Our command center team put together the 12 elements in our surge plan, which are now being used for a suppression plan.  

It's our duty as leaders to provide a sense of security and comfort. Creating a safe environment requires listening to people and guiding them to seek out reliable sources of information, such as the CDC. 

We have witnessed appreciation and support from firefighters, police officers, the clergy, businesses and more who provide a comforting salute or bring food.  A supportive community, whether it's nurses leaning on nurses or outpouring from the larger community, can be uplifting.

Trish O'Keefe, chief nursing officer of Atlantic Health System, President, Morristown (N.J.) Medical Center: Atlantic Health System's top priority will always be the health and safety of our patients, our team members and our communities. As this pandemic continues to evolve, we are reimagining how we deliver care to make sure everyone who needs our help continues to receive extraordinary care whether they are COVID-positive or not. We are particularly concerned about anyone who has put off urgent medical attention for serious conditions.

Key advice: Prepare and plan now. Here at Atlantic Health System we began planning for the impact of the novel coronavirus at the end of January, well before we admitted our first COVID-19-positive patient in early March. Through a strategic, phased approach, our medical centers demonstrated innovation and creativity by standing up new, dedicated units to manage expanded capacity and care for these critically ill patients. Our extraordinary team members — across all clinical areas — stepped into new roles and found new ways to deliver care.

Maureen White, RN, executive vice president & chief nurse executive of Northwell Health (New Hyde Park, N.Y.): Our top priorities at this time are: (1) the psychological and emotional well-being of our employees, (2) tracking and trending COVID patient data, and (3) planning for the return to a non-COVID state including the redeployment of staff and reductions in surge capacity.  

Key advice: My key advice would be to hope for the best, and plan for the worst. To accomplish this end, it is important to engage front-line team members in the planning process as soon as possible. Expectations regarding the possibility of overwhelming numbers of patients must be set early on. This will allow the front-line care team time to formulate and organize plans of action and processes to care for this surge of patients. Care models will also need to be redesigned to include functional team members whose role will be to assist primary care nurses in the delivery of care to these patients. The primary care nurse needs to understand they will be the quarterback for a larger number of patients directing other team members to perform certain tasks and/or functions. By engaging the frontline teams early on, they are better able to conceptualize this model of care and gain a greater comfort level in what might need to be done. Just telling the frontline teams that it might happen, is not enough, they need to be part of owning that potential reality. 

Ron Yolo, MSN, RN, vice president and chief nursing executive officer at CommonSpirit Health's Glendale (Calif.) Memorial Hospital and Health Center: Our current priority centers around keeping patients and staff safe during this COVID-19 pandemic. As new information gets disseminated from the CDC and state and local public health entities, we are continually adapting to these changes and implementing processes that are evidenced-based for the safety of everyone. Ensuring staff are geared with the proper personal protective equipment and other resources and tools they need during these unprecedented times, remains a top priority for our organization. Furthermore, as we enter the recovery phase of this pandemic and prepare to resume "normal" hospital operations, we are diligently examining our current policies and processes and incorporating lessons we have learned so our patients, physician partners, and communities have confidence that our hospitals are safe.

Key advice: I advise my fellow chief nursing officers to continually assess their readiness to deal with crises. Periodically evaluate your nursing workforce and your capacity to staff for a surge of COVID-19 patients. Work with your materials management department to gauge your PPE stock. Also, be transparent and continually round and listen to staff concerns at the front lines; they offer valuable suggestions that could alleviate a lot of the challenges we may face if there is another surge of COVID-19.


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