Staff Strategies to Meet Care Demands Throughout COVID-19 and Beyond

The system chief nurse executive (SCNE) is a complicated role accountable for advocating and standardizing nursing and care across the health system (Kingston, 2013). Core to this nurse leader role is system workforce optimization, with the responsibility to explore alternative care models, deem when new models are needed and lead the dissemination of new models across the health system. (AONE, AONL, 2015).  

Optimizing staffing models across the health system was an already complicated, multifaceted equation, with consideration balanced in patient outcomes, financial limitations and staff satisfaction (Leary & Punshon, 2019). The COVID-19 pandemic increased that difficulty as SCNEs were tasked to plan for an influx of critical, complex, highly contagious patients often in disproportionate distribution in a health system, while simultaneously addressing an excess of staff due to cancelation of elective procedures.  

In 2019, the Vizient Large System Nurse Executives Network (LSNEN) was established to meet the request of SCNEs for national collaboration and to address their professional challenges. LSNEN included SCNEs from across the country, with the intent to create a collective voice SCNEs and to influence the health care field by creating innovative solutions to today’s toughest challenges.  

In August 2020, LSNEN members sought to understand the staffing strategies most effective in their health systems through the initial surge of the COVID-19 pandemic. An outside consulting firm was enlisted to help develop a questionnaire for the 20 active network members in an effort to surface the successful system staffing strategies/actions that resulted in optimization of system staffing and summarize chief learnings needed for success moving forward. 

Key staffing strategies 

Thirteen SCNEs completed the questionnaire, a 65% completion rate, from which five key system staffing strategies utilized throughout COVID-19, emerged: 

Standardization of staffing practices – Standardization of labor tools such as staffing needs assessments, daily executive staffing summaries with projection of needs and leader standard work formed the foundation for central distribution of staffing resources. Aligning staff reporting and staffing expectations in this clear and detailed way allowed for a global understanding and ability for system staffing.  

Flexibility – COVID-19 created staffing disparities, decimat-ing the outpatient and procedural areas and overwhelming the infrastructure of the inpatient setting. SCNEs redeployed staff in the underutilized areas through cross-training and training nurses in more complex care processes. This work facilitated the advancement and incorporation of team nursing structures, the addition of COVID-19 specific roles—such as COVID-19 testing nurses and donning/doffing support—and the redeployment of staff to areas of greatest need.  

Centralized staffing office – SCNEs noted that the pandemic created the need to facilitate staffing at the enterprise level, which allowed for staff disbursement based on the hospitals or units of greatest need and facilitated distribution of staff based on skill sets. This was achieved through use of inter-hospital floating staff. The centralized staffing office also served as the point of distribution for agency staffing resources, again, ensuring appropriate allocation of staff to meet patient needs. 

Defined surge parameters – The pandemic acted as a test of health system surge capacity and staffing plans, allowing for refinement in definitions of surge levels with clear and specific triggers denoted to initiate alternative staffing models.  

Virtual care delivery – Virtual care delivery was not only enhanced in the ambulatory setting but also in the inpatient care environments in both ICU and general care settings. One organization was able to construct an eICU by utilizing iPads which required little overhead but facilitated the support of the ICU nurses. Another example of inpatient virtual care delivery occurred in the general care setting with the virtual nurse supporting admission documentation and patient education.  

Together, these strategies allowed SCNEs to achieve real-time effective staff deployment through a centralized process. Quick staff mobilization to the most impacted hospitals allowed many health systems to avoid staff furloughs. The SCNEs noted a number of these integrated solutions were concepts prior to COVID-19 but were accelerated based on need which enhanced their ability to act as a system. COVID-19 served as a common adversary, providing space to set aside individual needs and prioritize the system as a whole.  

The pandemic challenged the health care system and structure at a national level. As health systems reach the other side of this sentinel event, key learnings will inform future success. The SCNEs noted that the disruption of COVID-19 should serve as an opportunity to learn not only for future disruptions but also for optimal care day to day. Toward that end, the SCNEs identified eight key learnings imperative to consider for success moving forward in all care settings: 

• Flexibility – Increase flexibility in resource allocation and staffing through a centralized, standardized system approach. 

• Resource planning – Develop a plan for staff redeployment and assess annually, with metrics that define when plans are activated. Annually perform a skill set/need review, outline gaps and enact plans to address the gaps. 

• Culture – Leadership embodied being humble, real, kind, empathetic and accessible. Staff needs to feel valued through inclusion in decision-making and recognition. Utilize technology to ease the burden of joining meetings when staff are not on-site.  

• Virtual enhancement – Leverage learnings of the last year to improve virtual communication between staff, patients and families. Enhance virtual care delivery, through defined structure, staffing and metrics. Finally, prepare nurses through training for telehealth capabilities.  

• Wellness – Focus on staff well-being, balance and mental health with a 24/7/365 system. Weave well-being into the core of how the work is done with a strong longitudinal wellness approach, making episodic resources available on demand. Additionally, executives should think past the care continuum to include focusing on patient wellness in the community setting.  

• Equity – Partner with public health colleagues and community resources to address inequities utilizing social determinants of health.  

• Funding – Advocate for funding to support open access to care and promotion of care flexibility supported by telehealth.  

• Infection Control – Prioritize and understand infection control from bedside to boardroom. Utilize that understanding to guide care for patients differently and in a planned, proactive way. For example, systems can use “pandemic hospitals,” rather than caring for infected patients in every facility. 

SCNEs must be prepared to utilize the system workforce differently, maintaining agility and flexibility in a complex environment. COVID-19 has served as a significant disruptor, but it has proved to be a catalyst in advancing strategies and alignment across health systems. Perhaps most importantly, the pandemic provided an opportunity to derive key insights for future success.  

References

AONE, AONL. (2015). System Chief Nurse Executive Competencies. https://www.aonl.org/system-chief-nurse-executive-competencies

Leary, A., & Punshon, G. (2019). Determining acute nurse staffing: a hermeneutic review of an evolving science. BMJ Open, 9(3), e025654.

Kingston, M. B. (2013). The system chief nursing officer: An evolving role. Nurse Leader, 11(3), 27-29.

About the Authors

Nicole Gruebling, DNP, RN, NEA-BC, is associate vice president at Vizient Inc., Irving, Texas.

Anna Kiger, DNP, DsC, MBA, RN, NEA-BC, FAONL, is system chief nurse officer at Sutter Health in Sacramento, Calif.