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Nursing's non-negotiables for re-starting cancelled care

    This past week, Carol Boston Fleischhauer, hosted another round of pop-up executive forums—small, virtual conversations among CNOs to discuss their most pressing challenges with peer executives live. Session participants represented all regions of the country, and were at various stages of surge severity. During these sessions, participants discussed the key issues organizations face to re-start cancelled care including: competing priorities between organizations and providers, uncertainty regarding future surges, access to PPE and testing supplies, the anticipated influx of medical and behavioral health patients, highly variable levels of staff readiness, and predicted margin shortfalls.

    Given these concerns, we’ve outlined a starter list of nursing non-negotiables for re-starting canceled care, which were shaped and affirmed by these CNO discussions. My hope is that these non-negotiables will help you navigate the competing priorities and challenges that are to come. And keep in mind: this is a marathon, not a sprint. Be prepared for the long haul.

    Nursing’s non-negotiables for re-starting cancelled care

    1. Transition staff back to priority services areas without unraveling Covid care.
      During our discussions, many CNOs predicted a mismatch between the services that providers want to open and staff availability, with some concern that the wrong move could unravel Covid staffing models prematurely. This is particularly true for high surge environments where peri-operative staff were retrained to support Covid care. To avoid this, many organizations are planning to initially reopen at 50-60% capacity, allowing for the gradual transition of peri-op staff back to surgical services while minimizing Covid staffing disruptions.

      As your organization transitions staff back to surgical and procedural areas, keep the following in mind:
      • Identify priority areas using a systematic, and ideally evidence-based approach. Organizations are using various criteria to determine sequencing, including: by procedure, service line, provider, or revenue potential, as well as predicted need for post-acute or ICU care. Other organizations are using tools, such as Medically Necessary Time Sensitive (MeNTS) Prioritization tool, the Elective Surgical Acuity Scale, or the CMS tiers. Regardless of the approach, be transparent with staff about how you’re making sequencing decisions.

      • Determine the staff needed for continued Covid care and a potential second surge. You’ll need to decide whether a percentage of redeployed staff should be kept in reserve should a second wave hit. In addition, account for non-direct but essential Covid care, including newly created roles that support the pandemic response; ie, testing, PPE support, navigation, patient counseling/data collection, triage, etc. Make decisions regarding who will assume responsibility for these functions, as deployed staff resume permanent roles.

      • When matching staff to prioritized services, keep two things in mind. First, confirm the location and Covid status (including potential exposure) of staff. Second, ask staff to weigh in on their preferences. Some staff may be eager to get back to their “home” unit or care site, while others may not. Both of these factors will influence if and when you can re-open.
    2. Regardless if your organization saw a surge, provide and actively promote resources for emotional recovery.
      Surge severity will certainly influence the emotional support needed by staff, with the hardest hit staff experiencing high degrees of emotional trauma, grief, moral distress, and exhaustion. But, those organizations with a manageable surge or a surge that never materialized should still consider the emotional toll of the pandemic and how that will influence workforce readiness. Common themes include:
      • Almost universally, staff are concerned about safety, including adequate PPE and testing supplies. In addition to undermining resilience, it also erodes staff trust in the organization.

      • General employee health and well-being issues related to stress in the home (spouse losing job or laid off, child care challenges, or illness in the family) need to be factored in.

      • High rates of job anxiety, particularly for furloughed staff.
      In many ways, Covid-19 has only magnified existing challenges in the way we support staff. At a minimum, emotional recovery need to includes:
      • Assessing the emotional health of all staff and providing a variety of recovery resources, including peer discussions about experiences and one-on-one counseling. Some provider organizations have tapped into latent talent to provide robust, opt-in forums for frontline clinicians. This includes social workers, chaplains, palliative care specialists, hospice workers trained in psychological support, and students and faculty affiliated with psychology or social work graduate programs. Support can take a range of forms and I recommend reviewing this starter list for additional ideas.

      • Communicate early and often about emotional support resources. There are many communication channels to consider here: daily virtual meetings, emails, the intranet, staff huddles on units, etc. The key is consistency. To that end, I recommend crafting talking points to share with other leaders, including managers.

      • Commit to fully transparent communication about potential job uncertainty regarding permanent staffing. Staff are rightfully anxious about the future; every effort should be made to encourage job flexibility as cancelled care re-opens and medical volumes return.
    3. Standardize testing and PPE processes for employees before re-opening.
      Testing and PPE continue to be a major pain point, and that’s no different as organizations move towards re-starting cancelled care. Regardless of surge status, staff concern about their own safety continues to build in many areas. To address this, the majority of CNOs report routine monitoring of health status of employees before each shift, also relying on staff to report symptoms due to testing shortages. But, PPE questions remain pervasive, particularly as re-use standards loosen in non-surgical areas.

      Minimally, organizations must release employee standards that align with the CDC, state regulatory agencies, and system policies and ensure all staff are fully briefed on these standards. When communicating with staff, include the evidence-based source behind the standards and be realistic about current and future supply chain challenges. In addition, there are many other considerations when it comes to staff and patient safety. Some questions to consider include:
      • What is the minimum PPE needed for procedures, current Covid care on units, as well as any predicted future surges?
      • Do you have a mechanism in place to confirm daily PPE burn-rate in peri-op?
      • What’s the standard for PPE usage, cleaning for surgical patients?
      • Are there concerns over the perception of fairness as new PPE is provided to peri-op staff and patients, while other staff continue to re-use?
      • Do you have procedures for canceling surgery, should PPE levels be below threshold?
      • Do staff have interim employment expectations while waiting for results as part of your reopening process?
    4. Adjust peri-operative processes to accommodate for Covid, as appropriate.
      In our conversations, there is strong agreement that all peri-op processes require a thorough review, including how to leverage telehealth/virtual care for pre- and post-op care. Many organizations have rapidly adopted virtual care despite years of trying pre-Covid. This is one of the many advances organizations will need to keep an eye on—to avoid clinicians resorting back to legacy practice even where strong consumer support and demonstrated efficiencies exist. With appropriate stakeholders, we recommend reviewing all phases of peri-operative care to adjust for Covid needs, as well as the advancements in virtual care. Below is a starter list to consider when reviewing processes.
      • Integrate Covid risk assessment into pre-op visit and counseling for the patient and family. Consider the role of virtual care in pre-op visits.
      • Confirm standard for pre-op testing of surgical patients; including timeline.
      • Clarify visitor policy, including presence in holding areas.
      • Confirm PPE needs for staff, patients, and visitors. This may vary depending on the procedure, patient, etc.
      • Determine optimal post-acute facilities for referral and confirm support needed for receipt of select post op patients.
      • Enhance existing post-operative home management, monitoring, and navigation using virtual.
      Beyond an internal review of all peri-operative processes, we urge organizations to consider their patient communication and community outreach plans that outline patient safety measures and that reassures patients and encourages them to return. Patient communication needs to be proactive, leverage multiple channels, and include consistent messages that are reinforced by staff themselves, particularly nurses. For the wider community messaging, organizations are using a variety of channels, including: PSAs, town hall meetings, videos, and messages on their website.

    Final thoughts about re-starting cancelled care

    It's bittersweet to think about 2020 as the "Year of the Nurse." The Covid-19 epidemic has forced nurses to risk their personal safety to deliver care—many in some of the most difficult practice environments in living memory. Regardless if your organization saw a surge, there has been no finer showcase of nursing excellence, fortitude, compassion, and ingenuity than the past four months. As we move into Covid management, we must pause to recognize the incredible contribution of nurses—not only to patients and families, but to our communities. We’ve compiled a number of ideas on how to celebrate nurses, even with social distancing measures in place. I hope you’ll find these helpful.

    We are here for you

    As organizations re-open, nursing’s non-negotiables will evolve. Our entire team is available to be a thought partner with you. Email us with any questions you may have, but if you would like to schedule a call with either myself or someone from our research team, please reach out.

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