Nurse executives across the country are working to expand their acute staffing pool as much as possible before their organizations' Covid-19 surge. This includes redeploying RNs to the acute care front lines and cross-training their nursing workforce in the competencies most important for Covid-19 care.
While these trainings are an essential foundation for redeployed staff, online trainings and in-person "boot camps" only go so far. It takes years for most nurses to become clinically competent in caring for highly acute patients. So to deliver quality care to critical Covid-19 patients, organizations will have to scale the expertise of the few critical care nurses they already have at the bedside.
Use a team-based approach to scale critical care RN expertise
One way to do so is to implement a model that's been in nursing's playbook for decades: team-based staffing. Instead of assigning a small number of patients to one RN, managers assign a larger group of patients to several staff members. The theory behind this approach is that the collective wisdom of the group delivers better care to their assigned patients than one RN could do alone.
In Covid-19 care, this approach has the added benefit of scaling the expertise of the limited number of experienced critical care nurses. These nurses, either experienced RNs or acute care NPs, lead the team-based model. They are directly responsible for a limited number of highly complex care activities, but spend most of their time overseeing their team.
Here's a sample of Covid-19 team-based models CNOs have been experimenting with:
- Pairing ICU RNs with cross-trained med-surg RNs;
- Pairing ICU RNs, cross-trained med-surg RNs, respiratory technicians, and patient care technicians; and
- Deploying acute care NPs as team leaders with RNs and ancillary staff to support.
2 strategies for effective Covid-19 team-based staffing models
The risk of the team-based model is that team members won't know what they are directly responsible for, resulting in missed or duplicative care. To create an effective model, follow the two recommendations below:
- Clearly delineate team roles and responsibilities
- Designate an expert, and teach them to delegate
The most important part of team-based staffing is to establish clear roles. There's no one right answer for what each team member should be responsible for—that depends on the make-up of the team. But to prevent missed or duplicative care, each team member should know exactly which care activities they are responsible for, and what will be left to their teammates.
As a starting point, critical care managers should compile a list of care activities associated with Covid-19 care. The foundational nursing skills—initial assessments, basic IV administration—should be assigned to cross-trained RNs. Those specific to critical care should be assigned to the team leader, or performed by cross-trained RNs with leader oversight.
Choosing an expert will depend on each organization's available staff. Acute care NPs and experienced critical care nurses make for great leaders of Covid-19 teams. But experienced perioperative nurses or CRNAs can step in as well, as they have expertise in competencies critical to Covid-19 care (particularly ventilator management).
Regardless of who the leader is, it's important to set clear limits on what they are responsible for, and what they should delegate. Leaders will likely find delegation challenging, particularly for those without formal leadership experience. Managers will need to proactively support them in developing these skills. Consider the following strategies to do so:
- Teach leaders how to provide in-the-moment feedback. Any material organizations already have on hand to teach new managers how to deliver feedback is helpful. Another option is to equip leaders with our Guide to Delivering Actionable Feedback.
- Suggest that teams round together. Rounding is a great opportunity to establish a rapport, check care plans, identify missed care, and re-calibrate roles.
- Have managers debrief with leaders at the end of each shift about their experiences. In addition to improving leadership skills, these check-ins can also serve as an emotional support for team leaders. Use the following questions as a starting point:
- What tasks that you ordinarily perform are difficult to delegate? Why?
- What tasks are the easiest to delegate? Why?
- What tasks used to be difficult to delegate are now easy to delegate? What changed? How did you become more comfortable?
Scaling expertise isn't limited to nursing
The Covid-19 staffing shortage isn't just limited to critical care RNs. Several physician specialties, particularly intensivists, hospitalists, and pulmonologists, are also in high demand.
Organizations also need to think about how to scale their expertise, too. But unlike nurses, who have to be present in person to deliver care, their expertise can be scaled remotely through provider-to-provider telemedicine. One way to do so is to task hospitalists and redeployed ambulatory physicians with in-person assessments and care. When necessarily, remote critical care specialists can provide an expert opinion through a virtual assessment.
We will continue to share strategies of how organizations revamped their Covid-19 staffing models in the coming weeks. If you would like to share your organization's staffing model with us, please email me directly at RewersL@advisory.com.