Facing real-time challenges while responding to the COVID-19 pandemic, nurse leaders across the US implemented new ways of delivering care that demonstrated their true nature as leaders and innovators. The American Organization for Nursing Leadership (AONL) captures this spirit of innovation in its recently launched series, Leadership Beyond the Pandemic—discussions with nurse leaders exploring lessons from the pandemic that may prove effective for continued use in non-pandemic times to lower healthcare costs while providing quality care. The series was created as a follow-up to Leading Through Crisis: A Resource Compendium for Nurse Leaders, developed by AONL to equip nurse leaders early in the pandemic. Both resources were supported by the Johnson & Johnson Foundation and developed in collaboration with the Johnson & Johnson Center for Health Worker Innovation.
I sat down with Beverly Hancock, DNP, RN, NPD-BC, Senior Director for Leadership Development at AONL, Michael Bleich, Ph.D., RN, NEA-BC, FNAP, FAAN, and Deborah Zimmermann, DNP, RN, NEA-BC, FAAN, senior nurse executives and co-creators of the program, who shared insights they gleaned from nurse leaders across the country and some of the noteworthy models of care. An edited version of our discussion is below.
Julie: Let’s first talk about the survey that was sent to nurse leaders across the country, which is the foundation on which these resources are based.
Deb: Our vision was to bring together innovations and solutions to challenges that nurses were experiencing across the country, and to make them easily accessible for other nurse leaders to implement. We started by issuing a short survey and, within two weeks, received detailed and enthusiastic responses from over 100 healthcare organizations. In reviewing the results, we identified trends and ideas from the front lines that could be quickly incorporated into new care standards.
Michael: Rather than conducting a traditional prolonged study, we did a point prevalence survey, which is meant to capture a snapshot in time—what was going on in the hospitals and how the nurses were responding in real-time. In traditional research, we tend to look for high-volume trends with less attention to the “tails” of the bell curve. In coding the survey responses, we identified the most common ones, then we identified other, rarer responses that represented something new or innovative. It was this clustering of themes that led us to develop the specific podcasts and webinars that are part of the learning series.
Julie: Give me some examples of high-volume trends you saw in the survey responses.
Deb: Healthcare organizations that thrived noted team decision-making, horizontal communication and collaboration across inpatient, ambulatory, and post-acute care environments, and increased transparency and frequency of communication as key to their success. Siloes between departments disappeared, and in some instances, organizational hierarchies seemingly disappeared overnight allowing nurses to really step up as leaders.
Michael: What fascinated me was a return to team nursing that yielded an increase in effectiveness and efficiency. It made me wonder why team nursing isn’t current protocol if we default to it. Organizations also created new job roles for nurses based on work design, like a workforce vaccination team or an intubation for difficult airways team. This is innovation we hadn’t heard of before.
Deb: Another trend we saw frequently was nurses leveraging technology in new ways. In Boise, Idaho, a young nurse leader in charge of the telemetry unit expanded the IT capacity in the ICU, enabling the hospital to quadruple the number of ICU beds from 100 to 400. Data on a patient’s heart rate, blood pressure and other physiological parameters was fed to an inter-professional care team overlaid into the nursing unit so that they were able to monitor many patients at once and adjust to surges in patient volume. Without using the technology, the hospital would have needed hundreds of nurses to increase capacity in that way.
Michael: Leveraging technology is not innovative in and of itself, however, we saw examples of nurses leveraging technology in completely new ways. A common issue in Texas and surrounding states during the summer COVID-19 surge was that hospitals were simply running out of beds. A nurse leader at a critical access hospital licensed for only 30 patients in northern Texas struck a partnership with the local phone company and a durable medical equipment (DME) company to monitor, triage, and provide education and support for 300 COVID-19 patients in the surrounding communities. The DME company set up equipment to monitor patients’ vital signs and provide oxygen at home and the phone company transmitted vitals back to the nurses at the hospital. There was no script for doing this—this nurse leader wrote the script with a drive to serve the needs of the patient.
Julie: In essence, this nurse leader built a bridge between the health system and the community by working with unlikely partners and leveraging technology in new ways. That’s amazing! Let’s dive into the “tails” of the bell curve—the more unique examples.
Deb: On the evening news, you would see dramatic footage of helicopters medevac’ing patients from one place to another across Arizona, where hospitals are on average quite small and geographically dispersed. On the surface, it looked like chaos, but what was happening was a very synchronized, organized use of resources, which ensured that Arizona and the surrounding states could provide the right level of care at the right time so that no hospital would be overrun with patients. This was due to the efforts of a nurse leader who managed a call center for a large healthcare organization in the southwest and worked with the Arizona Department of Health to come up with a triage system to alleviate overcrowding in hospitals.
In the panel discussion (the Marriage of Acute Care with Community Care) we paired the nurse leader from Arizona with a nurse leader in Vermont, where the challenge was less in the acute care setting and more in post-acute care. The Vermont Department of Health brought in a nurse leader to educate staff in caring for higher acuity patients at skilled nursing facilities which resulted in earlier discharge from hospitals. This allowed the acute care facilities to reduce a patient’s length of stay and maintain their capacity to treat more severely ill patients.
Julie: Switching gears, I’d like to talk about the role of the empowered nurse leader. Were these nurses pro-active, and/or did they have a supportive and empowering environment?
Michael: In times of crisis, nurses do not think in terms of empowerment—it’s more about salvation. Nurses really proved to be the hub of the wheel; they were exploiting their skills and abilities without concern for traditional roles and boundaries. It was about nurses stepping into their power to salvage humanity.
Deb: It was beautiful to watch. The pandemic was so all encompassing that nurses stepped up and used their voices. We are the largest of the healthcare professions—nurses outnumber physicians nearly 5:1 and are 4.7 million strong. When answers to questions involving the care of patients did not exist, nurses cultivated a spirit of “real time” inquiry fueling innovation, research, and exponential changes in practice. As a chief nursing officer, I witnessed nurses collaborating across organizations on new clinical care guidelines for patients with COVID-19, consulting with colleagues on treating in place in skilled nursing facilities and shelters, and creating hospitals without walls in the community.
Beverly: As Michael said, nurses were developing solutions going outside of normal boundaries. Some of the traditional structures and administrative burden were lifted which opened opportunity for quick testing of ideas. It would be fascinating to study the enabling environment that COVID-19 created for nurse innovation.
Julie: What else did you learn from this experience?
Beverly: Nurses want to, and need to, be able to tell their story demonstrating their strong leadership and innovation. Reflecting on their experience is important work. These leaders have so much pride in their teams who came up with incredible, creative ideas. They were so grateful to be acknowledged for that.
Michael: Absolutely! Through our interviews, we discovered voices that really have never had their day in the sun. These are not the people that you see on the speaker circuit, these are critical access nurse leaders who have key roles in leading healthcare organizations across the country.
Deb: I agree. And we need to keep in mind the importance of creating the enabling environment for nurses to speak up, and to innovate. Nurses are well-known for their tenacity, bravery and compassion at the bedside; but they are less thought of as leaders and innovators. The COVID-19 pandemic has provided the opportunity for nurses to demonstrate other roles that we know they’ve always played: trailblazers, strategic thinkers, and yes, leaders in healthcare. My hope is that nurses continue to see themselves, and be seen by others, as leaders and step into their rightful place alongside physicians, pharmacists, and other healthcare providers in the inter-professional collaboration that is so critical to providing quality care.
| Beverly Hancock is senior director, Leadership Development at the American Organization for Nursing Leadership. |
| Michael Bleich is a senior professor at Virginia Commonwealth University School of Nursing, where he directs the Langston Center for innovation in quality and safety. |
| Deb Zimmermann is an AONL board member and Chair of the AONL Foundation. She served previously as a chief nursing officer in New York and Virginia and currently works with the medical reserve corps and the Department of Health on equity and access to education and care. |