The American Nurses Credentialing Center's Magnet® program to “raise the bar for nursing care delivery, new knowledge, and evidence-based clinical quality”1(p.IX) became a guiding force for developing the culture and operational plan for a 1000-bed field hospital at the Boston Massachusetts Convention and Exhibition Center named Boston Hope Medical Center. The field hospital, a 4-way collaborative with the Commonwealth of Massachusetts, the city of Boston, Mass General Brigham Health System, and Boston Health Care for the Homeless Program, had a 2-part objective to open a 500-bed post–acute care hospital for COVID-19 (coronavirus disease 2019)–positive patients and a 500-bed respite center for Boston's homeless COVID-positive patients. The leadership team began forming on April 1, 2020, with the mandate to open the facility for patients no later than April 10, 2020.
As leaders (codirector of facility: J.I.E.; chief nursing officer [CNO] for post–acute care hospital: S.H.J.); lead data, outcomes, and evaluation: B.B.B.), we were strategically positioned to develop and influence all aspects of the operations including the importance of hiring and developing a 1000-person workforce within 9 days. In order to accomplish this, we knew we needed to (1) hire clinicians from varied clinical backgrounds and experiences, (2) develop a robust orientation program that could be delivered once per day, every day, (3) create a learning environment, (4) develop flexible schedules, (5) embrace students and new graduates, (6) integrate a well-formed military unit into our emerging team, and (7) develop reporting metrics and outcome measurements.
Transformational leadership is an important component of the Magnet Model®. Never was there a better opportunity to adopt and carry out the principles of transformational leadership as these principles were a necessity in setting the mission, vision, culture, and operations for an inner-city field hospital. All leaders needed to embrace the importance of clear communication related to the strategic and operational plans of this post–acute care field hospital especially the importance of the quality and safety plan. At Boston Hope, it was imperative to have an organizational structure, processes, and expectations that allowed a new team to come together in an environment of mutual respect that supported the variation in experience and talents of team members.
Within the context of transformational leadership, we understood the importance of creating empowering team structures and supporting staff in the use of those new structures. We designed a nurse leadership model and successfully recruited a nursing team to execute on the vision set forth for the post–acute care part of Boston Hope, including 2 nurse directors and 2 to 3 nurse educators for the facility, supplemented with 1 resource or charge nurse per unit, per shift.
Staffing the Field Hospital
In order to staff the 500-bed post–acute care hospital side of Boston Hope, several innovative staffing models were leveraged based on evidence-based practice standards, as well as the nurse executive team's cumulative professional experiences. The Federal Government's Toolkit for Alternative Care Sites (2(p52) nurse staffing ratio recommendations were initially referenced and then adapted to account for the varying skill and mix of the Boston Hope staff. The hospital side of Boston Hope was built to accommodate 5 clinical units each with 48 beds, with each unit opening as patient volume increased. One of the clinical units was predominantly staffed by the Massachusetts General Hospital Institute of Health Professions senior immersion nursing students with 6 to 8 students, 1 faculty member, and 2 Boston Hope RNs to care for up to 48 patients. This afforded the students clinical oversight while meeting the educational objective of their immersion for increased autonomy of practice. Another clinical unit used an innovative staffing model and leveraged the state of Massachusetts waiver3 to allow graduate nurses who completed their nursing degrees but had not yet had the opportunity to sit for the board examination, to practice as RNs in response to the COVID-19 pandemic. In order to provide clinical oversight and professional guidance to these novice staff, a ratio was established of 5 experienced nurses to 3 graduate nurses or licensed RNs with practice experience of 6 months or fewer. The 3rd staffing model unique at Boston Hope was the deployment of a military unit of clinical staff. This intact team of nurses, medics, and physicians staffed 1 unit of 48 beds at Boston Hope, yet fully integrated with the Boston Hope practice expectations and clinical standards established by the leadership team. This yielded a collaborative practice with shared learning across military and civilian teams that was beneficial to staff and patient care.
With the staffing models defined and recruitment occurring at an extremely intense pace, a dynamic orientation and onboarding plan was critical. As nursing staff arrived at Boston Hope, they attended an approximately 1.5-hour central orientation to welcome them to the overall operations of the field hospital. From there, they completed personal protective equipment (PPE) donning and doffing training as well as N95 mask fit testing. Additionally, web-based trainings were assigned to staff to review standard clinical training (HIPAA, blood-borne pathogens, etc), as well as Boston Hope–specific training related to documentation standards and use of the adapted electronic medical record. Because of the need to preserve PPE supplies, the tour of the hospital and clinical training all occurred during a 1-day onboarding with an orientation checklist and dedicated preceptor. In addition, as graduate nurses and newly licensed nurses integrated onto the team, the need for a skills validation became clear to ensure the quality of the care and appropriate support of novice staff. The nurse directors, in collaboration with the CNO and nurse educators, created a standardized skill observation tool for a head-to-toe physical examination and safe medication administration. These were deemed the 2 critical success factors to practice safely as a graduate nurse. If a nurse either through self-evaluation or peer evaluation was deemed to need more support for his/her practice development than was feasible at Boston Hope, he/she was then offered another role at the facility such as a patient care attendant or PPE monitor in the donning/doffing tents. All graduate nurses had an identified mentor on each shift for any questions.
Providing for Safety
The Magnet empirical domains of evidence for resource utilization and development are in the Magnet Model component of structural empowerment. As a strategy for clinical operations is developed, it is important to be operating from the core principles of excellence, understanding the environment of care, and clearly defining roles and responsibilities for each team member. These principles were incorporated from the onset and guided our actions and leadership at Boston Hope. Staff empowerment and just culture were cultivated and evident in many ways at Boston Hope. As we admitted our 1st patients, nursing teams were diligent in identifying and requesting additional supplies or equipment to effectively care for patients in a convention center environment. A safety reporting system was established for staff to report events and near-misses. This system was broadly utilized and provided an opportunity to correct and improve the safety environment without delay. Other measures were implemented to advance a culture of safety and included the implementation of follow-up phone calls once patients were discharged, patient experience surveys, and interviews of patients while hospitalized at Boston Hope.
As we reflect on our experience, the applicability of the Magnet Model and specifically evidence-based practice and leadership standards were clearly needed, effectively implemented, and contributed to the high quality of care delivered to the patients served in our COVID-19 field hospital. Anchoring on this framework and the core principles of nursing excellence from the start afforded nursing leaders the opportunity to accelerate teaming and create an effective practice model in service to patients with COVID-19 and the broader community.
1. American Nurses Credentialing Center. 2019 Magnet Application Manual
. Silver Spring, MD: American Nurses Credentialing Center; 2017.
2. Federal Healthcare Resilience Task Force. Alternate Care Site (ACS) Toolkit
. 2nd ed. Washington, DC: Health and Human Services; 2020.
3. Baker C. (2020). Order authorizing nursing practice by graduates and senior students of nursing education programs. https://www.mass.gov/doc/guidance-authorizing-nursing-practice-by-graduate-and-senior-students-of-nursing-education/download
. Accessed April 12, 2020.