THE SEVERE acute respiratory syndrome coronavirus-2 (coronavirus-2019 [COVID-19]) pandemic has disrupted every aspect of life as we know it. Despite years of disaster preparedness training and execution, no one was ready for this. From the end of 2019, when reports first emerged of infections in Wuhan, China,1 to the early weeks and months of 2020, when the virus spread outside Hubei Province and confirmed cases accelerated across the globe,2 COVID-19 caught the world by surprise.
In the United States, the first serologically confirmed case was reported on January 20 in Washington State.3 On March 11, the World Health Organization (WHO) officially declared the COVID-19 outbreak a pandemic. All the while, critical shortages were emerging in supply chain materials, manpower resources, and coordinated public health response.2 This article describes the experiences of a national nursing association and acute care medical center during the first wave of the COVID-19 outbreak in the United States. From these very different perspectives, the professional nursing association responsible as the collective voice of US nurses and the lived experience of an acute care medical center in the first wave epicenter, nurse leaders in both organizations learned how to innovate, adapt in a crisis, and fundamentally change nursing practice.
A VOICE FOR NURSES
The American Nurses Association (ANA) is the primary voice representing and safeguarding registered nurses at all practice levels and locations across the United States. Fulfilling its 125-year mission to lead the profession and shape the future of nursing and health care, the ANA has played a pivotal role during public health crises, including the Ebola and Zika outbreaks. The nation's 4.2 million registered nurses regard the ANA as a trusted source for information, advocacy, and support.
The association is part of the ANA Enterprise, a family of organizations that includes the American Nurses Credentialing Center (ANCC) and American Nurses Foundation. These entities work together as a cohesive system to advance a vision, mission, and values that move nursing forward.4
In January 2020, ANA staff scanned early reports about a viral endemic in Wuhan, China. Concern grew due to the rapid explosion of transmissions, novel virus strain, and increasing evidence of an overwhelmed health care and infrastructure system. By February 2020, the ANA launched a nationwide survey of the workplace risks being faced by nurses—ultimately receiving more than 32 000 responses.5 Environmental scans were expanded across the ANA Enterprise to include staff and leaders from practice and policy, ethics, advocacy and government affairs, education, innovation, human resources, legal, ANCC, and communications.
In complex and turbulent times, organizations frequently develop formal or informal public-nonprofit relationships as a way to pursue shared goals and address common concerns.6 The ANA strengthened communication and collaboration with organizations including the American Hospital Association, American Medical Association, American Organization of Nurse Leaders, and state and federal agencies, such as the Centers for Disease Control and Prevention. The ANA continued to survey nurses in the field to understand concerns, fears, and needs. It also began to assess the possibility that large, in-person events such as conferences and meetings might have to be rescheduled or cancelled.
By the time the WHO declared COVID-19 a global pandemic in March 2020, confirmed cases in the United States exceeded 188 700 with 5200 deaths.7 At the ANA, what started as small weekly meetings in January had evolved into daily morning huddles involving staff from nearly every department. Business continuity planning began. All staff converted to work-from-home status. It soon became apparent that an overarching framework was required to coordinate rapidly evolving events—both externally to support registered nurses and internally to support team members.
RESPOND, RECOVER, AND THRIVE
In late April, with the response beginning to stabilize, daily morning huddles reverted to 3 days per week. Executive officers introduced a new framework: respond, recover, and thrive (RRT). RRT is an amalgamation of various disaster response and resilient leadership frameworks focused on prevention, protection, mitigation, response, and recovery.2,8,9 Leaders formed the COVID-19 crisis management response team (CMRT) (see Figure 1). To maximize autonomy and coordination, both the RRT framework and the CMRT were adapted to ANA Enterprise reporting structures at the work group level. Each work group was assigned 2 co-leaders and an executive officer sponsor to advocate for, and guide, decision-making and resource allocation. Each leader was appointed by the executive officers based on experience with crisis management and alignment with current role expectations and strategic priorities. One of the 8 co-leaders also served as CMRT chair, reporting to the executive officers who, in turn, reported to the ANA, ANCC Boards of Directors, and the America Nurses Foundation Board of Trustees.
Work group leaders crafted charters that identified their purpose, scope, membership, decision-making methods, and reporting structures:
- Incident management work group. Identify opportunities, address concerns, and facilitate and resource responses in support of practice and advocacy work resulting from the pandemic.
- Communications work group. Coordinate all internal and external communications to key stakeholders, boards, ANA members, customers, staff, and industry/association partners, and serve as a media conduit.
- Restoration work group. Lead efforts to reopen ANA Enterprise offices when the stay-at-home order is lifted. Under the guidance of the finance staff, update and develop financial models to continue to support programs and operations.
- New work/recovery work group. Examine new work and new ways of working using evolved and innovative products and services. Collaborate with the other work groups and the American Nurses Foundation to leverage opportunities for growth.
Work group leaders met weekly for critical status updates, cross-pollination of strategies, ideas, and resources, and to check on each other. Information was shared via our internal Microsoft (MS) Teams portal, regular updates during internal meetings (staff, leadership), and at key stakeholder meetings (eg, Commissions and Board of Directors).
Benefits of the new CMRT structure were quickly apparent. Work group leaders reported a high level of understanding and autonomy within and across groups. Work was increasingly coordinated, highly collaborative, and laser focused on the needs of nurses as the pandemic worsened. Data tracking and sharing multiplied (see Table 1). A weekly “think tank” of ideas ensued. As an enterprise, ANA recognized a new-found ability to rapidly mobilize, strategize, and prioritize.
Table 1. -
Sample Data Collecteda
|COVID-19 survey series
||Monthly to bimonthly
||ANA and American Nurses Foundation
||Weekly to monthly
||ANA and American Nurses Foundation
|Advocacy and regulatory actions
|Social media mentions; media requests
|Internal staff and family well-being (work from home)
||Daily to weekly
|Credentialing metrics—applicants, renewals
||Weekly to monthly
Abbreviations: ANA, American Nurses Association; ANCC, American Nurses Credentialing Center.
aUsed with permission from the American Nurses Association.
While these accomplishments generated a sense of pride, underlying exhaustion and concerns about unfulfilled workload continued to weigh heavily on the team.
By late summer, the relentless work pace of the previous 6 months began to ease. The CMRT work groups were well established, staff had adjusted to working from home, and work reflected the creativity, innovation, and sweat equity invested. Progress reports were shared weekly via MS Teams. Members, donors, and outside agencies lauded the ANA for its COVID-19 response.
From the start, the ANA never lost sight of the most important tenet: stay true to the mission.
Mission, vision, and values not only guided the CMRT's critical work, but also supported the RRT model's execution. For nurses, one value emerged above all: trust. Trust is a quality nurses cherish, as it provides the foundation for so much of the work they are called to do, especially at times of uncertainty and chaos. Nurses will remember ANA's trustworthiness—as a source of information, support, advocacy, and guidance—long after the pandemic is over. And the ANA will be right by their side, ready to respond to the next call. In the following section, the same early period of the pandemic is described from the lived experience of nurse leaders in the field, facing unparalleled mortality and adapting, innovating, and leading like never before.
A PATIENT CARE LEADER
NewYork-Presbyterian (NYP) is one of the nation's most comprehensive, integrated academic health systems, encompassing 10 hospital campuses across greater New York. Its employees are dedicated to providing the highest quality, most compassionate care to patients locally, nationally, and throughout the globe. In collaboration with 2 renowned medical schools, Weill Cornell Medicine and Columbia University Vagelos College of Physicians and Surgeons, NYP is consistently recognized as a leader in medical education, groundbreaking research, and innovative, patient-centered clinical care.
NewYork-Presbyterian/Columbia University Irving Medical Center (NewYork- Presbyterian/Columbia) is a Magnet-designated academic medical center located in the Washington Heights neighborhood of Manhattan. In March 2020, NewYork-Presbyterian/Columbia was at the epicenter of the COVID-19 pandemic. Patient care quickly evolved and required nurse leaders to make unprecedented decisions.
The COVID-19 pandemic presented unique challenges and opportunities for the NewYork-Presbyterian/Columbia nursing team. Inventory management, staffing, critical care beds, meals, housing, and transportation were just some of the concerns faced by the team during this crisis. The nursing leadership team worked tirelessly to meet these challenges, all while dealing with the unknown and fast-paced changes brought by this pandemic.
NewYork-Presbyterian/Columbia admitted its first COVID-19 patient on March 3. Initially, patients trickled in, allowing time to prepare the team and the facility. Even so, those early days were a scary time for the health care team, reminding many of the HIV/AIDS epidemics in the 1980s. A dearth of information fueled fear. However, as the surge picked up, attitudes changed and the war against COVID-19 truly began.
By mid-March, New York had the highest number of confirmed coronavirus cases in the country and Governor Andrew Cuomo declared a state of emergency. Uncertainty, stigma, and anxiety still predominated. And yet, as the rush of critically ill patients continued, nurses stepped up, prepared to confront this novel disease.
Within just a few weeks, the number of critically ill patients had risen to dangerous levels and intensive care units (ICUs) were near capacity. Measures were taken to address concerns about running out of ICU beds, ventilators, and critical medications. The medical center stopped elective procedures and converted ambulatory surgical units, as well as recovery rooms, into ICU bed space. While personal protective equipment (PPE) never ran out completely, it was necessary to take steps to conserve it, adding to the stress load. The nursing leadership team focused on securing the supplies and equipment necessary for nurses to do their jobs, as well as ensuring staffing resources were available to assist the fatigued health care team. Meeting these goals required innovation, ingenuity, teamwork, and financial resources.
The NYP Chief Nursing Executive and Chief Quality Officer convened a team of nurse leaders from across the enterprise and opened a COVID-19 command center to facilitate staffing and inventory needs for all campuses. The team worked quickly to shore up infrastructure, facility, staffing, and supply chain changes. Actions included:
- Established ICU beds in operating rooms (ORs) and on medical-surgical units, more than doubling ICU capacity. Clinical nurses working in these newly established ICU areas were assessed for competence and partnered with skilled ICU nurses to safely care for patients.
- Built field hospitals to relieve emergency rooms.
- Erected tents for patient screening and treatment of less acute cases.
- Created new efficiencies for patient care to conserve PPE, such as intravenous pumps outside of patient rooms and designated “green” and “red” areas in the halls.
- Revised nursing protocols on subjects including cardiac arrest, turning, and cardiopulmonary resuscitation.
- Fostered innovations to enhance patient care and the patient experience, including placing larger staff photographs in repurposed telemetry monitoring bags—allowing patients to see their faces without a mask—and using technology to communicate with family members outside the hospital.
As of early May, the United States had more known cases of COVID-19 than any other country. The number of cases in New York alone exceeded Italy and Spain. New York City was still the epicenter, with no end in sight. Nurses were tired, scared, and fighting with everything they had.
By mid-May, however, relief was in sight. The processes and procedures developed to accommodate the surge of patients proved effective, and teams were able to care for all COVID-19 patients who came through the doors. Nurses were redeployed from the ORs to the newly created ICUs and field hospitals. Extra staff and volunteers were in place, giving nurses a much-needed respite.
Throughout this trial by fire, nurses demonstrated courage. They felt a moral obligation to make patients feel safe—to touch them physically and emotionally and treat them like family since their families could not be with them. The hospital experienced a high mortality rate among COVID-19 patients, which was a completely new experience for the health care team. NYP outperforms on survival rates for all 6 areas measured by the government and has done so since 2016. But sadly, by May, more than 27 000 New Yorkers had died from COVID-19, many without any family present. Nurses demonstrated compassion by connecting patients with families through technology, such as video sharing platforms like FaceTime. Many of these connections were made just before a patient was intubated or as patients took their last breaths. A particularly challenging aspect was caring for critically ill colleagues, some of whom did not survive. And yet, nurses marched on and kept fighting.
Nurse leaders provided support in multiple ways and assured the clinical teams were aware of the services provided by NYP. Daily meals, respite rooms, chaplain and psychiatric services, open communication, free housing, child care, transportation to and from the hospital, and laundered scrubs were just some of the basics offered to frontline caregivers, who often spent 10 to 12 hours in PPE. These services were provided by the NYP enterprise and offered to all employees free of cost. Meals were distributed at each campus 3 times a day; housing was made available at nearby hotels, with bus transportation to and from work; bus routes were established throughout Manhattan to provide employees rides to work; and, childcare was provided in collaboration with facilities in Manhattan that remained open for essential workers (see Figure 2).
Adaptability was evident throughout the crisis, especially around alternate care models. Nurses found themselves redeployed and caring for patients they did not typically manage on their home units. Many were required to flex nursing muscles not used in a while. Alternate care models included:
- Team-based approach
- Help from local nursing students
- Volunteers from other US hospitals
- Specialized teams, including prone and turn teams
- Physicians trained in nursing skills, such as skin integrity assessments, positioning, and suctioning
As the COVID-19 crisis raged and staff settled into a new normal, interdisciplinary care took on a whole new dimension. Interprofessional colleagues worked alongside nurses to provide direct patient care for more than 13 weeks. Physical and occupational therapists, nurses, and physicians worked together on the prone team. Nurse anesthetists worked with anesthesiologists and perfusionists to establish care teams in newly converted ICUs. These interactions strengthened the team dynamic throughout New York-Presbyterian/Columbia. Staff felt grateful for each other and felt the gratitude of the community.
At the end of May, the team faced an entirely new challenge: recovery. Different care areas recovered in different ways. For example, surgical procedures slowly resumed, beginning with joint and spine surgical procedures. The ORs needed to be deep cleaned and brought back to normal function to accept surgical patients. At the same time, the ICUs were still above capacity and most patients were still COVID-positive. Nurses still needed help to accommodate high volumes of critically ill patients.
Medical-surgical units were decontaminated, and rooms restructured to their original use. Non-COVID patients slowly began to return to the hospital and nurses were again treating stroke, heart, and gastrointestinal issues. Team safety always remained a top priority throughout and required everyone to wear masks. Restricted visitation started, and the team worked to make sure visitors were following safety precautions to keep themselves, patients, and staff safe.
The focus for nurses was on renewal, including time to recharge away from the hospital, and a return to original units and roles. To harness the teamwork forged during the pandemic, nurse leaders built on successful interprofessional collaboration and a new-found respect for every role within the medical center.
As professional governance meetings resumed, the chief nursing officer asked nurses 2 key questions: What do we keep? What do we never do again?
Responses were grouped into 3 buckets:
- Let go or change—opportunities for improvement
- Keep—things that worked well
- Just do it—things that worked really well
Each item was assigned to a nurse leader responsible for developing tactics to eliminate or continue the process in the future (see Table 2).
Table 2. -
COVID-19 Learnings Action Plana
|Let Go or Change
||Just Do It
|Need PPE stockpile
||Free food and coffee
||Leadership video updates
|Standard work for conversion of units: equipment and supplies
|Faster development of protocols
||Bedside clinical support
|Improve communication of PPE guidelines
||Hard face masks/shields and goggles
|Clearer direction about policy/procedure changes
||SWAT Team (Surgical Workforce Access Team)
|Improve testing availability
||All clinically necessary disciplines go into rooms
|Do not double bed patients in heart center units
||Electronic devices to keep family informed
||Flexibility of shifts
|Do not float staff to different units daily; consistency
||Negative pressure rooms
|Educate on charting requirements—quick tutorials
||Cross-training deployed staff
||CVVH and dialysis team
|Facilitate quicker access to health care
||Pastoral care/psychiatry and social support for staff
|Travel nurses needed ASAP; improve onboarding
||Staff accommodations close to hospital
|Support team members handling nonnursing tasks
||Flexible bus schedules that coincide with staff schedules
|Routine Command Center updates and prompt follow-up
||Utilization of seasoned ICU nurses as resource nurses
|More RRT nurses
|Implement mandatory respiratory fit testing for all hospital employees annually
|Review skill strengths with employee before deployment
|Improve communication with pharmacy
Abbreviations: ASAP, as soon as possible; CVVH, continuous veno-venous hemofiltration; ICU, intensive care unit; PPE, personal protective equipment; RRT, rapid response team.
aUsed with permission from New York-Presbyterian.
COVID-19 has forever changed the health care landscape, and nowhere is this more evident than in New York City. The nursing leadership team at NewYork-Presbyterian/Columbia rose to the challenge and held steadfast through a months-long fight to ensure clinical nurses had the tools to do their jobs. Lessons learned have guided the road to recovery and prepared the organization for any future crises.
In this article, leadership of a national nursing association and a major academic medical center were tested in distinct yet parallel ways, as they responded to the COVID-19 pandemic during the first wave of the outbreak in the United States (January to August 2020). A willingness of each organization to take calculated risks, imagine the impossible, and succeed in uncertain and uncharted territory is described. Leaders rose to the challenge to deliver the best their organizations had to offer, both in service to their missions, their teams, and their communities.