FACED WITH RAMIFICATIONS of the COVID-19 global pandemic, health care systems all over the world have experience major ongoing disruption from 2020 through 2022. In the United state alone and as of February, 2022, more than 76 million confirmed cases of COVID-19 and more than 900,000 deaths have been reported.1 The number of cases continues to rise, with new variants reported throughout the country despite promising new vaccines with demonstrated effectiveness against COVID-19.
Health care systems continue to experience the sequential aftermath of this pandemic, with major care access, quality, safety, financial sustainability, and workforce considerations. When efforts to respond to a pandemic may seem insurmountable, opportunities still exist for meaningful transformational change. Evidence suggests that academic-clinical partners in trusting established relationships fare best in challenging times2 because they are able to make quick, synergistic adaptations amidst changing conditions.
A nursing partnership is described between an academic health center school of nursing (SON) and university hospital and health system to provide short- and long-term support to the nursing workforce shortage as part of a COVID-19 pandemic surge response. The partnership incorporated an academic-clinical integration framework that guided planning, clinical support actions taken, outcomes achieved, technology innovations, lessons learned, and future recommendations for education and practice partnerships.
The academic-clinical partnership between the University of Alabama at Birmingham (UAB) SON and the UAB Hospital and Health System (UABH) dates back 15 years when the first Memorandum of Understanding recognizing the UAB Nursing partnership was signed. The focus of the partnership has been on advancing nursing education, science, and practice through research, clinical placements, faculty practice, student engagement, and collaboration for nursing excellence and evidence-based practice (EBP).3
In 2016, the partnership was reengineered and further strengthened with the creation of a structured model and an ambitious strategic plan aligned with both partners' institutional strategic goals and objectives. A committee structure deriving from the 4 pillars of engagement, quality, financial, and advancement of knowledge was developed along with a designated work plan and evaluation blueprint.3 Regular communication between the partners occurs through standing monthly meetings and timely, just-in-time conversations. Ongoing continuous improvement, strategic planning retreats, documentation, and evaluation of outcomes are major elements of the work together.
In early December 2020, the chief nursing officer (CNO) at UABH reached out to the UAB SON Dean, expressing concern about an impending COVID-19 case surge that could potentially overwhelm the hospital and adversely affect the local community and state. As the only academic health science center and quaternary hospital in the state of Alabama, UABH is a major referral center in the southeastern United States and must be positioned at all times to provide needed services to a population requiring highly specialized care. The surge in COVID-19 cases in the community and state was expected to happen at a time when hospitalized patients were already at their highest, current staff was at its lowest, and the use of traveling nurses was at its peak. The COVID-19 pandemic surge response required clinical and academic partner support and thoughtful planning during this crisis to (1) mobilize additional qualified nursing personnel, (2) provide quality nursing care, and (3) operationalize an immersive educational clinical experience with faculty and students.
BACKGROUND AND FRAMEWORK
The partnership's initial COVID-19 surge response began in December 2020 and lasted through January 2021. The surge response depended on the robust academic-clinical partnership between the UAB SON and the UAB Academic Health System (AHS). The partnership was guided by an “academic-clinical integration framework”4 that combined the Quadruple Aim and the Learning Health System (LHS). The Quadruple Aim incorporated academic and practice elements for better outcomes in the areas of patient experience, cost per capita, health workforce experience, and population health. The LHS included research and knowledge, organizational structure, data and evidence, and quality improvement practices. As the COVID-19 care challenges increased and the need for qualified nursing personnel escalated, a rapid surge implementation response was needed. Through the partnership, more could be accomplished to meet critical nursing workforce and patient care needs than either partner could independently. The characteristics that enabled this surge response through the academic-clinical integration framework to move forward expeditiously are highlighted in Table 1.
Table 1. -
Characteristics of Academic-Clinical Integration in an Academic Health System
|1. Long-standing partnership, established trust, and collaboration among nursing academic and service leaders in an AHS.
|2. An AHS with nursing faculty and students familiar with UAB Hospital and UAB Medicine systems.
|3. An AHS Nursing Service accustomed to SON faculty and students.
|4. The flexibility and adaptive responses of both partners to pivot from standard operating procedures to innovate just-in-time approaches for service and learning.
|5. The ability to deploy faculty and student teams to areas of greatest need in the hospital setting and to target specific nursing services to improve outcomes.
|6. The willingness and support from UAB and Health System leaders to allow the partnership to move the surge response forward employing novel academic/partnership strategies.
Abbreviations: AHS, academic health system; SON, school of nursing; UAB, University of Alabama at Birmingham.
The academic-clinical integration framework laid the foundation for analysis of partnership planning, interventions, and outcomes. Combining the Quadruple Aim model with the LHS model creates a natural linkage and evaluation schema for academe and practice advancing the interests of both entities. This framework is highly relevant for academic health centers with alignment of health schools, hospitals, and health systems. Clinical practice leaders focus on outcomes that improve patient and workforce experience, population health, and health care costs, while academic leaders focus on the preparation of the future workforce, research, knowledge generation, and application of evidence to improve quality of care. Aligning the academic and practice entities using the academic-clinical integration framework created value-based outcomes that benefited both entities as evidenced further in the following sections.
The initial COVID-19 surge increased patient volume significantly in the UAB Health System at the end of November, 2020 through February 2021, in August of 2021, and again in January, 2022. While many industries suspended services, health care kept going through the most challenging conditions of all times. Those employed worked harder and longer hours, and many cared for the most acutely ill patients they had ever seen. Staff with community-acquired COVID-19 or quarantined because of family members with COVID-19 contributed further to significant nursing workforce shortages. Some nurses chose to leave the profession due to family needs, school closures, and other personal reasons. The increased number of diagnosed COVID-19 patients who filled intensive care and other units required more intense, high-acuity nursing care. Concurrently, travel nurses had limited availability due to hospital surges nationwide. This serious nursing workforce shortage at a time of greatest patient care need culminated in the perfect storm. With fewer nurses available to care for the increasing acuity in the hospital, the hospital was unable to cover necessary shifts, mandating an urgent call to deploy all nurses in the UAB Health System and community to the hospital. The dean of the SON approached the Health System CNO with a potential solution: mobilize faculty and students who would volunteer in a salaried role to assist with patient care over the December and January intersession. The CNO agreed while acknowledging the barriers that would need to be cleared to activate this idea. The dean consulted university administrators (provost, human resources, legal) to resolve administrative barriers that could obfuscate moving forward and then contacted the CNO and the SON's Associate Dean for Clinical and Global Partnerships to mobilize faculty and students to participate in the COVID-19 surge response. Both faculty and students had to be willing and ready to join frontline workers to care for COVID-19 patients at this crucial point in the pandemic, which meant they were willing to forgo semester and holiday break. Human resources teams from the SON and hospital facilitated transfer of common requirements for faculty or students in the areas of competency training, certifications, applications, salary, and scheduling logistics. Just as the plan for this initiative was being developed, COVID-19 vaccines (Pfizer and Moderna) became available for dispensation, allowing faculty and students to provide 2 major areas of support: caring for acutely ill patients including those with COVID-19 in the inpatient setting and vaccination support for priority populations in the university, health system, and broader community.
The academic-clinical integration framework coupled with the LHS principles guided our partnership as we enlisted faculty and students to engage in direct patient care, COVID-19 testing, and vaccine administration. The COVID-19 surge coupled with the serious nursing workforce shortage temporarily preempted partnership work on our annual goals. The COVID-19 surge response allowed students and faculty to participate and team together with nursing and medical colleagues to help support nursing care for acutely ill patients as well as vaccine administration. These mutually beneficial actions benefited faculty and students who needed increased clinical experience because of the initial COVID-19 limitations that excluded students and faculty from clinical environments. Similarly, clinical nursing partners benefited from the reinforcement of additional nursing hours of care provided by the students and faculty during the staffing crisis. Scaling up the COVID-19 surge response using the academic-clinical integration framework embodied not only mobilizing students and faculty to augment staffing but also engaging the minds and hearts of the faculty and students in these efforts so they were prepared to enter the high-acuity COVID-19 clinical environment. The common partnership goals, evaluation blueprints, and established relationships among academic and clinical leaders, faculty, and staff drove the joint work and actions taken.
PREPARATION FOR SURGE SUPPORT
The Associate Dean for Clinical and Global Partnerships issued a call for willing and able registered nurses on faculty at the SON to sign up for the effort at UABH. Within 24 hours of the call, a list of 50 faculty volunteers was identified and forwarded to UABH. After recruitment of faculty volunteers, an undergraduate faculty leader formulated a proposal that was approved by SON leadership. This proposal included the addition of volunteer senior-level nursing students in the COVID-19 surge staffing response; namely, third- or fourth-semester baccalaureate (BSN) students to assist with vaccinations and participate in faculty-led team-based care on clinical units. Both SON leadership and hospital partners quickly approved this proposal. Key decisions that drove the preparation and organizations for this surge support effort were as follows:
- Faculty and students participating in the support plan were hired as hospital employees;
- Administrative processes to approve and process faculty and students through the UABH human resources department were required;
- Faculty were hired as registered nurses in a secondary appointment in the UABH system beyond the faculty role at the UAB SON; and
- Students were hired as nursing student aides (NSAs) at UABH and students were allowed to bank clinical hours for the following semester.
Decision making was accelerated because of the urgent needs in patient care. With ongoing communication between the school, hospital, and university leadership, decisions and actions that would have taken considerable time under normal circumstances were enacted within hours. After the faculty-student collaboration proposal was formalized, it was presented to students and recruitment began on the academic side. Approximately 75 students volunteered to participate in the surge staffing. Of these BSN students, 50 were fourth-semester students who would be placed on care teams and the remaining 25 were third-semester students who served on vaccination teams. Hospital leadership identified high-needs areas that corresponded with the faculty and student skill sets. UABH colleagues sent faculty volunteers a COVID-19 Surge Assessment Survey to determine readiness and comfort level in patient care delivery. This survey asked what level of care the volunteers were willing to provide: level 1, 2, or 3 (Table 2). Based on this response, the survey then asked respondents to self-assess proficiency of certain skills. The list of skills varied depending on clinical area and level of comfort. This survey also queried faculty and students on their willingness to work in COVID-19 units.
Table 2. -
Competency Assessment Survey to Provide Nursing Services
Level 1: I can take a full patient load in an area I am comfortable/familiar with; individual patient assignment.
Level 2: I can perform basic clinical tasks in the clinical setting (with appropriate additional training/refresher). Would not take a patient assignment; team nursing assignment.
Level 3: I can perform nonclinical tasks in a clinical setting, such as answering phones; nonclinical support assignment.
On the basis of faculty response to the COVID-19 Staffing Survey, faculty members were divided into 3 groups: provide patient care independently, provide patient care with students, or administer vaccinations only. Our hospital partners identified units needing support staff. Two large intensive care units (ICUs) and 10 medical-surgical and specialty floors were identified including both ICUs and 3 floors that were COVID-19 units. On the basis of the survey results, teams of 1 faculty member with 4 students were grouped according to their skill level, comfort, and willingness to work in COVID-19 areas. Critical care faculty and advanced cardiac life support certified students were matched on COVID-19 ICUs, while the remaining faculty and students were matched for the other medical-surgical floors. Third-semester students went to the vaccination clinics.
Faculty-student teams were consistently assigned to a specific unit at UABH, and each faculty member was paired with a specific group of 4 students (1:4 ratio) for the entire surge response period. This approach ensured continuity on the clinical units, enabled consistency in scheduling, and assisted faculty and student teams in developing positive ongoing relationships with the nursing staff and others on their units. One faculty member served as lead to communicate with the hospital staffing representatives about the 6-week schedule plan for the faculty-student teams. Shifts were scheduled through the hospital's COVID-19 surge response center and communicated to the nursing staff on the identified patient care units.
Concurrently, rapid-cycle refresher training for EBP and competency assessment was developed to prepare faculty and students to enter clinical sites requiring coordination and collaboration among SON and clinical resources. Working with the Hospital Center for Nursing Excellence and the SON Simulation and Competency Suites, the academic-clinical partnership faculty and clinical staff teams worked together, cooperating on needed equipment, curriculum, schedules, onboarding, and logistics. Students did not have to be validated since they were already vetted on the needed skills through their BSN course work. Students received additional EBP training from the hospital in bedside testing and intravenous (IV) starts. The academic-clinical teamwork for the COVID-19 surge response began and continued as faculty and students entered the hospital within a week of mobilization. The EBP training areas included general nursing care skills identified from the COVID-19 Surge Assessment Survey (Table 3), competencies for clinical standards from UABH, personal protective equipment (PPE) donning and doffing, and proning techniques and procedures. This EBP refresher workshop was set up for all faculty members who were to participate in the COVID-19 surge response staffing. Faculty had the opportunity to perform EBP competency skills through simulation experiences. Hospital competency checklists from our clinical partners were aligned with clinical standards and taught by the SON's simulation faculty in the SON's simulation laboratories to surge response faculty. Faculty-student teams that were to provide proning support went through additional EBP simulation training on proper PPE donning and doffing and proning protocols for COVID-19 areas. The lead nursing faculty worked with the UABH educator in the medical ICU (MICU) to obtain the most current EBP protocols. A simulated ventilated patient scenario was created, and students and faculty practiced these protocols in teams to ensure quality and safety in the SON critical care simulation suite. Simulations were streamed into a larger classroom so that other faculty-student teams could observe all simulations. The MICU educator was zoomed in during the simulation session to observe the EBP proning protocols and to provide real-time feedback during the postsimulation debrief.
Table 3. -
Evidence-Based Practice Competency Skill Training
Insertion of IV catheter
Dressing change/wound care
Central venous line dressing change
IV pump programming
IV bolus medication administration
IM/SQ medication administration
Oral medication administration
Wasting of controlled substances
Abbreviations: IM, intramuscular; IV, intravenous; SQ, subcutaneous.
While rapid EBP competency skills training had to occur to launch the COVID-19 surge response, additional planning and communication with faculty and students regarding requirements for staffing, training, expectations, and general onboarding were crucial. Staff and faculty leaders met with the SON evaluation team to document initiative outcomes. Additional EBP training that was beyond the scope of the academic skills laboratory was also set up and facilitated by hospital educators to include training on infusion pumps, bedside testing, and IV catheter insertion practices specific to UABH protocols.
PROVIDING CLINICAL SUPPORT SERVICE
The faculty and students entered the clinical environment ready to work, willing to learn, and equipped to help an already exhausted workforce. Over the next few weeks, the student and faculty teams would continue to provide care using EBP clinical skills and physical support at the bedside on many units. As faculty and students began the experience, the welcome from nurses and other staff members was pervasive across the hospital.
Caring for the COVID-19 patient introduced acuity and complexity that required more nurses at the bedside. The students and faculty in the ICUs provided extra support for the proning process as well as “swimming” up to 20 patients per shift. While prone positioning helped improve the pulmonary function of the patients, it also afforded faculty the opportunity to teach students real-time complex decision-making. As faculty-student teams worked together to prone patients, they simultaneously discussed EBP interventions and protocols for improving and securing airway flow, preventing pressure injury, and minimizing hospital-acquired infection.
On the acute care floors, the faculty members were able to provide students with clinical supervision and support for EBP and multiple clinical procedures. Reinforcing the best available evidence, their clinical expertise and decision-making skills, and patient- and family-centered care values, faculty and nursing staff worked with students side by side to perform various tasks including vital signs, accuchecks, IV insertions, medication administration, mobility training, and many other time-consuming tasks. By supplementing the work of the nursing staff on these units, faculty and student teams provided needed support for the struggling staff and were able to increase clinical interactions and interventions with patients at a time when family interaction was minimal due to visitor restrictions.
In the community, faculty and students followed the Centers for Disease Control and Prevention vaccine protocols while they staffed vaccination sites to provide assessment, screening for contraindications, administration of vaccines, and assessment post–vaccine administration. They added workforce capacity for the health system at a time when the number of vaccines needed was high and the available UABH staffing was low.
At the end of the 6-week COVID-19 surge response period, faculty and students had become part of the team and the UABH staff reflected on the added value of the faculty-student teams in the clinical environment. The increased number of nursing hours provided additional clinical support at the bedside, and the students and faculty were recognized as high-energy team members who also raised the morale of the nursing staff at UABH. Staff suggested that school and clinical leaders consider sustaining the immersive team clinical experiences with students and faculty beyond the surge response.
Evaluation outcome data used to determine the effectiveness of the partnership's COVID-19 surge response incorporated elements of the integrated academic-clinical framework including selected elements of the Quadruple Aim and the LHS. Both quantitative and qualitative data were collected, which helped shape the lessons learned and informed future directions for the academic-clinical partnership.
Quadruple Aim outcomes
Data were collected for the number of faculty and student hours for workforce expansion as compared with overall nursing work hours during the surge response period from December 2020 through January 2021. An estimated cost per capita of care was calculated on the basis of the approximate payment for services by the faculty and students during this time as compared with the actual cost of temporary nursing agencies for the supplemental hours needed. Through the COVID-19 surge academic-clinical partnership response, the nursing workforce was expanded by more than 10 000 hours of hospital nurse staffing that were provided during 770 worked shifts. Faculty and students from the SON covered approximately 30% of the full surge hospital supplemental staffing needs during the December 2020 to January 2021 time period at a cost savings of at least 500% lower than if traveler nurses had been available for these assignments. Beyond coverage support for inpatient services, faculty and students also contributed more than 46 000 vaccine encounters across 4 community vaccine sites in the region during this time.
Qualitative debriefing sessions with faculty, students, and staff from assigned units were held to capture novel ideas and rich experiences. Findings from the debriefings suggested opportunities to adapt the current traditional clinical nursing education model to integrate both faculty and students on nursing units much like the surge staffing model. Interviews with nursing staff, faculty, and students revealed that the surge staffing model allowed students, faculty, and staff to work side by side as colleagues in a clinically integrated role as members of the nursing unit and team. The significance of consistent faculty-student team assignments on specific units was emphasized by staff and faculty on the basis of their familiarity with and dependence on faculty and students for workforce and patient care support. Faculty provided feedback that this model helped maintain their own clinical relevance, which enhanced their teaching and provided students with high-acuity real-time nursing experience. Students reported that the experience enabled them to work side by side with faculty and staff with constant reinforcement and correction as needed in their clinical decision-making and clinical skills, thereby enhancing their clinical competence and confidence. Staff reported that the presence of faculty-student teams on the surge response units offered much needed support and respite during a most challenging time, thereby enhancing the nurse and student workforce experience.
The development of an innovative electronic nurse staffing dashboard designed specifically for the Surge Response Initiative provided the instrument for measuring data on hours and shifts worked. This dashboard created in collaboration with UABH information systems and nursing leadership, provided real-time access to staffing data collected from a proprietary staffing system. Faculty, student, and nursing staff signed up for nursing shifts within the proprietary system, and data were collected and reported via a data set used to create the dashboard and provide immediate, actionable data for leadership decision making.
From an LHS perspective, the academic-clinical partnership organizational structure created a mechanism to augment nursing staffing during a critical nursing shortage and evidence was applied to improve care quality and access. Using the latest EBP protocols,5 proning teams of faculty and students assigned to the 2 ICUs were able to increase the number of critically ill COVID-19 patients who were turned in these units, leading to reduced COVID-19 mortality on these units. As part of the COVID-19 surge and the preparation of the future nursing workforce, a new NSA position was created with support from the state board of nursing, enabling nursing students to function at a higher level than patient care technicians based on tested clinical competencies. Eligibility for the NSA position entailed the following criteria: completion of the first year of nursing school, ability to pass UAB standard hiring protocols, competency training, and willingness to work 24 hours per 4-week schedule. Given the flexibility it offered, relatively low-cost alternative, and its recruitment potential for better practice-ready nurses, the NSA position has continued as a regular position within the nursing staffing model beyond the initial surge response and into 2021. The NSA program hired 74 students to date. Following the COVID-19 surge response UABH hired 20 (95%) of 21 NSAs who worked in patient care areas after graduation as registered nurses. Finally, the joint research findings and knowledge generated on specific aspects of the academic-clinical partnership are being disseminated in publications and national presentations to describe and share the mutual benefits and value for the overall partnership initiatives.
This unprecedented COVID-19 surge response allowed the nursing partnership to use an academic-clinical integration framework to present partnership outcome data and value to leaders in the university and health system in difficult times. Lessons learned fell into broad categories related to the Quadruple Aim and the LHS. These included providing additional needed patient care services to support the patient experience, improving health workforce learning, reducing the cost per capita of care, and addressing population health needs for COVID-19 vaccine and EBP protocols. The preparation and provision of clinical support enhanced nursing clinical proficiency and competency for students and faculty, expedited student professional socialization, and enabled nursing staff and faculty to recognize the advantages of clinically immersive experiences. Other lessons of the partnership helped the academic and clinical entities identify urgency as a driver of innovation, reinforce data analytics as a method of reflection, evaluation and future improvement, and experiment with new ways of recruiting and transitioning students and faculty to practice in conventional and crisis situations. A crucial lesson for faculty was the need for a “just-in-time approach” with detailed rapid planning to execute the clinical support services and evaluation. The crucial lesson for clinical nurses was that faculty and students could increase nursing staff capacity with structure and collaboration developed by academic and clinical leaders. These lessons continue to guide academic-clinical partnership innovation in education and practice.
This nursing partnership exemplar uses an academic-clinical integration framework to show how the alignment of service and academia in an academic health center can help supply essential nursing services in a nursing shortage crisis, reduce costs, amplify clinical experiences for students and faculty, and most importantly improve the patient and provider experience. Although this partnership developed and implemented a response to a COVID-19 pandemic surge response in an academic health center, the lessons learned from this academic-clinical partnership collaboration can be applied across educational and clinical settings. Based on the experiences associated with this surge response, the following recommendations for future nursing workforce shortages, pandemic-related or not, are advanced.
First, establishing solid academic-clinical relationships allows partners to collaborate amongst routine and dire situations. This observation requires that partner relationships be well-established and integrated over time to allow for quick pivots needed in complex, changing situations, while keeping the patient at the center within the context of the Quadruple Aim to improve health outcomes. Acting now to strengthen partner relations for inevitable future scenarios is imperative.
Second, deploying a response such as the one herein described necessitates an adaptable and ready team willing to engage in a give-and-take relationship to benefit students, organizations, patients, and communities. In self-centric environments where silo thinking is the norm, opportunities for innovation elude potential partners because these status quo cultures are not consistent with principles of an LHS and the Quadruple Aim. Change is a constant and must be embraced to sustain nursing excellence and strive for desired patient outcomes. The academic-clinical partnership in this surge response demonstrated successful and visible outcomes valued by both entities, resulting in more opportunities that continue to shape collaborations going forward.
Finally, evaluating and measuring the outcomes of initiatives are important to convince stakeholders of the value of partnership efforts including the allocation of resources needed to mount them. Also, having a framework that links the benefit analysis to the academic and clinical partner is essential for sustainability and to measure the impact.
This academic-clinical nursing partnership has been enabled by leaders who see the benefit and value of working together using a common framework to guide resource allocation, strategic planning and actions, and evaluation. As the literature notes, “Claims about making a difference are no longer sufficient; evidence of how much difference is being made is now required.”6 Opportunities for academic and clinical partners to improve outcomes of care for patients and populations while supporting the preparation of the nursing workforce are endless with strategic alignment of ideas, resources, and evidence. Working together through well-defined and mutually beneficial partnerships can potentially lead to collaborations for nursing excellence in education and practice, create new clinical education models, promote research and EBP, and most importantly result in better patient and population care.