It is the morning of April 2, 2020. Reports of 6.6 million jobs lost in 1 week play in the background, while the John Hopkins University School of Medicine Coronavirus Resource Center updates continuously on our desktops. There are 217,263 cases of the novel coronavirus in the United States and 965,246 cases worldwide as of 11:10 am EST, but this will change quickly. Our school's incident management dashboard also remains open at all times. Today, it reveals that 50 of our clinical sites (all of them) have been canceled/restricted, 2 clinical instructors have tested positive for COVID-19, a student has reported serious financial concerns, and another has requested a withdrawal.
By this afternoon, dashboard snapshots will look radically different; by the time this article reaches publication, they will resemble a historical archive. Nevertheless, the crisis management strategies we share will remain relevant because effective incident response is defined by the ability to maintain order during rapidly changing scenarios.1,2 This article describes a roadmap for academic crisis management, modeled on the National Incident Management System (NIMS). We have tailored this model to the unique needs of school of nursing and describe how the flexibility of this approach makes it applicable to nursing schools of varying sizes, across a spectrum of incidents. Although we apply COVID-19 as a case study, NIMS is designed to ensure effective leadership regardless of the crisis at hand.
NIMS: An Organizing Framework for Academic Crisis Response
Emory University's Nell Hodgson Woodruff School of Nursing (NHWSN) has used NIMS as its crisis response framework throughout COVID-19. According to federal 2017 NIMS guidelines, this system offers a template for organizations “to work together to prevent, protect against, respond to, recover from, and mitigate the effects of incidents, regardless of cause, size, location, or complexity.”1(piii) The NIMS provides (1) a set of organizing principles and processes, (2) a strategic approach to resource allocation, (3) reliable organizational structures that may be adopted across agencies, and (4) shared terminology and communication practices.
The NIMS emphasizes a “standard approach” and “unity of effort”; these values translate to consistent practices and protocols among individuals and between organizations, as they work toward shared objectives. Taking a shared approach helps to ensure interoperability; it also prevents redundancy of effort, particularly for people who are used to working in organizational silos, and reduces miscommunications.1-3 The NIMS was developed in response to the California wildfires of the 1970s. Wildfires are, by definition, rapid and unpredictable—they require a scalable response, or one that can be expanded and reduced based on changing situational demands. Yet, early California fire responses lacked agility; they were redundant and wasteful, as various units were often deployed without cohesion to one massive and shifting threat. Fire departments did not communicate with each other, and in some cases, they competed with one another for supplies. Their collective challenges often had more to do with organization and communication breakdowns than with insufficient resources.
In a similar way, our top challenges during the first 48 hours of the NHWSN COVID-19 response reflected our need for greater alignment across teams. Frantic, overlapping work was taking place across the school, and tasks were often more reactive than proactive. Before the Incident Command Structure opened a central communication channel between teams, efforts lacked unity of vision and effort.
Although our school did not use every element of NIMS, we were able to quickly identify the system components that were relevant to our needs and put them into place. We recommend that other nursing schools incorporate at least the following basic elements when responding to incidents like COVID-19 and that they “scale up” or add additional elements from NIMS guidelines if the size and scope of their incident requires a more complex response. We adopted the following:
- The core principles of NIMS: flexibility, standardization, and unity of effort.1,2
- An Incident Command Structure: This structured team coordinates activities that are designed to stabilize the crisis and protect people, property, and the environment.
- An Incident Commander: This person (in our case, the dean) leads the Incident Command.1,4
- An Incident Action Plan (IAP): The IAP is the central organizing document for an incident response. It helps all team members to understand the situation and work toward a shared objective.1,2 Appendix 1, Supplemental Digital Content, http://links.lww.com/NE/A849, shows the Emory Nursing IAP.
- A systematic means of maintaining situational awareness: We identified a set of daily metrics that section leaders would announce when updating the Incident Command Team during daily huddles; these numbers have acted as the school's “vital signs,” allowing us to track incident progress and signaling when corrective actions are needed.
- Centralized channels for sharing updates: Section leaders log daily metrics and share other updates through a work management system that sends automatic notifications to all team members in real-time.1,2
We also instituted a tiered system for daily meetings or huddles. As the 2012 Federal Emergency Management Agency Incident Action Guide notes, “incident action planning is more than producing the [IAP]. It is a set of activities, repeated each operational period, that provides a consistent rhythm and structure to incident management.”3(p1) Because the scope of our response is much smaller than many federal disaster responses, we chose to create our own structure for huddles. We did not adopt the traditional NIMS meeting series, called the Planning to Operations (P to O) cycle, which comes with detailed agendas and forms that were not immediately relevant to our situation.2,3
The following sections describe each of these components in greater detail. Like federal guidelines, this document is organized according to sections labeled Command and Coordination, Communications and Information Management, and Resource Management.
Command and Coordination
Assume a Management Objective
A cornerstone of NIMS is the concept of management by objective. During a crisis, when the confusion of an incident is compounded by personal fears and organizational uncertainty, a meaningful, shared objective can help your team to transcend the chaos. Team members can return to this concept when first-time issues arise, and both you and they will know their decisions reflect shared priorities. This eases uncertainty and reduces dependence on leadership for day-to-day decision making when time and resources are limited.1-3
The overarching goal of the Emory Nursing IAP has been to protect the health and safety of students, faculty, and staff, while ensuring academic, research, and business continuity. The united understanding that health and safety come first—ahead of protocols and performance—proved lifesaving when our community of caregivers experienced their first waves of toxic stress. Many in our community were working to reconcile family care, teaching and student responsibilities, research, and patient care during stay-at-home orders. Within a couple of weeks, stress became arguably our greatest challenge, and our objective helped to ensure that stress-related issues were addressed with compassion and consistency. When it came to teaching, this approach included an emphasis on allowing test and assignment extensions when requested and accommodating remote learning needs (such as paper testing even in virtual classrooms).
Create Your IAP
The Incident Commander establishes the central objective for your response with input from the Incident Command Team and, often in the case of nursing schools, with guidance and context from university leadership. The central objective does not exist on its own but rather is supported by a set of smaller goals and strategies that coordinate the work of the team as they move toward the central objective. These elements are typically organized into the IAP. You will quickly find the IAP to be an essential organizing tool, both for leadership and personnel. This agreed-upon primer can be quickly handed to volunteers, partners, and other schools or university officials to bring them up to speed when their efforts overlap with yours. It should be displayed in shared physical or virtual workspaces for easy reference by all.1,3
Establish Chain of Command and Span of Control
Nurses in clinical settings are likely familiar with chain-of-command as a lifesaving mechanism, but nurses in academia may be accustomed to alternative organizational structures and flexible reporting expectations (eg, siloed or matrix reporting). At all times, but particularly during a crisis, a clear chain of command—that is, an official, agreed-upon hierarchy for sharing information, making decisions, and assigning tasks—is integral to success. Chain of command streamlines communications, optimizes your team's workflow, and helps you to avoid secondary disasters related to mismanagement.1
Every individual should know who their 1 direct superior is—having 1 boss ensures that team members receive consistent messaging about their roles, provides a unified channel for sending and receiving updates (instead of diverting information through side channels), and helps people to sidestep the spectrum of sentinel events that can arise from communication failures. The dean or incident commander should know who they report to as well: During a crisis, schools are expected to align with the university in messaging and practice; an exceptional dean is one who can balance visionary leadership at the school level, with effective implementation of university plans.
Although any given department or response area can be quite large, each supervisor within the department should have no more than 5 direct reports. This is referred to as span of control within NIMS vernacular. Maintaining a compact span of control allows supervisors to take on a reasonable set of responsibilities and perform them well. The NIMS recognizes that a reasonable span of control may not be possible for every supervisor, in every organization. Redeploying personnel whose responsibilities are now low priority or requesting support from partners can help to optimize managerial assignments.1,3
Communications and Information Management
Meet More—Not Less—In the Midst of Crisis
For chain of command to work, your teams need to interface at frequent, set intervals. Area leaders should know they can depend on these meetings to report updates and troubleshoot issues with the Incident Command Team. These huddles might at first seem like a large time investment, especially when organizational demands have increased, but they will quickly prove their value by:
- Increasing transparency: Everyone will know the overall status of the organization and changes taking place in areas other than their own. When sweeping decisions need to be made, people will be aware of the context and rationale, reducing push-back.
- Boosting efficiency: When area leaders know they will be reporting on issues at set increments, it creates natural deadlines—people tend to feel motivated to make and share progress by the next meeting. This is especially true for teaching faculty who may normally work at their own pace or prioritize teaching responsibilities but now must triage and incorporate crisis-related tasks into their workflow.
- Revealing issues as they emerge: Because area leaders report daily metrics during meetings, changes from baseline may be identified, elevated, and addressed by all the necessary players immediately and at the same time. This approach also enables the dean to promptly raise public health and safety concerns to the university as they are identified at the school level.
- Building trust: Frequent communication builds trust among your team, which improves their ability to function. When all decisions are shared decisions, people do not need to take nervous guesses at what their boss expects or wonder if their job is secure. Individuals may be less hesitant to ask questions and share concerns when it becomes clear that, in a crisis environment, transparency saves lives.
At the height of the COVID-19 crisis, NHWSN teams were reporting to their area leaders, area leaders were reporting team updates to the Incident Command Team, and the Leadership Council was convening to discuss incident command findings daily. As this article nears publication, Incident Command Structure meeting frequency has been reduced to every other day. Meeting frequency, focus, and roles will continue to be scaled and modified as the pandemic evolves. (For instance, these meetings shifted to an operations and logistics-focus as re-opening plans were made.)
Standardize Modes and Methods of Communication
The school should create a centralized mechanism for rapidly communicating changes that occur between meetings. Although it is important to have an up-to-date telephone tree in place—for example, if someone needs to be reached urgently and they are away from their desk—telephone and text communications should not be the primary means of relaying messages. Instead, you should have a shared work management system where people can log in and instantly disseminate notifications to the whole team, across channels, at the same time.1,3,5 At NHWSN, even if a change has not occurred since the last incident command meeting, area leaders are expected to log their progress metrics in our work management system daily.
Practice Evidence-Based External Communications
When an incident occurs, you may find yourself under pressure to quickly release a statement on behalf of your organization. Although it is important to comment before misinformation can spread, it is also vital that your messaging is accurate and will bolster your incident response, rather than undermine it.1,5,6 Schools of nursing in particular may be faced with a flurry of emails and telephone calls from concerned parents, students, alumni, and others. One way to systematically assess these concerns is to instruct faculty and staff to log any questions they receive in a work management system. This can help you evaluate your community's needs before issuing one precise, high-capture communication that reflects both school and university priorities. Faculty and staff can then refer people to your communication or reiterate it using consistent language as new questions are posed. In our case, messaging that came from the dean was carefully timed to align with communications issued by the president and provost; department heads were then sure to release their messages in a way that followed and mirrored the dean's language, and faculty reiterated the information to students.
The following are tactics that all academic nurse leaders should know before issuing public statements:
- 1) Cover the basics: You will not have all the answers, but you can tell people how to protect themselves until more information becomes available. Any information you share must be accurate, should be verified by reliable sources, and include the 5 “w's” (who, what, where, when, why).
- 2) Keep it simple: Have a nonacademic reader give you feedback on your statement(s). Academic writers are used to jargon-heavy writing. During a crisis, this approach may be poorly received and can be overtly damaging. Keep your messages at a fifth-grade reading level, vary your sentence lengths, choose the most precise wording, and speak in positives rather than negatives. For example, the message should be “stay home except for trips to the grocery and pharmacy” instead of “do not come to campus.”
- 3) Be honest: When you do not know an answer, tell people and let them know what you are doing to learn more; address rumors or misinformation head-on.
- 4) Be human: People experience complex emotions during crises—stress, fear, anger, and hopelessness. Leaders can play a role in reducing the incidence of widespread trauma by conveying their own vulnerability and offering mental health resources as early as their first communication.5-8
Perhaps the most important element of your messaging is the following: Give people something to do. Stay at home, wash your hands, cough into your elbow—statements like these do more than safeguard public health; they restore people's power over the situation. Every message you issue should contain a clear, actionable take-away, resources for further questions (such as a hotline or text code), and commitment to routine communications moving forward.5-7
Know What You Have and What You Need
The odds that your school—and each of your partners—has everything necessary to independently survive a crisis are probably low. When you consider all of the personnel and supplies that exist across parties, your collective outlook becomes more promising. Work with your operations team, as well as community and practice partners, to create a resource tracking system.1,9 That should involve more than just a list of items. You and your partners should instead practice resource typing, a systematic process that defines each resource in 4 ways: (1) Kind: Is this resource a person, item, facility, or something else? (2) Category: What is the primary functional domain of the resource: student services, research, administration, and others? (3) Capability: What is the intended purpose of this item? What else can it do? (4) Type: Organizations that follow NIMS typically grade resources according to a consistent classification system to indicate minimal capability. Typing is determined based on metrics such as the number of real COVID-19 patients that a school's simulation laboratory could accommodate if need be. When resource typing, highlight resources that may be shared across organizations and serve multiple purposes.
For any organization, the credentialing of incident personnel is a fundamental aspect of resource management; for schools of nursing during a global health crisis, this process takes on special significance. Faculty, staff, and students may hold current or expired credentials across a variety of functional areas and specialties. For instance, a particular faculty member may simultaneously be a practicing telehealth nurse, hold an active APRN license, and specialize in nursing analytics. This person could prove essential along many lines of incident response, meaning their skills should be meticulously inventoried and their deployments carefully considered.1
Leverage Mutual Aid Agreements
During a crisis, strong partnerships can mean survival for you and your stakeholders. Mutual aid agreements are emergency contracts that provide a framework for efficiently sharing resources across organizations or jurisdictions. These agreements may include information on the duration of aid, how to license personnel across state lines, and protocols for shipping supplies. Mutual aid agreements may occur at any level of a response, although they should always be communicated up/down appropriate channels within your organization.1,9 In our case, agreements with practice partners such as Emory Healthcare (EHC) have been beneficial in multiple directions including data sharing. Specifically, coordinated data sharing has ensured real-time alignment and understanding between the 2 organizations, which enabled our students to stay in clinicals longer than most Georgia schools at the start of the pandemic, among other benefits.
Mobilize People and Resources for Mutual Aid Agreements
Mobilization refers to the process of activating and transporting resources in response to incident needs.1 If equipment or personnel are going to be deployed outside your organization, or if a facility is going to be repurposed, the expectations of those arrangements should be explicit. For instance, employees should know the date, time, and place of their departure, receive just-in-time training, and be told their anticipated length of deployment. Planning for demobilization should take place alongside mobilization.
Building trusting partnerships during noncrisis times can lay the foundation for effective resource mobilization.1,9 Some of the ways in which NHWSN and our practice partner, EHC, have helped each other to survive during COVID-19 include the following:
- NHWSN promptly returned a ventilator that EHC had given our simulation laboratory.
- Emory Nursing Experience, our continuing education program, donated gloves, procedure masks, and disinfectants to Emory Hospital after suspending in-person courses.
- Licensed nurses among NHWSN faculty volunteered to join a reserve of frontline nurses.
Arguably the most instrumental mutual aid agreement between NHWSN and EHC has been the activation of 1 large NHWSN building site for community COVID-19 screening. Thanks to NIMS protocols, it took less than 40 hours for EHC to request the space, NHWSN to vacate it, and EHC to start accepting patients.
Mobilizing People and Resources for Internal Redeployment
Within the context of severe economic fallout and millions of jobs lost, Emory has committed to not lay off any employees. Instead, our university has recognized that COVID-19 has created massive new challenges for our communities and that every person can play a role in addressing those challenges, regardless of their job description. The strategy of redeploying personnel for new business functions, rather than laying them off, has enabled NHWSN to execute a comprehensive virtual rollout spanning didactic and clinical coursework, simulation, and student support. This expanded technical infrastructure has been instrumental to teaching continuity. Supplemental Digital Content, http://links.lww.com/NE/A850, Figure 1, outlines the vendors and solutions we chose; these were made, in part, based on customer support capabilities, making them viable options for schools with varying information technology infrastructures.
Importantly, redeploying employees allowed us to speed up development for Project NeLL, our school's suite of applications for teaching, learning, and practicing nursing data science. By redistributing effort for the Project NeLL team and support staff during COVID-19, we have been able to expand NeLL's big data repository to include COVID-19 data (among other types).
Top Lessons Learned
Operating within the NIMS framework has taught us valuable lessons about crisis management, but some of our most important takeaways are not mentioned in federal guidelines. Here are our top 3 lessons learned, according to our incident command team:
- 1) Plan ahead, even when others grow comfortable: Planning should take place before crises occur. Ideally, your organization should update its incident command structure, situation-specific protocols (flood, fire, shooter, etc), and communication mechanisms at least annually. Crisis binders can include templates for press releases and media-ready exercises for leaders.1,5
- 2) Build a community of compassion: Many nursing professional bodies are anxious about upholding nursing standards in the midst of significant didactic and clinical format changes. These concerns are understandable, but nurses will become burnt out and experience personal risk if decisions place outdated rules ahead of people's basic needs. Some of our approaches to prioritizing wellness, which schools of all sizes may adopt, have included hosting virtual mental health first-aid trainings, streaming free yoga and meditation sessions, coordinating Zoom happy hours, and creating an online support group for work-from-home parents.
- 3) Foster innovation by building self-esteem: “In a high-pressure situation, a true leader becomes ‘an empowered giver' who takes responsibility without seeking credit,” said Dan Diamond, MD, who directed the New Orleans Convention Center Medical Triage Unit during Hurricane Katrina, in a 2018 interview. A leader is “a thriver who believes they have the power to make a difference, and they put other people first…they do everything they can to make other people look like heroes.”8 Show your team you trust them by engaging them in important, crisis-related tasks; this demonstration of your trust builds theirs in return and increases your team's agility. In normal times, it is often difficult to gain buy-in for change, such as the move to remote coursework, within academic settings. It can transform your team to realize that when hard times come and necessity dictates that decisions be made based on evolving data, they can be nimble and institute transformations that might otherwise take years to achieve.
This article chronicled the application of the NIMS to our school's COVID-19 response. We did not address every aspect of NIMS, which can be scaled up for larger incidents and organizations. Instead, we focused on the NIMS features that have been most relevant to our needs as a nursing school during a pandemic.
The authors thank the following individuals, both for sharing their insights and experiences regarding the NIMS and for their ongoing service to Emory School of Nursing during the COVID-19 crisis and beyond: Kristy Martyn, PhD, RN, CPNP-PC, Elizabeth Downes, DNP, MPH, FNP-C, CNE, Steve Ellwood, Adam Malm, Carolyn Clevenger, DNP, RN, GNP-BC, AGPCNP-BC, Sandra Dunbar, RN, DSN, Emory Kent, Melissa Owen, PhD, RN, CNE, FHFSA, Laura P. Kimble, PhD, RN, FNP-C, CNE, FAAN, FAHA, Ryan Lounsbery, and Lisa Marie Walsh, MSN, APRN, FNP-BC.
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