We created this series to offer new nurse managers basic tenets of leadership to help them succeed in this pivotal organizational role. Little did we imagine the chaos and disruption that were in store for all of us as the coronavirus pandemic has changed life as we know it. Hospitals have been reconfigured for the sole purpose of creating maximum capacity for infected patients. Elective surgeries and routine procedures have been canceled; ORs and postanesthesia care units have been turned into patient care units to provide ventilator support with anesthesia machines when there are no more ICU beds.
New protocols are being created and implemented in real time as physicians and nurses learn what to do and when to do it as they go. Clinicians are required to make immediate choices about how to best care for huge numbers of very sick patients who appear in EDs with breathtaking rapidity, and the ethics of allocating scarce resources when the pace is fast and actions need to be decisive have their own emotional toll.1 Rigid hierarchies and siloed fiefdoms that have characterized hospitals are rapidly breaking down as new models of teamwork take hold. This energy pulsating in hospitals is in sharp contrast to the eerily empty streets outside silenced by shelter-in-place orders.2
No nurse manager practicing today has experienced anything like the coronavirus pandemic; this will be a formative event for all nurses as we move into an unknown future. None of us has managed this degree of chaos, complexity, and uncertainty before so, in a sense, we're all new nurse managers trying to find our way. Here are some things to think about that may be helpful to you as you navigate this new reality.
Embrace your leadership role, even if you're uncertain about what to do
This time of crisis highlights the importance of the crucial organizational role you have as a nurse manager. You're the linchpin that holds a COVID-19 unit together, ensuring that patients get the best possible care. You're also the connector between patients and senior hospital leaders. It may be necessary for you to assume responsibility that you don't feel quite ready to take on. But rather than succumbing to fears and self-doubt, you may find yourself propelled by your core conviction that COVID-19 patients deserve excellent nursing care and you can help make that happen.
Know who your clinical and administrative resources are before you begin each day and never hesitate to ask for help in any situation when you need it. Asking questions to gather more information or clarify issues will give you the reassurance to proceed with your decision or find a new course of action. Remember that you have proven clinical skills and good judgment, so trust yourself when you must make an immediate call. If you're uncertain, think about a leader you want to emulate and imagine how he or she would act in this situation. Practice being like that leader because this is an important way we all learn how to shape our own leadership practice.
As a new or experienced nurse manager, you may find yourself on your own reconfigured unit or in a new physical location with your own staff or new staff members whom you don't know, some or all of whom are learning to care for ventilated ICU patients in real time. Take time to meet new nurses individually; be sure they know who you are and that you're there to support them. Connecting them to a more experienced nurse who can be an immediate resource may alleviate some of their anxiety and foster trust in you and their colleagues that will help them feel safe.
It's important to be visible and available to engage in patient care so that you can assess how individual members of your team are coping and see for yourself the demands and new challenges presented by caring for COVID-19 patients. Remember to do things that focus on staff wellness. Since wearing a mask all day is a barrier to drinking and eating, have water and healthy snacks readily available and remind staff members to stay hydrated and maintain their energy levels. Be sure individuals are taking regular breaks.
You may be asked to open a new COVID-19 unit on short notice. Your organization may have a special team to handle the logistics of doing this or you may need to reach out to several other hospital departments and coordinate their individual efforts. Although others are doing the actual work of setting up the unit, as the nurse manager you'll still need to be sure the unit is safe and ready for patients and staff. Are the beds configured in the best possible way? How many staff members do you need to provide care? What's the appropriate skill mix of nurses and patient care technicians? Is there someone to answer phones and be a central point of communication for you and the staff? Remember that some staff members will undoubtedly become ill or test positive for the virus and need to be out for long periods of time. How will you replace them?
If possible, negative pressure air flow or high-efficiency particulate air filters should be installed in patient rooms. You'll want to be sure there are sufficient levels of supplies for patients and enough personal protective equipment for staff members so they're safe, but shortages may likely occur. Try to preempt problems by working closely with supply chain managers to procure what your team needs and tap into the resourcefulness of nurses to preserve existing equipment. The pharmacy department will need to supply the unit with medication dispensing equipment and you'll need to be sure that all staff have access to it. What kind of documentation is required during this time of crisis? Are there enough computers to facilitate communication and documentation?
There will be many other details that need your attention, and some you'll surely forget until the need arises. Don't hesitate to reach out to a more experienced nurse manager colleague or your director for help in mobilizing other hospital departments. Remember that these are extraordinary times—no one has done this before and we're all learning.
Now, more than ever, your comportment is your most important management tool
Nurses are experiencing fears about physical and psychological safety at a very basic level while at the same time demonstrating acts of true heroism and unbounded compassion. One CNO described staff members as being “fearless, scared, exhausted, numbed, tearful, displaying every emotion possible,” so you as the nurse manager will find yourself coping with a whirlwind of human responses. Nurses are facing patient assignments that were unfathomable weeks ago as new blueprints to organize patient care are now created in real time, often with unfamiliar coworkers. Scarce resources necessitate the need for immediate gut-wrenching ethical decisions about who gets what kind of care.
For nurses to safely practice in this chaotic environment and meet these unrelenting demands, it's most important for you as the nurse manager to stay calm and focused.3 Many nurses are grieving for a world that's irrevocably changed and feeling unsafe because they don't know what's to come.4 Nurses who practice in non-ICU areas feel trepidation at the thought of providing care to four or more ventilated patients. Those who aren't yet reassigned may be anxious as they wait to hear where they'll be needed or may feel guilty about not being on the frontline of care.
One of the most important priorities you can establish for yourself is to be visible and stay connected to staff. As you strive to meet individuals where they are emotionally, it's okay to relax your boundaries a bit so you can connect with your staff on a very real and human level. This is a time to give people more room to express their feelings. For some people, the stress may be overwhelming, and their behavior will be distracting and disruptive. It may be necessary to listen, acknowledge the individual's feelings, and redirect behaviors to ones that support the team.
Express a vision for the day and acknowledge short-term wins
In your start-of-shift huddle, remind staff members that today's goal is to get patients and themselves safely through the day. People can keep going if they know where they're headed and why, so it's important to reiterate what we as nurses believe, what we're there for, and what matters most.5 Honor the courage and persistence of clinical nurses who've chosen to walk toward this crisis rather than walk away. In your communications, focus on facts, not opinions or hunches. Your unit may feel very intense and somber; there's lots of difficult news, but denying reality makes people assume you're out of touch. (See The devastating effects of COVID-19 on patients and staff.)
Staying focused on the present and acknowledging the small wins that come from a team working together to do their best can help bolster staff morale. Share instances when patients are extubated or discharged from the hospital to help staff remember that there are patients who survive. When things go wrong, and they will, let go of judgment as you ask, “How could we have done better?” Talk with your staff about how we're all learning to do this together; there are no established rules or protocols to guide the way.
Keep the voice of the clinical nurse in the conversation
The practice itself is always the best teacher, and good leaders look to nurses engaged in direct patient care for answers in challenging situations. The best way to understand the coronavirus pandemic isn't by listening to newscasts or briefings but by tuning in to the distress on the frontlines.7 Intentionally creating opportunities for nurses to speak about their experiences will validate the value and worth of the incredible work they're doing and lessen the tremendous burden they carry. Collecting exemplars of best practice will allow us to reimagine how we should model care going forward if there's a second wave or when these days are behind us. Just as many nurses caring for COVID-19 patients are reconnecting to the values, ethics, and passion that brought them into the profession, this pandemic may be an opportunity for nurses to use the same passion to own their practice in new ways.
Some nurses may choose to share their experiences with the public in newspaper op-ed pieces or on social media. You can help nurses learn to do this responsibly by teaching them to express themselves in ways where their message can be heard and the focus is on the goals, challenges, and outcomes of their work.
How can I possibly do this?
The extra emotional challenges and health risks to nurse managers during this time can be daunting. There's no way to sugarcoat that truth. One new nurse manager described it this way, “Each day as I enter the hospital, I take a deep breath, not knowing what I'm going to encounter during that workday. It's a feeling that brings initial trepidation, but through mindfulness I've channeled that energy into grit and determination. It's easy to get caught up in the frenzy and become unfocused in the chaos, but one thing I've learned is to take the day 1 hour at a time. When I feel overwhelmed, I remind myself why I went into the profession. I wanted to make a difference, help others, and provide purpose.”
Give yourself permission to feel the wide range of emotions you have and recognize that we all cope differently. Control what you can and practice letting go of those things that are beyond your control. Hard as it may be to do, this is the time to practice healthful behaviors in terms of eating, sleeping, regularly exercising, and using whichever mind-focusing activity helps you relax. Cut down on how often you engage in venues where fear feeds on itself, such as social media, cable news, and frenzied conversations with friends and coworkers. This isn't to say you should bury your head in the sand but do your best to distinguish between people who are speculating and those who have sound information. Seek out positive, high-quality connections with others, even if they're virtual. These practices may help you build the calm and positivity that you want to pass along to your staff and colleagues.8
Being optimistic about the future and at the same time being realistic is important. As you think about how to build on the good that comes from this time of extraordinary challenge and sadness, ask yourself how you've learned to focus your mind, control your stress, excel under pressure, work through fear, build courage, and adapt to adversity. Knowing these things about yourself can help you develop the spiritual and ethical resilience that will form you into a great leader who can transport people emotionally and sometimes literally from this place into a post COVID-19 world of healthcare.9 In many ways, this crisis is a key leadership moment and, in fact, may be your finest hour.10
The devastating effects of COVID-19 on patients and staff
Patients with COVID-19 often present a confounding clinical picture of seemingly improving over days and then worsening precipitously, requiring emergency intubation and complex treatment for the ensuing organ failure. Clinical instincts honed by observing patterns in disease pace and trajectory suddenly seem insufficient and unreliable.2 Dr Adam Brenner, who oversees the ICU at Mount Sinai Brooklyn, recently wrote in the New York Intelligencer Diary of a Hospital blog, “There are so many theories about what this is and the best way to manage it, and it just suggests to me that nobody really knows.”6 Clinicians find themselves launching new practices without guarantees of success and despite their best efforts, many patients will die, often in rapid succession. The unrelenting death toll of both young and old patients is traumatic for clinicians who've given their all to help patients survive. Many are overwhelmed and struggling to hold on to shreds of hope.
Nurses have spoken movingly about the weight of being the only person present with patients as they're dying, and the dilemmas created by deciding whether and how to allow family to be with patients at the moment of death. One nurse said, “It's heartbreaking to know that you're that person's everything. The weight of trying to fill the shoes of the people who can't be there is really heavy.” Always at the back of every clinician's mind is the danger of contracting the virus or bringing it home to their family. Many have chosen to isolate from family members, denying themselves the comfort and support that comes from meaningful connection. Physicians and nurses have become more dependent on and responsible to each other as the work family becomes a source of psychological protection and emotional support.
Managing staff members who are incessantly working long hours day after day under intense conditions to preserve life is something most of us have never done. You'll need to muster courage and perseverance you didn't know you had to do it. Your presence, support, and compassion and your willingness to lift the burden of care, even temporarily, will be what matters to staff members navigating untested waters and doing the very hard clinical and emotional work that's required of them. Helping nurses appreciate the value of care when cure isn't possible may help give meaning to the incredible work they're doing, even when death is the outcome. Pointing out the simple and specific ways in which a patient's dignity and humanity were protected in the midst of chaos may sustain the team. One New York City ED team have adopted the practice of honoring dying patients by stopping for 10 seconds, bowing their heads, stating the patient's name, and asking for silence. Some staff members may need real-time emotional support and you can help by making mental health professionals, clergy, and grief counselors available to them.