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Creating clinical nurse leaders during the COVID-19 outbreak

Bernhardt, Jean M. PhD, MHSA, CNP, NEA-BC

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Nursing Management (Springhouse): September 2020 - Volume 51 - Issue 9 - p 42-48
doi: 10.1097/01.NUMA.0000694872.75776.5b
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Healthcare systems around the world have been impacted by the outbreak of the coronavirus disease of 2019 (COVID-19). The anticipated impact on large numbers of patients required a rapid and uncertain response. Our hospital responded by creating respiratory illness clinics (RICs) in three locations prepared to care for mild-to-moderate suspected COVID-19 illness. To be operational, clinical nurse leaders (CNLs) needed to be onsite to manage patient flow, orient staff, address clinical problems, and support staff who were concerned about their own safety.

Ambulatory nurse managers provide clinical direction during normal operations. During the COVID-19 outbreak response, most nurse managers were overwhelmed with converting their traditional practice flow to virtual visits, reassigning staff being furloughed or redeployed to inpatient units. As such, they weren't available to manage RIC operations. For this, we needed to identify aspiring leaders to assume leadership roles.

Massachusetts General Hospital is an academic medical center with a large ambulatory care division. The general internal medicine division was tasked with creating RICs in preparation for the COVID-19 pandemic in March 2020. Within 48 hours, it opened its first RIC in the ambulance bay of the ED. Within 2 weeks, it opened three more RICs by converting traditional exam space into clinics staffed with primary care physicians and specialists, one-way patient flow to minimize virus exposure, testing rooms, and X-ray capacity. The RICs were operational 7 days a week for 12 hours per day with the ability to expand and contract operations depending on the duration of the pandemic response. At the time of publication, two RICs remained operational.

Clinic leadership

The general internal medicine division identified a collaborative team of established directors to implement clinical and administrative operations within the RICs. A nurse director known for collaboratively managing large-scale operations and crisis management was chosen to quickly set up a CNL team at each site to oversee daily operations. Due to the expansive hours of operation, the physical layout of each RIC, and the anticipated patient volume, it was determined that three to five CNLs were necessary in each RIC.

The decision to recruit aspiring nurse leaders was based on the idea that leadership behaviors were needed rather than positional status. Individuals who had previously demonstrated behaviors consistent with the guiding principles necessary for nurse leaders to manage crises developed by the American Organization for Nursing Leadership Crisis Management Taskforce were identified.1 A team of CNLs who possessed the following characteristics were sought: the capacity to understand a broad scope of operations yet explain parts in a concise and clear manner; the ability to function from a systems perspective in the face of uncertainty; previously demonstrated problem-solving skills in a calm, rational, decisive, and empathetic manner; and willingness to function within a prescribed leadership structure. The CNL job description highlighted managing daily operations, assigning and orienting staff, and supervising infection control measures. (See Table 1.)

Table 1:
Table 1::
CNL job description

The CNL job description included responsibility for advanced practice providers, RNs, and medical assistants. Advanced practice providers evaluated unstable patients in the waiting room and expedited care. RNs teamed with a physician and a medical assistant to assess vital signs, perform nasopharyngeal COVID-19 testing, and provide discharge instructions. Medical assistants gathered vital signs, informed patients about what to expect during the visit, escorted patients to X-ray, and performed phlebotomy and ECGs.

Recruiting nurse leaders

The speed with which the RICs opened made it impossible to implement a formal leadership development program. There were concerns that without one, it may be difficult to recruit CNLs.2 Initially, identified individuals were available to be released from their regular units, known for strong problem-solving skills, and had no performance issues.

The nurse director contacted individuals by telephone and asked if they were interested in learning about a possible leadership role in the RICs. The telephone call was a virtual interview confirming their interest, explaining the role and responsibilities, setting expectations, and discussing their current leadership competencies. Table 2 shows the questions that were asked to determine the individual's potential capacity to act as a CNL in a crisis management environment and the rationale for each question.

Table 2:
Table 2::
Telephone interview questions

Individuals were asked to contact the nurse director if they were interested in the position and wanted to be formally considered. The decision to offer a position to five individuals who were contacted early in the recruitment period was made during the telephone interview, which demonstrated that hiring decisions were made more rapidly earlier in the interview process.3 Decisions about those contacted later in the recruitment process were made after the telephone call was completed because further consideration about the individuals' expressed lack of confidence in taking on new experiences or stated discomfort with rapid change or uncertainty was needed. Deliberative reflection was undertaken to balance concerns about roadblocks to potential performance with lack of previous leadership development opportunities. Additionally, some individuals had been working in the first RIC when they were identified as possible CNLs for subsequently opening RICs. This permitted the nurse director to observe their ability to work within the RIC design and their capacity to adapt to rapidly changing workflows and incomplete information and establish relationships with others.

The CNL role

Because of how quickly the RICs opened, CNL onboarding was rapid. A job description was developed, and the nurse director oriented each CNL in each RIC. In general, operations across the RICs were consistent. The physical structure of the various RICs required some minor differences in workflow, but operations were meant to be consistent to allow staff and CNLs to move across RICs if needed.

A typical day for the CNL began with assigning and orienting staff to each position based on role type. The orientation initially consisted of staff members receiving a laminated index card indicating the major functions of the position, which the individual could refer to during the shift. The CNL briefly met with each role group, walking them through the RIC as if they were a patient while highlighting the functions of everyone on the team and answering questions. As patients checked into the RIC, the CNL coached staff members in moving the patient through the visit as efficiently as possible. This involved noticing abnormal vital signs that may have indicated impending clinical decompensation, addressing patient questions about care at home, and coordinating transfer to the ED as needed. One major responsibility of the CNL each shift was determining whether nurses conducting nasopharyngeal COVID-19 testing were competent in performing the procedure to guarantee specimen adequacy.

Through it all, ensuring that infection control measures were followed was critical. Staff members donned appropriate personal protective equipment (PPE) based on hospital policies consistent with their assigned role and patient contact. The CNL observed donning and doffing of PPE throughout the day, often needing to redirect staff members and mitigate their risk of exposure. Special care and cleaning instructions for equipment and negative pressure rooms were shared with staff each day.

A portion of every day was committed to supplementing patient care. The CNLs stepped in to gather vital signs when medical assistants took a break or performed an ECG when a medical assistant was escorting a patient to X-ray. They assessed distressed patients in the waiting room who were having difficulty breathing and moved them up to see a clinician. They performed nasopharyngeal COVID-19 testing to prevent delays when there were surges of patients. They cleaned negative pressure rooms to facilitate patients getting nebulizer treatments. They also managed administrative functions, such as calling for specimen pickups and coordinating transportation needs with ambulance companies.

Opportunities and challenges

Fourteen nurses agreed to serve as CNLs. (See Table 3.) The majority were from primary care practices. Five had previous leadership experience and four had been in formal leadership positions in the past. Approximately half were NPs. Two had master's degrees without advanced practice certification.

Table 3:
Table 3::
CNL practice and leadership characteristics

Over the course of their RIC assignment, CNLs shared three ongoing feelings. The first is that they felt energized to be doing different work. One CNL stated, “I'm invigorated by the opportunity to do something different.” Another noted, “It has been wonderful to meet so many great people that I never would've met if I didn't take this on.” Next, they expressed gratitude for being chosen to do the work. An RN with more than 30 years of nursing experience said, “I'm so happy you took a chance on me.” An RN with less than 10 years of nursing experience shared, “Thank you for helping me think of myself as a leader.” Last, they described vacillating between feelings of confidence and inadequacy. A surgical NP, who described herself during the telephone interview as decisive, shared, “I was amazed how much I learned so quickly, but often felt that it couldn't be true. That everyone knew I was a fake.” Similarly, a primary care nurse with only 3 years of nursing experience expressed awe with her new abilities, yet discomfort with delegating to others.

Participating in the safety of their peers was a specific area that presented the biggest operational challenge. Even though the CNLs were in the position to support their peers in understanding what PPE was needed and explain the organization's guidelines about what type of PPE was to be used during specific care functions, staff members often questioned or opposed the information they provided. The CNLs reported that staff members expressed concerns about their risk of exposure and often felt a sense of inequity because guidelines specified certain roles weren't eligible for full PPE beyond masks and eye protection in the outpatient setting. Although the CNLs felt empathy for the expressed concerns, they acknowledged that these decisions were beyond their scope of influence and they lacked the authority to specifically change PPE practices. Most took the opportunity to share with staff how they were protecting themselves and their own families.

Implications for nurse leaders

The development of the CNL role benefits the individual nurse and the organization. Providing interim leadership assignments brings together nurses from different practice settings and develops their leadership skills. As such, identifying nurses who can move into short-term positions supported by established leaders is one way of developing future nurse leaders. Nurse managers at the practice level can identify future leaders and mentor them before the need for new clinical leaders is necessary. Nurses who independently pursue educational and training opportunities may be possible CNLs. Specifically asking about leadership aspirations and highlighting leadership skills during performance evaluations and other goal-setting activities may help nurse managers discover individuals who've experienced barriers and biases to becoming a leader that the CNL role bypasses. Future leaders can be used to manage specific short-term initiatives while being supported and mentored by an experienced nurse leader.

The CNL role may reinforce the perception that an individual is capable of handling bigger challenges. When nurses enhance their ability to manage rapid change that impacts current results or lays the foundation for future results, they also build their résumé. During non-crisis times, those with CNL experience have the potential to strengthen the formal leadership structure because they better understand operational functions, strategic planning, and patient safety and quality issues. In combination with individual goal setting, future nurse leaders can take on progressively larger and more complex initiatives.

Furthermore, the short-term CNL role provides exposure to a leadership role for a specific period so nurses can determine their interest in other leadership positions. Two unexpected benefits of serving as a CNL during the COVID-19 outbreak were expanding professional networks and building relationships with others, which nurtured the CNLs' social nature in a time of separation and isolation. Organizations may benefit from bringing together CNLs after the crisis response as a way of supporting and courting these future leaders.

Creating opportunities for aspiring nurse leaders provides additional organizational benefits. The short-term CNL position allows an organization a similar opportunity to see if an individual shares its leadership values. Alternately, it provides forums for an organization to hear the voices of those who may not have historically applied for open leadership positions. It may also facilitate the opportunity for organizations to examine their hiring and promotion practices to ensure that they're inclusive of underrepresented groups.

Organizations benefit by not having to allocate scarce resources to formal leadership development programs when they need an immediate solution. Additionally, organizations avoid the potential difficulties of transitioning CNLs not well suited for the leadership position when the short-term need ends. Organizations should develop a formal debriefing program with CNLs to help them understand their experience and maintain their interest in future short-term assignments and their desire for ongoing mentoring and training in preparation for an established leadership position.

Supporting aspiring nurse leaders through interim leadership assignments engages nurses in a meaningful way and serves as a form of recognition to acknowledge achievements across the organization. Short-term assignments require organizations to distill their complex functions and operations into manageable pieces that others can quickly understand and implement. When this is done well, short-term CNLs can easily perform the necessary functions of supporting clinical operations.

Filling an immediate need

During the COVID-19 pandemic, nurse leaders in all organizations will be stretched thin at some point. Implementing the CNL role to enhance a hospital's leadership capacities provides an opportunity to fill an immediate need without overburdening current nurse leaders. Supporting aspiring nurse leaders in short-term assignments as CNLs provides experiential leadership development opportunities and creates a future workforce to fill nursing leadership vacancies.


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3. Frieder RE, Van Iddekinge CH, Raymark PH. How quickly do interviewers make decisions? An examination of interviewers' decision-making time across applicants. J Occup Organ Psychol. 2016;89(2):223–248.
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