The COVID-19 pandemic increased the number of patients requiring intensive care nationwide, leading to nurse staffing shortages in many units.
At the beginning of the statewide COVID-19 surge, a tertiary teaching hospital in the upper Midwest experienced a sharp increase in patients needing intensive care. To relieve the resulting staffing shortage, it implemented a pilot program to bring general care nurses into its 21-bed mixed specialty intensive care unit to free intensive care unit nurses to help staff the hospital’s COVID-designated units.
Using a team nursing model, the intensive care unit recruited, oriented, and incorporated 13 general care nurses within 4 days. Education and resources were developed to distinguish team nurses from intensive care unit nurses, introduce them to the intensive care unit environment, outline expectations, communicate between team nursing pairs, and guide charge nurses in making staffing decisions and assignments. Staff feedback identified additional resources, barriers, and successes. An adaptive process was used to improve and update tools and resources on the basis of staff needs.
The pilot program ran for 6 weeks. Positive outcomes included a reduced need for float nurses and self-perceived reduction in nursing workload. The principal barrier was charge nurses’ challenges involving staffing-to-workload balance based on the existing staffing model. This model identified productivity of a general care nurse and an intensive care unit nurse as equivalent, despite differences in their skill sets.
Team nursing in the intensive care unit is an agile tactic easily replicated in dire staffing situations.
Historically, inpatient nursing has been dominated by 4 nursing care delivery models: functional, team nursing, total patient care, and primary nursing.1 At a tertiary teaching hospital in the upper Midwest, primary nursing has traditionally been the model used on inpatient care units. In this model, care is patient centered and relationship based, requiring the nurse to maintain full accountability for the assessment, planning, implementation, and evaluation of a patient’s care 24 hours a day.2 Although there is little substantiated research on the efficacy of primary nursing, this care model has generally been viewed as superior to others because of its patient-centered approach and promotion of nurses’ professionalism, autonomy, and decision-making skills.3
Effect of the Pandemic on Nursing Care Models
On January 9, 2020, the World Health Organization (WHO) announced a cluster of nearly 60 pneumonia cases in Wuhan, China, stemming from a novel coronavirus (SARS-CoV-2). The first confirmed case of COVID-19 in the United States was reported 12 days after the initial WHO announcement, and the White House declared a US public health emergency due to the outbreak 2 weeks later.4 On March 11, 2020, the WHO classified the outbreak as a pandemic.5 At the end of 2020, the pandemic had resulted in more than 83 million cases of COVID-19 and 1.8 million deaths around the world.2
For several months into the pandemic, little was known about the characteristics of infection with and transmission of the new virus, or about how to treat COVID-19. The early response to exposure, display of symptoms, and suspected or confirmed cases involved a low threshold for quarantining individuals for 14 days after exposure to an infected person.6 As cases surged in a seemingly arbitrary pattern throughout the country, the cumulative effect of rising inpatient censuses and hospital staff absences due to illness and/or quarantine was significant staff shortages throughout health care institutions, and specifically in intensive care units (ICUs). In response, the Centers for Disease Control and Prevention issued guidance for health care organizations to help them operate effectively during the pandemic, including a comprehensive hospital preparedness checklist and strategies to mitigate staffing shortages.7
The upper Midwest did not experience a sharp increase in confirmed cases and hospitalizations until the fall of 2020. Experiencing similar challenges that other health care systems faced, our tertiary teaching hospital implemented several of the tactics recommended by the Centers for Disease Control and Prevention. These strategies included canceling nonurgent surgeries and nonessential meetings and classes, use of telemedicine technology, onboarding travel nurses, and preparing ambulatory nurses, advanced practice provider students, and nurse leaders for potential redeployment to inpatient bedside nursing.
As ICUs continued to experience an escalation in census and acuity, efforts aimed to offset the staffing-to- workload disparity remained insufficient. In response, nursing leadership proposed implementing team nursing as a strategy to support ICU staffing. Early in the pandemic, the Society of Critical Care Medicine published a resource for managing heavily burdened ICUs while optimizing the availability of scarce ICU-trained nurses, including the recommendation to implement a “tiered staffing strategy” that employed non-ICU nurses and non-ICU advanced practice providers under the direction of an ICU nurse.8
The tiered staffing strategy, like team nursing, originated in the 1950s as a result of the nursing shortage following World War II and the significant growth of licensed practical nurses and ancillary staff during that period. The philosophy was that the efforts of a diversified staff, directed by a professional nurse, would result in a quality of care far superior to what could be attained individually.9 Team nursing is most often described in nursing literature pertaining to general care environments.10–13 However, little has been written about the use of this model in critical care settings. Gill et al14 described piloting team nursing in an ICU using only intensive care-trained nurses in their model. In a review of the literature, we found no articles reporting the use of general care and critical care nurses within a team nursing model in the ICU setting.
Team Nursing Implementation
In response to nursing leadership’s call, the 21-bed medical/surgical/transplant ICU (which was not a COVID-designated unit) volunteered to pilot a team nursing approach. The aim of the pilot program was to collaborate with general care nurses to free critical care-trained nurses to help staff the hospital’s COVID-designated ICUs. This planning occurred under the direction to “move quickly and learn along the way.” The pilot program involved only nurses, to enable rapid implementation of the training and communication needed to achieve the goal of deploying ICU nurses to care for critically ill patients with COVID-19.
The first step was to identify general care nurses to reassign to the ICU. Because of the reduction in elective surgeries during the pandemic, nursing staff from 2 orthopedic specialty units were selected. The nursing leadership team, comprising the nurse manager, clinical nurse specialist, and nursing education specialist from the ICU, collaborated with the nurse managers on these orthopedic units. Together, they worked to recruit individuals who were interested in voluntarily undertaking a short-term assignment for an indeterminate time in the ICU. Thirteen nurses were identified, with experience levels varying from less than 1 year to 19 years, with the majority having only a few years of nursing experience.
Nursing administrative leaders initially recommended a 4-hour orientation for general care nurses moving to the ICU, as a possible hospital-wide implementation of team nursing further into the pandemic might not allow for more robust training. However, the leadership team decided to lengthen the orientation, recognizing that in addition to the challenges of implementing a new level of care coordination, the transition would be difficult not only for general care nurses unfamiliar with the ICU environment but also for ICU nurses adapting to a diminished sense of control and awareness of their patients’ status.
Orientation to the ICU involved an initial 8-hour observation shift to acclimate general care nurses to the unit’s environment, equipment, and patient population, including a brief overview of the significance of various alarms and expectations of the general care nurse regarding an alarm (Figure 1). Owing to the rapid implementation of this model, the general care nurses’ scope of practice remained the same during their roles as team nurses in the ICU; they were not trained to be responsible for ICU-level concepts, skills, or medications. Within a week, gaps in the general care nurses’ knowledge of the specialty populations within this ICU emerged, as well as a lack of general care skills more frequently used on medical units than on surgical units. In the pilot ICU, most of the patients have hematology and oncology specialty needs. Thus, nurses must have a specific skill set, including managing nasogastric tubes, enteric feeding tubes, and complex wounds and intravenous access. The orthopedic nurses, while highly skilled, lacked experience and confidence caring for this patient population. Therefore, a 4-hour training session was developed and implemented a week into the pilot program. During this “boot camp,” an experienced ICU preceptor provided hands-on demonstration of nursing skills frequently used in the pilot ICU that were within the general care nurses’ scope of practice (Figure 1).
Orientation to the ICU involved an initial 8-hour observation shift to acclimate general care nurses to the unit’s environment, equipment, and patient population.
The foundation of team nursing is strong leadership and clear communication.9 To avoid confusion among providers and ancillary staff, identification badge tags and door cards were created to differentiate general care nurses from ICU nurses. General care nurses were identified as “team nurses” instead of “general care nurses” to maintain confidence among patients and families that appropriately skilled nurses were caring for them. A team nursing Assessment and Agreement form was adapted for the ICU from hospital surge-planning resources (Figure 2). This form was to be used for each patient cared for by a team nursing pair, with the goal of clarifying responsibilities and avoiding the problem of “when it’s everybody’s job, it’s nobody’s job.” It was to be individualized for each patient depending on the complexity of their care, with attention to the comfort and experience level of the general care nurse.
Charge nurses were tasked with determining assignments for team nursing pairs based on patient acuity and availability of tasks appropriate for general care nurses to assist with, including caring for various combinations of ICU and progressive care unit patients (Figure 3). If there were no suitable team nursing assignments, the charge nurse would cancel the role of the team nurse, who would float to another unit.
Not far into the pilot program, we recognized the need to enhance cohesion and trust between the ICU nurses and the general care nurses. The literature supports this phenomenon: Brown et al15 reported that “more skilled” clinical team members can be reluctant to share responsibility and delegate to team members owing to perceived lack of competence. To enrich these relationships, the ICU nursing leadership team issued a call for “team nursing champions.” These “champions” were ICU nurses who were consistently open to pairing with general care nurses and willing to navigate the unfamiliarity of the pilot program. In pairing general care nurses with ICU nurses, charge nurses would give priority to champions if they were available when team nursing was needed. Many nurses (30% of the nurses on the ICU) answered the call, and most of them were preceptors or newer nurses.
In the postpilot survey, champions cited “wanting to try a new challenge,” “having more opportunities to teach,” and “wanting to be a part of the solution” as reasons for stepping up to the champion role. Those who did not become team nursing champions identified “lacking trust,” “a sense of increased workload on team nursing pairs,” or “wanting to be able to continue getting high- acuity patients” as reasons for declining the role. Cohesion between the general care nurses and ICU nurses was also promoted by including the general care nurses in email communications from the unit and posting “get to know me” forms with their pictures in the break room.
The pilot program lasted 6 weeks. Although the objective of the program was to free up ICU nurses to help staff the hospital’s COVID-designated ICUs, the actual result was not so robust. A review of staffing numbers indicated that the pilot unit was able to provide sufficient care with the combination of scheduled ICU nurses and general care nurses, resulting in fewer requests for additional ICU nurses from the pool of ICU nurses. In a few cases, ICU nurses were reassigned from the pilot unit to the COVID-designated ICU as general care nurses helped meet staffing needs. However, this occurred less frequently than anticipated, reflecting the pilot unit’s ongoing need for nurses with critical care specialty skills and the ability to care for high-acuity patients. Another consequence was a reduced need for ICU float nurses, who were then reallocated to the hospital’s COVID-designated ICUs.
A postpilot survey was distributed to all ICU nurses and general care nurses involved in the pilot program. It solicited nurses’ perceptions of their ability to provide appropriate and high-quality patient care both at the beginning and at the end of the program (Figure 4). Survey questions aimed to determine staff members’ perceptions of the feasibility of team nursing in the ICU and its impact on workload and patient outcomes. By the end of the program, responses were mostly positive regarding nurses’ perceptions of their ability to provide appropriate and high-quality care; however, ICU nurses felt less able to provide appropriate and high-quality care compared with the general care nurses. We attribute this finding to the ICU nurses’ hesitation regarding oversight of and delegation to a nurse not familiar with critical care practices. In addition, the need to implement the pilot program rapidly limited the ability to solicit nurses’ input before initiating a team nursing model, as well as recognition of the extra effort and oversight provided by ICU nurses.
Intensive care unit charge nurses, responsible for making team nursing assignments, reported the lowest perceived ability to provide appropriate and high-quality care to patients. This finding was supported by various factors, including the pilot unit being a small ICU compared with other ICUs, with a layout (2 pods) that made it difficult to make pairing assignments. The high-acuity patient population also made it burdensome to assign team nursing pairs, as the workload often requires one- to-one ICU care—a challenge that is amplified during periods of low census. In addition, the formula used to determine staffing needs posed challenges for charge nurses, as it considered general care nurses to have a productivity of 100%, equivalent to that of ICU nurses, without taking into account that the general care nursing skill set did not match that required in the ICU. Charge nurses were also faced with challenges regarding coverage for meal breaks, which generally required ICU nurses to cover for each other and general care nurses to cover for each other. When appropriate, the enhanced ICU assisted by virtually monitoring patients during breaks.
Communication between ICU and general care nurses improved as the program progressed.
Although well intentioned, rapid implementation of the pilot program magnified the stress of many ICU nurses, who were already dealing with unpredictability caused by the pandemic. Communication was a challenge, both among nursing staff and between the nursing leadership team and nurses. Nurses often commented that it was difficult to stay current with practices when they changed so frequently. With variable schedules and several days off between shifts, even small frequent changes contributed to the sense of unpredictability and heightened stress. Despite the provision of electronic resources, a quick reference binder, and numerous emails to communicate expectations and updates, it was difficult for nurses to feel informed amid the frequently changing guidelines in hospital practice. Communication between ICU and general care nurses improved as the program progressed. Nurses who used the Assessment and Agreement form regularly were more likely to perceive the pilot program as successful (Figure 5). This finding was probably due to the improved communication resulting from use of the form to help clarify roles and expectations.
An important component of practice change is evaluating patient and/or family response. Although patient and family perceptions were not formally evaluated during the pilot program given the rapid implementation of the program in the context of the COVID-19 surge, future iterations of the program should explore this element.
For ICUs considering implementation of team nursing as a short-term staffing solution, we recommend that a learning needs assessment first be conducted to identify nurses’ strengths and areas that may require additional training (Figure 6). Needs assessment and application of the team nursing model should involve early and frequent open dialogue involving key stakeholders. Staff nurses’ involvement in decision-making will reduce barriers more easily identified by frontline staff, improve their sense of control in a difficult situation, and enhance implementation and application. Nursing leaders should identify clear objectives and routinely evaluate and swiftly address patient safety issues, scope of practice concerns, and communication barriers. If objectives are not being met, leaders should advocate for discontinuing this approach and pursuing other interventions to mitigate staffing shortages.
Following the pilot program, the pilot unit’s staffing model returned to primary nursing. Through feedback and sharing among administrative and clinical education leaders, components of this model have been used to build new initiatives to address ongoing staffing challenges; the processes and tools from the pilot program have been successful in supporting both ICU nurses and nurses without ICU experience assisting in the ICU environment.
The ICU and general care nurses involved in the team nursing pilot program demonstrated exceptional teamwork, flexibility, and commitment to providing high-quality care for their patients as they navigated an unprecedented time in nursing history. The nurses’ direct involvement in the identification of obstacles, discovery of solutions, and the program outcomes has paved the way for other ICUs as they assess interventions for staffing shortages. Their willingness to participate, provide feedback, and adapt quickly highlights the integrity of the nursing profession. CCN
The authors thank all the orthopedic and intensive care unit nurses at Mayo Clinic in Rochester, Minnesota, for their extraordinary efforts to always put the needs of the patients first, no matter the barriers.
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To learn more about nursing during the COVID-19 pandemic, read “Beyond Burnout and Resilience: The Disillusionment Phase of COVID-19” by Gee et al in AACNAdvanced Critical Care, https://doi.org/10.4037/aacnacc2022248.