Training The Trainers

Now, add another layer to all of these responsibilities. As a Clinical Nurse Leader (CNL), you face these challenges not just for yourself but for the nurses you work with and supervise. Their problems become your problems. Sound challenging?

Well, kick it up one more notch and you get an idea of what Helene Bowen Brady DNP ‘17 does and the pressures she faces. As Director of the Clinical Nurse Leader program at Regis College, Brady’s job is basically to lead the leaders—the CNLs who play a key role on the front lines in their organizations. This rarified role at an university that has trained more than 600 nurses a year for decades means that she profoundly influences the next generation of nurses as a faculty member and in her role as nurse scientist at Brigham and Women’s Faulkner Hospital, where she previously served as Associate Chief Nurse, Practice and Innovation before joining Regis. “I’m confident that the education the CNLs receive at Regis prepares them to be effective leaders who make evidence-based, ethical decisions for themselves and for their patients during this unique health care crisis,” Brady says.

With a view from 30,000 feet and from the ground, Brady has a unique perspective on the current crisis and the future of the profession. Her main message? Every nurse, no matter what their level or the responsibilities on their job description, must assume the role of a leader.

Fast Breaking Facts

As CNL program director, I’m responsible for ensuring that our CNL graduates are prepared to practice in many different roles within complex health environments - clinical nurses at the bedside, educators, and nurse leaders. The definition of a complex health environment has certainly shifted since the start of this pandemic. One important focus for CNL education throughout the program is the ability to make the best decisions possible based on the most current evidence. However, “current evidence” has also taken on a very different meaning in the midst of this pandemic. In the past, current evidence may have meant a topic recently presented at a conference or a study published within the past few months, certainly within the past few years. Today current evidence may mean within the past few minutes! In the practice setting, leaders are sending out daily communications to guide general practice based on the most recent information whether it is the conservation of personal protective equipment (PPE) to assessing and treating patients with limited resources in an ever-changing environment. When treating individual patients, it is more important now than ever for interdisciplinary teamwork to make the best rapid-fire decisions with clinical information that is changing minute to minute. In one of my most recent Zoom classes, CNL students were sharing examples of the rapidly changing standards for care. Staff who are off for one day come back to find that the latest evidence is pointing to a change in how care should be delivered. In the midst of the uncertainty surrounding this crisis, one of the positives is the willingness of medical and research professionals around the world to share their findings with each other. The focus in on caring for patients today, not publishing research years from now.

Where individuals find fast breaking, factual information depends on who they are and their role. For health care practitioners, it is definitely the expert leaders from their organizations. For the Regis CNL students who are practicing nurses working on the front line, they are receiving updates on a regular basis from the leaders in their organizations. For individuals in the community, their information needs to come from reputable sources: the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the US Department of Health and Human Services (HHS), and the MA Department of Public Health (MA DPH) are among a few trusted sources. In MA, the governor has been holding daily briefings and has a team of expert professionals providing citizens with factual information.

Leadership Challenges in a Crisis

There are numerous behind the scenes challenges that nurse leaders face in any crisis. The difference today is that nurse leaders are not planning for a time-limited crisis but making plans for the long-term future – all while not knowing how long this will go on. The biggest challenge in any crisis is often staffing – ensuring that there are enough registered nurses and unlicensed nursing staff to provide care. For the inpatient units in a hospital, where most of the patients with COVID-19 will be cared for, ensuring adequate staffing is a top priority. Nurse leaders are thinking about the number and length of shifts that nurses can safely work, time off between shifts, the possible need for mandatory overtime, what to do when staffing is short, etc.

To address staffing needs, nurse leaders are looking at the number of staff available. When you read about increasing the number of ICU beds that are available in each hospital that means that nurse leaders have to increase staffing for those beds. These leaders need to strategize about how to increase staffing within a very short time frame. In most hospitals, ambulatory, procedural, and surgical units have either been closed or are seeing only emergency cases. Theoretically, all the nurses working in those units can be placed on the inpatient units – in theory. One thing that individuals outside of healthcare may not realize is that nurses have specific competencies for the practice setting that they work in. That means that nurses cannot just move from one practice setting to another without additional education and training. In order to increase staffing for the inpatient units those nurses who typically work in the specialty practice settings need additional education to have at least basic competencies and support to practice in that new setting. This means that educators in every organization are working day and night to support the transition of nurses from one practice setting to another. When these nurses arrive to the new setting, they need additional support from their colleagues on a daily basis.

Social Distancing/Lack of PPE/Getting Concerns into the Right Hands

Just as many citizens are being asked to stay at home and practice social distancing for the good of all, healthcare workers are being asked to adhere to new guidelines to preserve precious resources. Hopefully that will change in the future, but that doesn’t help when healthcare workers are caring for sick patients today. Recently, there have been numerous conversations in the media and at work places about the ethical dilemmas facing healthcare professionals who do not have the PPE (personal protective equipment) they need to safely perform their jobs. Are healthcare workers justified in leaving their positions if they feel that conditions are unsafe? In a few places across the country, healthcare workers who have publicly disclosed the lack of proper equipment have been fired or received public sanctions. This certainly has not been limited to healthcare workers - just think of Captain Brett Crozier who sounded the alarm about a COVID-19 infection aboard the USS Theodore Roosevelt and was removed from his role.

These are unusual times for individuals working in many different industries – not just people who enter healthcare or the armed services. Many individuals who never anticipated having a role in a pandemic are currently being exposed to COVID-19 in newly designated essential jobs (i.e. grocery stores, public transit, and delivery services, etc.). This is much different than nurses who enter the profession expecting that they will be providing care to sick people or those in the armed services who take an oath to protect our country putting themselves at risk. Nevertheless, just because you take an oath to serve your country or enter a profession knowing you will care for sick people, does not mean that you should not have the resources you need to do that in the safest way possible. The American Nurses Association (ANA) recently came out with a statement urging nurses who have experienced retaliation for raising concerns about their personal safety to file a whistleblower complaint online with OSHA. However, we know that responding to complaints takes time.

So should a nurse quit when they feel unsafe? That is a difficult question to answer and will always rest with the individual. With regard to lack of PPE, I think that this decision may depend on whether the individual thinks their organization is doing everything within its power to provide the resources needed to protect workers and to care for patients. There are daily [news] updates on what organizations and the local and state leaders are doing to address these needs. Before making a decision about quitting, the nurse would need to carefully review the ANA Code of Ethics with Interpretive Statements. Nurses can refuse to participate in morally objectionable actions but there are very specific exclusions for these. In an article published this month in the American Nurse Today journal (on a non-COVID-19 related topic), a member of the ANA Ethics Board reminds nurses that by entering the nursing profession, they have “a professional obligation to place the well-being and rights or patients at the center of their professional practice” (Swanson, 2020, p.54). Nurses need to remember this professional obligation. If a nurse decides not to work a scheduled shift due to a lack of PPE, that nurse would need to communicate the decision to leaders and ensure that there are alternative arrangements for patient care. What that means is that a nurse cannot just walk off the job for any reason– they have a professional responsibility to ensure their patients will be properly cared for if they do leave.

I do think that the lack of PPE in the US is reflective of the larger issue about the need for nurses to become more involved in health care policy issues. From my perspective, the US has not valued or funded public health initiatives as needed, which has contributed to the current situation. It is always easy to say that we are too busy or that it is someone else’s job to advocate for public health initiatives, climate change, clear air, etc. But if not us, then who? I hope that as a result of this pandemic, individuals from across the country realize the value of their voice and understand that we can make changes – one citizen at a time. If there is any positive from this situation, it may be that nurses and all citizens will become more involved in health care policy and advocacy. Earlier this semester in one of my classes, master’s nursing students were discussing their role (or lack of role) in health care advocacy and policy. Many of them wondered whether they even had a role or responsibility as a clinical nurse in advancing health care policy issues. This pandemic may change their minds. It is easy to think that this is someone else’s job to address a systemic problem but the current lack of essential equipment, qualified health care providers, hospital beds, ventilators, and on and on, is resonating with front line care givers. I hope that their concern will translate to action at the local, state, and national level to ensure that the US is prepared to address this ongoing pandemic in the coming months and to be better prepared for the next one.