1. Norman, Leslie DNP, RN, NEA-BC, FACHE
  2. DiGiovanni, Renee F. MSN, RN, NEA-BC
  3. Ford, Deborah A. MSN, RN
  4. Flores, Robert V. DNP, MHA, RN, NE-BC, FACHE

Article Content

Healthcare is at war with an invisible enemy called SARS-CoV-2. In January 2020, we had no idea that healthcare as we knew it would change forever with the declaration of a public health emergency due to the COVID-19 outbreak worldwide.1 One and a half years later, we were back on the front lines fighting the Delta and Omicron variants.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

COVID-19 has caused many disruptions in healthcare systems worldwide, bringing chaos to patient care, patient and family experience, quality, and finances. The influx of critically ill and infectious patients overwhelmed emergency medical and inpatient care providers. Hospitals responded with new safety protocols, limiting visitors and delaying nonessential services. Payne reported that over $1.4 billion in revenues were lost each day due to procedure delays or cancellations and deferred care, with an average 56% reduction in hospital traffic.2


Impacts on staffing have created another source of chaos for organizations. Since the spring of 2020, the pandemic has disrupted the normal supply and demand for nurses, while nurse burnout rates increased and organizational engagement declined.3 Recent nursing workforce surveys report that 22% of participants have considered leaving their current positions, with 60% of those individuals citing insufficient staffing as the primary reason. Evidence suggests increased workloads and emotional burnout may drive nurses from the profession altogether.4 The latest national RN turnover rates increased in 2021 by 8.4% to an all-time high of 27.1%.5 The top three reasons for turnover were career advancement, relocation, and retirement.5 It's estimated that post-COVID-19 nursing shortages coupled with prepandemic conditions will lead to approximately 13 million nurses needed globally to fill the gaps by 2030.6


Amid the chaos, organizational leaders must "learn on the job" to be nimble, respond to daily changes, and innovate to accomplish patient care needs while maintaining safety. This article describes one organization's leadership model and tactics during the Delta variant wave of the COVID-19 pandemic. Leaders responded with strategies to manage patient care models, communication, supplies and equipment, and staff retention challenges.


Theoretical framework

Chaos theory provides a construct for the organizational disruptions felt during the 2020-2022 pandemic. According to Gleick, the basic concept in chaos theory is that nonlinear systems change over time, and small changes that appear insignificant can lead to substantial disruptions of a system.7 As the pandemic ensued, routine modes of patient care changed and evolved rapidly, creating disruption in systems and processes that were previously standardized. Traditional leadership strategies and communication methods were no longer adequate for managing the business of healthcare among chaos; thus, new models had to be created.


Leader resiliency organizational learning model

Organizations adept at overcoming chaos during crisis integrate a leadership framework into daily operations to lessen disruption and create resiliency among the team.8 During the fourth COVID-19 wave, a new leadership framework to create an organizational combat model was necessary to support the chaotic and evolving needs of the healthcare organization. The framework consists of four essential components.


1. Decision-making speed

Rapid decision-making is essential during times of crisis due to a fast-changing landscape and an overload of information, particularly when multiple parties are involved. Leaders must overcome the natural tendency to lead by consensus and quickly convert to a rapid cycle decision-making model.8,9


2. Adaptability

Situational awareness is critical for adaptation, allowing leaders to discard old processes and prioritize what's essential now. Adaptable leadership includes identifying and including essential business partners, such as operations, ancillary services, nursing, security, and facilities services, to execute decisions seamlessly. Also, leaders prioritize and communicate what initiatives will be put on hold until the crisis is averted.8,9


3. Reliable delivery

Leaders should anticipate a loss of control during crisis events. Many facets may be outside of personal control, but resilient leaders maintain focus on the needs of the organization, patients, and team, sustaining a culture of accountability. Actions to support reliability include: writing down and managing daily priorities, determining and deploying measurable performance metrics, and maintaining personal and team self-care and wellness routines.8,9


4. Engage for impact

Leader engagement with the team is one of the most important actions in a crisis. People experience heightened emotions such as stress, anxiety, and fear during times of uncertainty and change. Leader presence and engagement supports team well-being and organizational engagement. Specific leadership actions, such as demonstrating empathy and compassion, aiding when needed, and recognizing individual and team contributions, are potent tools to support and foster resiliency.8,9


The organizational combat model was created through an interdisciplinary team of nursing and operational leadership to provide nimble resiliency strategies to overcome disruptive changes in healthcare, including the four components outlined above.



The organization described is a 700-plus bed quaternary academic medical center in the south-central US. The organization is affiliated with a major regional health system whose mission is to save lives and change them through innovative passion and the influence of diversified stakeholders. In March 2020, the organization entered the first wave of the COVID-19 pandemic as a major care provider in the region. At that time, the numbers of patients without COVID-19 decreased dramatically, allowing efficient use of those beds for COVID care. The COVID-19 peak census fluctuated between 160 and 377 patients during phases one to three. In July 2021, a larger fourth wave of the Delta variant hit, and the organization faced new challenges with routine care and the care of patients with COVID-19 competing for healthcare services.


Patient-care enhancement strategies

As an American Nurses Credentialing Center Magnet(R)-recognized hospital, the organization subscribes to the philosophy of transformational leadership, which supported the changing demands during the pandemic. Frontline nurses and unit leaders partnered with executive-level leaders to solve staffing shortages related to unprecedented patient volumes and policy changes regarding clustered care, isolation, COVID-19 testing, personal protective equipment (PPE), and visitation. To combine the organization's mission, vision, and values with the principles of patient, family, team, and self, the organization uses a professional practice model based on Koloroutis's work, Relationship-Based Care.10 The foundation of collaborative practice allows nurses, providers, and ancillary staff to deliver quality care. With the rising demand for bed capacity, the organization developed and deployed three strategies: rapidly opening new units, shifting to responsive staffing models, and pilot testing a novel patient discharge plan.


Turnkey COVID-19 unit deployment model

The organization had existing space for several 34-bed units that weren't occupied during the fourth pandemic wave. Because the organization serves as the regional referral center for the healthcare system, the decision was made to open these units as dedicated COVID-19 wards. A turnkey system was developed to quickly open and equip units with a standardized checklist, a core healthcare team, and a quick executive approval process. The core team, consisting of the administrative, supply chain, nursing, and ancillary members, met daily to identify equipment, supply, and staffing needs. Executive approval was sought as needed, and as a result, unit occupation was executed within 2 weeks.


Innovative staffing models

As the volume of hospitalized patients with COVID-19 climbed from less than 10 to over 350 in 4 weeks, leaders couldn't maintain standard nurse-to-patient ratios of 1:2 in critical care units, 1:4 in step-down units, and 1:5 in the medical-surgical units. The nursing team looked at scalable staffing approaches to shift rapidly from normal to pandemic conditions. Leaders used the Society of Critical Care Medicine's national tiered staffing guideline as an evidence-based framework to build new models for resourcing critical care and step-down units.11 Support staff and nurses, called "game-changers" (GC), were reassigned from non-inpatient units and clinics to assist with inpatient nursing care of high-acuity patients with COVID-19. The organization enacted three staffing models to safely support patient care needs. The Step-down, Critical Care Paired 1:1, and Critical Care Pod Models were implemented to provide an approach to augment patient care to match bed demands (see Figures 1, 2, and 3).

Figure 1:. Pandemic ... - Click to enlarge in new windowFigure 1:. Pandemic Step-down Care Model
Figure 2:. Pandemic ... - Click to enlarge in new windowFigure 2:. Pandemic Critical Care Paired 1:1 Model
Figure 3:. Pandemic ... - Click to enlarge in new windowFigure 3:. Pandemic Critical Care Pod Model

Postdischarge care model

An innovative discharge program was designed to decompress inpatient space and allow the influx of patients who tested positive for COVID-19. An interdisciplinary team developed a high touch COVID-19 surveillance program to safely provide early discharge to home for patients with COVID-19. The pilot evaluated if the current hospitalist model could be applied to the home setting virtually by reviewing the readmission rates of the study group. The care team identified inpatients with COVID-19 for eligibility to participate in a pilot early discharge-to-home program. Thirty rooms in a hotel attached to the organization were selected as a discharge location due to proximity to the ED.


Inpatients would be discharged up to 3 days earlier to the hotel as a surrogate home, with a thermometer, pulse oximeter, and needed prescriptions. Providers scheduled virtual remote monitoring check-in visits to check for changes in condition. Escalation protocols and support were established. The model has demonstrated innovative applications beyond a pandemic scenario. Program evaluation of the pilot discharge program is ongoing. Investigators are tracking clinical outcomes and readmissions. If successful, this program may be adapted for a future hospital-to-home model.


Communication strategies

Effective communication is crucial to the operation and success of any organization, and it becomes more critical when emergencies arise. The potential for communication breakdowns poses a risk to employees' and patients' safety and well-being. Communication from patient to family was disrupted due to changes in the visitor policies. Electronic tablets previously used for patient interaction with the patient portal were repurposed for provider-patient virtual visits in the inpatient setting. Patients also used them to connect with families and friends when hospital visitation was restricted.


Organizations should maintain clear, fluid, and regular communication with their employees, which helps increase staff members' confidence and sense of control.12 Throughout the pandemic, organizational leaders maintained multiple avenues of communication. Among the different levels of leadership, there were daily COVID-19 calls to discuss bed capacity and staffing. Open forums were held frequently using videoconferencing technology for leaders and employees. At these forums, executives shared general information and updates, and employees had the opportunity to ask questions freely. Every day, the CNO met with unit directors (UDs) for bidirectional listening and feedback from UDs and patient-facing staff. These daily exchanges allowed for quick adjustments to staffing, beds, and other critical resources and provided a pulse on the overall morale of the teams.


Enhanced supply chain and equipment management processes

Caring for patients with COVID-19 was complicated by concerns about preventing the spread of infections to staff. Clustering nursing care is a time-tested strategy to decrease staff exposure to infectious disease. Leaders identified remote monitoring of patients as a desirable goal to maintain safety for patients and staff. Critical care units had remote monitoring systems, but the medical-surgical and step-down unit rooms weren't equipped with this technology. Leaders decided to rapidly deploy an innovative monitoring technology that integrates with the electronic health record for continuous vital signs and pulse oximetry monitoring.13


To further protect patient-facing staff, a multidisciplinary team led by Infection Prevention implemented guidelines and processes to conserve PPE. Lockable bedside carts were obtained and placed in each patient room, stocked with frequently used items and supplies to reduce the need for employees to go in and out of rooms. Practice changes were made per CDC recommendations and communicated to all via emails, the organizational intranet, and daily shift huddles.


Staff retention efforts

The organization saw an increase in nursing turnover from 21.9% in 2019 to 31.29% in November 2021. As a result, the organization deployed innovative solutions to retain nurses at the bedside. Solutions were targeted at increasing compensation to compete with the market, offering flexible employment arrangements, and supporting staff well-being. (See Table 1 for an overview of compensation and contractual changes.)

Table 1: Retention i... - Click to enlarge in new windowTable 1: Retention incentives

Well-being and resiliency

The organization has a long history of supporting nurse well-being with a Care for the Caregiver program aligned with the American Nurses Association Healthy Nurse Healthy Nation initiative. Leaders recognized the need for additional support as the evidence demonstrates increased burnout during times of crisis, such as a pandemic.14-17 Burnout is characterized as emotional exhaustion and pessimism resulting from working in people-oriented occupations.17 To combat burnout and care for the psychological, physical, and behavioral well-being of staff, an Office of Professional Well-Being (OWB) was established. The OWB provided much-needed resources for teams to access, such as: 1) Cabana, a virtual support group; 2) In-person well-being support at departmental meetings; and 3) Silver Linings, a10-part virtual series to equip staff with tools and resources to address stressors and challenges in a fun way.


Lessons learned

As with any new or revised process deployment, there are lessons learned to help organizations course correct and adapt to changes necessary for success. Throughout the pandemic, the organization recognized successful tactics and opportunities for improvement.


The first cohort of GCs was redeployed from clinics and non-inpatient departments without input from the employees. Leaders recognized anxiety and disconnect among GCs practicing in unfamiliar areas. Many of these employees had been away from the bedside for varying periods of time and worked different shifts than a traditional inpatient employee. A clinical experience background and preference sheet was quickly implemented to match redeployed staff to the optimal practice setting.


Leadership implemented daily check-in rounds by l p.m. to capture real-time feedback and concerns. The nursing education team created an electronic nurse and patient care technician clinical resource guide for employees preceding their first "buddy shift." Also, a rapid-fire hands-on skills fair was deployed in the simulation lab to help refamiliarize clinicians with medication pumps, bar code scanners, and other clinical equipment. After gaining feedback from redeployed staff, we allowed staff to opt out of redeployment to COVID-19 units during subsequent COVID-19 waves. As a result of the opt-out option, the organization demonstrated a 6% decrease in turnover.


Another lesson learned was called "Operation Bunny Suit." Initially, employees were expected to don and doff PPE between patients. This process became taxing and consumed a large quantity of supplies. As the number of patients with COVID-19 increased, multiple units were converted to COVID-19 only wards based on feedback from leadership and staff. PPE liaisons were instituted in each lobby to expedite and assist personnel with donning and doffing. Through feedback, staff engagement and the ability to seamlessly care for patients improved as dedicated PPE stations, break areas, and hydration stations allowed staff to stay in their coveralls anywhere on the unit.


The organization realized early in the pandemic that establishing an Incident Command (IC) Center was essential for the combat model. IC was instituted around the clock and staffed by local and system leaders to capture and escalate critical patient-care needs raised by frontline staff and providers. The IC model assisted the organization in establishing a warehouse to stockpile equipment, PPE, supplies, and other essentials for quick deployment to the facility. Instituting daily leadership huddles was crucial to keeping up with the ever-changing dynamics of patient care and provided a crucial two-way feedback mechanism between frontline workers and leadership. Finally, learning and establishing change allowed the healthcare providers to focus on patient care through leadership support processes. As a result of lessons learned, a COVID-19 Playbook was developed to assist leaders during subsequent surges.


Adapt to change

The COVID-19 war has presented healthcare organizations with incredible challenges and opportunities to overcome adversity through innovation, creativity, and resiliency efforts. To preserve the ability to provide services to the communities we serve, organizations must aggressively adapt to change through lessons learned from previous events. The organizational combat model and its components offer a guiding vision for adaptation in times of turmoil. Leaders of one healthcare organization used this model to develop turnkey processes, innovative staffing models, sustainable supply chain programs, robust communication strategies, and long-term staff resilience. The model's components can aid healthcare leaders in reducing the impact of internal and external chaos and strengthening organizations for future growth and sustainability.


INSTRUCTIONS The COVID war: Building an organizational combat model to reduce chaos



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1. World Health Organization. State of the nursing report 2020. [Context Link]


2. Payne E. The cost of disruption. Benefits Pro. 2020. [Context Link]


3. Mensik H. 1 year of COVID-19 has changed what it's like to work in healthcare. HealthcareDive. 2021. [Context Link]


4. Berlin G, Lapointe M, Murphy M, Viscardi M. Nursing in 2021: retaining the healthcare workforce when we need it most. McKinsey & Company. 2021. [Context Link]


5. NSI Nursing Solutions Inc. 2022 NSI National Health Care Retention & RN Staffing Report. 2022. [Context Link]


6. International Council of Nurses. The global nursing shortage and nurse retention. International Council of Nurses Policy Brief. 2020. [Context Link]


7. Gleick J. Chaos: Making a New Science. New York, NY: Penguin Books; 1988. [Context Link]


8. Nichols C, Chatterjee Hayden S, Trendler C. 4 behaviors that help leaders manage a crisis. Harvard Business Review. 2020. [Context Link]


9. Ellis LD. The importance of meta-leadership during the COVID-19 crisis. Harvard School of Public Health. 2021. [Context Link]


10. Koloroutis M. Relationship-Based Care: A Model for Transforming Practice. Minneapolis, MN: Creative Health Care Management; 2016. [Context Link]


11. Halpern NA, Tan KS. United States resource availability for COVID-19. Society of Critical Care Medicine (SCCM). 2021. [Context Link]


12. Manzano Garcia G, Ayala Calvo JC. The threat of COVID-19 and its influence on nursing staff burnout. J Adv Nurs. 2021;77(2):832-844. [Context Link]


13. Sotera Wireless. ViSi Mobile System. [Context Link]


14. Denning M, Goh ET, Tan B, et al Determinants of burnout and other aspects of psychological well-being in healthcare workers during the Covid-19 pandemic: a multinational cross-sectional study. PLoS One. 2021;16(4):e0238666. [Context Link]


15. Lin Y-Y, Pan Y-A, Hsieh Y-L, et al COVID-19 pandemic is associated with an adverse impact on burnout and mood disorder in healthcare professionals. Int J Environ Res Public Health. 2021;18(7):3654.


16. Rainbow J, Littzen C, Gelt J. Nurse burnout: the next COVID-19 crisis? University of Arizona College of Nursing. 2020.


17. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2(2):99-113. [Context Link]