Authors

  1. Weiss, Rebecca L. DNP, RN, NPD-BC, CEN, CCRN-K
  2. Kennell, Jamilyn MSN, RN, OCN
  3. Lakdawala, Linda DNP, RN, CPAN
  4. Anzio, Nicole DNP, RN, CMSRN
  5. Klamut, Kimberly A. MSN, RN, CCNS
  6. Lucas, Wendy MSN, RN, CCRN, CCNS, BMTCN
  7. Antinori-Lent, Kellie MSN, RN, ACNS-BC, BC-ADM, CDCES, FADCES
  8. Mininni, Nicolette C. BSN, RN, MEd, CCRN-K

Abstract

The COVID-19 pandemic impacted every aspect of the personal and professional lives of healthcare providers. Nursing professional development practitioners are challenged with ongoing classroom education, new hire onboarding, and just-in-time education for staff. This article is intended to present the unique challenges that the COVID-19 pandemic placed on nursing professional development practitioners in a large academic medical center and how opportunities presented to revise old education practices.

 

Article Content

The COVID-19 pandemic impacted many aspects of the personal and professional lives of healthcare providers. National and local regulatory agencies adapted requirements and provided direction on adapting classes based on social distancing recommendations. Nursing professional development (NPD) practitioners are challenged with ongoing classroom education, new hire onboarding, and just-in-time education for staff. This article is intended to present the unique challenges that the COVID-19 pandemic placed on NPD practitioners in a large academic medical center and how opportunities presented to revise old education practices.

 

CLASSROOM CHALLENGES

One of the early challenges to continue traditional education practices was the implementation of social distancing. Social distancing guidelines from the Centers for Disease Control and Prevention (CDC) were implemented as a strategy to decrease virus transmission (CDC, 2020). The guideline recommended a maximum of 10 people in a room, with 6 feet spacing between each person. Early in the pandemic, many classes and meetings were placed on hold to allow social distancing and reduce exposure risk. Staff were also empowered to work remotely when possible. Several challenging decisions were required, such as what classes to place on hold, what classes to continue, and how to adapt to meet social distancing recommendations.

 

NURSING ORIENTATION

The hospital system onboards all nurses every week in groups of 5 up to 160 new hires in peak orientation seasons. A major challenge was to accommodate the large numbers of new nurses to the organization while practicing social distancing. During the first few weeks of room occupancy reductions, orientation numbers exceeded the 10-person-per-room recommendation. The Nursing Education and Media Departments collaborated to divide the new nurses into appropriately sized groups in separate rooms. Each room was supported with audiovisual equipment in the form of large display screens, microphones, and an educator. The lectures were then streamed virtually to each room, and presenters were rotated from room to room to keep everyone engaged. There are several streaming options; our system-supported platform is Microsoft Teams. The new nurses were understanding of this change and were flexible with this virtual learning style. No changes in the evaluations occurred when compared to before the pandemic after implementing social distancing and virtual education. Many nurses reported they felt the orientation team provided a safe environment for them and were excited to begin working on their hospital units.

 

RN REORIENTATION AND RN SUPPORT CLASSES

Two courses were created to prepare for a potential increase in RN demand from quarantined staff and an increase in patient care demands. The RN Reorientation class was for nurses who left the clinical bedside role within the last 2 years and worked in a nonclinical role, such as care management, procedural areas, or outpatient departments. Nurses attended an 8-hour class day with topics required by regulatory agencies, policy and procedure changes within the past 2 years, and annual competency requirements. Examples of content included a review of medication administration, restraints, blood administration, and phlebotomy. Included in the class day was a 4-hour electronic medical record class to review general documentation guidelines. The nurses were given a clinical orientation documentation record and skills checklist to use on their 1-week orientation to the designated nursing unit. Once their orientation was completed, they were assigned from the staffing resource pool to nursing units in need of staffing.

 

The second course was the RN Support class. This class option was created for nurses who have been away from the clinical bedside role for more than 2 years and worked in a nonclinical role. There were more nurses interested in supporting the bedside staff in this role. The aim of the RN Support role was to allow nurses to practice within the scope of their license safely. The nurses in this group received education on basic nursing care, like activities of daily living and general skills such as wound care, fall prevention, restraints, emergency response, infection prevention, and respiratory care. These nurses also attended a 4-hour electronic medical record course to review general documentation guidelines. These nurses were coassigned with a staff RN but would not perform high-level skills unless specifically trained (e.g., phlebotomy, blood transfusion, cardiac rhythm interpretation), give medications, or take and review orders. Each support nurse was provided a clinical orientation record and skills checklist and placed on a unit for one to three shifts of orientation.

 

CRITICAL CARE ESSENTIALS COURSE

The hospital is the main provider of the organization's regional Critical Care Course. The hospital's NPD practitioners were already evaluating the course structure and aspiring to shorten the 5-day lecture-based classroom course to a shorter critical care essentials course. The increasing need for intensive care unit (ICU) nurses to care for COVID-19 patients provided the opportunity for revisions. The critical care NPD practitioners reviewed the course outline and determined the appropriate essential knowledge for new ICU nurses and former ICU nurses returning to the bedside. The revised course time was decreased to two 8-hour synchronous virtual presentation days and 8 hours of asynchronous self-learning work. The self-learning work included American Association of Critical-Care Nurses webinars on the covered topics and instructional videos created by content experts teaching the course. During the months of March, April, and May 2020, over 40 nurses were educated by attending the revised Critical Care Essentials course. All participants completed a postcourse examination on site, and all participants successfully passed the examination. This was a higher pass rate than the traditional course.

 

CLINICAL ORIENTATION CHALLENGES

During the COVID-19 pandemic, unit-based clinical orientation practices were threatened by a 50% drop in overall hospital census. Initially, low hospital census was identified as an obstacle for orientees to obtain exposure to necessary clinical skills and placed them at risk to be temporarily reassigned to another unit. Prior to the pandemic, it was acceptable to extend a new nurse's orientation for 1-2 weeks if they did not experience the designated skills to be deemed competent for independent practice. New nurses not having a "full" patient assignment impacted the ability of the preceptor to validate clinical competency in prioritization, urgency, and flow management. There were also a few NPD specialists within the department who were among the vulnerable populations at risk if infected with COVID-19. These challenges stimulated NPD practitioners to creatively confront the challenge.

 

A method used to provide nurses on orientation with a full assignment was to assign the orientee with the designated number of patients for a full assignment at the start of their shift when possible. This might result in other nurses on the unit not having an assignment or having minimal patients. The nurse(s) with the lighter load were expected to be the "support" for the orientee and provided guidance on prioritization, delegation of tasks, and time management throughout the shift. This would allow the orientee to transition to independent practice, demonstrate competency, and prepare to come off orientation. Not all new hires were able to demonstrate competency on all unit skills during the low census phase of the pandemic. New hires were held accountable to request assistance if a new experience presented itself and use the charge nurse, NPD specialist, or preceptor to assist and support.

 

To better track skill competency, an individualized Learning Needs Checklist was adapted from the standard unit-based skills checklist. The Learning Needs Checklist outlined the skills that were not obtained during orientation for each new hire. When the NPD specialists met with the new hires, they went through skills documentation to identify learning gaps and missing experiences. Some skills could be introduced in a web-based fashion. For example, if a new hire was not able to see a chest tube on orientation, they were provided with a link to a video on chest tube setup and troubleshooting. The NPD specialist would follow up at the next new hire meeting to provide hands-on practice and/or answer any questions. If a self-paced method was not appropriate or available, the NPD specialist made a note on the "Learning Needs Checklist" to ensure that this topic was addressed once census increased and the opportunity was available. If a new hire was placed on an unfamiliar unit, NPD specialists and unit leadership would target patients who best aligned with the nurse's learning needs.

 

The NPD specialists among the high-risk population used a mobile video application accessible by all parties to meet with new hires. This method provided a temporary process to allow safe face-to-face meetings while maintaining social distancing. The NPD specialist would coordinate a date and time with the new hire that worked to meet virtually and keep unit leadership informed on updates.

 

JUST-IN-TIME EDUCATION

Just-in-time learning was essential during the pandemic to ensure all nursing staff were aware of the frequently changing best practices surrounding the COVID-19 pandemic. There were four focused areas to address prior to the expected surge of patients and during the early weeks of the pandemic.

 

Personal Protective Equipment

Proper donning and doffing reinforcement was paramount to ensure staff and patient safety. Just-in-time donning and doffing training was completed by infection control experts and NPD specialists for the staff at the bedside. Personal protective equipment (PPE) was pulled into a centralized location in each unit for ease of allocation to staff. The Nursing Education Department assisted with completing just in time fit testing for N-95 mask and powered air-purifying respirator education for those who were not able to be fitted with a N-95 mask.

 

PPE education evolved with each change in recommendations made by the CDC, the state, the local health department, and the health system. Fears and concerns regarding the constant change was managed through constant communication from leadership. Frequent virtual town hall meetings open to all staff were held. The information was shared with complete transparency from the number of cases across the hospital and health system to the status of available equipment and supplies, including face masks. Unit leaders continued the spread of information through huddles, one-on-one conversations, and e-mails. Unit leadership, infection preventionists, and NPD specialists were also rounding in the departments to answer questions and reinforce update on the current best practices for using PPE.

 

Parenteral/Enteral Updates

Clinical leaders and supply management worked closely together to obtain specialized and alternative equipment for peripheral and enteral high-demand items needed to care for the critically ill COVID-19 population. Twenty-foot-long extension intravenous tubing was added to inventory to allow nurses to place intravenous pumps outside critical care rooms, thus minimizing PPE usage. Education was provided to staff on appropriate use and setup.

 

Enteral feeding pumps were reallocated from homecare services to inpatient areas. Because of restrictions preventing on-site vendor support, just-in-time education with videos and hands-on practice were provided by NPD specialists for the new feeding pumps.

 

Quick Packs for Emergency Response

Caring for COVID-19 patients presented a need to explore safe practices in the event of emergency situations. During a rapid response, only necessary personnel and equipment entered the room in order to minimize contamination, decrease exposure risk, and reduce the use of PPE. Pharmacy added "quick packs" that contained commonly used medications in an emergency or rapid response call. The "quick packs" were available in the medication rooms as regulatory required them to be under lock, not openly available. The "quick packs" and other needed supplies were transferred to the staff in the room using a basin to avoid contact and contamination of other items and/or personnel outside the room.

 

Patient Education

Realizing the value of patient education and its impact on preventing readmissions, the NPD specialist who serves as the hospital's diabetes care and education specialist (DCES) continued to collaborate with staff nurses in the preparation of patients with diabetes for discharge. Those needing diabetes education, including insulin administration and self-monitoring of blood glucose, were trained in-person at the bedside while the DCES wore appropriate PPE. Because of limited visitation practices, patient caregivers who needed training received education via a "virtual visit" using a mobile video chat application. Special authorization was granted for specific situations where family members required hands-on training. All patients and their families were provided the DCES's contact information for support after discharge. Virtual visits were implemented if additional training or reinforcement was needed.

 

CONCLUSION

NPD specialists pulled together to adapt and implement innovative practices in order to ensure necessary classroom education continued, new hire onboarding was effective, and just-in-time education was provided. Many projects and meetings were put on hold during the pandemic. Prioritization of essential work allowed time for NPD specialists to redefine the delivery of essential education. The Nursing Education Department continued to function within budgeted hours. It is unknown at this time how these interventions will impact the new nursing hires who were oriented during the pandemic. Plans to monitor turnover, reported risk events, and staff satisfaction scores will be included as ways to evaluate the effectiveness of Nursing Education and Nursing Leadership support during this novel time. The pandemic has led to many positive workflow changes and challenged the NPD specialist to consider other platforms when creating, implementing, or facilitating education in an era following the COVID-19 pandemic.

 

Reference

 

Centers for Disease Control and Prevention. (2020). Coronavirus (COVID-19). https://www.cdc.gov/coronavirus/2019-nCoV/index.html. [Context Link]