1. Breaux, Amadae MSN, RN, CCRN-K

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In early March 2020, the spread of coronavirus across the United States brought the concern for adequate availability of inpatient hospital beds and personal protective equipment (PPE). As a result, many healthcare institutions preemptively canceled elective surgeries and procedures in attempts to retain beds and PPE for a potential surge of COVID-19-positive patients (Murray, 2020). On March 16, 2020, the University of Washington Medical Center made this difficult decision and redeployed the Surgical Services and Ambulatory Care Clinical staff to alternative departments within the hospital where they were transitioned into units dedicated to patients diagnosed with or were under investigation for COVID-19, stepping into various roles such as trained observers responsible for guiding healthcare providers in donning and doffing PPE (Kim et al., 2020). On March 25, the Associate Chief Nurse Officer (CNO) of the Northwest Campus mandated cross-training of a portion of operating room, postanesthesia care unit, and ambulatory clinic registered nurses (RNs) to acute care departments functioning in a newly developed role as a "nurse extender." The nurse extender is a role fulfilled by an RN who has an active state license currently employed within the organization. In an event that the organization were to experience a COVID-19-positive patient surge, acute care units will need to mitigate the patient-to-nurse ratio, and the nurse extender would be called on as a critical role to assist in patient care. The nurse extender would partner with another acute care RN and perform tasks such as administering oral medications, assisting with basic patient assessment and care, and documenting in the electronic medical record. The goal of the Nurse Extender Orientation Program was to provide a basis for an increase in clinical skills and comfort to perform duties in partnership with a primary RN working with COVID-19-positive patients.


Initial priorities for the clinical nurse educator (CNE) included an analysis of the current state of unit staffing mixes and responsibilities and then the determination of an effective future-state model. Because of a potential surge in mid-April, a short timeline added to the challenge of planning, implementing, and evaluating the program. Additional barriers included mitigating the wide array of background and experiences of the Surgical Services staff who were asked to transfer to an unfamiliar setting, as well as quickly meeting the demands of the staffing needs of the surging inpatient units, including those designated for COVID-19-positive patients. It was advantageous that the original request for this program originated from the CNO, which encouraged buy-in from key stakeholders like operational managers, clinical nurse specialists (CNS), clinical informatics, and nurse managers. Collaboration and communication between all key stakeholders allowed for the swift development and approval of a curriculum that included an 8-hour day of didactic and skills practice and three acute care unit shifts over a 2-week time period.


Three Nurse Extender Orientation classes were offered between April 3 to April 9, 2020, with outlined objectives that allowed each nurse to assess their perceived baseline competence, initiate hands-on practice at each station, and review the policy and procedures. Each class was limited to 12 participants to allow compliance with social distancing requirements and permit time for disinfection of equipment between each use. A total of seven staff members delivered the content of the Nurse Extender Orientation: One CNE, one CNS, and a graduate nursing student provided the didactic content that reviewed patient care topics such as medication administration, blood glucose monitoring, and specimen collection. To reinforce the content, the orientees had several opportunities to perform hands-on demonstrations at eight different stations; two orientees would review the equipment led by a CNE or a CNS at each station and, after 15 minutes, would rotate to the next station. In between stations, there was an expectation that the station lead would sanitize and clean equipment before the next pair would join in. At the end of the 8-hour class, 33 RNs completed an online postcourse evaluation with the following results:


* "I feel more confident after taking the RN Extender Orientation."-64% agree


* "I have an increased comfort level after taking the RN Extender Orientation."-73% agree


* "I have an understanding and knowledge of resources when performing delegated tasks given to me by the Primary RN."-97% chose true


* Average STAR rating of class-4/5



To provide ongoing support to the nurse extenders, the CNE, along with support from a graduate nursing student, scheduled individual meetings with each RN after they had been deployed to the acute care unit. Of the 33 RNs, some overarching themes ranged from reports of no concerns to experiencing issues with the electronic medical record or difficulties gaining access to online applications required to administer medications. Each nurse extender was given a checklist with "Nurse Extender Role Guidelines" that outlined tasks that were within scope to be delegated to them. In the planning stages of this orientation program, CNEs, CNSs, and nurse executives came to a consensus that this checklist was to be used as a guide and deemed as not required because the tasks were all within their current scope of practice of their original "home" department. The "Nurse Extender Role Guidelines" was meant to help guide the nurse extender through their orientation on a department that is unfamiliar to them. Forty-two percent completed the checklist and is kept on file in the Nursing Professional Development Department.


Since implementing the program, the expected COVID-19-positive patient surge did not occur; thus, the nurse extender role was not needed or deployed. However, this pool of potential team members is now trained and ready for deployment should a surge occur in the coming months, as social distancing restrictions are lifted. In evaluating the program, risks posed included the nurse extender feeling emotional distress from being displaced during the process. Other challenges included communication between managers, the operations manager, and the CNE regarding scheduling needs, displaced staff gaining access to essential online programs required to perform their duties, and badge entry access to doors within inpatient departments; perhaps staffing a full-time employee could be designated to oversee the scheduling and provisioning needs. However, in an overall appraisal of the program, including quantitative results and qualitative anecdotes, our objectives were achieved, despite the short timeline. Our organization and our frontline staff have comfort in knowing that should the future need arise, our nurse extenders are ready.




Kim C. S., Kritek P. A., Lynch J. B., Cohen S., Staiger T. O., Sayre C., Neme S., Nasenbeny K., Goss J. R., Dellit T. H. (2020). All hands on deck: How UW medicine is helping its staff weather a pandemic. NEJM Catalyst Innovations in Care Delivery. [Context Link]


Murray C. J. (2020). Forecasting COVID-19 impact on hospital bed-days, ICU-days, ventilator days and death by U.S. state in the next 4 months. medRxiv. [Context Link]