I have been a nurse since the mid 1980’s and during that time I have witnessed a variety of staffing and onboarding models. In the days of nursing shortages, we were using a team nursing approach where one RN directed the team of LPNs and certified nursing assistants to care for 10 – and sometimes more – patients. As the nursing shortage eased, we went to a primary care model where one RN cared for 5-6 patients on a medical/surgical unit and if the nurse was lucky, there would be a CNA to help with activities of daily living, vital signs, intake and output, and blood glucose monitoring. Often the CNA was shared with other RNs. In long-term care, the team model still exists but in this case the RN is responsible for many more patients.

Today we are in a crisis due to the coronavirus, or COVID-19. We are seeing a surge of patients that are overwhelming our healthcare system, and in many of the hardest hit areas, hospitals have been granted permission to increase their bed capacity. While that sounds wonderful to the public, it is a nightmare for hospital administrators and those of us on the frontline of care.

We need to ask ourselves the question, who is going to care for those patients?

The nursing shortage –we have talked about it coming back for the past 10 years – is now front and center. Not only are there not enough nurses to care for patients due to the surge beds we’ve added and the increased number of patients, but also nurses are getting sick from COVID-19. And let’s be clear, this shortage not only effects nursing; it is also affecting physicians, nurse practitioners, physician assistants and other healthcare providers and support staff in the hospital.


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COVID-19: Alternative Staffing and Onboarding Models

The healthcare system needs to find a different way to care for these patients and staff these beds. So, what can our healthcare systems do to increase staff quickly? 

1. Utilize existing staff.

First, look at the specialties within your hospital and utilize the staff you have. Many hospitals have cancelled elective surgeries so there will be nurses and CRNAs available to care for the increased number of patients. CRNAs and many PACU nurses have extensive critical care training; these individuals can work in critical care units after they’ve had a quick orientation or onboarding to those units. If you have nurse practitioners or physician assistants that work in specialties that are not admitting a lot of patients, such as cardiothoracic (CT) surgery, utilize those individuals to supplement your in-house hospitalist and intensivist teams.

2. Reach out to retired nurses and nurses in other specialties.

Bring in nurses who are retired or who are working in specialty practices that are not seeing a lot of patients. These nurses can be quickly onboarded to supplement your medical/surgical nurses. Let’s not forget LPNs and CNAs who can also deliver basic care to the patients.

3. Use seasoned med/surg nurses to work in stepdown units.

There is no reason a med/surg nurse can’t work alongside a stepdown nurse in a team model; the med/surg nurse can take care of the basic nursing needs while the stepdown nurse can focus on managing the patient’s more critical needs. Some hospitals may be forced to use experienced med/surg nurses in critical care to supplement the critical care nurses. It is crucial to remember the importance of competency in these situations. Focus on the skills the med/surg nurses can do and reserve the critical care skills for the critical care nurses.

4. Implement an “onboarding essentials” program.

We are in a crisis situation and don’t have time for a long, in-depth orientation program. Give the new team members the information they need to care for these patients alongside the more experienced nurses. Focus on the ‘need to know’ and leave the ‘nice to know’ for later. Have the professional development team work with vendors to create bundles of procedures and quick learning activities for each area that highlight the most common diagnoses and the core procedures the nurse will need to know, such as working the IV pumps, performing an ECG, inserting a urinary catheter or nasogastric tube in a med/surg unit. In critical care, focus on basic skills such as recognizing lethal arrhythmias such as asystole, ventricular tachycardia and ventricular fibrillation; putting on the cardiac monitoring electrodes correctly; and knowing the basics of ventilator management. The professional development team or staff educators are more important than ever in this situation because they are responsible for the rapid onboarding of nurses to new and different units and they can insure the nurses have the skills to deliver safe and effective care.

5. Implement the team model approach to care.

Have supplemental staff report directly to an experienced med/surg or critical care nurse. This will allow the experienced nurses in each area oversight of more patients and they will have sufficient nurse support to take care of the basic nursing needs of the patient. Each unit will have to determine how many patients the experienced nurse/team leader can handle based on the acuity and number of patients. This approach can also work with the medical service as well.