The Clinical Nurse Leader and COVID-19: Leadership and quality at the point of care

Rosemary L. Hoffmann, PhD, RN, CNL

University of Pittsburgh School of Nursing, Department of Acute & Tertiary Care

rho100@pitt.edu

Angela Battaglia, MSN, RN

Allegheny General Hospital

ang.battaglia5@gmail.com

Zachary Perpetua, MSN, RN

UPMC Passavant, Education and Development

perpetuazp@upmc.edu

Krystal Wojtaszek, MSN, RN

UPMC Presbyterian-Shadyside Hospital, Pittsburgh, PA

wojtaszekkl@upmc.edu

Grace Campbell, PhD, MSW, RN, CNL, CCRN, FARN

University of Pittsburgh School of Nursing, Department of Acute & Tertiary Care

gbc3@pitt.edu

On December 31, 2019, a patient with pneumonia of unknown cause in Wuhan, China was reported to the World Health Organization's China office (WHO, 2020). A rapid acceleration of similar cases in China and other countries soon followed. The cause was eventually isolated to a new strain of coronavirus called COVID-19. The first confirmed case in the U.S. was reported on January 20, 2020 (Holshue et al., 2020). COVID-19 was declared a Public Health Emergency of International Concern on January 30, 2020 (WHO, 2020), then declared a pandemic on March 11, 2020 (Chappell, 2020). As of May 5, 2020, there are over 1,100,000 confirmed positive cases in the US, of which over 68,000 resulted in death. Common presenting symptoms of COVID-19 include fever, cough, increased sputum production, and shortness of breath (ANA, 2020) and sometimes, gastrointestinal symptoms (Cheung et al., 2020). Effective containment is complicated by the fact that infected individuals may be contagious prior to manifesting symptoms; asymptomatic spread has also been suggested (ANA, 2020). As the number of individuals sickened by COVID-19 increases, the healthcare system has become overburdened and is experiencing critical shortages of personal protective equipment, intensive care beds, and appropriately trained staff to care for the large numbers of critically ill patients. These issues are likely to have ripple effects throughout the post-acute care continuum. Although many Clinical Nurse Leaders (CNL) function in acute care settings, there is growing evidence of these graduate-prepared nurses employed in public health (Rankin, 2015), clinical management, and other specialty areas (Commission on Nurse Certification, 2020). As COVID-19 challenges U.S. healthcare facilities' ability to pivot rapidly and repeatedly in the face of evolving circumstances, we argue that wide implementation of the CNL role is needed to facilitate optimal patient care across the continuum. We present key CNL competencies and skills for optimal pandemic response, and we include examples of these skills in action by CNLs currently in the practice arena.

The CNL role

The CNL role was created by the American Association of Colleges in Nursing (AACN) in 2003 (AACN, 2013). This graduate-prepared nurse possesses a unique skill set that includes quality, safety, education, and leadership. The CNL role was developed as an expert clinician equipped with graduate-level competencies in illness and disease management and critical thinking to analyze and interpret clinical interventions across the continuum of care (Harris, Roussel, & Thomas, 2018). The CNL possesses improvement science skills that s/he employs to improve outcomes at the point of care. The CNL understands microsystem issues and their relationship to larger organizational issues. This perspective provides a two-way flow of information to and from health system leaders as they direct an institutional response to the pandemic around issues such as assessing patterns of spread, patient acuity, appropriate staffing levels, and personal protective equipment utilization.

CNL competencies and skills integral to pandemic response

Improvement science

During a pandemic situation, a key responsibility is the initiation of protocols to keep staff, patients, and the community safe. Improvement tools utilized by the CNL to redesign health care include, but are not limited to, root cause analysis, Plan-Do-Check-Act cycles, flow charts, Pareto diagrams, statistical process control charts, and fishbone cause-and-effect analyses. These tools can identify breakdowns in safety protocols, quickly identify and implement interventions to improve screening and testing protocols, triage patients, or track and report data for COVID specific outcomes such as screening, characteristics of patients, and utilization of hospital resources.

Interprofessional practice and leadership

As a member and leader of effective teams, transparency is essential. Thus, CNLs collaborate with not only other members of the interprofessional team such as infectious disease pharmacists, physicians, and nursing leadership, but also with social work, clergy, and public health officials. Because persons from marginalized groups and those with low socioeconomic status are contracting COVID-19 at higher rates, the acute care setting and community-based facilities will benefit from CNL leadership as they consider social determinants of health to promote equitable targeting of resources and mitigation.

Finally, the CNL as a leader can initiate and participate in online discussions across the state and/or country regarding best practices in relation to screening or education. Information for staff and leadership changes dramatically within an evolving pandemic. This is especially true since currently there are no vaccines, scientifically established evidence for treatment, or antibody testing. Consequently, as a systems leader, the CNL brings together key team members to develop protocols and procedures that take evolving guidelines into account and can disseminate to various clinical areas quickly and efficiently. Furthermore, as a trusted leader, the CNL can clarify changing guidance for frontline staff, serve as a sounding board and convey those concerns up the chain of command to ensure that health system leadership is aware of the needs and perspectives of frontline staff. See Box 1 for an illustration of CNL leadership of the interprofessional team as the organization prepared its COVID-19 response.

Box 1. Example of interprofessional team leadership.

Toward the beginning of the COVID-19 outbreak in the U.S., a CNL's unit was designated as the COVID Unit for the Level 1 trauma center. The CNL brokered communication among nursing leadership, physicians, pharmacists, central supply, and facilities to problem solve the logistics of turning the unit into a negative pressure wing. During a discussion of nurse-to-patient ratios, the CNL was able to advocate for a temporary change to team nursing to eliminate the need to take medication carts into isolation rooms. This change in care delivery model preserved appropriate isolation precautions and maintained efficient staffing by stationing helper staff outside of the room to prepare medications, obtain supplies, and otherwise assist the in-room nurse. Team meetings were held routinely to assess patient volumes and determine whether further changes to the patient care delivery model were indicated. Finally, the CNL worked with university and health system leaders to assemble resources and a plan for the staff needing overnight accommodations or simply to shower prior to returning home to their families.

Alt-text: Box 1

Clinical informatics and technology

COVID-19 has highlighted the necessity of integrating technological processes, health, and medicine. Specialty nurses such as the CNL grasp the impact of informatics on healthcare outcomes. The CNL is prepared to efficiently utilize decision support tools to make real time decisions in the busy clinic setting, and to set up a pandemically focused nursing plan. CNLs can help nurses collect and manage clinical quality data without increasing burden at the point of care. For example, the CNL can document and track data regarding medical equipment usage in order to allow mobilization of supplies to areas of the unit or facility most in need, remotely collect patient data such as symptoms and vital signs, or obtain remote consents. The CNL can establish processes and procedures for telehealth visits and can work with clinical informatics to ensure that patient privacy and security are maintained.

Evidence-based practice

The CNL is uniquely prepared to synthesize research evidence and translate it into clinical practice. Rapidly changing patient prognosis demands integration of new or less commonly used treatments, such as prone positioning to improve oxygenation, in an informed manner. Seeking help from the hospital librarian, the CNL can review the literature, which suggests that the prone position is an effective strategy for COVID-19 patients in the intensive care unit (Dondorp, Hayat, Aryal, Beane, & Schultz, 2020). Unit-based continuing education session (with CEUs) that incorporate the evidence surrounding prone positioning can then be developed and rapidly deployed to nurses, respiratory therapists, and ancillary staff.

Policy, advocacy, and regulatory skills

The coronavirus has highlighted regulatory challenges at the two major federal agencies engaged in pandemic response: Centers for Disease Control and Prevention (CDC) and Food & Drug Administration (FDA). Major changes will be forthcoming in national policy and structure due to COVID-19, including changes to the federal government's stockpile of emergency medical supplies. These policy changes may be accompanied by changes in agencies such as CDC and FDA. During the pandemic, initially the CNL needs to be aware of any hospital and/or community healthcare policy regarding nurse to patient ratios for impatient microsystems throughout the facility, including step-down, telemetry, intensive care units, maternity and pediatric units. Armed with evidence regarding safe staffing and acuity-based care, the CNL may need to advocate for appropriate staffing levels for specialty practice areas and think creatively about temporary consolidations of services to maintain appropriate and safe staffing levels. Hospital policies must be reviewed for use and/or reuse of PPE and for prioritizing testing and treatment of nurses and other frontline providers who are exposed to COVID-19, so these individuals can be quarantined or safely returned to work.

Conclusion

As with any new healthcare crisis, the work of healthcare providers, including the CNL, will evolve. Data on treatment regimens, long-term effects of acute respiratory distress syndrome with COVID-19, effects of mental health issues as a result of stay in place orders, and the unknown negative effects of the virus on other body organs will demand flexibility from the healthcare system for the foreseeable future. Additional challenges will become apparent as more individuals begin to recover from acute infection, including care coordination, transitions of care, and initiating follow-up services such as post-COVID-19 rehabilitation for patients and family. Upcoming public health changes will include conducting contact tracing, primary prevention and its impact on frontline providers will continue to evolve and will necessitate continued agility by the healthcare system. What may transpire as a result of the last several months will be an increased need for interdisciplinary healthcare teamwork, collaboration with scientists, economists, and politicians.

Nurses are among the most fundamental workers providing care during the coronavirus crisis. We have demonstrated here that nurses with specialized, graduate-level education in leadership, quality, safety, and population health are ideally suited to facilitate responses to the demands of this health issue. These changes include fostering open communication between health system leadership and staff; furthering evidence-based practices in treatment and prevention; highlighting structural racism and other disparities in susceptibility to the disease and in its detection, treatment, and prevention; advocating for and developing policies related to the ethics of resource utilization during times of scarcity; and advocating for patient and staff safety. We have provided several examples of how the CNL skill set and fundamental aspects of practice can be applied to practice during a pandemic, to illustrate the utility of this crucial role. The CNL role is tailored for the challenges presented by the global COVID-19 pandemic and beyond.