A clinical and academic partnership: An exemplar from the COVID epicenter

The spring 2020 semester began as usual at Columbia University School of Nursing (CUSON). Faculty and students were engaged in classes and clinical rotations. However, in the middle of February, murmurs of the impending coronavirus crisis were starting in New York City (NYC). Anticipating how the growing crisis would affect CUSON, we begin preparing for the worst but hoping not to implement all aspects of our contingency plan, in which select classes would happen virtually, and some faculty and staff would be working from home.

By March 3, 2020, however, it was clear that we needed to cancel our global rotations. China and Italy rotations were the first to be cancelled, followed by 15 other sites ranging from India to Jordan and Ethiopia and Jamaica that were scheduled to commence on April 6. Shortly thereafter, our students' ongoing clinical rotations were rapidly being suspended by our partner institutions within New York City. The threat of a pandemic became a reality, and NYC quickly became the epicenter.

In addition to the cancellation of most clinical rotations, the school began to mobilize for the possibility that we would no longer be able to convene for any classes or meetings. To proactively prepare, the first week of March, CUSON faculty focused on establishing the infrastructure for remote teaching. The staff and faculty, with the support from many external offices, worked together to build the foundation for what would become our “new” normal. We quickly set up new Zoom accounts, learned how to use technology to meet and teach virtually, and we planned how to adapt all of our classroom courses to online delivery. It was a remarkable time of teamwork.

On Friday, March 6, 2020 we left the campus with the expectation to test our readiness for working offsite. With the anticipation of a looming major change in the way we teach — faculty and staff were armed with laptops, ready to enter the world of emergency remote teaching and doing business online. On Monday, March 9th, 2020 we officially entered Zoomland! Our preparation for a test run quickly became the reality; Columbia University announced the transition to e-learning for the entire university, and clinical rotations for our students were suspended until further notice.

We quickly directed our attention to the students' gaps in clinical experiences— clinical experience being the cornerstone of our master's direct entry (MDE) to nursing program and our Doctor of Nursing practice (DNP) program. The Columbia University academic health center leadership implemented a policy that no Columbia health science students be involved in the direct care of COVID-positive patients.

Given the suspension of clinical rotations at most of our affiliates and the condition that students do not care for patients diagnosed with COVID, clinical placements were extremely limited — almost nonexistent. Our students were planning to leave the metropolitan area for spring break and, given the cancellation of clinical and the onset of remote classes, the expectation was that they would not return to the campus area anytime soon.

We had a small window of opportunity — one week before the students left the metropolitan area for the rest of the semester — to negotiate with our clinical partners to allow our students to contribute to addressing the evolving pandemic. We directed our focus on the 180 MDE students who were close to graduation and who had only one semester of master's-level coursework to complete. These students were disappointed that their final and much anticipated clinical integration experience was cancelled. The crisis created opportunities to be creative, but we had to be cautious.

The CUSON leadership immediately contacted our major clinical practice partner, NewYork Presbyterian (NYP) Hospital, to explore ways that the school could assist during the pandemic, knowing that the hospital's nursing staff would need increased capacity as the pandemic continued to grow. The discussions were intense and carried the theme of urgency. The result was an innovative academic/practice collaboration, blurring the boundary between student and employee and between academia and clinical practice. We agreed upon a solution where our MDE students nearing graduation could voluntarily join the hospital nursing staff as paid nurse technicians in all settings, functioning under the supervision of a registered nurse. This program was initially designed to be working with non-COVID-positive patients while simultaneously being enrolled in a small group seminar facilitated by the MDE faculty. This combination strengthened the close link between academics and practice. The objectives of the ongoing academic seminar for students were to share with their peers and faculty the experience of working during a pandemic, to integrate nursing knowledge and processes through reflective, evidence-based nursing care, and to offer emotional support in the form of Circles of Care. Circles of Care, adapted from Commonweal's Healing Circles, were conducted online and provided a safe forum and helped the students process their feelings, fears, and sadness (Healing Circles, n.d).

As we were solidifying the innovative plan, AACN published a policy brief on March 25, 2020, (U.S. Nursing Leadership Supports Practice/Academic Partnerships to Assist the Nursing Workforce during the COVID-19 Crisis) that offered support for and was in alignment with our initiative (https://www.aacnnursing.org/Portals/42/Policy/Policy-Brief-US-Nursing-Workforce-COVID-19.pdf, n.d). However, our pre-licensure students were not going to function in the role of student, but rather as employees under the direction of a registered nurse. Specifically, the CUSON leadership reviewed the evidence and the professional recommendations regarding student participation in clinical and then consulted with the MDE faculty. The most recent AACN recommendation (March 20, 2020) was that “… it may be advisable as decisions are made to continue clinical experiences in healthcare facilities, in the interest of student safety, to limit student direct care of known or suspected cases of COVID-19 infection until better epidemiologic data are available. For now, other than limiting direct care of COVID patients, students in clinical settings may continue their roles as part of the care team.” (https://www.aacnnursing.org/News-Information/COVID-19/AACN-Recommendations, n.d) The faculty agreed that the MDE students have a solid knowledge base and skill set for safe practice and that well-informed students would ensure that they were working in conditions that limited their exposure to known or suspected cases of COVID-19 infection.

By March 16, 2020, all details were worked out with the start date of April 6, 2020. Plans were underway, with the support of the school's simulation team, for orienting student volunteers who were to be hired as nurse technicians caring for COVID-negative patients. The faculty and leadership at the school called a virtual town meeting to inform the students about the volunteer opportunity to work in the nurse technician position and 125 of the 180 MDE students volunteered.

By April 1, just over four weeks after the first patient was diagnosed in New York, the pandemic continued to widen and strengthen, and it was estimated that up to 70% of the patients in the NYP hospital system were COVID-positive, making the “non-COVID” work condition unrealistic. This was the reality — scary, uncertain, but real — and it was not possible to avoid caring for COVID-positive patients. The policy for all health science students persisted and no students at this time were not given permission to work with COVID-positive patients.

We struggled with the decision whether to allow our nursing students to work with COVID patients. But there were students who—given the choice after several guided discussions and knowing that they would be supervised by a RN and that faculty would provide appropriate personal protective equipment and be on tap to answer any questions they might have—felt strongly about assisting in this crisis. Plus, our faculty felt that the students were ready. We determined that well-informed students had the capacity to make the decision for themselves.

We then had a second town-hall meeting via Zoom with the MDE student volunteers. Presenters included two alumni who were working on the front lines, the VP/CNO from the partner hospital system, MDE faculty, and the Dean. The students were informed that there were no COVID-negative patients and that the nurse technician role would now involve working with COVID-positive patients. The students were encouraged to consider the situation carefully and to make a personal decision that would be right for themselves and their families. We were explicit that each student's decision was the right decision.

Courage takes many forms: sometimes it means stepping up, and sometimes it means having the judgment not to go into a risky situation. We acknowledged that this was a deeply personal and individual choice, and we honored each student's decision. Eighty-five MDE students voluntarily joined the hospital staff and began their work as nurse technicians.

Concurrent with this initiative for the MDE students, we were equally eager to be sure that our DNP students were actively engaged in the response to the pandemic. Despite the lack of traditional clinical experiences, the faculty sought alternative, safe activities for DNP students to contribute to the pandemic response in meaningful ways. DNP students filled over 180 volunteer slots in 10 different COVID projects, which include 3 COVID hotlines, telehealth patient encounters, obstetric outreach, and mental health phone calls. In addition, the senior level nurse anesthesia and acute care nurse practitioner students were invited back to our clinical partner's hospital system to complete their clinical hours and assist with patient care with COVID patients. These senior level students all have a critical care nursing background and the level of training completed that made them an asset to patient care in their specialty settings.

We were in frequent contact with hospital leadership offering our resources and assisted in recruiting nurses from our student body for employment opportunities. One-hundred DNP students voiced an interest in working “per diem” with the nurse anesthetist students working in the intensive care unit (ICU).

Our faculty continue to contribute to the pandemic response in their practices and are applying their skills in many areas, including the following: 1) doing as many shifts as possible in ICUs where the patients are COVID-positive and in EDs doing triage and testing; 2) transitioning urgent care walk-in centers into urgent care telemedicine for highly at-risk patients; 3) participating in clinical trials related to immunocompromised COVID-positive patients; and 4) continuing to provide primary care to adults and children in creative ways to maintain “social distancing” using technology, drive-through testing, parking lot waiting rooms, etc. CUSON faculty also assisted our major academic medical partner's Nursing Professional Development by conducting simulation training for some redeployed nurses. This enabled redeployed nurses to work competently in their newly assigned clinical area.

Our faculty are continuing to do all of this while teaching in a new virtual format, exploring virtual simulation platforms to incorporate into their teaching as an adjunct to, not substitute for, a clinical experience and providing backup for some of the hotlines.

An established academic/practice partnership was critical to quickly initiating these student experiences. Our hospital partner was familiar with our program, graduates, and faculty. CUSON faculty were confident in the ability of the nurses of our hospital partner to watch over our students as well as confident in the students' clinical knowledge and ability. Both parties benefited; the students and nurses learned from and inspired each other. Students were witnesses to the never-ending ICU admissions and to patients placed in operating rooms repurposed as ICU units and cared for by an interdisciplinary team of healthcare professionals in an alternate care model. This experience allowed the students to witness nursing leadership and flexibility at its best. The students expressed how honored they were to witness the role of the professional nurse during the crisis. The nurses led by example, working in challenging circumstances and stepping up where and when needed. The nurses also expressed their appreciation for the students' courage and commitment in volunteering to work during an unending tsunami of very ill patients who died in great numbers. The students' willingness to come and serve patients, to help connect patients to families who were not permitted in the hospitals for their safety, and to assist their nursing colleagues brought many strong New York nurses to tears of relief. We believe the already strong relationship between the school and the hospital will be even stronger, as they have moved from being students to being called “family”.

The ability of our partnership to quickly enable the students to contribute to addressing the overwhelming needs of the nurses and patients in a crisis could not have happened without an established academic/practice partnership. This partnership continues to be critical to our clinical educational process as our students learn not only clinical skills at the clinical sites but how to reimagine processes and patient care in times of crisis that will result in new processes in the clinical care arenas.

The spring 2020 semester will forever be a defining event that allowed CUSON to prepare our health system and educational programs to respond to future pandemics. We know now that teams of well-prepared professionals, educated and working together to the highest level of their practice, is essential to respond effectively and efficiently in a healthcare crisis.

Professional and regulatory agencies should assess the need for advanced practice registered nurses such as CRNAs and NPs to work independently of physician oversight as they were allowed during the COVID crisis. Allowing nurse practitioners to work independently with underserved populations will enable us to alleviate health disparities that impact health outcomes of COVID patients and to have a population better able to survive the next crisis. Our student nurses and faculty not only survived this pandemic, but they were agile, adaptable, and aggressive in providing necessary support to help save and comfort more people. We encourage all schools of nursing to proactively establish strong academic/practice partnerships that will allow such collaborations in future crises should they arise.