This past week, I hosted a series of virtual conversations with CNOs to discuss workforce and staffing readiness plans in preparing for a Covid-19 surge. Session participants represented all regions of the country, with some already experiencing a significant surge and others up to four weeks out. CNOs identified many ideas, but also raised questions that have yet to be answered.

What follows is an executive summary of the insights collected from these sessions, which is offered to assist you with staffing decisions. Your plan’s priority and sequencing will be influenced by when and how severe a Covid-19 surge is predicted for your locale, your pre-Covid-19 workforce demographics, and decisions about whether Covid-positive and symptomatic patients are to be geographically isolated within specific units, or if part of a system, certain sites. Regardless of which ideas you pursue, one thing is clear: everything that can be done in advance, should be done in advance.

Priority number one: Expand your acute care workforce as much as possible before the surge starts. There are two primary strategies to consider here.

1. Repurpose as many currently employed RNs for acute care support as possible. Organizations are moving staff from a variety of care sites and areas, including:
   
   
   • Closed services and outpatient procedural areas; such as outpatient surgery
   • Inpatient peri-op
   • Ambulatory care sites, clinics with decreased volumes
   • Non-patient facing departments, such as quality improvement, IT, decision support, revenue cycle, and supply chain
   • Home health (for those organizations who own a home health agency)
      
2. Increase temporary staff options. With costs for travelers/agency nurses at an all-time high, organizations are recruiting from a variety of sources, including:
   
   
   • Retired nurses
   • Independent nurse practitioners under temporary contracts
   • Student nurses
   • Faculty from academic partners to support student nurse oversight

Priority number two: Fast-track and optimize deployment of your expanded workforce. Once the potential workforce has been confirmed, there are two major considerations to address.

1. What steps can you take now to ensure these staff are ready-to-go when you need them? Some considerations include:
   
   
   • Assessment of all RNs identified for repurposing regarding learning needs.
     
     
   • Investment in accelerated training using existing curricula, online learning, legacy orientation modules, sim labs, and RN shadowing. As part of this, it will be critical to decide how to redeploy unit or house-wide educators during this time.
     
     
   • For temporary staff, HR processes will also be needed to expedite employment readiness, including: conducting health screenings, credentialing and badging, references, streamlined hospital orientation, skill checks and EMR competency.
      
2. How will you deploy staff in order to optimize experience and clinical competency? Some considerations include:
   
   
   • Decisions regarding what units or areas repurposed RNs could be deployed after training (Covid, non-Covid, etc.), including shift minimums on potential units for training purposes
     
     
   • Decisions about staffing model alternatives. Some CNOs are considering functional staffing models, such as the use of medication nurses. CNOs overwhelmingly report exploring team-based care options, often lead by ICU RNs. For example:
     
     
     • Pairing med-surg RNs with re-purposed RNs on non-Covid units/lesser acuity units (pulling from ambulatory, peri-op, etc.)
       
       
     • Pairing ICU with med-surg RNs on Covid units
       
       
     • Pairing ICU RNs, med-surg RNs, respiratory technicians, and patient care techs
       
       
     • Deploying acute care NPs as team leaders with RNs and ancillary staff to support
        
   • Decisions regarding support staff to reinforce the clinical team.
      
     • Creating roles for ambulatory MAs in acute care, and upskilling unlicensed personnel in areas with low volume to support care teams, such as sitters, transporters, etc.
       
       
     • Creating a float pool using RNs from units with decreased volumes that can serve as support to heavy units, for either full shifts or temporary relief to allow for meals and recovery time.
       
       
   • Decisions about retired RNs. Not all organizations are bringing back retired staff. For those that are, most are deploying them into special roles to minimize their risk of Covid exposure, including navigation, patient follow-up, call line support, temporary coaching, education, mentorship and other adjunct support roles at the unit level.

There are still many open questions related to staffing for a surge, including:

• Should work hours be modified? In particular, is the 12-hour shift excessive while staffing for this pandemic? Should shortened or staggered shifts be considered, and would they be supported?
  
  
• What is your strategy for new graduate RNs? Do you still commence employment on the timeline originally agreed to, and if so, do you have resources to adjust orientation, support, alternative placement, etc? This is an especially fluid situation, given state-by-state decisions about exam delays, options for short-term use of graduate nurses, etc.
  
  
• How can you best leverage your preceptors and nurse mentors?
  
  
• How do you respond to increased pressure for "hazard pay"?

Final thoughts about preparing for a surge

In the days ahead, you’ll be making hundreds of decisions on how to deploy, support, and protect your staff. So I’ll leave you my takeaways from this past week.

• Developing a surge workforce plan is a must for every CNO regardless of location. Key factors to consider include: when and how severe the predicted surge is in your areas, your pre-Covid-19 vacancy rate, and if you are an individual facility or part of a larger system that can geographically isolate Covid-19 or symptomatic patients.
  
  
• Staff readiness for working in different roles and staffing models, including versions of team based nursing will be essential. This is the time to innovate.
  
  
• If you haven't already, check any labor contracts for language related to ratios, job re-assignment, sick time, etc. during an officially designated health care crisis.
  
  
• Don’t underestimate the impact of Covid-19 care on productivity. For example, protective gear requires extra time, and patients on vents in prone positions will increase labor needs.
  
  
• Make sure all frontline managers are fully scrubbed in and onboard with the workforce plan that you commit to. Their support is a deal breaker.
  
  
• Staffing modifications without attention to staff resilience is a non-starter. Build targeted communication, emotional support, and stress-mitigation strategies before any surge hits. Be prepared to sustain those strategies over the long term.

We are here for you

This is a summary document to provide leadership insights. Our entire team is available to be a thought partner with you. Email us with any questions you may have, but if you would like to schedule a call with either myself or someone from our research team, please reach out.