Arkansas is experiencing some of the highest rates of COVID-19 cases in the country, leading to shortages of intensive-care unit beds and taxing an already overwhelmed workforce. At the University of Arkansas for Medical Sciences, the situation has forced leaders to look at different ways of deploying nurses, including a greater reliance on team-based care. Trenda Ray, chief nursing officer and associate vice chancellor for patient-care services at UAMS, recently spoke with Modern Healthcare Managing Editor Matthew Weinstock about steps the organization is taking to try and ease staff fatigue and burnout. The following is an edited transcript.
MH: Arkansas is one of the five or six states that are really exploding with COVID cases. How are you holding up right now?
Ray: It’s a daily struggle, and that’s the best way I can describe it. I came in energized for the New Year, almost excited to have the holidays behind us because we’ve heard about our impending surge for so long that a part of you just wants to get started on it. We have twice-a-day staffing calls, and as we talked through that this morning, it was a bit of a struggle.
We’re tired. You can tell the managers are tired. Our numbers are down, and it’s honestly starting to show. We struggle with … quarantines, illness, and then we were already struggling to hire enough nurses before the pandemic. And it truly has only made it that much more difficult.
MH: When you say your numbers are down, what do you mean by that?
Ray: Our staffing numbers. When we look at our daily numbers, we have to balance the number of staff that are out on quarantine and how that looks reflected on a schedule. And it changes from shift to shift and day to day. I said to our group this morning, I felt as though we’ve been lucky a lot, and our luck is going to start to run out probably in the coming weeks. We’ve managed to just scrape by.
We were looking ahead as we went into the New Year’s weekend, thinking it was going to be just terrible. We managed to get just enough of a reprieve in our census that those low staffing numbers made it OK. And I do worry sometimes that we’ve scraped by just enough that it lets our guard down a little bit, and it may make it harder as we start to see those (COVID case) numbers climb.
MH: Are there things that you’ve put in place over the past few months to boost morale in any way?
Ray: I hope so, and I think so. It feels like the pandemic is one of those things that we’ve constantly planned for, and then adjusted and planned for again.
But looking at our staff and the burnout in nursing, this was actually something we were addressing before the pandemic. And I’m so thankful. We actually knew we had a challenge here with burnout in nursing, and we’ve done a couple of things. One of them, which we started a few years ago, was Schwartz Rounds.
(That was designed and) put forward by the Schwartz Center for Compassionate Healthcare. And it really does give caregivers a place to share their experiences, to talk safely with one another. And talk about the challenges of working in healthcare, of grief, of compassion, fatigue, and then how you work as a team.
We had to stop doing them live. We’ve done them via Zoom and had the best attendance in the months following that change. We’ve had up to 170 people in some of those sessions. Nurses can join from home. They didn’t have that luxury before.
The other thing that we had done, I learned about a retreat that other organizations had held, focused on nursing burnout and wellness. We applied for and received an internal grant to set that retreat up. We started this fall with our nursing leaders. We will open it up this month to front-line nurses. It’s a very small number that are allowed to go every month. And that was prior to the pandemic and social distancing. Around 14 individuals attend the session. It’s a four-hour session focused on mindfulness, yoga, journaling, and healthy eating. And it’s sponsored and led by some of our most fabulous wellness experts here on campus.
Our chaplain training program takes time to round on the units and check on the staff, the nurses. I think some of these things that we put into place before the pandemic, as well as just the response that we’ve had from our partners within the institution and the community, have made a difference.
MH: UAMS is shifting some nursing staff because of the influx of patients, and bringing in nurses who may not have done critical care, as well as increasing the workload in terms of the number of patients they may be seeing. How do you manage that process, knowing that nurses already feel like they’re taking care of too many patients at one time?
Ray: This is really about how we talk with them around team nursing. And that’s what we’re talking about a lot. Nursing has always been a team sport. This has just taken it to a whole new level. It’s a reversal back to a way that we operated many years ago, but team nursing is the best approach we can come up with, as we move forward to stretch what we call our ratios, or our matrix—how many patients a nurse has on a shift.
We’re using some (other) staff across our campus. That’s the beauty of nursing. You can find yourself in any role as a nurse. We have nurses across the university who no longer practice direct patient care who are volunteering to come forward and to help us. They may not have been a bedside nurse in five years or so, but they know how. They know what the concepts are, and they can come in and work alongside our nurses, whether that be in the ICU or on the floor.
The same is true of our ICUs, as those numbers continue to climb and that staff becomes stretched. We can use that same concept and work with the med-surg nurse who comes into the ICU who may not be trained in critical care, but can support that ICU nurse who now needs to take care of a larger patient population as well. We’ve done some of that creative thinking. We’ve tried to create some internal travel-type positions for nurses in the community who really aren’t wanting to come back full time.
My goal right now is to plan and talk about the shifts where you show up and you don’t have enough (staff). What does that shift look like? What is that care team, and how can you work together to support the patients in the best way?
MH: How do you think some of these things will impact nursing in or year or two, once we are past the pandemic?
Ray: The first thing I think of is teamwork and the way that you get to know one another on a much more personal level during this pandemic.
Our nursing leaders are very accustomed to working within their unit or within their division; we’ve had to broaden that. Through these twice-daily calls, they’ve learned about one another’s challenges in ways that they didn’t have that transparency or the reason sometimes to know their struggles.
Those are some of the things that I hope we never lose. Maybe we won’t do twice-a-day calls. They won’t be quite so critical just to manage the flow of the day, but that learning with one another across specialties, across disciplines, we need to continue that.
The other thing, it’s really helped our nurses to learn as well. Nurses who didn’t reach outside of their division, who didn’t have to step into the shoes of their colleagues—some of our ambulatory nurses who came (to) inpatient (care) early in the pandemic and cross-trained, the things that they were able to learn from one another, we need to not forget those lessons and continue to build on them.
MH: Arkansas Gov. Asa Hutchinson in December made it easier to ramp up the hiring of nurses and speed up nurse licensure programs. What is the practical impact of that?
Ray: The best thing that brought for us was the opportunity for new, graduating nurses to get their application in with the state board and take their exam quicker. Think about a nursing student who has been in school for this long time, and may not have the several hundreds of dollars that it takes to prepare and sit for their board exam. He waived the board exam as well as expediting the testing process. It really has set them up where they can take their tests quickly and they can onboard as quick as possible.
We had already agreed to onboard nurses this January with a temporary license. We would normally bring on December graduates in February. This helped us move that date up to January. Some of them will have a temporary license, but many of them will already have a license if they’ve taken their board exams.
MH: Are you worried that people won’t go into nursing because of the pandemic? We’re seeing the opposite in medical schools where the applications for physician programs are apparently off the charts. They’re calling it the Fauci Effect. What are you seeing in terms of nursing?
Ray: We need some of that in nursing. I don’t know that we’re seeing that effect yet.
This was the year of the nurse, 2020. Little did we know what that was going to mean for us, and the spotlight that was going to have. I am concerned that we will not necessarily see the same effect. I hope we do. I hope people see what this profession means to our communities, to our society, because I cannot imagine being in any other discipline, any other profession right now.
