Nurse educator Adrianne Edlund talks about her experiences onboarding nurses new to critical care and adjusting nurse residencies – both before and during COVID-19 – at Strong Memorial Hospital in Rochester, New York. She shares lessons learned and best practices for adapting educational content and delivery for the current environment. Adrianne also touches on staying emotionally connected to nurses despite social distancing, and reflects on the unanticipated benefits of new ways of working.
Beyond the surge: developing formal learning vs. just-in-time education
Welcome to the American Association of Critical-Care Nurses COVID-19 Support Podcast Series. I’m your host, nurse journalist Jamie Davis. Our goal is to discuss important nursing practices during the COVID-19 pandemic and offer tips for nurses on the front lines or behind the scenes. We hear you, we’re with you and we support you. Thank you for joining us.
In this podcast series, we will do our best to provide you with the most current information from our incredible community of nurses. However, you should always check with the nursing practice standards for the state in which you are licensed and working as well as with the organization or healthcare facility where you work.
Today, we have nurse educator Adrianne Edlund on the show to chat about her experience orienting new nurse graduates to the critical care workplace during the pandemic, while also facing some unprecedented challenges. Let’s listen to Adrianne discuss breaking down silos and putting together a team nursing approach to patient care.
Hi Adrianne. I want to welcome you to our inaugural episode of the podcast series, and I’d like to start with having you introduce yourself briefly. Tell us a little bit about who you are and your background.
Sure. Thank you for having me. My name is Adrianne Edlund. I am a nurse in Rochester, New York, at Strong Memorial Hospital, which is part of the University of Rochester Medical Center. Currently, I’m one of the service-level educators for cardiovascular, thoracic, colorectal and dialysis. We have a pretty broad service that we cover; it’s myself and another service educator I partner with.
Prior to that, I actually was a progressive care nurse for a long time. I’m not going to say how long, because then people could do the math and figure it out, but I worked on the advanced heart failure transplant and artificial heart floor as a nurse as well as an assistant nurse manager. Before that, I worked at a small community hospital, so I’ve had quite a gamut of experiences throughout my nursing career.
I also work as a Joint Commission disease-specific surveyor, and I survey VAD [ventricular assist device] programs throughout the country, which is really exciting.
We’re going to be talking about new nurses. There are a lot of graduate nurses entering the workforce right now, and with everything that’s going on with COVID-19, why don’t you talk a little about what you do in your hospital system or what you recommend other educators do to support new nurses coming to the hospital amid everything that’s going on with COVID-19.
I’ve been a nurse for a long time, and I’d be lying if I didn't say that it’s scary right now. You like to know what’s going to happen, you like to be prepared, because as nurses, we have our checkboxes. We like to make sure we’re doing everything we’re supposed to, and it kind of feels like the rules are just constantly changing with this.
I think, for a new nurse, it’s a bit of a terrifying time to come in. I think it’s important they know that, clinically, they’re going to still get the skills they need. As educators, that’s the easy part. We can make sure we provide them with those skills and those opportunities and make them feel safe and supported in the care they provide, but the piece I don’t know they necessarily are aware of is that they really need to have an understanding of where they’re at emotionally.
It’s nerve-wracking. We’re reaching out, identifying mentors, identifying support people. One of the things I feel like I’ve done more in my role is kind of being that therapist or that sounding board for people, because there’s just so much unknown right now.
What do you do to bring them specifically into a critical care situation where they might be caring for patients with COVID-19? What are you doing in your system? How do you adapt to that particular patient group in your organization?
We’ve actually reallocated a lot of our cardiovascular service line nurses to go and work down in what we call our Highly Infectious Disease Unit [HIDU]. Initially, it was for Ebola preparations. Now it’s for the COVID pandemic, and a lot of these nurses had actually self-identified and said they wanted these opportunities, whereas others were a little bit more on the fence. From a need standpoint, we needed people to be able to provide a really intense level of care for that patient population.
One of the big things we focused on is recognizing that the background of everybody who’s going down is a little bit different; everybody’s experience is a little bit different. I’ve done more individual needs assessments, I would say. It hasn’t been anything formal; it hasn’t been sending out a survey and getting a robust amount of data back. A lot of it’s just been texting with somebody and saying, ‘Hey, listen. You floated to the HIDU last night, and you’re going to be down there for the next four weeks. What do you feel would be helpful?’ I’ve gotten a lot of really open, honest feedback from nurses as a result, which was really helpful. I think educators have the opportunity to tailor what they’re providing these nurses to make them feel comfortable and to make it be less of a scary time for them.
I know the unit educator who’s down in our HIDU had done a great job and developed proning education and on donning and doffing to protect themselves from a nursing standpoint, but we had nurses come back and say, ‘Well, that’s great, but I was partnered with an ICU nurse and I don’t know anything about a ventilator,’ or ‘I don’t feel comfortable drawing an ABG off an art line,’ so we recognized that we could fill that gap and developed a lot of education and just-in-time training, teaching and tip sheets and things to help meet that need.
One of the biggest fears I would say for our nurses was the ventilator. They’re progressive care nurses. We don’t have patients on ventilators. For our ICU nurses, that’s their bread and butter. I’m very lucky that I work in a very collaborative practice environment, and I snagged our respiratory therapist. We made a quick five-minute video, everything you need to know about a ventilator, and we pushed it out to all of the staff. The response was overwhelmingly positive. They just wanted to see the tools they would actually use in the environment, how they’re supposed to be working and hear from an expert. I think that’s the easiest way to really provide that support, and it doesn’t take a whole lot. You just have to reach out and find out what they’re looking for in order to meet the need.
In those situations where you have a more traditional learning environment or an educational opportunity, what are you doing to observe social distancing and things like that? Are you using technology more, or are you still operating inside a more traditional classroom setting at times?
It depends on what we’re trying to offer. Prior to all of this, we were in the process of changing populations along our service and blending the patient populations that different units take. We had been offering a weekly cardiovascular education series and they were really well attended, but as soon as the COVID pandemic hit, you have to have groups of 10 or less and follow masking, eyewear protection, all of those pieces. Unfortunately, at the time, the series went by the wayside. I will say we’ve gotten amazingly adept at using Zoom. All of our staff, without any training, just adopted it, and thankfully it’s a fairly intuitive system. We’ve used a lot of Zoom. We’ve recorded a lot of things.
I love to use video. I’m a visual learner, so any chance I get, I will run around with my iPad and do a video and pop it up onto our site and distribute it to people. I feel like that’s a good way for them to physically see things as they relate to some of our more traditional offerings, so when we’re onboarding new nurses, they go to a standard dysrhythmia course. We didn’t really have the time to change it up completely, but we still had to offer them that educational opportunity.
One of the things that we did, we brought in more people to do the teaching and split them into smaller groups, so that they were still receiving the education. A lot of it is just about being nimble and making sure you’re still meeting those needs. For onboarding new nurses, we were finding that just because of the social distancing piece, when they would bring in these big groups, they wouldn’t necessarily be able to do some of those skills that are required. Touching base with our unit-based educators, touching base with the staff nurses and saying, “OK, what didn’t you get an opportunity to do? Let’s pull you aside. Let’s take you out and make sure we give you those skills and opportunities.” It has been a really important piece.
In regard to those nurses in the middle of a residency period, maybe they were new nurses coming out last semester, what do you do to change their routine and has anything become different for them?
I could speak to it from our service line. Some of their preceptors all of a sudden were being brought down to work in our Highly Infectious Disease Unit, so it created a little bit of uncertainty for them. I think recognizing that they’re going to be nervous, they’re going to have a lot more questions, and they’re going to feel they need to be supported more was really important.
We did frequent check-ins, making sure they felt comfortable, making sure that they didn’t feel like they were kind of being just thrown at the wolves or anything. I think we’ve done a pretty good job as far as that goes. They develop a comfort level with their preceptor, they like their preceptor and then when their preceptor goes away, it’s like a piece of them. So making sure we partner them with somebody who’s still going to be able to provide clinical opportunities, and making sure their personalities mesh well together are a really important piece.
We didn’t send any of our new people to the COVID unit because it really requires pretty exceptional clinical thinking skills, and even if you don’t have a critical care background, you have to, in progressive care, really be able to advocate for your learning activities and learning needs, and recognize when you might be pushed into an area you’re not comfortable with, and that’s just not a skillset we expect our new nurses to have. I think that would be what I would recommend. I talk with people across the country, I’ve worked in a couple of different states and the experiences of new nurses have varied. Some nurses feel extremely supported and I like to think that our nurses felt that way, but there are other nurses who felt like they just ended up in a mass catastrophe, and you want to retain those people.
You spend a lot of effort onboarding them, and you need them to be there to be those clinical people. So, whatever you need to do to make sure they feel supported, comforted and prepared to take on that population is really important.
You mentioned talking to nurses who felt like they’d be kind of thrown into something and were over their heads a little bit. As the current surge is lessening in a lot of areas, what are your thoughts about transitioning from crisis mode back into a more conventional approach to nursing care, whether it’s changing the way we document or things like?
I think, overall, nurses want to do the right thing. They want to follow the rules. I think every nurse I know is our rule follower. That being said, if you are down and you’re observing practice, and maybe it’s somebody who doesn’t follow things appropriately or doesn’t do things the way they’re necessarily supposed to be done, you’re going to learn bad habits. We find we have to ‘unteach’ those bad habits. It’s too soon right now, because we’re just coming down our curve here in New York and hoping that we don’t have a second wave, but I think it’s really important to recognize it’s a possibility, that it’s one of the things that could result from this, so we audit, check in with people, do some of the skills observations.
One of the things we do is a skills refresher where we actually go around and go over how to do things properly. Sometimes it’s eye-opening, because people say, ‘Oh, I didn't learn it that way,’ so it provides us with a chance to check it and say, ‘OK, well, listen. You’re getting it from the horse’s mouth. This is the way you’re supposed to be doing it. If you have any questions, by all means, reach out to us.’ I think we’re going to have to do that a little bit more frequently, because these nurses are getting opportunities to see things they haven’t encountered before, and they’re learning from other people who may or may not have been trained correctly. That will be our responsibility going forward.
You mentioned that preceptors sometimes get pulled into other units. What are we doing to help newer nurses make that connection with either a different preceptor or a new preceptor they’re assigned to in the middle of some of the fear and unknown that’s going on in nursing care right now?
Especially for our ICU, we are very lucky we have a dedicated CNS who has not gone down and worked in the HIDU. She’s been that point person for those individuals and then myself and my other service educators. Cheryl and I work together, and I mean we’re talkers. We love to talk, so we go and we touch base with these people. ‘I’ll sign that from the nurse manager. OK, what’s their phone number? Let me text them. Let me see how things are going.’ We've done a lot of that informal communication.
I’m sure at times they’re like, ‘Who is this person texting me?’ But honestly, it ends up resulting in a really nice dynamic, and with everything that’s happened and the requirements for social distancing, I haven’t necessarily been able to have that one-on-one I had before with our new hires who were coming in. I haven’t been able to go and meet them and introduce myself, so a lot of it is trying to catch them on the units, and it’s not always possible. Having any sort of method to do that check-in piece is really important.
We’ve done a big push as an organization on that emotional piece of it. We’ve recognized that across the country. There are people who are really struggling and really having a lot of difficulty handling the situation. It’s not just in the hospital environment. I tell my husband going to work is easy. It’s coming home and having to learn how to homeschool and be there for my kids and all of those other pieces; that’s what’s really hard.
Recognizing that there’s outreach and support, that new nurses aren’t going to know what those resources are, and making sure it’s as transparent as possible is really important. From a leadership standpoint, I think it’s honestly right now the most important thing you could do.
You mentioned coming on the downside of the curve in New York, at the time we record this for you, and I’m wondering what you might think about moving forward. If there is another surge in the fall, what would you do in this downtime approaching you to prepare for the possibility of another ramp-up of cases?
That’s a great question. We’ve talked about that, because just now we’re starting phase one and lifting restrictions and everything, and that’s a big fear for those of us at the medical center. ‘OK, the weather’s getting nice, everybody’s going out and what’s going to happen? Are we all of a sudden going to be inundated, like we’ve seen happening in New York City? Even though it’s in the same state, it’s like two different worlds. It’s like Kansas to California. So what happened there isn’t necessarily reflective of what’s going to happen to us.
That being said, it’s like the Girl Scout motto: Be prepared. We have downtime right now. Our census is lower than it usually is. We’re building back up, but we have the opportunity to really not get thrown and to be a little more thoughtful in our planning.
We’re developing more formal education versus our just-in-time education that we had developed to make sure we meet these needs. The other thing that was really exciting is that during a crisis, either it tears people apart or it brings them together, and from a service standpoint, I really felt like it actually united us quite a bit. As educators, my counterpart, Cheryl, was doing the staffing for our service and checking in with all the units and seeing who they had, what did they need, so that we could allocate as many nurses as possible to go down to the Highly Infectious Disease Unit.
One of the things that came out of this is we were sending a lot of people across our service line. A cardiac surgery nurse isn’t needed, but cardiac medicine needed them or CCU needed them, so we were juggling within, which isn’t something we had done before. It’s actually created really good relationships, and it’s gotten people excited about some of the other populations.
From an educator standpoint, it got me excited that maybe someday I can envision cross-training them to everything and just having universally trained people. I don’t know whether that will happen in my lifetime, but we started doing team-based nursing as a service, recognizing that we could utilize more or allocate more resources with less nurses through a team-based approach. We had just started it when our curve kind of came down. We didn’t actually need to pull the trigger on it, but we wanted to free up our CICU nurses to be able to go down and help and be that ICU body in our HIDU.
We had a myriad out of progressive care and medicine nurses who were really excited to go to our cardiac ICU and get opportunities to partner because at least it’s cardiac; they know what they’re dealing with. We had started the cross-training process; we had actually done a lot of shadows, and the response was overwhelmingly positive. People were really excited about it, so I think it’s something I don’t want to stop. We’ve got the momentum, and knowing that this could change in a snap of fingers and we could all of a sudden be faced with an inundated medical system, I think it’s really important to continue that and make sure that we’re as prepared as possible.
It’s interesting to hear you talk about the way the changes have become things that you may continue to adopt, and the crisis has really enabled you to find new and better ways to operate. What are you looking forward to the most, though, when things start going back to normal as an educator?
I don’t want to say I’ve enjoyed it because that sounds weird right now, but it’s been different. It’s shaken things up a little bit. It’s made me be a little more innovative. I always felt like I was pretty nimble when it came to educational needs, but this kind of opened up my eyes that I needed to be a lot more nimble.
I don’t know that I’m necessarily looking for anything to go back, minus the idea that I’d like there to be less sick people, and people to be OK and able to be with their families, and less of that emotional stress. But honestly, I think it’s been a good opportunity for not just myself but for our service to band together and recognize that we could do something for a greater good. It’s not just about yourself and being siloed in what your responsibilities are. It’s really about a collaborative approach and being a team, and how can you achieve team success.
We mentioned at the beginning of this discussion that nurse safety is a big issue. Really, staff safety. It’s not just the nurses who are involved in patient contact and need to be protected, but I’m curious what your thoughts are. Is that going to change, and how is that going to be adapted to your normal onboarding process for new nurses now?
It’s really interesting. Having worked with The Joint Commission, donning and doffing is something that we get training on. As a nurse in the medical center, until this COVID piece came to fruition, I didn’t necessarily realize I was not doing every single step that I should be doing . It was an education on proper donning and doffing.
I think it’s really important to protect yourself and make sure you have the resources to provide the care you need to keep yourself safe as well as keep your patient safe. I think, as nurses, it’s a little bit counterintuitive to put ourselves first before taking care of our patients, but I think that’s something we’re going to really need to stress with new nurses. If you’re not there because you’ve put yourself at risk, you’re not going to be any good to the patient either.
A lot of it’s that ethical and moral ambiguity that kind of comes with things. Do I take time to put on my mask and all of my appropriate PPE before I ever respond to this patient in a code situation? The answer is yes. You have to rethink and retrain your brain that way. I mean nurses are helpers. You want to rush to the scene; you want to jump in and do absolutely everything you can, but again, you have to be mindful. We’re dealing with an unknown threat at this point.
Was there ever a point when you felt you needed to cut corners or you heard from other educators working with new nurses that there was a need to accelerate the process, because we needed to get people in place and working solo faster?
Not in my organization. I’ve heard from people, especially in New York City, where they were kind of forced into situations. We didn’t experience that same incremental increase like they saw there, so we had the time. I can understand where you need people to be in the right places. I feel like, thankfully, I myself had to really adapt and really push out education faster than I’ve ever done before. I get a topic by our director, such as, ‘Listen, we need to have something on this,’ and it was expected a couple of hours later. ‘Let's get this out. Let’s make sure the nurses have access to it.’ So from that standpoint, sure, but the nurses themselves know. We tried to be cognizant of the fact that there’s a lot of distrust out there.
You turn on the news and you see people protesting the fact that they don’t have enough PPE, that they’re not working with safe conditions. You see people are dying. Nurses, doctors, respiratory, I mean everybody, so it was really important as an organization not to shoot ourselves in the foot, and we wanted to make sure that our nurses knew that they were protected.
I’m very proud, as I said. I’ve talked to friends in other states about our hospital response. We never didn’t have the PPE we needed. People weren’t forced to do anything they weren’t comfortable with. We tried to request and see if they were interested. We did that check-in process I had spoken about where we made sure their educational needs were being met, and usually the nurses they partnered with were doing an awesome job and explaining those things, but they wanted to learn more.
Adrianne, it’s been great talking with you. We’ve learned a lot about how to help new nurses become more comfortable and about the educators who are working to bring them into the system during a crisis for all of healthcare. Thank you for taking the time to sit down and chat with me today.
Thank you very much, I appreciate it.
That will conclude today’s episode of the American Association of Critical-Care Nurses COVID-19 Support Podcast Series. You can stay up-to-date with us on our website, www.aacn.org. For more great updates, connect with AACN through Instagram at @exceptionalnurses.
You’ll definitely want to come back for our next episode when Adrianne returns to talk about bringing nurses from other disciplines and units in the hospital into the critical care environment and how it improved the team approach to patient care in her facility. I’m nurse journalist Jamie Davis. Thank you for joining us. We hear you, we’re with you and we support you.