The Silver Lining: COVID-19 Care Teams and Cross-Training

In This Episode

Adrianne Edlund, nurse educator at Strong Memorial Hospital in Rochester, New York, returns to share her powerful story of units coming together during COVID-19 to achieve optimal patient care and staff satisfaction. She discusses preparing staff for a COVID surge using a team-based model, and leveraging technology to rapidly develop “just-in-time” education. Her ongoing efforts to cross-train nurses have increased retention, enhanced collaboration and facilitated more nimble processes.

"As an educator, I don't think we have enough training in that emotional piece. We know how to meet the emotional needs of our patients, but meeting the emotional needs of our colleagues is a whole different ball of wax. "

— Adrianne Edlund, MS, RN, CHFN, NPD-BC

Highlights

02:53 —

Adapting learning tools and methods to suit the times

05:26 —

Using a team-based staffing model to maximize options

11:08 —

Recommendations for educators during a crisis

16:35 —

How this pandemic has changed my approach as a nurse educator

21:18 —

Striving for a healthy work environment in the midst of a crisis

Transcript

Jamie Davis:

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’re 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 talk about how bringing nurses from other disciplines and units in the hospital into the critical care environment has improved the team approach to patient care in her facility. Let’s listen to Adrianne discuss breaking down silos and putting together a team nursing approach to patient care.

Hi Adrianne. It’s great to have you on the program today to talk about the process of onboarding existing nurses into critical care units during everything going on with COVID-19. Before we ask the questions though, would you like to just give us a brief introduction? Tell us a little bit about yourself.

Adrianne Edlund:

Sure. Thank you. My name is Adrianne Edlund. I am a service line educator for cardiovascular, thoracic, colorectal and dialysis at the University of Rochester Medical Center, Strong Memorial Hospital. I have been in my role for about three years, and, prior to that, I actually worked for a very long time on our progressive care unit that cares for artificial heart transplant and advanced heart failure patients, where I worked as a staff nurse as well as an assistant nurse manager.

I worked at a community hospital before that, so I have the gamut of experiences from the community to the academic medical center. I also work for The Joint Commission as a disease-specific VAD [ventricular assist device] reviewer, which is very fun and rewarding. I really enjoy getting the opportunity to learn from other programs and bring back some of that to our own program.

Jamie Davis:

In the midst of everything that’s been going on with COVID-19 and how it’s struck systems in different ways, how did you as an educator in your system approach this crisis?

Adrianne Edlund:

It was a little bit daunting. We didn’t necessarily know what we were up against. I will say that I’m very lucky. I have amazing collaborative partners where I work. We wanted to provide education for progressive care and med-surg nurses who didn’t necessarily have or had a very limited critical care background. I partnered with our clinical nurse specialist in our cardiac intensive care unit. It ended up being almost a little book, by the time we were done, of tip sheets on front-line critical care topics. We did arterial blood gas, drawing from an art line, managing an art line, looking at mechanical ventilation and ARDS, pretty much a wide host of different topics that would be relevant in a critical care arena. We initially put them on our shared intranet page for people to access.

And then, as an educator, I wanted to make sure that people are actually using this, so I reached out to them and identified that they weren’t; they wanted something in their hand. They wanted to physically see it when they were there. We laminated them and made these quick little books. I personally hate doing that, because things change and then you have all these books out there circulating. It’s much easier too, if it’s on an intranet, to change it, but it was what the nurses wanted. They wanted something so that when they were working in these critical care areas, they could understand why they were doing it and what they were doing. They felt like they were really partnering in the care.

So it was exciting. It was exciting to see that we were building something that was meaningful. We relied on a lot of the resources provided to us by AACN – I pushed those out to all of our staff; you can never be too prepared – as well as the resources that the Society of Critical Care Medicine put out. And then one of the other pieces that we did was, communication is a big piece during all of this, and maintaining a culture of open communication, collaboration and transparency, I think, helps to foster trust.

I usually do a service-based newsletter that goes out to interprofessional groups throughout our service line that I put out monthly. I had to adapt and recognize that things were changing on a daily basis, and they were changing on an hourly basis. People needed a place to go to get that information. I wanted to make sure our nurses had the nuts and bolts. What has changed? What do you need to know in regard to caring for this population? I started doing that initially weekly and sending it out, and it was very well received. And then, thankfully, as things started to ramp down a little bit, we could go to every two weeks and identify educational opportunities.

Jamie Davis:

How did you decide on using a team-based model for patients with COVID-19?

Adrianne Edlund:

Leadership at our organization was able to see what was happening in downstate New York and in New York City, and recognized that they really needed to make use of the resources we have in place to provide optimal patient care. Unfortunately, we just don’t have a lot of ICU nurses. So how do you do more with less, while still providing the safe, quality patient care that you want? They had made that decision based on seeing what was happening across the state, as well as across the country.

And then we, as a service, recognized we have cardiac intensive care nurses whose knowledge is just amazing, and they’re a huge resource and asset to be able to provide this care. We wanted to have a way that we could really free them up to be those people to go down work in the Highly Infectious Disease Unit [HIDU].

So you had that level of expertise, especially when it came to ECMO. We adopted an idea to do team-based nursing at our service level, where we had somebody centrally allocating staffing and seeing where we had the need. We started cross-training our progressive care and medicine nurses who were interested in our cardiac intensive care unit and provided them with shadow opportunities. We had just actually started to get it rolling and our numbers came down so we didn’t have to pull the trigger, but we recognize that this is a great thing to have in our back pocket. And maybe we should be changing the way we provide care to be a little bit more nimble in case we experience a second wave, or if some other crazy pandemic hits. It’s hard to know what the future’s going to hold.

Jamie Davis:

It definitely is. And you talked about training and partnering with nurses from different units across the hospital. How did you pick up on which competencies were important to focus on for the non-ICU nurses in the team-based model you put together?

Adrianne Edlund:

Every single nurse, especially along our service line, we’re a very diverse service line. So one of our progressive care units takes care of PA catheters and is very comfortable with arterial line tracing. Then one of our other progressive care units takes care of sheets, but then our others don’t. A lot of it is knowing the knowledge base of the nurse going into it and what you’re going to need to supplement with.

The other piece is just checking in with them. I don’t think it can be overstated enough to have a conversation with them: ‘What do you feel comfortable with?’ I assumed prior to all of this, that all of my progressive care nurses were really comfortable with ABG interpretation. And that was a misstep on my part; not everybody is, not everybody uses it in their daily practice. It’s one of those things if you don’t use it, you kind of lose it. So, we recognized that we could be overlooking something that might be a need for them and developed the education to really tailor it to them. A lot of it was focused on individualizing the education.

Jamie Davis:

What kind of innovations did you find yourself having to bring to the fore when you were looking at educating non-ICU nurses in these settings? Were there any technologies you started to implement or things you brought in that you hadn’t used before?

Adrianne Edlund:

Sure. So we got really good at Zoom. I wish I had stock in Zoom because, my goodness, we use it like champs. Thankfully, it’s fairly intuitive so that people who’ve never used it before were able to figure it out quickly. So we use that for quite a few things. Obviously, there are some things that need to be done traditionally, and you need to do it in a classroom setting. We just had to make sure we were following appropriate social distancing.

The other piece is that I’ve always been somebody who is a visual learner. As a nurse, I have to touch, I have to do, I have to put my hands on it, and a lot of our nurses are like that. We recognize they really rely on that visual input. I have an iPad. I can go anywhere. So I reached out to a lot of our people who we can interact with and are experts on things. And we did a lot of videos, a lot of quick, just-in-time training that we put up on our site. We pushed it out to nurses and they loved that. They were actually seeing and working with the equipment we’re familiar with at our organization and getting that key information they need in order to provide a safe level of patient care.

Jamie Davis:

I like the idea of just-in-time training. You’re getting it out quickly and turning things around at a fast pace when needed. But I’m sure there were also other opportunities that didn’t change, where you had more traditional classroom settings that were just required because of the topic, the materials or the type of education that needed to happen. What did you do to deal with social distancing and keeping your students safe in that environment?

Adrianne Edlund:

A lot of it was relying on technology where we could to provide some of the content. We have a dysrhythmia class that we offer all of our new hires, and they have to complete it before they’re able to care for patients independently. It wasn’t something we could push back. They needed it in order to be able to successfully come off orientation, but we had to do it in groups of 10 or smaller. So it was pulling from other people who could teach the content. Thankfully, classroom space was wide open; nobody was having classes or anything. That piece of it wasn’t hard, but it was engaging and making sure people are comfortable teaching a topic that maybe they hadn’t covered before in order to be able to ensure these nurses got those opportunities.

A lot of it was just being creative, figuring out how you are going to do this. One of the things that we did is we just traveled to them and did skills, one-on-one in some situations because that’s what was necessary. They needed to demonstrate pigtail flushing, and they didn’t have an opportunity in orientation. We were focusing on those smaller groups, bringing it to them: ‘Let’s go over that. Let’s do those hands-on skills.’

Jamie Davis:

What would you recommend to educators in this situation that they add to their toolkit? What things did you add that you think are now essential and you’d recommend other educators adopt?

Adrianne Edlund:

I think as an educator, we want to do everything so neatly. When I conduct a needs assessment, I really want to get absolutely everybody and get as much information as I can to really make a determination, but that kind of went out the window with this. I really had to just individualize. I had to reach out to nurses and find out what they needed in order to make them feel supported, in order to make them be successful. It doesn’t necessarily have to be something formal; it can be a text message and email.

Honestly, I think I got the most open and best feedback by going through texts; who would have thought? That’s definitely going to be a go-to for me going forward if I need to talk with somebody. It’s not rigid, it’s not in a survey or anything, so they can really give you all their feelings and their feedback.

The other thing is as an educator, I don’t think we have training on that emotional piece. Having an understanding of how to do that, how to be successful, how to be supportive in order to help others, I think would be really beneficial. And I’m still struggling with it. I can deal with a family and help them through a grieving process, but your own colleague? It feels a little bit different, so identifying ways to make us more effective at that, I think is really important going forward.

Jamie Davis:

As you look at things, I know you said you’re on the downside of the curve at the time we record this, but things are so uncertain, and things could turn around at any time. It just feels like it’s hard for us to prioritize the way we educate moving forward. Is there anything you’ve done to put things in a certain order? What is the most important thing? How have you prioritized educational needs moving forward now that you’ve gone through this process once?

Adrianne Edlund:

I think one of the things that was pretty eye-opening was that we were able to identify some of the things we had taken for granted before that people naturally had experienced or had an understanding of. Now that we have this downtime, we can really develop more formal education in order to make sure everybody’s held accountable. Tip sheets are great to give out to somebody, but whether they read, they understand it, remains to be seen. There’s no way to really assess that aside from observing practice. we have the opportunity now to put a lot of this into our learning management system and to make sure it’s accessible to staff, so that we’re not scrambling if all of a sudden we have a second wave.

Jamie Davis:

What about the nurses you have cross-trained? You’ve got this team approach. They’ve come in. They’ve just soaked up all the information and knowledge you’ve been able to pour into them. How many of them have moved into the mindset of, ‘I like this. I like critical care. This is something that I think I might want to do’?

Adrianne Edlund:

We’ve actually had quite a few of those and it’s surprised me. I have been a progressive care nurse. I had done critical care and it wasn’t for me; it takes a very special person. Progressive care was definitely my background and my comfort level. We’ve had a handful of nurses who, especially those who have gone to the HIDU, as well as those who we had started doing that team-based shadowing opportunity over on our [inaudible] ICU, who said, ‘This is what I want to do.’

As an educator, it’s exciting because I feel my goal is to retain people. I don’t care where I retain you to, I just want to retain you. I want to grow you as a nurse and give you those opportunities. So we’ve had an opportunity to identify people who want a different experience and maybe if we hadn't, they might be looking at something elsewhere. It’s a way to retain them to our own service, as well as to recognize the skills they already have. And tailoring that orientation may actually make things more efficient and streamline things going forward. So I’m excited about it.

Jamie Davis:

We’ve talked a lot about the innovative things you’ve done that have worked. Is there anything you’ve tried that just didn’t work for you or things you've been doing that you would stop moving forward?

Adrianne Edlund:

I don’t know that I would necessarily stop doing anything, but I might augment my approach to learning. I’ve always done things so that they’re meaningful to nurses. Trying to identify it, let’s trim this down. I’m not somebody who feels it needs to necessarily have a lot of fluff. Let’s really get to what is going to allow you to be able to provide safe care.

Our regulatory things we have to do, but maybe trying to identify a way to drill that home. Why is this meaningful? Why do I need to know this information? I think if nurses feel like it’s relevant to a practice that is impactful somehow, then it will make them more likely to engage and understand and be involved in it. So I think that’s something I’ll bring back from this experience. And then just trying to find a way to be more emotionally in tune with my fellow colleagues and making sure I can support them. That’s something I haven’t been able to do thus far, and I want to definitely grow my experiences that relate to it.

Jamie Davis:

You just talked a little bit about this, but I do want to ask specifically how going through this crisis, over the curve and down the other side has changed the way you practice as an educator, but also you personally, as an educator.

Adrianne Edlund:

Prior to all of this, I always felt like a member of a team, but at the same time, I didn’t recognize there were silos that I was putting up. Then, all of us within our service line kind of did our own silo-type activity. I was the educator and this is my responsibility. I push out education, I make education and I do onboarding of new skills, but I didn’t necessarily see how I was involved in that cohesive team approach. It was hard at first – as a nurse, you want to be a helper. And this was probably one of the first times I wasn’t on the front lines. I wasn’t taking care of patients but trying to feel I was still doing something meaningful. At first, I struggled with it a little bit to be perfectly honest. How was I supporting my fellow nurses?

I think recognizing that I can provide them something that is meaningful, that’s going to make them be better at their practice, that’s going to make them feel more comfortable, and it’s going to allow them to understand the rationale of why they’re doing this and make them feel supported was huge. But it took me a little while to come to that. I struggled initially. I wanted to just jump into scrubs and go help out and do whatever to support my fellow nurses. I had to wrap my head around the idea that this is a different way to support them.

I think as a service line, these sorts of situations can either tear people apart or they can bring them together. We’ve always been a strong group, but I feel like we’re more cohesive and collaborative. Right now, we’re still utilizing our little staffing pool that we had done during the height of this to allocate people in the ID [Infectious Diseases] Unit. And now we’re using it to do allocate people to where they’re needed across our service line, trying to make sure everybody is feeling supported and everybody has the resources to provide the care they need to provide. And that’s something I really want to see continue, because it’s exciting and it’s very rewarding.

Jamie Davis:

If there is another surge of COVID patients down the road, or even another pandemic or some kind of incident that stresses your system in a similar way, how are you prepared to ramp up education again? Is there a need, do you feel, to accelerate the process to bring nurses onboard more quickly in different units, or are you really comfortable with doing things like just-in-time learning, the tip sheets and things that you’ve already talked about?

Adrianne Edlund:

I joked with my husband that we had the COVID pandemic, then there’s ‘murder hornets’ and it’s just ‘What next?’ And we had snow the other day here in Rochester, so who knows. It’s May. That being said, I don’t know that we necessarily need to accelerate the process, because I feel like you still need to provide them with structure and orientation and appropriate training opportunities for them to be successful. I do feel like sometimes, if you take shortcuts on that, ultimately people aren’t going to feel supported and they’re going to leave, and you’re kind of back to square one. That being said, though, it never hurts to look to see if there are ways to improve efficiency.

We have a pretty long critical care orientation, and I know that our clinical nurse specialists and our unit educators over there are looking at ways they can streamline the content. Are there ways they can onboard people differently and make sure they’re still getting those skills, but in a more efficient manner? I think it allows us the opportunity to step back and say, ‘Okay, during this what worked really well and then what didn’t? What would be beneficial going forward? If this were to happen again what would we have in place?’ Right now we have the luxury of time, so we should be using it to our advantage.

Jamie Davis:

If you run into an educator in a similar role as yours from another system, what would be the one key piece of advice you’d give them to be prepared for dealing with a COVID surge in their system?

Adrianne Edlund:

I think developing content is second nature to us. Coming up with a tip sheet is nothing; I can do that in an hour. I think figuring out the way you’re going to best meet the emotional needs and help support, especially your new hires. It’s terrifying to become a nurse. You go into it, you want to do all the right things, but you’re scared. And now you’re coming into it at the height of a pandemic. How can we, as educators, support these individuals, make them realize that they’re making the right decision, that they’re going into an amazing profession? And it’s not always going to be like this, kind of teasing out those pieces and everything to make sure we’re offering them the support they need. It’s got to be a scary time to be going into the healthcare field.

Jamie Davis:

Adrianne, one last question. We’ve talked about the technology you’ve used and the way leadership has stepped up to bring your other educators together into a more cohesive unit. Can you talk about how that has impacted the overall impression of a healthy work environment in your system from the top down?

Adrianne Edlund:

I felt very lucky and proud to work at the organization that I work at. We really have authentic leadership throughout all levels. Our chief medical officer actually sends an email every single day, along with doing town halls and things, but he sends one seven days a week that really breaks down where we are with this whole COVID pandemic. How is it impacting our medical center? What are the resources we need? What are the educational opportunities? What things are going to be available to people? So it’s helped to kind of create a culture of transparency. Our director for the cardiovascular and thoracic and colorectal dialysis service line does that as well. Initially, she was doing it seven days a week also. As we’ve tapered, she’s not doing it on the weekends, but it’s even more concise.

It breaks down to how many patients do we have in-house? How many of those patients are intubated? What are the needs? One of the great things they did from the beginning was, they were really honest and open with us about our PPE. We would see people on the news talking about not having PPE, and you hear about people dying from not having the PPE they needed to provide care.

We actually knew from an enterprise standpoint where we stood at all of our different facilities with PPE needs. Our organization is really innovative. They utilize different departments to help produce some of that. Our pharmacy department started producing their own version of hand sanitizer. So we were able to be really innovative in how will we address that. But nurses knew, PCTs knew, it didn’t matter what level of the organization you were, you knew where you stood as it related to PPE.

You never felt you had to use something sparingly. Obviously you weren’t going to over-utilize it, but you felt comfortable that you would have the tools you needed to provide the care in order to keep yourself safe, as well as keep your patients safe. We did a lot of town halls, so initially we had a Zoom phone call that we would do daily when things were kind of at their height with leadership across our cardiovascular services, including outpatient, which is not usual for us because inpatient and outpatient usually stay pretty separate. But it was really important because we were all working together, and a lot of the outpatient staff were coming to help us in the inpatient setting.

So we did that, and then we recognized we had to bring in all of our key stakeholders. Everybody should be invited to these conversations. And we were having weekly town hall meetings that our director ran, and she would bring up pertinent topics. We had infection prevention come and talk to us a little bit about the spread, what is known and antibody testing and all of that, as well as just where we stand as far as facility support.

It’s been a very proud moment for me to work at an organization where I feel very supported. I don’t feel that, as nurses, we have the same concerns that some of our colleagues across the country had. We really felt they embraced our safety. They recognize there was a lot of concern, a lot of fear and they did everything they could to potentially alleviate it.

I was very impressed with the way they approached this. Other centers could possibly learn from that. I’m not a big person into overcommunicating, but in situations like this, it doesn’t hurt to overcommunicate, because everybody’s on the same page; everybody has access to their email. They see that information; they can attend the town hall if they want more feedback. We had screensavers that covered all of the employee assistance opportunities and everything that were across all of our computers, so people knew they could reach out, in addition to the emotional check-in we were doing.

Jamie Davis:

Adrianne, it’s been great having you on the program, and thank you so much for your insights and sharing with us. We really appreciate everything you’ve had to say today.

Adrianne Edlund:

Thank you so much. I appreciate the opportunity.

Jamie Davis:

That concludes today’s episode of the American Association of Critical-Care Nurses COVID-19 Support Podcast. 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.

Please join us for our next podcast episode when we will be speaking with Cynda Hilton Rushton, professor of clinical ethics, about the importance of cultivating resilience in response to ethical challenges and moral suffering. I’m nurse journalist Jamie Davis. Thank you for joining us. We hear you, we’re with you and we support you.

Host and Featured Guest

Jamie Davis, BA, RN, NRP (ret.)

Host Jamie Davis is a nurse, healthcare journalist and novelist. His healthcare career began in emergency medicine working on an ambulance, ultimately advancing to the role of chief of emergency medical services (EMS). After retiring from EMS, Jamie continued his love of patient care as a nurse. Since 2005, he’s worked as a journalist covering nursing and emergency care topics, and has recently delved into writing novels – some with a healthcare twist featuring amazing nurses. He also enjoys teaching new nurses as adjunct faculty at Cecil College in Maryland.

Adrianne E. Edlund, MS, RN, CHFN, NPD-BC

Featured guest Adrianne Edlund is currently a service line educator for cardiovascular, thoracic, colorectal and dialysis services at Strong Memorial Hospital in Rochester, New York. She also serves as a Joint Commission reviewer, primarily focused on ventricular assist device programs. Her previous roles include progressive care nurse and assistant nurse manager. Adrianne is passionate about life-long learning and education for nurses, and has developed microlearning initiatives for both critical and progressive care nurses. She enjoys collaborating with other passionate nurses.