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In 2020, during the COVID-19 pandemic, nursing professional governance (NPG) clinical nurse leaders at Yale New Haven Hospital developed an innovative way to engage nurses in their practice. Utilizing an electronic platform, NPG leaders established a way to harvest best practices, innovations, and resources from clinical nurses and reputable sources to share with all nurses in every practice area. Support for NPG leaders to have dedicated time for this work accelerated the process and allowed them to engage with nursing leaders to enhance communication and support clinical nurses. This work demonstrated the value of NPG during a time of crisis.
Nursing professional governance (NPG) is an important structure to support clinical nurses during a crisis.
Technology allows clinical nurse engagement across settings and shifts, and accelerates communication.
Support by leadership to allow time for clinical nurses to engage with leaders to solve problems pays off.
Nursing professional governance (NPG) provides the infrastructure for clinical nurses closest to the bedside to make decisions about nursing practice using evidence to produce measurable patient outcomes. NPG ensures nursing quality, provides structure for nursing practice decisions, and professional development through engagement of bedside clinical nurse leaders.
At Yale New Haven Hospital (YNHH), a 1541-bed Magnet®-designated academic medical center, NPG is composed of 11 councils that are distinguished by specialty-specific service-line and 5 hospital-level councils. The service-line councils focus on nursing specialty practice that promotes decision-making at the point of service. Hospital-level councils focus on nursing practice from a broader hospital-wide perspective. Decisions made by hospital-level councils affect the entire YNHH nursing community. The YNHH Coordinating Council oversees the work of all the councils and connects those who are working on similar initiatives. The Coordinating Council ensures that the work being done within our NPG structure is aligned with our organization’s nursing strategic business plan.
In January 2020, over 500 clinical nurses and nurse leaders gathered to celebrate our 2019 accomplishments. Hosted by our Chief Nursing Officer, NPG leaders and council members presented at this wonderful event. During this event, we showcased evidence-based practice changes initiated by nurses throughout the year, which providing a great opportunity to celebrate ways we improved patient outcomes. As we reflect on that day in the large ballroom buzzing with intellect and excitement, there was not a single person there who would have predicted that a global pandemic was soon to strike, only weeks away. As time would tell, 2020 would certainly be the Year of the Nurse.
During the next few months the chair (E.L.) and chair-elect (K.B.) of our YNHH NPG Coordinating Council viewed the pandemic as a call to action. We did not allow the uncertainty posed by COVID 19 to stop us from embracing opportunities brought on by this unprecedented situation. In our effort to support clinical bedside nurse leaders during this crisis, we used the NPG structure to collaborate with nurse leaders and prioritize ways to meet our nursing communities’ pressing needs. The pandemic surfaced opportunities for nurses to ask questions, share innovations, and confirm best practices.
Structural Changes in the Early Weeks of the COVID-19 Pandemic
Our chief nursing officer (CNO) empowered us as NPG leaders by welcoming our active involvement in COVID-19 planning meetings regarding staffing, education, and personal protective equipment (PPE). In addition, we met regularly with service-line and hospital-level NPG councils, and focused our attention on COVID-19 nursing practice concerns. Our CNO gave us the tools we needed, specifically access to a web-based video conferencing platform to conduct our NPG business while adhering to social distancing guidelines. Routine agenda items were paused, and each council focused on COVID-19 concerns. We sought council member’s opinions on ways to improve patient outcomes, patient experience, and nurse engagement during this time. The NPG council members are known to be some of our most passionate, creative, “get it done” nurses. These are the nurses who, prior to the pandemic, had already shown incredible dedication and involvement in shaping the practice of nursing. Our NPG nurse members were ready and willing to voice their ideas and engage in problem solving on behalf of their nursing colleagues, and patients and families as the pandemic evolved and hit full force in Connecticut and the surrounding New England states in March and April 2020.
During the peak of COVID-19, every day was a new day. It seemed as though not a single regulation stayed in place for over 24 hours before it was updated or eliminated. Regulations that were historically enforced were lifted due to the circumstances. Changes around what we wore for PPE were changed, sometimes by the hour, based on new information on the virus as well as international shortages. Clear communication that was organized in a systematic way, became more vital than ever. Our organization used an incident command center structure as the hub for the most up-to-date processes and resources for our teams.
Nursing Concerns and Questions Wrought With Emotion
Nurses concerns were coming through different pathways. They came through manager and leader rounding, and through our councils both formally and informally, which yielded many concerns and fears. There was widespread fear regarding the shortage of PPE and the risk of getting the virus and/or bringing the virus home to their families. Deployment to different practice settings sparked anxiety. Nurses were concerned about where they were going to be deployed to, especially ambulatory nurses who were now deployed to the bedside to care for inpatients for the first time in years. Our teams had a significant need for emotional support because they were caring for more and more patients who were dying alone due to COVID-19 complications. Many nurses reported experiencing moral distress exacerbated by dealing with the COVID-19 illness trajectory.
Collectively, our clinical nurses had the clinical knowledge on exactly “how” we were going to get through the crisis, but needed the confidence to pull it all together during this time of uncertainty. They were networking with colleagues across the country and beyond through social media and brainstorming innovative clinical approaches to care. Because of our expertise, nursing leaders engaged members of the NPG councils in their daily decision-making. We participated in daily leadership huddles to provide insight for nurse training and deployment, and staffing models, and communicated regularly with the CNO. Leaders were listening to us, trusting us, and were providing transparency so that we could be flexible and transformative. Through council member engagement, the innovation started to really flow. We knew that we needed to capture the amazing clinical solutions nurses were proposing so they could be shared quickly and replicated.
Early on, the hospital initiated a Plan D disaster at the Hospital Incident Command Structure (HICS). This included daily briefings and a robust COVID-19 website for resources. This website housed critical information about PPE and protocols that was easily accessible to all staff. In addition, a call center was established for staff and community members to call with questions regarding anything to do with COVID-19. Nurses found this website to be excellent and the foundational hub for trusted truth; however, clinical nurses had very specific nursing practice questions and innovative ideas that they wanted to share. As NPG chairs, we felt a responsibility to support them and collaborated with leadership to brainstorm solutions. Nursing professional governance has a senior nursing leadership liaison that serves the role of senior mentor (J.M.H.) to NPG. Our NPG liaison guides us in approaches to nursing practices changes as well as directs us to appropriate teams and colleagues to include in NPG work.
Establishing Structures and Processes to Influence Outcomes
We embraced the inevitable challenges generated by the pandemic and decided to create an electronic space for nurses to pose questions, collaborate around best practices, and share innovations. Several years ago, NPG created a SharePoint web platform as an electronic method to communicate and develop practice changes from concept through implementation. We call this platform the MasterLog, which is framed by the steps in the Iowa Model Revised: Evidence-Based Practice to Promote Excellence in Health Care.
Nurses across the organization are familiar with this platform, so we made the decision to create a new section for COVID-19 in our MasterLog just for nursing. This platform is easily accessible from the EPIC clinical nursing documentation computer screen. With support from the Information Technology Department we created a tab titled, “YNHHS COVID-19 Practice Concerns and Innovative Ideas.” We created five subsections with clear, easy to navigate headings as follows:
“Submit COVID-19 Concerns and Innovative Ideas”:
Nurses click on this link that brings them to a simple template. The template has fields for name, unit, and contact information, fields to complete in the format of Situation, Background, Assessment, and Recommendation (SBAR), and the option to upload any relevant documents. Our goal was that within 24 hours, the nurse would receive a response from the NPG Coordinating Council chair regarding their submission. Behind the scenes, the NPG chair found answers to questions and evaluated the feasibility of innovations. See Figure 1 for an example of a completed template. In this example, an innovative idea was placed by one of our clinical nurses regarding standardized patient mealtimes to decrease exposure to the virus and use of PPE. After the request was submitted, our NPG Coordinating Council chair orchestrated meetings and communications about this request. The combined efforts resulted in endorsement from members of our food and nutrition department and NPG Coordinating Council, as well as the diabetes clinical nurse specialists, physicians, and CNO. Within 48 hours, this practice change was put into full effect, and the entire process around mealtime delivery was adapted to better protect our nurses and conserve PPE.
“Review Endorsed Innovative Ideas”:
This was a repository of endorsed innovative ideas. Any nurse could log on, at any time, and see all the ideas that had been submitted and the action taken so that there were not replication of requests. One example was an idea around communication from inside a precaution room. A clinical nurse posed the idea of having small whiteboards accessible inside the room so communication to outside of the room could be had without compromising infection prevention measures and also decreasing the amount of PPE used.
“Review Concerns Raised”:
It was important to make these questions easily accessible to nurses because we knew that if 1 nurse was asking a question, there were other nurses with the same question. Questions about blood product administration, housing, PPE use, and many others were all vital to ensure the safety of nurses and patients.
“Review List of Resources Available for Health Care Providers”:
In this section we provided extensive resources for nurses that included information from the Center for Disease Control, American Nurse Association ,and webinars provided by Lippincott. We aggregated education materials from numerous organizations such as American Association of Critical Care Nurses and Elsevier (i.e., tip sheets, pocket cards on frequently used intensive care unit medications, and free refresher courses). Wellness resources such as webinars and daily meditations by Dr. Jean Watson, some of our own internal YNHH wellness resources, and information from the American Organization of Nurse Leaders and the American Association of Critical Care was housed here. Lastly, under this tab, we had a section for “Quick Links,” which provided nurses with discounts and freebies for health care workers.
The hospital is fortunate to have the prestigious Yale University’s Harvey Cushing/John Hay Whitney Medical Library as our library. Our nursing librarian assists us with accessing all the library’s valuable resources. Her consultation is invaluable, because she provides us with up-to-the minute protocols and resources regarding COVID-19 clinician care and safety, PPE, consumer health, and the latest research findings and publications. All of this information is housed in this site.
What We Learned
We are grateful that we have a culture that includes NPG as a structure for nurses to be accountable for their practice, nursing quality, and nursing knowledge. Our leaders support this structure and view it as vital during a time of crisis. We have a trusting, collaborative relationship where creativity is supported. This support allowed us to be flexible and practice-focused. Our technology platform works to make sure that all nurses, on all shifts, and in all practice settings can engage in raising questions and bringing forth innovations. Providing the resource of the NPG chair’s availability to engage with councils during the pandemic allowed timely responses and dissemination of important information. As a practicing nurse in our intensive care unit, our NPG cochair acted as a link between what the clinical nurses were experiencing, and the work that was being done to support nurses on the frontlines. We realized that we have opportunities to move things more quickly on a regular basis, and we need ongoing harvesting and dissemination of innovations through technology.
During 2020, the Year of the Nurse, NPG was an important structure that supported clinical nurses during the crisis. The work of NPG built nurses’ confidence so they were better positioned to safely and confidently care for their patients and each other. The support of our chief nursing officer and nursing professional governance liaison was essential to the influence that our NPG structure and all of its members had on rapidly implementing practice innovations, timely communication, and providing system solutions to challenges created by the COVID-19 pandemic.
Kate Baron, MAIOP, RN, BSN, CNII, SCRN, is a Neuroscience/Neurosurgical Intensive Care nurse at Yale New Haven Hospital in New Haven, Connecticut. She can be reached at [email protected] Erica LaBella, RN, BSN, CNIII, is a Urology nurse in the ambulatory setting at Yale New Haven Hospital. Janet A. Parkosewich, DNSc, RN, FAHA, is a lead Nurse Researcher at Yale New Haven Hospital. Judith M. Hahn PhD, RN, NEA-BC, CPHQ, is the Director of Nursing Professional Practice at Yale New Haven Hospital.
Published online: October 26, 2020
Note: This paper and the work of Nursing Professional Governance would not have been possible without the exceptional leadership and support of Judith M. Hahn, PhD, RN, NEA-BC, CPHQ, director of nursing professional practice for Yale New Haven Hospital. Additional thanks to senior vice president and chief nursing officer of Yale New Haven Hospital, Ena Williams, MSM, MBA, BSN, RN, CENP, for the unparalleled support to the profession of nursing as well as each individual nurse at Yale New Haven Hospital. Deepest gratitude to Janet Parkosewich, DNSc, RN, FAHA, nurse researcher for Yale New Haven Hospital for providing language help and assistance in proofreading.