Each day of the COVID-19 pandemic is bringing new uncertainties, highlighting the remarkable flexibility of nurses to adapt clinical care. Nurses are rotating to different care settings, developing new care routines, and changing care practices, sometimes all within the same 12 hour shift. Amidst this whirlwind of adaptation clinical nurse specialists (CNS) have emerged as steady support.
CNS practice competencies encompass three areas called spheres of influence - direct clinical care, nurses and nursing practice, and healthcare systems. Prepared with this broad perspective and clinical expertise CNSs have the versatility needed to lead in uncertain times. CNSs are a valuable resource to the healthcare system. As an advanced practice nurse, CNSs are supporting direct care, teaching and guiding nurses at the bedside, leading system-level initiatives to address emerging demands, and providing real-time evaluation and feedback for rapid cycle system level adaptions. The COVID-19- pandemic brought to light the many abilities CNSs bring to transforming care in unchartered waters. Here are a few exemplars of CNSs flexing their practice and demonstrating versatility in support of our large quaternary healthcare system in the face of uncertainty during the COVID-19 pandemic.
IN THE DIRECT CARE SPHERE...
For most CNSs, direct inpatient care is not a sole responsibility. While much of the focus was on persons admitted with COVID-19, the hospitals continued to provide care to persons with other medical problems and health needs. In preparation for and during a surge of admissions, some of the CNSs shifted to functioning as bedside clinical care providers. Others restructured to provide support to bedside nurses and nursing staff, functioning as "helping hands" during periods of inpatient overload, working alongside staff nurses and providing assistance with care tasks such as dressing changes, specimen collection, intravenous line insertions, medication administration, and other treatments and interventions. CNSs joined nurse practitioners, physicians, and other providers on the internal medicine service in assessing patient status, partnering in care management, working with order sets, and updating electronic medical records. Visitors were restricted during this time and CNSs assisted in providing outreach to family members. CNSs were pivotal in harnessing technology and tele-health platforms for navigating new communication avenues between and among healthcare providers, patients, family and friends. CNSs performed telephone triage of suspected COVID-19 cases and managed virtual follow up related to COVID-19 test results.
IN THE NURSES/NURSING PRACTICE SPHERE...
CNSs are uniquely positioned to establish and maintain a supportive work milieu by role modeling positive behaviors in high anxiety environments. This skill was of monumental importance during the COVID-19 pandemic where tension ran high and fear of the unknown penetrated the frontline workforce. Nurses were being reassigned throughout the organization. Nurses from outpatient areas were being reassigned to inpatient clinical units and nurses working on inpatient units were preparing to transition to critical care units. This rapidly evolving situation and the uncertainty about working in an unfamiliar environment, lack of clarity about proper safety procedures, and conflicting information about personal protective equipment caused a wave of anxiety among the staff. CNSs used excellent communication skills such as listening, validating, reflecting and providing feedback, to support nurses and nursing team members creating a calming reassurance at the point of care. CNSs served as conduits for information to and from the frontline, seeking out answers to staff questions and bringing up-to-date information to back to staff.
IN THE SYSTEMS LEADERSHIP SPHERE...
The CNSs system-level leadership combined with clinical expertise was instrumental in planning care of the persons with COVID-19. CNSs served as consultants and collaborators in updating protocols related to use of Personal Protective Equipment (PPE) preservation, implementing best practices related to infection prevention and control, designing bundled care procedures to minimize staff exposure, and developing techniques for correct donning and doffing of PPE. CNSs served as consultants to the interprofessional team in creating new protocols regarding end of life care and emergency resuscitation addressing safe, quality clinical care in the presence of the virus. CNSs collaborated with providers and staff in infection prevention, nursing education, nutrition services, and supply chain management to meet the rapidly changing multifaceted needs of the persons admitted with COVID-19. As care areas expanded into nontraditional units and settings within the hospitals, CNSs were deployed into administrative and supervisory responsibilities.
ANSWERING THE CALL TO ACTION[horizontal ellipsis]
Highly regarded for their clinical expertise and thorough understanding of all aspects of the healthcare system, CNSs were called upon to function at the top of their license in the primary management of patients with COVID-19. In recognition of the potential shortage of physician or LIP providers to care for masses of patients infected with the virus, a team that included CNSs was designed as a creative solution. Providers specializing in internal medicine were tasked with primary management of patients with COVID-19 requiring hospital admission outside of the intensive care setting. The team was responsible for the management of up to 17 patients and consisted of four primary roles: team lead, assistant, documenter/scribe, and communicator. Leading the team was a physician whose primary role was patient management including assessment, plan of care, fielding phone calls, and responding to pages. The assistant was responsible for order entry and consultation to specialty services. A requirement for this role was high level familiarity and proficiency with use and navigation of the electronic medical record. The responsibility of the documenter/scribe was to enter patient notes including subjective information, assessment, and the plan of care for the patient. The communicator was responsible for updating family/significant others on the patient's progress and plan of care via phone. To maximize efficiency, each team member executed these tasks simultaneously in order to effectively manage the volume of patients. The diversity of the CNS is such that three of the four team member descriptors referenced above fall within the scope, ability, and licensure of the CNS role.
In Conclusion[horizontal ellipsis]
Florence Nightingale envisioned a kind of nursing where individually and collectively nurses would continue to evolve toward a level of expertise that continuously would meet the complex needs of patients and communities.1 CNS practice reflects what Nightingale imagined nursing would become. When 2020 was declared the Year of the Nurse by the World health Organization to commemorate Nightingales 200th birthday, no one could have predicted how an unknown virus would illuminate the contributions of the nursing profession. The COVID-19 pandemic has shone a spotlight on the importance of nurses and nursing practice. For CNSs, the pandemic provided a challenge that allowed us to showcase the importance of a versatile nurse expert. Whether serving as collaborator, educator, communicator, or consultant in the direct care, nursing practice or health systems sphere, CNSs have demonstrated that the role is a valuable asset in the healthcare organization.
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