Partnership allowed more nursing help

Kim Coston was feeling the stress.

A student in the Accelerated Bachelor of Science in Nursing (A.B.S.N.) program at the Duke University School of Nursing, she felt the program, designed for students who already have a bachelor’s degree, was moving so quickly that she wasn’t sure she was absorbing everything. “I decided to decelerate,” she says; slow down, catch her breath. “Then COVID came, and I got more than I asked for.” Classes moved online, and clinical education in the Duke University Health System was put on hold. Her roommate didn’t return from spring break. Lack of breathing space was no longer anything like a problem.

During that lull, she started getting e-mails from her dean, urging her to consider going to work in the hospital.

The health system and the school of nursing were both in a difficult spot. With non-care providers kept out of hospitals, nursing students were prevented from advancing in their clinical rotations and their vital final preceptorships, during which they are basically apprenticed to a working nurse. But at the same time that DUSON faced the crisis of what to do with suddenly sidetracked students, DUHS was facing the crisis of how to fill suddenly mushrooming new roles caused by COVID, especially because of new personal protection equipment (PPE) requirements that work more efficiently with staff assistance, and the constant need for personnel to screen people entering the hospitals and clinics.

THE FIRST THING we asked ourselves over here” when COVID hit, says DUSON chief of staff Diane Uzarski, “is how we could help. What could we do? Knowing there was a tremendous need for licensed and unlicensed people.” It’s an instinct, she says, that’s fundamental to nursing.

For those paying attention, nursing was in the foreground of those early moments of pandemic response.

“I remember an image,” says outgoing DUSON dean Marion Broome (Vincent Guilamo- Ramos M.S.N. ’17 takes over the job July 1), “when the New York fiasco was happening.” News reports regularly showed care of COVID patients, in highly restricted rooms with large glass windows. “I remember the newscaster talking about how the physicians were rapping on the window and telling them things, getting reports from them, how’s the patient doing, what should we do.” Getting reports from and having discussions with, that is, not the patients themselves. With the nurses.

The doctors were out in the hallway, outside the glass. “And the nurses were inside, and they would stay inside for six to eight hours because that’s the constant care they require. And it just kind of struck me as an analogy for what we’ve been saying for years: Nursing care is twenty-four/seven.”

Medical staff and specialists come and go, but nurses stay on wards and in rooms. And with COVID patients in intensive care, that usually means one nurse and one patient, together almost constantly. You can get surgery as an outpatient, Broome says. But “the reason you go to a hospital is for nursing care.”

THE UNPRECEDENTED UPHEAVAL caused by COVID demanded a rapid and unusual response, and for that the school of nursing and the hospital would need to work together. But that’s nothing new. That kind of collaboration between DUSON and DUHS already has a five-year tradition. It centers on DANCE (Duke Advancement of Nursing, Center of Excellence), a program that provides a space for members of the DUSON and DUHS nursing faculties and staffs to work together, to communicate, and to find ways to help one another. Members of the two staffs meet monthly, making requests, offering ideas, looking for opportunities.

DANCE coordinator Staci Reynolds offers examples of ways DUSON has stepped in long before COVID hit. The health system a few years ago recognized that because a cohort of nurses was nearing retirement, it was in a few years going to be short of perioperative nurses. The school of nursing created two electives for A.B.S.N. students, Reynolds says, “so we could create this pipeline to fill that lag.” Taught by DUSON faculty and experts at the health system, the electives have provided the nurses the hospital needs. On another front, DUSON faculty members do significant research work in nursing practice and quality. “So we teach staff nurses how to do continuous quality improvement in the clinical setting.”

“What it did,” DUSON dean Marion Broome says of DANCE, “was it provided a platform for when COVID hit. That communication was already there, relationships were already there.”

To tackle the COVID emergency, the partners created the brand-new Patient Services Aide (PSA) position. The PSA role offered students the opportunity to hire on as paid nurses’ aides. The job offered two roles. One was screening people entering the hospital or working on COVID wards with the list of questions we’re all used to by now: Do you have a fever? Have you been exposed? Do you have a cough? The other was supervising health-care workers as they donned and doffed PPE. “Even though you can’t get into clinical because of COVID,” recalls Coston of the e-mails she got from her dean, “you can still get experience this way.” She first signed on as a screener, the position with easier hours and less risk. But she was soon receiving e-mails from her hospital supervisor: “Hey, guys, y’all should pick up PPE instead of screening. We need a lot more help that way,” she recalls the e-mails saying. Coston decided to help.

In the hospital, each PSA is assigned a spot managing a few patient rooms on a COVID ward. When anyone goes into or out of a room, the PSA makes sure they don or doff their PPE in the proper order: when the mask goes on or off, when the shoe covers, when the gown. Recent graduate Cate MacQueen recalls: “It was a weird dynamic at first. ‘Hi, I’m a nursing student and I’m telling you how to put on and take off this equipment you have been putting on and taking off now for months.’ ” But she loved the job. She wasn’t providing nursing care, but “it was a really good environment to learn, even on the periphery,” she says, recalling watching camaraderie develop on the new COVID ward and watching nurses work shift after shift, remaining professional. Each room had a walkie-talkie, as did each PSA, who could be summoned to a room where they were needed or run for supplies or offer other support services to the working nurses. “I feel like that was a critical moment for me at the beginning of my nursing career, to see such resilience in such a difficult time.”

Coston felt she learned more as a PSA than even in her clinical rotations. “In clinicals we would never get to be on an ICU or see stuff like that,” she says. As a student, she’s an observer; as a PSA, she’s part of the team. “So the other staff is more inclusive, more accepting.” On her first day, a new nurse was starting, and a veteran nurse included Coston in her orientation. “She basically took her and me and walked us through her whole day. So I was shadowing also. I was like, ‘Whoa, this is cool. This is like clinical, but a thousand times better.’ ”

Anthony Morrow, another student PSA, agrees. “Some people would view it as, I’m just the PPE observer,” he says. “But I’ve learned about ventilators from respiratory therapists, I’ve learned so much about interprofessional education, interprofessional collaboration. On rounds, it’s nurse practitioners, physicians, residents, fellows, just everyone. And I get to hear those conversations, see how nurses give reports, how they phrase things.” In clinical rotations and during his preceptorship, “you can get so caught up in just wanting to make sure you do everything right that you don’t take time to look at the big picture.” As a student, he just watches; in his preceptorship, he’s just working. As a PSA, he can do both. “You can learn so much. That will put you way ahead of your colleagues who don’t have the opportunity to participate in it.”

Coston recalls seeing her first death while working a shift. One respiratory therapist was in the room, the other was outside and talked her through the process. “To actually have that experience, rather than watching video and online learning,” she says. “I can’t put the right word on it. Nobody wants [people] to die, but as far as learning goes….” And still being a student and having DUSON resources to lean on helped, too; when she struggled with what felt like the “just part of the job” response of those on the ward to the death, she had professors to discuss that with. And now Coston, a year ago considering slowing down her education to catch her breath, has clinical experience that places her at the head of her cohort.

The successful cooperation between DUSON and DUHS nursing has yielded a paper in the journal Nurse Leader called “The Power of Two.” The PSA program garnered a lot of attention; it has been so successful that it’s still running, even though nursing students have returned to hospital training. It has also been the subject of its own research paper, currently submitted for publication.

DANCE HELPED FACILITATE the assistance DUSON could provide in the crisis. And while the students had an opportunity to help early on through the PSA role, many DUSON faculty had to wait. Around a third of faculty do clinical work within the hospital, but it was rare for that work to dovetail with COVID needs. And staff and faculty without clinical positions had at first to stand aside, to watch as hospital nurses worked overtime. “It was hard,” Uzarski, DUSON chief of staff, says. “Because unlike our nurse partners at the health system, for the most part our staff and faculty are nonessential employees. I was an ER nurse during SARS and H1N1, an ICU nurse during the HIV epidemic, so I was on the front line when we had public-health crises in this country.

“Those of us who have been in nursing for many years and who are now nonessential kind of had survivors’ guilt,” Uzarski continues. “We had a little bit of remorse that we could not play more active roles.”

Not for long. DUSON faculty nurses quickly found ways to help. They filled in to provide student health services so those nurses could work at the hospital. They scared up PPE (from as far away as China); they offered to assemble masks and other equipment. They even offered to help do things like walk dogs or help with childcare for nurses working long hours in COVID wards.

DUSON teaches more than the A.B.S.N. students, though. More-advanced nursing students—nurse anesthetists, for example—were never kept out of the hospital, because keeping up the flow of new nurses was too important. “Mary Ann [Fuchs, DUSON’s associate dean of clinical affairs] needs more nurses,” Broome said. “Because they are tired.” And if most DUSON faculty couldn’t suddenly volunteer on COVID wards, they could perform services that kept working nurses on those wards.

“You may have seen some of the stuff that was done with tents for testing,” Fuchs says. “Faculty staffed the testing tents.” Every faculty volunteer swabbing noses in testing tents meant one more nurse remaining at their post in the hospital. Midge Bowers, DUSON associate professor and lead faculty for cardiovascular specialty, worked the tents, and she emphasizes that nurses do more than just the job. “I think the thing that nursing brings is they look at systems, and see what needs to get done. And they figure out how to get it done. The [hospital] nurses can’t be in two places at once; we still need to staff our clinics. So who’s kind of an integrated partner in all this? Often it’s a faculty member.” And while she’s volunteering at a vaccination clinic or helping suddenly organize a popup or drive-thru clinic somewhere, she’s also teaching.

“I’m also an educator in whatever space I’m in. I’ve sat beside physician colleagues, med students, PA [physician assistant] students, and they’ve never been taught on how to give an IM [intramuscular] injection. Nurses know how to do that.” So she teaches her fellow volunteers how to make the injections. “It’s not hard,” she laughs. “I could teach you to give a vaccine. It’s understanding: this is the way you want to get into the muscle, it’s not subcutaneous, to get an effective vaccine, you do it this way.”

And it’s not even just technical medical complexities; it’s noticing the kind of things nurses notice. An older person might need help walking to the recovery area; making yourself heard through a mask might require extra work. “And you have to know where the code cart is, and the fire extinguisher,” she says, recalling setting up the clinic in the Karsh Alumni and Visitors Center. “Even if it’s a campus building, we still need to be able to resuscitate somebody if they go down.”

Wherever she’s volunteering, she brings that whatnext? nursing spirit. “It’s seeing the problem and not just looking for one solution but anticipating the next problem and proposing a solution for that. We’re always forward thinking. I say I live my life in PDSA cycles.” PDSA stands for plan, do, study, act, and it’s foundational to nursing planning. She describes volunteering three times over the course of a week, “and there were updated processes every single time.”

That may be because of Remi Hueckel, assistant professor and faculty coordinator for the pediatric and neonatal nurse practitioner majors in DUSON’s master’s program. “I like to sit in the back and watch the flow, and keep my eyes on how things are going,” Hueckel says of the time she spends volunteering at the Karsh vaccine clinic. “Because I don’t have the responsibility of being an administrator assigned by the hospital to get the clinic up and running, I could just watch it going on.” That meant that she could watch systems and cycles, respond, and educate other volunteers. She cites an example.

“It just happened this week. We were getting started, and the lead that day asked, ‘Who’s been here before?’ ” Only the lead and Hueckel raised their hands. That day’s volunteers were nursing students, medical students, PA students: “All these health-professions learners finally getting to be with patients for the first time,” she says. “So we just pulled them around the table, and I walked them through. They practiced on each other, finding landmarks, figuring out how they were going to administer the vaccine. We walked through documentation, the importance of that. We talked about flow.”

And then the day got started. “And it was fun—again, I like to sit in the back so I can see everything. I just took a pause at one point. I looked around, and I thought, ‘This is great. We’ve taken them from the wide-eyed, yes, I want to help.’ I looked around at each one of them, and they were all engaged, enthusiastically talking with their people coming to get the vaccine. As stressed as they were in the morning, by 11:30 each one came back and was, like, ‘Hey, this is awesome.’

“And you would just feel the energy going on there. You can see it all coming together for them, and it’s kind of fun. This has been such a pleasure for us.” She gets to offer her services in a setting that not only trains students but improves the health of people in Durham. “Especially after everything we feel like we’ve been doing to support our students and our clinical colleagues, now we feel like there’s an impact in the community as well, and that’s very rewarding.”

SPEAKING OF COMMUNITY: “The community health piece is that we teach our community health course through students being partnered with organizations in the community,” says Irene Felsman, assistant professor and faculty affiliate of the Duke Community Health Improvement Partnership program (D-CHIPP). Groups of nursing students join with groups providing community services to vulnerable populations, learning about community health through practice. “So when this pandemic hit, we contacted our partners and said to them, ‘What’s your capability of having our students stay involved online?’ ” DUSON students have been meeting with some of the community’s most vulnerable populations, using Zoom, FaceTime, “any way our population can connect with us,” Felsman says.

She gives the example of Durham Housing Authority residents that students worked with: often older people, often marginalized. When COVID meant that phone calls had to replace in-person visits, “it was very difficult for people to relate that there was a nursing student on the other end.” So the professor worked out a system for the students, two at a time, to meet in person, outdoors, with the clients, after which the clients have functioned much better. “I thought that was very innovative.”

Felsman does a lot of work with the Latinx community, and she brings up Latin-19 (Latinx Advocacy Team & Interdisciplinary Network for COVID-19), started by DUHS physicians Viviana Martinez-Bianchi and Gabriela Maradiaga Panayotti when they recognized in April that almost 75 percent of patients in the ICU were Latino. They convened a weekly meeting, not unlike the monthly DANCE meetings, to make connections. Felsman was involved from the start, along with other nurses, physicians, and members of community groups. “Now we have 500 people on our mailing list.” And, of course, “I have a lot of student volunteers.” Felsman mentions the SER (Salud, Estrés y Resiliencia/Health, Stress and Resilience) Hispano Project, a research project she’s involved with that studies the stresses involved with acculturation on the health of Latino immigrants. Research through that project, focused on the effectiveness of giving COVID training to health promoters, has received funding through the $5 million expansion in money the university made available to the Duke-Durham fund in June 2020.

The point of all this work, Felsman says, is the way DUSON works with the community, whether through community organizations, student volunteers, or simply long-term connections between the school and its community. Nurses, in a way, are like cartilage. They absorb the inevitable shocks between the bone of community reality and the bone of the health-care system.

“We use the term ‘flex’ a lot,” she says. “And ‘creativity.’ I think that’s a lot of what we’ve done. During COVID it’s just become a lot more visible.”