By Dana Womack, Ph.D., RN, FAMIA, and Christine Jefferies, MSN, RN
The Covid-19 pandemic was a shock to hospital work systems around the globe. Over a short period, hospitals experienced a dramatic shift in the type and volume of services required by the populations they serve. All but the most urgent of outpatient services stopped while the most severely ill Covid-19 patients were admitted to receive acute or intensive care services.
In addition to collaborating with many professionals in establishing patient plans of care, Registered Nurses (RNs) are responsible for around-the-clock care delivery. Therefore, nurses’ continued presence is critical to sustained hospital operations during the Covid-19 pandemic. Nurses utilize professional judgment to anticipate, monitor, and respond to ever-changing patient needs, and they are recognized as ardent patient advocates. For the 20th year in a row, nursing has been named America’s most trusted profession (Gallup, 2022). In this article, we explore the utilization of RN adaptive capacity, specifically initiative and reciprocity, in sustaining patient access to hospital care during the Covid-19 pandemic.
Shocks and surprises
RNs are accustomed to high work tempo and variable patient demand as baseline characteristics of the hospital work environment. Nursing theorist Patricia Benner describes nurses’ ability to concurrently absorb, respond, and react to dynamic situations as thinking-in-action (Benner, 2009). Thinking-in-action involves clinical foresight and the skilled know-how of managing a crisis, which enables nurses to adapt to a wide variety of clinical, technical, and logistical challenges in everyday clinical care. Nurses’ baseline ability to think-in-action contributed to graceful extensibility during the early days of the pandemic. As time went on, repeated shocks to the system created situations in which hospital organizations and individual nurses needed to make adaptations that were beyond the routine adaptations that nurses make in everyday clinical care. Although Woods’ (2015) term sustained adaptability conventionally implies a longer timescale, the phenomenon of a work system changing how it adapts in the face of recurring surprises and adaptive shortfalls seems to apply here as well.
The global Covid-19 pandemic has presented hospital-based nursing work systems with multiple challenges, including a sudden increase in demand for patient care services, beds, ventilators, and personal protective equipment (PPE). Staffing patterns were highly disrupted as elective surgeries were canceled in anticipation of caring for an influx of patients with a highly contagious virus. Physical spaces were converted into new, makeshift patient rooms. Ancillary departments experiencing staffing challenges reduced service hours while shifting additional tasks to nurses. RN availability decreased as staff quarantined after exposure or called in sick after contracting the Covid-19 virus. RN availability further decreased as they left to become traveling nurses, retired early, or left the profession altogether. Vaccine hesitancy was an unexpected surprise that in some cases led to resignations or layoffs.
As the pandemic continues, nurses continue to draw from their own adaptive capacity in response to personal, patient care unit, and organizational pandemic-related pressures. Concurrently, hospitals are experiencing high staff turnover and weakening of the clinical “bench” as experienced staff leaves the bedside. In turn, hospitals must compensate for this growing experience gap by securing agency staff, hiring new nurses, and providing extra support to new graduate nurses whose in-person training rotations may have been abbreviated due to the pandemic.
Nurse initiative and reciprocity
Amidst this crisis, RNs have displayed considerable initiative (Woods 2019) in recognizing that organizations’ typical plans, and even their contingency plans, did not fit the demands of a global pandemic. Although nurses’ willingness to adapt without explicit authorization is not novel behavior, new instances of authority decentralization facilitated the extension of this effort. Examples of RN initiative in dynamic replanning include willingness to re-use personal protective equipment in the first wave of the pandemic, volunteering to redeploy from procedural areas to medical-surgical and intensive care units, and offering extra support to patients whose family members could not be at the bedside due pandemic-related hospital visitor restrictions.
During the Covid-19 pandemic, RNs also demonstrated remarkable reciprocity, committing to mutual assistance and being willing to expend their limited resources to sustain delivery of high-quality patient care, with the implicit understanding that other agents (e.g., peers, nursing management, hospital leadership, the public) would do the same (Woods 2019). Examples of pandemic-related reciprocity include nurses’ acceptance of the risk of caring for patients with a novel and highly contagious virus, working extra hours to support colleagues and sustain high-quality care, and taking on additional time-sensitive tasks such as respiratory therapy treatments and blood draws when ancillary departments needed to reduce service hours due to lack of staff. RNs skipped meals to keep up with the pace of work and risked bringing the virus home to children, elderly parents, and immunocompromised family and friends.
Consistent with their reputation as the most highly trusted profession, nurses’ willingness to exercise initiative and reciprocity has been assumed, and some would say taken for granted, during the pandemic. However, nearly two years on, RNs, alongside all humans, may be realizing a finite capacity to exercise reciprocity. RNs who extended themselves during the pandemic expected their organization to mutually support them by providing the staff and physical resources needed for high-quality inpatient care, and allowing them to take overdue vacation time. When staff and physical resources were scarce, reciprocity was extended as nurses continued to work in short-staffed units, worked extra hours, and helped onboard temporary float and agency staff. As RNs continue to experience understaffing and high work intensity, and as organizations telegraph the necessity of care delivery model changes to reduce labor costs in the future, nurses may begin to perceive a lack of organizational reciprocity. Indeed, despite high demand and high public trust, a reported 22% of nurses are considering leaving the profession, citing insufficient staffing, intensity of workload, emotional toll of the job, and lack of perceived support at work as driving factors (Berlin, 2021). Frontline workers in at least one state find themselves needing to engage with their state legislature to advocate for nurse-informed safe staffing levels during the current and future protracted public health emergencies (State of Oregon, 2022).
Such proposed regulations and career decisions of individuals hold potential for additional shocks to hospital work systems and new shocks for local communities. If hospitals are unable to secure adequate numbers of nurses to satisfy organizational or regulatory requirements, hospital beds may need to be temporarily or permanently closed, thus reducing patient access to care. Notable unknowns remain, including the success of hospital-at-home pilots and whether sufficient numbers of college students will continue to choose nursing as a profession. We anticipate that both nurses and healthcare organizations will continue to adapt how they routinely adapt to changing situations for some time to come.
Concluding thoughts
In this short commentary, we explored concepts from the field of Resilience Engineering (RE) to contextualize the experience of RNs during the Covid-19 pandemic. Nurses’ superlative expressions of initiative and reciprocity contributed to graceful extensibility in the hospital setting, but the number of nurses considering leaving the profession suggests that their adaptive capacity may be nearing exhaustion. To better understand the nature of eroding workforce adaptive capacity in the setting of protracted strain, we perceive the potential for fruitful collaboration among members of the RE and organizational psychology communities, particularly to increase our understanding of how repeated shocks may change individuals’ willingness to exercise initiative and reciprocity as time progresses under both nominal and extraordinary circumstances.
In our next article, we will discuss the applicability to this situation of an organizational psychology theoretical framework that has recently been used to explain employee burnout in meaningful work professions such as nursing. You may wish to brush up on your Woods & Wreathall (2008) because the framework proposes a familiar-looking stress-strain curve!
Dana Womack is an Assistant Professor at the School of Medicine and the School of Nursing at Oregon Health & Science University. Christine Jefferies is a Ph.D. student in the Cognitive Systems Engineering Laboratory at The Ohio State University.
References
Benner, P., Tanner, C.A., and Chesla, C.A. (2009). Expertise in Nursing Practice: Caring, Clinical Judgment, and Ethics, 2nd ed. Springer.
Berlin, G., et al. “Nursing in 2021: Retaining the healthcare workforce when we need it most,” May 11, 2021. Online: https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/nursing-in-2021-retaining-the-healthcare-workforce-when-we-need-it-most. Accessed Feb. 7, 2021.
Gallup. “Military Brass, Judges Among Professions at New Image Lows.” Jan 12, 2022. Online: https://news.gallup.com/poll/388649/military-brass-judges-among-professions-new-image-lows.aspx. Accessed Feb. 3, 2022.
State of Oregon. (2022). “Nurse Staffing Plan During an Emergency. Public Health Division Patient Care and Nursing Services in Hospitals Chapter 333, Division 510 Section 0140.” Online: https://secure.sos.state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=285508. Accessed Feb. 7, 2022.
Woods, D.D. (2019). Essentials of resilience, revisited. In M. Ruth & S.G. Reisemann (Eds.), Handbook on Resilience of Socio-Technical Systems. Edward Elgar Publishing.
Woods, D.D., and Wreathall, J. (2008). Stress-Strain Plots as a Basis for Assessing System Resilience. In E. Hollnagel, et al. (Eds.), Remaining sensitive to the possibility of failure. Ashgate.
Woods, D.D. (2015). Four concepts for resilience and the implications for the future of resilience engineering. Reliability Engineering & System Safety, 141, pp. 5-9. DOI:10.1016/j.ress.2015.03.018.