Understanding Redeployment During the COVID-19 Pandemic: A Qualitative Analysis of Nurse Reported Experiences

The COVID-19 pandemic resulted in an unprecedented disruption in nurse and healthcare working conditions. One significant issue experienced among frontline healthcare workers was the redeployment of nurses to various patient care units within the healthcare system. Redeployment refers to reassigning healthcare workers to alternative units or specialty areas. Before COVID-19, nurse redeployment was associated with poor nurse and patient satisfaction, decreased productivity, and impaired nurse-patient relationships (O’Connor & Dugan, 2017). Additionally, there is an association between redeployed nurses and an increase in staff turnover.

Nurse redeployment is not a new practice, though the circumstances of the COVID-19 pandemic amplified the problematic nature of reassigning specialized healthcare workers to alternate and often unfamiliar environments. Redeployment has been historically used to address staffing shortages (O’Connor & Dugan, 2017) and is often referred to as “being pulled” or “floating” to other units. Under normal circumstances, redeployment helps manage varying patient census and acuity. To comply with best practice, there is an effort to float nurses between like units, that is, a neonatal intensive care unit nurse floating to postpartum care to work in the nursery, however, this is not always possible. Some nurses are redeployed to unfamiliar units or specialty areas, leading to a level of discomfort. The Joint Commission’s (2004) position is clear regarding redeployment assignments; nurses redeployed to alternative environments should be assigned to units with similar patient populations and skill requirements. Additionally, floating nurses should possess the appropriate credentials to practice in their redeployed environment.

In 2009, The American Nurses Association (ANA) released a revised position statement regarding the rights of nurses when considering a patient assignment. The ANA (2009) is clear, that nurses have the right based on professional and ethical responsibilities, to accept, reject, or object to a patient assignment that puts patients or themselves at serious risk. The position statement goes on to specifically speak to redeployment or floating of a nurse. Before floating a nurse from one unit to another, management must consider the level of expertise, patient care delivery system, and any patient care requirements needed. If redeployment is necessary, the nurse should be assigned to a comparable clinical area (ANA, 2009). The obligation of professional nurses to raise concerns regarding any patient assignment that is not consistent with patient safety is supported by the Nursing Scope and Standards of Practice and licensure requirements (ANA, 2009).

Background

According to the Centers for Disease Control and Prevention (CDC), as of January 13, 2021, there were 329,593 deaths involving COVID-19 in the United States (US), with 210,460 (63.85%) occurring in an inpatient hospital setting (Centers for Disease Control and Prevention [CDC], 2021). The purpose of the redeployment of nurses during the COVID-19 pandemic was to alleviate staffing shortages due to the increase in patients and acuity levels. Temporary intensive care units (ICUs) in post-anesthesia care units (PACUs), operating rooms (OR)s, and step-down units were created to meet the demand of critical patients diagnosed with COVID-19.

As there was such a high level of patients diagnosed with COVID-19 at the height of the pandemic, the virus impacted staffing ratios. To meet staffing needs, nurses were redeployed to these temporary ICUs. As some nurses did not have critical care experience, The Society of Critical Care Medicine (SCCM) recommended tiered staffing for mechanically ventilated patients. SCCM suggested ICU nurses take on teams of three non-ICU nurses and oversee the care (Halpern & Tan, 2020). However, deploying healthcare personnel to unfamiliar areas with a lack of critical care or emergency care skills can alter typical healthcare safety measures, compromise patient outcomes, and risk the professionalism of nursing (O’Connor & Dugan, 2017). While there has been much discussion about redeployment stress, few formal studies have described these practices and interventions or reported the impact of redeployed nurses from noncritical care environments to higher acuity environments.

Awareness of the impact of redeployment during the pandemic is increasing. The National Institute for Health Research (NIHR) in Great Britain announced a multimillion-dollar investment for projects that investigate the long-term impacts of COVID-19. One of the chosen grant projects includes the investigation of the impact of redeployment during COVID-19 on nurse well-being, engagement, and retention (Lawton, 2020-2022; Award ID: NIHR132041). The findings from this study can add to the existing literature regarding redeployment and the vulnerability American hospitals and their staff face during a pandemic. Ultimately, aiding in the development of new policies to facilitate effective pandemic response in the future that would support nurses to participate in redeployment in a safe and nontraumatic way.

Aim

The purpose of this manuscript is to report the qualitative findings of a parent survey study. The research question guiding this work was to explore the traumatic stress experienced by American frontline nurses during the initial surge of the COVID-19 pandemic in the spring of 2020. With healthcare professionals’ mental health and debriefing of environmental concerns being points of focus in the pandemic's aftermath, understanding these experiences is essential. Data will enhance the ability of health systems to support redeployed workers and create policies and practices that promote a positive and safe work environment.

Review of Literature

Raith et al. (2021) conducted a retrospective analysis after they repurposed a 23-bed neuro-intensive ICU in the United Kingdom. The ICU capacity increased by 21.7% to 28 beds, including 18 COVID-specific within 10 days. This increase in ICU capacity led to a change in nurse-to-patient ratio from 1:1 to 1:4 or 1:6, complying with the SCCM's recommended model of nurse-led teams. A condensed ICU training program was developed for redeployed nurses including a brief unit orientation and an introduction to mechanical ventilation. In an attempt to create personal protective equipment (PPE) breaks, ICU and non-ICU nurses rotated every 2 h. The researchers found a decreased ICU mortality rate from COVID-19 (41.4%) compared to the overall mortality rate in England, Wales, and Northern Ireland (43.2%). However, there was no discussion regarding nursing's perception regarding their redeployment during the COVID-19 pandemic.

In one New York facility, ICU beds were increased from 104 to 283 by the opening of a temporary ICU. Brickman et al. (2020) trained 413 nurses in critical care in 10 days using a newly developed 3-hour curriculum incorporating the cardiac, pulmonary, and renal system functions, anticipated therapies, and procedures for COVID-19 patients. Additional training included ventilator management, medications and infusions, continuous renal replacement therapy, documentation, hemodynamics, shock, and critical care skills. Redeployed nurses were from the following units: medical/surgical, PACU, procedure areas, stepdown units, and the OR. Educators designed the critical care orientation to the level of experience each nurse had. This program is undergoing evaluation and analysis of training efficacy and reception. Similarly, at Emory Healthcare in Atlanta, Georgia, educators developed a redeployment tool to help relocate staff members based on their specific skill sets. Additionally, they developed a training program on critical care competencies for those nurses redeployed to COVID-19 testing units (Brickman et al., 2020).

Multiple health systems stopped elective or scheduled surgeries during the pandemic. This created a large pool of available perioperative nurses. Massachusetts General Hospital (MGH) transitioned perioperative areas within the hospital to surge units. MGH used a nurse partnership model in which redeployed RNs were matched with ICU nurses. Procedural nurses and Certified Registered Nurse Anesthetists (CRNAs) working in areas such as endoscopy, cardiac catheterization, interventional radiology, and offsite ambulatory surgery centers, were transitioned to the newly created ICU (Retzlaff, 2020). The transition to the ICU setting was more seamless for PACU nurses (Retzlaff, 2020).

CentraCare St. Cloud Hospital in Minnesota also found that the transition for PACU nurses to the ICU was relatively easy, indicating that all redeployed PACU nurses had an ICU background (Retzlaff, 2020). Even with an ICU background, all were required to participate in education and shadowing experiences. However, the Minnesota hospital required less training for the nurses who did not redeploy to the ICUs (Retzlaff, 2020). These nurses were sent to various areas with a range of responsibilities, such as assisting with patient care activities on a dialysis unit or nursing home or assigned to assist with critical tasks such as asking screening questions, providing masks, and taking temperatures at admission. All redeployed staff completed orientation checklists to monitor and ensure competency and were provided supervision as needed by staff RNs on the units (Retzlaff, 2020).

San Juan et al. (2021), completed a systematic review analyzing 20 papers, of which five were pertinent to the U.S. health system. Themes found in the study results included redeployment components such as redeployment implementation strategies and learnings; redeployed staff experiences and strategies to address their needs; redeployed staff learning needs; training formats offered and training evaluations; and future redeployment and training concerns. Some of the main findings regarding redeployed staff experiences and strategies to address their needs included the finding that staff anxiety and stress was heightened by lack of support and working night shifts. Additionally, having the opportunity to opt-out of redeployment or self-isolate without divulging personal information was a common theme found from the reporting staff (San Juan et al., 2021).

Panda et al. (2021) analyzed the strategies used for the redeployment of healthcare workforce by hospital leaders across the globe during the COVID-19 pandemic surge. Nine hospital leaders from five countries were interviewed (the United States, the United Kingdom, New Zealand, Singapore, and South Korea). The leaders’ responses were categorized into three main themes, process, leadership, and communication which represented effective practices and lessons learned when preparing and executing workforce redeployment plans (Panda et al., 2021). The theme of the process discussed the attempt to balance the clinical surge demands while also attempting to place the redeployed staff in positions with similar skill sets or capabilities. The theme of leadership described the need to have one main source of contact for each designated unit. Participants believed this would assist the training and on-boarding of staff, and the ability to customize learning to each individual. The final theme of communication highlighted the need for transparency. Daily contact with staff regarding educational opportunities, resource utilization, and trends in data or testing seemed to promote a supportive culture among the deployed staff.

Prior to COVID, VanDevanter et al. (2014) completed a mixed-methods study that explored nurses’ experience in the immediate disaster of Hurricane Sandy in New York City and the subsequent deployment. The data revealed major challenges experienced by the nurses related to practice, psychological challenges, and decreased accessibility to usual resources, such as peer and supervisory support, which increased their overall stress of the deployment experience. VanDevanter et al. found sub-themes including concerns about working in an unfamiliar environment, limited orientation to the new unit, professional liability, lack of consistency of assignments, schedule uncertainty, assignment load, psychosocial challenges, experiencing distress, concerns about future employment, and management of the deployment period.

Methods

Findings

Strengths and Limitations

The authors recognize several limitations in this work. Though rich in examples and details, data was collected in a single survey collection, limiting the ability to ask clarifying questions to the participants in the study. During data analysis, it was determined it would have been helpful to understand the practices regarding redeployment at each institution, that is, whether or not the hospital was following Joint Commission best practices for redeployment. Additionally, there is very little published evidence surrounding redeployment and the psychological impact on deployed staff, limiting the context available for analysis of the data. The limited previous evidence surrounding this topic also resulted in the inability to have a more structured framework for data analysis. Future research would benefit from further qualitative data collection and the use of validated instruments on distress and burnout.

Clinical Implications

COVID-19 has required rapid, and at times, drastic, changes to the way hospitals function. The large influx of patients forced changes to staffing models and overall hospital setup. Nurses endured the brunt of these changes and reported finding they were requested to work in specialty units they felt inadequately trained for. The nurse commentary revealed three major concerns associated with redeployments; (1) working outside of one's specialty area, (2) the impact of interpersonal dynamics, and (3) challenges presented by the environment. Despite the complexity of these issues, much can be done to improve the experience of redeployed healthcare staff.

Participants were concerned with working outside of their specialty area. While nurses are licensed as general practitioners of their profession, many specialize in a particular area of healthcare or with a specific patient population. Nurses may go on to receive certification as specialists in their respective areas after satisfying requirements that include years of practice or completion of an advanced training program. Nurses working in critical care environments are required to achieve certification in advanced cardiac life support (ACLS) which prepares them to respond with emergency intervention, whereas nurses practicing in lower acuity environments may not need this certification. Nurse specialization to the level of certification has been linked to improved patient outcomes (Kendall-Gallagher & Blegen, 2009; Nelson et al., 2007).

While this study did not focus on specific certifications of nurses, the concern that nurses expressed regarding care quality and patient safety when working outside of their specialty area necessitates greater conversation. Redeployment practices should honor the skill sets of specialty nurses. Doyle et al. (2020) recommended that redeployed staff be delegated care tasks such as hygiene, rather than being expected to provide specialty care. Redeployed staff were found to be able to provide adequate and timely care when redeployed in a more task-based model.

Health systems may be well served to engage in staff sharing across similar units. In this model, similar units have shared employees that rotate, serving patient populations with similar needs and acuity levels. This practice would be consistent with The Joint Commission (2004) recommendations on staff redeployment, with nursing staff caring for patients that are appropriately matched to their skills and training. Kroh and Hurlock-Chorostecki (2009) reported a shared staffing initiative between two ICUs resulting in nurses reporting higher levels of morale and job satisfaction. Furthermore, as census requirements fluctuated, critical care staffing needs were better met and patient outcomes were not negatively impacted when evaluated through retrospective analysis.

Staff sharing across units addresses the concerns related to working with familiar coworkers. Amid a large majority of negative comments regarding redeployment experiences, working with familiar coworkers was identified as a positive experience by many participants. Alternatively, redeploying nurses and their support personnel as teams may also aid in providing some comfort to redeployed staff members on new units.

If staff sharing or team redeployment models are not feasible, health systems must ensure that nurses receive adequate orientation and are equipped with sufficient training to provide safe patient care. In this study, nurses reported caring for patients of increased intensity from their typical patient assignments without preparation they perceived to be adequate. Brickman et al. (2020) showed that rapid training and deployment of non-ICU nurses into the ICU environment was feasible. They demonstrated this could be completed relatively quickly, and in their case, it was a 3-hour curriculum followed by in-person supervision by seasoned ICU staff. Although follow-up data is not yet available, this type of training system could successfully be implemented into a hospital educational curriculum, over a longer period of time, in anticipation of future increased ICU needs. Hettle et al. (2020) asserted that redeployment practices should focus on sustainability regarding both quality patient care and staff wellbeing.

Establishing a pool of nursing staff who are willing to be redeployed in times of need, and who would receive annual or bi-annual competency checks, could keep their skills up to date and decrease the number of staff who need rapid training in times of crisis. Establishing a pool of nurses who are willing to accept this redeployment is important because research has shown that “frequent floating can lead to staff dissatisfaction and compromise patient safety because a dissatisfied employee may not deliver the same level of care as a satisfied one” (Hendron, 2011, n.p.). Health systems must recognize the skills that registered nurses (RNs) possess in their specialty areas. Every RN is not trained to care for every level of care, and they cannot easily transition from one level of care to another, specifically when moving from non-ICU care to ICU care. Understanding the training required to competently practice within various levels of care should be used to plan for deployment to a more fit unit, mirroring their current practice.

When possible, supplies should be stored and organized in a similar manner from unit to unit (O’Connor & Duggan, 2017). Working in an unfamiliar environment and needing additional time to locate needed supplies can decrease nurse productivity in the redeployed environment (O’Connor & Duggan, 2017). Providing an orientation to the new unit is a needed step for nurse leaders to take when assigning redeployed staff to their units. Consistency in the set-up of unit supply stations can create a sense of familiarity and would aid in this orientation process. Consistent communication regarding the estimated length of the redeployment, as well as a chain of command for expressing concerns, is also needed. Consistency in documentation requirements in the electronic health record (EHR) would also benefit redeployed staff. This was a concern of numerous study participants. Documentation of care is integral to safe patient care, communication between team members, and reimbursement.

Future research should address the mental stress that redeployed nurses have described. Many of the responses from this survey demonstrated that being deployed to an unfamiliar unit, which required a different set of skills, caused emotional and mental stress. This increased stress may contribute to future challenges in nurse retention from their current positions or even the profession as a whole. It is important to consider the context of the greater survey study that was completed by the research team. With healthcare professionals’ mental health and debriefing of environmental concerns being points of focus in the pandemic's aftermath, understanding these experiences is essential. The inquiry aimed to employ the TSQ to assess the prevalence of traumatic stress among American frontline nurses following the initial COVID-19 surge in the United States. Of participants, 185 of the 298 (58.7%), had a positive score on the TSQ, indicating a risk for PTSD (Hernandez et al., 2021). On the TSQ, the participants’ mean total score was 5.88, the median was 6.0, and the mode was 7.0. In clinical practice, 6 is considered a “positive” screening and would prompt a clinician to perform diagnostic interviewing for potential PTSD. This data will enhance the ability of health systems to support redeployed workers and create policies and practices that promote a positive and safe work environment.

Conclusion

The results of this qualitative study add to the existing literature regarding redeployment and the vulnerability hospitals and healthcare staff face during a disaster or pandemic-related events, such as COVID-19. Crisis response includes debriefing. This data can serve as a debrief to assist in understanding nurses’ experiences of redeployment during the COVID-19 pandemic. Hospitals and healthcare institutions must develop a redeployment program to support nurses during a future disaster or pandemic. Healthcare staff who are redeployed should feel valued and supported. Accessibility to resources, information, and open communication can be helpful to reduce uncertainty. Attention to the implications of the redeployment process is necessary to support staff with changes. The findings of this analysis can assist in the formation of new policies to facilitate effective pandemic response in the future that would support nurses to participate in redeployment in a safe and nontraumatic way.