A student nurse in the MICU: Leveraging unexpected leadership on the frontlines of COVID-19.

The early days of the COVID-19 response were characterized, for me, by a feeling of ominous restlessness: a subtle symptom each nurse has been trained to recognize as an early indication of hypoxia. The inability to act was suffocating. Nursing students had been dismissed from clinical locations across Georgia in a matter of hours; Emory's classes were delayed, and then moved online, forcing me into the silence of my studio apartment. I was cornered between directives from my family and professors to stand down and a visceral need to do something.

On the morning of March 21st, I biked the empty mile to Emory University Hospital and reported to the Medical Intensive Care Unit—my first shift back as a patient care technician following Spring Break. I had spent nearly a year in this role and many overtime hours on the Unit Practice Council, but my return did not feel like coming home. The usual bustle of collaborative learning that fills the teaching hospital was replaced with the sound of nervous breaths through wrinkled masks. COVID-19 had just infiltrated the hospital, and our unit was already overwhelmed. As a student care tech, one of my key responsibilities is stocking every room and patient cart with the necessary supplies; but when I reached for the supply closet handle, it did not turn—the masks, gloves, and gowns had been locked. In that moment, I could not help but wonder how the next 12 hours would impact my concept of nursing and the vision I had for my career.

Florence Nightingale, whose 200th birthday happens to be the day after my May graduation, once said, “I attribute my success to this—I never gave or took any excuse.”

What I discovered during that shift was the army of unexpected frontline leaders, redeploying their skills, and leaning into the crisis—no excuses. Patient care technicians were tracking personal protective equipment (PPE) reserves, vetting protocols, and clustering care with registered nurse (RN)s to preserve lifesaving supplies. Unit clerks were explaining Emory Healthcare's no-visitor policy to family members with shared heartache and empathy, and requesting exceptions when appropriate. Chaplains were mindful of patient loneliness amidst the no-visitor policy, becoming a calm voice of support for health care workers and calling (instead of visiting) COVID-19 patients to offset PPE demand. Nursing students were stepping into leadership roles remotely, acting as call center technicians, packing medical kits, donating blood, and delivering supplies to community members in isolation.

While the current demands on nursing leadership are profound, deans and nurse executives must not overlook the natural leaders, emerging around us, through unexpected ranks. Among nursing students, care techs, and support staff, there are untapped solutions to COVID-19 challenges. At this moment, many of these individuals are taking initiative to consolidate and repurpose limited resources to solve problems. Leaders who act swiftly can leverage this energy to improve work flow, reduce cost, and ease stress during this crisis and beyond. For instance, nursing leadership could:

Emory BSNs undergo a professional development series and an evidence-based practice course, which emphasize clinical leadership skills, and have served me well during this time. This training in delegation, communication, and calm under crisis has enabled me to remain poised and work strategically on one of Emory Healthcare's hardest-hit units. There are countless crisis management modules appearing online now, which health systems and nursing schools could share with students and nurses, including the free COVID-19 modules offered by Emory Nursing Experience.

Emerging nurses who are adept in synthesizing literature, clinical practice guidelines, and news sources could help the school or health care facility to develop policies as new COVID-19 evidence unfolds. These updates could inform important curricular changes as well, given that the American Association of Colleges of Nursing (AACN) has recommended nursing schools integrate curricula on COVID-19-related topics, such as PPE, quarantine, and isolation protocols (AACN, 2020).

As of March 30th, a policy brief set forth by National Council of State Boards of Nursing (NCSBN), AACN, and other organizations recommends employing student nurses when appropriate (Policy brief: U.S. nursing leadership supports practice/academic partnerships to assist the nursing workforce during the COVID-19 crisis, 2020) Employment of US-educated international nursing students nearing graduation is especially pertinent because student visas will likely expire before the crisis is over. Utilizing final-year nursing students as assistive personnel will not only ease systemic burden, but will expose emerging nurses to unit flow, foster self-efficacy, and demonstrate crisis management strategies at a time when nurse residency preceptors may have limited time for teaching.

Emory Health care has instituted a series of surveys requesting that employees submit free-text questions and concerns, which are being promptly addressed in daily email updates. This survey could be expanded to ask how workflow and division of responsibilities could be improved at the frontline. Other options for conducting this sort of dialogue could include virtual open forums, staff meetings, and/or post-lecture Q/A sessions.

Last, remember that even the most determined and tireless individuals on your team are facing extenuating circumstances right now. Your people will perform better—on the unit and in the classroom—if you institute support services and policies of flexibility. Alongside their 12-hr shifts, many frontline leaders must now navigate home schooling for their children. Students with learning disabilities must grapple with taking tests remotely or on screen, which may not meet their Americans with Disabilities Act (ADA) requirements. People are coping with the loss of loved ones to the virus, family hospital separations, visa expirations, eviction notices, and the list continues. In their guidance for institutes of higher education, the Centers for Disease Control and Prevention recommends recording all lectures, initiating digital counseling services, and coordinating reliable housing and meals, among other suggestions (CDC, 2020). Consider the unique challenges and needs of your nurses and students, away from the bedside or outside the classroom, and work with them to customize solutions.

During what is arguably the biggest health crisis in the last century, it is more important than ever for nursing leaders to set new expectations for themselves and their teams, rather than pushing to meet old ones. Let us not give or take any excuse, nor squander our best resources during this fight.