key: cord-0811881-34s2r7oh authors: Balluck, Julie; Asturi, Elizabeth; Brockman, Vicki title: Use of the ADKAR® and CLARC ® Change Models to Navigate staffing model changes during the COVID-19 pandemic date: 2020-08-20 journal: Nurse Lead DOI: 10.1016/j.mnl.2020.08.006 sha: 8990288ec1aba69d04a78c8fb3566fbb5dae7046 doc_id: 811881 cord_uid: 34s2r7oh Abstract In early 2020, hospitals faced unprecedented patient volumes resulting from the COVID-19 outbreak. Nurse executives at a faith-based, not for profit healthcare system, quickly responded to ensure safe staffing, conservation of personal protective equipment (PPE) and implementation of infection prevention strategies. A significant challenge was safe staffing for the expected patient surge. To address this, a team of nurse executives utilized the ADKAR change model to guide a transition from primary to team nursing. The processes varied between hospitals, but core principles and implementation strategies were the same. This article will discuss the quick but methodical journey one health care system experienced. In early 2020, the world collectively faced a global pandemic that challenged modern healthcare as never before. As the COVID-19 crisis unfolded, nurses across the country were faced with the challenge of managing a high volume of patients with an emerging infectious disease, the stress of personal protective equipment (PPE) shortages, while simultaneously implementing ever-changing guidelines around infection prevention strategies. At the same time, hospital routines and processes drastically changed to ensure social distancing, increasing bed capacity for the anticipated surge of patients, and new clinical practices to ensure staff and patient safety. A significant challenge for nursing leaders was how to prepare for the anticipated surge in patients, particularly for those requiring critical care if there was a mismatch of supply and demand of nursing staff. To address this issue, a team of nurse leaders at the faith-based, 25-hospital Texas Health Resources healthcare system utilized the ADKAR® and CLARC® change models to guide a change in the staffing model from primary nursing to team nursing. This model allowed nurses to be safely deployed, and practice within the systems hospitals from areas that had services closed or significantly decreased. Even though the processes varied between small, medium and large hospitals, the core principles and implementation strategies were very similar throughout the system. Team nursing is a care delivery system model developed in the 1950s, in which a team of clinicians shares responsibility for a group of patients under the direction of an J o u r n a l P r e -p r o o f RN. 1 The original design of team nursing was in response to a nursing shortage, and this was the primary reason we chose this model. 1 The implementation of the team nursing model was part of our emergency planning response to the likelihood that we might have more patients than nurses, due to the increasing number of patients with COVID-19, as well as the possibility of nurses becoming ill themselves. With team nursing, coordination of care is shared by members of a group; the team may include registered nurses (RNs), licensed practical nurses (LPNs) and other nursing personnel, but the team leader is most often a RN. 2 The team holds shared responsibility and accountability for a group of patients. A care team using the team nursing model is a group of care providers of varying skills and training levels working together to provide care for a group of patients. 3 We believed the team nursing model would allow us to capitalize on underutilized and available nursing resources, such as those from outpatient clinics and procedural areas. At the time, elective procedures were placed on a State ordered hold for several weeks to ensure staffing, supply and hospital capacity resources were conserved. With team nursing, providers usually care for a larger group of patients. This allows each caregiver to leverage their individual skills, competency and talent to care for patients, when demand exceeds staffing resources. Typically, in a team nursing model, the team leader coordinates care and utilizes team members most efficiently and effectively to meet the patient's needs. 3 There are various roles on the team, based upon composition. Still, a collaborative approach allows for patient care needs to be J o u r n a l P r e -p r o o f met, while also reassuring staff they would not be in a situation where patient safety would be compromised, and the integrity of their license would be maintained. At Texas Health, we were fortunate to have more time on our side to plan and prepare than many of our colleagues in other parts of the country. The time allowed us to quickly conduct basic nursing competency refresher labs for those nurses who had been out of the acute care and intensive care settings for an extended period. The Texas Health Resources University (THRU) team quickly mobilized these skill labs and competency checkoffs to allow our labor-management pool to assign staff, based on skill level and clinical competence. Team nursing is a more productive option when utilizing staff who are not familiar with a unit or not familiar with some tasks. Tasks were delegated based on competency rather than patient assignment. 4 Additionally, using a change management tool to quickly educate and deploy the team nursing care model, it allowed this change to be entity and even unit specific, depending on the current status of staffing resources. While deploying team nursing was initially planned as a temporary solution to ensure safe patient care, this conceivably could be used beyond the initial crisis brought on by COVID-19 as a tactic to manage future crisis which may impact staffing resources. Executive RN sponsor (officer) and sponsor coalition: Nursing officers and directors responsible for making decisions and giving direction that impact the care team. Sponsors are responsible for: • Being active and visible in leading initiatives • Approaching change with a positive attitude and proactive mindset • Using both the ADKAR® and CLARC models to lead themselves and others through change (see references for more information) • Developing just-in-time training or a resource manual for the team to quickly orient and be brought up to speed on recent updates. • Address questions or concerns raised by the nursing staff or providers Primary RN (Team Leader): Home unit RN who is assigned to a group of rooms or patients to coordinate and supervise care. This RN is responsible for, but not limited to: • Complete initial admission, physical assessment, patient screening, medication administration and reconciliation and to delegate tasks of care. • Complete head-to-toe physical assessment 1. We change for a reason. In our case, it was in response and part of our emergency planning related to the anticipated surge from the COVID pandemic. Although moving from primary nursing to team nursing would impact almost our entire nursing team, staff verbalized relief that there was a plan in place to manage the unknown ahead. There was a consistent message and a unified approach to the plan from the top down. Ongoing evaluation was necessary to elicit feedback and monitor the level of morale, while identifying barriers, crucial to navigating change. It was important for Primary RNs to arrange for the team to meet at regular intervals daily/weekly to brief on new developments of information and provide a supportive role. 2 The nursing leaders used the CLARC® model to lead our teams by playing the following roles throughout this change: • Communicator: Explain why changes are being made and how they impact the team and their patients. • Liaison: Report to sponsors (senior leaders) how the change is impacted and being received by your team and share information from leadership with your team. • Advocate: Demonstrate your commitment to the change and promote a positive attitude. • Resistance Manager: When resistance to change arises, make time to understand and address the root causes of resistance. Using the above CLARC principles to support the teams during this event facilitated a smooth transition which we believed was due to the intentional communication and ongoing presence of leaders who made themselves available to discuss concerns, address immediate issues, and provide overall reassurance. One example of this occurred at a smaller entity when staff exhibited some resistance because they did not feel their roles were clear. The CNO and nursing leaders used additional tools from CLARC to work through the concerns, assisting in clearly defining the staff patient care responsibilities with the team nursing model. ADKAR® is an acronym that represents the five tangible and concrete outcomes that people need to achieve for lasting change (Table 1) . 6 Below, we outline these outcomes and how they looked at Texas Health during this process. needed about the team nursing model and who should share that information, such as the sponsor (CNO) and entity nursing leaders. Although we did not have all the answers, it was necessary to over-communicate in an open, direct and honest way. We were truly in it together. Desire to support the change: Leaders identified how willing our nursing team was to participate in the team nursing model and approach. We discovered that most of our nurses wanted to help in whatever capacity he or she was able to do so safely. We initially received hesitation from our operating room (OR) staff. Once they understood this was a task-driven model, they volunteered to lead the proning efforts for our J o u r n a l P r e -p r o o f patients in the ICU, leveraging their expertise related to safe patient positioning, a critical skillset in the OR. Knowledge of how to change: We shared information in various forms on team nursing and how it would look at each of our entities. During leader rounding and townhalls, we validated that individuals had an understanding of the team nursing model and why we were taking this approach. Ability to demonstrate skills and behaviors: As we set up skill refresher classes for some of our nurses from non-traditional practice areas, we validated which individuals who could support the team nursing model and approach. This also included educating our nurse managers and supervisors on this nursing care delivery model, as this was new to them too. Reinforcement to make the change stick. We identified how and who should reinforce the use of the team nursing model/approach. This included daily shift safety huddles led by the nurse manager or charge nurse to check in with the team and receive feedback on how to maintain this change. Outcomes related to patient quality and safety continued to be measured during this change in our patient care delivery model. We found our outcomes remained consistent at similar levels to what we measured with primary nursing. When hospitals were faced with unprecedented patient volumes resulting from the COVID-19 outbreak, Texas Health nurse executives needed to utilize a rapid cycle change model to prepare for a variety of scenarios. While keeping patient safety and nurse satisfaction as a priority, the nurse executive team quickly responded by J o u r n a l P r e -p r o o f developing an alternative staffing model based on a team nursing approach, to ensure safe staffing. By using the ADKAR® and CLARC® change models to guide a change from primary to team nursing, they were able to put plans in place to meet the demands, whether it was caused by a decrease in the available workforce, or a surge of patients. The processes varied between hospitals, but core principles and implementation strategies were the same. As a result, the goal of the safe patient staffing was achieved, and plans remain relevant in the event there is another situation to warrant a change in our primary nursing care delivery model in a short period of time. J o u r n a l P r e -p r o o f Team nursing: Experiences of nurse managers in acute care settings Medical Dictionary for the Health Professions and Nursing © Farlex Team nursing: A collaborative approach improves patient care The trials and tribulations of team-nursing Change management the people side of change The Prosci ADKAR Model