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Abstract
Background The emergence of the COVID-19 pandemic led to an increased demand for hospital beds, which in turn led to unique changes to both the organisation and delivery of patient care, including the adoption of adaptive models of care. Our objective was to understand staff perspectives on adaptive models of care employed in intensive care units (ICUs) during the pandemic.
Methods We interviewed 77 participants representing direct care staff (registered nurses) and members of the nursing management team (nurse managers, clinical educators and nurse practitioners) from 12 different ICUs. Thematic analysis was used to code and analyse the data.
Results Our findings highlight effective elements of adaptive models of care, including appreciation for redeployed staff, organising aspects of team-based models and ICU culture. Challenges experienced with the pandemic models of care were heightened workload, the influence of experience, the disparity between model and practice and missed care. Finally, debriefing, advanced planning and preparation, the redeployment process and management support and communication were important areas to consider in implementing future adaptive care models.
Conclusion The implementation of adaptive models of care in ICUs during the COVID-19 pandemic provided a rapid solution for staffing during the surge in critical care patients. Findings from this study highlight some of the challenges of implementing redeployment as a staffing strategy, including how role clarity and accountability can influence the adoption of care delivery models, lead to workarounds and contribute to adverse patient and nurse outcomes.
- Nurses
- COVID-19
- Duty Hours/Work hours
- Teamwork
Data availability statement
No data are available.
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WHAT IS ALREADY KNOWN ABOUT THIS TOPIC
Healthcare organisations globally were required to move away from conventional models of patient care delivery to manage the unprecedented surges in patient care that came with the COVID-19 pandemic.
WHAT THIS STUDY ADDS
This qualitative study of nurses identified effective elements of adaptive team-based models of care employed in intensive care units during the pandemic, challenges experienced with these pandemic models of care and areas for consideration in implementing future adaptive care models.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Findings from this work highlight areas for consideration when adapting alternative models of care in hospital settings and inform healthcare leaders of the importance of forward planning for future pandemic situations.
Introduction
Healthcare models of care underwent extraordinary change after the 2020 WHO declaration that the COVID-19 outbreak was a global pandemic. Healthcare organisations globally have since struggled with unpredictable, highly complex staff management decisions as new variants were identified and different waves of the virus created unprecedented surges of patients requiring admission to acute care settings. These multiple, ongoing complex situations demanded departures from conventional models of patient care delivery, most apparent in critical care intensive care units (ICUs) as nursing and other healthcare staff were mobilised to meet pandemic patient care needs.
Traditionally, the impetus for changing models of care has been organisational leadership beliefs, fiscal considerations and nursing staff shortages.1 With the emergence of the pandemic, increased demand for hospital beds led to unique changes to both the organisation and delivery of patient care. The COVID-19 pandemic resulted in the need to ensure appropriate care provision for the surging volumes of critical care patients that overwhelmed ICU bed capacity globally.2–9 The Society of Critical Care Medicine (SCCM) in the USA urged hospitals to ‘adopt a tiered staffing strategy in pandemic situations’.6
Adapted from the Ontario Ministry of Health Plan for an influenza pandemic,10 the SCCM tiered staffing model augments experienced ICU staff with non-ICU staff from a variety of health disciplines (eg, physicians, anaesthesiologists, non-ICU nurses, pharmacists, respiratory technologists, etc).6 In tiered staffing models, staff work together as a team to provide care for a group of patients organised together in a hub or pod, with ICU staff performing specified elements of care that require their highly specialised knowledge, such as mechanical ventilation, while non-ICU staff perform other care tasks for which they have the expertise to support patients overall.3 4 6 8 9 11–14
The teams were organised in a pyramid structure, with a designated care provider leading the team (figure 1). A document was developed by the provincial Critical Care Command Centre to guide healthcare settings in the implementation of team-based models of care for increasing health human resource capacity in response to COVID-19 surges in both acute and critical care settings.15 The guidance document included planning, implementation, and evaluation materials that sites could adapt to their individual settings. This involved providing team members with educational materials and hospital guidelines outlining infection prevention education, personal protective equipment training, disease management, role expectations and scope.15 Indeed, the team-based model of care developed by Critical Care Ontario to address staffing during the COVID-19 pandemic in February 2021 has been acknowledged by the American Hospital Association as an exemplar that serves as a guide to organisations for planning and implementing models of care during a crisis.11 Throughout the COVID-19 pandemic, the study ICUs implemented these team-based models with patients organised into pods based on acuity to coordinate care delivery.
Critical care team-based adaptive model of care. *Adapted from Critical Care During a Pandemic (April 2006), htps://www.cidrap.umn.edu/sites/default/files/public/php/21/21_report.pdf.37 Key considerations: (1) a team-based concept will be applied uniquely in each organization; (2) critical care and non-critical care trained individuals work together in teams and (3) additional skills education to support staff who do not ordinarily work in critical care. RN, registered nurse; RPN, registered practical nurse.
The unique aspect of COVID-19 staffing models of care was the redeployment of staff to ICU from non-critical care units, an unprecedented approach necessitated by the severe staffing challenges caused by the volume of sick patients entering the health system. The focus of the new team-based staffing models was on effective management of the sudden surge in critically ill patients and also maintaining quality care and staff safety.7 Indeed, these models are best described as adaptive because of their dynamic nature and amenability to alteration in response to patient care demands and as providers adapted to unfamiliar units, teams or practices.2 5 9 16 17 Canadian hospitals also faced an influx of COVID-19 patients requiring critical care and moved to team-based ICU models of care to maximise health human resource capacity during pandemic surges.
Understanding the effectiveness of the adaptive models of care implemented during the pandemic can inform future health leadership decisions on staffing, work environment and care delivery. Our study aimed to examine staff perspectives on adaptive models of care employed in ICUs during the COVID-19 pandemic.
Methods
Design
We used a descriptive interpretive qualitative design to explore staff nurse and nursing management team perspectives of the adaptive models of care implemented in hospital ICUs during COVID-19 through focus group interviews.18–22 A descriptive-interpretive research design was appropriate as it includes a range of widely practiced qualitative methods that involve asking open-ended exploratory research questions to guide the study, gathering verbally expressed experiences to answer these questions, meticulously and systematically analysing these accounts, achieving a descriptive-interpretive comprehension by carefully and accurately representing the meaning of the reported experiences.20 Following this, the design includes arranging these understandings into groups of similar experiences and observations (categories, themes, codes, etc); acknowledging and disclosing researcher interests and preconceived notions, as well as organising concepts (if applicable) that may aid in understanding and organising experiences, observations and categories and integrating categories into a cohesive narrative discussion.20
Focus groups are useful when researchers are seeking a range of ideas or feelings about a topic and wish to uncover factors that influence individual perceptions21 while allowing individuals to express themselves freely as part of a group.22 Focus groups aid in understanding different perspectives between groups or categories of people, for example, where individuals in decision-making positions such as management team members may perceive situations differently than staff who are not in managerial roles.21 It was particularly important in this study to capture the specific knowledge and experiences that staff identified through a focused discussion on the implementation of adaptive models of care during the pandemic, as no previous experience working in these models of care exists. In addition, identifying learnings from the perspectives of the staff working within these adaptive models of care is essential to informing care models for managing care during future pandemic situations. The study followed the COnsolidated criteria for REporting Qualitative research (COREQ).23
Setting
The study was conducted in eight hospitals from an academic health network in a large urban community in Canada, comprised of over 6.5 million people. This health network functions as the tertiary and quaternary care hub for the sickest and most complex specialised patients in the region. All study sites had implemented team-based models of care in their ICUs following the provincial guidance document; thus, the adaptive models were relatively homogenous in nature.15
Sample
We used a purposive sampling approach to recruit direct care staff (registered nurses) and members of the nursing management team (nurse managers, clinical educators and nurse practitioners) to maximise diversity of perspectives.24 Diverse groups of individuals provide a broad span of knowledge, expertise and viewpoints in focus groups that can guide the development of resolutions for dealing with complex situations.25 Study participants came from 12 different ICUs stratified across the eight study hospitals. Separate focus group interviews were set up with staff and members of the management team, with participants in each of the staff and management team focus groups coming from across the different hospitals and ICUs.
Individuals from each group were recruited via a study email in which the potential participants were provided with a letter of information about the study that outlined the background and purpose of the study and provided details on the study methods, procedures and consent process. We aimed to recruit five staff from the direct patient care group and four from the management team at each site to achieve sufficient levels of information to achieve thematic saturation of the data.21 A smaller number of management team members were sought at some sites as participants due to the lower presence of such members in each patient care unit in contrast to the nursing staff. The sampling requirements were achieved with 45 direct care nursing staff and 32 management team members (19 managers, 10 educators, and three advanced practice nurses) participating (see online supplemental appendix 1).
Supplemental material
Patient and public involvement
Patients and the public were not involved in this research.
Interview guide
The interview guide aims to focus the group discussion while inspiring conversation about the research and making certain that all the desired information is pursued in a similar manner with each group.26 Healthcare providers worked together in teams during the pandemic, and the study investigators were interested in the team-based models of care implemented during the pandemic; thus, the decision was made to develop a semistructured interview guide comprised of six open-ended questions relevant to all team members (see online supplemental appendix 2). Interview guide topics included information about the adaptive model of care implemented, identification of what made an effective or less than effective model of care, workload challenges experienced with model enactment; and systems needed to support the implementation of future adaptive models of care.
Supplemental material
Data collection
The interviews were conducted virtually using a video conferencing platform; participants called in from different sites, primarily from a workplace office or meeting room. Only the study investigator and research assistant were visible on the video conferencing screen. Prior to commencing each focus group session, we reviewed the study information sheet with participants. This covered the study’s objectives, the discussion procedures (including the intention to audio record them), potential risks and benefits, as well as measures to safeguard privacy and maintain the confidentiality of participants’ responses. We made sure to address any queries from participants before obtaining their verbal informed consent, which was recorded at the start of the session. Participants were encouraged to freely discuss their experiences related to the questions outlined in the interview guide. The interviews were conducted from May to October 2022, with the majority ranging between 50 and 55 min in duration, as they were conducted virtually while the pandemic was still underway.
Data analysis
The interviews were audio-recorded and transcribed verbatim. Transcriptions of the focus groups were analysed, and themes from the data were developed by applying thematic analysis following the stages outlined by Braun and Clarke.27–29 In the data analysis process, NVIVO V.12, along with traditional pen and paper methods, was employed. Phases of thematic analysis included: (1) familiarisation with the data, which included reading and rereading the data and noting initial ideas; (2) systematically generating initial codes across all of the data by including data relevant to each code; (3) searching for themes by gathering and collating data relevant to the potential themes; (4) reviewing and checking the themes and generating a thematic map; (5) defining and naming themes through ongoing analysis and (6) reporting on selected compelling examples from the analysed data.27–29 Transcriptions from the first interview were reviewed by the lead researcher, preliminary codes were assigned, and initial themes were developed. These initial themes were then reviewed, discussed and further reanalysed by a second member of the research team to ensure consistency and make sure information shared during the interview was clarified to enhance the trustworthiness of the analysis.28 This iterative process was repeated after the second interview, with both researchers reading through the transcripts, assigning codes, integrating codes into existing themes and developing new themes. For the remaining interviews, transcripts were read, and themes were reviewed as the data were grouped and sorted based on themes that occurred most frequently and were considered representative of overall meaning to participants, thereby ensuring data saturation and rigour in the data analysis.21 27–29 In this way, content from the data guided the development of the main themes and subthemes emerging in the final analysis (see online supplemental appendix 3).
Supplemental material
Results
The thematic analysis uncovered three key themes about adaptive models of care (figure 2): (1) effective elements, (2) challenges experienced and (3) areas of consideration for future implementation moving forward. Further analysis identified subthemes for each theme. Effective elements of the adaptive models of care comprised subthemes relating to (1) appreciation for redeployed staff, (2) organising aspects of team-based models and (3) the ICU culture. Challenges encountered with the adaptive models of care included subthemes of (1) heightened workload, (2) influence of experience, (3) disparity between model and practice and (4) missed care. Subthemes related to areas for future consideration moving forward were: (1) debriefing, (2) advanced planning and preparation, (3) the redeployment process and (4) management support and communication. Little discordance between staff and management team member views was noted in the analytic process, with the exception of the final thematic area of ‘moving forward’ in the future, where the majority of comments emerged from staff.
Key themes related to the utilization of adaptive intensive care unit models of care.
Effective elements of adaptive models of care
Appreciation for redeployed staff
Introducing adaptive models of care allowed redeployed nurses to provide additional support to ICU staff, for whom a great deal of gratitude was voiced, providing a sense of relief at a stressful time.
When the redeployed nurses came I was like ‘oh my God, this is amazing. We get help’. We were super thankful for them. (Staff # 30)
I think most of the ICU nurses loved them. They were such a help with workload. A lot of them wanted to learn, so it was a very positive kind of atmosphere. (Manager # 108)
Organising aspects of team-based models of care
Participants’ views showed that characteristics inherent to the adaptive model of care contributed to care effectiveness, including the structural configuration of the pods, gaining a broader knowledge of all patients in the pod and improved care coordination within a small team.
Grouping patients into a pod, not just having one big unit, and having a designated leader in that pod was helpful…We were our own little community in the pod where we were able to fixate on those specific patients. (Staff # 07)
Getting report on the entire pod was new for me. You knew what was going on with everybody around you. You were more able to help each other out because you knew who the sickest patients were and everybody was on the same page. (Staff # 42)
…they were able to work with a smaller group of staff and patients rather than trying to coordinate half the unit or the whole unit. There were extra hands and the opportunity to delegate some work. (Manager # 101).
ICU culture
The important role of the ICU staff and nurse educators in supporting the integration and sustainment of redeployed staff into the adaptive models of care was very clear.
The ICU nurses were very, very supportive to the redeployed staff…At our hospital we were always buddied with an ICU nurse, even when we had finished orientation. (Staff # 05)
The nurse educator was the key to the success of redeployment…She was always visible, set the tone, let us know what the expectations were, and was always there for us. I was redeployed for 11 months and always felt comfortable and safe because of her. (Staff # 23)
Several participants attributed model success to the particular ICU, the staff and their commitment and moral approach to care.
The team that we worked with were mainly senior experienced nurses that were able to delegate. We worked well together. I think that the specific ICU that management picked for the pod model of care was what made it work. (Staff # 37)
ICU nurses have a very high standard of care. I would speculate that any success from these models had a great deal to do with the culture of the staff involved in providing the care. They felt like they had a moral obligation to these patients that were suffering so much. (Manager # 113)
Challenges with adaptive models of care
Heightened workload
Study participants frequently acknowledged the unprecedented physical and cognitive workload experienced with multiple surges of very ill COVID-19 patients, emphasising the additional workload caused by supervising and teaching new team members.
We had increased patient-to-nurse ratios and they were patients of an extremely high acuity. If you had a patient like that…prior to the pandemic, it would have been 1:1 nursing, or even two nurses to that one patient. (Staff # 44)
It was a combination of both physical and mental workload. When we changed to the adaptive staffing model the patient ratios were quite astronomical. We were seeing a 1:4 or 1:5 patient load for one ICU nurse in a pod. And that ICU nurse was supervising all of the redeployed staff. (Staff # 11)
They did a lot of coaching and teaching which, along with having to manage three or four ICU patients on their assignment, was an added stressor. (Manager # 109)
Influence of experience
Further challenges in implementing the new model of care highlighted the importance of nurse experience in caring for complex ICU patients. Experienced nurses spoke of the toll of unpredictability, which demanded flexibility as they adapted how they educated and redeployed staff.
For those that hadn't had critical care experience, it felt like we were training these redeployed staff …There was no consistency. You wouldn't know until the shift arrived how much education or re-education you had to do, how much oversight was needed. (Staff # 35)
It was difficult - you had to be flexible. One day you were working with a deployed nurse with 20 years of experience and the next shift…with somebody that had one or 2 years of experience. (Staff # 14).
The ambiguity surrounding role clarity and practice scope with redeployed nurses was an added challenge.
Every day was an unknown. They would begin each shift with the redeployed nurse by having a discussion surrounding their experience and capabilities and what they felt safe doing. Then…assign them duties and responsibilities. This became an element of every shift, every day during the pandemic. (Educator # 124)
Delegation to the redeployed staff was never clear. The roles of the deployed staff seemed very limited. Some were very hands-on and involved in the care and others …only when called on. And some would operate like ward aides, not practicing to scope. You had to integrate them in and find appropriate work tasks for them. That was an additional challenge that was borne by the ICU RN. (Educator # 129)
Disparity between model and practice reality
Participants identified a lack of congruence between the proposed model of care in contrast with what actually took place in practice.
The main issue for me was the plan on paper was ‘xyz’ acuity of patient and ‘abc’ staffing. If patients with that acuity had come in, it might have worked…, but the acuity was double or triple what was expected. (Staff # 21)
When we implemented the adaptive model of care the ICU nurses were to do the critical care elements of care. However, there ended up being lots of critical care elements and not a lot of basic care that the redeployed nurse felt comfortable handling. (Manager # 104)
Staff modified the proposed model of care, moving away from the team-based approach and back to their original ICU primary model of care.
We didn't do what our hospital had laid out for us. We completely re-adapted it and stuck with our primary care model. When the redeployed people came, we sat and had a little huddle with them and we said ‘okay, listen, this is what we'll do’…and we came to an agreement. (Staff # 29)
You know, they actually reverted back to primary care. The planned model was a team nursing model which is not what we normally do - we do primary nursing. (Manager # 106)
Participants also emphasised that infection control guidelines implemented by the Infection Prevention and Control (IPAC) department related to the management of COVID-19 patients proved limiting to the implementation of the proposed care models.
The idea was that our work could be divided up into tasks, with somebody doing the feeds, somebody else doing the baths, somebody else the basic patient care. But…We were instructed by IPAC to cluster our care. That meant going into the room, doing all the care at once, and getting out of the room to reduce our exposure. So these models couldn't work out as planned, they weren't practical. (Staff # 36)
Missed care
Concerns with care left undone were described when discussing the need to prioritise care within and between acutely ill patients.
If there’s only 70% or less of nurses available for care, head-to-toe repositioning at least twice a shift becomes more of a guide than a practice. You had to skip some care. If I don't have time, that patient’s going to get turned when I can…And not doing the repositioning, we saw patients develop more pressure injuries. (Staff # 3)
Oral care was one of the first things to go, also wound care and dressing changes. A dressing starting to come off for a central line, normally I would change it. But if I was really busy….I have to prioritise and go and do my meds. (Staff # 19)
People didn't report as many patient incidents. They either didn’t have the bandwidth to or they just weren't able to pay the attention they needed to. Things were probably missed. I'm sure they were. (Manager # 119)
Omitting care had a personal impact on staff, causing moral distress from not being able to provide their usual high standard of ICU patient care.
You don't want to give bad care to the patient, so it would create moral distress. You want to do a good job, so it would suck when you feel like you're not doing total care or you know that you missed stuff that day. So you go home upset and unsatisfied. (Staff # 41)
Moving forward with adaptive models of care
Debriefing
Participants indicated that the termination of the adaptive care models was sudden, with limited follow-up, acknowledgement of or evaluation of them.
When the pod model of care finished, and the hospital got back to normal, there were no meetings, no reviews, nothing. It was just here one day and gone the next - as if nothing even happened. Absolutely no communication and no follow-up by anyone…with us. (Staff # 10)
I arrived at the ICU for my shift one day and was told we were done. And sent back to my own unit. No one thanked us. No one spoke to any of us to ask us how it went, what could be done better. (Staff # 27)
Advanced planning and preparation
Participants found that better advanced pandemic planning and preparation are needed going forward, especially as it relates to ensuring redeployed staff work at full scope and that the unique features of specialty nursing practice are actively considered.
The preparation of the redeployed staff needs further work. A lot of times it felt like there was an RN standing next to me but they were practicing as an aide. So really getting that group prepared and ready to engage…Bring out their skills, their expertise, their leadership and truly take some of the burden off of the ICU nurses. (Staff # 25)
We have different specialties and you have nurses going into those for a reason. You can't make an ICU nurse in two days, just as you can't make an oncology or a cardiology nurse in two days. All of those skills and the critical thinking that you develop, comes with the experience of working in a field with those specific patients, over a period of time…I think what the institutions forgot is that ‘a nurse is a nurse is a nurse’ is not the case. (Staff # 09)
Preparation for the COVID-19 pandemic was felt to have focused more on redeployment efforts, overlooking the importance of education for ICU nurses in implementing team-based models.
The team-based nursing approach is difficult for ICU nurses. We’re used to having control of what’s going on and knowing everything from tip to tail about our patients. To switch to team-based nursing was something that I have never learned or functioned within my practice, so it felt not as safe…It was a big frame of mind shift for us. (Staff # 33)
Participants thought it was important that future implementation of adaptive models be supported more fully by organisational processes.
During a pandemic you’re trying to onboard and orient so many people you really need human resources to work proactively. You need processes to implement this model of care. At a corporate level, they need to pull the names of all the nursing staff across the units who have critical care experience, identify their experience and education, and create an internal nursing pool. The processes to ensure we have somewhat of a smooth transition for team members coming into an ICU environment should be created now and be at the ready. (Educator # 126)
Redeployment process
Redeployment processes varied across hospital sites. Improving transparency around the operational and logistical processes of redeployment was emphasised as a key issue.
They came from everywhere, all over the hospital. Some were volunteers some were voluntold. (Staff # 38)
I can't tell you how many registered nurses work in ‘professional practice’ roles, deemed essential to stay in those roles during such a crucial time, that they couldn't be redeployed…in some capacity…We were working short-staffed, taking double and triple assignments in the ICUs. (Staff # 40)
I think if people could volunteer to be redeployed that might be better. While I understand that’s not how things could work during the pandemic, we know from this experience that it would be better if we got staff who wanted to be here. (Educator # 123)
Management support and communication
Variation in management visibility and support was recognised by participants, who saw a greater management presence in the early stages of the pandemic than later ones.
In the first wave, we saw the senior nursing team, sometimes the CEO, they came around, they spoke with us. Then all of a sudden it was just gone. I think a lot of us felt very unsupported after that, and there was so much uncertainty, things were all over the place with information changing so often. Our clinical manager was there every day and doing her best to be supportive, but I didn't see anyone above her once the second wave began. (Staff # 45)
Gaps in communication were evident, perhaps reflective of the speed with which the adaptive models were implemented during the surge in COVID-19 cases; participants described limited staff preparation and a lack of written policies on practice accountability.
Very little preparation took place. Essentially you went on your days off and there wasn't a pod model, and came back and there was a six-bed pod with very critically ill patients and a binder to refer to. We had very little guidance on how that pod was to be managed. (Staff # 04)
We take our scope of practice very seriously…the College of Nurses was very clear that our accountability remained unchanged with these new care models. They even posted a statement to this effect on their website. So, at the end of the day, it was the ICU nurse who was liable for patient care…there were no clear policies in place to back us up regarding the staffing model and what the redeployed nurses could really do within it. (Staff # 22)
Discussion
Findings from this study provide insights into how adaptive models of care implemented in hospital ICUs during the COVID-19 pandemic were experienced by nurses and management team members. Participants highlighted their gratitude towards redeployed colleagues, who in turn emphasised the positive and supportive culture they encountered from ICU staff and educators.
ICU care is typically organised around a primary delivery model where one nurse is responsible for planning and delivering a patient’s care.1 It is not uncommon for ICU staff to lack familiarity or practice experience working in team-based nursing models organised in pods or groups, as seen during the pandemic. Despite this, participants noted some aspects of team models were useful in supporting ICU patient care, including hearing reports on all patients in the pod and working together as a smaller group.
Higher levels of nursing workload related to patient complexity, acuity and volume have been widely reported to be related to caring for COVID-19 patients.30 31 The distinction with this study is the additional cognitive workload burden that ICU nurses faced when adopting models of care comprised of redeployed staff. In these models, the critical care-educated ICU nurse was responsible for planning and coordinating patient care, task delegation and team oversight.8 Additionally, they provided direct patient care when the redeployed nurse did not, often while responsible for their own patient care assignment.
The importance of experience and specialty preparation for nursing staff providing complex patient care was reinforced in this study. Much of the added cognitive workload experienced by ICU nurses resulted from the need to assess the readiness for the practice of the redeployed nurse and provide on-the-spot education. This, combined with the fluctuating complexity of patients during different waves of the pandemic and changing infection control practice guidelines, complicated care model implementation.
The disparity between the planned model and practice may have led ICU nurses to create workaround solutions, reverting back to primary nursing to solve role clarity problems they faced with redeployed staff.32 Similarly, staff shortages during COVID-19 resulted in reprioritization of patient care, delayed or missing care and potentially contributed to adverse events. This rationing or inability to provide care because of resource limitations33 resulted in nurses experiencing moral distress and dissatisfaction and impacted their home and work-life balance.
Comments from participants differed between staff nurses and management team members within the theme related to areas for future consideration moving forward, in particular in the sub-theme areas of ‘debriefing’ and ‘management support and communication’. Debriefing after critical events is acknowledged as a key element in improving team culture and patient safety in healthcare.34 Study participants had not been debriefed as of the time of the focus groups, a reflection, perhaps, of the somewhat ambiguous trajectory of the pandemic while this study was underway. Organisations remained poised to reimplement adaptive models of care in the event of another care surge. At the same time, participants appreciated the recognition and acknowledgement of their efforts and the challenges they faced. It was not until May 2023 that the head of the WHO declared that COVID-19 no longer qualified as a global emergency.35 As organisations stabilise and pandemic protocols scale back, it will be crucial for management teams to seize opportunities for reflection and debriefing on staff experiences during COVID-19. This will help ensure that future responses to similar situations are robust and effective.
This study underlines the importance of advanced planning and preparation for critical events, including engaging IPAC and staffing services to alleviate some of the challenges experienced here. This includes ensuring adequate education of redeployed staff so that they work to their full scope of practice while acknowledging the depth of knowledge required for specialty nursing areas like the ICU. Education for team members and others leading teams about the adaptive model of care was also emphasised. Our study also shows that organisational, data-driven systems, as well as a pool of experienced staff, are key to the smooth implementation of adaptive models of care. We learnt from our participants that these systems should include information on staff specialty experiences, such as working with teams and leading teams, skill level and interest in a redeployment experience. Transparency around personnel selection and the voluntariness of approaches were also noted. Redeployment of non-ICU-educated staff to critical care environments was a unique staffing approach to emerge with the COVID-19 pandemic, which may explain the variations in approaches described.
Finally, it is clear from our work that, similar to other studies conducted during the pandemic,7 9 36 leadership and management support, communication and visibility play a pivotal and ongoing role during critical events. Implementation of mechanisms to enhance management visibility and support for nursing staff in models of care that emerge following the pandemic is essential to creating stable work environments that are focused on nurse retention.
Conclusion
The implementation of adaptive models of care in ICUs during the COVID-19 pandemic provided a rapid solution for staffing during the surge in critical care patients. Findings from this study highlight some of the challenges that can occur when implementing redeployment as a staffing strategy. Further research exploring the sustainability of redeployment in relation to staff satisfaction and retention is needed to inform models of care for use in emergency or communicable disease epidemics in the future. We showed that role clarity and accountability can influence the adoption of care delivery models, particularly those that are team-based. Workarounds and missed and delayed care resulting in adverse patient and nurse outcomes are the ripple effects of rapid organisational change. It is imperative for healthcare leaders to debrief staff on models implemented, update education and preparation plans and ensure internal data systems exist to enable rapid, transparent deployment in future health human resource challenges.
Limitations
The main limitation of our study stems from conducting all interviews within healthcare settings in a large metropolitan area that primarily caters to very ill patients, thereby potentially limiting the generalisability of the findings to mid-sized or smaller hospital settings. In addition, the inclusion of staff from different healthcare professions (eg, medicine, respiratory technology) that played major roles in the care delivered to ICU patients during the COVID-19 pandemic may have provided a more complete picture of the adaptive models of care.
Data availability statement
No data are available.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the university health sciences research board (Protocol #: 00042034), Hospital A (REB#2022-2973-10114-4), Hospital B (REB#22-0007), Hospital C (REB# 22-0038-E), Hospital D (5305), Hospital E (REB Ref. # 860-2203-Mis-375), Hospital F (REB ID#1077), Hospital G (REB #22-5232) and Hospital H (REB# 22-033). Participants gave informed consent to participate in the study prior to taking part.
Acknowledgments
We want to acknowledge the 14 nurse executives of the academic health sciences network for their support for this study and the site contacts from the eight participating sites for facilitating access to the institutions and their Research Ethics Boards. We also want to thank all of our study participants for sharing their experiences with us.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors LMH conceived the study idea, developed the research protocol and acts as study guarantor. LMH, SC and LJ were involved in the refinement of the study design. LMH and VR were involved in data collection and analysis. All authors were involved in the refinement of the interview questions and assisting in the interpretation of the study findings. LMH drafted the manuscript, with initial editing provided by VR, SC and LJ. All authors were involved in the review and editing of the manuscript and gave approval of the version to be published.
Funding This study was funded by the Toronto Academic Health Sciences Network (TAHSN) Chief Executive Officer Committee.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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