key: cord-0747176-yxphojb5
authors: Chan, Garrett K.; Waxman, K. T.; Baggett, Margarita; Bakerjian, Debra; Dickow, Mary; Grimley, Karen A.; Kiger, Anna J.
title: The Importance and Impact of Nurse Leader Engagement with State Nursing Workforce Centers: Lessons from the COVID-19 Pandemic
date: 2021-08-27
journal: Nurse Lead
DOI: 10.1016/j.mnl.2021.08.014
sha: d3d06d440c5fc8627205fe9e0baf9c297ede41a5
doc_id: 747176
cord_uid: yxphojb5

The COVID-19 pandemic caused unparalleled morbidity and mortality across the globe. Healthcare agencies, public health departments, and academic institutions experienced widespread disruption to usual operations. These events had an adverse impact on the nursing workforce. Nurse leaders in California rallied to identify and remediate the effects of COVID-19 on the nursing workforce. This article describes the strategy and interventions. Nurse leaders should invest resources in state workforce centers to ensure the health and supply of a strong nursing workforce.

During the COVID-19 pandemic, many clinical agencies, public health departments, and communitybased organizations experienced crushing numbers of patients, employees, and community members affected by the SARS-CoV-2 virus. Nurse leaders played an essential function in their clinical settings were providing the best patient care possible while also addressing employee physical and mental health. Nurse leaders also supported public health initiatives by providing COVID-19 testing and vaccination events in collaboration with local public health departments. These clinical activities provided a massive safety net to ensure the health and well-being of local communities, employees, and patients. While the COVID-19 pandemic was taking its toll on individuals and communities, it also affected the larger nursing workforce in multiple ways. The purpose of this article is to describe how one state's nursing workforce center partnered with nurse leaders within the state to address macrolevel nursing workforce issues during three phases of the pandemic.

In California, HealthImpact is the designated nursing workforce and policy center. HealthImpact is a member of the National Forum of State Nursing Workforce Centers (www.nursingworkforcecenters.org), also known as the Forum. The Forum is comprised of statewide entities and organizations who focus on a combination of different aspects of the nursing workforce such as the nursing pipeline, supply and demand of nurses, educational preparation, workforce development, policy and advocacy, and research. HealthImpact's vision is a highly skilled health care workforce optimizing health through innovation, interprofessional leadership, and nursing excellence. Our mission is to shape health care through workforce strategy, stakeholder convening, and policy advocacy. Prior to the pandemic, we created a workforce strategy framework to guide activities of the workforce center ( Figure 1 ). There are 6 key areas of nursing workforce preparation and development: Supporting the Kindergarden-12 th grade pipeline, pre-requisite education for nursing, pre-licensure education at the RN and APRN levels, upskilling the workforce, retention and well-being, and understanding the migration of nurses. Migration is defined as understanding the geographic movement, academic progression, changes in clinical specialties, and leaving the profession.

At the beginning of the pandemic, HealthImpact capitalized on its established roles as the nursing workforce and policy center and statewide convenor to establish a pandemic coalition to create initiatives to support the nursing workforce and pipeline. Key nursing stakeholders groups within the coalition included the Association of California Nurse Leaders, American Nurses Association\California, California Hospital Association, California Organization of Associate Degree Nursing, California Association of Colleges of Nursing, Butte-Glenn Community College District, Health Workforce Initiative, San Diego Family Health Centers, California Association of Public Health Nurses, California Nursing Student Association, University of California, San Francisco (UCSF) HealthForce Center, and the California Simulation Alliance. The coalition represented practice, academia, workforce development, public health, and students. Throughout the COVID-19 pandemic, HealthImpact used the workforce strategy framework to stay focused and create initiatives in different phases of the pandemic to support and advance the nursing workforce with the coalition.

Pandemic Phase: March 2020 -October 2020

In California, this phase of the pandemic was characterized by a rapid acceleration of COVID-19 cases, statewide stay-at-home orders, disruption of usual healthcare delivery and operations with preparation for mass casualties, disruption of academic operations and teaching, and supporting the physical and mental health and well-being of the workforce. With these challenges, the coalition identified three priority areas within the HealthImpact workforce strategy framework: Pre-licensure education, upskilling the workforce, and retention and well-being.

Four key issues the coalition addressed in this phase of the pandemic related to pre-licensure education were 1) addressing the loss of clinical placements, 2) establishing regulatory authority for nursing students to practice in clinical settings, 3) use of effective and high-quality simulation, and 4) policy advocacy for increased use of simulation in disasters. Academic and clinical practice nurse leaders created guidance documents for schools of nursing and clinical agencies to support and encourage safe academic-practice partnerships during the pandemic. 1 The coalition worked with the California Board of Registered Nursing (BRN) to also create official guidance documents to explain the various roles nursing students can assume to contribute to the workforce during the pandemic. 2 Simulation has been shown to be a highly effective pedagogy to achieve learning objectives and outcomes for nursing students. 3 The BRN had regulations that required a minimum of 75% of the clinical education hours being in direct care of patients, which meant that up to 25% of clinical education hours could be in simulation. The Department of Consumer Affairs approved a waiver to decrease the minimum number of direct care hours down to 50% in certain circumstances. 4 Increased flexibility related to simulation was needed during the pandemic when schools of nursing moved to distance learning and clinical agencies restricted the access to clinical placements. 5 The California Simulation Alliance, a program of HealthImpact, led many initiatives to support the increased use of high-quality simulation by making simulation scenarios available for free, training hundreds of nursing faculty on simulation and debriefing to create safe teaching and learning environments, creating new COVID-19 scenarios, writing letters to the Governor, and writing a white paper on the efficacy of simulation in achieving learning objectives. 6 The coalition supported Assembly Bill 2288 (Low, Statutes of 2020, Chapter 282) that codified the Governor's waiver for increased use of simulation in disaster situations. 7

To ensure that the workforce had the necessary skills to address the direct clinical care and public health aspects of the pandemic, the coalition created and curated resources for nurses and nursing students. 1 The Governor asked retired nurses and nursing students to join the workforce, 8 so the coalition created a toolkit to help introduce or refresh essential knowledge in responding to the pandemic. The coalition created an "informed consent" document that delineated the benefits, risks, and considerations for clinicians and students responding to the pandemic. 9 This document was particularly important to prepare nursing students to understand the work and potential ethical issues they might encounter should they choose to be direct care clinicians.

The coalition recognized early in the pandemic that mental and physical health, burnout, and social isolation were high priority areas for nursing leaders to address. Many California nursing associations created or advertised initiatives to support nurses' well-being early in the pandemic. Webinars, podcasts, and toolkits were created to provide direct care nurses and nurse leaders with education and documents to keep the nursing workforce healthy.

During this phase of the pandemic, California saw the beginning of a plateau of cases. There was also an increased resumption of essential healthcare services, the early rollout of limited supplies of the vaccine, vaccine equity issues, fatigue and deaths of healthcare workers and students, and beginning discussions of policy waivers as being permanent. The coalition focused on understanding the wellbeing and migration of the workforce and upskilling the workforce for this phase of the pandemic.

HealthImpact had been conducting an annual newly licensed RN survey since 2010. It had been an employment survey until 2019 when additional questions related to social determinants of health and education were added. The survey was sent out to newly licensed nurses in the last calendar quarter of 2020. Additionally, the UCSF HealthForce Center created and sent out questions related to the impact of COVID-19 on the general RN workforce employment and well-being in collaboration with the BRN. Data from the two surveys are being analyzed. Results will articulate the health, migration, and employment of the workforce. Additionally, the Association of California Nurse Leaders and the American Nurses Association\California created additional resources, webinars, and podcasts to support the well-being and health of nurses.

Vaccine administration became a major focus of the pandemic response to achieve herd immunity. Nurse leaders worked quickly to organize vaccination events within clinical agencies and in the community to support the public health initiative. HealthImpact created VaxForce (www.vaxforce.org), a volunteer registration and matching system for interprofessional healthcare licensees and students to staff vaccination events throughout California especially in communities of color and hard-to-reach communities. Many healthcare professionals did not have experience in doing vaccination events in the community. Educational resources were given to the volunteers and competencies were validated. Nurse leaders supported VaxForce through advertising and mobilizing their networks.

In its first 3 months, VaxForce mobilized 182 health professional volunteers in 22 vaccination events administering 5,435 vaccines. VaxForce established relationships with 7 community-based organizations whose work is in 5 counties with a Centers for Disease Control 

During this time period, California saw decreases in COVID-19 cases, an increased supply of the vaccine and vaccine equity, an increased proportion of people who were vaccine-hesitant, a resumption of healthcare services, vigorous policy discussion on post-pandemic changes in healthcare, and an increased incidence of healthcare worker fatigue, burnout, moral injury. The coalition focused on prelicensure RN education, upskilling the workforce to address vaccine hesitancy, and migration and wellbeing of the workforce.

As colleges and universities re-opened and were establishing post-pandemic operations, academic administrators saw the value and success of simulation as a pedagogy. Faculty were more comfortable in employing simulation as a pedagogy because they were trained on the international standards of simulation and debriefing. So, the coalition focused on policy and legislative efforts to ensure that the increased percentage of simulation could be available to qualified educational institutions who would follow international standards of simulation both during and beyond times of disaster. Statewide nurse leaders engaged in educating policy makers and advocacy efforts.

As vaccine hesitancy became the next major public health concern, VaxForce partnered with nurse leaders, a telehealth organization, and public relations, marketing, and events experts to create an initiative, Trust A Nurse, Ask A Nurse (TANAAN). Vaccine hesitancy exists on a continuum. On one end of the continuum, there are people who absolutely refuse to get the vaccine. However, on the other end of the continuum, there are people who want to get the vaccine but have difficulty accessing the vaccine. Between these two poles, there are the "wait and see" and "only if required" groups. 10 An additional challenge that contributes to uncertainty and confusion by the public is the rapidly changing scientific information. 11 Communication from the Centers for Disease Control and Prevention, the federal government, and social media is one-way, 12 meaning that information is sent out to the public without the opportunity for an individual's questions to be asked and answered. Insurance status is also an important factor in vaccine hesitancy. Approximately 71% of Latinx people between the ages of 18 and 64 years who are vaccine hesitant are uninsured. Additionally, between 22% and 27% of Spanishspeaking Latinx adults report difficulty finding information about COVID-19 vaccines or are not able to communicate in Spanish when signing up or getting vaccinated. 10 Given many people in Black and Latinx communities do not have health insurance or easy access to care, having a conversation with health care providers may not be easy or even possible.

TANAAN is a free telehealth virtual hotline staffed by RNs that can be accessed by community health workers (CHWs) or the public via a smartphone or computer in English and Spanish. RNs have access to the latest up-to-date information from trusted scientific sources to provide support during the encounter. Nurse leaders are supporting TANAAN by engaging their staff and association membership to participate in this statewide initiative.

The coalition continues to interpret the data and create meaningful interventions to understand how to support the nursing workforce and the migration of nurses. Professional nursing associations are collaborating to synergize efforts to increase their offerings to support nurse well-being, mitigate burnout and moral injury, and increase professional fulfillment.

The COVID-19 pandemic illustrated that our usual response to an international and prolonged disaster required different strategies, interventions, and perspectives. Nurse leaders need to be more flexible, agile, and innovative in our responses to a global pandemic. We cannot hold onto previously held beliefs and ways of operating.

The threats to the stability and well-being of the nursing workforce and pipeline into the profession were multifactorial and required a strategic analysis and multi-pronged approach to addressing the issues at a statewide level. There will be a tendency to revert back to the previous status quo. Nurse leaders at all levels need to persevere to create a new vision for the profession and the workforce and codify the best parts of the pandemic lessons into the "new normal."

Nurse leaders need to take care of their own institutions and the individuals within those institutions. At the same time, we cannot achieve the new vision for the profession and the workforce without working collaboratively and supporting nursing workforce centers. 

The NCSBN National Simulation Study: A Longitudinal, Randomized, Controlled Study Replacing Clinical Hours with Simulation in Prelicensure Nursing Education

Guidance on Waiver Restrictions on Nursing Student Clinical Hours under DCA Waiver DCA-20-03

The Impact of COVID-19 on the Nursing Workforce: A National Overview. OJIN: The Online Journal of Issues in Nursing

Governor Newsom Announces California Health Corps, a Major Initiative to Expand Health Care Workforce to Fight COVID-19

Risks and Considerations for Clinicians and Students Responding to COVID-19

KFF COVID-19 Vaccine Monitor: COVID-19 Vaccine Access, Information, and Experiences Among Hispanic Adults in the U

Public Perceptions of Conflicting Information Surrounding COVID-19: Results from a Nationally Representative Survey of U

Acknowledgments: none.Funding: This work was supported by unrestricted grants from Upskill California, Health Workforce Initiative of the California Community Colleges Chancellor's Office, California Organization of Associate