Debra Fox is not your typical UNLV nursing PhD student. That is because she balances her graduate courses while also serving as the Chief Nursing Officer at University Medical Center in Las Vegas, one of the biggest public hospitals in the United States. The Chief Nursing Officer (CNO) is accountable for the leadership of all nurses and their professional and clinical practice within the hospital. Specifically, Fox is accountable for ensuring that all facets of clinical operations, quality and regulatory standards, fiscal stewardship, and research and innovation are met.
Those responsibilities, in addition to her academic workload, are now magnified by the coronavirus outbreak. Fox manages not only her own stresses, but the pressures of the nurses around her. I sat down with her to discuss UMC’s response to COVID-19, what it’s like balancing her job with her PhD classes, and how she sees the state of nursing changing as a result of the pandemic.
Fox describes managing COVID-19 at UMC as a microcosm of the national response: trying to keep patients alive and employees feeling safe and calm. To accomplish that, there are multiple levels a CNO must deal with in managing an outbreak of this severity including developing rapidly evolving policies and clinical workflows, ensuring critical supplies such as PPE are well managed and available, creating dedicated COVID-19 nursing units and assuring that dynamic surge plans to expand bed capacity and nurse staffing are realistically developed and possible to execute. Fox says part of the challenge is keeping up with the rapid changes from the Centers of Disease Control and Prevention (CDC) and then apply those changes in real-time for all departments, not just nursing. “It’s ancillary clinicians, like respiratory therapy and pharmacy. It’s an open medical staff encompassing hundreds of physicians, including residents, and trying to get them all aligned with major process changes so clinical care remains safe, integrated, and reflective of up-to-date guidelines.” Those changes could shift daily, but Fox and other hospital leaders still have to educate the staff on these changes and implement them.
Additionally, she manages the emotional wellbeing of the people on the frontlines, which proved difficult at first. “One of the things we maybe underestimated was the level of fear employees brought with them”, says Fox. “For the first time in my tenure at UMC (5 years), I had nurses that refused to care for patients, specifically COVID patients. I had hundreds of nurses fear for their own health or that of their family members often leading to requests for accommodation, FMLA, or reassignment.” She added this, along with major shifts in patient volumes initially led to shortages of critical care nurses, but an excess of nurses in other specialties. While this shortage wasn’t ideal, part of leadership is knowing how to handle your team. “If I have a nurse who is so frightened that she doesn’t want to take care of a COVID-19 patient, then I find another unit for that nurse to work on, and I find a nurse that’s willing to switch places. Wherever we could make an accommodation, we did.” Moreover, Fox said she always made sure to have enough support staff so no one felt they were alone and we found alternative work for nurses and other staff who were on units experiencing shifts in volume so they could maintain their work hours.
Managing the effect of an unprecedented global pandemic on your team is obviously challenging for any leader. Fox says the key is not to be coy or ambiguous about what’s going on. “You have to recognize these are well-educated, intelligent people, and they are capable of understanding the facts. So, we try to over communicate and we communicate the truth. When employees ask for the data, we’ve always tried to be very honest, presenting the facts to the best of our ability as we knew them at the time”.
Improving communication proved to be critical to convey the changes being put in place, particularly for Fox as the CNO. “As leaders, especially in nursing, face-to-face communication was the best”. Each week, Fox and her entire nursing leadership team rounded on every nursing unit to say ‘thank you’ and to bring treats and education about wellbeing and stress reduction. She created a ‘Fox Flash Video’ each Friday to update staff about critical updates. In addition, on-the spot education was done at change-of-shift huddles, and FAQ’s were delivered that were created by Infectious Disease physicians and Infection Control Preventionists to ensure everybody understood why we were doing what we were doing, what their role was, and addressing nurses as they came forward with individual questions or concerns”. She says they also started using new communication media. Fox not only live streams with patients and nurses on duty in every nursing unit, but UMC extended their new technological applications for teleworking more employees, something new for the facility.
Fox worries about having enough Personal Protective Equipment (PPE), evaluating the vendors who sell them, and determining if their equipment is medical-grade and FDA approved. She says hospital staff were educated on how to use PPE; they also had to figure out ways to repurpose masks and make sure everyone was masked around entrance and exit points. The priority around PPE was so great, Fox says they created a brand-new position called “PPE Expert”, who did nothing but control and manage access to PPE. Access to equipment was another accommodation Fox provided for her nurses. “As long as my nurses wear the right PPE at the right time, if they want to wear a homemade mask over it because it makes them feel safer, I don’t care if they do that. If a staff nurse wanted to wear goggles and a face shield, I didn’t care. Anytime an employee said they needed to change their mask, we never questioned it. We gave them another mask, gown, whatever we needed to do so they could stay safe when caring for COVID-positive patients who needed us.”
Atypical Patient Population
Despite being in a hospital setting, Fox says it was not easy to see the outbreak or its impact ahead of time. “The ramp up was not as profound as what New York or Chicago or Detroit experienced. Our ramp up started with just a very gradual increase in individuals who were having vague flu-like symptoms. We weren’t seeing patients that fit the typical COVID profile.” She added each week, UMC saw a 15-20% increase in patients who either tested positive for COVID-19 or were ruled out for the virus. But at a certain point, she says they saw a dramatic rise in the acuity of COVID-positive patients who demonstrated more traditional COVID symptoms.
What made foreseeing the outbreak impact in Las Vegas so difficult is twofold, both of which could tie into each other. First, Fox says they analyzed predictive models based on other parts of the country, but they didn’t match what Las Vegas was going through. “We used the Washington model, the World Health Organization model, and another model from Stanford. All of these gave us different possibilities about what to expect, and none of the things panned out to what we actually saw because these models are often predicted on when self and community isolation began in earnest. Often, the models are more valid at a state or macro level than at the individual community level.” This unpredictability could have to do with what Fox calls an atypical patient population in Las Vegas. She noted, “We saw patients who were younger (people in their late fifties to mid-sixties without the traditional co-morbidities who presented with varying degrees of COVID symptoms. These symptoms often rapidly progressed, sometimes within hours, resulting in respiratory failure requiring ventilator support. At one point, we had 3 ICUs full of COVID patients many on ventilators requiring aggressive proning.”
Fears of a massive outbreak cooled off as numbers stabilized and eventually started declining. Fox argues although we are reporting more positive cases, that’s due to more testing than before. She says many of the COVID-19 positive patients could have always been there. “I believe many people started getting sick in late December and early January. We saw an influx of really intense flu symptoms, and we are wondering if that wasn’t our initial surge of COVID and we’ve been on a roller coaster in our community rather than that bell curve that other parts of the community have seen.”
Balancing Work and School
Working as a CNO while studying in the UNLV nursing PhD program has not been easy for Fox. Recently, she admitted the competing schedules forced her to take an incomplete on her research independent study from last semester because it was too difficult to balance the two. The dual workloads won’t end anytime soon: Fox is still on track to start her PhD dissertation this Fall. The dissertation is a large secondary data analysis of Assignment Despite Objection (ADO) evaluative rubric data, specifically how situational disruptions impact nursing practice and how those practice impacts correlate to changes in nursing quality outcomes and the occurrence of patient safety events in nursing departments that are adequately resourced. Nevertheless, Fox says it’s not impossible to achieve work-school balance, as long as you stay organized and ahead of your assignments. She also credits the UNLVSON faculty and staff for their support.
A New Normal
As the reopen phases continue, Fox doesn’t mince words about the potential future of nursing post-COVID-19. She sees a difficult climb for nursing over the next several years, citing ongoing economic hardships for both the Las Vegas community and its hospitals (including layoffs and struggles for new graduates finding jobs). Fox claims. “I think you will see nurses that continue to practice within the walls of hospitals be challenged with fewer resources to do their jobs. You will see healthcare services be re-evaluated as prudent fiscal stewardship forces every organization to make hard decisions moving forward”. For now, all the hard work from Fox and other hospital leaders has led to an enhanced work culture at UMC. Fox says people are in a better rhythm, and she no longer gets refusals from nurses on caring for COVID-19 patients. UMC provided ongoing support to their staff including free meals, high leadership visibility, and setting up a small area for employees to buy essential products like toilet paper and disinfectants. Fox says this has helped change the emotional attitude of staff to feel more secure and supported while at work.
Fox says they are now more prepared if a second wave of COVID-19 occurs. “UMC is focused on making good fiscal decisions as the Las Vegas community reopens and begins its economic recovery so it can continue providing quality healthcare to all. UMC is also taking the lead in providing COVID-19 testing for the community and business entities trying to reopen including the casinos, schools, and other Clark County entities. UMC will continue to partner with the community leadership helping to plan for a possible secondary surge of COVID-19”.
She cites various forms of goodwill shown by the community from businesses making PPE; restaurants donating meals to staff, and faith-based groups doing telephone check-ins for patients and families who weren’t allowed to visit loved ones due to self-isolation or quarantine. “Just like with 1 October, we have so many people who just want to say thank you, or they want to find some way of helping to know they contributed”, says Fox. “Those are the people we’ve seen tremendous outpouring of help and grace. It just shows human beings are still inherently good and want to be kind and do the right thing.”
By Joseph Gaccione, with Debra Fox (RN, MSN, Chief Nursing Officer, University Medical Center)