Think back to your first day at a new job. It was probably difficult to remember who was who or the steps for logging into the network, let alone keep track of where the coffee or the printers or the bathrooms were.

Now imagine you are a clinician and the new job is taking care of Covid-19 patients using new or refreshed skills in an unfamiliar ward or intensive care unit.

Since the pandemic emerged in December, doctors, nurses, respiratory therapists, and other clinicians around the world, including thousands in the U.S., have been redeployed to new roles or new locations to care for the thousands of patients admitted to hospitals with Covid-19. Most of them had never before cared for a patient with this new disease.

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That’s happening now in Texas, California, the Midwest, and other regions where cases are surging, just as it happened in New York City, Boston, Detroit, and other cities hit hard by the epidemic in the spring.

Have you been redeployed to a new unit or hospital to treat Covid-19 patients? Describe how it went.

 

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The redistribution of clinicians to treat patients using new or updated skills in unfamiliar locations without sufficient orientation can be harmful to patients and clinicians. Clinicians live in fear of becoming infected and dying, as close to 900 have already done in the United States alone. They fear bringing the virus home to their children and parents and friends. And they fear harming patients because there are not enough staff members to turn a patient on a ventilator or because they didn’t know that a treatment recommendation had changed.

In routine, nonemergency situations, the process of bringing in and orienting a new clinician, known as onboarding, is a nonstandard process that is created and managed locally within individual hospital units. A labor and delivery unit might onboard new clinicians one way, while a surgery unit on the floor below might use a completely different procedure. The process generally focuses on logistics such as parking, access to and use of the electronic health record, privacy compliance training, and meeting other staff members.

Onboarding clinicians during a pandemic poses challenges that go far beyond logistics.

As part of our research on onboarding for Ariadne Labs, we interviewed seven physician leaders across five health systems in New York City, Boston, and Springfield, Mass., who had developed and/or implemented programs to rapidly bring in clinicians in an effort to begin understanding onboarding during the time of coronavirus. Each leader described having no road map for this work; all described “making it up as we went along.” Their observations fell into three main categories: responding effectively to fear and anxiety, clarifying procedures for delivering care, and intentional relationship building. (You can read the full report here.)

Addressing fear and anxiety

The leaders expressed surprise at the degree of fear and anxiety they saw among clinicians being onboarded. In addition to fears of becoming ill themselves or transmitting the infection to family members, many clinicians worried about harming patients or appearing incompetent, worries that were magnified by having new roles.

Addressing uncertainties like, “How much choice will I have in where I’m deployed?” or, “What is our patient population like and how will it evolve?” helped alleviate some of these fears.

Clinicians were also understandably worried about providing the best possible care to patients with Covid-19, a novel disease about which new — and changing — information arrived almost daily. Leaders suggested making every effort to redeploy clinicians not more than “one degree of separation” from their current roles, in other words, roles in which they could still use familiar knowledge and skills or work with people they knew. They also recommended reassuring clinicians that they wouldn’t be asked to do things they weren’t comfortable doing.

As one leader put it, redeployed clinicians needed the “confidence they could do this and would be safe doing it. Everything else was gravy.”

In that vein, it also became apparent that a support system could help smooth the transition. Making sure that redeployed clinicians can easily access “elbow” support (someone who will stand next to them to observe and coach) at any time throughout the duration of redeployment from a clinician familiar with the disease and the operations of the unit was reassuring. It sent the message, “You will never be alone.”

Patients are cared for by other human beings. Once these caregiving humans feel personally safe, they can turn their full skills and humanity toward their patients.

Clarifying procedures for delivering care

The practice of medicine involves knowing both what needs to be done as well as how to get it done. Caring for patients with Covid-19 involves learning about a single disease in the setting of rapid updates in information about pathophysiology and treatment. The paramount interests of clinicians redeployed to new sites of care included learning how to do the essential tasks of admitting and discharging patients, ordering tests and consults, and documenting their work through the mechanism of an unfamiliar electronic medical record or dictation system.

To respond to these needs, leaders recommended creating a systematic and standardized practice to ensure that every clinician gets the same basic onboarding. It should include logistical and operational knowledge specific to the care unit, including protocols for transferring patients, emergency procedures, weekend coverage, and using the electronic medical record.

The baseline process should be adapted to accommodate any special training required, such as management of ventilators or current standards of care for chronic diseases such as heart or kidney failure. Offering review and practice options for advanced cardiac life support, central line placement, and intubation can help reassure clinicians who may be coming on board with dormant skills in these areas.

It’s also essential to provide both observation and supervised practice of donning and doffing personal protective equipment, ideally overseen by staff experts, such as operating room nurses.

We noted that an organized and efficient onboarding can not only improve the performance of clinicians and reduce the risk of harm to patients, but can also help decrease redeployment-related fear, anxiety, and uncertainty.

Relationship building

Best practices support the rapid formation of teams among new people doing new tasks. The rapid onboarding process during Covid-19 should be intentional about making these connections before redeployment or at the outset of it.

Hybrid teams with the broadest possible distribution of knowledge and skills can be effective. That might involve mixing attending physicians, resident physicians, and advanced practice providers from different specialties. Ensuring that clinicians with limited or remote experience caring for critically ill inpatients are paired with those who know their way around such patients is essential.

One of the limitations of caring for patients with Covid-19 is being swathed in personal protective gear to the point that it can be hard to tell who on the team is who. Finding ways that one clinician can immediately recognize another — large name badges, identifiers on face shields, color coded arm bands, and the like — is a small but important way to not only build the team but make it work safer and more efficiently.

Building relationships does more than assist with onboarding. It also protects clinicians’ well-being. The experience of caring for patients with Covid-19 is unique and stressful and shared among colleagues. Support at work that cannot be offered by a friend or partner who has not shared the experience can play a role in helping clinicians cope during this time.

Lessons learned for Covid-19 and beyond

Rapid redeployments to respond to surges in Covid-19 cases offer unique opportunities to evaluate onboarding systems under stress and learn which aspects are most important when time and resources are limited.

Lessons learned from these interviews can help leaders in pre-surge geographic areas plan as they begin to redeploy clinicians. They can also improve the process of onboarding clinicians, about which little is known, which will continue independent of the current need for rapid redeployment.

Susan Haas is a physician and lead investigator for Ariadne Labs’ work on reducing the risks to patient safety of health care system expansion. Rachel E. Smith is physician assistant, a clinical implementation specialist at Ariadne Labs, and a doctoral student in public health at Johns Hopkins Bloomberg School of Public Health.

Onboarding during Covid-19

To accompany Haas/Smith First Opinion on hospital orientation during Covid-19
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