Table 1

Study characteristics (n=118)

Theme 1: valuing new roles and teams

This theme captures perspectives regarding the new roles (eg, clinical externs, donning and doffing safety officer, rehab assistant) and teams (eg, team-based nursing, rapid intubation teams, clinical extern resource pools, pandemic pods) created over the course of the pandemic.

One notable example was the clinical extern role that initially emerged out of the team-based nursing model of care in the ICU. These extern positions were then scaled to other clinical areas in some participating sites and continue as part of organisational strategies to support transition to practice and staffing needs. Throughout Ontario, clinical externs were nursing students and other health professional learners who were hired as unregulated care providers to work with nurses and team members to support fundamental patient care. As one participant noted, ‘the addition of externs has been great because they’re solely for bed baths and turns’. (Registered Nurse, Site 4–013) Referred to as ‘an extra set of hands’ by both clinical externs and point-of-care nurses, clinical externs assisted with care activities (eg, bathing, feeding, turning, answering call bells, taking vital signs in general internal medicine and starting and making a drip in ICU). As one registered nurse shared: ‘There was other alternate care providers, students near the end of their practicum … they were able to do toileting’. (Site 3–014) The scope of practice of clinical externs was akin to that of a personal support worker (PSW). However, some participants described the clinical extern as having more autonomy and thus providing more benefit in times of high need, when regulated staff were occupied with critically ill patients. This theme is described in the following two narrative excerpts.

When you look at nurses and PSWs, clinical externs fit nicely in the middle between the two. We’re able to do anything that a PSW does. We’re delegated different tasks that the nurse would otherwise do. Whereas for nursing students, we’re given more autonomy when it comes to medication administration. (Clinical Extern, Site 4–027)

Essentially an extern [is] similar to a PSW. We would definitely help with repositioning, turning, if they happened to call the bell we would attend to it if the nurse is busy. Always just making sure that the staff is well supported, doing rounds if they need anything. Just to have that extra set of hands to help out. (Clinical Extern, Site 4–28)

The introduction of clinical externs into the care model was largely seen as beneficial. The clinical extern role was described as ‘mutually beneficial’ with nurses gaining extra support in the units and clinical externs benefitting from real-time, hands-on experience across different clinical settings. As one clinical extern noted: ‘It’s been really helpful for the nurses on the unit, the managers, and even the unit clerks to say, we don’t have to find a floor duty from a PSW agency, we’ve got an extern at least. It helps keeping it internal, it helps relieve some of that pressure from them’. (Site 4–026). Managers and unit clerks were benefiting from having an internal pool of clinical externs to draw to staff clinical units and a ‘feeder for recruitment’. Opportunities were created for nursing students doing their clinical placements on the units to be hired as clinical externs, who when they graduated were recruited into a nursing position. A director shared, ‘We had to pivot to create some resources to help support the added demand on the department. We’ve converted over 100 clinical externs into permanent nursing roles, not necessarily permanent nursing roles, it’s a feeder into our recruitment. So it’s mutually beneficial and we continue to sustain our workforce. So that is one thing that we’ve- definitely want to hold onto’. (Site 4–033).

Participants also shared the need to keep the clinical externs as part of the staffing model moving forward, as noted by another participant: ‘The addition of externs has been great … I like the continuing of externs’. (Registered Nurse, Site 4–013). A clinical nurse specialist noted, ‘We added clinical externs to out model of care and they’ve been a big help. Supporting the nurses and also giving them the experience of a post-anesthesia care unit (PACU)’. (Site 4–003)

Other new roles created included extern mentor coordinators who supported the clinical externs, a donning and doffing safety officer to ensure safe personal protective equipment (PPE) practices as noted: ‘I was a safety officer on our COVID unit that was only for COVID-positive or query COVID-positive patients. My role was basically to help with the clinical staff, the nurses on the unit, make sure that they were properly donning and doffing their PPE. We would sit in the hallways on the unit and when someone was going in a room we would make sure it [PPE] was going on properly … [and that] they were doffing the PPE properly to reduce the spread of COVID’. (Social Worker, Site 3–011). Other healthcare support workers provided support to patients and families with emotional support, including a provincial programme shared by a clinical nurse leader: ‘The province did start a program because they were noticing a shortage of care aids. They hired healthcare support workers [to] come to the sites [to provide] social support because families [were not] able to come in then. They’re connecting families on Zoom and telephone calls and just visiting with people. That really helped for the emotional support’. (Site 1–022). Rehabilitation assistants were also created to provide functional support to patients noted by a director: ‘One of the things that we did was introduce a new role, we introduced rehab assistants to work under the direction of a physiotherapists, occupational therapist, or speech language pathologist to provide functional support. Which has worked out wonderfully for us. We’ve won an award for it on team-based care and interdisciplinary care’. (Site 1–025)

Education roles were also created to support staff with their new roles including ‘to support the clinical externs, we took the funding for the clinical extern program and created a mentor coordinator role … who would report to the manager. We created another level of infrastructure in the department’. (Director Site 4–033)

New team-based models of care were also developed to address the pressures associated with the increasing complex needs of patients and HHR shortages. For example, team-based nursing was introduced in several hospitals to bolster capacity in ICUs. Team-based nursing consisted of an experienced critical care nurse leading a small team of non-critical care nurses working together to provide care to ICU patients. Flexibility and variability emerged in this type of model, as illustrated by the following quote: ‘We were quite flexible as to how they want to manage that type of care. Whether the three nurses have a dedicated patient, and if anything were to change then they would defer back to the critical care nurse. For instance, the three nurses would work together, they would take on care for all three patients all together and be responsible for all three all together. Maybe the primary nurse for the most sick patient will be the ICU RN, and that would be their main focus and the other would be acute focused and be cared for by the non-critical care nurses’. (Clinical Nurse Specialist, Site 1–007)

However, there were challenges experienced: ‘When we started team nursing, it was encouraged that if safe and appropriate, we would ‘de medicalize’ patients that we could. So that means maybe reducing the frequency of their vital signs’ assessments and therefore reducing the amount of documentation. However, given the nature of the patients that come to the ICU, that often wasn’t possible’. (Advanced Practice Nurse Educator, Site 2–003)

Further, participants expressed that this approach was not fully realised and was inconsistent because of lack of support, changing team members with varying experience, and the varying needs of patients as noted ‘I know that there was a goal at one point to introduce a team-based model and I'm not sure that that was ever really fully implemented or that there was support there because when we went to that team-based model, there should have been support provided by team members to individual nurses, so that they could provide fulsome care to patients’. (Clinical Nurse Specialist, Site 2–006). One participant shared concern around team-based nursing as it ‘looked different every day, team-based nursing model was often inconsistent because it depended on the experience of the redeployed nurses’. (Advanced Practice Nurse Educator, Site 2–003).

Other new teams were created to address the staffing shortages. For example, an experienced nurse led an interprofessional team of providers including OTs and PTs, who took on functions outside of their core scope including ‘suctioning, vital signs’ (Director, Site 6–001). In another organisation, this approach was not well received as one participant noted, ‘We tried pods so you had up to four ICU patients with an extender and an ICU nurse. We trialed it only for about 24 hours or so, but there [were] senior nurses who were just in tears … and there was a few serious safety events (eg, people self-extubating)’ (Nurse Manager, Site 2–012). Another new team that was created was Rapid Intubation Teams or Airway Teams. These teams usually consisted of anaesthesiologists, nurses and respiratory therapists who were on call within the hospital to come together when a COVID-positive patient required intubation and transport to critical care. In another participating site, a clinical extern resource team was created where clinical externs were deployed to the areas most in need. Uncertainty around where they would be deployed was shared as a challenge for clinical externs: ‘We’re a pool of clinical externs and we sort of assign out availability on certain days, but we don’t know which unit we’re going to be assigned to until the day of our shift’. (Clinical Extern, Site 4–027)

Theme 2: being redeployed

This theme includes how healthcare professionals (predominately nurses) were redeployed to other clinical areas to work (eg, PACU or general internal medicine to ICU). This also included being redeployed to repurposed spaces designated for COVID-19 positive or suspected positive patients (known as cohorted) or additional beds open within existing units or other units. For example, one participant shared, ‘we had a special pool of nurses who would only work in the COVID unit’. (Director, Site 1–001) while another noted, ‘our unit was supposed to become a COVID unit. We were redeployed each shift. We might be on a different floor each time or we might be helping the COVID units’. (Registered Nurse, Site 2–005) Several participating sites opened additional ICU beds in other acute care units (eg, PACU and cardiac care units where space was available due to decreased surgical cases). Participants also spoke of being redeployed into alternative roles, units and areas such as long-term care, intensive and critical care settings.

As noted: ‘We mostly redeployed nurses who are former critical care trained nurses from my clinical areas. They (clinical nurse educators) were former critical care nurses who were redeployed to critical care’. (Patient Care Manager, Site 1–005)

The home unit of the redeployed staff also varied, with professionals (including medical residents) being pulled from areas such as psychiatry, surgery and PACU, outpatient care and critical and ICU subspecialties such as cardiology. As one physician shared, ‘The residents all got redeployed completely to different areas. We didn’t really have any residents in the operating room with us at the time. They all went off and had to go work in intensive care units. They were all over the place’. (Site 1–026)

Participants described that responsibilities of being redeployed varied based on the setting they were redeployed to, with some engaging in their full scope of practice to care for critically ill patients while others took on supportive roles as one participant described: ‘A lot of the units ended up starting to think about this group of staff will do this area, this group of staff will do this area, and we won’t cross them over. Just to be able to ensure that they there wasn’t sort of cross-contamination’. (Manager of Privacy and Risk, Site 5–007)

Further, some participants described volunteering to be redeployed as one clinical nurse specialist shared: ‘Some of our nurses were redeployed, we had a few nurses who were volunteered to actually join when LTC was in dire straits. Our nurses have critical care and a lot of assessment skills so they could be redeployed to those critical care areas’. (Site 4–003) Interestingly, one participant shared that one benefit of redeployment was that it enabled collaboration and understanding of workflows in the areas (ie, critical care) that nurses were redeployed to:

We’re more frequently redeploying cardiac ward nurses to or cardiac surgery ICU and our cardiac ICU on a regular basis, when we’ve done everything that we can to try and fill vacancies. We tried to instead of it being just a dictated approach of ‘you’re going there now’, we tried to first get people to volunteer, and I think we were lucky, in that we had enough staff that were willing and wanted to do it. I think it did build some collaboration and understanding of each other’s workflows. It’s been helpful to recruit for critical care nurses from the wards who had experience. (Patient Care Manager, Site 1–002)

As part of redeploying clinicians, organisations sought to match staff and clinicians’ skillsets and scope of practice to meet acute patient needs, particularly in intensive and critical care settings. This strategy was employed to safeguard patient safety by ensuring that staff who were not familiar with critical care could be initially assessed for their skillset to determine which care activities they could perform. As a registered nurse shared: ‘They recruited staff from other floors who have no experience working in ICU to be part of this model of care where you’re paired with an existing ICU nurse. You’re allowed to look after ICU patients, but not providing necessarily ICU skills. You could do other nursing care that’s within your scope that you currently have on other floors. But you can’t touch like ventilators, or any medications that required titration or things like that. Because they didn’t get the training yet’. (Site 4–018)

Organisations shared they developed a colour-coded system to identify and categorise staff skillsets to determine who possessed a strong knowledge of critical care practices, and who could be assigned to provide fundamental care for patients, including bathing, feeding, ambulating and turning. The delegation of fundamental care was given to other healthcare providers (eg, clinical externs, extenders), which in turn allowed the registered nurses to engage in more acute care tasks. The following two quotes provide examples of this subtheme.

It was like a traffic light, like a green level which is pre-COVID, yellow and then red, depending on critical care capacity, and staffing. So, during yellow we would be doubling vented patients, and you may or may not have an extender, though during red we had extenders. But sometimes for your vented patients you had three or four patients. We had, we tried pods as well, so you had up to four ICU patients with an extender and an ICU nurse. (Nurse Manager, Site 2–012)

Making assignments where you had to make sure that your green patients, definitely your RPNs could have. Your yellow patients meant that if they were talking to me and they felt that the patient was starting to change, that now I had to look at maybe changing the assignment and change—moving them or swapping patients. And that happens quite a bit during the day is that the patients would suddenly start to go from green, yellow, and then red, which red automatically became an RN patient, and that also made me jump in as well. (Registered Nurse, Site 5–008)

Theme 3: enhancing coverage

This theme includes how clinicians extended their work to other clinical areas and how additional staff, increased work hours and workload were strategies employed to manage staffing pressures. For example, pharmacists reported increasing their coverage across units to ensure that critical areas were staffed during patient surges in the hospital. As one participant noted, ‘How the cross-covering works is like I am still predominantly on one floor. Right now, I’m predominantly on the ward. I’m just cross-covering the ICU where there’s no one there’. (Pharmacist, Site 3–019) Cross coverage was also mentioned in the context of covering for redeployed staff who were aiding other units and areas. Some participants shared that staffing algorithms and strategies were created to secure back-up staff in the event of staff sickness or leave. Participants also spoke of working extended hours (including overtime), doing more hours than casual or part-time employment, and doubling up on assignments to meet patient needs and flow demands. One participant shared that they expanded hours of operation from a 5-day to a 7-day model in their unit. The following narrative illustrates this theme.

Having that third pharmacist on the weekend allows for one of the pharmacists to go see the new admissions so it alleviates the workload on Monday and also our hours on the weekend continue until 9. So we’re open seven days a week until 9 pm. So, there were less orders to come into on Monday because we don’t close at 5 anymore, we close at 9 so there’s a pharmacist who’s there verifying orders all the way up until 9 o’clock. (Pharmacist, Site 4–002)

What ended up happening is there’s five clinics, six clinics, that run through us, and there were a couple weeks where there was only two of us full-timer girls on, and then, we had a lot of casual and part-time girls coming and covering. (Registered Nurse, Site 4–019)

We shifted to a seven day model. It started off being 12 to eight, and then it became 11 am to 7 pm, shifts, seven days a week. (Physiotherapist, Site 2–016)

Across all participating sites, participants shared insights around the impact and consequences of creating new roles and teams; being redeployed; and having to enhance coverage. One participant shared that an exodus of experienced nurses and an increase in new and inexperienced nurses (eg, clinical externs, internationally educated nurses) affected ‘wound outcomes’ (Clinical Nurse Specialist, Site 4–006) and another participant noted: ‘having a bunch of orientations to the unit was pretty stressful—seeing the quality of care and worrying about all the patients not getting their quality of care’. (Registered Nurse, Site 1–027)

Another consequence of redeployment, and in some cases enhancing coverage without extra staff, care was left undone or delayed as noted in the following excerpt: ‘to pull a health discipline staff out of their regular therapy duties, means that therapy is not being done, right, so it’s quite dramatic or it’s not being done in the way that it’s traditionally done, or done during regular time’. (Registered Nurse, Site 4–001) There was also fear and anxiety expressed by those who were waiting to be redeployed and those that were redeployed as illustrated in the following two narrative examples:

There was, I don’t want to say fear, but that kind of anxiety that hey there might be a time where we’re all being asked to redeploy, or we’re all being moved to other places. But initially it was just a few subset of nurses that either were redeployed to LTC or asked to come back to the ICU to support us. (Registered Nurse, Site 2–003)

There was also this worry that we were going to get redeployed. We never—my team never did get redeployed to provide essentially nursing care, personal care to people in the hospital—but I do know of other similar teams that were redeployed. Is it going to happen? And that was really difficult. (Social Worker, Site 5–008)