This time last year, the World Health Organization had just declared COVID-19 a pandemic. Health systems around the world were simultaneously caring for unprecedented numbers of critically ill patients and creating alternative ways of working based on new and often-conflicting information and limited resources.

Advocate Aurora Health, one of the top 12 largest not-for-profit, integrated health systems in the nation and based out of Illinois and Wisconsin, turned to their nurses—counting on them in key traditional nursing leadership as well as non-traditional leadership roles, and empowering them to drive collaboration across levels and departments and create new approaches. From tapping into their telehealth expertise to care for more patients by redesigning a well-established, nearly two-decade-old Tele-ICU, to developing symptom-checking apps, to defining clear communication practices within leadership, to listening and responding to its 22,000 nurses and frontline team members across 26 hospital sites—nurses helped transform the health system from within and impacted care delivery in lasting ways.

The Johnson & Johnson Notes on Nursing team spoke with five nurse leaders from Advocate Aurora Health to learn about their roles in creating Advocate Aurora’s COVID-19 playbook and driving long-term change.

Meet the Nurse Change Leaders from Advocate Aurora Health

· Pictured in the middle is Chief Nursing Officer Mary Beth Kingston, PhD, RN, NEA-BC, FAAN who co-led the System Incident Command team for Advocate Aurora’s integrated multi-state health care system and provided broad clinical, logistic and communication leadership for the COVID-19 response.

· Pictured bottom-left is Regional Chief Nursing Officer and System Vice President, Clinical Operations Margaret Gavigan, MSN, MBA, RN, NEA-BC, who coordinated AAH’s initial operational response to the pandemic as part of the System Incident Command Team. She now oversees Illinois Nursing Operations, working with site CNOs; and system, regional and site leadership teams, the Illinois Patient Command Center, System Infection Prevention; and System Tele-ICU. She is also leading the system strategy for “Connected Health” with the goal to transform care delivery through the seamless integration of people, process and technology using virtual care as a cornerstone for improvement.

· Pictured top-right is Regional Chief Nursing Officer and System Vice President Jane Dus, DNP, RN, NE-BC, who co-led Advocate Aurora’s systemwide COVID-19 surge staffing team and was one of the leaders for clinical response, helping to create recommendations, policies and guidelines for all COVID-19 related clinical activities. Jane also partnered with the digital marketing team to create and implement “SafeCheck” – an app to screen team members for COVID-19 symptoms beyond just body temperature.

· Pictured top-left is System Vice President and Chief Nursing Informatics Officer Katie Barr, RN, MSN, who led the HIT Clinical Application Team and helped implement better tools for the Employee Health team, including an internal “bot” for team members to log possible exposure, making it possible to monitor team members daily. She is now leading the technology workgroup as AAH manages through the vaccine journey.

· Pictured bottom-right is System Vice President, Nursing Quality and Practice Sharon Quinlan, RN, MSN, MBA, NEA-BC, who guided the Employee Health Emergency Response Team to establish a new data infrastructure for reporting and managing exposure, formed a clinical management team for decision making on virus exposure and return to work guidelines, and built multiple COVID-19 team member testing sites that later served as templates for community testing sites.

J&J: How did COVID-19 affect Advocate Aurora?

Mary Beth: At our high point, we had about 1,200 inpatients and over 800 home care patients. Leadership at our Illinois and Wisconsin hospitals came together early on and decided to focus resources on COVID-19, and for the CNO and CMO to co-lead the response in a historic first for our organization. There was uncertainty at the start, but we found that communication and transparency allowed us to make decisions quickly. We set up bi-directional communication and clear protocols—for example, asking leaders of our response teams to use email to flag issues for immediate attention, and then cascading consistent information down to individual teams.

Advocate Aurora formed multidisciplinary teams like the System Incident Command Team, the Employee Health Response Team, and the Clinical Application Team with nurses in leadership roles where we could drive the system’s approach and inform decision-making. One of our nurse leaders, Jane Dus, led the development of an app while another, Katie Barr, was building an internal “bot” for our team members to log potential COVID-19 exposure. Elevating nurses early on had a major impact on our ability to provide care throughout the pandemic. Their leadership, expertise and perspective informed everything from the way we balanced infection prevention with transmission to how we built camaraderie within units and structured ourselves to flexibly redeploy resources as the crisis evolved.

Sharon: At the start of the pandemic, so much was unknown and yet a lot of new information was coming at us at the same time. When positivity rates and hospitalizations spiked, we determined our greatest need was the health of our team members. If our team members weren’t healthy, we couldn’t provide quality care for our patients. I was asked to lead an employee health response team and within 24 hours we identified issues with our data infrastructure, employee testing and exposure guidelines. We established employee health leaders within our patient service areas and a clinical exposure team led by a nurse-physician dyad. Over time, we set up data infrastructure for managing exposures, testing and obtaining results—it was foundational for our system. What was so gratifying was our early and rapid crisis response and the ways in which everyone came together and worked so hard to deliver what our system needed.

J&J: Under your leadership, what were some of the innovative ways your nursing team worked to provide patient care and keep your team members safe?

Margaret: We innovated in many wonderful ways that really demonstrated the skills and resilience of our staff. We also developed playbooks to give immediate, up-to-date and verifiable resources related to any policy, procedure, or guideline to clinicians and leaders on site. For example, the COVID-19 Information Center provides information related to exposure guidelines and testing centers and is easily accessible to our staff on our internal website. More recently, as new treatments for COVID-19 have emerged, we have developed a playbook on running those clinics.

We also embraced technology and redesigned workflows to optimize virtual care to meet our needs. We placed an emphasis on predictive analytics, which uses a patient’s trends and information to allow us to better predict potential clinical deteriorations. In organizations with our scale, you can easily cross-pollinate by sharing innovations and best practices. We were doing things like this before the pandemic and now with COVID-19 we are doing it every week. We are good at it, but we want to be great at it—so we are still committed to learning and trying to improve one year later. To do so, we want and need to continue cultivating ideas from the people who are doing frontline work, and at AAH we do that through our bottom-up approach and nursing shared governance.

Jane: Evidence-based practices keep patients and team members safe. However, as we learned more about the virus, new information about testing and PPE guidelines emerged daily and it was challenging to keep up. Working with the best evidence available and our practice leads, the team made frequent updates and changes to address the clinical needs of our patients.

Imagine being an OR nurse reassigned to the COVID-19 floors, or someone who’s back at the bedside for the first time in a while. The Nursing Education and Professional Development team created a web-based program, “Surge Orientation Staffing” (SOS), to assist the nurses who had been asked to return to the bedside to feel more comfortable caring for patients in the environment. Additionally, a team-based support model was developed as a tool for those who were new team members or returning to direct patient care. This offered the opportunity to be paired up to learn from each other and act as an extension of care.

We also created “Zen Dens,” supplied with comfortable lounging stations and care kits to address fatigue and the physical toll of long-term PPE use. Complimentary healthy snacks and hot beverages were available daily for recharge and relaxation breaks.

In addition, we partnered with our digital marketing team to design an app called “SafeCheck,” which became a hallmark in helping us identify team members who were COVID-19 positive, however, would have still passed a temperature screening if that was the only method of check we used. The app was developed and implemented to symptom-screen for all COVID-19 symptoms in addition to fever.

Throughout this time, supporting the direct care nurses and working to keep them safe was also personal for me because my husband was a frontline nurse caring for COVID-19 patients. I heard firsthand from his perspective and saw the impact of this work. It made it real for me.

J&J: What do you think Advocate Aurora did differently that helped your health system weather challenges presented by the pandemic?

Margaret: We made incredible changes during this time: 300+ new nursing practice changes; accommodated 350 more critically ill patients in our Tele ICU without adding staff; our Illinois Patient Command Center facilitated 704 more patient transfers into our system than the previous year; we reassigned 5000+ team members to new roles; we created 200+ new policies, workflows and protocols for Infection Prevention just to name a few of the changes. Nurses are accustomed to leading during times of crisis, but it truly was because of our coming together as a team at every level of the organization that helped us weather the pandemic. It was because we are privileged to have highly competent, dedicated, selfless, courageous, and compassionate nurses, nursing assistants and team members and leaders of all disciplines at AAH that made the difference during this challenging time. It is also our culture of always putting the patient first, understanding that our team members are our greatest asset and that quality/safety is our number one priority and is the basis of how we make decisions that also guided us during this time and helped us meet this unprecedented challenge.

Mary Beth: Nurse leadership rose to the occasion and delivered across our system. I am very fortunate not only to have a supportive leadership team, but also an incredibly talented one with diverse skills and experiences. We support each other and work with colleagues to address challenges across the system—whether implementing daily calls to share information calmly and quickly or listening and responding to concerns by providing things like snacks and comfort kits.

Peer-to-peer support was also crucial. There was a time when we had so many patients on extracorporeal membrane oxygenation (ECMO) at one of our large sites, we put out a call to one of our hospitals in Wisconsin and they sent nurses over for weeks—and vice versa when they had a surge. Everyone helped each other out. It inspired us to roll out peer-to-peer support programs in more sites and we look forward to seeing the impact that will have.

J&J: How has the past year changed or enhanced nurse-led innovation at Advocate Aurora?

Sharon: This year really amplified the voice of the nurse within our health system, and that’s here to stay. We had a very strong shared governance structure prior to the pandemic—a team that I support —and we relied on it heavily to hear the aggregate voice of nurses on the front lines of care.

For example, we were concerned about our nurses’ ongoing resilience, so we pulled all our system nursing councils together in a huge online forum. We asked more than 100 nurses what would be most helpful to them through this crisis and combined their input—what we were able to distill was powerful. Using their feedback, an interprofessional system team authorized a pandemic help package that, to a large extent, was driven by the nurses in shared governance.

I have already seen changes in the organization where nurses’ voices are stronger. We are recognized as leaders in the pandemic and that recognition can propel us to strengthen our voice further—I know it has propelled me to strengthen mine.

Katie: Overall, this year helped us assess what we were doing, what we’re using to do it, and how we can improve it. From an employee health perspective, at first we didn’t know what we needed. There was a lot of on-the-fly thinking to identify the problems we needed to solve, and then we really took a step back to see what we could give to our team members, whether a more efficient way to report exposures or better tools, like tests, monitoring systems and tracking methods.

For example, we had a lot more team members leaning on our Employee Health Department and the phones were overwhelmed. We developed an online bot to help team members who thought they had been exposed figure out what to do and to address the backup on the phone lines. In about a week, we also created a centralized hotline for employee health—one place for people to call—which lifted the burden from local Employee Health teams, improved their ability to prioritize and benefitted clinical thinking.

J&J: Do you have any advice for nurses at your health system and beyond who are interested in new leadership or innovation opportunities?

Katie: Before the pandemic, I don’t know if I ever would’ve said I was innovative. But I’ve realized that innovation is not always bright and shiny; it’s what you can do to make a situation better—and that it might be using something you’ve already got in your toolbox. Nurses already have a special skillset, including learning, having good assessment skills, reading a room and knowing when anxiety levels are going up—skills that will help us do anything. My advice is to believe in your skillsets and use them to solve a problem.

Jane: Nurses at the bedside have so many great ideas. Their unique position and nursing lens, gives them insight to best patient practices. We know that listening to them is the best way to improve patient care. I really encourage nurses to talk to their managers and share their ideas. So much of what we implemented came from our team members speaking up and letting us know what they needed in order to deliver safe patient care. Don’t be afraid to speak up and let your voice be heard.

Mary Beth: Nurses are natural leaders and compassionate caregivers. There’s tremendous power in our ideas and perspectives. Caring is based on skill, expertise and experiences. Nurses are also great multitaskers, so while we’re caring for patients, we are also constantly thinking about what needs to be done, assessing and adjusting. Remember that tapping into your experiences in science, care and compassion can make you a powerful nurse leader and innovator.

This pandemic has highlighted several issues but also has provided some silver linings. We now look to nurses for leadership roles and for leading major system initiatives. For instance, we know the importance of family in the healing process, but this was severely disrupted during the pandemic. Patients were unable to see their families and we needed to find a way to make that possible again. There was ingenuity within the nursing team to ensure our patients felt connected—they provided tablets for virtual visits and virtual vigils with family and caregivers. We have also seen a remarkable increase in workforce flexibility and the ability to work in other clinical areas. It’s not about getting back to normal—it’s about figuring out how we can innovate to meet the needs of our new reality. Overall, I couldn’t be prouder of our team and I can’t wait to share these learnings to other health systems to propel nurse-led innovation.