By Megan A. Brissie, DNP, RN, ACNP-BC, FNCS, Duke Regional Hospital, Duke Health, Department of Neurosurgery; and Lindsay Marchetti, MS, PA-C, Strong Memorial Hospital, University of Rochester Medical Center, Neurocritical Care
The COVID-19 pandemic has both created and exposed an assortment of challenges for healthcare systems, one of which is an increased need for healthcare workers.1-3 This increased need is due to both patient surges and loss of healthcare workers due to exposure, infection or other factors.1,4 Many COVID-19 patients require emergency and intensive care, and provider shortages in these specialized areas is especially challenging as trained staff are not easily replaced.2,4
Advance Practice Provider Utilization
Within critical care, it has previously been reported that advanced practice providers (APPs) have assisted in filling a grave gap in the demand for intensivists by increasing access to critical care in a cost effective, efficient and multifaceted manner.5-7 In this new, highly stressed era of healthcare, the role of the APP within the United States has been leveraged in a unique way. APPs have had to adapt their practice to meet not only the needs of their patients, but also the healthcare system itself. Many states have also now enacted emergency legislation further expanding the scope of practice for APPs to meet patient demands.8
Impact on Advance Practice Providers
In this volatile healthcare environment, APPs have felt a dynamic, and sometimes unsettling, shift in their roles within the healthcare system. In a modeling study analyzing the healthcare workforce in the United States, Bayham and Fenichel found that nurse practitioners (NPs) and physician assistants (PAs) have the highest unmet childcare obligations among healthcare workers.9
While some APPs have been redeployed from their practice areas to provide frontline care in testing, diagnosing and treating patients diagnosed with COVID-19, others have been furloughed as a cost-saving measure while physician counterparts have not experienced similar hardships. The level of education provided during redeployment has also varied widely reflecting the evolving understanding of the virus and the need for enhancements to dissemination of evidence-based practice guidelines and establishment of new healthcare policies and procedures.10
Perspectives from the Neurocritical Care Society’s Advanced Practice Providers
The Neurocritical Care Society (NCS) has a dynamic group of providers within its ranks that includes clinical nurse specialists (CNS), NPs and PAs who practice within neurology, neurosurgery and critical care. In view of these recent seismic shifts in practice, the NCS Advance Practice Provider Section performed a survey to evaluate the impact of the COVID-19 pandemic on APPs within NCS, assessing its effects on clinical practice, patient care, team structure and finances in order to better prepare for future pandemic needs.
The NCS-approved survey featured 60 questions assessing the APP response to the pandemic, and was developed by a working group of eight NPs, PAs and CNSs from across the United States. The survey link was distributed to more than 400 APPs within NCS from September-October 2020. Thirty APPs from across the United States provided complete responses to analyze. Most respondents, 80%, practiced at academic medical centers in large urban areas, while the remainder of APPs practiced in community and rural settings. Approximately 70% of respondents reported working as dedicated neurocritical care providers and a third of respondents reported six or more years of clinical practice experience.
Over 70% of APP respondents reported taking direct care of COVID-19 patients. Various modalities for educational preparation were utilized to meet patient needs to prepare the APPs to care for this newly emerging disease process. This included utilization of national organization educational updates, webinars, published guidelines, hospital education modules and peer-to-peer training. However, despite reports of redeployment, nearly 80% of respondents were not redeployed to other care areas to meet patient needs, with the remaining 20% reporting being reassigned to provide care in COVID-19-specific ICUs. Although the majority of respondents reported that COVID-19 patients received care from a diverse group of providers, including attending physicians, fellows, residents and APPs, providers from outside dedicated critical care settings were often recruited to meet patient needs when demands could not otherwise be met. This included APPs from both inpatient and outpatient settings.
Nearly 40% of respondents reported that their neurocritical care units experienced reduced APP staffing. This was due to several reasons: reallocation of APPs to COVID-19 specific ICUs in some cases, a need to protect staff from exposure to possible illness, decreased neurocritical care unit census, implementation of block scheduling and need for cost reduction. Of note, provider shortages in neurocritical care units created by redeployment were not filled by other APPs but instead by other care providers, most often fellows. Fifteen responding APPs reported that patient-to-provider ratios remained the same at their institutions, while six reported that ratios increased, and six reported that ratios decreased based on patient needs.
Most APP responders (74%) agreed that they were appropriately utilized during the pandemic response. Specific comments included that “APPs are trained and adaptable to meet such patient care needs and flexible in their practice to meet the demands,” that it was “recognized that they could work to [their] full scope,” and that “they provided consistency for patient care, [while being] up-to-date on current treatments.”
Strikingly, despite feeling as though neurocritical care APPs were utilized appropriately, 53% of responders reported decreased job satisfaction. They cited increased stress (13), increased workload (10), financial constraints (7) and fear of getting COVID-19 (6) as the main causes for the acute shift in job satisfaction. In a field already plagued with widespread burnout this rate of frustration and exhaustion was alarming. APPs reported feeling underappreciated for their medical knowledge, with one describing feeling “constrained to a structure where they [were] supervised by fellows and [felt they] could have been working more autonomously.” Other institutions reported APPs “were not utilized at all, only fellows and residents.” Another APP reported that the “resident workforce was excluded/banned from caring for COVID-19 patients…and were pulled out of ICUs, leaving APPs to do the lion’s share of the care for these patients, [therefore] stressing staffing.” Being able to recognize the skills, training and expertise that all multidisciplinary healthcare providers can provide during such challenging times to meet patient care needs is crucial to sustaining the healthcare system and meeting patient care needs.
One contributor elaborated that “during the initial wave of the COVID epidemic the critical care leadership team relied heavily on experienced APPs … who were the first providers in the hospital to be called upon to assist the medical ICU team when the patient care demands began to surge. Despite the challenges faced during the spring COVID-19 surge, the neurocritical care team universally recognized that their flexibility, exertion and sacrifice were necessary.” Now, in the midst of the second wave, the “critical care APPs have again been called-up to assist with the rising numbers of critically ill COVID-19 patients. The exhaustion of the group is palpable.” The greatest singular hardships that APPs reported experiencing during the COVID-19 response were financial impacts. The most common financial hardship, reported by over a third of respondents, was loss of their annual raise. Individuals also cited a loss of educational funds (10), retirement benefits (10) and travel funds (7), with only 25% of respondents saying they did not experience a financial impact. Despite these hardships, the critical care APPs continue to step forward demonstrating that they are capable of providing exceptional patient care to even the sickest of patients.
Based on the responses we received, APPs within NCS have shown great flexibility, adaptability, creativity and dedication to patient care in the dynamic roles they have fulfilled during the COVID-19 pandemic. As many regions continue to respond to surges and anticipate ongoing demands until vaccination goals are met, APPs represent a valuable pillar of the healthcare system and should continue to be utilized to meet patient care needs to their full scope of practice. However, the NCS APP survey also suggests that healthcare systems should work with APPs to ensure financial security and job satisfaction during times of increased stress and clinical burden to prevent APP burnout.
We thank the NCS Advance Practice Provider Section for providing valuable feedback on the APP responses we received about their experiences during the COVID-19 pandemic. NCS also wishes to thank all APPs and NCS providers for their efforts taking care of neurocritical care and COVID-19 patients alike during this difficult time.
- Black JRM, Bailey C, Przewrocka J, Dijkstra KK, Swanton C. COVID-19: the case for health-care worker screening to prevent hospital transmission. The Lancet. 2020;395(10234):1418-1420.
- Peiffer-Smadja N, Lucet JC, Bendjelloul G, et al. Challenges and issues about organizing a hospital to respond to the COVID-19 outbreak: experience from a French reference centre. Clin Microbiol Infect. 2020;26(6):669-672.
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- Mascha EJ, Schober P, Schefold JC, Stueber F, Luedi MM. Staffing With Disease-Based Epidemiologic Indices May Reduce Shortage of Intensive Care Unit Staff During the COVID-19 Pandemic. Anesth Analg. 2020;131(1):24-30.
- Fry M. Literature review of the impact of nurse practitioners in critical care services. Nurs Crit Care. 2011 Mar-Apr;16(2):58-66. doi: 10.1111/j.1478-5153.2010.00437.x. PMID: 21299758
- Pastores SM, Kvetan V, Coopersmith CM, Farmer JC, Sessler C, Christman JW, D'Agostino R, Diaz-Gomez J, Gregg SR, Khan RA, Kapu AN, Masur H, Mehta G, Moore J, Oropello JM, Price K; Academic Leaders in Critical Care Medicine (ALCCM) Task Force of the Society of the Critical Care Medicine. Workforce, Workload, and Burnout Among Intensivists and Advanced Practice Providers: A Narrative Review. Crit Care Med. 2019 Apr;47(4):550-557. doi: 10.1097/CCM.0000000000003637. PMID: 30688716.
- Woo BFY, Lee JXY, Tam WWS. The impact of the advanced practice nursing role on quality of care, clinical outcomes, patient satisfaction, and cost in the emergency and critical care settings: a systematic review. Hum Resour Health. 2017;15(1):63. Published 2017 Sep 11. doi:10.1186/s12960-017-0237-9
- EP, Pittman P, Frogner BK, Spetz J, Moore J, Beck AJ, Armstrong D, Buerhaus PI. Ensuring and Sustaining a Pandemic Workforce. N Engl J Med. 2020 Jun 4;382(23):2181-2183. doi: 10.1056/NEJMp2006376. Epub 2020 Apr 8. PMID: 32268021.
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- Diez-Sampedro A, Gonzalez A, Delgado V, Flowers M, Maltseva T, Olenick M. COVID-19 and Advanced Practice Registered Nurses: Frontline Update. J Nurse Pract. 2020 Sep;16(8):551-555. doi: 10.1016/j.nurpra.2020.06.014. Epub 2020 Jun 18. PMID: 32837398; PMCID: PMC7301091.