Effective Decision-Making During the Pandemic

Even before the COVID-19 pandemic, there were times when we might have wondered who made the latest decision that impacted our work and our work environment. Over the course of the pandemic, hospitals used incident command centers to more effectively manage the crisis. Incident commands result in a more direct take-charge style of management compared with the participatory management style that many of us are used to; especially those who have robust shared governance programs.

Our incident command started in March 2020. By the end of May, we were fortunate to experience a decrease in COVID-19 admissions. This situation provided a window of time for us to evaluate our initial response and obtain critical feedback to inform process improvements for future surges.

Staff nurses and program managers’ feedback (via an online survey and small-group face-to-face listening sessions) identified the following key barriers to more effective decision-making:

• Uncertainty – We didn’t know what we didn’t know. It was difficult to determine the facts and develop a shared understanding of what was a fact at any given moment.
• Rumors – Hearsay stemmed from the uncertainty and lack of clear communication channels.
• Lack of input from subject matter experts and key stakeholders – specifically direct-care nurses and nurse managers. The incident command structure can be so streamlined that it may create a silo that separates the decision-makers from key information.
• Stress – Let’s face it, these are really stressful times. When we’re stressed and dealing with rapid, constant change it can be difficult to stay focused and make evidence-based decisions.

Work groups were formed to address the top three priority themes and recommendations identified by survey responders. We implemented short-term strategies, including the following:

• Developed online self-report skills assessment for all nursing staff. This assessment helped focus our refresher courses, which were needed for future in-house deployments.
• Established routine video chats for the management group, facilitated by the nurse executive. The frequency (daily, weekly) depended on surge intensity. Set agenda items kept the message focused: space, people/staff, equipment, supplies, concerns from managers/staff.
• Clarified communication structure and ways for managers to remain visible for staff.
• Ensured support/stress relief services are available 24/7.

COVID-19 has forced many of us to return to the basics. We’ve managed this change as we educate colleagues to become “helpers” in acute and critical care settings and refocus care to “just” the essentials, knowing that our limited time, energy and resources don’t allow us to do everything. We can use a similar back-to-basics approach to decision-making. Following are some strategies to help us implement effective decision-making:

Direct Care Nurse

• Continue using nursing’s foundation for effective decision-making: the nursing process (Assess, Diagnose, Plan, Implement and Evaluate).
• Participate in shift and daily huddles. These formats are great for sharing information to ensure everyone has the same data moving forward.
• Utilize unit- and facility-based nursing shared governance (NSG) structures. NSG gives us a framework to engage nurses at all levels to evaluate information, determine what proposed changes may mean for care delivery, discuss how to implement change, and support one another throughout the process.
• Recognize the universal stress of the pandemic, and be kind to yourself and others when extra support is needed. Your perspective and expertise are necessary for effective decision-making, and managing your emotions will help you be heard.

Nurse Managers/Leaders

• Routine rounding – Request staff input, acknowledging their expertise at the point of care.
• Ask three key questions when making decisions:
  • Have all perspectives been heard and considered?
  • Do we have all the information available at this time to make the best decision?
  • How will we know the decision is the correct one? (i.e., outcome measures, timeline for evaluation)
• Participate in and support NSG processes, even if sometimes it means brief or fewer meetings.
• Clarify potential conflicting information between system, facility and unit levels.
• AACN’s podcast “Leadership at Its Best: Supporting Staff Nurses in a Pandemic” provides additional strategies.

Organizational Leaders

• Engage stakeholders in decisions – especially those with expertise at the point of care.
• Use a formal process to obtain feedback from stakeholders to inform future decisions.
• Provide a clear mechanism for staff to provide input or ask for clarification from top leadership/incident command.
• Consider using this checklist to evaluate your facility’s organizational resilience.

Please share your tips for effective decision-making. What back-to-basics decision-making structures have helped you navigate a COVID-19 response?