My Specialty

Clinical Nurse Manager, ICU, Kristina Lawrence, Valley Presbyterian Hospital

Rising to the challenge of the new normal in the age of COVID-19

Please tell us about the trajectory of your nursing career

My grandmother was a nurse instructor, so I basically grew up in the classroom and apparently had nursing in my blood. I worked fulltime as a unit secretary while doing my prerequisites and then attending nursing school. Once I was licensed, Valley Presbyterian Hospital essentially created a position for me in the recovery unit.

Since they didn’t have an educator in that unit at the time, I was lumped in with the new grads being trained in the ICU. So, I actually received ICU training from the start. I did recovery for three months and was then hired for an ICU position.

When there was an opportunity in nursing leadership on our unit, I was encouraged to apply, even though I still wanted to be on the floor. I spent six months in a hybrid position that was equally split between patient care and management, and was then asked to interview for the fulltime ICU clinical nurse manager position that I currently hold.

What was it like to start in ICU as a relatively new nurse?

ICU was always my thing. During my final semester in nursing school, I enjoyed an eight-week ICU rotation at a Level I trauma center, which was exciting and fast-paced.

Most of us who love ICU and ER are adrenaline junkies, but I prefer ICU because I like to have more time to get to know patients and their families. The relationships in the ER are just too brief for me. I also like to see how patients’ care evolves over the course of treatment. We often say that the ER is chaos and the ICU is organized chaos, and organized chaos is where I function best.

The scariest part about starting in ICU is not knowing what you don’t know. New grads face the constant terror of hurting someone; you don’t want to miss details that will harm the patient. That said, the nurses here were quick to jump in and take care of me when I needed it the most.

When COVID-19 broke, when did you first see signs in your ICU?

The first case to rule out for COVID was in the beginning of March. The surge happened in the beginning of April. We got hit with about four cases, and then it expanded to eight very quickly. Some weeks are very busy and then taper off, so we keep asking ourselves, “Was this the surge or just a temporary plateau?”

Tell us about protection of staff in the treatment of COVID-19

IV poles and other equipment are kept in the hallway outside the room to minimize the need for staff to enter the rooms. Our ventilators don’t have detachable screens, so we can’t run the vents from outside the room like some hospitals are doing. However, since we have to go in every two hours to turn intubated patients to prevent skin breakdown, vent care and turning are clustered.

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When needed, we use the MAXAIR CAPR, which is a battery-powered air-purifying respirator with a helmet and face shield that provides positive airflow through a filter. We also use N95 masks with face shields, gowns and gloves whenever necessary. through a filter. We also use N95 masks with face shields, gowns and gloves whenever necessary.

Our hospital was very aggressive about obtaining PPE from the beginning. The normal channels were exhausted early on, so we found alternative channels and chose to pay double or even triple the price so that our staff could count on being protected no matter what.

What about keeping staff members’ families safe when they go home from work?

Since all elective surgeries have been canceled and those units closed, all surgical scrubs have been redirected to staff treating patients with actual or suspected COVID-19. Scrubs are all washed in-house and everyone wears work shoes that can be easily wiped down and disinfected.

All staff change in and out of their scrubs at work, so they go home wearing clean street clothes and a pair of clean shoes.

RCPs, housekeeping, and other staff are also issued scrubs. Our housekeepers and other ancillary support staff are the unsung heroes of this entire situation. Nurses get a lot of credit, but those other departments are just as crucial. After all, where would we be without clean rooms, meals and a smoothly operating physical plant?

How are your nurses doing these days?

At first, there was a sense of heightened anxiety, but our nurses and other staff have handled it with grace as we’ve moved into our “new normal.” As mentioned above, we’re put a great deal of energy into their safety, which assuages some of their very understandable anxiety.

The nurses have had to be very adaptable. Policies and procedures had to change multiple times per day as we got up to speed. It was a hectic time for everyone, and we have remained ready to pivot as new data emerges.

Tell us more about this “new normal” as we face the rest of 2020.

Our census fluctuates and will likely continue to do so. In our unit, staffing is the biggest challenge; having a sufficient number of clinicians on board will continue to be a priority. Some staff worked crazy shifts at the beginning, but, with more travelers available, things are now much better and have settled down into a sort of rhythm.

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We’ve had to relearn the practice of nursing in this novel context. For instance, when someone is experiencing a cardiac or respiratory arrest, you want to run in and save them, but COVID-19 demands a change in mindset. You have to stop at the red line at the door of the patient’s room and make sure your PPE is sorted out. This takes precious time, but everyone has to be protected, even when you’re trying to save a life.

We also have to think about how to care for other patients in the ICU. People are still having non-COVID-19 related medical crises, and they also need our protection and care. We simply won’t allow anyone to fall through the cracks for any reason.

How do you prepare for what may emerge in the months to come?

We’ve designated the pediatric ICU as our first overflow unit; it has 10 beds and our ICU has 20, giving us a 30-bed overall capacity. We also have a second surge plan in place for increased census. We have to take it day by day and week by week.

We’re currently holding our breath in terms of the current stay-at-home order. With more people out and about in the city, we can expect things to change.

What are your thoughts on the Year of the Nurse (as declared by the World Health Organization) in light of nurses’ role in this pandemic response?

The Year of the Nurse and Midwife calls attention to the ways in which nurses constantly innovate.  COVID-19 has forced us to reinvent many aspects of our approach to patient care. For example, when a patient presents with myocardial infarction symptoms and shortness of breath, we also need to swab them for COVID-19.

Some of these changes may seem small, but they have a big impact on our practice. We’re learning to cluster care even more efficiently and adding more tools to our nursing toolbox.

The pandemic also calls on us to find new ways to empower and inform patients’ families, even when the patient is intubated and the family can’t physically visit. We now call patients’ families at least once per shift to check in and ask if they have any questions or concerns, just as if they were actually in the room. There are so many little things we’ve reinvented.

The challenge has made it an interesting time to be a nurse: You get to use your critical thinking to its utmost and learn so much from the evidence-based practices that are coming to light. This being the Year of the Nurse and Midwife is appropriate on many levels.

What would you say to a novice nurse with interest in the ICU?

It’s a hard to place to start out as a new grad. Some people just know it’s for them and are successful. Others don’t do so well.

The most important thing is to have a total passion for learning and for deeply understanding how body systems interact. You must be willing to use your experience, build on your background, look deeply at what’s in front of you and keep learning and growing day after day. You have to be a passionate, open-minded critical thinker who’s willing to accept that there will be many times when you just don’t know what to do. You simply can’t let your pride get in the way of asking questions.


Keith Carlson, RN, BSN, CPC, NC-BC, has worked as a nurse since 1996 and has maintained the popular nursing blog Digital Doorway since 2005. He offers expert professional coaching for nurses and nursing students at www.nursekeith.com.


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