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Use of the ADKAR® and CLARC ®
Change Models to Navigate Staffing
Model Changes During the COVID-19
Pandemic
Julie Balluck, MSN, RN, NEA-BC, Elizabeth Asturi, MSN, RN, NE-BC, and
Vicki Brockman, DNP, RN, NE-BC, NEA-BC

In early 2020, hospitals faced unprecedented patient volumes resulting from the
COVID-19 outbreak. Nurse executives at a faith-based, not-for-profit health care
system quickly responded to ensure safe staffing, conservation of personal pro-
tective equipment, and implementation of infection prevention strategies. A sig-
nificant challenge was safe staffing for the expected patient surge. To address this,
a team of nurse executives utilized the ADKAR change model to guide a transition
from primary to team nursing. The processes varied between hospitals, but core
principles and implementation strategies were the same. This article discusses the
quick, but methodical, journey one health care system experienced.

I
n early 2020, the world collectively faced a global principles and implementation strategies were very
pandemic that challenged modern health care as similar throughout the system.
never before. As the coronavirus disease 2019
(COVID-19) crisis unfolded, nurses across the country TEAM NURSING: WHAT IS IT?
were faced with the challenge of managing a high Team nursing is a care delivery system model devel-
volume of patients with an emerging infectious disease, oped in the 1950s in which a team of clinicians shares
the stress of personal protective equipment (PPE) responsibility for a group of patients under the direc-
shortages, while simultaneously implementing ever- tion of an RN.1 The original design of team nursing
changing guidelines around infection prevention stra- was in response to a nursing shortage, and this was the
tegies. At the same time, hospital routines and pro- primary reason we chose this model.1 The imple-
cesses drastically changed to ensure social distancing, mentation of the team nursing model was part of our
increasing bed capacity for the anticipated surge of emergency planning response to the likelihood that we
patients, and implementing new clinical practices to might have more patients than nurses, due to the
ensure staff and patient safety. increasing number of patients with COVID-19, as well
A significant challenge for nursing leaders was how as the possibility of nurses becoming ill themselves.
to prepare for the anticipated surge in patients,
particularly for those requiring critical care if there was
a mismatch of supply and demand of nursing staff. To
KEY POINTS
address this issue, a team of nurse leaders at the faith-
based, 25-hospital Texas Health Resources health care  Change must be managed through the use
system utilized the ADKAR and CLARC change of a change model, such as ADKAR, to guide
models to guide a change in the staffing model from the process.
primary nursing to team nursing. These models  Ongoing communication and collaboration
allowed nurses to be safely deployed and practice at all levels are essential.
within the systems hospitals from areas that had ser-
 Role clarity and responsibility are key to
vices closed or significantly decreased. Even though the
staff understanding and implementation of
processes varied between small (Figure 1), medium
the new model
(Figure 2), and large (Figure 3) hospitals, the core

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 Figure 1. Example From a Small Hospital

540 December 2020 www.nurseleader.com

Figure 2. Example From a Medium Hospital

With team nursing, coordination of care is shared nursing resources, such as those from outpatient clinics
by members of a group; the team may include regis- and procedural areas. At the time, elective procedures
tered nurses (RNs), licensed practical nurses (LPNs), were placed on a state-ordered hold for several weeks
and other nursing personnel, but the team leader is to ensure staffing, supply, and hospital capacity re-
most often a RN.2 The team holds shared responsibility sources were conserved.
and accountability for a group of patients. With team nursing, providers usually care for a
A care team using the team nursing model is a larger group of patients. This allows each caregiver to
group of care providers of varying skills and training leverage their individual skills, competency, and talent
levels working together to provide care for a group of to care for patients when demand exceeds staffing re-
patients.3 We believed the team nursing model would sources. Typically, in a team nursing model, the team
allow us to capitalize on underutilized and available leader coordinates care and utilizes team members

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 Figure 3. Example From a Large Hospital

most efficiently and effectively to meet the patient's pool to assign staff, based on skill level and clinical
needs.3 There are various roles on the team, based competence.
upon composition. Still, a collaborative approach al- Team nursing is a more productive option when
lows for patient care needs to be met, while also utilizing staff who are not familiar with a unit or not
reassuring staff they would not be in a situation where familiar with some tasks. Tasks were delegated based
patient safety would be compromised, and the integrity on competency rather than patient assignment.4
of their license would be maintained. Additionally, using a change management tool to
At Texas Health, we were fortunate to have more quickly educate and deploy the team nursing care
time on our side to plan and prepare than many of our model, it allowed this change to be entity- and even
colleagues in other parts of the country. The time unit-specific, depending on the current status of staffing
allowed us to quickly conduct basic nursing compe- resources. Although deploying team nursing was
tency refresher labs for those nurses who had been out initially planned as a temporary solution to ensure safe
of the acute care and intensive care settings for an patient care, this conceivably could be used beyond the
extended period. The Texas Health Resources (THR) initial crisis brought on by COVID-19 as a tactic to
University team quickly mobilized these skill labs and manage future crises that may impact staffing
competency checkoffs to allow our labor-management resources.

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SUGGESTED TEAM ROLES Team RN
Float RN or cross-trained RN assigned to the unit who
Executive RN Sponsor (Officer) and Sponsor
will:
Coalition
Nursing officers and directors responsible for making  Complete patient screening and medication
decisions and giving direction that impact the care reconciliation
team. Sponsors are responsible for:  Complete focused patient assessment as needed
 Assess changes in patient condition and escalate
 Being active and visible in leading initiatives
concerns to the primary RN and/or charge nurse
 Building a coalition of leaders and peers who can
 Medication administration, including those in which
support effective change
they have a level of comfort
 Communicating directly with managers and em-
 Complete patient ambulation, range of motion, ac-
ployees who are impacted by decisions and changes
tivities of daily living, bathroom assistance
 Perform nonspecialized skills such as routine dressing
Unit Manager and Supervisor changes, and IV starts, phlebotomy, insert/remove
Nurse leaders who direct daily operations and team Foley catheters, empty gastroduodenal drains
management in a care unit. Managers and Supervisors  Complete patient teaching as delegated by the pri-
are responsible for, but not limited to: mary RN
 Transport patients with monitoring
 Approaching change with a positive attitude and  Delegate tasks to patient care technicians (PCTs)
proactive mindset  Donning/doffing observer, hall monitor, emotional
 Using both the ADKAR and CLARC models to lead support, and assist with meal breaks
themselves and others through change (see reference6  Documents interventions on the disaster navigator
for more information)  Routine rounding
 Developing just-in-time training or a resource
manual for the team to quickly orient and be brought
up to speed on recent updates. Home Unit or Float PCT/2nd Team RN/LPN
 Address questions or concerns raised by the nursing
 Follows current unit routines and tasks as directed by
staff or providers
the primary RN
 Runner—Bring items to and from the rooms, so staff
Primary RN (Team Leader) in rooms do not have to remove PPE and put back
Home unit RN who is assigned to a group of rooms or on, also assist with donning/doffing, keeping isola-
patients to coordinate and supervise care. This RN is tion stocked
responsible for, but not limited to:

 Complete initial admission, physical assessment, pa- THE USE OF ADKAR IN IMPLEMENTING TEAM
tient screening, medication administration and NURSING
reconciliation, and to delegate tasks of care Before implementing the team nursing model, the
 Complete head-to-toe physical assessment leaders at Texas Health looked to the ADKAR change
 Medication administration, including pain manage- model for support. The Prosci ADKAR model pro-
ment and titration of drips vided leaders with the tools to better communicate,
 Assess changes in patient condition explain, and train care team members while imple-
 Complete specialized skills where team RN is not menting a change. There are 5 tenets of Prosci change
trained management, and these include:
 Complete patient teaching
 Communicate with provider(s) 1. We change for a reason. In our case, it was in response
 Primary contact for patient’s family and significant and part of our emergency planning related to the
others anticipated surge from the COVID pandemic.
 Complete, review with patient and print discharge 2. Organizational change requires individual change. Although
instructions moving from primary nursing to team nursing
 Documents interventions and details of care in the would impact almost our entire nursing team, staff
department-specific portion of the medical record verbalized relief that there was a plan in place to
 Delegate as needed manage the unknown ahead.

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544
December 2020

Table 1. ADKAR Change Management at Texas Health Resources

With ADKAR You Will

Questions to Ask Yourself Action Steps to Take Without ADKAR You Will See. Hear.

A What is the nature of the change? Draft effective and targeted More resistance from employees I understand why.
Awareness Why is the change needed? communications Lower productivity
What is the risk of not changing? Share the why and the vision
Provide ready access information
D What’s in it for me (WIIFM)? Demonstrate your commitment Higher turnover I have decided to.
Desire How is this a personal choice Advocate for change Delays in implementation
Will I decide to engage and Engage influencers to foster employee
participate? participation and involvement
K Do I understand how to change? Provide effective training with the Lower utilization or incorrect usage of I know how to.
Knowledge Where can I be trained on new proper context new processes and tools
processes & tools? Facilitate education for, during, and Greater impact on customers and
How do I best learn new skills? after the change partners
Create job aides and real-life
applications
A Am I demonstrating the capability to Facilitate coaching by managers, Sustained reduction in productivity I am able to.
Ability implement the change? supervisors, and subject matter
Am I able to achieve the desired experts
change in performance or behavior? Offer hands-on exercises, practice and
time
Eliminate any potential barriers
R What actions can I take to increase Celebrate successes individually and Employees will revert to old ways of I will continue to.
Reinforcement the likelihood that this change will as a group doing work
continue? Reward and recognize early adopters The organization creates a history of
Give feedback on performance and poorly managed change
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accountability
3. Organizational outcomes are the collective result of individual exhibited some resistance because they did not feel
change. The communication of “the why” behind this their roles were clear. The CNO and nursing leaders
change was extensively communicated to our nursing used additional tools from CLARC to work through
team across the THR system. Communication strate- the concerns, assisting in clearly defining the staff pa-
gies included e-mail, town hall meetings, staff meetings, tient care responsibilities with the team nursing model.
leader rounding, and weekly webinars.
4. Change management is an enabling framework for managing CHANGE MANAGEMENT
the people side of change. During times of change, it is ADKAR is an acronym that represents the 5 tangible
stressful; add in a global pandemic, and it adds a and concrete outcomes that people need to achieve for
layer of complexity that most of our leaders had lasting change (Table 1).6 Below, we outline these out-
never experienced in their careers. Leaning on an comes and how they looked at Texas Health during
evidence-based change management theory was this process.
essential to provide structure during this period of Awareness for the need for change: The leaders identified
great uncertainty. what information individuals needed about the team
5. We apply change management to realize the benefits and nursing model and who should share that information,
desired outcomes of change. Planning for this degree of such as the sponsor (CNO) and entity nursing leaders.
change in the unit practices included education in Although we did not have all the answers, it was
staff meeting presentations and via electronic necessary to communicate in an open, direct and
communication.5 honest way. We were truly in it together.
Desire to support the change: Leaders identified how
There was a consistent message and a unified willing our nursing team was to participate in the team
approach to the plan from the top down. Ongoing nursing model and approach. We discovered that most of
evaluation was necessary to elicit feedback and monitor our nurses wanted to help in whatever capacity he or she
the level of morale, while identifying barriers, crucial to was able to do so safely. We initially received hesitation
navigating change. It was important for primary RNs from our operating room (OR) staff. Once they under-
to arrange for the team to meet at regular intervals stood this was a task-driven model, they volunteered to
daily/weekly to brief on new developments of infor- lead the proning efforts for our patients in the intensive
mation and provide a supportive role.2 care unit, leveraging their expertise related to safe patient
positioning, a critical skillset in the OR.
LEADING OTHERS THROUGH CHANGE Knowledge of how to change: We shared information in
The nursing leaders used the CLARC model to lead various forms on team nursing and how it would look
our teams by playing the following roles throughout at each of our entities. During leader rounding and
this change: town hall meetings, we validated that individuals had
an understanding of the team nursing model and why
 Communicator: Explain why changes are being we were taking this approach.
made and how they impact the team and their Ability to demonstrate skills and behaviors: As we set up
patients. skill refresher classes for some of our nurses from
 Liaison: Report to sponsors (senior leaders) how nontraditional practice areas, we validated which in-
the change is impacted and being received by your dividuals could support the team nursing model and
team, and share information from leadership with approach. This also included educating our nurse
your team. managers and supervisors on this nursing care delivery
 Advocate: Demonstrate your commitment to the model, as this was new to them, too.
change and promote a positive attitude. Reinforcement to make the change stick. We identified
 Resistance Manager: When resistance to how and who should reinforce the use of the team
change arises, make time to understand and address nursing model/approach. This included daily shift
the root causes of resistance. safety huddles led by the nurse manager or charge
 Coach: Help your employees build knowledge and nurse to check in with the team and receive feedback
ability to adopt new behaviors and practices on how to maintain this change. Outcomes related to
successfully.5 patient quality and safety continued to be measured
during this change in our patient care delivery
Using the aforementioned CLARC principles to model. We found our outcomes remained consistent
support the teams during this event facilitated a smooth at similar levels to what we measured with primary
transition that we believed was due to the intentional nursing.
communication and ongoing presence of leaders who
made themselves available to discuss concerns, address CONCLUSION
immediate issues, and provide overall reassurance. One When hospitals were faced with unprecedented patient
example of this occurred at a smaller entity when staff volumes resulting from the COVID-19 outbreak, Texas

www.nurseleader.com December 2020 545

 Health nurse executives needed to utilize a rapid-cycle 3. Dickerson J, Latina A. Team nursing: a collaborative approach
change model to prepare for a variety of scenarios. improves patient care. Nursing. 2017;47(10):16-17.
4. O'Connell B, Duke M, Bennett P, Crawford S, Korfiatis V. The
While keeping patient safety and nurse satisfaction as a trials and tribulations of team-nursing. Collegian.
priority, the nurse executive team quickly responded by 2006;13(3):11-17.
developing an alternative staffing model based on a 5. Hiatt JM, Creasey TJ. Change Management: The People Side of
team nursing approach to ensure safe staffing. By using Change. Fort Collins, CO: Prosci Inc.; 2012.
the ADKAR and CLARC change models to guide a 6. The Prosci ADKAR Model: Why It Works. Prosci website.
Available at: https://www.prosci.com/resources/articles/why-
change from primary to team nursing, they were able the-adkar-model-works. Accessed July 28, 2020.
to put plans in place to meet the demands, whether it
was caused by a decrease in the available workforce or Julie Balluck, MSN, RN, NEA-BC, is chief nursing officer at
a surge of patients. The processes varied between Texas Health Harris Methodist Hospital – Hurst-Euless-
hospitals, but core principles and implementation Bedford in Bedford, Texas. She can be reached at
strategies were the same. As a result, the goal of the safe JulieBalluck@texashealth.org. Elizabeth Asturi, MSN, RN,
patient staffing was achieved, and plans remain rele- NE-BC, is chief nursing officer Texas Health Dallas in Dallas,
vant in the event there is another situation to warrant a Texas. Vicki Brockman, DNP, RN, NE-BC, NEA-BC, is chief
change in our primary nursing care delivery model in a nursing officer at Texas Health Cleburne in Cleburne, Texas.
short period of time.
Note: We sincerely acknowledge the help and support
of the executive team from Texas Health Resources,
and the team at Texas Health Resources University
REFERENCES (THRU) for the resources and support during this
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546 December 2020 www.nurseleader.com