Redeployed staff and better teamwork: how COVID-19 has transformed nursing
Staff on the front-line at UCLH consider the lessons learned during the pandemic
- University College London Hospitals NHS Foundation Trust (UCLH) began preparing to receive patients with COVID-19 in early March 2020
- Wards were transformed to cope with COVID-19 cases, with staff redeployed in new roles
- Staff explain how teamwork and the removal of hierarchical structures helped them adapt quickly to changes as the pandemic developed
When the World Health Organization designated 2020 International Year of the Nurse and Midwife, no one could have known that the world’s attention would be fixed on all front-line healthcare workers as COVID-19 spread around the globe.
This year also happens to be the 200th anniversary of Florence Nightingale’s birth, a compelling hook on which to hang the first global celebration of nursing.
International Year of the Nurse has been dominated by COVID-19
Perhaps with her in mind, the media has reached for the image of nurses as angel and/or hero during the pandemic. But there’s far more to nurses than that – as indeed there was to Florence Nightingale.
She was known to colleagues as ‘the lady with the hammer’ rather than the lamp because she used a hammer to gain access to core medical supplies kept under lock and key during the Crimean War. This illustrates her courage and commitment to her patients.
The Victorians cemented the more genteel image of ‘the lady with the lamp’, but if Florence Nightingale was here today, she would likely be fighting to ensure her nurses had the right personal protective equipment (PPE).
Wards were transformed and new units opened to cope with COVID-19 cases
Times change, but professionalism, skill, resourcefulness, flexibility, courage, know-how, organisation, good humour and compassion characterise the nurses for whom COVID-19 has meant redeployment away from their usual specialty.
In a remarkably short time, University College London Hospitals NHS Foundation Trust (UCLH) repurposed much of the main hospital to cope with COVID-19 cases, with wards transformed, new units opened and many nurses posted to unfamiliar roles.
The eye of the storm has been the much-expanded critical care unit and two new wards created for patients who have stepped down from intensive care to the high dependency respiratory units (HDRUs), in which one of UCLH’s improvisations, the continuous positive airway pressure (CPAP) machine adapted for COVID-19 patients, has been used.
This machine was adapted from an Italian model by consultant Mervyn Singer and his team. A prototype was produced by the Mercedes Formula One team in a few weeks.
This innovation was so important that when the first COVID-19 patients arrived in intensive care, they were maintained on the adapted CPAP machines rather than ventilators.
‘Preparing critical care at UCLH was a success but it wasn’t easy and we’re still learning. There won’t be a return to ‘normality’ inside two years, if ever’
Elaine Thorpe, critical care matron, University College Hospitals NHS Foundation Trust
The transformation of UCLH’s critical care in preparation for COVID-19 began around 2 March, with consultations with members of the Intensive Care Society and professionals in hospitals in Italy, China and other countries that had already been affected.
The message from the Italian medics was ‘Prepare, prepare, prepare’ and this was taken to heart by UCLH deputy chief nurse Rabina Tindale and critical care matron Elaine Thorpe and her team.
Adaptability has been key to successful redeployment of staff
The transformation of critical care was planned like a military operation. A tactical lead role (who was an ICU consultant) was created to oversee the process. The whole of the third floor of the main hospital, which has 12 operating theatres, became an extension of critical care; 35 beds were replaced with 86 intensive care beds, all with the ability to ventilate patients.
Intensive care units (ICUs) normally have one nurse to one patient; the proposed ratio for COVID-19 was one nurse to five patients if necessary.
Preparing critical care at UCLH was a success, ‘but it wasn’t easy, there were lots of things to learn along the way – and we’re still learning. There won’t be a return to ‘normality’ inside two years, if ever,’ says Ms Thorpe.
Many nurses from across the trust were deployed to intensive care, where adaptability has been paramount.
Katie Tracey returned to critical care after three years working on UCLH’s newly introduced electronic health records system.
She says: ‘We did care grouping and allocated tasks to the most suitable member of staff – for example, ward nurses did some medications, observations and nursing care, and even the redeployed doctors took on roles they wouldn’t usually do, such as some nursing tasks.’
Before the pandemic, introducing role changes took many months of negotiation. But COVID-19 has concentrated minds and obstacles have fallen away. There has been no scope for narrow role demarcation here.
Redeployed staff had to improvise to adapt to new roles
Improvisation has characterised the whole pandemic experience at UCLH, as well as a necessary absence of people pulling rank. Consultant in critical care Jim Down describes the teamwork as wonderful, saying it involved ‘intubation teams, proning teams, lines-access teams, echocardiogram teams, transfer teams and redeployed specialists’.
‘This couldn't have happened without them all,’ he says.
Treatment has evolved rapidly with experience. Dr Down says peripherally inserted central catheters have been put in much earlier during the pandemic, often after only four days when proning is required.
‘The lines are great because they have a lower infection rate and can stay in much longer,’ he says. ‘They’re probably easier for proning too, and more secure than neck lines, which helps when patients are being turned over. The lower infection rate is the most proven benefit and having a team that comes to put them in has been a huge help.’
Communicating using PPE has been a challenge
Clinical nurse specialist (CNS) Liz Simcock, who usually works in haematology and oncology, leads the central venous access team.
‘We’re used to going into ICU because cancer patients are often very sick,’ Ms Simcock says. ‘The difference here is that we have to put on full PPE, which impedes communication. Some patients are intubated and they can't communicate. And those who are awake are often on high-flow oxygen masks.
‘That’s been one of the most challenging things. They can’t really see you through the visor and you can’t really hear them.’
For Katie Tracey, returning to ITU has been both a response to the crisis and a way of getting back to front-line clinical work. She found in the operating theatres, repurposed for critical care, that the equipment was a different standard to those in ICU.
‘Some people found that quite stressful. The monitors and ventilators can vary in different areas, with different values and parameters, making the job that bit more tricky,’ Ms Tracey explains.
‘Thankfully, we’ve never run out of PPE on a single shift,’ she adds. And that’s down to people like Phil Adams-Howell, clinical procurement lead nurse.
His recent focus has been chasing down PPE and his role is typical of so many unsung professionals working behind the scenes.
‘Full PPE impedes communication. They can’t really see you through the visor and you can’t really hear them’
Liz Simcock, clinical nurse specialist, UCLH
A bespoke well-being team has provided support for nurses working in ICU
Life in critical care is often stark. The unit has a dedicated clinical psychologist and well-being team, a service that is much appreciated.
Ruben Costas, who has worked in intensive care for ten years, says: ‘Usually, they follow up patients who’ve been in ICU because they can experience post-traumatic stress disorder, but they also support the staff.
‘During the pandemic, the demand for psychological support for staff has increased and the psychology team were there to help us.’
Five lessons from the pandemic and how to embed them in practice
Learning points that teams in other organisations and settings might reflect on:
- Staff have learned to be flexible, often making changes to respond rapidly. Perhaps now is the right time to consider what we should retain in our nursing practice and embed as routine?
- Reflective practice can help us notice our achievements and build resilience. How can we protect time to ensure reflection is built into our working days?
- The process of reflection can help us see where we might be struggling and benefit from the support of others. What do we need so that we can safely connect with how we are feeling?
- The Nursing and Midwifery Council Code remains the cornerstone of our professional practice. We have been required to rapidly adapt. Is there anything we should now do to embed safety and good governance, protecting our patients and colleagues?
- What one extra thing can we do to support our mental health? Who can we ask to help us with this?
Nurses are good at reading non-verbal signs
The fact that nurses spend long periods with patients means they can develop antennae that perhaps cannot be cultivated any other way.
Julie Jenks, an advanced nurse practitioner and lead nurse for the benign urology unit, describes something at the core of nursing expertise.
‘Having been in nursing 20-odd years you can intuitively read more from the non-verbal signs from a patient and tease out more than perhaps medical colleagues do.’
Ward T7 in the main hospital has been the new HDRU where patients go after critical care. Everything here is new and full PPE is administered to nurses coming on shift by speech and language therapists at the door.
The patients, although stepping down from critical care, still require help with breathing. This involves the CPAP machine and sometimes tracheostomies. Here, you might find a dermatologist setting up the CPAP and a research nurse performing tracheostomy care.
Changes in PPE policy required adaptability
Cat Sullivan, who usually works as a palliative care CNS, recorded her impressions of work in this new setting. Key elements were the PPE and the CPAP machines.
‘A characteristic of the time was the rapidity with which we were required to change. At first PPE rules changed regularly, often so that we were asked to use more – for example, at a cardiac arrest.’
Simple rules of thumb helped in negotiating the rigours of wearing PPE, she says.
‘Masks alone are more widely used now. I usually found it easier when in full PPE – gloves, apron and a mask – rather than mask alone. Entering one side of the ward and exiting the other and understanding how to use the bins helped to mitigate the fear of making mistakes.’
In some areas, coronavirus testing stations were located hours away from the hospital, but testing for front-line staff at UCLH was located nearby. Tests were ‘brief but very uncomfortable’, says Ms Sullivan.
While working on the HDRU, she cared for several patients for whom the CPAP was no longer helping.
‘Healthcare is hierarchical, but the pandemic seems to have removed a bit of that, which is great as teamwork is the only way to get things done’
Lillian Odoch, practice educator and deputy sister in critical care, UCLH
‘On one occasion I was with a CNS colleague and we set up a syringe driver to help a patient get settled. His wife, an older woman, came to visit him. She sat on the bed for 15 minutes but eventually found the PPE was too much, so I took her aside and spent two hours with her then making sure that she was able to get home safely.
‘We tried to socially distance from her, but she suddenly got close to my colleague and gave her a big kiss on the cheek. It happened so fast there wasn’t much we could have done to stop her.’
Personal sacrifices during the pandemic
Military metaphors have abounded during the pandemic. An image from a WH Auden poem, In Time of War, where ‘a telephone is speaking to a man’ comes to mind when critical care matron Ms Thorpe described how iPads were set up next to beds.
Here, rather than a telephone, an iPad was speaking to an unconscious patient as this was the only way their family could be somehow near. It was a poignant symbol of the impact of the virus.
Nurses’ lives are affected by coronavirus both in hospital and outside of it.
Sandhya Andrew, an outpatient staff nurse at the Royal National Throat, Nose and Ear Hospital who was deployed to UCH, has worked on many different wards during the pandemic but has perhaps experienced a greater dislocation in her home life.
‘People in my family have a medical condition so I can’t look after COVID-19 patients and return home at night,’ she says. ‘That’s why I’m staying in a hotel. I have a five-year-old boy waiting for me. But it’s something for him to be proud of as well. When he’s older he can say: “My mum worked with COVID patients”.’
Nurses have shone as good leaders and strategists
A key aspect of nursing obscured by the ‘angel/hero’ trope is that, alongside their clinical portfolio, nurses are often good leaders and strategists.
‘I like to create order out of disorder,’ says Lillian Odoch, a practice educator and deputy sister in critical care. ‘Healthcare is hierarchical, but the pandemic seems to have removed a bit of that, which is great as teamwork is the only way to get things done.’
CNS Ms Sullivan sums up the mood of the hospital: ‘Camaraderie and an apparent lack of hierarchy have been a blessing that staff will remember.
‘It’s been at times hard to socially distance within the hospital. Sometimes we seem to forget but its always front-of-mind – and full PPE has the advantage of allowing a rare hug.’