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• To understand why healthcare staff training had to be overhauled during the coronavirus disease 2019 (COVID-19) pandemic
• To familiarise yourself with the changes required when moving from face-to-face to virtual training
• To appreciate how the role of clinical nurse educators had to evolve during the pandemic
In nursing, there has traditionally been significant emphasis on face-to-face staff training, but in 2020 methods of delivering staff training had to be overhauled in response to the coronavirus disease 2019 (COVID-19) pandemic. Rapid and extensive changes to staff training were made across care settings to ensure that service needs were met and that everyone’s safety was maintained. At one large acute trust in London, the clinical nurse education team used Lewin’s change model to make adaptations to staff training and embed these changes in practice. The team transferred most of the training onto a virtual learning platform and used this as an opportunity to review and enhance the accessibility and inclusiveness of training. This article describes how staff training was transformed and how the role of clinical nurse educator evolved at the trust during the COVID-19 pandemic. The author also demonstrates how Lewin’s model of change can be applied to make changes and embed them in practice.
Nursing Standard. doi: 10.7748/ns.2022.e11772
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondence Conflict of interestNone declared
Clark-Maxwell AL (2022) Transforming staff training at an acute trust in response to COVID-19. Nursing Standard. doi: 10.7748/ns.2022.e11772
AcknowledgementsThe author would like to thank Dr Sharin Baldwin for providing constructive feedback on this article. The author would also like to acknowledge the learning and organisational development team and the wider multidisciplinary team at London North West University Healthcare NHS Trust, who have worked collaboratively to make fast-paced changes happen during the pandemic.
Published online: 30 May 2022
Nursing care is associated with a range of physical tasks, so there has traditionally been a significant emphasis on face-to-face staff training. In 2020, the way in which training was delivered to nurses had to change significantly as a result of the coronavirus disease 2019 (COVID-19) pandemic, which prompted an overall reassessment of how to interact safely, in healthcare settings and beyond. The social-distancing rule of keeping a two-metre distance between individuals reduced the number of people who could be in the same room simultaneously. In acute hospitals, as in healthcare settings in general, alternatives to face-to-face training had to be identified and new procedures introduced. These rapid and extensive changes to staff training delivery were required to ensure service needs were met while everyone’s safety was maintained. Clinical nurse educators were at the forefront of implementing these changes.
At London North West University Healthcare NHS Trust, the clinical nurse education team had an important role in keeping the skills and knowledge of staff up to date during the COVID-19 pandemic. The changes to staff training dictated by the pandemic were implemented using Kurt Lewin’s model of change (Lewin 1947). This enabled the team to make rapid and extensive changes and embed them in practice in a transparent and consistent manner. This article describes how staff training was transformed and how the role of clinical nurse educator evolved at the trust during the pandemic.
The psychologist Kurt Lewin (1890-1947) is best known for his three-step model of change, which he developed towards the end of his life and was based on his work on field theory, action research, group dynamics, and social and organisational change (Burnes 2020). In an article published in the year of his death (Lewin 1947), Lewin summarised his approach to behavioural change in a section entitled ‘Changing as three steps: unfreezing, moving, and freezing’. Lewin (1947) wrote:
‘A successful change includes therefore three aspects: unfreezing (if necessary) the present level L1, moving to the new level L2, and freezing group life on the new level.’
Since then, this has been referred to as Lewin’s three-step model of change and has become the best known, and arguably the most influential, approach to organisational change (Burnes 2020). Although Cummings et al (2016) argued that the three-step model of change was not actually developed by Lewin but took form after his death, Lewin’s model still became understood as the foundation of change management and continues to influence change theory and practice (Cummings et al 2016).
Figure 1 shows one of many interpretations of Lewin’s three-step model of change, where the second and third steps have been renamed ‘change’ and ‘refreeze’.
• The coronavirus disease 2019 (COVID-19) pandemic meant that the way in which training was delivered to nurses had to change significantly
• An online messaging platform was adopted by the author’s trust and used by the clinical nurse education team to deliver live training sessions
• Various training aspects needed to be considered, including how to reduce the risk of infection and how to upskill staff redeployed to COVID-19 units to care for critically ill patients
• To enhance the accessibility and inclusivity of the training, the team used a blended-learning approach, featuring a mix of visual and audio resources
The COVID-19 pandemic meant that staff training at London North West University Healthcare NHS Trust could not continue to be delivered in the traditional manner. When planning the changes to staff training, various aspects needed to be considered, including how to reduce the risk of infection and how to upskill staff redeployed to COVID-19 units to equip them with the skills required to care for critically ill patients (Baldwin et al 2020). The changes required clinical nurse educators to be proactive, adaptable and innovative, and were fully supported by the management and senior leadership at the trust.
Research relating to virtual learning in healthcare is limited, so the clinical nurse education team sought to transfer knowledge from businesses and universities. Knowledge transferred from the business sector was related to interacting on virtual platforms and leadership styles. Knowledge transferred from university settings was related to making training accessible to all learners through reasonable adjustments and making learning resources user-friendly.
To conduct the changes, the clinical nurse education team used Lewin’s three-step model of change:
• In the first step (‘unfreeze’), the focus was on determining what needed to be changed.
• In the second step (‘move’ or ‘change’), the focus was on making the changes using a collaborative approach.
• In the third step (‘freeze’ or ‘refreeze’), the focus was on reinforcing clinical nurse educators’ skills, celebrating successes and embedding changes.
Before the COVID-19 pandemic, the digitalisation of healthcare had been extensively discussed, with the UK government making plans for the NHS to go ‘paperless’ or ‘paper-light’ and to ‘harness the information revolution’; however, these digitalisation plans had been criticised because of shifting priorities, slipping timescales and a lack of funding (The King’s Fund 2016). Such digitalisation plans had also assumed that contacts within the NHS – whether between staff and patients or between staff themselves – would continue to occur face to face.
In 2020, in response to the pandemic, an online messaging and conferencing platform (Microsoft Teams) was rolled out across the NHS so that service needs could continue to be met. NHS Digital announced that the platform would be available for free for a limited time period ‘to counter the increased risks associated with COVID-19’ (NHS Digital 2020). The platform was therefore adopted at the trust and used by the clinical nurse education team for delivering live training sessions, for example on medicine management, restorative clinical supervision, assertiveness training and preceptorship.
Before the COVID-19 pandemic, staff at the trust undertook generic training on infection control as an e-learning module on the employee learning management system (ELMS). The training was clinically focused, covered the routine use of personal protective equipment (PPE) and was adapted to each department’s needs. With the pandemic, it became imperative that all staff received standardised PPE training based on the evolving national guidance.
While a specific PPE e-learning module was being developed and before the two-metre distancing rules came into effect, the clinical nurse education and the infection control teams delivered face-to-face training sessions in clinical areas, emphasising the various types of PPE and how to don and doff PPE safely. From February 2021, PPE training was delivered using an e-learning module on the ELMS that staff could access at any time. This increased the accessibility of training and reduced the time needed to train large numbers of staff.
Medicine management training changed from face-to-face sessions with around 100 learners before the pandemic to an e-learning module on the ELMS followed by one live virtual training session on the Microsoft Teams platform with up to 40 learners. Because the number of learners per virtual training session had been capped at 40, the frequency of sessions was increased to ensure service needs were met.
Before the pandemic, venepuncture and cannulation training was delivered to groups of up to 15 learners from 9am to 3pm, starting with theoretical aspects followed by practical aspects. The practical aspects of venepuncture and cannulation training were deemed to be unsuitable for virtual delivery and the trust agreed that these would be delivered face to face. The theoretical aspects of venepuncture and cannulation were covered in an e-learning module that staff had to complete before attending the practical face-to-face session.
To maintain everyone’s safety, a risk assessment was completed by the facilitator and the learners before each practical session. Learners’ risk assessment focused on COVID-19 symptoms (such as cough, fever, loss of taste and/or smell) and whether the person had been in contact with someone who had COVID-19. The facilitator’s risk assessment focused on environmental risk factors, such as the number of learners that could safely undertake training at any one time, social-distancing requirements, number of doors (entry and exit), the cleaning of equipment, checking if learners had any symptoms and ensuring learners did not wear their uniforms to the sessions.
During the practical sessions, clinical nurse educators and learners had to wear face masks, as well as face shields in some cases. This led to communication challenges, since masks made it increasingly challenging for learners to understand the facilitator’s instructions and feedback. Initially, the number of people per practical session was limited to eight (seven learners and one facilitator), but this made social distancing challenging, so the number of learners was reduced to two, with one or two facilitators. The practical sessions lasted for 45 minutes and ran back-to-back.
Maslow’s hierarchy of needs emphasised the importance of personal safety and security as basic requirements of human beings (Maslow 1943). The COVID-19 pandemic contributed to anxiety and many other negative emotions among healthcare staff, who may have been concerned for example about becoming infected, being redeployed to a new area, or infecting their family. Clinical nurse educators therefore had a dual role: train staff while supporting them emotionally (Baldwin et al 2020).
This emotional support was particularly relevant in the context of face-to-face training, which was unlikely to be delivered or received effectively if a basic need such as the safety and security of participants was not addressed. Clinical nurse educators had to reassure staff that safeguards such as risk assessments, reduced number of learners, use of PPE, and the cleaning of equipment and door handles were in place to preserve their safety during face-to-face training. Information about safety was widely and openly communicated, which assisted in reducing staff members’ anxiety.
Managing teams virtually requires the organisation and coordination of team members in various locations (Serrat 2017). It also requires clarity of purpose, a deep understanding of people, processes and technology, and the ability to stimulate group participation. Group participation can compensate for any loss of content resulting from the inability to deliver practical hands-on education virtually (Serrat 2017).
When clinical nurse educators began to manage the live virtual training sessions in the trust, it was crucial that they determined learners’ information and communications technology (ICT) skills, established clear learning outcomes, promoted learners’ engagement and reduced misunderstandings that could have resulted from using a virtual learning platform. Also, some learners took part in virtual learning sessions in the same open-plan office as colleagues, but socially distanced, which sometimes caused issues such as background noise and technical interferences.
The use of two contrasting management styles was explored during initial virtual training sessions: a transformational leadership style, which employs empathetic language and encourages feedback, and a transactional leadership style, in which the leader sets an explicit direction (Jaffe and Lordan 2020). The transformative style proved more effective and was therefore adopted by the clinical nurse educators. Using a transformational leadership style supported the team to meet learners’ needs, enabled open discussions between facilitators and learners, encouraged learner engagement, enabled time for questions to check learners’ understanding, and enabled learners to participate in discussions enriched by lived experience.
With the introduction of virtual learning, it became crucial that clinical nurse educators possessed the adequate ICT skills and were familiar with the software used, so that they would be able to navigate the virtual training platform, develop a positive learning environment, encourage learners’ participation and overcome any potential technical difficulties. A step-by-step guide, with all relevant information collated in one place, was developed to assist clinical nurse educators in setting up and managing the virtual training sessions. This guide became referred to as the ‘clinical nurse educator’s guide’ and it reflected local and national policies and procedures, and complied with information governance requirements. The guide ensured that the delivery of virtual training by clinical nurse educators was consistent and was also useful in assisting colleagues from other teams to develop their technical skills.
The Equality Act (2010) protects people against discrimination, in the workplace and in society, on the grounds of nine ‘protected characteristics’: age, disability (defined as a physical or mental impairment that has a ‘substantial’ and ‘long-term’ negative effect on a person’s ability to undertake normal daily activities), gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. This means that employers must ensure they do not discriminate against staff members and that they make reasonable adjustments, including in staff training.
There is consensus in the literature that learning and teaching need to be accessible and inclusive, but there is no consensus about how this should be achieved (Lawrie et al 2017). However, inclusive teaching and learning do require collaboration with learners who have disabilities so that the needs of all learners are addressed (Draffan et al 2017). According to Sennett (2016), virtual learning environments can be adapted to suit the needs of students with dyslexia. Providing a user-friendly and inclusive virtual learning environment requires consideration of three factors (Sennett 2016):
• Accessing information – information should be easy to access and the number of steps students have to take to access information should be reduced.
• Interaction – learning can be made interactive by offering group activities in breakout rooms, quizzes, polls and discussions linking theory and practice.
• Personalisation – students should be able to personalise information according to their needs to avoid information overload, for example with the provision of assistive technology.
The clinical nurse education team was determined to develop an inclusive culture in staff training at the trust and undertook a review of the accessibility and inclusiveness of virtual teaching methods. To enhance the accessibility and inclusivity of the training, the team used a blended learning approach. This involved training sessions featuring a mix of visual and audio resources, which were also transcribed to increase their accessibility. According to a systematic review of the literature by Coyne et al (2018), a blended learning model incorporating video-assisted online resources can be useful when teaching clinical skills to healthcare students including nursing students. Blended learning increases students’ knowledge and skills and is often preferred by students because of its flexibility (Coyne et al 2018).
Several strategies were used to evaluate the changes made to staff training and explore how it could be further enhanced. To assess the effectiveness of virtual training sessions, reflections and feedback were gained from staff and clinical nurse educators. This enabled the clinical nurse education team to explore challenges and barriers, as well as identifying any positive aspects of the changes made to staff training. The challenges included the fact that learners were initially unfamiliar with the functions of the virtual learning platform. This was addressed by the facilitator explaining the platform’s functions to learners at the start of each session. One positive aspect of delivering training in a virtual format was that it reduced the amount of time staff members spent away from clinical areas by avoiding the need to travel.
A clinical nurse educators’ forum was set up in the trust in August 2020. The forum’s goals were to evaluate the changes made to the trust’s training programme, make training resources increasingly evidence-based, and streamline training processes while enabling differentiation between various clinical specialties and identifying further training developments. The forum also assisted the clinical nurse educators in determining priorities for staff training. Forum meetings took place every six weeks on the virtual learning platform. During meetings, clinical nurse educators emphasised areas for discussion, which were debated until a consensus was found regarding the optimal way forward. The forum was supported by the wider multidisciplinary team. For example, when the PAN IV Therapy Passport project was underway (Health Education England 2022), the ELMS lead attended the forum to discuss issues regarding the project’s implementation on the trust’s ELMS.
Celebrating success is crucial to motivating staff and sustaining change in the long term (Costa et al 2019). The clinical nurse education team was a runner-up in the trust’s COVID HEART Heroes Best Partnership Working Award, while the trust won a national nursing workforce award in 2020 for being the best workplace for staff learning and development. This made the clinical nurse education team feel increasingly united and sparked renewed enthusiasm to develop and improve training opportunities for staff using virtual learning platforms.
In the future, staff training at the trust will continue to be delivered using a blended approach with a focus on accessibility and inclusion. It is likely that, where it has been identified that a mix of face-to-face and virtual training is beneficial, the practical aspects will be taught in face-to-face training sessions, while theoretical aspects will be taught virtually via e-learning modules on ELMS, via live virtual training sessions and sometimes a combination of both.
When planning virtual training sessions, the clinical nurse educators at the trust found they needed to consider the following:
• Not all equipment used by staff to access training, such as computers, tablets and mobile phones, have audio and camera functions.
• Staff have varying levels of ICT skills.
• The number of learners per session needs to be manageable so that all learners have the opportunity to engage. The larger the group, the less opportunity there is for interaction. At the trust, the number of learners per virtual training session has been capped at 40.
Based on the team’s experience of the changes made to staff training at the trust during the COVID-19 pandemic, a number of recommendations to clinical nurse educators for supporting a positive learner experience of virtual training sessions have been made (Box 1).
Before the virtual training session
• Familiarise yourself with the virtual learning platform and undertake a ‘trial run’ of the session
• Develop a step-by-step user guide to the virtual learning platform for learners
• Check that training resources are accessible and inclusive, making reasonable adjustments where necessary; reasonable adjustments may include:
• Secure adequate administrative support, including for inviting learners to the session, registering attendants, and signposting them to information and communications technology (ICT) guidance
At the start of the virtual training session
• Set clear ground rules considering information governance and safeguarding issues
• Explain the functions of the virtual learning platform, for example how to mute background noise and how to use the ‘raised hand’ function; also, emphasise the ‘caption’ function on the virtual learning platform to enable learners to apply subtitles and/or transcription of the live training session
• Ensure that your administrative support team registers attendants and signposts them to ICT guidance
During the virtual training session
• Use the camera in a manner that promotes connection with learners by:
• Give learners opportunities to ask questions and share their views
• Use interactive apps such as Slido (www.sli.do) – a quiz and polling platform – to assess learners’ progress
• Include adequate breaks
• Promote learners’ engagement and participation, notably by:
At the end of the virtual training session
• Debrief and give learners the opportunity to provide verbal feedback regarding how they felt the session went
• Let learners know where they can find transcripts and videos from the session
• Check that learners have access to assistive technology software such as speech synthesis, word prediction and spellchecking; an example is ClaroRead Windows (www.clarosoftware.com), which reads any on-screen text out loud
After the virtual training session
• Give learners the opportunity to provide written feedback, for example via online polling tools; learners may be reluctant to give feedback if they can be identified, so it is important that they have the option of giving feedback confidentially
• Review learners’ feedback to determine whether there are any elements of the sessions that need to be improved
• Reflect on how the session went, considering the positive aspects and the areas for improvement
• Plan the improvements you want to make for the next sessions
• Share lessons learned with the wider team while maintaining learners’ confidentiality
The COVID-19 pandemic has accelerated digitalisation in healthcare and prompted an overhaul of staff training delivery methods. At the London North West University Healthcare NHS Trust, the clinical nurse education team supported staff throughout the pandemic, transferring most training onto a virtual learning platform. This has been an important learning experience for the clinical nurse educators and has enabled them to develop the foundations on which accessible and inclusive training will become embedded at the trust. There is room for further improvements, notably by introducing digital champions to develop staff’s ICT skills, a measure under consideration at the trust.
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