Expert advice

Could dilution of ICU skill mix become the new normal once this pandemic is over?

Nursing should beware the long-term implications of decisions taken to contain COVID-19

The COVID-19 pandemic is not a war but this has not stopped the use of war-like clichés; healthcare staff are ‘on the front line’ and those carrying out their duties despite inadequate personal protective equipment are ‘heroes’.   

Prime minister Boris Johnson is not Winston Churchill, and the Westminster cabinet is certainly no government of national unity. There is, however, one characteristic of the response that offers a parallel to wartime governance and deserves attention – the longer-term implications of rapid, perhaps hasty policy decisions made to deal with an existential emergency.

Healthcare decisions taken in an emergency can morph into sustained transformation

In nursing, these emergency responses have included redeploying nurses into clinical areas where they may not be fully skilled or experienced.

Social media shows the concerns nurses have about this redeployment, both in terms of their own abilities while working in unfamiliar environments and the broader implications of possible skill dilution and patient safety. One obvious example is the reduced specialist nurse skill mix in intensive care units (ICU) that has enabled a surge in capacity.

The question is – when the pandemic is over, do we return to pre-COVID norms in ICU and elsewhere, or does the ‘new normal’ and a cash-strapped NHS lead to sustained changes in the nursing workforce profile?

History tells us structural change made to nursing in wartime can last decades into peacetime

History gives us a lesson; nursing shortages during wartime led to the Nurses Act in 1943. This created a new second level of trained nurse – the state enrolled assistant nurse – with shorter training courses. 

After the war, the word ‘assistant’ was removed and enrolled nurse numbers increased markedly, peaking at a third of the NHS nursing workforce in the early 1980s.

Throughout the post-war period, there were also increasing concerns about the blurring of roles between registered nurses and enrolled nurses. This was ultimately resolved with Project 2000 in late 1980s, which phased out the enrolled nurse role.

An emergency wartime response led to a fundamental 50-year long-term change in the nursing workforce profile. Now, the profession must be clear what its longer-term workforce priorities will be, after the COVID-19 ‘war’ is won.

James Buchan is professor in the faculty of health and social sciences at Queen Margaret University, Edinburgh


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