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COVID-19 ‘surge’ training: helping nurses provide compassionate end of life care

Redeployed staff learn about communication skills and their roles as witness bearers

Redeployed staff learn about verbal and non-verbal communication and their roles as witness bearers

  • The surge in cases of COVID-19 required a rapid workforce reorganisation and staff needed swift, effective training in the skills needed to care for patients
  • How a three-day surge programme helped prepare staff and volunteers who had little or no end of life care experience
  • Nurses were asked to draw on personal experiences of difficult situations to aid sensitive communication with end of life patients and their families
Picture: iStock

Nurses have always played a critical role in the provision of end of life care.

But the COVID-19 pandemic has presented new challenges for nursing staff and health and social

Redeployed staff learn about verbal and non-verbal communication and their roles as witness bearers

  • The surge in cases of COVID-19 required a rapid workforce reorganisation and staff needed swift, effective training in the skills needed to care for patients
  • How a three-day ‘surge programme’ helped prepare staff and volunteers who had little or no end of life care experience
  • Nurses were asked to draw on personal experiences of difficult situations to aid sensitive communication with end of life patients and their families
Picture: iStock

Nurses have always played a critical role in the provision of end of life care.

But the COVID-19 pandemic has presented new challenges for nursing staff and health and social care services, as well as for patients and families.

New challenges for those providing end of life care

There are new infection control issues to consider, with carers being both potential patients and vectors, and there are specific COVID-19 symptoms to address.

During the pandemic, many nurses have been redeployed to work with patients who were dying from COVID-19, sometimes with little or no previous experience of end of life care.

In the case of some people with COVID-19, their lives may end suddenly and unexpectedly, and their carers may feel unprepared to provide compassionate care.

End of life care and COVID-19: take part in the Nursing Standard-Marie Curie survey

Addressing COVID-19 end of life care questions

At the University of Surrey we developed an end of life care preparation session for healthcare staff that formed part of a ‘surge programme’. Its aims were to enhance confidence and competence to care well for those dying from COVID-19 and their families.

Questions that were explored included: What is a good death? What symptoms might people dying of COVID-19 present with and how can they be alleviated? What communication issues may arise? What are the ethical challenges and underpinning values of providing a good death? And, finally, how can healthcare professionals care well for themselves so they can give the best possible end of life care to patients and their families?

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What is a surge programme?

The expectation of a surge in patient volume due to the pandemic demanded a national response from all health and social care providers.

As part of NHS England’s guidance for the management of COVID-19, rapid workforce reorganisation was required. This meant preparing new surge hospitals, widespread redeployment of nurses and fast-track recruitment of staff who were returning to or were new to the NHS.

These rapid changes also required the development of a fast-track education programme.

In Surrey this role fell to the integrated care system, in which NHS organisations and local councils work together. This collaborative group, formed in 2018 through a partnership of 11 local health and social care organisations, developed the ‘surge training cell’.

The training programme offered statutory and mandatory induction alongside specific training to enable staff who had been redeployed, volunteers or those supporting their own patients, to deliver the best possible care during the pandemic.

As the training required large teaching spaces, clinical simulation and expert teaching to support the volume of participants and deliver the rolling programme over a short period, the University of Surrey team joined the collaboration.

Learning about what makes a good death

Our three-day training programme supported registered and unregistered staff from a range of backgrounds. Much of the training was provided online but clinical simulations were used to practise and develop clinical skills such as venepuncture, infection control, catheterisation and reading electrocardiograms.

End of life care is a critical aspect of care, and the participants were assured that they were all capable of the person-to-person skills required. We then invited them to respond to a question underpinning the session: what is a good death?

Any discussion about end of life care must be managed sensitively and we opted to begin with professional and personal experiences, inviting participants to share their views of what ‘a good death’ meant to them.

Each session involved two facilitators who talked about their own experiences. The participants generally had little previous professional experience of end of life care but most had experienced the death of a family member.

Discussion around ‘a good death’ led to the group identifying the elements considered important for a good death, as talked about in this blog by Marilyn A Mendoza.

Participants talked of the importance of being comfortable and pain-free, not being alone, being in a calm environment, surrounded by loved ones and having choice. This led to reflection on how these elements may be compromised by COVID-19, where care recipients may be in a hospital or care home without families present. They may also be with healthcare staff who are wearing personal protective equipment (PPE) and they may not have had the opportunity to engage in previous advance care planning conversations.

Alleviating end of life COVID-19 symptoms

Participants came to the surge programme with a strong desire to help but they also had fears and anxiety related to changing roles and new challenges in practice as a result of the pandemic. In addition, those with little experience faced uncertainty regarding their ability to provide end of life care for people.

To some extent, uncertainty was overcome by rehearsing care responses. We guided participants through common side-effects of COVID-19, identifying them and exploring the range of care and treatment options.

At the beginning of the pandemic, many people would not have been familiar with COVID-19 symptoms beyond fever and cough. The training used Association of Palliative Medicine (APM) guidelines to present each of the five common symptoms – pain, fever, delirium, cough and breathlessness – and offer clear advice on how to manage them.

‘In COVID-19 cases, where family and friends cannot visit, nurses are asked to bear witness to a person’s end of life, providing some comfort to the dying and the bereaved’

For example, the guidelines acknowledge the role of communication and reassurance, and simple measures such as adequate lighting to help overcome confusion or delirium, making this an inclusive and holistic approach.

Participants were also informed of potential pharmaceutical interventions, such as levopromazine, a drug used for delirium.

Picture: iStock

A structure for approaching possible clinical situations

The APM guidance includes end of life management and it was important to acknowledge that, whatever their role, participants might be involved in end of life care. It was also important to remind participants – and ourselves – that many more people are likely to recover rather than die after contracting COVID-19.

The APM guidance gave us a useful structure to explore some clinical care scenarios. Those who were not experienced in care found it helpful to share, and learn from, the experience and expertise of other participants. For example, a mother shared how she responded to fever in a child and a palliative care physiotherapist shared the ‘calming hand’ exercise for breathlessness, which helps recover breathing.

The National Institute for Health and Care Excellence has published a range of rapid guidance documents that cover COVID-19 management in more detail. The APM document was chosen as the guidance for symptom control as it helps people adapt rapidly to new settings and challenges, and covers related topics, such as ethics, communication and self-care.

Communication challenges in COVID-19 care

Communicating verbally and non-verbally and ‘being with’ someone as they are dying are central features of good end of life care.

However, the psychological and existential work of supporting a person towards the end of life, developing care planning conversations over time and communicating with the person and their loved ones have been challenging during the pandemic.

A key intervention that responds to the fears, anger and loneliness that dying often brings is sensitive human contact and presence. Nurses are always called on to be compassionate caregivers. But with COVID-19, where family and friends cannot visit, we are also asked to be channels or conduits of love between people and to bear witness to a person’s end of life, providing some comfort to the dying and the bereaved.

Course facilitators worked with participants to reflect on sensitive ways of communicating with families who cannot be there with the person when they are dying, reassuring them that even though they cannot be present, their loved one will not be alone.

Discussions focus on how to see the person behind the patient and how to involve the family; for example, encouraging the family to send in pictures of the person, to write a letter or to use technology to communicate.

Participants were invited to consider their own experiences and what brought them comfort in similar situations.

Being a witness-bearer can offer a great deal of comfort to a family, but it requires nurses to be supported themselves.

Careful and compassionate communication between colleagues has become more important than ever. Just as we face new challenges in our own clinical settings, our colleagues in the community, social care and charitable sectors face challenges too – professional, personal, clinical and ethical.

Broaching difficult subjects with family and friends by telephone is sensitive and participants were given time to talk about this and share strategies for doing it well. They were also offered resources on compassionate communication by phone.

Ethical issues

A pandemic raises many challenging ethical issues, for example, decisions about the allocation of resources such as ventilators and PPE. A central value is minimising harm.

This is one of the four ‘principles of biomedical ethics’ and highlights the importance of reducing the spread of infection and keeping carers safe.

The other principles are: respect for autonomy; beneficence (do good); and justice or fairness. These values continue to apply to end of life care during the pandemic, as do the professional values outlined in the Nursing and Midwifery Council code.

‘While end of life care has always been an integral part of nursing care, the acute and rapid nature of COVID-19 changes the pace and focus of that care’

Other components of end of life care during the pandemic are elements of ‘slow ethics’ (Gallagher 2020). These include:

  • Stories Inviting and listening to the stories of those in our care.
  • Sensitivity to the context, culture, experiences and dignity of patients and their families.
  • Solidarity Recognising that the pandemic affects all of us and we should all strive to learn from, and work with, each other.
  • Scholarship Learning from previous research and theory that helps us better understand end of life care and pandemic ethics.
  • Space Making physical space and time to reflect on care practice.
  • Sustainability Bearing in mind that our responses to patients and families will endure into the long term and we need to strive to do our best to make the end of life experience as good as possible.

Person-centred care for patients and their families

COVID-19 has moved death and dying to the centre stage. While end of life care has always been an integral part of nursing care, the acute and rapid nature of COVID-19 changes the pace and focus of that care.

Nurses will need to give both the best physical care possible and ‘person-to-person’ engagement and comfort to people who are dying, ideally in partnership with near or distant family members.

The COVID-19 crisis is likely to be the defining moment in the careers of many of us. We face huge professional as well as personal challenges in providing end of life care, including perhaps facing our own mortality.

This requires emotional intelligence, supportive workplaces and caring for ourselves as well as for patients, families, colleagues and communities.


Find out more


Ann Gallagher is professor of ethics and care, Amy Dopson is head of continuing professional development, David Brighton is a teaching fellow and Caroline Nicholson is professor of palliative care and ageing, all at the School of Health Sciences, University of Surrey

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