The resultant effect of over 40 000 nursing vacancies before the COVID-19 pandemic, our current workforce absence level being high because some colleagues are off sick or shielding, and with the current lockdown on international movement meaning that our planned pipeline of international nurses joining us has ceased, has required us to review how we nurse our patients.
Fortunately, the NHS did not see the predicated overwhelming rise in demand, and occupancy levels have remained lower than originally thought. However, with a very different practice environment requiring constant use of personal protective equipment (PPE), a national ‘no visitors’ policy and the level of unavailability of staff, has required us to look at alternative models of nursing.
My clinical background is in critical care, and this is where I have undertaken weekly clinical shifts during the COVID-19 response. The Faculty of Intensive Care Medicine (2019), which publishes guidelines for the provision of intensive care standards, details the contribution of a wide variety of roles that support patient care from a medical, nursing and allied health professional perspective. The faculty has always advocated that level 3 patients (those requiring advanced respiratory support alone, or basic respiratory support together with support of at least two organ systems) must have a registered nurse/patient ratio of a minimum of 1:1 to deliver direct care.
The guidance is prefaced with narrative detailing that, where robust evidence is limited in relation to nurse staffing in critical care, professional consensus, or established practice, has been used to develop the standards.
NHS England and NHS Improvement published specialty guidance (2020a) in response to COVID-19 needs. This advised us to review a variety of roles to blend a skill mix to meet need at this time. It also recognised a more task-oriented approach to patient care, which in my Trust was translated into a team approach to critical care nursing.
An NHS England and NHS Improvement framework (2020b) was useful in shaping our considerations around the following.
In terms of safety:
In terms of efficiency:
In terms of patient-centredness:
As the COVID-19 rate increased, so did the demand for adult critical care of level 3 patients and, in line with the NHS England and NHS Improvement guidance, we adopted a team-nursing approach. Care was delivered by two teams of nurses, who rotated through 2-hourly sessions in and out of the unit to enable a break from PPE, time to document care, time to hydrate and take a break. As a returner to critical care, the systematic approach to team nursing in critical care has been personally very supportive and felt professionally safe. Although a task-oriented approach overseen by a team leader in charge feels very different, it also feels as though a high standard of care has been given. We are currently reviewing a number of areas and benchmarking a number of patient outcomes to evaluate our current approach to nursing care.
The Faculty of Intensive Care Medicine has issued a bridging document as the NHS starts to resume activity that was cancelled prior to COVID-19 (2020). It recognises that there are large groups of patients whose treatment was cancelled in preparation for the COVID-19 response and is understandably nervous that the measures implemented at speed in terms of nursing ratios will continue as the new norm, without due consideration.
In its 2019 guidance, the faculty concluded that it was essential that standards and recommendations for operating a critical care service were subject to ‘regular review and revision, as new evidence becomes available and practice changes’. The 2019 faculty guidance also advocated that intensive care areas must develop healthcare support worker roles to assist registered nurses in delivering direct patient care and in maintaining patient safety. It also recognised the advanced roles that can be realised in critical care.
There are many positive areas for consideration that the COVID-19 response has afforded us. Several colleagues are excited that the learning from the emergency staffing response could now be more formally evaluated to enable greater opportunities for skill mix and career development in critical care nursing that was not previously routinely offered. We will aim to take any opportunities to contribute to future reviews, learning and sharing that could enable fully established teams to deliver high-quality care for patients and their families.