Service evaluation of a COVID-19 critical care orientation programme

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), termed COVID-19, remains a public health emergency of international concern (World Health Organization (WHO), 2020). Its major impact has been on healthcare systems, which have had to rapidly adapt to respond to the high numbers of patients requiring critical care (Wu and McGoogan, 2020). As a result, health professionals working in non-critical care settings were redeployed into acute and critical care areas. In the first wave of COVID-19 in the UK, south London had the greatest burden from COVID-19, with critical care admissions of confirmed cases exceeding 1200 (Intensive Care National Audit and Research Centre (ICNARC), 2020). University Hospital Lewisham (UHL) is an NHS district general hospital in south London. Prior to the pandemic, the hospital consisted of 470 beds and an 18-bed critical care unit (8 intensive care (level 3) beds and 10 high dependency (level 2) beds. At UHL critical care capacity was increased to 26 level 3 beds; however, at times capacity peaked over four-fold to 34 patients requiring ventilation. To alleviate pressure and create additional critical care capacity, patients were transferred to neighbouring teaching hospitals that had a much larger pre-pandemic critical care capacity (Isted et al, 2020). This article outlines the results from a service evaluation of redeployed clinical staff at UHL during the first wave of the pandemic (March to July 2020).

Background

Critical care areas faced particular challenges during the pandemic (Anandaciva, 2020). In the early stages of the pandemic, recognising the need to increase the nursing workforce, many hospitals rapidly developed and provided short-term training courses for health professionals being redeployed into critical care settings. At UHL, staff with previous critical care experience were identified through a workforce e-survey, following which the human resources workforce team liaised with line managers to ascertain if staff with previous critical care experience, or those willing to volunteer, could be redeployed. Concurrently, staff working in services with dramatically reduced capacity were also identified for redeployment. However, there was concern that redeployed staff could present a risk to patient safety. In addition, a lack of appropriate preparation would have a negative impact on critical care staff struggling to maintain a service while supporting their new peers (UK Critical Care Nurse Alliance (UKCCNA), 2021).

A key mission of all UHL critical care education and research staff is to support patient care. With educators deployed into key clinical roles, the lead author (a clinical academic) was tasked with organising, designing and developing a training programme for staff being redeployed to critical care. A small team of critical care and outreach nurses volunteered to support the development and delivery of training. Given the need for urgent and rapid acquisition of new knowledge and competencies, ‘just in time’ training, was used. This develops and delivers practical critical care knowledge and skills in a short time frame. This approach is an accepted form of training in critical safety settings, for example, in the military and aviation, with the delivery of time-relevant and work-based education (Weiner and Rosman, 2019; Goh et al, 2020). This training methodology allowed for the development of rapid training resources and on-the-job teaching. This combination proved extremely positive, and within 36 hours a training programme had been written, peer reviewed and training commenced. As evidence on the treatment of patients emerged, the programme was adapted to include new recommendations. It was challenging to deliver the orientation programme within local and national requirements for social distancing (Wanless et al, 2020; Educational Technology, 2020). A blended learning approach was adopted, following recommendations by a Cochrane systematic review, that e-learning alone is associated with only a small positive change in practice when compared to traditional learning and teaching methods (Vaona et al, 2018).

The course provided rapid, targeted COVID-19-specific training, which oriented and prepared staff to work in critical care (Table 1). The main aim was to match re-deployed staff to the available staff skill mix and patient acuity, using supervision by trained critical care nurses, to maintain standards and patient safety. To meet UHL minimum requirements, the focus was on key essential care topics, which could be safely carried out by these redeployed, non-critical-care-trained staff. In consequence, the learning outcomes of the programme focused on the holistic management of COVID-19, with the fundamental aspects of critical care integrated throughout. Advanced critical care interventions such as ventilation strategies, arterial blood gas (ABG) interpretation and manipulation of ventilation settings were deemed the responsibility of staff who were already trained in critical care.

Development of the training workshops

Given the high numbers of COVID-19 patients being admitted to critical care, the situation caused a dilemma. On the one hand, management wished to support critical care services by instantly importing identified staff. On the other hand, critical care staff were desperate for this additional support, but knew they did not have the time to carry out the orientation and skills training needed. Resolving this dilemma was challenging, and negotiation between management and practice staff was a key role.

The education team designed the programme to include activities that facilitated active learning, using a case-study approach, with theoretical and practical skills sessions. In addition, to meet social distancing requirements, face-to-face content focused on the essential ‘hands-on’ aspects of the training. This reduced the risk of potential transmission of COVID-19 across the staff undertaking training. To support this approach, learning materials were initially made available via the hospital's e-learning platform and then, for ease of access, a dedicated Moodle e-learning platform site was set up.

Over a two-and-half-month period, 131 clinical staff participated in the orientation to critical care one-day workshop. The majority of those trained were nurses, with representation from other allied health professions including operating department practitioners (ODPs), healthcare assistants and support workers. Physiotherapists supported critical care physiotherapy teams, after receiving a tailor-made local induction. This is in line with the national approach to workforce redeployment of health professionals to critical care (NHS England/NHS Improvement, 2020; 2022). As soon as training began, it was evident that a major concern of these volunteers was that they ‘would get it wrong’, causing them to be fearful and uncertain (Vindrola-Padros et al, 2020). Current and previous studies of nurses redeployed to critical care during a pandemic identified that inadequate training increased stress levels (Ives et al, 2009; Liu et al, 2020) and the confusion caused by frequently revised policies and guidelines added to anxiety and the perception of risk (Lam and Hung, 2013; Camilleri et al, 2020). In consequence, the starting point of the training was to allay their fears, and it was unanimously agreed that interactive and face-to-face learning was necessary. ‘Myth busting’ was used to give them the opportunity to safely voice concerns and challenge misconceptions. This entailed presenting opposing arguments and debates for current issues such as the differences between SARS-CoV and SARS-CoV-2 (COVID-19), myths and facts about transmission and shared discussion of the reality of intensive care and life-threatening critical illness.

These sessions revealed that the participants' fears had been exacerbated by the media portrayal around critical care provision and COVID-19. Their perception was of a service without drugs, a lack of personal protective equipment and no ventilators, resulting in patients denied treatment and left to die alone. The critical care leadership team was keen to provide as much information as they could, and actively worked to dispel these particular myths. Only once these participants accepted the reality of the situation could the training begin. An added advantage of this approach was that it served as an icebreaker as participants realised their fears were shared by their peers. The education team made a conscious effort to make sure that all participants had access to mental health wellbeing resources and apps, and understood their importance, which was epitomised by the phrase ‘It's OK to say, I'm not OK’.

Concerns regarding staff safety during training were an ongoing challenge. Educators used a dynamic risk assessment to adapt training as appropriate, and as national and local guidance changed. To protect all staff accessing training venues, additional cleaning teams were made available to decontaminate teaching areas and all equipment after use. There were ongoing discussions regarding whether redeployment education should move from blended learning to a fully online training programme. Camilleri et al (2020) described the successful development of a remote online critical care course, with no practical component. At UHL it was decided that, while preparatory work could be conducted virtually, the clinical element needed to be delivered and practised in a safe environment, a converted ward, used for simulation and resuscitation training. This provided sufficient space for the practical elements of the programme. The short timescale meant the development of a full online course would have delayed delivery, which in turn would have had an impact on critical care services. The blended learning approach allowed for theoretical content to be delivered virtually, and then clinical skills delivered and assessed face to face. This also provided participants with resources they could refer to at a later date.

At UHL there was already a mandatory training e-learning platform and a Moodle platform. For ease of use, the decision was taken to use the Moodle platform, as this allowed the education team to rapidly develop and revise content, and it also facilitated the addition of interactive quizzes and other resources such as guidelines, which was crucial as the updating of resources was necessary during the evolving pandemic. An additional challenge included participants having access to laptops and internet connectivity and having IT skills. It is acknowledged that nurses may have limited digital literacy skills and/or access to a computer (Health Education England (HEE) and Royal College of Nursing (RCN), 2015). As a consequence, some nurses may have relied on accessing an NHS computer in a clinical setting or training room. This was not possible in the pandemic. It also has to be noted that the availability of virtual learning content does not mean students will engage with the learning activities (HEE and RCN, 2015; Educational Technology, 2020).

An iterative quality improvement cycle was followed to address the continually changing evidence and critical care practices. Examples of changes to the teaching content included adding a session on end-of-life care and adaptations in documentation, including a move away from electronic prescribing to paper-based drug charts. This was authorised by the Governance and Risk Team, due to the high volume of patients and redeployed staff not being able to access electronic prescribing. Following each session, feedback from facilitators and delegates was collated via a short post-workshop questionnaire. Educators regularly engaged with the frontline critical care teams to identify areas to focus on and to highlight changes in practice that needed to be reflected in training materials. Examples included the move from invasive ventilation to the use of non-invasive ventilation and the potential rising numbers of patients requiring tracheostomy care, a skill with which not all staff might have been familiar.

Aim

The aim was to carry out a service evaluation of the training outcomes from rapidly redeployed staff who worked in critical care during the first wave of the COVID-19 pandemic (March to July 2020).

Methods

There were two parts to the service evaluation. First, an impact evaluation questionnaire was distributed immediately after completion of the training. To address the validity and reliability of the data collection tools used, it is accepted that using existing, validated instruments is preferable to developing new tools (Korb, 2012), with new tools needing to be piloted and tested before use. An evaluation form used after resuscitation training was adapted, which included a Likert scale and free text sections for each topic.

An e-survey questionnaire was distributed to all health professionals who had participated in the one-day orientation to critical care workshop between March and July 2020, and were identified as working at UHL. This second questionnaire was based on the first one, but had additional questions on the respondents' experiences in practice. The survey was distributed using onlinesurveys.ac.uk. For anonymity, a unique URL was used, as this gave the project team no access to respondents' personal details and therefore protected confidentiality. All health professionals with an NHS email address who took part in the workshop were invited to complete the anonymous questionnaire. The online survey enabled the respondents to complete the questionnaire on an NHS computer, personal laptop or mobile phone. It is recognised that reliability (consistency) and validity are essential in questionnaire research (Bannigan and Watson, 2009). The questionnaire had previously been evaluated (Carter et al, 2020). Any adaptations made by two of the project team were then piloted for clarity, with consistency of data and appropriateness of response checked by the other authors and compared with the initial questionnaire. Only minor changes were made, including correcting typographical errors. The overall questionnaire was accepted following the changes.

The service evaluation was registered with the Research and Development office before undertaking the study, whose staff oversaw the evaluation. They concluded that separate NHS National Research Ethics Service approval was not required.

The datasets were uploaded to IBM SPSS software (version 25). Missing data were coded in SPSS and have been presented in each results table. Descriptive statistics (numbers and percentages) were used to analyse the raw data generated. Cronbach's alpha test was used to check for consistency and reliability for the Likert scale questions. Thematic analysis was used to analyse responses from open-ended questions. Cronbach's alpha was used to give a comparative indicator of internal consistency.

Results of the course evaluation

Figure 1 shows the results of the one-day critical care workshop evaluation. Of the 131 who attended, 124 responses were returned. These were overwhelmingly positive; however, this was pre-clinical experience. One respondent reported the essential skills were ‘not useful at all’ but that all other areas were appropriate, but offered no feedback in the free text question to explain their answer. The findings from this first evaluation have been included as part of the iterative process for comparison.

Results of the e-survey

A total of 131 health professionals attended the orientation to critical care workshop at UHL and 116 NHS email addresses were made available for the e-survey. Forty e-survey questionnaires were completed and analysed. The response rate was deemed an acceptable return (Bryman, 2012).

Just over half of respondents (n=21, 52.5%) had been redeployed into critical care, which highlights that, although staff were identified and completed the orientation course, for several reasons not all staff were able to be redeployed. The majority of respondents were nurses (n=31, 77.5%), as well as health care assistants (n=2, 5%), support workers (n=2, 5%), a doctor (n=1, 2.5%), an operating department practitioner (n=1, 2.5%), a medical student (n=1, 2.5%), a health visitor (n=1, 2.5%) and a midwife (n=1, 2.5%).

• 28 out of 40 respondents (70%) had volunteered to work in critical care as part of the COVID-19 surge plan
• 25 out of 40 respondents (62.5%) did not have prior critical care experience before attending the workshop
• 21 out of 40 respondents (52.5%) went on to work in critical care as part of the surge plan Reasons for not redeploying (n=19; 47.5%) included:
• Not required (n=10, 25%)
• Unable to be released due to work commitments (n=2, 5%)
• Redeployed to other key areas (n=3, 7.5%)
• Other responses included retirement; already working in a COVID-19 ward; or contracted COVID-19 and on return to work could not be released from their previous key clinical role (n=4, 10%).

The length of time the 21 redeployed staff worked in critical care varied:

• 2-7 days (n=2, 9.5%)
• 1-2 weeks (n=3, 14.3%)
• 3-4 weeks (n=4, 19%)
• >5 weeks (n=12, 57.2%).

Participants were asked to look back at their experiences over the past few weeks and to identify which aspects of the orientation to critical care course they found useful and least useful (Table 2 and Table 3). Table 2 indicates that, in all categories, there was one participant who found the clinical skills not to be helpful. However, cross-referencing individual topics against participants revealed it was the same respondent, who gave no written reason for their score. It has to be accepted that with a programme designed for a disparate group with a wide range of skills and expertise, it is difficult to meet all learners' expectations (Learning Theory, 2022). That so many found the majority of sessions relevant and useful, supported use of this ‘just-in-time’ training (Peebles et al, 2020). Cronbach's alpha for both the initial and follow-up questionnaire, showed an acceptable degree of consistency. The initial questionnaire (Figure 1) showed a Cronbach's alpha of 0.880, which shows an acceptable degree of consistency. The second Cronbach's alpha score (0.959) is higher than the first, which indicates that, as the questionnaire was completed once respondents had gained clinical experiences, it impacted on the relevance of each topic taught. Both showed an acceptable degree of reliability and consistency.

Comments from respondents emphasised the need for ongoing support when in practice and for refresher training to maintain skills:

‘I have found the organisation and support outstanding. I have continued to be given training throughout.’

Respondent 7

‘I have much more confidence in working at critical care setting.’

Respondent 22

‘As a sexual health nurse who has not worked on wards for years it was all quite overwhelming and like becoming retrained in a new job rather than a refresher!’

Respondent 13

‘If we are likely to have ongoing need for redeployment with COVID-19/future pandemics, would it be helpful to have ICU or ward nursing study days as part of yearly training requirements for those earmarked as ‘redeployable’?

Respondent 15

Discussion

Using ‘just in time’ training

The COVID-19 pandemic has increased the use of the ‘just in time’ training approach across the care spectrum. For example, Lingum et al (2021) argued that it should be part of a community response to the rapid rise in admissions as hospitals attempted to create capacity. In critical care, Ragazzoni et al (2021) identified the need for the rapid redeployment of staff in a hospital in northern Italy. Hospital staff attended an initial training programme followed up with an additional face-to-face training package delivered in a ‘matter of days’ (Ragazzoni et al, 2021). As south London experienced the first surge in infections in the UK, the opportunity for pre-training and competence assessment was not possible. However, on reflection, depending on the participants' professional expertise, additional training may have been needed to build competence.

Although it had been agreed that redeployed nurses would work under the supervision of a critical care nurse, in reality, the term ‘critical care nurse’ appeared to be open to interpretation. In the height of pandemic, the UKCCNA (2021) reported that a junior nurse, who had completed their critical care induction, may have had to work alongside redeployed staff in a supervisory role. This is a situation that is potentially highly stressful for nurses and could challenge patient safety. In retrospect, it is acknowledged that in the exigencies of the first wave of the pandemic, the UKCCNA (2020) found this happening across the UK. However, it points out that this should not occur in normal practice, although it recognises that, in exceptional circumstances, where all other options have been exhausted, this situation may arise again.

The role and expectations of redeployed UHL staff differs from other studies, because a range of different professional groups were involved, not just nurses. A ‘buddy system’ was set up for staff redeployed to critical care. Marks et al (2021) also developed a buddying model for redeployed staff, placing non-experienced nurses with a critical care specialist nurse. However, at UHL, ‘buddys’ were allocated each shift—owing to constantly changing staffing levels, it was not possible for each redeployed staff member to be permanently attached to the same person. The education team acted as the point of contact for redeployed staff and would work with them and provide support. In addition, recognising the impact of being redeployed in a pandemic, staff were invited to attend regular vital wellbeing cafes, delivered online by a specially trained team.

Future training

Development of the materials at UHL was a challenge, as the education team was mainly made up of clinical staff and only met each other when tasked with the development and delivery of training. At the time, there was no available pool of personnel or accessible resources to support development and implementation; nor were there any national recommendations for topics to include or modes for delivery of the workshops for the multiplicity of professional groups and varying skill levels of those being redeployed. Blended learning was chosen as it facilitated the application of theory directly to simulation and ultimately practice (Lawn et al, 2017). However, the findings suggest that, because of the mix of skills needed for critical care, with hindsight it may have been appropriate to offer two levels of training, had time allowed—one for experienced nurses and one for healthcare support workers or students, for example.

There are now several regional, national and international workshop programmes available for staff being redeployed, such as programmes run by the EU (C19 Space, 2020).

When future surges occur, it is important to recognise that individuals with previous training and experiences should be proactively identified, as many hospitals may not have had the resources to focus on retraining or introducing new programmes. In future, there is scope for the development of an online training package to maintain the knowledge and expertise of staff identified as redeployable who could provide support for surges in demand for critical care. Nevertheless, critical care nursing will always require competencies for patient safety, and individuals must be competent to practise safely before undertaking nursing practice (Critical Care National Network Nurse Leads Forum (CC3N), 2018). There is evidence that a fully online course does not address the crucial issue of fear and anxiety for those being redeployed into a high-risk area, and that blended learning should be used (Lawn et al, 2017; Vaona et al, 2018). Further, it has to be noted that there will always be a need to adapt and orientate staff who have completed national or international training programmes to local practices.

Limitations

From the perspective of the team and the respondents, the main limitation of the training was its length—one day of practical training. The team accepted the urgency of the situation, but inevitably, as educators, would have preferred time to allow for greater depth to be given to each topic and to be able to formally assess competence in participants, depending on their role.

This service evaluation identified the need to address fears, anxieties and to provide support on the ground. The wellbeing cafes and informal follow-up in practice were the training team's way of offering ongoing support, within the limited resources available. The importance of this was recognised by UHL and wellbeing and formal psychological packages have since been made available for all staff.

Conclusion and recommendations

This service evaluation has demonstrated the ability and willingness of an organisation to respond to the COVID-19 pandemic and to prepare staff who needed to be redeployed. The training worked because those who designed the education and training programme came from clinical practice, with a background of supervision and mentorship. The findings from the second questionnaire confirmed the relevance of the topics included. The linking of a clinical academic provided support with programme and content development, a collaboration that reduced the theory–practice gap, despite the short time frame and the urgency of the situation.

‘Just-in-time’ training has its place in emergency settings, but should not stand alone or be seen as a permanent solution. It is the first step in a rapid response to ever-changing and evolving clinical situations. The evaluation has highlighted the importance of face-to-face contact in extreme situations such as the pandemic, to facilitate reassurance, provide support and address fears and anxieties. Had this not occurred, participants might not have been as receptive to training or to understanding the reality they were about to enter.

Recommendations include the need for a further evaluation 6 to 12 months after completion of the first. Any further evaluations should include the perspective of the critical care nurses working with their newly redeployed colleagues. It is important to recognise that different professional groups have different needs. In consequence, further training programmes should include different levels based on professional expectations. For example, some participants requested additional topics such as basic arterial blood gas interpretation and invasive ventilation. Finally, the COVID-19 pandemic is likely to be an enduring challenge for months and even years, resulting in peaks and troughs of patient numbers. Therefore, a formalised workforce plan needs to be established that balances the needs of the healthcare system against COVID-19 and future pandemics.

KEY POINTS

• At the beginning of the COVID-19 pandemic, critical care services required more staff to help with the increase in critically ill patients
• In one south London hospital, a one-day orientation to critical care workshop was rapidly devised and run for redeployed health professionals, supported by e-learning
• Evaluation of the workshop was largely positive and an e-survey some months later revealed those areas that were most useful to participants who had been redeployed
• Respondents valued the knowledge and reassurance of the teaching team in a stressful situation

CPD reflective questions

• Reflecting on your experiences of working during the pandemic, how has it affected your professional practice?
• Two years after the start of the pandemic, what additional educational training would have been helpful or is still needed?
• Review your organisation's plans for future infectious disease outbreaks, how might these impact on you and your team?