The emergence of the COVID-19 pandemic presented challenges and opportunities for advanced clinical practitioners (ACPs) to use their knowledge, skills and experiences to deliver high-quality care to patients (Health Education England (HEE), 2020), optimise their contribution in meeting the needs of the population and offer new methods of working (HEE, 2017).
This article will examine the role, skill and knowledge set of ACPs used to lead the induction, education and training of employees redeployed to a COVID-negative Nightingale ward commissioned to meet the needs of the local population in the first wave of the COVID-19 pandemic, and discuss their role in maintaining high-quality, safe care (HEE, 2020).
ACPs transform and remodel care pathways, enabling the safe, effective sharing of their advanced skills and knowledge across traditional professional boundaries (HEE, 2022). The NHS Long Term Plan (NHS England/NHS Improvement, 2019a) highlighted that ACPs are central to transforming service delivery to meet the needs of local populations by providing enhanced capacity, capability, productivity and efficiency within multidisciplinary teams.
Pandemics require healthcare organisations to evaluate their workforce and resources (Minissian et al, 2021), necessitating innovative work streams and models of care to safeguard workforce sustainability (Hettle et al, 2020) and deliver high-quality care (Royal College of Nursing (RCN), 2021).
Successful redeployment of employees is multifactorial (San Juan et al, 2022) and depends on staff availability (Payne et al, 2021), skill and knowledge set (Hettle et al, 2020), and results in continued service delivery (Doyle et al, 2020). San Juan et al (2022) identified trust induction, training and education as fundamental components of successful redeployment.
The Nightingale ward was created to reduce the increasing pressures on inpatient bed capacity. It was achieved by transferring medically optimised patients into transitional beds while awaiting discharge, and supporting a shift in NHS organisations from creating critical care capacity to developing pathways to support patients to rehabilitation in community settings (Wise, 2021; NHS England/NHS Improvement, 2019b; NHS England/NHS Improvement and HEE, 2022).
Health professionals' learning needs fluctuate depending on their previous experiences and redeployment role (San Juan et al, 2022). Redeployment may elicit apprehension pertaining to knowledge and skill set (Veerasuri et al, 2020), and experiences of working in unfamiliar environments (Coughlan et al, 2021; Payne et al, 2021). However, the RCN (2021) suggested that redeployment also presents opportunities for individual development and shared learning opportunities that can enhance high-quality safe, patient-centred care.
Aims
The primary aim of this retrospective service evaluation is to examine the experiences of registered nurses redeployed to a COVID-negative Nightingale ward during the first wave of the pandemic in the UK, in the context of preparedness for deployment and patient safety.
The objective of this service evaluation is to improve knowledge of staff preparedness for redeployment and the impact on care quality and safety.
The evidence identified in this service evaluation has the potential to influence strategies for workforce planning in the wake of disaster recovery to prepare an agile, flexible and sustained workforce that can maintain patient safety.
Method
Study design and setting
The service evaluation used a retrospective analysis of the experiences of nurses redeployed to a Nightingale ward in a secondary care NHS organisation during the first wave of the COVID-19 pandemic in the UK.
The Nightingale ward opened on 20 April 2020, received its first patient on 4 May 2020 and closed on 4 July 2020. Purposive sampling was used; the sample size was determined by the number of redeployed members of staff from the employing trust and a local primary care organisation (Cresswell and Plano-Clark, 2018).
Data collection
An online questionnaire developed by the trust's service improvement and innovation department was distributed to 88 redeployed staff members on 6 August 2020. The survey and information about the study were emailed out on 2 September 2020, followed up with a reminder email to improve the response rate and the completion date was 9 September 2020. Taking part was voluntary.
The comprehensive staff survey comprised 80 questions, with a wide range of thematic enquiry including facilities management, environmental ergonomics, clinical governance, quality, staff wellbeing, induction, training and education and to staff experience.
Data were extrapolated from the staff survey to meet the two thematic lines of enquiry: preparedness for redeployment; and patient safety. The data revealed five themes.
Ethics and governance
Service evaluations do not require ethical approval (NHS Health Research Authority, 2022). Completion of the questionnaire was regarded as implied consent to take part in the staff survey (Payne et al, 2021).
Data analysis
Descriptive statistics, as a method of analysis, describe and summarise collected data, measure central tendency, variability and correlation (Sullivan-Bolyai and Bova, 2018).
Descriptive research aims to illustrate the phenomenon under investigation. It was therefore an appropriate method of data analysis as the intention of this service evaluation was to understand the experiences of nurses redeployed to the Nightingale ward, not the population of redeployed health professionals in general (Dahlberg and McCaig, 2010).
Results
Eighty-eight members of staff were redeployed to the Nightingale ward: 78 from the trust, and 10 from the primary care organisation. The response rate was 34.0% (n=30). Of those who responded, 93.4% (n=28) were from the employing trust and 6.6% (n=2) from the primary care organisation.
The key findings are summarised in Figures 1–5.
Discussion
Redeployment as a consequence of the COVID-19 pandemic was widespread within the UK (Faria et al, 2020) and across healthcare organisations worldwide (Sarpong, et al, 2020). To meet the needs of the population, the COVID-19 pandemic required health professionals to be adaptable in providing care in foreign clinical environments and to unfamiliar patient groups (Veerasuri et al, 2020; Ball et al, 2022).
The British Medical Association (BMA) (2021a), NHS England/NHS Improvement (2019b; 2020a; 2020b), HEE (2020) and the Nursing and Midwifery Council (NMC) (2018) all state that health professionals were required to complete the necessary training and education before undertaking a new role as a result of COVID-19. NHS England/NHS Improvement (2020b) guidelines state healthcare organisations are responsible for providing training and education to their workforce, supported by governance structure throughout the period of redeployment (RCN, 2021), to ensure safe, high-quality care.
More than three-quarters (76.7%; n=23) of participants concurred that the trust induction provided redeployed employees with the knowledge and skills required to perform their job role. In contrast, 20.0% (n=6) of participants disagreed that the induction programme was beneficial (Figure 1); this is in contrast with the Impact of COVID-19 on the Nursing and Midwifery Workforce (ICON) study (Ball et al, 2022), which found that 62% of redeployed nurses reported their education and training were inadequate or nonexistent.
The learning requirements of redeployed employees fluctuate, depending on their employment history and job role, which necessitates that training and education are delivered at an appropriate level of complexity, with content relevant to their new role (Wroe et al, 2020; San Juan et al, 2022). However, it has also been suggested that successive teaching sessions can lead to information strain that is overwhelming and reduces the retention of information (Marks et al, 2021).
Trust induction serves to establish organisational culture and values (Deng et al, 2020), facilitating governance and care quality (Care Quality Commission, 2022), providing employees with the knowledge, aptitude and proficiencies to fulfil their job role (Dragomiroiu et al, 2014) to safeguard patient safety (Boyd and Sheen, 2014).
NHS England/NHS Improvement (2019b) urged trusts to streamline inductions to reduce replication and take previous training into account in line with the NHS Long Term Plan (NHS England/NHS Improvement, 2019a) and the Interim NHS People Plan (NHS England/NHS Improvement, 2019c), in order to establish an agile and flexible workforce that can address unpredictable exigencies on healthcare organisations (Patri and Suresh, 2017).
A 2-week induction, training and education programme was produced jointly by the redeployed ACPs to prepare employees for their roles in the Nightingale ward. Induction was delivered by representatives from the parent trust, who delivered mandatory and statutory training to meet the regulatory, legal and national policy framework for employment (RCN, 2022). The ACPs facilitated training pertaining to technical and non-technical competencies, and theoretical education to compensate for skill fade, loss of knowledge and practising outside habitual clinical environments.
The ACPs delivered education and training based on their clinical backgrounds and specialist interests to meet the learning and development needs of the redeployed workforce. Interactive, theoretical presentations were developed in the context of the evidence base to facilitate the knowledge and skills for safe and effective practice (NMC, 2018). Competence and capability were measured by assessment at the end of individual teaching sessions by means of multiple-choice question quizzes and the use of trust peer-review assessment tools to ensure safe, high-quality patient care.
Wroe et al (2020) reported that 98.7% of participants found training and education were beneficial in providing up-to-date theoretical knowledge and technical and non-technical skills to compensate for skill fade as a consequence of practising outside acute clinical environments. They also discussed the advantage of an in-house medical education team in relation to lean working and establishing an adaptable and flexible training programme in crisis situations to meet organisational service demands (Wroe et al, 2020). The Lean Enterprise Academy (2021) promotes the principles of lean working, which is consistent with streamlining the patient journey to deliver safe care and helping health professionals to reduce waste and treat more patients efficiently with existing resources (Ahmed et al, 2018; Mousavi Isfahani et al, 2019).
The NHS Institute for Innovation and Improvement (2017) supported the implementation of lean working into healthcare organisations on the basis of improving quality and enhancing patient care and experiences; furthermore, LeMahieu et al (2017) recognised the value of lean learning in education relating to knowledge transfer between individuals, thus maximising learning opportunities.
Wood et al (2021) stated that ACPs are ideal candidates to deliver training and education because they have up-to-date clinical knowledge and experience in acute clinical environments as well as advanced technical and non-technical skills. Thus, the ACP role is an example of lean working, delivering adaptable and resilient training to meet the demands of redeployed health professionals in crisis situations by exploiting existing resources to meet the delivery of high-quality patient care (Wroe et al, 2020), and support the delivery of clinical education in the continued fight against COVID-19 (HEE, 2020).
San Juan et al (2022) suggested that redeployment can present novel opportunities for individual development via informal or experiential learning, which can, in turn, enhance care quality and safety. Experiential and informal learning is founded in active participation and hands-on experience, which fosters a culture of sharing knowledge and experiences (Ward, 2022), allowing for real-time application into clinical practice, supporting knowledge retention (Cheng et al, 2020) and critical thinking (Horntvedt et al, 2018), and improving clinical competence (Li et al, 2022) thus improving patient safety (Horntvedt et al, 2018).
Deployment to the Nightingale ward facilitated the accumulation of clinical backgrounds, generating a wealth of knowledge and skills. Participants agreed that learning from colleagues was beneficial, showing that redeployment presents learning and development opportunities (Hettle et al, 2020; Payne et al, 2021; San Juan et al, 2022) (Figure 2). Eraut (2010) established that the majority of learning emerges informally and experientially while working alongside colleagues, with individuals seeking knowledge and skill development (Jeong et al, 2018).
NHS England's National Quality Board (2013) asserted that there is a clear correlation between patient outcomes and having ‘the right people, with the right skills, in the right place, at the right time’, placing the responsibility on NHS organisations for the quality of care delivered, and to take full and collective responsibility for staffing capability and capacity. The National Quality Board (2013) defined capability as having the experience, skill and knowledge to deliver high-quality, safe patient care, while competence concerns the ability to perform a task measured against a standard (Mitchell et al, 2019). O'Connell et al (2014) suggest that competence measures the aptitude to complete a task but not the transferability of knowledge and skill from one clinical environment to another.
The BMA (2021b), HEE (2020), Health and Care Professions Council (2020) and General Medical Council (2020) all stated that redeployed employees are required to understand their new role, and not perform any task beyond their level of training and competency. However, it has been proposed that redeployment has necessitated health professionals to work beyond their competencies to meet the needs of the population in response to the COVID-19 pandemic, questioning the safeguarding of high-quality, safe care (Hettle et al, 2020; Coughlan et al, 2021).
NHS England/NHS Improvement (2019b) acknowledged that redeployment may elicit apprehension from health professionals with respect to knowledge, skill set and experiences (Hettle et al, 2020), and the effect of working in unfamiliar environments (Doyle et al, 2020). The RCN (2021) stated that employers are expected to consider employees' employment history in relation to their skill set, knowledge and clinical experiences, and their competence to deliver and safeguard high-quality, safe care.
Undergraduate healthcare programmes facilitate the development of the core competencies required to register with respective regulatory bodies, after which practitioners develop specific competencies within their clinical arena (Price and Campbell, 2020). Redeployment may require health professionals to revisit the core competencies of their undergraduate training programmes and previous clinical experiences (Kaufman, 2018).
Faria et al (2020) identified that redeployed practitioners had an acceptable competence in the completion of core duties and tasks; however, one in five of UK doctors reported being uncomfortable with the tasks delegated to them during redeployment (BMA, 2021b), reaffirming the necessity for induction, training and education (Faria et al, 2020).
Health professionals are on the frontline of healthcare delivery and are accountable and responsible to their regulatory bodies for ensuring quality and safe patient care (Department of Health and Social Care, 2011); however, employing healthcare organisations are responsible for improvements, delivery and failures in care quality (Alderwick et al, 2017).
This study found that redeployment did not compromise nurses' ability to maintain patient safety on the Nightingale ward (Figure 3). Patient safety is the primary issue in healthcare (Fermariello, 2016; Flott et al, 2017), which mandates efforts to reduce risk, harm and errors as the direct result of healthcare delivery (World Health Organization (WHO), 2019). Patient safety outcomes are underpinned by the quality of care delivered (Wang et al, 2020), necessitating continuous improvements and learning from errors (WHO, 2019), facilitated by quality and clinical governance (National Quality Board, 2011). The Francis report (Francis, 2013) highlighted failures in the analysis of adverse or never events and, as a result, risk management and clinical audit were made statutory components of clinical governance (Pearson, 2017), with lessons learned and service improvements put in place to reduce risk (Health and Social Care Committee and Science and Technology Committee, 2021).
The Nightingale ward staff survey did not question participants on their experience of maintaining patient safety in the context of adverse or never events. The author investigated the possibility of adverse or never events by undertaking a review of the medical emergency team (MET) forms and incident reports through the trust's Datix reporting system. This review found that one MET call had been placed upon the identification of a patient with a national early warning score (NEWS) of seven and one Datix form corresponding to the MET call. The identification of a MET form and corresponding Datix form illustrates that a missed episode of care did not occur, as it showed correct escalation by the ward team. This demonstrates that none of the redeployed employees were practising beyond their scope of competence, capability and capacity, which can be attributed to the benefit of induction, education and training (Figure 1) and informal and experiential learning (Figure 2) to maintain patient safety.
The lack of incidents reported through Datix shows that redeployed staff were able to maintain patient safety (Figure 3). Jones et al (2015) discussed how misses can be identified only through the act of an incident report being completed, raising the question of the number of unreported near misses that may compromise patient safety as a result of intrinsic and extrinsic factors that could affect incident reporting (Archer et al, 2017); this is beyond this scope of this article. Communicating concerns has been reported to decrease human error and avoid system failures (Okuyama et al, 2014); however, staff typically fail to raise concerns and those who do are typically ignored (Roberts, 2017).
Quality in healthcare comprises timely, effective, patient-centred, efficient, equitable and safe care (Health Foundation, 2021). Participants were questioned on their ability to deliver high-quality care to their patients during redeployment (Figure 4), and 93.3% were satisfied with the quality of care they provided. The NHS 2020 staff survey (NHS England/NHS Improvement, 2021) found that 82.1% of participants were satisfied with the quality of care provided. The authors acknowledge the significant disparity between the sample population of the Nightingale ward staff survey and that of the NHS staff survey (NHS England/NHS Improvement, 2021) and recognises results could be different because the staff responding to the 2020 NHS survey were working in their usual, pre-pandemic environment.
Most (86.7%) participants reported favourably about their ability to deliver the care they aspired to (Figure 5). In contrast, the RCN (2019) reported that 61.0% of nurses were too busy to deliver the care they aspired to and the NHS Staff Survey, 2020 (NHS England/NHS Improvement, 2021) found that 69.7% of participants reported being able to deliver the care they aspired to.
The NHS staff survey (NHS England/NHS Improvement, 2021) reflects the wider population of health professionals, and does not highlight the proportion of nurses: as such, the results of the RCN employment survey (2019) may be more relevant in the context of nursing.
The findings of the Nightingale ward staff survey (Figure 5) may represent bias as they result from working in a COVID-negative environment, with a favourable nurse:patient ratio and access to senior staff, and may not be representative of employees deployed to COVID-19 positive environments or elsewhere across the trust.
Limitations
The central limitation of the study relates to the design of the questionnaire, resulting in predetermined data for analysis. The questionnaire was not piloted and, as such, reliability and validity were not confirmed before to distribution (Moule et al, 2017).
The response rate of the Nightingale ward staff survey is also a limitation of the study: non-responders may hold opposing views so the survey may be biased (Moule et al, 2017). Not participating in a survey can be attributed to stress, burnout, fatigue and time constraints because of workload (Morton et al (2012), the influx of COVID-19 related emails (Faria et al, 2020) and targeting in the midst of a pandemic (Wood et al, 2021), so non-respondents may be an important group who are not accurately represented
Conclusion
The limitations of this study relate to the predetermined questions of the staff survey and the modest response rate; nevertheless, this service evaluation illustrates important aspects of the redeployment of nurses to a Nightingale ward in response to the first wave of the COVID-19 pandemic in the UK.
The COVID-19 pandemic challenged healthcare organisations to restructure their services, redeploying health professionals to the frontline to meet unprecedented demands from the general public.
The service evaluation acknowledges that redeployment can be viewed as a threat or an opportunity. Data analysis found that staff preparedness for redeployment was directly influenced by trust induction, education and training, corroborating the literature relating to medical and surgical practitioners and allied health professionals.
The ACP-led induction, training and education programme implemented for Nightingale ward staff facilitated the acquisition of skills and knowledge required to perform in the redeployed job role. However, the delivery of the programme did not meet the needs of the whole deployed workforce; this may be attributed to saturation of learning or the level of content or teaching method not being appropriate. Nevertheless, the development of an education team using the principles of lean working was a success and should be recommended to bridge the gap in emergency situations, as competence, skills and knowledge directly impact on the delivery of high-quality, safe care. The role of ACPs was paramount to the successful delivery of the trust induction, education and training programme and this demonstrates the broad scope of advanced practice and the ACP contribution in the fight against COVID-19.
Maintaining patient safety is fundamental to health care. This service evaluation illustrates that redeployment does not jeopardise patient safety, nor the ability to deliver the care to which nurses aspire. There is a causal relationship between the ability to deliver high-quality care and knowledge, skills and competence. This article has identified the positive impact of ACPs on trust induction, education and training, and the subsequent benefit to high-quality care delivery.
This service evaluation gives an insight into the positive experiences of redeployment to the Nightingale ward; it also highlights areas that require improvement, and strategies to mitigate the effects of the pandemic on employees.
KEY POINTS
- During the pandemic, healthcare organisations redeployed staff to meet the unprecedented demands of local populations
- The advanced clinical practitioner role is central to successful redeployment, in preparing redeployees through induction, education and training, providing the knowledge and skills to practise competently in their new role
- The successful application of lean working principles is recommended to bridge the gap in emergency situations, through the application of knowledge transfer between individuals, maximising learning opportunities, as competence, skills and knowledge directly impact on the delivery of high-quality, safe care
- Redeployment does not jeopardise patient safety, nor nurses' ability to deliver the healthcare they aspire to give
CPD reflective questions
- How can you apply the principles of lean working in your practice to develop an agile and flexible workforce?
- How could you apply your core skills in a constantly changing workplace environment?
- How could the four pillars of advanced practice help meet the continued need to provide a flexible and agile workforce?
- Was your skill set, knowledge and competence exploited to its full potential during the COVID-19 pandemic? How could you have employed these to meet the demands of the general public at the time?