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  • When and how should we transition safely into ‘normal work’ in healthcare?

    Summary

    In her latest blog, Claire reflects on the last few months working as a critical care outreach nurse during the pandemic and looks to the future and how we can transition into the new 'normal'. She urges us all to work together to redesign our health and social care services, building a service that meets all our needs.

    Content

    It's been a busy few months to say the least. Preparing for the pandemic, sourcing correct personal protective equipment (PPE), redeploying staff, acquiring new staff, making ventilators, redesigning how we work around the constraints, writing new policies, new guidance, surge plans, and then the complex part… caring for patients.

    If I am honest, when this all started it felt exciting. Adrenaline was high, motivation was high, we felt somewhat ready. There was a sense of real comradeship. It felt like we were all working for one purpose; to safely care for any patient that presented to us in hospital.  

    We were a little behind London by about 2–3 weeks, so we could watch from afar on how they were coping, what they were seeing and adapting our plans as they changed theirs. Communication through the ITU networks was crucial.

    Clinical work has been difficult at times. The initial confusion on what the right PPE to wear for each area added to the stress of hearing that our colleagues in other places were dying through lack of PPE. The early days for me were emotionally draining. However, this new way of dressing and level of precaution is now a way of life for us. I have come to terms that I am working in a high-risk area and I may become unwell, but following guidance and being fastidious with donning and doffing helps with ‘controlling’ my anxieties in catching the virus.

    Some parts of the hospital remained quiet. Staff had been redeployed, elective surgery cancelled and the flow of patients in the emergency department (ED) almost stopped. I remember walking through ED and thinking: where are the people who have had strokes?  Have people stopped having heart attacks? Are perforated bowels not happening anymore? 

    The corridor in ED is usually full. Ambulances queuing up outside, but for a good few weeks the ambulance bays were deserted. The news says over and over again "we must not overwhelm the NHS". I always have a chuckle to myself as the NHS has been overwhelmed for years, and each year it gets more overwhelmed but little is done to prevent winter surges, although it's not just winter. The surge is like a huge tidal wave that we almost meet the crest of, but never get there, and emerge out the other side.

    I sit in the early morning ITU meeting. We discuss any problems overnight, clinical issues, staffing and beds. We have seen a steady decline in the number of ITU patients with COVID over the last week or so. The number of beds free for COVID patients were plentiful. We have enough ventilators and staff for them. This is encouraging news. I take a sigh, thinking we may have overcome the peak.  

    In the next breath, the consultant states that we don’t have any non COVID ITU beds. We have already spread over four different areas and are utilising over 50 staff to man these beds (usually we have 25 staff).

    So that’s where the perforated bowels, heart attacks and strokes are. The patients we are caring for had stayed at home too long. So long, that they now have poorer outcomes and complications from their initial complaint. These patients are sick. Some of the nurses who are looking after them are redeployed from other areas; these nurses have ITU experience, but have moved to other roles within the hospital.  This wasn’t what they had signed up for. They were signed up for the surge of COVID positive patients. I’m not sure how they feel about this.

    As the hospital is ‘quiet’ and surgical beds are left empty, there is a mention of starting some elective surgery. This would be great.  It would improve patient outcomes, patients wouldn’t have to wait too long, so long that they might die as a consequence. However, we don’t have the capacity. We have no high dependency/ITU beds or nurses to recover them.  

    We would also have to give back the nurses and the doctors we have borrowed from the surgical wards and outpatients to staff ‘work as normal’, depleting our staff numbers further.

    Add to the fact that lockdown has been lifted ever so slightly, the public are confused, I’m confused. With confusion will come complacency, with complacency will come transmission of the virus and we will end up with a second peak.

    If we end up with a second peak on top of an already stretched ITU and reduced staffing due to the secondary impact on non COVID care, the NHS will be overwhelmed. This time we will topple off that tidal wave.

    It’s a viscious cycle that I’m not sure how we can reverse.

    My plea, however, is to ensure we transition out of this weird world we have found ourselves in together. We usually look for guidance from NHS England/Improvement, but no one knows how best to do this. The people who will figure this out is you. If your Trust is doing something that is working to get out of this difficult situation, please tell others. We are all riding the same storm but in different boats.  

    I would say that I am looking forward to ‘business as usual’ – but I can’t bare that expression. 

    Now would be a great time to redesign our services to meet demand, to involve patients and families in the redesign – to suit their needs.  We have closer relationships now with community care, social care and primary care, we have an engaged public all wanting to play their part. Surely now is the time we can plan for what the future could look like together?

    The Government has announced that Ministers are to set up a ‘dedicated team’ to aid NHS recovery. We need to ensure that patient and staff safety is a core purpose of that team’s remit and the redesign of health and social care.

    Would you be interested in being on our panel for our next Patient Safety Learning webinar on transitioning into the new normal? If so, please leave a comment below.

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    Dear Claire,

    this sounds so familiar! I too work within an outreach service as a PDN for the level 1 areas in 'normal' times. I have been working clinically within the critical care units (from 2 units to 4 during peak surge) and experienced the same amazing professional camaraderie that got us all through the initial preparatory days of the waiting game, to then the full onslaught of a peak like we have never experienced. With that came physical challenges, emotional angst and toil, dilemmas and conflict. We are now entering an even more strange lull, where we are keen to embrace moving forwards out of lock down but anxious about what that will mean and the impact for us in a few weeks/ months time. We still haven't returned to outreaching yet, partly due to the demands of the units trying to manage both covid and non-covid pathways and similarly how we will access these different pathways within the ward structures to maintain safety for us, our colleagues and our patients. I am very keen to hear what other areas are finding is working for them and how we are learning from the experiences of the last few months.

    As a health care professional and a patient, Tthank you to you and the wider Patient Safety Learning community for all you have done, are doing and will do.

    Sarah

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