Claire Cox

We have just come out of a second lockdown. This time my experiences working in the NHS are very different from the first lockdown back in March 2020. As you may have read in my past blogs, the first lockdown wasn’t really a lockdown for me. As a critical care outreach nurse I was going to work as usual; however, the work I was doing had changed. The way we were adapting our environment, our processes was almost exciting – to be able to directly influence rapid change in a usually bureaucratic organisation was novel. I remained at work, there was no furlough, and there was no isolation, no Joe Wicks and no cleaning out my cupboards, unlike some of my non-NHS friends. This time, the second lockdown, things were different for me. I have come away from clinical practice and have entered the world of patient safety management. Not only have I started a new role, I have started it in a new Trust. Moving into a new role in a new Trust during a global pandemic has been challenging to say the least. I had spent the past 24 years in the same Trust, the people around me had seen me grow up – literally. Many of my past colleagues felt like family. It would take me a day to walk round the wards, just once, as every five steps I would meet someone I knew for a chat. I knew who to ask if I had a problem, I knew the nuances of each ward and most importantly, I had tacit knowledge of how work ‘got done’ and how to ‘get it done’. During the first lockdown I spent much of my time on the intensive care unit and the COVID wards. There was great sense of comradery, team work and a support network. Yes, the work was difficult, but we had each other and we were able to openly talk about our fears, shed tears and sometimes laugh about what had happened throughout the shift. In an odd way, it felt comfortable. The second lockdown working for the NHS could not be more different for me. I have changed roles completely. I have been interested in patient safety for a number of years and have done a little quality improvement (QI). Quality improvement in the patient safety space is something that I very much enjoyed as a nurse; however, I found that I didn’t have the time, the headspace or, sometimes, the support to immerse myself into a project that made an impact. It always felt as if I wasn’t doing QI ‘properly’. We were dipping in and out of it, not always following a methodology and grabbing time here and there to write bits up. It often felt we were papering over the cracks and not addressing the bigger problem or tackling multiple problems in a strategic manner. The upside of doing QI clinically is that you can see the impact your change has made in the work that is being done. Working with many of the stakeholders, who you have a close relationship with, you are able to have brief chats with them about the project without the need for formalised meetings. You feel as if you are making a difference to your world and the patient’s experience. Being a quality improvement and patient safety manager seemed the logical next step for me. But I now find myself in an alien world. Weirdly my surroundings are very familiar – I’m working from home. So how do I do QI from my dining room table, in a huge new Trust with people I have never met? It can’t be done. I can’t make any meaningful change in my own house 60 miles away from a hospital I have not worked in… can I? During the beginning of my Darzi fellowship we were ‘taught’ to pay attention to the way we were feeling and the stories we were telling ourselves. The story I was telling myself was not enabling me to be open to the new challenges and opportunities that were awaiting. I remembered being in my comfort zone back in my old role. Yes, I missed that feeling of knowing what I was doing and feeling confident, but I also remembered why I wanted to move. I want to make meaningful differences to the patient experience, safety and to make it easier for staff to do the right thing at the right time. If I was going to move to a new role, I was stepping out of my comfort zone. When stepping out of your comfort zone it will feel uncomfortable at times (most of the time). At the moment I am orbiting the fear zone and trying desperately to break into the learning zone. Although the fear is real, it’s manageable. Slightly odd as it almost feels like excitement too. Image from 'Step outside your comfort zone' Action Coach Learning within a new role is always difficult. You might spend time watching others, taking example from role models, shadowing and asking questions when problems or queries arise… but what can you do when there isn’t anyone to ask, when there is no one to watch, no one to guide you? Skype, MS Teams, Zoom – there are many online tools to help. Interacting with people via a computer is not natural to me. I expect it can’t be natural to anyone? I have come from a role where interacting with people is the main part of the job. Picking up subtle cues from body language, tone of voice and mannerisms count for so much. This is almost impossible to achieve from a computer screen. Striking up a rapport with someone new is a real skill and a skill I prided myself on. The skill I had in reality doesn’t seem to work online. My humour is lost (my jokes were rubbish anyway), time is often limited and conversation is structured around tasks – relationship building comes with time, talking at break times and sharing stories. The team I work with have been amazing. They are there at the end of the phone at any point. I have been supported. But I’m longing to be surrounded by a bustling environment again. Where ideas can be bounced around, projects discussed and problems resolved rather than booking in one-dimensional, online meetings. This won’t be forever, but we are in the midst of working in a different way and finding our feet. As for QI from the dining room table… it can’t be done. I can’t make any meaningful change in my own house 60 miles away from a hospital I have not worked in… can I? Yes you can. You can make a huge difference. My next blog will be how working remotely you can make relationships, influence and introduce change.

The recommendations set out in the report are addressed to all leaders who influence the workplace experience of nursing and midwifery staff Recommendations Key recommendation 1: Authority, empowerment and influence Introduce mechanisms for nursing and midwifery staff to shape the cultures and processes of their organisations and influence decisions about how care is structured and delivered. Key recommendation 2: Justice and fairness Nurture and sustain just, fair and psychologically safe cultures and ensure equity, proactive and positive approaches to diversity and universal inclusion. Key recommendation 3: Work conditions and working schedules Introduce minimum standards for facilities and working conditions for nursing and midwifery staff in all health and care organisations. Key recommendation 4: Teamworking Develop and support effective multidisciplinary teamworking for all nursing and midwifery staff across health and care services. Key recommendation 5: Culture and leadership Ensure health and care environments have compassionate leadership and nurturing cultures that enable both care and staff support to be high-quality, continually improving and compassionate. Key recommendation 6: Workload Tackle chronic excessive work demands in nursing and midwifery, which exceed the capacity of nurses and midwives to sustainably lead and deliver safe, high-quality care and which damage their health and wellbeing. Key recommendation 7: Management and supervision Ensure all nursing and midwifery staff have the effective support, professional reflection, mentorship and supervision needed to thrive in their roles. Key recommendation 8: Learning, education and development Ensure the right systems, frameworks and processes are in place for nurses’ and midwives’ learning, education and development throughout their careers. These must also promote fair and equitable outcomes.

This guidance set out by Public Health England explains how patients/the public and clinicians can mitigate falls.

This article, from John Hopkins Medicine, demonstrates some breathing exercises for you to try at home to aid recovery.

This blog in the BMJ, recognises that bullying also occurs with in patient advocacy role and the patient community.

This resource includes: What is medicines management? The right medicine for the right patient and the right time Becoming an independent prescriber Competencies and maintaining competence Specialist prescribing Delegation Unregistered staff and social care Administration Prescribing and administration Transcribing Nursing associates and medicines management Summary of available guidance

Background: Acute kidney injury (AKI) in critically ill patients is multifactorial. There is little reliable UK data on the incidence and outcomes of patients with COVID-19 and AKI outside the ICU. At this stage we do not have a full understanding of the aetiology of AKI in COVID-19 and the pathogenic role of systemic inflammation, hypovolaemia or other COVID-19 related pathology (such as thrombotic microangiopathy) in its genesis. Volume status is critical in reducing the incidence of AKI but the balance between respiratory and kidney function can be challenging. Preventing avoidable AKI should be a key goal of the management of hospitalised patients, to reduce demand for renal replacement therapy (RRT). AKI should be promptly recognised and managed appropriately, within the limits of our current understanding. AKI confers an adverse risk of mortality and its presence reflects underlying morbidity and current illness severity. The presence of AKI should inform assessments of prognosis and in some cases the appropriateness of escalation of care. It is critical that we build on existing processes and knowledge and carry on doing the things we currently do well.

Key points: Student paramedic practice, especially in the placement environment, mirrors human factors seen post registration, but also has its own unique set which require further research. The relationship between student and mentoring paramedics is a unique and important human factor in student development. Many clinicians may not feel prepared or willing to undertake a mentorship role. More training and support for mentoring paramedics would be of benefit. Emotional stresses faced by students when they initially encounter emotive aspects of the placement environment should be recoginised. Institutions and placement providers should encourage students to identify and practise coping mechanisms as well as offer support. Placement environments vary nationally and globally, and due to the nature of the job, it is difficult to nurture confident students and clinicians. However, adaptions could be made to reduce stresses on both parties.