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Over the last 3 months we have seen NHS organisations work at lightning speed to adapt and serve their communities in response to the COVID-19 pandemic. With the shutting down of routine surgeries and outpatient services, care providers have adapted in an extraordinary way. Wards have been emptied as beds have been made available, while theatres and recovery rooms have been turned into intensive care beds – capable of looking after acutely unwell ‘level 3’ patients – overnight. These unprecedented changes deserve praise and commendation but, beyond this praise, what can we learn from COVID-19 and the scale of change we have seen? It was famously argued that it takes 17 years for research to impact frontline services.[1] . Due to this, immense interest has centered around how innovations, or new ideas, are diffused and how this process can be sped up.[2] Various barriers exist to the spread of new ideas and change – not limited to bureaucracy, a lack of resources to create change, and cultures – for example organisational culture. Due to these barriers the NHS and its subsequent organisations can appear as monolithic – slow to change or adapt to any innovations. But COVID-19 has turned this assumption on its head, with expansive structural and procedural overhaul seen in the last few months alone. It has led observers to ask how this has happened and, more importantly, how we can facilitate change in the future. As we reflect on these months, the psychology of a crisis can be helpful in understanding staff behaviour. There are three stages – emergency, regression and recovery.[3] In the emergency stage, energy and performance goes up as staff ‘fire fight’ in the crisis. However, the move towards the regression and recovery stage will see staff become tired and lose their sense of purpose before needing direction on how to recover and rebuild. These latter stages are symptomatic of the current state for NHS staff. Utilising theories of change, perhaps we can identify why this change happened so quickly. The impending doom felt by staff was palpable in March. The Nightingale field hospital was being built to cope with the immediate storm of COVID-19 patients needing ventilatory support and providers were told to free up beds. In business, this is coined the ‘burning platform’ and is a key driver of change. A burning platform is a term which describes the process of informing people of an impending crisis and is used to cultivate immediate change. This ‘burning platform’ is a simple analogy and based on an incident in 1988 of an oil rig worker who, when faced with an impending burning platform, jumped into freezing water. Whilst of course this sense of urgency can’t be replicated every time change needs to happen, for professionals working at the start of the pandemic, this is exactly what was replicated. Perhaps change happened so fast as professionals and staff had no other choice but to respond to the burning platform of COVID-19. Creating a sense of urgency is also argued as being integral to another organisational theory of change – Kotter’s 8 Step Process for leading change. The first stage – creating a sense of urgency – is characterised by a distinctive attitude change which leads workers to seize opportunities to make changes imminently. But NHS staff have already responded to the immediate urgency presented by COVID-19, so what happens next will be telling. Apart from creating the NHS’s own burning platform, adaptations that can be seen across the NHS are not following any other theory of change. The NHS – a highly complex and bureaucratic set of organisations – has seen providers innovate, change and adapt without the traditional ‘red tape’ of the NHS. NHS providers are no longer following a model, instead working out what is best for the patients they serve. For community providers and primary care this includes virtually treating patients to limit their risk to COVID-19. Changes that have taken years to discuss are now happening overnight – for example some hospital providers integrating IT systems to improve cohesion. With so many innovations, it is crucial that we learn from what is happening. Organisations should be supported to identify and collect information on the changes that are happening on local levels. With this wealth of information, organisations can learn what made local change possible and what the drivers of innovations were. This insight is undeniably useful as it can help us all understand the drivers of change locally and galvanise change in the future. This must be made into an organisational priority. While organisations remain in firefighting mode, now is a crucial time to take stock, capture these changes, and hold on to what is useful as the NHS – and wider society – recovers. References 1. Morris Z, Wooding S, Grant J. The answer is 17 years, what is the question: Understanding time lags in translational research. J R Soc Med 2011;104:510-20. 2. Turner S, D’Lima D, Hudson E, Morris S, et al. Evidence use in decision-making on introducing innovations: A systematic scoping review with stakeholder feedback. Implementation Science 2017;12. 3. Wedell-Wedellsborg M. If You Feel Like You’re Regressing, You’re Not Alone. Harvard Business Review [Internet] 2020.

This web page includes: Films The framework Community Breaking bad news Ceilings of treatment Resources Evidence-based advice for difficult conversations, by Professor Ruth Parry, Loughborough University Poster and sketch note Telephone call checklist

The free version of Hospify is available right now and is in daily use at over 150 clinical sites around the country including London North West University Healthcare Trust, County Durham and Darlington, University Hospitals North Midlands, Frimley Park and Lincolnshire Community NHS Trust. Hospify is also backed by Innovate UK, Wayra Velocity Health (in partnership with Telefonica and MSD Pharmaceutical), Kent Surrey Sussex AHSN and the UNISON and Managers in Partnership Unions. A premium version of Hospify specifically designed for healthcare teams is also now available. Called the Hospify Hub, it features an online admin portal for onboarding staff, a web app that syncs with users’ phones, broadcast messaging/paging with document attachments and a survey and data collection tool. Please email info@hospify.com for more details or visit hub.hospify.com to set up a Hub and give it a try for yourself.

This video is the first on several that have been shared in a series of tools and techniques to help you and allow you to help others.

The activity book helps introduce children to ICUs, has activities to help them understand what ICUs do and what they might see when they visit one. They can write about how they feel, and their relative, if they would like to. The book also comes with an information sheet for parents or carers, about ways to support the child during this difficult time.

After working last week and caring for patients who were pending COVID-19 swab results, four days later I woke feeling unwell. A slight cough, tired, pale, feeling freezing cold but no temperature and generally feeling rubbish. This carried on for a few days, I then ended up with common cold-like symptoms and a residual cough. Normally, I probably wouldn’t call in sick, I would have just carried on. Following current guidance, I called in sick and was advised to take the next 7 days off. At this point testing was unavailable for NHS staff. I was sat at home not knowing if I had the virus or not while my colleagues were having to pick up the slack. If I am completely honest, I was glad I didn’t have to go back. I was anxious that we didn’t have the right personal protective equipment (PPE), systems for donning and doffing were not in place, we didn’t know what to expect over the coming days, training for redeployed nurses and doctors was not happening. I just didn’t want to go back anyway. I felt a coward. Over the coming days while I was at home, my husband then became ill, then my youngest son, then the eldest. All with mild symptoms, but still no idea if we had it or not. While I was off, I was contacted by the ‘staff welfare team’. It was just a quick phone call to see how I was, but it made all the difference. I felt like I wasn’t just a ‘worker’ off sick, I was someone that they cared about and were obviously keen to make sure I was coming back! This has never happened before. Reluctantly, I return to work, but it was like I had stepped into a different Trust. Wards with infected patients were labelled as RED wards; huge signs were outside the wards with designated places to don and doff PPE. There were clear guidance on which PPE to wear displayed in poster format. There were green footsteps and red footsteps on the floor enabling you to know which area you were in. PPE safety officers had been deployed to reassure and ensure all departments have enough stock. It felt safer. Leadership at all levels is being tested at this time. Where I work in Brighton, we are invested in ‘Patient First’. This is headed up by our Kaizen Team. All staff are trained in differing levels of quality improvement (QI). All wards and departments have improvement huddles, where they can raise a mini project and see it through. We all speak the same QI language. I dread to think what would happen if we didn’t have this in place during this awful time. By having this process, it has empowered ALL staff to speak up and give permission for frontline staff to improve processes where they work. Our executive leadership team have done an amazing job in such a small amount of time. They have increased ITU capacity, they have reshaped rotas, redeployed staff, re employed staff, transformed patient pathways (red and green pathways), pooled staff, set up systems for donations… There has been so much achieved in a short amount of time; the top-level organisation has been incredible. All this in seven days. They have been phenomenal at strategy, planning and overall management and leadership of what I call ‘the big stuff’. What they are not so good at is the ‘small stuff’. We, frontline workers are brilliant at this. The practicalities of work – where can I don and doff, where the bins should be, how do I know this bed has been cleaned? What do we do when someone dies? Can relatives visit? How do we know who is who in PPE? How can we make sure we don’t contaminate clean areas? How do we take blood now? We know what needs to be improved, we know what is missing. It’s the small details that worries staff, it’s the small details that can save lives. As I was walking seeing patients from different wards, I heard staff saying – this isn’t right – we could improve that. They can raise a ticket on the huddle board and they could initiate the change. If the change could be replicated else where in the Trust, the Matron or ward manager can then raise it at the Bronze meeting, the bronze would then raise it to Silver and then implemented. I often hear that we use a top down, bottom up approach but never really thought it works, as there is so much red tape involved in healthcare. Quite often frontline ideas never reach the top level and they fall flat. This time it’s very different. To test the system, you need to stress the system. This system of QI and communication is working. We are all learning together. None of us have dealt with a pandemic before. Frontline staff have been given the permission to improve the way real work is done, quickly and safely, while the top-level management are concentrating on strategy, planning, implementation and co-ordination of services. We are listening to each other, we are rapidly changing and adapting, the whole Trust is in a constant state of PDSA cycles. It feels dynamic, proactive and controlled. If this pandemic happened 10 years ago in our trust, I am convinced that we would not be in the position we are now. We have enough intensive care beds, we have the capacity to expand further, we are ready.

Watch the video or access the link below for more information about PatientAider.

This article is about accepting that our working lives are difficult, that this is a big part of the attraction of our work and that it is wise to look at ways in which both team and personal resilience can be improved.

We will need to work in different ways from usual and the focus should be what information you share and who you share it with, rather than how you share it. The following advice sets out some of the tools that you can use to support individual care, share information and communicate with colleagues during this time. This includes communications tools where data is stored outside of the UK. This advice is endorsed by the Information Commissioner’s Office, the National Data Guardian and NHS Digital.