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My original plan for this blog was to explore why change is a bit Marmite – some of us love change (the ‘bring it on’ group), and others less so. Then the COVID-19 jar was opened and everything changed. We are all impacted in different ways, both staff and patients. Whether it’s even more time at work, less time with those we love, wanting to be at work but having to self isolate, loss of our identity as the one who always does x or y, how as patients we interact with our NHS, or the loss of those we love. Transitions are challenging William Bridges says it isn’t the changes that do you in, it’s the transitions. Change is something that happens to people, even if they don't agree with it. Transition, on the other hand, is internal. It's what happens in people's minds as they go through change. Change can happen very quickly, while transition usually occurs more slowly as we internalise and come to terms with the details of the new situation that the change brings about. Stages of transitioning include: Ending - letting go of the old ways and the old identity. The neutral zone - going through an in-between time when the old is gone but the new isn’t fully operational, when the critical psychological re-alignments and re-patterning take place. New beginnings – when we come out of the transition and develop a new identity, experience a new energy and discover a new sense of purpose. 3 tips for dealing with transition So what can we do to ease the transition? Here’s my three As for the day: Acceptance Accept that we will each make our transition at different paces. For some shock and denial through to acceptance and hope is rapid, for others it may take longer. So more than ever looking after each other is key. Steve Covey’s talks about making a deposit in the emotional bank account: understanding your friend, your colleague, a small act of kindness. What will be a deposit for you, may be a valuable withdrawal for them. Appreciation There’s already a zillion examples of people moving hell and high water to do what needs to be done to best respond to COVID-19, positive energy is thriving. Appreciating this is just as important. We can show our appreciation locally in our teams, on an individual basis or by joining the nation in clapping those who are helping to keep our world turning,. Awareness Be aware of high levels of anxiety and exhaustion in yourself and those around you. We are all stressed by different things. For some it’s spending too much time alone. Others ambiguity and uncertainty. Some will struggle most with decisions they think are illogical, last minute or require super human endeavours. Knowing our own limits and triggers and those of people around us is key. When you spot them, pause just for a vital moment, take a brief step back before anyone keels over and think through next steps. Explore information and ideas and talk them through with others. And where you can see that someone isn’t in a good place, give them permission to re-charge their batteries so their brilliance can continue to shine. “Not in his goals but in his transitions man is great.” —Ralph Waldo Emerson References William Bridges, Bridges Transition Model, 1988. Stephen R. Covey. The seven habits of highly effective people. Franklin Covey, 1990. Previous blogs by Sally Leading for improvement Immunity to change How a single piece of paper could help solve complex patient safety issues The art of wobbling: Part 1 The art of wobbling: Part 2

Content will be updated and added to but currently includes: essential guidance from the NHS, UK Government, WHO and BMJ public Health England – personal protective equipment (PPE) infection prevention and control resources for staff working in critical care setting resources for staff working in acute hospital setting resources for staff working in primary care and community setting resources for return to work healthcare staff resources for pharmacy staff end of life care Covid-19 wellbeing for staff. The additional content will include new sessions and content curated from different sources such as existing HEE e-LfH sessions and materials from other organisations.Please follow the link below for the latest programme updates and to access the materials.

As a working parent, life has always been a juggling act… during this crisis I’m dropping a few balls and I feel totally out of control. I have always been an organised person. When I say organised, I mean that the kids get to school, I get to work, dinner is cooked, clothes are fresh, the house is clean, and we have time for fun. The last few days our worlds have turned upside down. The kids don’t go to school, my work is not what I know anymore and I’m too scared to go, dinners are not the usual (we had spam fritters and tinned potatoes last night), clothes are boiled washed, the house stinks of bleach and we can't go out. We shall get used to this new normal, I know that we all need to find a routine that will comfort us, even if that is making up new house rules or putting up a timetable for the kids (that went in the bin after 48 hours). I’m getting used to being a bit of a crap mother at the moment. I’m getting a bit shouty, more than usual and I don’t like it. We are eating weird stuff I have found in the back of the freezer as I am limiting the amount of time I go out; I don’t recommend a frankfurter curry… bit salty. I'm trying to home-school the kids as the school will only take the boys when I’m at the hospital – this is to make sure everyone can get to work. If anything, this is what is going to send me over the edge first! The boys are fighting, they refuse to do the work set by the school, I try and help but I can’t understand it, they ask for snacks constantly, they want to go out with friends and, what with everyone online, the internet is slow. It’s been 48 hours of lockdown and I think I shall have an 'inset' day tomorrow. I know in my last blog I spoke of my husband and his business going a bit t***s up, it’s the least of the worries at the moment. The government has set out lots of support for him and his employees. He will be ok, his employees will be ok, we will be ok. This was a huge part of the stress we were under last week, but things have changed. I have been doing extra shifts at the hospital to cover sickness. Many of our outreach team are in self-isolation due to family members being unwell or they are unwell. During these shifts I have witnessed the very best of our NHS and the Trust I work in, so why am I dreading my next shift? Fear. Never have I felt that my life is at risk during my 24-year nursing career. I have worked all over the world. Working in a refugee camp, being the only blonde, white woman, you would have thought I would feel scared or threatened. No, I was welcomed and respected. I have been driven at high speed in taxi in South Africa, racing away from armed car jackers when I was a repatriation nurse (admittedly this was a brown trouser moment), but it was one isolated incident. Being fearful of a job I love is so upsetting. The medical admission unit is filling up with ‘red’ patients (COVID positive) and the ITU is starting to see its first patients. As an outreach nurse we are seeing the sick patients. They cough all over me. I have no idea if they have the virus or not. I am not wearing scrubs; I wear my outreach uniform which I launder at home, but I do have access to surgical masks, aprons and gloves. A sick patient who is positive needs to go to the ITU. It’s my job to transfer them. I turn up with the ward nurse in an apron, gloves and surgical mask. They are wearing powerhoods or the N95 masks, scrubs, full plastic covering from head to foot, they have access to a shower after work and they have support from intensive care doctors. I feel totally underdressed and ill equipped. The nurses on the ward have been caring for this patient while wearing a surgical mask, apron and gloves. This patient was not receiving aerosoled treatment and the personal protective equipment (PPE) guidance is being followed, but I can’t help thinking that the wards are getting a raw deal. They are working in a 'soup of droplets'. I caught a glimpse of one of the cleaning staff changing the curtains of the COVID positive patient who had left the ward to go to the ITU. He also had just a surgical mask and his normal uniform. I felt sad. I can’t help thinking that this isn’t right. I don’t think we have the right protective equipment. Surely, we should not be wearing and laundering our own uniforms? We get told by our management, who get guidance from the Public Health England, so should we just accept it? If it feels wrong, it usually is wrong. Would they come and work a shift here in their clothes and be happy washing it at home? Probably not. There are not any showers for nurses at work. We bring this virus in to our homes on our uniforms, risking our children, our family and friends, not to mention ourselves. I feel filthy. I rush upstairs to shower while the uniform is boiling in the washing machine. Scrubs are at a premium. There are not enough to go around. I am upset over many things; I feel I can't do anything properly and feel useless. Everything we have ever known is different. I would like to end this blog on a high note… The sun is shining, just in time for lockdown.

This guidance includes; What are RRTs and CCO services? What is COVID-19? Why is COVID-19 important to the RRT and CCO service? Overarching principles Safety of the RRT responders Identification of suspected / confirmed cases Use of NIV, CPAP and high flow nasal oxygen Method of activation of the RRT Coordinating a response to a patient with suspected / confirmed COVID-19 Use of non-ICU staff as members of the responding team Training of staff.

ITU handover Bedside checklists Transducing arterial lines Arterial line sampling Bedside monitoring Observations Ventilation basics Activity sheet. About the author Sam is a registered nurse who works for a Trust on the South Coast of England

Although participants tended to feel a general obligation to work during an influenza pandemic, there are barriers to working, which, if generalisable, may significantly reduce the NHS workforce during a pandemic. The barriers identified are both barriers to willingness and to ability. This suggests that pandemic planning needs to take into account the possibility that staff may be absent for reasons beyond those currently anticipated in UK planning documents. In particular, staff who are physically able to attend work may nonetheless be unwilling to do so. Although there are some barriers that cannot be mitigated by employers (such as illness, transport infrastructure etc.), there are a number of remedial steps that can be taken to lesson the impact of others (providing accommodation, building reciprocity, provision of information and guidance etc). The authors suggest that barriers to working lie along an ability/willingness continuum, and that absenteeism may be reduced by taking steps to prevent barriers to willingness becoming perceived barriers to ability.

Today I was both humbled and deeply moved. The Royal Free Trust (RFT) continue to take the health and well-being of it's staff seriously. I’m proud to say I’m one of them. In response to COVID-19, a multidisciplinary group have been tasked to specifically look at how staff can be supported through the pandemic. It recognises that the support will need to be multi-faceted and my role as the founder of SISOS (Safety Incident Supporting Our Staff) and present SISOS lead will be to help provide emotional peer-led support for our staff alongside chaplaincy and varied mental health professionals. Released from my clinical role (scrub nurse) for the foreseeable future, I will be able to focus on, and will endeavour to promote and support, the emotional safety of my colleagues Trust wide. The mental health first aid training I undertook in preparation for my SISOS role will surely be put to the test. None of us know what obstacles and challenges we will have to face, both in our private and professional lives, as we race off track, gathering speed and moving towards an unknown destination. By and large, I envisage the peer support SISOS provides will be achieved remotely: telephone, WhatsApp, Facetime, text, emails. The experience we have gained allows us some insight into how this support will be received and I feel positive. Who could possibly have predicted two years ago when SISOS first evolved the events of the last few weeks. Implementing, embedding and sustaining a peer support initiative has thrown up many challenges but we are reassured that our colleagues can be confident of genuine emotional support from peers who are guided and supported by professionals within a Trust which cares. SISOS: caring is our passion Human being is our highest banding Read my other blogs on the SISOS journey: Part one Part two Part three Part four

Difficult to know where to start with this blog. Like the rest of the world, I’m anxious. We don’t know what is happening, we have not experienced anything like this before. When COVID-19 first arrived in late February (it felt like it snuck up on us, but I’m not sure that is the case), there was talk about some people having to work from home. This really suited me as I could easily do this in my role at Patient Safety Learning and it would mean I would be around more for my two boys. My boys are 12 and 14. Trying to parent boys of this age I find challenging at present. They seem to need me more than ever. I try to be a good parent, but usually feel guilty about letting them on the Xbox too long, feeding them chips more than once a week or not always knowing where they are or who they are with, especially if I am at work. I have normal parenting worries of bringing up teenagers. They are still at school today. How long that will last, I don’t know. The school has already set up online work for them and checked we all have internet access. My parents have said they will look after them if this is the case, so I can still go to work. The boys are delighted this will be happening at some point and can’t really see the long-term implications. If the Xbox doesn’t go down like it did last night – they should be fine. My parents are not old – in their 60s. Dad has a bad chest so I don’t want him to be put at any risk of catching the virus. With me going in and out of the hospital, I will be like a super spreader. I have told them to stay indoors and I won’t see them for a few months. I call them three times a day to keep a check on them. I think they think I’m mad. I’m just worried. As a nurse, my financial situation is stable. Working for the NHS is amazing; paid sick leave up to 6 months, great holiday entitlement and the likelihood of being made redundant in a clinical role is slim. I appreciate this ‘bubble’ that I work in. Yes, I’m usually skint at the end of the month, but I know I can work extra if needed and I will be paid at the end of the month – without fail. My husband on the other hand is different. He is self-employed. He employs six people. He has already had to lay one person off at the end of last week. Today he is giving the warning shot that they are all at risk of losing their jobs by the end of April. He has bills and wages to pay, funds are due to run out at the end of the month. My husband said to me last night that he feels that he has failed. He hasn’t – this is not his fault or anyone else’s fault. This is unprecedented. The mental health of everyone is at high risk here. It is affecting everyone in different ways. The mental health charities and services will be in demand – they are also under-resourced and overstretched as it is. My clinical background is cardiology, intensive care and critical care outreach. My skills are needed in the hospital at present. I want to help where I can. But I need to be at home with the kids, I need to be supportive of my husband who is going through a turbulent and worrying time with his business, I also feel pressure to help out clinically. My colleagues are going to work. Staff who shouldn’t even be going into work; many I know who have just finished chemotherapy, are immunosuppressed and who have underlying health problems. Healthcare workers are not immune, they are normal people too. We had a discussion at home this weekend. I shall work extra shifts at the hospital. Luckily my boss at Patient Safety Learning is understanding and is in full support. If I am honest – I am very nervous to what I may witness in the coming weeks/months. I have worked in difficult situations in the past. Working in a field giving aid to 30,000 migrants on the Greek/Macedonian border was what I thought hell was. I saw pain and suffering on a grand scale. However, this was relatively short lived and confined to certain groups of people. This is not. This is affecting everyone, no matter how much money you have, the colour of your skin, nationality or religion and there is nothing you can do about it. We do not have enough resources to care for the amount of people who will need it. Working on the intensive care unit, you are protected. You have your patients who have access to everything they need – doctors, nurses, drug and equipment. If we are to start rationing resources or restrict who will receive treatment and who doesn’t, it will make caring for patients on the wards unbearable. I have been called in to work clinically on Thursday. Nurses have had to self-isolate for different reasons. I have never felt scared to go to work before. I don’t think I am prepared to watch people die from this virus. I shall blog an update later this week. I would urge anyone to write their account on how they are feeling or what it is like to be you, whether you work in a care home, in theatres, in primary care or as a support worker, or even if you have been affected by the virus – your stories may help others and may help to inform future care and policy if this was to ever happen again. We all need to highlight what’s happening now that needs to be attended to. Join the conversation in our Community area.

The NHS Patient Safety Strategy, published in June 2019, sets out three strategic aims around Insight, Involvement and Improvement which will enable it to achieve its safety vision. It defines the Involvement aim as ‘equipping patients, staff and partners with the skills and opportunities to improve patient safety throughout the whole system’. A key action associated with this is a proposal to create Patient Safety Specialists within each NHS organisation in England. The strategy explains that ‘giving everyone in the NHS a foundation level understanding of patient safety is critical, but we also need experts to lead on safety in their own organisations’.NHS England and NHS Improvement have published draft Patient Safety Specialist requirements for public consultation. Patient Safety Learning welcome any increase in patient safety capacity and expertise in the NHS and have provided specific feedback on the draft requirements for this role. In our response we identify several areas where we believe these can be improved, including the following points: Patient Safety Specialists having a clear and direct reporting line to a named executive director on the Board with an assigned patient safety role and to a non-executive director with a similar role. Ensuring that the requirements identify key relationships for the role holders not identified in the draft document: Medical Examiners, Coroners, Healthcare Safety Investigation Branch, Governors, Non-Executive Board Members, HR Directors and NHS Resolution. Including a requirement that Patient Safety Specialists should demonstrate that they have the right skills and experience to work with patients, families and their carers on patient safety issues. They should also show that they can support their organisation to engage effectively in co-production with these groups. The need to strengthen the requirements for the individuals holding these roles to have knowledge and experience of: Investigations, Complaints, Just Culture, Systems Thinking and Human Factors. Giving consideration to how Patient Safety Specialists will engage with frontline staff, who are notable by their lack of reference in the draft requirements.

Six months ago, I left my band 7 managerial role to work as a band 5 agency nurse on the wards. Despite the band drop, this move has financial advantages which will help me to achieve some personal goals. Signing up After successfully completing the recruitment process, I am asked to attend mandatory training. This includes basic life support, manual handling and infection control. The usual, run of the mill stuff. I can book shifts a week or a day in advance, but these shifts can change to any speciality or department in the hospital, depending on staffing levels. I book my first shift after six years of having not worked within a ward setting. An unsafe start I turn up to the shift and introduce myself to be met with a mutter. The team and I receive handover and I am allocated my bay of patients. I notice I have twelve patients, three more than the other nurses. I reiterate this is my first time here and that I haven’t worked in ward work for some years. I ask if it would it be possible for someone to show me around – resuscitations trolley, toilets, codes to the drug cupboards. General housekeeping. I receive a grunt and a point, followed by some numbers hurled at me, along with keys. Ok, perhaps they’re just not morning people. I will give them the benefit of the doubt. Off I go to introduce myself to my patients and to immediately make use of my prioritisation skills, escalating any concerns I have to the seemingly disengaged shift leader and (more helpful) doctors. I find that my patients are acutely unwell and in need of a lot of care. I have to remind myself of my 13 years’ experience and how good I am at communicating, reassuring myself I will be ok. Hours later and still no toilet break Seven hours later, hungry and in need of a wee, I ask my shift leader if she could cover me so I can take a break. I am met with, ”your patients are too unwell for you to leave them for 15 minutes, and I don’t have the staff to cover you”. Followed by the ultimate toxic saying within the NHS, ”that’s just how we do it here, always have”. I start to feel neglectful that I would even have thought to have a drink and pass urine. Ten hours pass and still I haven’t had any water or a wee. Three emergencies have taken place without me even having had a proper induction. I take solace in my bond with my patients and lovely doctors who understand how it feels to be isolated and new to an area. Speaking up Perhaps out of dehydration and kidney shut down, I find the voice to politely approach the other nurses and shift leader. I explain that my patients are now stable and highlight my own personal fluid needs. I mention that I still haven’t received an induction. No one has asked me my skills or background nor if I know how to use the different IT systems (drug charts are now on computers). Again, I am met with, “well you choose to be agency, we just all get on with it here”. These are words that frighten me. It isn’t safe to get on with it. I felt out of my depth, overwhelmed, deprived of basic human rights and unwell. Losing confidence Then, a patient’s relative approaches me to say, ”I didn’t want to trouble you as you were running around looking so busy, but dad has chest pain”. At that point my heart breaks. How have I given the impression that I am the unapproachable one on this ward? Have I neglected this poor man? The same man who had cried with laughter at a joke I had made about some TV show we both watched the night before while I was catheterising him. Protocol follows and I investigate his chest pain. No acute cause. Phew. I still leave his side feeling that I am terrible at this. The end of my shift approaches, still no break, still no water or food. Handover time… I introduce myself to the night team. Finally, someone kind welcomes me to the ward. They tell me they all feel like they are doing a bad job and not giving satisfactory care. I think they are trying to reassure me. I cycle home in tears; shattered and broken. The next day I have serious doubts about my own ability. I call my agency and have a long chat with my recruitment consultant (who has never set foot inside a hospital and works on commission). His response? ”Well, you don’t have to go back”. I start to have serious doubts about my choice to work in this way and feel even more perplexed that our wards and teams have become like this. What a difference a day makes My next shift is in an emergency department. Dreading it, I don’t sleep the night before and I turn up riddled with anxiety about what is to fall upon me. I meet the team and prep myself to ‘kill them with kindness’. Everyone is pleasant and welcoming. The senior nurse asks me about my skills and mandatory training and shows me around. She informs me of their expectations and what I could, in return, expect of her team. It seems so simple, a five-minute job, huddling with your team for the sake of patient safety. But what a huge impact it has on my shift. My patients are more acute, I am busier and still don’t urinate. But I am supported and able to escalate concerns without being gas-lighted. Final thoughts I have now booked all of my shifts on that busy emergency department, simply because of the manager. I respect her management style and her approach to the safety of her unit. She doesn’t use those unhelpful and unsafe words, ”we just get on with it” or ”that’s how we do it here”. Since becoming a bit more settled in this world of agency nursing, I have spoken with matrons and lead directorate nurses within this trust about my experience. Often met with, ”what can I do about that?”. But sometimes met with, ”I will look into how that particular ward manages staff safety”. The latter leads on to better patient safety. Key learning points Inductions to new staff in new areas, should be mandatory. It should be the nurse in charge's duty to support junior staff. Doing safety rounds and checking in on all staff would help to manage workload, support flow and build confidence and reassurance among staff on duty. Safety huddles at the beginning, middle and sometimes end of each shift are a simple way of combating so many of the patient safety issues raised in this account. Early warning scores should be displayed and visible for all professionals on duty. They should be checked regularly and actioned accordingly.