Nursing and related management
in the time of COVID-19

1 April 2020

The COVID-19 pandemic represents an unprecedented period of change and rapid adjustment in UK healthcare provision. The work of frontline nurses often goes beyond pure treatment, providing care, support and regular human contact with patients. How is the tension between social distancing and nurses’ obligations to look after patients to be resolved?

The Government's Strategy

The UK Coronavirus Action Plan sets out the government’s plans and actions for managing the COVID-19 outbreak. The Coronavirus Act 2020 has introduced new powers for medical professionals, public health professionals and the police to allow them to detain and direct individuals in quarantined areas at risk or suspected of having the virus; and to make room for emergency registration into the professions. Christina Orthodoxou explores the Act in her article here.

The Action Plan sets out provisions in place for pandemics including:

  • Maintaining a strategic stockpile of the most important medicines and PPE for healthcare staff;
  • Daily monitoring of the stockpiles with additional stock being ordered where necessary;
  • The establishment of coronavirus assessment services to lessen the impact on emergency departments and other clinical settings; and
  • The establishment of specifically tailored and effective services responding to this outbreak.

The Plan sets out the phased response approach that has been adopted:

  • The Contain phase;
  • The Delay phase;
  • The Research phase; and
  • The Mitigate phase

Each of the phases emphasise the dissemination of information around hygiene practices; the rapid response to instances of known COVID-19 cases; provision of a base level of welfare; and a consistent level of healthcare provision both for COVID-19 cases and continued care for non-COVID-19 patients.

But in practice, how does this apply on the ground to members of the profession?

Caring for those who may be infected

Nurses and associated professions are still governed by the Code which continues to require them to make sure patients’ individual needs are recognised, assessed and responded to without undue delay. Emphasis is placed on making ongoing risk assessments to ensure that the right balance is struck between providing care and maintaining safe practices. It is therefore in the interests of practitioners to regularly check the NHS and Public Health England websites to ensure they are familiar with the most up to date guidance and recommendations.

The real consequence of this is that those amongst the profession who sit in managerial roles have a pertinent duty to ensure that they are fully aware of the living circumstances of those working underneath them, making sure they are familiar with those who may, for example, reside with people who have characteristics that fall within the list of those who are at increased risk of severe illness from COVID-19.

The NMC has released a joint statement recognising that registrants may need to depart from established procedures in order to care for patients. They place emphasis on nurses using their professional judgement to assess risk and to find the best way to provide care, whilst still working within the limits of their competence. The regulator emphasises the Code’s flexibility in circumstances like this, pushing their recognition of the need to ensure that nurses are aware they will not be criticised for working outside of their day to day remit as long as they remain within reasonable parameters of their working knowledge and training.


The task for managers

With this in mind, managers may wish to consider the use of close supervision and reporting, and/or encouraging peer reviewed working wherever possible. When turning their minds to redeployment, in particular when working with members of the profession who have specifically returned to practice to assist with the COVID-19 response, thought should be given the placing those individuals in areas of work that properly reflect their last specialism and instead moving already practising nurses across to areas dealing directly with COVID-19 cases. It may be safer to retrain nurses who are used to dynamic environments to deal with COVID-19 and to allow returners to move back into their comfort zones as they adjust to practising again.

Managers and individuals should bear in mind that members of the nursing profession are practitioners who view their roles as a vocation, there is often an ethical or moral draw towards being helpful and acquiescent to requests to work in areas that require personnel. The limits of competence should remain at the forefront of the individual’s mind when making decisions about whether to agree to redeployment.

In short, each nurse is responsible for their own compliance with the Code.


Students entering practice

Early registration has been introduced for students on a voluntary basis. Students in their third year can opt to take their last six months as a placement. However, they will need to make an informed decision as to whether they enter practice. The NMC website contains substantial guidance to assist with making that choice. Emergency standards for nursing and midwifery education have been introduced to last only for the duration of the emergency period. They include new standards to ensure that all students’ learning outcomes can continue to be met in a safe and effective way, and amendment to existing standards to provide flexibility in ensuring appropriate supervision and support for students in each year of their programmes. It should be noted that although the standards reflect a substantial relaxation over certain areas, there is still a requirement to comply with the minimum 4600 training hours and the maximum two third clinical weighting remains.


Safe clinical practice

Understandably, a significant concern amongst the profession is ensuring they are able to work with suitable PPE. It represents a vital part of infection control and protection for workers. Stories are rife from nurses and other healthcare professionals in front line work drawing attention to the lack of availability of PPE. For example, a campaign from one group of doctors at the time of writing this article has raised over £1m to privately source PPE, as they were so concerned by the lack of protection being given to them at work.

The guidance for practice varies according to whether the practitioner specialises in primary, secondary or community health.

Public Health England (PHE) recommended PPE ensemble for healthcare workers within a metre of a patient with possible or confirmed COVID-19 is:

  • Fluid repellent facemask
  • Apron
  • Gloves
  • Eye protection if there is a risk of splashing

The recommended PPE ensemble to be used for aerosol generating procedures on patients with possible or confirmed COVID-19 is:

  • FFP3 respirator
  • Long sleeved disposable gown
  • Gloves
  • Eye protection (disposable goggles or full-face visor)

The guidance is worryingly silent on what practitioners should do if they are presented with patients who are or may be COVID-19 positive and they do not have access to adequate PPE. It would seem that it again falls to the nurse to exercise reasonable professional judgement and ensure that they can practice safely. If this is a regular occurrence, the concerns should be escalated amongst line management in the usual manner and reported using the contact details set out above. Senior management should keep the situations under review and actively monitor whether it is indeed safe to continue to provide treatment and care if such equipment is in short supply.


Judgement is key

In short it seems that the focus at this stage is on pragmatism and professional judgement. This represents a period of time that is unprecedented in many of our lifetimes.  Nurses should take time to ensure that any decisions they make around practice, redeployment, and clinical care are properly informed and reasonable. Communication with line management should be encouraged and regular and frequent and consistent checking of the latest guidance from the NHS and Public Health is highly recommended.


About the author

Abimbola is a Barrister at 25 Bedford Row. She specialises in criminal and regulatory defence work. Her regulatory practice concentrates on the medical industry, with nurses as a specific focus.

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