25 March 2020

COVID 19 is a global health emergency and its emergence in humans has seen widespread infections resulting in mostly mild and moderate illness. However, COVID-19 can also cause severe and life-threatening illness in some of the population. Recent clinical data from both China and Italy has highlighted the need for ensuring that sufficient critical care capacity is available with appropriate estate, equipment, and expertise to deal with the increased demands that COVID-1 creates. The critical care requirement is well above that normally available and needs a different approach to developing the required workforce.

We recognise that critical care nursing is highly specialised and takes years of training and education working alongside other members of the multi-professional team. Team effectiveness is paramount in this situation and is defined by strong and trusting relationships, expertise and the contribution and skills of all its members. In this unprecedented time, we realise this will be personally and professional challenging for all staff and we will ensure that we support you as much as possible. The demand for critical care capacity in the United Kingdom will grow faster, and will not allow the time for traditional approaches to training, skill mix and capacity management. Critical care nurses will be required to work, think and respond in very different ways to how they have become accustomed. This will include participating in advanced decision-making on end-of-life care and decisions around providing or stopping advanced life support sometimes much earlier than they have been used to.

The immediate focus of healthcare services in the next week and sustained over the following months is to, as safely as possible, make additional critical care capacity available to meet demand. This will require staff with associated expertise such as those currently working in operating theatres, respiratory and emergency care to work in the critical care centres and units and to be supported and supervised in practice alongside experienced critical care nurses.

We as nursing leaders of the critical care nursing organisations and of the UK’s health and care services have worked swiftly and intensively to find a practical and workable policy response to this. The following joint statement and annex paper, outlining principles for increasing the nursing workforce in Adult critical care, is endorsed by the signatories below.

UK Critical Care Nursing Alliance, CC3N British Association of Critical Care Nurses Intensive Care Society, RCN CCF and NoRF (National Outreach Forum) recognise that:

• There is a requirement to support existing critical care nurses in their roles.
• Critical care nurses supporting the redeployed workforce will provide supervision and expertise in delivery of critical care.
• Guidance to nursing staff on the professional and workforce issues will be provided.
• Critical care nurses will be required to take a team working approach rather than a ratio approach to patient care in order to deal with a surge in patients requiring critical care support.
• Other nurses, doctors and Allied Health Professions will be required to support the critical care workforce which will be challenging in terms of both their skills, knowledge and welfare.
• Critical care nurses will need to be supported to manage increased numbers of patients while supervising non intensive care colleagues.
• The psychological impact of a team working approach and caring for increased volumes of sick patients, many of whom will die must not be underestimated.

The Nursing and Midwifery Council recognises that:

• The NMC recognises that these unprecedented times will present challenges to nurses working in critical care. Those who will be affected include:
  • Those nurses who may not have worked in critical care settings previously and are unfamiliar with caring for patients with severe and life threatening conditions
  • Those nurses asked to provide critical care in alternative critical care settings
  • Experienced critical care nurses who are accountable for the delegation of care to less experienced colleagues
  • The NMC recognises that nurses will feel anxious about the likelihood of concerns being raised about the decisions they make, and the actions they take in these very challenging circumstances. If a concern is raised about a registered nurse we will always consider the specific facts of the case, taking into account the factors relevant to the environment in which the nurse was working. We would also take account of any relevant information about resources, guidelines or protocols in place at the time, and how these factors
    influenced their professional judgement.
  • In this context, critical care nurses should feel confident about using their professional judgement when delegating duties to colleagues, and be able to provide a rationale for their decisions. We encourage nurses who carry out delegated care and duties to work in partnership with their more experienced nursing colleagues and the wider multidisciplinary team, to ensure that risk assessments and decision making is shared and informed by relevant professional guidance, and the values and principles set out locally.

The Chief Nursing Officers of England, Scotland, Northern Ireland and Wales pledge to support:

• Staff in the development of skills and knowledge alongside their colleagues ensuring a focus on positive health and wellbeing.
• A flexible, pragmatic, staged approach to additional capacity in line with national surge escalation plans.
• An emphasis on team working rather than a ratio approach in staffing models.
• Ensuring that critical care leadership in the multi-professional teams is clear and explicit to provide support to staff .
• Staff to work outside of their normal practice area, including delivering critical
  care in non-critical care environments.
• Nurses working in different ways and in different environments ensuring that
  they are appropriately supervised and that care is delegated to them (using a
  suitable framework) by critical care specialists.
• The provision of training and consistency in work force which is a key component of any increase in capacity.
• That prior to working in the new environment rapid blended learning, simulation and direct care education are provided.
• The dependence on and support required for returning nurses, recognising that critical care and hospital wards have changed in recent years and that these nurses may have practised in a very different environment.

Royal Colleges and trade unions will:

Provide expertise with and on behalf of their memberships to inform the development and implementation of guidance.

• Ensuring professional support is paramount within the context of this emergency.
• Ensure redeployment guidance will be offered for nurses supporting the delivery of critical care.
• Support their members in health care support roles (HCSW) in critical care settings who are working in clinical practice during the emergency where appropriate.
• Health trade unions should continue to be consulted regularly at a local and national level on contingency and emergency planning, and on proposals for service reconfiguration and the temporary staff redeployment.

In conclusion

We would like to take this opportunity to reiterate our thanks and ongoing gratitude to all of you for your continuing dedication and commitment during this time, which is difficult and worrying for us all. We recognise this is an emergency situation and staff will be working under real pressure scenarios. Our goal is a return to previous operating arrangements as soon as practicable.

In a rapidly changing situation, we do not yet have all the answers but please be assured that as leaders of the nursing and midwifery community, we are committed to continuing our work together and sharing further updates with you as soon as we are able to. If you have any concerns relating to your practice in this area, we would ask you to raise them through your line manager structures in the normal way.

Ruth May | Chief Nursing Officer, England Charlotte McArdle, Chief Nursing Officer,
Northern Ireland

Jean White | Chief Nursing Officer, Wales Fiona McQueen, Chief Nursing Officer, Scotland

Andrea Sutcliffe | Chief Executive and Registrar, NMC

Dame Donna Kinnair | CEO, RCN

Sara Gorton | UNISON Colenzo Jarrett Thorpe, National officer (Health), Unite the union

Julie Platten | CC3N

Nicki Credland | British Association of Critical Care Nurses

Suman Shrestha | UK Critical Care Nursing Alliance

Andrea Baldwin | Intensive Care Society, Nurse Professional Advisory Group

Graham Brant | Co-Chair National Critical Care Network Directors’ Group