Reflections on a new dawning of unconditional positive regard, collaborative practice and grit – redeploying in the NHS during the COVID-19 crisis
Lead Author – Laura Chalmers Strategic lead for Collaborative Practice and Interprofessional Learning at Robert Gordon university firstname.lastname@example.org
Julie Gillespie – Practice Education Lead – Allied Health Professions NHS Grampian email@example.com
Karen Allan – Professional Lead for Health Care Support Workers NHS Grampian firstname.lastname@example.org
In response to the COVID-19 crisis, multiple cohorts of allied health professionals and dental nurses have redeployed as healthcare support workers across a large city and remote and rural healthcare settings. In preparation for this role, training and insight into the role, the challenges of stepping out with professional role and embracing the skills of others at a time of crisis are explored. Reflecting on participants anxiety and perceptions of resilience and respect a new dawning of unconditional positive regard may be an enlightening consequence of COVI19.
Against a backdrop of the COVD-19 emerging crisis the Health Secretary for Scotland, Jeane Freeman put the NHS in Scotland on emergency footing and asked for an immediate reconfiguration of the health service to meet the challenges of COVID19 (Freeman 2020). The primary purpose: to support the provision of fundamental, yet essential care for patients in hospital settings. One of the strategies to meet the demand for care – the redeployment of dental nurses and allied health professionals into areas of need within the NHS. Redeployment has in the past been a measure to safeguard jobs – to avoid redundancy. Redeployment in the face of a global pandemic takes healthcare professionals from their area of expertise and places them in an area within the health service where the need is greater, often not within their own professional field. The added challenge for the dental nurses and allied healthcare professionals redeploying in NHS Grampian in Aberdeen and Aberdeenshire is that they are redeploying in the role of another – as a healthcare support worker (HCSW). Grampian has a wide spread remote and rural population that brings with it many unique challenges for 21st century healthcare.
The redeployment is in many cases directly into COVID-19 positive clinical areas as well as those with no COVID-19 related patients.
In collaboration with senior managers and clinical educators in the UK National Health Service (NHS), a suite of face to face training events was designed and delivered by Robert Gordon University (RGU)
Working in small groups whilst socially distancing, participants attended 5 skills stations, all essential to patient care in ward settings.:
- National Early Warning Score (NEWS) and escalation of concerns
- Bed making and laundry segregation
- Urine analysis and hand hygiene
- Basic Life Support
- Personal patient care
The sessions were delivered in RGU which opened the campus and the clinical skills centre to accommodate strict social distancing. In a period of “lockdown” and social distancing 150 dental nurses and occupational therapists, physiotherapist, dieticians, speech and language therapists and podiatrists attended the university over a 6-day programme. Rotating through the 5 skill stations in the clinical skills centre, the participants took part in every skill station. Utilising a strength-based approach: a focus on personal qualities and the inner strength of people (Zwart et.al 2015), small group teaching, robust discussions, skill acquisition and skill rehearsal has taken place. The focus was not only on the essential skills being taught: the interprofessional nature of the groups were celebrated. Innovative facilitation of all of the sessions promoted interprofessional working, collaboration in learning and focus on participants learning with, from and about one another (CAIPE 2010).
Deliberate illumination of the rich professional expertise and experience is brought to every session, enhancing not only collaboration in learning but in the approach to redeployment in a new role at a time of crisis.
The collective understanding of the expertise of one another and the appreciation that `we are all in this together` brought about a new and emerging `team` of healthcare professionals about to embark on unknown challenges. Their individual competence in their own professions is unquestioned, their competence as a redeployed HCSW is another matter. The authors would suggest that they take to the new role a wealth of healthcare knowledge and experiences that will enhance the new skills they are asked to apply in practice. Tacit knowledge of unique professional expertise does not leave a person because they are in a different role. Landry et al (2006) draw upon a concept of a knowledge-value chain where a non-linear framework maps knowledge acquisition, creation and destruction, integration and sharing/transfer, replication and protection and performance innovation. It can be argued that all of these skills will allow the redeployed professional to function at a level in a new role that the unprepared may not.
Safe and effective healthcare relies on successful teaming, whether in times of crisis or not, where teaming is considered a verb and therefore a deliberate act (Edmonson 2012). When working within one’s own profession, functioning at expert level, teaming is an essential element of the professional role and responsibility. Recognised models of organisation have emphasis on planning, detail, roles and responsibilities, budgets and are essentially predictable. The unpredictable nature of the crisis at hand though, especially for those being asked to work out with their own expert field is heightened by their sense of fear despite the function and structure of the NHS.
Stepping out of this professional role into the role of another, the expectation is that that all of their professional skills will accompany the person. Would difficulties lie in the performance of the new role and where your role sits in the team and would the unconditional positive regard follow the role or the professional? This is an area for future research.
Unconditional Positive Regard
In the cohorts of dental nurses and AHPs that the authors taught, at no time was the role of HCSW viewed as a lesser role, that it was not a professional role by the dental nurses and AHPs redeploying. What was demonstrated in the teaching sessions was an unconditional regard for the HCSW role and the crucial nature of it within the COVID-19 crisis response. The authors would suggest that in the grand scheme of modern healthcare – never before has the collaboration between practitioners, regardless of their field been as evident.
Does collaboration make for collective competence?
Collective competence however is an issue for all healthcare teams, those who are striving for collective competence and those unaware of their incompetence. Contemporary healthcare education produces individual competence in the novice expert (Boreham,2004 and Linguard 2012), so how does the novice expert learn to team? The redeploying AHPs are already expert practitioners their willingness and ability to effectively team may not be affected by their novice status.
It was clear to the educators that many of the AHPs were anxious at the start of the sessions and therefore this may inhibit their learning. This was therefore addressed early, bringing the whole cohort together at the beginning of the day. Broad discussions relating to their fears of redeployment, fears of stepping out of their professional role and into another at a time of impending and actual crisis. Participants were invited to explore their anxiety at the start of the day and their anxiety levels at the end of the day of face to face teaching.
A paper-based questionnaire was developed by the lead educators at RGU and the NHS. Likert scale questions and open text questions gathered qualitative data relating to participants anxiety in regard to the impending redeployment and on their newly acquired knowledge and understanding of essential nursing skills.
Participants self-reported their anxiety levels at the start and the end of the day as high, medium or low anxiety using Likert scale. At the start of the day 49% reported high levels of anxiety. The main concerns expressed concerned the new extended roles that may involve carrying out personal hygiene or toileting and the worry of working in a ward setting with acutely unwell patients. Many of the professionals that attended worked in out –patients’ clinics and had never been involved in intimate or personal patient care.
What emerged was the real value in each of the stations that came from the rich discussions in the groups. Individuals from different professions had open and honest conversations, shared concerns and were able to ask questions. Professions were able to share knowledge and skills that provided both practical and emotional support to each other: effectively sharing professional knowledge. Rotating through the stations they worked with 5 different educators – it was vital that the educators were consistent in the messages they were portraying. The cumulative effect of this was evident in the feedback within the comments about how re-assured they felt at the end of the training.
At the conclusion of the sessions, anxiety levels were visibly lower and the reported levels had dropped to 8% in the High category and risen to three-fold in the Low category to 62%.
When planning this training, there was a suggestion that it be delivered as on an online learning package due to the limitations of “Lockdown” and social distancing. The educators resisted this. The data from the questionnaire and feedback highlighted the value in bringing participants together working in small groups to equip them with practical skills. The role the learning has played in emotionally preparing AHPs and dental nurses for redeployment is remarkable.
“I feel I have more awareness and understanding of the role I may have to do” Dietician
“Staff reduced my concerns and increased my confidence they were all very re-assuring. Content covered was very useful, it covered content I had no idea about!” Occupational therapist
“Fear the unknown – re assured by staff teaching skills in a way that made them less scary” Podiatrist
“Being able to ask questions and not feel stupid made a world of difference” Speech and Language Therapist
“Working in small groups, relaxed and able to talk openly and not be judged” Dental Nurse
“Learning with other AHPs and learning about he role of the HCSW has been a revelation” Physiotherapist
Finding the tool in your back pocket
Anxiety in healthcare is of course not a new phenomenon although is reportedly increased as a result of COVID-19 (Shanafelt 2020) however there is potential for increased stress and anxiety both in relation to fear of contracting the virus in practice and the anxiety of how this will affect us socially and economically. The additional layer of anxiety for AHPs redeploying in a different role in response to the COVID crisis was evident both in the data collected at the sessions, and indeed on the faces of the participants at the start of each session. It was therefore appropriate to also bring the participants together at the end of the day of learning. The purpose was not only to debrief the day, gathering their thoughts and experiences but to directly address the need for them to gain some control and recognise their ability to endure, to be resilient.
The skill and knowledge level of healthcare professionals is of course an essential component of high-quality care in the NHS – with or without pandemic. A core strength in the delivery of high-quality care is resilience (Sull et al 2015) ……or grit by another name. Angela Duckworth’s (2017) view that grit can be grown from the inside out and developed due to lived experiences, reflective thinking and a desire to move forward are the cornerstones of the gritty professional. The redeploying professionals are engaging in the situation as a challenge to be met allowing an increase in ability to engage both creatively and decisively (Gonzales 2003) when turning towards the unknown.
Redeployment in the NHS for AHPs as HCSWs was not a choice, in reality: a directive. No choice was offered and for many the redeployment signalled the defiance of the most basic instinct of all – fear and self-preservation. Perhaps what kept the group moving forward and not running from the danger is not only the professionalism of the participants but the willingness to “serve”. Is this negated by fear for those who on any other day would feel the altruism of professional healthcare life. The authors would assume not. The need to serve is also felt acutely by the authors themselves, the need to feel that we were helping.
What strikes the authors is that many of the participants had never in their careers worked in a hospital, let alone is an acute clinical area in the face of pandemic and evolving crisis. Surely this is GRIT by another name.
Reinke and Baldwins (2004) work on the relationship between perceptions of leadership and the levels of trust between employees and managers resonates with the need to serve. Much of this work is based upon Greenleaf’s seminal work on servant leadership (1977) that the key to successful leadership is trust and the powerful message of service before self. The comparisons with the AHPs redeploying in crisis are there, that the trust in the NHS machine, the trust in their professional skills and the need to serve are interrelated. This is a great testament to professional leadership – to embrace the role of another leaving professional tribalism behind. There is significant evidence that professions tend to problem solve within their own professional “tribe” and that is only when taken out of the tribe will professions interprofessionally problem solve (Braithwaite et al 2016). Perhaps COVID19 is a new dawning of the unconditional positive regard required for positive team working and collaborative practice.
Vulnerability and stewardship
One of the participants in conversation with the authors discussed the “stewardship of their redeploying role” – to walk in the shoes of another healthcare worker, with the view of “handing it back once crisis has passed”. There is a distinct paucity in the literature discussing stewardship in healthcare. What is discussed is at odds with the concept of professional silos, professional tribalism (Braithwaite et al 2016) and the safety that exists in one own professional knowledge. The appreciation and positive regard for the role of the HCSW was a bright light in the response to the pandemic. Brene Browns (2018) phrase – rumbling with vulnerability – says it all. That despite fear and anxiety the vulnerability that change brings did not bring about anything other than an unconditional positive regard for the roles and responsibilities of others. This is no longer a theory of collaborative practice – it is an enlightened understanding of existing healthcare professionals. Would this have been as clear without the pandemic?
Of the dental nurses and allied health professions, occupational therapists, physiotherapists, dieticians, podiatrists and speech and language therapists, not one of the 180 particiapnts said no to redeployment or took sick leave. Despite many reservations, uncertainties and fears – they redeployed the day following the teaching sessions. Time will tell if the pandemic has dawned a new era of collaboration, collective competence and unconditional positive regard……………..the authors would like to think so!
BOREHAM,N. 2004. A theory of collective competence challenging the neo-liberal individualisation of performance at work. British Journal of Educational Studies. 52 (1) 5-17
BRAITHWAITE J, CLAY-WILLIAMS R, VECELLIO E,et al. 2016 The basis of clinical tribalism, hierarchy and stereotyping: a laboratory-controlled teamwork experiment. BMJOpen 2016 https://bmjopen.bmj.com/content/bmjopen/6/7/e012467.full.pdf Accessed 09/06/20
BROWN,B. 2018. Dare to Lead. Vermillion. London
DUCKWORTH,A, 2017. GRIT. Vermillion. London
EDMONSON.A.C 2012. How organisations learn, innovate and compete in the knowledge economy. Jossey-Bass. San-Fransisco
FREEMAN.J. 2020. NHS Scotland placed on emergency footing to deal with the Coronoviris outbreak. https://www.holyrood.com/news/view,nhs-scotland-placed-on-emergency-footing-to-deal-with-coronavirus-outbreak_15239.htm Accessed 09/06/20
GONZALES,G. 2003. Deep survival. Who lives, who dies, and why. True stories of miraculous endurance and sudden death. W.W.Norton & Company. Paulist Press. New York
GREENLEAF,R,K. 1977. Servant Leadership: A journey into the nature of legitimate power and greatness. New York
Landry R, Amara N, Pablos-Mendes A, Shademani R, Gold I: The knowledge-value chain: A conceptual framework for knowledge translation in health. B World Health Organ. 2006, 84 (8): 597-602. 10.2471/BLT.06.031724
LINGUARD,L. 2012. Rethinking competence in the context of teamwork. https://books.google.co.uk/books?hl=en&lr=&id=-AueDgAAQBAJ&oi=fnd&pg=PA42&dq=rethinking+competence+linguard&ots=jjGP1_1c1s&sig=X4S_rIiDdfpwe35vAmXPBD5Y6UU#v=onepage&q=rethinking%20competence%20linguard&f=false Accessed 27th April 202
REINKE,S,J, BALDWIN,N 2001. Is anybody listening? Performance evaluation feedback in the U.S. Airforce. Journal of Political and Military Sociology, 29 (1) 160-176
ZWART. R.,. KOTHAGAN,F,A,J., ATTEMA-NOORDEWIER,S. (2015) A strength-based approach to teacher professional development, Professional Development in Education, 41:3, 579-596, DOI: 10.1080/19415257.2014.919341
SHNAFELT,T.,RIPP,T., TROCHEL,M. 2020 Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic JAMA June 2, 2020 Volume 323, Number 21
SULL, A., HARLAND, N. & MOORE, A. Resilience of health-care workers in the UK; a cross-sectional survey. J Occupational Medicine and Toxicoogyl 10, 20 (2015). https://doi.org/10.1186/s12995-015-0061-x
Unconditional positive regard, COVID-19, Redeployment, Interprofessional, allied health professional, resilience