Lack of Preparedness

Despite the strengths, the findings suggest that nursing in the UK has been facing serious challenges that started before the outbreak of the ongoing COVID-19 pandemic. Healthcare organisations’ lack of response increased the magnitude and intensity of nursing staff problems. For example, the Royal College of Nursing estimates that pre-COVID-19, there were 50000 registered nurse vacancies across the UK. ¹⁴ This indicates that even before the disruptive impact of COVID-19, nurses were working in difficult conditions, which aggravated the situation and increased vulnerability. The impact of the COVID-19 pandemic on the UK healthcare workforce is yet to be fully realized; however, there is an ever-increasing body of evidence that suggests nurses are susceptible to increased levels of stress and anxiety while working through the pandemic. ^{Reference Greenberg, Weston, Hall, Caulfield, Williamson and Kong15,Reference Labrague16} Worryingly, nurses’ susceptibility seems to be higher than other healthcare professionals, ^{Reference Greenberg, Weston, Hall, Caulfield, Williamson and Kong15,Reference Shechter, Diaz and Moise17} which might be attributed to the fact that they spend more time delivering direct patient care and in the absence of patients’ own support networks, are vulnerable to vicarious trauma as they adopt direct social or emotional support roles for their patients.

Redeployment, a critical workforce strategy during the COVID-19 pandemic, has caused additional occupational related stress for many nurses. This study revealed that nurses redeployed during COVID-19, suffered high levels of stress and anxiety, and felt unsupported and abandoned during their redeployment. Such findings are in line with others on the subject such as Shanafelt et al. ^{Reference Shanafelt, Ripp and Trockel18} In previous studies, evidence has demonstrated that the fear of being redeployed to an unfamiliar environment may be greater than the fear of any pandemic pathogen. ^{Reference Considine, Shaban and Patrick19} This is problematic. Maslow’s hierarchy of needs outlines a fundamental requirement of safety and belonging; only once these are met will nurses be in a position to experience esteem and feeling of self-fulfillment which in turn will motivate them. If these needs are consistently not met, there is likely to be burnout and feelings of self-depletion, with an associated negative impact on nurses’ abilities to fulfil their role.

Healthcare organizations’ disaster-preparedness need to be revised urgently to take into account the impact of day-to-day operations on the overall resilience of the service and ensure that healthcare workforce is at the core of any preparedness. Achour et al. ^{Reference Achour, Munokaran, Barker and Soetanto20} argued that stress and burnout are ‘the sleeping cell for healthcare failure,’ indicating that this problem has been existing for a few years before COVID-19. Healthcare organisations need to ensure that there are key indicators to measure staff resilience supported by policies and regulations for enforcement.

Empowering Nursing Staff

Despite high levels of stress and anxiety, this study demonstrated the presence of a flexible workforce which supports the ongoing use of redeployment in disaster medicine. This is not an uncommon phenomenon. A professional duty of care combined with altruism, often results in a nursing workforce willing to attend to patients despite their own mental health concerns. ^{Reference McMullan, Brown and O’Sullivan21,Reference Pincha Baduge, Morphet and Moss22} The question must be, at what cost? Research suggests the relevant issue is not about the willingness of staff to attend to major emergencies such as COVID-19, but their ability to respond to events like this without suffering physically and mentally as a consequence of their attendance. ²³ In their guidance for staff being redeployed during COVID-19, the Royal College of Nursing refers explicitly to the potential for positive professional opportunities redeployment might provide. ^{Reference Sull, Harland and Moore24} Despite the documented challenges of redeployment, a group of nurses in this study were able to describe positive outcomes and benefits of their experience. This can be extrapolated to positive effects of career development through broadening of experience and knowledge.

Positivity about redeployment was associated with increased years as a registered nurse. It is worth noting this group still reported feeling stressed and anxious, but it might be assumed they had higher levels of resilience therefore enabling them to manage their stress, accommodate, and recover from the change to their working practices. This observation is corroborated by other studies such as Sull, et al., ^{Reference Sull, Harland and Moore24} who suggested that resilience in nursing increases with age and banding. Further evidence from the COVID-19 pandemic suggests older nurses experienced less stress levels, ¹⁴ and younger, less experienced nurses experienced increased stress levels. ^{Reference Roberts, McAloney-Kocaman, Lippiett, Ray, Welch and Kelly25}

Moving forward, might it be argued that profiling should be used to redeploy those nurses deemed more resilient? It is not a prospect widely supported. There are concerns about highlighting resilience in certain groups of staff as a beneficial characteristic. An over emphasis on nurses being ‘resilient’ is challenged by nurses and nurse academics. ^{Reference Traynor26} There is the potential that treating resilience as an individual’s trait could lead to a lack of organizational responsibility. The critical question is, how should nursing staff be supported so that a successful redeployment does not rely on an individual’s inherent resilience? How may redeployment be recognized as an opportunity instead of a source of stress and anxiety with potentially detrimental effects on staff and by association, patients? Both are relevant questions when asked in the context of an NHS organisation that relied on the movement of nursing staff between wards pre-pandemic due to staff shortages as well as during COVID-19. Both are also questions that might be answered with structured and visible leadership indicating the organizational commitment towards nursing staff resilience and empowerment.

Nursing leaders need to recognise that they have the power to influence the work environment, ^{Reference Wei, Sewell, Woody and Rose27} and step up to support staff wellbeing. Consistently, studies of members of the armed forces demonstrate that vertical team cohesion between leaders and their teams is highly correlated with positive mental health. ^{Reference Jones, Seddon, Fear, McAllister, Wessely and Greenberg28} There is evidence that during the COVID-19 pandemic, support and care from leaders has benefitted healthcare workers. ^{Reference Que, Shi and Deng29} In contrast, the results of this study illustrate a group of staff who were deficient of leadership, their concerns related to poor communication and lack of engagement from leaders, and an associated sense of abandonment. The logical question to ask therefore is if more effective leadership would have prevented this group of nurses feeling so stressed and anxious about their redeployment. There is an indication for the use of the Transformational Leadership model which is closely associated with high levels of staff engagement, empowerment, and retention. Such results are obtained through a combination of effective communication, visibility, and accessibility. ^{Reference Prado-Inzerillo, Clavelle and Fitzpatrick30} Crucially, these are 3 key factors that the redeployed staff in this study were calling out for. In order to develop a more resilient healthcare service, healthcare organizations are required to commit to more effective leadership, to empower actions, and help nursing staff develop a more attractive work environment. Nursing workforce demonstrated that they consider redeployment as a professional and moral requirement and even as an opportunity for development; however, the lack of organizational commitments and support is what makes them less motivated, anxious, and incapable to be redeployed.

Communication

Findings established that participating nurses have a strong aversion to the autocratic process they experienced. There is an argument for formal, early pre-pandemic engagement with staff by leaders to ensure that staff members are cognizant of the fact that cancellation of elective procedures and associated redeployment of staff is a recognized pandemic workforce strategy. Engagement with pandemic preparedness strategy would have meant that staff would know redeployment was likely, feel more prepared, and less affronted, at the instruction to redeploy at short notice. Such strategies are reflective of conclusions of previous studies where ‘self-choice’ around working in a pandemic situation was advocated with ongoing involvement in pandemic planning. ^{Reference Ehrenstein, Hanses and Salzberger31,Reference Shabanowitz and Reardon32} Healthcare organisations need to consider communication between redeployed nursing staff and line management as early as possible to allow for more training and education to offset some of the concerns nurses felt at working in unfamiliar areas with unfamiliar patient groups and associated equipment. Having an early communication will also allow staff to manage their personal lives more carefully and appropriately. Personal circumstances (e.g., childcare) are a key factor for the continuity of healthcare service, yet they tend to be overlooked by healthcare organisations. ^{Reference Achour and Miyajima33,Reference Achour, Elhaj and Ali34}

Leadership

Findings suggest that there is a sense of mistrust in leaders who were perceived to be far from the frontline and not engaging with redeployed staff. Staff members were seeking visibility and a sense that those making decisions understood the issues they were facing on their redeployed placement. The absence of effective leadership during disaster response generates a negative environment where nurses feel less supported formally and search for alternative forms of support. Findings established that while participants clearly felt the pressures of their redeployment, few accessed formal support services, despite the majority of staff declaring they knew where to access such support. Does this mean that things were not as bad as they describe? Not necessarily; nurses were electing to rely on informal peer support offered by colleagues, line managers, friends, and family. The use of peer or social support in nursing is not unusual. ^{Reference Greenberg, Weston, Hall, Caulfield, Williamson and Kong15,Reference Liu and Aungsuroch35} Is it possible that redeployed staff were put off the formal support services, believing that they had been put in place by people who were not visible to them and as such are unlikely to understand what they need? If so, such attitudes could compound an existing issue found in team driven professions such as nursing, where those injured by stress from their work and in need of support may be reluctant to seek it out, due to concerns about stigma. ^{Reference Watson, Brymer and Bonanno36} Support services are required where the onus is not on the individual to actively seek out help, for example, break out areas to encourage peer to peer support.

While it is clear that redeployed nurses in this study felt they needed more support from their leaders, the challenging context in which this redeployment was set cannot be negated. Those tasked with making and implementing difficult decisions regarding staffing may argue there was little time for long discussions and negotiations. Furthermore, the social distancing precautions demanded by COVID-19 prevented any formal gatherings or meetings of redeployed staff which would be the natural starting point when developing a new workforce team. In response, it can be argued that face to face meetings are not the only tool to providing visible, accessible leadership. There is a need to provide sustainable accessibility to leadership through formal redeployment guidance and policy, combined with active visibility of nursing leaders. Theories of leadership draw a fine line between management and leadership, what can be learned here is that leadership is not well understood by ‘leaders’ which makes them more ‘managers’ than ‘leaders’ and thus their focus is on getting things done more than supporting people to do things.