Coronavirus (COVID-19) delivering maternity and neonatal services through the pandemic: beyond Level Zero - guidance
Guidance for NHS Boards for the management of maternity and neonatal services in Scotland in their continued response to COVID-19 and to aid health boards with local service planning.
Annex Two – Clinical Guidance for Neonatal Nurse Staffing During COVID-19 and Beyond Level Zero
| Version control | changes | date |
|---|---|---|
| V0.1 | Initial Draft | 23/04/20 |
| V0.2 | 2nd draft S Stewart comments from deputy CNO /professional advisors | 24/04/20 |
| V1.0 | S Stewart comments from deputy chair SPENs group and professional advisors | 28/04/20 |
| V2.0 | S Stewart Amended template guidance | 29/04/20 |
| V3.0 | S Stewart updated to version 1.2 of professional judgement template | 29/04/20 |
| V3.1 | Updated in line with Beyond Level 0 guidance Aligned to maternity guidance and draft for Neonatal nurses group |
27/09/2021 |
This guidance applies during COVID-19 emergency only and should not be used when the emergency is over.
Aim
To provide clinical reference guidance to support decision making in neonatal services and remobilisation during the extreme circumstances of the COVID-19 pandemic . This professional guidance should be used in conjunction with the nationally developed professional judgment template (appendix 1) and real time staffing resource (appendix 1) to inform nursing/midwifery staffing requirements.
Driver
During the COVID-19 pandemic it is anticipated that changes will be required to service delivery or clinical models as a result of a number of factors which will vary according to specialty. These include increasing demand, reduction in staff availability due to absence, requirement to implement social distancing measures, provision of mutual aid to other health boards or provision of care in social care settings. It is therefore highly likely that current staffing models and in particular skill mix may no longer be achievable or appropriate. A planned approach to changing staffing models and skill mix is required to ensure that associated risks can be mitigated in a planned way and that the best possible care can be provided.
In order to achieve a more consistent approach to staff modelling and changes to skill mix in a planned way in neonatal nursing services this clinical guidance has been developed to support clinicians to identify where changes may be required to service and clinical models and the risk mitigating factors which should be considered during the different stages of the pandemic, taking account of the local context where the modelling is taking place.
The professional judgement staff modelling template has been developed to provide a consistent approach for clinical and workforce managers. This allowed them to quickly calculate the whole time equivalent (wte) staffing requirement based on the professional judgement of the user in line with the clinical guidance, whilst recognising variation in clinical settings and models of care. In wave two there was a recognised need for a consistent system wide approach to inform identification, recording, mitigation and escalation of risk
Clinical Guidance for Maternity and Neonatal Care During COVID-19 Pandemic and Beyond Level Zero.
The Scottish Government has issued guidance to Boards related to maternity care during the pandemic ‘Delivering Maternity and Neonatal Services: Moving Beyond Level Zero’
Guidance is available relating to clinical care provision in neonatal care from a number of sources including the Royal College of Paediatric and Child Health (RCPCH) and the British Association of Perinatal Medicine (BAPM), and has been collated by the Scottish Perinatal Network at the link below:
https://www.perinatalnetwork.scot/covid-19
Guidance on adaptations which may be required to neonatal nurse staffing is not discussed in these documents.
Nursing and Midwifery in Neonatal Services Staffing During COVID-19
Nurse staffing requirements in neonatal units in NHS Scotland are normally determined using BAPM professional guidance regarding optimal nurse staffing and the Healthcare Staffing Programme workload planning tool, as part of the common staffing method. This recognises the evidence that a higher nurse:baby ratio, especially with nurses and midwives certified as ‘Qualified in Specialty’ (QIS) in neonatal nursing care , is associated with a better outcome for babies. Professional guidance described in the BAPM Service Standards states that the minimum nurse to baby ratio should be 1:1 for babies receiving intensive care (QIS nurses only), 1:2 for high dependency care (QIS nurses either directly delivering care or supervising registered nurses) and 1:4 for special care.
Neonatal Nurse Staffing During COVID-19
As the Coronavirus pandemic is an unprecedented situation, it is recognised that it is highly likely that the availability of nursing staff who usually work in neonatal services, including QIS neonatal nurses, will reduce due to staff absence. The NHS Scotland Test and Protect contact tracing programme has had a positive impact on reducing community transmission of COVID-19 however this has resulted in high numbers of clinical staff being notified and subsequently requiring neonatal staff to isolate depleting the available workforce. As the numbers of staff isolating or absent with COVID-19 increased; this significantly reduced the staffing required for direct clinical care. This guidance was updated to included exemptions for critical staffing in July 2021. The guidance for self-isolation was further updated and can be found here.
It will therefore be necessary for nurse staffing to be altered for the duration of the pandemic to ensure staff with experience in neonatal care are utilised in the most effective way. During peak periods it is envisaged that non-neonatal care staff will be required to deliver nursing care under the supervision of experienced neonatal nurses and that skill mix of registered to unregistered staff may have to be altered.
A flexible, pragmatic and staged approach, with an emphasis on team-working rather than a ratio approach, will need to be considered in order to utilise neonatal skilled staff effectively and ensure the most effective care to vulnerable neonates.
Consideration should be given to the possibility of utilising staff from other clinical specialties. When considering deployment of staff from other areas a comprehensive risk assessment must be made to ensure that there is a whole system approach to risk assessment and that movement of staff does not have the unintended consequence of disabling other services. In order to ensure a whole-systems approach it will be necessary to prioritise access to different staff groups dependent on pressures being experienced across the system, whilst ensuring the most effective use of transferrable skills in different clinical settings.
Examples of the type of staff who may be made available are:
- Paediatric or general nurses or midwives who have recent/previous experience in neonatal care
- Paediatric nurses who have experience in paediatric critical care or high dependency care
- Registered paediatric or general nurses or midwives with no previous experience in neonatal care
- Nursery nurses, maternity care assistants and clinical support workers with previous experience in neonatal or paediatric care
- Nursery nurses, maternity care assistants and clinical support workers with no previous experience in neonatal care
- Advanced neonatal or paediatric nurse practitioners where they can be released from medical rotas.
Scenario Planning for Care Provision
A risk-assessment approach should be taken to introducing new staff groups and altering skill mix in the neonatal environment. Some scenarios are provided below for intensive, high dependency and special care categories which are intended to provide some guidance on level of risk when staffing in each stage is no longer sustainable, movement to the next stage is advised. Moving through each stage will be dependent on local availability of staff and should take account of the local context in which the service is delivered. Equally, services should revert to the previous stages as soon as local context allows, with the ultimate aim of returning to a pre-COVID-19 state. Boards may concurrently be at different stages, based on service pressure acuity, complexity of care and availability of staff.
It is also essential, when considering staffing requirements, to use the scenarios to consider the clinical leadership required to support staff working out with their normal scope of practice, and those who are supervising and delegating to them. Resources for clinical supervision and delegation can be found at the bottom of this document. These examples are intended as guidance and should be used in conjunction with local escalation policies at all times.
Neonatal Intensive Care
Standard 1:1:1 care by a QIS neonatal nurse.
Stage One: Normal Service Provision
Full range neonatal services
Staffing:
Existing substantive neonatal staff
- Maintain numbers and skill mix of registered to unregistered staff
- Care by experienced neonatal nurse or those with previous experience in neonatal intensive care/ANNPs
- Student nurses and midwives have direct or indirect supervision depending on need (recognition that students retain supernumerary status which differs from wave one)
Stage Two: Moderate Pressures with Contingencies
Staffing:
Base this on reduced skill mix, ratios will need consultation with stakeholder and guidance on nurse to level of baby i.e. critical care national guidance
Stage Three: Highest Pressures Managed Locally
Staffing:
As above
Stage Four: Corporate Escalation, The Highest Level of Risk
Staffing:
As above
Neonatal High Dependency Care for 6
Standard 1:2 care by a QIS neonatal nurse either directly delivering care or supervising registered nurses with experience in neonatal care
Stage One:
1 nurse QIS
2 nurses with experience in neonatal care
Stage Two:
1 nurse QIS
1 nurse with experience in neonatal care
1 nurse or midwife with no previous experience in neonatal care
Stage Three:
1 nurse QIS
2 nurses with no experience in neonatal care
Stage Four:
1 nurse with experience in neonatal care overseen by nurse QIS
2 nurse or midwife with no previous experience in neonatal care
Neonatal Special Care for 12 neonates
Standard: 1:4 supervised by nurse QIS
Stage One:
1 nurse with experience in neonatal care
1 nursery nurse/HCSW with experience in neonatal care
1 nurse or midwife with no previous experience in neonatal care or 1 other HCSW with experience in neonatal care
Stage Two:
1 nurse with experience in neonatal care
1 nursery nurse/HCSW with experience in neonatal care
1 nurse/midwife, nursery nurse or HCSW with no previous experience in neonatal care
Stage Three:
1 nurse with experience in neonatal care
2 nurse/midwife, nursery nurse or HCSW with no experience in neonatal care
Stage Four:
2 nursery nurses and/or HCSWs with experience in neonatal care
1 HCSW with no experience in neonatal care
Indirect supervision provided by a nurse with experience in neonatal care
Clinical Supervision and leadership
At a time of significant change, it is essential that all staff working out with their normal scope of practice have leadership, and that accountability, roles and responsibilities are clear. Clinical supervision will be particularly important at this time for all staff to support their health and wellbeing. This includes the need to ensure effective and timely clinical supervision is in place, to support staff working in new clinical areas, as part of new teams and undertaking new roles, and to support their wellbeing. Links to the some of the national resources are available below
All registered nurses and midwives can delegate tasks to others in accordance with the NMC code. Further support for decision making in relation to delegation can also be found in the decision support framework produced by the Northern Ireland Practice and Education Council which has been adopted for use in the 4 countries of the UK. This may be helpful to neonatal nurses when delegating or supervising staff who have been deployed to neonatal services as a result of COVID-19.
Applying scenarios to professional judgement decision making template
The template requires local information on numbers of patients or beds, the length of shifts, the percentage absence and the skill mix required per shift. Using professional judgement, this enables the user to calculate the minimum number of locally experienced NHS substantive staff to ensure a nurse with local knowledge and expertise per shift. This also allows for variation to the skill mix dependent on availability of staff. The ultimate aim is to clearly identify the number of staff required to provide care whilst giving consideration to a significantly altered skill mix and associated risks as the pandemic progresses.
Within the template there is step by step guidance and definitions of key terms. There are pop-up explanatory notes throughout the template. The output will highlight if there is a shortfall in the current wte, which indicates that more staff may be required, or alternatively, if there is capacity for staff to be deployed to another area.
It should be noted that the calculation does not include time for clinical leadership and management.
The professional judgement decision making template and associated guidance for use is available as a supporting document published with this guidance.
Reference / further guidance documents:
Scottish Government Information and Support on Covid-19
Perinatal Network Near Me technology
RCOG & RCM - Guidance for antenatal and postnatal services during Covid-19
SIGN - Maternal Critical Care during Covid-19
Contact
Email: Amy.Brown@gov.scot
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