Nights and days at the Nightingale

Ever since the pandemic first stuck, CSP members have been directly involved in efforts to mitigate and manage the spread of the disease. 

Across the UK, physiotherapy staff have been using their skills, experience and expertise to address the coronavirus crisis and provide critical care and rehab to affected patients.

Retired physiotherapists have been re-registering to offer their support, final-year physio students have been fast-tracked into clinical posts and many members have moved into new roles and settings, to help meet an increased demand on health and care services. 

Some physio staff have also been working at the NHS Nightingale hospitals, which were set up in ten locations across the UK. 

The first of these was the London Nightingale, based at the site of the ExCeL conference centre in east London. 

The venue, which was converted in under two weeks into a fully equipped medical facility, opened with 500 beds – all equipped with ventilators and oxygen – and enough potential capacity to provide support to 4,000 patients. 

Following this, NHS England set up six more temporary hospitals – a 5,000-bed capacity facility at Birmingham’s National Exhibition Centre; a 1,000-bed hospital at Manchester’s Central Convention Complex; a 500-bed hospital at the Harrogate Convention Centre; a 300-bed facility at the University of the West of England in Bristol; a 200-bed Nightingale in Sowton, Exeter and a 460-bed hospital at a site in Washington, Tyne and Wear. Similarly, in Northern Ireland a 230 bed facility was set up in Belfast, and Wales and Scotland both opened 300 bed Covid-19 hospitals, in Cardiff and Glasgow. 

At the height of the crisis the London Nightingale had around 50 physiotherapists working in its ICU; working on a 12.5-hour shift pattern, 24 hours a day, seven days a week. 

Other physios at the site were recruited as part of the hospital’s proning teams, following the same 24/7 shift pattern, and also acting as bedside clinical support workers. 

Physiotherapists at the hospital were also in prominent leadership positions, among them chief AHP Rachael Moses, who had responsibility for the development and running of AHP services. 

She now praises the ‘massive response’ the Nightingale received from AHPs who were keen to offer their support, as they received over 400 expressions of interest in the first two weeks after the hospital opened. And more than 300 physiotherapists got in touch, all eager to be involved. 

‘They were mainly MSK physiotherapists who weren’t currently working in practice,’ Ms Moses says. 

The physios who were eventually recruited to the London Nightingale came via three main routes. Health organisations were able to nominate their physiotherapists to provide support, and this was the main route for the site’s ICU/respiratory physios. 

‘Physios were also able to independently apply through the London Workforce Hub, which was the case for many who had been furloughed or were in private practice and found they couldn’t do their normal work,’ Ms Moses explains. 

And some of the physios – who were already registered with the HCPC or were eligible for the emergency register – were among those who decided to return to practice, specifically to help combat Covid-19. 

‘We also had a range of AHPs working in roles across Nightingale hospitals in both their professional roles and also outside of their normal roles, in bedside clinical support roles,’ Ms Moses adds. 

Intensive care physios 

Prince Charles opened the London Nightingale, via a video link, on 1 April and a few days later the first Covid-19 patients were admitted. 

‘When the first patient arrived you could hear a pin drop – it felt like such a huge moment,’ says Amy Bowling, who worked as a respiratory physio at the site. 

‘It brought strangers from different backgrounds and disciplines together and we felt so much unity, as we were all working towards the same goal.’ 

Anthony Gilbert, the hospital’s deputy lead physio, was also on the unit that day. His role at the Nightingale saw him supporting the operational running of the physio team; assisting with induction, training and workforce planning, as well as working clinically. 

‘My day usually started at 7.30am when I met the outgoing night shift team and the incoming day team,’ he explains. 

‘I’d be present for handover, make notes of any points of escalation and the rest of my day would be a combination of non-clinical duties or working clinically on the ward.’ 

Mr Gilbert says he, and all the other physios working on the ICU, were required to perform a wide range of tasks. 

‘On the ward we’d don our PPE and spend up to three hours treating patients, who ranged from acutely and medically unwell ventilated patients to extubated patients on the step down unit.’ 

For ventilated patients he says the physios: ‘provided guidance and instruction on positioning, managing respiratory function, passive movements and proning as required.’ 

Whereas treating patients on the step-down unit ‘involved setting up non-invasive ventilation for those who had been extubated, providing support with secretion clearance, active range of movement and mobilising – which included active assisted rolling, sitting on the edge of the bed and standing and walking.’ 

Rebecca Smith, who worked at the hospital as a respiratory physio, says: ‘By the time patients reached us we were finding that their chests were very productive. 

‘So we did lots of manual techniques, rolling and repositioning, and saline lavage suctioning was invaluable due to a lack of humidified circuits. 

‘We also helped with proning and washing and changing patients, when we had time to.’ 

Fellow respiratory physio, Daisy Garvey, says their roles also saw them working closely with ICU nurses, to help clear chest secretions, as well as liaising with consultants about ventilated patients. 

‘We helped with respiratory weaning from the ventilators, and also rehabilitation once patients came off the ventilator,’ she explains. 

Alongside the challenge of taking on new roles the Nightingale physios also had to get used to working whilst shielding themselves, and their patients and colleagues, from the infectious nature of Covid-19. 

‘Communicating in PPE was one of the hardest challenges,’ says Aldo Russell de Boer, who worked as one of the hosptal’s proning team leads. 

‘Any messages had to be initiated with clear eye contact, slowed down and made succinct, with re-affirmations being standard practice.’ 

The physios also had to get used to new ways of working, including long hours and different shift patterns. 

‘Physiotherapy shifts tend to be 37.5 hours a week, and during the day, so working 50 hours a week, including night shifts, was quite different,’ says Ms Bowling. 

Ms Garvey agrees: ‘For me, the change to working 50 hours a week over two days and two nights was tough. And it also meant staying away from home in a hotel for five nights a week.’ 

And for some, being away from their loved ones,was one of the hardest aspects. 

The work was really tough and not seeing my partner and children was incredibly difficult,’ says Mr Gilbert. ‘But we all made sacrifices to be there.

Innovation and learning  

Due to the unprecedented timescale in which the London Nightingale was established, Mr Russell de Boer says the induction he and his colleagues received was ‘understandably put together in a short space of time – but reassuringly it included many elements that were familiar for any healthcare setting, such as the importance of communication, team working and escalating concerns.’ 

He was also impressed by the fact that the teaching faculty updated their training methods in real-time, adapting it for the following day’s cohort in response to attendees’ feedback. 

‘And an important area that was drawn upon from many of our colleagues was the importance of our undergraduate experiences, student placements and the training received as a junior. 

‘Those experiences provided core skills that clearly prepared us well and were readily transferable to the Nightingale environment.’ 

Michael Barker, physiotherapy team lead at the hospital, says one of the things he loved about working at the Nightingale was the innovative learning culture it established. 

He explains that the hospital became the first NHS service to have a bedside learning coordinator (a brand new role in the NHS) who fed back daily learning from all the professionals to the quality and learning team. 

‘And the quality and learning team then also referenced external “sources of truth” and relayed these collective learning points to the clinical teams on a daily basis,’ he says. 

‘It was truly amazing and a system from which many NHS trusts and private sector providers could benefit.’ 

Adding to this, he says, the wide range of professions worked incredibly well together due to a shared sense of equality and respect. 

‘There was a flat hierarchy at the Nightingale,’ he explains. ‘And this allowed the physio voice to be heard at board level as well at the bedside.’ 

Ms Bowling feels this approach led to safer and more effective care for patients. ‘One of the things I would love to see across the NHS is the lack of hierarchy and the openness that we had at the Nightingale,’ she says. 

‘For instance, a particular highlight for me, was going to one of the ops meetings and explaining a little bit about how we treat patients on the unit, and what a good day looks like for us. 

‘It was nice to know that the management team had a good grasp of what we do as a profession, and to see how much other professions respect physiotherapy and our role within the ICU setting – and it was great to gain an insight into what other roles involve, such as the operating department practitioners.’ 

All of the professions involved also benefited from a ‘continual opportunity to learn from each other’, says Michael Douthwaite, who worked as a clinical lead physio at the hospital. 

‘The hospital had such a ‘can do’ attitude, which was inspiring for everyone and promoted an incredibly positive working environment,’ he explains. 

‘We faced some difficult clinical experiences along the way, but it was fantastic the way everyone pulled together to support each other, both professionally and personally.’ 

Ms Smith agrees. She found that the Nightingale fostered a dynamic culture of openness, which promoted shared learning and smoothed operational procedures. 

‘No question ever felt stupid – because everyone was out of their comfort zones, so you weren’t automatically expected to know an answer,’ she says. 

‘I had the opportunity to ask doctors, nurses, ODPs and clinical scientists loads of questions and in return I had lots of staff asking me about what we do. 

‘We also attended daily ward rounds and openly discussed ideas with all members of the MDT, and we provided some teaching with the nurses that didn’t usually work on ITU, who gave us great feedback.’ 

On ‘stand-by’ but ready to reopen  

In May, the London Nightingale was put on a ‘stand-by’ status, after the capital’s other hospitals expanded their ICU capacity and the number of severely affected patients proved, thankfully, to be less than the original, worst-case forecasts had projected. 

However, the hospital remains prepared and ready to reopen, in the event of a second surge of the virus and, should this happen, many of the physios who initially worked there would possibly return. 

Since the hospital went on ‘stand-by’ Ms Garvey, and many of her colleagues, have been dismayed at how their work and the purpose of the first Nightingale Hospital has been portrayed. 

‘I’ve felt frustrated by media and friends saying it was a failure that all the beds weren’t needed,’ she says. 

‘When in actual fact it would have been terrifying if London had needed to ventilate 4,000 people, so it’s a relief that all the beds weren’t needed. 

‘One day, while on the ward, I took a moment of reflection and looked down at all the rows of ward spaces, and I imagined it full of patients, and it gave me goosebumps…I felt so pleased it wasn’t needed to that extent!’ 

Mr Russell de Boer agrees. ‘I expect that with hindsight the scale of the Nightingale may be challenged from an economic view point in certain areas of the media and political forums,’ he says. 

‘But I hope those discussions don’t overshadow what was achieved in such an incredible short space of time, the challenges many of the staff undertook, and the lives that were saved there.’ 

Ms Bowling adds that she also noticed misconceptions in the media about the ‘factory like’ care patients were received at the hospital – which was ‘so different from what we saw on the ward’. 

‘We were very fortunate to have a team of medical professionals who had the sole focus of communicating with patients, friends and family, giving them regular updates and passing their messages onto us,’ she explains. 

‘And we treated every patient as an individual and had photos, information about their usual lifestyle and letters around their bedside. 

It doesn’t matter if a hospital had 4,000 patients or 40 patients, our job as physios remains the same – to holistically treat the person in front of us as well as we possibly can.

And, she adds, in uncertain times and in an ever changing climate, that’s what physiotherapists are continuing to do ‘by putting patients at the heart of everything we do.’ 

• Robert Millett