From Volume 47, Issue 7, July 2020 | Pages 565-568
During the COVID-19 pandemic, many healthcare professionals were redeployed to an environment outside of their normal day-to-day practice. Being immersed in a different environment from dentistry, in this case the Nightingale Hospital London, allowed us to reflect upon which skills we could bring and take away from an alternative workplace to enhance our profession and patient care.
At the beginning of our Dental Foundation Training year in September 2019, we were given advice on the challenges we would face as newly qualified graduates. Little did anyone know that, within a few months, we would halt routine dental treatment, experience a global pandemic that would inconceivably change the way that people around the world live and work, and be redeployed to a purpose-built hospital to assist clinicians in an Intensive Care Unit (ICU).
In March 2020, Dental Foundation Trainees and a large number of healthcare personnel from a wide range of specialties were asked to volunteer to staff the Nightingale Hospital London. Located in the ExCeL Exhibition Centre, it was planned that we would support our medical colleagues treating intensive care patients due to a new disease; COVID-19 caused by coronavirus (SARS-Cov-2) (Figure 1).1
ICU is an unusual setting for Foundation Dentists. We faced unfamiliar terminology, a wider range of care and largely obstructed oral cavities. We encountered procedures far removed from the dental setting, such as Do Not Attempt Resuscitation (DNAR) forms, last offices and intubation. It was staggering to witness a large ICU with so many critically unwell patients. For some of us it was the first time seeing a patient intubated or, sadly, pass away. After weeks of seeing the mortality count of this disease increasing, we could fully appreciate each of those figures as an individual with a life of their own.
We set out to write this paper as a group of four Foundation Dentists who worked at Nightingale. Our aim is to shed some light on our experience of redeployment during the pandemic and identify the aspects of the hospital which created a positive healthcare learning environment, which could be applied within the dental profession. Many of the aspects of this experience were related to the Dental Foundation Training Curriculum.2
The first step on our journey at Nightingale was an induction to prepare us for our new environment. We were given online modules created by Health Education England and the World Health Organization. Inductions varied considerably, largely based on the feedback from the previous cohort and continual updates regarding the coronavirus itself. Feedback is an important aspect of healthcare and can improve professional practice.3 Clinical stations were designed to mimic the hospital environment. This allowed us to acclimatize and acquire knowledge in a safe environment. As outlined by the General Dental Council's redeployment guidance, we were trained and competent to undertake this new challenge.4 We left with an overriding sense of duty and pride in making a difference in any way possible and were reminded of why we pursued a career in healthcare.
Healthcare is provided by multidisciplinary teams who depend on effective communication to guarantee patient safety and high-quality patient care.5 Teamwork was, therefore, a crucial part of the ethos of Nightingale patient care, especially as it was a new environment for many.
At Nightingale, dentists were designated Clinical Support Workers. We worked with 1–4 patients recording observations, running blood gases and emptying catheters. Our team consisted of registered nurses who were supervised by an ICU nurse. There were also general ward doctors (qualified doctors from different specialties, for example orthopaedics) and, finally, there were anaesthetists and ICU doctors.
We worked 12.5 hour shifts, two days followed by two night shifts. Full personal protective equipment (PPE) was worn on the unit, including a fit-tested mask, gown, gloves, hairnet and visor. Wearing large labels with our name and role was essential as no one had worked with one another before and faces were unrecognizable (Figure 2). The PPE and noisy environment within the ward created barriers to communication with each other and patients. Utilizing closed loop communication was essential to ensure instructions were communicated correctly to prevent mistakes. This could be beneficial in dentistry, for example when speaking with a nurse to prevent miscommunication.
A further appreciation developed of how fortunate we are as dentists to have conscious patients. All of our communication training had this prerequisite, so it was an adjustment to speak to a sedated patient. Initially, it felt embarrassing to speak aloud, but modelling from our colleagues, who managed to reduce a high blood pressure with some kind words and the squeeze of a hand, gave us the hope that each of the people we cared for may be able to hear us. It's in those moments that we could appreciate how good communication can be life-changing.
The leadership team at Nightingale ensured that we operated with a flattened hierarchy, which can reduce the likelihood of mistakes and improve communication within a team.6 In a workplace with an established hierarchy, senior members of staff may be perceived as intimidating and overlook opinions of their subordinates. The promotion of a workplace culture where individuals of a superior rank respect and value contributions of their subordinates can improve organizational performance and quality of work life for employees.7 Dental professionals equipped with better skills in leadership could benefit the general public's health and positively change the culture within the profession.8 Through witnessing the positive effects of this environment, we identified a need for dentists to receive more training on leadership to ensure implementation of a flattened hierarchy.
In healthcare there is an onus on reporting errors in individuals or systems in an attempt to avoid repeat mistakes. Unfortunately, this can mean we fail to appreciate excellent practice. Through the use of the Greatix system, we were able to identify episodes of peer-reported excellence. The correlation between positive appraisal is linked to greater staff morale through feeling valued in the workplace.9 Moving forwards, we think this system should be applied regularly within dentistry.
Nightingale promoted a blame-free culture. This created an open and friendly environment where one could call on any member of the team for help and they would oblige without hesitation. It was clear that everyone's focus was prioritizing patients' best interests. Raising concerns has been shown to reduce human error and prevent detrimental system deficiencies.10 However, more evidence suggests that, in healthcare settings, staff fail to speak up or, those who do, are ignored.11 Despite being at the heart of a pandemic, there was a good morale and a sense of community. Although there was a wide range of staff grades, from trainees to established consultants, Nightingale was a new environment with one common purpose for all: to help in the national effort to save lives (Figure 3).
Oral health was a discipline upon which we could offer guidance. We were called to the bedside of patients with oral issues that were causing concern to ward staff. These included traumatic ulcers, bleeding, mobile teeth, candidosis and bacterial biofilm. Xerostomia is common in hospital inpatients due to polypharmacy, oxygen therapy and nil by mouth.12 Those factors were relevant with our patients, often running at a negative fluid balance, intubated and on a concoction of medication and oxygen therapy. In addition to patients' risk of periodontal disease and caries, we learnt more about other factors affecting ICU oral care, such as the introduction of oral pathogens into the lower respiratory tract, and mobile teeth potentially causing airway obstruction. Oral discomfort, intra- and extra-oral trauma can be overlooked in ICU. Factors affecting this could be the inability to see intra-orally, gaps in oral health training,12 and more urgent concerns for the critically ill patient.
Providing oral care to intubated patients is important as it can reduce the risk of developing ventilator-associated pneumonia (VAP), from 24% to 18%.13 Evidence suggests that oral pathogens contribute to VAP as a result of oral secretions entering the lower respiratory tract from around the cuff of the endotracheal tube (ETT). Mechanical disruption of the plaque biofilm and oropharyngeal suction is therefore important.13,14 However, brushing a patients' teeth and keeping areas clean around an ETT is understandably daunting for most healthcare workers, and the task itself is technically difficult. We identified that this was an area where existing guidance (eg Mouth Care Matters) could be better implemented within intensive care protocol, for example through mouth care training or bedside resources,15 and encouraged by the willingness of our colleagues to work and learn together.
We were impressed with the eagerness of others to learn about mouth care. As dentists, we understand the rationale and importance of mechanical removal of plaque and teach our patients to do so on a daily basis. We found ourselves using the same mantra to educate our new colleagues. We reassured their concerns about gingival bleeding and that mobile teeth could be brushed if care was taken, informing them that improvements could be achieved by sustained brushing habits.16,17 Seeing oral health in the perspective of the body reinforced the importance of overall holistic care for the whole patient and not just their mouth. The link between oral health and many systemic diseases has been well established18,19,20 and they share modifiable risk factors. It is our duty to educate our patients and colleagues on this bidirectional relationship between physical and oral health.
After taking care of our patients, we were encouraged to look after ourselves. The ethos of holistic care extended beyond the patients in the ward, to each individual who worked there. The principles of psychological PPE taught in our training ensured that we could protect our mental health alongside our physical health. There was an onsite wellbeing centre for people to relax and de-stress, as well as staff available who were ready to listen and offer advice. This was important as many were confronted with life and death situations for the first time. Knowing that this service was available reinforced that we were not alone, and we had someone to turn to if work became overwhelming. Healthcare workers can struggle with occupational stress which can, in turn, lead to burnout, distress and deterioration in mental health,21 so the availability of these services in normal healthcare settings could be beneficial to quality of work life.
There is no doubt that the demand for healthcare is at an all-time high; both the general public and the NHS have been burdened with psychological challenges. Something that we have learnt from our time at Nightingale is that much of the resilience of an organization lies in the social bonds between staff. As we were isolating away from family, and physical connection was sparse, the connections we made during this experience helped keep morale high, despite the circumstances. During difficult times we relied on the social interaction with our new colleagues.
To conclude, Nightingale was a life-changing experience. The unpredictability of coronavirus and how it shaped hospital working environments brought together an otherwise unlikely mix of individuals and skill sets. It allowed us to unite with our fellow healthcare professionals and be reminded of what we have in common: our patients' best interests. The devotion and care which our colleagues gave to the patients truly inspired us. This reinforced why we pursued a career in healthcare and highlighted the need for self-reflection and continual development. Whether you were a consultant, nurse, porter or cleaner, each person held a vital position in ensuring care for patients and each other.
Working at Nightingale was different from our initial expectations of a Dental Foundation Training year. However, this has been a learning opportunity that links back to our Dental Foundation curriculum.2 For example, understanding the dynamics of multi-professional working, reflection and recognition of educational opportunities. We can appreciate the positive aspects of dentistry, in particular, continuity of care, developing rapport and seeing patients on a regular basis. Upon returning to practice, we will bring the lessons we learned in communication, how to implement a positive work culture and the importance of common purpose with a wider perspective of healthcare outside of dentistry.
