Healthcare Quarterly

Healthcare Quarterly 24(2) July 2021 : 27-32.doi:10.12927/hcq.2021.26550
Responding to the COVID-19 Pandemic

Health Professional Redeployment and Cross-Training in Response to the COVID-19 Pandemic

Lisa A.S. Walker, Amanda J. Pontefract and Debra A. Bournes

Abstract

The onset of the COVID-19 pandemic in March 2020 required hospitals to respond quickly and effectively to ensure the availability of healthcare professionals to care for patients. The Ottawa Hospital in Ottawa, ON, used a five-step process to ensure organizational readiness for redeployment of regulated health professionals as and when necessary: (1) define current scopes of practice; (2) obtain discipline-specific input; (3) develop strategies based on literature review and government dictates; (4) identify potential duties; and (5) ensure support for staff. With hospital management support, this plan was readily implemented. Results are discussed in terms of operational outcomes (e.g., number and type of deployments) and staff experience. Outcomes were positive and led to recommendations for improved organizational readiness.

Introduction

The impact of the global COVID-19 pandemic began to be felt in Canada in early 2020. Given reports of hospitals in other jurisdictions (i.e., Lombardy, Italy; New York, New York), a valid concern arose regarding the potential for Canadian hospitals to reach surge capacity. The experience of these other jurisdictions also raised concerns about the potential effects of the pandemic on healthcare workers and the resulting strain on the healthcare system as a whole. These concerns were the impetus for strategic planning to allow health professionals to take on alternate roles within the organization if necessitated by the situation. This paper describes the process used to establish guidelines regarding the redeployment and cross-training of regulated health professionals at an academic health science centre in response to the COVID-19 pandemic, ensuring that staff members felt competent and safe to perform their duties in their new role(s).

Background

Before the onset of the COVID-19 pandemic in March 2020, there was scant research literature regarding the ways in which health professionals (other than nurses and physicians) might contribute to supporting patient care in the event of a surge in patient volumes and/or staffing challenges. The research literature that focuses on pandemic or surge capacity medicine, in general, states that a successful response to such situations demands that roles be well defined, staff work in an integrated way with systems already in place and staff be cross-trained to take on functional roles outside their typical scope of practice (Einav et al. 2014). Such situations require staffing needs to be met in a flexible way so that those with adaptable skill sets are available to perform other roles if required.

To facilitate flexibility and adaptability, the Ontario government announced an emergency order (Government of Ontario 1990a) allowing health service providers (as defined by the Public Hospitals Act [1990] or the Mental Health Act [1990]) to override collective agreement obligations to allow them to respond to the COVID-19 crisis. The emergency order outlined provisions to allow the following: redeploying staff to different locations in (or between) facilities of the hospital or to COVID-19 assessment centres; changing work assignments, schedules or shift assignments; deferring or cancelling vacations; employing part-time or temporary staff; using volunteers to perform work; and providing training/education to staff in order to carry out the redeployment plan. Ontario Regulation 16/21 also allowed for the redeployment of healthcare providers to retirement homes and long-term care homes given the burden of the pandemic on patients and staff in these facilities (Reopening Ontario [A Flexible Response to COVID-19] Act, 2020). The Ottawa Hospital (TOH) immediately launched an interdisciplinary response to set up COVID-19 assessment centres and to ensure that the organization was ready to manage pandemic-related surges in patient volumes and/or staffing challenges.

To ensure adequate capacity for a potential influx of patients during the first phase of the pandemic, TOH established COVID-19 cohort units and readied teams to support surges in intensive care units. In addition to closing non-essential outpatient and surgical services and using virtual care to minimize exposure or transmission, the organization immediately began determining how staffing resources could be optimized across disciplines and health professions. The response of our nursing colleagues is outlined in a companion article in Nursing Leadership (Montoya et al. 2020). A parallel initiative was initiated by TOH health professionals, the process of which is described in this paper. To ensure that we were able to respond optimally to the pandemic, it was necessary to keep our workforce healthy and ensure that sufficient personnel were cross-trained to allow them to perform functions critical to the organization in the event of staffing shortages (Rosenbluth 2010). This paper outlines our response during the first phase of the pandemic, which began in March 2020. Although the data reported in the current paper refer to our response between March and December 2020, this early planning has allowed us to continue to respond as needed as the pandemic has progressed. It became particularly important in the third phase (April 2021) when deployment of health professionals and implementation of collaborative care teams in acute care became a critical pandemic management tool.

Objective

The objective of this initiative was to establish guidelines regarding the redeployment and cross-training of regulated health professionals at an academic health science centre in response to the COVID-19 pandemic, ensuring that staff members felt competent and safe to perform their duties in their new role(s).

Development of the Cross-Training Plan

The development of a cross-training plan included five steps (Figure 1). First, we defined the current scope of practice for all healthcare professions. Second, regulatory colleges governing each healthcare profession were contacted to determine if there were any discipline-specific dictates. Third, a strategy for redeployment was developed based on a literature review, government dictates and adherence to the collaborative care team model (Montoya et al. 2020) already established at TOH. Fourth, potential roles were defined and trainers were identified. Fifth, a staff support strategy was established to ensure that the emotional needs of healthcare professionals were met in order to ensure staff wellness and resiliency. Each step is discussed in more detail in the following sections.


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Step 1: Define current scopes of practice

The professions at TOH included in this review are psychology, occupational therapy, physiotherapy, speech-language pathology, dietetics, audiology, respiratory therapy, pharmacy, spiritual care (comprising members of the College of Registered Psychotherapists of Ontario) and social work. Each regulated health profession in Ontario must adhere to the guidelines of both the Regulated Health Professions Act, 1991 and the acts governing their own discipline. Social work is regulated only by the Social Work and Social Service Work Act, 1998. Each of these professions is permitted to engage in specific controlled acts; an exception applies to speech-language pathologists who may have a delegated act. These duties can only be completed by those authorized to do so and, thus, cannot be performed by an unauthorized health professional who has been redeployed. As such, an important first step was to determine which acts were unique to each profession and what roles the members of each profession currently have within the organization. Notably, at TOH, the controlled act of psychotherapy is shared by several professions, including psychology, social work, spiritual care and occupational therapy. Both occupational therapists and social workers may be permitted to practise the controlled act of psychotherapy if, by self-assessment, they meet the minimum required standards as outlined by their respective colleges (College of Occupational Therapists of Ontario 2018; Ontario College of Social Workers and Social Service Workers 2009). Other examples of controlled acts include the following: communicating a diagnosis (psychology); communicating a diagnosis identifying a disease, a physical disorder or dysfunction as the cause of a person's symptoms (physiotherapy); performing various physical procedures (e.g., treating a wound below the dermis, physiotherapy); pricking the skin for blood sampling (dietetics); prescribing a hearing aid (audiology); performing various procedures such as intubation, suctioning or administering a substance (respiratory therapy); or dispensing, administering or prescribing drugs (pharmacy).

Step 2: Obtain discipline-specific input

Information was sought from each of the relevant Ontario regulatory colleges to seek their direction on which tasks their members could and could not perform during the pandemic. All colleges were sympathetic to the demands on the healthcare system resulting from the pandemic and were open to redeployment. The common theme in the responses received was that members cannot perform the controlled acts of another discipline but, as employees of the hospital, can be directed to perform other tasks. It was also commonly emphasized that by self-assessment, members must feel safe performing those tasks and believe that they have sufficient training.

Step 3: Develop a strategy based on literature review and government dictates

A review of relevant research literature was performed, although information on redeployment in a pandemic or other emergency situation was scant. The Canadian government provided some guidance based on potential influenza pandemics (Government of Canada 2004). The common theme throughout this literature and government guidance was that redefining the scope of practice is reasonable in the context of a pandemic. In addition, it was recommended that redeployment of personnel should be directed by a triage and scarce resource allocation team, or equivalent (Kuschner et al. 2007), to manage any resulting ethical challenges with regard to provision of care. At TOH, a leadership team that included health professionals collaborated with the pandemic deployment coordinator to identify a redeployment strategy for the health professions that were prepared to make rapid and potentially difficult decisions. Other leadership groups were responsible for parallel planning for nurse and physician staffing concerns.

The literature review provided little information specific to the roles of health professionals in a pandemic. Instead, most of the literature focused on nurse and physician roles. Nonetheless, guidance provided by the literature suggested that health profession leadership and in-patient unit managers should collaborate to identify which tasks were critical. Employees who possessed similar and applicable skill sets could then be identified. The literature recommended the training method of "train the trainer" in an "on-the-job" format when possible (Rosenbluth 2010).

In addition to the decisions made about staff redeployment at an organizational level, as suggested by the literature, decisions also occurred at an in-patient unit level. Health professionals were prepared to enter a collaborative care team model (CCTM) (Adams et al 2015) in conjunction with our nursing colleagues to ensure that the needs of individual patients could be adequately met. In this model, an experienced registered nurse (RN) with expert clinical skills and knowledge was accountable for a specific group of patients. When patient–nurse ratios were increasing beyond a manageable workload, nurses and health professionals from other clinical areas were redeployed to assist. The RN was designated as the collaborative care leader and became accountable for providing and coordinating care for a specific patient assignment via these additional staff. Collaborative care teams were created based on available staff; their experience and skills; patient volume and acuity; and the potential impact of anticipated admissions, discharges or other changes (e.g., COVID-19 outbreaks affecting large numbers of staff). A more detailed description of the CCTM, including the establishment of a new clinical care assistant role for senior nursing students (Adams et al. 2015), can be found in the companion article (Montoya et al. 2020).

Step 4: Identify potential duties

The next step of the development plan was to list potential duties that could be carried out by members of a profession. Representatives from each profession provided input and identified potential trainers for the duties indicated. The committee acknowledged that the implementation of the training would be different depending on the tasks and personnel required. Please see Table 1 for a list of potential roles and the associated trainers (available online here).

Step 5: Ensure support for staff

A key recommendation gleaned from the literature and our own experience at TOH was to include a staff support strategy. The emotional toll on front-line workers during a pandemic is substantial and must be considered in order to ensure a resilient workforce (Heath et al. 2020). This is particularly relevant given the impact of the pandemic and the uncertainty regarding its duration. Messaging about self-care and mental health resources was present across several levels of our organization, including daily e-mail communications from senior leadership during the early days of the pandemic and regular check-ins by health profession leadership and unit managers. Seeking help to cope with the unprecedented situation was normalized, and the importance of self-care was repeatedly and regularly emphasized. Staff were informed of the normal responses to extraordinary stress so that they could differentiate those from more maladaptive responses that might require the services of a mental health professional. Staff were provided with readily available resources both in-house (employee wellness program and a support line run by the Psychology department) and in the community (e.g., Canadian Psychological Association–listed psychologists who have volunteered to provide free psychological services to front-line healthcare providers).

Deployment Outcomes

Operational outcomes

Discipline leaders identified staff to be deployed. Staff were selected for deployment based on service closures (e.g., closed outpatient clinics), and staff members who volunteered for deployment were prioritized. Approximately 30 health professions' staff members were redeployed. This represents approximately 5% of the total number of regulated health professionals at TOH (excluding respiratory therapists). The number is approximate, given that some staff members work on multiple services and, thus, there may have been some duplication in the reported numbers. Our organization had no prior expectations about how many staff members would be deployed given the unique situation. Notably, the number of health professionals deployed was low, given that most deployed staff members were from our population of nursing colleagues as well as the student nurses recruited to serve as student nurse orderlies and clinical care assistants (Montoya et al. 2020). Their skill set was needed given that the redeployed roles were largely for patient assessment in the COVID-19 screening centre and in long-term care homes providing nursing care or related supervision.

Healthcare professionals assisted in the pandemic response by performing different duties than usual, both inside and outside their typical scope of practice. Example roles that redeployed health professions' staff undertook included a COVID-19 symptom screener (both at front entrances to the hospital and in-patient units), a liaison between staff on COVID-19 units and non-COVID-19 units and a personal support worker at long-term care homes. In addition, healthcare providers from some professions were asked to perform new roles within their scope of practice to assist in the organization's pandemic response. The following are examples from spiritual care, psychology and social work.

Spiritual care practitioners

Spiritual care practitioners launched a telephone hotline serving residents in long-term care homes and their families who did not have their own spiritual care services. Although spiritual care practitioners were providing services reflective of their usual roles, the format was new, and the recipients were outside our organization. What was reported as being particularly valuable about this service was the provision of information and ideas about how rituals surrounding death and grief could be adapted to conform to government dictates regarding physical distancing.

Psychologists

Psychologists introduced and have continued to operate an in-house staff support line. Staff using the service are informed at the start of each call that what is offered is not psychotherapy. Instead, we are offering support during the pandemic to our fellow healthcare workers based on a peer support model. Staff who are looking for psychotherapy or other interventions are provided with information on other resources.

Social workers

Social workers prepared for a command centre response to address discharge planning should in-patient social workers be off work because of having to isolate at home or take on additional child-care responsibilities. They also conducted staff wellness checks, hosted peer support meetings and provided virtual support to admitted patients.

Leadership and staff experience

Profession leaders were asked if they would do anything differently in the event of future requirements for surge capacity. It was suggested that staff members who had been deployed in previous stages of the pandemic be made available to train future deployed staff both in terms of providing training as well as helping to emotionally prepare them for the experience. Leaders also mentioned the possibility of decreasing staffing requirements in ambulatory care areas where patient volumes were drastically decreased to ensure adequate in-patient capacity. In general, leadership is now better prepared to implement earlier deployments or other service-related changes in response to successive waves of the COVID-19 pandemic.

Staff members who were deployed were asked to rate their level of confidence in their new role on a scale from 1 (not confident) to 5 (completely confident). The mean value of the responses was 3.5. The majority felt that the training they received was adequate for them to be confident to perform in their new role. One staff member noted that confidence increased as time passed, given that changes were implemented to assist redeployed staff as needs became clearer. Staff members were also asked to rate their satisfaction with their deployment experience on a scale from 1 (completely dissatisfied) to 5 (completely satisfied). The mean value of the responses was 3.8. When asked if they would recommend their deployment experience to colleagues, 75% of respondents replied with a "Yes."

When asked to provide any additional comments about their deployment experience, one deployed employee suggested that staff were not used to their full potential given that audiologists at other organizations were authorized and trained to perform COVID-19 testing (swabbing), and it was felt that this would have been a helpful role at TOH as well. There was also a comment about a lack of clear guidelines regarding the tracking of hours in deployed roles to ensure eligibility for the government pay supplement. Communication challenges were also identified.

Discussion

A review of outcomes revealed that a small proportion of TOH health professionals were redeployed. This suggests that redeployment was generally not required for high-priority care needs. Instead, professionals were able to focus on the provision of regular duties. Notably, in response to the directive to reduce face-to-face patient contact when possible, some disciplines changed the way their standard services were delivered. For example, aside from assessments that continued with in-person delivery, psychologists were able to use technology and continue to provide psychotherapy and treatment interventions via virtual platforms. This was in keeping with guidance from the College of Psychologists of Ontario designed to minimize the transmission of the virus. It was made possible by the foresight of hospital administrators in ensuring that staff members were provided with laptops and appropriate software so that services could be delivered remotely. Similarly, the same technology options allowed social workers who were isolated (due to infection control requirements) to provide remote support to patients and families as well as their colleagues in other units. It also allowed spiritual care providers to expand their services to those outside the organization in the long-term care sector (a population in great need of such services during the pandemic). Thus, even the employees who were not redeployed were able to find alternative roles to contribute to the pandemic response.

The health professionals who were redeployed were primarily required to act as front-door or unit screeners. While a select few were sent to long-term care homes to provide personal support services, this was generally a placement that was delegated to our nursing colleagues who volunteered for these positions in large numbers. The training provided to the deployed personnel came from a variety of sources but was largely informal and offered by supervisors or peers with the appropriate skills sets. Some written training documents were made available via PowerPoint presentations, but the level of skill required for the deployed positions was not high enough to warrant intensive training. Generally, employees felt adequately trained to perform their new duties. Suggestions from deployed employees to improve the process for future deployments included clearer instructions regarding tracking of hours to determine eligibility for government wage supplements.

There were no adverse events reported beyond front-door screeners having to deal with some discourteous staff members. While this behaviour remains unacceptable and was condemned by the organization in communications to staff, wherein the need for kindness and compassion was emphasized, it can likely be attributed at least in part to a high degree of stress experienced by the healthcare providers during the pandemic (Heath et al. 2020). Fortunately, there were no cases of COVID-19 transmission to redeployed health professionals.

Recommendations for the Future

As a result of the redeployment process for health professionals, it is recommended that organizations develop a sustainability and readiness plan to ensure a quicker and more efficient response to future situations involving surge capacity. At TOH, we used the redeployment plan developed to help manage care needs in acute care in the third wave of the COVID-19 pandemic (April 2021). We will also be incorporating such a plan into standard practice so that we can maintain a high level of readiness moving into the future. Based on our experience, we plan to use our Professional Advisory Committee – an interdisciplinary committee with representation from the relevant health professions and senior management leadership – to perform annual reviews to ensure that the current redeployment and cross-training model remains appropriate. These reviews will involve checking for any changes to legislation regarding controlled acts as well as incorporating new information or new hospital procedures. Consultations with other similar organizations can also be incorporated into the review process given the feedback that health professionals were used effectively in additional roles in other organizations. A formal document will remain on file and be available to hospital leadership to ensure ease of implementation in future instances of surge capacity.

About the Author(s)

Lisa A.S. Walker, PhD, C. Psych, is a clinical neuropsychologist whose clinical role includes providing neuropsychological assessment on a consultation neuropsychology service at The Ottawa Hospital. She is an assistant professor of Medicine and an adjunct professor of Psychology at the University of Ottawa and an adjunct research professor of both Psychology and Cognitive Science at Carleton University. She is also a co-lead of the Multiple Sclerosis Research Group with the University of Ottawa Brain and Mind Research Institute in Ottawa, ON. She can be contacted at lwalker@toh.ca

Amanda J. Pontefract, PhD, C. Psych, is a clinical, health and rehabilitation psychologist and psychology profession leader at The Ottawa Hospital. She has an academic appointment as a clinical professor in the School of Psychology, University of Ottawa in Ottawa, ON. She is on the Executive of the Psychologists in Hospitals and Health Centres section and a member of the Professional Affairs Committee of the Canadian Psychological Association.

Debra A. Bournes, RN, PhD, was a chief nursing executive and vice president at Regional Cancer Care, The Ottawa Hospital, and regional vice president of the Champlain Cancer Program, Ontario Health (Cancer Care Ontario) in Ottawa, ON, at the time this article was written. Debra is a doctoral-level nurse who was on the Senior Management Team at The Ottawa Hospital and the Provincial Leadership Team of Ontario Health for cancer care in Ontario. She is the former chief nursing officer with Ontario's Ministry of Health and Long-Term Care. Her work has been cited as a promising practice by the Canadian Health Services Research Foundation and named as national best practice by the Canadian Council on Health Services Accreditation.

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