What will the ‘new normal’ look like for nursing?

COVID-19 is going to be with us for a while – as are some of the related changes to care

COVID-19 is going to be with us for a while – as are some of the changes to care introduced during the pandemic

  • The COVID-19 pandemic prompted a huge reorganisation of services, with new wards set up, remote consultations put in place and nurses redeployed
  • As the number of COVID-19 cases begins to fall, the need to prevent infections remains, and services are beginning to build their ‘new normal’ as people who have been staying away from the NHS start to return
  • We hear from nurses working in emergency care, cancer care, community nursing and mental health on how they are rebuilding services and coping with the backlog of appointments
Personal protective equipment is still a necessity Picture: Shutterstock

The pandemic prompted a huge reorganisation of health services

The COVID-19 pandemic has caused disruption to health and social care on a scale never seen before.

Surgeries were cancelled and screening services halted while emergency departments (EDs) and hospital wards reconfigured to ensure COVID-19 patients were separated from other patients.

Nurses have been redeployed and a network of temporary hospitals, known in England as NHS Nightingales, were built across the UK.

But while the number of new cases falls – for now, at least – NHS leaders and ministers are urging services to start returning to normal – or at least a 'new normal'. Nurses are at the forefront of this work.

We have spoken to nurses working in emergency care, cancer care, the community and mental health to find out how services are changing.


Changes to emergency care

EDs were completely reconfigured in the early weeks of the pandemic, with COVID-19 patients kept separate from other patients.

Often known as red and green zones or hot and cold, these new arrangements are likely to continue in the long term. Nurses are playing a crucial role, triaging patients at the front door by taking their temperature to ensure anyone with suspected symptoms is channelled to the right side.

Temperature testing helps nurses detect suspected cases of COVID-19 Picture: iStock

Senior practice development nurse and RCN Emergency Care Association member Justin Walford says he expects such arrangements will be kept for the ‘foreseeable future’ as infected patients are still arriving and the NHS needs to be prepared for a possible second wave.

Emergency departments adapted as COVID-19 cases began to fall

Justin Walford: ‘Remote consultations
have not always been enough’

At his hospital, the Royal Sussex County Hospital in Brighton, the changes were relatively straightforward as the nature of the buildings on the site meant the ED was spread across two distinct areas. The only major modification was erecting of a wall close to the exit to keep patients apart.

In a number of places the zones have been flipped in recent weeks as the numbers of people infected have decreased and patients without COVID-19 symptoms have started to return. In April, the number of ED attendances in England was under half what they were before the pandemic but they started to rebound a little in May.

Mr Walford says: ‘We are beginning to see some of the patients that stayed away during the peak. Minor injuries are reporting that people with strained wrists and ankles are coming in.

People who stayed away during the pandemic are returning

‘But the real worry is the stroke patients that stayed away and the patients with suspected cancer symptoms that did not come forward – we are going to be dealing with the consequences of that in the coming months.

‘We have also seen more people starting to come in who are in mental health crisis. Patients have had to rely on remote and telephone support – and for some that has not been enough.’

Roisin Devlin on nurse shortages:
‘There are some green shoots emerging’

Northern Ireland’s South Eastern Health and Care Trust nursing modernisation manager Roisin Devlin says the numbers coming to the Ulster Hospital ED have now returned to pre-pandemic levels.

Ms Devlin, who was the clinical manager for unscheduled care during the pandemic, says converting the Ulster Hospital ED has been a ‘logistical nightmare’ with Portakabins now being used and a separate ambulance drop off area created.

Waiting lists will soar as services struggle to return to normal

She says the arrangements will be continuing too – as will the changes made throughout the hospital.

Beds have been taken out of wards as the ‘old, cramped’ buildings did not lend themselves easily to social distancing, she says.

She says this will affect routine and emergency work. The NHS Confederation has warned of rising waits for routine treatments, predicting the waiting list in England alone could more than double to 10 million by the end of the year as services will not be able to get back to normal.

Ms Devlin says there is scope to ‘do things differently’ that might have an impact on the backlog, including more virtual consultations, while continued use of the private sector for routine work may continue.

Pandemic may help boost nurse numbers

A recent survey of more than 150 NHS leaders by NHS Providers showed both measures are being commonly deployed by hospitals.

She also believes the pandemic might actually help boost nurse numbers in the short term at least.

‘We’ve seen a rise in student placement applications, so there are some real green shoots emerging.

‘Although I am expecting we may see an increase in people retiring. It has been a really difficult few months and I can imagine we may see people taking early retirement at some point.’

Changes to cancer care

Unlike routine care, the hope was to keep cancer services running. But screening services stopped completely in Northern Ireland, Scotland and Wales, while in England they were severely disrupted. Cancer Research UK estimates more than two million people may have missed out on screening during the peak of the pandemic.

It has also become clear patients with the early signs of cancer have stopped coming forward for treatment – NHS England data show that in England the number of GP urgent cancer referrals fell by 60% in April compared with the same period in 2019.

There has also been a slowdown in the numbers starting treatment – down 20% compared with last year.

‘People are still afraid of using the NHS’

Mark Foulkes: ‘There may be a surge
of patients with cancer’

UK Oncology Nursing Society president-elect Mark Foulkes says it is clear cancer services have been ‘badly affected’ in terms of capacity and also public confidence.

‘Cancers haven’t suddenly stopped and it is now possible that we will see a "surge" of patients with cancer. But I fear people are still afraid to come forward and use the NHS.

‘We are going to have to run some awareness campaigns if we are going to address this.’

In the meanwhile, treatment services are beginning to reopen. During the peak of the pandemic, cancer treatment was centred around some of the major sites with spare private sector capacity being used.

In London, cancer treatment was led by the Royal Marsden, University College Hospital and Guy’s and St Thomas’ hospitals.

Some innovations will continue

Mr Foulkes says this had a major effect on clinical nurse specialists with some redeployed to wards and many clinics carried out virtually or on the phone.

He says those who were redeployed have now returned with services restarting in local hospitals with treatment confined to COVID-free units, isolated from the rest of the hospital.

The Hope for Tomorrow mobile cancer care unit, which is staffed by members of Airedale
NHS Foundation Trust

Buses have been used to take cancer treatment into the community

Pat Dyminski: ‘Many patients have
been stressed by the pandemic’

But services have also started using other innovations, which look likely to continue long term.

The use of stereotactic ablative radiotherapy has been expanded, while some areas have started using chemotherapy buses to take treatment into the community.

Airedale NHS Foundation Trust in West Yorkshire is one of the areas that has done this. It already had one bus, but with the help of the charity Hope for Tomorrow it started using a second one at the start of the pandemic.

Lead cancer nurse specialist Pat Dyminski says patients appreciate the facility.

‘Patients feel very safe. They have been stressed and have high anxiety during the pandemic.

‘But this saves them coming through the hospital and we find for a lot it fits into their lives.’

Changes to community care

Services in the community have been affected in a variety of ways. Crowded waiting rooms are a distant memory for general practice nurses who are turning increasingly to remote consultations to reach patients, while health visitors have also had to rely on technology.

Alison Morton: ‘Safeguarding issues
have been missed’

Institute of Health Visiting director of policy and quality Alison Morton says on management instruction, consultations carried out by health visitors were done remotely during the peak with some areas seeing staff redeployed in significant numbers.

She believes this was a ‘mistake’ and will have led to cases of domestic violence and abuse and safeguarding issues being missed.

And she adds: ‘It’s not just the most vulnerable that have lost out either. Imagine having a baby at the start of the pandemic and not being able to see a health visitor or meet with other parents and babies.

‘We know how important the first year of life is. The toxic stress experienced in this period and beyond could have lifelong implications for children.’

Vulnerable families are being prioritised as health visitors tackle the backlog

She says services are only slowly returning and staff face a ‘big backlog’ in missed appointments.

Julie Green: ‘Community services
have seen an increase in demand’

‘We have been told to see vulnerable families and those that are not known to us. It will take time to get things back to normal.’

But in district and community nursing it has been a different story. RCN district nursing forum chair Julie Green says services have never stopped – and have, in fact, seen an increase in demand.

This, she says, has been prompted by GP practices moving to remote consultations and increasing demand for end of life care as people stayed out of hospital and hospices.

She says teams have been doing this while trying to get hold of adequate personal protective equipment (PPE) and providing enhanced video support to care and residential nursing homes.

COVID-19 has created a ‘new group of long-term sick’

Professor Green says more recently caseloads have begun changing with an increase in people who have tried to self-manage problems, such as pressure ulcers, coming forward, not to mention growing numbers returning home from hospital ‘deconditioned and immobile’ after being treated for coronavirus.

She predicts the latter will become ‘the new group of long-term sick’.

‘The ongoing impact of COVID-19 is going to be significant,' she says.

'District and community nursing was already under-resourced. If services are going to cope, teams need to be properly funded and resourced.

‘Some teams have seen extra staff deployed – specialist nurses, returning retired nurses, tissue viability nurses – and many are now returning to their own services.’

Mental health nursing

Video consultations have been used
as much as possible Picture: iStock

Mental health nurse leaders are concerned the pandemic could have exacerbated existing problems.

RCN professional lead for mental health Catherine Gamble says a lot of face-to-face contact was also cut back on by mental health nurses in the community, while community crisis teams, which kept seeing patients, were undermined by a lack of personal protective equipment (PPE).

‘Digital technologies have been used – but to varying degrees of success. We’re beginning to notice the impact with the EDs reporting increasing number of patients coming in with mental health problems.

‘Mental health nurses are the cement between the bricks – the work they do is vital in keeping people well.

Self-management may have proved difficult during lockdown

Catherine Gamble: PPE can be unsettling
for patients

‘But it is not just about services not being available. There are a lot of people who were able to manage their mental health by using things such as leisure facilities, gyms and libraries, but they were all closed down and some of them still aren’t open.’

Ms Gamble is also concerned about the lack of clarity over PPE, saying its use in inpatient settings could present a self-harm risk and, across services more generally, its use by staff might act as a barrier to care as it can be ‘unsettling’ for patients to see staff in masks and visors.

‘We need more clarity about its use and to consider the implications,’ she adds.