Has the COVID-19 crisis changed community nursing practice in the UK forever?
From conducting nurse-patient video consultations to donning goggles, masks and gloves, community and district nurses have had to make rapid adjustments in an ever-changing environment during the pandemic
COVID-19 has been called the biggest healthcare challenge in a generation.
As nurses continue to provide care in the community through the pandemic, many have had to make rapid adjustments in an ever-changing environment.
And this has been felt no more so than in community nursing – from patients being discharged from hospital into the community to free up 15,000 acute beds in England alone, to more than 1.5 million people told they are at risk, or extremley high risk, of becoming seriously ill from COVID-19 to underlying health conditions. Not to mention existing caseloads.
All the while, these feats have been achieved amid a backdrop of anxiety over supply of personal protective equipment (PPE) and testing capacity for front-line staff.
Here, community-based nurses tell us how they have coped with and delivered care amid the ongoing pandemic.
Karen Banham, district nursing sister
Karen Banham works for South Tees Hospitals NHS Foundation Trust. Her team have implemented a number of changes in response to the COVID-19 crisis.
These include ringing patients ahead of any home visits and going through a questionnaire to check if they have any symptoms.
Other practical changes include changing the type of wound dressings.
Changes include switching to longer-lasting honey-based wound dressings
‘We always use inadine as our primary choice of dressing to dry wet wounds, but this needs to be changed twice a week,’ she says.
‘Instead, we’ve switched to a honey-based dressing as this can be left on for seven days.’
The team follow-up with a phone call between dressings, and patients always have their contact details so they can talk through any concerns.
They have also looked to involve patients’ wider support networks, where appropriate, to help reduce the frequency of home visits needed.
Teaching patients’ cleaners how to supervise home-administered insulin injections
‘A couple of patients that we go to see have dementia and require insulin,' Ms Banham says.
Personal protective equipment
An online survey of 3,438 UK nurses conducted in early April found that two thirds of respondents said they did not have adequate access to face masks, goggles and visors
Source: RCNi online survey
‘They self-administer, but we have to check to make sure they have dialled it up properly or we might need to put the needle in if they are having difficulties.
‘Both patients have cleaners who go into their homes, so we’ve taught their cleaners how to supervise the injections. This has reduced our visit frequency from daily to twice-weekly at weekends, and that’s helped.’
One consequence of the changes to their working day means Ms Banham’s team are in the office together more often, which can be tricky because of lack of space.
Another issue they have encountered is around referrals.
A week before the UK-wide lockdown was announced on 23 March, NHS England chief executive Simon Stevens wrote to all NHS and foundation trusts, GP practices and primary care networks and providers of community health services setting out steps to reduce the spread of the virus.
Community health providers taking ‘full responsibility’ for hospital patient discharge to free up 15,000 acute beds
These included community health providers taking ‘immediate full responsibility’ for urgent discharge of all eligible patients identified by acute providers on a hospital discharge list, with the aim of freeing up 15,000 acute beds used by patients awaiting discharge or with lengths of stay over 21 days.
‘I understand hospital wards want to discharge patients as soon as they can, but it seems as though they’re not always thinking about it – they just want them out of the door’
Karen Banham, district nursing sister
For example, one day in April, Ms Banham's team received four referrals. One was for a patient who required a daily clexane injection (an anticoagulant) for 28 days. The patient and her family were not taught how to inject while in hospital.
Another referral was for a woman in her eighties who had been discharged from hospital after having a hysterectomy. The hospital had advised that a district nurse would visit every day to check her dressing, when the patient had a live-in carer.
‘Sometimes the wards are referring to us, but when we delve deeper, they are sometimes a little inappropriate,’ says Ms Banham.
‘I understand hospital wards want to discharge patients as soon as they can, but it seems as though they’re not always thinking about it – they just want them out of the door.’
Who is deemed at high-risk of becoming seriously ill from COVID-19?
At the beginning of the UK lockdown, the government sent a letter to 1.5 million people deemed to be at high, or extremely high, risk of becoming seriously ill from COVID-19.
People deemed at high risk include those:
- Aged 70 or over
- With heart disease
- With a non-severe lung condition, such as asthma, chronic obstructive pulminary disease, emphysema or bronchitis
- With diabetes, chronic kidney disease or liver disease
- Taking medication that can affect the immune system (such as low doses of steroids)
People deemed as extremely high risk, and advised to shield at home until the end of June, include those who:
- Have had an organ transplant
- Have blood or bone marrow cancer, such as leukaemia
- Are having certain types of cancer treatment
- Are taking certain types of immunosuppressive medication
- Have a severe lung condition, such as cystic fibrosis or severe asthma
Tim Hebbert, primary care advanced nurse practitioner and clinical service lead for care homes
Tim Hebbert works in a large general practice partnership at Sandwell and West Birmingham NHS Trust. He is also care home lead for Your Health Partnership primary care network, which provides support to more than 220 people across 30 care homes.
Mr Hebbert says his team have moved to working remotely including carrying out telephone and video consultations with care home staff, patients and their relatives.
This did cause an increase in anxiety with his team and the care homes initially. The team were worried they wouldn’t be able to maintain a therapeutic relationship via remote working practices. However, they’ve since discovered they can work more remotely than otherwise expected.
Shaping care with two-way interactive consultation videos for vulnerable patients
‘We have housebound and care home residents who have long-term dermatology issues,’ he says.
‘They would normally benefit from accessing specialist dermatology clinics, but due to specific issues with these patients, this hasn’t been possible. We have always managed to share photographic evidence (with consent) for a dermatology opinion, but this is a dry and impersonal review of a single issue.
‘We continue to visit individual patients, but only when we need to answer a specific clinical question that cannot be answered through remote consultation – and restrict visits to a maximum of 15 minutes’
Tim Hebbert, primary care advanced nurse practitioner
‘Through the use of video, we have managed to get these vulnerable patients reviewed by a dermatologist with the support of carers and district nurses in a two-way interactive consultation in their place of care. It’s enabled us to provide truly shared care.’
‘We have at no time stopped visiting care homes’
While using video calls is proving beneficial, Mr Hebbert stresses that they continue to visit patients during the COVID-19 pandemic.
‘We have at no time stopped visiting care homes,’ he says. ‘We continue to visit individual patients, but only when we need to answer a specific clinical question that cannot be answered through remote consultation.
‘When visiting, we wear appropriate PPE and restrict visits to a maximum of 15 minutes.’
Perhaps the key issue of the COVID-19 crisis for all healthcare professionals has been access to PPE.
An online survey of 3,438 UK nurses by RCNi, carried out in early April, found two thirds of staff said they did not have access to adequate PPE at work, such as face masks, goggles and visors.
Almost one third (31%) said they used their own money to buy PPE and one in ten resorted to making their own, our survey found.
Practice nurses are ‘having to practically beg for masks and alcohol hand gels’
One practice nurse described how they and colleagues had fashioned home-made masks from pillowcases, while nurses working in adult social care described feeling as though they had been 'forgotten'.
'It has been atrocious, we are community nurses attending to very vulnerable patients,' said one community nurse.
'We are having to practically beg for masks and alcohol hand gel. We are putting not only our patient's lives at risk, but also our families and our own.'
The government has since pledged that more than 1 billion items of PPE had been distributed across health and social care settings.
‘Once everyone raised concerns, the PPE situation gradually improved’
Birchwood Grange is a 150-bed care home in London rated outstanding by the Care Quality Commission in February.
Deputy manager and nurse Linda Simpson describes their PPE supply situation as one that is improving.
‘Supply was a little slow to start with and we did struggle at the beginning,’ she explains.
‘Once everyone started to raise concerns, it gradually improved.
'We have a steady supply coming in, but we don’t have more than a few days supply at a time. Although we do know now when the next supply is coming.’
Biggest challenge is communicating rapid guidance on COVID-19 virus
Mr Hebbert says concerned family and friends ‘constantly’ ask if he has the correct PPE.
‘Some have offered to either buy or make it for me,’ he says.
‘But I can honestly say that I have at no time visited a patient without the correct PPE for that clinical setting or procedure.’
He says the biggest challenge he has had is communicating rapid guidance in COVID-19 virus guidance.
‘This is a new virus and each day we are learning more about how it behaves and how we need to manage it safely.’
In the care homes the ANP team provides support to, access to PPE has varied.
Seven-day supply of PPE ‘lifeline’ for care home staff
‘Some of the homes have more PPE than the guidance recommends, while others have struggled at times to purchase their own from suppliers,’ says Mr Hebbert.
He says that his trust, Sandwell and West Birmingham NHS Trust, recommended that every patient discharged from hospital to adult social care setting should be provided with a seven-day supply of PPE, and a direct contact to arrange further supplies if needed.
‘One care home manager said this was a lifeline for her and her staff.’
‘We’re providing end of life care as normal during the pandemic’
High-quality end of life care has been vital during the COVID-19 pandemic, says Sandwell and West Birmingham NHS Trust primary care advanced nurse practitioner Tim Hebbert.
Amid concerns over the provision of anticipatory medication in the local area, processes are in place to ensure these medicines are available in advance of when they are required and in the quantities they may be needed to ensure effective symptom control.
Referrals process now streamlined to specialist palliative care services
‘We have changed processes locally to enable injectable medication to be sent electronically,’ he says.
‘This saves both clinicians and carers time as they no longer need to travel to deliver or collect paper prescriptions. We have also streamlined the referral process to specialist palliative care services and district nursing for palliative patients.’
Conversations around resuscitation and advance care planning have inevitably come to the fore during COVID-19 and this has led clinicians, patients and their families to think about these matters again, says Mr Hebbert.
His team have contacted each care home they support to facilitate these conversations.
Concerns over misuse of advance care plans and ‘do not attempt to resuscitate’ notices
Every patient is treated as an individual and their wishes for resuscitation have been documented clearly in their medical records, he explains. In cases where patients have lacked capacity, the team has spoken to their relatives or those with power of attorney.
In April, concerns over misuse of advance care plans – including ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) notices – led the Nursing and Midwifery Council (NMC) and the General Medical Council to issue a joint warning to registrants to ensure person-centred care continues during the COVID-19 pandemic.
NMC chief executive Andrea Sutcliffe said in April: ‘In recent weeks I have been disturbed by reports of blanket DNACPR orders being applied to groups of people without their involvement or any individual assessment of their needs. This is completely unacceptable.
'We know the best care is person-centred and tailored to people’s individual needs.’
‘It angers me when I hear the term ‘‘blanket DNACPRs” in the media,’ Mr Hebbert adds.
‘I have seen no evidence of this in my area or in areas where my colleagues and friends work. We are providing individualised patient-centred conversations about advance care planning.’
Striving to provide best possible end of life care
At South Tees Hospitals NHS Foundation Trust, Karen Banham's district nursing team is striving to provide the best possible end of life care.
‘We had four patients die over Easter weekend from long-standing illnesses,’ says Ms Banham.
‘We have the charity Herriot Hospice Homecare locally to help with providing care in the last few days of a patient’s life. If the hospice doesn’t have capacity, one of my nurses will go in and provide that care and that’s what we did over Easter.
‘We’re providing end of life care as normal.’