Coronavirus in the community: the innovations helping nursing services keep up
Collaboration has helped staff face the enormous challenges involved in caring for people in the community
- Long-term complications of COVID-19 infection will pose new care challenges for community nursing services
- Redeployment of staff to acute care settings has not been replicated to deal with growing workloads in the community
- Community nurse teams have developed innovative and collaborative approaches out of necessity that should be maintained as part of the ‘new normal’
Community nurse Rosy Watson recalls a care home she visited recently that had been affected by COVID-19.
Sadly, some residents had died – but the pandemic had also left its mark on those left behind.
Ongoing physiotherapy and nursing needs for those recovering
‘Others are still frail,’ says Ms Watson, clinical lead community nurse with Norfolk Community Health and Care NHS Trust. ‘Their dependency scores have increased and they need bed care and extensive moving and handling interventions.
‘These effects of COVID-19 are going to have prolonged impact on health and social care systems. Each patient in that care home who was affected by COVID-19 weeks ago still has ongoing physio, occupational therapy, dietetic, nursing and increased social needs.
‘The community nursing teams are ideally placed to identify these needs and ensure they are assessed and met.’View our COVID-19 resource centre
Coping with the after-effects of COVID-19 in the community
Community nursing teams saw their caseloads surge in the pandemic and now, as the NHS tries to move back to some sort of normality, they are coming under even more pressure.
As Ms Watson points out, COVID-19 leaves patients with increased health and care needs, even after they have apparently recovered, and most of these people will be at home.
This is adding to existing workload pressures, as well as to the particular challenges of the pandemic – such as changing working practices, social distancing, personal protective equipment (PPE) and, of course, death and bereavement.
This has meant community nurses are facing even heavier workloads and challenges than usual.
An already stretched workforce in a public health crisis
Although district and community nurses are rising to the challenge, innovating and, in some cases, accelerating improvements, coping with the current situation and future demands is a huge task.
‘Pre-COVID, district nursing and community nursing was already over-stretched,’ explains Carolyn Doyle, RCN professional lead for community and end of life care.
‘The political agenda was around moving care closer to home and out of hospital, against a backdrop of a workforce where there was a reduction in numbers. We were already struggling – and then you bring COVID into the mix.
‘I have to say that the community nurse teams are amazingly resilient, but of course it’s an ageing workforce, so lots of staff were off shielding, looking after family members, while trying to provide care and keep their job going and supporting their colleagues.’
Redeployment of staff only goes one way
One of the issues, Ms Doyle says, is that while the focus was on acute care – with community staff being redeployed into hospital settings – the work in the community did not go away. ‘I get that – we were all planning for a huge surge of patients needing intensive support in intensive care units so community nursing was almost seen as something that just goes on in the ether,’ she says.
But now that the first phase of the pandemic has passed, there has not been a similar movement of resources from hospital to community, where there is a real and growing need, she warns.
‘Community nurses will always do well because they’ve got such a community perspective and we are a nursing family, and when the chips are down, we’ll do our best to provide everything we can,’ says Ms Doyle.
‘But moving through the pandemic and getting into that next phase, people who have survived COVID-19 are coming out of hospital with lots of complications, increased acuity, lots of long-term conditions – they are going to need an awful lot of care.’
Effects of exhaustion, distress and low morale on community nurses
Nurses working in the community have been reporting exhaustion and a high level of distress, says Crystal Oldman, chief executive of the Queen’s Nursing Institute – but they have also risen to the occasion, displaying impressive innovation and creativity.
‘In the community you have long-term relationships with patients and their families, so it was quite distressing to have a number of people that you’ve been supporting for weeks or months die quickly. We had a lot of reports of that,’ she says.
‘There was also a sense of being undervalued because – quite rightly – it was all about the intensive therapy unit (ITU) capacity in the beginning, but not understanding that actually there were a huge number of people being cared for at home with COVID-19 already, whether diagnosed or undiagnosed.’
There were practical difficulties too – for example, in the early stages when nurses did not know whether their patients had COVID-19 or not, there was a lack of PPE – and later, there was a blanket order that PPE has to be used all the time.
‘It’s much more difficult to do your job and it takes a lot more time to put the equipment on and take the equipment off,’ says Dr Oldman. ‘It’s more difficult to do that in the community, arguably, than it is in a hospital, because you’re working in a non-clinical environment all the time in people’s homes and then stepping out into the pavement or corridors in shared flats and so on. It makes it much more difficult, challenging and time-consuming.’
There have been positive developments, however, including moves to make better use of technology, enabling community teams to communicate with each other digitally.
‘It’s highlighted the underinvestment there has been in the community in hardware and software, and some of the bureaucracy around data-sharing has fallen away. This is absolutely a positive to be taken away,’ says Dr Oldman.
QNI’s Talk to Us listening service for nurses
The pandemic has taken its toll on the community nursing workforce, says Queen’s Nursing Institute chief executive Crystal Oldman.
‘They are exhausted. One of the things we did quite early on in the pandemic was to respond to the nurses who were telling us how distressing all this was in the community, and that they felt this wasn’t what they went into nursing to do.
‘They were taking care of patients who weren’t technically diagnosed with COVID, but they were dying, and they were taking care of them and their families.
‘That’s the big difference in the community – you are looking after them and their families in their own home at the points of acute illness and death. For some [patients], they were taken too soon. For others with COVID-19 who weren’t in hospital, their relatives couldn’t visit, so that’s also distressing for nurses to try to facilitate a good death without having relatives present, or being able to hold hands.
‘We were hearing this and taking calls from nurses telling us how distressing things were, so we have set up our Talk to Us listening service for nurses in the community, so that they’ve got a safe space to come and unload to a nurse who is trained in listening. It has been popular, so we know there is a need.’
More resources are needed for the ‘Cinderella service’
Ben Bowers, a community palliative care nurse studying for a PhD at the University of Cambridge, went back into practice during the COVID-19 crisis to help with the anticipated increase in workload. But he warns it is now that the pressure is piling up in the community.
‘Suddenly people who have been trying to self-manage, or manage with just the help of their family, have found it’s not sustainable. So across the community, not just in palliative care, what’s happening is the amount of people who need help is rapidly increasing,’ he says.
People are also asking for help at a later stage, which is tough for nurses.
‘Emotionally you like to build up a rapport with people and you like to get to know them and their families,’ says Mr Bowers. ‘If it is last-minute crisis it feels like you’re constantly trying to play catch-up and it’s just not a good way to do care.
‘People are coping well. They’ve been under a lot of strain for a long time – community has not let up, and a lot of changes [in ways of working] were made quickly, which takes a lot of brain power and energy. You’re dealing with a crisis where you’re constantly working with a lot of uncertainty in your own life as well as professionally.
‘But now it’s got busier in the community at about the same time as people like me are going back to doing what we were doing before, so there’s less help, while the demand is dramatically increasing.
‘Community services have never been seen as a priority. Community nursing is a bit of a Cinderella service, and it needs a lot more resources than it’s had.’
Accelerated practice: innovation in community care
The pandemic has led to changes in the way nurses deliver care in the community, and some of these may become permanent, says community palliative care nurse Ben Bowers.
Circumstances have acted as a spur to innovation. ‘One of the big things that’s changed nationally is that family carers, if suitably supported, could be asked, if they are happy to, to give their loved ones end of life care drugs,’ he says. ‘There was already a trend towards that, but it’s been accelerated. That could be liberating for some family carers or patients who feel they don’t want lots of professionals coming in.
‘Some of the things we’ve started to do may become so ingrained in practice that people feel it’s acceptable to do’
Ben Bowers, palliative care nurse
‘Also, if it takes two hours to get a nurse to give someone an injection for pain relief, if the family carers have a form [of medication] that they can put under the tongue, or if they have been trained to and feel confident enough to give an injection, with some phone support at the time, that might mean the person gets better symptom control, and the family feel more empowered.‘
- RELATED: How to verify the death of a patient
However, Mr Bowers says, this new approach must be balanced.
‘The flip side of that is that we need to make sure family carers don’t feel obliged to do this – there needs to be an alternative plan,’ he says. ‘That has always been injectable drugs that doctors and nurses come to give.
‘There are plenty of examples of accelerated practice – nurses in the pandemic are able to verify death, which is a dramatic change and potentially can be quite empowering for the nursing profession. Another change is that care homes can repurpose drugs during the pandemic.
‘This [pandemic] is going to go on for a while, so I suspect some of the things we’ve started to do may become so ingrained in practice that people feel it’s acceptable to do, and legislation may follow to make it a long-term plan.’
Building on the positive working practices established during the pandemic
Rosy Watson points out that while the NHS as a whole is beginning to get back to ‘normal’, for community staff, the workload never went away.
‘All through the pandemic we’ve been business-as-usual, providing care to people who need nurses to visit them,’ she says. ‘Obviously the workforce has been affected, with people having their own reasons to shield, and so on, but on the whole, everybody has been understanding, there’s been fabulous collaboration. We’ve had support from GP surgeries, we’ve had innovation – we’ve introduced efficiencies, and although they were introduced in response to the COVID crisis, these efficiencies are now embedded.’
- RELATED: Community nursing and COVID-19: when this is all over, I don’t think things will go back to how they were
Ms Watson’s trust, for example, has established a community response team that is integrated, with staff from health and social care.
‘Each case is discussed and that case is a person – it’s person-led and patient-centred,’ she says. ‘So the conversation is not about what’s the best thing for the acute hospital, or what’s the best thing for social care – it’s about the best thing for the person.’
Promoting the value of community nursing
The pandemic has fostered better collaboration, she says, and is also showing the value of community nursing. For example, organisations are working together more closely to optimise discharge from acute hospitals.
Community nursing input is essential to this process, she says, in part because they often know the patient and their circumstances.
‘There’s an opportunity for further collaboration. It’s been a difficult time, but there are positives, and we need to build on those,’ she says.
Jennifer Trueland is a health journalist