COVID-19: how the NHS and the nursing profession have coped so far

As lockdown continues across the UK, we take stock of the impact on and response from healthcare services and staff

Unprecedented is a word used frequently in healthcare, but never has it been better applied than in the current situation.

Nurses in almost all settings are on the front line as the UK is engulfed by the COVID-19 pandemic.

Nurses step up despite ‘enormous personal risks’

From emergency departments to care homes, primary care to respiratory wards, nurse across health and social care are working to look after those affected – or preparing to do so.

RCN general secretary Dame Donna Kinnair is ‘hugely proud’ of how the nursing profession is responding to the unfolding crisis.

‘It is something we have never seen before,’ she says. ‘If our predictions are right, it will be astronomical. We have not seen anything like it in peace or war time.

‘Nurses have stepped up to the plate, including our third-year students. Nurses are working on the front line and working with enormous personal risks. Nurses will provide care they always have.’

Since COVID-19 was first identified in China in December 2019, the virus has marched rapidly around the globe, reaching dozens of countries.

Warnings from overwhelmed healthcare systems in Spain and Italy

In Europe, Spain and Italy were particularly hard hit in March, with thousands of deaths and dire warnings from healthcare staff there about the impact on their hospitals.

In the UK, strict restrictions that seek to limit social interactions – closing schools, pubs and many businesses – to slow the spread of COVID-19 have affected the whole population.

Cases of illness and deaths related to the virus have been increasing since the first UK cases were recorded in late January.

Uncertainty over need for travel restrictions and self-isolation

Britons who were in Wuhan in China, the city at the centre of the outbreak, were flown back in late January and quarantined in NHS staff accommodation at Arrowe Park Hospital in Merseyside.

• RELATED: Coronavirus: Britons on evacuation flight to be quarantined in NHS staff accommodation

But no travel restrictions were in place during the February half-term break in the UK, and people travelling back from European 'hotspots' were unsure about the need to self-isolate. 

There was a slow trickle of cases reported throughout February. The first death in the UK was reported on 5 March. 

Cases rose throughout March as the NHS planned and prepared for a likely avalanche of patients.

By the third week of March, hospitals were treating hundreds of cases, and intensive care was starting to feel the strain.

View our COVID-19 resources

COVID-19

What is it?

COVID-19 is the disease caused by a new coronavirus (CoV) called SARS-CoV-2. CoVs are a large family of viruses, with some causing less severe disease, such as the common cold, and others causing more severe disease, such as Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS).

What are the symptoms?

Fever, cough or chest tightness and dyspnoea are the main symptoms reported. While most patients have a mild illness, other cases are severe, with some people requiring intensive care. People can also be asymptomatic.

The government is instructing people with a fever and/or a new, continuous cough, to self-isolate for 14 days if they live with other people. People who live alone should self-isolate for seven days.

How did it begin?

On 31 December 2019, the World Health Organization was informed of a cluster of cases of pneumonia of unknown cause detected in Wuhan, China. A new CoV was subsequently identified from patient samples. The disease spread rapidly through the city of Wuhan and then to other areas of China.

How is it spread?

While the routes of transmission of COVID-19 are not fully understood, other CoVs are mainly transmitted by large respiratory droplets and direct or indirect contact with infected secretions. Other CoVs have also been detected in blood, faeces and urine.

Under certain circumstances, airborne transmission of other CoVs is thought to have occurred via unprotected exposure to aerosols (suspension of fine solid particles or liquid droplets in air) of respiratory secretions and sometimes faecal material.

How important is infection prevention and control?

The government is urging all healthcare staff and members of the public to maintain good hand hygiene. All staff, patients and visitors should decontaminate their hands with alcohol-based hand rub (ABHR) when entering and leaving areas where there are patients with suspected or confirmed COVID-19.

Hand hygiene must be performed immediately before every episode of direct patient care and after any activity or contact that potentially results in hands becoming contaminated, including the removal of PPE, equipment decontamination and waste handling.

Adapted from Public Health England guidance 

Temporary hospitals prepare for an expected flood of patients 

The government announced a new temporary hospital, which would eventually provide 4,000 beds, was being developed at the ExCel exhibition centre in east London.

• RELATED: COVID-19: health secretary announces new temporary hospital named after Florence Nightingale

The Nightingale Hospital, which opened on 3 April, is staffed by NHS professionals, with the help of the military. The government says it has ordered thousands of extra ventilators in preparation for a spike in cases. Similar temporary hospitals are also planned for Birmingham, Manchester, Bristol and Harrogate.

Daily briefings from prime minister Boris Johnson, senior medical leaders and politicians were established as the public was told to stay at home.

Rapidly-changing guidance was issued by the government to limit social contact and to try and contain the spread of the virus. Schools and nurseries were closed to all children except those with key worker parents, or those who are vulnerable, have a social worker or are entitled to special needs support.

Soon after that, pubs, leisure centres, restaurants, cinemas, theatres and cafes were instructed to close their doors as normal life came to a halt.

RCN calls for improved personal protective equipment for all healthcare staff

Professor Kinnair says the RCN is involved in discussions and planning at the highest levels of government: ‘We have been able to input the voice of nurses on the ground and we have had continuous updates on the preparations being made.’

Despite that, the RCN has been calling for action on improved personal protective equipment (PPE) and more testing for the disease among healthcare staff. Clinicians have been widely reported stating they could not access the PPE they need to protect their health.

• RELATED: COVID-19: RCN demands action over ‘unconscionable’ lack of PPE

Initially this was dismissed by health and social care secretary Matt Hancock, but he appeared to acknowledge there was a problem when announcing the military would help deliver more masks, gowns, hand sanitisers and other essential equipment to hospitals and other NHS providers.

• RELATED: COVID-19: army called in to distribute supplies to NHS front-line staff

Concerns remain over the quality of protective equipment

Professor Kinnair says the PPE situation appears to be improving on the ground, but that the RCN remains concerned about the situation.

Nurses who feel they cannot get the PPE they are entitled to should raise this locally with their employer and with the RCN, she says.

Jim Bethel, a nursing lecturer at the University of Wolverhampton who has volunteered to go back into NHS clinical practice during the crisis, says there are widespread concerns about PPE. Supplied equipment is falling well below what is needed, he suggests.

‘Sometimes even PHE-standard PPE is in short supply and people are having to decide how likely it is that a patient has COVID-19 based on symptom severity and only use PPE for the people considered "high-risk" patients.’

• RELATED: COVID-19: government issues new PPE guidance for healthcare staff

Testing for front-line staff becomes a contentious issue

The government has faced calls for all front-line healthcare staff to be tested, with more than 1.3 million people signing a petition set up by a junior doctor.

• RELATED: COVID-19: thousands sign petition calling for front-line NHS staff to be tested

Healthcare staff have been calling for increased testing so they know whether there is a risk of them passing on COVID-19 to patients and to avoid unnecessary self-isolation. 

On 26 March, NHS England chief executive Sir Simon Stevens announced staff testing would be rolled out across the NHS, starting with critical care nurses, other staff in intensive care, emergency departments, ambulance services and GPs.

'As the testing volumes increase, we want to widen that to a wider range of essential public service workers, including our social care services, as well as continuing with vital patient testing,' he added.

Health and social care secretary Matt Hancock admitted on 3 April that government has ‘a huge amount of work to do’ to meet its new target of 100,000 coronavirus tests a day in England by the end of April.

Retired nurses return to support NHS colleagues

Bolstering the nursing workforce was central to the government's response to the pandemic, and this included issuing a plea to retired nurses and third-year students to join the workforce.

Thousands heeded the call: as of 11:45am on 27 March, the Nursing and Midwifery Council had received 7,510 applications to join the temporary register from students and former nurses across the UK.

• RELATED: COVID-19 emergency register for nurses: how it will work in practice

NHS England says returners will receive a contract that reflects standard terms and conditions such as working hour protections, pay arrangements, and annual leave entitlement.

Third-year nursing students can opt to undertake their final six months of their programme as a clinical placement.

The Covid-19 temporary register will have specific conditions of practice for students to ensure appropriate safeguards are in place, the NMC says. 

Students not in the first year or final six months of their course are also being encouraged to boost the workforce. They will be invited to opt-in to an arrangement where they spend 80% of their time in clinical practice, which would be remunerated, and 20% in academic study.

Nurses share their concerns about the heightened risk of front-line work

Despite extra numbers of nursing staff, the impact on nurses during the pandemic is expected to be huge. Many are being deployed to new, potentially unfamiliar, areas or they are having to self-isolate as they may have become infected.

‘The temptation for any healthcare professional on the front line is to keep going. We need to make sure we are drinking enough and eating enough, so that we can keep going’

Dame Donna Kinnar, RCN general secretary

Nurses have taken to social media to share their concerns, including whether they would get sick pay if they were agency staff, and what to do if they were being forced to work but had health conditions that left them at higher risk of becoming seriously unwell.

One nurse with asthma said: ‘I am expected to work. I’m petrified of going in tomorrow. Especially as I have just been off with an exacerbation of asthma. I just don’t know what to do.’ 

Lack of PPE has been a major concern.

One nurse said: ‘Nurses all want to help, but one of the reasons the NHS is bringing back retired nurses and students is because they know that those on the front line will start to drop like flies. The PPE they are supplying is not sufficient for the job.

‘We are already having to borrow from other wards due to a shortage and we are not even in the thick of anything yet. Surely they should be supplying enough to keep us all safe?’

Nurses face difficulties getting basic supplies while continuing to work

Dawn Bilbrough, a critical care nurse in York, broke down in tears in a video shared by the BBC after she found the supermarket shelves after working a 48-hour shift.

• RELATED: COVID-19: nurse praised by health secretary after plea on panic buying

Support for nurses during and after the pandemic will be essential, nursing leaders have warned.

Intensive care unit (ICU) nurses will need psychological support to be in place for them, as nurse-to-patient ratios fall during the pandemic, according to British Association of Critical Care Nurses chair Nicki Credland. She said that the one-to-one nurse-to-patient ratio will end across the UK’s ICUs during the crisis. 

Nurses ‘need to remember self-care’ during the crisis

Professor Kinnair urges nurses to protect their health throughout the pandemic, which could last months.

Eating healthily and staying hydrated will be important to help nurses maintain their health, she says.

‘We will look after patients, but we also need to have some self-care,’ she says. ‘The temptation for any healthcare professional on the front line is to keep going. We need to make sure we are drinking enough and eating enough, so that we can keep going. These things will help with the resilience of the workforce.

'Nurses will provide the care they always have, but I am looking to nurses to take care of themselves as best they can.’

What we can learn from the COVID-19 ‘war’ in Italy

Nurses in Italy have told Nursing Standard about the gruelling experience of working during the COVID-19 pandemic that has ravaged the country.

Italy, especially in the north, has seen high rates of infection and recorded hundreds of related deaths a day throughout March.

President of the Italian Nurses Association Walter De Caro says that COVID-19 arrived in the country ‘like a war’. He says nurses use military language to describe the experience: ‘They stay at the front line to fight the battles and win the war.’

In late March, Mr De Caro said 5,000 healthcare professionals – about 9% of the workforce –  had been infected, and some had died.

• RELATED: COVID-19: death of four nurses overseas highlights need for PPE, says ICN chief

Nursing and medical students who were close to finishing their courses were expediated through to registration, and all nurses were deployed to clinical areas. Volunteers, retired and military medics were also brought in.

‘It’s like going to war with paper shields and plastic guns’

Walter De Caro, president of the Italian Nurses Association

The military built two field hospitals to care for some of the affected patients.

‘In some hospitals, in the first week of the outbreak, most nurses did not return home,’ Mr De Caro says. ‘They slept in the hospital and worked for hours and hours. Hospitals have been overwhelmed by patients. There are serious problems in terms of adequate numbers of doctors and nurses, personal protective equipment, ventilators and other supplies.’

Lessons from Italy: prepare with extra equipment and more staff

He said among the lessons that should be learnt from Italy’s experience by other countries is the importance of having enough staff and sufficient PPE, along with the training to use it properly.

‘Some colleagues said to me that PPE is totally missing in some situations. It's like going to war with paper shields and plastic guns. It is obvious people are going to get infected.’

Erika, a nurse from Brescia, describes how wearing PPE, while vital, is uncomfortable. ‘You spend the 12-hour shift with that suit and mask on that squeezes you everywhere and hurts everything – your nose, cheeks, ears. You sweat, your visor tarnishes and you have been holding your pee for at least five hours. Not that it matters, you cannot give up. You only think about helping your colleagues.’ 

Erin Dean is a health journalist