Never before has there been such a nationwide focus on the NHS. Daily TV briefings have been watched by record-breaking audiences, with viewers focused on the spread of infection, emergency department attendance, in-patient numbers, intensive therapy unit admissions and the tragic rising death rates.
Silently, in the background, district and community nursing teams have not stopped delivering complex care within patients' homes. In fact, the demand for their care has increased, with many reporting the need to undertake 20-plus patient visits during each shift. Each visit is complicated by a range of additional pandemic-related demands: donning and doffing of personal protective equipment (PPE), often in driveways, doorways and garages, and the need to communicate while wearing a mask. These make the provision of key information challenging, laborious and time-consuming.
There have been some positives from this newly imposed way of working. Reports of increased self-management, with patients more engaged, confident and concordant, especially in the area of wound care, which, on occasion, has actually optimised the healing of complex wounds. Some teams have welcomed additional team members, with staff deployed from services that were ‘stood down’ during the pandemic. This has led to enhanced clinical collaboration, reciprocal learning, increased bonding and, thus, stronger professional relationships. However, others have reported having no additional staff and, with team members being required to shield, they have continued to deliver an increased level of care, albeit with a smaller team. Some have even had to delay their annual leave to ensure the uninterrupted provision of care.
The rapid and effective engagement with innovative technology has underpinned the adaptation of clinical teams to new ways of working; indeed, the skills of virtual triage have been perfected, enabling the facilitation of complex discharges from secondary care and improving patient outcomes. Technology has supported positive working; teams have reported weekly ‘virtual’ chats with primary care networks, video conferences with GPs in patients' homes and providing care homes with support via video consultations, augmenting staff support at a time when only essential visits were permitted. Technology has also enhanced communication between the community team members; video conferencing used for handovers, workload allocation and for patient reviews. This swift and essential engagement with technology has certainly developed new ways of working, saving time, improving peer support and providing a conduit for rapid advice and support for remote decision-making. The pandemic has highlighted the innovative, amazing and adaptive workforce within community nursing, although it has not been without personal impact; indeed, remote and isolated staff have missed the support of a physically present team, especially when the delivery of care has been particularly upsetting or challenging.
Sadly, there have been negatives, too. District and community nursing visits have often been extended to provide psychological support to manage the impact of lockdown and the extreme loneliness that many patients have experienced. Other demands have resulted from the withdrawal of services as a result of the pandemic. New patients, who would not ordinarily receive community nursing services, have become the new ‘housebound’ and have required their care be delivered at home. This reduction in service provision has varied geographically, but, for some, it has resulted in an exponential increase in caseload demands. Patients have elected to refuse admission due to concerns about the risks posed by COVID-19, preferring to remain at home for their care; this has included those with long-term conditions, younger acutely ill patients and those approaching the end of life. In some areas, GPs have continued their provision of care, albeit in a revised manner; however, some surgeries have limited attendance, and home visits have been minimised. Where GP access has been reduced, community nurses have experienced challenges liaising with GPs, making relatively simple processes long-winded and time-consuming. Worryingly, there are reports of palliative diagnoses and ‘do not resuscitate’ discussions being delivered over the telephone; in these situations, it is the district nurse who has been left to control the damage this approach to the delivery of bad news invariably causes. Changes to service provision have exposed a crucial need for GP and community nursing services to work together more closely to optimise the care provided for patients.
There has been a considerable increase in the number of people requiring palliative care at home, who often present to community nursing services in the final days of life. Most often, these are not COVID-19 related cases but are characterised by late presentation to the service, which may be attributed to the patient or their family requesting discharge or refusing admission due to the publicised restrictions around visitors in hospital wards. At home, there can be a little more freedom to have close family visiting at such a challenging time. This, alongside the closure of many hospices for in-patient care, has created a considerable impact on community services. These challenges have been exacerbated by delayed access to vital equipment, the additional time required to don and doff PPE and the sheer emotional challenge of communicating with those at the end of life while wearing a mask.
District and community nursing teams are concerned about the ongoing impact of healthcare delivery during the pandemic. The risks associated with late diagnosis, reduced availability of treatment, delayed access to screening and limited elective surgery are considerable; it may be many months before the impact is felt, but these patients are still out there. A number of trusts have reported reduced presentations of patients with a range of conditions, including chest pain, strokes and mental health issues; these conditions have not opportunely gone away while COVID-19 distracted us, and they will slowly but surely become apparent. As the lockdown eases, teams report seeing an increase in requests for visits from patients with ‘new’ wounds or pressure damage; often, their initial attempts to self-manage have failed and their condition has deteriorated. The concern is that these patients represent the tip of the iceberg, and, as the fear of contact with health services diminishes and there is a perceived return to business as usual, the numbers will increase. Teams are certainly reporting increased referrals of complex patients and, as the pressure of the wave of the pandemic lifts, increasing numbers of patients are being discharged, post-COVID, who are now deconditioned, immobile and dependent; these are the new long-term sick.
The daily updates from the Government have stopped, the constraints of lockdown are being reduced and most services have reopened. District and community nursing services never closed; indeed, they have been busier and more challenged than ever. Teams are concerned that the spotlight that COVID-19 provided to their services will diminish, and district and community nursing will fast return to pre-COVID ‘Cinderella days’, to a service that is delivered behind closed doors, unseen and not valued. District and community nursing staff are exhausted, and morale is low; now is the opportunity to recognise the essential service provided by our district and community nursing teams. During the pandemic, community nursing expanded its service to protect secondary care, allowing them to focus their provision on COVID-19 in-patient care, unhindered by the needs of the chronically sick and those approaching the end of life. Moving forwards, the demands on community nursing are unlikely to abate; this is the opportunity for effective staffing, appropriate funding and suitable resourcing of district nursing.