The COVID-19 pandemic has put the NHS under unprecedented pressures, although it could be argued that the NHS was already working under extreme demands to meet the needs of an ever-changing population while striving to achieve quality care (West et al, 2020). This article explores how community nursing teams can use strategies to reduce work-related stress and promote wellbeing in staff. Before the pandemic struck, there was already a growing concern into the psychological wellbeing of nurses, with an increasing focus on burnout (Tahghighi et al, 2017). The pandemic has exacerbated this and created burnout among nurses: a recent nursing survey revealed that 76% of nurses believed that, since the pandemic, their own levels of stress and burnout have increased (Royal College of Nursing (RCN), 2020a). Burnout can be defined as a syndrome caused by long-term stress in the workplace that has not been successfully managed (World Health Organization (WHO), 2019). There is compelling evidence that working under extreme circumstances has caused stress in the workplace and high levels of turnover in staff and intentions to quit. The NHS national staff survey revealed that 44% of nurses and midwives had become unwell due to work-related stress (RCN, 2020a). Farmer (2019) reported that, in the first 8 months of 2019 alone, 1 million NHS nurses had mental health-related sickness. The Queen's Nursing Institute (QNI) (2020a) reported that district nurses have had very little support or recognition during the pandemic in comparison to staff working in acute hospital settings; this is despite the fact that community nurses have also required to continue working remotely with increased demands on caseloads, particularly palliative care. Poor recognition of their efforts has had an impact on morale in the workplace (QNI, 2020a). Middleton (2016) concurred with the QNI that district nurses are overlooked, despite being key players in holding the NHS together. West et al (2020) highlighted that the growing gap between capacity and demand in community nursing settings has led to staff reporting feeling ‘exhausted’ and ‘broken’ district nurses' caseloads have no capacity limit, which becomes a challenge when presented with limited resources and stress-related sickness. Hall (2016) believed that managing stress in community nurses must be prioritised to ensure that nurses feel valued, and, if this is not prioritised, then staff retainment will continue to be compromised. McKinless (2020) agreed with the importance of managing stress in the workplace and reported that retention of nurses and job satisfaction have become an issue due to the stresses and complexities in community nursing. The nursing 2030 vision, which was shared by the Chief Nursing Officer Directorate (CNOD) of Scotland (2017), aims to achieve a nursing workforce that is prepared to meet people's needs and the complexities of care. It recognises that nurses require the education and skills to identify issues around nurse staffing levels and present the evidence to ensure that adequate numbers of nurses are available (CNOD, 2017). Similarly, West et al (2020) recognised that autonomy, belonging and contribution are required to ensure that nurses' wellbeing is supported and they remain motivated. The NHS Long Term Plan (NHS England, 2019) committed to investing in community health services because it acknowledged the increasing complexities and challenges faced with patient care in the community sector and the difficulties to manage this with understaffing and limited resources. In addition, it aims to provide the same values for its staff as those that they strive to achieve for their patients (NHS England, 2019). Consequently, since the COVID-19 pandemic, the NHS People Plan 2020/2021 (NHS Our People, 2020) has proposed the need to transform NHS culture and look after the health and wellbeing of colleagues as the service continues to respond to new challenges. The QNI voluntary standards (2015) stated that district nurses should promote the mental health and wellbeing of people and clinically supervise, manage and appraise staff. In addition, it is also a legal requirement for employers to protect employees from stress (Health Service Executive, 2019).
Why do mental health and wellbeing need to be promoted?
Public Health England (PHE) highlighted that mental health and wellbeing promotion should be advocated by all healthcare professionals. One-in-six adults will experience some form of mental health problem during their lifetime (PHE, 2019). The All Our Health framework provides guidance on how to promote mental health and wellbeing among patients, and it recommends that leaders and managers ensure a safe environment for both patients and staff, to promote mental health in the workplace (PHE, 2019). The making every contact count (MECC) approach embedded in the framework aims to approach and encourage behavioural changes to improve health and wellbeing in communities. For specialist practitioner qualified district nurses (SPQDNs), MECC should be promoted not only to patients but with their staff as well, along with the information required to deliver a MECC approach (Craig and Senior, 2018). Promoting mental health and wellbeing has many benefits, including increasing self-esteem, increasing productivity and building up a resilience to illnesses (James, 2018). Craig and Senior (2018) argued that a greater emphasis is needed on promoting health and wellbeing to prevent disease. Therefore, SPQDNs must develop ideas to help promote health and wellbeing in community nursing teams, and it is imperative that measures are put in place to support staff in the workplace to minimise stress and ensure that quality of care is not compromised.
Staff retention issues and the economic burden of workplace stress-related sickness within the NHS directly affect patient safety and experience (NHS England, 2018). By investing in the health and wellbeing of staff, the resulting improvement in job satisfaction and reduction in sickness will be beneficial to all organisations (Blake et al, 2013). Stress in the workplace can be caused by numerous factors, such as increased workloads and traumatic incidents, and this can affect both individuals and the whole team; further, chronic stress is associated with burnout (Upton, 2020). Additionally, a study conducted by Durkin et al (2015) revealed that nurses who did not manage their own health and wellbeing were more likely to experience burnout, reduced resilience to stress and compassion fatigue. The COVID-19 pandemic has caused an increase in community caseload, and staff's own anxieties around the virus are additional contributing factors to workplace stress among nurses (Duncan, 2020). Compassion fatigue-defined as detachment between nurses and patients in distress-is a concern in healthcare (Dzubak, 2020). It is detrimental to patients' safety and satisfaction with their care, and it has been associated with an increase in nursing errors (Dzubak, 2020). Upton (2020) agreed with this and identified a link between unmanaged stress leading to compassionate fatigue and increased mistakes and poor professional judgement. Consequently, patient care is at a significant disadvantage if nurses' health and wellbeing are not managed (Stelnicki et al, 2020). Therefore, SPQDNs must develop the ability to identify compassionate fatigue and burnout, to be better able to help their teams.
What can SPQDNs do to support nurses' health and wellbeing?
It is crucial that SPQDN team leaders have the correct procedures in place to be able to support staff and signpost to resources when they are needed (Glasper, 2019). The Thriving at Work report provides guidance for all employers to support staff with mental health problems and recommends that employers should routinely monitor staff's mental health and wellbeing (Stevenson and Farmer, 2017). It is imperative that SPQDNs have an understanding of and insights into the signs of stress and burnout among their community nursing teams; common signs include irritability, anxiety, being withdrawn and changes in diet (Mind, 2021). By acknowledging these signs of stress, a conversation can be initiated using open questions. REACT mental health awareness training is available from the NHS and is aimed at empowering leaders to support mental health and wellbeing. This training provides guidance on identifying when staff require support and how to initiate conversations (NHS, 2020). Some SPQDNs hold regular one-to-one clinical supervision sessions with their teams. Clinical supervision can be defined as a process of monitoring a nurse's practice and promotes self-reflection (Monteiro Teixeira et al, 2016). Bifarin and Stonehouse (2017) recognised that clinical supervision is overlooked due to the pressures on day-to-day practice, even though it can improve both job satisfaction and wellbeing among nurses, which leads to improved efficiency. Moxham and Gaghan (2015) concurred with this view and recognised the benefits of clinical supervision on staff wellbeing and self-awareness, which contributes to improving the quality of care in all aspects of nursing. Thus, SPQDNs must value and make time for clinical supervision due to its positive outcomes on quality care. Making time for regular supervision should be perceived as just as important as delivering patient care (Bifarin and Stonehouse, 2017). Carrying out regular, one-to-one clinical supervision sessions for community nurses provides staff with the opportunity to talk openly and reflect on their own practice.
Developing resilience in nurses can be perceived as just as essential as promoting wellbeing, to ensure quality care (Traynor, 2017). Resilience can be defined as having the ability to endure setbacks and frustrations and as a process in which someone recovers promptly from a specific incident (Traynor, 2017). Kelsey (2018) argued that not all nurses can be resilient, and a person's own personal circumstances may make this difficult. It is important that SPQDNs recognise this and support their teams with compassion. For a team to function effectively, it must build a strong emotional resilience and emotional intelligence (Kelsey, 2018). Lai et al (2020) stated that good mental health is a result of personal resilience. Raising awareness of self-care and coping mechanisms for stress management within the workplace will help to develop resilience. According to Hudgins (2016), leaders should practice self-care and coping strategies to support reliance in themselves and their team, and a resource to support this is the RCN's Healthy You document (RCN, 2020b). All nurses require access to high standards of mentorship and emotional resilience training to enable them to develop resilience and emotional intelligence (Kelsey, 2017). On the other hand, Traynor (2017) argued that, unless the environment that nurses are working in is improved and the challenges community nurses are facing are addressed, nurses will fail to develop resilience.
Since the COVID-19 pandemic hit, there have been numerous online resources available for health professionals aiming to promote self-care and wellbeing. Free access to wellbeing applications, including Headspace and Big Health, was secured by NHS England and NHS Improvement (NHS England, 2020). Smartphone apps are becoming increasingly popular resources in mental health, and they may be a cost-effective way to improve mental health and wellbeing (Callan et al, 2016). However, Bakker and Rikkard (2018) argued that there is little evidence to support the effectiveness of apps. SPQDNs have a responsibility to manage a district nursing team and ensure that all staff feel valued, and proactively showing interest in staff members' wellbeing achieves this (QNI, 2015). Having an awareness of the online resources available and making these known to the team is an effective way of promoting self-care.
A concept developed in many hospital trusts throughout the COVID-19 pandemic is providing a respite area for staff to use. These respite areas have been called several names, such as wobble rooms, rainbow rooms, safe rooms and/or wellbeing centres (Nair, 2020). The purpose of these facilities is to provide a place where staff can go to remove themselves from the clinical environment to reflect or gain comfort. They create a positive atmosphere and provide opportunities to talk with others in terms of counselling (Blake, 2020). Gasper (2019) recommended that implementing simple measures, such as quiet rooms, food and drink and a space where colleagues can talk and debrief, can have a significant impact on the workforce. However, despite time out being essential for staff, open space is not always available, particularly when social distancing guidance must be adhered to, and it has been a challenge to establish such spaces in community settings. The QNI has recognised the benefits of wobble rooms in acute hospital settings and have established a virtual wobble room that community nurses can access twice a week if they are feeling overwhelmed and require time out. This initiative has received positive feedback: it has helped nurses feel less isolated and well supported in looking after their own emotional wellbeing (Nair, 2020). Alongside the virtual wobble rooms, the QNI also has a 24-hour phone number for community nurses requiring emotional support (QNI, 2020a). However, the virtual wobble room is not accessible 7 days a week and does not give nurses the opportunity to remove themselves from the clinical environment to gain composure in the way that physical wobble rooms in hospital settings do. Thus, this concept needs further development for community nursing services.
Challenges to promoting mental health and wellbeing in community teams
A challenge for SPQDNs is role modelling a good work-life balance; with increasing pressures in community healthcare, it is recognised that SPQDNs often work extra hours and even respond to emails during off-duty hours (McKinless, 2020). Duncan (2020) believed that district nurse leaders have found it increasingly difficult to achieve a work-life balance during the pandemic. Modelling behaviour of working to an excess sets an expectation that the team should replicate this (Ellis, 2017). It can also prevent staff from approaching team leaders, as they are aware of the pressures the latter face daily. Getting to know team members allows SPQDNs to be aware of changes in behaviours and enables them do identify early signs of stress (Ellis, 2017), although this can be a challenge in larger community nursing teams.
Conclusion
SPQDNs are required to manage, teach and support staff, along with managing complex caseloads (QNI, 2015). Team leaders should provide staff members access to resources, such as counselling, and encourage peer support (Stelnicki et al, 2020). Nurses develop the ability to manage emotional stresses in the workplace, but, over time, emotional encounters can lead to burnout and compassion fatigue, which affect patient experience. If leaders fail to care for their staff, then the quality of patient care is jeopardised. The COVID-19 pandemic has impacted community nursing teams and will continue to do so, and this has led to a growing need to provide adequate support to encourage self-care and safeguard staff wellbeing (Blake, 2020). Reducing workplace stress in nursing is challenging for SPQDNs, but it is essential in terms of supporting community nursing teams' mental wellbeing and resilience. By doing so, quality care can continue to be delivered to patients.
KEY POINTS
- Community nurses are experiencing increasing workloads and case complexity among those with at-home nursing needs
- Community nurses are experiencing stress and exhaustion and failing to manage their own health and wellbeing
- Specialist practitioner qualified district nurses (SPQDNs) are responsible for providing a positive working environment and supporting and supervising their teams
- Promoting mental health and wellbeing comes with its challenges and barriers in implementing strategies that are effective.
CPD REFLECTIVE QUESTIONS
- How has an increase in work-related stress impacted patient care in recent months?
- What strategies are effective for nurses to manage their mental health and wellbeing?
- What are the barriers to promoting mental health and wellbeing in a community nursing setting?