Never before has there been such a nationwide focus on our NHS; daily TV briefings with record breaking audiences have focused on the spread of infection, ITU admissions and the tragic rising death rates. Silently, in the background, District and community nursing (DN) teams have continued to deliver complex care within patients' homes. In fact, demand for their care has increased, with many reporting the need to undertake many more visits each shift. Visits are complicated by pandemic-related demands including donning and doffing of PPE, and the need to communicate whilst wearing a mask that makes the provision of key information challenging, laborious and time consuming.
There have been positives from this new way of working; increased self-management with engaged, confident and concordant patients as partners in their care. Some teams have welcomed deployed staff members from services that were ‘stood down’, leading to enhanced clinical collaboration, reciprocal learning, increased bonding and stronger professional relationships. Others, however, have not had additional staff but have continued to deliver increased levels of care often with a smaller team due to shielding.
The rapid implementation of innovative technology has underpinned the adaptation of clinical teams to ‘new ways’ of working, with the skills of virtual triage perfected, complex discharges facilitated and patient outcomes improved. Technology has supported positive working; weekly ‘virtual’ chats with Primary Care Networks, video conferences with GPs in the patient’s home and care homes support via video consultation, augmenting staff support at a time when only essential visits were permitted. Technology has enhanced communication between team members; handovers, workload allocation and patient reviews have all been transitioned to online with time saving and improvements to peer support. Indeed, the pandemic has highlighted the innovative, amazing and adaptive workforce within community nursing, but this has not been without personal impact; 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.
There have also been negatives. DN team visits have been extended to provide psychological support to manage the impact of lockdown and the loneliness that many patients are experiencing. 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 that their care be delivered at home. This reduction in service provision has varied geographically but, for some, has resulted in an exponential increase in caseload demands. Many patients have refused admission due to concerns of the risks posed by COVID-19, preferring to remain at home for their care; including those with long term conditions, the younger acutely ill and those approaching end of life. In some areas, General Practice have continued their provision of care in a revised manner; however, some surgeries have restricted attendance and minimised home visits. Where GP access has been reduced, community nurses have experienced challenges to liaise with GPs, making 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 DN who is left to minimise the damage such an approach to delivering bad news invariably causes. Changes to service provision have exposed a crucial need for general practice and community nursing services to work together more closely to optimise the care provided for patients.
Considerable increases to those requiring palliative care at home are evident, often presenting to DN teams in the final days of life. Most often not Covid-19 related cases but characterised by late presentation, 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 impacted community services. Challenges have been exacerbated by delays to vital equipment, time required to don and doff and the sheer emotional challenge of communicating with those at the end of life whilst wearing a mask.
DN teams are concerned about the ongoing impact of health care access during COVID-19. Risks of 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, rest assured, these patients are still out there, they have not opportunely ‘gone away’ whilst Covid-19 distracted us, they will slowly but surely become apparent. As the lockdown eases, teams report increasing requests for visits from patients with a ‘new’ wound or pressure damage; often initial attempts to self-manage have failed and their condition has deteriorated. These patients may represent the ‘tip of the iceberg’, and as the fear of contact with health services diminishes and a perceived return to ‘business as usual’, numbers will increase. Teams report increased referrals of complex patients and, as the pressure of the pandemic lifts, increasing numbers of patients are being discharged, post-Covid, deconditioned, immobile and dependent; these are our new long-term sick.
Daily Government updates have stopped, the constraints of lockdown are being reduced and there is talk of services ‘reopening’. DN services never closed; indeed, they are busier than ever. Teams are concerned that the spotlight provided by COVID-19 on their services will diminish and community nursing will return to pre-Covid ‘Cinderella days’; a service delivered behind closed doors, unseen and not valued. DN staff are exhausted, morale is low; now is the opportunity to recognise the essential service provided by our teams. During the pandemic, community nursing expanded their service to protect secondary care, it allowed 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 their life. Moving forwards, demands on community nursing are unlikely to abate; this is the opportunity for effective staffing, appropriate funding and suitable resourcing of District Nursing.
There have been positives from this new way of working; increased self-management with engaged, confident and concordant patients as partners in their care. Some teams have welcomed deployed staff members from services that were ‘stood down’, leading to enhanced clinical collaboration, reciprocal learning, increased bonding and stronger professional relationships. Others, however, have not had additional staff but have continued to deliver increased levels of care often with a smaller team due to shielding.
The rapid implementation of innovative technology has underpinned the adaptation of clinical teams to ‘new ways’ of working, with the skills of virtual triage perfected, complex discharges facilitated and patient outcomes improved. Technology has supported positive working; weekly ‘virtual’ chats with Primary Care Networks, video conferences with GPs in the patient’s home and care homes support via video consultation, augmenting staff support at a time when only essential visits were permitted. Technology has enhanced communication between team members; handovers, workload allocation and patient reviews have all been transitioned to online with time saving and improvements to peer support. Indeed, the pandemic has highlighted the innovative, amazing and adaptive workforce within community nursing, but this has not been without personal impact; 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.
There have also been negatives. DN team visits have been extended to provide psychological support to manage the impact of lockdown and the loneliness that many patients are experiencing. 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 that their care be delivered at home. This reduction in service provision has varied geographically but, for some, has resulted in an exponential increase in caseload demands. Many patients have refused admission due to concerns of the risks posed by COVID-19, preferring to remain at home for their care; including those with long term conditions, the younger acutely ill and those approaching end of life. In some areas, General Practice have continued their provision of care in a revised manner; however, some surgeries have restricted attendance and minimised home visits. Where GP access has been reduced, community nurses have experienced challenges to liaise with GPs, making 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 DN who is left to minimise the damage such an approach to delivering bad news invariably causes. Changes to service provision have exposed a crucial need for general practice and community nursing services to work together more closely to optimise the care provided for patients.
Considerable increases to those requiring palliative care at home are evident, often presenting to DN teams in the final days of life. Most often not Covid-19 related cases but characterised by late presentation, 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 impacted community services. Challenges have been exacerbated by delays to vital equipment, time required to don and doff and the sheer emotional challenge of communicating with those at the end of life whilst wearing a mask.
DN teams are concerned about the ongoing impact of health care access during COVID-19. Risks of 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, rest assured, these patients are still out there, they have not opportunely ‘gone away’ whilst Covid-19 distracted us, they will slowly but surely become apparent. As the lockdown eases, teams report increasing requests for visits from patients with a ‘new’ wound or pressure damage; often initial attempts to self-manage have failed and their condition has deteriorated. These patients may represent the ‘tip of the iceberg’, and as the fear of contact with health services diminishes and a perceived return to ‘business as usual’, numbers will increase. Teams report increased referrals of complex patients and, as the pressure of the pandemic lifts, increasing numbers of patients are being discharged, post-Covid, deconditioned, immobile and dependent; these are our new long-term sick.
Daily Government updates have stopped, the constraints of lockdown are being reduced and there is talk of services ‘reopening’. DN services never closed; indeed, they are busier than ever. Teams are concerned that the spotlight provided by COVID-19 on their services will diminish and community nursing will return to pre-Covid ‘Cinderella days’; a service delivered behind closed doors, unseen and not valued. DN staff are exhausted, morale is low; now is the opportunity to recognise the essential service provided by our teams. During the pandemic, community nursing expanded their service to protect secondary care, it allowed 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 their life. Moving forwards, demands on community nursing are unlikely to abate; this is the opportunity for effective staffing, appropriate funding and suitable resourcing of District Nursing.
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