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The pandemic has placed unprecedented demands on nurses – and their responsiveness has come at a cost to wider healthcare and their own well-being
It is a year since the UK first went into lockdown and society was upturned by the pandemic.
Nursing Standard. 36, 4, 14-17. doi: 10.7748/ns.36.4.14.s11
Published: 31 March 2021
For the NHS and social care providers, that has meant coping with two deadly waves while trying to keep services running for other patients.
Nurses have been at the forefront of this, from caring for the sick to overseeing the reorganisation of services and being redeployed, or managing redeployment.
RCN general secretary Dame Donna Kinnair calls it one of the toughest periods the profession has faced, but one in which nurses have risen to the challenge.
‘The pandemic has demonstrated the best of nursing,’ Professor Kinnair says. But, she adds, this has come at great personal cost.
‘Some have paid the ultimate price. Others are facing burn-out and what they need now is the opportunity to rest and recover.’
So, what has it been like for those on the front line? And how has nursing changed during the year of COVID-19?
Hospitals have been at the forefront of the fight against the virus.
‘I have done eulogies for five staff – and it never gets easier’
Anna Stabler, executive chief nurse, North Cumbria Integrated Care NHS Trust
There have been more than 450,000 admissions, with daily numbers peaking in the first wave in April 2020 at more than 21,000, before hitting 39,000 in the second wave in January 2021.
Hospitals have been completely overhauled, with red, amber and green zones established for patients who are COVID-19-positive, suspected or negative.
Emergency departments have been split in two, with separate entrances created. Inside, wards have been re-purposed and non-urgent work scaled back and moved off-site in some cases.
North Cumbria Integrated Care NHS Trust executive chief nurse Anna Stabler, who oversees nursing teams at two acute hospitals, says there has been ‘major upheaval’.
‘Staff have been fantastic. They have really stepped in when needed. We redeployed theatre staff into ICU, respiratory nurse on to wards along with school nurses and health visitors in the first wave.’
Ms Stabler says seeing the scale of death has been hard for staff.‘The second wave was worse – we had over 300 patients in at one point, that’s half of our beds and twice the number from the first wave. I was really worried.’
But she says perhaps the most difficult aspect has been losing colleagues – it is thought almost 1,000 UK healthcare workers have died of COVID-19.
‘We have had five members of staff die with COVID – three of them nurses. They are our family – our NHS family. We have had a minute’s silence for each and I have done eulogies. I’ve done it five times – and it never gets any easier.’
Critical care has, of course, been at the sharp end of this.
The total numbers in intensive care – both COVID-19 and others – peaked at almost 5,500 in England in late January 2021, nearly 60% above the occupancy level seen the previous winter.
British Association of Critical Care Nurses chair Nicki Credland says coping with such demand and seeing so many people dying has caused both ‘physical exhaustion and psychological trauma’ among members.
‘Staffing ratios have been dire throughout both surges – from one-to-one to one-to-four in some areas.
‘What is often overlooked is the impact of no visiting. It has caused increased stress to nursing staff who have taken this element of emotional responsibility in place of the family.’
She says the second wave was probably worse as there was less support because other staff were not redeployed in such significant numbers and other services did not stop running to such an extent.
‘What is often overlooked is the impact of no visiting. It has caused increased stress to nursing staff who have taken this element of emotional responsibility in place of the family. It’s taken its toll on staff. We are seeing nurses struggling with PTSD – it is very concerning.’
Staff nurse Areema Nasreen was one of the first nurses in the UK to die after developing COVID-19.
The staff nurse at Walsall Manor Hospital died early in April 2020, having spent weeks in intensive care. She was just 36 and the mother of three children.
To honour Ms Nasreen’s memory, her family, the senior leadership at Walsall Manor NHS Trust and the hospital’s charity, Well Wishers, have worked together to set up a scholarship in her name to help someone become a nurse. There have been scores of applications, with the chosen person due to start training in September. The scholarship is aimed at a person living locally who would have struggled financially to become a nurse.
Ms Nasreen had worked her way from a role as housekeeper at the hospital to become a nurse. Her sister, Kazeema Afzal, who herself works as a healthcare assistant at the trust, says: ‘My sister was so special and everyone who met her or worked with her felt the same way.
‘Areema’s passing has been a big loss for our family and the community – each day gets worse. But my family does feel so much better looking forward to seeing the scholarship in her name.
‘Areema was inspirational and people did want to be like her, which is what this scholarship is all about. It’s about keeping her memory going.’
For nurses working in the care sector, there has been quite a striking difference between the two waves.
National Care Association director Anita Astle says: ‘The first wave was horrendous.’
Ms Astle, a nurse by background, is managing director of Wren Hall nursing home in Nottinghamshire.
‘One minute we were preparing for it and within days we were living it,’ she says. ‘It happened so fast, but all the focus was on the NHS and hospitals. We felt abandoned.’
During the first wave, much of the focus from government and NHS leadership was on acute care and managing those patients – many community nurses were redeployed.
She adds: ‘Our sector relies on support from community NHS services, but that disappeared in the first wave. I guess they were pulled into supporting hospitals. But it really felt like we were on our own.
‘We could not get hold of PPE– I remember ringing round for days on end trying to get FFP3 masks and everywhere said no. We could not get clear guidance about what we needed to do.’
Ms Astle says in the second wave the sector has coped much better.
This has been borne out by statistics – 40% of COVID-19 deaths in the first wave in England and Wales were of home residents, compared with 26% in the second wave, according to a Nuffield Trust analysis of Office for National Statistics data.
‘Over the summer care home nurses and managers had a chance to talk and meet at conferences,’ she adds.
‘The advice and support improved – the importance of zoning and cohorting is now recognised. But that means more staff are needed.
‘We have still seen outbreaks in care homes, it has not been possible to remain unscathed, but on the whole it has been much better.’
Cancer has been one of the services the NHS has been told to prioritise even during the two peaks of COVID-19.
In the first wave, the number of patients coming in for urgent checks and starting treatment dropped – and it was not until last autumn that they started to get back to pre-pandemic levels.
The numbers held steady during the second wave. But that has only been made possible by overhauling the way services are run.
During the first wave, cancer treatment was centred on some of the major sites with spare private sector capacity also used.
Over the summer, cancer services were able to reconfigure. Surgery was able to return in many hospitals which had appropriate space and more theatres, and where COVID positive and negative patients could be easily kept apart.
But nurses have also had to innovate. Clinical nurse specialists have started doing virtual appointments for regular check-ups and rehab. Chemotherapy has been taken out into the community, thanks to greater use of home-based treatments and mobile chemotherapy clinics.
UK Oncology Nursing Society president-elect Mark Foulkes says it has been a ‘complete re-organisation’.
He says moving inpatient wards out to the private sector made things very difficult, with everything from ordering a test to getting an opinion from a cardiologist taking more time.
COVID-19 deaths among health and care workers in England, Wales and Scotland to 11 March 2021
454,085 admissions to UK hospitals for COVID-19 to 22 March 2021
40% of people who died with COVID-19 in the first wave of the pandemic lived in care homes
Source: Nuffield Trust
And, he points out, cancer services still had to cope with redeployment, particularly during the first wave when clinical nurse specialists were moved into areas such as palliative care and intensive care.
‘It has been better during the second wave, but in some hospitals staff have still been moved.’
That is why the first wave remains the most troubling for him.
‘We had some very difficult decisions, especially early on. Telling palliative care patients they cannot continue to be treated or delaying someone’s surgery was an incredibly hard thing to do and distressing.’
‘Community nursing does not attract much publicity, as it happens behind closed doors. But we have responded quickly and courageously. We are as fatigued as our hospital colleagues’
Gail Goddard, district nurse and member of the RCN community and district nursing forum
Cancer services also face the prospect of the long tail of COVID-19 – the cases that have yet to be diagnosed.
Macmillan Cancer Support research suggests there may be as many as 50,000 cases across the UK that would have been diagnosed normally if it was not for the fall in numbers coming forward via GPs, screening and A&E.
Queen’s Nursing Institute chief executive Crystal Oldman says the focus on hospitals has masked the role nurses in the community have played.
Dr Oldman says: ‘District and community nurses have been treating as many, if not more, patients with COVID-19 – those who are discharged from hospital and those that never made it to hospital. We forget that too easily.
‘It has been hard. In the first wave, district nurses were really struggling to get hold of PPE, while staff such as health visitors and school nurses have been redeployed often into quite difficult and challenging situations for them.’
Gail Goddard, a district nurse in London and member of the RCN’s community and district nursing forum, agrees the role she and her colleagues have played has sometimes been overlooked.
‘Community nursing does not attract much publicity or interest as it happens behind closed doors.
‘We have responded quickly and courageously to all the challenges, constantly changing and flexing the way we work to meet the needs of those who need us, but we are as tired and emotionally fatigued as our hospital colleagues.’
Ms Goddard says this is because they have had to provide more end of life care as well as coping with a ‘large increase’ in referrals of frail older people, some of whom are patients recovering from COVID-19, while others have become more unwell with other conditions but have not sought or received the help they needed.
Another element of the community nursing family that has not received the attention it perhaps deserves is general practice nursing.
RCN professional lead for primary care nursing Heather Randle says: ‘Right from the very beginning general practice nurses have played an important role. They’ve been there throughout, providing a regular service. Their doors have always been open.’
And, what is more, she says, they are now at the forefront of the undoubted success story of the pandemic.
Up and down the country, it is practice nurses who are helping lead the vaccination teams in the local clinics, as well as carrying out many of the jabs.
‘They are leading the roll-out – and none of this has been at loss of other services.’
COVID-19: Remembering the nursing staff who lost their lives rcni.com/nurses-tribute