The NHS Long Term Plan (NHS England, 2019) acknowledged that nurses were under pressure even prior to the pandemic. Over the past 10 years, recruitment has not met demand, and there were 38 785 nursing vacancies unfilled in December 2019, when details emerged of the first cases of COVID-19 in Wuhan, China (NHS Digital, 2020). During the past 10 years, this decrease in staffing has been reflected in the community nursing specialism, with the number of qualified district nurses reducing by 43% (Queen's Nursing Institute (QNI) and Royal College of Nursing (RCN), 2019).
The pressures of community nursing are recognised as having similarities with but also differences from those faced by nurses working in hospital settings. Although the causes of workplace pressures may not exactly align, absence rates attributed to mental health have been consistently high in all nursing professionals and appear to be increasing (Table 1).
Table 1. NHS sickness absence rates (last accessed February 2021)
| Month and year | Percentage of nursing staff absence attributed to mental health | Increase/decrease |
|---|---|---|
| January 2020 | 24% | — |
| February 2020 | 25.4% | +1.4% |
| March 2020 | 20.3% | -5.1% |
| April 2020 | 17.3% | -3% |
| May 2020 | 25% | +7.7% |
| June 2020 | 30.2% | +5.2% |
| July 2020 | 31.7% | +1.5% |
| August 2020 | 31.3% | -0.4% |
| September 2020 | 28.2% | -3.1% |
The causes of stress within district nursing were examined and acknowledged as individual to the role (QNI and RCN, 2019). Financial budget constraints, high workloads and unlimited caseload capacity have long been considered to cause frustration, and, more recently, the additional burden of IT administration with inadequate equipment has increased the pressures further (Box 1).
Box 1.Stressors in community nursing
| Continuous change |
| Poor referrals |
| Lack of capacity to cover absence (including backfill) |
| Lack of support |
| Poor management |
| Cuts to staffing/allowances/uniform/parking |
| Career uncertainty |
| Unpaid hours |
| The unlimited caseload capacity |
| Isolation |
| Heavy workload |
| Administrative burden, including frustration with IT |
Queen's Nursing Institute, 2016
The pandemic
During the COVID-19 pandemic, there has been rapid expansion of the community nursing caseload. Many of the specialist services have reduced or withdrawn face-to-face care to enable the vulnerable to shield, and ambulatory care services, such as treatment rooms, were closed. These factors, combined with increased volume of discharges from hospital, put additional strain on an already pressured service (Green et al, 2020). Relocation of staff from these services into community nursing teams increased workforce numbers, although this required careful management of resources by the district nurse leader, as many were restricted to only working within their field of expertise.
This rapid expansion led to an increase in visits for skilled community nurses and an increased acuity of caseload. There was a requirement to reduce pressure on secondary care through admission avoidance and, therefore, acceptance of rapid discharges. During this time of adaptation to meet the needs of the patients, there was little time to consider the effect on the workforce. Teams were encouraged to focus on recruiting into any available vacancies to ensure that well-resourced teams can support one another and absorb fluctuations in caseload levels (Bradby, 2020). However, despite having a fully staffed team, there was always the risk that staff were required to self-isolate. Many nurses contracted the virus or had family who were unwell, and, in some areas, several members from the same team were absent for up to 14 days. This required district nurse leaders to use cross-locality working, with nurses often working in unfamiliar locations and, in areas of large outbreaks, to maintain safe service delivery. The sharing of resources enabled allocation of routine daily visits, but posed a challenge to the district nurse when trying to manage skill mix in relation to caseload acuity. There was rarely capacity to accommodate many unscheduled visits, and, as such, work had to be carefully prioritised and deferred, if necessary, to ensure patient safety.
With the challenge of increased workload, depleted teams and reducing the risk of nurses contracting COVID-19, there was a rapid shift to remote working platforms, such as Microsoft Teams, and remote consultation technology. The QNI (2018) identified that IT is often a source of frustration for community nurses, especially when there is inadequate training and support when initially introduced. Unfortunately, due to the need for quick adaptation at the beginning of the pandemic, there was no time for gradual introduction to the new ways of working. Meetings and huddles moved online, application-based platforms were used for nurse-to-nurse communication, and there was a sudden reduction in physical interaction with the team. All face-to-face contact between nursing colleagues took place while wearing full personal protective equipment, which caused increased levels of stress, especially when facing emotionally challenging situations and being unable to debrief with other professionals who understand the role (Allan and Elliot, 2019). Even at present, there has been little opportunity to examine how individual nurses felt about the changes. Bradby (2020) supported the findings of the QNI that technology remains to be an additional source of stress to nurses and acknowledged that managing stress in community nursing continues to be a challenge.
Wellbeing
The term ‘wellbeing’ is subjective and highly dependent on personal perspective. Allin and Hand (2014) explained that it is a broad concept that is often closely linked with terms such as quality of life and life satisfaction. ‘Wellbeing can be understood as how people feel and how they function, both on a personal and a social level, and how they evaluate their lives as a whole’ (Michaelson et al, 2012). The pressures experienced by nurses in their personal lives were unprecedented during the pandemic. Three-quarters of the NHS workforce are female (NHS, 2019), and this is mirrored in the community nursing workforce, 71% of whom are over the age of 40 years (QNI, 2009). The pandemic posed many multifaceted challenges, with many nurses having family and caring responsibilities in addition to professional concerns. Kennedy (2020) explained that many were fearful of becoming infected and posing a risk to their families. They were also likely to be affected by the lockdown restrictions in place, which may have weakened their support networks, including the childcare provision on which they rely to be able to attend work. Many families also faced a change in financial situation, with possible loss of household income; despite a 12% wage reduction in real terms in the last decade, nurses' salaries may now be the main family income source (Buchan et al, 2017).
Prior to the pandemic, nurse suicide rates were already 23% higher than those of the average UK citizen (Office for National Statistics, 2017). NHS staff were feeling the strain of working in an organisation that had not offered the flexibility and adaptation required to meet their changing needs throughout their working lives (NHS, 2019). The community nursing service had already demonstrated flexibility, adaptability and resilience in managing growing caseload numbers (QNI, 2018). With COVID-19 came investment in the IT infrastructure, and the improved connectivity enabled nurses who were shielding or self-isolating to assist the team remotely while working from home. This new way of working allowed the nurse to help the team while following Government guidelines. They were able to answer emails, make calls and complete referrals so that visiting nurses did not need to complete these. Despite this helping to reduce pressure on the team, it may have negatively impacted the wellbeing of the nurses working from home. Mendes (2018) explained that the blurring of the line between work and home lives may have detrimental effects on both personal and professional lives. Nurses working at home need to have a clear understanding of work time and when this should be stopped. Cole-King and Dykes (2020) warned that burnout is an ever-present risk throughout this pandemic for all nurses, with the combined demands of caring for family, colleagues and patients. Nurses having to work from home or unable to support the team when knowing they are struggling are at risk of altruistic distress through feelings of guilt.
Evidence has been examined relating to pandemic experiences, and it has been predicted that frontline health workers are likely to experience mental distress of some form due to their role (Marshall et al, 2020). However, Maben and Bridges (2020) suggested that, perhaps, the feelings experienced by the nurses during the pandemic do not necessarily predict poor mental health outcomes, and caution should be exercised around wanting to label what may be normal reaction to an abnormal period in life. A literature review relating to stress in district nursing concluded that, through promotion of healthy coping techniques, adequate support, appropriate training and ensuring workload is managed, the negative impact of stress on the community practitioner can be reduced (McKinless, 2020).
There have been rapid advances in wellbeing services provided to nurses during the pandemic, although these are often difficult to access if working remotely. Hospital staff have seen the provision of decompression rooms, which have been a valuable source of respite to employees. Mendes (2017) advocated the use of these rooms as a stress-free area, which is useful for mindful practice and reflection, but also recognised that this is not practical in the community setting and that, perhaps, training should be provided to community staff to allow them to self-decompress in a variety of locations throughout the working day. Referral to occupational health services and associated wellbeing resource information is also often inaccessible without the use of office-based intranet services. Prior to the pandemic, the nurse would be able to source this information easily, but during the pandemic, with limited and time-restricted access to office facilities, this has become more difficult.
The district nurse as a leader
The qualified district nurse has unique skills and knowledge which allow them to lead a team of professionals with the goal of admission avoidance and enabling the smooth transition of patients from hospital to home (QNI, 2016). The pandemic has been a time of huge pressures, but district nurses have demonstrated their ability to adapt, evolve and prioritise. The important next steps must include using the new technologies available to benefit all aspects of nursing, including caring for teams and nurses. Hospital-based nurses often have access to intranet services, wellbeing rooms created as safe spaces and occupational therapy resources on site (Green et al, 2020).
Maben and Bridges (2020) explained that there are many ways in which individuals can contribute to team wellbeing (Table 2). The district nurse as a team leader can be supportive by maintaining communication with the team and managing the workload through careful triaging and allocation of resources. Being visible and promoting clear and honest communication is vital, as well as referring to support services as needed. The district nurse should ensure that the team is enabled to communicate openly and is aware that its wellbeing is a priority. Being approachable provides the opportunity to identify nurses who are feeling overwhelmed who can be signposted to appropriate services. It is also imperative that senior nurses feel supported and be a role model for self-care by encouraging the use of management techniques, such as mindfulness. Gazmuri (2018) suggested mindfulness in practice to improve concentration in times of high pressure and to calm the mind.
Table 2. NHS sickness absence rates (last accessed February 2021)
| Individual/peer | Teams | Leaders |
|---|---|---|
| Meet own basic needs | Respect individuality | Be visible and approachable |
| Have breaks | Check on each other | Regular communication |
| Use calming strategies | Support new members | Recognise team achievement |
| Meditation/mindfulness | Give recognition | Remind staff that wellbeing is priority |
| Buddy system | Provide welcoming break room | Facilitate access to support available |
| Peer support conversations | Weekly review meetings around wellbeing | Monitor psychological health |
| Support new staff | Create opportunity for small online groups | Provide training to new staff |
| Work shorter shifts | Buddy new staff with more experienced team members | Ensure management available outside work hours |
| Rest between shifts | Boost each other's wellbeing | Shorter/flexible shifts |
| Check in on wellbeing at end of each day | Remove non-urgent business | |
| Rotate staff from high stress areas | ||
| Share successes | ||
| Plan for recovery after COVID-19 | ||
| Consider own need for safe space |
The World Health Organization (2020) provided guidance for managers on how to support metal health and psychological wellbeing during the pandemic (Box 2). The emphasis shifts clearly to the ways in which the manager can reduce the burden on the nurse. Now, many months into the pandemic, nurses have adapted to the IT resources at their disposal and are able to communicate more effectively using these platforms. The use of chat groups for non-patient-related communication has been embraced, which allows staff safety with regard to regular check-ins, requests for support and peer communication. Murphy (2019) found that, through using online group chat, there was improved wellbeing among the team; they felt less isolated when working alone, and they were able to interact easily without being distracted from busy workdays by multiple phone calls. The importance of breaks and flexible work patterns is also emphasised, and, as such, the district nurse should endeavour to meet work pattern requests when able to maintain safe staffing, and actively encourage the team to take their allocated breaks (Maben and Bridges, 2020).
Box 2.Guidance for managers
| Provide good quality communication and regular updates |
| Rotate stressful roles |
| Encourage and monitor breaks |
| Implement flexible shifts |
| Buddy system |
| Use digital methods to keep in touch |
| Allow time for peer support to happen |
| Ensure and facilitate access to mental health and psychological support |
| Avoid repeated crisis responses |
| Focus on long-term occupational capacity |
| Remember to self-care. The manager is a role model in positive stress management |
World Health Organization, 2020a
Resilience training is often cited as a tool to manage the stress experienced by nurses during the pandemic. It has been proposed that, by openly acknowledging the difficulties being faced both personal and professionally and providing resources and support to manage these, the district nurse can foster resilience in the team (Kennedy, 2020). Conversely, Maben and Bridges (2020) argued that resilience is an individual trait and, therefore, highlighting this fosters the notion that this is the individual's responsibility alone. By this logic, staff who may have attended the resilience training who are feeling overwhelmed by working extended hours in emotionally challenging situations may feel that they have personally failed. Therefore, it is to be considered that resilience is a mutual responsibility of the individual and the organisation.
The challenges
It has long been recognised that nurses whose wellbeing is negatively impacted by their work will likely not be able to provide the best possible care to their patients (Mendes, 2018). Prior to the COVID-19 pandemic, district nurse leaders were already facing increasing pressures relating to skill mix, geographical challenges of caseloads, growing workload and increasing acuity of patients. In the community service, there is no limit to admission numbers, and, therefore, stringent caseload management has always been key in minimising the waste of valuable resources. It remains imperative that referrals are triaged by the district nurse who can assess the timescale required for initial contact and ensure that the visiting nurse has the relevant skillset to complete the visit without feeling overwhelmed or unsupported. The prevention of inappropriate and unnecessary additional workload and avoiding misallocation versus skill mix has been key in mitigating the pressure on community nursing teams (Chilton, 2017).
Additionally, during the pandemic, there were the new challenges of rapidly increasing caseloads, skill mix limitations, inexperienced teams with redeployed members and the difficult task of ensuring correct allocation of patient needs to nurse competency (Gould, 2017). These factors caused additional stress to both the district nurse and the team. As a leader, the district nurse has a moral and ethical duty to protect their team from physical or psychological injury, which may occur through working excessive hours in periods of high stress (Duncan, 2019), and to ensure that work is allocated only to someone who is trained and competent to complete the task (RCN, 2016).
Conclusion
The mental health and wellbeing issues faced by nurses are not entirely new, but the pandemic has highlighted these. Historically, the district nursing leader has tried to mitigate the impact of caseload pressures on team wellbeing through protection of break times, flexible working patterns, team connections and careful consideration when allocating workload. The COVID-19 pandemic placed additional strain upon the already maximised service by forcing community professionals to work in isolation from their teams with increasingly busy and complex caseloads.
Positively, the pandemic has expedited progress towards the vision outlined in the Long Term Plan (NHS England, 2019) and highlighted the need for a focus towards addressing the psychological requirements of the nursing workforce. The community nurse has specific wellbeing needs that differ from those of nurses in the hospital setting. The new and improved IT infrastructure has been used to promote team connections when working in isolation. The use of online platforms for non-patient-related communication has been used successfully to foster open dialogue and remind the community nurse that they are not alone.
By facilitating overt recognition of the needs of the community workforce, the pandemic has positively influenced a shift towards addressing this, rather than relying solely on the district nurse to mitigate daily pressures. There is now ongoing innovation and progress relating to decompression training, self-referral services and telephone support services that are specifically for the community team. It has taken a pandemic to elevate the importance of nurse wellbeing, but, as compassionate leaders of teams, it is district nurses' duty to make efforts to build on the progress made.
KEY POINTS
- Nurses have consistently high levels of sickness related to anxiety, depression or psychiatric illness
- Resources to support mental wellbeing are often inaccessible to nurses working remotely with limited access to intranet systems
- It is important that the district nurse considers the mental wellbeing of the team and the constraints of skill mix when managing the workload
- The requirement to support wellbeing in community nursing is not new, but has just been brought to the fore by the pandemic
CPD REFLECTIVE QUESTIONS
- How can we support one another while working remotely?
- If you or a colleague were feeling in need of support external to your team, do you know where you would go?
- What does wellbeing mean to you?
- How do you decompress after a busy day?