Community nursing: another front line

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The main difficulty we have is the fact that our doors are always open. We are unable to say sorry we are full…

Keep Our NHS Public has received this heartfelt account from an NHS nurse working at the interface between hospital care, community health and social care. Often ignored or undervalued, teams of community staff are on a different front line, working in small teams, under-resourced and hit by high vacancies and cost-cutting, and often working on their own in people’s homes with high levels of pressure and clinical responsibility. They are delivering life-maintaining essentials such as daily insulin injections and responsibility for the support of patients at the end of their life. Faced with demands to maintain safe services during strike days, they are already running a service that our writer regards as unsafe and unfair. She is a Clinical Nurse Lead in a community nurse team working for an NHS trust.

Community health services under immense strain

With the RCN strike now underway, I thought I would share this insight into how community nurses are coping. Community teams are so often forgotten. Alongside our large patient case-load requiring regular home visits for care (sometimes several times per day), our community nurse team gets new referrals from acute trusts. These come without any notice, for a next day visit or even same day sometimes and often they are very poorly patients who are going home for end-of-life care. With growing pressures on the wards, we have noticed discharge planning is often terrible. We are concerned this will get worse in winter pressures. We cover 365 days a year 8-6pm linked into an overnight service but our team is small and diminishing.

The main difficulty we have is the fact that our doors are always open. We are unable to say ‘sorry we are full’ – we have to accept any new patient that needs our services, even when we may only have two nurses and two health care assistants (HCAs) at full capacity and relying on help from colleagues in the second team to manage our pre-existing patient caseload. Just to cover our urgent and highest priority patients, we need a team of five – registered general nurses (RGNs) and HCAs – and two seniors. A fully staffed team needs seven staff and two seniors. The only waiting list we reluctantly use is for continence issues. Anything else has to be triaged and prioritised alongside all our current patients, so that we see them in order of priority. Our insulin-dependent diabetic patients get the best care as they MUST be seen, so they will take priority. The only other new referrals we are able to prioritise are end-of-life care and symptom management in last days, and urine catheter problems.

We have just been informed about a new government initiative for ‘virtual wards’, which we are told will be staffed by volunteers from community services. (But no one has volunteered, and we have been told staff members may be put forward.) The health ministers who have started this project are simply out of touch – we cannot spare anyone.

On strike days we will have to cover our highest priority visits and anything urgent that gets called in. It takes a minimum of five staff for around 40 visits, and two seniors to allocate the following day’s work and co-ordinate the shift. That is a normal day for us. So, I cannot see how we will actually be able to release any staff to the picket line?

I can’t imagine A&E or the ward will be much better.  Some of my nurse colleagues feel they cannot strike. Some simply can’t afford to lose a day’s pay. Everyone agrees the current service is not safe.  (Just to say – when I wrote this I assumed we would strike – but it has not happened in this trust as yet – we were informed it could go ahead in the next days announced for the New Year – if there is no agreement made)

However, most staff are not asking for more money just for themselves, but because we cannot afford to lose any more nurses. We already have four full-time nurse vacancies – some of these have been unfilled for more than a year. Adverts are out but no one applies. We have had some luck recruiting HCAs but they are mostly inexperienced and require a lot of time to train, They are then repeatedly seeing patients for things which a qualified nurse should be doing, and this presents a safety risk

My team’s nurses regularly have had to deal with critical and demanding scenarios on walking into a patients home:

Patients in an extreme state of undress, mentally distressed and even with weapons in the room; patients who have attempted suicide knowing our team would find them rather than a family member; patients who have died alone in neglected state, or others found at home in need of resuscitation; serious safeguarding concerns unaddressed, leaving patient and staff vulnerable; and multiple occasions of patients being discharged home to completely unsafe environments, without food or adequate clothing at home. Staff have often made decisions to spend their own money to buy emergency supplies for these patients.

Palliative care
Palliative care is an essential service for patients at the end of their lives and so often delivered in the community in recent years, especially since COVID. People are so much more likely to choose to die at home and want to avoid being in hospital at all costs.  This vital health care has increased and is part of the current pressures. District nurses (DNs) are the ones in my area who are called out to administer end-of-life care including injections, to provide pressure care and equipment and to verify those expected deaths.  The hospices are involved but have clear boundaries and if they say ‘we are at capacity’ they have no-one to send out.  DNs by comparison will never say no to a patient at the end of life with symptoms needing palliative care. They just have to cancel another patient’s visit to fit these in. Or on many occasions compassionate nurses will just say ‘I will stay late’, ‘I’ll finish my notes at home’. I have seen many of my colleagues, after months of taking their work home with them, think ‘I can’t do this any longer, I’m too stressed… I’m going to look for a new job… I’m thinking of leaving nursing altogether’.

It has become so stressful for my colleagues struggling to cope. Inevitably we have seen an increase in human errors and feel that we are constantly putting our registration at risk – there is always the chance that there will be a serious incident at some time.

We are trying to keep morale up at present but it’s tough, I don’t know what the future holds, but something’s got to change.

Written by a Clinical Nurse Lead in an NHS community nurse

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