As part of the NHS response to Coronavirus (COVID-19), we have made changes to the services we provide
A district nurse’s day is just like the weather; it’s unpredictable! As I look out of the window in the morning I question, will I become a drenched in the heavy wind and rain which had been forecast or will I remain dry in the ‘20%’ of predicted sunshine? The changes in the weather can impact on the day of the district nurse, but to be on the safe side I opt for my raincoat.
It’s 8.15am on my early shift and I am responsible for holding the Team’s mobile phone. My day starts by embracing digital technology from home as I take handover from the night staff via Microsoft Teams. The night team have nothing too significant to hand over. The phone rings, a community staff nurse is reporting that she has a temperature, due to COVID-19, and she will have to self-isolate pending her swab results. I reassure her, encouraging her to rest and take care of herself and then I reschedule her list of patients, prioritising the care of the most vulnerable. I quickly pack away my laptop, pick up my mobile phones, my lunch, my raincoat and I wave goodbye to the dog as I set off to my first patient.
As I start on my journey the phone rings again; answering hands-free, I hear the tearful voice of a patient’s wife who is calling on behalf of her husband who is vomiting. I’m only around the corner, so I quickly make a call to ask a staff member to visit my planned patient who requires insulin administration. I arrive at the elderly couple’s house and quickly don my PPE; the wife has tears in her eyes and says, ‘he’s been like this all night, but I didn’t want to bother you’. I reassure them both that I was here, and I would help them the best that I can. After administering a prescribed anti-emetic injection to manage the gentleman’s sickness, I sit with the couple to reassure them both we are a phone call away and would always come, no matter what the time they needed us. The gentleman reaches for my hand and says, ‘you have many more patients to see so I can wait’. The wife is upset and goes on to say how lonely they both are during lockdown; before lockdown, she said, ‘we always had an open door with many visitors each day’. I’m faced with a frequent dilemma - how can I just pack up leave, right at this second? Luckily, at that moment, the care agency staff arrive and, as much as I want to stay and chat, I know I need to contact the team leader and head back to the office to pick my diary and dressings for the rest of my visits. I contact the hospice nurses involved in the gentleman’s care to update her and request a prescriber review; she says she would be visiting later today to review.
It is a big responsibility working with such autonomy in the community and taking responsibility for making decisions about my patient’s care. I am passionate about my role as a district nurse and couldn’t imagine doing anything else. The community has opened up so many opportunities for me; I have developed new skills and continue to develop, even undertaking the specialist practitioner course at the moment. I am directly involved in shaping self-care for my patients with long term conditions. Indeed, I am humbled by my role, but positive, empathetic and competent in delivering holistic and compassionate care to my patients.
The caseloads of all district nurses have increased significantly in recent years, both in terms of caseload numbers but also the complexity of the care that we are required to deliver. District nurses and their community teams have to be adaptable to a variety of locations for care delivery and always provide care without the ‘resource’ and immediate support experienced by colleagues working in a hospital environment. The role, however, enables my patients to feel at ease in their own home, and it builds trust and relationships between the nurse and patient.
Unfortunately, at the moment, many of the patients I see have COVID symptoms or have had a positive COVID test. For some, that is reason why they require end-of-life care or, for others, it may be a contributory factor for somebody we would have been visiting anyway. COVID-19 has presented us with many challenges, not least the inability to touch or offer a hug to my patients, when many really need this at the moment. In anxious times, I always want to put my patients at ease, so I’ve had to rethink my reassurance methods; indeed, eye contact is the way to connect more than ever before. Behind my mask my smile is hidden, but hopefully my eyes convey the reassurance that my smile gave to patients and staff before COVID-19.
The phone rings and a voicemail is left from the hospice team, informing me that one of my palliative patients had passed away in the night. The family have requested that we visit this afternoon, so I add this to my patient list. My caseload list is my ‘bible’ and without this I would be lost. My first stop is the office. I need to check in and make sure all is ok for the day ahead. I check and there have been phone calls from patients, surgeries and social workers. I prioritise and deal with the urgent messages and allocate the extra calls to the team. I also quickly check my emails; there are too many to read in any detail, but I will check back later.
Walking to my next patient, I hear a cheer of congratulations from a few people as I walk past the registry office, smiling over to the newlyweds. Walking over the brow of the hill I can see the cathedral and am thankful to work in such a beautiful cathedral city. Betty greats me at the door and says ‘is that you Amie? I can’t tell with your mask on!’ Betty expresses that all of the PPE is a worry for some patients; I reassure her this is the best way to protect us both from the virus. Betty’s smile beams at me; it’s the highlight of her week getting to see the district nursing team. Betty is concerned her leg wound is not improving so I discuss the Doppler assessment booked for next week and explain how this may aid the healing process. She says she feels reassured and is happy her concerns had been listened to and that a plan is in place. Whilst carrying out her wound care, I note Betty has lost weight. Betty’s daughter has not been able to visit her mum to deliver her usual home cooked meals due to shielding. As a result, Betty has been having to resort to microwave meals which she really isn’t enjoying. I call Betty’s daughter and discuss the local volunteers who are offering to support the vulnerable during the pandemic. Betty’s daughter says she has planned to cook her mum some tasty food and have it delivered. As Betty’s District Nurse, I’m not just visiting for her wound, I’m discussing her diet, where she is sleeping, how she’s mobilising and am looking at the bigger picture of contributing factors in Betty’s health, focusing on holistic care and considering the whole person.
My next visit leaves me on the doorstep for 10 minutes with no answer; the next-door neighbour informs me the gentleman has been taken into hospital overnight following a fall. I make a note to close this referral when I’m back at the office and await a hospital discharge referral once he’s well enough to return home.
The ‘on-call’ phone rings just as I get to my car; it’s the hospice nurse requesting that I commence a syringe driver for the palliative gentleman I saw this morning. She has sent the prescription to the pharmacy and the drugs will be ready in an hour. I contact the gentleman’s wife and request they give me a call once the medication has been collected from the pharmacy. The wife doesn’t want to leave her husband as this will cause him distress, so I liaise with pharmacy and they agree to deliver his medication.
The traffic lights in the centre of the town catch me every time, especially during rush hour (I always say I’m not coming this way again, but it’s always too late!). I spend several minutes queuing whilst the traffic starts to move. I walk into the office to a much appreciated delivery of cakes and scones from a local tea room; these are for the team to say ‘thank you’ for our efforts during the pandemic. It is overwhelming, but sadly there is no time to stop for coffee and a cake yet! I make a quick pit-stop for a toilet break and I collect the syringe driver box. As I head out of the office the phone rings; it’s a new patient enquiring when they can expect a visit. I agree to call them call back later in the week and make a note in my diary to update the allocation system.
Now to the next patient! I arrive just in time to a patient who requires their lunchtime insulin. My patient is pleased to see me, since I hadn’t seen them personally for a few weeks. It is so rewarding to see their health improving.
I call to see the bereaved family, as requested this morning. I offer my deepest condolences; they don’t invite me as they knew how busy I am, but just wanted to pass something onto the team. It’s a ‘thank you’ card and a beautiful flower arrangement for the team. The card read ‘To all the angels without wings; thank you for the kindness and compassion you all showed towards our dad. He died with dignity and peacefully and we will be forever grateful for your presence’. This brought a tear to my eye; I expressed my thanks on behalf of the team and I left for my next patient wiping away a tear from my cheek.
I arrive to commence the syringe driver for the gentleman approaching the end of his life. His wife sobbed, confiding in me that in all their 70 years married life they had never been apart. She explained that was why she couldn’t leave him to collect the drugs and she thanked me for arranging the delivery. The patient was comfortable and settled but his breathing had altered, and I could see he was imminently going to pass away. I suggested his wife sat with him and I gave them some privacy. After a very short period of time, I heard the wife say ‘a golden heart has stopped beating’ as she lay on his bed next to him and thanked him for a wonderful life. I stay a little longer and support his wife; they have no children, only close friends and these are unable to visit due to the COVID-19 restrictions. The wife said she did not want her husband to leave their family home but knew he had to. Before I leave, I help to make the necessary arrangements with the funeral directors. I feel sad as I was not being able to comfort her with a hug as I would prior to COVID-19. District nursing evokes a variety of emotions throughout the day.
The phone is ringing yet again; this time a staff member needs advice regarding palliative medication. We chat and I support them to make their clinical decisions. The phone rings again, straight after, it’s the family of a palliative patient who are requesting a review for their pain and nausea. I visit and assess; I administer medication that resolves the pain and nausea quickly. I decide to increase the palliative visits for this patient in order to support and reassure them and their family.
There is still one more patient to see, I glance at the time; there are simply not enough hours in the working day. I dash back to deliver ‘handover’ at the office base. Handover is via a digital call; digital technology really has changed the way we work in the community; it creates so many opportunities for communication, but it will never beat ‘face-to-face’ contact. I really miss that ‘face-to-face’ contact and catching up with colleagues over lunch. I have time for a quick break; a cake and cup of coffee are presented to me (I really do work with some kind and caring people). It’s been a busy day and, already, it’s time to start the allocation of the next day’s work. As the caseload holder, I need to allocate work for the next day using my professional judgement to ensure the skill mix of staff is safe for the delivery of care that is required. As I do this, the phone rings; it’s a staff member calling in sick. I now have no staff to cover the shift; tomorrow is my day off, but I offer to work to ensure that the shift is covered. I check my emails, return the missed phone calls and update the allocation system from my ‘to do’ list. Tomorrow’s work is allocated, and the shift is covered safely.
It’s back out on the road to see the final patient on my list for today. I visit my patient to administer their insulin, but when I arrive they are in a hypoglycaemic state. I urgently need to raise their blood glucose, so I find a sugary product and help them take this. Half an hour passes before I can safely administer their insulin. Whilst there, the care agency calls to say they will be 30 minutes late; insulin administered, I prepare an evening meal for my patient to ensure their insulin and meals are given in a timely manner, to avoid a further hypoglycaemic episode.
5.30pm: It’s been another rewarding day. Looking after patients, sorting out problems, making sure patients and their families are given the support they need and giving the team both leadership and direction. I have laughed with my patients and at times, I have cried with them! I finish the day as I started, looking out of the window wondering if it will rain and hoping it’s not too wet for the next shift.
District nurses are the hidden heroes of the NHS. 2020 was the ‘Year of the Nurse and Midwife’ and our chance to showcase and celebrate the profession. COVID-19 had different ideas, but we continue to do a great job, despite COVID.