Appreciation for the efforts of staff battling coronavirus in intensive treatment units (ITUs) and accident and emergency (A&E) around the country is widespread. But outside the general hospitals, other forms of healthcare continue to be needed. People are still having babies. Those with psychiatric conditions still need support. And those with terminal illnesses – other than the virus – are still dying.
For the individuals working with these groups, the virus is causing new challenges which have to be met with limited support.
Laura Jones is a community midwife. Before the outbreak, her work centred on checking up on pregnancies and newborns in residents’ homes. Now, social distancing has made that a struggle, with patients increasingly insistent on doing their own check-ups.
“Pregnant women are in the vulnerable group being told to avoid contact with others – but they can’t,” she says. “They don’t know what they’re looking for, and Google isn’t going to tell them.”
This is one example of the difficulties created by the emphasis on limiting contact. Other forms of contact that have had to be curtailed include patients’ proximity to friends and family.
Alice Fisher, a peer support worker on a locked mental health ward for women with schizophrenia and various personality disorders, says the necessary suspension of visits from relatives has contributed to rising anxiety, sometimes resulting in incidents requiring restraint.
“We’re trying to convince patients that they’re in one of the safest places,” Fisher says. “But that makes them feel like their families outside the ward aren’t safe.
“We do have patients whose partners are older or have underlying health conditions. I don’t know how we’ll handle it if these women start losing their families. Ironically, there’s been little talk of their mental welfare because we’re so concerned about their physical safety right now.”
Little direction, she says, is given for managing reasonable fears. “There’s no guidance on empathy.”
Palliative services have taken similar measures. Aline Anscombe is a nurse at a hospice providing end-of-life care which is usually open twenty-four hours to visits from unlimited numbers of friends and family. But visiting hours have now been heavily restricted, with only one visitor allowed at a time.
This is seriously detrimental to the wellbeing of patients with families of more than one, Anscombe suggests, and to the wellbeing of relatives too – who are now more likely to miss their loved ones’ deaths. As well as restricting visitors, cards, flowers and photographs have been banned from patients’ bedsides.
Patient-staff contact is harder to limit, though, and puts those whose work shouldn’t require them to be in contact with the virus at direct risk. While encouraging women to continue to access their care appointments, Jones is also conscious of endangering herself and her family – a feeling exacerbated by a lack of guidance.
“For community workers – all community workers – there’s been no information about going into people’s houses and how to protect yourself once you’re inside,” she says.
On mental health wards, continuous close contact is often necessary for patients considered a risk to themselves or others. Before visitors were banned, one of Fisher’s patients appeared to have symptoms and was confined to her bedroom – but as an at-risk individual, she also required a member of staff with her at all times. The team had to figure out how to perform the necessary observation while keeping a two-metre distance.
“We could stay across the corridor from her bedroom, with the door open. But if she had a self-harm incident, the staff member would have had to intervene,” Fisher says. “There’s no way around it.”
Staff shortages are among the primary concerns for all health workers. Anscombe’s hospice now has three beds ready for terminal coronavirus patients, and as a result, is no longer allowing volunteers – who normally equal professional staff in numbers – to help, vastly increasing the workload for nurses.
There’s also no accommodation available for hospice staff who live with vulnerable people and may therefore have to move out while they work. One option being discussed is a bed on the ward.
Uncertainty underpins everything. At present, there are no contingency plans for an outbreak on Fisher’s ward. Normally, she says, if a patient goes to general hospital, a staff member goes with them – but that would now endanger the staff member.
The general hospital could agree to take on a patient’s mental health care, but they don’t often have the capacity. And the practicalities of providing comprehensive mental health care in an ITU or busy Covid-19 ward seem unimaginable.
This means management could decide to keep patients with coronavirus on the mental health ward, where it would spread like wildfire – particularly since the only PPE available there is paper masks and antibacterial gel.
Fundamental to these issues is a lack of information. Fisher says there needs to be better communication between mental health providers on plans, as well as centralised, co-ordinated guidance on what is expected of them during the crisis.
But that information deficit isn’t particular to mental health care. Jones also doesn’t know whether her visits or home births will continue to be possible as the crisis escalates, and already, in many cases, doesn’t know what to advise her patients.
She’s currently trying to decide how to proceed with a pregnant woman with two young children and no childcare, who’s expected to come to the hospital for scans. Both visiting the family’s home and requiring them to travel seem like unnecessary risks.
“At the moment, we as individuals are expected to make decisions,” she says. “We shouldn’t have to. We need hierarchical authority to assess those situations.”
Anscombe’s ward has more of a sense of the role it will play in the crisis, but its capacity to fulfil that role fluctuates. If staffing levels are high enough, the coronavirus patients due to come in any day should have dedicated, separate nurses.
But staffing levels are never high enough. The virus may also end up taking up more beds, and where others requiring palliative care will go in that scenario is as yet unspecified.
From all this uncertainty stems an anxiety that Jones says is particularly painful because it’s rational. She and her colleagues worry that they’re going to infect vulnerable patients or their own families, or that they won’t be able to get food because they’re working while everyone else is stockpiling.
Those worries won’t be therapised away, however many well-meaning platitudes about ‘pulling together’ her hospital management email out.
All three women speak of waiting. For those working at a distance from the virus, healthcare has become a time bomb.
That they will have to deal with the crisis, in some way, is guaranteed, whether as a physical or mental health concern, amongst patients on a ward, or in individual homes. But the form that effort will take, and the impact it will have on staff, remain unknown.
Above all, there is a need for more detailed governmental guidance, which relies on an acknowledgment that coronavirus is not only being fought on the frontlines. It is, and will be, fought by those in all forms of healthcare – from birth to death, and everything in-between.
For staff in those forms of care, the only certainty is that, whatever happens, their work will continue. It will have to.
Resigned to this, Fisher says: “We’ll work something out when it’s happening. We won’t have a choice.”