Written evidence submitted by Diocese of Rochester (WBR0030)

Summary

This submission represents the experiences of volunteers from local churches in Kent who offer chaplaincy within care homes.  During the pandemic we have seen the alarmingly negative consequences for the care homes we support, and the dire impact on staff morale, with ample evidence of exhaustion and burnout.  Staff are facing the trauma of losing residents prematurely in difficult circumstances.  They are shouldering additional work and struggling to access the resources needed to care safely for residents.  They feel undervalued and unprotected and face a legacy of post-traumatic stress disorder and moral injury. 

Urgent action is needed to secure the jobs and wellbeing of staff, many of whom work in businesses under threat following multiple deaths of residents.  It is vital homes receive the resources they need, particularly PPE and testing, and that support is offered so that businesses do not collapse, rendering vulnerable older people homeless.  Attention to the mental health of the care home workforce is vital in working through trauma, moral injury and other adverse impacts of the pandemic.  Ways of marking the deaths and celebrating the lives of residents and staff lost to Covid are vital.

Introduction and Reason for Submitting Evidence

This evidence is submitted by Julia Burton-Jones, on behalf of the Anna Chaplaincy team within the Church of England Dioceses of Rochester and Canterbury (covering Anglican churches in Kent, Medway, Bromley and Bexley). 

Anna Chaplains provide spiritual care for all older people, whether they have strong, little or no faith, as representatives of their local church (annachaplaincy.org.uk).  Most are volunteers, and they tend to be lay pastoral workers, though some are ordained within the Church of England.  Their focus is on responding to the spiritual needs of older people, whether they are living in their own homes or a care home.  A key role is listening to the person’s story and helping them find meaning and purpose at a time of life when they may be facing considerable loss and challenge. 

Anna Chaplains work alongside agencies supporting older people, including care home staff, voluntary sector organisations delivering social care, and domiciliary agencies. They are in a prime position to hear the stories and experiences of the care workforce; integral to their role is offering chaplaincy to those caring for older people, in family or professional roles.  They seek to be a voice for older people (especially those who are seldom heard) and to represent the perspectives of those who care for them. 

During the pandemic Anna Chaplains have remained in close contact with the older people they support, switching their services to regular phone contact, in many cases.  They have also maintained links with care home staff, enabling them to understand the extreme pressures faced by the workforce in recent months.  This submission reflects these contacts with care homes and is based on a June consultation with members of the Anna Chaplaincy network in Kent, Medway, Bromley and Bexley on the impact of Covid-19 on care homes.  The consultation included two virtual focus groups and email correspondence.

What has the impact of the COVID-19 pandemic been on resilience, levels of workforce stress, and burnout across the NHS and social care sectors?

Our contacts with care homes paint an alarming picture of distress and exhaustion among staff, who are living with a mix of deep emotions following the events of recent months.  Many describe feeling ‘abandoned’, with the focus especially early in the pandemic on protecting the NHS.  There is anger over the pressure felt to receive residents from hospital settings without prior testing.  And, of course, many are exhausted and demoralised following months of extreme pressure.  There is heartbreak over the excess deaths among resident populations.  And there is fear over their future employment, with the viability of the care homes where they work threatened, sometimes through loss of large numbers of residents to Covid-19, and more generally the understandable reluctance on the part of families to place frail elderly relatives in permanent care during a pandemic.

These are some of the ways in which we are hearing that the care home workforce is facing additional stress which places it at risk of burnout:

• PPE-related pressures

There has been well reported difficulty acquiring the requisite PPE, with community groups supporting homes in sourcing this in some cases.  Where PPE is available, its use is unfamiliar to staff – the places they work are home to their residents, not clinical settings.  Covering their faces feels alien to care home staff who know how heavily older people, especially those with dementia, rely on facial expressions and lipreading.  They can see the bewilderment caused to residents, who may be frightened and resistant to receiving care.  Staff are having to work extra hard to reassure and convey information – telling the person they are smiling still under the mask or using tablets or notebooks so that the person can also read what they are saying where cognitive ability allows.

• Trauma linked to multiple deaths

Unlike in acute hospital settings, staff forge close bonds with residents they support, over many months, sometimes years.  They work hard to build trusting relationships, to overcome the anxiety of the older person who may feel lost and abandoned.  Deaths hit staff hard at the best of times.  Seeing several residents die a painful and difficult death from Covid in quick succession has led to trauma.  The psychological impact cannot be processed because demands are unrelenting – there is no space or time to stop and grieve, alongside sorrow that the person died without family and cannot be mourned appropriately because of the restrictions on funerals.  A likely long-term battle with grief and post-traumatic stress disorder is anticipated for some staff.

• Moral injury

Added to the deep sense of loss over deaths of residents has been the risk of ‘moral injury’ for those who fear they inadvertently brought the virus into their care home or took it back to their own families.  Moral injury occurs when a health or care professional feels they were forced into decisions or actions that go against their values and principles, causing harm to another person. Staff in care homes who were obliged to work with insufficient PPE are an example of this.

• Reduced staffing

Care homes have been operating under reduced staffing for a variety of reasons.  Staff members have been off sick with the virus themselves or have needed to shield at home.  Use of bank and agency staff has been discouraged because of the risk this will mean the virus being taken between settings.  In a sector where staffing ratios were already set at a minimum level due to under-funding over many years, this has caused team members who are able to work to face exceptional demands on their time and energy.  Exhaustion has been felt by staff at every level, and there is fear over the impact of a potential second wave on the capacity to carry on withstanding Covid-related demands.

• Loss of community support

Many care homes are vibrant communities in normal times, with constant visitors and positive engagement with the local community.  When care homes went into lockdown, most of this support from volunteers and community groups ceased.  Meaningful occupation for care home residents is linked to visits from external groups, including local church visits – activities staff suddenly found themselves without this infrastructure of help which allowed varied engagement and stimulation.  Where the community groups like faith organisations have continued to link in a limited way – supplying craft materials and ideas, visiting in gardens, or speaking with residents through phone or table, this has been greatly appreciated by activity organisers.  They have expressed to us the sense that all their hard work building bridges into the local community has been destroyed.  Homes have also missed out on the support of visiting professionals whose visits are greatly reduced; this means they are left to assess and respond to needs with which they would previously have received outside advice and help.

• Decline in levels of ability in residents

Linked to the lack of visits and the need, in some cases, to isolate residents in their rooms, staff report that levels of ability and engagement have reduced quicker than would have been the case without lockdown, particularly for those living with dementia.  This has added to the demands on staff, as residents who were previously active now need more personal care.  We hear of homes where senior staff have no choice but to assist at meals, so great are the extra demands.

What is the current scale of workforce burnout across NHS and social care?  How does it manifest, how is it assessed, and what are its causes and contributing factors?  To what extent are NHS and care staff able to balance their working and personal lives?

Morale in the care home sector was fragile before the pandemic.  Care home staff felt undervalued by UK society, misunderstood and belittled.  They bemoaned the negative press coverage they received and told us their skills and commitment went unrecognised.  They compared their lowly pay, and poor terms and conditions, with other areas of employment and felt the injustice.

The pandemic has brought some encouragement, in that the social care workforce are now seen as key workers, more visible and appreciated to a greater extent.  Anecdotally, applications for jobs in social care in our area have increased.  There have been damaging impacts on the care home workforce, however, since the beginning of the pandemic.  We would like to stress the seriousness of these effects on staff morale. 

Poor morale and burnout are manifest in problems with mood, emotion and energy in staff members.  We have seen ample evidence of this lowered mood and reduced energy.  Some care homes are harder than others to contact through email or telephone, where Anna Chaplains have sought to offer support. It seems the response to lockdown in some homes has been to turn inward.  Conserving resources includes minimising contact with the community. There is also a heroic but at times counterproductive tendency to protect residents at all costs, which can mean keeping at bay relatives, friends, and community supporters who might offer Covid secure ways of engaging residents and so supporting staff.  The anger expressed by some visitors over the lack of access to residents inevitably prompts further defensiveness in staff, who already feel beleaguered and alone in their mission to shield residents from harm.  Rising tensions will further impinge on morale.

What are the impacts of workforce burnout on service delivery, staff, patients and service users across the NHS and social care sectors?   

The tireless efforts of care teams, often at the expense of their own private and family lives as they choose to live in the care home, are having the desired effect in many settings.  Many homes have had no cases of Covid, and in others the spread has been limited through the valiant efforts of staff.  This state of heightened alert and isolation for care homes cannot continue without harm to staff, residents and family members: 

• The impact on staff is physical and emotional exhaustion and mental ill health.  They are unable to offer the level of support they know is needed, due to time and energy constraints, and this dents morale.
• For residents who are now relying on staff for aspects of support that had been provided by friends, family and external partners, the level of service is reduced; this is through no lack of commitment on the part of staff who are giving tirelessly, but a result of them being stretched to the limit.
• For relatives and friends, the limited capacity of staff to facilitate virtual visits at times of heightened stress compounds the anxiety and distress over being unable to see their family member in person.   

What further measures will be required to tackle and mitigate the causes of workforce stress and burnout, and what should be put in place to achieve parity for the social care workforce? 

To mitigate causes of stress and burnout in the care home workforce we need to:

1. Ensure adequate supplies of PPE for all care homes
2. Ensure testing is readily available for all care homes
3. Find safe ways to allow bank and agency cover
4. Find safe ways to bring back external professional support and advice
5. Ensure care homes are not pressured to take patients discharged from hospital who may have Covid-19
6. Learn lessons, document them and form plans in case of a future pandemic
7. Show respect and value the contribution of the care home workforce
8. Protect care home businesses that have been hit badly and risk going under because they have lost a large number of residents.
9. Allow staff access to therapeutic support in working through PTSD, moral injury and other mental health issues caused by the pandemic.
10. Give opportunity to mourn the deaths of residents and colleagues who have died from Covid, potentially facilitated through Anna Chaplaincy and local churches.

To achieve parity for the social care workforce, we recommend:

a)      Better employment protection and terms and conditions which allow staff to take sick leave without being penalised financially, with some staff forced to go to work despite showing symptoms of the virus.  The privatisation of social care under community care legislation has left staff disadvantaged in comparison with those working within the NHS.  A living wage for care staff is a modest demand.

b)      A national solution to the vexed question of payment for social care which has remained unresolved for far too long, leaving older people to fund their own care and care homes underfunded where fees are paid by local authorities.

c)       Incentives to join the social care workforce so that it is seen as a worthwhile career option akin to working in the NHS.

Our partner organisation The Bible Reading Fellowship (home of Anna Chaplaincy) has published a series of five booklets to support care home staff during lockdown  (https://www.brfonline.org.uk/collections/new-titles/products/anna-chaplaincy-carers-guides-pack). These mainly give suggestions for offering spiritual care to residents while churches are less able to do so, but one guide is about self-care, and has ideas for combatting fatigue and increasing resilience.  Churches in Kent are donating the guides to local care homes.  We hope they are received as a token of our care and support.

Julia Burton-Jones

Sept 2020