COVID-19 is caused by a novel coronavirus, specifically severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has spread across the globe (Del Rio and Malani, 2020). It has been a challenging time for people working in health care, particularly for nurses, who have played a critical role in caring for patients amid the strains put on the healthcare system during the pandemic (Schroeder et al, 2020). Much of the literature has focused on the challenges of closed services, redeployed staff and nurses feeling frustrated while trying to deliver compassionate, evidence-based care (Schroeder et al, 2020).
The 6Cs—care, compassion, courage, communication, competence and commitment (Table 1)—are considered fundamental to nursing care and are essential building blocks for establishing a therapeutic relationship between a nurse and the patient and family (Crotty and Doody, 2015; Baillie, 2017). This article looks at how we are delivering the 6Cs of nursing, with a primary focus on care and compassion during the pandemic. The vital role played by touch in the care of the patient and family will also be considered.
Table 1. The 6Cs of nursing
| Commitment | Every nurse should demonstrate a commitment to uphold professional standards (Nursing and Midwifery Council (NMC), 2018) |
| Care | At the core of nursing, those in our care should get the right care for them throughout the lifespan (Emergency Nurse, 2015) |
| Compassion | When care is provided with empathy, and respect and dignity are present. How the individual views the care provided (Emergency Nurse, 2015) |
| Competence | Nurses should have a commitment to self-competence and ensure that care is provided within that scope of competence (NMC, 2018) |
| Communication | Can be verbal and non-verbal. Nurses must use a range of communication techniques and ensure communication is appropriate to the person's beliefs and culture to ensure the health care provided is optimum (NMC, 2018) |
| Courage | Courage can be viewed as a moral ethical value, being used to address ethical practices (Lindh, 2010). It enables the nurse to have a self-awareness and the strength to speak up to improve care, as well as to adapt to changing working practices and challenges (Emergency Nurse, 2015) |
Caring and the values of nursing
Caring has historically been considered the essence of nursing (Fahrenwald et al, 2005). There are many definitions and theories of caring, but most scholars consider that it is complex and needs to be defined by the individual (Blasdell, 2017). A literature review by Drahošová and Jarošová (2016) that focused on the concept of caring in nursing suggested that nurses believe caring is characterised by individual attitude, attentiveness, experience and sensitivity. They also highlighted the importance of communication using active listening, understanding and empathy (Drahošová and Jarošová, 2016). According to Lukose (2011:27):
‘Nursing is a caring science … human beings are connected to each other in the caring process; a nurse's humanity embraces the humanity of others to preserve the dignity of self and others.’
Caring, said Lukose (2011), is central to nursing and it means being there for the patient and their relatives in whatever way is needed at the time.
In response to some of the challenges highlighted in the Mid Staffordshire NHS Foundation Trust Public Inquiry. (Francis, 2013), Cummings and Bennett (2012) developed the ‘Compassion in Practice’ strategy for NHS England, known as the 6Cs of nursing, a national strategy for nurses, midwives and care staff. It highlighted the level of care that must underpin the culture and practice of all organisations that deliver care and support, with the 6Cs as a cluster of values that highlight compassion throughout healthcare practice. These values are relevant to all fields of nursing and nurses across all bands throughout the lifespan of a patient and are threaded throughout the Nursing and Midwifery Council (NMC) Code (2018); NHS England/Nursing Directorate (2013).
Although Ritchie and Smith (2015) put forward critical thinking as the ‘7th C’ of nursing, at present it is coronavirus or COVID-19 that is the additional C impacting on the established 6Cs. The COVID-19 global pandemic has greatly altered the nature of services being provided to patients. Many staff have been redeployed to other wards or different hospital areas, with many now routinely wearing full personal protective equipment (PPE) (Jackson et al, 2020; Luis and Vance, 2020) (Figure 1).
Figure 1. Full personal protective equipment
COVID-19 restrictions
The long-term prognosis for those who have been ill with COVID-19 remains unclear, for both children and vulnerable populations, such as those with chronic medical conditions and older people (Cipriani and Di Fiorino, 2020; Frauenfelder et al, 2020; Murthy et al, 2020). Age has been identified as a significant risk factor for both the severity of COVID-19 symptoms and the subsequent impact following recovery (Brown et al, 2020; McMichael et al, 2020; Wu et al, 2020). To reduce the chance of infection with SARS-CoV-2 and falling ill with COVID-19, social isolation and a ban on visitors to nursing homes, long-term care facilities and hospital settings was implemented for extended periods (World Health Organization, 2020). This made it difficult for all patients in these facilities, who have had to cope with confusion, isolation and loneliness—aspects that have been exacerbated for those who have also become ill with COVID-19 (Brown et al, 2020; Duffy and Richardson, 2020; O'Shea, 2020; Wakam et al, 2020; Wang et al, 2020a). The view of Hoy and Harris (2020) is that the physical separation intended to protect people's physical health may lead to unintended emotional and relational consequences. The pandemic has also put huge strains on the nursing workforce (Chen et al, 2020; Jackson et al, 2020), who have faced additional burdens in trying to implement the 6Cs of nursing.
The pandemic has had many social consequences, provoking fear and anxiety for many patients (Brown et al, 2020). Additionally, many patients have been missing that sense of physical closeness, leading many to feel angry about the situation (Ornell et al, 2020). Ho et al (2020) found that 53.8%, of 1210 participants across 194 cities in China rated the psychological impact of the pandemic as moderate or severe, with 16.5% reporting moderate to severe depressive symptoms. Concerns were also raised that patients being treated for COVID-19 were not allowed visitors, even if they were dying (Wakam et al, 2020).
Impact of no visitors
According to Nelson (2020: e554), the pandemic created an additional ‘layer of fear, anxiety, and distress’ due to the ‘no-visitor’ policies introduced in hospitals and nursing homes throughout the UK. It is clear that such restriction in hospitals have affected all patient groups—from limited presence for parents with babies in neonatal intensive care units (NICUs) to residents in nursing and care homes (Bliss, 2020; Comas-Herrera et al, 2020; Mahoney et al, 2020).
Until the recent lifting of restrictions, in some exceptional circumstances, the ‘no-visitor policy’ was eased, with ministers declaring that, when possible, close relatives could visit their loved ones to say goodbye (Cook, 2020). Although this was a comfort to some family members, it may also have been a source of tension, and it is unclear how many hospitals and care homes allowed this and restrictions may still be in place in some areas, such as for outpatient appointments. In practice, this may have translated to only the patient's partner being allowed to visit, with other family members unable to see their loved ones.
During the pandemic, the family member visiting has been expected to wear full PPE, which in many cases presents a barrier and makes the experience daunting for all those concerned. Then there are patients who have no loved one to visit them, and this can also be challenging for staff, as they are unable to make up for this as they would do under normal circumstances. These restrictions on visitors have not only been difficult for families, but have also led patients to complain of greater social isolation and reduced interaction with people (Munshi et al, 2021).
Hospital staff have recognised the value of their practices of family-centred care and care of the dying patient at such a time and implemented strategies in an effort to ease the separation of families. Many areas used technology to keep families and patients in touch at the end of life, for example arranging ‘visits’ through webcams and virtual meeting apps; some areas kept patient diaries (not only for patients in intensive care or at the end of life, neonatal units also kept diaries for fathers or siblings who were unable or scared to visit); in others, staff made drawings of trees, based on the patient's hand print; and made knitted hearts, placing one in the hand of the deceased and sending the other to the patient's family (Cook, 2020). The challenge throughout has been to ensure the physical acknowledgement of love, while also maintaining infection control measures. Nurses certainly have an important role as ‘conduits of love’ between patients and their families in end-of-life care, enabling loved ones to share messages by phone and other technologies (Hutchings, 2020).
Cook (2020) described how staff on one COVID-19 unit stood in silence, as a mark of respect, when the body of a deceased patient who had no loved ones left the ward and how this gesture had helped staff. Limited visiting led to a shift in how family-centred care was prioritised during lockdown measures, in that it was not possible to fully implement holistic family-centred care in its traditional form.
The pandemic has certainly resulted in a reduction in social interaction and a lack of physical closeness (Brown et al, 2020). Many patients have found themselves isolated because they have been nursed in isolation (historically called ‘barrier nursing’) in hospital, while others have felt isolated even in their own homes. However, research appears to have focused mainly on the emotional impact of the pandemic on staff or the wider population (Lima et al, 2020; Ornell et al, 2020; Wang et al, 2020b). A systematic review by Abad et al (2010) highlighted the impact of isolation nursing on patients. Uncertainty and loss of control are key themes expressed by patients experiencing isolation nursing care: they have less frequent contact time and communication with the nurses caring for them, leading to an overall lack of physical contact (Abad et al, 2010). Nurses therefore need to learn to assess and communicate with patients in their ‘new normal’ environments, focusing more on their non-verbal communication skills, such as body language, tone and volume of voice (Sagar et al, 2020).
The wider impact on care
Although patient-centred care may be affected during the pandemic, concerns have been increasing that at this time the wider health needs of the population have been neglected (Tedesco et al, 2021). Certainly, Crawley et al (2020) reported concerns about a decline in uptake and availability of many childhood health services (Table 2). This may be in part due to the service changes that have been made, with staff being redeployed to hospital settings or temporary service closure (Adam et al, 2020; Murphy et al, 2020; Weilongorska and Ekwobi, 2020). It may also be due to lack of uptake, with some people fearing to attend appointments during the pandemic, or assuming that some services are suspended (Kadambari et al, 2020).
Table 2. Wider COVID-19 health concerns
| Impact |
|---|
|
Source: adapted from Crawley et al, 2020
Globally, access to elective care and health prevention services has been affected, due to the closure of psychiatric elderly care community assessment centres and delays in scheduling or postponement of elective operations (Jacobs et al, 2020). Hearing clinics, opticians and dentists were closed or were offering limited services over prolonged periods (Barabari and Moharamzadeh, 2020; Saunders and Roughley, 2020).
Nonetheless, irrespective of the current situation, nurses must be driven to deliver compassionate, evidence-based care.
Compassion
Compassion is an important value that motivates patients to co-operate in all aspects of care (van der Cingel, 2011). Compassion can enable the patient to be seen as a unique person and the recognition of each individual's uniqueness is the basis for providing individualised care (Ghaljeh et al, 2016). During the COVID-19 pandemic, nurses have been commended for their compassion as well as their courage in the face of not only staff shortages, but also shortages of basic PPE (International Council of Nursing, 2020; Smith et al, 2020). Neville (2020) suggested that the circumstances in which health care has found itself in the COVID-19 pandemic mean that, as nurses, we should be looking at different ways of delivering creative compassion. One area that we should consider that can enable us to provide better patient care is the role of touch and how we can deliver compassion when physical contact is limited.
The importance of touch
Touch, in its simplest form, is considered to be a core aspect of nursing practice (Aveyard et al, 2002). It can be used to convey affection and is central to the provision of comfort, particularly during stressful times (Holt-Lunstad et al, 2008; Connor and Howett, 2009).
Touch helps nurses to demonstrate care and compassion and has historically been seen as a central component to healing (Krebs, 2001; Doherty et al, 2006; Iseminger et al, 2009), although Benner (2004) suggested that comfort and touch are endangered arts in the nursing profession. Health professionals undoubtedly use touch in all aspects of the care they provide, from greeting people to holding their hands to reassure them we are there (Lawton, 2017). Touch has even been called the ‘mother of all senses’ (Montagu, 1986). Previously, Rosa et al (1998) suggested that therapeutic touch is part of nursing practice and is based in mysticism, while Hertenstein et al (2006) demonstrated that nurses have an innate ability to decode emotions via touch alone. It has been suggested that interpersonal touch is a fundamental aspect of human nature (Sin and Kool, 2013).
Touch can stimulate the production of oxytocin, which may reduce the stress of a particular situation (Striepens et al, 2011; Tang et al, 2020). Henricson et al (2008) studied touch and the use of tactile touch in intensive care, and found significantly lower levels of anxiety in patients in the touch intervention group compared with the non-intervention group. When touch is significantly reduced, as has happened during the COVID-19 pandemic, patients can develop ‘touch starvation’, which has been associated with increases in stress, anxiety and depression (Pierce, 2020). Field (2011) suggested that ‘touch starvation’ or ‘hunger touch’ threatens our sense of being in the world, our connectedness, growth and also our ability to flourish. The pandemic has affected our ability as nurses to touch our patients prompting Durkin et al (2021) to suggest that we must enhance other methods of communication to compensate. Although touch is considered to be a deeper form of communication than verbal communication, it is also linked to presence and intention (Westland, 2011). According to Pype et al (2021), we need to work across healthcare disciplines to explore other ways of delivering high-quality care while our ability to touch is restricted.
‘Presence’ instead of touch—finding solutions
Nurses and patients benefit from touch as an indicator of ‘presencing’ and as reassurance in critical care settings (Adomat, and Killingworth, 1994; Usher and Monkley, 2001). If nurses are unable to use touch when they are distancing themselves from patients, then perhaps an awareness of presence can help. This has been explored by Trueland (2020), who examined the challenges of communication and expressing compassion in order to provide care while social distancing. Some of the responses in Trueland's (2020) study illustrated that nurses are frustrated by the lack of family involvement with patients and are trying to find solutions. In Waco, USA, nurses piloted the use of internet-enabled tablets in hospices where patients could only receive limited visits (Hoy and Harris, 2020).
As previously highlighted, there is a need to use online technologies to provide social support networks and offer a sense of belonging not just for patients in the community but also those in hospital (Newman and Zainal, 2020). Nurses need to embrace the use of such technologies to ensure that they are able to deliver effective nursing care. Examples of nurses adopting technology to support patients include placing smartphones to a patient's ear or enabling relatives to talk with their loved ones in hospital, or with those isolating at home, by facilitating interactions through videocalling apps such as Skype, WhatsApp or FaceTime (Wakam et al, 2020).
Despite the challenges to nursing care, it is clear that nurses are trying to make a difference (Luis and Vance, 2020). Both nurses and nursing students are showing their commitment and courage to providing the best care to patients, demonstrating the use of all the 6Cs (Cook, 2020). Nurses, as key stakeholders in health care, face many challenges during the pandemic, as they manage scarce resources, redeployment and strive to deliver evidence-based care (Luis and Vance, 2020).
Compassion fatigue
Compassion and self-care compassion fatigue is not a new concept and, in comparison with other work environments, health sector workers have a higher instance of compassion fatigue (Allen et al, 2017). Although a resource pack on compassion produced for NHS England/NHS Improvement (Flourish team at Hope For The Community CIC, 2018) acknowledged that compassion is a vital element of nursing care, Clyne et al (2018) identified that there also needs to be compassion in the workplace, not only for colleagues, but also for ourselves. The resources presented considered how a more compassionate culture can be created in the healthcare setting and set out four elements necessary for achieving compassion in a workplace (Table 3).
Table 3. Elements to a compassionate workplace
| Element 1 | Culture and values |
| Element 2 | Actions and activities |
| Element 3 | Leadership and management |
| Element 4 | Policies and procedures |
Clyne at al (2018) found that staff viewed compassion in their workplace as little acts of kindness alongside an organisational culture of care, feeling valued and part of a functional supportive team. During the COVID-19 pandemic staff have been challenged in many ways, and teams have had to change how they work as staff are redeployed. Nurses have also had to cope with greater challenges about their interpretation of the nature of care and how they can deliver it (Maben and Bridges, 2020). Some have struggled to give as much priority to their own psychological and mental health as they give to their patients (Maben and Bridges, 2020).
Conclusion
The 6Cs are the core values of nursing, however nurses' ability to apply them has been challenged, as usual care practices have been adapted to meet the challenges of the COVID-19 crisis. Despite the difficulties, compassion and care remain paramount for the patient, the families and for the self—nurses are striving to adapt the care they provide to meet the needs of both patients and the ‘abnormal’ care structures.
Future studies will no doubt be published on the impact of the COVID-19 pandemic on staff and patients; however, the consequences for patients, staff and the general population may never be fully comprehended. The themes highlighted in this article have demonstrated that nurses are prepared to take the initiative and be flexible in adapting their practices to ensure that the 6Cs of nursing are followed in the care of every patient.
KEY POINTS
- This article is an exploration of how COVID-19 impacted on nursing care and NHS services at the start of the pandemic
- Implementing the ‘6Cs’ of compassionate care during the pandemic presented nurses with challenges, particularly around communication and touch
- It is important to reflect on and appreciate the impact of the pandemic on patients and carers, and to recognise the ability of nurses and other NHS staff to adapt to ensure care and compassion for patients and families
- From the professional side, there are also issues to recognise around compassion fatigue and the importance of compassion in the workplace
CPD reflective questions
- Consider how your practice has changed in response to the COVID-19 pandemic. Have your feelings changed?
- Reflect on how you have adapted your practice to ensure optimum patient care
- Consider how the challenges faced in nursing and the 6Cs might be used to inform future nursing practice and patient services
- Reflect on how the pandemic has impacted on you and your working environment. Consider any strategies you could use to support resilience and minimise the risk of compassion fatigue