It was the late May bank holiday of this year and Charlotte Hudd was supposed to be on a shift at the care home where she worked on the Isle of Wight. Instead, she was being wheeled from an ambulance into the A&E department at St Mary’s hospital in Newport, the island’s county town, still wearing her nurse’s uniform.
Hudd had been worried about her job affecting her health for a while. Since catching Covid at work in January 2021, she had come to dread mornings when she would wake up feeling like “there was an elephant sitting on my chest”. There were heart palpitations, breathlessness, fatigue and a terrifying brain fog – an unwelcome window into what it must be like to have early onset dementia. It was worse on work days, anxiety adding to the mix.
That morning, she set off for work at 6.15am. By 10am, a colleague was calling an ambulance. Her symptoms had escalated, plus there was pain down her left arm, the classic sign of a heart attack. Later, dressed in a hospital gown, with wires attached to her body, she found herself wondering: “Is Covid going to finish my career … my life?”
For Hudd, 49, nursing had been a childhood dream. She remembers opening a ward at home with dolls and teddies. After starting a family in her 20s, she began her training in 2006. She spent time on wards, before gravitating to care home nursing, where she developed varied clinical skills, looking after people with long-term illnesses, mental health conditions and end-of-life needs. “In a home, it’s nurse-led,” she says. “You have more autonomy and responsibility.”
In England alone, there are about 36,000 registered nurses working across 4,350 nursing care homes. When the pandemic struck in early 2020, Hudd was working as a charge nurse at a home in Portsmouth, commuting from the Isle of Wight, where she lived with her husband and daughter (she has two other, grownup children).
Until 12 March 2020, government guidance in England maintained that it was “very unlikely” that Covid would enter care homes. Even so, Hudd and her colleagues kept a close eye on the daily updates. When lockdown began, the home put a stop to visits. It quickly became clear that residents were suffering as a result. “When people living with dementia are upset, behaviour can manifest as not eating and crying,” Hudd says. A rota was drawn up for residents to have social time in the lounge (everyone spaced out, windows open). Among families, there were “mixed feelings” about how the home should respond – some wanted visits, others wanted a stricter lockdown. The tough work of mediation fell to the care home staff.
PPE shortages caused further stress. Hudd’s home was in an impossible situation: it called around local businesses, universities, anyone who might have spares, and even fashioned gowns from bedsheets. “When it became compulsory to wear a mask in the home, stock was like hen’s teeth,” she says. “When we had lunch, we’d seal it in a little freezer bag, have our lunch, then put it back on.” This was only the start of a gruelling year on the frontline of the Covid crisis, during which she witnessed care homes being ravaged by the virus, before contracting it herself.
Back in St Mary’s hospital, tests ruled out a heart attack, pointing instead to long Covid. Hudd was discharged that evening. Nursing during the second wave of the virus had also left her with PTSD, the physical effects of anxiety exacerbating her long Covid symptoms and vice versa. Six months after contracting the virus, she says: “I get random palpitations. I can be in Tesco and it will suddenly stop me. I have to make sure I don’t get anxious, then it will pass.”
Even before Covid hit the UK, nurses were under pressure. The NHS Staff Survey 2019 revealed that 70% of nurses and midwives were working unpaid overtime every week. A workforce crisis was predicted as student numbers dropped after the removal of the nursing bursary, while many nurses were approaching retirement. “We were not in a great place when the pandemic began,” says Patricia Marquis, the acting director for England of the Royal College of Nursing (RCN), a trade union. “Across the UK, in the NHS alone, there were 40,000 to 50,000 nursing vacancies. That doesn’t take into account vacancies outside the NHS, particularly in care homes.”
In March 2020, the world was learning rapidly about Covid – and locking down. Nurses couldn’t stay at home, though: they suddenly found themselves on the frontline, exposed.
Of all healthcare workers, nurses work most closely with their patients, getting to know them, handling complex, delicate and personal aspects of care. During the pandemic, nurses held the hands of dying people, suppressed the fear of bringing the virus home and faced day after day of relentless, understaffed shifts. We clapped them during the first lockdown, put rainbow symbols of solidarity in our windows and expressed shock at PPE pressure marks on their faces in social media selfies. But as the pandemic wore on and we itched to get back to our normal lives, nurses couldn’t turn away. What toll has this long 18 months taken?
RCN analysis this spring revealed that at least 952 health and care workers had died with Covid, but the trade union says the true number is probably much higher. Many more contracted the virus and are, like Hudd, living with long Covid. An ONS analysis in April showed that health workers were worst affected by the illness, with 122,000 NHS employees reported as having it. Even those who escaped the virus have not escaped the psychological impact of working in the face of it. A Nursing Times survey from March 2021 revealed that 84% of nurses felt more stressed than they did before the pandemic, while 62% said the mental health support available nationally was inadequate. Now, they face a fight for pay, too, with the government’s much-delayed pay offer – a 3% raise – falling short of many nurses’ expectations. The RCN and other unions are consulting members on next steps – including the possibility of industrial action.
When the first wave began, Emily Huntingford, 31, was working as a cardiac nurse in an east London hospital, looking after patients who had had heart attacks or had other life-threatening conditions. She was living nearby with her partner, a theatre nurse.
Like Hudd, Huntingford didn’t go straight into nursing, waiting instead until her mid-20s. A sociology module at university inspired an interest in palliative care, so, alongside a charity job, she volunteered at a hospice. Here, she witnessed nurses bringing dignity to patients’ final days. “I saw the impact nurses have on people. I thought nursing could give me the sense of fulfilment I was searching for in a career. It wasn’t a decision I took lightly.”
Covid meant some NHS services had to be scaled back as resources were redirected to critical care. Huntingford’s unit became eerily quiet. “You felt that nagging sensation you weren’t being helpful,” she says. New processes were hastily enacted. When one patient came in needing an urgent operation, the rules required two negative Covid tests before surgeons could go ahead. While they waited, the patient suffered a cardiac arrest. “We were unable to revive her,” Huntingford says. “It was devastating.”
As Huntingford heard more about the desperate situation in intensive care, she applied for redeployment. After only three hours of training, plus one and a half shifts shadowing a critical care nurse, she moved to an intensive care unit. Where once three wards was enough, now it had expanded to six to accommodate the influx of Covid patients, making space for about 50 people.
The first day “was an awful shift”, she says. Alone in a side room, caring for a very unwell man, she desperately monitored the unfamiliar machines. The decision was made to prone him – a group manoeuvre that involves turning a patient on to their front to improve oxygen levels. When colleagues asked if she was ready, Huntingford remembers “feeling like a rabbit in the headlights, completely out of my depth”. Fortunately, there was plenty of colleague support – the nurse in charge put her at ease.
In the first wave, most of Huntingford’s Covid patients were in their mid-50s or 60s. They were predominantly men; many were black or from ethnic minority backgrounds. Many patients were ventilated and on dialysis. Intensive care patients often experience multiple organ failure. Nursing staff must monitor machines, administer drugs and keep equipment clean to prevent infection. Then there are core nursing tasks – keeping people fed, hydrated, pain-free and washed, and preserving their skin by turning them regularly. “It is very physical,” she says. “I don’t think my back is the same.”
Usually, intensive care patients are visited by loved ones. During the first wave, this wasn’t allowed until death was near – and the NHS didn’t yet have the technology for video calls. Huntingford found this particularly difficult. “I’ve had a relative in intensive care, so for me family-centred care is so important,” she says. “I would hold phones to patients’ ears and tell families that they might be able to hear, so please talk away to them.”
When it was time for the final goodbye, “it was just awful. You want the family to experience a nice death, but they’re getting over the shock of what their relative looks like.” The sickest patients from other London hospitals were being transferred to Huntingford’s unit, so most were intubated and unconscious. “It’s such an aggressive virus; it does awful things to your body. There were relatives saying: ‘Come on, wake up,’ not accepting that this was it.”
While Huntingford used to have conversations like this in coronary care, they might happen twice a year. Now, it was once a week. Giving each family the time and support she felt they deserved took “a huge emotional toll”. This weight followed Huntingford home. She threw herself into running, to help her “decompress”, as well as cooking. As the months wore on, she no longer had the energy for even these small distractions.
There are 122,591 overseas nurses registered in the UK – 17% of the nursing and midwifery workforce. As Covid cases surged, measures were put in place to bring even more into the NHS to join the pandemic effort. Early data showed that black, Asian and minority ethnic nurses were disproportionately affected by Covid and less likely to have adequate PPE. A Public Health England report suggested historical racism may have contributed to this lack of access and made it more difficult for BAME nurses to raise concerns about PPE or being exposed to Covid infection.
Eva Omondi, a theatre and recovery nurse in Luton, was redeployed to a Covid intensive therapy unit (ITU) when routine operations were postponed. Like Huntingford, she comforted countless grieving families who lost loved ones in Covid’s first wave. “Relatives had not seen the patient for so long,” she says. “They were crying and you can only tell them we did the best we can. It was very, very painful.”
The Omondi family – Eva, 48, her husband, Fredrick, and their four children, who are between 11 and 26 – came to the UK from Kenya in 2012, when Fredrick began PhD studies. Omondi had trained as a nurse and midwife in the 90s, motivated by the lack of healthcare knowledge in her home village, Kochia. She saw the move to the UK as a chance to develop her nursing skills.
However, she has had to endure stresses unique to overseas nurses. In 2015, while applying for a six-year work visa after getting a full-time NHS role – the family had travelled originally on Fredrick’s academic visa – she learned of the new immigration health surcharge (IHS). This fee for NHS services (then £200 a year for each person applying), introduced by the coalition government that year, had to be paid upfront for all six years. For Omondi’s family, this meant thousands of pounds they didn’t have, forcing them to borrow.
Paying it back has been hard. Overseas nurses have no recourse to public funds – no subsidised childcare, tax credits, council housing or other benefits. Omondi was trapped in an impossible cycle: to pay debts, she needed to work overtime; to work overtime, she had to pay for childcare. She was forced to send her two youngest children to live with family in Kenya, which was a “painful ordeal”. Another son left to study in Malaysia.
When the pandemic began, Omondi was “constantly worried about my children alone in a far country”. Worry was widespread at work, too. Guidelines kept changing. There were PPE problems. Opening a box of masks, “you would look at the label and see it expired years ago”, she says. It has since emerged that 45% of the UK’s PPE supplies were out of date when the pandemic struck.
Omondi also worked overtime in A&E, maternity and recovery wards. Every nurse feared catching the virus, but there was added peril for Omondi, whose clinically extremely vulnerable husband was shielding. “I was so afraid to do overtime,” she says. Her fears were confirmed in March 2020 when she developed chest pains, coughing and a fever: “I thought I was dying.” At this stage of the pandemic, she couldn’t access a test. She couldn’t work for two weeks, then had to isolate when her eldest son tested positive for Covid. Later in the year, she fell ill again. Each time, she missed out on vital pay and overtime. She was forced to turn to friends, charities and food banks.
Going back into the ITU was tough: “Those 12-hour shifts were quite traumatising. You’d dread going back the following day. But because I am a nurse, I had to keep coming.” Omondi was relieved when she was asked to cover for a maternity recovery nurse who was shielding, allowing her to leave intensive care after two months. More good news followed. Omondi had been campaigning for the IHS to be scrapped since 2018. In May 2020, under pressure from the RCN, MPs and the public, the government announced healthcare workers would be spared the fee. Omondi was overjoyed.
In August, her children boarded a flight to the UK. Omondi had been working yet another overtime shift, but arrived home before they pulled up to the house. “They could not even wait to get their suitcases out – they came knocking on the door, shouting: ‘Mummy! Open the door! Finally, we are back!’” They ran about the house, hugging Omondi, telling her they would never leave her again. That night, they all slept together in the same room. “It was a good, good moment,” she says.
Despite the fear and uncertainty, many nurses felt buoyed up by the camaraderie and public support in the first wave. “Everyone was respecting lockdown, there was the Thursday clap,” Huntingford says. “It was humbling to have this public outpouring of respect.” Huntingford decided to make a permanent move into critical care nursing, impressed by the intensity of care she had witnessed and the warmth of her colleagues.
In late May 2020, the government announced plans to ease restrictions in England. People told Huntingford they were surprised to discover that she was still nursing Covid patients. By the summer, rising case rates and the government’s “eat out to help out” initiative were starting to worry the RCN’s Marquis. Suspension of NHS services had created long waiting lists. “Nurses went from the pressures of Covid to the pressures of trying to catch up,” Marquis says. “There was no break.”
Over the summer, Hudd tried out a nursing role as a clinical adviser in ambulance control, answering 999 and 111 calls. But she found she missed face-to-face care and landed a job at a smaller, community-focused elderly-care home on the Isle of Wight. As autumn approached, parts of the UK were subjected to lockdown measures, but on the island there was a sense of “misplaced security”.
On Boxing Day, England went into lockdown. Visits to the home ceased. A handful of staff had contracted the virus. When Hudd arrived back at work on 3 January after a couple of days off, the situation had deteriorated. Her manager had Covid. The virus had spread to residents, too. Four days later, she says, “I was the last nurse standing”. Hudd’s manager had been contacting agencies in a desperate bid to find backup staff. There was no one.
Hudd knew there was only one option: she had to move into the home. She tried to hold off panic, retreating to the medicine cupboard to cry where no one could hear. “Living in” for one or two days is not unheard of in social care, but this time it would be at least 10. She was committing to the 24/7 clinical care of more than 20 residents, many with complex needs or Covid and nearing the end of their lives. Usually, there would be five or six nurses covering the week. Now, there was one. The remaining care staff were exhausted. Residents were distressed, isolated in their rooms. “For them, an hour alone probably feels like a week,” Hudd says. “You might hear someone crying: ‘Where is everyone?’”
While Hudd slept in half-hour snatches, she kept a monitor connected to a patient with intensive care needs by her ear, so she could respond to any sounds. “It was like being a soldier on guard duty,” she says. In between, she would check on residents with complex health needs, administer medicines to end-of-life patients, make preparations for morning drug rounds and, increasingly often, deal with a death. Hudd and her colleagues lost 10 people to the virus – nearly half of the home’s residents.
Ensuring a “loving, comfortable, humane” death for each individual was Hudd’s priority. “It felt an enormous privilege to be alongside people at this significant point,” she says. She was adamant families should have a final visit. “These were the most sterile end-of-life visits I’ve done in my career. But the main thing was they got to say goodbye.”
With most of her care worker colleagues now isolating, the search for staff became desperate. Eventually, two care workers travelled from London to stay for a week. The remaining staff grew close. “The trust we built up between ourselves was really quite awesome,” says Hudd. She remembers ordering one of the youngest members of the care team to go home and rest after back-to-back 12-hour shifts. “As I waved goodbye, I felt like a big piece of me had been wrenched out. Living in so much uncertainty … you connect with people.”
In Huntingford’s hospital, Covid cases were steady from September until early December. She and her partner managed to have Christmas Day off together, but they knew what was coming. She volunteered for redeployment again, to the Covid unit at another London hospital. For her first shift, there were 60 Covid patients; two weeks later, there were 140.
In intensive care, there should be one nurse to one patient. During the second wave, this was impossible. “I was, as a very new intensive care nurse, given responsibility for three or four patients,” Huntingford says. “It was completely overwhelming.” Alarms were constantly sounding, indicating that a patient’s oxygen levels were running low. Huntingford had to run between beds. She felt “completely out of control, that there were ticking timebombs around me”.
During one shift, a family had come to say goodbye to a man in his 50s who was close to death. To give them privacy, screens were placed around his bed. “We had this still moment, where they were sharing stories about him,” Huntingford says. “Then I thought: ‘I have to check on my other patients.’” She dashed to another patient; his oxygen levels were dangerously low. With every other nurse overloaded, no one had noticed. “Everywhere you turned, there would be a new emergency happening.”
In the first wave, one death a week felt horrifying. Now, deaths were coming every day. The emotional burden was huge. Many nurses have described “moral distress” – the psychological impact of being physically unable to provide the right level of care. “I found it very difficult to rationalise with myself that I’d done a good enough job,” Huntingford says. “We felt a guilt that we weren’t doing enough.”
She witnessed senior staff struggling, too: nurses overwhelmed by yet another death, a surgeon “starting to crumble”. “We were all on such a knife-edge,” she says. “A lot of us now feel like we’re waiting for everything to catch up on us. I used to always read up on my patients. I’m not doing that at the moment. I’m scared that, if I see they’ve passed away, that’s another patient I know that’s died. There’s been too much death. To bring any more into your life, it’s unthinkable.”
Support from her family and partner (who was also redeployed to intensive care) helped her cope. “I’m fortunate that I have people who understand what I’ve been going through,” she says.
Another positive of the second wave was the advent of “family liaison hubs”, which sprang up in hospitals all over the country. Using iPads allowed families to see patients, despite many being unconscious. This felt “odd” at first, Huntingford says, but was a huge improvement. As April approached, there were “heartwarming moments”: patients who had been intubated were getting their voices back. Huntingford was able to take some to higher floors to watch the sunset. Moments like these – and her supportive colleagues – reaffirmed Huntingford’s decision to enter nursing. “In some ways, it’s been an incredible year for nurses. It’s shown us at our best. The versatility of us as a profession is just incredible,” she says. “But it’s come at a huge cost.”
During the second wave, Omondi was able to work in maternity recovery again, avoiding a return to ITU. “It was a big, big relief,” she says. Although work was stressful, she concentrated on helping her children settle back in.
In spare moments, she joined a new campaign: asking the government to give overseas healthcare workers indefinite leave to remain (ILR). This would grant them access to crucial benefits and remove the fear and costs associated with visa renewal. Omondi envisions a time when overseas nurses can change jobs without risking their immigration status and don’t have to share houses to save on rent and childcare, or use food banks or charities. “The overseas person feels very vulnerable,” she says. “Nurses need peace of mind. We are living destitute lives here.”
Before her six-year visa was due to end in February 2021, Omondi began applying for ILR. Due to the huge cost – nearly £15,000 for her family – she asked the Home Office for a fee waiver. In October 2020, she received a letter saying she qualified. She sent her application. Four months later, a response arrived: a fee waiver could not be used for ILR after all. Her application was denied. “My body went numb,” Omondi says. “I was crushed. For the first time, I felt that suicidal feelings were coming into my head. I looked at how much I’ve worked, how much I’ve given this country. I’ve been a diligent taxpayer, I’ve not had any benefits and I’m a frontline worker who has worked through the pandemic.”
A colleague found her crying in the corridor and comforted her, but it took days to sink in. “I went through a process of grieving, asking: ‘Where did I go wrong? Where do they expect me to get the money?’ I was feeling useless, undervalued.”
The Omondis were put on a 10-year family route to ILR. (They were able to remain in the UK because, in November 2020, the Home Office had extended a scheme offering free one-year visa extensions to overseas healthcare workers whose visa expired before the end of March 2021.) They are still denied access to council housing and other benefits. Omondi hopes the 10 years will be counted from their arrival in 2012, making them eligible to apply for ILR again next year. Even so, she doesn’t know where she will find the £15,000 and has decided to set up a crowdfunding campaign.
After a relentless 18 months, many nurses are mentally and physically exhausted. “Frankly, they need a break and that’s really difficult, because they also know patients need them to keep going,” says Marquis. Mental-health and long-Covid support, plus a fair pay rise, will be vital to recruitment and retention, she adds.
In July, the government announced a 3% pay award for NHS staff in England. It is far below the RCN’s desired 12.5% and short of the 4% offered in Scotland, which has already been rejected by RCN members (Wales offered 3% and Northern Ireland has yet to announce). The RCN is consulting members on what action to take and has a £35m strike fund ready. “It felt completely insufficient to say that our skills, professionalism and dedication, which has been on full display, were worth such a meagre increase,” says Huntingford.
Polling by Nursing Standard in May showed that 90% of nurses do not feel valued by the government. An RCN survey said 36% were thinking of leaving the profession – two-thirds citing pay. Huntingford is already seeing it happen. “I’m getting emails on a weekly basis with someone else’s leaving card to sign,” she says. “People don’t have the energy to be activists, they’re just saying: ‘I’m out.’” Hudd says pay and conditions in social care must be addressed, too. When she was signed off sick with Covid, she discovered she was entitled only to statutory sick pay – £96.35 a week.
In June, with Delta variant cases increasing, Covid patients started to be admitted to Huntingford’s ward again. “When I heard, I got this prickling sensation all over my body. I suddenly felt on guard; my adrenaline was pumping,” she says. “That’s a feeling I get now when I see a colleague I haven’t seen since redeployment, or when I’m using certain equipment – catapulted back to this really horrific time.” Colleagues have told her they are prepared to resign if the third wave is as bad as they fear. “We’ve chosen a selfless career, but enough is enough.” She has just been called for redeployment. “There’s something psychologically really bad about having to make these changes to your life all over again,” she says. “But I am mentally preparing.”
In July, Omondi’s tireless campaigning was recognised with a 2021 RCN Award of Merit. But she, too, has seen colleagues transferring to different areas of nursing or retiring early. “Everybody is feeling really let down,” she says. “The risk we put our lives in, watching our colleagues and patients die – that should be reason enough for the government to appreciate us.” Seeing ministers taking part in the “clap for carers” felt “insulting … that clap was their easy way out”.
Omondi is still working nights on recovery wards and has seen a tightening of Covid procedures as the Delta variant spreads. With vaccinations and better PPE supplies, people are more confident than last year, she says, “though the fear is still there”. She says the pandemic has exacerbated the plight of overseas nurses: “It’s painful that you can give so much to a government that doesn’t give anything back.” She is determined to keep fighting for ILR and hopes the recent change of health secretary may help. “Sajid Javid is from an overseas background – maybe he will look at it differently.”
When Hudd returned to work part-time after contracting Covid, she put on a brand of mask with a distinctive smell and was “teleported back in time to living in the home”. She sought support from her faith community, her family and other nurses and decided to reduce her hours. Yet repeatedly returning to the scene of distressing memories had an impact. “I was finding it difficult to get past the ghosts in that care home,” she says. “I’d go into a room where I’d had long, intense hours of difficult nursing care and there’d be a different occupant. It felt like life was moving on and I wasn’t able to.”
She took the tough decision to resign. The heart-attack scare confirmed her decision to step back, after a decade in the job. “I was determined to power through it, but it wasn’t really working. I need time to recover,” she says. Now she feels able to manage her physical symptoms, but at times anxiety is overwhelming. She has started counselling through the NHS and found vital support from other nurses. Relearning the piano and taking walks with her dog have brought moments of light into her life, while she recently climbed Mount Snowdon for Cavell Nurses’ Trust. She hopes the temporary break, although “scary”, will extend her nursing career: “I won’t be the same person I was before, but I hope I am competent to continue being at the coalface.”
She has just accepted a part-time care home role, starting later in the year, and feels a mix of “quiet optimism and apprehension”. “Crisis situations make you evaluate. I want nursing to be a part of me. I don’t want it to destroy me.”
In the UK and Ireland, Samaritans can be contacted on 116 123 or by emailing firstname.lastname@example.org or email@example.com. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org.