How has COVID‐19 affected mental health nurses and the delivery of mental health nursing care in the UK? Results of a mixed‐methods study

Accessible summary What is known on the subject? During the COVID‐19 pandemic, there has been research considering the impact on medical healthcare professionals and the mental health needs of the general population. However, limited focus has been placed on mental health services or mental health staff providing care in the community and in hospitals. While nurses make up the largest section of the mental health workforce in the UK, the impact that this pandemic has had on their work has been largely ignored. What the paper adds to existing knowledge? This paper provides a unique insight into the experiences and impact that the COVID‐19 pandemic has had on mental health nurses across a range of community and inpatient settings to understand what has changed in their work and the care they can and do provide during this crisis. This includes exploring how services have changed, the move to remote working, the impact of the protective equipment crisis on nurses and the difficult working conditions facing those in inpatient settings where there is minimal guidance provided. What are the implications for practice? By understanding the impact the pandemic has had on mental health nursing care, we can understand the gaps in guidance that exist, the challenges being faced and the impact the crisis has had on care for mental health service users. By doing so, we can plan for the ongoing nature of this pandemic and the aftermath that the crisis may leave for our service users and workforce alike. Abstract Introduction While evidence has emerged concerning the impact of COVID‐19 on the general population and the challenges facing health services, much less is known regarding how the pandemic has directly affected the delivery of mental health nursing care. Aim This paper aimed to explore how COVID‐19 has affected the ability of mental health nurses to deliver care in community and inpatient mental health services in the UK. Method We investigated staff reports regarding the impact of the COVID‐19 pandemic on mental healthcare and mental health service users in the UK, using a mixed‐methods online survey. A total of 897 nurses across a range of inpatient and community settings participated. Discussion Key themes within the data explore the following: new ways of working; remote working; risks of infection/infection control challenges; and the impact on service users. Targeted guidelines are required to support mental health nurses providing care and support during a pandemic to people in severe mental distress, often in unsuitable environments. Implications for Practice Service developments need to occur alongside tailored guidance and support for staff welfare supported by clear leadership. These findings identify areas requiring attention and investment to prepare for future crises and the consequences of the pandemic.


| INTRODUC TI ON
The COVID-19 pandemic has placed an increased demand on health and social care services, with major pressures faced by intensive care unit services in general hospitals (McCabe et al., 2020). Throughout the pandemic, restrictions placed on individuals, workplaces and services have led to increased concerns about the impact that the pandemic would have in both the short and the long term on mental health services . A rapid synthesis of published material from the earliest phase of the pandemic (Sheridan-Rains et al., 2020) highlighted a broad picture of deteriorating mental health for those with existing difficulties. This review mirrors the emerging picture where much of the empirical literature has placed focus on the impact of the pandemic on individuals (Cheung et al., 2020;Fernández-Aranda et al., 2020;Mazza et al., 2020;Mertens et al., 2020;Mind, 2020;Pierce et al., 2020;RCPsych, 2020;Qiu et al., 2020;Wang, Pan, et al., 2020;Young Minds, 2020), with less focus on how it has affected services and the care provided.
Consequently, there is a need for mental health services research to understand the impact of the pandemic and the resulting changing landscape to ensure policymakers, commissioners and service providers can act to address the needs of those with pre-existing mental health problems, those at risk of developing mental health problems, and the professionals and other staff working in services.
This includes the need to focus on the experiences and perspectives of mental health nurses (MHNs) .
In one of the first studies to focus on the impact of COVID-19 on mental health services from the staff perspective, Johnson and colleagues published results exploring the experiences of 2180 mental health staff from a range of sectors, professions and specialties . Initial results highlight immediate infection control challenges and concerns regarding new ways of working.
Multiple rapid adaptations and innovations in response to the crisis were described, especially remote working, which was cautiously welcomed but successful in only some clinical situations. The impact and challenges facing healthcare services are likely to disproportionately affect nursing staff who, in the UK at least, make up the highest number of qualified staff in the mental health workforce (NHS, 2017). We are already seeing the negative impact that COVID-19 has had on nurses in ICUs, COVID-19-designated hospitals and departments involved with treating COVID-19 patients, with these nurses reporting higher scores in mental health outcomes .
The crisis has exacerbated the long-standing problems faced by nurses in relation to inequalities (e.g., lower pay, higher numbers of women in the profession and high levels of BAME individuals in nursing roles), inadequate working conditions and chronic excessive work pressures, exemplified by the increasing vacancies, absenteeism, turnover and intentions to quit reported prior to the pandemic, with staff having reported feeling "broken," "exhausted" and "on their knees" (The Kings Fund, 2020). Beyond issues related to workload and stress, the sobering impact of the pandemic can be seen with the cost to life that has been seen within this workforce, with Aim: This paper aimed to explore how COVID-19 has affected the ability of mental health nurses to deliver care in community and inpatient mental health services in the UK.

Method:
We investigated staff reports regarding the impact of the COVID-19 pandemic on mental healthcare and mental health service users in the UK, using a mixed-methods online survey. A total of 897 nurses across a range of inpatient and community settings participated.
Discussion: Key themes within the data explore the following: new ways of working; remote working; risks of infection/infection control challenges; and the impact on service users. Targeted guidelines are required to support mental health nurses providing care and support during a pandemic to people in severe mental distress, often in unsuitable environments.
Implications for Practice: Service developments need to occur alongside tailored guidance and support for staff welfare supported by clear leadership. These findings identify areas requiring attention and investment to prepare for future crises and the consequences of the pandemic.

K E Y W O R D S
community mental health care, COVID-19, infection control, inpatient mental health care, mental health nursing, psychiatry, remote working many nursing staff, including mental health nurses, working on the front line during COVID-19 having lost their lives (RCNi, 2020).
Mental health nurses are the staff group most likely to be involved in face-to-face interactions with patients in inpatient settings who may be highly distressed and/or frustrated at the restrictions typically imposed that include the use of rules and procedures to maintain safety, enforced medication, seclusion and restraint (Bowers et al. 2013), even before further pandemic-related impositions. Additionally, a high proportion of admissions to mental health wards are now enforced detentions under the Mental Health Act, further fuelling the potential for conflict and use of containment measures (Akther et al., 2019).
Consequently, this paper provides a unique and more detailed in-depth analysis of the responses from mental health nurses that responded to the Johnson et al. (2020) survey. To our knowledge, this is the first work that has highlighted the experiences and needs of MHNs during the pandemic.

| Aim
The aim of this study was to explore how COVID-19 has affected the mental health nurse workforce in order to understand what changes to services have been made and how these affect the care and treatment that MHNs provide across a range of mental health settings.

| ME THODOLOGY
The findings reported in this study were drawn from data collected from a survey exploring the perspectives and experiences of staff working in mental health inpatient, community and specialist services across the UK during the early stages of the national COVID-19-related restrictions, from 22 April 2020 to 12 May 2020. The university research ethics committee approved this study. The King's College London research ethics committee approved this study (MRA-19/20-18372). The survey included both structured and open-ended questions and followed a branching system allowing for sections of questions relating to specific settings (e.g., inpatient or community) and specialities (e.g., sections dedicated for staff working in perinatal settings). Given the lack of literature regarding the specific MHN experiences, we conducted a secondary, more detailed analysis of this survey data using the responses provided by participants describing themselves as nurses.

| Questionnaire design
The wider research team carried out a rapid review of the literature regarding the impact of COVID-19 on mental health, academic and professional journals, news media, and organizational web sites, and followed relevant social media topics. The themes and content of this rapid review shaped the development of this questionnaire design and were further informed by the NIHR Mental Health Policy Research Unit (PRU) working group for this study (about 30 people, including clinicians, researchers and people with relevant lived experience), and the PRU Lived Experience Working Group. Both groups discussed the study at online meetings and identified important topics for inclusion. Nine further clinicians provided email summaries of the challenges they were currently facing and how they were being addressed. Pilot testing was then conducted with 17 clinicians who provided feedback on the length, acceptability and relevance of the questionnaire and on problems with specific items. Following this, a final version of the questionnaire was agreed.
The questionnaire included questions covering a range of sections to address staff experiences during COVID-19. These sections  . The study used an explanatory mixedmethods design, a methodological design consisting of two distinct phases: quantitative followed by qualitative (Creswell et al. 2003).
The qualitative data are collected and analysed second in the sequence and help elaborate on the quantitative results.
Responses to quantitative questions were scored on a 5-point Likert scale of relevancy ranging from "extremely" relevant, "slightly" relevant to not relevant or not applicable. The inclusion of a range of open-ended qualitative questions, which were incorporated throughout the questionnaire, allowed participants to add details to the quantitative responses. Further details regarding the development of the survey and recruitment can be found in the publication describing the whole data set .
Participants were presented with all questions, both qualitative and quantitative, with no questions being mandatory. Demographic questions were at the end of the questionnaire meaning that fewer participants completed this section than earlier questions related to their practice.

| Analysis
All data for participants who identified as a MHN were extracted to Microsoft Excel. Quantitative data were then imported to SPSS 26 for analysis (IBM, 2019). The quantitative data were used to produce descriptive statistics to summarize relevant aspects of the responses. Participants were not required to answer all questions; therefore, descriptive percentages were calculated based on the total number of participants who provided an answer to that question rather than from the full sample.
The qualitative data were analysed within Excel, using a thematic analytic approach, as outlined by Braun and Clarke (2006).
Team members read and re-read the data noting aspects of interest.
Following this, a list of codes was generated. Microsoft Excel was used to record the extracted chunks of data and associated codes.
Following initial coding, related codes were sorted, grouped and labelled as preliminary themes, defined as the central concepts that capture and summarize the core point of a coherent and meaningful pattern in the data (Braun & Clarke, 2006).
Participants responded to a range of the quantitative and qualitative items. As questions were not mandatory, the number of participants responding to each item varied across the survey meaning that denominations presented within the results represent those who answered each item.  Table 1, and Table 2 outlines the demographics of the sample. The sample has a considerably lower representation of nurses from non-White ethnic backgrounds than are reported in the nursing workforce (Marangozov et al., 2017).

| Description of sample
The top concerns that participants identified as very or extremely relevant to their work are outlined in Table 3 below, with   Table 4 outlining the differences in concerns of those working in community and inpatient settings.

| Impact on working
3.2.1 | New ways of working As outlined in Table 3, the top concern for MHN participants was the quick adaption that many had to make to their way of working, with over 60% of all participants feeling this was too quick. This was the top concern for community staff who largely had to adapt to working remotely and providing services via the telephone and new video and online platforms. Many reported that using such new technologies was hampered by logistical challenges such as poor Internet connection, hardware availability and lack of privacy to conduct appointments. a Participants may work across more than one sector (e.g., NHS and voluntary), in more than one setting (e.g., an inpatient service and crisis assessment service) and with more than one patient group (e.g., working age adults and forensic). Percentages for these variables therefore do not add to 100%. b Percentages are of participants that provided an answer.

TA B L E 1 Participants by sector and specialism a,b
This move to remote appointments and care had mixed results with some participants noting it as a useful method of ensuring continuity of care. In contrast, others felt that this method did not lend itself well to some populations for a range of reasons including access, logistics and lack of trust:

| Impact on service users
The impact of changes was reported to be a considerable worry for MHNs in relation to how this influenced the care provided to service users, with 40% of the sample (n = 331 of 776) feeling that the statement "service users no longer getting an acceptable service due to service reconfiguration" was very or extremely relevant to their work. This was one of the top concerns that MHNs had regarding the impact of COVID-19 on themselves and their work (see Table 3).
Over half of the sample (n = 394 of 736, 53.5%) were concerned about the lack of access to usual support from NHS mental health services for service users.
As service users with severe mental illness (SMI) have higher comorbid physical health conditions, several participants raised concerns over the reduction in services to support these additional medical needs or fear of attending services for physical health needs: "[increased concern for those] not accessing physical health care, not wishing to burden services including A and E." (Community Service Manager, North East England) Twenty per cent (n = 150 of 731) of the sample noted concern regarding service users' access to and administration of medication:

| Risk of infection
A prominent theme within the data was the concern that the MHN workforce felt in relation to the risk of COVID-19 infection. This was the second leading concern for participants across all sectors (e.g., inpatient and community settings) (see Table 3), with over half of participants reporting they were worried they could be infected in work. This concern regarding risk was the top concern for inpatient MHNs with two-thirds (67.8%) of inpatient nurses reporting this was very or extremely relevant to them (see Table 4), with risk to service users and family or friends also being a concern for over 60% of the inpatient MHNs. Such level of concern was lower in the community MHN sample with 47.1% reporting concern for their own risk and 41% regarding concern for risk to family or friends. Considerably, lower levels of concern were reported in relation to risk to service users (see Table 5).

| The work environment
Across both the community and inpatient settings, MHNs reported that the work environment made it incredibly difficult to follow social distancing guidelines or infection control measures effectively.
When asked "Is it practical to follow consistently the rules you have been given on infection control at work?" almost half of participants (n = 270 of 609, 44.3%) answered no. Both the ward layout and office spaces posed considerable issues. Those working in the community and using office space noted that the layout of buildings, lack of computers and space meant it was "impossible to keep 2 meters distance" from colleagues as the space was too small and too congested.
"The environment doesn't allow the guidance to be followed."

(Adult Inpatient Service, North East)
Within inpatient settings, these challenges were more pronounced with shared rooms and ward layout meaning social distancing was unachievable or difficult and that the environment was "impractical for proper infection control." "Self-isolation -none of the rooms are ensuite so young people that are   a Participants may work across more than one sector (e.g., NHS and voluntary), in more than one setting (e.g., an inpatient service and crisis assessment service) and with more than one patient group (e.g., working age adults and forensic). Percentages for these variables therefore do not add to 100%. b Percentages are of participants that provided an answer. each office. Any restraint/debrief means we break social distancing." (CAMHS Inpatient Service, London)

| The challenges with personal protective equipment (PPE)
The lack of PPE was cited by many as a significant issue.

| Service users' wellness and understanding
In addition to the challenges facing MHNs directly, many noted that the nature of working in mental health services, particularly where there are high levels of acuity, meant that social distancing and adhering to guidelines was difficult even where PPE was available and space was provided, due to service users being mentally unwell.
Almost half of the sample (n = 359 of 727, 49.4%) reported concern that service users may have difficulties understanding or following current government requirements on social distancing, self-isolation and/or shielding. Staff reported that in many cases, service users may lack trust in the services or have diminished cognition and this may explain the challenges that MHNs on wards experienced in relation to problems with social distancing and adhering to guidelines:

| Sources of support
When asked about the main sources of support that MHNs felt were very or extremely useful to them during the pandemic, 70% of MHNs said the support and advice from managers was key. In particular, the guidance regarding clinical issues developed by managers and local leadership within mental health settings was important to staff navigating the changing landscape. This helps MHNs to overcome some of the key challenges identified, namely the frequently changing and confusing nature of guidance and its lack of specificity to mental health settings that bring perhaps unique challenges.
More generic sources of support via the sources such as the media or voluntary groups were felt to be less useful for staff than these more MHN-led sources.

| DISCUSS ION
To the best of our knowledge, this is the first paper to report in detail the experiences of mental health nursing staff during the COVID-19 pandemic. While many of the issues identified reflect similar themes reported within the original study of the wider mental health workforce , the analysis presented in this paper shows the key and often unique challenges and concerns that face MHNs. The findings highlight the major challenges facing inpatient MHNs in providing care and treatment while wearing PPE and maintaining social distancing with patients who may not have capacity to understand guidelines, and within environments that are often unsuitable and unadaptable.
Furthermore, this paper highlights the added complexity of providing care safely on wards where there are potential suicide risks and the need to implement restrictive practices when required.
This unique complexity is generally missing from the wider literature and unlikely to be addressed within more generic guidelines.
While many of the challenges facing community-based MHNs are reflected in the wider professionals' experiences of rapidly moving to remote working, many MHNs continued to provide care, treatment and support in people's homes in the community, often in challenging environments. Throughout, the guidance for these MHNs was reportedly lacking and needs addressing swiftly to reduce the risks that are placed on the workforce and those they are caring for.
The response to the COVID-19 crisis has irrefutably had a significant impact on mental health services (Marshall et al., 2020;Moreno et al., 2020). As we have seen in the emerging literature surrounding this topic, MHNs are experiencing similar work stresses as other healthcare professions in relation to changes to workload and moves towards the use of remote technologies (Sheridan- Nuffield Trust, 2020). Many of these shifts in clinical practice, especially the greater use of technologies and remote working, are likely to remain. Therefore, the commissioning of services, preregistration nursing education and the continuing professional development of MHNs will need to consider and evolve in line with the emerging lessons of the pandemic. Additionally, the need for reliable hardware, Internet connection and support including appropriate training is necessary in ensuring that care can be provided on these platforms in the uninterrupted manner that face-to-face sessions require. As shown in the findings, MHNs are concerned over increased remote appointments in circumstances where this means that some people may not get seen, such as those without access to Internet or hardware and people with psychosis experiencing paranoia. It is therefore important to research and understand the impact of remote appointments on therapeutic relationships with service users, particularly with those where it is not easy or perhaps appropriate.
These issues also need to be considered to ensure that the socioeconomic inequalities already facing service users regarding access to services are not widened by requiring laptops, stable Wi-Fi connections, mobile data and housing with privacy, which are currently considered a luxury rather than a right. The findings presented in this paper also draw attention to the wider inequalities that face mental health service users. Patients from Black, Asian or other minority ethnic communities are likely to be disproportionately represented in our inpatient wards (Barnett et al., 2019), and those with severe mental illness are more likely to develop physical health comorbidities such as diabetes, cardiovascular and respiratory illnesses (Reeves et al., 2018). All of these are linked to a higher risk of having severe outcomes in those who contract COVID-19 (Aldridge et al., 2020;Clark et al., 2020;Wang, Pan, et al., 2020;. Hospitals are noted as hot spots for people being infected with COVID-19. These risks may be due to some of the challenges outlined within this paper, such as difficulties adhering to social distancing or donning PPE in cramped environments, meaning these populations are at a considerable additional risk. Consequently, the difficulties noted within this paper as experienced by staff within these settings must be considered and acted on to ensure the safety of this vulnerable patient population and the staff that care for them. Shortages of PPE have been widely reported within other healthcare environments (Kamerow, 2020;Livingston et al., 2020) Even where PPE has been available and both staff and service users are following guidance to socially distance, the environments in which staff are working appear to impinge on their ability to do so. This was salient for wards, which have been noted for years as being out of date and posed challenges for safety in relation to ligature protocols (CQC, 2017). This new crisis adds to the evidence that many buildings and wards in which care is being provided are no longer fit for purpose when facing new crises and challenges and highlights the need for investment and environmental planning within our mental health services.

| Limitations and future directions
While the study allows initial insights into how COVID-19 has impacted on mental health nursing, there are limitations to consider. Firstly, it must be noted that these data present only staff perspectives. There is a need to consider questions regarding the impact on care from the service user and carer perspectives to fully understand the impact COVID-19 has had on mental health services. In addition, a key limitation is that the study numbers across groups are not similar or matched meaning that the study lacked power to undertake comparative statistical analysis. There is a need to address the homogeneous nature of the sample. While recruitment efforts were made to target Black, Asian and ethnic minority (BAME) populations, the sample remains lacking in diversity; thus, findings are skewed to represent a white sample rather than acknowledging specific risks and issues that may be in play for BAME colleagues.
Furthermore, it must be highlighted that the data were taken from a wider national study of all healthcare professionals and there were no nursing-specific questions within the survey. The findings highlighting the need for specialist nursing information and guidance point towards the need to conduct research specifically designed for our mental health nursing colleagues' experiences. We hope that this paper will start the conversation towards designing nurse-led research within this area to address aspects that more general mental health research may be missing.
Future research should consider a longitudinal perspective on this pandemic, using repeated data points to see whether and how experiences have or have not changed over the course of the pandemic and in the long term.

| CON CLUS ION
The findings have shown key areas that require attention and guidance during the ongoing COVID-19 crisis. This includes the challenges of the swift shift to remote working in community services, ensuring the safe use of protective clothing in people's homes or on cramped wards, and the need for targeted guidance and support for MHNs working in inpatient settings, where they are faced with unique challenges in maintaining social distancing and interacting with mentally distressed and confused patients. These findings show that mental health nurses face unique challenges and are impacted differently across different sectors. COVID-19 is not necessarily a shared experience; therefore, research needs to provide a more focused lens on individual settings, e.g. inpatient wards, child and adolescent services, older people's service, eating disorder units, and crisis and assertive outreach services, to ensure these are managed effectively. This paper touches on some of the current demands and challenges identified, but we also need to consider how much and how fast the system will need to change if we see a rapid escalation of mental health presentations over the next year as a consequence of the pandemic, and how mental health nursing staff will be supported or prepared for this.

| RELE VAN CE S TATEMENT
This paper provides insight into the impact that the COVID-19 pandemic has had on the service and care that mental health nurses are expected to and can provide. As a workforce that often requires ongoing face-to-face contact with service users, many in serious distress, in inpatient and community settings, it is important that we understand their experiences and the challenges and risks that face this workforce. This will enable us to ensure that future planning, guidance, support and safeguarding can take place during the ongoing and future crises.

ACK N OWLED G EM ENTS
We would like to acknowledge the hard work carried out by the COVID-19 Mental Health Policy Research Unit Group who were involved in the original Johnson et al. (2020) study in which these data have been taken from for a secondary analysis. We also thank the clinicians who took time to complete and feedback on our pilot survey, and all participants for taking time from the pressures of the pandemic to respond to the crisis.

SJ & AS are grant holders for the NIHR Mental Health Policy
Research Unit.

AUTH O R CO NTR I B UTI O N S
SJ and AS made the initial plan for the study. SJ, AS, CDL, NVSJ and UF contributed to protocol development. SJ drafted the survey.
CDL developed the online version. AS, NVSJ and UF commented.
CDL and AS led on recruitment strategies. UF, NVSJ, JHS and RL planned, coded and summarized qualitative data. UF, LB and AS drafted the manuscript. All authors contributed to and approved the final manuscript.

E TH I C A L A PPROVA L
The King's College London research ethics committee approved this study (MRA-19/20-18372), which involved mental health staff in the UK completing an online questionnaire.