What nurses say about short-staffing and how it’s harming patient care

Abstract

Nine out of ten nurses feel their professional values are being compromised by understaffing, a Nursing Standard poll reveals.

Nurses in acute, community and care home settings responded with one message – they can’t provide the level of care they would wish because there are just not enough of them.

Some feel out of their depth at having to care for complex patients outside their specialty. Others feel obliged to stay late to get the job done.

‘Care in the profession has gone… [we’re] only interested in getting beds emptied for emergencies to come in,’ one nurse told us. ‘I’m unable to give good-quality care on a daily basis.’

Respondents told us they cannot take breaks because of understaffing

Picture credit: Getty

What the survey tells us

Our findings, drawn from the responses of 2,064 nurses, will leave no one in any doubt about the toll short-staffing is taking on nurses – as well as patient care.

We ran the six-question Safe Staffing and Professional Values survey online from 22 February to 8 March using the survey software SurveyMonkey. The responses were analysed by Nursing Standard.

Some of the 9% of respondents who said their professional values had not been compromised admitted this had come at personal cost.

‘I have to stay after my shift has finished, go in early and don’t get breaks,’ one nurse said.

Lack of breaks and working extra hours unpaid emerged as a theme. One respondent said: ‘I have forgone proper breaks to maintain my values and ethics’. Another said: ‘I have to stay after my shift has finished, go in early and I don’t get breaks.’

A nurse academic said they had noticed this during visits to practice settings: They told us: ‘I am aware mentors increasingly use their own time to complete student documentation. Lack of consistency in shift patterns and frequent changes, often to cover unexpected shortfalls, leaves staff sleep-deprived and without work-life balance.’

How to raise a safe-staffing concern

The RCN’s advice for nursing staff includes:

• If there is immediate risk, speak to a manager or senior colleague urgently

• Consult your employer’s formal policy on raising concerns in the first instance

• Keep records and notes throughout the process for future reference

• RCN members can call the college on 0345 772 6100 or talk to their local RCN rep

• Find the RCN’s guidance on raising concerns at tinyurl.com/RCN-raising-concerns

Risks to patient safety

The implications for patient safety seem obvious and a gynaecology nurse offered a worrying insight into caring for patients outside the specialty.

The survey findings

94% said an understaffed work environment affected the quality of care and treatment they had been able to provide

91% said their professional values have been compromised by understaffing in the past 12 months

61% said their employer tried to address the problem but had been ineffective

26% said their employer ignored the issue

83% said they had reported a safe staffing concern to their employer

76% said they would report a colleague if they made a mistake due to understaffing

Source: Nursing Standard 2019 Safe Staffing and Professional Values survey

‘We have found ourselves having to look after some really complex poorly medical patients and feeling completely out of our depth and knowledge,’ the nurse said.

They described having to care for patients with complex medical conditions such as stroke and not knowing how to monitor the equipment or appropriate drug doses. ‘Our ward manager has been at the end of her tether… when she has shown some authority and complained and tried to stand up for us as a team it has been suggested she reports to occupational health for stress and behaviour change,’ she said.

A children’s nurse said staffing problems affected the most vulnerable patients.

‘High-dependency unit ratios that were previously one nurse to one patient have changed to 1:2 or 1:3,’ the nurse said.

The plight of nurses in the chronically understaffed care home sector comes through loud and clear. One respondent said: ‘I’m expected to look after 44 residents on two floors for a 12-and-a-half-hour shift.’

Even though almost all respondents said they had reported a safe-staffing concern, employers were often incapable of, or unwilling to, address the issue. ‘Patients’ well-being is the last thing on the system’s agenda,’ said one nurse.

‘They know but [there is] nothing they can do, as they rob Peter to pay Paul to staff wards,’ said another.

A nursing home nurse who flagged up safety fears said: ‘I was told it wasn’t unsafe, just not ideal. That was me and one carer on a night shift for 34 residents in a nursing home.’

‘They flatly refused to accept there was an issue and aggressively told me I was wrong when I raised it,’ another nurse said.

‘This cannot continue’

RCN acting general secretary Dame Donna Kinnair said our survey shows nurses are being put in an untenable position.

She said: ‘It’s hard to find a member of nursing staff, no matter where they work, who isn’t affected by unsafe staffing.’

‘These results make clear that current conditions cannot continue – whether in the NHS or beyond.

Nurses in care homes talk of being stretched by lack of staff

Picture credit: iStock

‘Front-line nursing staff can blame decisions taken at the national level for what they’re seeing in their workforce.’

The Nursing and Midwifery Council (NMC) requires registrants to document and escalate any potentially harmful incidents.

It is apparent from the survey that nurses feel conflicted about reporting others’ errors. Some 9.5% of respondents said they would not report a colleague who had made a mistake through short-staffing that had resulted in, or risked, patient harm.

One nurse told us: ‘The trust would put all the blame on the colleague rather than resolve the staffing issue, as it has done again and again for years.’

‘If management were aware of unsafe staffing then no, I wouldn’t report a colleague,’ another nurse said.

Do I need to refer myself to the NMC?

Marc Cornock (pictured), a nurse, academic lawyer and senior lecturer at the Open University, writes:

You may wonder why anyone would want to alert the NMC to an error on their part that could result in a fitness to practise investigation. There are several reasons. First, nurses and midwives are required to do so in certain circumstances. Clause 23 of the NMC code states it is a requirement in respect of criminal cautions and convictions, and for restrictions placed on practice.

There are two other main reasons for self-referral to the NMC:

• Being aware of an issue that is, or may be, affecting patient care and doing nothing may be seen as a more serious offence than the one you are failing to report

• It shows insight into your practice and the circumstances of the incident, for instance, poor staffing levels, that contributed to it. Insight can be a mitigating factor

Download the NMC’s guidance on the professional duty of candour at tinyurl.com/NMC-duty

How do I refer myself?

A form on the NMC website has all the details needed to make a self-referral. Go to tinyurl.com/NMC-self-referral

Before self-referring you should speak to your trade union or professional organisation representative. RCN members can call 0345 772 6100 or speak to their local rep.

You should also inform your manager or employer what you are intending to do and why.

Unfair to blame staff

‘I would report the incident to ensure the patient’s safety but would be unwilling to identify the staff member as, due to understaffing, I do not feel the blame could be put fairly on his/her shoulders,’ one nurse explained.

A few nurses said they would report colleagues, but with ‘great difficulty’, to help raise awareness of unsafe staffing.

The Department of Health and Social Care intends to publish a workforce implementation plan later this year as part of the NHS Long Term Plan.

A spokesperson said: ‘There are over 16,300 more nurses since 2010, 52,000 nurses in training and we have made more funding available to increase university places.’

A law on minimum safe staffing levels in adult acute care came into force in Wales in April 2018 and a safe staffing bill is going through parliament in Scotland.

The RCN is planning a campaign to lobby for a safe staffing law in England. In 2017-18 England, there were 41,722 nurse vacancies in England, according to NHS Improvement.

The RCN estimates vacancies in Scotland are running at 4.5% and the college says no data are available for Wales or Northern Ireland.

RCN England director Patricia Marquis said: ‘England needs a law that holds the government accountable for ensuring enough nurses are available to meet the needs of the population.’

Safe staffing in Australia: do mandated ratios make a difference? rcni.com/Australia-staffing