(Check out a new book on working and struggling in the NHS – the ‘Sick of it all’ book’s Facebook page is here. Email us if you are interested in getting a copy or organising a book event. We will organise a book event on the 9th of July 2022 in London, book your free ticket here.)
The struggle for better staffing levels is a struggle against stress, burnout, bitching and bad vibes amongst colleagues and against the neglect of patients. If we are overworked, everyone loses out. During recent and current strikes in Germany, we could see that the struggle for better staffing levels is possible. We translated a couple of articles that you can find here.
In Germany, workers managed to put the ball in management’s court: the new collective contract says that for each understaffed shift that you work, management has to either give you time off or compensate you financially. This should be an incentive for them to finally do something about the issue (- it still has to be seen if that really changes things on the ward floor).
The struggle for better staffing levels is a joined-up struggle. If nurses are overworked, they cannot help healthcare assistants (HCAs) with washing patients or making beds. If, as a result of that, HCAs are overworked, then they can’t give a hand to housekeepers during tea rounds or meal-times. The whole situation is a chain reaction of bad vibes and stress. The question is: how we can turn the fact that we work together and are dependent on each other’s work into a collective strength?
Below you can find some material for discussion. We start with a report from a housekeeper in a hospital in the South-West of England who organised a petition against low staffing levels on her ward. We then have a detailed interview with a nurse about how work is organised and divided on her ward and how staffing levels impact her work. We finally have a response from a nurse in Germany who compares conditions in the UK with his local hospital.
If you work in the health sector, why don’t you send us some notes on your own experiences and thoughts on the matter!
*** Petition against bad staffing levels
I’ve been working on a covid ward in Bristol for the last year, and like most of the other hospital wards, it has been chronically understaffed. Bank workers (who are like internal agency workers) are being sent text messages offering 50% more to come in for extra shifts. Expecting any permanent staff to come in for extra shifts after they’ve already worked three 12.5 hour long shifts when tax claws back most of the extra money anyway, is unlikely, and it’s only a short-term fix. We’re used to chronic understaffing on our ward, but with all of the staff catching covid at one time or another and being off sick, things were even worse.
After being covid-free for a couple of months, we’re now in the middle of another outbreak. Many of the patients need 1:1 care, which we can’t give them. More patients are at higher risk of falls. Many just want a chat because they’re going stir-crazy, and we don’t have time to just sit down with them. Around 6 nurses have left my ward in the last few months, another three are planned to leave over the summer. This is unprecedented. But inevitable when nurses and healthcare assistants are running around trying to keep things from going into absolute meltdown.
A few months ago, a wandering, confused, and aggressive patient, who should have been under 1:1 supervision, punched a worker in the ribs, fracturing one. A patient almost died of a suicide attempt because they weren’t able to be watched continuously. The NHS can do the bare minimum to patch people up, but without a long-term staffing plan – which includes higher wages, shorter shifts, and better terms and conditions – and workers’ fighting back – it will carry on being run into the ground.
On my ward, we decided to write a collective letter to the Chief Exec of the Trust to voice our anger. 40 staff signed it: from cleaners to staff nurses. At the very least we should be letting the people know we are not happy. This was a small first step, intended to galvanise some people into action. I prepared people for the fact that the letter per se wouldn’t do much, but tried to get them to think of ways we could use the letter to widen the action. Predictably, the Chief Exec gave us a standard reply, but the fact that a few of us went to hand the letter in personally, and the fact that we then put the news of it into the union newsletter and distributed this around the hospital made management sit up a bit.
But people on my ward didn’t want to do much after the letter. I suggested we go to other wards, or say we wanted a face to face meeting, but everyone retreated, people got scared and nervous. Many choose to leave the job instead. So, what next? Some of us will do a bigger petition across the hospital calling for solutions to understaffing and stress. In the hospital strikes in Berlin, they demanded extra pay or time off in lieu every time their ward was understaffed. Maybe this is something that most staff can get behind at my hospital. We know we need more action across different groups of workers, different departments, different unions. We just need to try different things at different times to see if anything sparks a more engaged and sustained response from workers. That this coincides with the upcoming pay offer will be important. Let’s see if people are up for it…
*** Interview on staffing levels with a nurse, April 2022
Question: In order to compare staffing levels, it’s obviously important to know what nurses have to do, which differs from place to place, especially of course on an international level. On our ward the usual staffing level is 1:8 for patients in single rooms and up to 1:10 in bays. That means that one nurse and ideally one health care assistant look after eight to ten patients. What does this mean in terms of daily work tasks?
The first thing we do is handover, which can take up to 20-30 minutes. Then the drug round, which often means you have to find the drugs that you need. It’s all still done on paper, the drug charts. The drugs are often out of stock. If you’re lucky they are in the drug trolley that each nurse gets, which contains common medication, such as pain relief or antibiotics. Some drugs might be in the patient’s room if they have their own medication. The next place where you can search is the general cupboard on your ward, but sometimes you have to go to other wards or order from the pharmacy. The drug round can take 1-1.5 hours. In some Trusts you are more protected, you wear a red apron saying, ‘I am doing my drug round, please don’t disturb’, so people can concentrate better and make less errors. General medication is only checked by one nurse, but injections and IVs are checked by two nurses. You often find prescription errors in the drug charts, mistakes that doctors made, for example forgetting to sign a prescription.
If you have the time you then support your health care assistant, like washing patients who need help, getting them dressed or making beds. You then do clinical observations, basically a round of checking blood pressure, pulse, temperature, and so on. If they had the last check at 6 o’clock in the morning they are due again at around 10 o’clock, unless they are poorly and need checking more frequently. That takes you to around 11 to 11:30am. You start your 12 o’clock drug round, which might have IVs in it. Each time you see a patient on the round there might be something they need, like getting to the toilet. Then you have tasks that the doctors requested on their morning round, that should usually be done by then. You might have bloods to take or families to call or people might have to go for scans. Then there is lunch-time, people might need assistance with eating. You then do an afternoon set of clinical observations at around 2 o’clock. There might be patient discharges, then you have to get the notes ready, inform pharmacy, contact district nurses and get them ready for going home. You then have an evening drug round at about six o’clock. There can be a lot of IVs in that. Then you start thinking about writing notes, so eight sets of notes. In general, you have to finish all the paperwork by then. You prepare the handover for the next nurse. The three daily drug rounds definitely take up most of the time, then the observations, in particular when patients deteriorate and you have to do them hourly, then all the documentation.
Question: So what creates the actual stress? Is it that there are too many tasks for the day or is it the way things are organised, for example, because hierarchies and responsibilities are not clear?
Stress can develop because you think you are not doing a good enough job for your patients. I remember having patients who had been given bad news and not being able to spend enough time with them exploring that bad news, because there are a hundred other things to do. If you have an end-of-life patient, you are supposed to check them hourly. You often feel that you’ve failed them, that you had no time to give them mouth care, personal care, some time to talk. The stress can also come from a fear of mistakes. I often found drug rounds stressful, because things were often not clear and you had to chase things up, because otherwise it would fall back on you. Often you have trouble getting hold of doctors or pharmacy to verify information. Sometimes it takes half an hour to sort out one drug for one of your patients. A lack of teamwork can also make people feel stressed. You are visibly stressed while someone sits down and has a cup of tea.
Question: Do you often have to stay longer to finish your work?
When I joined the ward as a newly qualified nurse, the ward manager said: “You’re newly qualified, you won’t go home on time”. For the first four to six months I stayed on late every single shift, at least fifteen minutes, up to an hour. Finishing paperwork, checking things, going back over my drug charts. Then I started to get into more of a routine. Perhaps I became less conscientious about my notes. If patients were well, perhaps I didn’t write each detail down like I was at the beginning. They tell you as a nurse that if you do good documentation and it can be proven, that that speaks in your favour if you ever get taken in front of the NMC [Nursing and Midwifery Council). That’s in the back of your mind. I think when they stopped allowing visitors during the first phase of Covid, we got some of our time back. We wouldn’t be stopped that often and asked questions. We were able to leave on time then. I moved to the high-dependency unit, where you only have four patients. Although people are sicker, you manage to go home on time.
Question: If you had a health care assistant with you, does a staffing ratio of 1:8 feel understaffed?
That can also depend on the skill of the health care assistant. You have some HCAs who won’t do blood sugars or observations or the documentation, because they say they don’t know how. Then you have HCAs who are so trained up, they do your bloods for you. It is such a wide range. The skill mix. And they are not very good at putting a very experienced HCA with a new nurse. Often it is the other way around, experienced HCAs want to work with their friends, the more experienced nurses.
Question: You mentioned that bad teamwork is a stress factor. What is a hindrance to more conscious working together?
I think it’s a culture thing. About feeling you shouldn’t ask people to help you. Some wards are bad at not organising breaks. It’s all done individually, if you find a ten minute slot, you just go on your break. On other wards it’s better organised, there is a clearer structure and you know that you are covered when you are on break – someone knows what has to be done while you are on break. You have a quick conversation with someone, before you go, and they cover you. And you would do it for them, so they don’t have to worry during their break. On some wards that’s not the case. No one would take a message, for example from doctors, while you are away. Everyone just tries to keep their head above water and their section in order.
Question: What would it take to introduce such a bit more conscious cooperation on a ward? The NHS is so formalised and hierarchical that people might often feel that they cannot change anything themselves?
I think unless the nurse in charge doesn’t go to people and tell them that this is your time to go on break, it would be difficult. But then people have also been burnt, when those people who took over during break have made mistakes with ‘their patients’. People stopped trusting each other. Because it will come back on you. They think: “I’d rather do it myself”. In the community you have just one pair of eyes checking that the medication is right.
Question: Who decides whether to take on new patients, even in a situation of low staffing? Do normal nurses have a say?
I think they could, I’ve seen it happen. I’ve been on the receiving end of it. For example, when one of my patients died, the head nurse told me that they won’t immediately report it to the department that retrieves deceased patients from the ward, just to give me a little breathing space and not immediately fill that room again. But I think that when there are planned discharges, that goes above the level of the person that is in charge of the ward. The head nurse reports what potential discharges there are, then the top people will keep on phoning asking how you get on with the discharges. Ultimately is the decision of the people above the ward level.
Question: In Australia in some organised hospitals the union just closes beds if staffing levels are too low.
The problem is that their solution is to bring in agency staff and agency staff can often cause more work for the regular staff, as they might not know the protocol of how to do things. The head nurse or ward manager don’t trust the agency staff, so they give them the easiest patients, the least amount of work to do. The agency staff have no desire, I mean, they don’t have any ties to the ward, they don’t feel the need to help the other staff. That’s of course not always true. Bank staff often return to the same ward, agency staff rarely. There is often an atmosphere towards agency staff: “She earns three times as much as we do for this shift, let her do it”. If you have intensive care skills you earn £40 to £50 an hour. That’s a problematic solution for staffing issues. In the local community hospital they run teams with one permanent staff and three agency staff at the moment. Agency staff come from places like Leeds or Liverpool, they get food and accommodation paid for the four, five shifts that they are here. The feeling of the permanent staff is: why is management not paying for training, why don’t we get unskilled, why are we paying for accommodation?!
Question: In Germany the union demanded that for each understaffed shift that you work you get extra holiday or a compensation payment. What do you think about this, are there other things that could reduce stress?
The skill level is important. If you have more skilled healthcare assistants, that makes your life so much easier. They used to get all kinds of training, but they stopped that. For me. That created also a bit more of a partnership with the HCA. At the beginning of each shift, if I didn’t know the HCA, I would ask them: what can you do, can you do blood sugars, clinical observations, bloods? Sometimes they say they can, but they are not prepared to do it, as they are on a Band 2 shift. At the other local hospital every HCA is trained on the same level; that creates a different situation, when everyone knows what people can do. With staffing we were kind of lucky, because we always had a nurse in charge who didn’t have patients themselves. So they can be an extra person to help out. Another thing that would decrease the workload would be to stop duplicating documentation. Why do I have to write down the same thing in three different charts? IT can make a difference here, it often means that you have all information accessible, rather than having to spend ages looking around for it. My worry when it comes to the German demand is that if I get extra time off after an understaffed shift the ward will be understaffed on a different day. Who stops them from riding me, asking me to come in on my day off? It’s not really addressing the issue of general lack of staff. You give people more time off, the nurses that I know would use it to pick up an extra agency shift.
Question: I guess it’s a double edged sword, as it also makes everything even more transparent by recording each work step electronically and management can squeeze out any spare time. The same with the skill mix, if nursing associates now do a lot of nurses’ jobs, just for much less pay.
True. I just try to get some teamwork going. I tend to inform the HCAs in my section, for example, about what the doctor told me regarding the development of a patient. Some HCAs respond: “Why are you telling me this? This is not my information.” In general many HCAs are not kept in the loop, though they should be. There is a problem of trust, as well. Many nurses think that ultimately it is their head that is on the line, they pay for mistakes that HCAs make. There is no protection in that sense.
Question: All this really hampers communication and cooperation. The HCA knows most about the actual physical-emotional state of the patient, but has little medical knowledge. The nurse checks the main inputs and outputs, but might neither get proper insights from the HCAs or the doctors. The doctors only see the medical notes with the daily reports, really. They only have filtered information. How do you see this problem?
I think it varies. Where I trained it was all done through the electronic system. They would send you messages with instructions, but you might not communicate verbally with the doctors. In other wards where I have worked they really wanted doctors to talk directly to the nurses. Don’t just change something in the drug chart, talk to the nurse about it. For a while they tried whiteboard systems, where doctors would write things down outside patients’ rooms, but they gave that up. Because the doctors change so often, you just start to get into a routine with your doctor and they all move around again and you have to start from scratch. Little things, like, conversations between nurse and patient about their usual medication or changes in their wellbeing, are not passed on to the doctors.You have to challenge them sometimes. If they enter a patient’s room I tend to challenge them: who are you? They are often surprised that I ask. They might be specialists in this or that field, but I want to know what they are doing. If you have eight patients it is difficult to keep up with all these separate conversations. With less patients it is easier to catch what is going on. There is not really a formalised handover between door and nurse. There is only a ward round between doctors and multi-disciplinary staff and the nurse in charge, they go through each patient. The medical team might say the patient is fit for discharge, then the physios say they haven’t sorted the stairlift in the patient’s house yet. The nurse in charge gathers their information from the nurses during the day. There is no direct input from the bedside nurses. In intensive care or in the community this is different, there the nurses participate in these kinds of ward rounds.
Question: Are you as a nurses sometimes asked to do things above your qualification level? And what would it mean if you say no? If I, as a HCA say no, then a nurse will have to do the job. What happens if you say no?
Sure, I was asked as a newly qualified nurse to look after a patient with a tracheotomy, without having had the training. If you say no you open yourself up to pressure from your colleagues. Often it’s not a question of training or skills. They don’t really ask you to do things that you’re not trained for that much. But if a doctor asks me to take blood from a patient I can tell them that I will do it later in the day, showing them the list of tasks that I still have to do. If the doctor wants to get it done before the afternoon, they have to do it themselves. It is hard to handover a job to the nurse on the next shift though, you can get bad vibes, despite all the talk about 24-hour care and the fact that some tasks can wait. There is also no direct financial incentive to do extra training. It looks good on your CV, perhaps in that way there is, if you want to move up to Band 6. You can train as a HDU [High Dependency Unit) nurse, but that doesn’t mean that you get paid more. You just look after sicker patients, perhaps fewer of them.
Question: The difference between HCAs and nurses is that we can’t hand out medication. The difference between nurse and doctor is that you can’t prescribe medication?
Some nurses can, you have to go through a prescriber course. Then there are so-called ACPs, advanced clinical practitioner, that’s a masters course. Then you can diagnose and prescribe. You can essentially do what a junior doctor does. In a way it is similar to a nursing associate, basically a trained HCA who can do what we nurses do. There are some blurred roles.
Question: Is there any collective behaviour regarding being understaffed?
I remember during Covid we were understaffed, we had no people to re-stock equipment. Each time you needed something you had to leave the ward, taking all your PPE off. We wrote an incident report, saying that our staffing was not good enough and that is the impact it had on the patients and us. I am a big fan of putting in incident reports if the staffing is not right. That’s the only way that things are acknowledged. But the feedback we got was: “Every time you put one of these reports in, a nurse has to take the time out of their day to go through it, having less time to help on the ward.”
Question: How easy is it at the moment to just get a different, less stressful job in the sector? That seems to be the main way that people deal with stress. Individually.
There is definitely a, ‘let’s get out’ mentality. A lot of people working in the community wouldn’t go back to the hospital ward. Hospitals always prioritise the emergency departments or intensive care units when it comes to staffing. If you shout the loudest, you get something. I see Band 6 lead nurses tweaking patient reports a bit, showing them as sicker than they are, just in order to keep some staff on the ward. So that you wouldn’t have to send your own staff away to allegedly needier areas of the hospital.
Question: What about the recruitment of overseas nurses, what kind of conditions do they face?
There is one Trust that basically organises the recruitment for all Trusts in the wider region. They go out to Dubai, India, Philippines and do recruitment fairs, do local job interviews. Often nurses already know people here, former colleagues or family members who might also work in the sector. Nurses who arrive from the Philippines or India have a clause in their contract that says that they have to work for a Trust for three years or they will be asked to potentially pay back the recruitment costs. That’s pretty awful. British nurses who went to work in Saudi Arabia, in contrast, were offered a bonus if they stayed for a whole three years. Another problem they are facing is driving, having their driving license accepted. They get three months’ accommodation paid for, then they usually have trouble finding a place to rent. Every Trust has a different policy here. There is a grassroots organisation now that organises monthly Zoom meetings for foreign nurses, where they can share their experiences. They focus, amongst other things, on the issue of language, like, medical language. People might know English, but medical terms are a hurdle. A lot of foreign nurses get stuck on Band 5. They don’t get the training or support. During the pandemic they were often sent to work on Covid wards, over-proportionally often. There is a huge Philippino nurses network, they denounced this practice.
*** Response from a nurse in Germany
If I compare the report to my situation here at the University Clinic in Freiburg I see some differences. Here we have to bear in mind that the conditions at the 40 University Clinics in Germany differ a lot from conditions in the other 1,800 general hospitals.
- Drug rounds
The general staffing level of 1:8 is more or less the same. But when it comes to drug rounds, they tried hard to ‘liberate’ nurses from the 1 to 2 hours that it takes to do the medication rounds by making the process more ‘lean’. On wards with a lot of standard medication e.g. on orthopaedic wards or post-accident surgery where people get their own medication plus pain relief, medication is prepared and allocated by machines (currently a test-run). The night-shift (two people for 25 to 30 patients) then controls the medication for the whole next day. On wards with more complex medication with a lot of day-to-day changes (pancreatic surgery, oncology) so-called medical-technical assistants (MTAs) prepare the oral medication – again, it’s the nurses on night-shift who double-check. So it tends to be a ‘two-pairs of eyes’ principle, when it comes to oral medication, which, according to my own experience, has lowered the rate of medication errors.
On all wards one shift prepares all IVs for the following shift, meaning using the digital patient data to print the labels with barcodes, getting the IVs dosage from the ward cupboard etc., but the administering nurse does the final preparation. The trays with the day medication are distributed by the night-shift at 5am to patients’ rooms – unless patients have cognitive impairments. IVs and medications are administered in a three-shift system at fixed times (7am, 2pm, 8pm/10pm depending on medication). Even the pain relief has been mechanised during the last two years. There is a type of inhaler for the first three days after surgery, patients were able to self-administer a pre-fixed dosage at certain intervals. This turned out to be too expensive, or the consultants were not able to agree on a common system.
To conclude, a lot of medication work has been taken away from the nurses / nurses have been ‘relieved’ from that work. Not everyone likes that, because administering medication is seen as a core task. From the point of view of the MTAs it is a very repetitive task, e.g. when two MTAs prepare the trays for 90 patients, using scissors to cut the right amount of pills still packaged, so that the nurse only has to pop them. It’s often two older women sitting in a room full of medication, on part-time, with a coffee-machine, doing just that.
- Division of labour
There are two types of HCAs, the two year apprenticeship as a care assistant is the classic form. More and more people do that, because the three year apprenticeship to become a nurse is made more and more demanding, the exams become more difficult. Many people just want to finish after two years. When it comes to ward rotas, other people work as HCAs as well, such as volunteers, student nurses. Usually there is one HCA per ward. During the early shift there are additional MTAs for taking blood; during the evening and night shifts the nurse has to decide if she takes blood samples herself or asks the doctors/consultants to do it. Then there is a ‘Primary Nurse’ who hasn’t got patients, but deals with admissions and discharges etc. And a so-called ‘Care Expert’ who can be consulted with when it comes to complex questions that nurses are not familiar with. There is usually one ‘Care Expert’ for 6 to 8 wards.
So in a way there are more people located around the nurse who do various tasks, there is a wider ‘skill mix’.
For the last ten years we have been using digital documentation with direct links to the labs and all ‘diagnosis departments’ (imaging etc.). All professional groups have access to this data, using the ward computers. We used to discuss the consequences, in terms of more supervision and surveillance and in terms of what happens to the additional ‘free time’ that is created – will they squeeze more work in, use less people? Before the digitalisation the night-shift had to prepare or reproduce the analogue patient data, which was at least 1 to 2 hours work every night! So they can turn over more patients during the day-shift and need less women-hours during the night. When things were on paper, stuff was always ‘wandering around’ from doctor to diagnosis to nurse. You had to take ‘temporary notes’ or waste time finding the documents. In this sense it saves time. But you also have to sign with your name at any point of documentation.
- Other comments
I don’t really come across situations where people don’t dare to say that they are not confident or trained to do certain tasks.
Our three shifts are more or less the same length now. The handover has been reduced to 20 minutes. This used to be 1.5 hours, where you would actually have 30 minutes for handover, 30 minutes to chat and 30 minutes to go home earlier.
I think we should ask less about the question of ‘what creates stress’, but the question of ‘how do you work together’ and ‘how can we use this to resist or fight for better conditions’.