Agency nurses: trapped in a pandemic staffing paradox

Far from getting extra work due to COVID-19, many have struggled to obtain shifts in the expanded NHS workforce

  • Activity is down in many areas of the NHS, but it can be hard for agency nurses to obtain furlough pay
  • Some feel they are not given the right PPE and are left out of fit-testing for masks
  • Buddy systems, IT log-ins and other practical steps can help agency nurses adapt to unfamiliar teams in difficult circumstances
Awoman stands at a window looking out; during the COVID-19 lockdown many agency nurses have had fewer shifts due to changing NHS staffing demands
Picture: iStock

When the coronavirus pandemic began, some agency nurses may have thought that they would be called on in greater numbers as demand for nursing staff escalated.

In fact, many say shifts are in short supply.

Fewer shifts as elective and routine care is suspended

Suspension of elective work by acute hospitals and a huge reduction in people going to emergency departments has meant work has dried up for some.

One agency nurse, who works mainly in paediatrics and asked to remain anonymous, says she obtained only one shift in three weeks. She had been reluctant to work in other areas but eventually agreed to look at roles in adult nursing, although not in intensive care units (ICUs).

Former NHS matron Sally Rowley, who now works agency shifts in emergency, medical admissions and cardiology, says her work has largely disappeared – and says bank staff are also likely to be affected, as activity in many areas of the NHS has been on hold.

‘I find it strange that the government has returned people off the register to working status before taking on fully compliant agency nurses’

Agency nurse

Ms Rowley says that while recently retired nurses have been called on to return to practice, many require mandatory training, whereas agency nurses are up to date and able to deploy immediately.

Another agency nurse, who asked not to be named, said: ‘I find it strange that the government has returned people off the register to working status before taking fully compliant agency nurses into the workforce. I would have happily been allocated to my local hospital and worked at their rates during the crisis.’

New nurse-patient ratios in ICUs

ICU is one area where there was expected to be massive demand for staff. Although agencies are reluctant to talk about the money on offer, some have advertised rates of up to £600 a day – often with free accommodation – for nurses willing to work with COVID-positive patients for extended periods.

However, patient-staff ratios have been loosened in ICUs, with up to six patients being looked after by one ICU nurse, supported by other nurses and also operation department practitioners, according to British Association of Critical Care Nurses chair Nicki Credland.

Some other areas have also been using agency ICU nurses, with plenty of nursing agencies advertising jobs in this area.

To date, the Nightingale Hospitals – critical care temporary hospitals designed to look after thousands of COVID-19 patients – have been under-occupied. The London Nightingale, for example, had a capacity of 4,000 patients but had never gone close to that number at any one time before being placed on stand by.

Nicki Credland, chair of the British Association of Critical Care Nurses
Nicki Credland

And while hospitals had been asked to plan for significant staff sickness rates of up to 30%, many seem to have experienced less than expected.

The Health Service Journal reported that internal NHS England data suggested nursing sickness rates were around 10% in April. This may have reduced the need for temporary staff.

Fewer shifts can quickly turn to financial difficulties for agency nurses

Clearly, any drop-off in work can present an agency nurse with financial difficulties very quickly.

Agency nurses, including those who are employed through an umbrella company, can be furloughed under the government’s scheme. The government has said it would pay 80% of the wages of furloughed workers until the end of June, up to a limit of £2,500 a month.

From 1 July, employers can bring back to work employees who have been furloughed, for any amount of time and any shift pattern, and still claim the government grant for 80% of their usual hours.

For some agency staff who find themselves without work this scheme may be a godsend. But there are limitations – the nurse would have to be furloughed for at least three weeks, and normally cannot do any paid work during this time.

And the regulations mean they are likely to need either the agency or an umbrella company to verify the furlough.

Anecdotally, this can be hard to do, because agencies may argue that other suitable work is available. Nurses who are self-employed may also benefit from a payment of £2,500 a month and can continue working without penalty. There are restrictions on who is entitled to claim under both these schemes.

Some nurses remain fearful about taking on roles in areas of elevated risk

Just like other healthcare workers, agency nurses have concerns about whether they are getting the right personal protective equipment (PPE) for the job and accessing testing if they contract the virus, or if a member of their household has COVID-19 symptoms.

Many agencies emphasise that full PPE is available when they advertise roles. However, some nurses say they remain fearful about taking on roles in areas of elevated risk, such as an ICU. They have also voiced concerns about working in some nursing and residential care homes where there have been deaths.

These are worries for permanent staff too, of course. But agency staff may feel particularly vulnerable, with one media report of an agency nurse losing shifts after raising concerns about PPE.

‘As an agency nurse it is always in the back of your mind that your footing to raise an issue is less stable,’ says Ms Rowley.

One agency nurse told Nursing Standard she had been working on a COVID-19 ward wearing just a surgical mask, despite patients ‘spluttering’ over her. She said permanent staff had been fit-tested for FFP3 (filtering facepiece) masks, but agency nurses had not.

Statutory sick pay of just £94 a week may be the only option

Lesley Jones, an agency nurse who developed mild COVID-19 symptoms
Lesley Jones: ‘My agency did not know
how to access testing’

There has been uncertainty over COVID-19 testing too.

Lesley Jones, an agency nurse who developed mild COVID-19 symptoms, says: ‘My agency did not know how to access testing, so I sat it out. My symptoms were very mild and it was only when I lost my sense of taste and smell that I thought this could be COVID.

‘It is worrying to think I could have worked during this time and infected others. Surely an agency ID card should have been sufficient to access testing.’

Agency nurses going between different workplaces could be carrying COVID-19 into any of these settings, she says.

Agency nurses are finding the lack of sick pay and other benefits problematic – especially if they contract coronavirus or are forced to self-isolate because a family member has symptoms. Statutory sick pay of just £94 a week may be the only option for them.

For those running wards, agency nurses are a crucial part of the workforce

In the event of a nurses’s death, the dependants of staff in the NHS pension scheme should receive death-in-service benefits. Agency staff are unlikely to have similar provision to protect their families, although the government recently announced that if front-line staff working in an area with COVID-19 die of it, their families could be eligible for a £60,000 payout.

Agency nurses are included in this, and the prospect of a degree of financial assistance for loved ones would no doubt offer some reassurance to agency nurses who are working alongside their staff colleagues in the COVID-19 response.

‘People don’t know the layout, how things are done or the policies’

Elaine Maxwell, clinical adviser to the National Institute for Health Research dissemination centre

For many nurses running wards or departments, agency nurses are a crucial part of their workforce. While there is some evidence that relying too heavily on temporary staff can lead to more patient falls and even patient deaths, it is also the case that having too few staff on shift is associated with poorer patient outcomes – and is likely to contribute to staff stress.

Elaine Maxwell, a clinical adviser to the National Institute for Health Research dissemination centre, makes the point that staffing in ICUs currently includes permanent ICU staff, bank and agency nurses, some nurses who have volunteered to return to the nursing register, nurses redeployed from other parts of the hospital who may not have ICU experience, and operating department practitioners.

‘People don’t know the layout, how things are done or the policies,’ says Dr Maxwell, who has herself returned to the nurse register to bolster the temporary workforce in response to COVID-19.

Increase in patient mortality when a third to a half of nurses are temporary

Chiara Dall’ora, a researcher at the school of health sciences at Southampton University
Chiara Dall’ora

What does that mean for those managing them? Chiara Dall’ora, a researcher at the school of health sciences at Southampton University who has looked into the impact on patient mortality of temporary staff, offers some reassurance.

She says there is only evidence of an increase in patient mortality when between a third and a half of registered nurses caring for them on each shift across the day are temporary.

‘Fortunately such days were relatively rare – about 4% in our sample – but common enough to cause concern given the sharp increase in risk,’ she says.

Keeping the proportion of temporary nurses below this on each shift should be a key consideration.

However, she suggests that important factors in poorer outcomes may be a lack of familiarity with how the ward is run and how the team works. ‘Having a team that you are part of makes an enormous difference for patients. Make sure that a team is created as much as possible so that agency nurses feel part of that team rather than just a resource that is pulled in and then released.’

As hospital services transform to deal with the pandemic, many staff – permanent and temporary – are working in areas and teams that are unfamiliar. ‘Leaders need to ensure there is a team spirit and cohesion among people who have never worked together before,’ Dr Dall’ora adds.

Dr Maxwell says the way temporary staff are deployed may also make a difference. She says there are basically two approaches from NHS organisations – to deploy temporary staff as a generic pool where individuals may only find out where they will be used immediately before a shift, or to see them as part as a team, with fixed assignments to an area.

Not having an IT login or hospital pass adds to agency nurses’ stress

All staff need access to practical and psychological support, says Dr Dall’ora. This may just be debriefing or may extend further. Practical solutions can include mid-shift discussions focused on well-being, buddy systems, ensuring that temporary staff know who they report to and ensuring they are able to ask for support if they want it, she says.

Temporary staff need to know what PPE is available to them, the procedures for doffing and donning, and be fit-tested where necessary. They also need to know how to access testing for themselves. Dr Maxwell says some hospitals have a team of staff who explain PPE and deal with any difficulties.

Agency nurses say niggles such as not having a log-in for the IT system or a pass are likely to persist and may become even more frustrating and stressful for them in an already fraught workplace.

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