Revealed: what nurses say about short-staffing and how it’s harming patient care
Nurses open up about the risks to patient safety – and their work-life balance
Nurses open up about the risks to patient safety – and their work-life balance
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. I'm unable to give good-quality care on a daily basis,' one nurse told us.
What the survey tells us
Our findings will leave no one in any doubt about the toll short-staffing is taking on nurses – as well as patient care.
Of the 2,064 nurses who took part:
- 94% said an understaffed 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
- 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
Some of the 9% who said their professional values have not been compromised admitted this had come at personal cost.
‘I have forgone proper breaks to maintain my values and ethics’
‘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.'
‘We have had to look after really complex, poorly medical patients and feel completely out of our depth’
Gynaecology ward nurse
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.'
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.
'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.
Nursing shortages in care homes
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.
‘It’s hard to find a nurse who isn’t affected by unsafe staffing’
Dame Donna Kinnair, acting general secretary, RCN
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.’
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‘These results make clear that current conditions cannot continue – whether in the NHS or beyond.
‘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.
Do I need to refer myself to the NMC?
Marc Cornock, 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 and all that entails.
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 could be, affecting patient care and doing nothing may be seen as a more serious offence than the one the individual is 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
To download the NMC’s guidance on the professional duty of candour click here.
How do I refer myself?
There is a form on the NMC website that has all the information needed to make the self-referral.
Before self-referring you should speak to your trade union or professional organisation representative so you receive the appropriate advice and support.
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.
Blowing the whistle – or not
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.
‘I would report the incident to ensure the patient's safety but would be unwilling to identify the staff member’
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.
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‘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.
RCN tips on how to raise a safe-staffing concern
- 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 RCN on 0345 772 6100 or talk to their local RCN reps
‘Increase in nurse numbers’
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.
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No safe staffing laws are in place in England or Northern Ireland.
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,' she said.
Nursing Standard ran the six-question ‘Safe Staffing and Professional Values’ survey online from 22 February to 8 March using the survey software SurveyMonkey. The 2,064 individual responses were analysed by Nursing Standard.
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