Shortages in Staffing for Enhanced Patient Care

Nurses are an essential entity in healthcare because they play a vital role to provide care to patients in a continuous manner (RCN, 2017). This assignment is a reflection on my experience during my 2.2 placement in a general male inpatient ward, using the Rolfe Reflection framework (Rolfe et al. 2011). I chose this framework because it is simple, has clarity, as well as provides opportunity to assess all aspects of a situation to determine personal strengths and weakness. I will follow the three stages, namely: What happened, So What and Now What? The second part of the assignment will be a critical appraisal of the issue raised from the reflection which is shortage of nursing staff and analyse the impact on patient care, nurse practice and National Health Service. The assignment will further critically analyse the government response to the issue shortage of nursing staff. Furthermore, the assignment will highlight the importance of leadership and professionalism in nursing practice and how this tie into the Nursing and Midwifery Council Code of Professional Standards (NMC,2018).

WHAT

On my 2.2 placement, a patient diagnosed with Schizoaffective Disorder was due to go on leave under section 17 of the Mental Health Act 1983 which provides permission to the clinicians to grant leave of absence to a detained patient for a specified duration, considered as part of their treatment plan (Mental Health Acts,1983). However, the leave could not be facilitated due to shortage of nursing staff. While conducting the therapeutic observation, l witnessed the patient superficially cutting himself and l sounded the alarm, thus, calling for help from other nursing staff on the ward.

SO, WHAT

My mentor the nurse-in-charge, appropriately dressed the wound and used effective communication skills to de-escalate the situation. She quelled the bias her colleagues displayed, that the patient self-harmed to seek attention. My mentor feedback to the nursing team on duty and the psychiatrist in a non-judgemental manner, to collaboratively care for the patient. As a nursing leader, in a crisis, the leader require to have enhanced communication ability to interact with patients and colleagues, thus, controlling the problem to avoid escalation and relapse and implement collaboration in care delivery (Song and Lee, 2016).

The mentor also displayed critical thinking to make an appropriate decision in a crisis (Kim, 2018) by increasing his level of observation and had one to one interaction with the patient, carried out risk assessment and physical observation. This was the first time I witnessed self-harming behaviour and I felt anxious about what could happen to me or the patient at the moment and how would l handle such a situation if it happened in the future. In response to this incident, I had supervision with my mentor. My mentor expressed effective professional socialisation and she informed me with presentation of appropriate evidence regarding the way such incidence in future is to be managed without panic and calmness.

Therapeutic engagement with patients is important in understanding patient distress including the use of effective communication skills to de-escalate the situation in a chaotic environment (Kingston and Greenwood, 2020). Furthermore, evidence suggests that nurses who maintain effective continuous therapeutic interaction with the patients are able to access positive regards from the patients as well as able to develop empathetic and trustful relationship between them (Hartley, Raphael, Lovell and Berry, 2020). This was effectively displayed by my mentor as she was treating and interacting with the patient hence it provided a good learning experience for me. One of the leadership skills required to be present in the nurses is dedication to excellence as it the way in which quality care with no error can be reached to the patient (Gunter et al., 2017). My mentor did expressed dedication to excellence as she showed passion towards arranging the best care to be provided to the patient executing self-harm to manage and avoid relapse of the situation even under staff shortage condition.

The National Institute of health and care excellence states that the individual who self-harm must be cared for with compassion, respect, and dignity without any display of inequality (NICE, 2013). My mentor followed the policy by expressing compassion to the patient regarding his situation and developed an individualised care plan that would prevent him from further self-harm (Charlton, 2015; NMC, 2018). The NICE guidelines states that people who have self-harmed are required to be psychologically assessed to determine their care as well as professionally monitored to avoid relapse of the condition (NICE, 2013). My mentor completed the mental assessment of the patient and communicated with other staff, thus, continued monitoring of the patient prevented further self-harm which ensured his safety. This helped in assessing patient’s current mental state that triggered him to engage in self-harming behaviour, and help the carers understand what they could do better in terms of ensuring the patient does not self-harm and ensuring the safety of the patient and those around him.

One of the major issues of working within the ward that have led to the occurrence of such a situation is staff shortage. This is evident as arrangements to be made and health assessment to be done to approve the leave of patients could not be done due to lack of workforce (Sasso et al., 2019). The cancellation of leave led the patient to self-harm out of frustration and anger.

NOW, WHAT

My reflection on this incident has shown me the importance of effective leadership and professionalism in ensuring and improving safety as well as quality care for patients. In the future, I intend to become a transformational nursing leader so that I can deliver quality care to the service users by collaborating with colleagues and patients. Adhering to policies of care supported the patient and avoided further self-harm. Thus, in the future, I will commit to adhering to the policies and the NMC code of conduct. In future, to prevent such issues from arising ensuring the ward has adequate staffing.

The broader issue to be considered is the impact of shortage of staff in healthcare on the patient. Lack of adequate staffing to facilitate therapeutic observation of patients makes it hard to prevent cases of self-harm of inpatients. To overcome such incidences nursing staff should engage in effective team working, regular communication and staff being vigilant to their best ability. Moving forward, I am going to further explore the staff shortage an issue in mental health and how it impacts the patients and government response towards managing the issue.

Critical analysis of the staff shortage in mental health

One of the major issues identified from the reflection is shortage of nurses compared to demand in delivering care. In the UK, shortage of nursing staff is widespread across several disciplines within the NHS. This is evident in the October 2018 report that there are nearly 41,000 vacancies of nursing posts in England within the NHS, equal to 1 in 10 posts being vacant (Buchan et al., 2019). In the UK, between April and September 2020, 0.9% increase in registered nurse was seen with 0.1 % (7,142 to 7,151) growth in people who registered both as nurse or midwife (NMC, 2020b). However, due to low job satisfaction and environment, more nurses are showing avoidance to involve in the profession which leads to nurse shortage. This is evident as even after the increase in the registered nurse there is still 40,000 vacancies left in the NHS England (RCN, 2020). Data from the NHS Staffing Survey, states that 28% of the respondents stated that there is lack of qualified staff to deliver care to the patients (NHS, 2019a). The RCN report mentions that nearly 33,000 of the nursing posts in England, are filled by the recruitment of temporary nursing staff (RCN, 2020). This indicates that the shortage of nursing staff in the UK has become a real and major problem which is considered to be growing unless appropriate recruitment actions are taken.

One identified cause of nursing staff shortage in the UK is lack of effective remuneration and low salary as per industry standards (Metcalf, 2016). This is evident as the average starting salary of a nurse in the UK is £24,214 per annum which as per NHS Agenda for Change pay rates (Prospects,2019). A yearly pay rise of 1% is allocated for the nurses (Siddique, 2020). These rates are considerably low in comparison to the average UK national salary of £30,800 per annum (ONS, 2020). It is evident from the report by Kirby (2017), that from 2016-2017, nearly 20% nurses left the profession compared to the number that were recruited. Moreover, 67% respondents in the NHS Staffing Survey stated that they have to work unpaid overtime every week (NHS, 2019a). This informs us that nurses are not effectively remunerated for their effort to provide care to the service users which leads to nurses feeling devalued and demoralised which has resulted in scores of nurses leaving the NHS for better opportunities elsewhere and abroad (Marć et al., 2019). However, the big deficit of supply and demand of nursing staff in the NHS is leading to create negative impact on the nurses as well as patients. This is because nursing shortage is causing nurses to work under pressure which has reduced their ability in spending adequate time and effort to deliver quality care to the patients. It has also increased the rates of errors in practice which unfortunately may harm patients (Chang et al., 2018). However, the exact number of errors caused by the nurse shortage are unable to determined, but it is mentioned that error in care caused by nurse shortage is causing NHS to bear £2.5 billion each year (Sud and Szawarski, 2018).

The lack of support towards continuous professional development in the NHS is another cause for increased vacancies. As nurses are not advancing in the careers, there is lack of job satisfaction as they experience increased professional complexity in performing their role. This results in nurses feeling frustrated due to being unable to deliver effective care because they are not getting the continuous professional development and they are not advancing in their careers resulting in more resignations (Drennan and Ross, 2019). Moreover, nurses report that they get penalised for reporting failure in care, instead of being supported to identify problems and get support to resolve them (Fasbender et al., 2019). This lack of support has again left nurses demoralised and sometimes victimised for whistleblowing.

Another apparent reason for staff shortage in the NHS is due to Brexit (NHS 2020a). In NHS, nearly 170,000 out of the 1.28 million nursing staffs were found to be migrant and non-British individuals. The introduction of Brexit has created a change in the recruitment policy along with altered freedom of movement of the nurses. It has resulted in many migrant nurses leaving UK, thus creating nursing shortage (Wells, 2020).

The study by Aiken et al. (2014) mentions that if 60% of degree-educated nurses are present in the EU hospitals with a 1:6 nurse-to-patient ratio, then it is able to avoid 3,500 deaths in single year. However, in the UK, the average nurse-to-patient ratio is 1:13.4 (unison, 2017). According to Stephenson (2018), nurse shortage in the UK has led to cause 3% rise in patient risk of death. This indicates that there is increased staff shortage in the UK, and it has resulted in higher risks of fatality and untimely deaths among the patients. This is because lack of nurses makes the vulnerable patients fail to receive appropriate care at the right time in turn leading them succumb to death or increase their crowding in the emergency room out of delayed care created by nurse shortage (Halter et al., 2017). In the report by Farrah (2019), it is mentioned that 95% of the 550 nurses surveyed believed patients are at risk of experiencing errored care due to shortage of nurse in the NHS. This indicates that the result of nurse shortage is development of risky health consequences for the patients.

A survey organised that evaluated 30,000 shifts provided the data that 55% of respondents from the survey reported that there was shortage of one or more than one registered nurse in the last shift. Moreover, in the survey, only 40% registered nurses reported that they were able to provide quality care as expected by the patients irrespective of staff shortage situation whereas 42% expressed failure in delivering care at par the determined quality and stanrads (Borneo, 2017). The data proves that the consequence of nurse shortage is leading to limited care delivery.

The study by NHS (2020a) mentions that nursing shortage is experienced in the UK because of Brexit. In NHS, nearly 170,000 out of the 1.28 million nursing staffs are found to be migrant and non-British individuals. The introduction of Brexit has led to create change in the recruitment policy along with altered freedom of movement of the nurses. It has resulted many migrant nurses to leave the NHS in turn creating nursing shortage for the patients (Wells, 2020). The other issue which has currently raised nurse shortage in the UK is the ageing workforce. This is evident as reports from April to September 2019 in the UK revealed 5.57% (2,220) nurses were seen to get into the 61-65 age bracket. The increased age has led many nurses to leave the profession out of inefficiency due to age-related issue, in turn, creating shortage in the workforce as adequate recruitment could also unable to be made due to Brexit and other issues (Launder, 2019).

To tackle the nurse shortage issue in the UK, the NHS has a Five Year Forward View which outlines plans to increase nurse training university places, and revamp nurse education so that newly qualified BSc nurses are immediately employable in the healthcare sectors upon graduation (NHS, 2017). However, in 2018, at the second-year review, it was noted that the number of applications and university acceptances on the nurse training program has reduced. Furthermore, the number of nurses graduating (Buchan, 2019) following the change in nurse training curriculum has dropped. Thus, the Five Year Forward Plan has not succeeded in improving nurse numbers, thus far, even those in the making.

The Five Year Forward View Plan also outlined a new nurse retention program that will be run through the collaboration of NHS Improvement and NHS Employers to support more than 30 NHS trust with the highest turnover of staff. This will allow the collaborating agencies to develop strategies that support the trust in retaining nurses to avoid overall shortage in the nursing profession (NHS, 2017). The response created a positive impact on resolving nursing shortage to some extent, by improving the retention of nurses and midwives as evident in 2016-17 whereby 9 out of 10 nurses and midwives (92%) stayed in their profession in the UK compared to the UK national average of 83% in any profession (Stephenson, 2019).

Another aspect of the Five Year Forward View Plan was facilitating return to practice of at least 50,000 registered nurses in England who are presently not working in the NHS to be encouraged to return to practice. New nurse training takes 3 years at a cost of £50000-70,000 but return to practice costs £2000 for one year. Thus, it is cost as well as time effective to reduce staff shortage (NHS, 2017). The plan also includes a new fast track programme known as “Nurse First” through which graduates from other nurse disciplines can fast track to becoming qualified in other disciplines including mental health and learning disability health management to reduce staff shortage in these areas (NHS, 2017). The NHS Long Term plan indicates that to reduce nursing shortage, new strategies and policies that support international recruitment of nurses is to be adopted. This is because it would help to recruit non-British national in the profession in turn acting to reduce the shortage of workforce (Buchan, 2019).

How the NHS can improve working conditions for nurses

The Royal College of Nursing UK to respond to the issue of nursing shortage has decided to improve the work environment for the nurses where their efforts would be effectively valued. This is to boost their motivation in continuing to work in the profession and deliver quality care because valuing the effort of the nurses would make them feel respected which are part of them to feel motivated (RCN, 2020). Furthermore, in the Marmot Review, the government developed piloting models which would help nurses to collaborate with family members of patients in reducing some responsibility from the nurses in providing care to the patients. This is evident as in the plan it is determined that trained nurses are going to train the family members of the patients regarding the primary care are to be provided to the patient so that some responsibility such as delivery of medication, bathing of the patient and others are reduced from them. It is required as the reduction of the responsibilities would provide existing nurses have more time and energy in arranging secondary care of the patients in an effective manner even under the nursing shortage situation (Institute of health equity, 2010).

The successful implementation of the strategies and government initiatives in lowering nurse shortage in the UK would positively impact the patients or the service users to experience less waiting time and crowding to access care and improve the quality of the service they receive. In order to achieve this, the nurse-patient ratio is planned to be improved which in turn would facilitate creation of an improved working environment whereby a nurse can deliver higher quality care (Campbell et al., 2020). The shared workload will reduce fatigue and burnout, thus, retaining nurses who physically and psychologically can deliver care with accuracy and there could be less room for error resulting in reduced patient mortality rates (Nantsupawat et al., 2017).This is because there would be less patients per nurse to be managed creating scope and time for the nurses to be deliver care in relaxed manner to the patient with appropriateness. Moreover, it would make the nurses avoid working overtime like in previous situation where they cannot manage time out of responsibility to care for increased number of patients beyond their original capability (Nantsupawat et al., 2017).

Conclusion

Reflection on practice is a good tool to inform practice, improve future practice and identify good practice and room for improvement. In the above discussion, evaluation of the mentioned incident is done to understand what went well and what did not go well, along with areas for improvement. I learned from the reflection that transformational leadership is effective leadership style used in nursing. The shortage of staff was the most pressing factor identified in the placement and acted as the key reason for the delay in arrangement of leave of the patientThe causes for nurse shortage explored in this essay are low salary and remuneration, high turnover, lower job satisfaction, hindered work environment and others. The impact of the shortage of nurses is that it raises error in care, lower quality of care, increased mortality of patients, nurse burnout and others. The NHS Five Year Forward plan has indicated strategies to support nurses returning to practice, improving nurse training, improving nurse retention and others to reduce the nurse shortage crisis.

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