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Sister says working A&E night shift is 'more stressful than war zone'


A senior nurse at one of Wales’s busiest accident and emergency departments has described a weekend night shift as more stressful than working in a warzone.

The sister at the University Hospital of Wales in Cardiff, who previously nursed soldiers on the frontline during the 2003 Iraq invasion, said she had to make decisions “that put patients at risk and put staff under extreme pressure”.

“I can guarantee that the nurses with me in the emergency unit today are facing higher levels of stress than we ever did in that warzone”

A&E sister

She described how a pregnant woman miscarried on the floor of a triage area in view of strangers and how she was forced to leave an unconscious patient in the care of junior staff and “hope to God he didn’t aspirate, have a massive bleed or fit”.

“I spent weeks in and out of the trenches being shelled, nursing soldiers under trolleys as the warning sirens went off,” she wrote in an account of her experiences. “I know what stress is.

“I know what it is like to work under pressure and yet I can guarantee that the nurses with me in the emergency unit today are facing higher levels of stress than we ever did in that warzone,” she said. “We cannot as a senior nursing team continue to put our staff and our patients under this stress any longer.”

She detailed how the unit was unable to cope with the number of patients coming in due to a lack of beds and experienced staff.

At one point during the night there were five seriously ill patients being looked after by just two qualified nurses. “These were patients that should have been looked after by at least one qualified nurse each, if not two,” warned the unnamed nurse.

She said that when she got home she got into bed and “sobbed my heart out”, and could not sleep for worrying about the decisions she had made. But she goes on to say that “it was not an unusual night”.

The nurse’s account of a Sunday night shift, described as “shocking” by nursing leaders, was originally shared with managers at a meeting with emergency unit staff last month.

It was not originally intended to be made public, but was found pinned to a hospital notice board and copies were subsequently circulated to Welsh media.

“It describes the very real, very challenging level of serious, complex care that is being provided on an almost daily basis.”

Andrew Cairns

Managers at Cardiff and Vale University Health Board, which runs the hospital, have said they are taking a range of measures to cope with “extraordinary demand”, including opening more beds, bringing in extra staff, re-deploying staff from elective to non-elective care and from non-clinical to clinical duties.

Chief executive Adam Cairns said that while the nurse’s account was difficult to hear it had acted as a “powerful motivator” when it came to finding solutions to “these significant challenges”.

“These challenges are not unique and are being faced across the UK,” he said. “But here in Cardiff and Vale we are working tirelessly at all levels to meet this extraordinary demand. Sharing this story and the realities of how hard it is on the frontline is an important part of that.”

A board spokesman highlighted a number of factors that had caused extra pressure at the hospital this December. Compared to the same time in 2013,these included a 24% increase in calls to GP out of hours, a 30% increase in referrals from teams in the community, a 12% increase in 999 calls in the Cardiff and Vale area and nearly 100 hundred extra emergency admissions.

Tina Donnelly, director of the Royal College of Nursing in Wales, was “shocked” by the contents of the account.

“I don’t think I have ever read anything as shocking,” she told Nursing Times. “We have got to look into the trauma faced by clinical staff who are working under constant pressure right now without seemingly having any relief.

“This is an example of a senior ward sister having to go off duty thinking she has not delivered appropriate care due to the huge demand and challenges in the way the area is managed,” she said.

“This nurse has demonstrated that she had an inadequate skill mix, insufficient staffing levels to deal with the demand and this is not an isolated case,” added Ms Donnelly, who has herself served in Afghanistan.

“This is an example of a senior ward sister having to go off duty thinking she has not delivered appropriate care due to the huge demand and challenges”

Tina Donnelly

She revealed the RCN in Wales had been working with staff in the A&E department in question for the last four months “over staffing issues and complexities of care and skills mix” and had met with the director of nursing and chief executive.

She said there was a need to review escalation policies and staffing. “There were seemingly quite a lot of clinical staff that needed supervision and not the seniority in the nursing staff to deliver that – this is exactly the kind of issue we have been raising with the health board,” she said.

“You cannot cut corners in emergency care areas where you know you could potentially be putting nurses at risk but more importantly patients at risk,” she told Nursing Times.

“This nurse has shown tremendous courage in speaking as she did to managers and we need the health board to demonstrate – not just to her but to all nurses there – that they have listened and will actively recruit a skill mix that is conducive to the patient acuity levels in those departments,” she said.

However, Ms Donnelly went on stress the problems at the hospital were symptomatic of system-wide issues in the NHS in Wales, including nursing staff shortages and increased demand, which also affected services across the UK.

Royal College of Nursing Wales

Tina Donnelly

The RCN estimates there is a shortage of 1,000 nurses in Wales and is supporting a private member’s bill to enshrine safe staffing levels in law – currently being examined by the Welsh Assembly.

Ms Donnelly said other possible solutions for reducing pressure on emergency departments included introducing seven-day working for GPs, streamlining GP appointment systems and greater co-location of primary care and emergency care services allowing patients to be swiftly diverted.

Welsh first minister Carwyn Jones said the nurse’s story demonstrated the “great pressures” facing many hospitals.

He said the Welsh Assembly government was taking steps to reduce pressure on A&E departments including improving the provision of GP services around Wales.


Readers' comments (22)


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  • You can include operating theatres in that description.

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  • And of course this is one of the reasons why it is imperstive to retain out of hours payments - to attract staff to these very challenging hours!

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  • All of these directors and chief execs of trusts who are 'shocked' are really needing to get themselves back on the 'shop floor' and stop burying their heads in the sands!!!! This nurse's account is by no means unusual and in actual fact is happening every night in not just ED or acute admissions but in wards in hospitals all over the country!!! SACK the service managers who shield this information from the top and utilise the money for better staffing on the wards and beds in areas that are safe!!! I'm sick of seeing patients nursed in corriders and in makeshift areas that are unsafe!! Start protecting nurses and focus on patient safety as opposed to the focus being on squeezing as many patients through an already crowded and unsafe hospital! Makes me sick!!!

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  • Nothing new here.

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  • I too am a senior sister in A & E and cannot remember a time when we have been so stretched. Additionally the voices of clinical staff are not being heard by managers who are highly paid but rarely seem to be held to account for the decisions that they make.

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  • If there is nothing new here (and having read Graham Pink's book, the themes are established enough in NHS history), perhaps the new stuff needs to be what is done about it. There does seem to be a disconnect between senior managers prior awareness and what was actually going on but the response this time at least reads like a little bit more accepting of the reality spoken of (hard to do otherwise given recent NHS history). Now the disconnect between politicians of all parties and the difficult facts underlying NHS provision in the immediate future and after needs to be dealt with. 7 day working via reduction of current enhancements will not increase the supply of nurses (indeed it may drive nurses away) even if it might reduce costs of night cover, and certainly will not stretch to the extraordinary degree required to meet the pressures this nurse has described. Time for politicians of all parties to talk about the real choices the country has to make in May....

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  • RCN is part of the problem, according to Tina Donnely RCN Wales, they have been working on the unit for the last 4 months, so why is she shocked at this nurses account? Can't they see for themselves or do they need things spelt out before they take any action.

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  • This is nothing new, as said. This is the NHS at the moment, nationwide. When concerns are raised by the lower ranks, as is the protocol, they are being ignored. Time and time and time again. It is a war zone, whatever area you're in. And the managers are not bringing the situation to the government, because they are then deemed to have 'failed'. And that means the trusts being fined, losing money, losing status and the managers want to keep their very well paid jobs. Those with integrity either leave or break down.

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  • same in general practice, according to the media, surgeries are only open 9-5 , that all the worlds problems are the fault of nurses, I think I will be a banker, no skills required, make millions and then retire at 30

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