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We must speak out when shortages put patients at risk


A shortage of health visitors and school nurses has led to patchy child services says Rosalind Godson

The Department of Health held a public consultation last autumn to discuss the forthcoming quality accounts, the latest stage in the quality framework. All NHS providers - acute services from 1 April 2010, with community services joining next year - will complete this annually to show quality improvement, as it is acknowledged that doing things right the first time saves problems occurring later on.

In the community, nurses are already familiar with Transforming Community Services, where practitioners will deliver good quality as standard and constantly seek to improve services. Ideally, therefore, services should be benchmarked against quality standards in the national service frameworks, the Healthy Child programme, You’re Welcome quality criteria and National Institute for Health and Clinical Excellence guidance.

This has to be put in the context of all staff being expected to improve their productivity, by which managers mean improving outcomes with fewer resources.

‘Child protection services cannot be adequately sustained because health visitors are not able to visit families in their homes and carry out proper assessments’

In reality, most primary care trusts have stringent cost saving packages in place, leading to frozen posts, a lack of training and a reduced service. This is compounded by the fact the commissioning arms of PCTs are entering into outcome based contracts with provider arms, which frontline staff have no hope of fulfilling. This is partly because a poor use of skill mix has led to an erosion of sufficiently trained staff who can deliver those outcomes.
School nurses, health visitors and district nurses, for example, are now asked to cover for absent colleagues or take on a vacant caseload, even if they are having difficulty coping with their existing one. In some areas, this is obscured by the use of corporate caseloads. This is where caseloads are amalgamated across the PCT with a view to prioritising all the work and sharing it out evenly among fewer staff. But this still means that staff are overwhelmed as the workload is impossible. They can no longer deliver a suitable service and may not even finish the priority tasks.

Meanwhile everything must be properly recorded and entered into the all consuming computer system. This leads to staff taking client records home to complete in the evening as there is simply no time in the working day.

Continuing practice development is impossible to arrange as there is no one to cover; some nurses, particularly practice nurses, are told to do their professional updating in their own time. Clinical supervision gets neglected, and there is no time for reflective practice. When staff complain, they are told to prioritise their work, but they did that several years ago - there is no more slack in the system.

For a planned change of service to take place, there are clear protocols: there must be a 13 week consultation with all stakeholders, including service users; there should be a needs assessment and an equality impact assessment to make sure health inequalities are not widened. The new service should be supported by policies that have been drawn up and passed by the joint staff side committee.

Sadly, many places have resorted to crisis management to cover shortages, resulting in patchy services throughout the country, and lots of ineffective work:

  • Child protection services cannot be adequately sustained because health visitors are not able to visit families in their homes and do proper assessments;
  • Staff are drafted into areas where they don’t know the patients, families or the issues;
  • Parents find that their health visitor led clinic has changed to a baby weighing one, where they can no longer expect advice and support;
  • Special schools suddenly find that their school nurse has been withdrawn and they are offered a skeleton medicine giving service instead;
  • Teachers find that school nurses have been stopped from helping to deliver the health and sex education modules;
  • Looked after children’s nurses find that there is no one available to do the annual health assessments.

Crisis management is often conducted by email; a new directive appears in the inbox, with no opportunity for discussion about how it relates to existing policies and protocols. Sometimes the situation may be unsafe, such as when a community nursery nurse is told to cover a clinic on her own, in a venue not known to her and with no procedures in place. Or when school nurses are told to do home visits in the holidays, with no clarity about whether the families are expecting this.

The consequences to staff morale are devastating, with many losing motivation and desperate to retire. When a practitioner is told to double their work, the implication is that previously they had spare time - but they will have been telling their manager for months that they are unable to cope with the workload.

Is there a way to deal with this professionally? All registered nurses, including managers, must ensure they work within the Nursing and Midwifery Council’s code of conduct. The code is clear that nurses must advocate for patients, supervise and support those to whom they have delegated work, deliver evidence based care, work within the limit of their competence, and report concerns in writing if the environment of care is putting people at risk. It is time we did so.

About the author

Rosalind Godson is professional officer at Unite


Readers' comments (10)

  • I'm sorry but this is happening across the board. Nurses speak out all the time, I myself have lost count of the amount of incident forms I have put in due to too few staff being on the ward, only to have them ignored by management over and over and over again.

    It is a joke, and it will always continue as long as the idots at the top place monetary issues over patient care.

    There are only two things that will solve this problem.

    a) A national strike by Nurses to demand better working conditions and staffing levels.

    b) A legalised Nurse/patient ratio across all spheres that ALL hospitals/PCTS/schools/etc have to abide by.

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  • and yet there always seems to be the money for yet another layer of management??!!!

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  • I'm reading your article which is putting in words what I've done countless times as Mike says, speaking out, putting in incident forms and thinking every day I'm pressurised to breach my code of conduct.
    What you don't mention though is the reality of the cost in speaking out, which I've watched just as many times that some people are willing to take and many not. At my place of work which has been NHS and sold to the private sector, their priority is targets and financial savings directed toward their pockets not the taxpayers. Speaking up about the lack of safety through formerly acceptable channels has earned me, and my colleagues who do stand up, the title troublemakers, so confident are they that they say it at meetings in front of RCN reps.
    Good article, but in islolation of the effects of that and the price of doing that, lacks support and ends up adding to the weight of the sword of Damacles over each of our heads.

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  • That is why those incident forms are so important mate, to cover your own arse when the proverbial hits the fan.

    Nurses are our own worst enemies here, too many Nurses insist on working unpaid overtime to cover all the work that still needs to be done, too many Nurses just bend over and accept it, and too many Nurses do not even say anything.

    If more Nurses like myself and anonymous above spoke out, if we banded together and went on strike, or even if every one of us very simply worked to rule, then this would not happen. Management would be FORCED to get more staff in. They would have no choice.

    Furthermore, I wonder from a legal standpoint how far this would get in court if we accused the NHS as a whole of gross neglect?

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  • Got to agree with Mike on this.
    It is time for nurses to stand up and say "we have had enough"!
    We are seen as an easy target due to the fact the "nurses would never strike as it would put patients at risk".
    We should strike because our patient ARE being put at risk!
    It is time for our unions including the ineffective RCN and help us to protect ourselves and our patients!!
    And keep hitting management with incident forms, I do and I will continue to do so!!

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  • Anonymous | 15-Jun-2010 8:10 am, absolutely. But the problem still exists in exactly how do we start organising this? I am currently working to rule and pursuading as many people as I can to do the same. But Nurses are historically one of the most apathetic and subservient groups, and there are far too many who will just carry on with the status quo. How exactly do we start a movement? How exactly do we get a leader, a union or the RCN or even the Nursing times to campaign for this? To galvanise those of us who believe this should happen into one unified force, and pursuade everyone else that there is finally a way to fight? How?

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  • I agree with Mike.
    Nurses are under pressure job cuts, short falls in staffing, yes keep filling in the forms, if you are involved in a complaint/incident you need to have recorded your concerns. After 38 years nursing I feel the profession has been devalued our skills and knowledge ignored when concerns our voiced. We are looking at 25 staff being lost moral is so low nurses are becoming angry I for one would like more action from the RCN they have become weak what are we paying our fees for?.

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  • Maybe that would be a good start, I've stopped paying the RCN now. It makes me sick that that useless bunch have had a penny of my money.

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  • Rosalind is right. I am an HV covering far too many families and too many colleagues who have had enough and are on long term sick / absence. As long as targets are met, quality is irrelevant.

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  • Hi Mike,

    Maybe it's time to use the like of the social networking sites to our advantage. I know most nurses will not want to start this for a fear of persecution, but just maybe we can all be heard in one voice there, or perhaps the use of e-petitions on the website!! And just maybe the NT will help us on this matter! Just a thought.

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