Understaffed nursing shifts leading to ‘red flag’ events

At the 2024 Unison Health Service Group Conference, national nursing officer Stuart Tuckwood unveiled the results of the Only Enough is Enough campaign report.

“We are supportive of seeing legislation, but we need to see that it makes a real difference”

Stuart Tuckwood

This report surveyed nurses, midwives, healthcare support workers, nursing associates and operating department practitioners about the state and impact of staffing during their shifts in hospitals.

The published data was based on 1,358 shifts during October and November 2023 from six unison branches: Aneurin Bevan Health, University Hospitals Birmingham, Cardiff and Vale, Cambridge University Hospitals, Liverpool Hospitals Health and Cornwall Acute Health.

On almost two-thirds (63%, or 879) of shifts, survey responses stated that there were not enough staff to deliver patient care.

According to the survey, on 50% of the 879 shifts with unsafe levels of staff, a ‘red flag’ event – as defined by the National Institute for Care Excellence (NICE) – happened.

For example, on 37% of the unsafely-staffed shifts, there was a delay of 30 minutes or more in providing pain relief to patients.

A further 26% of shifts saw vital signs not assessed or recorded as planned and on 17% of unsafe shifts there were less than two registered nurses present at any point.

Meanwhile, when looking specifically at nursing shifts, at least one “important nursing task” – such as assessing patient pain and making sure the patient is positioned in a way that was comfortable and limited the risk of pressure damage – was omitted or delayed on 41% of shifts.

Night shifts were more likely to be unsafely staffed in the six areas surveyed, and more understaffed night shifts than day shifts had at least one red flag event or nursing task omitted.

Concerningly, 75% of survey respondents who attempted to escalate staffing problems said their employer did not take “sufficient” action to enable the delivery of safe patient care.

Stuart Tuckwood, Unison head of nursing

In the 25% of cases where action was taken, measures included redeploying staff – a controversial move which can leave other areas short staffed – bringing in bank or agency workers and reducing service activity such as cancelling operations or closing beds.

Of the total number of shifts surveyed, 500 were based on responses from registered nurses and midwives.

Of these 500 shifts, 69% were recorded as being without enough staff to deliver safe patient care, 45% had at least one red flag event and 55% had at least one important nursing task omitted or delayed.

Following the survey’s results being published, Unison has called for a “national commitment” from the UK governments to work with health unions to make sure action is taken “to finally end the shortages of nurses, midwives and other healthcare professionals”.

The union also called for the “strengthening” of staffing policy and legislation and a review of escalation policies.

Mr Tuckwood said the campaign and report would, for future years, be expanded beyond the six areas.

In turn, he hoped this would mean the union could create a detailed picture of the impact and scale of unsafe staffing nationally.

“It shed a lot of light on interesting issues relating to safe staffing, and there is some new information in there,” he said.

“There are a few pieces of research here and there [on the impact], but nothing, I think, as comprehensive as this. Those red flags, produced by NICE, those are things that are really sensitive to nurses’ workloads and staffing levels. That’s why we put [questions about] those in there.

“As you can see in the report, some nurses are missing taking vital signs, or not being able to administer medicines; but it’s not just clinical tasks, there is patient care, fundamental to a nursing role, those were the things being missed even more often so that’s really worrying.”

At the Unison conference after the survey was unveiled, nurses and other healthcare staff discussed the need for improvements on staffing.

Some healthcare staff called for the rollout of safe staffing laws, such as those in place in Scotland and Wales, across the rest of the UK.

Others pointed out the limitations of such laws. For example, section 25B of the Welsh legislation – which requires nurse staffing levels to be calculated and maintained – only covers acute medical and surgical inpatient settings and paediatric wards at present, although there are hopes it will be extended in future.

“I felt vulnerable and unsupported, and I suffered greatly”

Emma Dale

Mr Tuckwood added: “We are supportive of seeing legislation, but we need to see that it makes a real difference.

“We’re not interested in something being passed that’s not going to make any kind of meaningful difference to our members. We currently have the opportunity to negotiate in England with the NHS on this.

“We’re able to use the evidence from these kinds of campaigns to inform that.”

He said Unison was “pushing” for more policies on safe staffing.

“It needs to be something tangible,” he said. “That’s why doing something like this and supporting union branches to work on it is so important.

“So yes, we need to see the national unity, national change, but it has to be backed up by local action.”

Similarly, Janet Maiden, a deputy ward sister at a haematology unit in London, said that she would back legislation being added to England but felt that alone would not fix the problem.

“The levels of staffing we have meant that, every day, you work very hard to try and give everybody what they need, but if nurses are honest, they can’t,” she said.

Ms Maiden said that, due to low staffing levels, she had witnessed lapses in the washing and other basic care needs of patients.

She noted that the poor retention of nurses was having a knock on effect: senior nurses were less experienced than their predecessors, and less able to support understaffed wards.

However, Ms Maiden said she was “cynical” about legislation as a means to fix the problem alone.

Emma Dale, who works at Aneurin Bevan University Health Board, told the conference that she backed the expansion of the law in Wales as well as the introduction of legislation in England.

She said: “We are pleased to have the legislation in Wales, which helps some areas plan and maintains safe nurse and midwife staffing levels.”

However, Ms Dale added that the laws in Wales had their limits: “I worked in forensic mental health, on an area not covered by the legislation in Wales, and it resulted in me finding myself in a difficult situation with a pile of patients in distress and no one there to support me.

“I felt vulnerable and unsupported, and I suffered greatly. As a consequence, I sadly moved out of the area of specialty and into administration.”