Jump to content
  • What it feels like working with unsafe staffing



    This blog has been written by a healthcare worker and demonstrates the reality of what it is like caring for patients and families while being chronically low on staff. They describe the impact this has on staff morale and the impact it has on patients, patients family members and the relationship between staff and patients.


    So, what does it feel like working in chronically depleted staffing levels?

    "We are down three nurses today" – this is what I usually hear when I turn up for a shift.  It has become the norm. We work below our template, usually daily, so much so that when we are fully staffed, we are expected to work on other wards that are ‘three nurses down’. 

    Not an uncommon occurrence to hear at handover on a busy 50-bedded medical ward.  No one seems to bat an eyelid; you may see people sink into their seat, roll their eyes or sigh, but this is work as usual. ‘Three nurses down’ has been the norm for months here, staff here have adapted to taking up the slack.  Instead of taking a bay of six patients, the side rooms are added on making the ratio 1:9 or sometimes 1:10, especially at night. This splitting up the workload has become common practice on many wards.

    "That was a good shift" – no one died when they were not supposed to, I gave the medications, I documented care that we gave, I filled out all the paperwork that I am supposed to, I completed the safety checklists. 

    Sounds a good shift?  Thinking of Erik Hollnagel’s ‘work as done, work as imagined’ (Wears, Hollnagel & Braithwaite, 2015) – this shift on paper looks as if it was a ‘good shift’ but in fact:

    • Medications were given late; some were not given at all as the pharmacy order went out late because we had a patient that fell.
    • Care that was given was documented – most of the personal care is undertaken by the healthcare assistants (HCA) now and verbally handed over during the day – bowel movements, mobility, hygiene, mouth care, nutrition and hydration.  As a nurse, I should be involved in these important aspects of my patients’ care, but I am on the phone sorting out Bed 3’s discharge home, calling the bank office to cover sickness, attending to a complaint by a relative. It’s being attended to by the HCA – so it's sorted?
    • I have documented, probably over documented which has made me late home.  I’m fearful of being reprimanded for the fall my patient had earlier on.  This will be investigated and they will find out using my documentation what happened.
    • The safety checklists have been completed for all my patients;  comfort rounds, mouth care, falls proforma, bed rails assessment, nutritional score, cannular care plan, catheter care plan, delirium score, swallow test, capacity test, pre op assessments, pre op checklists, safe ward round checklist, NEWS charting, fluid balance charting and stool charting… the list is endless. 
    • Management have made things easier with the checklist ‘if it’s not written down it didn’t happen’ so now we can ‘tick’ against the check list rather than writing copious notes.  However, I cut corners to enable me to complete all my tasks, some ticks are just ‘ticks’ when no work has been completed. No one would know this shift would they?

    What looks as if it has been a ‘good shift’ for the nurse, has often been the opposite for the patients and their family. There is a large body of research showing that low nurse staffing levels are associated with a range of adverse outcomes, notably mortality (Griffiths et al, 2018; Recio-Saucedo et al, 2018).

    What is the safest level of staff to care for patients? 

    Safe staffing levels have been a long-standing mission of the Nursing and Midwifery Council (NMC)/Royal College of Nursing (RCN) in recent years. In the UK at present, nurse staffing levels are set locally by individual health providers. The Department of Health and professional organisations such as the RCN have recommended staffing levels for some care settings but there is currently no compliance regime or compulsion for providers to follow these when planning services (Royal College of Nursing 2019).

    I was surprised to find that there are no current guidelines on safe staffing within our healthcare system. It left me wondering… is patient safety a priority within our healthcare system? It seems not.

    While the debate and fight continues for safe staffing levels, healthcare staff continue to nurse patients without knowing what is and isn’t safe. Not only are the patients at risk and the quality of care given, but the registration of that nurse is also at risk. 

    What impact does low staffing have on patients and families?

    ‘What matters to them’ does not get addressed.  I shall never forget the time a relative asked me to get a fresh sheet for their elderly mother as there was a small spillage of soup on it.  I said yes, but soon forgot.  In the throes of medication and ward rounds, being called to the phone for various reasons, answering call buzzers, writing my documentation, making sure Doris doesn't climb out of bed again, escorting patients to and from the CT scanner, transferring patients to other wards – I forgot. 

    My elderly patients’ daughter was annoyed, I remember she kept asking and I kept saying "in a minute", this made matters worse.  She got annoyed, so that I ended up avoiding her altogether.

    How long does it take to give her the sheet? Five minutes tops, so why not get the sheet?

    MY priority was the tasks for the whole ward, tasks that are measured and audited on how well the ward performs by the Trust; filling out the observations correctly, adhering to the escalation policy, completing the 20 page safety booklet, completing the admission paperwork, ensuring everyone had their medication on time, making sure no one fell – changing a sheet with a small spot of soup on it was not on my priority list. 

    It was a priority for my patients’ family.  My patient was elderly, frail and probably wouldn’t get out of hospital alive this time.  Her daughter was the only family she had left.

    It’s no wonder families feel that they are not listened to, are invisible, are getting in the way and not valued. 

    These feelings do not encourage a healthy relationship between patients/families and healthcare workers. Studies have shown that involving patients and families in care is vital to ensure patient safety. Patients and their relatives have the greatest knowledge of patients and can often pick up subtle signs physiological deterioration before this is identified by staff or monitoring systems (O’dell et al, 2011).  If our relationship is strained, how can we, as nurses, advocate for the safety of our patients?

    So, what impact does low staffing have on the staff member?

    "Fully staffed today!" The mood lifts at handover.  People are sat up, smiling, quiet excitable chatter is heard.  This uplifting sentence is quickly followed by either: "Let’s keep this quiet" or "someone will be moved" or "someone will have to move to XX ward as they are down three nurses".

    Morale is higher when wards are fully staffed.  The mood is different. There are people to help with patient care, staff can take their breaks at reasonable times, staff may be able to get home on time and there is emotional support given by staff to other staff – a camaraderie.

    The feeling does not last long.  Another department is ‘three nurses down’. Someone must move to cover the shortfall. 

    No one wants to go

    When you get moved, you often get given the ‘heavy’ or ‘confused’ patients. Not only that, you are working with a different team with different dynamics – you are an outsider. This makes speaking up difficult, asking for help difficult, everything is difficult: the ward layout, where equipment is stored, where to find documentation, drugs are laid out differently in the cupboard, the clinical room layout is not the same. The risk of you getting something wrong has increased; this is a human factors nightmare, the perfect storm.

    I am in fear of losing my PIN (NMC registration) at times. At some point I am going to make a mistake.  I can’t do the job I have been trained to do safely. The processes that have been designed to keep me and my patients safe are not robust.

    If anything, it is to protect the safety and reputation of the Trust, that’s what it feels like.

    Being fully staffed is a rarity. Being moved to a different department happens, on some wards more than others. Staff dread coming to work for threat of being moved into a different specialty. Just because you trained to work on a respiratory, doesn’t mean you can now work on a gynae ward. We are not robots you can move from one place to another. I can see that moving staff is the best option to ensure efficiency; but at what cost?

    Another problem in being chronically short staffed is that it becomes the norm. We have been ‘coping’ with three nurses down for so long, that ‘management’ look at our template. Is the template correct, we could save money here? 

    If we had written guidance on safe staffing levels, we still have the problem of recruitment and retention of staff; there are not enough of us to go around.

    Thoughts please...

    • Does this resonate with you?
    • Has anyone felt that they feel ‘unsafe’ giving care?
    • What power do we have as a group to address this issue of safe staffing levels?


    1. Wears RL, Hollnagel E, Braithwaite J, eds. The Resilience of Everyday Clinical Work. 2015. Farnham, UK: Ashgate.

    2. Griffiths P et al. The association between nurse staffing and omissions in nursing care: a systematic review. Journal of Advanced Nursing 2018: 74 (7): 1474-1487.

    3. Recio-Saucedo A et al. What impact does nursing care left undone have on patient outcomes? Review of the literature. Journal of Clinical Nursing 2018; 27(11-12): 2248-2259.

    4. O’dell M et al. Call 4 Concern: patient and relative activated critical care outreach. British Journal of Nursing 2001; 19 (22): 1390-1395.

    About the Author

    The author has asked to remain anonymous.

    0 reactions so far


    Recommended Comments

    There are many bad things about the work situation you describe. The worst thing about this (to my eyes) is that this describes the norm, not the exception. And the attritional effect of constantly having to scramble to meet the minimum needs of your patients, comply with regulatory demands and trying to keep your patients comfortable, cared for and treated well must eventually wear you down.

    It raises a number of questions.

    First, it's clearly not safe. Lack of of cover means you can't give patients the attention they may need. If a patient's condition deteriorates suddenly, nurses busy elsewhere may not be available to notice, let alone act.

    Second, it's exhausting trying to keep all the plates spinning without a break. And exhausted care staff will get emotionally drained, they make mistakes, and their reserves of patience and goodwill will get exhausted. 

    Then they, quite sensibly, leave. Making the problem worse.

    Third, if this, or something like this, is happening on every ward in every trust (and we don't hear much about trusts being fully staffed these days) then, on the numbers you describe here, 2 nurses are doing the work of 3. In effect, you are subsidising the NHS with your extra effort.  And if this is the norm, then the Trust will begin not to treat this situation as an aberration, but as the new standard operating model.

    This is wrong.

    Simply put, this is an economic problem. Demand outstrips supply. As Alison Leary said at the Patient Safety Learning Conference yesterday, the NHS, unlike businesses, determines how much it chooses to afford then tries to meet demand.

    Your blog demonstrates that this isn't working. In economic terms, a chronic shortage of nurses is prima facie evidence that nurses are, in hard cash terms, undervalued. If the NHS made nursing more economically attractive for people to do (by paying nurses more, by paying for more nurses and by subsidising training) more people would become nurses, the job would become easier, and this problem would go away.

    This won't happen, of course, unless enough people understand the problem and push for a solution. And pieces like this one that you have posted can only help.

    Thanks for sharing it.


    • 1 reactions so far
    Link to comment
    Share on other sites

    Thank you, I'm a little late, but only just had a chance to read your fantastic, excellently written blog.

    It hugely resonates with me:

    "‘work as done, work as imagined’ (Wears, Hollnagel & Braithwaite, 2015) – this shift on paper looks as if it was a ‘good shift’ but in fact......"

    I loved learning about this concept at the Patient Safety Congress last year....it's just so true........ and we so need to curb the checklists....they started to help save time and act as reminders, but there are now checklists to check that you have checked the checklist! Does it actually prompt and prove the task is completed?

    I also really appreciate how you have explained the uplift experienced following the unusual announcement "we're fully staffed today!!" at handover.  Starting a shift with a positive, motivated mindset is key for me.

    I can only imagine how morale would suddenly be improved if staffing issues were solved! With better morale....magic happens! Ideas flow and motivation returns and staff are keen to work on positive changes to allow continuous growth.

    Have I felt 'unsafe' giving care? Unfortunately yes, and generally due to being over stretched.  The best nurses in the world are still only human with one pair of hands.  As an Outreach nurse I see too often the corners that are cut to allow the nursing time to be stretched among so many patients at one time.  It's destructive on all levels!

    I hope we see changes made soon and would love to see safe staffing levels mandated nationally.  When considering what makes for "safe" staffing ratios, I sincerely hope that 'work as done, work as imagined' is fully appreciated and blogs like this are read!

    Thank you for taking time to write this piece. ?

    • 2 reactions so far
    Link to comment
    Share on other sites

    Create an account or sign in to comment

    You need to be a member in order to leave a comment

    Create an account

    Sign up for a new account in our community. It's easy!

    Register a new account

    Sign in

    Already have an account? Sign in here.

    Sign In Now
  • Create New...