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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? References 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.

I work in, both, the work imagined and prescribed, but practice in the world of work done. It’s interesting working in both worlds and has made me ask these questions: Why this happens? What are the consequences? How can we manage this disconnect? Real-life scenario What happened? A patient on a ward needs a nasogastric tube (NGT) for feeding and giving medication due to an impaired swallow following head and neck surgery. The nurse prints off the policy for placing an NGT from the Trust's infonet. The nurse inserts the NGT and checks the policy on how to test if it is in the correct position. The tube could be in the stomach (the right place) or it could be placed in the lungs (not a great place for medicines and feed to go!). The nurse calls the nurse in charge for support. It’s been a long time since she has placed an NGT and she wants to check she iss doing the right thing. The senior nurse arrives, before the feed is commenced. The senior nurse notices that the policy that the nurse is using is out of date. Checking the position of NGTs had changed. The senior nurse prints out the updated policy – NGT was in the correct position. This was a near miss event. So what? If an NGT is in the lung and you give medication and liquid feed there is a high chance the patient would contract fatal pneumonia at worst or a protracted stay on the intensive care unit on a ventilator at best. In both these cases, it would need to be declared to the regulators as they are classed as serious incidents. What next? This incident was one of many near misses that were collected over four shifts. This incident was discussed with the Deputy Chief of safety within that Trust. His first reaction was: "When was this? We had a Datix last year of the same incident – why has this happened again and why don’t I know?" It was true, there were a few similar incidents last year and an action plan was put in place to mitigate another incident like this happening again. All the old policies were to be removed from the infonet and replaced with the updated versions. Not only this, the Trust was now moving towards a web-based search facility that enables the clinician to have all the updated evidence for policies, antibiotic therapies, prompt charts, documentation and prescribing advice. The guide would be updated and the old policies would automatically be replaced, thus mitigating clinicians using out of date policies and procedures. The document management system was put in place to ensure it is easier to do the right thing. So, if this forcible function was in place, how did this incident happen again? Not all staff know about the new document system. Some nurses think this search facility is for doctors only. Nurses are prohibited to use their mobile phones on the ward. Clinicians not always able to get to a computer. It takes too long to update when opening the browser – therefore people are using it offline. The final point is an interesting one. Making it easy to do the right thing is one of a number of aspects that a safe system is comprised of; however, if part of that system i.e. the Wifi is not set up to support the change, that system is at risk of a ‘work around’. Work arounds are what healthcare staff do to enable them to get through that shift without immediate detriment to themselves or the patient, make swift complex decisions easily and to ‘tick the box’. Time is a precious commodity, especially when you are a frontline worker. We know the document management system will have the updated policy; we wait for the download. We wait. We wait a bit longer. Eventually it loads. Remembering it takes a long time, we save it and use it ‘offline’ for future access. By using the guide offline makes it quick and easy. We are using Trust policy; however, that policy may now be out of date. So what? Implementation of this online guide was made to make our lives easier and safer for patients and ourselves. Due to an oversight of how clinicians ‘actually’ use and interact with this change in the work environment, it could have an adverse outcome for patients. How would the safety team know this was happening? Near misses seldom get reported. Chance meetings in corridors, chance conversations overheard, a reliance on staff that may know the answer – if we ‘fixed’ the problem for that near miss, why should we report it? No harm came to the patient after all. We have a good culture of reporting in the Trust; however, our safety team are overwhelmed with incidents to investigate. The current system is set up to investigate when harm has happened rather than seeking out ways to prevent harm. I’m part of the problem, so I can be part of the solution? I would welcome any support on this. Does anyone have any solutions or strategies in place where frontline staff are involved in the reporting of near miss events and are part of the solution to mitigate them?

The key outcome is the development of a wearable medical device which is CE Marked and ready for a qualitative and quantitative evaluation study, which ultimately could assist 25,000 adults with a CVC for HD across the UK (Source: Renal Registry). The proof of concept pilot study is planned to start by the end of the 2018/19 financial year. MedConNecT North have also facilitated further connections with clinicians, and Tookie are now working with the Great North Children’s Hospital in Newcastle with Dr Yincent Tse and Dr Heather Lambert, Consultant Paediatric Nephrologists. Together they have developed a paediatric version of the Renal Vest, which has also been CE marked. In addition, Tookie Limited has been awarded an NHS Supply Chain Framework contract for Tookie products which is now live and has recently achieved ISO 9001 status.

Day 2 – Visit to the medical ICU and medical ward Today started off with a 10-minute meeting with the medical emergency and cardiac arrest team at RUSH University Hospital, Chicago. This team consisted of a critical care outreach nurse, the medical intensive care unit (ICU) doctor, a respiratory therapist and a pharmacist – "yes, a pharmacist!" This is so drugs can be sent up to the ward without delay, pre-prepared and appropriate for the patient. Respiratory therapists assist with intubation and oxygenation of the patient. Unfortunately, the meeting was cut short due to a ‘code blue’, a cardiac arrest. I’m not sure what I was expecting; a bunch of doctors and nurses calmly following the protocol while dramatic music was playing in the background maybe? Seems I must watch too much drama on TV. It was nothing like that. For all those who work in a hospital and are aware of what a cardiac arrest is like where you work… it was like that. Lots of people in a room, some initial disorganisation, lots of voices, equipment being sought, people walking in and out of the room trying to find stuff, sounds familiar? It was like that. Nurse patient ratio is 1:2 on the medical ICU. In the UK our ratio is 1:1 for ventilated patients; they require close observation as they may pull out their breathing tube. The patients here at RUSH are cared for in single rooms and to ensure they do not pull their tubes out they physically restrain their patients using straps on the wrists. This practice is unheard of in the UK. When questioning the ICU team they were shocked that we chemically restrained our patients, as they don’t use as much sedation as the UK. "One of the intubated patients was sat up comfortably watching TV, a sight we had not seen before!" Family members play a large part in care here. They allow 24-hour visiting and encourage them to stay with the patient overnight on the sofa bed in the room. Family members play an active role in the ward round, they are able to voice their concerns and make suggestions. At RUSH hospital there are around 700 beds, 100 of these beds are ICU beds. The ICU beds are not as much as a premium as they are in the UK. If a patient on the ward or ED needs a bed there is minimum waiting time. The whole hospital is paperless: documentation, doctors notes, pharmacy, drug charting… everything. "Imagine an IT system that talks to pathology, imaging and pharmacy." By having everything computerised it allows for more robust patient safety solutions by using a forcible function. For example, nephrotoxic drugs cannot be prescribed to a patient who has an acute kidney injury (AKI) showing up on their blood results; the computer will not allow it until certain checks have been completed. Some hospitals use this technology; however, it is not yet standard practice. That morning we also attended a ‘town hall meeting’. This was a meeting where the Chief Operating Officer (Cynthia) informed staff of what new plans there were for the hospital, strategies and updates. Questions from the floor were actively encouraged from an audience of over 200 people! Questions ranged from parking problems to staff safety. The town hall meeting is held four times a year and is a chance for staff to engage with the senior leader team. "Conversations were honest and non-hierarchical." In the afternoon we observed on an acute medical ward. Processes such as patient escalation, end of life care, track and trigger scoring, and patient observations were different to the UK. Critical care outreach teams (CCOT) are in their infancy here, while the UK has established CCOTs since the early 2000s. Granted, the UK CCOTs are not standardised; however, this is something that the National Outreach Forum are working towards. Today was enlightening; it highlighted the importance of collaboration of the RUSH CCOT and the UK CCOT. We can learn so much from each other, building lasting relationships that will, in-turn, improve outcomes for our patients. Read part 1 of Claire's blog

Q: Why was the training needed? A: A trust audit found that mortality for NIV was higher than the national average. We looked at previous training for nurses and there was no clear record for most ward areas using NIV. Some nurses had training, but this was several years old. The trust had also upgraded all the NIV machines as the previous machines were no longer serviceable. This gave a great opportunity to ‘rebrand’ NIV and provide current and appropriate training for all those using NIV. Q: What inspired you to take on this project? A: I work in an amazing team of highly skilled and resourceful nurses. We each have areas or ‘projects’ that we work on, looking to develop knowledge and skills among other nurses and to support unwell or deteriorating patients in ward areas. Since joining the critical care outreach team, I have been inspired by my colleagues to look at situations with the aim of ‘how can we improve this?’ and look at practical solutions to issues that may arise. Training ward nurses is an excellent way of passing on knowledge and skills, increasing safety and improving patient care. Q: What did you do? A: I began by gathering current training records and speaking to ward nurses about how they practice currently and the NIV care given. I found that many nurses did not have an up to date record of training, had gaps in their knowledge and lacked confidence in using NIV. We asked the reps supplying the new machines to carry out machine updates, including how to operate the machine, cleaning, storage and maintenance. I then planned a pilot training day for nurses working in the acute medical unit, which included indications for starting NIV, assessing and recognising a deteriorating patient, analysing arterial blood gases and using the machines in practice. From the pilot training day and the feedback from the nurses, I adapted the training to include more simulation and patient scenario training, as well as a troubleshooting workshop for everyone to have a chance to use the machine. Following this I set up monthly study days, working with the practical development nurses in the areas using NIV, and invited all nurses from these areas to sign up and attend the day, whether they had previous NIV experience or not. Ten nurses attend each of these days and an up-to-date database is kept for the whole trust. I gathered information at each day, asking the candidates to score their confidence out of 10 before and after training. I also worked with the NIV steering group during this time to update the trust NIV policy to reflect the most recent British Thoracic Society standards for NIV care in acute wards. Q: You work full-time, how did you find the time to complete the project? A: A lot of the initial background work, planning teaching sessions and administrating the study days was done in my own time. My manager has been very supportive from the beginning and since the first few months I have had some protected management time to continue planning, administrating and improving the training. Q: What challenges did you face? A: The administration has been really challenging: booking rooms, updating the online booking form, contacting candidates and managers about non-attendees or issues that arise. It has also been a huge undertaking, we have identified 230 nurses that need training, some of whom only work nights! There has been a varied response from ward areas, some being very supportive and others taking a lot longer to engage with the training. Nurses attend who have no prior experience of NIV right through to those who have been using NIV for over 10 years, this can be difficult to pitch the training at the right level. Q: How did you overcome these challenges? A: I have now got a more robust system for administration, this mainly involves a lot of forward planning, organisation and writing everything down! I have kept going and kept going with trying to engage all ward areas and managers, we are getting there – but it remains a work in progress. I have had to develop the teaching from scratch and have learnt as I’ve gone along! Feedback from the candidates after each day has been invaluable to ensuring the training is relevant and interesting for everyone there. I have also used the KSS e-learning NIV package to provide some pre-reading, especially for those with no prior experience. Q: Has the project made a difference? A: Yes! We asked candidates to score their confidence before and after training, with on average this improving from 3/10 to 8/10 following training. We have improved nursing training records from unrecorded to 49% across the trust and competency from unrecorded to 20% in just over a year of training sessions. We are aiming for 80% so we have a bit more work to do. We are currently doing the national NIV audit in the trust and I hope this will reflect some of the improvements in training to patient care and outcomes. Q: How have you ensured that this project is sustainable? A: We have recently asked some senior nurses on the wards using NIV to take on additional responsibility as ‘link nurses’ for NIV. They will help to deliver bedside support on clinical shifts and assess competency for nurses in their ward areas. I have completed a standardised template for the days, so in theory any one of my critical care outreach team colleagues could pick up the training folder and run a training day. I am also looking at working with the senior respiratory physios to deliver ‘update training’ for nurses who have attended training to keep up with any recent policy changes and have a chance to refresh their NIV knowledge if needed. Q: Do you have any advice for anyone starting a quality improvement project? Or top tips? A: Evidence is essential. Have a clear standard that you are working towards, make sure you have gathered some evidence as to why your project is needed, and have a measure that you can look at to show how you are improving things. Not only does this help continued motivation and interest in your project, but it also helps with securing more support from managers and those you are trying to engage with. Look at sustainability right from the beginning. It’s easier to start something first time then have to go back and re-do things later down the line. Stay positive! It’s easy to feel disheartened in an under-resourced and challenging environment, sometimes it feels like no one else is aware of what you are doing and the difference it can make, but keep talking about it, and keep being positive, and eventually others will get on board! Q: What are your future plans? I will continue the training until we reach our goal of 80% competency. I am working with physio colleagues to develop ‘update sessions’ so that competency can be maintained. I will continue to inform and update ward leaders and managers to keep the momentum going. As a team we have used the database structure I created to help track other areas of competency such as tracheostomy training. I have created a poster to represent the work I have done over the last 12 months and will look to do this yearly to show how far we have come. Please contact me if you are planning or implementing a similar project, I would love to hear about it and share resources and ideas.