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Difficult to know where to start with this blog. Like the rest of the world, I’m anxious. We don’t know what is happening, we have not experienced anything like this before. When COVID-19 first arrived in late February (it felt like it snuck up on us, but I’m not sure that is the case), there was talk about some people having to work from home. This really suited me as I could easily do this in my role at Patient Safety Learning and it would mean I would be around more for my two boys. My boys are 12 and 14. Trying to parent boys of this age I find challenging at present. They seem to need me more than ever. I try to be a good parent, but usually feel guilty about letting them on the Xbox too long, feeding them chips more than once a week or not always knowing where they are or who they are with, especially if I am at work. I have normal parenting worries of bringing up teenagers. They are still at school today. How long that will last, I don’t know. The school has already set up online work for them and checked we all have internet access. My parents have said they will look after them if this is the case, so I can still go to work. The boys are delighted this will be happening at some point and can’t really see the long-term implications. If the Xbox doesn’t go down like it did last night – they should be fine. My parents are not old – in their 60s. Dad has a bad chest so I don’t want him to be put at any risk of catching the virus. With me going in and out of the hospital, I will be like a super spreader. I have told them to stay indoors and I won’t see them for a few months. I call them three times a day to keep a check on them. I think they think I’m mad. I’m just worried. As a nurse, my financial situation is stable. Working for the NHS is amazing; paid sick leave up to 6 months, great holiday entitlement and the likelihood of being made redundant in a clinical role is slim. I appreciate this ‘bubble’ that I work in. Yes, I’m usually skint at the end of the month, but I know I can work extra if needed and I will be paid at the end of the month – without fail. My husband on the other hand is different. He is self-employed. He employs six people. He has already had to lay one person off at the end of last week. Today he is giving the warning shot that they are all at risk of losing their jobs by the end of April. He has bills and wages to pay, funds are due to run out at the end of the month. My husband said to me last night that he feels that he has failed. He hasn’t – this is not his fault or anyone else’s fault. This is unprecedented. The mental health of everyone is at high risk here. It is affecting everyone in different ways. The mental health charities and services will be in demand – they are also under-resourced and overstretched as it is. My clinical background is cardiology, intensive care and critical care outreach. My skills are needed in the hospital at present. I want to help where I can. But I need to be at home with the kids, I need to be supportive of my husband who is going through a turbulent and worrying time with his business, I also feel pressure to help out clinically. My colleagues are going to work. Staff who shouldn’t even be going into work; many I know who have just finished chemotherapy, are immunosuppressed and who have underlying health problems. Healthcare workers are not immune, they are normal people too. We had a discussion at home this weekend. I shall work extra shifts at the hospital. Luckily my boss at Patient Safety Learning is understanding and is in full support. If I am honest – I am very nervous to what I may witness in the coming weeks/months. I have worked in difficult situations in the past. Working in a field giving aid to 30,000 migrants on the Greek/Macedonian border was what I thought hell was. I saw pain and suffering on a grand scale. However, this was relatively short lived and confined to certain groups of people. This is not. This is affecting everyone, no matter how much money you have, the colour of your skin, nationality or religion and there is nothing you can do about it. We do not have enough resources to care for the amount of people who will need it. Working on the intensive care unit, you are protected. You have your patients who have access to everything they need – doctors, nurses, drug and equipment. If we are to start rationing resources or restrict who will receive treatment and who doesn’t, it will make caring for patients on the wards unbearable. I have been called in to work clinically on Thursday. Nurses have had to self-isolate for different reasons. I have never felt scared to go to work before. I don’t think I am prepared to watch people die from this virus. I shall blog an update later this week. I would urge anyone to write their account on how they are feeling or what it is like to be you, whether you work in a care home, in theatres, in primary care or as a support worker, or even if you have been affected by the virus – your stories may help others and may help to inform future care and policy if this was to ever happen again. We all need to highlight what’s happening now that needs to be attended to. Join the conversation in our Community area.

Key facts The occurrence of adverse events due to unsafe care is likely 1 of the 10 leading causes of death and disability in the world. In high-income countries, it is estimated that one in every 10 patients is harmed while receiving hospital care. The harm can be caused by a range of adverse events, with nearly 50% of them being preventable. Each year, 134 million adverse events occur in hospitals in low- and middle-income countries (LMICs), due to unsafe care, resulting in 2.6 million deaths. Another study has estimated that around two-thirds of all adverse events resulting from unsafe care, and the years lost to disability and death (known as disability adjusted life years, or DALYs) occur in LMICs. Globally, as many as 4 in 10 patients are harmed in primary and outpatient health care. Up to 80% of harm is preventable. The most detrimental errors are related to diagnosis, prescription and the use of medicines. In OECD countries, 15% of total hospital activity and expenditure is a direct result of adverse events. Investments in reducing patient harm can lead to significant financial savings, and more importantly better patient outcomes. An example of prevention is engaging patients, if done well, it can reduce the burden of harm by up to 15%.

Six months ago, I left my band 7 managerial role to work as a band 5 agency nurse on the wards. Despite the band drop, this move has financial advantages which will help me to achieve some personal goals. Signing up After successfully completing the recruitment process, I am asked to attend mandatory training. This includes basic life support, manual handling and infection control. The usual, run of the mill stuff. I can book shifts a week or a day in advance, but these shifts can change to any speciality or department in the hospital, depending on staffing levels. I book my first shift after six years of having not worked within a ward setting. An unsafe start I turn up to the shift and introduce myself to be met with a mutter. The team and I receive handover and I am allocated my bay of patients. I notice I have twelve patients, three more than the other nurses. I reiterate this is my first time here and that I haven’t worked in ward work for some years. I ask if it would it be possible for someone to show me around – resuscitations trolley, toilets, codes to the drug cupboards. General housekeeping. I receive a grunt and a point, followed by some numbers hurled at me, along with keys. Ok, perhaps they’re just not morning people. I will give them the benefit of the doubt. Off I go to introduce myself to my patients and to immediately make use of my prioritisation skills, escalating any concerns I have to the seemingly disengaged shift leader and (more helpful) doctors. I find that my patients are acutely unwell and in need of a lot of care. I have to remind myself of my 13 years’ experience and how good I am at communicating, reassuring myself I will be ok. Hours later and still no toilet break Seven hours later, hungry and in need of a wee, I ask my shift leader if she could cover me so I can take a break. I am met with, ”your patients are too unwell for you to leave them for 15 minutes, and I don’t have the staff to cover you”. Followed by the ultimate toxic saying within the NHS, ”that’s just how we do it here, always have”. I start to feel neglectful that I would even have thought to have a drink and pass urine. Ten hours pass and still I haven’t had any water or a wee. Three emergencies have taken place without me even having had a proper induction. I take solace in my bond with my patients and lovely doctors who understand how it feels to be isolated and new to an area. Speaking up Perhaps out of dehydration and kidney shut down, I find the voice to politely approach the other nurses and shift leader. I explain that my patients are now stable and highlight my own personal fluid needs. I mention that I still haven’t received an induction. No one has asked me my skills or background nor if I know how to use the different IT systems (drug charts are now on computers). Again, I am met with, “well you choose to be agency, we just all get on with it here”. These are words that frighten me. It isn’t safe to get on with it. I felt out of my depth, overwhelmed, deprived of basic human rights and unwell. Losing confidence Then, a patient’s relative approaches me to say, ”I didn’t want to trouble you as you were running around looking so busy, but dad has chest pain”. At that point my heart breaks. How have I given the impression that I am the unapproachable one on this ward? Have I neglected this poor man? The same man who had cried with laughter at a joke I had made about some TV show we both watched the night before while I was catheterising him. Protocol follows and I investigate his chest pain. No acute cause. Phew. I still leave his side feeling that I am terrible at this. The end of my shift approaches, still no break, still no water or food. Handover time… I introduce myself to the night team. Finally, someone kind welcomes me to the ward. They tell me they all feel like they are doing a bad job and not giving satisfactory care. I think they are trying to reassure me. I cycle home in tears; shattered and broken. The next day I have serious doubts about my own ability. I call my agency and have a long chat with my recruitment consultant (who has never set foot inside a hospital and works on commission). His response? ”Well, you don’t have to go back”. I start to have serious doubts about my choice to work in this way and feel even more perplexed that our wards and teams have become like this. What a difference a day makes My next shift is in an emergency department. Dreading it, I don’t sleep the night before and I turn up riddled with anxiety about what is to fall upon me. I meet the team and prep myself to ‘kill them with kindness’. Everyone is pleasant and welcoming. The senior nurse asks me about my skills and mandatory training and shows me around. She informs me of their expectations and what I could, in return, expect of her team. It seems so simple, a five-minute job, huddling with your team for the sake of patient safety. But what a huge impact it has on my shift. My patients are more acute, I am busier and still don’t urinate. But I am supported and able to escalate concerns without being gas-lighted. Final thoughts I have now booked all of my shifts on that busy emergency department, simply because of the manager. I respect her management style and her approach to the safety of her unit. She doesn’t use those unhelpful and unsafe words, ”we just get on with it” or ”that’s how we do it here”. Since becoming a bit more settled in this world of agency nursing, I have spoken with matrons and lead directorate nurses within this trust about my experience. Often met with, ”what can I do about that?”. But sometimes met with, ”I will look into how that particular ward manages staff safety”. The latter leads on to better patient safety. Key learning points Inductions to new staff in new areas, should be mandatory. It should be the nurse in charge's duty to support junior staff. Doing safety rounds and checking in on all staff would help to manage workload, support flow and build confidence and reassurance among staff on duty. Safety huddles at the beginning, middle and sometimes end of each shift are a simple way of combating so many of the patient safety issues raised in this account. Early warning scores should be displayed and visible for all professionals on duty. They should be checked regularly and actioned accordingly.

Key findings 59.7% think their organisation treats staff who are involved in an error, near miss or incident fairly. This is a 1 percentage point improvement since 2018 (58.3%) and continues a positive trend since 2015 (52.2%). 71.1% think their organisation takes action to ensure that reported errors, near misses or incidents do not happen again. 73.8 think their organisation acts on concerns raised by patients / service users (2018: 73.4%). 61.1% gives them feedback about changes made in response to reported errors, near misses and incidents (q17d) This is a 1 percentage point improvement since 2018 (60.0%) and continues an upward trend since 2015 (54.1%). 71.7% would feel secure raising concerns about unsafe clinical practice. This is a 1 percentage point increase since 2018 (70.7%). 59.8% were confident that their organisation would address their concern .This has continued an upward trend since 2017 (57.6%).

This powerpoint presentation from the Birmingham Women and Children's Hospital NHS Foundation Trust explains the data backing up this fantastic initiative.

In this article, Dan looks back at the Donabedian Model, a framework for measuring healthcare quality, and suggests why this might be an over simplification and why we must also look at human factors when we think about patient safety. We are humans and we can, do and will make mistakes, so we have a personal responsibility to acknowledge and address this as a contributing factor for patient safety incidents and harm. How do we begin to address our individual responsibilities? How can each of us reduce the personal risks we pose for our patients? How do we begin to address the moral imperative to recognise and then overcome any professional complacency that may interfere with our performance? Dan believes by enhancing human performance within healthcare settings this will serve as the ultimate key to improving quality and safety. Recognition by clinicians of their own tendencies toward complacency and their own vulnerabilities toward making mistakes is to encompass a mandate for personal professional commitment and improvement. If patients are harmed on the frontlines in healthcare settings, then it is on the frontlines that many of the solutions can be found and safety improvements nurtured. First recognising, and then modulating, the human factors liabilities that exist on the frontlines and overcoming the challenges of professional complacency will be necessary steppingstones towards sustained improvements in providing patient safe care. Clinicians, managers and leaders need to work collaboratively to understand and overcome the challenges that human factors pose when addressing individual performance.

I was employed as a healthcare assistant in a care home, where I worked for about three months. During this time, I found out that patient safety and quality of care were undermined by healthcare assistants, and the management and the nurses did not seem to realise it. Examples included: Carers were given a box of gloves each and they were expected to use them for up to two weeks. When asked for more gloves, the manager would check the last time they took a box of gloves and would question what they had done with the last ones they collected. In order to save the gloves, carers used one pair of gloves to deliver personal care to three to five residents before changing them. They would take the rest of the gloves home and bring them back to work in the next shift. Genital care was totally neglected. Residents’ genitals were not cleaned. I spoke to a nurse in another unit about this and all she said was she thought it was being done. When carrying out personal care to one lady, I found dried faeces wrapped in her pubic hair which took me a good number of minutes to clean. When I finally finished doing it, the lady pointed at her private part and said to me “it can breathe now” and when I asked why, she said “because it has been washed”. Infection control. One of the problems was that there was never any soap in the bathrooms and places where there were wash hand basins. So, after personal care, especially after caring for residents who had opened their bowels, we could only wash our hands with clear water. Hand sanitiser dispensers were hanging empty with no sanitising gel, so no opportunity for either visitors or staff to sanitise their hands whilst in the care home. Healthcare assistants apparently had no clue about catheter care, even those working at the nursing unit where there were a few residents that had catheters. I never saw any of them doing catheter care and one day when I was doing it, my colleague was really frightened, held my hand back and said I was going to pull the catheter out. Most of the times when residents opened their bowels, carers would either clean it very shallowly, or they would only take out the soiled pads and replace them with clean ones without cleaning the area at all. As such, when you took over the shift, during the first checks you would think that a resident had opened bowels but find out that the pad was dry and clean at that moment, but the faeces on it and on their skin was dried up. Oral and nail care was another issue. Carers never did oral care, and those who bothered to document would say “resident denied oral care”. Some of the residents’ beds were not functioning, especially in the nursing unit where most of the residents were bed-ridden. This meant that healthcare assistant staff had to bend and strain their backs each time they were giving personal care, which would lead to backaches. After trying to share my concerns on the above issues with three nurses to no avail, I was only left with the choice of talking to the management. I wrote a letter of observation, accompanied by some recommendations. I ended my letter by letting the management know that I was ready to discuss my concerns with them at any time. They did not call me up for any discussion. A change in behaviour... A few days later I started noticing a change of behaviour from all staff towards me. Most of them did not talk to me, many times I found out that people were whispering things about me as when they saw me approaching them they would stop talking. One unit reported that I was very slow, and I was never assigned to work there anymore. People ignored me when I tried to join in a conversation. Each time I was working, nobody would let me do personal care. I was only allowed to work as an assistant to fellow healthcare assistants. In some rooms where I went in first and started doing personal care, they would tell me that I was taking too much time. My opinion on anything did not count. One day when I came to work, there was a small problem which needed to be fixed between one of the nurses and myself, but she refused to listen to me and insisted that I should go back home. I went home as she had asked, and the next day I called and told the manager that I was sent home last night. He started blaming me based on what the nurse had told him, which was not true, without listening to my own side of the story. I insisted that he should call a meeting where he could listen to both of us, because what the nurse had said was untrue. His response to me was that I would need a reference from him so I should be careful about the way I did things. However, he finally accepted and we agreed on a date for the meeting. But when it came to the day of the meeting, the nurse was not there. I explained myself to my manager, in the presence of the secretary. His response to the letter I wrote with my concerns in was that he appreciated it, but he thought that the care home was not the right place for me, and that he thought that I was too qualified for the job. He suggested that everybody felt threatened with my presence. I told him that that it sounded to me like he wanted to remove me from my job; a job which I very much wanted to do. When I came back for the next shift, I discovered that my shift had been cancelled and I had been replaced by someone else. I spoke to a senior carer who called my manager and he told me that he was not expecting me to come to work because of what had happened the other night. I went back home. The next day he called and told me that after due consideration, he had decided to extend my probation time to a further three months, and that I should compose myself, come to work and do only what I was expected to do. Psychologically tortured As I continued working, things got worse each day. I experienced colleagues laughing at me, talking about me, not talking to me, ignoring me; the list could go on and on. I was psychologically tortured. I developed a violent headache. Each time I thought I was going back to work I felt sick, got palpitations, felt so hot as if I had fever, at times shivering, with painful nerves. I kept asking myself whether I was wrong to have done what I did. I did a lot of self-counselling and told myself that I was going to stay at the workplace if I was not dismissed. This was because I was planning to write more letters. I had only highlighted a few of the many issues in my first letter. My hope was that one day someone was going to understand me and things would improve. One night I stopped a colleague from putting a pad on a resident she had not cleaned properly. I cleaned the resident and did vaginal and catheter care, before putting on the pad. There was another resident who was very wet, from their pyjamas to the bedding; my colleague wanted us to only change the pad and let the resident lay with the wet clothes on the wet bed “since they were going to wash her in the morning anyway”. This was the 1am check, and I argued that I could not imagine her being able to fall asleep in that condition. We ended up changing the resident’s pyjamas and putting a towel and an extra pad on the bed to make her feel comfortable. Forced into resigning My colleague became angry with me. I was surprised because I had done nothing wrong. There was altercation and she confronted me. I couldn’t tell anyone as no one would believe me. I felt excluded and alone and the only thing that came to my mind was that I should resign. When I finished work in the morning I went and told my manager that I was resigning. He told me that I was expected to give two weeks’ notice and that I should write my resignation letter that day, which I did. He told me it was rather unfortunate that it hadn’t worked out for me in the care home… Did I do the right thing? What would you do?