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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.

What is Redthread? Redthread, a Youth Violence Intervention Programme, runs in hospital emergency departments in partnership with the major trauma network. The innovative service aims to reduce serious youth violence and has revolutionised the support available to young victims of violence. Every year thousands of young people aged 11–24 come through hospital doors as victims of assault and exploitation. It is then, at this time of crisis, that our youth workers use their unique position embedded in the emergency departments alongside clinical staff to engage these young victims. Redthreads extensive experience tells us that this moment of vulnerability, the ‘Teachable Moment’, when young people are out of their comfort zone, alienated from their peers, and often coming to terms with the effects of injury, is a time of change. In this moment many are more able than ever to question what behaviour and choices have led them to this hospital bed and, with specialist youth worker support, pursue change they haven’t felt able to before. Redthread workers focus on this moment and encourage and support young people in making healthy choices and positive plans to disrupt the cruel cycle of violence that can too easily lead to re-attendance, re-injury, and devastated communities. Redthread and the Homerton Redthread is embedded within Homerton’s A&E department. The Redthread youth work team work hand in hand with the emergency department team to safeguard young people between the ages of 11-24 who are at risk of violence or exploitation. Emergency department clinicians send referrals for at-risk young people to the Redthread team, who work on an individual basis with the young people to support them and endeavour to alleviate the risk in their environment. Redthread achieves this by liaising with statutory services such as CAMHS, Children’s Social Care and Housing to ensure that the young person is being placed first. By linking up services, Redthread ensures that the young person is the focal point and that help is being given, without duplicating existing services. Redthread works in several major trauma centres across the UK; however, the Homerton practice is the first community hospital based service. The Redthread service would not be possible without the support of the emergency department staff. Not only is the clinical and non-clinical body supportive of the service and actively referring young people, the emergency department as a whole takes an active interest in Redthread’s work – talking to Redthread staff about their work, fundraising and attending training sessions. Thanks to the initial efforts of emergency department doctors and nurses in gaining funding and support for this project at Homerton, and the continued work and collaboration by the emergency department and Redthread, the service has excellent track record after its 1 year of service. The Redthread youth workers work closely with young people in a way that clinicians do not have time to. This means that patients are cared for both medically and holistically. Though difficult to quantify results, a strong qualitative difference to the service is that there is a caring external presence within the emergency department. For young people in crisis, being seen one-to-one by someone in a non-clinical role means that there is someone solely on their side. In a lot of cases, a Redthread worker might be the first person in a long time to ask if they are ok, and to see them for who they are as opposed to the trauma that they have suffered. For the emergency department team, having a constant youth work presence acts as a reassurance that when a safeguarding issue does arise, this will be followed up and the young person will continue to be cared for. The emergency department safeguarding has improved as awareness has grown among staff members of safeguarding procedures. The Redthread collaboration has also prompted staff to be more inquisitive with the patients they see, and to consider how that patient’s behaviour may be a manifestation of underlying problems. As such, young people coming into the emergency department are safer as they are more likely to be seen and understood by clinicians, as well as receiving long term assistance as part of the emergency department care package. As the first community hospital in the Redthread network, the Homerton Redthread team have tailored and changed their service to best fit the community it serves. The team spend longer working with young people, in addition to working more closely with them than in other hospitals – taking on a constant role in our young people's lives. The breadth of presentations seen at Homerton has also resulted in a broader case-load. The result is a service which is ready to adapt to individual cases to best serve young people both in hospital and out in the community. Redthread at Homerton are also innovating and adding value structurally by meeting young people at the earliest opportunity – the statistic is that young people present to hospitals like Homerton four to five times on average before they are injured to the extent that they have to be taken to a major trauma centre. By being embedded in a local hospital such as this, we have an opportunity to engage people and help them to change their trajectories and avoid escalating harm. We’re also pioneering work around contextual safeguarding, by listening to young people and feeding back to local authorities when for example unsafe spaces in the community are identified.

Main findings: Many investigations were of poor quality and took too long to complete. There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating deaths. There was a lack of family involvement in investigations after a death. Opportunities for the Trust to learn and improve were missed. Of the 1,454 deaths recorded at the Trust during this period, 722 were categorised as unexpected by the Trust. Of these 540 were reviewed and 272 unexpected deaths received a significant investigation.

What’s the worst thing you have ever seen? For those that work on the frontline in healthcare you may have heard this question asked many times… usually by friends or people you meet when you are trying to relax outside of work. They often want to hear some awful blood and guts story, something unusual being stuck in an unfortunate person’s orifice or a heroic story of a dramatic rescue. We all have something to tell along these lines. Especially when you work in ED, like me. Yep, they are awful episodes, especially for those involved, these awful stories often happen in ED. Car crashes, trauma, cardiac arrests, injured, sick children… you name it, I’ve probably seen it. When tragic things happen, we have support to get us through them. We have support from our wonderful work colleagues who understand – most of the time black humour gets us through. I want to tell you about the worst thing I ever saw, I still see, we all still see. It wasn’t a one off, I didn’t get any support, we didn’t get any support. In fact, it went unnoticed and it happened multiple times and often for hours on end. It’s like being in a recurrent bad dream, the trouble is that it isn’t a dream. It’s real and it's probably happening in hospitals up and down the country today. Rose tinted spectacles… It’s a Tuesday afternoon. It’s a warm, sunny day. I have had 2 whole days off. I’m rested and ready for the day ahead. I drive to work in a good mood. Today is going to be a great day. I walk up to the ED entrance. My hopes of a good day are dashed. There are already eight ambulances outside. I hear the sirens of another in the distance coming up the road. Perhaps the department was already empty… it might not be that bad? I step inside. Two paramedics wheel an elderly man up to the desk. He looks frail, he has a bruised face and blood running from his nose. He looks frightened. He has fallen in his rest home. "… you will have to park him in the corridor, love..." The corridor is now an ‘area’ in our ED. It’s not a walkway between two clinical areas, it’s now clinical area itself. We even have allocated a ‘corridor nurse’ to care for this group of patients. The corridor is full. Each side of the corridor there are people. People on trollies, in chairs, in wheelchairs. I feel their eyes staring at me. Someone is calling out for water, someone has vomited on the floor, an elderly lady is wandering around with her hospital gown on, it's not done up properly and everyone can see her bottom. Every few steps I take I hear someone ask when they are going to be seen. I see a couple crying, trying to console each other in full view of the onlooking people who have nothing else to do but wait. I must walk down to get to the staff room to start my shift. I feel like I am running the gauntlet. I need to get changed and get on with moving people out of the department. I hear staff members muttering "thank god the day staff are here" and "good luck, you’re going to need it". Ok, If I was able to nurse the way I have been taught; ensuring patients are listened to, made comfortable, had medication on time, are given food and water, turned if required, clean… basic nursing care, maybe I wouldn’t feel as crap as I do when I go home. Maybe I’m in the wrong job? But… this type of nursing takes time. Time is forever ticking, especially in ED. It's all about flow. Get them seen, treated and moved – within 12 hours. Sounds a long time 12 hours, doesn’t it? It’s not in healthcare. Blink, 12 hours have gone in a flash. Site managers constantly circle the nurses’ station with their clip boards, trying to strategically place patients on appropriate wards. Single sexed bays, side room, isolation rooms, monitored beds, surgical, medical, trauma, elective, the list goes on. It must be like playing one of those online strategy games, but it never ends. I’m now waiting for handover. The noise is deafening. White noise. I try and block out other people’s instructions, conversations, phones ringing, doors banging. My senses are overloaded. Not only is it too loud, the smell of stale alcohol and vomit is left in the air from an overdose that came in earlier, the irony smell of blood left by lady with a bleeding ulcer, the heat of the corridor and a hint of pseudomonas from a leaking leg ulcer – there are no windows here to give us any relief. This is my next 12 hours. People who are wearing lanyards appear. I see them when things go ‘tits up’. No idea who they are, what they do or where they come from. Never have they spoken to me and I have never seen them speak to a patient. They arrive in immaculate clothing and smell fresh, whereas I have been here a few hours and already blended in with the current smells. They are obsessed with how long people have stayed in the department. I see them frown and start talking to the site managers, who then speak to our nurse in charge, who then will speak to me. "We need to move X number of patients out of here in the next 2 hours." So, if I choose to help a man who may have soiled himself – this may take up to 40 minutes. That’s too long. I should have been preparing my patients to move off. But then if I don’t help him, the ward he moves onto will report me. Notes to prepare, IV antibiotics to give with in 1 hour, comfort rounds every 2 hours, mouth care, turn charts, feeding regimes, safety documentation to be completed, toileting, venepuncture, sepsis pathways, NEWS charting, escalation protocols… so many targets to be met. I can’t do this. It’s impossible. ‘The standard you walk past is the standard you accept’ Every time I walk down that corridor – I say this in my head. I have failed. We have failed our patients. That is the worst thing I have ever seen.

In this report the CQC have seen much good and outstanding care, in particular around: responsiveness staff interactions with patients effective treatment leadership and engagement with staff and patients. However, there were a number of areas where services needed to make substantial improvements: governance clinical audit safety culture.

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This short, moving, animation has been produced to support the Justice for LB campaign.

This is an interview with sepsis survivor Julia, who gives insight into her own personal battle with the condition.

On this page you will find more about the work PSCs are doing around: Culture Deterioration Maternal and Neonatal Care

MEs are a key element of the death certification reforms, which, once in place, will deliver a more comprehensive system of assurances for all non-coronial deaths, regardless of whether the deceased is buried or cremated. MEs will be employed in the NHS system, ensuring lines of accountability are separate from NHS Acute Trusts but allowing for access to information in the sensitive and urgent timescales to register a death. This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites. To date, the following learning points have been identified and explored: End of Life Care, ceilings of care and avoidable admissions Some investigations have highlighted cases where the End of Life Care pathway could have either been established or fully implemented, where this would have been of benefit to patients and their families. Some patients may not have been cared for in the right location, and some admissions could have been avoided if the End of Life Care pathway had been suitably established and followed. Early detection and response to physiological deterioration, and effective communication Response stretched by implementation of National Early Warning Score (NEWS) but still learning around effective communication of escalation. The use of standardised communication tools is essential. Record keeping and organisation of medical records Some learning was identified in relation to the accuracy and completeness of medical records. It was evident that not all records are reflective of the clinical picture. Discussion with specialty teams is vital to support the investigation An independent review by the ME should be further supported by speciality ‘experts’, and if possible, peer review from other trusts can be sought to allow for full independent review. Seeking speciality opinion from those not directly involved with the case within STHFT has also been shown to be effective. Pathways for links to wider clinical governance processes have been strengthened.

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

What can I learn? Introducing power of the patient Tricky conditions: understanding disease, diagnosis and decisions What everyone should know about getting the best care The patient's side of the call for better

What can I learn? The role and responsibilities of maternity safety champions. How to build relationships at board-level and with stakeholders. Suggested activities to promote best practice. Signposting to existing safety initiatives and improvements that can offer support. Are you a maternity safety champion? Share your experience and discuss your work with other maternity safety champions on the hub.

What will I learn? What is telehealth? How could telehealth help me? What is telecare? How could telecare help me? How to get telecare products and services What do I need to consider when buying telecare products? What should I do next?

What can I learn? This web page gives you information on: the friends and family test patient insight group an animation on how the quality framework works.

FOAMcast reviews Dr Josh Farkas's PulmCrit blog posts on 'Renal microvascular haemodynamics in sepsis: a new paradigm' and 'Renoresuscitation: Sepsis resuscitation designed to avoid long-term complications', in which he posits that renal protection in sepsis may prove beneficial for patients.

Central Manchester University Hospitals NHS Foundation Trust Case study: Improving management of deteriorating acutely ill patients Improve compliance with an Early Warning Score protocol A flowchart for the escalation of deteriorating patients Western Sussex NHS Foundation Trust Case study: Using electronic bedside observation to target support to deteriorating patients and facilitate research and development of new triaging and scoring systems University Hospitals Bristol NHS Foundation Trust Case study: Empowering a clinical champion to ensure effective use of the World Health Organization surgical safety checklist WHO checklist

Podcast and a transcript available.

Who is this aimed at? This tool kit is aimed at everyone. There are different sections for each target group What will I learn? Kidney health Recognition and response to AKI Primary care management post AKI episode Embedding a holistic approach to AKI