The quiet scandal - September 2012

Public protection, patient safety and the quality of care are all inextricably linked with the performance of nursing staff – to state the obvious. So it follows as night follows day that the state of nurses’ mental and physical health has a defining influence on patient safety. Every practitioner knows all too well that if you are feeling tired, stressed, overworked and fed up, you cannot give of your best. You are more likely to make mistakes, your concentration drops, motivation is low, and accidents and injuries are more frequent.
Some striking research by the Royal College of Nursing illuminates the backstory. Around 92% of nurses regularly work extra hours, a third usually work four or more hours a week overtime, and around half regularly do unpaid overtime. These are staggering findings, yet they don’t find their way into the mainstream media alongside endless nurse-bashing stories of poor care. Think about it: health services would grind to a halt if nurses and midwives stopped moonlighting and working extra hours. Put another way, services are kept going by employees who give their time gratis when they should be having a break or going home, and by people who are working extra shifts after a busy working day. In both scenarios they are likely to be tired and stressed – thus putting patients at greater risk.
Being a practitioner is usually busy, demanding, emotionally loaded and physically tiring. An ordinary shift can be exhausting, even more so when you have skipped breaks because numbers are down, or stayed on to supervise untrained staff, or gone yet another extra mile to help a patient after your shift ends. And people who do agency work on top of a full working week don’t do it for fun or to pay for frills, but to make ends meet – keep the kids well clothed and fed, support an unemployed partner or pay the mortgage.
Extremely hard work and long hours have always been part of nursing. Even in the supposedly golden days when life was slower and more gentle, whether through compassion or necessity people routinely missed breaks, worked long shifts, and moonlighted. No one has ever grasped this nettle: employers are in denial, while practitioners just keep going and never draw the line. Rarely discussed outside professional circles, perhaps this is the real scandal of our health services.
It is really alarming is that things are getting worse, not better. ‘Staff reported mixed emotions of feeling pilloried, hard worked, stressed and abused on the one hand but proud and satisfied on the other.’ No change there, then – this was reported in 2003 by the now defunct Commission for Health Improvement. Cuts, pay freezes and unemployment are hitting pockets and pushing people to work overtime or double shifts for less money. Front line staff in health and social care are being laid off and skill mix diluted while demand, throughput and the complexity of patients’ needs continue to rise. There will be even less staff support. Amid the chaos and instability of an expensive, unnecessary and deeply resented NHS reorganisation in England, more horror stories will be easy to find.
Everyone is holding their breath to see how the long-awaited report on Stafford Hospital will play out. The government and the media might use it as another excuse for nurse-bashing and victim-blaming, and a rationale for pushing through ‘tough’ measures that don’t really get to the heart of the matter. If inquiry chair Robert Francis QC has really grasped what makes the health system dysfunctional, he should recommend that the pay freeze is lifted, skill mix is enriched, staffing levels are improved, and front line staff are properly supported. All that will help to promote a safety culture in these troubled times. Dream on?

My book The Politics of Health explored these themes back in 1985. Plus ca change?