Lack of nurses leads to system failure

The NHS and British nurses: from heroes to villains.
The NHS and British nurses: from heroes to villains.

Britain’s National Health System has been rocked by a scandal at the Mid Staffordshire NHS Foundation Trust, where cost cutting and nurse shortages led to a system-wide failure to keep patients safe.

An estimated 400 to 1200 patients died as a result of poor care at Stafford Hospital, a small district general hospital in Staffordshire, England, in a 50-month period between January 2005 and March 2009.

The scandal has sent tremors through the British health system and led to a public inquiry, the findings and recommendations of which were recently released and will have far reaching consequences for British nursing.

The Francis Inquiry, held over 139 days, heard dramatic evidence of poor care. A striking aspect of much of the testimony to the inquiry related to how a lack of basic nursing care, as opposed to clinical errors, led to injury or death.

Some of the accounts of neglect were harrowing. Requests for assistance to use a bedpan or to get to and from the toilet were not responded to. Patients were left on commodes or in the toilet for far too long. They were also left in sheets soiled with urine and faeces for considerable periods of time. Considerable suffering, distress and embarrassment was caused to patients as a result.

The causes of these instances of poor care included, in a small number of cases, staff who appeared uncaring. More often there were inadequate numbers of staff on duty to deal with the challenge of a population of elderly and confused patients. There may also have been a lack of training in continence care and difficulties may have been compounded by infection control problems.

“It is difficult to believe that lapses on the scale that was evidenced could have occurred if there had been an adequately implemented system of nursing and ward management,” inquiry chair Robert Francis QC said.

The inquiry received striking evidence about the incidence of falls, some of which led to serious injury. Many, if not all, took place unobserved by staff and too many were not reported to concerned relatives for too long, or only when they saw an injury for themselves.

The reason for the incidence of falls and other safety concerns was, the report observed, probably attributable to a combination of a high dependency level among the mix of patients, combined with too few staff, or staff not sufficiently qualified to cope.

Immune to the sound of pain

While much of the blame has been laid at systemic failure arising from cost cutting and staff shortages, nurses, doctors and frontline staff have been widely criticised for allowing the poor care to go unchallenged. Francis identified a litany of cultural and organisational deficiencies including:

  • bullying
  • target-driven priorities
  • disengagement from management
  • low staff morale
  • isolation
  • lack of candour
  • acceptance of poor behaviours
  • reliance on external assessments
  • denial

“I consider that staff morale had been low for some time before the concerns about the Trust came to the public’s attention,” Francis said. “The constant strain caused by financial crisis, staff cuts and the consequent difficulties in delivering an acceptable level of care have taken their toll. Many staff will have been concerned about their job security, while others will have felt the stress of the target-driven culture already described.”

The inquiry heard many strong views from diverse sources about the inadequate numbers of nurses. One doctor, who started work in Accident and Emergency in October 2007, said: “… the problem was primarily that there just were not enough staff. The nurses were so under-resourced they were working extra hours, they were desperately moving from place to place to try to give adequate care to patients. If you are in that environment for long enough, what happens is you become immune to the sound of pain.”

Hijacked for other agendas

The Mid Staffordshire scandal has led to a frenzy of media sensationalism and attempts by the Conservative government to use it for its own agenda.

“NHS: no one is safe” was a headline in the Times newspaper that was typical of the reaction by the right-wing press. Much indignation has fixated on nurses, with undue emphasis on a handful that appeared uncaring.

British health minister Jeremy Hunt has used the scandal to soften up the public to the idea of the private sector taking over NHS contracts. Prime Minister David Cameron has openly advocated tying nurse pay to performance in looking after patients.

These knee jerk reactions stand in contrast to NHS patient surveys that show more than 90% of patients leaving hospital say their care was good or very good.

Lessons for Australia

NSWNMA General Secretary Brett Holmes says there are many lessons for Australian nurses to draw from this terrible British experience.

“The positive profile that the community holds of nurses and midwives can not be taken for granted. If care ever falls below expected standards we can expect close scrutiny by the public and the media,” he said. Brett says there are also sobering lessons for our public health system.

“There are differences between the British and New South Wales health systems. The NHS has a stronger reliance on an assistant workforce than we have, but that excessive substitution remains a real and imminent threat in Australia with growing projected nursing workforce deficits.

“The Francis Report graphically documents the appalling outcomes for patients when health services rely on inadequate numbers of trained nursing staff and have excessive reliance on non-nurses to perform nursing work.

“It backs up our arguments that mandated minimum staffing levels are necessary to ensure that benchmarks, budgets and organisational culture do not replace the patient as the focus of service delivery.

“And it provides a real-life contemporary example of the consequences of running a system with not enough nurses to deliver decent care.”