What keeps me awake at night? Usually it's nothing work related but in recent weeks the delivery of safe staffing certainly has. As the ultimate accountable registrant to the Trust Board and external regulators for safe staffing, the current response required to meet the demand of patients is possibly the most challenging time of my and many chief nurses' careers. Joining daily local system and regional calls to work together to make decisions relating to transferring critically ill patients across the region, with the aim of caring for patients in the safest place in the area, has led to colleagues sharing their respective deteriorating nurse staffing ratios.
The UK Critical Care Nursing Alliance (UKCCNA) has recently released a position statement, circulated by NHS England and NHS Improvement to all Chief Nurses. This acknowledged the enormous pressure that critical care nurses are experiencing at present and the significant negative impact this is having on nurses' mental health and wellbeing (UKCCNA, 2021).
However, at a time when all of my colleagues are declaring derogation away from 1:1 nursing for level three patients (those requiring advanced respiratory support, or basic respiratory support plus at least two organ systems) (Faculty of Intensive Care Medicine and Intensive Care Society, 2018)), the UKCCNA guidance is not reflective of the majority of critical care areas, who are derogating in most cases to 1:3 or 1:4, and even some reported cases of a ratio of 1:6.
In its November 2020 statement, UKCCNA supported the development of guidance to deliver care with derogated levels in the first wave, stating its position that these bedside nurse staffing ratios set out ‘should not be exceeded unless mutual aid options have been exhausted and appropriate escalation has taken place’ (UKCCNA, 2020):
It argued that patient safety and staff wellbeing will be best secured if these ratios are maintained. The UKCCNA in its 2021 statement has requested that the four UK nations provide further guidance on how to manage the increased workforce requirements associated with additional expansion of critical care capacity, and goes on to criticise bureaucratic challenges to redeployment—particularly to those colleagues working outside of the NHS at this time. It also makes further reference to nurse wellbeing, citing a range of resources for support.
It has been extremely important to me to keep very close to the frontline care delivery nurses, to ensure that I am fully exposed to the current challenges, to enable me to lead the most appropriate response. One of the themes that I have heard is the challenge of professional vulnerability and guilt bought about by the challenges to consistently delivering safe and effective care. I have been asked a number of times to formally write to the nurses in our organisation to acknowledge the professional challenges and outline what we have done to mitigate these risks. A number of my peers were also being asked to write to their teams and together we discussed this with our national colleagues.
Following this, the four nations' Chief Nursing Officers and the Nursing and Midwifery Council (NMC) wrote to all registrants (May et al, 2021). The letter acknowledged the pride felt in the way in which our profession had responded to the demands of this second wave of pandemic, and acknowledged at this time, as the pressure continues to rise, how staffing shortages will impact on staff in a profound manner personally and professionally, throughout the coming months. In order to go some way towards supporting how we deliver care, the joint letter recognised the ongoing need for individuals to respond, including working outside of normal roles, recognising how stressful this can be, while reminding us to raise concerns of these implications.
The letter anchored us back to the NMC Code (NMC, 2018), fundamentally reminding us to use our professional judgement to assess risk and make sure people receive skilled care, coupled with using our knowledge and skills to prioritise care. The letter did provide a level of confidence that, in the event of any complaint raised against an individual, the NMC would consider all cases individually, taking into account the factors relevant to the environment in which a professional is working.
The letter was a welcome scene-setting formal communication on which to personalise the context my organisation is operating within, and enabled me to do so. As we continue to consider all potential actions we may take, I hope to continue to feel supported that the experience of our judgement and prioritisation will underpin the right decision-making in the context in which we continue to practise.