Redeployment: A Patient Safety Issue

The press has all been full of headlines about staffing levels in the NHS, but this is probably a problem across healthcare around the country.

What this does is provide the perfect patient safety quandary, how do we keep all the areas safe. This often results in the redeployment of nursing staff to different areas, but does this provide the required levels of safety. It appears that having several areas in an “amber” staffing level is preferable than one red area. It is simple logic, but does this create an unrealistic expectation on staff that means the safety is better but only at a barely satisfactory level? Do we think that any of these decisions influences the efficiency of a ward? Is the ward safe and effective?

I would hazard a guess that if you asked a patient if they would like renal surgery from a neurosurgeon then the answer would be a resounding no. I would take this thought process a step further and say that most hospital management staff and execs would say no. The expectation of a highly trained and specialised neurosurgeon being able to conduct renal surgery to the same level of skill as a highly trained and specialised renal surgeon, would appear on the surface to be a ludicrous assumption.

These assumptions do not appear to be a consideration for the nursing staff both registered and unregistered. The common phrase is that there are a number of transferable skills that can be applied to many different areas, and to a certain extent that is true. We can conduct the observations and administer medication but what about some of the more technical skills, the layout and team dynamics of the area that you are redeployed to.

Let’s use a Safety Engineering Initiative for Patient Safety (SEIPS) to show some of the lesser appreciated risks to redeploying staff and consider some ways to reduce the risks.

Person

When we look at the effect that it has on the person then there is an increase amount of stress that the individual will feel. I can remember the feeling of dread that comes over the staff when they are told that someone needs to go somewhere else to work. There is the manifestation of the reputation of the receiving unit, whether it is fair or not. Then there is the inevitable feeling that it must be someone else’s turn to go, then the consideration that if I don’t make eye contact then they cannot choose me. If you are lucky, then someone will volunteer.

If you follow this thought process, it can be extremely disruptive to the handover period, if it has not been confirmed that someone will have to go but there is a risk, then people may focus on this and not the information that is being delivered – a double whammy on the patient safety front.

There is then the team leader and the stress it places on them. How can they ensure that it is fair, that the same person is not being “donated” every time. What effect will this have on the team? Who should go, the most experienced nurse but that will have the most detrimental effect on the team, but they may have the best coping strategies, in this event. Or the junior member of staff, this is likely to have the least negative effect on the team but could increase the stress of the individual staff member.

The effects it has on both the donor unit and the receiving unit can be quite unsettling. For instance, the person being moved has their stress levels increased but so does the receiving team. They are receiving an unknown quantity – what skills does this person have? Will they fit into the team? How disruptive will this be? This can be magnified for the person in charge, as they become the focal point for many questions, where is this piece of equipment? What is the code for this cupboard? What is the normal routine on the ward?

Many people view nursing as a set of transferable skills and this is true to a certain extent but when we specialise in a certain field for many years, we lose some of the skills but also may use different documentation and applications, so we may not have access to the correct IT systems, which also prevents integration to the team. For example, I was recently told about an ED nurse that was sent to help on a ward, but they did not have access to the electronic observation system, as ED does not use this system. They also did not have access to the Electronic Prescribing and Medication Administration (EPMA) system because, again, the ED did not use it. This meant that this staff member felt impotent on the ward as they could not help to the full extent of their abilities and the receiving team, had their workload increased due to the inability of the whole team to use the IT. A negative unintended consequence of a good intention?

Physical Environment

Whilst many ward areas look similar, when you look in more depth then you start to notice differences. Some of them are minor and will not appear to be too troubling. There are some major changes in environment that would need to be addressed before starting to work in the new area. Items such as, the cardiac arrest (crash) trolley will need to be identified. A point you would think is fairly obvious, but you would be surprised by the number of clinical; areas that would not necessarily do a local induction. Assumptions abound in the NHS, and the use of substantive staff, leads many to assume that everyone knows where cardiac arrest trolleys are on the ward, but this is not always so.

The layout of a treatment room is on that can have a significant impact on how someone works in the clinical area. For instance, are the medication pots in the same place as on the donor ward. What about syringes, needles and flushes. You could also extrapolate a little further and ask if the member of staff can access the room, often codes or swipe access is required.

Other things would need to be located such as staff toilet and break room (if the ward has one – but that is a different conversation).

Then there are the bays that the loaned member of staff is allocated to, where are they, are they numbered in the same way? Wards number bays, refer to them by colour and even use letters to identify them. These differences can occur on the same floor and the same specialities. Then on top of that, are any bays used for higher acuity patients, those needing more regular observations, at greater risk of falling.

Tools and Technology

The tools and technology will generally be replicated across the wards but what if we take a ward-based nurse and ask them to work in the Emergency Department (ED). The tools change in most cases, we find that the use of EPMA systems is less widespread in EDs, than on wards. We may be asking staff to complete medication administration on paper prescription charts for the first time in their career as a Registered Nurse. The monitors are different and have several attachments that the wards would have no reason to use.

The reciprocal arrangement of taking a nurse from ED to a ward has possibly greater safety issues as the access to be able to use the digital systems can be greatly reduced. We now see Electronic Patient Records – still not that common in EDs, electronic systems for recording observations and the already mentioned EPMA. I have heard of one ED nurse being moved and was unable to access the EPMA and the electronic observations, so provided nursing care but could not help with 2 very labour and time intensive activities. The nurse felt that they were a hinderance and not a help!

Tasks

It can be that many tasks on wards remain the same, the end result should be the same but there may be differences. An admission may require more assessments on a ward whilst the emphasis may be different in ED, due to the needs of the patient. The ED may have several admission routines for those that are likely to be admitted and for those that are possibly will go home. What about the patients in minors, do they need admission?

Whilst a discharge may follow the same pathway between clinical areas, there are different teams to liaise with. This can cause some problems as the relationship between the nurse and the discharge officer is not present. There is no interpersonal relationship.

Equally, there may be different defined follow ups as you change speciality. I am sure we can all recount stories of people misinterpreting abbreviations, as they move areas. I know I have had to check abbreviations and then felt a little stupid, as it was something really obvious, when you knew it. What are the safety implications if you misinterpret an abbreviation.

The planning, evaluation and co-ordination of care is fairly standard nowadays but still requires access to the tools to be used. The only caveat here is that there is a need to be aware of what the endpoint should be. How can a patient be assisted to get there? Is there anything that the patient should not do? For GI surgery that may be can they eat post op or do you need to wait for gut motility to improve? If they have had an epidural, can they go home before they PU? Many will consider these simple questions but put yourself in the place of a nurse, recently qualified, who has been working in a medical environment for the last 3 months?

Finally, we get to a task which will be standard and that is the administration of medication. Or is it?

External Factors and Pressures

The external pressures on the NHS are well presented and often well-known. There is the need to reduce the waiting lists, both a government promise to the people but also a NHSE priority. This results in many of the staff being told to do more with the same, (if they are lucky, but often with less). The downside to this is that the staff member who has been moved comes under increasing pressure to perform at their normal standard. This is partly due to the expectation that nursing skills are transferrable to all clinical areas, but all clinical areas require some degree of specialist knowledge.

There is also the recent industrial action for some professions and ongoing industrial action for others, has highlighted the perception of wages and working conditions that is held by the workforce. When combined with the negative media portrayal of jobs in the NHS, it is increasingly difficult to retain and recruit staff into these roles. This places greater pressure on the organisation to utilise their staff to fill staffing gaps in different ways.

This all has an impact in other areas of the system, particularly in the training and support provided to the staff.

Equally, there remains an external pressure to be continuing to provide safe and effective care. That always requires a delicate balancing act for ICBs and Trusts, the need to rationalise the availability of care, patient safety and the available staff.

Organisation

The organisation remains under pressure from many sources, and this is transferred into the redeployment of staff, from having to balance the books, to stretching the finances as far as they can go. These two factors create the situation where a transaction takes place and, in the push, to hit some targets, others are left by the wayside for the time being.

There is also the way that these transactions are communicated to the workforce. The NHS is riddled with stories of poor communication, where decisions being taken high up in the organisation are inadequately explained to the workforce, leaving the workforce questioning their value and worth to the organisation.

Staff are left wondering why they must constantly support other areas that cannot recruit into vacancies at the detriment to the care given to their patients. There is a real risk that the organisation begins to view the staff as units of labour and not individual staff with their own needs. The risk here is that the staff become disillusioned with the organisation and leave. Or worse, they leave the NHS completely.

As previously mentioned, the need to maintain the safest possible clinical environment with the available staffing levels. Is it safer to have several “amber” areas or one red area and several green areas. Moving staff may be the only option for the organisation but the risks need to be considered before, during and after the redeployment of staff. Not just the impact of the move on the staff, but the whole gambit of human factors that moving staff invokes.

Make it easier!

So, I started on this blog and stated that there may be steps we can take to make it easier for people when they are moved.

The first would be the welcome and to consider how people may feel about the movement from one ward to another.

A way to reduce the stress of those staff members that are moved to a new ward is to try to keep the staff within their own speciality, where possible. This is where the oft quoted standardisation can be effective. Imagine if you entered a treatment room on a different ward and all the syringes, fluids, needles were in the same place. That would reduce the stress but also reduce the time taken to do the routine tasks. A move towards a safer and more efficient process?

Where possible the use of a EPMA system that informs the practitioner of how to make the medication up, the rate it needs to be administered at. One that is used throughout the hospital. By having one system throughout the hospital the training would be standardised and all staff would have access to it. This would ensure that staff being redeployed for staffing reasons, can use an important system upon arrival at the new place.

The other thing that an EPMA system would do, is to reduce the risk of errors when administering unfamiliar medications. This would not replace the need to check medication as per the code of professional conduct for the various professions.

We could expand the one standard EPMA system to one EPR system throughout the organisation. Standardising the documentation and input systems. Again, this would have ramifications not just for moving staff but also the movement of patients. The notes would automatically follow them and staff in a new area would be able to access the records and be experienced in the use of the system.

Furthering the thought of how to make it easier for those being moved, would multi-disciplinary notes help. The split of nursing notes and every other role in the organisation, has never really made sense to me. This means that in order to find out what the plan is for the patients that you are now caring for is reliant on a really good handover from a nurse in charge, who is probably stressed and already under pressure due to staffing or by reading the recent entries in multiple locations to ensure that medical plans, physiotherapists plans are put into place.

Summary

The redeployment of staff to meet safer staffing levels on wards and departments is a necessary measure for Trusts to take. It has to be noted that making all areas amber in their staffing is more preferable than having one red area.

This does not mean that it is not risk free and the lines of management that make these decisions need to to consider the impact of moving staff

There are ways to reduce the stress and in some cases, fear that an individual may be experiencing. One of the most important is the local induction, where is everything, who is everyone and what codes do they need to know. It is at this point that the Nurse in Charge can state what their expectations are. They can assess what skills someone possesses but also say what they want them to do. This can also be used to reduce the authority gradient by using names and empowering the loaned member of staff to do what they can and not worry about what they cannot. Equally, inviting questions and empathising with the staff member will have a good effect on them.

There is an inevitable shift in efficiency, reducing it and also reducing some of the safety aspects. Nurses do have transferable skills between clinical specialities but after a short period of time, they become used to their routines and procedures. It is this specialist knowledge that is lost when transferring staff to different clinical areas.

We need to remember that optimising staff well-being will bring results in better patient outcomes, experience and safety.