COVID-19, unsustainable pressures and staffing levels

Under the Health and Safety at Work Act and the Health and Safety at Work Order (Northern Ireland) your employer has responsibility for the health and safety of staff and others who may be affected by the work activity. This would include patients and the public.  

As a registered nurse, midwife, health visitor or nursing associate, you have safety responsibilities under the NMC code but your employer is ultimately responsible for taking all reasonable steps to ensure safe systems of work and an environment that is safe for staff, patients and the public.

Although health care assistants support workers (HCSWs) and assistant practitioners (APs) are not regulated by the NMC or any other professional body, the NMC code is useful when considering best practice.

Your employer should for example:

• authorise the use of agency staff where possible
• consider reducing demand by cancelling elective surgery
• run proactive and aggressive recruitment campaigns for permanent and temporary staff
• consider redeploying staff
• seek support from other agencies (including the military and other emergency services if available).

Under health and safety legislation, your employer should also be risk assessing other work related health and safety issues, made worse by the current demands. This should include the risks to staff and patients from fatigue and tiredness, mental distress and putting in measures to reduce the risk.

Here are some practical examples of what your employer could do:

• provide easily accessible nutritious hot meals and snacks/drinks along with rest areas (such as wobble rooms) around the clock so staff can have some downtime
• use existing in-house psychology and mental health teams to provide outreach help to staff and bereaved relatives close to the ward areas
• implement effective rostering of breaks and maintain focus on peer and manager support to help all staff take their breaks
• organise taxis home for staff who are too exhausted to drive home safely
• ensuring that shower and locker facilities are accessible – some organisations have brought in extra capacity including portacabins and portable showers to allow staff to change in a safe socially distanced way at the start and end of their shift
• consider placing a suggestion box outside the unit or in changing areas for staff ideas on what little things that can be done to ease the pressure.

Please also see the section mental health and self care.

During these challenging times, you may be finding it difficult to maintain your mental health and wellbeing when coping with so much uncertainty and turmoil at home and at work. We recognise how extremely difficult it is for you. It is normal to feel distress, sad and/or anxious in such times.

Don’t hesitate to reach out for help and access resources such as helplines, chat rooms or other sources of mental health support. Talk to your colleagues, if you think there is more your employer could be doing to make things easier, then raise it with them. We know that the best ideas come from the staff doing the work.

For tips and resources on self care and looking after your mental health please see COVID-19 and your mental wellbeing.

If you need further emotional support, you can access the RCN Counselling service, who are operating as normal to support members during this time.

You may also find these resources helpful:

NHS Pathways
Rest, Rehydrate, Refuel
Time and space
OpenLearn: Understanding depression and anxiety
e-Learning for Healthcare: Introduction to Mindfulness
Scotland - Turas Learn: Psychosocial mental health and wellbeing support for staff.

Under the Health and Safety at Work Act and Health and Safety at Work Order (Northern Ireland) as an employee you have a duty to take reasonable care of your own health and safety and to co-operate with your employer on health and safety matters. In practice, this means following policies and procedures and reporting any safety concerns.

Please see our guidance on COVID-19, unsustainable pressures and redeployment.

You should wherever possible, follow your organisation's incident reporting procedures (for example, complete a Datix or incident form). However, we recognise that in the current circumstances this could be a challenge.

The RCN has developed two letters to support you to document and report concerns. If you are a nurse, use our model letter for nurses. If you are a nursing support worker, use our nursing support worker model letter. It can be frightening to do this on your own, so try and get as many colleagues as possible to sign the letter. Give the letter to your manager at the end of your shift and keep a copy yourself.

You should also document patient safety issues or missed care in the patient notes. For example, if you should have been doing observations on a patient every two hours but only managed to do them every four hours, document this and the reasons why.

We understand that this may not improve this situation in terms of safe staffing and that much of this is outside your employer’s control, but our letter will help you document concerns in a quick and easy way. 

If the matter remains unresolved, please see our raising concerns section.

What types of incidents should I report?

The Health and Safety Executive (HSE) describes an incident as a:

• near miss - an event not causing harm, but has the potential to cause injury or ill health (in this guidance, the term near miss will include dangerous occurrences), or an
• undesired circumstance - a set of conditions or circumstances that have the potential to cause injury or ill health, for example, lack of appropriately trained nursing staff to safely move and handle patients.    

What about reporting psychological harm?

The RCN encourages members to report any work-related harm to their psychological health including work related stress.

If you don’t feel able to complete our letter or if you are worried about confidentially, log your concerns in writing with your occupational health provider who can support you to make your manager aware of the problem.

If you need support, contact us and see our mental health section.

What if the staffing situation does not improve?

If the situation does not improve despite submitting our letter, your next step is to formally raise concerns.

Organisations must have effective procedures in place to allow nursing staff and their representatives to raise any concerns in relation to staffing, equipment, policies and processes for managing COVID-19 and unsustainable work pressures at the earliest opportunity.

Nursing staff should feel able to raise concerns without detriment and should receive timely feedback on their concerns.

Please see:

• our raising concerns guidance 
• our refusal to treat guidance
• and speak to your line manager.

If you have followed these steps and the issue is still not resolved, please contact us.

Can I refuse to treat patients because the staffing levels are not sufficient?

Please see our refusal to treat guide and speak to your manager about your concerns in the first instance. Our guidance for members around the process to follow if the PPE provided is not appropriate may also be useful in these circumstances, but we recommend that you contact RCN Direct on the number below before making this decision. 

If the matter is not resolved, contact us for further advice.

We are working in extraordinary times and it is likely that your workplace will have reviewed its usual staffing model to try and ensure care is safe. There is no simple tool or method that will enable you to do this easily. The RCN Nursing Workforce Standards maybe to help you consider the situation in your own workplace. In addition, our library subject guide contains a number of additional resources and background information. 

As members of the UK Critical Care Nursing Alliance (UKCCNA), the RCN has a clear position in relation to staffing levels in ITU.

See our advice guide for student nurses.

What is the role of RCN safety representatives?

RCN safety representatives should be kept informed of measures being taken to protect staff and there should be mechanisms in place that allow safety representatives to raise concerns with senior managers, health and safety, or infection control leads on behalf of staff.

Members who are concerned should speak to their local RCN safety representative and/or contact us.