Staff shortages and the impact on patients
This is the 2021/22 edition of Monitoring the Mental Health Act
Key points:
- Issues around workforce retention and staffing shortages remain the greatest challenge for the mental health sector, with pre-existing difficulties exacerbated by the COVID-19 pandemic and staff retiring or leaving for other jobs.
- Understaffing can affect the safety of patients and staff, with a lack of therapeutic interventions leading to an increased risk of violence and aggression on the wards. In addition, chronic staffing shortages have led to challenges around the ability of staff to respond to incidents, and to untrained staff being asked to take on responsibilities they may not be able to carry out safely. These factors can increase the risks of closed cultures developing.
- Staffing shortages have affected patients’ ability to access therapeutic care, with a lack of patient involvement in decisions about care, reduction in ward activities, and patients’ leave being cancelled.
- The shortage of qualified mental health nurses is a systemic issue, which has led to services seeking other solutions, such as employing ward managers and other professionals to substitute for nursing cover. However, this has led to staff taking on responsibilities they may not be qualified for, which is having an impact on their safety and wellbeing.
- A number of providers have told us about the work they are taking to mitigate staffing resource issues. This includes supporting staff motivation, ensuring a better mix of skills of staff on duty, particularly on night shifts, and increasing in-house training requirements.
In last year’s Mental Health Act annual report we noted the impact of the COVID-19 pandemic on staff wellbeing and the knock-on effect this was having on staffing vacancies in the sector. As highlighted in our 2021/22 State of Care report, issues around workforce and staffing shortages remain the greatest challenge for the mental health sector.
During 2021/22, we have seen mental health services continuing to struggle with staffing levels. Staff sickness, including COVID-19 related sickness and self-isolation, have exacerbated difficulties posed by pre-existing staffing shortages.
Impact on patient care
Not having the right levels and skill mix of staff can affect services’ ability to provide safe and effective care and treatment that is in line with the guiding principles of the MHA Code of Practice.
Through our monitoring visits, both staff and patients have told us that a lack of staff means people are not receiving the level and quality of care they have a right to expect. In one service, staff told us they did not have enough staff and recognised that the care they provided could be better if they had time to develop relationships with patients.
Staff reported that they were under a lot of pressure, with not enough staff to cover the work. They told me that they provided the best care that they could. They said that they could provide a better standard of care if they had time to develop relationships with patients.
Ward for older people with cognitive mental health conditions, mixed gender, August 2021
The importance of therapeutic relationships was reflected in feedback from patients who told us they preferred the staff they knew and had developed relationships with. However, we heard that patients were not always able to build these relationships because of the high use of agency staff. In some services, such as eating disorder wards, patients told us that agency staff seemed unfamiliar with their ward type, and as a result could appear unprofessional or unfeeling when working with them.
In our feedback to the Health and Social Care Committee on workforce in July 2022, we emphasised that reliance on agency staff who do not have an ongoing therapeutic relationship with patients can increase the risk of services using excessive levels of restraint and seclusion. As we set out in our closed culture guidance, the use of restrictive practices including restraint and seclusion are both inherent risk factors and can be warning signs that closed cultures are developing.
The ward did not have adequate staff to meet the needs of patients. There was a high use of agency and bank staff and this impacted on some patients care. For example, staff told us the patient in long-term segregation frequently had staff less familiar with him as he was nursed behind a locked door. This impacted on staff’s willingness to open the door and engage with the patient. On the day of the visit we noted that the long-term segregated patient had one staff member who was new and the other was from an agency.
Assessment and treatment unit for patients with autism, April 2021
This year, we have continued to hear about the impact of staffing shortages on patients’ access to therapeutic activities. This includes staff not having enough time to provide ward-based activities or one-to-one nursing, and patients’ leave being cancelled. Feedback from our MHA reviewers suggests that in some cases a lack of activities was also due to wards not putting these back in place following the COVID-19 pandemic. This lack of meaningful activities can affect patients’ recovery.
Patients told us that staff were busy and more staff were needed, especially in the school holidays. Patients liked the activities that were available but told us that these got cancelled regularly and they watched films a lot instead. Patients told us that low staffing levels affected their access to regular named nursing sessions, supported activities and accessing the external areas. Staff were sometimes too busy to support access to the garden.
Acute ward for men and women, October 2021
Patients who I spoke with had mixed feelings about their care and treatment on the ward. They said that leave was cancelled most days because there were not enough staff to escort them. They also said that the sensory room, which could only be accessed with staff, was rarely used because there were no staff available to open it and support patients while using it. The advocate told me she had not seen any activities taking place on the ward since she started her post in January 2021 and leave was cancelled regularly.
Acute admission ward for women, April 2021
The availability of occupational therapists could affect what, if any, therapeutic activities were provided. In some services, occupational therapists or activity co-ordinators were only available during the weekday. This meant that on evenings and weekends it fell to nursing staff to provide these activities on top of their usual nursing tasks.
On some wards, we found that a lack of meaningful activities was in part due to vacancies in occupational therapy posts. On others, occupational therapy staff were being asked to help make up staffing numbers. While hospital managers in one service told us that this had helped in maintaining positive engagement with patients, having to cover nursing roles meant they were often not able to carry out their core role.
“There’s been no meaningful activities, so you get from the patients that actually they’re bored out of their minds and there’s nothing happening. That’s due to the fact that they didn’t have an OT [occupational therapist], and you ask them how long there hasn’t been an OT and they’re like ‘oh, well, months because we haven’t been able to recruit one.”
MHA reviewer
We have also seen the effect of staffing shortages on services’ ability to follow least restrictive practices. This includes, for example, people having limited access to garden areas, with some patients telling us they were regularly unable to get fresh air. A number of services told us that staffing numbers or skill mix could affect whether they are able to open garden doors. As we raise in our guidance on closed cultures, failing to allow people to have regular access to fresh air could be an indicator of people’s human rights being breached.
All the patients that we spoke with told us that the ward was short staffed and that this affected many aspects of their care such as access to the garden, leave, visitors, activities, for example gym and communal rooms that required supervision such as the activity kitchen and laundry. One patient told us:
“I’ve been assessed and staff said that I should be able to use the kitchen and the gym but there are no staff to do it with me so I sit here colouring in everyday – and I had to buy those myself as well because the staff haven’t got any resources.”
Psychiatric Intensive Care Unit for women, September 2021
As highlighted in our last report, we continue to encourage services to challenge outdated, institutionalised and overly restrictive practices in favour of patient choice and a human-rights based approach. We have seen examples of services taking steps to make improvements, including reviewing blanket restrictions, exploring availability of ward activities, improving patient access to staff for support, and increasing staff training to support patients in distress.
Impact on patient safety
Through our monitoring activities we heard how staffing shortages, and the lack of therapeutic activities, could put people’s safety at risk. Patients told us that a lack of activities increased the risk of violence on the wards because people were bored. Staff shortages, and lack of appropriately trained staff, have also led to challenges around the ability of staff to respond to these incidents.
Patients described the ward as “violent” and some patients linked this to boredom. Patients on both wards told us there was not enough to do that interested them. Three patients commented that if you didn’t like the activity or could not leave the ward you were left with nothing to do. We observed tension on the ward.
Acute wards for men and women, December 2021
Pressures caused by understaffing are creating issues with observation checks. In some cases inexperienced staff are given tasks, such as constant observation, that may be inappropriate for their level of training and responsibility. In other cases, we heard that staff shortages had led to observation checks being missed because staff were too busy. In addition, we heard of patients being left isolated, leading to concerns for their safety.
One patient told me that observation checks on patients were regularly missed by ward staff as they were too busy. They had timed their own observation checks and confirmed that they were not consistently carried out.
Acute ward for men and women, June 2021
When we started our visit, we found there were 12 staff on duty when the ward stated they needed 17. The 12 staff were needed to cover the constant observations which left no staff to deal with patients on intermittent observations, to administer medicines, complete seclusion reviews or complete other tasks. One patient told us that there weren’t always enough staff so they could go off the ward. One carer said there were not always enough staff for them to take the patient off the ward. This carer felt seeing the patient on the ward was not always safe as staff were not available or nearby if there was an issue.
Assessment and treatment unit for patients with learning disability, March 2022
In particular, staff shortages are having a negative effect on patients who need constant observation. Enhanced, continuous observation provides an opportunity for prolonged therapeutic engagement. However, it can be difficult and exhausting for both patients and staff. As a result, we were concerned to see staff carrying out constant observations of particular patients for long periods. On one ward, staff told us they could be observing the same patient for over 8 hours without breaks, which MHA reviewers felt could have an impact on the quality of care patients receive.
We were told by senior staff that staff changed observations every 2 hours. This was not the case during our visit. Ward staff stated it was usual practice to be on constant observations for prolonged periods without breaks. During our visit, staff had been on the same patient observations from 7.30am to approximately 4pm and had not been able to take a break...
We are seriously concerned about the quality of the observations, alertness levels of staff and their wellbeing as well as the welfare of the patients. At the time of our visit there were not enough staff to enable ward staff to take a break from enhanced observations. Staff told us they moved from observation to observation. Staff looked worn out. This potentially could have an impact on the delivery of care to patients.
Learning disability ward for men, October 2021
Understaffing makes it difficult for any member of staff to give their full attention to their tasks at any point in time. For example, at one mental health ward for children and young people, patients told us that they were waiting for staff support. We witnessed staff being pulled in multiple directions and having to continually reprioritise the tasks at hand. Consistent staff shortages can be an inherent risk factor in the development of closed cultures.
We observed that:
- both registered nurses had to stop doing essential tasks on several occasions due to the need to reprioritise.
- registered nurses and the specialist nurse spent significant periods of time trying to juggle staff rotas to cover gaps and observations on the ward.
- staff were being asked to change what they were allocated to do and at times staff needed to recheck what they should be doing.
- a student nurse was asked to do a task that they seemed inexperienced to do.
- staff were rushing to complete tasks before deadlines, for example contacting the patient’s bank 5 minutes before it closed and checking there was adequate medication for the weekend just before the deadline.
Children and young people’s mental health ward, October 2021
To address concerns related to understaffing, services told us about steps they were taking including, for example arranging training and support for staff, closer monitoring of staffing issues by managers, and more one-to-one protected time for patients and nurses. Other steps included employing additional activity co-ordinators and involving psychology staff in debriefs following incidents.
Staffing and staff welfare
A number of providers have told us about the actions they are taking to mitigate staffing resource issues. This includes employing ward managers, matrons and other professionals such as occupational therapists to substitute for nursing cover. In addition, we have heard of services moving substantive staff around hospital sites to provide cover, and staff working additional shifts. However, the juggling of staff cover across hospital sites can lead to periods of dangerous understaffing. For example, on one ward patients and staff told us how low staffing had led to staff working alone.
Patients and staff reported that the staffing establishment was too low to provide safe care and treatment. Patients and staff told us that shifts regularly ran on less than the establishment, had inexperienced or unfamiliar staff and did not have enough female staff to support the female side with observations and physical care. Staff told us that on occasions staff were working alone on the male side as others were pulled into the numbers on the female side.
High dependency rehabilitation service, July 2021
Hospital managers have told us about the challenges they face in managing staff shortages and skill mix. Agency nurses can earn substantially more than permanent NHS staff, and pay can be even higher for night shifts. This can affect the morale of permanent staff. For example, substantive staff in one unit told us that they felt that they had to work twice as hard for a much lower salary than agency staff, and that this potentially caused bad feeling.
It can also mean that it is difficult to ensure a mix of permanent and agency staff on night and day shifts. As a result, agency workers may not have the level of support and supervision they require. Many patients have told us that they dislike the fact that night-shift staff are largely unknown to them and that this makes them feel vulnerable. As stated in our guidance How CQC identifies and responds to closed cultures, we know that a high use of poorly inducted agency staff who do not know people’s needs can be a warning sign of a closed culture.
Some services are making additional efforts to ensure there are more permanent staff on night shifts so there is a better skill mix. Others have increased in-house training requirements as well as talking to staffing agencies about the training they provide.
The ward manager told us that she was aware of some issues around closed cultures within the night staff team when she started in post. Two members of staff have since left and issues appear to be resolved. The ward manager has also requested that night staff work some day shifts so that they can keep in touch with the ward ethos. She has also started a 6-monthly rotation for staff between the 2 wards which has received mixed reviews. Two staff were not happy and have left but other staff have embraced the new experiences and challenges.
Wards for older age adults, May 2021
We have also seen some services hiring staff from a limited pool of agency or bank staff to maintain continuity of staffing as much as possible. One provider told us that this has been made more difficult by changes to off-payroll working rules from April 2021 (IR35 legislation). This meant that block booked agency or bank staff were choosing not to continue to work at its hospital. Services are also looking at packages to offer staff for recruitment and retention, including recruiting from overseas.
Many services hold frequent safe staffing meetings to review staffing resources across units, to anticipate and request bank and agency cover in advance of need. Some services have a constant ‘dynamic’ staffing allocation, to expand and reduce teams to mirror the needs of patients on each ward.
We have a pro-active weekly ‘huddle’ that takes place each Friday chaired by the service manager along with all ward managers to review the staffing going forward for the next 7 days. At this meeting any gaps are identified, and plans are put in place to ensure that the wards are staffed to the establishment levels. The Daily Demand Management (DDM) meeting then reviews the dynamic staffing needs for the day covering all adult mental health wards including the rehabilitation inpatient units. This review identifies where the acuity peaks are balanced against our staffing profile, then if required staff are relocated to ensure that wards can deliver safer care. This DDM process also reviews the number of qualified staff available on each ward, ensures that preceptor [newly qualified] nurses are working alongside another qualified nurse, and that there are sufficient staff to effectively manage and lead ward rounds.
Redwood acute unit, Highbury Hospital, Nottingham Healthcare NHS Foundation Trust, July 2021
Some services continue to maintain cohesive and stable teams. Good management and support of motivated staff is a key factor in this. The geographical location of units can be another factor. Some units have little staff turnover because staff are settled and happy where they live. Others are in areas that struggle to attract staff for reasons ranging from expensive costs of living in some local areas, to lack of amenities and housing stock in others. Services situated in commuting distance of other units offering London-weighted pay can also struggle to recruit. Units that report stable staffing appear most likely be valued by staff and patients.
Patients told us:
- “This ward is by far the best and I have seen a variety of hospitals”
- “Everybody feels like family”
- “Nurses speak to you like a human being”
- “It is brilliant here. It has uplifted me”
- “All the staff are great, caring and calm”
The staff told us:
- “Considering the year we have had we have done exceptionally well”
- “I love working here”
- “The team is like a family. You feel safe. You will be backed up”
- “Our ward is so well organised”
- “The manager is literally the best”
- “The consultant is always on the ward, very present”
Waterston ward (acute for men and women), Forston Clinic, Dorset Healthcare Trust, April 2021
However, many of the current measures to address staffing issues are not sustainable – the shortage of qualified mental health nurses is a systemic issue, which requires a system-wide response. These measures are also having a detrimental effect on staff wellbeing, with patients themselves telling us they were concerned about staff being overworked and exhausted.
Patients noted that staff were working extra hours to avoid agency staff being used, which they appreciated, but they were concerned about staff being overworked, exhausted and strained.
Personality disorder unit for women, November 2021