Emergency care nurses facing ‘significant distress’, investigation finds

The Healthcare Safety Investigation Branch (HSIB) has today published a new report outlining the “significant distress” faced by NHS staff in emergency departments and wards, and across NHS 111 call handling centres and ambulance services over the past year.

“They have shared with us the distress over delays and the harm that it is causing to patients”

Neil Alexander

The interim report, which comes as part of a wider ongoing investigation into issues around patient handover to emergency care, has raised fresh concerns about the health and wellbeing of NHS staff as they deal with rising demands.

It also warned of the potential impact that staff stress and burnout could have on patient safety.

Investigators interviewed staff across urgent and emergency services, including nurses, about the “emotional impact of their work”.

The report said “many staff cried or displayed other extreme emotions” while describing their working environment, the difficult decisions they are forced to make in relation to patient care and the “burden of moral distress”.

Emergency department staff had told of the “challenging decisions” they had to make regarding which patients in queuing ambulances to take into the department for treatment.

“Staff described this as often being ‘the most unwell, unwell patient’ and said they experienced moral distress when they were unable to ‘do the right thing [by all patients],” said the report.

Meanwhile, ward staff had described being “unable to discharge patients from hospital to an appropriate place of care”.

Separately, emergency ambulance dispatcher staff told investigators it was “common to worry about ‘How many people are we going to kill today?’” because of not being able to send ambulances to patients.

Investigators were also told how staff struggled to switch off from work or engage with friends and family.

Some who lived alone spoke of “isolation and despair at going home to an empty house after a difficult and challenging day at work”, added the report.

Common words used by staff during interviews included 'broken', 'anger', 'tired', 'numb', 'hurt', 'powerless', 'failure', 'depressed', 'helplessness', 'relentless' and 'demoralising'.

“There is no doubt that NHS staff have faced significant challenges this winter with record demand for urgent and emergency care”

NHS spokesperson

Overall, evidence gathered by the investigators suggested NHS staff in urgent and emergency services showed “strong elements of stress, moral injury, harm from incivility and burnout”, the report said.

When staff experience such issues, “these can have significant impact on patient safety from both individual and team perspectives”, warned the report.

The investigation team worked with a health psychologist for this report, who advised that “continued challenges in getting patients to the right place of care will lead to further deteriorations in staff wellbeing”.

The report also explored the support available to staff and found the current approach to staff wellbeing services was “reactive” and relied on staff seeking support.

“Many felt it was only prioritised by healthcare organisations when there was time to do so and that sometimes it came too late,” added the report.

The HSIB put forward two recommendations following its latest findings, including that NHS organisations provide “time and safe spaces for staff to engage in reflective practice and talk about the emotional impact of their work, with support from people with expertise in staff wellbeing”.

In addition, it called on NHS England to include staff health and wellbeing as a “critical component” of patient safety in its patient safety strategy.

Lead investigator Neil Alexander said: “This report reflects the in-depth conversations we have had with staff over the course of this investigation about the emotional impact of their work.

“They have shared with us the distress over delays and the harm that it is causing to patients and how this has affected their personal wellbeing.”

Responding to the findings, an NHS England spokesperson said: “There is no doubt that NHS staff have faced significant challenges this winter with record demand for urgent and emergency care, high levels of bed occupancy, difficulties discharging patients, and the combined impact of Covid and flu making this the busiest winter ever.”

They highlighted that the safety of both patients and staff was “vital” and said the NHS “takes staff health and wellbeing incredibly seriously”.

The spokesperson added that there were plans to publish an “update” to its NHS Patient Safety Strategy which would “include detail on staff safety”.

Meanwhile, Sir Julian Hartley, chief executive at NHS Providers, said at “the heart” of the problems highlighted in the report were “systemic issues”, including high demand, low capacity, delayed discharges and workforce shortages.

Sara Gorton

“This feeds into a deeply challenging work environment right across the system, which leaves staff feeling they can’t provide the care they want to – leading to a sense of moral injury, further exacerbating a difficult situation,” he added.

Meanwhile, Unison head of health, Sara Gorton, added that “agonising decisions” in emergency departments could be “traumatising for staff as well as patients”.

“These are just people at work having to deal with extraordinary situations because of the extreme pressures on the system,” she said.

Ms Gorton warned that the “unbearable stress” experienced by NHS staff was also a “major factor” in people leaving their jobs.

The report follows the findings of an exclusive Nursing Times survey which showed two in five nursing staff say their mental health is worse now than it was during the peaks of the Covid-19 pandemic.

Overall, more than 40% of respondents described their current mental health and wellbeing as “bad” or “very bad”.

The results, published earlier this month, have informed Nursing Times' ongoing Are You OK? campaign on nurse wellbeing.