The NHS Patient Safety Strategy: Safer culture, safer systems, safer patients (July 2019) was a significant milestone in the journey towards safer care, with improvements in safety being tied to advances in technology and increased staff and patient engagement. It came at a time when few could have foreseen the impact of COVID-19 on the NHS frontline, particularly the significant and disproportionate effect of the pandemic on the Black, Asian and Minority Ethnic community (“BAME”). As at 21 April 2020, countries reported to the World Health Organisation (“WHO”) that over 35,000 health workers were infected with COVID-19. In the UK, whilst making up only around 20% of the overall healthcare workforce, around two-thirds of healthcare staff who have died are from a BAME background. The reality of those impacted is no doubt, significantly worse due to underreporting.
The COVID-19 pandemic has unmasked the huge challenges and risks health workers face globally, including health care associated infections and risks to psychological and physical well-being. WHO has rightly thrown the spotlight on staff safety for World Patient Safety Day 2020, with its theme: Health Worker Safety: A Priority for Patient Safety, which acknowledges that working in stressful environments also makes health workers more prone to errors which can lead to patient harm.
As in September 2019, the city of Geneva, the headquarters of WHO, and at least 80 other cities around the world, will light up iconic places and monuments in orange to symbolise the central role patient safety plays in countries’ efforts to achieve universal health coverage. In September 2020, this will provide a very visible public recognition of health workers’ efforts globally to provide safe healthcare every single day for patients even in times of crisis. The day provides a moment to pause and reflect on world initiatives such as the draft Global Patient Safety Action Plan 2021-2030 which aims to provide Member States and other stakeholders with an action-oriented framework to facilitate the implementation of strategic patient safety interventions at all levels of health systems globally over the next 10 years. Health workers are at risk of violence all over the world with between 8% and 38% suffering physical violence at some point in their careers. Many more are threatened or exposed to verbal aggression and social stigma because of their work. NHS Resolution reported that £53.4 million will be spent settling 1,255 claims for assault received by NHS Resolution between 2013 and 2018, which equates to the cost of 1,700 nurses for one year. The COVID-19 crisis and resultant shortage of staff and resources has seen increased levels of violence against health workers, leading WHO to call for zero-tolerance of violence against health workers in the workplace and for social support and respect for health workers and their families to have renewed focus.
The connection between staff well-being and patient safety has long been understood globally with research showing that registered nurse burnout is associated with higher infection rates and that patients cared for in a hospital with better work environments were 16% more likely to survive after an in-hospital cardiac arrest. Yet anxiety, stress and burnout are increasingly being cited as sickness absence reasons amongst the sector with 92% of Trusts being concerned about staff burnout and 38% of surveyed nurses saying they worked in excess of their contractual hours to plug the gap of staff vacancies. With current calls for evidence by the Health Select Committee Inquiry examining workforce burnout across the NHS and social care, we await further commentary on these pivotal issues.
It is clear that, without addressing the recruitment and retention challenges, staff shortages and the mistakes which come with them are likely to continue. The current UK pipeline of students is not enough to replace nurses who retire and whilst there are positive reports of a renewed interest in people wishing to join the medical profession, the UK’s reliance on international nurses poses a Brexit risk. Nevertheless, the UK government remains optimistic, with Trusts being told that they need to increase international recruitment by 41% to significantly reduce current nursing vacancies.
In the meantime, it is increasingly apparent that the traditional methods of employee support assistance programmes, such as a referral to Occupational Health, are, on their own, no longer sufficient and mental health interventions should be delivered as part of a holistic health and well-being strategy. COVID-19 has, fortunately, fast-tracked these interventions with psychological support programmes being set up globally, such as access to mental health helplines and apps, greater numbers of trained Mental Health First aiders and an encouragement for line managers to hold individual conversations with staff about their wellbeing.
During COVID-19, the BMA reported that occupational factors, such as more BAME staff working in patient–facing roles, contributed to a disproportionate impact of COVID-19 on BAME staff. Importantly, and perhaps of greater concern, was the finding was that BAME doctors were almost twice as likely not to feel confident raising concerns as white doctors and nearly 64% of BAME doctors reported having felt pressured to work in settings with inadequate PPE, compared to a third of doctors who identified as white.
In July 2019, NHS Resolution acknowledged that challenging the NHS’ workplace culture is key to improving patient safety, introducing the guidance: Being fair: Supporting a just and learning culture for staff and patients following incidents in the NHS. The guidance stresses the need for the NHS to involve users of care services and staff in safety investigations. The racial inequalities highlighted by COVID-19 demonstrate an urgent need to proactively ensure that all voices from an inclusive and diverse perspective are heard and applied when following this guidance and having conversations around patient safety. This will assist in creating culturally appropriate and inclusive policies and practices as part of efforts to improve reporting and data collection and build a safer, more engaged workforce.
Whilst we may question why it has taken a pandemic for us to make changes, it is crucial to staff well-being and patient safety that the renewed focus on the importance of staff support remains an organisational priority.