Principles for return to service – staff recovery and patient safety

As the UK governments begins to map the nations’ route out of lockdown, the Royal College of Nursing is calling for the nursing voice to be at the table as return to elective and other services are considered.

First and foremost, staffing levels must return to pre-Covid levels as a minimum, particularly in areas such as Intensive care where ratios were diluted to unsafe levels.  It is recognised that recovery from this pandemic will take years; during that long term recovery the fundamental issues of an under resourced nursing workforce must be tackled head on.

The college is increasingly concerned about the health and wellbeing of our members and their ability to provide current services safely and sustainably. The debate on the timing and process for returning to ‘normal’ service level must have patient-need at its centre – but that cannot come at the expense of our members’ well-being.

Pre-pandemic evidence showed increasing cases of work related stress, burnout and mental health problems amongst our members. Over the past 12 months, RCN Counselling services have seen a rise in frequency and intensity of referrals for workplace stress, trauma and incidences of moral distress. Sustained moral distress can evolve into moral injury which is defined as: “profound psychological distress which results from actions, or the lack of them, which violate one’s moral or ethical code” (Williamson et al., 2020).

Unlike the formal psychiatric diagnosis of PTSD, moral injury is not classified as a mental illness but RCN is concerned that individuals who experience moral injury may be at increased risk of developing mental health problems. Terms such as PTSD should be avoided without appropriate diagnosis.

The professional nursing voice must drive decisions and ensure services are only restarted when patient and staff health and well-being has been risk assessed in all sectors.

Patient treatment and care should not become financially driven political targets. The focus in the short to medium term needs to move away from arbitrary targets and be driven by patient need and the ability to safely staff services.

The impact of the pandemic on primary care and community services has been less public but no less significant. These services continue to manage far more patients in their own homes in order to alleviate pressure on inpatient beds. We have outlined eight staff recovery and patient safety principles which must guide health service and employers in planning the return to ‘normal’ service delivery:

1. Even with extensive vaccination programmes, the occupational risk to our members remains high. As variants continue to emerge, a higher level of PPE (specifically FPP3 face masks) must be used.
2. Occupational health services must be available at the point of need to support the psychological and physical wellbeing of staff. It is also of the utmost importance that employers  recognise the signs of decreased psychological well being and educate the workforce about them and act to avoid occurrences of moral injury and its associated risks. Additionally, all employers must fund sufficient, timely and ongoing access to confidential counselling, bereavement and psychological trauma support for all staff. They must be able to self-refer to these services and be given time off to attend. 
3. Training and support must be provided for return to substantive roles and changes in health care provision should it be requested, such as refresher training. Effective and regular supervision must be in place help to identify and address issues of moral injury and strengthen patient safety.
4. Nursing staff across organisations must inform and agree to recovery plans, which need to take a phased approach to the reintroduction of services, enabling staff to adapt to the change. Plans must consider `lessons learnt` regarding new ways of working and take opportunities to provide efficient and effective services to patients within an agile and responsive working environment for staff. 
5. Rest and recuperation for health care staff must be central to decision making on getting patients safely back to diagnostics and missed treatment. There must be funded and supported time out - not limited to annual leave - for all staff, regardless of where they work and for those who have been impacted by Covid-19.  There is a body of evidence linking the health and wellbeing of the nursing workforce with patient outcomes, therefore for the benefit of both staff and patients it is essential that staff are supported to recover and work in a safe environment.
6. Risk assessments which include all areas of immediate and future risk to health and social care staff balanced with the risk to patients of further delay to treatment must be undertaken by the multi-professional team.   Employers must meet their legal duties under health and safety legislation and assess the risk of stress related ill health in the nursing workforce and take measures to control the risk. 
7. The increased risks faced by Black, Asian, and minority ethnic (BAME) nursing staff must be considered and reduced as far as possible in all actions and undertakings as services return. Further, employers and governments must tackle the underlying causes which have contributed to worse outcomes for BAME staff.
8. Staff must be enabled to raise concerns, particularly around patient safety and situations where their own mental health and well-being is at risk. Staff should be assured that they will be dealt with fairly and in confidence. Data collation is essential and must include mechanisms for `raising and escalating` concerns as well as data on staff covid-19 infections acquired in the course of their work (published monthly). 

The impact of Long Covid needs to be factored into recovery plans.  The introduction of specialist clinics is welcome but these need to be scaled at pace to meet growing demand. Long Covid must also be recognised as an occupational disease requiring appropriate policy, occupational health and support.

Given the risk of a significant number of nurses choosing to leave or retire in the coming months, governments and employers must consult with trade unions on the development of a recovery and retention strategy for staff. 

Finally, the UK Government must not relax public messaging or implement incentives for people to mix in groups. We have seen mixed messages directly result in increased pressure on the health and care system. Public messaging must continue to reinforce the importance of hands, space and face.