Running on empty: the reality of nursing in A&E

To nurse is a privilege. To be with individuals at some of the worst, and best, moments of their lives is not something most people experience in their day-to-day working lives, and it’s hard to articulate the sense of purpose and fulfilment that can bring. I’m loath to ever describe nursing as a vocation: I think to do so undervalues the expertise, skills and capability that nurses work incredibly hard to achieve and maintain.

In part, this is why – alongside my job at the Health Foundation – I continue to maintain my connection with the front line by working as a registered nurse in the emergency department at a central London hospital.

Since I qualified, the growing pressures on NHS services, deterioration in aspects of population health and widening inequalities have become increasingly palpable. Shifts have become progressively more strenuous and stressful, and in the last year it is no longer uncommon for colleagues to become tearful due to being completely overwhelmed. It has now reached a point where entire shifts feel like a sprint.

Where I work, we used to have a ratio of 1:4 nurses to patients. Lately we have been working 1:5 and sometimes 1:8. This is a result of chronic staff shortages – both from unfilled vacancies and from staff themselves being too ill to work. With more than 1 in 10 registered nurse posts across the NHS vacant, the overall sense of morale is low. Support from colleagues is often limited to a quick check-in as you dart past them in the corridor or as you both rummage for supplies in stock rooms.

Being spread so thinly puts safety at risk, both for patients and staff. It’s also unfair to patients and their families. A&E is frightening and difficult to navigate, the environment is alien, loud and lonely. With more patients in the department than I have ever experienced, it feels overcrowded. On my last shift we had 178 patients in A&E – around 6 months ago, the average would have been about 80. Each time I pass the packed waiting room or squeeze down a cramped corridor it feels like the order of the department is unravelling and we are inundated, working against a great tide that cannot be slowed. In a space not designed for this number of people, it quickly feels oppressive.

Patients themselves are more unwell and presenting with more complex conditions. Increasing numbers of patients have comorbidities and serious illness, meaning they require more intricate care that takes more time to deliver. Routine nursing care such as hanging IV fluids or giving a medication can be delayed, and staff end up rushing to try and stay abreast of their responsibilities.

On a recent shift over the festive period, I was looking after five patients. Two of them were older people who had fallen at home. One needed to stay in hospital for orthopaedic treatment and had to be in a side room having tested positive for COVID-19 on admission. The other had been admitted to hospital to allow time for social care support to be arranged. Both patients were in the department for the entirety of my 12-hour shift and were still there 3 days later. They each saw six staffing shifts come and go. 2 years ago this would be considered a major incident and a failure of care, but now it is the norm.

One of my other patients had self-identified to police officers as having a mental health crisis, and the officers then brought the patient into A&E to seek medical advice. The patient was disorientated and anxious, and needed reassurance as they waited for psychiatric review. The patient’s family members, who live abroad, were incredibly grateful for the few minutes I spent talking with them on the phone to explain what had happened. I just wish I could have spared more time to sit with the patient as I once would have been able to. Instead, a hurried check-in round the doorway was just about manageable.

My final two patients that day were both clinically unwell, one with sepsis and the other having epileptic seizures. Each of their conditions warranted them being in resus beds, but they had to give way to other patients who were even more unwell. Both needed concentrated care, which I tried my utmost to deliver, but because of the sheer volume of work and competing priorities, I ended up running behind with other responsibilities such as routine observations and drug administration. There is no doubt that quality of care slipped for these patients. Their accompanying relatives were rightfully very concerned, and yet were almost apologetic, sympathising with the sheer level of demand being placed on staff. After a few hours the two patients were moved into other areas of the department and were immediately replaced by two more. It is truly relentless.

As my shift comes to an end, I am running on empty and feeling guilty that I couldn’t deliver better care. The nurses on the night shift come in to take over. In normal times, they would bring a fresh wave of energy as we handover. Instead, it feels like bracing friends for a painful and unnecessary battle. I leave with a heavy heart, knowing that the next 12 hours will be just as difficult as the last.

I remember, when I was little, watching a magician trapped inside a glass box try to escape by unlocking various padlocks as water rose rapidly around him. I recall my panic as the drama unfolded, with the magician escaping only in the nick of time. That is the closest I can come to articulating how a shift in A&E currently feels, although there is no magic escape in sight for A&E staff. Like a race against both tide and time, I’m barely able to keep my head above the water. It’s draining and heart-breaking in equal measure and I feel visceral anxiety, and anger.

We’ve known this crisis is coming, and without concerted action, we know it will continue. Recent projections from the Health Foundation’s REAL Centre point to NHS trusts and general practices facing a continuing shortfall of 36,700 full-time equivalent nurses relative to demand by 2030/31.

I see first-hand the incredible work of the NHS and I’m incredibly proud to be a nurse, but the system is no longer coping. Staff are leaving, and I can’t blame them: the unrelenting pressure is soul-destroying and unsustainable. Nurses are striking for the first time ever, not just about pay – money isn’t what drives most of us to do our jobs – but about working conditions and the inability to provide safe, effective care. This does not come easy to many, and the might of this action should be seen for what it is – a final, defiant cry for help.

Heather Wilson (@Heathers_health) is a Programme and Policy Officer in the Healthy Lives team at the Health Foundation, as well as being a registered nurse.