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Of Human Right and Human Gain?

July 17, 2014

Here’s an example of a red flag event: ‘It seemed to her that they had been standing there for hours and hours, holding those silly little red flannel flags that no one would ever notice. The train wouldn’t care. It would go rushing by them and…crashing into that awful mound. And everyone would be killed…”Oh, stop, stop, stop!” cried Bobbie. No one heard her…But afterwards she used to wonder whether the engine itself had not heard her. It seemed almost as though it had – for it slackened swiftly, slackened and stopped, not twenty yards from the place where Bobbie’s two flags waved over the line’ (From The Railway Children by E Nesbitt, 1905).

And here are some others: ‘Unplanned omission in providing patient medications; Delay of more than 30 minutes in providing pain relief; Patient vital signs not assessed or recorded as outlined in the care plan; Regular checks on patients to ensure that their fundamental care needs are met as outlined in the care plan’ (From Safe Staffing for Nursing in Adult Inpatient Wards in Acute Hospitals by the National Institute for Health and Care Excellence (NICE), 2014). Spot the difference anyone? That’s right – in the classic of children’s literature, quick thinking averts disaster. In the possibly-soon-to-be classic of fudge, disaster is already well under way.

The ‘nursing red flag’ is a strange beast – one which attempts to contain, within a single phrase, two highly conflicting concepts. On the one hand we have the guideline’s entirely praiseworthy ethic of  ‘patient-centred care’ – borne out by the ‘red-flag events’ which mainly relate to poor or potentially dangerous patient experience such as pain, deterioration and pressure sore development. On the other, we have a tacit ‘green light’ to the idea that, for most of the time, Trusts can run wards on the lowest numbers they think they can get away with, and take action only if it looks as though something really awful (a red flag event) is about to happen. The upshot is that red flags are not waved as a way of preventing bad outcomes, but to signal that they’re already occurring. Can anyone explain how being in pain for half-an-hour represents ‘patient-centred’ care?

The question is particularly relevant when you consider the similarities of the ‘red-flag’ system to the ‘just-in-time’ approach to stock control that has been widely adopted in industry and retail. Online investments directory Investopedia defines just-in-time as ‘An inventory strategy companies employ to increase efficiency and decrease waste by receiving goods only as they are needed in the production process, thereby reducing inventory costs. This method requires that producers are able to accurately forecast demand’. On this reading, the underlying logic of ‘red flags’ appears as nothing more than a crude attempt at workforce management – one which is apparently willing to countenance a patient being in pain for half-an-hour if the return is financial saving. This isn’t patient-centred care. This is commodification – of patients and nurses alike.

According to the guideline, a nursing red flag event ‘should prompt an immediate escalation response by the registered nurse in charge. An appropriate response may be to allocate additional nursing staff to the ward’. To say this isn’t really the answer seems ungrateful I know – but I’m going to say it anyway. Logging an event is extra work in itself. Then, when help arrives, it’s in the form of nurses, not psychics. The already-floundering permanent member of staff will have to stop whatever he or she is doing and give a handover to ensure a safe working knowledge of the patients. Takes time. May end up causing yet more delay.

But aside from these purely practical matters, there is a more theoretical question: will all red flags be indistinguishably scarlet? Could it be that tones of fuschia, maroon and even palest coral will eventually find themselves creeping in? The guideline specifically states that red flags can be reported by ‘any member of the nursing team, patients, relatives or carers’. How then should managers react to a patient who complains that he feels like he’s waited half-an-hour for analgesia but can’t be completely sure because there’s no clock in his side room and he left his watch at home? Is that a red flag? Or just a delicate shade of pink?

And what of the nurse who, owing to other pressures, hasn’t got round to giving the analgesia? She’s pretty certain that the patient is mistaken about how long he’s been waiting – he’s in pain after all, so it’s bound to seem longer than it really is. Should she swallow her doubts and go along with him in the hope of securing a much-needed extra pair of hands for the ward? Or should she be truthful, and in so doing risk alienating the patient? Will nurses who raise the alarm ‘too regularly’ be demonised for ‘trying it on’? Or glibly suspected of ‘gaming’ the system – by taking longer than they need to over the drugs round for example? The point I’m making here is that in trying to forge a single solution to two very disparate problems (how to ensure sufficient staff; how to contain costs), nursing red flags cannot help but create new dilemmas all their own.

Tensions between these polar opposite aspirations are already starting to show. Just this week the Health Service Journal pointed out ‘that the staffing data published in June on the NHS Choices website used aggregate figures for registered and non-registered nursing staff, which had the effect of obscuring trusts’ results for registered nurses only’. Subjecting the figures to its own analysis, the magazine found that ‘more than three quarters of acute NHS providers have missed their own targets for the number of hours worked at their hospitals by registered nurses’. In response, Susan Osborne, Chair of the Safe Staffing Alliance, called the figures published by NHS Choices ‘misleading and a fudge’.

Beyond all this lies an even bigger temptation for hard-pressed Trusts: that of tailoring their target staffing figures to the level they know they can afford rather than the level they know to be optimal. The NICE guideline stipulates that Trusts must use an approved tool to calculate their staffing requirements, but they are free to choose which one. NICE has yet to officially endorse any of these tools, but in the longer term, it will be interesting to see which of them prove most popular. What’s the betting it will turn out to be the ones that predict lower numbers?

The Safe Staffing Guideline is welcome in the sense that it forces Trusts to focus on the crucial but all-too-often conveniently neglected area of nursing numbers. But this is only the beginning. Constant vigilance from staff, from service users, from watchdogs and from the media will be needed to ensure that Trusts don’t simply use ‘safe staffing’ as an excuse to offer false reassurance and to introduce new working practices which benefit employers and managers rather than nurses and patients. With its implicit assumption that all must be well unless someone says it’s not, the ‘nursing red flag’ could be seen as a handy way to square the cost/safety circle. The guidance tells nurses they must ‘Keep records of …red flag events’. I’d add to that: keep records of the response you get when you escalate them as well.

For the NICE Safe Staffing Guideline, see:

For the Nursing Times story on published staffing figures (similar to the HSJ story), see:

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