Many of the locations in which I have worked, have appeared to be grossly understaffed in terms of the clinical workload which is expected to be processed by the cast room staff. It is not an easy task to define a workload which is reasonable.
There are numerous variables which may affect the staff working as cast technicians; and also their patients. Cast technicians will probably acknowledge that it is never a simple patient number issue because we may remove 30 casts from uncomplicated injuries in an hour or we may be asked to apply a single cast, which could very easily occupy 90 minutes of actual clinical time.
When staff are working to complete the clinical work within a dedicated clinic time slot, many factors will conspire to make staff feel that they are not performing their duties well. Clinicians arriving substantially later than the start time to work in a heavily overbooked clinic will apply an unwanted pressure on cast room personnel.
Too many complex cases, such as post surgical cases, arriving in a fracture clinic and requiring wound care, clinician involvement and very specific complex casting techniques will add to the workload. Ward requests made too early or too late within the treatment cycle being added to clinic lists and thereby increasing the overall workload.
Keeping casts technicians working in this state of stress, often because of their inability to deal with the excessive workloads, is little short of workplace abuse. Overbooked clinics and irrational fracture clinic management adds to the burden of the cast technician.
Staffing policies may dictate that skilled personnel are not being appointed within any particular NHS Trust hospital. The use of untrained healthcare assistants (HCAs) in the cast room is another commonly seen strategy utilised by managerial staff; ostensibly to ameliorate the chronic shortage of appropriately skilled staff.
The continuing low-level non-appointment of skilled professional staff is usually seen when a permanent staff member falls ill or retires. The use of agency staff is often not approved because local NHS Trust policy does not permit this type of casual expenditure.
The workload is not usually adjusted to reflect a reduced cast room workforce. The cast room staff will be working at full stretch. It is probable that the work undertaken will be carried out at a reduced clinical standard because of the pressure to clear a backlog of patients within a specific time frame.
Another low level management strategy is to insist that cast room personnel ‘cover’ their own staff annual leave periods. In a cast room employing three people there will be eighteen to twenty four weeks of annual leave (this is dependent on the service length of each staff member) which will require staff who are already in post to cover the temporary or planned absences of their work colleagues .
This could amount to a time period spanning almost half a year where the cast room example given above (three full-time equivalents) is known to be understaffed. The complexity of the clinical casework being requested, administrative clinic management strategies, patient numbers and staff quality contribute to mismanaged departments.
Knowledge, skills and experience, NHS Trust policies and immediate clinical imperatives, are all factors which affect the cast technician’s ability to work without feeling pressured by the workload.
It is likely that getting all of the factors just right, to prevent cast room personnel from feeling as if they are working in a highly-pressured environment, is a matter of good fortune. Having the required amount of luck and aligning (eliminating) all of the factors which contribute to a poor working experience for the cast technician is rare indeed.
While it may not be viewed as deliberate abuse of staff, one can easily see how it would be regarded as institutional abuse. It is this frantic working environment, missed meal breaks and enforced overtime (when combined with a tendency to undervalue the work of a cast technician) which leads to staff having extended illness time away from the workplace; with ‘stress-related illness’ being cited as the primary reason for a staff member’s extended absence.
It would be naive to ignore the fact that the NHS pays its full-time employees full pay for up to six months of any single illness episode, followed by six months of half pay.
Cast room staff, who do not feel generally very well treated or appreciated, may also want to take a six month rest at the expense of the employing authority. If they are aggrieved about workplace issues, it is a relatively short step to believing that they are initiating a well-earned rest and a small measure of appreciation.
The Health and Safety Executive (HSE) has written about workplace abuses in the document entitled Preventing Workplace Harassment and Violence. It defines harassment and violence and discusses the terms prevention and identification and the range of problems associated with managing the issues raised.
We ought to be able to agree that staff who are being badly treated by managements (who deliberately keep permanent staffing levels low and workloads high) are being illegally abused by their workplace managers.
It is clear that work-related stress is an entity that has to be addressed by managements. Kerr et al (Occupational Medicine 2009;59:574–579) produced a well-referenced paper entitled HSE Management Standards and Stress-related Work Outcomes.
The paper detailed the results of surveying 707 staff using the HSE Management Standards Indicator Tool; which is a series of 35 questions that were put to employees. The paper noted that higher management standards ratings are associated with increased job satisfaction, decreased work-related anxiety and depression and a lower incidence of near misses and errors.
The HSE Management Standards Indicator Tool is also relevant to the work of cast technicians. Our work may be difficult to quantify in precise terms because of the wide range of activities which we undertake. Nevertheless, the management standards tool provides a means of illuminating deficiencies in the management of our work.
Which cast technician has not faced seemingly impossible clinic numbers and time constraints that preclude lunch breaks? The obvious corollary is that we are all too often working beyond our planned shift pattern times. We end our planned work shifts by staying late (in order to finish the clinic work) and this is another frequently experienced requirement of the work of a cast technician.
When this type of working practice is a very regular occurrence, it begins to take on the appearance of institutional abuse. Worse; when the managerial staff have been made aware of the issues and keep the staffing levels and orthopaedic and fracture clinic management practices the same, it appears to be the result of a deliberate local policy.
It is common to see near-miss events under such conditions and whatever methods of notification are used (IR1, Datix &c.) one suspects comprehensive failures of management are the root cause, especially where no action results from completing the protocols to advise them of incidents which may potentially cause harm to patients.
The HSE has helpfully provided a document entitled How to tackle work-related stress; which is a simple 9 page guide for employers who would wish to implement a management standards approach to reducing stress in the workplace.
It is an easy to follow document and cast technicians could point their managers to it; so that it may serve as a means of reducing some of the workplace stresses which are frequently seen in the cast room environment.
Specific issues may include noise levels, crying children, lack of working space,
ad-hoc break times, workload pressures caused by clinic overbooking, expectations from staff such as working against the clock (several different clinics in a single day) constantly working late to complete the work, failure to send staff for further relevant training courses, chronic understaffing and poor skill mix.
All of the forgoing indicates a lack of support for the staff member and may be contributing to them working under a series of small and varying pressures which, when combined, will serve to create a continuously stressful working environment.
The management standards approach for dealing with work-related stress is very well documented on the HSE website and comprises six elements. The first element is Demands. This addresses the ability of the employee to cope with the demands of the job.
The next element is Control. It examines the amount of say an employee has in how they do the job. Another crucial element in the management standards approach is Support. This element looks at the way the organisation supports the employee and the resources it puts in place for the employee to use.
The management standards require the inclusion of a separate Relationships element. This component looks at positive ways to avoid conflict and unacceptable behaviours such as staff bullying. That staff should have an understanding of their Role is another important element of the management standards for work-related stress.
Staff must understand their role and it should have no conflicts with other assigned roles. Change and how it is managed and communicated at the organisational level constitutes the final element in the management standards approach to dealing with work-related stress.
The HSE have produced a book which details a step-by step approach to managing the causes of work-related stress. It is also available as a free PDF format download from the HSE website. Managing the causes of work-related stress. It gives employees an insight into solutions that can be proposed to managers, where the working conditions are perceived to be less than ideal.
With the tools and information provided by the HSE, it should be possible for cast technicians to discuss their working environment and their immediate concerns with their line managers.
This should lead to management structures which permit cast technicians to work under vastly improved conditions. The resulting improvement in staff conditions will have positive implications for patient safety, delivered care and staff attendance records.