On our annual off-ward training day this year, I listened with small astonishment to the utter nonsense some of my colleagues were spouting.

The training consisted of a number of sessions on different fundaments of care, including patient nutrition, hydration, mobilisation and deterioration. Each session was led by a member of the clinical team with a professional interest in the subject – dieticians, researchers, critical care nurses etc – and involved at least some element of interactive activity from the twenty or so nursing staff in attendance. Quite often this included questions regarding our role and actions taken: “how do you conduct a risk assessment”, “how should you respond” etc. In answering, however, there appeared to be very little discernment between what you should do (or work-as-prescribed) and what you would actually do (or work-as-done). And much of what they described did not at all match the reality of what I had witnessed and experienced on the ward.

The gap that exists between work-as-prescribed and work-as-done is well established in existing literature and has been extensively explored in a range of ward-settings. In healthcare, much discussion focuses on how the gap might be narrowed to in such adaptive environments where no two interactions are the same. What is noted in a lot of these studies, however, is that the reality of this gap is often obscured by staff reporting. For many reasons, staff descriptions of what they do (or work-as-disclosed) often more closely aligns with work-as-prescribed then work-as-done. While possibly due, in part, to the difficulty of distilling complex, haphazard and messy scenarios into clear descriptions of process, Suzette Woodward writes that this phenomenon is likely due to existing cultures in healthcare discouraging people from speaking out.

In a strict hierarchical environment, in which your professional registration is tied to an ethical and legal responsibility to uphold safe and quality care, admitting not following best practice comes with significant personal risks. And while the circumstances that might have led to any shortfall in care might not be the individual’s responsibility – such as chronic understaffing, excessive workloads, patient acuity, inadequate resources and support from management – staff have learnt that speaking out about these things is very unlikely to lead to anything being done about them. Unless you feel as though your response is valued, that it is being listened to and leant from, then answering honestly as to reality of the day-to-day constraints on practice might feel like too much of a personal risk to take, especially when you know your admission is unlikely to affect change.

When looked at like this, failure to disclose work-as-done might be understood to be driven less from a “culture of fear” and more from a “culture of indifference”, in which the reality of working conditions is assumed known but not cared about.

This was something that was felt particularly acutely on non-critical care wards during the pandemic. Staff were redeployed from these areas to service ICU and HDU in order to maintain the 1:1 and 1:2 staff to patient ratios in these areas closely as possible. General wards, however, remained open, full and significantly understaffed. This was true of the second wave especially, when winter pressures and the fall out of the first lockdown meant high admission rates. During this time, the ward I worked on was staffed at 8:1 and 9:1 as standard (I know of other specialities that were at as much as 12:1) and our ability to do our jobs was significantly compromised. We saw the impact this had in the timeliness and quality of care we delivered, and witnessed the effect this had on patient outcomes, complications and deaths.

The divisional managers would regularly come by and ask us how we were doing. We would answer that we were understaffed, overstretched, and exhausted; that we couldn’t keep our patients safe, were unable to complete basic care tasks, and that patients were in pain and dirty and dying alone. And they listened and nodded and thanked us and continued to take staff away.

We understood why it was happening, we also understood that management were probably doing their upmost to protect staff and patients, and that there was likely very little that could be done. But it felt as though no one cared.

Even now, out of the dozens of inquiries and reviews into staffing during the pandemic, very little is known or written about nursing numbers and outcomes on general wards. And the NHS is still yet to mandate a minimum nurse-to-patient ratio across England.

Back to our training day, and it appeared that staff chose from two types of responses when asked about their work. While a few emphasised their inability to do the task as prescribed due circumstances and constraints, the majority described working as prescribed – often even repeating the evidence basis and rational for practice. It wasn’t that they were intentionally misleading anyone. Rather, it likely seemed easier, safer, and perhaps even futile to acknowledge the full extent of the challenges they faced in doing their job the way they knew they should. Considering the context (a learning environment where the staff’s knowledge basis was being assessed) this pattern of responses is hardly surprising. But it is revealing.  

The training day was a clear reminder of the gap between how care is supposed to be delivered and how it actually happens on the ward. This disconnect isn’t just theory—it’s something staff deal with every day, shaped by heavy workloads, staffing shortages, and a culture that makes it hard to speak openly. This reluctance to speak is part of a broader issue in healthcare, where the gap between policy and practice is not just overlooked but not likely not adequately understood, making it even harder to address. Without real efforts to listen and act on what frontline workers experience—especially during crises—healthcare risks staying stuck in a cycle where problems are ignored, staff feel unheard, and patient care suffers as a result.