In the past five years numbers of nurses in England have risen by 4.6%: but the numbers of hospital admissions have risen by 12.3%. One in nine nursing posts are vacant. But if nurses are to be brought back in to the profession and new students attracted they must be given the hope of delivering a safe, effective service to patients.
Campaigns for improved nurse staffing levels in NHS hospitals, many of them modelled on similar campaigns in the US, Australia or less ambitious proposals that have become law in Wales and Scotland, all tend to refer with more or less precision to the proportion of patients to qualified nursing staff.
There is indeed a clear link established between higher levels of admissions per Registered Nurse and increased risk of death during an admission to hospital. These findings highlight the possible consequences of reduced nurse staffing: they point to the need to reject policies that encourage the use of nursing assistants to compensate for shortages of RNs.
Hospital management and ministers in England have been primarily seeking to avoid adopting any fixed nurse:patient ratio, even steering clear of the suggestion of a maximum of 8 patients per registered nurse set out in the Francis Report.
In 2013 a report from the National Quality Board and Chief Nursing Officer, ‘How to ensure the right people, with the right skills, are in the right place at the right time: A guide to nursing, midwifery and care staffing capacity and capability’, rejected defined staffing ratios in favour of the use of “evidence, evidence-based tools, professional judgement and a truly multiprofessional approach.”
In October 2015, a letter from ‘arms-length bodies’ to Trusts attempted to clarify contradictory messaging between requirements to achieve safe staffing and “the need to intensify efforts to meet the financial challenge.” It argued that the 1:8 ratio that NICE had highlighted as a potential alarm bell to trigger review of staffing levels, should be treated as a “guide not a requirement.”
NICE was told to stop work on ratios – not least because a quarter of trusts responding to surveys reported that the 1:8 level was being exceeded (i.e. more than 8 patients per registered nurse) on more than 65% of shifts.
In England management and government preference, especially in the light of staff shortages, and the problems of recruitment, has been to substitute warm words for hard action, despite evidence in California that firm action to ensure the quality of care helps recruit and retain nursing staff. UNISON’s report 2017 Ratios not Rationing explained clearly the positive impact it can have:
“In California, the number of actively licensed registered nurses increased by nearly 100,000 following the enactment of a staffing ratio law. Vacancies for registered nurses plummeted when the ratios were first implemented and turnover and vacancy rates have fallen far below the national average. There has also been a dramatic increase in the number of students interested in nursing as a career. These improvements show that ratios could be the answer to the current staffing crisis in the health service in the UK.”
The most substantial recent case study outside England also points to the need for a fixed maximum ratio of patients per nurse – and far fewer than 8:1. In Queensland the introduction of a mandatory ratio “has saved almost 150 lives and helped the government save millions of dollars.”
The study, reported in Nursing Times looks at the actual impact of imposing a legal ratio of one nurse to four patients for morning and afternoon shifts, and one nurse to seven patients for night shifts for selected acute surgical and medical hospital wards and mental health units across 27 hospitals in Queensland since July 2016.
“They have also avoided 255 readmissions and 29,200 hospital days, with an estimated cost saving of between $55.2m to $83.4m (£30.7m to £46.5m). In addition, the average nurse on wards included has seen their workload reduce by one to two patients during the day, and one to three on a night shift.
“Reductions of one patient per nurse were associated with a 9% less chance of a patient dying in hospital, a 6% less chance of readmission within seven days, and a 3% reduction in length of stay.”
These are important findings, and undermine the routine claims of staff shortages and added cost.
But there is also evidence of the advantage of a proper skill mix on wards, which can also save lives.
A paper published during the summer in the BMJ Quality and Safety points out the need for adequate staffing levels of “nursing support” – which in England are normally Health Care Assistants – not as any kind of substitute for registered nurses, but as important additional support.
The US-based study developed a data set to allow researchers to measure staffing for each unit and each shift.
Its findings that additional support staff alongside registered staff helped improve patient outcomes raise the question of whether this is because when support staff numbers are low, registered nurses wind up doing more of the work they would do, “such as delivering and retrieving food trays, transporting patients, obtaining supplies and equipment and arranging transportation” to the detriment of patient care.
The study also suggests that while support staff are “not formally trained in patient assessment and monitoring, nonetheless contribute to these tasks as part of their contact with patients and through a developed ability to recognise patients who may need attention by others on the staff.”
“When nursing support staff are less available, this contribution to the safety of patients is reduced.”
The evidence is clear: we need sufficient qualified staff per patient, supported by sufficient support staff – HCAs, clerical, housekeeping and porters – to allow them to do their job. Without the full team the safety of patients can be jeopardised.
The campaign needs to be taken forward to learn these lessons and demand safe staffing on NHS wards.
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