Alamy

Analysis

Researchers and nurses debate merits of ward staffing levels Academics suggest ratio of one nurse to eight patients will save lives, but ministers unconvinced. Nick Triggle reports TALK OF introducing minimum nurse-topatient ratios is nothing new. However, after years of discussion, it seems the talk finally is being turned into action. In April, the Scottish Government made it mandatory for healthcare providers to use workforce planning tools to ensure they have the right numbers and mix of staff. While this is not the same as setting recommended levels, it can be seen as a significant step in that direction. In England, meanwhile, first the Francis inquiry suggested that minimum levels be explored for each specialty, and in September the House of Commons health committee called for hospitals to display publicly the staff numbers they have on wards and whether these are sufficient. There is also an ever-strengthening evidence base showing that numbers of nurses directly affect quality of care. A recent study (Ball et al 2013) found that missed care involving, for example, pain relief and comforting patients, is likely to occur in areas with high patient-to-nurse ratios. Unsurprisingly, nurses looking 8

November 2013 | Volume 20 | Number 7

after fewer patients are more likely to ensure their patients receive treatment and pain management on time. Similar issues were identified in the 2009 RCN employment survey. In addition, there is a wealth of evidence produced by the RN4CAST consortium, a research group involving teams from 12 European countries. It has found that hospitals with more than eight patients per

registered nurse on general wards during daytime shifts see about 20 deaths a year more than better staffed hospitals. It is this work that led this year to the Safe Staffing Alliance, which includes the RCN, Unison and the Patients Association, to call on care providers to consider the ratio as marking the limit of safe practice. Ward staffing The government in England maintains that it is not up to Whitehall to decide about staffing on individual wards. However, ministers accept that hospitals need some help and have promised to ask the National Institute for Health and Care Excellence to look at what guidance is needed. National Nursing Research Unit deputy director Jane Ball thinks greater clarity would help. Figures published in The Times newspaper last month, based on data from a previous study (Ball et al 2012), showed that nearly half of wards were falling below the one to eight ratio. ‘This is not a recommended level; it is the danger zone. Trusts should be worried when they hit a one-to-eight ratio, as this is the point at which we know mortality rates are higher. To have so many places with staffing below this level convinces me it is time we had guidance.’ But, she says, the government should go further, pointing to the accepted practice in critical care of having at least one nurse to two patients, or one to one for ventilated patients. ‘There is evidence to suggest that we can determine what is appropriate for different types of settings and set these as fundamental standards.’

Ward quotas across the world Victoria, Australia In 2001, Victoria became the first state in the country to introduce mandatory nurse-to-patient staffing levels. For general medical and surgical wards, the ratios range between 1:4 and 1:6 during the day and 1:8 and 1:10 at night, depending on the type of hospital. Other wards, specialising in care of older people, rehabilitation and children, have their own designated ratios. Figures (RCN 2012) suggest the number of nurses re-entering the workforce has increased.

California, US In 1999, the state of California passed legislation covering staffing levels, although it took five years to phase in fully. For general medical and surgical wards, the standard is 1:5. Again, other units, from psychiatric to care of children and young people, have their own ratios. Research (RCN 2012) shows that, on average, nurses in California care for one patient less than those elsewhere in the US. Mortality rates in the state are lower too. NURSING MANAGEMENT

Downloaded from RCNi.com by ${individualUser.displayName} on Nov 29, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.

Analysis

Falling numbers However, questions are being asked about whether all trusts in England will be able to achieve recommended staff levels, given falling employee numbers in the NHS. Since the last election, the nursing and midwifery workforce in England has fallen by 3,000 full-time equivalents to just over 307,000, according to data from the Health and Social Care Information Centre. RCN director of policy Howard Catton says setting safe staffing ratios could help force policymakers to address the issue of shortages. ‘To protect patient care, now is the time for more clearly defined standards. It must be made mandatory for trusts to use established planning tools to ensure there is the right mix and number of staff.’ Guidance on safe staffing levels in the UK is available at tinyurl.com/RCN-stafflevels and details of the RN4CAST study are available at tinyurl.com/rcn4cast Nick Triggle is a freelance writer

References Ball J, Pike G, Griffiths P (2012) RN4CAST Nurse Survey in England. tinyurl.com/RN4CAST-report-2012 Ball J, Murrells T, Rafferty A et al (2013) ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality and Safety Journal. tinyurl.com/care-undone Royal College of Nursing (2012) Mandatory Nurse Staffing Levels. tinyurl.com/mand-staff-levels

NURSING MANAGEMENT

Report proposes better integration of hospital and community services iStock

This has been done already in other parts of the world, such as Australia and the US (see panel). However, lack of clarification from government here has not stopped some NHS hospitals in England experimenting with staffing ratios. One such is Salford Royal NHS Foundation Trust, whose managers have accepted the one-to-eight ratio as a minimum. However, they also recognise that many wards require more nurses and, in early summer, Salford Royal wards started displaying the number of staff and the number there should be. The target number is based on an acuity and dependency tool developed by the Association of UK University Hospitals. Salford’s deputy director of nursing Peter Murphy says the system is working well so far. ‘We have a teleconference each morning to determine what staffing is needed and, if there is a shortage, to see if a reallocation of nurses is required.’

Commission argues that major redesign of secondary provision will improve collaboration and patient care, writes Nick Triggle A RADICAL overhaul in hospital management is needed to ensure patients are not passed unnecessarily and wastefully around the care system, according to an expert group. The Future Hospital Commission says that such reorganisation would require greater flexibility from doctors, nurses and other healthcare professionals. It recommends, as a guiding principle, that, unless clinically necessary, patients are not moved once admitted to hospital, which contrasts with the multiple moves people with complex conditions may endure now as they are moved between specialties. The report states that such a system of transfers damages patients’ experiences; it also ‘propagates waste’ and ‘compromises the delivery of co-ordinated care’. The commission says that the emphasis needs to be on bringing care and, consequently, healthcare professionals to patients. To achieve this, its report proposes designing hospitals centred on three hubs: ■■ A medical division, to ensure hospital generalists and specialists work closely together and with partners in the community. ■■ An acute care hub, to improve co-ordination between emergency care, intensive care and other specialties that look after acutely ill patients.

■■ A clinical co-ordination centre to act as an operational command centre for the hospital, taking charge of patient information and care planning. The importance of seven-day working is stressed, with the report arguing that resources should be spread evenly across the week, even if it means services have to operate at 80 per cent capacity. It also proposes that the concept of discharging patients should end, pointing out that people often need further care after they leave hospital. It therefore suggests that care planning should start on admission. This would require greater integration with secondary, community and social care, so hospitals can be seen much more as part of local health systems. Commission lead fellow Tim Evans says: ‘It could mean hospital doctors and nurses running clinics in the community. This is already happening in the best places, and it is fair to say doctors could probably learn from nurses in this respect. The key point is we need to think differently both in and out of hospital.’ Health secretary Jeremy Hunt has backed the report, describing it as ‘bold and refreshing’. But RCN management and leadership forum chair Jane Valle thinks the NHS should proceed with caution. ‘The idea of putting patients first seems obvious, but it doesn’t always happen, so it is helpful to have it set out this way. ‘However, we need a clearer idea about how it can be achieved. Patients may need to be moved for perfectly legitimate reasons. For example, it is widely accepted that patients have better outcomes when they are treated in specialist stroke units, or there could be a situation where someone has to be moved to critical care. ‘We have to be careful how we define what is done for clinical reasons and what is not.’

Find out more For details of the commission and its report, go to www.rcplondon.ac.uk/projects/ future-hospital-commission November 2013 | Volume 20 | Number 7

Downloaded from RCNi.com by ${individualUser.displayName} on Nov 29, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.

9

Researchers and nurses debate merits of ward staffing levels.

Researchers and nurses debate merits of ward staffing levels. - PDF Download Free
345KB Sizes 0 Downloads 0 Views