Feature
Safety in more than just numbers Gillian Leng outlines the benefits of new guidelines to ensure safe nursing and midwifery staffing levels Correspondence [email protected]
Abstract
Gillian Leng is deputy chief executive and director of health and social care at the National Institute for Health and Care Excellence Date of submission October 29 2014 Date of acceptance October 29 2014 Author guidelines rcnpublishing.com/r/ nm-author-guidelines
The National Institute for Health and Care Excellence (NICE) is developing a series of evidence-based guidelines on safe staffing with a focus on nursing and midwifery care. This article discusses how these recommendations could be put into practice to ensure that staffing across the NHS is safe enough to provide good quality care for patients. Keywords Safe staffing, patient safety, evidence-based guidelines THERE IS no question that the care delivered by nursing and midwifery teams strongly influences how well patients do. We know that, when staffing levels are not right, staff can be pushed to the limit and patients do not receive the care they deserve. This leaves a trail of activities left undone, with no time to talk to patients, provide medications promptly or keep a watchful eye to prevent harm. Whether someone is admitted to hospital, having a baby or learning to manage a chronic condition at home, nurses and midwives are the professionals who are likely to handle their care. However, there are many challenges to achieving safe nursing and midwifery staffing. We are faced with an increasing older population, more patients with long-term conditions being treated with complex treatments, and issues around handling multimorbidity. Hospitals and services have to deal with higher turnover, with more patients coming through the door and greater pressure to reduce how long people spend in their care. The Department of Health and NHS England have asked the National Institute for Health and
20 December 2014 | Volume 21 | Number 8
Care Excellence (NICE) to develop evidence-based guidelines to advise the NHS about safe staffing across a range of settings. The NICE safe staffing guidelines are designed to offer a clear and logical process for organisations to use when determining safe staffing. The recommendations focus on delivering safe patient care and making sure that hospital management, alongside nursing and midwifery staff, are clear on best practice to achieve this. The first guideline, published in July, focused on adult inpatient wards in acute hospitals (NICE 2014). Work is underway on the next two pieces of guidance, looking at maternity and emergency care settings, with publication due in 2015. Following this, NICE will look at a range of other settings, including mental health, learning disabilities and children’s services. The guidelines begin from the top, looking at organisational strategy and what needs to be considered by hospital board members, senior management and commissioners to support safe staffing. Across our guidelines, the message is that the focus must be on patient-centred care. From a young person with a broken arm, to someone giving birth for the first time, to an older person with dementia, boards must be accountable to ensure that service users receive the care they need, wherever they are, whatever the time of day. There is strong evidence that better patient outcomes are associated with care delivered by highly skilled staff (NICE 2014). Our guidelines call for plans that would allow care to be delivered by registered nurses and midwives with delegation to other members of staff as appropriate. As part of their planning, hospital boards must also allow capacity to deal with planned and predictable variations in the staff available. NURSING MANAGEMENT
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This could be around seasonal variations such as the incidence of people with the winter vomiting bug, or staff requirements such as study leave. Forming the backbone of each guideline are the ‘safe-nursing indicators’ or ‘safe-midwife indicators’, which spell out the patient and staff outcomes that managers and registered nurses or midwives deal with on a day-to-day basis in each setting. These indicators, which can include the occurrence of falls, medication errors or missed breaks by staff, should be monitored regularly and reviewed at least every six months to gauge if changes in establishment are needed. Accountability for final staffing and budget decisions falls with the board but management is advised to work alongside senior ward-level staff who have specific training and are responsible for establishments when making decisions. Staffing needs to be flexible; no amount of planning can predict precisely the variety of patients who walk through the door, and staffing shortfalls that immediately affect the ability to provide safe care may occur without warning. Management must support flexible approaches to staffing that allow escalation and action in real time. This includes putting procedures in place for staff, patients and their families or friends to report the ‘red flags’ outlined in the guidelines, which warn when immediate action is required. Proposed responses include delegating activities to other staff or using temporary staff to avoid compromising care in other areas.
Front line The nurses and midwives working on the front line are best placed to collect information and take action on a daily basis. The guidelines include recommendations on the factors they need to monitor and the process for using these to determine safe nursing or midwifery staffing. The factors cover direct patient care and other tasks that members of staff need to carry out, such as taking the time to speak to carers, supervising junior staff or carrying out audits. Considering ward layout is also important because more time might be needed to observe patients in separate rooms or to access resources in wards. Each guideline will include a detailed, although not exhaustive, list of the types of ongoing and one-off activities that affect staffing requirements. Professional judgement and knowledge of local patient needs can be used to build on these lists. Alongside use of a NICE-endorsed toolkit, such as the Safer Nursing Care Tool we endorsed recently and others that are being assessed, NURSING MANAGEMENT
The nurses and midwives working on the front line are best placed to collect information and take action on a daily basis the recommendations provide step-by-step calculations for how to employ staff effectively. Assessing how to use your staff is about balancing the average amount of nursing hours with the appropriate knowledge and skill mix of the staff who are available. Delegation is valuable and, where appropriate, certain activities can be carried out by trained and competent support staff or other members of the multidisciplinary team. The knowledge and skill levels of other staff, as well as the availability of planned registered nurses and midwives to support and supervise, should be considered to ensure safe delegation. Implementing our safe staffing guidelines will improve quality and safety of care across all NHS hospitals and community healthcare services nationwide. There are already many hospitals and services doing great work to ensure that safe numbers of staff are available. In field-testing each guideline and speaking at conferences, I have met many nurses and midwives who strive for excellent patient care. With NICE guidelines and the associated endorsed toolkits, and the professional judgement of experienced healthcare professionals working in hospitals or in the community, we are taking important steps to make sure patients are provided with safe, adequate care wherever they are.
Find out more For details of the NICE safe staffing guidelines, go to tinyurl.com/ls9ref8 Reference National Institute for Health and Care Excellence (2014) Safe Staffing for Nursing in Adult Inpatient Wards in Acute Hospitals. www.nice.org.uk/ guidance/sg1 (Last accessed: November 4 2014.)
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
December 2014 | Volume 21 | Number 8 21
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Safety in more than just numbers Gillian Leng outlines the benefits of new guidelines to ensure safe nursing and midwifery staffing levels Correspondence [email protected]
Abstract
Gillian Leng is deputy chief executive and director of health and social care at the National Institute for Health and Care Excellence Date of submission October 29 2014 Date of acceptance October 29 2014 Author guidelines rcnpublishing.com/r/ nm-author-guidelines
The National Institute for Health and Care Excellence (NICE) is developing a series of evidence-based guidelines on safe staffing with a focus on nursing and midwifery care. This article discusses how these recommendations could be put into practice to ensure that staffing across the NHS is safe enough to provide good quality care for patients. Keywords Safe staffing, patient safety, evidence-based guidelines THERE IS no question that the care delivered by nursing and midwifery teams strongly influences how well patients do. We know that, when staffing levels are not right, staff can be pushed to the limit and patients do not receive the care they deserve. This leaves a trail of activities left undone, with no time to talk to patients, provide medications promptly or keep a watchful eye to prevent harm. Whether someone is admitted to hospital, having a baby or learning to manage a chronic condition at home, nurses and midwives are the professionals who are likely to handle their care. However, there are many challenges to achieving safe nursing and midwifery staffing. We are faced with an increasing older population, more patients with long-term conditions being treated with complex treatments, and issues around handling multimorbidity. Hospitals and services have to deal with higher turnover, with more patients coming through the door and greater pressure to reduce how long people spend in their care. The Department of Health and NHS England have asked the National Institute for Health and
20 December 2014 | Volume 21 | Number 8
Care Excellence (NICE) to develop evidence-based guidelines to advise the NHS about safe staffing across a range of settings. The NICE safe staffing guidelines are designed to offer a clear and logical process for organisations to use when determining safe staffing. The recommendations focus on delivering safe patient care and making sure that hospital management, alongside nursing and midwifery staff, are clear on best practice to achieve this. The first guideline, published in July, focused on adult inpatient wards in acute hospitals (NICE 2014). Work is underway on the next two pieces of guidance, looking at maternity and emergency care settings, with publication due in 2015. Following this, NICE will look at a range of other settings, including mental health, learning disabilities and children’s services. The guidelines begin from the top, looking at organisational strategy and what needs to be considered by hospital board members, senior management and commissioners to support safe staffing. Across our guidelines, the message is that the focus must be on patient-centred care. From a young person with a broken arm, to someone giving birth for the first time, to an older person with dementia, boards must be accountable to ensure that service users receive the care they need, wherever they are, whatever the time of day. There is strong evidence that better patient outcomes are associated with care delivered by highly skilled staff (NICE 2014). Our guidelines call for plans that would allow care to be delivered by registered nurses and midwives with delegation to other members of staff as appropriate. As part of their planning, hospital boards must also allow capacity to deal with planned and predictable variations in the staff available. NURSING MANAGEMENT
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This could be around seasonal variations such as the incidence of people with the winter vomiting bug, or staff requirements such as study leave. Forming the backbone of each guideline are the ‘safe-nursing indicators’ or ‘safe-midwife indicators’, which spell out the patient and staff outcomes that managers and registered nurses or midwives deal with on a day-to-day basis in each setting. These indicators, which can include the occurrence of falls, medication errors or missed breaks by staff, should be monitored regularly and reviewed at least every six months to gauge if changes in establishment are needed. Accountability for final staffing and budget decisions falls with the board but management is advised to work alongside senior ward-level staff who have specific training and are responsible for establishments when making decisions. Staffing needs to be flexible; no amount of planning can predict precisely the variety of patients who walk through the door, and staffing shortfalls that immediately affect the ability to provide safe care may occur without warning. Management must support flexible approaches to staffing that allow escalation and action in real time. This includes putting procedures in place for staff, patients and their families or friends to report the ‘red flags’ outlined in the guidelines, which warn when immediate action is required. Proposed responses include delegating activities to other staff or using temporary staff to avoid compromising care in other areas.
Front line The nurses and midwives working on the front line are best placed to collect information and take action on a daily basis. The guidelines include recommendations on the factors they need to monitor and the process for using these to determine safe nursing or midwifery staffing. The factors cover direct patient care and other tasks that members of staff need to carry out, such as taking the time to speak to carers, supervising junior staff or carrying out audits. Considering ward layout is also important because more time might be needed to observe patients in separate rooms or to access resources in wards. Each guideline will include a detailed, although not exhaustive, list of the types of ongoing and one-off activities that affect staffing requirements. Professional judgement and knowledge of local patient needs can be used to build on these lists. Alongside use of a NICE-endorsed toolkit, such as the Safer Nursing Care Tool we endorsed recently and others that are being assessed, NURSING MANAGEMENT
The nurses and midwives working on the front line are best placed to collect information and take action on a daily basis the recommendations provide step-by-step calculations for how to employ staff effectively. Assessing how to use your staff is about balancing the average amount of nursing hours with the appropriate knowledge and skill mix of the staff who are available. Delegation is valuable and, where appropriate, certain activities can be carried out by trained and competent support staff or other members of the multidisciplinary team. The knowledge and skill levels of other staff, as well as the availability of planned registered nurses and midwives to support and supervise, should be considered to ensure safe delegation. Implementing our safe staffing guidelines will improve quality and safety of care across all NHS hospitals and community healthcare services nationwide. There are already many hospitals and services doing great work to ensure that safe numbers of staff are available. In field-testing each guideline and speaking at conferences, I have met many nurses and midwives who strive for excellent patient care. With NICE guidelines and the associated endorsed toolkits, and the professional judgement of experienced healthcare professionals working in hospitals or in the community, we are taking important steps to make sure patients are provided with safe, adequate care wherever they are.
Find out more For details of the NICE safe staffing guidelines, go to tinyurl.com/ls9ref8 Reference National Institute for Health and Care Excellence (2014) Safe Staffing for Nursing in Adult Inpatient Wards in Acute Hospitals. www.nice.org.uk/ guidance/sg1 (Last accessed: November 4 2014.)
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
December 2014 | Volume 21 | Number 8 21
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