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Elizabeth Robb: 'Act on the evidence and introduce minimum nurse staffing levels'

Address the issue of staffing to prevent care being left undone, nursing burnout and shameful incidents, such as those at Mid Staffs, urges Elizabeth Robb

Nowadays not a week goes by without us hearing a story about poor nursing care. The most recent one, recounted in the House of Commons by Anne Clwyd MP about her husband’s care, appears to have reignited the media view that nurses are callous and have lost all compassion. Once again, we hear that basic care costs nothing and that smiling and being kind are all that is required.

Although our hearts go out to those who have lost a loved one and found the care they have received to be wanting, this is not the only picture of NHS nursing care. Of course, we must root out and be completely intolerant of poor care, ensuring the individuals responsible are held to account - but we must not forget that the vast majority of nursing care is actually very good. We hear little of this now and it is time we remembered that nurses have not lost compassion or their ability to care. It is still there but compassion does cost. It costs in terms of time, energy and emotional effort.

Good leadership and a set of values such as the chief nursing officer for England’s 6Cs - care, compassion, competence, communication, courage and commitment - excellent as they may be - are simply not enough. We need to tackle poor levels of registered nursing staff and the elephants in the room of organisational cultures that favour financial savings and activity targets rather than patient centredness and quality outcomes. Values alone will not meet the ever-increasing demand for healthcare, the dependency levels of many patients or rising public expectations.

“Poor registered nursing staffing levels were part of the problem at Mid Staffordshire Foundation Trust”

Poor registered nursing staffing levels were part of the problem at Mid Staffordshire Foundation Trust and are likely to be commented on in the forthcoming final Francis report. The recent Care Quality Commission report underlined that 16% of organisations fell short of the standard on safe staffing. That is of concern; although it makes clear that good staffing levels did not guarantee good care, low registered staffing levels were associated overall with care being of poorer quality.
The evidence abounds that higher levels of unregistered practitioners are associated with higher mortality rates and increased lengths of stay, failure to rescue and higher levels of reported patient safety incidents.

There is also evidence that fundamental nursing care is a complex and emotionally intensive occupation. Being unable to meet all the care needs of patients, together with leaving work undone, adds to the emotional burden for caring nurses. We know from psychological evidence that when we become overloaded and unable to meet the demands that are placed on us, there is a danger of a loss of humanity. We must support the profession to ensure we mitigate these risks, caring for and supporting each other by standing up for what is right for patients and preventing burnout.

At the CNO’s conference in December, it was heartening to hear health secretary Jeremy Hunt say that nurse staffing
numbers should never be at the expense of quality of care. He said nurses have a difficult and complex role and that his
job was to support us in taking forward the vision for nursing and midwifery. That is music to the ears of most of us in the nursing profession - we now need him to have the courage to act on the evidence and support a minimum level of registered nurse staffing numbers. This would prevent further care being left undone, nursing burnout and shameful incidents, such as those at Mid Staffordshire and other recent examples of poor patient care.

Do you want to keep up to date with the latest from the Francis Report into the Mid Staffordshire Foundation Trust? Visit our tailored Francis Report channel with the latest rolling news and analysis

Elizabeth Robb is chief executive of the Florence Nightingale Foundation

Readers' comments (46)

  • All we need now then is a competent Chief Nurse (England) who will push an agenda based on real issues (like inadequate staffing and poor skill mix) instead of wasting time and effort on "fluffy" topics like the ridiculous "C" project which provides ammunition for the tabloid press and will produce no improvement in care for patients!

    Thanks for the report Elizabeth ! You come closer to the real issues than the discredited so called "Leader" !

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  • is this the same jeremy hunt who now wants families to wash and feed patients as there is not enough money to employ staff?

    why does it take something like the Francis report until something might actually get done about staffing levels and skill mix. nurses have been complaining for years about this and no-one listened to us. now that we might actually be getting chief nurses on our side do you think the media might just leave us alone to get on with doing our jobs.

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  • A recent 200m pound Study, commissioned by McStuddies at the University of Studdiness, studied the effect of studying in the study against studying in the library. Our colleagues at The Institute of Studying, In Studyville USA, recently concluded that environment plays a significant role in the effectiveness of studying. However, further studies are now required and we will publish our Study 'The Effect of Studying In The Study' when we have studied how long the average study takes to study.

    Chief Nurse Stu Dy, realising that his brain was in danger of imploding, resigned from his voluntary position on the Board of Studdyers, claiming that he did not enter nursing to study studies but to look after patients.

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  • As a now burnt out nurse all i can say is i enjoyed my job giving the best i could to my patients on a daily basis as did the majority of the people i worked with whatever their role. Now i have had to walk away from the NHS as my mental and physical health was deteriorating rapidly what did my matron say? just hang in there a bit longer it will get better - 4months later i walked away. I feel exhausted, sad, angry that i cant do the job i enjoyed so much not to mention my pension being sacrificed but when it comes down to it no one cares about me or others like me, i am very lucky to have a supportive husband. I still cant help but miss the job, patients, colleagues and not using all my skills every day. Somehow the government must realise hospitals cant run like businesses because we are dealing with humans not robots so it is impossible for good care to be given on current staffing levels as usual we need more indians and less chiefs. Good luck to you all and look after yourselves as no one else will.

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  • Anonymous | 29-Jan-2013 11:17 am

    I take it you don't like studies then?

    I don't mind them. In fact, I like having evidence to prove what I know to be true. What I don't like is the fact the we don't use the evidence as a stick to beat the government over the head, preferring instead, to criticise those who gather rhe evidence on our behalf. I also know that it is a phenomenon peculiar to the nursing profession. I wonder, is it a lack in our education and/or intelligence? Because no other profession is this stupid and self destructive.

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  • Yes But

    We need to tackle poor levels of registered nursing staff and the elephants in the room of organisational cultures that favour financial savings and activity targets rather than patient centredness and quality outcomes. Values alone will not meet the ever-increasing demand for healthcare, the dependency levels of many patients or rising public expectations.


    Elizabeth is, of course, right - but didn't people already know that ? It has been pointed oput many times, on this website.

    christine ranson | 29-Jan-2013 2:09 pm

    Many nurses, are now saying much the same as you do there - who is listening ?

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  • Anonymous | 29-Jan-2013 2:52 pm

    I heard on the radio only yesterday that scientific studies are designed to prove that things are not true! Presumably this is the 'nul hypothesis' and presumably this refers to all types of research!

    I like the post of Anonymous | 29-Jan-2013 11:17 am but I am not quite sure whether it is true or false! A further study is obviously required to thoroughly investigate this with another (? conclusive ?) report to file for posterity in the dust gathering archives! I say this as I am not sure whether any of the other millions of reports already filed have ever been conclusive! I would think not otherwise there would be no need to carry out any further studies!
    No worries about financing any further studies, I am sure there unlimited millions still available to play with and waste for such ongoing projects.

    Well done both for your comments and vivid imaginations. It is good to still find a few nuggets of good humour here and there in these austere times.

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  • Anonymous | 29-Jan-2013 3:30 pm


    Anonymous | 29-Jan-2013 2:52 pm

    I guess when I'm on here, I'm neglecting the null hypothesis! Poor practice I know, but what the hey, I'm on my own time.

    Nothing wrong with a null hypothesis to be rejected, disproved or long as we also realise that accepting the null hypothesis does not mean that it is true and rejecting the null does not prove the alternative. It is still a hypothesis which must conform to the principle of falsifiability. Fisher has a lot to answer for!

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  • Just out of interest. Can anyone tell me where the funding for research comes from? There seems to be a line taken on quite a few threads, that money is being 'wasted' on research and studies.

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  • Money spent on research and development and all those sorts of things is well spent when someone takes notice of it and acts on it. Where the money comes from we don't know but there seems to be an awful lot of it around. Is spending money on management consultants telling us what we already know really 'research money". What I think nurses are all getting fed up with are the numerous and seemingly endless initiatives and studies that keep happening in nursing which cost an awful lot of money but don't seem to have any positive effect on either patient care, staffing levels, skill mix or nurses welfare.

    Surely there is enough evidence now to prove that health-care in whatever form doesn't have enough staff, enough money, enough beds, - the list just goes on and on but nothing seems to change.

    Every single shift, in every single setting, nurses go on duty knowing that work will be left undone,it's not work that is okay to hand over to the next shift but work that we cannot physically get through on our own shifts. It's not being able to care for our patients properly, not being able to make them comfortable, not being able to take any break ourselves which research also shows is not healthy.

    When we see millions of pounds spent on another initiative we groan and just want money spent on getting more staff to look after patients to the high standard that we all expect. We do not want to leave patients uncomfortable - whatever the media like to say we know what the now infamous 6c's are all about.

    The comment I posted about 'studies' is just tongue in cheek although I have my doubts.

    All we want is enough staff to look after patients, is that really too much to ask?

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  • another day and another headline story about closing beds and 'capping' admissions. what is going on? the Whit in London closing down wards and nurses accommodation, Romford capping the number of A&E admissions, Lewisham A&E closing - is the plan for the total destruction of the NHS ever going to stop.

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  • Have just read the Guardian story about the A&E 'capping' in Romford. They are seeing 40,000 more patients than they planned for, they receive more blue lights than any other London hospital, there are not enough doctors, patients are being treated on trolleys.

    Are they expecting the nurses and doctors to be the ones turning patients away, who is going to shut the door and say 'sorry but we are closed, no more room at the Inn, you'll have to come back later. Who is going to decide who can come in and be treated? What was the reason patients are being treated on trolleys - not enough hospital beds for them to be transferred to maybe?

    Surely the reason many patients go to A&E is because there is a shortage of community care, out of hours GP and district nurse services.

    If patients are turned away then won't they just go to another hospital?

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  • Anonymous | 29-Jan-2013 11:26 pm
    Anonymous | 29-Jan-2013 6:11 pm

    You are ignorant about where research money comes from, so how do you know that there is a lot of it around? Why do you confuse 'studies' with 'initiatives' and lump them together as if they are the same thing? They are completely different and very often unrelated. The problem with many initiatives is that they ignore good evidence which can point to the opposite. But I thank you for your honesty.

    The fact is that research money comes from a variety of sources. Quite a lot comes from academic institutions, pharmaceutical and medical device companies, charitable trusts, endowment funds, the CSO (Chief Scientist Office) and other sources which are ring-fenced for research only. Funds for research are never taken from health services. (In the same way that the funding for defence, education, local government, etc are also separate). In fact, a huge amount of money is paid into the NHS by researchers and it is a recognised income stream for the NHS. I am currently working on a study which is funded by the CSO, charitable trusts, university funding and endowment funds. I am an NHS nurse and the study is paying the NHS for my post. Research money is not spent on 'Management Consultants'. The process for getting a study or piece of research off the ground is actually a protracted process which requires an incredible amount of work to get through ethics committes, justifying and re-submitting revised study proposals, applying for funding (which is essentially going around to various sources with cap in hand and they don't give it away easily), all whilst continuing to be a full-time clinician.

    So please stop lumping research into everything that you think is wrong with the NHS. Without it, your patients would be much sicker or dead, your job would not have all the brilliant drugs, equipment, procedures, etc. which make it tolerable. You wouldn't be able to work at all without the evidence gathered by research. Also, management are not interested in research, so they are nothing to do with us.

    The problem is that nurses themselves don't use research to help their cause. The evidence exists; that work has and is being done. Take the evidence to the unions, the management, the government and USE it to gain better staffing levels and skill mixes. It's up to you.

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  • anon 8.59 - I don't think nurses need to take any more evidence about staffing levels or skill mix to the unions, management or the government - it's out there in the papers and on the news every day.

    We don't have much 'brilliant equipment' on our ward, most of what we have is clapped out, pretty much like the staff.

    Do you know how much money is spent annually on management consultants and where that money comes from?

    What do you feel about initiatives such as the 6c's, hourly rounding, 'Too Posh To Wash'.

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  • "What do you feel about initiatives such as the 6c's, hourly rounding, 'Too Posh To Wash'."

    how little they all have to do with real nursing!

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  • Anonymous | 30-Jan-2013 12:03 pm

    Did you read my post? Initiatives are NOT studies. They are nothing to do with research or studies and I don't understand why you are confused.
    The 6 Cs are NOT research based. They are just a silly idea in Jane Cummings and Viv Bennett's heads.
    Please quote me any research on this, 'Too posh to wash' thing ? I don't believe that such a phenomena exists outside of the media and short-sighted people. It has nothing to do with studies or research.
    I don't know how much 'management consultants' make a year, but paying them at all, in my view, is too much. However, they are nothing to do with research either, so I don't know why they are lumped in with studies, in your view.
    I take that you wear a certain type of uniform: that you have hospital beds for your patients; equipment for taking vital signs; resus equipment; medication for your patients; drug delivery pumps and systems; syringes; etc; procedures and protocols for carrying out your patient interactions safely; etc, etc. NONE of these would be available for your use and care of your patients if extensive and ongoing research and studies had not been done.
    That has everything to do with nursing. Sweeping, thoughtless generalisations based on no knowledge about nursing and nurses are widespread in the media and public domain. It is disappointing to see it within the nursing profession itself. Like I said. Nurses need to decide what to do with the evidence. It would benefit them much more than taking shots at those who work hard to give them that evidence.
    As for 'real' nurses? One would hope that a real nurse would have, at least, a working knowledge of research, how and why it is done and how to apply it.

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  • anon 1.19 - thanks for your kind comments. the 'real' nurses comment was not mine.

    'Too Posh To Wash, Reflections on The Future of Nursing' - created by Thinktank 2020health.

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  • Anonymous | 30-Jan-2013 1:44 pm

    Re: 'Too Posh To Wash, Reflections on The Future of Nursing'

    As far as I'm aware, it is a collection of essays, not research. However, I am ideed familiar with the work of 2020 Health as a not-for-profit research organisation.

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  • does anyone here have a recipe for chocolate crispy cakes, our ward manager is leaving at the weekend and apparently they are her favourites? thanks.

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  • tinkerbell

    on NHS change day 13.3.13 some managers, well 2, have pledged to come onto the wards and have a look to see what's going on.

    Too little, too late? Possibly rearranging the deck chairs on the titanic exercise.

    If you are a frontline worker with a bit of spare time you can also bake some cakes by the way or get involved in some fund raising i guess by selling them on the wards.

    I haven't made this up you know.

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