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Nurses must be 'empowered' to raise staffing concerns, Francis tells MPs

Frontline nurses should be “empowered” to raise concerns over short staffing and be protected when they do, the chair of the Mid Staffordshire Foundation Trust public inquiry has told MPs.

Appearing before the Health Select Committee today, Robert Francis QC spelt out his ideas for new minimum staffing tools for individual clinical areas and how a legally-binding duty of candour would help nurses working on wards to speak out.

Both are among 290 recommendations in his seminal report published last week.

He told the committee that nurses should not be put in situations where they were faced with having to prioritise care due to lack of staff. But if they did find themselves in such a situation, they should be empowered to pass on their concerns, he said.

“[In] a circumstance where a nurse comes on duty and discovers there are two nurses and 30 patients – all in desperate need – and clearly she has to prioritise what she does… What she must do, and is under a duty to do, is to inform her manager that this can’t possibly go on.

“I want to ensure those who are professionally responsible on the frontline are not just left with nothing to do, I wish to see them empowered to express a view and by doing that they are defending their own position,” he told the MPs.

“Let’s use that defensiveness to ensure the responsibility gets to where it should be where someone is capable to do something about it,” he added.

The barrister, who led the probe into Mid Staffordshire Foundation Trust, said the increased transparency and accountability should be backed up by new minimum staffing tools developed by the National Institute for Health and Clinical Excellence.

These should cover both the ratio of staff to patients and the skill mix between registered and non-registered staff.

The tools would provide “evidence based guidance” to trusts, so they knew whether they had enough nurses to “provide safe and proper care in an individual clinical setting”, Mr Francis said.

MPs asked why he had not recommended a general minimum staffing ratio. For example, the Royal College of Nursing said in 2006 that skill mix should not fall below 65 registered nurses to 35 healthcare assistants.

But Mr Francis said: “It is difficult and probably not helpful to have overall staff ratios because circumstances change on a day-to-day basis.”

He also told the committee there was a lack of accountability throughout the NHS. “By that I mean anyone from a sister running the ward to the head of the NHS and secretary of state,” he said.

Everybody in the NHS should be “personally responsible for their actions and have to reflect on that”, he said.

Readers' comments (31)

  • In reality, nurses do share their concerns with the Heads of Nursing and senior nurses. It is their decisions that need to be questioned

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  • "But Mr Francis said: “It is difficult and probably not helpful to have overall staff ratios because circumstances change on a day-to-day basis.”"

    maybe difficult but not impossible otherwise how do other countries manage to have legal minimum ratios?


    Has Mr Francis read the NMC code of conduct?

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  • wonderful. does NMC have a virus? I just tried to access the site to look at the code and my IE9 has stopped working with a message from say windows will close the programme!

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  • What a joke! We are continually being told that we don't have the budget to book extra staff so guess what? nurses cannot give the care they would like and patients and families complain! Ward Managers should be held responsible for this not the poor overworked nurse !

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  • if our patients complained we asked them if they would like to complain to the direction. the serious ones did!

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  • Audit Trails of Complaints/Concerns need to be introduced so those who ignore/victimise can be brought to book.

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  • Perhaps Francis ought to have said Senior Management should be expected to be able to read, understand, verify and act upon reports made by front line staff who should not be classed as 'whistle blowers' but as responsible professionals fulfilling one of the responsibilities which go with their job.

    But that would put responsibility for and awareness of any 'mishaps' or potentially bharmfull situations firmly on the shoulders of those who are in a position to rectify such problems.

    But isn't that one of the tasks in their remit?

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  • michael stone

    I think Francis and I are thinking along similar lines (I've posted several times on this - one being):

    Comment on: Toby Knightley-Day: 'Nurses should take ownership of the Friends and Family Test'
    DH Agent - as if !'s comment 23-Jan-2013 11:01 am

    There is a definite flavour of the day, that NHS services are to be assessed by patient experience as well as by easily measurable outcomes. Nurses have this 'advocate for the patient' position, and if you ask 'well, aren't doctors also doing their best for patients ?', I think the obvious conclusion is that nurses have this advocacy role, because they interact most directly and often with the patient (amongst clinicians).

    So, while I do not want clinicians to design the feedback mechanisms necessarily (I would prefer the simple 'instruction' to patients and relatives 'Please tell us, if you think we are doing something wrong'), I think logically it is almost impossible to deny that nurses are the best-placed clinicians to collect patient feedback 'in the round', and to pass this feedback upwards.

    'once we get past the issue of capacity and time and yet another form to fill in'

    I do not want, this feedback from patients to be 'form-based': I would like nurses to have 'an officially sanctioned role in collecting and passing on informally-gathered patient feedback': I would like nurses to be empowered to say 'We work with the patients, and having discussed what they are telling us nurses, many patients are not happy about ......'.

    But yes, it does require a culture change, and yes it is about authority and decision-making (however, my proposal does not affect who eventually makes decisions - my suggestion, would be to introduce more transparency into the grounds on which decisions are based, and the problems considered important).

    Instead of the 6 C's, I would like front-line nurses to act as 'Guardians of good culture' on an official basis: if nothing else, this would to some extent address the 'we are never listened to' complaint.

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  • My 36 bedded surgical unit was staffed with 3 trained and one untrained at night, same at weekends, and four and two on weekday mornings, three and two on weekday afternoons. We were elective and receiving, and on most days of the week we considered this to be an unsafe level of staff due to the workload. The response was that we had a full complement and could not therefore be considered "short staffed". I was also admonished for completing incident forms on occasions when i really felt we were not coping, and was told not to submit further reports, as all incident reports pertaining to staffing were being deleted unless a patient was willing to be named as having complained about staffing levels. When patients are asked this, they decline because they don't want us to get into trouble! We need official ratios, every day of the week, regardless of the area we work in, just like the Australians do...

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  • it doesn't sound like good management or good nursing practice to have to wait until a patient complains! what a mentality. one would imagine that managers are also concerned about their good reputation!

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  • Anonymous | 13-Feb-2013 12:47 pm

    Australian Nurses actually took industrial action, including working ONLY their rostered hours, taking to the streets in marches and going on strike (ensuring the provision of emergency cover and essential services) to achieve decent staffing levels. They are active within their unions and they have robust union leadership. They don't accept the bullying behaviour of management and are well supported by the public. Nurses in this country simply aren't up for the fight.

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  • The Francis report states that nurses must be more open and transparent but we have been instructed by our trust that we are not to communicate with the media etc. We tell the managers that our staffing levels are dangerous but they don't care - so who else can we tell without putting our jobs on the line? Our trust has just been highlighted by the union for its low staff morale - which the management denied, but how can nurses make their views known when we are effectively gagged? I cannot provide the care to a standard that I aspire to because the staffing levels are so low - and if anything goes wrong, its always the nurses who get the blame - its no wonder our morale is low!

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  • Dear Nurses all of you. Join Patients First UK www.patientsfirst.org.uk and we can support and advise how to raise a concern over patient safety. We have a strong voice and we are growing bigger every day........supporting nurses and doctors throughout the UK. regards. Patients First Scotland.

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  • this is so true, on previous threads i have tried to get this point across. i am deeply saddened and worried for nurses who are experiencing difficulties like this. Managers don't care and when it comes to the crunch we are used as scapegoats.

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  • I raised my concerns to my manager, then her manager, and then her manager. I ended up with a discaplinary letter, because my managers were "dismayed and disappointed that I continued to talk about being short staffed, despite them telling me about the BUDGET"!!! - I found a new job!
    Maybe Francis would like us to write directly to him when staffing is an issue, because nobody else wants to know!!!!!

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  • As a Student Nurse in the 80's training at a London hospital, we were belittled by our then Nurse Manager, when, after one particular night-shift working on an incredibly busy cardiology ward, we voiced our concerns about the dangerous staffing levels: 1 RGN, 2 students and 1 Care Assistant. It had taken some courage to go and speak to her, but we came away feeling that we had wasted our breath - and her time -, that our concerns were not important, and that there was no point in trying to improve the situation because nothing would alter. It seems that over the 20+ years since then, it has steadily got worse, and we have well and truly reached crisis point! How can anyone possibly deliver appropriate, high standards of patient centred care, with any degree of compassion, patience and kindness, when it is a case of crisis management -across the board now - the minute you start your shift? I despair.

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  • tinkerbell

    Anonymous | 13-Feb-2013 2:24 pm
    thanks for this link. Just reading through it later and will probably join. I'll join anything that will give patients and nurses a fighting chance to receive and offer quality care.

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  • To all those who have difficulty in making themselves heard !

    Whistleblow to the CQC anonymously if you wish.

    Ensure you say "Patients are being put at risk because of ............"
    Make sure that you mention that your management will not listen/take action/ignore incident reports etc.

    Here is the link to the CQC guidance document which you can download.

    http://www.cqc.org.uk/sites/default/files/media/documents/rp_poc_100494_20120410_v3_00_whistleblowing_guidance_for_employees_of_registered_providers_afte_pcaw_comments_with_changes_tracked_for_publication.pdf

    Most important ! The CQC telephone number
    03000 616161

    Make sure all your colleagues have this number.

    All that is left for you do do now is make lots of calls!

    The CQC will respond - post Francis report they will not take any chances!

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  • yes, nurses should be enpowered but they are not, no-one cares what we think. do people seriously think anyone cares what good honest hardworking nurses do all day or what they worry about. of course not.

    anyone who has ever tried to raise a concern will know that it is a complete and utter waste of time, you just bang your head against a wall, do your best and go home knowing that it's a complete crap job.

    yes, we report it, we go to our unions, our managers, our reps, our governing bodies - goodness me some of us even threaten strike action, get in touch with the cqc, go on marches but we are nurses and we are at the bottom of the pile.

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  • Anonymous | 13-Feb-2013 5:38 pm

    "yes, we report it, we go to our unions, our managers, our reps, our governing bodies - goodness me some of us even threaten strike action, get in touch with the cqc, go on marches but we are nurses and we are at the bottom of the pile."

    Actually, (whilst some do), very few nurses do any of the above. When was the last time any nurses went on a march? And how many nurses were there? When was the last time any nurse participated in industrial action? It's too easy to 'list stuff' that only a few nurses, in relative terms, have ever done. The vast majority of nurses in the UK do not complete incident forms (or insist on feedback once they have done so); have never raised a concern with the CQC; don't get in touch with their unions about staffing issues; have never voted in a union ballot; have never gone on a march; have never lobbied their managers; and certainly haven't even considered taking industrial action of any kind. By all means, have a good old moan, but let's not kid ourselves that nurses do anything that is effective to change the situation. They don't.

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