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'Failure to rescue' linked to higher HCA ratio

The higher the ratio of healthcare support staff to hospital nurses the more likely surgical patients are to die from potentially treatable complications, a UK study has found.

Researchers from the University of Southampton and Dr Foster Intelligence analysed data on staffing and outcomes from 146 hospitals in England between 1997 and 2008.

Their study, published in the International Journal of Nursing Studies, showed the more support staff were employed, compared to registered nurses, the higher the rate of “failure to rescue” in hospitals.

Hospital trusts has regularly been accused of diluting the registered workforce by employing increasing numbers of cheaper support staff.

Lead study author Professor Peter Griffiths, chair of health services research Southampton University, said they had found no strong evidence that having more HCAs helped registered staff work more effectively.

“There is simply no support here for increasing the proportion of HCAs in order to improve registered nurse efficiency,” he told Nursing Times.

Last week it was revealed that London’s acute trusts saw a 5.7% rise in the number of HCAs they employed from 2010-11 to 2011-12. The numbers rose from 6,827 in September 2010 to 7,215 in September 2011, health minister Daniel Poulter said in answer to a parliamentary question.

Overall, the study found patients in hospitals with more nurses and doctors had a significantly lower risk of failure to rescue.

“Lower rates of failure to rescue were associated with a greater number of nurses per bed and doctors per bed,” the study authors said.

However, they also found that a higher number of doctors relative to the number of qualified nurses was also a factor in reducing mortality risk – suggesting that failure to rescue was not a specifically nurse sensitive indicator.

The authors also found a steep increase in deaths among older patients compared to younger ones. Although this would be expected to some extent, they said, there was no obvious reason for such a sharp increase.

For example, the failure to rescue rate was 1.6% for patients aged 18-39, but 0.5% for those aged 65-75 and 20.6% for those over 75.

The research follows on from the final results from one of the largest workforce studies of its kind, RN4CAST, which was published last year and provided significant evidence linking the hospital nurse workforce with quality of care.

Royal College of Nursing chief executive and general secretary Peter Carter said: “This research confirms what frontline nurses know: having too few nurses on a ward does not just make nursing more difficult, more importantly it puts patients at risk.

“As this research shows, it is not only the number of staff which presents this danger, it is the level of skill available on a ward at a given time. This must include enough registered nurses, who are fully trained in identifying that a patient is deteriorating, and able to intervene themselves or summon the correct help.”

He added: “We believe that there should be a guaranteed ratio of registered to non-registered nursing staff on duty. This report contains further undeniable evidence, if it were needed, of the clear and present danger of low staffing levels in UK hospitals.”

 

Readers' comments (35)

  • I reject this piece of research!

    England's Chief Nurse who is based in the Department of Health has stated that the only problem with Nursing and Nurses in this country is the blindingly obvious (to her ) need for nurses to possess more "C's" preferably a clutch of 6 !

    Take notice of this deluded woman ! She has got a real grip on the nursing professions problems !

    These problems have nothing to do with increasing patient dependency, poor RN staffing levels and excess numbers of care assistants. Poor "management", targets and a tick box approach to providing care are all supported and endorsed by the Chief Nurse(England).

    These researchers from nasty Dr Foster and the Southampton University will really have to be reeled in and silenced. There is a huge risk that people will believe what they say and the "6C" initiative will be exposed for what it is worth which precisely nothing ! It is nonsense !

    But please don't tell anyone that it was me that told you !

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  • How much research does the Government need to recognise that not having enough registered nurses costs lives?

    The Mail published an article about the above yesterday. Over 300 responses and many quite vitriolic towards nurses. I find it depressing.

    I can see this getting a lot worse before it gets better. We really need stronger leadership, sooner rather than later.

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  • michael stone

    This piece of research has the huge plus-point of having analysed data from UK hospitals: all too often, foreign research, where there will inevitably be more variance from UK/English health-system circumstances, seems to be quoted as a guide to what the NHS ought to do.

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  • DH Agent - as if ! | 23-Jan-2013 10:40 am

    sad NHS don't take more lessons from abroad in countries with highly functioning and more successful services!

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  • michael stone

    Anonymous | 23-Jan-2013 10:49 am

    It depends on the thing being discussed - with different types of ratio between what we call HCA/nurse/doctor in other contries, and different qualifications within those categories, simply lifting studies from foreign systems is flawed. This isn't like testing whether a particular antibiotic kills a given bacterium.

    Lots of 'evidence' in the NHS is about systems that are so complex, as to make the evidence fairly dubious. Consider complaints about treatment in Care Homes - I have no doubt that there were figures before Winterbourne View, and those figures would have been used as the basis of various analyses, but after WV the number of reported incidents increased manyfold !

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  • http://tinyurl.com/9wrny4b
    This is the full article. Obviously as a manager, I have the time to read this. Lying on a chaise longue being fanned by ostrich feathers and eating peeled grapes.....
    The BIG caveat if you look at the conclusion is that they didn't disaggregate medical staffing. So you might have "enough" nurses but then not enough doctors to e.g. approve a dose change or carry out some sort of intervention (a high number of patients are medical not surgical). They also include day cases, which is a bit weird (younger, healthier people more likely to have that than complex elderly?). Plus they didn't measure what comorbidities patients had on admission.
    But the literature in surgery elsewhere shows that it isn't "the more you do, the better you are" it's actually inversely proportional to activity. There's a closer correlation between good outcome and e.g. ratio of nurses to patients in ITU or infection control (etc etc).
    Oooh, roast swan for lunch, must dash.

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  • DH Agent - as if ! | 23-Jan-2013 11:13 am

    sad NHS don't take more lessons from abroad in countries with highly functioning and more successful services!

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  • Re comment by 'The manager' above. Thanks for engaging in the full paper and you are quite right - we were unable to dis-aggregate qualified staff for some analyses - the finding the having MORE doctors per nurse (or more nurses per doctor if you like) is associated with higher levels of failure to rescue is instructive though - clearly you need BOTH and medical input is crucial here. We included day cases because this ensures that the population studied is constant across hospitals - day case rates still vary hugely. Because few of these patients experience life threatening complications few of them are likely to enter the analysis though. [Peter Griffiths - lead study author]

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  • I don't think it is the amount of HCAs to Nurses is the problem with failure to rescue but the problem lies with the person who play's doctor and recognition of a time to act . The signs of a patient deteriating can easily be reported to the appropriate staff however, it is when to act is the biggest descision and this is rearly made by HCAs. Chain of command and who decides to call the doctor or the emergency team. Even though more staff is required to tailor for the ever growing patient numbers in hospitals and care homes.To deal with new and complicated illnesses training will have to be provided to those who work in high risk areas of nursing to maintain life until the nurse or doctor arrives.

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  • Colin Jordan

    I don't think it is the amount of HCAs to Nurses is the problem with failure to rescue but the problem lies with the person who play's doctor and recognition of a time to act . The signs of a patient deteriating can easily be reported to the appropriate staff however, it is when to act is the biggest descision and this is rearly made by HCAs. Chain of command and who decides to call the doctor or the emergency team. Even though more staff is required to tailor for the ever growing patient numbers in hospitals and care homes.To deal with new and complicated illnesses training will have to be provided to those who work in high risk areas of nursing to maintain life until the nurse or doctor arrives. And perhaps this is the reason for more registered nurses to be borne in to the system because of there training?

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  • HCAs and nurses have to be capable of judging the signs of deterioration in a patient and take appropriate action and when to call a doctor. when it is not an immediate emergency it is often a question of keeping the patient under very close observation and administering the necessary care. this is made exceedingly difficult in areas where patient care demand is very high and in the absence of adequate staffing levels of all grades and cause observations of vital signs or treatments to be missed.

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  • I would argue that what we need is staff trained to spot deterioration - and some registered nurses are sadly poor at this. In my opinion we will shortly see HCAs evolving to become the new enrolled nurses and they will be good at their job.

    Remember that huge amounts of nurse education is in psychology / sociology etc and thus not necessary in a rescue scenario... So perhaps well trained HCAs could be a vital part of the solution? Dr Carter seems to be denigrating the HCAs he wishes to recruit to his union as he wants their money.

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  • There are a number of issues involved here - trained staff: HCA staffing ratio's. Medical officers experience, bed blocking and trained staff experience and a system that often prevents timely intervention.
    When I worked in the US on a busy surgical unit, I was responsible for 6 patients total. A HCA would be assigned to work with myself and another nurse...taking care usually of basic care needs. As a RN I was required to complete a head to toe physical assessment every 4 hours of my shift and document. If I assessed changes, or if it was evident any of my patients had ran into difficulty I would call a resident, but if he/she couldnt respond in a timely fashion or give me appropriate orders over the phone, I would call the consulting physican, give him/her the findings of my head to toe physical assessment- changes found and obtain orders over the phone and put them into action....this is critical, putting orders into action whilst waiting for a doctor to arrive on the floor makes a huge difference.
    I have to say working in the US was the only time I truely felt like the professional I was trained to be. Trying to attend to the needs of 10-12 patients in the NHS is a nightmare and soooo unfufilling!

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  • Anonymous | 23-Jan-2013 2:20 pm

    if nurses are not capable of spotting deterioration in their patients they have no place on the register of qualified practitioners. Full Stop!

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  • 23 jan 2013 2:57 pm
    that sounds about right BUT!!!!! Iam a higher clinical support worker as the name dont mean anything to any one grades higher unless to get them out of the sh*t because thay have too much paperwork?
    sorry we are the eyes and ears for staff nurses and do the job thay dont want to do?

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  • there is enough evidence to PROVE that patients survive better when there are enough suitably experienced staff to look after them, notice when they deteriorate and know how to care for them until medical help arrives.

    There is no excuse, HCAs do a wonderful job, nurses do a wonderful job, critical care outreach teams do a wonderful job, doctors do a wonderful job, the trouble is, there are not enough of any of them and there are not enough critical care beds.

    Surely the solution is to ensure you have enough of the right staff, suitably experienced and trained in the areas where they work - doesn't matter if they are trained nurses or HCAs. Everyone should have the knowledge and confidence to know how to recognise a sick or deteriorating patient and know how to look after them.

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  • George Barnes

    Jenny Jones | 23-Jan-2013 3:33 am

    You took the words right out of my mouth!


    Peter Griffiths | 23-Jan-2013 1:25 pm

    Could you please ensure our venerated leader "England's Chief Nurse" gets a copy of your report - you can scribble six "C"s in all of the margins if you want to ensure she reads it!


    The Manager | 23-Jan-2013 11:22 am

    Good to see you have gotten into the habit of using a "moniker" - it really does allow people who follow your messages over a period of time to 'recognise' you and appropriately weight the importance of your replies. I have personally already given you a high rating - not only do you know what you are talking about but you also have a wicked sense of humour - but don't tell Tinkerbell I told you that... she gets jealous very easily!

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  • Thank you George! Kind of you, but I don't really know much, which is why I read these posts because they're more edifying than most of what's in my inbox. BTW I am sat on my sofa unable to work out how to zip together the onesie I got for Xmas so am just using it as a blanket. Can you imagine what a disaster I'd be on a ward?!

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  • The Manager | 23-Jan-2013 7:05 pm

    here we go with the jargon again. what on earth is a 'onesie'. I can only conclude from your comment it is some sort of jumpsuit (for Managers)!

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  • Anonymous | 23-Jan-2013 7:27 pm

    Google it. It isn't jargon. Don't let ignorance fuel your comments. Oh, and onesies are for everyone.

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