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Survey: low staff levels threaten care

Seven out of 10 nurses believe that staffing levels in their ward or care setting are inadequate to deliver “safe, dignified, compassionate care”, a snaphot survey has revealed.

The overwhelming majority of respondents also supported the introduction of minimum patient to nurse ratios, the research by Unison found.

The union carried out a snapshot survey on 6 March, asking UK nurses working shifts during a 24 hour period to record information on staffing and workload as well as their views on the situation that day.

Initial findings from the research, covering the views of nearly 1,600 nurses and healthcare assistants, have been published in a report today. It was presented at Unison’s healthcare conference in Brighton.

The report – titled Care in the Balance (attached, right) – said 73% of respondents felt they were too understaffed to provide safe, dignified and compassionate care and 91% said they were in favour of the introduction of minimum nurse to patient ratios.

One nurse said she was upset after four patients were left in wet beds for too long. She said: “This is unacceptable and upsetting seeing standards of care drop because of staffing levels, or should I say lack of staffing levels.”

Another respondent said: “Crisis has become the norm.”

In addition, many respondents reported being unable to take breaks or meals due to what the report said was “unreasonably high workloads”.

Another major concern of staff highlighted by the survey was the repeated use of agency or bank staff, who were viewed as not having the same workplace knowledge as regular staff and were not always able to work at the same speed or standard.

Nurses also said they felt they would be held accountable if anything went wrong regardless of factors such as understaffing.

The survey also found almost two thirds of staff, 62%, reported working some overtime on 6 March with only one in 13 receiving any payment for it.

The findings chime with a Nursing Times survey last year which found more than 75% of nurses feared for their patients’ safety due to inadequate staffing levels, poor ward layout and the bad attitudes of colleagues.

The Unison survey results will fuel the debate over whether mandatory minimum staffing levels should be imposed.

Such ratios have already been introduced in California and parts of Australia, and are favoured by UK healthcare unions and some academics.

However, patient ratios remain a controversial issue for the profession with some nurses feeling it would be too complex to account for factors such as variations in patient acuity or staff sickness absence. Others have warned that setting a minimum could actually lead to employers viewing a minimum ratio as the maximum level of staffing they need to be safe.  

Chief nursing officer for England Dame Christine Beasley told the Mid Staffordshire Inquiry in the risk was “instead of becoming the floor, they become the ceiling”.

Unison head of nursing Gail Adams said: “I understand the complexity and people’s apprehension about it becoming the norm and it becoming a ceiling. But the reality is from what nurses are telling us is that we are already there. I think very much that nurses feel we’re already at the bare bones.”

She told Nursing Times the finding that “surprised me and actually worried me most significantly” was the high percentage of respondents concerned about inadequate staffing levels on the day of the survey, which she said was not a “bad day” in terms of general demand.

“We didn’t have seasonal weather affecting staffing, we didn’t have high episodes of flu; it wasn’t a Monday where there had been loads of emergency admissions over the weekend. On that bog standard day about 70% of respondents said their staffing levels weren’t adequate to deliver effective, compassionate care.

“That we didn’t expect. We expected some people to say it but not the overwhelming majority of respondents, so that for me indicates we are at the bottom level.”

The Department of Health and NHS Employers, which represents trusts, have so far rejected calls for the introduction of ratios.

NHS Employers director Dean Royles said: “We believe employers should continue to take advice from their own chief nurses and professional advisors as their main guide on staffing levels. National guidance to employers can be helpful but crude national ratios could be too rigid and limit the NHS’ ability to plan its workforce according to local needs.”

But Unison said it would seek to campaign for national legislation on staff to patient ratios and would be using the survey to discuss stafing levels with trusts.

Ms Adams said: “We’re not advocating a single nurse to patient ratio level, universal across every single service. What we are advocating is that we need to work collaboratively with others to identify minimum sets of staffing levels across different services to make sure they are appropriate.”

She said more detailed research on the patient to nurse ratios identified in the survey are set to be published later in the year, following external scrutiny by academics.

Readers' comments (18)

  • I am wondering if pts are scored on a daily basis to determine their acuity. It would seem that scoring indicators would help determine staffing levels.

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  • "She said more detailed research on the patient to nurse ratios identified in the survey are set to be published later in the year, following external scrutiny by academics."

    Has anybody carried out a meta-literature search on the patient to nurse ratios as there already seems to be a vast body of literature on this going back a great number of years and based on informed professional opinion.

    What is the point of waiting until later in the year for another report on a survey when all is needed is to heed the repeated evidence from nurses working on the front line and reports in the media, including the daily press, that there is a shortage of staff which impacts on patient safety and quality of care.

    Urgent action is now needed on the substantial evidence already available and not waiting for the generation of further research and reports.

    There was a report on CNN news last night 23.04.12 citing that the serious nursing shortage in the UK and that nurses are being recruited from Portugal to fill a shortage at the Queen Elizabeth Hospital in King's Lynn, Norfolk. I was unable to find a written copy of this report and in the video it appears that a large recruitment drive took place by the head of nursing in 2011 so it seems rather strange that last night (1) they were reporting this shortage now and (2) in view of the numbers of nurses now out of work in the UK and newly qualified nurses seeking employment.

    video of last night's CNN report of nurses fleeing Portugal to work in the UK

    Spanish and Portuguese nurses fill the gaps in the NHS

    Nurses are quitting crisis-hit Spain and Portugal for the UK, in search of better jobs and training opportunities

    • Michael Howie
    •, Tuesday 20 December 2011 17.00 GMT
    • Article history

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  • No wonder nurses find it so hard to stay compassionate in their work - minimum staffing ratios may well help them to remember why they came into the job in the first place!

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  • It doesn't help when Mr Lansley seems to imply quality of care is not increased by having more staff.

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  • reduce red tape and paperwork and quality of care will improve.

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  • I couldnt agree more with the above comment about excessive red tape and paperwork.

    I work as a bank nurse. I often have a very brief handover and have to rely on prewritten handover notes to look after a patient. If I need further information, trawling through copius notes and rambling care plans in the file isn't often an option due to time constraints.

    We really do need to get away from the tick box mentality that so prevails and invest that time in real patient care.

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  • Anonymous | 24-Apr-2012 8:04 pm

    isn't that an issue to be put to the new Nursing Quality Forum?

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  • this topic has gone on and on, and no-one is listening!! Why - it costs money.

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  • "Survey: low staff levels threaten care"
    Talk about stating the Bl***ing obvious.

    It isn't threatening care it is already affecting care!

    a nurse working finishing a 12 hour shift was told by the duty manager that she had to continue working to cover the night shift until a nurse was found. She was told that if she refused, she would be disciplined. She then had to work a further 5 hours.
    Managers do not care as long as they do not go over their budget.

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  • Anonymous | 25-Apr-2012 9:01 am

    surely she had the right to refuse and there must be some legal protection for employees - even nurses!

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  • anon 9.01

    I remember working with a nurse who offered to stay on to work the night shift after a late as the night nurse didn't turn up and he couldn't get any one to cover. He was threatened with discipline as he might 'not be safe' and told he had to go home, they would find someone from another ward.

    Nothing came of it of course but how things have changed. We are constantly being asked if we can 'just stay a few more hours' or work extra shifts during the week because bank nurses prefer to work the nights or weekends as the money is better.

    We keep on discussing bed shortages, lazy staff, poor managers and staff shortages, there are several threads going on at the moment about the same old subjects. Why do we need to keep on repeating ourselves.

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  • there will probably be loads more surveys and research reports to come and maybe nothing will ever be done about all the shortages, at least until there comes a major breaking point to force some kind of action.

    apart from front line nurses themselves, managers and others seem much more comfortable inspecting the work of others and reporting on it, and earning a lot of money through such activities (should I say more aptly passivities!) than actually taking any action. the same can be said for the authorities who commission this work, who may not even take the trouble to read the reports and really make an effort to understand the problems.

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  • I can not agree more to all the comments. Its really sad that such an issue is going on in a developed country as UK. I left the ward as a junior sister to the OPD clinic. The staffing levels on the ward was just so low. This was an acute surgical ward! Due to this, most bank and even agency nurses refused to take a shift on the ward. Even nurses rostered to work, will call in with excuses. Who blames them! No one wanted to work in such an environment. When we book more nurses, the shifts are cancelled due to 'costs'. The ward manager resigned and i followed for my piece of mind and sanity.

    The sad thing is, it is always the patients who suffer. There is so much a person can do. Even the best nurses are not coping. This issue has been going on for years! why is someone not listening. People are so quick to judge and blame nurses. This must change!!!.

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  • Anonymous | 25-Apr-2012 11:37 am

    "I can not agree more to all the comments. Its really sad that such an issue is going on in a developed country as UK. "

    not only a developed country, but one of the richest (previously classed in the G8 although I am not sure where it now stands but most probably still in the G20)!

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  • Stop giving vast sums of our taxes away to, Europe, India, and illegal immigrants, at this point in time when we're in a second recession, Mr Chancellor, and thenyou will find there will be plenty of cash in your coffers, to be able to reinvest in the NHS, Schools, Police, Fire and ambulance services, instead of trying to claw back a few crumbs by cutting these vital services.
    There are local elections coming up in May, so.... pulll your finger out and start doing YOUR job properly, for once.

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  • Anonymous 25:Apr-2012 11:31am

    Spot on with your comments 'managers and others seem more comfortable inspecting the work of others and reporting on it'
    I would like to add my own comment here of reporting on what nurses haven't done well and yes no solution to the problem well maybe some more paperwork thrown at it.
    Maybe more staff could help the problem - dream on.

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  • we never got praise or even acknowledgement from anybody in the organisation for work well done and when we got too much positive feedback from our patients our ward team was broken up!

    If we were overloaded when on alone and with an overflow in the corridors, a medical emergency such as a cardiac arrest, a patient pulling a central catheter out or unannounced admissions all we ever got was not a boss rolling up their sleeves to help but instead inspecting the ward to see what had not been done or telling you somebody was asking for something such as a bed pan when you are up to neck in an emergency, or a patient complaining that they had been left on a bed pan which happened occasionally but not without good reason. Sometimes, which must have something to do with Sod's Law, there are periods like this when work is particularly hectic and everything happens at once and then the negative feedback starts to accumulate and have a very negative effect on nurses.

    Instead of looking forward to going off duty one leaves the hospital with a tirade of internal negative talk, self analysis and self criticism asking oneself what one has omitted, forgotten, what could have been done differently or better, why others were angry, why one was short with somebody, etc.

    One day I woke up from this bombardment of negative behaviour when it occurred to me that i could walk onto my ward for a shift or walk onto any other ward (which we sometimes did to beg, borrow or steal and sometimes even to lend a helping hand or occasionally for a friendly or supportive chat) and
    I could also, without any knowledge of the work that had been done, note all that had not been done. For some reason this seems to stand out more than the good and important work done! I would not dream of offering such damaging criticism however and even if it is not my ward and I see the only nurse is rushed off her feet or otherwise engaged I have no difficulty in fetching or emptying a bed pan or lending a hand where needed, and if offered, accepting their thanks graciously, but no matter if not - but criticism where it is not merited or constructive and helpful to the other is most definitely not on my agenda.

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  • We are already working well understaffed when we spoke to the sister she was very angry about us having written a list of concerns i.e. patients not being washed and dressed before lunch and the impact that this had on care of others she said that she would look at levels over the next week then came back and said that we were staffed appropriately when I asked about an increase in the dependency of patients I was told that the patient dependency was not even an issue so I don't think that minimum staff levels will make any difference

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