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Ward staffing pressures leave vital care undone

A “staggering” amount of necessary care is left undone by nurses at the end of shifts because of staffing pressures, according to latest findings from a landmark nursing study.

The study authors said there was also a “clear relationship” between the number of tasks left incomplete and the number of registered nurses per patient.

The latest subset of interim results from the RN4CAST study into Europe’s nursing workforce was presented last week at the Royal College of Nursing international research conference in London.

Previous findings from the study, published in the BMJ in March, showed nurses in England were second only to Greece in considering themselves burnt out. 

The new data is focused on nurse staffing levels in England and their impact on care. Researchers from the National Nursing Research Unit at King’s College London and the University of Southampton surveyed nearly 3,000 nurses working on around 400 general medical and surgical wards at 31 acute trusts.

Nurses were asked how many staff were on duty on their last shift. The average registered nurse to patient ratio was nearly 1:9, ranging from 1:8 during the day to 1:11 at night. There was also significant variation between trusts, from five registered nurses per patient at the best to 11 at the worst.

Nurses were also asked whether necessary tasks had not been completed due to lack of time and which out of a list of 13 activities had not been done. Overall 87% of respondents said at least one necessary activity was left undone. 

Two thirds of nurses said they had not had sufficient time to “comfort or talk” with all patients who needed it and half had not been able to spend sufficient time educating patients and family. In only one area – pain management – did less than 10% of respondents report finishing their shift having left a task incomplete (see below).

NNRU deputy director Jane Ball, who presented the results, described them as “staggering”.

“Nurses are reporting significant amounts of care that is being left undone due to lack of time,” she said. “This is a significant volume across a wide range of care that is being reported as left undone.”

The researchers also found the number of necessary tasks left undone was linked to the nurse to patient ratio.

Ms Ball said: “There is a definite relationship. In the best staffed areas nurses reported an average of three aspects of care left undone, where on the worst areas, it’s more like four or more.”

The findings add to growing evidence of the importance of staffing levels in ensuring quality of care, at a time when NHS managers are increasingly seeking to cut nurse posts in order to make savings. 

As reported by Nursing Times last week, Unison carried out a snapshot survey of nearly 1,600 nurses on 6 March. It found 70% believed staffing levels in their ward or care setting was too low to deliver “safe, dignified, compassionate care” and 91% backed minimum ratios.

A Nursing Times survey carried out in February found a similar percentage of nurses believed staffing levels had regularly dipped below safe levels over the last year and 72% wanted mandatory ratios introduced.

The RCN also supports mandatory nurse staffing levels. Delegates at RCN congress last April voted overwhelmingly in favour of their introduction. 

RCN director of communications Fiona Johnson, who chaired the conference session, called on the profession to “bang the drum” about the new findings and use all its “networks and opportunities” to highlight them.

Jill Maben, the director of the NNRU who was recently appointed as an expert advisor to the Nursing and Care Quality Forum, said she would give the data to the forum’s “time to care” workstream.

She said: “We have an opportunity at the moment in that we have the Nursing and Care Quality Forum. I’ll be making sure this evidence gets to the group.” 

However, the topic of nurse to patient ratios remains open to debate, with some in the profession believing that differing patient acuity levels make it too complex to set ratios, and others warning the minimum ratio could end up being viewed by managers as a maximum level of staffing they need to be safe. 


Snapshot reveals levels of incomplete care                           
Task: Percentage of nurses who said task was left undone at end of shift:
Comfort/talk with patients 66%
Educating patients and family      52%
Develop/update nursing care plans    47%
Adequate patient surveillance 34%
Adequately document nursing care  33%
Oral hygiene 29%
Frequent changing of patient position    28%
Planning care   28%
Administer medications on time 23%
Skin care    21%
Prepare patients and families for discharge      20%
Treatments and procedures    11%
Pain management  7%
Source: RN4CAST study 

Readers' comments (19)

  • I work 1:10 during day 1:15 night. The HCA's have been increased but there are so many tasks they are not allowed to do and this puts too much on the staff nurse.
    I do not leave my shift feeling satisfied with what I have achieved I leave feeling I have failed my patients as so much is not done and even though you hand it over you know the next shift will be probably not have chance.
    The final kick in the teeth comes when it is your fault when something is not done following an audit.
    I would welcome mandatory staffing levels.

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  • where I worked we did not leave the ward until our work was completed unless it could, safely and without detriment to the patients or risk being forgotten, be put off until the following day or later in the week or even later depending on its importance, when there were more staff or more time, if there were a larger quota of staff on the following shift or if our colleague or colleagues on the next shift agreed or offered to take over the tasks.

    but then in different hospitals, in different parts of the world, with different organisation of work, at a different point in time allowed for this wheras in many instances it may no longer be possible.

    It seems in this disastrous economic climate the whole system in the UK and globally needs to be scrutinised under a high powered microscope to find new ways of producing goods and delivering services in the most efficient, rapid cost effective manner without compromising quality in any way and without losing the vital and central focus on needs of each individual as both provider and user of goods and services.

    If we are to survive, each and everyone of us needs to be involved in, and take responsibility for, every stage of this endeavour no matter how small or large our contribution.

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  • so the evidence is there, what happens now?

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  • George Kuchanny

    Indeed Anonymous | 1-May-2012 11:49 am
    What should happen is that every single ward in the country should be examined by every single line manager. And examined properly. From the right perspective.

    That is what should happen. Now.

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  • Right we have now got the evidence what will happen now, NOTHING as the trusts will say they have no money so no more nurses. Why is it that when trust restructure to save money it is not upper management that are decreased it is the workers on the shop floor.

    i would like to see mandatory staffing levels but they would not be met.

    I am frequently working on a ward that is short staffed as it is a flex ward that has got no money to employ the multi-disciplinary team it needs to be effective. The ward was supposed to close but due to bed pressures it is still open.

    This government keep saying that they want to improve the NHS no they don't they want to run it into the ground, as for patient care well they all go to places that have the correct patient to staff ratio or Private. so don't see what they are doing to the NHS.

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  • No surprises there then!!

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  • The main problem with nurses and getting their essential, financial, needs fulfilled is, I believe due to their failure to back their union representatives, and lack of support, when they are asked to take any kind of industrial action. Patients don't suffer because nurses strike, they suffer because they don't.

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  • I feel sad that someone has seen fit to post the following
    "where I worked we did not leave the ward until our work was completed unless it could, safely and without detriment to the patients or risk being forgotten, be put off until the following day or later in the week or even later depending on its importance, when there were more staff or more time, if there were a larger quota of staff on the following shift or if our colleague or colleagues on the next shift agreed or offered to take over the tasks."
    Fine when it was only once in a while and every now and again you got off early but why should anyone have to do unpaid work every day because they are being asked to look after too many patients all the time. Why should any of us feel guilty for wanting to be paid for working?
    As others have said there is now a proper study to back up what nurses have been saying for a long time so what will happen next? I wait in hope

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  • Not new, nurses have been highlighting this problem for a long time, but unfortunately they don't do it in the right why, by trying to 'cope' and failing to fill in incident forms each time there is under staffing,they do their [patients a huge disservice.
    They allow management to get away with disgraceful ratios who know full well that when the poop hits the fan the blame will fall on nurses for not caring or daring to have degrees.
    Until nurses stand up and fight for better ratios, they will continue to be walked all over and not only them but their patients will suffer. but they prefer to moan in the staff room, or polish their halo and proclaim what a martyr they are for their patients.
    wouldn't even need a strike. A work to rule and the immediate stoppage of unpaid hours would be sufficient.
    I honestly believe if nurses made a stand on ratios for their patients benefit they would gain public support.

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  • Florence

    I work 30 hours per week over 4 days or 3 nights. I am usually late in finishing by 30 -40 mins at least twice a week. This is because I have to complete essential documentation I know I delegate and handover tasks appropriatley. I only get paid extra if I stay late to attend a meeting. We do not consistently recieve any time owed back.Most of my colleagues are late getting off with the same frequency as I am and for about the same amount of time. Our documentation is robustly audited and quite rightly so as this is essential. However a false picture is being painted. I find it impossible to complete our carepathway during the shift as Im generally helping my HCA to complete the food, fluid and comfort charts. I feel rushed , stressed and disatisfied as I cannot give the standard of care the Patients deserve.

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  • And now we are being told we need to improve our hourly wardrounding.

    What's the point in a very expensive survey being carried out.

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  • no worrries, once the PMs directives of hourly rounds are implemented all will be well once again!

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  • Anonymous | 1-May-2012 10:17 pm

    I agree completely. I used to contribute regularly to NT, but have more or less stopped. The moaning without actually doing anything effective is the biggest problem facing nurses today. I can't stand it.

    I will continue to vote in union ballots and take industrial action when required (if enough get of their backsides and actually vote). I will continue submit my adverse event reports when staffing levels are too low. I will continue to work to my prescribed hours - no more, no less (and it took years for me to learn that lesson). I will continue to lobby my local MP, union leaders, managers, colleagues, patients and anyone else who will listen. But in my heart of hearts, I know that my greatest enemy is the apathetic martyrdom of the vast majority of my colleagues, who will NEVER learn or acknowledge the harm they are doing by facilitating and perpetuating the status quo.

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  • anonymous 3- May- 2012 8:39am

    ok point taken, we are trying to do our best within the constainsts we are battling against. On that particular shift at that particular time we are doing our best! Yes we are doing ourselves no credit but leaving our patients when they need us is that a crime! I understand what what you are saying though, but we are human and we feel for the next shift.

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  • Florence

    It is true that as Nurses we are often our own worst enemy by doing the unpaid overtime. I do so regularly and it has almost become accepted practice in our area. Apathy and a lack of willingness to change is not the issue in my area of practice. I regularly complete the incident forms and as a clinical area we are always reviewing our practice. To see where we could improve our time management. We are also forever highlighting our concerns over staffing levels to management.The reality is that our staffing levels are not appropriate for the speciality.On a personal level as a Nurse it is part of my job to complete concise written communications. Its also the fear of litigation and disciplinary action that motivates me to stay behind and complete the paperwork. Myself and my colleagues simply cannot,on most occasions stop during the shift and complete paperwork. The only way I can do it is take the documentation into our ward based staff room and complete it during my break!!! Why should I ?? Its true we are our own worst enemies. At least this has motivated me again to speak to my manager and raise this at our next team meeting. Less moaning Mo !! More action !!

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  • Anonymous | 3-May-2012 11:06 pm

    So you will continue to perpetuate the dreadful system in which you work.

    What needs to happen, is a complete shift in the thinking of many nurses. If what you are doing currently, leads to hours of extra, unpaid work which have become the norm, then you are giving permission for your employers to take full advantage of that. Why employ more nurses, when the staff you already have will work for hours without the need the compensate them in any way? Better still, you can continue to increase their workload because they will never challenge you in any meaningful way or in significant numbers. When things go wrong with patient care, you can always blame the nurses, they'll probably think that it's their fault anyway and will accept the blame. They are fractured, politically naive and lack the courage to even walk off a ward in time. Plus you can freeze their pay, change their conditions and attack their pensions (making them work longer, pay more and get less). They won't object at all. The perfect workforce.

    Anonymous | 1-May-2012 7:14 pm is absolutely correct. We are hurting our patients by allowing this to continue.

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  • Thats why i left the ward environment, BONKERS!! How can 1 person be made reponsible for the care of so many patients?? How I didnt make major mistakes and/or kill anyone Il never know. I don't miss going home feeling like a burst ball either!

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  • Ditto. I had to leave for my own mentality. I could see a 'big bang' coming my way and I wasn't going to be accountable for it. the conditions were dreadful and patients weren't receiving the care they deserved. Bye bye to the clinical area and I will never go back. I'm repeatedly told, 8 years down the line its sooo much worse now. That's hard to picture and very sad.

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  • What is the answer then? pack up and go home at shift end thus leaving work undone? There will never be enough staff - I have worked in NHS for 39 years and the staffing issue has mostly been dire.There have been patient dependency models but staffing did not alter really but I was allowed to close beds if staffing : patient dependency indicated this but this idea did not last long!

    It will never change unless nurses as a whole are proactive - maybe striking, work to rule but I could not do this - so not sure how we will change nursing numbers.
    As anonymous stated - Nurses "...are fractured, politically naive and lack the courage to even walk off a ward in time. Plus you can freeze their pay, change their conditions and attack their pensions (making them work longer, pay more and get less). They won't object at all. The perfect workforce".

    What is the answer? Our patients need something sorted, as do we as nurses.

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