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Nurse leaders divided over minimum staffing levels

Three of the most senior nurses in the NHS have warned the government against introducing minimum staffing levels, as the profession becomes increasingly divided over the issue ahead of the government’s response to the Francis report.

In a letter published in the Times today the three hospital directors of nursing say they “do not support Whitehall second-guessing what nursing levels should be for each hospital”.

The letter is signed by Eileen Sills of Guys and St Thomas’ Foundation Trust, Katherine Fenton of University College London Hospitals and Flo Panel Coates from Barking Havering and Redbridge University Hospitals Trust.

It comes in response to calls from the Prime Minister’s Forum on Nursing and Care Quality for the government to introduce a minimum ratio immediately to “bridge the gap” while more detailed guidance is developed by the National Institute for Health and Care Excellence.

As revealed by Nursing Times on Saturday, the forum has urged the government to “take account” of the existing “evidence that a ratio of more than eight patients per registered nurse significantly increases the risk of harm and constitutes a breach in patient safety”.

The letter in the Times states: “On the eve of the government’s response to Robert Francis’s inquiry into Mid Staffordshire NHS Foundation Trust, we want to urge caution when it comes to mandating minimum staffing numbers and ratios.

“The right numbers of staff will vary depending on the sickness and dependency of the patients and the skill of the staff. It is not something that can be mandated for a whole country.”

The government is expected to publish its full response to the Francis report tomorrow. As revealed at the weekend, it will introduce a new criminal offence for healthcare staff found guilty of wilful neglect.

It is also expected to include new guidance on setting safe staffing levels – seen by Nursing Times – which says boards should review staffing levels at least twice a year.

Readers' comments (29)

  • I can't say I'm surprised by the attitude of these three senior nurses. The one simple measure that the government could introduce that would benefit patients and staff equally would be to introduce minimum staffing levels. These three are thinking more about budgets than the welfare of their staff and patients.

    I'm now even more clear that the government needs to introduce the offence of wilful neglect to curb behaviours of managers with attitudes akin to these three.

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  • Unfortunately minimum staffing levels are not a simple measure to introduce and I don't support them either.
    One of the risks is that some organisations will see these as "maximum" instead of minimum staffing staff and we will have very little leverage in arguing for more when we have essentially said we can manage with a defined number. Clinical judgement in a live environment must prevail in my view.

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  • Anonymous | 18-Nov-2013 12:06 pm

    Reluctantly, I too find myself agreeing with three directors. That's a first.

    Unfortunately, the debate about staffing levels and skill mixes is a complete dog's dinner in this country. All led by a clueless government pandering to what it thinks the public wants to hear. Another disaster in the making.

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  • I pray every day that clinical areas and community teams could have the minimum number of nurses their establishments say they should have. Every night patients are being put at risk where there is 1 nurse instead of 2. Every day that there's one less nurse people have to wait longer, go without or suffer. We have establishments (even though they merge and disestablish to kid us we've got enough)
    If these 3 nurse leaders are confident they always have enough nurses in every area they are responsible for to give patients the time and care they need then I am a monkey's aunt.
    I'm sure Victorian cotton mill owners said the same thing about their staff. Shame on them for not living the reality to which they consign others.

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  • Anonymous | 18-Nov-2013 12:45 pm

    Couldn't agree more: it is easy for the three senior nurses to make statements like that from the safety of the boardroom, safe in the knowledge that they're not the ones that are going to have to face irate patients and their relatives on the wards and departments where staff can't appropriately care for them due to poor staffing levels.

    Minimum staff/patient ratios are not the whole answer but I think they would act similarly to the NEWS scores in that staff could use it as a 'trigger' to escalate concerns re staffing - it would give staff something concrete in which to base an argument on e.g. Why are there only 2 RGNs on duty when the minimum number for this many patients is 3!

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  • Anonymous | 18-Nov-2013 12:06 pm
    mags | 18-Nov-2013 12:14 pm

    I concur. Minimum staffing levels will become the maximum regardless of dependency. The variety of acuity tools are barely fit for purpose.

    Anonymous | 18-Nov-2013 12:45 pm

    "If these 3 nurse leaders are confident they always have enough nurses in every area they are responsible for to give patients the time and care they need then I am a monkey's aunt."

    I have sympathy with what you say. The motives of these people is always suspect. But on the subject of setting minimum staffing, these 3 nurse directors are actually correct. Appropriate and adequate staffing levels are not the same as minimum staffing levels.

    "“The right numbers of staff will vary depending on the sickness and dependency of the patients and the skill of the staff. It is not something that can be mandated for a whole country.”"

    For example, if the minimum mandated staffing level is set by the government at 1:8, then no further discussions will take place on whether or not that is appropriate. Anywhere working with levels of 1:6 or 1:7, no matter the dependency, will immediately lose staff. We all know that 1:8 is nowhere near adequate, so why let the government legislate on this and leave with no room to be flexible. Be careful what you wish for, you might not actually like it when you get it. Minimum staffing levels isn't what everyone hopes it will be.

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  • i tend to agree that minimum staffing levels will become a maximum- but i had been working as the only registered nurse with 24 patients! yes i had three other staff but as a registered nurse i would be pulled in all directions- meds were late while managing a patients physical needs, constantly being called away to the phone- so yes there should be minimum introduced but to bridge the gap whilst honest assessments of individual areas are made to ensure the skill mix and registered to unregistered are assessed accurrately for the individual needs of the wards

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  • when are people going to realise that minimum staffing levels won't be set at a number that is anywhere near enough nurses to do the job?! really, they will use it as an excuse to pull the numbers out of the air and serve out redundancies to those excess to new requirements. has nobody learned anything from this government's record? they will not use evidence based research to conjure up the figures. they will simply look at the nhs wage bill, decide on the number of staff they can afford and hey presto, there will be your ratios. honestly folks, wake up. i don't know anything about these 'nurse leaders', or their motives, but they are right about this particular point.

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  • Anonymous | 18-Nov-2013 2:10 pm

    That's true and what people also need to be aware of is that many nurse directors will be very keen to adhere to any government mandated staffing levels. So those disagreeing with these 3 will be agreeing with the majority of nurse directors, who are looking closely at staff wage bills and rubbing their hands with glee as they tote up the P45s.
    I think everyone here is in agreement that we need better staffing levels. Australia is doing better than us because the fight (and therefore the staffing levels) was initiated by the unions and their proactive membership. They said, "We want these ratios!" and then went out on marches and on strike to get them.
    Here, it is the government doing all the deciding. The person who was complaining that he/she was the only trained nurse working with 3 other staff would probably find her/himself working with only 2 other staff. 1:8 doesn't mean 1 'trained' nurse to every 8 patients. Like people have said, "Be careful what you wish for..." Minimum WILL be the new maximum.

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  • I think people on here are on a different planet. The government is proposing a minimum qualified nurse to patient ratio. That might be 1:12 on a general ward on nights and 1:8 on days. Anything is better than what many of us who actually work on wards currently find themselves working with now.

    Like my colleague who regularly works 1 qualified to 24 patients, I think she'd rather replace two or even three of those HCAs for 1 RGN - I know I would.

    I think you may find that the number of qualified staff in theatres and ITU might be up for discussion and people may be transferred within Trusts, but overall qualified staff levels wouldn't reduce.

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  • Nurse leaders, who elected them as nurse leaders. They are director of nursing supposedly to advocate for nurses at board level. They are no longer nurses in the plebeian sense. The article headlines them as representing nurses which if you ask any nurses worth their salt will probably spit in your face saying no. In California USA they have nurse patient ratio and it's working fine, let's not dish it out before trying it.

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  • lionnot thundercat | 18-Nov-2013 5:46 pm
    "California USA they have nurse patient ratio and it's working fine, let's not dish it out before trying it."

    Hmm. It wasn't working that well in the acute area where I had been working, before leaving California in June this year! Or indeed in many other areas. Let's not try it before we have the evidence and a plan, eh?

    One of my colleagues did say that it was working well in Australia, but the journey to their nurse patient ratios has been very different.

    I think that is the point. The government 'nursing forum' here has recommended a minimum ratio of 1 registered nurse to every 8 patients. Where I work, we currently have a ratio of 1:7 and that is a stretch. To reduce that would cost lives, but bring in a minimum ratio and that is precisely what would happen. The government won't implement the recommendations of the Francis Report, so why would anyone be daft enough to think that they will listen to a 'nursing forum' (government appointed of course)? Registered will be diluted to mean anyone with a bit of basic training. How many of us are seeing vacant registered nurse posts filled by HCWs? They will be the 1 in the 1:8.

    The person who is accusing people of being on another planet needs to get into his/her space vehicle and return to earth.

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  • The difference in Australia is they have a half decent union, we've got Dr Carter's RCN - we've got no chance.

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  • I have to agree that my concern would be that the minimum would be the maximum. 1:12 on nights and 1:8 on days for trained staff:patients is not enough.

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  • Anonymous | 18-Nov-2013 9:47 pm

    I agree. We also have Unison, Unite and others who are very quiet and ineffective.

    However, a union is only as effective as its membership. They asked us to vote on the pension issue and only 16% bothered to vote in the ballots. Meaning the unions had no mandate to take action. The union members must accept the responsibility for how that has all ended up!

    Nurses in Australia are prepared to take to the streets in protest and take strike action.

    We should be fighting for nurse patient ratios of 1:4 in a normal busy ward, and have proper evidence-based levels for every area. I cannot believe that there are those who would be satisfied with 1:8. If you have such low aspirations for yourselves and your patients, then maybe you deserve the government mandated staffing ratios that are plucked out of the air and not evidence based.

    Did anyone actually read the letter written by Sills, Fenton and Coates Panel? They don't have a problem with agreed and appropriate staffing levels per se, but they have a problem with government mandated staffing levels. That is a stance I supported, long before they wrote their letter. I am glad that they agree with me.

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  • Crap unions always blame their members - you never hear Unite slagging off their membership.

    I'm not sure where you all work, but it's clearly not on general medical wards in district generals as 1 RGN to 8 patients would be a 50% increase to what we have now. With respect, I think some of you are too far removed from the actual coal face and need a reality check as 1:4 won't happen but 1:8 might and it would make an unbelievable difference to me and colleagues like me, who currently struggle with 1:12.

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  • michael stone

    Anonymous | 18-Nov-2013 12:06 pm

    A rather obvious problem - that if you set minimum staffing levels they will quickly become maximum staffing levels (and also 'assumed to be safe') - and one also made on BBC Radio 4 this morning by Jane Cummings.

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  • Anonymous | 19-Nov-2013 1:24 am

    Which unions "...always blame their members."? I've never heard any. I am a union member and I am critical of the union leadership and its members. But my union has never been critical of its membership. Even the RCN has never been critical of its membership and I think anyone who is a member needs their head looked at. It is too easy to make these silly little claims without foundation, isn't it? A union IS its members. But it is just easier to blame the leadership isn't it? Why don't nurses vote in ballots (you know that is how to change the leaders you don't like and support calls for action)? Why don't nurses ever do anything to improve their situation?
    You are right though, you don't where we all work, and you are conceited and wrong to think that you are any in a worse situation than any other nurse. I guarantee that if this government brings in minimum staffing levels, then you will NOT see 1 RGN for every 8 patients. You will see one member of staff for every 8 patients (fewer RGNS) and you will be much worse off. I also guarantee that you will be back on these threads moaning about how much worse off you are compared to everyone else.

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  • Anonymous | 19-Nov-2013 1:24 am

    1:4 happened in Oz so i reject your argument that it wouldn't happen. i work in a busy general medical ward and i know that 1:8 is not nearly enough, so i am not prepared to settle for that.

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  • Reluctantly I have to agree with the fact that setting minimum staffing levels at 1:8 RNs or otherwise is absolutely not enough. There would be great danger that the minimum would be the maximum regardless of the area. People need to think outside just where they are working and look at the whole picture. Everywhere is different and the same amount of patients in different wards have greatly differing needs and dependencies. Some places may have the same amount of staff but different levels of experience and skills. 1:8 would still not be enough. We should not aim so low.

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