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More than seven patients per nurse risks missing vital care

Wards should have seven patients or less per registered nurse to avoid missing vital care, according to latest UK nursing research by leading academics.  

They found the number of patients per nurse on duty was significantly linked with the incidence of unfinished care by nurses, or “missed care”, and called for it to be used as an early warning for potential patient safety concerns and unnecessary deaths.

The study, by the National Nursing Research Unit at King’s College London, found more than eight out of 10 hospital nurses had to leave care undone on their last shift because of staffing shortages.

It also revealed that when number of patients per registered nurse was over seven significantly more care deemed vital by nurses to patient safety was missed.

In May this year the Safe Staffing Alliance, which includes the Royal College of Nursing, Unison and the Florence Nightingale Foundation, said one nurse should look after an absolute maximum of eight patients.

The NNRU findings come as senior nurses are set to warn hospital regulators that they should monitor staffing levels and latest workforce figures revealing a drop of 1,000 NHS nurses in England in one month.

The researchers argue that hospitals could use a nurse-rated assessment of “missed care” as an early warning measure to identify wards with inadequate nurse staffing, rather than relying on mortality indicators that reveal problems after they have happened.

“Missed care is a more direct indicator of quality deficiencies with a clear pathway to adverse patient outcomes and experience,” they said this week in the journal BMJ Quality & Safety.

“As the inquiry into excess mortality at Mid Staffordshire Foundation Trust critically shows the consequences of poorly informed experiments to improve the efficiency of the nursing workforce can be disastrous,” they added.

The study, carried out between January and September 2010, involved 46 acute trusts in England.

Researchers, led by the NNRU’s deputy director Jane Ball, surveyed 2,917 registered nurses working in 401 general medical and surgical wards.

Nurses were given a list of 13 care activities, with 86% reporting one or more had been left undone due to lack of time on their last shift.  

Most frequently left undone activities were comforting or talking with patients, educating patients and developing or updating care plans. Pain management, and treatment and procedures were the least likely to be missed.

More care was left undone on day and afternoon shifts than night shifts.

The study also revealed nursing workforce levels. The average number of patients cared for per nurse during a day shift was 7.8, compared with 8.8 in the afternoon or evening, and 10.9 at night.

Fewer elements of care were missed and the odds of missing any care were significantly lower when nurses were caring for the fewest patients – six per nurse or less – compared with when nurses caring for the most – around 12 or more patients per nurse.

The practice environment, as rated by nurses, was also significantly associated with missed care. There were fewer missed activities on wards where the environment was rated as positive in terms of factors like support from management and nurse-doctor relations.  

“Our findings clearly show that nurses are more likely to report care being left undone when they are working on shifts with high numbers of patients per registered nurse,” the authors said.

“For NHS hospitals to significantly reduce the amount of care left undone would require a change to a daytime shift average of just over seven or fewer patients per registered nurse providing care.”

But they add: “Our findings raise difficult questions for hospitals in a climate where many are looking to reduce—not increase – their expenditure on nurse staffing.”

A report published last week showed that hospital foundation trusts in England were looking to cut their nursing workforce by 4% across 2014-16, following a short-term increase this year in response to the Francis report and the Keogh review.

The level of the challenge for some hospitals is also demonstrated by the ratio of 14 patients per nurse recently identified by the Keogh review on the largest ward at The Dudley Group Foundation Trust.

Lead study author Ms Ball told Nursing Times: “As we saw in the Keogh review, this study demonstrates the importance of registered nurse staffing levels to the quality and outcomes of patient care.”

“By looking at ‘care left undone’ due to lack of time, we can understand more about the association previously found between nurse staffing levels and patient mortality,” she said. “The study provides an indication of the scale of the staffing problems we face.” 

She pointed out that only the top 40% of hospital wards in the study had nurse staffing levels sufficient to significantly reduce the chances of care being left undone. The majority had staffing levels that were insufficient to meet patient needs on every shift.

“Having data on the actual numbers of patients per registered nurse on duty, as opposed to the number of posts per bed, is essential to robustly assess and monitor staffing levels, and ensure they are sufficient to meet patient needs and provide care safely,” she told Nursing Times.

Peter Carter, chief executive and general secretary of the Royal College of Nursing, said: “These are depressing findings and unfortunately not surprising.

“When nurses are overloaded with tasks, and have extremely limited time to complete them, something has to give. Without enough staff on the ground it’s vital care such as having the time to talk with, and reassure, patients that suffers,” he said.

“We need to prevent poor care by making sure wards are well staffed, not just use poor care as an early warning sign. We urge all employers to make use of this research.”


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Readers' comments (47)

  • A Registered Nurse used to look after a whole ward and the care was ten times better than today. The Enrolled Nurses where the main carers and where eccellent at their job-big mistake to upgrade them to do paper work and computer records. RG are now trained as managers, not nurses, Sisters time taken up with money allocation for bathrooms etc, audit and Personel work to counsel "overworked" nurses. Lets get back to organised routine, where ths Sister knows what everyone is expected to do or be doing at any given time. From a die-hard disciplinarian!

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  • all these investigations by academics and civil servants on what nurses have been warning for years, and have already predicted a serious crisis, seem useless. by the time they come to be considered for any action and the situation has deteriorated even further a new and further inquiry will be called for instead of implementing any improvements.

    it is so much easier for those not directly involved in delivering care just to observe, ask questions, tick boxes and push paper than it is to make any decisions and ensuring meaningful action is taken and then continue to monitor its effectiveness.

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  • Oh for Godness sakes!!! We all know this and have been verbalising this for years. It now taks a "Study" to reiterate what we, the people who have to care for the patients, already knew.....but still nothing will be done about it.

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  • My tears drool down, oh! NHS what's going to happen, the forcing work load on nurses!
    Poor HCA are have to carry out the more physical exerting part, patients care mostly performed by HCAs, one HCA to 8 to 10 patients. nurses have no time to work together with HCA to deliver safe and quality care to vulnerable patients, Nurses take ample time to serve medication, no matter howmany years of work experience, they take time as newly qualified nurse. Continuity of work equip an individual's efficiency, it seem this category is continuing same speed and same manner which eat time and more of the work and interaction with patients are done by HCA,PLEASE not all one out of ten find real nightingal

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  • Well well well, what a waste of valuable resources. Not rocket science and shouldn't have needed a study to reinforce it. The fact of the matter is...... there aren't enough nurses on the wards. Just look at how Australian nurses work, 1:4, perfect ! I don't know of any Aussie nurse who doesn't love her job and feels she's providing quality care, plus goes home with enough energy to enjoy the rest of her day instead of feeling stressed and exhausted.
    Such a pity that something as blatantly obvious as staffing levels needs to be discussed continually. Rationing care certainly isn't the answer !!

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  • and the tories answer.....CUT more nursing posts...brilliant

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  • Well, nothing new here is there really? Its not the Tories cutting nursing staff numbers, its the individual Trusts who decide who to hire and fire and most - it would seem - would rather hire media consultant, IT consultants and a host of other non-job people rather than retain those who work directly with patients.

    However, the number of specialist nurses and modern matrons and project nurses etc wandering around aimlessly where I work is unbelievable!

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  • We all knew this for years but nobody is listening to us instead we are been subject to scrutiny. No one values our hard work and dedication. Managers should come out to their offices and get their hands dirty because we all know that shortage of staff will continue because of this so called money saving.

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  • It is not difficult to see why there is only one Nursing research facility in this country.

    Anonymous | 30-Jul-2013 1:24 pm

    "Just look at how Australian nurses work, 1:4, perfect ! I don't know of any Aussie nurse who doesn't love her job and feels she's providing quality care, plus goes home with enough energy to enjoy the rest of her day instead of feeling stressed and exhausted."

    And do you know why that is? Because Aussie nurses didn't sit around blaming everyone else for their lot. They got off their backsides, took to the streets, took on the government and had the courage to co-ordinate and carry out effective industrial action. And won.

    So what are you going to do with this latest evidence? Are you going to use it to back up the case for action, rally your colleagues and come out fighting for statutory ratios? Or are you going to moan about those who added to the evidence supporting your cause? I guess the answer is already obvious.

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  • Anonymous 5.17pm - have you ANY idea what a specialist nurse does? We do not need to be griping at fellow nurses, it's fairly clear you don't yet know much about the roles. Which nurses in particular wander around aimlessly - is it the orthopaedic practitioners, the A&E specialists, the diabetes nurse, the vulnerable adults and child protection nurses? Or maybe the continence, tissue viability, medicines management, transplantation, respiratory, epilepsy, parkinsons nurses? What are the projects that the project nurses are working on? Have you asked, and if so, do you think the projects are valid or useful, and if not have you made that known and explained why you think that? I'm sure any of them would welcome you spending a day with them to help advise them on their performance, and then together you could approach management to resolve any issues you find. You may be surprised at what you see, and I hope you'll learn not to criticise until you really know the full extent of somebody else's role.

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  • Again and again we are being told by 'researchers' exactly what we have been saying since Thatcher connived the destruction of the NHS as a caring service. Converting and restructuring it to run as if it were a profit making business enterprise.

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  • Anonymous | 30-Jul-2013 11:12 am

    "all these investigations by academics and civil servants on what nurses have been warning for years....."

    What's wrong with being an academic?
    Which civil servants and from which departments were involved with this?
    Which nurses and with what evidence have been saying what for years? (Names and links to published research please).

    The truth is that nurses have been mumbling their complaints in a pointless fashion for years. With very few exceptions, nurses do not complain effectively or lobby their unions, or vote in union ballots. They do not participate in any organised or cohesive moves to improve their working conditions. In fact, they stay behind, don't take their breaks and work extra hours for free (whilst bleating in martyred tones about their dreadful lot in life) therefore perpetuating the management view that "you don't have to hire more staff when the mugs will do it for free".

    Here's the thing. Whatever view you hold, without evidence, is just an opinion.

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  • Excuse me, I'm telling you off now, so complain as you will and get it removed, but I'll know you've read this and that will give me a great sense of satisfaction.

    This section of the website is called "opinion" so less of the attitude and let people have their opinion, don't try and turn it into some formal debate so you can show off. Picking someone's post to bits is unnecessarily provocative and makes you look like a div.

    By sweating the small stuff you risk hampering what is a wonderful forum for people to share in their very real concerns for a profession they love. We're all suffering and there's no way out in sight, its frightening.

    People make sweeping statements without backing them up when they're passionate about stuff don't they... for example "with very few exceptions nurses do not complain effectively or lobby unions".

    If you can't apologise or modify your tone, please know that I genuinely think you are a div and I might not be the only one. Quote THAT source! Maniacal laugh maniacal laugh...

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  • LOVE the word "div"!

    Haven't heard it in yonks

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  • Anonymous | 31-Jul-2013 1:59 am

    You are not excused. It is a shame that you have such a problem with comprehension, but let's try to help you out.

    Now, if you read the last sentence again,
    "Whatever view you hold, without evidence, is just an opinion.", you wll notice that there is nowhere that I have said holding an opinion is wrong, as you have assumed. But an opinion will not be helpful in backing up a case for change. Evidence, on the other hand, will. This is an evidence based profession, athough you clearly don't understand that. Okay? Understand? It is rather a moot point anyway, because nurses wouldn't even approach anyone in government with an opinion, never mind evidence.

    FYI. I would never have request to have someone's post removed. Not my style, but perhaps it is yours. In any event, it is the editorial staff who remove comments here.

    Peple like you take offence at justified criticism, hence your bizarre and OTT reaction. But that is your problem, not mine. Come back to me when you have a reasoned argument and can stop behaving like a div.

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  • Anonymous | 31-Jul-2013 9:19 am

    I don't see any cause or excuse for rudeness in the comments and demanding responses instead of challenging arguments in a proper and respectful manner is not going to get them. it just deviates from the main issues and tends to block what could have been an interesting discussion. unfotunately it happens all too often in NT comments making it rather a waste of time.

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  • michael stone

    Roger Hodgson | 30-Jul-2013 7:49 pm

    Roger and others - and I have complained about this to the DH - are pointing out that this research is only 'telling us what we already knew': which is true.

    But the NHS almost never works on 'believing the ruddy obvious until it is disproved', especially for policy making: politicians dismiss 'what everyone knows' as 'anecdotal and not robust' unless someone does some 'formal research' to prove the obvious - then politicians either say 'other researchers dispute that' or, increasingly these days, 'It is up to the NHS to allocate its resources, not us'.

    You can't win, until by shouting to the public, you make politicians think they are in danger of not being re-elected, so far as I can work out: even then, they are likely to try and 'flannel' you instead of actually doing what (most of) the public want.

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  • tinkerbell

    'By sweating the small stuff you risk hampering what is a wonderful forum for people to share in their very real concerns for a profession they love. We're all suffering and there's no way out in sight, its frightening'

    well said, we are made of flesh and bone and some have given the best part of their life to a profession they love, no wonder we get a bit emotive. You can't intellectualise about it all sometimes, just a case of letting off steam at seeing something you love being destroyed. Let's all rally and unite together try to change this madness and destruction.

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  • tinkerbell

    i'm ripping up sheets for bandages and boiling water as we speak for what is becoming a war zone, OUR NHS, as was.

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  • 7 posts in before we started denigrating one another, then its like the chimps tea-party at the zoo. You could at least try to make it funny.

    I think our problems as Nurses stem from the fact that, secretly, deep down, we all imagine that we are the worlds champion at Nursing, but EVERYONE else is rubbish in comparison. As a result, we can't help pulling each others hair out the first chance we get.

    ( The real culprits are the giant lizard shape-shifters/ Bilderbergs/ Chupacabras/ Rosthchilds/Illuminatii/ Masons/ MI5)

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