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EDITOR’S COMMENT

'Address staffing levels to give Francis real legacy'

The long-awaited Francis report’s fundamental purpose was to influence government to change healthcare to ensure the public’s safety. Its purpose was to make sure that a Mid Staffs scandal can never ever happen again.

The question of how many of those 290 recommendations the government will implement remains to be seen - the prime minister is positive about mandatory training for healthcare assistants but lukewarm about regulation; they are trying to “sweep away” the outmoded way the Nursing and Midwifery Council operates but unclear how to resource the increased duties afforded to the regulator for revalidation.

But many of Robert Francis QC’s recommendations will count for nothing while nurses are still overstretched and understaffed.

Now don’t misunderstand me. What happened at Mid Staffs was inhumane, inexcusable treatment of patients. The way patients were spoken to, deprived of food and drink and left in soiled beds was more to do with a lack of compassion than a lack of nurses.

Our understaffing survey featured heavily in the media. This reveals public concern. They know a main factor in the provision of quality care is having adequate staff

But we do know that frequently nurses feel unable to spend time with their patients, talking to them, finding out if they are comfortable and how effective their pain medication is. They are struggling to help their patients get to the toilet, wash or eat, especially on wards with lots of older people who are highly dependent.

Our survey on understaffing in last week’s issue showed 76% of the 595 nurses who responded felt their wards were “dangerously understaffed” “sometimes or always”. This survey featured heavily on the BBC, Sky, ITN and a host of national and local radio stations and newspapers. This reveals public concern. They know one of the key factors in the provision of quality care is having adequate staff.

Mr Francis’ suggestion that NICE tools are used to evidence staffing ratios and numbers is a good start, and let’s hope this leads to a sensible conversation - and more importantly - action.

The evidence Mr Francis heard at the public inquiry, including from the then chief nursing officer for England Dame Christine Beasley, was pretty equivocal on staffing numbers.

She claimed that setting such numbers would mean they would become the “ceiling not the floor”. Fair point, but in some trusts, that would still be an improvement.

Many trusts continue to cut nursing posts and replace qualified nurses with unqualified HCAs. If Francis is to have a real legacy for public protection, then making sure the service gets enough people to do the job - and do it well - should be non-negotiable.

Jenni Middleton, editor

jenni.middleton@emap.com. Follow me on Twitter @nursingtimesed

Readers' comments (52)

  • http://www.iom.edu/~/media/Files/Activity%20Files/Workforce/NursingCredentialing/2013-JAN-14/Linda%20Aiken.pdf

    You must see Slide 8, and research the Nurse Work Index and how that, along with ratios, affects our patient outcomes.

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  • "Our survey on understaffing in last week’s issue showed 76% of the 595 nurses who responded felt their wards were “dangerously understaffed” “sometimes or always”

    Yet Ms Jane Cummings, CNO England, in her response to the Francis Report, published in Nursing Times, does not once mention under-staffing as a concern. Surprise, surprise-not. This woman's ongoing refusal to acknowledge under-staffing as a cause of concern and of poor care is a disgrace. It just shows that her role as CNO is totally useless, as she is clearly a government poodle and wont say anything that might rock the boat and upset her political masters. Time for nurses to have a vote of no-confidence in her I think.

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  • Let's not turn this into a CNO bashing opporunity again.

    This problem has been around since, well I can't remember exactly, but I do remember when the first redundancies of nurses happened in my own Trust.

    When the working time directive led to a reduction in junior doctor hours, nurses were seen as the answer. We expanded our competencies and took on new roles, it was cheaper than employing more doctors you see.

    Then a few years down the line, having allegedly lifted nurses pay to reflect these expanded roles, it became obvious that this wasn't affordable either, so the next step has been a slow and painful erosion of nursing. This has been done by downgrading posts, making nurses redundant as part of restructuring to facilitate this and reducing overall headcount and it has just never stopped.

    Having got away with it then, it has continued and nursing continues to be the target for cost savings. There is a complete lack of understanding that whilst we may be amongst the largest part of the workforce and therefore look like being an expensive resource, we are also one of the most important when it comes to quality of care, safety and compassion - the patient experience.

    So this is not a problem of Ms Cummings making, or indeed Ms Bennett (her counterpart at the DH). It is a problem that has been made by nursing - allowing this to happen at all. I lay the responsibility for much of this at the door of all of the local Directors of Nursing who have not stood up and fought against this and for not having the courage to make sure that those at the very top understand so that they can do the same.

    Sadly, in our fear driven culture, everyone is so keen to present a good image that we undermine our own argument by making sure the problem remains invisible when we should be making it blatantly obvious.

    So next time your Trust has a visit from anyone in one of these top jobs, or from an important inspection agency, don't try and hide the impact that is damaging your ability to give great care, tell it how it is.

    If you don't have the courage to do this, then you really don't have the right to attack anyone for not doing somethinig about it.

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  • What is Ms Cummings role if it is not to stand up for nurses. She is in the position to do it. If people are bashing her it is because she steadfastly refuses to speak up about staff shortages. Nurses on the wards have been stripped of all power and are bullied and victimised if they speak out. Ms Cummings should be speaking for us, she refuses to do so.

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  • try telling this to the chief exec here at rotherham where 750 jobs are to be lost...all in the line of saving money...the francis report means nothing here im afraid!!!

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  • Anon 12 feb 5.03pm

    I have said for a long time Chief Execs have too much power, that one person at the top can make or break a Hospital - as Stafford proved! We also have a Chief exec who plays his own game in our Trust and he is systematically destroying our Hospital.

    Why are they allowed to get away with it?

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  • How much power does the CNO have?
    Can she command trusts to get more nurses?
    Can she demand Nurses to get respect?

    Nures can talk about understaffing until the cows come home, have dinner, get their makeup on and go clubbing and nothing will happen.

    Why?

    You need to talk to the public. The only way Nurses will be respected and change the NHS is by talking to the public.

    The survey was a good start and the Francis Report is out but Nurses must keep up the momentum.

    Nursing has many, many friends out there. There are people who deeply care about Nurses and Nursing but you need to tell them what is happening because they don't know.

    People will march in London for you. I only know what is happening as I am writing a play about Nursing otherwise I wouldn't know at all.

    Leave the hospitals
    Tell the nation

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  • Our HCA/CSA colleques are not unqualified.
    They have qualifictions such as NVQ Levels 1, 2 or 3 or they may have Open University Qualifications such as the Certificate in Health and Social Care. In the modern age they may hold a higher level of academic qualifiction than qualified nurses who are SRN or RGN level 1. We are going through the profesionalisation of the non-registered health care workforce and we should be justly proud of these fundermental changes.
    We need to all stand together and fight for the highest standards of care and professionalism.

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  • Sarah Stanley | 12-Feb-2013 7:25 pm
    "Why are they allowed to get away with it?" - Probably government puppets!

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  • michael stone

    Part of this, is to allow patients/relatives to see at a glance who is present and doing the work: so, if nurses wear blue, then HCAs should wear a different colour {yellow springs to mind}. To many laymen, everyone 'at the bedside who isn't a doctor' will probably be regarded as 'a nurse' - so a ward with 3 nurses and 3 HCAs would look the same as one with 1 nurse and 5 HCAs.

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  • If I was in a hospital I simply wouldn't have a clue the difference between HCA and a Nurse and if I was in hospital I probably wouldn't really care. I'd just want to get better

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  • Staffing levels are cut to save money. Doesn't help when nurses then work more bank, hides staffing deficiencies + makes those nurses more tired. We all need the money too. Then when bank staff is exhausted, agency staff are called in, costing even more money.
    Have seen excellent nurses taking up more agency work, less bank work + sometimes where they used to work. But better conditions + pay for them for the same job. When working overtime anywhere other than the NHS, is it still 1.5x and 2x you're normal rate? Not if you're working on bank, more or less same rate as your regular hours. Why, because some people will continue to work as they need the money to pay bills.

    Re CNO bashing. I think her role is to disseminate government strategic policies into strategic/tactical policies at trust level. Some people get promoted out of direct patients contact + experiences of frontline staff. If everything about public service is a vocation, I don't hear many senior execs, directors or MPs offering to have a substantial pay cut to work for a better society with the right community spirit. The money saved can be used to enhance care of everyone.

    DH Agent - as if ! | 13-Feb-2013 11:14 am.
    Its not only patients that have trouble telling who' who and what they do. How many times do staff get confused between medics, pharmacists, specialists (doctors + nurses) etc around the wards in their own smart clothes and especially commencing new rotation. Even harder to distinguish their grade. As far as patients know, everyone's a nurse unless they look like a doctor (even if they're a nurse). Just carry cheap stethoscope + say you're still in training (life long cpd) + confuse everybody. Maybe 'too posh to wash' sprang up from confusing non-nurses with higher degrees, from those who actually do the work ;o)

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  • DH Agent - as if ! | 13-Feb-2013 11:14 am

    Apologies for this brief diversion, but since you enquired about the fate of the poor unfortunate Haggis the other day. The latest news is unfortunately thus:

    News Flash

    Re: Haggis. They are under threat of extinction!
    .
    Whist it is widely known that the inhabitants of the British Isles have very conservative tastes in food they are known to consume Haggis, yet have recently made a huge scandal on discovering horse on their plates!

    These poor wee, sleekit, cow'rin, tim'rous beasties (the Haggi) were last sighted some weeks ago migrating northwards towards Scandinavia and many have tragically drowned in the North Sea.

    Whilst the eating habits of these very shy creatures remains unknown, as this strange, highly secretive and ritualistic phenomenon has proved impossible to observe by teams of expert scientific researchers over the years, it is now believed they feed on Trolls, and possibly Leprechauns, as a few have also been sited on the Emerald Isle. Trolls, anywhere other than Scandinavia are also becoming more rare as it is generally agreed that they should not be fed otherwise they can cause a nuisance!

    The Human-Haggis-Troll food chain is now becoming an issue of the greatest concern! Whilst not wishing to encourage the increase of the Troll population outside their natural habitat, please help to save the Haggis. The problem is of the utmost urgency and to this end a Save the Haggis Fund for further research into their eating, social, migratory and breeding habits has been set up under the most honourable patronage of His Royal Excellency, The Chief of Trolls!




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  • Staffing levels are cut to save money. Doesn't help when nurses then work more bank, hides staffing deficiencies + makes those nurses more tired. We all need the money too. Then when bank staff is exhausted, agency staff are called in, costing even more money.
    Have seen excellent nurses taking up more agency work, less bank work + sometimes where they used to work. But better conditions + pay for them for the same job. When working overtime anywhere other than the NHS, is it still 1.5x and 2x you're normal rate? Not if you're working on bank, more or less same rate as your regular hours. Why, because some people will continue to work as they need the money to pay bills.

    Re CNO bashing. I think her role is to disseminate government strategic policies into strategic/tactical policies at trust level. Some people get promoted out of direct patients contact + experiences of frontline staff. If everything about public service is a vocation, I don't hear many senior execs, directors or MPs offering to have a substantial pay cut to work for a better society with the right community spirit. The money saved can be used to enhance care of everyone.

    DH Agent - as if ! | 13-Feb-2013 11:14 am.
    Its not only patients that have trouble telling who' who and what they do. How many times do staff get confused between medics, pharmacists, specialists (doctors + nurses) etc around the wards in their own smart clothes and especially commencing new rotation. Even harder to distinguish their grade. As far as patients know, everyone's a nurse unless they look like a doctor (even if they're a nurse). Just carry cheap stethoscope + say you're still in training (life long cpd) + confuse everybody. Maybe 'too posh to wash' sprang up from confusing non-nurses with higher degrees, from those who actually do the work ;o)

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  • What is it certain managers and politicians fail to comprehend about a trained to untrained nursing staff recommendation of 60% to 40% ?
    Indeed RCN recommends 65% to 35%.
    The service cannot be expected to provide the highest levels of care with threadbare staffing and an unacceptable skillmix.

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  • michael stone

    'PDave Angel | 13-Feb-2013 6:58 pm

    If I was in a hospital I simply wouldn't have a clue the difference between HCA and a Nurse and if I was in hospital I probably wouldn't really care.'

    But have you not noticed, how annoyed RGNs are at a media headline of 'poor care by nurses', when on closer inspection it turns out that many of the 'nurses' were actually HCAs ?

    And, wouldn't the 'reality of staffing ratios' be much easier to discern, if you could simply stick your head through the door of a ward, count 2 blue uniforms and 3 yellow ones. and write down '2 nurses and 3 HCAs present' ?

    I agree with the 'I would want to get better' point, of course !

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  • I have recently been interviewed for a senior position within our local community trust. It was for a band 8a. The interview was just before the Francis report. I knew the interview has been lost when I said that I would ensure that those working with Looked After Children would be monitored to ensure that they acted with compassion, to which I was challenged in a very sarcastic manner 'and how exactly are we going to measure compassion for the commisioners?

    I rest my case

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  • When things go wrong,
    As they sometimes will,
    It's the Registered Nurse,
    Who takes the wrap.

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  • Susan Markham

    Chronic Registered Nurse under staffing on the wards is nothing new - nor is the persecution of Nurses who try to alert the public (whistle-blow) to the dangers. There have been some notable cases over the last 35 years... all of which sound depressingly familiar. The links below are well worth reading - but have the Prozac close at hand.

    Three and a half decades ago there was the case of Graham Pink - a nurse at Manchester’s Stepping Hill Hospital in 1989... yes THAT Stepping Hill!


    http://www.patientprotect.org/pink.htm


    Two decades ago there was the case of Karen Reissmann - nurse at the Manchester Mental Health and Social Care trust in 1990


    http://www.guardian.co.uk/society/2008/mar/12/nhs.health


    And the bullying culture is not merely restricted to Nurses. Even Gary Walker, the CEO of the United Lincolnshire Hospitals trust in 2008 was sacked for warning Sir David Nicholson that patients were in danger from serious under-staffing.


    http://www.dailymail.co.uk/news/article-2278341/Gary-Walker-NHS-chief-whistleblower-paid--million-quiet-2nd-hospital.html


    Of course there was the case of Terry Bryan, former charge nurse at Winterbourne View residential care home for people with learning disabilities near Bristol who faced similar problems when he tried to get the authorities to take his concerns seriously. He even contacted the Care Quality Commission before he went public.


    http://nursingstandard.rcnpublishing.co.uk/campaigns/care-campaign/features/speaking-the-truth


    For those people who have previously said on here that “nurses should speak up on behalf of their patients more" I advise you to go to


    http://www.freewebs.com/bruiseduk/whistleblowing.htm


    It’s a long and detailed report (reading it is about as enjoyable as eating dry toast) but about half way down the page (Section Three) it gives the statistics about the number of complaints made to the Public Concern at Work’s hotline.

    A high percentage of these calls were made by Doctors and Nurses (these are not the internal “incident reports” that are used on NHS wards.)

    This tends to disprove the myth that Nurses do not report their concerns - they do, and not just internally. Between 2002 and 2010, a total of 13,406 people contacted its helpline for advice, around one third of these were nurses.

    When you see the figures keep in mind that a fairly recent survey of 3,000 nurses found that 84% said they would worry about victimisation, personal reprisals or a negative impact on their career if they were to blow the whistle.

    But of course all the problems of under-staffing would be resolved overnight if only Nurses would adhere to the 6Cs - amiright or what? ;)

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  • DH Agent

    'Nurses' is also a generic term referring to anybody on the wards providing nursing care.

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