Debates about care failings must include staffing levels, insists Jane Ball
The “crisis in nursing” debate is reaching a crescendo. The latest Care Quality Commission report on the quality of hospital care has sparked reaction and comment from every corner - the radio, on TV, the newspapers and even in my local shop. Everyone has a view about the trouble with nursing today.
While theories abound as to the root of the problem, the one fact upon which armchair experts seem to agree is that nursing isn’t what it used to be. Nurses don’t care like they used to.
Let’s take a step back from the hand-wringing. What are the facts and figures about nursing and how it’s delivered?
The CQC report looked at dignity and nutrition on 200 wards caring for older people in 100 NHS acute hospitals. On the dignity standard, 60 hospitals complied fully, while 28 needed to improve and 12 would need to take action to comply. None were “a cause for major concern”.
The CQC found standards of care varied greatly - good care was flourishing on one ward while another in the same building was getting it badly wrong. So what do they think is going wrong?
“It’s not just the niceties of care that suffer when too few nurses are on duty. Research shows that patients in hospitals with poor nurse staffing levels are more likely to die”
They flagged three underlying causes - the culture set by management and leadership, attitudes of staff and care becoming too task-focused, and last - but by no means least - resources. While having enough staff does not guarantee good care, the CQC says “not having enough is a sure path to poor care”.
Yet how many commentators and armchair experts reflected on staffing levels as a key part of the problem, and hence part of the solution? From what I caught of the coverage, very few. So let me remind you about some other facts and figures.
- 52% of nurses in the NHS say there are too few nurses to provide a good standard of care;
- One in ten patients report there are never or rarely enough nurses available;
- Two-fifths of nurses in the UK say care is compromised at least once a week due to short-staffing. And nurses who report that care is regularly compromised are on wards with twice as many patients per nurse as those who report it is never compromised.
The evidence base has grown both nationally and internationally in the past decade. The conclusion is that there is a clear association between nurse staffing levels and quality of care and, indeed, patient outcomes.
It’s not just the niceties of care that suffer when too few nurses are on duty. Research shows that patients in hospitals with poor nurse staffing levels are more likely to die.
Yet staffing levels vary hugely - from one ward to the next and from one hospital to the next. In a recent study by King’s College London, the ratio of patients to nurses on general medical/surgical wards for a day shift varied from five patients per nurse to an average in some hospitals of 11 patients per nurse. Other research shows ratios vary by specialty. On the face of it this makes some sense. Or does it? Is it acceptable that care of older people wards have two patients more per nurse than the average across all wards?
Ensuring care is delivered well is complex. It relies on good management and leadership, a culture that expects and fosters high quality, efficient care delivery processes, working well across boundaries, and staff who are engaged and have access to the development they need. But the bottom line is you need to have enough nursing staff. Nursing care requires nurses.
Ratios that vary from five patients per nurse to 11? I know which ward I’d rather be on - as a nurse or a patient.
Jane Ball is deputy director, National Nursing Research Unit, Florence Nightingale School of Nursing and Midwifery, King’s College London, and author of the Guidance on Safe Staffing Levels in the UK