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'Armchair experts must face the facts – staffing levels affect care'


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


Readers' comments (12)

  • michael stone

    Obviously staffing levels affect care !

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  • michael stone

    I was very pressed for time - and a little 'vexed' - when I wrote my previous post. To elaborate, and to agree with Jane. I am now going to get 'all philosophical', yet again.

    Above a certain staffing level, the effect of adding more staff is not noticeable improvement, and can even be a deterioration. Below a certain (the 'we are already operating at 100% efficiency' point) staffing level, reducing staff numbers must by definition adversely impact on patient care, and also hugely increase staff stress-levels.

    Politicians invariably suggest, without any proof, that 'by improving behaviour and removing 'wastage/slack', you can reduce overall staff numbers without reducing care', something which can only be judged afterwards, and is very unlikely to be true, if the staff numbers are already 'marginal'. I use 'overall staff' to include staff not on the front line, as 'Yes we are spending less money, but it shouldn't reduce front-line staff numbers' is a claim often made, but hardly ever true !

    You don't really need all that much evidence - but Jane has provided some - to realise that something like the NHS is very unlikely to ever be 'over-supplied' with staff: so it is always the 'best guess in the absence of any evidence' that spending less money, will result in less staff, and less good care.

    I'm sorry, that is all very unscientific and 'non-evidence based' - even so, anybody who doesn't already know it 'must be true' would not be my choice as an 'analyst'.

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  • There is a wealth of information on staffing levels and patient acuity and a number of measures used to calculate skill mix with needs of the patients.
    Why in this day and age of 'evidence base' are we not using these?

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  • It isn't just staffing levels, it is QUALIFIED staffing levels! And Harry, we ARE using it, we HAVE used it, but a combination of useless unions, no support and an NHS being run on business and profit models has ensure that the evidence - and Nurses - are continuously ignored. That is until a Mid Staffs happens.

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  • Thank you, Mike, and well said! I still feel the pain of what is happening even though I'm no longer involved.

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  • michael stone

    Harry Dodd | 1-Nov-2011 10:59 am

    I have no doubt there is a LOT od 'evidence base' - but is it 'sane' ?

    I see all manner of 'papers/articles' which quote things such as results from other countries, and you need to be certain you really are comparing apples to apples, and not apples to pears, to really rely on comparisons. And unlike 'does this antibiotic kill this bacterium ?', things like staffing requirements are complicated !

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  • No Michael, staffing requirements are not complicated. They are just not. Not to us.

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  • Of course staffing levels affect care. When I started on this journey as a nursing assistant 25 years ago this month I worked on an elderly ward. Those days you were tripping over staff yet things didn't always get done on time especially at meal times, and that was without all the food handling regs. Nowadays when I walk on a elderly ward you sometimes struggle to find staff as they are all busy. Maybe the armchair critics should try feeding a ward of dementia patients before the food drops below the stipulated temperature and see how they get on or more to the point before they get extremely frustrated.

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  • Anonymous | 1-Nov-2011 6:44 pm

    I remember the days of better staff/patient ratios too. Mind you, a lot of the staff were students! There are a great deal of things that I don't miss about my early years in Nursing, but I do miss having more staff and more time.

    mike | 1-Nov-2011 3:55 pm

    Spot on. It isn't difficult at all.

    Harry Dodd | 1-Nov-2011 10:59 am

    You are right. The evidence exists, so why don't we use it?

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  • when i worked in the uk i had 7dependent patients to look after and an occassional hca with me. we were constantly short staffed. the team work was good and we all helped each other but patient care was compromised. we didn't get the breaks we were entitled to because we were looking after patients. we filled in incidents form daily.when we did get more staff such as students or supernumary staff the patients were happier, staff were more relaxed, less complaints were recieved from patients and relatives, assessments were able to be filled up to date as a mandatory requirement. i am now in australia where i can nurse properly with my 5 patients and still have assistance when required and be paid twice as much.

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