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Survey: Nurses question impact of Francis report at frontline


More than half of nurses believe their ward or unit remains dangerously understaffed one year after a seminal report drew attention to the dangers of staff shortages, according to our latest survey, which suggests little has changed at the NHS frontline.

Robert Francis QC and 2014 survey

Robert Francis QC published his report on the high profile care failings at Mid Staffordshire Foundation Trust on 6 February 2013, setting out a raft of recommendations focused on improving care and patient safety.

Six months later the government unveiled its full response to the report, outlining measures requiring trusts to regularly publish details of staffing levels and encouraging the adoption of ideas like hourly rounding and supervisory status for ward managers.

Nursing Times wanted to gauge if the report has had an impact, for better or worse, on nurses working on the frontline and its legacy for nursing.


The legacy

Our survey of 526 nurses, carried out last month, found that 42% of respondents thought the Francis report would improve things in the long term for the NHS and nursing, and 6% said they were already seeing positive changes as a result.

But 28% said it would make no difference and 24% warned that it had led to unfair criticism of the profession and the NHS in the national media and from politicians.

One respondent said: “The Francis report could lead to positive change – but so far budgeting concerns and political agendas seem to have undermined positive recommendations.”

Another added: “The focus of criticism from the media has been on nurses, whereas doctors were also criticised in the report but this has been ignored. All the good and hard work nurses do daily seems to be virtually invisible.”


Staffing levels

Latest workforce figures, published last month, show hospitals were employing 2,400 more acute, older people’s and general nurses in October than they were in February.

But our survey reveals that the situation varies for nurses, with 39% of respondents warning that staffing levels have worsened where they work over the last 12 months and 37% that they have stayed the same – only 22% reported an improvement.

Our survey also suggests trusts need to recruit many more nurses if they are to reduce pressures faced by staff. Half of respondents warned that their ward or unit was “sometimes” dangerously understaffed and 7% that this was “always” the case. More than a third – 37% – said the average number of patients per nurse was 10 or more.

One respondent noted: “Although my organisation has been recruiting more nursing staff they have been inexperienced and have had to be supervised, so in some cases have made matters harder.”

Another said: “There just aren’t the number of nurses out there to recruit and I believe this will only get worse.”

The results suggest only marginal improvements since January last year, when we surveyed nurses on similar issues. Then, 11% said they were “always” dangerously understaffed and 44% said there were 10 or more patients per nurse on their ward.

Worryingly, a third – 33% – of respondents said patient safety had got worse over the past 12 months. This compares to 19% who said patient safety had got better and 48% who said there had been “no change”.

However, the survey suggests a slightly better story for care standards in general. Two-thirds – 65% – of respondents said they had witnessed “poor care” in their ward or unit over the past months, but this compares favourably to 76% in our survey last January.

Mid Staffordshire was criticised for putting financial targets ahead of patient safety. Asked to describe how they perceived the strategic focus of their trust, nearly half – 49% – said it was focused on financial targets more than quality of care. However, this does represent an improvement on the 65% in our survey last year.


Raising concerns

On a more positive note, a third of respondents said they were encouraged to raise concerns about care or poor practice and felt they were listened to by managers. But this was tempered by 19% who said they were not encouraged to raise concerns and felt ignored if they did and 11% who felt they were actively discouraged from raising concerns.


Skill mix

Despite warnings in the Francis report about divergent skill mix ratios between registered nurses and unregulated healthcare support workers, this year’s survey suggested little improvement and in some places a worsening of the situation.

Around one in five respondents – 22% – said there had been an increase in HCAs compared to registered nurses on their ward or unit over the past 12 months, compared with 69% who said it had stayed the same and 9% who said there had been an increase in nurses versus HCAs.


Rounding and supervisory status

Nursing Times asked nurses about three nurse-focused ideas in particular that were recommended by Francis.

More than a third said their organisation counted ward or nursing team managers as supervisory or supernumerary to the ward or team’s nursing provision – something the Care Quality Commission has been asked to look for in its inspections. Of these 12% said their trust had introduced the measure over the last 12 months.

A further 10% said their trust had indicated it intended to introduce supervisory status in future, but 39% said it had not been mentioned.

Around 20% said hourly rounding by nurses had been introduced on all wards, while 12% said it was in place on most wards and the same percentage on a few wards. But a third said the initiative was still not used at their trust.

The situation was worse still for Schwartz rounds – monthly meetings where staff discuss specific patient cases or a set of circumstances they may face. Just 15% said Schwartz rounds were used and more than half – 54% – said their trust had not mentioned their introduction.

Two third of survey respondents said they worked in hospital trusts, with the majority – 42% – describing themselves as staff nurses. A further 20% described themselves as ward managers and a similar percentage as specialists.

Francis report 2014 survey

Francis report 2014 survey


Read some of the comments made by nurses in response to the survey:

“I returned to practice full of hope but am left with nothing but utter despair. The NHS is a shambles, unfortunately it is being run by the very people the whistleblowers tried to expose years ago.”

“The dependency of patients is much greater now and the staffing levels have not changed to accommodate this. We are classed as not short staffed but do not have enough staff to give patients the time and care they need and deserve.”

“Everyone is working hard and management take advantage of caring nurses who don’t complain and work 45-50 hours a week for no extra money… Burn out is a massive issue”

“Conscientious staff are doing as much as possible for as many as possible in as little time as possible – whilst at the same time ‘carrying’ less conscientious staff.”

“What can I say , I still love being a nurse but am sick of the way we are being treated by our employers, by the government and by the press.”


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More on the Francis report


Readers' comments (9)

  • this will only get worse as hospitals will get rid of staff to save money due to the so called "20bn efficiency savings" brought on by this govt

    the only way is to vote out these idiots...they never have and never will care about our NHS!!

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  • michael stone

    Hunt is writing in the Daily Telegraph today, about the positive changes post-Francis, and about 'new systems' which have been introduced and have improved things (re raising concerns etc).

    He didn't actually describe, the new systems.

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  • tinkerbell

    Poor Sir Robert Franis, so much effort so little return.

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  • Too many managers sending themselves off on expensive leadership programmes etc etc. They are so far removed from the patient apart from glib PR photo opportunities.

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  • tinkerbell

    Yes there are the exception to the rule, a good manager, but we are mostly lions led by donkeys. Sorry but the it is the infestation of management that has been the downfall of nursing when nobody is listening to the clinicians on the frontline.

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  • michael stone

    tinkerbell | 6-Feb-2014 12:54 pm

    Sorry - this is well off topic - but I think the Lions led by Donkeys one, from WW1, should probably be dropped. Taking advantage of a library booksale, I possess an interesting book about WW1 - I'm reasonably sure that the 'donkeys' had a fair grasp fo the situation. In fact, the author's contention, was that the problem with WW1 was that it was so much more difficult to attack and win ground, that whoever did attack was then so depleted, that the other side could take the ground back soon afterwards by counter attacking. So you got stalemate and yo-yo.

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  • In the NHS management hierarchy, particularly pre Frances, the "donkeys" worshipped at the alter of cost cutting when patients and safety should have been priority. They turned a blind eye to the concerns of the lions battling with poor resources and low staffing levels.

    The latter have mainly taken the blame for what has been perceived as lack of compassion. We now have those managers (not all I know there are good ones) espousing the 6 c's as if they invented the terms. It might make them look good it might make them feel better but the reality is they are the same people who let it go wrong in the first place. Is there any wonder we read reports such as this.

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  • tinkerbell

    A blind eye indeed they did turn. Shameless that some still don't realise they have caused harm.

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  • My wife is a Staff Nurse working night shift on a busy medical ward of 28 beds. Most of the patients are elderly and the majority are falls risks and a high proportion dementia patients. \she is regularly scratched, bitten or spat at and even punched, which no amount o security reports will ever attempt to address because the patient is not “with it”. Understaffing means the regular staffing for a night shift is one trained and normally two auxiliary staff but occasionally three. This is shocking when you consider there is nobody available to check controlled drugs with, allow for a meal break and there is a regular expectation for there to be admissions through the night and the potential for one of the experienced auxiliary staff to be sent to another ward and be replaced with a disinterested agency nurse. It is essential that legislation is brought in which demands a minimum staff:patients ratio so we can be sure that not only our nurses nut also our patients are protected. Management appear oblivious to the problems and staff are to scared to raise the issues for fear of reprisal.

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