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Do you feel that money is put before safety in your organisation?

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Editor Jenni Middleton discusses this week’s revelations surrounding the nursing associate role

- We must not put pounds before patients

- There is evidence that graduate nurses provide higher-quality and safer care

- We don’t have enough graduate nurses to provide that care so we must be pragmatic

- NHS Improvement chief nurse to support directors of nursing in making staffing decisions

A few days after a letter on staffing levels was issued to providers by NHS England, Monitor and the Trust Development Authority last year, I hosted a conference for directors of nursing. The letter had told recipients that the ratio of one qualified nurse for every eight patients should be considered as a guide, and not a hard and fast rule they must stick to. And no, they weren’t being told that they could employ more nurses if they wanted – even though leading nurse researchers such as Professor Jane Ball believe the 1:8 ratio is not even a safe minimum but rather a “danger zone”.

Some directors of nursing told me the letter would have their finance directors rubbing their hands together in glee (honestly, one director told me her FD did exactly that in front of her after reading the letter) and heading back to their spreadsheets grinning from ear to ear.

“Union leaders have described replacing band 5s with the new role as ’slave labour’”

That’s why it is a real cause for celebration that NHS Improvement’s chief nurse Ruth May has stated this week that she will support directors of nursing who are put under pressure to staff their organisations in a way that could be considered unsafe.

The nursing associate role has in the main fuelled this concern. Union leaders have described replacing band 5s with the new role as “slave labour” and “nursing on the cheap”. My initial response was that nursing is already pretty cheap, and every year the government continues to cut nurses’ pay by freezing pay or giving below-inflation rises, it makes nursing progressively cheaper.

My other response is that at a time when we have so many nurse vacancies, the point about substitution is a moot one.

However, there is evidence that being cared for by a graduate nurse is safer and provides a higher-quality experience for patients.

“The greater the number of graduate nurses at the hospital bedside, the lower the mortality”

This week, research by Linda Aiken, director of Penn Nursing’s Center for Health Outcomes and Policy Research, Peter Griffiths, chair of Health Services Research at the University of Southampton and Anne Marie Rafferty, from the Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, says hospitals that employ more nurse assistants relative to the number of professionally qualified nurses have higher mortality rates, lower patient satisfaction, and poorer quality and safety of care.

The study, published in BMJ Quality and Safety, found that the greater the number of graduate nurses at the hospital bedside, the lower the mortalityUnion leaders have described replacing band 5s with the new role as “slave labour” , the better the quality and safety of care, and the more likely it is that patients will be happy with their care.

I realise that the introduction of the nursing associate role is inevitable – there are gaps in care provision that we just cannot fill with graduate nurses. However, we must make sure this role is not used to give finance directors a year-round grin. It must not to be used to substitute band 5s, but to add resource where it is desperately needed and to harness a desire and a talent for caring.

As I’ve said before, holding that line can be difficult – and chief nurses will need all the support they can get. So it is good news that Ruth May is offering to provide it, and support their staffing decisions with evidence. Perhaps this will also help those who make decisions about how NHS money is spent to understand that sometimes, patient safety has to be paid for and invested in. 

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