It’s wrong to ignore the evidence that says staffing levels impact on care, says Jane Ball
Sixty per cent of hospital inpatients are over 75, and one in four has dementia. So it’s no surprise that getting staffing right for older people in hospital is seen as critical for getting hospital care right in general. Yet older people’s wards are characterised by the lowest staffing levels and most diluted skill-mix. Is that acceptable?
The Royal College of Nursing recently launched recommendations on the ratio of patients per registered nurse on older people’s wards - setting it between five and seven patients per nurse. The debate around staffing ratios has been hotting up; the latest Policy+ published by the National Nursing Research Unit reviews the evidence and asks: “Is it time to set minimum nurse staffing levels in English hospitals?”
Guidance on minimum staffing levels has existed for some specialties for years - for example in intensive therapy and neonate units, and on children’s wards. So why not for older people’s wards? Some argue staffing ratios are too blunt an instrument, that this is regulation at its worst, taking away local responsibility for decisions that should be made at a local level. I’m all for local health service managers using robust approaches to plan staffing to ensure there are sufficient staff with the right skills to meet patient need. But the evidence suggests that all too often, and especially as cost pressures really bite, that is not happening.
‘Let’s rigorously debate the best way of ensuring nurse staffing levels are at an acceptable level in older people’s care, but let’s not ignore the evidence and say the number of nurses on duty makes no difference’
Recent research shows huge variation in the staffing levels not just between specialties but between wards of the same specialty. Our research found that, on average, older people’s wards have nine patients per registered nurse on a day shift - two more than the recommended level.
In the US, 15 states have legislation covering staffing levels in healthcare. But California is the only one that enshrined specific nurse to patient ratios in law. Research reported by Linda Aiken in 2010 suggests it has been effective in raising staffing levels and lowering patient mortality rates. So we know that setting nurse to patient ratios can work. But is it the best approach for us in the UK?
My worry is that in the current climate, with huge financial challenges and the NHS in the midst of major upheaval, managers and unions are approaching the debate from increasingly polarised positions. Nobody wants to find their trust is the next Mid Staffs, but how to ensure staffing levels are safe is hotly contested. My concern is that, as legally enforceable ratios are debated, the discussion stops being about our shared goal of making sure there are enough staff with the right skills to deliver cost-effective care to a high standard - instead, we argue about mandated minimums. Harry Cayton, the chief executive of Council for Healthcare Regulatory Excellence, recently asserted in Nursing Times’ sister magazine Health Service Journal that: “There is no direct correlation between number of staff and good or bad care, so mandated staffing levels cannot be necessary.”
Well, actually Mr Cayton, I have to disagree. There is evidence - and it’s been steadily increasing in volume and sophistication over the last 10 years. Better staffing levels don’t necessarily guarantee better care, but insufficient nurse staffing makes good care nigh on impossible to achieve.
So by all means let’s rigorously debate the best way of ensuring nurse staffing levels are at an acceptable level in older people’s care, but let’s not ignore the evidence and say the number of nurses on duty makes no difference.
- For further information see tinyurl.com/PolicyPlus
Jane Ball is deputy director, National Nursing Research Unit, King’s College London