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'Insufficient staffing makes good care nigh on impossible'


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.

Jane Ball is deputy director, National Nursing Research Unit, King’s College London


Readers' comments (6)

  • I think that we fail to recognise at our peril the role of staff in short staffed wards who actually DO offer good care. Ms Ball - what actually do you mean by "good care"?
    If you mean that certain tasks and clinical interventions cannot be undertaken so frequently then Yes - it is obvious that these cannot be done with lower numbers of staff. This is a contravention of the nurses code of conduct (not undertaking what has been clinically assessed and prescribed). However, there are many staff who work in understaffed areas who are polite, respectful and very kind to the older person - some nurses are compassionate and others (which i have seen very recently in the nursing provision to my father in hospital) are not.

    Finally - whilst I agree in principle what you are trying to say (bearing in mind my comments above) we must now acknowledge that apart from children's wards ALL wards are full of older people.
    According to Tadd W et al (2011) over 70% of hospital patients are over the age of 60. So we should not have older people wards - they are everywhere - and include me, a working nurse.

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  • Anonymous | 3-Apr-2012 3:23 pm

    While I agree with you that many nurses still provide excellent care while on short-staffed wards, the point of the article is care in general would improve if nurses weren't so overstretched. The fact is we are failing older people in reports, regardless of whether or not we are polite and caring because we just can't be everywhere at once. If you have a couple of seriously ill or difficult patients that require monitoring it's very easy to not give the nice lady in bed 5 all the time she needs, and deserves, because you're too busy, and she doesn't want to bother you because of that.

    Additionally, I refuse to believe we have people entering this profession as uncaring, thoughtless individuals, or that Nursing would attract them. I think it's far more likely that stress over the years is contributing to burn out rates - stress which could be reduced by properly staffing wards. Even with 7 patients to a nurse, it's a difficult task ahead so I don't think it's much to ask. Even at our most stretched we're delivering excellent care and value for money for the NHS - imagine what we could do given proper staffing levels.

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  • The truth of this headline is so obvious that it shouldn't even have to be said. Less nurses = less ability to nurse. If less nurses are nursing more patients then it stands to reason that they are going to become stressed, anxious, even depressed about the situation they find themselves in. Stress is now an accepted medical condition. If a nurse is feeling stressed then they are likely to convey less compassion to their patients.

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  • Anonymous | 5-Apr-2012 1:12 pm

    there is a French expression which says when the vase is empty there is nothing else to offer anybody else.

    I experienced this, following bereavement, to my own cost and it was not a voluntary action that I was in any way control of.

    If your own vase drains through lack of support and attention then once it is empty there is nothing else to drain out of it to offer to others and any care you have to deliver just becomes a series of learned mechanical tasks until somehow, often through distance and support, it gradually fills up again. this can be a very slow, and sometimes painful process, but by gaining awareness of what happened and why it should speed up again until it once more becomes full.

    this must be something akin to near 'burnout' and depression caused by stress from the job, no time to think in order to make the best decisions rapidly, loss of the ability to think clearly during grief, lack of understanding and support from colleagues and others, recognition that you need time and space to recover, and non-fulfilment of your expectations to perform to the highest standards and frustration at the perceived expectations that others have of you.

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  • government took advice from the CEO of Sainsburys and introduced his ideas of general management of his food chain stores to the NHS in the 1980s. This experiment has sadly failed.

    As the NHS and staffing levels and morale have now hit rock bottom and is being in part turned over to private companies like Virgin perhaps there would be nothing further to lose by speaking to Clive Schlee, the CEO of Prêt-à-manger, whose philosophy is to employ more staff and grow his business in times of austerity (on the premise that demands for cheaper food is higher and their stores are busier), and to make sure they are are enjoying themselves and are fully engaged in their work and with their customers so that they get the best service and encouragement to return! Surely this is a healthier outlook for staff and patients than the current system top heavy with non-clinical management and all its associated problems?

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  • I agree some of the best customer service and most polite and happy workers I found in an Apple Store where there staffing levels were obviously sufficient- I have recently returned to practice after ten years and am horrified to find one qualified nurse and one HCA caring for 12 patients in a busy surgical ward. On my last ward it was one nurse and one NA for 7 patients, the care was extremely good and you left your shift on most days feeling as if you had done a good job of caring for your patients - now all I see are nurses looking drained and rushed and worried - something's got to give!

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