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Jane Ball: 'The Francis inquiry tells us inadequate staffing costs lives'


If anyone needed it, the Francis inquiry provides us with a significant reminder that nurse staffing levels matter, and that inadequate staffing not only damages the quality of care but ultimately leads to loss of life.

If you’ve followed the media coverage over the last few weeks, you might have formed the impression that the inquiry was primarily about how nurses came to treat patients without dignity, that it has been an investigation into abuse and neglect, looking at how the system failed to prevent or detect such neglect. And presented alongside are discussions and opinion pieces: how could nurses be so uncaring? Where has their compassion gone? And how can we change nursing, to ensure only those with compassion enter the profession in the future? And of course, the inevitable anxiety: are nurses “too posh to wash”, “too clever to care”? Do the real problems stem from an educational preparation that is too academic?

We leapfrog the concepts so quickly - bad care, bad nurses, wrong people going into nursing and wrong training. But fortunately, Robert Francis QC does not so summarily try and join the dots. He and his team have provided a detailed and insightful account that offers a carefully observed and intelligent analysis of the problems at Mid Staffordshire, and in the system of which it is a part.

And of course it a complex picture of multiple facets and layers. But there are some strong and recurring messages: a culture where staff dare not speak out; putting targets before patients; inadequate nurse staffing levels; and understanding associated risks to patients - the risks of substandard care and unnecessary death.

Sadly, understaffing is not rare in NHS hospitals. In parts of Australia where minimum staffing levels have been set, acute wards are required by law to have sufficient registered nurses on a day shift to provide a ratio of not more than five patients per registered nurse. The worry with setting such minimums is that they may become the maximum, that employers will stop trying to determine the number of staff needed (using reliable and independently validated tools as Francis suggests) and rely instead on the “just enough” minimum. It may protect from the worse extremes, but might it lead to lower levels being accepted in many hospitals?

These concerns would be entirely valid if we were confident that most hospitals have good levels of nurses on their wards. But the evidence - not just from the one trust on which Francis focused, but from national research data - is that the majority of wards do not have enough nurses on duty. Nine out of 10 nurses on acute wards say they left necessary care undone on the last shift they worked. And why? Because they lacked the time. Out of 31 trusts covered in this study, only three had an average ratio of fewer than six patients per nurse. In this context, far from reducing staffing, setting a limit of five patients per nurse would lead to a widespread increase.

The research linking nurse staffing levels to patient mortality is substantial, and nurses in practice often respond to this with amazement that it even needs doing - is it not obvious? Obvious to us as nurses it may be, but we see around us evidence of this message going unheeded. Nurse staffing levels that fall well below the standards that are deemed “basic” elsewhere mean most patient care is provided not by nurses, but by healthcare assistants. And each time financial pressures increase, it is the nursing workforce that is cut.

That inadequate registered nurse staffing levels costs lives does not appear to be driving policy or practice; in the economic climate, it is a difficult truth to face.

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


Readers' comments (28)

  • Good article. The evidence from the Francis Report and research does indeed exist.

    "That inadequate registered nurse staffing levels costs lives does not appear to be driving policy or practice; in the economic climate, it is a difficult truth to face."

    That is the crux of the matter. I take the view, and I know that I am in the minority, that the powers that be need to be persuaded. Nurses taking effective and constructive industrial action might focus their attention better on just what should drive policy. But I won't be holding my breath.

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  • Of course there are not enough nurses to look after patients properly, we're tired of saying the same old thing over and over again. There are no set nurse-patient ratios so nothing will change. No-one listens, no-one is ever held accountable.

    Nurses are constantly told to report unsafe staffing levels, when they do no-one does anything about it anyway. If you do report it you get ignored or fobbed off with some excuse about funding, if you don't report it you are accused of 'failing' in your duty.

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  • mags | 19-Mar-2013 8:24 am
    Agreed. When will nurses learn that simply complaining about staffing levels will never do any good?

    Anonymous | 19-Mar-2013 11:06 am
    Nurses in Oz took to the streets in unified action and targeted strikes and marches. Unless UK nurses are prepared to do the same, then you will still be moaning for many years to come.

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  • Anonymous | 19-Mar-2013 11:06 am

    i'm afraid that they don't have to listen to you when you complain about staffing levels, because there are no compulsory minimum levels with which they must comply. that's the point. Anonymous | 19-Mar-2013 12:34 pm is right. you will continue saying the same old thing over and over again until that changes. i think that it would be better to take action similar to that in australia, than to keep on complaining to people who don't listen.

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  • The Francis Report merely confirmed what common sense already told us. None of the Francis Report recommendations have been acted upon so what was the point of it.
    Until there are minimum staffing numbers, improved staff-patient ratios, regulation of HCAs, managers being accountable for failings, ward sisters actually looking after patients, staff not being bullied then management, the unions and the govt will get away scot-free and no-one will ever be held accountable.

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  • Anonymous | 19-Mar-2013 6:34 pm

    So stop moaning and blaming everyone else and go on strike!! Jeez.

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  • Mags, I'd be really interested to know what you think of this
    I am trying to use the payments we get to directly reflect staffing levels so that in an ideal world, the busier we are/ more dependent patients we have, the more nurses. The time lag is a problem I know.
    I am also trying to use the nursing literature to put in cut offs so that if e.g. staffing drops below what the most senior nurse regards as safe, we shut the ward. The trust refuses to open new beds because of cost and I have little confidence in the CCG plans to manage demand as they've not produced much over the last few years and the trust is just getting busier and busier.
    But I think better use of the tariff might be the key even if this gets a little techie....
    Apologies for management jargon, am just trying to do my bit to help.

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  • anon 10.30 - how do we go on strike? what do we need to do to start strike action and how long does it take to organise. Do we just refuse to go into work and what do we do in the meantime?

    what are the staffing levels like where you work.

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  • if you shut the ward where do the patients who need to be admitted go? we used to shut wards in the 90's but we didn't seem to have so many patients in those days, do ITU's close beds nowadays when they don't have enough staff or do the staff just look after more patients?

    someone has mentioned going on strike, until we do how do we look after patients safely with the staffing and resources we have?

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  • Nothing will change until nurses reclaim their power. Yes, they are exhausted, demoralised and intimidated by unsupportive managers BUT it is only they who can do something about it.

    It is imperative that nurses engage differently with each other - break the negative cycle of moaning that pervades the NHS - overtly support each other. If nurses pull together they will have a unified voice that is hard to ignore.

    How do they do this? Dogged determination, committment and courage.

    I don't know if striking is the answer but I do know that it's unlikely to happen while nurses are as disempowered as they currently are.

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  • Short-staffing and inappropriate skill mix also have a very negative effect on the staff, it increases stress, increased sick time, puts nurses under immense pressure and all these things obviously affect patient care.

    Why doesn't anyone take any notice of what we are saying - we know the media read these posts, why don't they help us and get behind us for a change instead of constantly criticising everything we do.

    If we do go on strike I don't think we will get any public support unless it is known that we are striking for the good of our NHS and our patients - not for our own wellbeing, paycuts or pension cuts because no-one except nurses themselves care about those things.

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  • Occasionally my ward is left with 2 qualified during night shift to care for 28 patients, with atleast 2 post op patients, 2 HDU tranfers after major surgery like whipples,gastrectomy,liver resection, 2-3 patients on epidural/PCA,patient on lysis,epoprostinal infusion, 5-6 patients on TPN,10-15 IV meds to administer .They are expected to complete all the tasks and ensuring accurate documentation is done.This happens when 1 qualified is sent over to another area to make safe staffing level.How safe is this practise??????????

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  • Can some one introduce 6S's for safe staffing level and the 6C's will be automatically implemented.

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  • Anonymous | 21-Mar-2013 9:50 am

    If you don't go on strike or do something equally drastic, things will get much, much worse. It isn't a popularity contest. If Joe Public wants decent healthcare, then he needs to realise that it has to be properly funded. Our wellbeing is intrinsically linked with standards. That has to be realised by everyone. Especially nurses.

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  • For anonymous 20/3/13 - yes your concerns are understandable, but when nurses strike - as they did in the 80's (spookily when we had a previous tory government who didnt care)- emergency care will be protected. I think most nurses would prefer a "work to rule", ie most elective admissions will be stopped and staff depoloyed to help with emergency admissions. Also a strike need'nt be "all out", but planned in advance on particular days.
    A similar strategy happened when the Ambulance Service went on strike in 1990 (AGAIN under a uncaring tory government) where most areas (apart from some large metropolitan areas) still continued with 999 calls but not routine. Conservative Kenneth Clarke is on record of calling paramedics "glorified taxi drivers" in the house of commons during this time, which amplifies what out of touch conservative politicians think of all essential health care workers.

    Until we strike, we will continue to be treated poorly by this multi millionaire government who care more for tax cuts for millionaires than improving health care within the NHS.

    We all know that wards are woefully understaffed, and we all take the blame in the media as "uncaring" when the spotlight should be concentrated on poor management and staff provision.

    The only way of bringing this terrible and worsening situation to the fore is to strike. We should all stop bleating about it and do something more constructive, like petitioning our respective unions to back us with strike action.

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  • anon 3.45 - I don't remember ever going on strike in the 80's or 90's - I do remember the strike by ambulance drivers, fire service when nurses when out in sympathy and joined marches. Those were the days of NUPE and the Socialist Worker outside hospitals, did nurses go on strike?

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  • Anonymous | 21-Mar-2013 6:18 pm

    "...did nurses go on strike?"

    Yes they did. I was a student nurse, in NUPE at the time and remember very clearly marching through the centre of Glasgow with thousands of other nurses in 1982 (I think it was in May). There were a serious of actions. I seem to remember two-hour stoppages amongst other days of action. We got a decent wage rise out of it.

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  • mags | 21-Mar-2013 6:51 pm

    I was there too and I remember it well Mags! Also, the iconic front page picture in the Daily Record of a nurse during the march in full rant-mode, and the headline "We Won't Budge". Those were the days.

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  • Anonymous | 21-Mar-2013 7:53 pm

    I remember that so well!

    Nurses were out on strike again in 1988. By that time I was working in Africa, so wasn't involved. There are actually a few other examples of nurses striking, but it has usually been in small numbers, because the vast majority of nurses who belong to a union are in the gutless RCN.

    From a report at the time,

    "A ward sister explained that “this action is not only, or even primarily, about pay. Nurses are extremely angry and bitter about the state of the NHS and frustrated they cannot deliver the care their patients need. They are fed up with closures of wards and cuts in services, with staff shortages, with moral blackmail and exploitation, underfunding of pay awards, and the governments declared intention cutting taxes rather than increasing health service funding. Nurses are incensed by Margaret Thatcher’s comments that it is nurses who are guilty of ruining the NHS”.

    How familiar is this?!!

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  • mags | 21-Mar-2013 8:11 pm

    How familiar is this?!!

    Stunning to see such a statement which nails so many of the SAME problems, STILL happening 30 years later...under another Tory government with the same attitude towards nurses. Difference being that at least nurses then actually did something about it.

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  • So far it doesn't seem as if anything recommended in the Francis Report has been taken seriously or implemented.

    I remember standing outside the hospital gates where I trained in the late 80's, early 90's and wanting to sign up to NUPE but was told we couldn't.

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  • Gosh that was rocket science! Lol

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  • Anonymous | 22-Mar-2013 10:24 am

    Who told you that?

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  • anon 1.35 If you were already in the RCN could you also join NUPE or UNISON

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  • Nurses I respect you.
    You must realise you are the line stopping utter total chaos in all the hospitals and you are all trying your very, very best.

    Yet you all must organise and tell the public what is going on.

    Take out full page adverts in the newspapers.

    Do secret filming in wards showing us what is going on and throw it on YouTube. The public does not have a clue what is going on inside hospitals.

    You must explain to the public.

    Me? I am writing a play about all this

    The CEO:
    "A hospital is like a factory. Patients come in, they get treated and then they leave. This hospital will be the most efficient in the country. We will exceed targets."

    Jasmine a nurse: I am being bullied by the chief surgeon and he hates me. Why is he doing this to me? Why? Everybody knows but no one is helping me. What have I done so wrong?

    Alison a nurse: Listen. You have suspended Jasmine which means I am a nurse down. I need another nurse. I have 16 patients and I can barely cope. Don't you get it? Don't you understand? There will be a disaster soon. And who will be blamed then?

    Matron: We don't have any more nurses. I cannot conjure one out of thin air. We have no more resources, no budget. You have to do the best you can. You need to improve anyway, as your performance figures are bad. These are what you been being measured on

    Alison: How?

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  • Anonymous | 22-Mar-2013 6:58 pm

    You just needed to leave the RCN and join whichever union you wished.

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  • People can join any number of unions, so long as you pay, or not be in any union. The question is why, though there may be reasons why some people do and it could be quite personal. Its the same with joining professional organisations. People may have different roles, in which they can apply their different skills and experiences into their jobs (eg. teaching, management, older people care specialist and voluntary roles).
    The issue arise if you require union assistance for representation, you would have to pick which one to help you. Also if you hold any positions of office, you would not be able to hold a position in another competing/comparable organisation due to possible conflicts of interests.
    If people are that proactive, then all credit to them and sounds like they're more likely to be valued by their colleagues, patients, family and friends.

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  • Inadequate staffing definitely affects quality of care and recovery times, which in turn has an impact on everyones lives.
    It doesn't look or sound good when its clearly stated that cutting nursing workforce prolongs patient suffering and kills people faster. A root-cause analysis of patient mortality might not be welcome if conducted and made public.

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