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