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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)

  • 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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