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Katherine Fenton and Ann Casey: 'Locally set nurse to patient ratios allow us to offer dedicated care'


No single nurse to patient ratio can be applied safely across all wards without taking into consideration patients’ needs, say Katherine Fenton and Ann Casey

The government’s recent recommendations about nurse staffing are great. They are long overdue and a number of us senior nurses have been pushing for these guidelines for years. They allow local decision making based on sound evidence. With this, we can base our response to our own patient groups on their acuity and dependency requirements using evidenced-based tools, such as the Safer Nursing Care Tool.

That so many significant organisations have signed up to these guidelines, including the National Quality Board, Care Quality Commission, NHS England and the Department of Health, gives us a platform to all work together to the same standards and requirements, which are clearly set out in the recent publication How to Ensure the Right People, with the Right Skills, are in the Right Place at the Right Time.

At University College London Hospitals we have used the Safer Nursing Care Tool to determine nursing establishments for our inpatient wards for some years. In practice this means we collect data on the level of acuity and dependency of every patient on every ward every day in February, June and September of every year.

As well as letting us know how many staff we need for each ward, it also helps us identify the nurse to patient ratio for each individual ward. This is important as we all know the level of acuity and dependency of patients varies according to the patient group being cared for, and there is no single nurse to patient ratio that can be applied safely across all wards without taking into consideration a patient’s individual needs.

‘Every member of the nursing team knows how to ensure their concerns regarding staffing levels are heard and acted upon’

As you may have seen in some of last week’s media, we have a quality and safety board in a public area of every ward. This board displays ward-specific information, including the number of days since the last pressure ulcer or fall, patient satisfaction, incidence of infections, patient experience and feedback, as well as staffing information such as vacancies, sickness and nurse to patient ratios on the shift. This information is updated at least daily when all the nursing staff as well as members of the multidisciplinary teams, such as the doctors, pharmacist and therapists, gather together to review quality and safety on the ward.

We call these the quality and safety huddles, which provide an excellent opportunity for all staff - regardless of their seniority - to be listened to, express concerns, and/or hear/give positive feedback about patient care to each other. Questions that can be heard at this time include: “How can we prevent this happening again?” This really allows the staff ownership of the problem and to be part of the solution in improving outcomes for their patients. At this time of year, for example, we are aware that some infections become more prominent, presenting risks for our patients and staff; as a result, a regular part of the current conversations include: “Have you all had your flu vaccination; if not when will you be having it?”

Where the nurse to patient ratio specific to that ward is breached, we have an escalation policy so every member of the nursing team knows how to ensure their concerns regarding staffing levels are heard and acted upon. The policy includes the chief nurse’s telephone number and also the telephone numbers of all the deputies.

Underpinning our working life at UCLH are the principles of safety, kindness, improving and teamwork - it is a values-led culture that each and every one of us lives each day in our work. This provides an excellent arena where staff can be open, honest and escalate concerns.

Katherine Fenton OBE is chief nurse; Ann Casey is senior nurse; both at University College London Foundation Trust


Readers' comments (3)

  • Unfortunately the tool isn't fit for purpose. It's currently being used as 'evidence' to justify culling many ward nursing posts at UCLH as part of 'workforce review'. Funny how no-one really cares about acuity tools or workforce numbers until there is a drive to save money...

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  • I agree with Anonymous | 4-Dec-2013 7:54 pm.

    Too many 'nurse leaders' seem to forget that we have evidence based tools already and that their stuff is essentially unvalidated and some of it isn't even tested.

    Do we allow other local decision makers to disregard decent research based evidence and design care on the back of an envelope, just as they please?

    Heaven help us if they start coming up with their own biased and untested local ideas on cancer treatment...

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  • Interestingly enough, where I work, they wanted a new nursing model with more nurses , so they hired 100 from abroad, the plan being that they would downband some of the band 6s, lose most of the HCAs, which equalled the same amount of staff on shift but with a higher nursing to HCA ratio.

    So now they have employed all these extra nurses but are not doing the nursing model as they cannot afford it with their budget and plans have been shelved. Setting staffing numbers locally means that hospitals can understaff their wards if their budget is not big enough. Money before patient safety and care.

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