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Safe staffing pioneers: Welsh law focuses on appropriate nursing levels


Hospital nurses dashing about to the sound of buzzers, trying to balance caring for patients while desperately trying to find more staff for their wards has become a familiar tale in Wales.

While this scenario may chime with nurses in other parts of the UK it is only Wales that has made history in trying to confront the issue with legislation.

“The upshot of this law will be that nurses will find themselves working alongside an appropriate number of staff”

Kirsty Williams

It became the first country in Europe to introduce legislation around safe nurse staffing after its Nurse Staffing Levels (Wales) Bill received royal assent in March, becoming the Nurse Staffing Levels (Wales) Act 2016.

The law has largely been greeted with exultation with advocates claiming it will “strengthen the arm” of frontline nurses.

But in reality will it be able to create lasting change and how quickly can that be done?

Before the bill was passed by the Welsh assembly, its members heard from nurses giving evidence who spoke of the constant pressure they felt under when at work with too few staff, which revealed the clear case for a law change, according to the RCN Wales’ director Tina Donnelly.

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Tina Donnelly

As health boards are required to comply with the legislation – after statutory guidance for the law has been drawn up following this month’s election in Wales – Ms Donnelly said it will immediately provide those nurses with a voice to challenge staffing levels.

“From our perspective talking to nurses, they have said nobody listens to them at the moment,” said Ms Donnelly.

The law will require health boards to ensure “sufficient” nurse staffing levels are maintained at a level that has been calculated using the professional judgement of the nurse in charge of the shift, a workforce tool to ensure the acuity of patients is considered, and in a way that takes into account recommended staffing ratios.

“You will have to close beds for that period of time while the nursing care levels are unsafe”

Tina Donnelly

It will initially apply to NHS hospitals only, in adult acute and surgical wards, but the legislation is able to be extended to other settings in the future.

While staffing guidance for hospitals recommending average nurse to patient ratios – of 1:7 for day shifts and 1:11 for night shifts – was produced by the chief nursing officer for Wales in 2012, research by the RCN found this was largely not being met.

However, the CNO’s ratios are expected to underpin statutory guidance and so many trusts have been making increased efforts in the past year to improve their nurse numbers through international recruitment in anticipation of the law, said Ms Donnelly.

There have also been greater workforce planning efforts made to account for sickness, annual leave and maternity allowances, said Ms Donnelly.

But it had been a challenge for health boards and, she noted, the new legislation importantly required the professional judgement of the nurse – which could call for levels of staffing above the ratio and expose trusts that are failing to comply.

She noted the existing shortage of 1,200 nurses in the NHS in Wales, the fact international recruitment was already being utilised, and recent boosts to nurse training places not being felt for another three years.

As a result, the law’s introduction in its early stages was more likely to lead to bed closures than instant, widespread increases in nurse numbers, she said.

“It stands to reason, if you’ve got a ward that is unsafe in terms of staffing levels your first point is to bring in extra staff off your bank, and if you’re not able to do that that then you go to agency,” she said.

But if these measures still meant a health board was not compliant with the law, she said: “If you then have a situation whereby you are unable to staff a medical or surgical ward, you can’t just bring people from other areas of the hospital. You will have to close beds for that period of time while the nursing care [levels] are unsafe.”

“That potentially may mean an increase in waiting lists and that will be for the government to respond to with resources, or to accept that as an unintended consequence,” she added.

She warned this scenario would “not be acceptable” to the general public, and so should result in government action to increase nurse numbers.

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Angela Hopkins

Angela Hopkins, recently retired executive director of nursing, midwifery, therapies and health sciences at Betsi Cadwaladr University Health Board, agreed the legislation would pressurise the government to continue boosting training places.

Wales health minister Mark Drakeford announced in February a 10% increase in commissions – an extra 135 nurse training places, bringing the total to 1,418 – for this year, following a 22% boost in places in 2015-16, of 230 extra places.

“In the future, with the legislation, there will be much more focus on the commissioning of nurses to be educated up to graduate level. Without that commissioning, we are never going to be able to achieve the levels we need,” said Professor Hopkins.

“There will be much more focus on the commissioning of nurses to be educated up to graduate level”

Angela Hopkins

However, she there was also a desire within the NHS to provide more care in the community, suggesting the law’s lasting impact would not be infinite increased recruitment of hospital nurses.

The law’s introduction would also see more initiatives introduced by employers to improve nurse retention, said Professor Hopkins, who pointed to Betsi Cadwaladr’s own scheme to showcase staff excellence.

“That’s the starting point for us – so what measures we can put in place to ensure nurses we do employ have a good work experience and want to stay locally supporting the local population,” she said.

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Kirsty Williams

One of the main driving forces behind the legislation, Welsh Liberal Democrats party leader Kirsty Williams, said its introduction would in itself improve retention and recruitment.

Ms Williams, who put forward the proposed law in 2013 through a private member’s bill, said international evidence showed similar nurse staffing legislation in other countries had proven to be a “powerful” tool for attracting more nurses into the profession.

While there may be increased agency nurse usage initially, in the long-term former nurses or those who have moved into agency work would be reassured to return to practice within the NHS, she said.

“We know many people have left the profession or are working in agencies but what international evidence does show is that having the confidence to know you’ll be on a ward supported by the correct number of colleagues and you will be able to do job properly has proved a great incentive for bringing people back to nursing and encouraging people to stay in frontline nursing for longer,” she said.

“Knowing you’ll be on a ward supported by the correct number of colleagues has proved a great incentive for bringing people back to nursing”

Kirsty Williams

Meanwhile, the inadequate supply of student nurses seen in the past should not be repeated under the new legislation, she said, because it will require health boards to carry out accurate workforce planning that supports safe staffing.

In addition, employers will by law have to report levels of compliance to the government and will also be monitored by the regulatory body Healthcare Inspectorate Wales, she said.

Despite the current staffing challenges in the country, Ms Williams firmly believes as the legislation becomes embedded within Wales over the coming years, benefits will be seen on wards across the country.

“The upshot of this law will be that nurses on these wards will find themselves working alongside an appropriate number of staff that will allow then to do the job they were trained for, hopefully making it easier for them to proactively nurse their patents and give them the time and attention they need to do their job properly,” she said.

The Nurse Staffing Levels Act (2016) in summary:

  • Health boards must ensure there are sufficient nurses to allow the nurses’ time to care for patients sensitively
  • The Welsh government must develop guidance setting out how to determine locally appropriate and safe nurse staffing levels – initially for adult acute medical and surgical inpatient wards
  • Boards must designate a person to calculate the number of nurses appropriate to provide care, take all reasonable steps to maintain the nurse staffing level, and inform patients of that level
  • When calculating the staffing level, a designated person must exercise professional judgement and take into account the appropriate ratio of nurses to patients using evidence-based tools
  • Each board must submit a regular report setting out the extent to which nurse staffing levels have been maintained and the impact that not maintaining them has had on care, for example complaints

Readers' comments (3)

  • This bill has made no difference to the staffing levels at the Welsh hospital where I work, we are short of trained nurses almost every shift.
    We have asked for bed closure to maintain patient safety but this is ignored due to the constant lack of bed capacity and the amount of ambulances that are being held outside A&E

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  • I fully support this bill but I fail to see how it will be enforced whilst adhering to the cap on agency spending. The government is living in a fantasy world, sounds great on paper but in reality the NHS is so short staffed that the area I work in is struggling to staff 1 nurse to 16 patients and with the changes to the bursary I can only see a further decrease in qualified nurses. It's about time the government seriously started looking into why there is such a recruitment and retention problem (would it not be a suitable start by surveying all NMC registrants for their opinion) as there is more to this crisis than staffing levels alone.

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  • I must agree that this bill has not helped on the Acute Surgical ward in Wales that I work on. We are most shifts short staffed and have recently lost more staff thus making safe staffing levels impossible. We have been provided with agency staff for some of the shifts but this is so inconsistent, and as our more experienced staff have left the skill mix is appalling. I have worked on this ward for almost 20 years but am now considering leaving later in the year,as I feel more and more pressure being put on the nursing staff, I have suggested that we need to close beds short term to ensure the safety of the patients and also the staff, but to no avail. I cannot see any answers at the moment to help save the NHS in Wales and feel fearful for my grandchildren future health care.

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