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Red flags and magic numbers

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Services are struggling and nurses want a “magic number” for safe staffing levels. Without that, workforce planning will only becoming increasingly difficult and conversations with bosses about the need for extra staff more challenging.

That was the message that was emphatically put across by some senior nurses at a staffing conference I attended this week.

Unfortunately, the academic and policy experts also in attendance delivered a tough response, saying there was no magic one-size-fits-all ratio for safe nurse staffing across all settings. It’s just too complex, they noted, with what works for a care home not necessarily working for an emergency department.

But, from what I can see, that does not mean some conclusions cannot be drawn based on the research available for different settings.

“What works for a care home not necessarily working for an emergency department”

For example, one expert said that as an absolute bare minimum, what should not be forgotten (in hospitals at least) is the point at which the risk of harm is known to increase. When the ratio of one nurse to eight patients is exceeded, evidence from adult inpatient wards in acute hospitals has clearly shown that you are in trouble, said Professor Peter Griffiths from the University of Southampton.

However, the complexities surrounding nurse staffing do not stop there. The discussion between the nurses at the conference also turned to the variation in methods used to carry out calculations. Current guidelines highlight the importance of using evidence-based tools to help inform staffing decisions. But as one deputy chief nurse at the event lamented – there does not exist a standardised workforce tool that has been endorsed nationally and which everyone is expected to use. But surely this only adds to the difficulty of understanding where safe staffing levels lie and being assured that workforce plans are robust?

“There does not exist a standardised workforce tool that has been endorsed nationally”

Of course, NHS trusts and care organisations are not just sitting around waiting to be told what to do. They are drawing their own conclusions about what tools fit best with them and some are conducting their own research. But it seems to me the degree to which this actually results in improved nurse numbers will vary greatly, depending on how much time and money each employer can afford to put in (not to mention whether they can even get hold of the staff, considering the national shortage.)

And when the investment in workforce planning is made, it might not provide an easy solution. For instance, Nottingham University Hospitals has developed an app for mobile devices that allows nurses at ward level to record staffing levels and send out red flags which give an up-to-date summary to chief nurses.

But it found it difficult to identify a direct correlation between red flags and staffing levels, and the number of falls, pressure ulcers etc. The trust is not stopping there though – it is working on new ways to predict how a change in nurse numbers could result in a future avoidance of harm. However, for the moment there are no firm conclusions.

“The CQC used to deliver a harsh reprimand if it uncovered high vacancies”

Away from these discussions at the conference, I have also begun to notice an apparent change in the way the Care Quality Commission is dealing with nurse staffing levels. The regulator used to deliver a harsh reprimand if it uncovered high vacancies, telling trusts they must be filled. Now it seems to be more accommodating, making no comment on some services with high vacancies, while telling others with similar levels that they should be filled.

For example, at an inspection last year Black Country Partnership NHS Foundation Trust was found to have a 21% nurse vacancy rate among its specialist community mental health teams for children. Some wards at the trust had higher vacancy rates than this, but the CQC only made reference to the fact the community teams should fill their vacancies.

The CQC said last summer it is trying to take a more “sophisticated” approach instead of just dictating “crude staffing levels based on arbitrary standards”.

“Why is there is not more of a collective national effort to sort it out?”

This seems to me to be in part yet another acknowledgement of the sheer complexity of how to determine safe nurse staffing. And also the lack of a national evidence to deal with that complexity.

So if workforce planning is a highly complex activity that individuals – and organisations as a whole – are struggling to do, the main question I have been left with is why is there is not more of a collective national effort to sort it out? Why not invest in more UK research to get as close as possible to the best methods for safe staffing across each setting and services?

Just because the “magic number” is a myth, does it mean safe staffing should be left down to individual nurses and organisations to work it out on their own?

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