Staff on hospital wards can continue to use the ratio of one nurse to more than eight patients as evidence of the point at which there is increased risk of harm during day shifts, according to a draft version of new national workforce guidance that also promotes evidence-based tools to calculate staffing.
However, the draft acute adult inpatient guidance, published today by the regulator NHS Improvement, stressed that nurses should also note that no single nursing staff-to-patient ratio could be applied across all wards of the same type, as per previous guidelines.
“The biggest safeguard we have got to have to ensure great quality of care is the registered nurse”
Specifically, the document recommends staffing levels should be calculated by using an evidence-based workforce tool, as well as by comparing against other similar wards and organisations, and also by using professional judgement – though warning that individual opinion should not be relied upon solely.
Today’s draft guidance for acute settings was produced after revisiting staffing guidelines already completed by the National Institute for Health and Care Excellence two years ago.
NICE’s work on safe staffing across a range of settings was controversially suspended in 2015 by NHS England and the Department of Health, just as the research body was on the brink of publishing documents recommending minimum nurse ratios in accident and emergency departments.
Today’s document states: “While NICE guidance identified evidence of ’increased risk of harm associated with a registered nurse caring for more than eight patients during the day shifts’, they clearly stated there is ‘no single nursing staff-to-patient ratio that can be applied across all acute adult inpatient wards’. We have found no new evidence to inform a change to this statement.”
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It also stressed that decisions about how many nurses work on hospital wards cannot be left to individual judgements but need to be evidence based.
The document warned trusts not to rely solely on professional judgements, which it said were “considered subjective and may not be transparent”, adding that “a triangulated approach” was needed.
As a result, it said trusts should “triangulate” information such as the rate of falls, pressure ulcers and other ward data, including complaints and staff sickness using evidence based acuity tools to calculate staff numbers.
Organisations should only use professional judgement to address specific local issues, stated the draft guidance – titled Safe, sustainable and productive staffing: An improvement resource for adult inpatient wards in acute hospitals.
In addition, the document said staffing levels should include uplifts for issues such as study leave and sickness, and trusts should have “float” nurses who can be moved to different wards during times of peak demand.
nurse with clipboard
Although it made reference to the importance of multi-disciplinary staff, it accepted “there is little workforce modelling or planning evidence on how this has been successfully achieved”.
Trusts are also advised to benchmark themselves against other organisations using a new staffing metric – known as the care hours per patient day (CHPPD) measure – which shows the average hours of care provided per patient by nurses and healthcare assistants in a 24-hour period.
While also acknowledging the involvement of non-registered nursing care staff, it makes clear “the registered nurse hours must always be considered in any benchmarking alongside quality care metrics in order to assess the impact on patient outcomes”.
Alongside the guidance, NHS Improvement has published summaries of existing evidence on nurse safe staffing to help inform local decisions.
One of the summaries, prepared by Southampton University, said: “While the odds of adverse outcomes were generally increased when average staffing fell below the 1:8 threshold, better outcomes were often associated with higher staffing levels and ratios of 1:7 and lower.
“For some services, significant increases in risk occurred well below this threshold. While not giving a clear ‘safe’ staffing level this evidence reinforces that a 1:8 threshold represents a level at which risk is known to be increased, not an optimal, safe staffing level,” it noted.
The guidance was produced by an independent committee for NHS Improvement, which was chaired by Hilary Chapman, chief nurse at Sheffield Teaching Hospitals NHS Foundation Trust.
“The evidence is clear that the 1:8 ratio is not a ‘target’ staffing level for all circumstances and therefore should be triangulated with local assessments and professional judgement to determine what is required,” she told Nursing Times.
Today’s draft guidance is one of seven safe staffing resources due to be published by the regulator for consultation in coming months.
Ruth May, NHS Improvement’s executive director of nursing, told Nursing Times that the regulator was developing safeguards to ensure organisations complied with the recommendations laid out in the staffing resources.
“But the biggest safeguard we have got to have to ensure great quality of care for patients is the registered nurse, wherever they are – whether that’s on the board or in a clinical setting. We will, though, be developing safeguards prior to the final publication,” she added.
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NHS Improvement has also published today draft guidance for safe staffing in learning disability settings. A consultation on the adult acute and learning disabilty settings documents will run until 3 February.
Meanwhile, it has also published a separate joint consultation with the Care Quality Commission on future checks on the “effective use of resources” by acute trusts, which includes workforce factors such as agency spend, skill mix, rostering technology, turnover and sickness.