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Nurse supervision of HCAs ‘must be factored into staffing’ under new Wales law

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Healthcare assistants providing care under the supervision of nurses must be considered when calculating staffing levels under new laws in Wales, draft guidance suggests – though those close to the document admit that it must be made clear it does not mean HCAs should be counted as nurses.

Proposed statutory guidance for implementing the Nurse Staffing Levels (Wales) Act 2016 states that a designated senior nurse must include “the number of registered nurses and the number of persons providing care under the supervision of a registered nurse” when assessing staffing for wards.

“The designated person must calculate the number of nurses appropriate to provide patient centred care”

Draft statutory guidance 

“The designated person must calculate the number of nurses appropriate to provide patient centred care that meets all reasonable requirements in that situation using the triangulated methodology set out in the guidance below,” said the document, which was published last week.

“The number of nurses means the number of registered nurses and the number of persons providing care under the supervision of, or discharging duties delegated to the person by, a registered nurse,” it added.

Tina Donnelly, director of RCN Wales – which has been involved in drawing up the guidance – said it was often overlooked that more nurses were needed due to delegation duties.

“When calculating staffing, people often don’t take into consideration that when you are designating a registered nurse to look after patient, they have additional duties of supervising non registered care workers,” she told Nursing Times.

“Often, while the skill mix is right, registered nurses may need to provide direct supervision for quite a high proportion of those support workers and that might take away from the nurse having time to provide direct care,” she said.

However, when asked by Nursing Times, Ms Donnelly acknowledged the wording of the draft document might create confusion and lead some to wrongly believe that assistants could be used to help bolster nurse staffing figures.

The head of the RCN in Wales stressed it was important for the consultation – which is open until April – to iron out any confusion about this requirement and any other issues stemming from the proposed guidance.

“The fact that this might be confusing means it needs clarification and that’s what the consultation is about. We’ve got a year to get this right,” she said.

The new law was passed in March and requires Welsh health boards and NHS trusts to maintain staffing levels that are calculated using professional judgement and evidence-based workforce tools, and by taking into account the acuity of patients, and ratios of nurses to patients.

“Registered nurses may need to provide direct supervision for quite a high proportion of support workers”

Tina Donnelly

It will initially only apply to adult acute medical and surgical inpatient wards, which will be required to abide by the legislation from April 2018.

The draft statutory guidance, released for consultation last week, lays out the method for calculating staffing levels and details of how NHS organisations will be required to maintain them.

It states that a designated senior nurse – such as the executive director of nursing for the board – should determine the nurse staffing levels required to meet patients needs, as assessed by the ward nursing team.

For the organisation to maintain its staffing levels, this means “having the number of registered nurses and healthcare support workers the required establishment and its planned roster require”, it later states.

The guidance says this should be achieved by using employed staff, but “temporary workers can be engaged if required”.

The triangulated approach required is the use of professional judgement, the use of an evidence-based workforce planning tool, and consideration of how far patients are sensitive to nursing care.

The guidance suggests professional judgement should include consideration of a range of factors including the qualifications, competencies, skills and experience of the nurses, the effect of the use of temporary staff and how far administrative duties will need to be carried out by nurses.

Royal College of Nursing Wales

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Tina Donnelly

Once this has been taken into account, a staffing increase of 26.9% should be factored in to allow for any unexpected staff absence.

In considering the intensity of nursing care needed, analysis of data including patient falls, pressure ulcers and medication administration errors should take place.

The calculation should be “undertaken every six months when the tool data is entered, when there is a change of use/service or if the designated person deems it necessary”, states the draft proposal.

Ms Donnelly said that, while a report of staffing should be produced every six months, a record of staffing using the legally required calculations should be available on a shift by shift basis.

She also stressed that the statutory guidance should go “hand in hand” with a set of nursing principles developed in Wales that state staffing level ratios should be 60% of registered nurses to 40% support workers.

The consultation on the draft guidance opened on 7 December and runs until 7 April.

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