Downloaded from http://fn.bmj.com/ on September 5, 2017 - Published by group.bmj.com
Editorial
Nurse staffing to patient ratios and mortality in neonatal intensive care Alan C Fenton,1 Sue Turrill,2 Caroline Davey3 Recognition of the importance of one-to-one nurse staffing ratios in neonatal intensive care (IC) is not new: since the 1990s, successive studies and quality standards—including the British Association of Perinatal Medicine Standards for Hospitals Providing Neonatal Intensive and High Dependency Care1—have stated unequivocally that the sickest babies require this level of nursing. Indeed, this is no different from the one-to-one nurse staffing ratios required in both paediatric and adult IC. In 2009, the Department of Health set this staffing ratio as the national standard for England, stating that “High-quality neonatal services…rely on having an adequate and appropriate workforce”. These same ratios also apply in Scotland2 and in Wales.3 Neonatal services, in common with many areas within the National Health Service, are under considerable pressure. Despite the development of a National Service Specification for Neonatal Critical Care, covering all levels of care delivered within neonatal units, it is clear that many neonatal services do not achieve recommended levels of nurse staffing. This is due to a number of factors including increased activity in addition to staff recruitment and retention issues. The extent of nursing staff shortfall in some areas has led to suggestions that current recommendations for staffing are unrealistic and that these should be reduced to an ‘achievable’ level. However, some hospital trusts that provide clearly structured development programmes for new nurses have been able to maintain consistent nursing establishments. Previous studies on staffing levels have often focused on nurse activity during delivery of care rather than outcomes. The paper by Watson et al4 is, therefore, both a timely and welcome addition to an area where there is still a paucity of
1
Newcastle Neonatal Service, Newcastle Upon Tyne, UK; 2Independent Consultant in Neonatal Nursing, Leeds, W Yorks, UK; 3Chief Executive, Bliss, London, UK Correspondence to Dr Alan C Fenton, Newcastle Neonatal Service, Ward 35, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK; [email protected] F186
evidence supporting the value of nurses in neonatal units. The clarity of the study’s key finding is stark: a decrease in the proportion of IC days on which one-to-one nursing was provided was associated with a statistically significant increase in the in-hospital mortality rate. In lay terms: insufficient staffing in neonatal IC means that more babies die. However, evidence is also clear that we are getting further away from meeting this standard rather than closer to it. The study itself highlights that during the study period of 2008–2012, the provision of one-to-one nursing in tertiary neonatal units actually declined. Most recently, the 2015 Bliss Baby Report: Hanging in the Balance5 showed that the overall shortfall in nurses in England across all three levels of neonatal care has become more acute over the last five years. The most serious pressures were in neonatal IC units where there was a 10-percentage-point rise in the number unable to meet standards on nurse staffing levels. In recent years, we have seen an increased focus on introducing quality improvement programmes into English healthcare. Reducing mortality is clearly one of the most important measurable quality outcomes for neonatal care, and therefore, recognising and addressing the results of this study should be an urgent priority for healthcare management strategies. Over 90 000 babies were admitted to neonatal units in England, Scotland and Wales in 2014, with 13.7% of the care days these babies received being IC.5 Increasing the one-to-one nursing time for babies in IC is likely to have a significant impact on the mortality of these most vulnerable patients. The results will be unsurprising to those working in neonatal IC, given the very low percentages currently being achieved for one-to-one nursing in many units. The reported summary statistics and monthly medians are worrying and show ongoing, systematic lack of attention given to ensuring funded nursing establishments in neonatal units meet the demands of the Service. Although the authors do not discuss this, it would be fair to assume that the main reason one-to-one nursing is at its lowest and has reduced by 7.2% over the five years of the study is due to
the low numbers of registered nursing staff working clinically in neonatal units. Continued reductions in neonatal nursing numbers alongside shortfalls in establishment funding5 have resulted in the vast majority of units falling far short of being able to meet mandated national staffing standards. One of the limitations recognised by the authors is the number of nurses holding a specialised neonatal qualification within the data collected. Accepted national standards also state that 70% of the registered nursing workforce establishment at each neonatal unit should be qualified in specialty. Registered nurses undertake additional post-registration education (qualification in specialty) to achieve a level of competence that enables them to provide safe and effective care for this unique population. Their knowledge and skills base also ensures that they are able to detect immediate changes to physiological stability that can be acted on at an early stage. Diluting the one-to-one ratio in IC reduces this level of safety and potentially increases the negative impact on mortality and morbidity. Nurses also spend time using a range of supportive interventions for parents and families that have been shown to improve early developing attachments and reduce the long-term negative psychological and social outcomes seen with families who experience NIC.7 Looking outside of infant mortality, ‘family morbidity’ should also be valued in terms of the positive impact of increasing nurse education, training and time, not forgetting the consequent reduction in health costs. For the babies being admitted to neonatal IC units every single day, and for their parents and families, there is an inevitable impact of persistent understaffing, despite the undoubted commitment and hard work of all the professionals caring for them. As highlighted in the Bliss Baby Report, parents applaud the dedication of neonatal staff, but fundamentally recognise the picture of understaffing: “There were never enough nurses working in the neonatal unit”, said one; another commented, “Sometimes there was a definite shortage of experienced nurses on the unit and that was very frightening…[it] kept us awake at night”. Having a baby in neonatal IC is already an incredibly stressful situation; when parents also have to worry about whether there are enough nurses to provide the right care for their baby, it can be simply unbearable. In November 2015, the Secretary of State for Health announced a new ambition to reduce the rate of stillbirths,
Fenton AC, et al. Arch Dis Child Fetal Neonatal Ed May 2016 Vol 101 No 3
Downloaded from http://fn.bmj.com/ on September 5, 2017 - Published by group.bmj.com
Editorial neonatal and maternal deaths in England by 50% by 2030.8 While welcome, the announcement has so far singularly failed to acknowledge the importance of improving staffing levels in order to reduce neonatal deaths despite consistent information from neonatal professionals. In addition, while the Secretary of State has acknowledged the mistake made by the coalition government in 2010 in cutting the number of student nurse places commissioned, it is still far from clear whether the government’s plans to replace student nurse bursaries with loans, as outlined in the 2015 Comprehensive Spending Review, will have the desired effect of increasing the number of nurses trained or will just put a barrier in the way of those who wish to join the profession.9 While there are clearly significant resource requirements, the medical and nursing leadership within the neonatal community have a major role to play at both network and unit level in addressing another facet of staffing issues, that is of recruitment and retention in the face of turnover. This affects units to different degrees for reasons that may not be immediately apparent. Large neonatal units may not be able to provide adequate opportunities for staff progression; high occupancy rates may predispose to ‘burnout’. Family-centred care is now firmly on the neonatal agenda. A key component to implementing this is a nursing establishment that is adequately supported, nurtured and professionally developed from
induction and throughout their subsequent career. Watson et al’s study concludes that further research in this area would be valuable: to calculate in more detail the cost-effectiveness of one-to-one nursing ratios, to explore what the optimal levels of nurse staffing would be and to establish how this is achieved in practice. While these are all undoubtedly fruitful areas for future research, there is already a sufficient body of evidence to justify a renewed focus on working towards achieving the national standards set for one-to-one nurse staffing in neonatal IC. If not now, when?
Arch Dis Child Fetal Neonatal Ed 2016;101:F186– F187. doi:10.1136/archdischild-2015-310156
REFERENCES 1
2
3
4
Contributors All authors were equally involved in the planning, writing and reviewing of the editorial. Competing interests CD is chief executive of Bliss, the premature and sick baby charity. Bliss provided funding for the NESCOP (Neonatal Economic, Staffing and Clinical Outcomes Project) Group, including for this study’s lead author SW.
5
6
Provenance and peer review Commissioned; internally peer reviewed. To cite Fenton AC, Turrill S, Davey C. Arch Dis Child Fetal Neonatal Ed 2016;101:F186–F187.
7
Received 18 December 2015 Revised 31 December 2015 Accepted 4 January 2016 Published Online First 9 February 2016 8
▸ http://dx.doi.org/10.1136/fetalneonatal-2015309435
Fenton AC, et al. Arch Dis Child Fetal Neonatal Ed May 2016 Vol 101 No 3
9
Standards for Hospitals Providing Neonatal Intensive and High Dependency Care—1996, 2001, 2005 and 2011 editions. British Association of Perinatal Medicine. http://www.bapm.org/publications (accessed 17 Dec 2015). Neonatal care in Scotland: a quality framework. 2013. Scottish Government. http://www.gov.scot/Resource/ 0041/00415230.pdf (accessed 17 Dec 2015). All Wales Neonatal Standards (2nd edn). NHS Wales, 2013. http://www.wales.nhs.uk/sitesplus/documents/ 862/All%20Wales%20Neonatal%20Standards% 202nd%20Edition%20v2%2005%2008%2013.pdf (accessed 17 Dec 2015). Watson SI, Arulampalam W, Petrou S, et al. The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study. Arch Dis Child Fetal Neonatal Ed 2016;101: F195–200. Bliss baby report 2015: hanging in the balance. Bliss. London, 2015. http://www.bliss.org.uk/babyreport (accessed 17 Dec 2015). Neonatal Data Analysis Unit (NDAU) Report 2014. Imperial College. London. https://www1.imperial.ac.uk/ resources/A07E2FB9-D7D7-4795-9DEC-80DBDCB 085BE/ndau2014reportv1.3.pdf (accessed 18 Dec 2015). Melnyk BM, Feinstein NF, Alpert-Gillis L, et al. Reducing premature infants’ length of stay and improving parents’ mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit program: a randomized, controlled trial. Pediatrics 2006;118: e1414–27. https://www.gov.uk/government/news/new-ambitionto-halve-rate-of-stillbirths-and-infant-deaths (accessed 17 Dec 2015). http://www.nursingtimes.net/roles/nurse-educators/ hunt-promises-proper-consultation-on-bursary-plans/ 7000865.article (accessed 17 Dec 2015).
F187
Downloaded from http://fn.bmj.com/ on September 5, 2017 - Published by group.bmj.com
Nurse staffing to patient ratios and mortality in neonatal intensive care Alan C Fenton, Sue Turrill and Caroline Davey Arch Dis Child Fetal Neonatal Ed 2016 101: F186-F187 originally published online February 9, 2016
doi: 10.1136/archdischild-2015-310156 Updated information and services can be found at: http://fn.bmj.com/content/101/3/F186
These include:
References Email alerting service
Topic Collections
This article cites 2 articles, 2 of which you can access for free at: http://fn.bmj.com/content/101/3/F186#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Press releases (11) Epidemiologic studies (929) Child health (1515) Neonatal and paediatric intensive care (341) Neonatal health (928) Infant health (857) Neonatal intensive care (246)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Editorial
Nurse staffing to patient ratios and mortality in neonatal intensive care Alan C Fenton,1 Sue Turrill,2 Caroline Davey3 Recognition of the importance of one-to-one nurse staffing ratios in neonatal intensive care (IC) is not new: since the 1990s, successive studies and quality standards—including the British Association of Perinatal Medicine Standards for Hospitals Providing Neonatal Intensive and High Dependency Care1—have stated unequivocally that the sickest babies require this level of nursing. Indeed, this is no different from the one-to-one nurse staffing ratios required in both paediatric and adult IC. In 2009, the Department of Health set this staffing ratio as the national standard for England, stating that “High-quality neonatal services…rely on having an adequate and appropriate workforce”. These same ratios also apply in Scotland2 and in Wales.3 Neonatal services, in common with many areas within the National Health Service, are under considerable pressure. Despite the development of a National Service Specification for Neonatal Critical Care, covering all levels of care delivered within neonatal units, it is clear that many neonatal services do not achieve recommended levels of nurse staffing. This is due to a number of factors including increased activity in addition to staff recruitment and retention issues. The extent of nursing staff shortfall in some areas has led to suggestions that current recommendations for staffing are unrealistic and that these should be reduced to an ‘achievable’ level. However, some hospital trusts that provide clearly structured development programmes for new nurses have been able to maintain consistent nursing establishments. Previous studies on staffing levels have often focused on nurse activity during delivery of care rather than outcomes. The paper by Watson et al4 is, therefore, both a timely and welcome addition to an area where there is still a paucity of
1
Newcastle Neonatal Service, Newcastle Upon Tyne, UK; 2Independent Consultant in Neonatal Nursing, Leeds, W Yorks, UK; 3Chief Executive, Bliss, London, UK Correspondence to Dr Alan C Fenton, Newcastle Neonatal Service, Ward 35, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK; [email protected] F186
evidence supporting the value of nurses in neonatal units. The clarity of the study’s key finding is stark: a decrease in the proportion of IC days on which one-to-one nursing was provided was associated with a statistically significant increase in the in-hospital mortality rate. In lay terms: insufficient staffing in neonatal IC means that more babies die. However, evidence is also clear that we are getting further away from meeting this standard rather than closer to it. The study itself highlights that during the study period of 2008–2012, the provision of one-to-one nursing in tertiary neonatal units actually declined. Most recently, the 2015 Bliss Baby Report: Hanging in the Balance5 showed that the overall shortfall in nurses in England across all three levels of neonatal care has become more acute over the last five years. The most serious pressures were in neonatal IC units where there was a 10-percentage-point rise in the number unable to meet standards on nurse staffing levels. In recent years, we have seen an increased focus on introducing quality improvement programmes into English healthcare. Reducing mortality is clearly one of the most important measurable quality outcomes for neonatal care, and therefore, recognising and addressing the results of this study should be an urgent priority for healthcare management strategies. Over 90 000 babies were admitted to neonatal units in England, Scotland and Wales in 2014, with 13.7% of the care days these babies received being IC.5 Increasing the one-to-one nursing time for babies in IC is likely to have a significant impact on the mortality of these most vulnerable patients. The results will be unsurprising to those working in neonatal IC, given the very low percentages currently being achieved for one-to-one nursing in many units. The reported summary statistics and monthly medians are worrying and show ongoing, systematic lack of attention given to ensuring funded nursing establishments in neonatal units meet the demands of the Service. Although the authors do not discuss this, it would be fair to assume that the main reason one-to-one nursing is at its lowest and has reduced by 7.2% over the five years of the study is due to
the low numbers of registered nursing staff working clinically in neonatal units. Continued reductions in neonatal nursing numbers alongside shortfalls in establishment funding5 have resulted in the vast majority of units falling far short of being able to meet mandated national staffing standards. One of the limitations recognised by the authors is the number of nurses holding a specialised neonatal qualification within the data collected. Accepted national standards also state that 70% of the registered nursing workforce establishment at each neonatal unit should be qualified in specialty. Registered nurses undertake additional post-registration education (qualification in specialty) to achieve a level of competence that enables them to provide safe and effective care for this unique population. Their knowledge and skills base also ensures that they are able to detect immediate changes to physiological stability that can be acted on at an early stage. Diluting the one-to-one ratio in IC reduces this level of safety and potentially increases the negative impact on mortality and morbidity. Nurses also spend time using a range of supportive interventions for parents and families that have been shown to improve early developing attachments and reduce the long-term negative psychological and social outcomes seen with families who experience NIC.7 Looking outside of infant mortality, ‘family morbidity’ should also be valued in terms of the positive impact of increasing nurse education, training and time, not forgetting the consequent reduction in health costs. For the babies being admitted to neonatal IC units every single day, and for their parents and families, there is an inevitable impact of persistent understaffing, despite the undoubted commitment and hard work of all the professionals caring for them. As highlighted in the Bliss Baby Report, parents applaud the dedication of neonatal staff, but fundamentally recognise the picture of understaffing: “There were never enough nurses working in the neonatal unit”, said one; another commented, “Sometimes there was a definite shortage of experienced nurses on the unit and that was very frightening…[it] kept us awake at night”. Having a baby in neonatal IC is already an incredibly stressful situation; when parents also have to worry about whether there are enough nurses to provide the right care for their baby, it can be simply unbearable. In November 2015, the Secretary of State for Health announced a new ambition to reduce the rate of stillbirths,
Fenton AC, et al. Arch Dis Child Fetal Neonatal Ed May 2016 Vol 101 No 3
Downloaded from http://fn.bmj.com/ on September 5, 2017 - Published by group.bmj.com
Editorial neonatal and maternal deaths in England by 50% by 2030.8 While welcome, the announcement has so far singularly failed to acknowledge the importance of improving staffing levels in order to reduce neonatal deaths despite consistent information from neonatal professionals. In addition, while the Secretary of State has acknowledged the mistake made by the coalition government in 2010 in cutting the number of student nurse places commissioned, it is still far from clear whether the government’s plans to replace student nurse bursaries with loans, as outlined in the 2015 Comprehensive Spending Review, will have the desired effect of increasing the number of nurses trained or will just put a barrier in the way of those who wish to join the profession.9 While there are clearly significant resource requirements, the medical and nursing leadership within the neonatal community have a major role to play at both network and unit level in addressing another facet of staffing issues, that is of recruitment and retention in the face of turnover. This affects units to different degrees for reasons that may not be immediately apparent. Large neonatal units may not be able to provide adequate opportunities for staff progression; high occupancy rates may predispose to ‘burnout’. Family-centred care is now firmly on the neonatal agenda. A key component to implementing this is a nursing establishment that is adequately supported, nurtured and professionally developed from
induction and throughout their subsequent career. Watson et al’s study concludes that further research in this area would be valuable: to calculate in more detail the cost-effectiveness of one-to-one nursing ratios, to explore what the optimal levels of nurse staffing would be and to establish how this is achieved in practice. While these are all undoubtedly fruitful areas for future research, there is already a sufficient body of evidence to justify a renewed focus on working towards achieving the national standards set for one-to-one nurse staffing in neonatal IC. If not now, when?
Arch Dis Child Fetal Neonatal Ed 2016;101:F186– F187. doi:10.1136/archdischild-2015-310156
REFERENCES 1
2
3
4
Contributors All authors were equally involved in the planning, writing and reviewing of the editorial. Competing interests CD is chief executive of Bliss, the premature and sick baby charity. Bliss provided funding for the NESCOP (Neonatal Economic, Staffing and Clinical Outcomes Project) Group, including for this study’s lead author SW.
5
6
Provenance and peer review Commissioned; internally peer reviewed. To cite Fenton AC, Turrill S, Davey C. Arch Dis Child Fetal Neonatal Ed 2016;101:F186–F187.
7
Received 18 December 2015 Revised 31 December 2015 Accepted 4 January 2016 Published Online First 9 February 2016 8
▸ http://dx.doi.org/10.1136/fetalneonatal-2015309435
Fenton AC, et al. Arch Dis Child Fetal Neonatal Ed May 2016 Vol 101 No 3
9
Standards for Hospitals Providing Neonatal Intensive and High Dependency Care—1996, 2001, 2005 and 2011 editions. British Association of Perinatal Medicine. http://www.bapm.org/publications (accessed 17 Dec 2015). Neonatal care in Scotland: a quality framework. 2013. Scottish Government. http://www.gov.scot/Resource/ 0041/00415230.pdf (accessed 17 Dec 2015). All Wales Neonatal Standards (2nd edn). NHS Wales, 2013. http://www.wales.nhs.uk/sitesplus/documents/ 862/All%20Wales%20Neonatal%20Standards% 202nd%20Edition%20v2%2005%2008%2013.pdf (accessed 17 Dec 2015). Watson SI, Arulampalam W, Petrou S, et al. The effects of a one-to-one nurse-to-patient ratio on the mortality rate in neonatal intensive care: a retrospective, longitudinal, population-based study. Arch Dis Child Fetal Neonatal Ed 2016;101: F195–200. Bliss baby report 2015: hanging in the balance. Bliss. London, 2015. http://www.bliss.org.uk/babyreport (accessed 17 Dec 2015). Neonatal Data Analysis Unit (NDAU) Report 2014. Imperial College. London. https://www1.imperial.ac.uk/ resources/A07E2FB9-D7D7-4795-9DEC-80DBDCB 085BE/ndau2014reportv1.3.pdf (accessed 18 Dec 2015). Melnyk BM, Feinstein NF, Alpert-Gillis L, et al. Reducing premature infants’ length of stay and improving parents’ mental health outcomes with the Creating Opportunities for Parent Empowerment (COPE) Neonatal Intensive Care Unit program: a randomized, controlled trial. Pediatrics 2006;118: e1414–27. https://www.gov.uk/government/news/new-ambitionto-halve-rate-of-stillbirths-and-infant-deaths (accessed 17 Dec 2015). http://www.nursingtimes.net/roles/nurse-educators/ hunt-promises-proper-consultation-on-bursary-plans/ 7000865.article (accessed 17 Dec 2015).
F187
Downloaded from http://fn.bmj.com/ on September 5, 2017 - Published by group.bmj.com
Nurse staffing to patient ratios and mortality in neonatal intensive care Alan C Fenton, Sue Turrill and Caroline Davey Arch Dis Child Fetal Neonatal Ed 2016 101: F186-F187 originally published online February 9, 2016
doi: 10.1136/archdischild-2015-310156 Updated information and services can be found at: http://fn.bmj.com/content/101/3/F186
These include:
References Email alerting service
Topic Collections
This article cites 2 articles, 2 of which you can access for free at: http://fn.bmj.com/content/101/3/F186#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Press releases (11) Epidemiologic studies (929) Child health (1515) Neonatal and paediatric intensive care (341) Neonatal health (928) Infant health (857) Neonatal intensive care (246)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
