DANIEL MITCHELL
ANALYSIS
Safety guidance is no substitute for mandatory minimum staffing Proposals for ensuring safe nurse numbers on acute wards are being greeted with disappointment, as well as hope. Kat Keogh finds out why Patient safety is not a simple numbers game – a point emphasised in draft guidance on safe staffing levels. The National Institute for Health and Care Excellence (NICE) was asked by the Department of Health to draw up guidance in the wake of the Francis report into the Mid Staffs scandal. NICE says patients in acute settings are at risk if a nurse has to care for more than eight patients at one time. The institute has drafted guidelines on how it believes nurses and 14 may 21 :: vol 28 no 38 :: 2014
managers should set and monitor staffing levels to ensure the best possible patient care (see box overleaf). The Francis report linked chronic understaffing to poor care, but the government has repeatedly rejected calls for minimum staffing levels, instead arguing that numbers should be set at a local level by individual employers. Although NICE acknowledges staffing should never dip below the one to eight ratio, it too stops short of recommending mandatory staffing levels.
Unison’s head of nursing Gail Adams says the draft guidance represents a missed opportunity. This follows a recent Unison poll of almost 3,000 nurses that found 45 per cent were caring for eight or more patients on wards. ‘The most effective mechanism to ensure patient safety is the introduction of national, mandatory, minimum staffing levels on wards,’ Ms Adams adds. ‘We welcome NICE’s recognition of the link between caring for eight patients or more and the increase in
NURSING STANDARD
ANALYSIS
risk to patients, but it is a shame that it falls short of calling for a national mandatory minimum.’ The NICE guidance echoes the warning by the Safe Staffing Alliance – a group of senior nurses brought together by Nursing Standard – that care becomes unsafe when staffing levels exceed one nurse to eight patients. But alliance chair Susan Osborne says the one-to-eight ratio should be treated as a ‘bare minimum’ rather than a number to aim for.
Slow response
The healthcare consultant accuses the government of taking too long to address the question of safe staffing. ‘Problems at Mid Staffs were first being raised back in 2007,’ Ms Osborne says. ‘Yet here we are in 2014 and NICE was asked only a few months ago to put this guidance together. It is an absolute scandal and says a lot about how seriously the government was taking the issue.’ A Department of Health spokesperson insists safe staffing was an important part of the government’s response to the Francis report, which it published last November. In addition to the NICE guidance, there will be ‘unprecedented’ transparency on nursing numbers, with all NHS trusts now required to publish staffing levels online from next month. Display boards will also be introduced on every ward detailing how many nurses are required and how many are actually present. England’s chief nursing officer Jane Cummings has previously said that a centrally set nurse-to-patient ratio is not the answer. ‘There has been debate about whether there should be defined staffing ratios in the NHS,’ she says. ‘My view is that it missed the point – we want the right staff, with the right skills, in the right place at the right time. There is no single ratio or formula that can calculate the answers to such
NURSING STANDARD
complex questions. The right solution will differ across organisations.’ The guidance includes details of ‘red flag events’ – incidents that should alert managers there is an urgent need for extra nurses (see box right). NHS England director of nursing for the Midlands and east region Ruth May welcomed NICE’s focus on quality of care, as well as numbers. ‘I am pleased about the red flags, as it is not all about numbers,’ Ms May told the NICE annual conference in Birmingham last week. ‘You can have 100 per cent of nurses needed on your shift, but if they are all bank and agency nurses, you will not get the right care delivered.’ A consultation on the guidance is open until June 10. Separate guidance covering areas including community, children’s, maternity and mental health settings is still to be drawn up. Lord Willis, who is leading the Shape of Caring review, which is examining the training of nurses and healthcare assistants, says the NICE guidance is a step forward. ‘More nurses means fewer deaths,’ the Liberal Democrat peer told a reception marking International Nurses’ Day in parliament last week. ‘But this is not about eight patients to every nurse. There may be occasions when you need one nurse to a patient’.
‘IT IS A SHAME NICE FALLS SHORT OF CALLING FOR NATIONAL SAFE STAFF LEVELS’ – Gail Adams RCN head of policy Howard Catton says it is important to keep the momentum going on safe staffing. ‘This is certainly not a case of “job done”,’ he adds. ‘Safe staffing has moved from an issue for the profession to one that has been debated by politicians and the public. Having employers and ward leaders recording how many nurses they need on wards will help us to determine what sort of workforce we will need in the future’ NS Go to: tinyurl.com/mk9xpk2
THE TELLTALE SIGNS OF IMPENDING THREATS TO CARE Red flag events – the signals for managers that patients are at risk According to the NICE draft guidance, an example of a ‘red flag event’ is when the number on shift is 25 per cent lower than is deemed necessary. Other red flag events that could be signs there are not enough nurses on the ward include: 4A delay of more than 30 minutes in giving a patient planned pain relief, or missing medication altogether. 4Failure to record or assess a patient’s vital signs as outlined in his or her care plan. 4Not completing regular checks on patients as outlined in their care plan, including failing to ask patients to describe their level of pain, not making time to assist visits to the toilet where there is a risk of falls, not ensuring the items a patient needs are within easy reach, and failing to make sure the patient is comfortable or that the risk of pressure ulcers is assessed and minimised. Red flag events can be reported by any member of the nursing team, patients, relatives or carers, the NICE draft guidance states. ‘Red flags’ should be reported to the nurse in charge, the trust management or to staff in patient support services. NICE states that the nurse in charge needs to respond to a red flag event immediately, which could mean asking for additional nursing staff to be put in place. All red flag events need to be recorded so the information can be used to help set safe levels of nursing staff in future. may 21 :: vol 28 no 38 :: 2014 15
ANALYSIS
MONITOR QUALITY AS WELL AS QUANTITY – THE NICE GUIDE FOR MANAGERS AND BOARDS The NICE draft guidance tells employers to: 4Ensure wards and departments have enough nursing staff to provide safe care at all times. 4Be aware that the higher the proportion of registered nurses, the better patient outcomes are. 4Agree the required ward or departmental nursing establishments and ensure they are signed off by the appropriate ward leader or matron, with a final sign off by the chief nurse. 4Make sure planned and predictable shortages are covered, for example during the winter when staff sickness absences increase. 4Be flexible with nursing numbers to meet patient needs, but not to the detriment of other wards. 4Review the nursing establishment on individual wards at least twice a year. 4Ensure the number of planned nurses and the number of nurses available is reviewed on a shift-by-shift basis. 4Monitor ‘red flag events’ (see page 15). 4Ensure nurses in charge have appropriate experience and training to monitor staffing levels every day. When calculating the number of staff required, nurses in charge of each shift should: 4Use their professional judgement to make a final assessment of staff requirements. This includes taking into account patients’ nursing needs and previous red flag events. 4Consider patient factors. Patient need is the main element when calculating nursing requirement. Patients’ nursing needs should be assessed to see if additional nurses are needed. This could include difficulties with understanding or confusion for patients with learning disabilities, dementia or 16 may 21 :: vol 28 no 38 :: 2014
other mental health problems. Increased risk of clinical deterioration and end of life care should be considered. 4View any patient-related condition that requires the continuous presence of a nurse as needing one-to-one care and should be factored into the nursing numbers. 4Take ward factors into account. Patient turnover, rather than the number of beds, should be considered. Planned and unplanned admissions, discharges and transfers should be included in the equation. 4Include ward layout and size as a factor, particularly the need to ensure the safety of patients who cannot be observed easily, and the distance needed to travel to access resources. 4Consider nursing staff factors. As well as direct nursing care, those in charge of each shift should take into account other time-consuming activities, such as communicating with relatives and carers, managing the nursing team and ward, professional supervision and mentoring of nursing staff. 4Plan for predictable absences such as holiday, maternity leave and professional development, as well as unexpected absence such as sickness. Board members, senior managers and ward managers should monitor whether they have the right number of nurses through nursing indicators that include: 4The recording of falls, hospital-acquired pressure ulcers and medical administration errors. 4The recording of paid and unpaid overtime, and whether staff work through breaks. 4The number of nurses on shift compared to planned numbers. 4A reliance on agency or bank nurses for filling shift slots.
COMMENTS FROM OUR FACEBOOK PAGE ‘The ward I work on averages six per nurse and we can struggle to give optimal time and care every day. And this is with an HCA to help. I would say one to four, maximum five.’ ‘Nurses are accountable for the environment, staff, visitors, mentoring and supervising healthcare assistants. Add admissions, discharges, deteriorating patients and those with high confusion and it is a full-on mix. A one-to-eight ratio is a luxury for most nurses.’ ‘One nurse to eight patients is pushing the acute care envelope.’ ‘It depends on the type of patient. In minor surgery or day cases, eight patients is easy. But sometimes even caring for two patients is demanding.’ ‘This guidance is for day shifts. I work nights, and there are two nurses and two healthcare assistants for 30 patients.’ ‘It comes down to dependency. Independent surgical patients may need as many interventions, as an elderly, immobile patient on an acute ward. Skill mix plays a big part too.’ ‘In community nursing, we regularly visit 20 patients in a seven-and-a-half-hour shift. This includes end of life syringe drivers, IVs and chest drains – these are not quick visits.’ Share your views on the Nursing Standard Facebook page
NURSING STANDARD
ANALYSIS
Safety guidance is no substitute for mandatory minimum staffing Proposals for ensuring safe nurse numbers on acute wards are being greeted with disappointment, as well as hope. Kat Keogh finds out why Patient safety is not a simple numbers game – a point emphasised in draft guidance on safe staffing levels. The National Institute for Health and Care Excellence (NICE) was asked by the Department of Health to draw up guidance in the wake of the Francis report into the Mid Staffs scandal. NICE says patients in acute settings are at risk if a nurse has to care for more than eight patients at one time. The institute has drafted guidelines on how it believes nurses and 14 may 21 :: vol 28 no 38 :: 2014
managers should set and monitor staffing levels to ensure the best possible patient care (see box overleaf). The Francis report linked chronic understaffing to poor care, but the government has repeatedly rejected calls for minimum staffing levels, instead arguing that numbers should be set at a local level by individual employers. Although NICE acknowledges staffing should never dip below the one to eight ratio, it too stops short of recommending mandatory staffing levels.
Unison’s head of nursing Gail Adams says the draft guidance represents a missed opportunity. This follows a recent Unison poll of almost 3,000 nurses that found 45 per cent were caring for eight or more patients on wards. ‘The most effective mechanism to ensure patient safety is the introduction of national, mandatory, minimum staffing levels on wards,’ Ms Adams adds. ‘We welcome NICE’s recognition of the link between caring for eight patients or more and the increase in
NURSING STANDARD
ANALYSIS
risk to patients, but it is a shame that it falls short of calling for a national mandatory minimum.’ The NICE guidance echoes the warning by the Safe Staffing Alliance – a group of senior nurses brought together by Nursing Standard – that care becomes unsafe when staffing levels exceed one nurse to eight patients. But alliance chair Susan Osborne says the one-to-eight ratio should be treated as a ‘bare minimum’ rather than a number to aim for.
Slow response
The healthcare consultant accuses the government of taking too long to address the question of safe staffing. ‘Problems at Mid Staffs were first being raised back in 2007,’ Ms Osborne says. ‘Yet here we are in 2014 and NICE was asked only a few months ago to put this guidance together. It is an absolute scandal and says a lot about how seriously the government was taking the issue.’ A Department of Health spokesperson insists safe staffing was an important part of the government’s response to the Francis report, which it published last November. In addition to the NICE guidance, there will be ‘unprecedented’ transparency on nursing numbers, with all NHS trusts now required to publish staffing levels online from next month. Display boards will also be introduced on every ward detailing how many nurses are required and how many are actually present. England’s chief nursing officer Jane Cummings has previously said that a centrally set nurse-to-patient ratio is not the answer. ‘There has been debate about whether there should be defined staffing ratios in the NHS,’ she says. ‘My view is that it missed the point – we want the right staff, with the right skills, in the right place at the right time. There is no single ratio or formula that can calculate the answers to such
NURSING STANDARD
complex questions. The right solution will differ across organisations.’ The guidance includes details of ‘red flag events’ – incidents that should alert managers there is an urgent need for extra nurses (see box right). NHS England director of nursing for the Midlands and east region Ruth May welcomed NICE’s focus on quality of care, as well as numbers. ‘I am pleased about the red flags, as it is not all about numbers,’ Ms May told the NICE annual conference in Birmingham last week. ‘You can have 100 per cent of nurses needed on your shift, but if they are all bank and agency nurses, you will not get the right care delivered.’ A consultation on the guidance is open until June 10. Separate guidance covering areas including community, children’s, maternity and mental health settings is still to be drawn up. Lord Willis, who is leading the Shape of Caring review, which is examining the training of nurses and healthcare assistants, says the NICE guidance is a step forward. ‘More nurses means fewer deaths,’ the Liberal Democrat peer told a reception marking International Nurses’ Day in parliament last week. ‘But this is not about eight patients to every nurse. There may be occasions when you need one nurse to a patient’.
‘IT IS A SHAME NICE FALLS SHORT OF CALLING FOR NATIONAL SAFE STAFF LEVELS’ – Gail Adams RCN head of policy Howard Catton says it is important to keep the momentum going on safe staffing. ‘This is certainly not a case of “job done”,’ he adds. ‘Safe staffing has moved from an issue for the profession to one that has been debated by politicians and the public. Having employers and ward leaders recording how many nurses they need on wards will help us to determine what sort of workforce we will need in the future’ NS Go to: tinyurl.com/mk9xpk2
THE TELLTALE SIGNS OF IMPENDING THREATS TO CARE Red flag events – the signals for managers that patients are at risk According to the NICE draft guidance, an example of a ‘red flag event’ is when the number on shift is 25 per cent lower than is deemed necessary. Other red flag events that could be signs there are not enough nurses on the ward include: 4A delay of more than 30 minutes in giving a patient planned pain relief, or missing medication altogether. 4Failure to record or assess a patient’s vital signs as outlined in his or her care plan. 4Not completing regular checks on patients as outlined in their care plan, including failing to ask patients to describe their level of pain, not making time to assist visits to the toilet where there is a risk of falls, not ensuring the items a patient needs are within easy reach, and failing to make sure the patient is comfortable or that the risk of pressure ulcers is assessed and minimised. Red flag events can be reported by any member of the nursing team, patients, relatives or carers, the NICE draft guidance states. ‘Red flags’ should be reported to the nurse in charge, the trust management or to staff in patient support services. NICE states that the nurse in charge needs to respond to a red flag event immediately, which could mean asking for additional nursing staff to be put in place. All red flag events need to be recorded so the information can be used to help set safe levels of nursing staff in future. may 21 :: vol 28 no 38 :: 2014 15
ANALYSIS
MONITOR QUALITY AS WELL AS QUANTITY – THE NICE GUIDE FOR MANAGERS AND BOARDS The NICE draft guidance tells employers to: 4Ensure wards and departments have enough nursing staff to provide safe care at all times. 4Be aware that the higher the proportion of registered nurses, the better patient outcomes are. 4Agree the required ward or departmental nursing establishments and ensure they are signed off by the appropriate ward leader or matron, with a final sign off by the chief nurse. 4Make sure planned and predictable shortages are covered, for example during the winter when staff sickness absences increase. 4Be flexible with nursing numbers to meet patient needs, but not to the detriment of other wards. 4Review the nursing establishment on individual wards at least twice a year. 4Ensure the number of planned nurses and the number of nurses available is reviewed on a shift-by-shift basis. 4Monitor ‘red flag events’ (see page 15). 4Ensure nurses in charge have appropriate experience and training to monitor staffing levels every day. When calculating the number of staff required, nurses in charge of each shift should: 4Use their professional judgement to make a final assessment of staff requirements. This includes taking into account patients’ nursing needs and previous red flag events. 4Consider patient factors. Patient need is the main element when calculating nursing requirement. Patients’ nursing needs should be assessed to see if additional nurses are needed. This could include difficulties with understanding or confusion for patients with learning disabilities, dementia or 16 may 21 :: vol 28 no 38 :: 2014
other mental health problems. Increased risk of clinical deterioration and end of life care should be considered. 4View any patient-related condition that requires the continuous presence of a nurse as needing one-to-one care and should be factored into the nursing numbers. 4Take ward factors into account. Patient turnover, rather than the number of beds, should be considered. Planned and unplanned admissions, discharges and transfers should be included in the equation. 4Include ward layout and size as a factor, particularly the need to ensure the safety of patients who cannot be observed easily, and the distance needed to travel to access resources. 4Consider nursing staff factors. As well as direct nursing care, those in charge of each shift should take into account other time-consuming activities, such as communicating with relatives and carers, managing the nursing team and ward, professional supervision and mentoring of nursing staff. 4Plan for predictable absences such as holiday, maternity leave and professional development, as well as unexpected absence such as sickness. Board members, senior managers and ward managers should monitor whether they have the right number of nurses through nursing indicators that include: 4The recording of falls, hospital-acquired pressure ulcers and medical administration errors. 4The recording of paid and unpaid overtime, and whether staff work through breaks. 4The number of nurses on shift compared to planned numbers. 4A reliance on agency or bank nurses for filling shift slots.
COMMENTS FROM OUR FACEBOOK PAGE ‘The ward I work on averages six per nurse and we can struggle to give optimal time and care every day. And this is with an HCA to help. I would say one to four, maximum five.’ ‘Nurses are accountable for the environment, staff, visitors, mentoring and supervising healthcare assistants. Add admissions, discharges, deteriorating patients and those with high confusion and it is a full-on mix. A one-to-eight ratio is a luxury for most nurses.’ ‘One nurse to eight patients is pushing the acute care envelope.’ ‘It depends on the type of patient. In minor surgery or day cases, eight patients is easy. But sometimes even caring for two patients is demanding.’ ‘This guidance is for day shifts. I work nights, and there are two nurses and two healthcare assistants for 30 patients.’ ‘It comes down to dependency. Independent surgical patients may need as many interventions, as an elderly, immobile patient on an acute ward. Skill mix plays a big part too.’ ‘In community nursing, we regularly visit 20 patients in a seven-and-a-half-hour shift. This includes end of life syringe drivers, IVs and chest drains – these are not quick visits.’ Share your views on the Nursing Standard Facebook page
NURSING STANDARD
