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Analysis
Stroke mortality falls when nurse staffing levels higher Research findings add weight to campaign for safer nursing ratios across wards. Louise Hunt reports THE RESULTS of a study that found higher weekend nursing levels on stroke units significantly reduced the risk of patient death have been welcomed. The study provides valuable evidence to support the RCN’s national drive for safer staffing. It is the first research to examine the association with higher mortality rates for stroke patients admitted on weekends, reported in previous observational studies, and the difference seven-day working by specialist physicians and registered nurses makes to patient outcomes. Significantly, it found that mortality outcomes after stroke were associated with the intensity of weekend staffing by nurses. ‘The findings have implications for quality improvement and resource allocation in stroke care,’ the researchers conclude. Led by Benjamin Bray from King’s College London, the researchers analysed data from 103 stroke units in England comprising 56,666 patients admitted between June 2011 and December 2012, extracted from the Royal College of Physicians’ stroke register. 8
October 2014 | Volume 26 | Number 8
They found that higher nursing ratios – three nurses per ten beds – were associated with a significantly reduced risk of death, and lower nursing ratios – 1.5 nurses per ten beds – with a higher risk of death (see box). A below-average nurse/bed ratio was associated with as much as a 35% increased risk of death. By contrast, above-average nurse/ bed ratios were associated with a 20-30% reduced risk of death and in these units there was little difference observed for patients admitted on weekdays or weekends. Conversely, patients admitted on weekends to stroke units with belowaverage nurse/bed ratios had a higher risk of death than those admitted on weekdays. There was no evidence of a significant relationship between stroke units having seven-day ward rounds by specialist stroke physicians and mortality. However, those stroke units with higher nurse/bed ratios were more likely to have seven-day physician working, the study found. Caroline Watkins, the UK’s only nursing professor of stroke care, based at the
University of Central Lancashire (UCLAN), says the study is ‘absolutely fantastic’ news for nursing as it marks ‘the first time there has been hard evidence to support staffing levels’. She says previous research by the UCLAN stroke research team found that people nursed on stroke units did better than those on general wards and benefited from multidisciplinary team input. Recognition has also grown that more than one nurse per ten beds is needed to achieve better patient outcomes. ‘We now know if you are going to do more than the minimum basic tasks on a stroke unit you need more than that, so it doesn’t surprise me the study found that to do a really good job you need more staff.’ However, she advises that as it is an observational study, examining associations between numbers, it should be seen as an important first step towards more robust research. Simply increasing nursing ratios on stroke units would not necessarily produce the same results, she suggests. ‘It is not just about the number of nurses, but about the skill mix – the ratio of nurses to healthcare assistants (HCAs) and getting the right balance.’ It is important, she says, for there to be enough HCAs to provide the hands-on
Main findings ■■ Weekend nursing ratios were strongly associated with mortality outcomes, not only for patients admitted on weekends but also for those admitted on weekdays. ■■ Patients admitted on weekends to stroke units with 1.5 nurses per ten beds had a 30-day mortality risk of 15%, the equivalent to one excess death per 25 admissions. ■■ Patients admitted on weekends to stroke units with three nurses per ten beds had a 30-day mortality risk of 11%. ■■ For patients admitted to stroke units, mortality risk did not differ whether stroke specialist physician rounds were seven days a week or fewer. Many stroke units in the UK already carry out five-day consultant ward rounds. NURSING OLDER PEOPLE
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Analysis
Effect of 24/7 care The findings come as no surprise to nurses working in enhanced stroke services that have invested in raising nurse ratios, particularly in advanced specialist nurses. ‘We knew that advanced nursing care 24/7 is having a positive impact on patients, and now we have the evidence to prove it,’ says Carol Croser, lead nurse for stroke at York Teaching Hospital NHS Foundation Trust. Having senior nursing staff available 24/7 means the unit is able to meet national stroke guidelines and provide enhanced treatments. ‘It makes such a difference having senior nurses available at the weekends,’ Ms Croser says. ‘They provide the leadership and confidence in staff to make sure everything is happening in a timely manner.’ Ms Croser says she hopes the study will serve to protect and increase nursing levels on stroke units, as well as bolster the drive for safe staffing levels across wards. This, too, is the RCN’s hope. Responding to the findings, general secretary Peter Carter, said: ‘It is unacceptable that stroke patient mortality rates are higher at weekends when staffing levels tend to be lower. ‘Only with the right number of nurses, with the right skills, can we ensure patients are properly looked after with dignity and compassion.’ Louise Hunt is a freelance writer
Reference Bray B, Ayis S, Campbell J et al (2014) Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: prospective multicentre cohort study. PLoS Medicine. 11, 8: e1001705. doi: 10.1371/journal. pmed.1001705 (Last accessed: September 3 2014.)
NURSING OLDER PEOPLE
Mandatory guidelines aim to raise quality of meals in hospital Getty Images
support required for these dependent patients. At the same time, it is important to ensure nursing levels allow for staff to be freed for training and sharing knowledge with their teams. ‘This research highlights the importance of having the right nursing staff levels every day of the week,’ Professor Watkins says. ‘It shows that in some professions you may not need the same intensity of input every day, but for nursing it is important to ensure the same level of care 24/7.’
New measures arising from an investigation into nutrition in the NHS will involve extra support to help older patients to eat. Nick Triggle reports OLDER PATIENTS will need extra support if new standards for hospital food in England are to be achieved, nurse leaders are warning. The mandatory guidelines – to be enforced via the NHS standard contract from next year – cover everything from the quality of food to the support patients receive to eat meals. Ministers agreed to them in August after recommendations from the Hospital Food Standards Panel, a group of independent experts set up by the Department of Health to investigate nutrition in the NHS. Hospitals in Scotland and Wales already have nutritional standards in place. Catering teams are being asked to ensure the quality and variety of food is sufficient by taking steps such as serving fish twice a week, not using salt when cooking rice, potatoes and other vegetables and ensuring half of desserts are fruit based. Meanwhile, nursing teams have been ordered to take measures such as screening for malnutrition on admission and weekly during stays, ensuring care plans identify nutritional needs and protecting mealtimes. The key for older patients, who are most at risk of malnutrition and missing meals in hospital, will be ensuring those who need help with eating receive it. RCN executive director Janet Davies believes staffing levels may have to be
addressed. ‘Many patients need help to eat. For example, it can take up to 45 minutes to assist someone with dementia to eat even a small meal so staff need to have enough time to help feed patients.’ Help from relatives National Nurses Nutrition Group chair Liz Evans agrees, saying older patients will require ‘extra support’, but that staff should not underestimate the role relatives can play. ‘Sometimes older patients, especially those with dementia, will only eat when they have someone there. This is where the patient’s family can play a vital role,’ Ms Evans says. ‘But in some places the rules about no visitors have been taken to the extreme.’ She says there needs to be a wider shift away from food being seen as a ‘hotel service’ to it being a ‘fundamental part of care’. As well as pledging to introduce the mandatory standards, ministers also said hospitals will be ranked on the NHS Choices website for the food they serve. The ratings – based on feedback from the patient-led assessments of the care environment inspection programme – will cover quality and choice as well as information about whether menus are approved by a dietitian, fruit is always available and food is offered between meals. But others are questioning whether the measures will have the intended impact. Campaign for Better Hospital Food co-ordinator Alex Jackson, who resigned from the panel earlier this year, says the standards are not ambitious enough and the safeguards put in place ‘woefully inadequate’. Panel chair Dianne Jeffrey, who is also chair of Age UK, says the recommendations will help ‘busy hospital staff’ meet the needs of patients. Nick Triggle is a freelance writer
Reference Department of Health (2014) The Hospital Food Standards Panel’s Report on Standards for Food and Drink in NHS Hospitals. www.gov.uk/government/publications/establishing-foodstandards-for-nhs-hospitals (Last accessed: September 4 2014.)
October 2014 | Volume 26 | Number 8
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Analysis
Stroke mortality falls when nurse staffing levels higher Research findings add weight to campaign for safer nursing ratios across wards. Louise Hunt reports THE RESULTS of a study that found higher weekend nursing levels on stroke units significantly reduced the risk of patient death have been welcomed. The study provides valuable evidence to support the RCN’s national drive for safer staffing. It is the first research to examine the association with higher mortality rates for stroke patients admitted on weekends, reported in previous observational studies, and the difference seven-day working by specialist physicians and registered nurses makes to patient outcomes. Significantly, it found that mortality outcomes after stroke were associated with the intensity of weekend staffing by nurses. ‘The findings have implications for quality improvement and resource allocation in stroke care,’ the researchers conclude. Led by Benjamin Bray from King’s College London, the researchers analysed data from 103 stroke units in England comprising 56,666 patients admitted between June 2011 and December 2012, extracted from the Royal College of Physicians’ stroke register. 8
October 2014 | Volume 26 | Number 8
They found that higher nursing ratios – three nurses per ten beds – were associated with a significantly reduced risk of death, and lower nursing ratios – 1.5 nurses per ten beds – with a higher risk of death (see box). A below-average nurse/bed ratio was associated with as much as a 35% increased risk of death. By contrast, above-average nurse/ bed ratios were associated with a 20-30% reduced risk of death and in these units there was little difference observed for patients admitted on weekdays or weekends. Conversely, patients admitted on weekends to stroke units with belowaverage nurse/bed ratios had a higher risk of death than those admitted on weekdays. There was no evidence of a significant relationship between stroke units having seven-day ward rounds by specialist stroke physicians and mortality. However, those stroke units with higher nurse/bed ratios were more likely to have seven-day physician working, the study found. Caroline Watkins, the UK’s only nursing professor of stroke care, based at the
University of Central Lancashire (UCLAN), says the study is ‘absolutely fantastic’ news for nursing as it marks ‘the first time there has been hard evidence to support staffing levels’. She says previous research by the UCLAN stroke research team found that people nursed on stroke units did better than those on general wards and benefited from multidisciplinary team input. Recognition has also grown that more than one nurse per ten beds is needed to achieve better patient outcomes. ‘We now know if you are going to do more than the minimum basic tasks on a stroke unit you need more than that, so it doesn’t surprise me the study found that to do a really good job you need more staff.’ However, she advises that as it is an observational study, examining associations between numbers, it should be seen as an important first step towards more robust research. Simply increasing nursing ratios on stroke units would not necessarily produce the same results, she suggests. ‘It is not just about the number of nurses, but about the skill mix – the ratio of nurses to healthcare assistants (HCAs) and getting the right balance.’ It is important, she says, for there to be enough HCAs to provide the hands-on
Main findings ■■ Weekend nursing ratios were strongly associated with mortality outcomes, not only for patients admitted on weekends but also for those admitted on weekdays. ■■ Patients admitted on weekends to stroke units with 1.5 nurses per ten beds had a 30-day mortality risk of 15%, the equivalent to one excess death per 25 admissions. ■■ Patients admitted on weekends to stroke units with three nurses per ten beds had a 30-day mortality risk of 11%. ■■ For patients admitted to stroke units, mortality risk did not differ whether stroke specialist physician rounds were seven days a week or fewer. Many stroke units in the UK already carry out five-day consultant ward rounds. NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Analysis
Effect of 24/7 care The findings come as no surprise to nurses working in enhanced stroke services that have invested in raising nurse ratios, particularly in advanced specialist nurses. ‘We knew that advanced nursing care 24/7 is having a positive impact on patients, and now we have the evidence to prove it,’ says Carol Croser, lead nurse for stroke at York Teaching Hospital NHS Foundation Trust. Having senior nursing staff available 24/7 means the unit is able to meet national stroke guidelines and provide enhanced treatments. ‘It makes such a difference having senior nurses available at the weekends,’ Ms Croser says. ‘They provide the leadership and confidence in staff to make sure everything is happening in a timely manner.’ Ms Croser says she hopes the study will serve to protect and increase nursing levels on stroke units, as well as bolster the drive for safe staffing levels across wards. This, too, is the RCN’s hope. Responding to the findings, general secretary Peter Carter, said: ‘It is unacceptable that stroke patient mortality rates are higher at weekends when staffing levels tend to be lower. ‘Only with the right number of nurses, with the right skills, can we ensure patients are properly looked after with dignity and compassion.’ Louise Hunt is a freelance writer
Reference Bray B, Ayis S, Campbell J et al (2014) Associations between stroke mortality and weekend working by stroke specialist physicians and registered nurses: prospective multicentre cohort study. PLoS Medicine. 11, 8: e1001705. doi: 10.1371/journal. pmed.1001705 (Last accessed: September 3 2014.)
NURSING OLDER PEOPLE
Mandatory guidelines aim to raise quality of meals in hospital Getty Images
support required for these dependent patients. At the same time, it is important to ensure nursing levels allow for staff to be freed for training and sharing knowledge with their teams. ‘This research highlights the importance of having the right nursing staff levels every day of the week,’ Professor Watkins says. ‘It shows that in some professions you may not need the same intensity of input every day, but for nursing it is important to ensure the same level of care 24/7.’
New measures arising from an investigation into nutrition in the NHS will involve extra support to help older patients to eat. Nick Triggle reports OLDER PATIENTS will need extra support if new standards for hospital food in England are to be achieved, nurse leaders are warning. The mandatory guidelines – to be enforced via the NHS standard contract from next year – cover everything from the quality of food to the support patients receive to eat meals. Ministers agreed to them in August after recommendations from the Hospital Food Standards Panel, a group of independent experts set up by the Department of Health to investigate nutrition in the NHS. Hospitals in Scotland and Wales already have nutritional standards in place. Catering teams are being asked to ensure the quality and variety of food is sufficient by taking steps such as serving fish twice a week, not using salt when cooking rice, potatoes and other vegetables and ensuring half of desserts are fruit based. Meanwhile, nursing teams have been ordered to take measures such as screening for malnutrition on admission and weekly during stays, ensuring care plans identify nutritional needs and protecting mealtimes. The key for older patients, who are most at risk of malnutrition and missing meals in hospital, will be ensuring those who need help with eating receive it. RCN executive director Janet Davies believes staffing levels may have to be
addressed. ‘Many patients need help to eat. For example, it can take up to 45 minutes to assist someone with dementia to eat even a small meal so staff need to have enough time to help feed patients.’ Help from relatives National Nurses Nutrition Group chair Liz Evans agrees, saying older patients will require ‘extra support’, but that staff should not underestimate the role relatives can play. ‘Sometimes older patients, especially those with dementia, will only eat when they have someone there. This is where the patient’s family can play a vital role,’ Ms Evans says. ‘But in some places the rules about no visitors have been taken to the extreme.’ She says there needs to be a wider shift away from food being seen as a ‘hotel service’ to it being a ‘fundamental part of care’. As well as pledging to introduce the mandatory standards, ministers also said hospitals will be ranked on the NHS Choices website for the food they serve. The ratings – based on feedback from the patient-led assessments of the care environment inspection programme – will cover quality and choice as well as information about whether menus are approved by a dietitian, fruit is always available and food is offered between meals. But others are questioning whether the measures will have the intended impact. Campaign for Better Hospital Food co-ordinator Alex Jackson, who resigned from the panel earlier this year, says the standards are not ambitious enough and the safeguards put in place ‘woefully inadequate’. Panel chair Dianne Jeffrey, who is also chair of Age UK, says the recommendations will help ‘busy hospital staff’ meet the needs of patients. Nick Triggle is a freelance writer
Reference Department of Health (2014) The Hospital Food Standards Panel’s Report on Standards for Food and Drink in NHS Hospitals. www.gov.uk/government/publications/establishing-foodstandards-for-nhs-hospitals (Last accessed: September 4 2014.)
October 2014 | Volume 26 | Number 8
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