Safe Staffing

It is time we took a firm stand in the battle for safe staff levels

Experts say we must use the evidence to win the case for appropriate staffing, reports Adele Waters.

Nursing Standard and the Florence Nightingale Foundation invited experts to come together to discuss how evidence about nurse staffing can be used to fight workforce cuts. They agreed a statement spelling out the principles of safe staffing. This will be promoted through the Care campaign run jointly by Nursing Standard and the Patients Association. The campaign aims to improve fundamental nursing care.   

This article was first published in Nursing Standard, Vol 26 No 50, August 15 2012. 

Over the past 20 years there has been a wealth of evidence that demonstrates a link between nurse staffing levels and good patient outcomes. So why do nurses have to fight so hard for safe staffing levels?

In conjunction with the Florence Nightingale Foundation, Nursing Standard gathered a team of workforce experts to find out. Focusing discussion on the NHS in England, they began by considering the urgent need to address staffing cuts.

The roundtable panelists

  • Gail Adams, head of nursing, Unison
  • Simon Andrews, senior charge nurse, Royal United Hospital Bath NHS Trust Nursing Standard award winner
  • Jane Ball, deputy director, national nursing research unit, King’s College London Reseacher for the ‘RN4Cast’ study, an EU-funded study, relating nurse staffing to patient outcomes
  • Jim Buchan, workforce expert and professor in the faculty of health and social sciences, Queen Margaret University, Edinburgh
  • Howard Catton, head of policy, RCN Lead on staffing and workforce
  • Judith Ellis, dean, London South Bank University Developed staffing tool for paediatric care that was adopted across the UK
  • Baroness Audrey Emerton Nurse and peer
  • Paul Fish, acting associate director of nursing, County Durham and Darlington NHS Foundation Trust Researching a PhD examining nurse staffing and its effect on nursing-sensitive patient outcomes
  • Ruth Holt, chief nurse, Leeds Teaching Hospitals Developed a robust staffing tool
  • Keith Hurst, independent researcher and analyst Co-developed the AUKUH staffing tool now known as the Safer Nursing Care Tool (SNCT)
  • Elaine Inglesby, director of nursing, Salford Royal NHS Foundation Trust Member of David Cameron’s nursing and care quality forum and workstream lead for ‘time to care’
  • Alison Leary, nurse, mathematician, researcher and consultant Specialist areas are pattern recognition and articulating the value of specialist nurses
  • Elaine Maxwell, strategic lead for patient safety at the Health Foundation Trustee of the Florence Nightingale Foundation
  • Katherine Murphy, chief executive, Patients Association, Care campaign partner
  • Professor Elizabeth Robb, chief executive, Florence Nightingale FoundationSafe Staffing in the NHS

The panel

‘The sense of the workforce out there now is that they are just being left to get on with it – to wither on the vine – and that no one is doing anything to stop unsafe staffing levels,’ said Gail Adams, Unison’s head of nursing. ‘We need to look at how we can support registrants to raise concerns more effectively.’

The RCN and Unison support the introduction of minimum staffing levels and see the forthcoming report from the Mid Staffordshire NHS Foundation Trust Public Inquiry (the Francis Report), and the likely subsequent publicity, as an opportunity to push this message.

Howard Catton, head of policy at the RCN, said: ‘Over the next few months there will be some unique opportunities to influence prime minister David Cameron’s nursing and care quality forum, the new chief nurse’s strategic plan and the bodies being created by the Health Act, and to capitalise on interest from the Francis Report.’

Certainly many nurses would like to see greater attention paid to safe staffing. Simon Andrews, a senior charge nurse at the Royal United Hospital Bath NHS Trust and Nursing Standard’s ward manager of the year, said: ‘There is enough evidence to demonstrate that increased staffing levels have a beneficial effect on patient experience. But increased numbers of staff cost money, and trusts may not consider the evidence because of that.’

Many of our experts were appalled by a recent article written by Harry Cayton, chief executive of the Council for Healthcare Regulatory Excellence. He wrote: ‘There is no direct correlation between number of staff and good or bad care, so mandated staffing levels cannot be necessary.’

Mr Cayton was contacted by Nursing Standard and says that he stands by the views he expressed in the Health Service Journal in March.

Elaine Maxwell, strategic lead for patient safety at the Health Foundation and a former director of nursing, commented: ‘However, that Harry Cayton can say there is no relationship and get away with it when he is in a senior position horrifies me. Perhaps we have not told the story well, but there is clearly a relationship.’

Jane Ball, deputy director at the National Nursing Research Unit, King’s College London, agreed. ‘Given the research evidence, how is it that Harry Cayton and others in similarly influential positions can hold that view?’ she asked. ‘Understanding those positions is important because it may help us to approach these issues from a different perspective.’

Independent healthcare consultant and researcher Alison Leary said the complexity of nursing was frequently underestimated. ‘I often hear people say “nursing is not rocket science” but, as someone who was training to be a rocket scientist, I can tell you nursing is more difficult. It is still seen as a rather simplistic activity that, almost, anyone could do. We have to get better at articulating its complexity.’

Elizabeth Robb, chief executive of the Florence Nightingale Foundation, pointed out that there are detractors within the profession. ‘There has been much research published, but we have still got colleagues who seem unwilling to accept it. We need to make a more convincing case. We must make the evidence work for us.’

The experts’ statement on staffing and quality

The evidence indicates that there is a relationship between registered nurse staffing and safety, patient outcomes, patient experience and cost.

You/we cannot afford not to act on this evidence because getting registered nurse staffing right:

  • Saves lives.
  • Assures quality care.
  • Improves health outcomes.
  • Reduces adverse events.
  • Saves money.
  • Increases staff morale and retention.

Getting registered nurse staffing wrong:

  • Risks lives.
  • Costs money.
  • Results in poor care, low staff morale and high staff turnover.
  • Reviewing registered nurse staffing is vital to ensure and maintain a reputation for high quality care.

Local review is necessary to ensure contextual factors such as team composition, skill mix, complexity of care, geography, acuity and dependency are given appropriate weight.

Regular or on-going review of staffing requirements is essential because the patient population and clinical needs are dynamic. (Ideally this should be real time aiming to match direct care hours to patient need.)

Board review of registered nurse staffing will enable its members to feel confident about quality and safety, reduce risks to reputation and of litigation, and increase competitiveness.

Benchmarks for registered nurse staffing levels should be developed for all care settings, informed by available evidence.

Registered nurses work in collaboration with other healthcare professionals and are assisted by support staff, such as healthcare assistants. Safe staffing is not only about registered nurse numbers, it is also concerned with ensuring appropriate skill mix and role development, high quality clinical leadership, and a positive organisational culture.

So did our panel agree that the evidence setting out the impact of nurse staffing on patient outcomes is sufficiently robust to convince policymakers, ministers and executive board members to re-think their views on nursing establishments?

Contributors weighed up the shortcomings of the research one by one. They agreed that studies are often conducted at macro level, which made conclusions less easy to apply at local level. There is a lack of evidence that takes account of the whole workforce and how it affects patient outcomes. In addition, nurses’ contribution or value is not measured positively, in terms of effectiveness or patient benefit, but negatively in terms of absence of harm or numbers of adverse events (as a proxy for safety).

While the group recognised these fl aws in the evidence base, they concluded there is sufficient evidence to make a case that could help drive investment in nursing. Essentially the research is good enough.

Exploit the data

‘There is an overwhelming amount of data,’ said Keith Hurst, independent researcher and analyst. ‘The information is there, we just need to learn to use it better.’

Mr Catton added: ‘I see policy being made on a lot less evidence than we have on safe staffing levels. I do not think we should be shy about using that evidence opportunistically.’

Baroness Audrey Emerton, nurse and peer, agreed: ‘The research is clear and simple: the more registered nursing staff you have, the less time patients spend in hospital, and the more effective and cost-effective care becomes.’

Professor James Buchan, workforce expert and professor in the faculty of health and social sciences Queen Margaret University, Edinburgh, said: ‘Can we come at this in a way that will shift the agenda? I believe there is an opportunity to push a new message now, with a straightforward set of statements.’

There was unanimous support for this idea and Judith Ellis, dean of London South Bank University and NMC deputy chair, said the central message should be affordability. ‘When you present any politician or board with arguments to improve or retain nurse staffing, you meet the argument: “we cannot afford to do this”. But we should turn this argument on its head to say “you cannot afford not to do this”. We must not be apologetic about that.’

Katherine Murphy, chief executive of the Patients Association, said she would like to see more nursing directors making a stand on nurse staffing. ‘It is time the directors of nursing stood up and were heard on this issue. It is easy to blame the ward nurses, but often they are not the ones making decisions that affect the dignity and safety of patients.’

But calculating safe staffing is an increasingly complex task for nurse directors, the meeting heard. They face having to justify staffing requirements according to local circumstances – such as case mix and the number of non-nursing posts in teams. They also need to gain the most value from the nursing establishments they have.

Elaine Inglesby, director of nursing at Salford Royal NHS Foundation Trust and a member of the prime minister’s nursing and care quality forum leading its ‘time to care’ workstream, Information on staffing levels is there, we just need to learn how to use it argued: ‘Minimum staffing levels do make a difference, but it is also about how we use those staff and which systems and processes are in place to support them.’

Ruth Holt, chief nurse at Leeds Teaching Hospitals, said: ‘It would be great to have one off-the-shelf product to work out staffing, but the real world does not work like that. In any clinical area there is a diverse range of professional staff, and skill mix and numbers will vary as a result.’

Meanwhile, the ‘care closer to home’ agenda is driving up patient acuity in hospitals, added Paul Fish, acting associate director of nursing at County Durham and Darlington NHS Foundation Trust. So securing the correct nurse staffing is even more critical. ‘If you are in an acute hospital bed, you are acutely unwell and the second you are not, you are going home. That needs to be clearly factored in’.