Unconvinced of the case for mandatory staffing levels? Read this

The publication of NICE guidelines on nurse staffing levels got me thinking: how do we define ‘safe’ staffing?

I trained in the old apprenticeship system but I do not see that as any kind of ‘golden age’. Graduate education is the way forward, not primarily to put ourselves on an equal level with other healthcare professionals, but because nurses need the in-depth knowledge and skill-learning opportunities and these are best provided in universities.

I also think that, as patient care becomes ever more complex and demanding, more rather than less hands-on care should be given by registered nurses. But this belief is not just some way-out crusade. It is backed up by ever-more robust evidence that cannot be ignored if we are to fulfil our professional responsibilities - and that would not be ignored if this concerned a new drug or medical intervention.

The message about safe staffing is in danger of becoming lost in the ongoing argument for ‘skill mix not numbers’. Both are essential. What is vital is ensuring safe nurse-to-patient ratios (NPRs).

To do this, we need unambiguous definitions of what we mean by nurses, patients and NPRs. Specifically, it is essential to know whether or not the N in NPR includes: registered nurses only, as in US and Australian studies; registered nurses and support staff; or the registered nurses in charge of wards.

As Sir Bruce Keogh (2013) said, the larger and more amorphous the unit the less useful and accurate is the information. In other words, overall hospital NPRs give more reassuring, though possibly misleading, results because they include staffing in intensive care and high dependency units, as well as emergency departments, in addition to the registered nurses who are not involved in direct care on the wards. They mask the reality of ward staffing.

Nurse-to-patient ratios that include unregistered staff also portray situations better than they are. Ward level staffing ratios, or even better, those that refer only to registered nurses are the only NPRs that reflect ‘real-life’ workload and staffing and allow for meaningfully accurate comparisons to be made within and between wards and hospitals.

I would argue therefore that the number of patients each registered nurse is allocated or told he or she has to care for, is the ratio that should be used. This should, if possible, be a real-time figure whether the data is captured on paper or electronically.

We also need clarity about what we mean by skill mix. On the whole, band mix, that is the ratio of registered nurses to healthcare support workers, is used as a proxy for skill mix. As important is knowing about the education, skill and experience that staff have in each band.

These data are needed and should be accurate and reflect the reality at patient-care level simply because research shows that there is a stepped relationship between the number of registered nurses, or the number of registered-nurse hours per patient day, the educational qualifications of the registered nurses and band mix to important outcomes such as patient mortality.

What the evidence shows

We all know that we should care for patients using the best available evidence. Since the mid-1970s, research has shown links between quality of care and nursing. Until recently however many of these studies were small. Since the 1990s this has changed.

Twenty years ago, Aiken et al (1994) demonstrated that mortality rates increased by 7% for every patient added to a RN’s workload. Her 2002 study showed that for surgical patients in the US the odds of patients dying (overall or subsequent to complications) in hospitals in which the average NPR was 1:6 were 14% higher than in hospitals in which the average NPR was 1:4, increasing to 31% higher in hospitals in which the average NPR was 1:8 (Aiken et al 2002).

Rafferty et al (2007) obtained similar results in UK hospitals: those with the poorest NPR had 26% higher mortality. In that study, average NPRs (as reported by the nurses themselves) in the UK were 1:10 for England and 1:9 for Scotland. In the latest RN4CAST survey of 46 English hospitals, the overall average day shift NPR was 1:8 and in some wards almost 1:11.

The most recent review states: ‘The evidence across 14 studies consistently suggests that the risk of hospital related mortality was 9% lower in ICUs, 6% lower for medical patients, and 16% lower for surgical patients for each additional RN FTE per patient day’ (Kane et al 2007).

In addition, the richer the skill mix i.e. the higher the proportion of RNs to support staff, the better the outcomes even if that results in lower numbers overall.

Last but not least, there is increasing evidence the better educated and qualified the RN the better the patient outcome (Aiken et al 2003, Kutney-Lee et al 2013).

Exactly how and why this happens is still not fully explained, though studies in the US by Needleman et al (2011) and in the UK by Ball et al (2013) suggest it reflects the relationship between staffing levels and activities left undone especially ‘patient surveillance’, which is so critical to the early identification of changes in a patient’s status.

If one RN is looking after 11-12 patients with much of the direct hands-on care being given by other staff she has many fewer opportunities for surveillance than if she looks after five or six patients.

For me it is crucial that there are sufficient RNs to enable them to carry out that constant surveillance by being close to the patient’s bedside. I also think the number of patients each RN is allocated - or said she had to care for on her shift - is the most meaningful ratio, and is the one which should be used.

Staffing numbers on display

The chief nurse at Guy’s and St Thomas’ NHS Foundation Trust, London, Eileen Sills, fears that having staffing levels posted at ward entrances heightens patient anxiety. Her concern raises a number of issues, about staffing levels in general and about making the public aware of them.

This reminds me of similar discussions in the past about whether or not patients and relatives should be told they had cancer. Sometimes relatives might be told but not the patient as ‘they would not be able to cope’.

Today that attitude has changed. We know that being given good information prevents or reduces anxiety rather than increasing it. If the staffing information is presented clearly there should be no problem with it being understood. The ‘required’ numbers or NPR as determined by the patient classification or staffing system currently being used and the actual numbers on duty for each shift should be available.

Given that RN staffing is such an important factor in ensuring treatment is carried out properly and assuring good clinical outcomes I believe patients and relatives have a right to know that these will not be compromised by inadequate staffing and to have the risks and benefits of the available staffing explained. Of course where there is a sudden, unexpected mismatch between staffing and patient needs, nurses, as always, will do their best to ensure safe care is not compromised.

However, this is quite different from a situation where the agreed RN numbers and grade mix do not, and cannot, meet the levels identified as necessary to meet patients’ needs. If that is the case, just as we explain the risks and benefits of treatment, should we not also have to explain the potential risks of not being able to do all those things we are meant to do? Perhaps all we have to do is to answer the following question: ‘If your mother were a patient in your hospital, would you feel confident to leave her there alone, knowing she would be safe from error or avoidable harm?’ If we cannot answer yes, without any ifs and buts, then surely we cannot and should not leave others’ mothers, fathers, sisters and brothers there.

Ensuring ‘everyone knows where the buck stops’

I support the need for everyone to know who is responsible for a patient’s care. A board behind the bed has been the usual way because it helps to have a wall to put it on and because it is easily seen by any member of the care team. Wall charts have also been used in the past. All raise issues of balancing visibility with patient confidentiality.

Eileen Sills pointed out a key issue is ensuring such boards are up to date. Another is coping with the fact that many patients come under the care of either a multidisciplinary team which inevitably has multiple members or more than one consultant. The larger the hospital and clinical division the more likely (as I can vouch from recent experience), this is to happen. To date during my recent encounter with the NHS I have counted seven consultants, all excellent, but I would be hard pushed to know which one is the one in charge.

With nurses it is even more complicated. When the nursing process and primary nursing were in vogue the idea was that the name of both the primary nurse and assistant/secondary nurse were displayed and that one or the other would be on duty. Such continuity is almost impossible to achieve with shift patterns, days off and the shorter length of patients’ stays.

During any 24-hour stay in hospital a patient receives care from at least two (day and night) ‘nurses’ if 12-hour shifts are worked, and three with eight hour shifts. Allowing for days off, annual leave and the usual NPRs, and the grade mix of most ward teams, that number will increase. So whose name goes on the board? Is it the RN who plans care? Who gives care? Who supervises the HCSW giving the care? Some activities such as giving medication are still done as rounds rather than on an individual basis. How does that affect the decision? Should it be changed each day or each shift?

What I want to know as a patient or relative is:
• Who is actually looking after me (or my nearest and dearest) today, all day and all night? Whom do I ask for a bedpan, to make me comfortable, monitor my pain levels and take appropriate action?
• Who can answer my questions about my illness, treatment, discharge, etc. and take decisions, urgent or routine, about my/your care and treatment, be that medical or nursing?

I trained in a hospital (Guy’s) where patient allocation was the norm. I can testify to how much patients appreciated knowing who was ‘their’ nurse. On some wards the allocation was for just one shift, sometimes for a week and sometimes for longer still. Longer periods were both more satisfying and paradoxically could be more stressful.

One of the things we did was to tell ‘our’ patients that we were their nurse when we began our shift, to tell them when we were about to go off the ward for a break or off duty and when we would be back, and ask at that point if they needed anything before we left. I did it then because that was what we were taught to do.

Later in my career research showed me that these apparently simple actions had a knowledge base. But it is easy to forget how the routines which are so familiar to us are so baffling to patients.

Simply letting your patients know who you are and where you will be is such a simple, yet effective measure of reassurance. That sense of linkage, of knowing and understanding between nurse and patient, is a key component in reducing the anxiety of patients, ensures decision making can be tracked and provides immense satisfaction for the nurse.

About the author

Jennifer Hunt is a professor of nursing and member of the Safe Staffing Alliance

References/further reading
Aiken L, Smith HL, Lake ET (1994) Lower Medicare mortality among a set of hospitals known for good nursing care. Medical Care. 32, 8, 771-787.
Aiken L et al (2002) Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. Journal of American Medical Association. 288, 16, 1987-1993.
Aiken L et al (2003) Educational levels of hospital nurses and surgical patient mortality. Journal of the American Medical Association. 290, 12, 1617-1623.
Ball J et al (2013) ‘Care left undone’ during nursing shifts: association with workload and perceived quality of care. British Medical Journal. BMJ 10.1136/bmjas
Kane RL et al (2007) The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 45, 12, 1195-1204.
Keogh B (2013) Review into the Quality of Care and Treatment Provided by 14 Hospital Trusts in England: Overview Report.
Kutney-Lee A et al (2013) An increase in the number of nurses with baccalaureate degrees is linked to lower rates of post-surgery mortality. Health Affairs. 32, 579-586.
Needleman J et al (2011) Nurse staffing and inpatient mortality. New England Journal of Medicine. 364, 1037-1045.
Rafferty AM et al (2007) Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. Int J Nurs Stud. 44, 2, 175-182.