This article is not peer-reviewed. You are advised to read this article in bits, according to which parts interest you. If you would like to engage constructively in some of the issues here, I can easily be reached on my twitter thread @legalaware_coys.

Introduction

The concern is that the NHS hospital setting is fundamentally designed incorrectly. It at face value appears to be running  within a budget, imposing ‘efficiency savings’ and hoping that patient safety will be achieved within this budget. It could instead with health care managers sitting down with a big spreadsheet and working out how much money they need to run the health service with an adequate level of patient safety? By this mean, “basic issues” are covered, where the whole of geriatric care is not dependent on one Foundation Year doctor with a bleep covering all geriatric wards, hoping that there won’t be simultaneous emergencies.

Forgetting this general design issue for a moment, more specifically should there be a minimum nursing staffing level for nurses? This seems like a basic enough question, doesn’t it? Most people have a gut feeling for where nurses appear too rushed on a hospital ward or care home, and yet this policy issue generates quite diverse opinions. Is the question one of these?

But don’t worry this article is not intended as an advert for Marmite. It has dawned on many that this policy strand is extremely complicated, and indeed relatively recently King’s College Policy+ of March 2012 asked the question, “Is it time to set minimum nurse staffing levels in English hospitals?” Firm conclusions are necessarily tempered by pooling results from different jurisdictions, different healthcare systems, different mixes of registered nurses/healthcare professionals, different mixes of Trust nurses and “bank nurses”, different mixes of full-time vs. part-time nurses, different geographic demands (different populations, different prevalence and incidence of disease), different service demands (acute, subacute, chronic, or similar), different care settings (care homes, hospitals), different patient demographics (e.g. age), and so it goes on. However, the mere complexity of it perhaps suggests the response should not be one of this:

This prestigious King’s College Nursing Unit extremely helpfully concluded:

•  International evidence suggests that mandated registered nurse to patient ratio can improve nurse staffing and lead to better recruitment, generate a more stable workforce, and more manageable workloads for staff. The impact on patient outcomes is less clear but there is evidence that the resultant lower caseloads are related to lower levels of patient mortality.
• Ratios and recommendations are specialty specific. Existing recommendations are focussed on clearly defined and delineated settings, where patient need is relatively predictable and consistent. Data about current staffing related to safe and ffective care delivery is needed to determine the appropriate ‘minimum’ or recommendation for a wider range of settings, such as acute care for older people.
• There is a need to clarify how existing ratios are expressed and to explore other measures of staffing, such as nursing hours per patient, or per bed.

[ This report can be accessed here.]

Wind the clock forwards, and policy makers are enmeshed in a narrative – in some quarters = which blames risks in patient safety with efficiency savings and understaffing of nurses. In contrast, Dan Poulter was reported on 6 March 2013 as saying that minimum nursing staffing levels are “not the answer”.

The report in the Health Services Journal goes as follows:

“Health minister Dan Poulter appeared yesterday to reject the Francis Report’s call for nationally recognised minimum nurse staffing levels.

Addressing a conference on the Report of the Mid Staffordshire Foundation Trust Public Inquiry, Dr Poulter also said the Government’s response, due at the end next month, would not address in detail each of the inquiry’s 290 recommendations.

Asked about Robert Francis QC’s proposal that the National Institute for Health and Clinical Excellence develop nationally recognised minimum nurse staffing levels for a range of healthcare settings, Dr Poulter said he had “not seen the evidence that supports that”.

“Sometimes when you put in mandatory standards you can have a drive to the bottom,” he told the conference, organised by think tank the King’s Fund. “I don’t think staffing ratios [are] the answer.””

The wider debate

Goryakin, Griffiths and Maben (2010) found that nurses can provide cost effective care, compared to other health professionals. On the other hand, more intensive nurse staffing can be associated with both better outcomes and more expensive care, and therefore cost effectiveness was not easy to assess.

Certainly the overall trends in nursing care across a number of jurisdictions is interesting. For example, Duffield and colleagues (2011) report:

“The longitudinal study results show that although there had been increased investments in nursing over the 5-year period, they were primarily in specialized nursing units, such as critical care and ED, and primarily in metropolitan hospitals. At the same time, there was increased casualiza- tion (rates of part-time hours worked) of the nursing workforce and downward substitution, converting nursing positions to AIN. These findings parallel similar trends in many countries including the United States (Bureau of Labor Statistics, 2008) and may reflect the fact that policy makers believe that ICU/ED nursing work is more difficult than general nursing so more staff are provided.”

Baeyens and Closon (2010) recently observed that important differences are seen in the nurse(+aid)-to-bed ratio between the different EU countries. These differences were documented by a questionnaire send to all EU and EFTA countries. It looks very difficult to find a reason for these important differences, sometimes seen within one country. Unsurprisingly the authors concluded that further research was urgently needed to find out what is the minimum staffing level, adapted to the workload, for the quality of the care, the job satisfaction of the nurses and the satisfaction of the patients and their families.

Regulation

At this point, it certainly is useful to know the rough direction of travel of the healthcare regulators. Professional bodies and associations in the UK have put forward recommendations for nurse staffing levels in different specialities, and this is an important consideration for the Policy+ cited previously. For example, it is recommended that every patient in a critical care unit has access to a registered-nurse with a post registration qualification in the specialty, and that there is a ratio of 1:1 for ventilated patients (British Association of Critical Care Nurses, 2009). Whilst on children’s wards, a daytime registered-nurse to patient ratio of 1:3 is recommended for children under 2 years of age, and 1:4 for other ages (Royal College of Nursing, 1993) On mental health (psychiatric) wards, the Royal College of Psychiatry  suggests that a daytime ratio of 1:5 RN’s per patient is likely to be needed for acute wards. However, in general arbitrary minimums (sic) are warned against, in that “the determination of appropriate staffing will involve dialogue between managers, nurses and other clinicians” (Royal College of Psychiatrists, 1998).

In the UK, nurses currently comprise the largest single group in the health care workforce in many countries, and account for a significant proportion of all health expenditure. In the late 1990s it was estimated that spending on nursing and midwifery staff contributed almost half of all spending on healthcare in the UK (Jenkins-Clarke, 1999; Richardson, 1999). In recent years, there has been an increasing interest in demonstrating the impact  specifically of this crucial part of the health care workforce. Studies have examined the impact on patient outcomes of variation in the numbers of registered nurses, skill mix changes within the nursing workforce and skill mix changes in the wider clinical team involving substitution between doctors and registered nurses.

It may be stating the blindingly obvious but low staffing levels in intensive care environments have been shown to be associated with a number of adverse outcomes, including increased mortality (Tarnow-Mordi et al., 2000). Nonetheless, not all studies have been totally conclusive by any stretch of the imagination: for example, while an overall statistical association between increased nurse staffing levels and decreased adverse patient outcomes was not found by McGahan and colleagues (McGahan et al., 2012), most studies demonstrated a trend between increased nurse staffing levels and decreased adverse patient outcomes in an acute intensive care setting in Australia. Staff morale falls and fatigue increases as a result of frequent changes in off-duty and no opportunity for ‘down time’ (Marquis and Hupson, 2003). It is generally reported that patient care is jeopardised and untoward incidents increase (Giraud et al., 1993). Hospital-acquired infection rates increase (Vicca, 1999) and there is also an increase in needle-stick injuries (Clarke, Sloane and Aitkin, 2002). Human observations reduce and dependence on technology occurs, with a decreased ability to detect incidents (Buckley et al., 1997). This evidence appears to be generally consistent.

In the real world, according to Massey, Esain and Wallis (2009), managing nurse shortages is a major challenge in Trusts today given the worldwide shortage of nurses.To fill the gap created by a lack of permanent staff UK government agencies have increasingly used bank and agency staff. Managing this type of staffing effectively and efficiently, in the context of shrinking healthcare funds, is a major challenge in providing safe and quality healthcare. They found a predictable bank and agency staffing pattern, wherein bank and agency nursing staff were used with increasing frequency towards the end of the week. Demand for bank and agency nursing staff occurred because of: hospital practices that fund a fixed staff establishment for nursing units, while patient numbers and acuity are variable; poor forward planning; sickness, and absence due to professional development or staff training.

Asking the wrong question?

However, Buerhaus argued the following in 2009:

“The imposition of mandatory hospital nurse staffing ratios is among the more visible public policy initiatives affecting the nursing profession. Although the practice is intended to address problems in hospital nurse staffing and quality of patient care, this commentary argues that staffing ratios will lead to negative consequences for nurses involving the equity, efficiency, and costs of producing nursing care in hospitals. Rather than spend time and effort attempting to regulate nurse staffing, this commentary offers alternatives strategies that are directed at fixing the prob- lems that motivate the advocates of staffing ratios. “

This article, from the US jurisdiction, very much had the perspective of healthcare as a business, with Buerhaus further noting:

“Hospitals, like any other business, must decide how much and what type of capital and labor to purchase and the how to combine these resources so that they can produce the desired quantity and type of patient care services (its output) subject to some level of quality. Hospitals also purchase and combine other capital and labor inputs to produce non-clinical care services required to support the delivery of patient care, such as admitting, environmental services, accounting, human resources, etc. Because they have to pay for capital and labor inputs, hospital decision-makers take into account the purchase price of each input. Further, most acute care hospitals are paid according to fixed rates for a substantial portion of their patient population and thus face strong economic incentives to use the least costly combination of inputs.”

The author concluded with a more “flexible” approach (which in policy terms goes well with ‘autonomy’, ‘choice’ and ‘independence’):

“Imposing nurse staffing ratios reduces the flexibility hospitals need to adjust to changing demands to provide patient care, impedes hospitals’ ability to take full advantage of all of the labor and capital inputs they have purchased, and is counterproductive to building constructive relationships between nurses and hospitals. Rather than focusing on forcing hospitals to staff nursing units according to ratios, which are likely to create new problems for nurses, advocates of nurse staffing ratios should consider redirecting their efforts toward fixing problems currently facing the nursing workforce and addressing longer-term problems asso- ciated with the age and supply of RNs. Maintaining and strengthening a flexible approach to nurse staffing, not imposing mandatory nurse staffing ratios, is the key to the long-term survival, advancement, and prosperity of the nursing profession.”

UNISON

This is an issue of considerable importance to nursing stakeholders as one would expected. This concerning the UNISON staff survey of 2013 is currently on their website:

UNISON will be running its second safe staffing levels survey on the 5th March we want all members of the nursing family to tell us what their shift was like. Did you have enough staff on duty to deliver safe, dignified and compassionate care, can you raise concerns easily in your organisation, are you listened to and are they acted upon tell us.

The purpose of the survey is to find out what staffing levels are like in workplaces across the country on a regular day. Staff are asked to keep track of the nurse-to-patient ratio (the number of patients per nurse, in other words) in their workplace and then answer questions in an online survey.

The survey can be found here

Please note that survey responses must be filled in by 09:00 Monday, 11 March to be counted.

Guidance about the survey & the questions it will ask can be found below, download this today so you collect the correct information tomorrow. Help us to improve your working conditions and patient care. If you are not a member of UNISON it’s not too late to join but you can still take part in the survey.

Please download the guidance for further information.

Join UNISON

Instinctively it seems like a marmite issue, “Should there be a minimum staffing issue?” requiring a yes or no ‘binary’ answer. Certainly different stakeholders will have valid opinions on this, and be able to qualify their answers on the basis of their own experiences and mindset. That being the case, the answer may be more one of “yeah, but…” This is ‘work in progress’.

References

Audit Commission (2002) Recruitment and Retention: A Public Service Workforce for the Twenty-First Century. Audit Commission for Local Authorities and the National Health Service in England and Wales, London.

Baeyens, J.P., Closon, M.C. (2010) Differences in nurse (aid) staffing in acute geriatric departments in general hospitals in Europe.  European Geriatric Medicine 1: 320–322

British Association of Critical Care Nurses (2009) Standards for nurse staffing in critical care (updated 2010), Newcastle upon Tyne: BACCN.

Buchan, J., (2004) A Certain Ratio: Minimum Staffing Ratios in Nursing. A Report for the Royal College of Nursing. RCN, London.

Buckley TA, Shor TG, Rowbottom YM, Oh TE. (1997) Critical incident reporting in the intensive care unit. Anaesthesia May;52:403e9.

Buerhaus, PI. (2009) Avoiding mandatory hospital nurse staffing ratios: An economic commentary  Nurs Outlook 57:107-12. 0029-6554/09/$

Bureau of Labor Statistics. (2008). Occupational outlook handbook, 2008– 09 edition. Retrieved July 18, 2008, from http://www.bls.gov/oco/ ocos083.htm.

Clarke SP, Sloane DM, Aitkin LH. (2002) Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health 92:1115e9.

Duffield, C., Diers, D., O’Brien-Pallas, L., Aisbett, C., Roche, M., King, K., Aisbett, K. (2011) Nursing staffing, nursing workload, the work environment and patient outcomes. Applied Nursing Research 24: 244–255

Giraud T, Dhainaut J, Vaxelaire J, Joseph T, Journois D, Bleichner G, et al. (1993) Iatrogenic complications in adult intensive care units: a prospective two-centre study. Crit Care Med 21:40e51.

Goryakin, Y., Griffiths, P, Maben, J. (2011) Economic evaluation of nurse staffing and nurse substitution in health care: A scoping review. [Review.] International Journal of Nursing Studies 48: 501–512

Jenkins-Clarke, S., (1999) Does nursing needthe dismal science’? The case for economic evaluations in nursing. Journal of Research in Nursing 4 (6), 448.

Lynn Massey, A., Esain, A., Wallis, M. (2009) Managing the complexity of nurse shortages: A case study of bank and agency staffing in an acute care Trust in Wales, UK. International Journal of Nursing Studies 46: 912–919

Marquis B, Huspon C. (2003) Leadership role and management function in nursing; theory and application. Philadelphia: Lippincott, Williams and Wilkins; p. 305.

McGahan, M., Kucharski, G., Coyer, F. (2012) Nurse staffing levels and the incidence of mortality and morbidity in the adult intensive care unit: A literature review.  Australian Critical Care 25: 64—77.

National Nursing Research Unit. Policy+. (March, 2012) Is it time to set minimum nurse staffing levels in English hospitals? http://www.kcl.ac.uk/nursing/research/nnru/policy/Policy-Plus-Issues-by-Theme/Whodeliversnursingcare(roles)/PolicyIssue34.pdf

Rafferty, A.M., Clarke, S.P., Coles, J., Ball, J., James, P., McKee, M., Aiken, L.H. (2007) Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. International Journal of Nursing Studies 44 (2), in press, doi:10.1016/ j.ijnurstu.2006.08.003

Richardson, G., 1999. Identifying, evaluating and implementing cost- effective skill mix. Journal of Nursing Management 7 (5), 265–270.

Royal College of Nursing (2003) Defining staffing levels for children’s and young people’s services, London: RCN.

Royal College of Psychiatrists (1998) Not just bricks and mortar: Report of the working group on the size, staffing, structure, siting and security of new acute adult psychiatric inpatient units. London RCP.

Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ. (2000) Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 356:185e9.

Vicca AF. Nursing staff workload as a determinant of methicillin-resistant Staphylococcus aureus spread in an adult intensive therapy unit. (1999) J Hosp Infect 43:109e13.