Demanding safe staffing levels to ensure quality nursing care

Can cash-strapped health boards afford to ignore safe staffing levels?

RCN Wales is warning that undignified care due to inadequate staffing levels will continue unless nurse-to-patient ratios are mandated. Sue Learner reports.

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This article was first published in Nursing Standard, Vol 27 No 31, April 3 2013

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Former health minister for Wales Lesley Griffiths announced last month that an acuity tool, allowing sisters and charge nurses to determine safe staffing levels on their wards, would be available by next year. But critics say this is not enough to address the increasing problem of undignified care caused by ongoing cost-cutting.

The Safer Nursing Care Tool, expected to be implemented in 2014, will offer ward leaders the option of assessing the severity of patients’ conditions, whether they are likely to deteriorate and what their ongoing needs will be.

Ms Griffiths announced the tool before she was replaced by Mark Drakeford in a ministerial reshuffle. She said: ‘Having the right number of staff with the right skill set is recognised to be a key factor in providing safe, high-quality care.’

Nurse staffing levels in the UK are under the spotlight after Robert Francis’s report into poor care at Mid Staffordshire NHS Foundation Trust found that one of the principal causes was low staff-to-patient ratios as a result of cost-cutting.

Reports by Health Inspectorate Wales since 2011 have highlighted that seven out of 12 hospitals in Wales did not have enough staff, and this was affecting their ability to provide dignified care.

As a result of the inspections, many health boards have been told by the Welsh Government to review staffing levels ‘to ensure that patient care is not compromised due to short staffing’.

However, with health boards operating on reduced budgets and Wales unwilling to follow in the footsteps of Scotland and introduce mandatory staffing tools, it is unclear whether this will be achieved.

Shadow health minister and Plaid Cymru AM Elin Jones says the inspections show that, in most instances, ‘staffing numbers in Wales are simply inadequate’.

She adds: ‘It is particularly worrying that local health boards have been asked to continue cutting staff numbers until they meet budget constraints, so it is likely they will fall even further.’


RCN Wales director Tina Donnelly argues that staffing levels go hand-in-hand with the degree of compassionate care given by nurses. She says: ‘The RCN launched its Time to Care campaign two years ago because we believe understaffing means many nurses do not have the time to give patients appropriate care or demonstrate compassion.

‘If you need to administer medication to 32 patients, you are going to be rushed. You will not have time to have a meaningful dialogue with each patient. How can you demonstrate you are being compassionate?

‘You need time to engage with each patient and enable them to feel that you understand their needs. But these days, if nurses spend the time they need to with patients, they will be criticised for not giving other patients their medication on time.’

Ms Donnelly works shifts at hospitals in Wales so she can follow up problems when nurses alert her to them.

‘I can see nurses are very busy and are dealing with patients who have increasingly complex needs. I have spoken to well-qualified nurses who are leaving the profession because they cannot give the level of care they want to.’

Community pressure

Wales is in the process of integrating health and social care, which means more care is being shifted into the community. Ms Donnelly is concerned that there has not been an increase in the number of community nurses to reflect this. District nurses are now expected to care for a growing number of patients who have increasingly complex needs, she says.

‘If you discharge patients from the acute sector into the community, you obviously need to have the nurses there to care for them,’ she adds. ‘I am disappointed that the figures for district nurses have not gone up.’

There has also been a drop in the total number of nurses being trained in Wales. In 2006, 1,271 pre-registration nurse places were commissioned. This year there are 956.

RCN Wales has challenged commissioning decisions with the Welsh Government and assembly members. In particular, the college focused on last year’s 37 per cent drop in the number of child branch student places.

Following discussions with the chief nursing officer for Wales, Jean White, there has been an increase in the number of places from 64 last year to 104 this year.

Dr White has issued guidance saying that the number of patients being cared for by a registered nurse should not exceed seven during the day and 11 at night.

But Ms Donnelly says the RCN knows of hospitals that are not meeting these ratios. ‘We have knowledge of poor staffing levels that we have discussed with the health boards, government officials and health regulators. Many wards in Wales are often running at 95-100 per cent bed occupancy when staffing levels are set for 82-85 per cent occupancy.’

Ms Donnelly believes there is an urgent need for mandated safe staffing levels that set out the number of patients each registered nurse should care for. The RCN is also calling for a guaranteed ratio of registered to non-registered nursing staff on duty: 65 registered nurses to 35 healthcare assistants.

Balancing budgets and staff

Clear guidelines

A recent report by the Welsh assembly’s public accounts committee called on the Welsh Government to rule clearly on what constitutes minimum staffing requirements for safe and sustainable midwifery services, after it found staff shortages at maternity units in Wales.

But the government maintains that the onus is on the local health boards to ensure they have the right number and the appropriate mix of staff on wards.

The situation is not helped by the fact that health boards are under enormous financial pressure. Wales is the only part of the UK that has not had its health budget protected. The seven health boards in Wales are each having to make savings at a time when demand is rising, according to Ms Donnelly.

She points out: ‘Our emergency units are working at full capacity and there is not a single health board that is meeting its targets for seeing patients on time. The system is under immense pressure, with low staffing levels a daily occurrence. This, in turn, puts pressure on the nursing staff who are trying to give the best care to their patients.

‘Maybe we should be looking at GPs working seven days a week. There is an unprecedented demand for health care in Wales and something has got to give’

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