Item nine: It's in the mix

Resolution submitted by the RCN Cumbria Branch

That this meeting of RCN Congress asks RCN Council to lobby to ensure appropriate skill mix is integral to patient safety and the quality agenda

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Marie Hannah from the Cumbria Branch asked Congress to support a resolution for Council to lobby to ensure that appropriate skills mix is integral to patient safety and the quality agenda.

She expressed deep concern about reports of patients dying as managers showed more interest in balancing the books than ensuring standards of care are maintained. The expectation is that trust boards will take appropriate actions to maintain public trust, said Marie. She urged Congress to differentiate between 'active' or immediate errors and 'latent' errors which often lay dormant but become obvious when combined with other factors. These, she said, were the greatest threat to the safety of the NHS. Marie described nurses as "often the final ingredient to the lethal brew which had long been cooking".

Marie summarised by saying that nurses can feel brow-beaten to meet targets rather than provide care and we need to ensure that measurements taken reflect the care given.

Paul Young from the North and Tyne branch seconded the resolution. He reminded Congress that one in three community nurses are aged over 50 and one in three practice nurses are aged over 55. Where, he asked, are his future role models going to come from? Patient safety is integral to the argument, he said and urged Congress to support the resolution to ensure that health care staff had the appropriate skill mix to treat them.

The resolution received much support from a number of speakers. Evelyn Nicholls spoke passionately about her experiences of working in elderly care where, she said, it was essential to have skilled, specialised nurses to deliver the highest quality care.

Catriona Forsyth received huge support from the Congress floor as she urged members to complete incident forms whenever staffing levels or skill mix impacted on patient safety. Gail Brooks pointed out that this resolution will also benefit health care staff as unsafe staffing levels cause stress, burn out and then mistakes are made.

Harvey Morgan stressed the importance of getting the numbers and quality of staff right as this will impact on student nurses getting good practice placements and supporting mentors.

The resolution was passed with the overwhelming support of Congress.

For: 431 (99.77%)
Against: 1 (0.23%)
Abstentions: 1

Background

The NHS financial deficits of 2006/07 led to a reduction in the number of registered nurses employed, and a resulting dilution of skill mix. There are fears that the current economic downturn will result in a similar outcome.

Some UK clinical services — intensive care units, burns care units, acute hospital paediatrics and maternity services — have already set nurse staffing levels in the form of professional guidance which may, or may not, be implemented. The risk of setting such nurse staffing levels or nurse/patient ratios — either in the form of voluntary guidance or mandatory legislation — is that while the level set is the minimum requirement, this is often interpreted as the maximum level for practice. In addition, the registered nurse staffing levels are frequently lower for certain patient sectors, for example, elderly care settings both within and outside of the NHS.

Lord Darzi's NHS next stage review report High Quality Care for All (Department of Health 2008) elevated the quality of care to become an organising principle for the NHS in England, putting it alongside effectiveness and access to health care. This renewed focus on patient safety and care quality opens up opportunities to review both the appropriateness of nursing staffing characteristics, and the introduction of clinical quality indicators in England. In Scotland, there is a statutory duty on the NHS to undertake workforce planning.

The RCN policy document Setting appropriate nurse staffing levels in NHS acute trusts (2006) brought together research evidence linking nurse workforce characteristics (numbers, staffing levels, skill mix ratios and education) to patient outcomes: data on nurse staffing levels and nursing workforce numbers: methods available for setting nurse staffing levels at ward level, and discussion about the whole question of setting nurse staffing levels..

The RCN's recommendations included a minimum benchmark for the skill mix of the ward establishment (rather than shift) of 65% registered nurses to 35% health care assistants, unless or until a ward nurse staffing review is undertaken in accordance with the 13 RCN principles laid out in this document. The RCN's benchmark of 65% registered nurses: 35% health care assistants was used by the Health Care Commission as part of its 2007 investigation into patient mortality from C difficile at the Maidstone and Tunbridge Wells NHS Trust.

Overseas, mandatory registered nurse staffing levels have been set (although not necessarily implemented) in California in the United States, and in Victoria, Australia.