8 Safe staffing levels

Resolution submitted by the RCN Central Manchester Branch

That RCN Congress urges Council to campaign for legally enforceable staffing levels to safeguard standards in the current economic climate

Progress reports

Submitted by: Central Manchester Branch
Council lead and committee assigned: Sue Fern, Nursing Practice and Policy Committee and Anne Wells, Membership and Representation Committee
Committee decision: Integrate project into ongoing work stream
Members involved: Laura Collier, Central Manchester Branch and Cat Forsythe, UK Safety Representative Committee and Central Manchester Branch

Final summary update at May 2012

The RCN produced a paper, available on the RCN website, on mandatory staffing levels which looks at the use of benchmarks and ratios. A toolkit that activists and members can use to monitor their workplaces is also being developed. The RCN published a report in March 2012 that laid out recommendations to address issues on safe staffing in older people’s wards.

In England the RCN worked with Baroness Emerton to table amendments to the Health and Social Care Bill calling for the development of mandatory safe staffing levels. The amendment was withdrawn in the face of government opposition although there was agreement to look further at the evidence supporting safe staffing levels.

In Northern Ireland the Normative Staffing Project is developing regionally-agreed nurse staffing range for general medicine and surgery based on 70/30 skill mix. Work is also being piloted by the RCN on A&E staffing.

RCN Wales continues to call on Local Health Boards to demonstrate safe staffing levels and remains concerned about staff working extra hours, high levels of bed occupancy, unfilled vacancies, lack of maternity and sickness absence cover, reliance on temporary staff and a ban on CPD being provided during work time.

The Scottish Government reviewed the staff projections process in 2011 and the RCN remains concerned about the risks of workforce projections and workforce plans in the context of financial pressures

Update at November 2011

The work for this agenda item falls under the remit of the RCN’s Future Nurse Future Workforce project; an RCN project which looks at seven key areas of nursing. This item sits with the project’s Workforce and Staffing Levels work stream.

An introductory teleconference with item proposer Laura Collier, Central Manchester Branch, has been held to discuss the background to the Congress resolution and the work of the Policy and International Departments and RCN Future Nurse Future Workforce group, looking at how the work will be taken forward.

A paper will be produced looking at the use of benchmarks and ratios in nursing care, evaluating where they exist and whether or not they are used. This will be followed by the development of tools that activists and members can use to monitor their workplaces, which will inform the RCN’s future position on mandatory staffing levels.

In October 2011 the RCN tabled an amendment to the Health and Social Care Bill calling for the NHS National Children's Bureau to oversee the development of mandatory safe staffing levels, and to ensure the 65:35 skill mix in general wards is maintained and that these measures are incorporated into future commissioning and inspection programmes. Item proposer Laura Collier, Central Manchester Branch, and seconder Cat Forsythe, UK Safety Representatives Committee were informed in early October 2011 that the RCN were supporting amendments to the Health and Social Care bill tabled by Baroness Emerton.

The decision to call for this amendment was a result of ongoing dialogue at RCN Council, RCN Nursing Practice and Policy Committee, and RCN Future Nurse Future Workforce meetings.

The debates on staffing levels were heard on 30 November 2011. It received much support from across the House of Lords but was withdrawn in the face of government opposition. However, it is important to note that as part of their responses to this and debates on frontline nursing care, the government did agree for the Department of Health Professional Advisory Board to further review the evidence supporting safe staffing levels.

At present the RCN and Baroness Emerton are reviewing the potential routes open to re-tabling this amendment.

The RCN will also be publishing guidelines on staffing for elder care and a policy position on mandatory staffing levels.

Useful links:

Debate report

Concerns about patient care and the wellbeing of nursing staff were raised in a debate which called on RCN Council to campaign for legally enforceable staffing levels.

Proposing the resolution, Laura Collier from the Central Manchester branch, said: “Patients have a right to good care, so why can’t it be a statutory right for care to be carried out by a nurse who is not always rushing around.”

Seconder Cat Forsyth, from the UK Safety Representatives Committee, highlighted how the debate was not just relevant to the NHS, but also the independent and voluntary sectors and social enterprises.

Julian Newell, from the Emergency Care Association, feared there would be a ‘haemorrhage’ from the nursing profession if safe staffing levels were not introduced; while Anita Muir from the Education Forum felt low numbers of staff have an impact on student placements.

“We have a duty of care to our patients, but who has the duty of care to us,” asked Lucy-Leigh Schultz, from the Eastern region; while Margaret Devlin, from the Southern branch, felt a statutory level would always be treated as the minimal level.

Dougie Lockhart from Dumfries and Galloway branch, said statutory staffing levels have been introduced in Australia, New Zealand and the USA, and felt there was no reason why it could not happen in the UK.

Result

For: 80.17% (372)
Against: 19.83% (92)
Abstentions: (26)

Background

Resources in health care are more limited than ever. At a national level reassurances are given that health funding and front-line services will be protected and NHS employers are advised to actively assess the impact that any planned changes to workforce may have on quality. Nonetheless by the end of 2010 the RCN's Frontline First campaign had identified 27,000 NHS jobs earmarked to go from across the UK.

There is debate about the most effective way of safeguarding the quality of patient care and an ongoing tension between centralised controls versus local freedom. Furthermore, staffing levels are repeatedly highlighted in the media in relation to inadequate care in failing trusts, where insufficient staffing is identified as a key factor.

In England, many NHS providers have greater freedoms (through foundation status) but the context of care is more regulated. All providers (not just NHS) must comply with Care Quality Commission standards – one of which relates to staffing.

Health and social care services in Northern Ireland are integrated, so prescribed staffing levels would need to reflect the full range of care settings in which registered nurses and health care assistants practise. In Wales, meanwhile, the RCN has called specifically for staffing minimums in its Welsh Assembly election campaign Nursing Matters.

In the meantime, the RCN in Scotland is calling for health care employers to make appropriate use of the full range and expertise of all members of the nursing team. In the current economic situation employers are using methods to reduce the costs of their nursing workforce. While some are legitimate others have the potential to impact adversely on patient care and an already over-stretched workforce – for example, replacing registered nurses with health care support workers as a cost cutting measure.

Research (Aiken et al, 2010) shows that mandated staffing levels are associated with significantly lower patient mortality rates. In 2004, California introduced minimum licensed nurse-to-patient ratios, while in Victoria, Australia, legally mandated nurse-to-patient ratios were introduced to improve the recruitment and retention of staff. The Australian Nursing Federation commissioned two surveys to explore the impact of ratios on nurses in Victoria, and 96 per cent of nurses surveyed considered ratios were essential for ensuring manageable workloads (Gordon et al., 2008).

The RCN has already undertaken a number of work streams on this issue including a review of the use of ratios in 2004, producing a policy briefing relating to setting ward establishments in NHS acute settings in 2006, and publishing new guidance and a position statement on safe nurse staffing levels in 2010.

The RCN policy position is that health services need robust data on current staffing as well as data on patient outcomes and quality in order to assess the adequacy of staffing, and the RCN has proposed staffing indicators which include a nurse-to-patient ratio.

References and further reading

Aiken LH, Clarke SP, Sloane DM, Sochalski J and Siber JH (2002) Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction, Journal of the American Medical Association, 288 (16), PP. 1987-1993

Buchan J (2004) A certain ratio?: minimum staffing ratios in nursing: a report for the Royal College of Nursing, London: RCN

Gordon S, Buchanan J and Bretherton T (2008) Safety in numbers: nurse-to-patient ratios and the future of health care. New York: Cornell University Press