RCN parliamentary briefing on nurse staffing and workforce planning
The Royal College of Nursing (RCN) is the largest nursing union in the world representing over 390,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets in the UK. The RCN promotes patient and nursing interests on a wide range of issues by working closely with government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary groups. The following parliamentary briefing sets out the current challenges to workforce planning and nurse staff and proposes a number of recommendations.
Creating a sustainable workforce
Members of the nursing family deliver the majority of direct patient care. They have been crucial to meeting government targets to improve health care over the last ten years. The continuing delivery of high quality patient care depends crucially on having a sufficient pool of skilled and highly motivated nursing staff to meet the demands of the service in the future.
Recruitment and retention
The RCN welcomes the drive to increase the number of nurses which has meant an increase in registered nurses in the NHS by 23% full time equivalents in England since 1997. However, the recruitment drive has not ended staffing shortages, prevented nurses working unpaid overtime or reduced reported heavy workloads. There are serious deficiencies in workforce planning in the NHS that need to be addressed:
• 180,000 nurses are due to retire in the next 10 years. Around 100,000 are aged 50 and another 80,000 are aged 55.
• Nurses in the community, district nurses, community psychiatric nurses and health visitors, for example, tend to be older.
• 60% of nurses work an average of an additional six hours per week (J Ball, RCN 'Managing to Work Differently', 2005).
• In a recent RCN/ICM survey (2007) over half of nurses surveyed (51%) rated their morale as either very poor or quite poor, whilst almost a third said an unsatisfactory pay award would make them consider quitting the NHS altogether.
• We are beginning to see a reversal in the trend for overseas nurses to seek employment in the UK and instead we are seeing UK and overseas trained nurses moving to jobs in North America and Australia where there is a shortage crisis.
• There are early signs of a future shortage of registered nurses. Indeed the Department of Health has predicted a shortfall of 14,000 nurses by 2010.
Nurse staffing levels
Nursing levels should be maintained at an appropriate level. There has been a growing demand on health services whilst patient nurse ratios have remained the same. In addition, there is growing evidence to link the number of registered nurses in the acute hospital sector to patient outcomes including quality of care and patient satisfaction and, clinical outcomes such as adjusted mortality rates and morbidity rates, contribute to the imperative.
The Healthcare Commission report Ward Staffing found that patient satisfaction and clinical outcomes such as the incidence of pressure sores relate more to the number of experienced and skilled registered nurses employed by the trust than total numbers. Independent research in the UK by Professor Anne Marie Rafferty, University of London, reveals that for surgical patients in 30 NHS acute hospitals mortality increased by 12% to 49% in hospitals with the lowest registered nurse to patient ratios. Put another way, patients are more likely to die in the surgical settings studied when there were fewer registered nurses on the ward.
Determining the threshold or ideal equation of registered nurse to patient ratios is complex, such as seriousness of patient illness, case mix, treatment and so on. Therefore a mandatory approach is not appropriate. However there are some key principles which ward managers can apply to determine appropriate (rather than minimum) nurse: patient ratios.
Within the NHS skills mix ratios have remained an average of 62 of registered nurses and 38 health care assistants over the last five years whilst the seriousness of patient illness and bed occupancy has all increased. The RCN guidance recommends that a skill mix of 65% registered nurses to 35% health care assistants is regarded as the benchmark for the general ward nurse staffing establishment (RCN policy guidance (2006) Setting Appropriate Ward Nurse Staffing Levels in NHS Acute Trust). The Healthcare Commission used the RCN benchmark in their investigation into the Maidstone and Tunbridge Wells NHS Trust and the subsequent report that said that 14 out of 20 wards fell below this recommendation (Healthcare Commission investigation into C-difficile Maidstone & Tunbridge Wells, 2007).
International recruitment
International recruitment grew rapidly in the late 90s and last year accounted for about 40% of new entrants to the Nursing and Midwifery Council (NMC) register. Apart from data from the NMC register on nurses entering the UK, there is no monitoring of the movement of international nurses either in the NHS or the Independent sector. There is no available data on the movement of nursing staff between the four UK countries.
The NMC register not only shows the inflow of nurses into the UK, but it also shows the ‘outflow’ of nurses from the UK to other countries. UK ‘loses’ nurses to Australia, New Zealand, Canada, the USA and Ireland. In 2005/06 the NMC reported that 7,800 nurses looking to work outside of the UK, with almost 35,000 nurses over the past four years emigrating. There is an impending global nursing shortage and the likelihood is that there will be an increased trend towards outward migration of nurses from the UK.
RCN recommendations
• A comprehensive central function for workforce planning across the UK health sector to ensure that gaps in knowledge are filled and trends can be monitored including international flows.
• The RCN recommends that a skill mix of 65% registered nurses to 35% healthcare assistants is regarded as the benchmark for the general ward nurse staffing establishment.