Implementation of Safe Staffing Ratios in an NHS Organisation; by reviewing mandatory staffing levels and their introduction in Australia and New Zealand.

This report describes a personal and professional leadership journey carried out as part of a Florence Nightingale Travel Scholarship during 2014/15. The report highlights the reasons why I applied the objectives that I set up and the benefits I have achieved from my scholarship.

I wanted the chance explore how safe staffing ratios had been mandated and introduced in Australia and New Zealand. The rationale behind the ratios used; the affects demonstrable or claimed since their introduction; the part played by Senior Executives of nursing in their establishment and the influence in the ongoing debate on the links between nurse to patient ratios and compassionate and harm free care, particularly during a time of economic downturn.

Objectives

• To understand the evidence to support safe staffing ratios
• To understand how mandatory nurse staffing levels have been introduced in Australia and the contrasting model in New Zealand of acuity/depend and demand.
• To ensure that senior executives of nursing are united in achieving the overall aim of compassion and harm free care and by direct causality demonstrate nursing ratios contribution to the finance bottom line.
• To grasp lessons learnt and implications for the NHS on mandatory safe staffing levels. Is there such a thing as a universal truism in the context of trained professionals to support workers to patients to quality and safe care.
• Whilst reviewing safe staffing, I took the opportunity to explore methods of dynamic staffing reviews as prediction of safety.

It was particularly important for me to speak to front line nurses on their experiences of working in an environment which ensures staffing levels are maintained.  As professional carers, did the system work? Was it working well? Did they themselves believe that their numbers were the key to safety? Were there any reservations that prevented the system maximising the levels of care and support being given to patients.

Also, did their executives support the maintenance of ratios?  What worked well, what could still be improved?  What additional factors meant help or hindrance to the levels of staff to patients to care ratios?

Conclusion

The Florence Nightingale Travel Scholarship allowed me to explore an international perspective on a hot topic of universal interest “To understand how the subject of safe staffing is being addressed in another hemisphere.”

My study tour revealed to me the multifaceted relationships that exist between care quality, safety and staff ratios. That an algebraic formulae whilst comforting in its simplicity is no guarantee of compassionate safe care. That in many ways the best ambitions of nursing and health legislations are dependent on the individuals sense of support in an organisation which in turn, requires engaging leadership and sustained review to be valid and vital.

The evidence exists to link inadequate staffing to the drop in safety for patients. There are other factors that need to be taken into account, such as physical design of the ward, bed numbers, patient turnover, skill mix and workability of support services and other health care professionals.

However, without a fundamental standard for baseline safe staffing, all the variables are incidentals. There have been too many reports into unsafe care with poor staffing at the core to ignore the issue. However, what my study revealed to me is this is merely a base camp from which to aspire to the summit of zero harm.

On the publication of the recent Francis Report, David Cameron said

“The Government has so far resisted calls to introduce mandatory staff ratios in the wake of the Mid Staffordshire scandal, arguing that it would not necessarily improve patient care and could lead to organisations seeking to achieve staffing only at the minimum level.”

Financial constraint during an economic downturn, means increasing pressures on staffing and worries that workforce levels may affect quality.1 Currently there are no minimum staffing levels for National Health Service Organisations; individual providers are responsible for determining staffing locally within Trusts.

The Royal College of Nursing has lobbied for safe staff levels and voted in favour of legally enforceable nurse staffing levels.2  Ratios are simple to use and where they lead (as I believe would be in the majority of cases) to improve staffing levels, they can create a more stable workforce. A workforce which is therefore more experienced at ward level more resilient and less dependent on cover from agencies or bank staff with all the inherent risks.

Professional bodies and associations in the UK have put forward recommendations for nurse staffing levels in different specialities. It is recommended that every patient in a critical care unit has access to a RN with a part registration qualification in the speciality and that there is a ratio of 1:1 for ventilated patients.3 On children’s wards, a daytime RN to patient ratio of 1:3 is recommended for children under 2 years of age, and 1:4 for all other ages.4

On mental health words, the Royal College of Psychiatry suggest a daytime ratio of 1:5 RNs per patient is likely to be needed for acute wards, but they go on to confirm about the use of minimums and recommend that the determination of appropriate staffing will invite dialogue between managers, nurses and other clinicians.5

This is a common themed recommendation on staffing and accompanied by a proviso to take into account specifictoral factors based on clinical need and other factors that influence staffing requirements (environmental and support mix). Staffing ratios cannot of themselves, obviate the need for robust mechanisms which monitor compliance and outcomes as well as potential impact on patients.

As a member of the Berwick Review, the Safe Staffing Alliance and National Nursing and Care Quality Forum, I am concerned we need to strengthen the nursing voice from senior leaders within organisations to ensure safe staffing ratios to benefit patients and staff. I believe there is a link to adequate staffing to the safety of patients. Of course there are other factors which need to be taken into account, but whilst it is easy for Trusts to demonstrate financial solvency, it is possibly easier still to miss care failings in both morbidity and mortality and patient experience.

As a member of the Safe Staffing Alliance, we have campaigned for national minimum staffing levels since 2012. Robert Francis revisited the issue of staffing levels in 2013 once he had seen evidence from the Alliance and the National Nursing and Care Quality Forum and stated “It’s evidence (that) ought to be considered with regard to whether there is some sort of benchmark, which at least is a bit like mortality rates – an alarm bell which should at least require questions to be asked about whether it is possible for a service to be safe.”

Further research in this jurisdiction is needed to elucidate the factors influencing the staffing levels of nurses and the mix of nursing personnel in hospitals.6

My tour of Victoria (Australia) and New Zealand allowed me to study first hand the purported benefits to patients and hospital staff where mandatory staffing ratios have been implemented or alternatively, the dependency / demand model for determining nursing hours required.