Nursing Workforce – Safe Minimum Staffing Levels

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2014 Health Care Service Group Conference
1 January 2014

UNISON has long been concerned with inadequate staffing levels on hospital wards leading to compromised patient care. This was borne out in the Francis Inquiry and Keogh reports.

The shortages of Registered Nursing Staff, appropriate skill mix and overall staffing levels to carry out the fundamental care of patients is now at crisis levels. Despite the recent mandated use of workforce and workload planning tools in Scotland to determine the nursing workforce we can evidence that nurse staffing remains at a consistently poor level throughout the four countries.

Unacceptable levels of Bank staff usage can affect quality and consistency of care as well as putting ‘substantive’ staff, who have a requirement to supervise and delegate work, at significant increased risk. Bank staff themselves can also be put at risk when working in areas which they are not familiar with and while working in those areas being expected to carry out duties which they may not have the necessary core skills and competences to complete.

Conference reaffirms that there should be statutory minimum nurse staffing levels. The law should set a minimum ratio of one registered nurse to four patients for general ward areas, which is supported by international evidence. There should also be legal standards on caseloads for community staff. Conference welcomes the work done in Scotland together with the Scottish Government to look at safe staffing tools.

Conference also welcomes the statement from the Safe Staffing Alliance, of which UNISON is a member, published in May 2013. Based on evidence from the RN4CAST study and elsewhere, the statement recommended:

1) Planning for nurse staffing on wards is undertaken in every ward in every trust, supported by evidence based tools / methodologies to set core establishments sufficient to maintain safe nurse to patient ratios.

2) Ward sisters (or equivalent) are empowered to make day to day decisions on staffing and resource levels with the authority to act on those decisions.

3) Ward sisters and nurse managers are supported by the Director of Nursing and the Trust Board; the Trust Board must be accountable for staffing levels being maintained at the calibrated safe and appropriate levels.

4) Under no circumstances is it safe to care for patients in need of hospital treatment with a ratio of more than 8 patients per registered nurse during the day time on general acute wards including those specialising in care for older people.

5) If registered nurse staffing falls below a ratio of 1 nurse to 8 patients (excluding the nurse in charge) it is a requirement that this be reported and recorded; there is evidence that risk of harm to patients is substantially increased at these staffing levels.

6) Trusts are required to report the frequency of such incidents publicly and to take immediate action to remedy the breach. If breaches occur regularly this must be escalated through the Trust’s Risk Management systems.

7) Registered nurses must at all times be supported by a sufficient number of health care assistants and a senior registered nurse in charge of the ward.

Conference is concerned that where registered nurses are looking after more than eight patients this is a significant clinical risk, and that this is happening all too frequently. Conference believes much better ratios need to be in place to deliver safe, effective, and compassionate care. Further more support from enough Healthcare Assistants (HCAs) (or equivalent) is vital for patient safety and care.

Conference notes the requirement on staff to raise concerns, both contractually and within professional codes of conduct. Conference also congratulates UNISON on the Be Safe campaign, which can be used by all staff to highlight concerns.

Given the evidence that it is a significant clinical risk for registered nurses to care for more than eight patients on an acute ward, UNISON should be supporting our members to raise concerns each time this occurs and employers should be dealing with that risk and reporting it openly and transparently.

Conference therefore calls on the Service Group Executive to work with the Nursing Occupational Group to launch a campaign with other trade unions, patient groups and other interested parties to:

a) campaign for the achievement of a ratio of 1 registered nurse to every 4 patients in general ward areas and higher levels of nurse staffing which directly relate to patient dependency and location;

b) produce targeted materials for ward based nurses urging them to raise concerns when they are caring for over 8 patients, and to let their branch know they have done so;

c) produce a fact sheet summarising the evidence behind the clinical risk of caring for more than 8 patients;

d) support this with bargaining advice to branches on getting employers to introduce safe staffing levels (including registered nurses and HCAs), monitor incidents where staffing levels breach 1:8, reporting breaches appropriately, and taking steps to remove the risk;

e) support branches and regions to get community groups and the public in support of safe staffing levels;

f) call on NHS England and the devolved bodies to fund further research into safe staffing; including on safe levels of HCAs, safe levels on night and weekend shifts, and safe staffing in community settings.

g) work with the National Institute for Health and Care Excellence (NICE) to develop effective staffing methodologies based on patient dependency and numbers, not on bed occupancy;

h) campaign that NICE’s workforce tools are mandatory across every organisation. In the absence of organisations using those tools, the minimum nurse to patient ratio should be the default position, and must be monitored by the CQC or the equivalent inspectorate in the relevant devolved nation.

i) campaign to reduce the use of bank staff and have the bank hours converted to substantive posts;

j) campaign to ensure that staff have the appropriate core skills required to deliver safe and effective care.