Nurse:patient ratios – time for a target?

‘My concern about this kind of management babble, and those who possess the presentational skills to get away with it, is that it throws a warm comfort blanket around the issue and creates a cloud of obfuscation.’¹ The quote is from Andrew George, MP for St Ives, in the House of Commons, concerning a passage in the National Quality Board Report. In brief, the MP advocates a minimum nurse-to-patient staffing ratio in UK hospitals of one registered nurse per eight patients as a mandatory standard. The ‘management babble’ refers to the contrary opinion that the issue of staffing levels, particularly nursing staff levels, is highly complex, requires detailed consideration and judgment in different environments, and would not be aided by a crude ‘one size fits all’ directive. The Safe Staffing Alliance, taking the same stance as the MP, points to a plethora of evidence that low nurse-to-patient staffing ratios correlate with hospital mortality.² However, the alliance also comments that while the 1:8 ratio is the level at which patients will certainly be at risk, this ratio does not constitute a recommended minimum. Fortunately, the majority of daytime nursing shifts in the UK have better ratios than this and the majority of trusts meet this ratio most of the time.³

The issue of nursing ratios was of course thrown into stark relief by findings at the Mid Staffordshire Trust where financial constraints had reduced ratios strikingly. The Berwick report, Improving the safety of patients in England, recommended that the government, Health Education England and NHS England should assure that sufficient staff are available. ‘[Hospitals should] ensure staff are present in appropriate numbers to provide safe care at all times.’⁴ However, the report did not recommend a mandatory minimum level. One specific recommendation was that the National Institute for Health and Care Excellence (NICE) should examine the evidence on safe staffing levels. NICE has now committed itself to producing guidance on safe efficient levels for nursing at ward level for adult inpatient wards by July this year (2014) and for a number of other hospital and community settings shortly thereafter.⁵

There is time for debate, before the guidance merges in the summer, on how NICE's recommendations will be implemented – bearing in mind that when they appear ‘the health departments in England and Wales may choose to issue advice to the NHS on their implementation’.⁶ The government in England has thus far, like Berwick, decided against a mandatory minimum staffing ratio, but from April 2014 will require hospitals to publish monthly staffing levels and how far they comply with safe staffing guidelines.⁷ In due course these guidelines will be those recommended by NICE. The avoidance of mandating a minimum overall nurse-to-patient ratio is based on both an avowed wish to avoid a target culture and the fear that the minimum would become the norm.

Three issues come to mind. If over 80% of trusts are meeting that minimum requirement for daytime nursing (and nearly 20% are not),³ a mandatory requirement would surely rapidly provide a route to forcing improvement on the latter. Low ratios constituted a common theme among the 14 poorly performing hospitals with high standardised mortality rates highlighted by Sir Bruce Keogh.⁸ Crude though a mandated minimum level target for nursing:patient ratio might be, it would have the virtue of both simplicity and comprehensibility. Resented though it was at the time, the 4-hour waiting time target in accident and emergency departments was the effective tool in improving the emergency service in the NHS.

The second comment comes from the difficulty that NICE will face when it issues guidelines applicable over many different areas of NHS care (adult wards, paediatrics, maternity, mental health, etc).⁵ Nursing care in UK hospitals is now delivered by a variety of staff with different levels of qualification and training. It has been argued that a healthcare assistant does twice as much direct patient care on the wards as a nurse.⁹ The recent Cavendish report emphasised the lack of uniformity of training – indeed in some cases the lack of any training – of the 106,000 (minimum estimate) healthcare assistants who are so integral to delivering hands-on care (for comparison there are about 380,000 registered nurses practising in the UK).⁹ NICE's guidance will ‘focus on nurse staffing levels, alongside nursing assistants, in relation to the care requirements of different types of patients.’⁵ With the competences of healthcare assistants so variable and ill-defined it seems unlikely that the guidance forthcoming will be so crisp and clear that lack of compliance can be readily recognised.

Finally – an issue emphasised by the Royal College of Nursing's 2013 labour market review¹⁰ – minimum nursing levels will require a minimum number of nursing staff nationally, whether this is to be monitored by the blunderbuss of a mandatory overall target or by the sum of compliance to a number of carefully constructed local guidelines. The Royal College of Nursing has again emphasised the insecurity of the national supply of nurses and highlighted a forthcoming reduction in the number newly qualifying between 2014 and 2016. Yet the number of applicants for nursing training continues to be buoyant. Reducing nursing numbers has appeared as an easy hit when savings are sought, and review of hospital trusts’ plans for the future suggests this trend may well continue.¹¹ In some form or other monitorable standards to demonstrate safe nursing levels are essential, not least to prevent an inadequate number of nurses nationwide. Prior experience suggests the simpler the better.