Minimum nurse staffing levels are only part of the picture

Perhaps one of the mostly hotly debated issues before and since the publication of the Francis Inquiry report has been the question of whether there should be nationally set minimum nurse staffing levels.

While the case for the connection between inadequate staffing levels and avoidable harm has been largely made (for instance by the Health Committee, Dr Foster and the Keogh Review), I find interesting that there has been opposition to setting a minimum level from a number of different perspectives.

The policy community have largely argued that, by specifying a minimum, there is a risk that it becomes a 'ceiling' rather than a 'floor', with the possible unintended consequences of nurse numbers being cut in some places on the assumption that this would be safe.

From a more evidence-based perspective, people have argued that the complexity of care in today’s hospitals means that a single figure would be misleading and, again, could result in inappropriate staffing in the most complex areas of care.

The improvement community have rightly argued that, given many of the current inefficiencies in how we provide care, setting a minimum would risk complacency in seeking opportunities to release time to care through workflow redesign.

That so many different perspectives have challenged the concept of a national minimum staffing level serves to illustrate the complexity of the issue.

The conclusion of the Berwick group was that national organisations should assure that sufficient staff are available to meet the NHS’s needs now and in the future; while healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported. The government has responded in Hard Truths by recommending a number of actions including, most prominently, public reporting of ward level nurse staffing data. 

The position we have reached is positive but it is not without potential pitfalls. For me, a number of things need to be kept in mind during implementation.

Firstly, boards of provider organisations will be expected to demonstrate detailed understanding of the workforce in their organisations, not just in total but at the level of individual clinical settings. Given that the workforce is the single largest resource in the delivery of healthcare, this is essential.

However, the complexity of care means that boards will need to be supported in doing so, with clear and practical guidance on how they can fulfil this role and what assurances they need from clinical leaders. They will need to know not just what data they need to see, but which approaches can be applied to ensure appropriate and efficient staffing throughout their services.

Secondly, data on staffing levels by ward is to be published monthly on an open website. This transparency must be a good thing – we have seen how publication of comparative data has improved quality in surgical outcomes and prescribing practice, among other things.

However, we have also seen how the pressure to get the 'right' numbers has pushed individuals to present data in ways that are misleading. We have seen reporting of data become an end in itself rather than a management tool to make improvements. It is essential that ward level staffing data is used actively in operational management to make care safe in realtime, rather than as something that is passively reported up the line for others to act upon. Publicly reported data should be the by-product of good management, not a goal in its own right.

Lastly, while nurse staffing levels are no doubt a fundamental requirement of good quality care in isolation, they will not guarantee safe or compassionate care. Healthcare is a team sport.

Just as it is important to have the right number of nurses, there needs to be appropriate numbers of healthcare assistants, junior doctors, allied health professionals, portering, administrative staff and consultants for care to be safe, effective and sensitive to the needs of the individual. And these staff need to be surrounded by structures, processes and a culture that enables them to work together effectively.

One of the projects we are funding is seeking to develop a tool that brings together actual staffing levels from across professions with data such as bed numbers and clinical outcome measures. It is being designed enable staff to have an informed and objective discussion about managing staff numbers, helping them identify potential issues early.   

The events that took place at Mid Staffordshire NHS Foundation Trust between 2005 and 2009 were not a failure of nursing. They were a failure of leadership to recognise that the quality of care cannot be judged through single numbers.

Waiting times and finance only told part of the story of what was happening. Similarly nurse staffing levels will only tell part of the story of care – leaders need to be expected, encouraged and supported to use a range of data actively and comprehensively to manage their services.

Jo is Director of Strategy at the Health Foundation, www.twitter.com/JoBibbyTHF