16th January 2015
The Patients Association response to the:
National Assembly for Wales on the issue of:
Safe Nurse Staffing Levels
The Patients Association is an independent national health and social care charity
established over 50 years ago and has a long history of campaigning to ensure that
the voice of patients is heard within the Health and Social care system. We achieve
this through research, campaigns to support patients’ rights, lobbying Government to
address healthcare issues affecting patients and speaking up for patients and carers.
The Patients Association also provides an advisory national Helpline service to
thousands of patients each year who raise concerns about their experiences with
healthcare providers. The nature of these enquiries cover issues such as poor care
(particularly of elderly people in hospital), delayed or cancelled operations and
problems with the complaints services.
This offers us a wealth of information, with a database consisting of thousands of
cases, spanning many years and giving us a unique insight into the diverse nature of
concerns raised by patients themselves. In order to make the best use of this
information, the Patients Association provides data analysis and statistical research
to detect emerging trends and patterns, and any concerns can be targeted towards
improving patient care.
The Patients Association welcomes the opportunity to contribute to the National
Assembly for Wales on the issue of Safe Nurse Staffing Levels. We hope that our
insights and expert advice are able to help shape the health and social care
landscape for the benefit of patients.
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1. Safe and effective staffing
1.1 Role of Healthcare Assistants
Healthcare assistants predate the establishment of the nursing profession. Even
after the introduction of the 1919 Nurses Bill which heralded the formation of the
General Nursing Council, the predecessor of today’s NMC, the numbers of health
care assistants continued to grow. Healthcare assistants are a valuable and much
needed asset of the health service.
Nearly one million healthcare assistants are employed to provide care within health
and social care settings – often to the most vulnerable people in society, including
the dying, yet they are not regulated and their training is patchy. Regulation of
doctors, nurses, midwives and all other health practitioners in the UK has been
established to ensure that those who enter those professions are educated and
trained to an adequate standard, that they maintain their competence and that
sanctions can be imposed when their competence or behavior falls below a certain
standard. As healthcare assistants provide vitally important care to some of the most
vulnerable people in society, there can be no justification for their not being
regulated. The system of regulation would be totally self-funded so would be no
burden on the public purse.
We are worried at what appears to be an imbalance currently, between the utilisation
of healthcare assistants in the place of registered nurses. We are concerned that as
healthcare assistants cost less to recruit and pay, many Trusts and hospitals are
becoming increasingly reliant upon them to give an appearance of improved staffing
levels. However, because of being unregulated, receiving minimal training and
supervision, they are often unable to provide for the fundamental caring needs of
patients, through no fault of their own. We are increasingly hearing that healthcare
assistants are undertaking tasks which should only be performed under supervision
from a trained and registered nurse. We have also heard from many patients who
are unable to distinguish between different nursing roles and healthcare assistants.
We would reiterate our support for the proposals put forward by the Willis
Commission with regard to its recommendations for the on-going professional
development of nurses should also be applied to the healthcare assistants.
We would want to take this opportunity, supported by Health Education England (and
in association with the Royal Colleges) to ensure that the training offered is of a
suitable standard and of a correct focus; to ensure that the skills of healthcare
assistants is such that they complement, and support the skills of registered nursing
staff.
1.2 Role of registered nurses
It is very important that registered nursing staff are available to offer nursing care to
patients. We have been concerned for many years that skilled nurses are spending
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too much time dealing with paperwork and non-clinical duties. It is important that
when establishing the required skill mix on a ward or in a care home, that the
appropriate numbers of registered and suitably trained nurses are available. The
clinical needs of the patient must come first and this must be reflected in planning.
This is particularly important in the case of end-of-life care, where it may be
necessary to have 1:1 specialist nursing 24 hours a day. When dealing with patients
who are at the end of their life, (and their families) the NHS has only one chance to
get treatment and care right. It is therefore essential that adequate provision is in
place to cover staff sickness, annual leave and maternity leave.
2. Planning
The Patients Association accepts that there is no single nursing staff to patient ratio
that can be applied to all wards. There are staffing levels that have been developed
and are in use in ITU and Pediatric departments. These have been developed by the
Department of Health and with input from professional bodies.
We believe that there should be a greater emphasis on bringing specialist staff and
equipment to the patient, rather than the patient having to be moved around the
hospital. Spending time in hospital can be very distressing and disorientating for
patients, especially for older people and those with conditions such as dementia. It is
therefore very important that this distress is minimised by ensuring that services and
staff are able to meet the needs of patients. This may require additional nursing staff
to be recruited and trained.
It is very important that when planning staffing numbers, managers do not
underestimate the time that is required for nursing staff to communicate effectively
with patients and their families. Communication is a key issue that continues to
emerge from our Helpline. Patients and their families expect (and deserve) to have
adequate time devoted to an explanation of the issues surrounding their treatment. It
is therefore essential that adequate numbers of trained staff are available to provide
this level of care. For many patients, communication is just as important as the
clinical treatment that they receive. Furthermore, a lack of communication can be
very distressing for patients and their families.
Communication is a perennial problem throughout the NHS, and not just amongst
nurses. We regularly hear from patients who have experienced issues with
communication. In healthcare, clear and effective communication is vital, yet we
continue to hear reports where patients have been confused or bewildered by poor
communication. Furthermore, we also hear regularly from patients who are not
engaged with properly by nurses or caregivers – for example we have heard from
patients and their loved ones who were provided with an incontinence pad rather
than being asked if they could walk to the toilet. Nurses and caregivers must listen to
the needs of patients and be prepared to act on those needs in order to ensure they
receive humane care that respects their dignity.
While clinical skills amongst nurses and caregivers are vital, they must be coupled
with an ability to be compassionate and to communicate effectively with patients.
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The essentials of good care must be the focus and cornerstone of all nursing care.
All nurses and caregivers must have an intimate grasp of the principles and the
practice of good patient-centred care.
3. Responsibility and Accountability
The responsibility of Trust Boards and Commissioners to sign off workforce levels
with the Chief Nurse/Director of Nursing as the designated Board member is
welcomed. The Director of Nursing, together with the member of staff in charge of
the A&E department should review staffing levels on a daily basis and agree the
staffing numbers and expertise. They should be accountable for any
shortcomings. Nursing and management responsibility for the nursing workforce
should be the responsibility of Directors of Nursing/Chief Nurses but we know that in
many trusts, whilst accountable for the nursing workforce levels, they frequently have
no direct management responsibility for the nursing and midwifery workforce. Instead
they provide professional nursing advice to general managers who hold the budgets
for this workforce.
4. Complaints
We believe that at the heart of patient-centred care, there should be the requirement
that patients be informed of how they can make a complaint if they wish to do so. It is
obvious that inadequate staffing levels and inadequately qualified and trained staff
are going to have a direct bearing upon the quality of patient care. Patients therefore
should have the right to complain if they feel that safe staffing standards are not
being met. As patients are at the centre of healthcare (and it is they who ultimately
benefit or suffer as a result of poor staffing), they have an important role to play in
assessing and commenting upon the adequacy of staffing levels.
Every year we receive many calls to our Helpline from patients who are confused
about the complaints procedures in health and social care settings. Many patients
are either not aware that they are “allowed” to make a complaint or are reluctant to
complain, particularly as they fear that the quality of the care that they receive may
decline if they do so. Furthermore, those who did complain have had to deal with
complex, bureaucratic systems and are unhappy with the response that they have
received; and are even more confused about how to take the matter further.
We believe that the NHS needs to do more to raise the awareness of the complaints
procedure. We also feel that the NICE guidelines should make specific reference to
the rights of a patient, as expounded in the NHS Constitution - as we have argued
for in many previous consultations.
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