Nursing skill mix in acute
mental health in-patient
environments
Jane Sayer, Programme Director
(Nursing Excellence)
Richard M Jones, Specialist
Nurse Researcher
Why is skill mix important?
• Current financial climate
• 1 in 10 patients report that there were rarely or never
enough nurses available on in-patient units (CQC, 2010)
• Positive effect on outcome supported by evidence
MHMDS report on 2010
• 5.1% increase in use of inpatient facilities (8.5% of
total MH users)
• 30.1% rise in number of people detained under
MHA (lower level of 17.5% possible)
• Number of voluntary patients falling for 4 years
• Number of women detained via courts or prison
saw an 85% rise last year
NHS mental hospitals are increasingly being used to care for and
contain people who pose a risk to themselves or others (MHMDS,
2010, Bowers & Flood 2008)
The effect on outcomes
•
•
•
•
26% higher mortality in hospitals with poorer nursing levels
Higher burnout rates
Twice as likely to be dissatisfied in their job
More likely to report low/ deteriorating quality of care on their
wards
Rafferty 2007
• MH environments: higher staffing levels = lower re-admission
rates. Substantially better outcomes achieved when attention
patients received from staff was taken into account
Coleman & Paul 2001
• 9% of suicides could have been prevented by increasing staff
numbers and 6% by increasing beds and services
Appleby et al 2006
The cost of in-patient care
• Fivefold cost variance between UK MH trusts (£4.3 to
£24.6 million)
Associations between nursing cost per bed and
performance indicators were found
Bowers & Flood 2008
• Conflict and containment in in-patient mental health
settings in England estimated at £178.5 million per year
Flood et al 2008
‘whilst low registered nurse
staffing levels should be
considered a risk factor for
poor quality care, increasing
nurse staffing may not be a
sufficient solution’
NNRU (2009)
Addressing grades
RN- LPN- HCA- NA
• Higher levels of RN= lower rates of adverse outcomes
Needleman el at (2002)
• Higher RN levels = less likely to die in hospital. Higher
levels of LPN more likely to die
Person et al (2004)
• Violence associated with discrepancy between acuity
and available staff
• Higher skill mix and BSc qualified nurses associated with
fewer incidents of violence
Roche et al (2010)
• Higher LPN investment = more pressure ulcers, and
wage saving more than offset by additional treatment
costs
Hendrix and Foreman (2001)
• Mental health environments in the UK are mostly staffed
by the most junior, least qualified workforce, yet they
care for the most acutely (and increasingly so) unwell
patients
Needleman (2006) 3 options
1.
Increase proportion of RN hours but not total nursing
hours
2.
Increase total number of hours of RNS and LPNs
without changing proportion
3.
Increase proportion of RN hours and total number of
nursing hours of both groups
References.
Appleby, L. Shaw, J. and Kapur, N. (2006) Avoidable deaths: five year report of the national
confidential inquiry into suicide and homicide by people with mental illness. University of
Manchester.
Bowers, l. and Flood, C. (2008) Nurse staffing, bed numbers and the cost of acute psychiatric care in
England. Journal of Psychiatric and mental health nursing. 15 630-637.
Coleman, J.C and Paul, G.L (2001) Relationship between staffing ratios and effectiveness of inpatient
units. Psychiatric Services. 52, 1374-1379.
CQC (2010) Supporting briefing note: issues highlighted by the 2009 survey of patients in NHS
hospitals in England.
Flood, C. Bowers, L. Parkin, D. (2008) Estimating the costs of conflict and containment on adult
inpatient psychiatric wards. Nursing Economics. 26, (5).
Hendrix, t. and Foreman, s. (2001) Optimal long term care nurse staffing levels. Nursing economics.
19 (4) 164-175.
MHMDS (2010) the information centre for health and social care. In-patients formally detained in
hospital under the MHA 1983 and patients subject to SCT. Annual figure. England 09/10- October
2010.
Needleman, J. et al (2002). Nurse staffing levels and the quality of care in hospitals. New England
Journal of medicine. 346 (22) 1715-1722.
Needleman, J. (2006) Nurse staffing in hospital: is there a business case for quality? Health affairs.
25 (1) 204-211.
Person, S. et al (2004). Nurse staffing and mortality for medicare patients with acute myocardial
infarction. Medical care 42 (1) 4-12.
Policy+ (2009) Is there a case for the UK nursing workforce to include grades of qualified nurse other
than the registered nurse? (21) October.
Rafferty, AM. Et al (2007) Outcomes of variation in hospital nurse staffing in English hospitals: cross
sectional analysis of survey data and discharge records. Int. Journal of Nursing studies, 44 (2)
175-182.
Roche et al (2010) Violence toward nurses, the work environment, and patient outcomes. The Journal
of Nursing Scholarship. 42 (1) 13-22
Average staffing and patient data- NHS
wards by speciality (all shifts), (RCN 2009)
Mental health
Adult
Paediatric
Older
adults
All
No. of beds
19
26
20
27
24
Total No. of patients
17
25
15
25
23
Occupancy (%)
88
99
80
95
95
No. of RNs
2.1
3.1
3.6
2.5
3.1
Number of HCAs
2.1
2.0
.8
2.7
2.0
Total staff on duty (RN+HCA)
4.3
5.1
4.3
5.2
4.9
RNs as a % of total staff
50
62
83
48
61
Mean across all RNs
9.2
9.1
4.6
11.3
8.7
Patients per member of nursing
staff (mean across total)
4.1
5.4
3.8
5.2
4.9
No of cases.
76
451
124
103
1011
Patients per registered nurse