Discuss and Critical Analysis of Safe Staffing Levels Of Nurses How It Has Impact In Patient Care In Relation To Health Policies?
The nursing workforce is an integral part of the health care settings as nurses have a major role in achieving better patient outcomes, and they can be considered as an important care provider among the whole health care setting (Potter et al. 2013). Staffing levels of nurses is an ongoing concern and influences the safety levels of both the nurses and the patients. Nurse staffing refers to the mix of registered nurse expertise with the appropriate needs of the people receiving nursing care in the context of situation and practice settings (Mashimo et al. 2013). The provisions of suitable nurse staffing are required for reaching safe and quality outcomes. This is achieved by multifaceted and dynamic decision making processes that consider a wide range of variables (Yang, Hung and Chen 2015). Staffing shortage refers to an insufficient mix, number and experience level of registered nurses and ancillary staffs to proper care of the patients. Hospitals that have low nursing staffing have a tendency to have higher rates of poor patient outcomes. There lies a strong relation between adequate nurse-to-patient ratio and safe patient outcomes (Fram and Morgan 2012). Nurse staffing policies increase nurse staffing (Shin, Park and Huh 2014). However, authorised nurse staffing ratios without suitable mechanisms to provide help achieve targeted ratios have a tendency to force the health care settings, especially those settings which are concerned about safety, to develop tradeoffs in other investments or services that can have unintended negative results for their patients (Shin 2013). The present writing is a critical analysis of safe staffing levels and its impact on patient care and the health policies on this concern.
Health care systems across the globe, including the United Kingdom, are facing many struggles to improve the quality of care and control the costs of care. In some countries, greater investment in hiring qualified nurses is an integral part of the strategy used by health care settings for improving the quality of care. However, in some, policymakers of health care sector seek substitute qualified nursing workforce with less expensive assistive staff. Many researches are present that throws light on this debate and tries to draw the conclusion on the relation between nursing staff and quality of life in hospital settings (Van den Heede and Aiken 2013).
Higher registered nurse staffing has a vital relation with low rates of hospital-related mortality, cardiac arrest, failure to rescue and hospital-acquired infections. The influence of inadequate registered nurse staffing on the safety of the patients is strong and consistent in almost all care units in a hospital setting (Aiken et al. 2012). No studies directly do the task of examining the aspects that significantly influence policies for nursing staffing. Very few studies address the role of agency staff (Paek et al. 2015).
In the context of nurse staffing issues, it is desirable to throw light on incidences that have taken place in the past and throw light on the impact of inadequate nursing staffing on patient care quality and overall functioning of the health care setting. One such incidence in the history of public health issues is the Stafford hospital scandal. The Stafford hospital scandal was a major concern in the history of public health as it highlighted poor care and the high rate among patients at a city hospital in England. The scandal took place in the late 2000s. Around thousand patients were found to be dying due to poor care over the time span of four years (Mohammed et al. 2013). In 2010, a complete public enquiry took place chaired by Robert Francis. The inquiry considered of strong evidence based on which actions were taken against the nurses. One of the reasons that contributed to such drastic decline in patient care was inadequate staffing. As a result of poor nursing staffing, devastating results were witnessed. Issues of unsafe nursing staffing were thus highlighted (Francis 2014). The Nursing and Midwifery Board (NMC) of the United Kingdom held hearings for the nurses who were adjudged to be unfit for nursing practices (dailymail.co.uk 2014).
The different health organisations of the country put forward guidelines for maintaining an appropriate nursing staffing levels at the hospital settings. Staffing levels have always been an issue. Patients have the ultimate right to receive care by appropriately experienced and qualified nurses. This right of the patients is enshrined within the National Health Service (NHS) Constitution (Nice.org.uk 2014). The NHS ACT 1999 makes overt the corporate accountability of the board for delivered nursing quality. The responsibility of the nurses regarding safe staffing is stipulated by the Nursing and Midwifery Council (NMC). This covers the overall registered nursing force in the country (legislation.gov.uk 2016). The report of the Health Select Committee 2009 states that insufficient staffing levels have been a major factor in undermining patient safety in many cases. In one year, more than 30,000 patient safety issues were recorded by the National Patient Safety Agency (NPSA) that has relation with staffing issues. Short staffing can compromise on the care of the patients in a direct and indirect manner. Recurrent short staffing causes increased stress among the staffing and reduced staff well-being. This leads to high sickness absence and more leaving of the staff. No proper evidence suggest that NHS ward level staffing has witnessed improvement. NHS recommends that staffing planning must be taking place at all levels-regionally, locally and nationally. The results would ideally use regional and local plans. Having a strong base for planning staffing is critical, and it must be an integrated form (Safestaffing.org.uk, 2016). Ensuring staffing levels solely rely on the right establishment. To adjudge the number of staffs required for appropriate care requires the deep look into competencies and roles of all staff groups. Staffing levels will be affected to a great extent by how certain things are carried out, in terms of effectiveness and efficiency of processes. Changes that need to take place by the help of initiatives may bring alteration in the staffing level required for maintaining same care quality (England.nhs.uk 2016).
Policy making for patient safety in relation to nursing staffing has some issues in it. One such key issue is that more work needs to be undertaken for determining optimal nurse staffing skill mixes and how needs have the tendency to vary across different health care settings. The limited evidence are not in the support of introducing a nurse in the direct role of care-giving below the highest level of registered nurse. The cost effectiveness of nursing staff decisions depends on short term and long term considerations. Evidence on relationships between patient outcomes, skill mix and costs is limited. Most researches are from the other countries, mainly the United States. More research in the United Kingdom is required to confirm whether relationships and assumptions of present studies hold for other health economies and nurse education systems (kcl.ac.uk 2016). Nurses must have a greater role in making up policies for health care. The reason is attributed to the fact that nurses have a strong influence on the reduction of medical errors, improvement of patient safety, promotion of wellness, improvement of care quality and coordination of care by the healthcare system (Kitson et al. 2013).
The NHS puts forward a policy to standardise staff groups of the procedures and processes for addressing staffing shortfall. It also addresses the expectation of National Quality Boards recommendations for policies for addressing staffing shortfalls. The policy has been implemented from March 2015, and the next date for review is February 2018. The aim of the policy is to promote safe staffing levels and adequate skill mix. This is in order to deliver high quality care. Patients have a right to be cared for by appropriately qualified and experienced staff in safe environments, and this is enshrined in the NHS Constitution. Trusts must ensure that they have the right staff, with the right skills, in the right place. This is a duty of the Trust Board and the Trust must demonstrate safe staffing in order to comply with Care Quality Commission’s (CQC) regulatory framework and standards. Furthermore, the Nursing and Midwifery Council (NMC) (2008) makes it clear that all Registered Nurses and Midwives are professionally accountable for safe practice in their sphere of responsibility, ensuring that risk is managed appropriately.
The roles and responsibilities of the health care settings are outlined in the policy. Each health care setting must have an agreed position in relation to safe nurse staffing and skill mix. Another responsibility is the final sign-off of safe nurse staffing and skill mix establishment, and to conduct regular establishment reviews to ensure that safe staffing and skill mix are being delivered operationally. All health care settings must comply with the national requirements (NQB) for monthly submission of Nurse staffing fill rates. Evidence based staffing levels must be taken to the Board for sign-off at least every six months. Any proposed changes to the nurse staffing and skill mix establishment, required to deliver service redesign projects, must be discussed at Board level. Heads of nursing teams must be accountable for staffing and skill mix in the clinical areas they are responsible for. They also hold responsibility for escalating the concerns present to the executive teams. Lead Nurses to have responsibility for managing day-to-day and potential risk in relation to nurse staffing and skill mix establishment in accordance with Trust policy, escalating to the Head of Nursing as required. Moreover, they are responsible for investigating any adverse effect related to skill mix and nurse staffing. Senior nurses are professionally accountable for safe nurse staffing and skill mix. They have responsibility for managing day-to-day actual and potential risk in their ward or department relating to nurse staffing and skill mix establishment. All staffs must ensure that insufficient staffing is addressed and taken into account on a daily basis. If inadequate staffing and skill mix is not resolved, it is identified via incident reporting and red flag events are recorded. They are also accountable for working with fellow staff to position staff effectively in line with their job description and code of conduct (Nursing Staffing Shortfall Escalation Policy 2016).
The National Quality board (NQB) guidance 2013 outlines the expectations of NHS organisations regarding need of strong escalation processes of nurse staffing. The NQB guidance states that staff should be aware of the escalation policies in place, flag where they think staffing capacity and capability falls short of what is required and be able and prepared to use the escalation policies. All lead nurses must maintain a record of escalation, the reasons why and mitigations taken to address nurse deficiencies. All other nurses must undertake evaluation and risk assessment of the staffing levels by shift basis. All wards must have a record of decision making around nurse staffing where escalation has been required. Nurses may have a strong influence on health policy and this would protect the quality of care by access to required recourses and opportunities.
Nurses have individual views on health care issues and influence health care policies in different ways. With a common understanding of nurses’ policy influence as a concept, nurses will recognize the importance of policy making in the health sector and their influence on this process and also on patients’ outcomes. Nurses have their own views on maintaining staffing levels and skill mix in health care settings. Therefore they must be taken into account and their views and opinion must be put focus while making policies in relation to nursing.
NHS Trust Development Authority and Monitor recognise that agencies play an important role in the health care sector. National organisations including Monitor, National Institute for Health and Care Excellence (NICE), NHS, Department of Health (DH), Cabinet Office and the Treasury, are leading other workstreams to help trusts manage their temporary workforce spend. This includes increasing supply of permanent staff and clarifying guidelines on safe staffing. The proposed agency spending rules outlined in this paper are therefore part of a national programme of work to help trusts meet the complex workforce challenges facing the healthcare sector. In June 2015, the Secretary of State announced rules to help organisations reduce their spending on agencies. The proposal put up was that maximum hourly rates are to be paid by the trust. Use of approved frameworks for procuring agency staff must be mandatory. There must be an annual ceiling for total agency spending. The NHS spending has been put focus on due to the overspending. It has been described as the worst for a generation. The seriousness of the spending allocation of NHS was thus highlighted. Overspending on shortfall of permanent staff, agency staff, inefficient use of permanent staff and difficulties in recruitment are constantly affecting NHS (gov.uk 2016).
The Health and Social Care Act 2012 puts forward major changes to the NHS in England. The progressions specifically gives attention to general practitioners and different experts known as clinical commissioning groups (CCGs). The Act brings about the transfer of of a large portion of the obligations that previously resides with the Department of Health to politically independent NHS Commissioning Board which was then later called NHS England. Moreover, the Act brings into focus the health related monetory controller with a demand for making preparations for anti-competitive actions. The Act has provisions for extensive refurbishing of the basic structure of NHS England. It sets recommendations for options on financial matters. There has been much critical analysis of the actions taken up by the NHS. On on hand, the Health Minister was found to be stating that NHS has been doing good in maintaining fund over the lasr few years. On the other hand, the Health Secretary stated that the present government cannot be trusted with the funding issues. There may be a collision in the actions taken up the NHS. The policies have resulted in a downfall in services which has put forward longer waiting lists, difficulties for patients to access GP services. It has been noticed that £3billion has been wasted on reorganisation which sees frontline staffing levels reduced. With the NHs struggling to make sure that there is a safe staffing levels, there is a shortage found in nurse workforce. Cummings (2003) opines that by ensuring the proper right staff at the right palce nad at the right time, patients would be given the care they need and is supported by NICE. The author also suggests that on safe staffing for nursing care must be given by introducing “red flag events” that warn staff in charge that there are insufficient staffing levels on wards (massnurses.org 2016).
The Royal College of Nursing recommends that health departments must undertake work needed for identifying the efficacy and prevalence of planning approaches for better nurse staffing. Inexpensive and effective systems need support by the different health departments. Staffing reviews require board level commitment. Decisions must not be taken in the vacuum, and all significant decisions must involve the nurses. Regular evaluation is needed and the results must be heeded and implemented in a constant manner (rcn.org.uk 2016).
UNISON is a large trade union in the United Kingdom. A significant part of the organisation are NHS registered nurses and NHS managers and clinical support workers. The organisation puts up valuable comment in relation to nursing staffing (Gillen 2015). UNISON states that safe staffing levels have not witnessed improvement over the past year. This comes up in spite of the fact that government claims to have an increase in nursing numbers. The annual UNISON study conducted on 2015 showed that there is an issue of overstretched and demoralised nursing workforce, and inadequate staffing delivers undignified, unsafe and uncompassionate care for the patients. The respondents of the survey think that staffing levels have got worse since 2010. The survey carried out by UNISON states that staffs are still not able to take care of all the patients they are supposed to take care of. Some comments included that the government must always put patient care on the top of the priority list, and money must not be the concern and that staff stress must be given more attention. Moreover, UNISON says that NHS is under operation in an environment where financial straightjacket is prevalent. As there is no money for funding adequate staffing levels, midwives and nurses are finding it difficult to keep their health services going. There is no doubt that midwives and nurses have no acceptance of the guidance that is present for nursing staffing as such guidance does not meet the requirements and need of the nurses either. This puts up the need for having a nationally set compulsory minimum patient-to-nurse ratio that is solely based on the needs of the patients (unison.org.uk 2015).
The report comes up a year after the National Institute of Clinical Excellence (NICE) put up guidance on safe staffing levels. More than sixty percent of the respondents stated that NICE guidelines have not made any significant differences and staffing levels have not seen improvement. The survey reveals that when ‘red-flag’ events occur as a result of a nursing staffing shortage, actions are not taken up in an appropriate manner at all times (Nice.org.uk 2014). UNISON is suggesting the National Institute for Health and Care Excellence (NICE) guidance to be amended so that care for eight patients or more is classed as a ‘red-flag’ event. Red-flag events are those events that indicate emergency or need for immediate action on a certain issue. It is a demand that actions need to be taken up. NICE has drawn up a list of such ‘red-flag’ events that can be reported by omissions in medication administration, lack of patient monitoring and delays made in pain relief intervention (Kleebauer 2014).
The Berwick review into patient safety, undertaken on 2013, is an independent report from the Department of Health, the United Kingdom, on how to improve patient safety in the NHS. A significant part of this element is nursing staffing. The review puts up some valuable recommendations. Staffing levels must be steady with the proof on safe staffing and must be adjusted to the local context and patient acuity. The primary recommendation is that NICE must undertake steps for developing guidance based on data. Organisations must routinely analyse and give the proper response to local measures that are warning signals of safety issues like staffing levels (gov.uk 2016).
The Department of Health, the United Kingdom, has put forward a report called ‘Hard Truths’ that is a government response to the case of Staffordshire hospital scandal. In the report, it has been mentioned that all NHS bodies must ensure that all shifts and all wards must ensure that they have the necessary staffing level for patient care. The Care Quality Commission will monitor the actions taken and performance delivered so that no patient is put on the risk of harm and suitable staffing levels is one the core elements of the registration regime of the Care Quality Commission (gov.uk 2016).
The Department of Health, the United Kingdom, has put forward a report known as the ‘Patients First and Foremost’ report that is the first government response to the report of the NHS public inquiry on the scandal of Staffordshire. This report stated that proper staffing as measured by skills and a number of nurses is vital for giving proper care but minimum ratios, and staffing numbers lead to a lack of flexibility to seek a minimum level of staffing. The report recommends that the Care Quality Commission needs to use evidence-based tools for determining staffing numbers (gov.uk 2016).
Ethical principles of health care comes into focus in the context of the need of delivering high quality care. Proper staffing is needed for maintaining ethics in the delivery of quality care. The ethical concerns that are present in delivery of nursing care are autonomy, beneficence, no-maleficence, justice or fairness. Emphasis is on establishing a relation, collaborative care and maintaining human dignity. The main aim is to do no harm to the patients and not neglect the needs of the patient. They must be given justified care (Lillemoen and Pedersen 2013).
In conclusion, it can be said that on an overall basis, there is an accumulating proof of the relation between nurse staffing and outcomes of patients. This is specially in relation to higher skill mix of the nurses. There is emerging evidence that curvilinear relation lies between the two aspects, suggesting that cost-effectiveness of using registered nursing levels, as a tool for quality improvement will become less cost-effective. Policymaking must be done according to the fact and evidence present for the particular issue. A rapid change in thr health care sector, by implementing different policies, is crucial for enabling effective care to patients. Fundng issues is a major challenge in the path of high quality care. One such aspect is nurse staffing. In spite of political differences between all parties, the funding system within the NHS is in crisis it is under-resourced and unfair. Insufficient budgets appear to take the frontline. Changes in financial concerns are needed. Inadequate staffing levels are impacting on treatment and the recovery process for patients within the NHS and other services including the adult health care service. A call for action is needed once achieved tangible rewards are ahead for the NHS staff and patients. There is a need to incentivise good health a better future is possible and nurses and other professionals are the leaders who can influence changes in a system that is under enormous pressure.
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