The UK population continues to grow, while nursing numbers have remained static for several decades. Compounding matters, The King’s Fund and Nuffield Trust have reported a 25 per cent increase in nurses and midwives leaving the NHS from 2012 to 2018, from 27,300 to 34,100. In short, in the UK, we now have far fewer nurses relative to the general population than we used to.
What does this mean for patients’ care experience? The situation sounds bad, but how bad? Common sense would suggest that patients will experience poorer care when nurses are overstretched, and there’s plenty of anecdotal evidence to support that interpretation. But there are also positive stories, and claims about greater efficiency compensating for fewer staff.
Now a study in BMJ Quality & Safety provides direct observational evidence suggesting that lower nurse-patient ratios really do result in poorer health-care interactions.
Jackie Bridges at the University of Southampton and her colleagues observed how patient-staff interactions varied across six NHS physical healthcare wards in England depending on the ratio of nursing and healthcare assistants to patients. In total, the researchers carefully rated 238 hours of care, which included over 3000 interactions between 270 patients and healthcare staff.
Overall, 10 per cent of those interactions were rated as negative – specifically “negative restrictive”, such as patients being moved without warning or sworn at; and “negative protective”, such as patients having to wait for medication. Crucially, the researchers found that the odds of a negative interaction increased significantly as the number of patients per registered nurse increased.
Lower numbers of registered nurses working on a ward were associated with more negative interactions regardless of whether or not healthcare assistants (support staff without a nursing qualification) had been brought in to make up the numbers. Having more healthcare assistants on shift only helped if there were enough registered nurses to supervise them.
As this was a purely observational study, rather than experimental, some caution is required, as the authors note: “a causal inference [about staffing levels] cannot be directly made”. Nevertheless, this is such a helpful piece of research, that’s clearly consistent what nurses have been saying for years: that they need enough of them on shift to be able to ensure that patient care is high quality.
This isn’t to “do down” healthcare assistants, who are undervalued enough, but it is highlighting the importance of good quality supervision. It also doesn’t mean that nurses go round looking over the shoulders of their more junior colleagues, but is consistent with the argument that patient-carer interactions will be more universally positive when there are sufficient nursing staff to deal with queries, show more junior staff what to do, talk through dilemmas, model excellent patient care, and acknowledge difficult feelings that caring roles can bring up.
The study reminded me of the time I’ve spent working in mental health wards, a job which was adrenaline-fuelled and unpredictable but which I loved, and where I worked with brilliant nursing colleagues who were often rushed off their feet.
Media coverage of care quality in the NHS often blames individuals, and especially nursing staff, for failures. Poor care is never excusable or acceptable, but it is important to recognise that there are perfect storms of working condition which make it more likely. Negative cultures in organisations, lack of staff resources, destructive leadership, can all play their part.
The Francis Report, published in 2013, highlighted the devastating effects of a lack of compassionate care and the need to have cultures where people feel they can speak out about poor care, and where compassionate care is supported. Much has been done since to champion compassionate leadership and compassionate care, but this new study shows how, in the aftermath of austerity and with not enough staff to go round, it’s harder for these principles to be put into practice. For any of us – nurses included – if we are stressed, tired, under emotional pressure and not given enough time, we tend to behave less nicely. It’s not news that a lack of time has a negative impact on caring behaviours.
There’s been much about staff wellbeing in the papers recently, with initiatives to offer mindfulness, yoga, exercise classes and the like. Interventions on an individual level can be hugely helpful and useful to know about. At the same time, it’s not good enough to offer interventions to reduce unnecessary stress caused by an uncaring system.
High quality compassionate care in hospital settings requires sufficient nurses to deliver the care and to supervise their junior colleagues. Anything less is setting up staff to fail and setting up patients for a greater likelihood of negative care. Nurses need to be cared for too, by their employer and by their colleagues, and a bare minimum is making sure there are enough colleagues on shift for it to feel safe. This new research adds to a body of evidence that takes the blame off the nurse and squarely places the responsibility on the system to do better.
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