Nursing levels

There has been a lot of discussion about inadequate staffing levels. It's abundantly clear that having too few qualified nursing staff on wards compromises patient care and results in more deaths. The evidence consistently shows this. Accounts within clinical practice consistently illustrates this. Patients admitted (and their course, with some unnecessary deaths) consistently experience this.

It's therefore not surprising to me that when the Healthcare Commission investigated shabby care in hospitals, they found ward staff to be good, but management systems not supporting them (through cutting costs and not staffing wards with adequate numbers/adequate qualified staff). Subsequently the Care Quality Commission (CQC) have done the same. The CQC regulates hospitals, challenging them on quality and services. How deeply have their investigations and reports rocked managers worlds?

Has it changed anything in practice?

We learnt of the woeful outcomes at Mid Staffordshire NHS Foundation Trust with the report stating :
"It appears that some staff from whom we heard were often demotivated, undervalued and working in an understaffed and stressful environment"
"The staff who worked on these wards all agreed that there was a shortage of nursing staff."
"We heard these wards were significantly short of nurses, especially at nights and weekends."
"Some staff expressed the view that there were insufficient nurses before the reorganisation and that there were fewer after."
"Many witnesses noted that there were too few nurses and that those that were there were doing their best in difficult circumstances."

The Mid Staffs report described good nurses doing the best they could. To my knowledge, nobody was reported to the NMC for poor professional practice. Nor should they be. They worked as well as they could within the environment that managers generated for them. Indeed, the independent and detailed investigation found and documented that the nurses worked inordinately hard and beyond their duties, putting in huge effort to care for their patients.

The issue wasn't poor nursing, the hospital was fortunate and had great nurses. The issue was the the hospital, to save cash, didn't staff the wards with enough nurses (i.e. qualified staff) to keep patients safe. How huge is that. Not that there weren't enough nurses for gold standard care. Not that there weren't enough nurses for reasonable quality care. There weren't enough staff for safe care. Patients needlessly died.

But time's moved on.

Things surely have improved. Lessons learned. Erm, sadly it seems not. Scarborough looks to be operating in a scarily similar manner to Mid Staffs.

So it goes.

This week I read a new report by the CQC. This is dear to me, since it's about older adult mental health services, within a Trust providing mental health services. Not mine, I may add. The CQC are positive about the Trust. "The Trust has cooperated fully with us during the course of our enquiry . . . the Trust has not waited for the publication of our report. It has proactively started a process to improve its mental health service for older people."

One unit was terrible (and closed), the other units were fine.

So it's a decent Trust, with decent units, providing decent care. The management structure quickly made management changes and 'fessed up to shoddy care, investigating things themselves and reporting themselves to the CQC and making changes themselves. All genuinely poisitve stuff, the way the Trust behaved really does seem sound.

Most of the problem seems to have been one unit which was doing quirky things which nobody knew about. Things like using strong opiate analgesics inappropriately and hooking folk with dementia up to syringe drivers to control agitation. This was a huge error in governance which the Trust raised it's hand up and sorted out. Grand.

So the Trust, a decent Trust, find an area of rubbish care, sort it out and 'fess up to the CQC they've been rubbish, they're investigated and all's seen to now be okay.

Apart from one area.

Page 30 : "We looked at the relative costs of nursing staff against the trust’s spend on senior managers and managers for the years 2005/06 to 2008/09. Our analysis showed that while the spending costs for qualified nurses had dropped over that period from £26.1 million to £25.4 million and for unqualified nurses from £14 million to £12.5 million, the costs for senior managers and managers had risen from £4.5 million to £6.8 million"

"Our impression as we visited the older people’s mental health inpatient units was of highly dedicated ward managers, nurses and nursing assistants working under constant pressure. On more than one occasion, we came across ward managers who were trying to do their best for their patients with too little resource and fearful that they had not covered every aspect of patient care and the management of their ward."

Page 52 : "We found that members of staff working in these clinical effectiveness and risk roles in the trust appeared to have a good grasp of what needed to be done but were frustrated by the lack of effective systems to enable them to feel as confident as they should around overall clinical governance and compliance."

The CQC evidence that the wards were understaffed and staff knew what needed doing. And the Trust board spent a lot on management and moved from generating loss to generating surpluss. What have the Trust done to support nursing colleagues on the ward?

They closed the ward. They appointed a lot of Modern Matrons. They appointed a Director of Nursing.

Okay, I'm sold that they need the Director of Nursing but the Board minutes reporting ". . . outstanding concerns against overspending on in-patient wards and [the Director of Finance] pointed out the need to ensure optimum ward rotas," leaves me cold. More nurse management, less ward nurses.

The pages on community staff levels, case loads of 27.2 cases/staff is a whole post in itself, with community resources and practice meritting discussion. But to stay vaguely on topic, suffice to say that governance of ward process and staffing on the in-patient ward lead to grim patient care.

How many Trusts are staffing in-patient units well? How many Trusts are staffing in-patient units, if not well, at least adequately? Gah. So it goes.

Read the report from the CQC and see what you make of it.