Safety in numbers: why we need more nurses15 May 2014 | by Peter Carter
Better care for hospital patients
The health watchdog Nice warned last weekend of an ‘increased risk of harm’ in understaffed hospitals, a view backed by other recent research. Here, a nurses’ leader argues for investment in an expanded and well-trained workforce to meet the challenges of the future
“Maybe saints come cheap,” remarked the renowned classicist Professor Mary Beard, while discussing the priority given to caring for the most vulnerable people in our society on the BBC?Radio 4 programme A Point of View last week. It is a fair question, and an important one.
Last weekend, the National Institute for Health and Care Excellence (Nice) published the first of a series of guidelines on safe nurse staffing levels for English hospitals. Among other warning signs, it recognised the “increased risk of harm” if a registered nurse is regularly caring for more than eight patients at once.
To those lucky enough not to have spent much time in hospital in recent years, this might just seem to be a technical issue. But if you or a loved one needs care, it takes on a much greater significance. Having enough staff with the right skills becomes the difference between safe and unsafe care. It is also the difference between performing a set of tasks and anticipating the needs of vulnerable patients.
Pope John Paul II once said that “a society will be judged on how it treats its weakest members”, and I for one believe that how we staff our hospitals is a very important test of this. Do we want a health service that reduces caring to a series of tasks, or items on a chart to be checked and moved on from? Or do we want nurses who are looking for subtle signs of deterioration, building a rapport so that patients can confide their anxieties, and supervising their junior colleagues to care more effectively? The bottom line is this: if you are caring for a ward full of highly dependent people on your own, the best that can often be delivered is a task-based approach. Without enough staff, this can prove very dangerous.
To understand what that means, let us get away from the old idea of what a hospital ward is like. The Carry-On film image of patients sitting around for weeks “recuperating” from illness or surgery is a far cry from the modern NHS. Patients are often acutely ill, and with more than one long-term condition. It is arguable whether the image of a nurse doing little more than plumping pillows was ever realistic, but it is ludicrous to imagine that this is all patients need from a modern nurse.
The last century has seen unprecedented progress in technology and medical treatments to “cure” or at least contain disease. The new challenge is to see the same progress and priority in the concept of “care”. The latest estimates suggest that the number of over-65s in the UK is set to increase by half, and the number of over-85s to double by 2030. Many of those older people will be fit and well. Many will have survived cancers and other conditions that would once have cut short their lives. And many will have chronic health needs as a result of those conditions and treatments.
There are many demands on the public purse, from educating children to alleviating poverty, but with increased numbers of older people we have also created a new vulnerable class, with new and distinct needs to be met. Until you have cared for a frail older person, it is difficult to understand how fragile their bones can be, and how thin their skin. It takes experience and care to move someone who cannot move themselves, just as it takes care and understanding to speak to a person who is confused, anxious or suffering from dementia.
And how are we caring for these people? Sadly, in some cases, on the cheap. The generation who lived through the Second World War and built the NHS are too often left in understaffed hospitals, or cared for by staff who are exhausted and demoralised.
Professor Beard believes that the way we are currently treating older people will one day be judged as harshly as Bedlam and the treatment of those with mental health issues now is. But in the case of Bedlam, there was no clear solution – the mind was still very poorly understood. Nowadays, we absolutely know how to give good care, so failing to do so may be a greater sin.
Our most recent research found there are more than 20,000 nursing vacancies unfilled in the English NHS. Following the publication in February of the report by Robert Francis QC into the failures at Mid Staffordshire NHS Trust, it is only right that more work is done to make clear what staffing levels are needed for the real circumstances on the ground in hospitals. That way, we can get the right people through training and into the wards and clinics where they can make a difference.
Nice is right to warn that one registered nurse caring for more than eight patients can represent a dangerous lack of staff – but there are circumstances where one caring for five people would also be inadequate. One to eight must never be allowed to become the default setting for care when the skill is there to deliver to a high standard. The NHS also needs to look at the barriers it places in front of care – the endless paperwork, estimated to take up two and a half million hours a week of nurses’ time. Of course, some paperwork is needed to keep care safe. But it is not what nurses come into the profession to do.
To those who criticise the fact that nurses now have degrees and a professional outlook, I ask: what would it say about us if we did not want to attract the best people into the profession? If we stopped training our nurses by making them spend more hours on clinical placements than any other country in the Western world? If we did not recognise that the needs of the sick have changed, and many may have survived cancer, strokes and dementia, and now need someone to try to understand them?
The evidence is there in favour of having well-educated staff who can listen to subtle signs, and to advocate for patients or supervise less experienced staff. Florence Nightingale said, “I attribute my success to this – I never gave or took any excuse.” In no walk of life does that authority come without education and respect.
Let us hope that all of these reports and studies do bring us to the moment our sick and elderly need to see – when we as a people recognise the value of care as a part of all our futures. We believe that the commitment and expertise is there to improve the lives of the vulnerable, but there will always be an excuse not to invest in it. It is down to us, as the heirs of Florence Nightingale, to decide not to accept that excuse.
• Peter Carter is chief executive and general secretary of the Royal College of Nursing.
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