An article by the Nursing Times (26/03/2019) explained that nurses are critical to safety, but a ‘simple algorithm’ doesn’t exist to determine exactly how many nurses should be staffing a ward. Hundreds of studies have shown association between nurse staffing and safety, satisfaction (patient and staff) or omission of tasks which, having experience on a range of wards, I can’t imagine anyone would find surprising. So, when I raised with my matron that I don’t feel safe on the ward, being informed that we have ‘safe staffing levels’ made me wonder why I bothered.
Safety isn’t the number of staff on a piece of paper. Yes, it contributes towards safety but without taking into account skill mix, experience, environment and patient mix it is not sufficient to say two nurses and four healthcare assistants makes the ward safe.
Being based on one of the sites that has access to a seclusion suite, we tend to have patients admitted who have higher risks of needing seclusion, which makes sense. However we have the same levels of staffing as sites without a seclusion suite, meaning that the nature of the patients we care for is not considered when looking at ‘safe staffing’ levels. Person-centred working means that there is not a ‘one size fits all’ treatment for patients, so surely having this approach to staff numbers is a contradiction to person-centred care.
Is there a facility for staffing to be fluid? The nature of healthcare across the board is unpredictable, and unexpected events can happen on any shift, but staff who are used to assessing risk can be utilised to address this. For example implementing a system where the ‘safe staffing’ levels are a minimum, and assessments can be made daily on each specific ward relating to risk factors and needs of patients along with the skill mix of staff.
Take the following scenario as an example.
I’ve just cobbled this together but I hope it shows how much variation there can be on 3 wards on the same unit. Ward A definitely seems to have got a raw deal, with several risk factors noted. But of course, the safe staffing levels would be the same for all three wards. If staffing levels could be reactive to different factors however, it is surely common sense that this would impact on patient (and staff) safety.
If you think about hours of escorted leave as a single factor, ward A will likely struggle to facilitate this leave, assuming everyone wants to take their full leave. If we add on 10 minutes to every hour to accommodate signing the patient in and out, signing money in or out (which needs 2 staff), escorting staff member going getting their coat etc, this will add 90 minutes, meaning escorted leave will now take up 10.5 hours of staff time. Now let’s consider protected mealtimes / medications between 08:00 and 09:30; between 12:00 and 13:00; and between 18:00 and 19:00, and you can see there are limited daytime hours, and that more than one patient may need to be escorted out at any one time. Add to that patient choice, in that when staff are free to escort might not match up with the patient’s preferred routine, which can cause conflict. It might be wise to add in some ‘discussion time’ about the smoking policy, and trying to justify why the patient can’t have their own cigarettes out of their locker when they are going out of the grounds to smoke. This single factor has taken up more and more staff time, but there aren’t any duties that can be neglected just because there are several patients with escorted leave.
It astounds me that these factors are not taken into account, and how easily the standard ‘safe staffing’ number is rolled out to a complex and ever-changing human environment. It reeks of an out of touch system with short-sighted goals, and results that prioritise paper over people.
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