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Q: What is Safe Staffing? A: It kind of depends who you ask…

June 3, 2013

“If you haven’t got the nurses, you can’t do the care! It’s just common sense innit? The more trained staff you’ve got, the better your patient care’s gonna be – that’s gotta be right. Trouble is, them upstairs in their posh offices” – conspiratorial glance upwards – “they just don’t wanna hear it”.

Anyone who has ever hung around a nurses’ station is bound to have heard opinions like this. And why not? Rising admissions, staffing cutbacks, paperwork, politicking and public hostility in the aftermath of the Francis Report mean that nurses are feeling the pressure like never before. As the single staff nurse on duty this morning runs around trying to complete the drug round so she can move on to the IV’s while simultaneously answering the phone, supervising the untrained staff and pointing the doctors in the right direction, who could blame her for thinking ‘what I really need is some help‘. Thank Heavens for the Safe Staffing Alliance!

The Safe Staffing Alliance (SSA) is a pressure group formed of nursing and patient organisations, plus a number of prominent individuals, who have come together under the banner of demanding a mandatory minimum staffing ratio of eight patients per registered nurse during the day on general acute wards. The Alliance reportedly came into being last summer but has gained increased visibility and momentum in recent weeks, not just from the publication of the Francis Report, but also following surveys by the Royal College of Nursing (RCN) and Nursing Times and some very pertinent research findings from Professor Peter Griffiths.

Professor Griffiths, Chair of Health Services Research at the University of Southampton, is an internationally respected authority on health care workforce research. By his own admission, his subject is sometimes seen as a dry one. All that changed in March this year when a paper he presented at the RCN’s Annual International Research Conference in Belfast set the juices well and truly running amongst the nursing cognoscenti.

Entitled Nurse, care assistant and medical staffing: the relationship with mortality in English Acute Hospitals, the presentation was based, according to the Nursing Times, on ‘survey data from the RN4CAST nursing workforce study published last year and examined mortality rates, workforce and bed numbers for 137 acute trusts’. Disappointingly for such landmark research  – it will be cited for years to come, trust me – the RCN has not released any transcript or video online; although it has – tantalisingly – reproduced tiny reproductions of the accompanying powerpoint screens. So what did Prof Griffiths actually say? It’s a question with a slightly unexpected answer: it kind of depends who you ask.

The Nursing Times has reported on Prof Griffiths’ work a number of times in the past year, always majoring on anything that relates to health care assistants (HCAs). No surprise then that after the Belfast conference, it was straight back to business: an item headlined Mortality higher in hospitals with more unregistered staff cut right to the chase with the news that ‘there is a link between higher death rates and the proportion of healthcare assistants employed in NHS hospitals’. Using unashamedly tabloid-esque language, the article then informed readers that ‘a study by  the University of Southampton found trusts with a higher number of unregulated HCAs…had a higher mortality rate’.

Thereafter, the whole piece was dominated by the finding that ‘a higher HCA-to-bed ratio increased the mortality rate up to a maximum of 5.4% more than would be expected’, with little mention of any other aspect of the presentation. Prominently positioned beneath the Peter Griffiths piece was a second article entitled Fewer nurses and more HCAs in NHS, outlining recent changes in the  workforce skill mix. So…Yeah, OK, you can stop now. We get the message. Loud and clear.

Over at the Nursing Standard, things were seen a little differently. Under the headline Dangerous staffing levels defined as more than eight patients per nurse, the magazine was completely silent on  those parts of Prof Griffths’ paper that related to HCAs. Instead coverage focused on his decision to support calls for a 1:8 trained-staff-to-patient ratios as a mandatory minimum. The professor was quoted as saying that he ‘had resisted calls for minimum staffing levels in the past, but evidence from recent studies showed that expecting one person to care for more than eight patients was dangerous’. He went on to add that ‘rather than mandating a nurse staffing level, I am defining a dangerous level…staffing below that level should be reported and recorded as a patient safety incident putting every patient on the ward at risk.’

(Interestingly, neither journal reported the finding that ‘every ten per cent increase in batchelor’s [sic] nurses is associated with seven per cent reduction in odds of patients dying’. Perhaps they agreed to gift that one to the Daily Mail).

So: two mags, one story, two different versions of events. What’s all that about? One possible explanation is the fact that the Nursing Standard is owned by the RCN, and the RCN doesn’t want to risk upsetting its subs-paying HCA membership. The Nursing Times, unencumbered by such considerations, is free to throw one hundred per cent of its weight behind trained nurses. More broadly however, the whole episode is highly illustrative of the extreme sensitivity currently surrounding any discussion of HCAs by nurses.

As an occupational group, HCAs have never been so firmly in the spotlight. Although the government rejected Robert Francis’ calls for registration, history is likely to judge this as a missed opportunity, something that slowed but did not stop an inexorable momentum.  But combined with an economic background of belt-tightening and redundancy fears, this could also be a toxic mix which sets the stage for a resurgence of nursing’s never-very-well-hidden professional anxieties.

If evidence shows that eight trained nurses per patient is the minimum safe ratio, then fair enough – let’s campaign on that. But let’s NOT use it as an excuse for fingerpointing, retrenchment and defensiveness. Safe staffing is not about privileging one professional group over another. Prof Griffith’s research should act as a springboard to further questions about how to re-draw professional boundries while still ensuring that all grades of staff are properly equipped to reach their full potential in providing the most effective care for everyone.  In this context, the timidity of the RCN is not a hopeful sign.

As an organisation that represents both nurses and HCAs, it really shouldn’t be sitting on the sidelines. It should be the referee.

Further reading:
For the RCN’s powerpoint screens, see
For an abstract of the research on which Prof Griffiths’ presentation was (presumably) based, see
/S0020-7489%2812%2900365-3/abstract The full article (which is bound to be far more subtle and nuanced than anything I’ve said in my own shameless grab for publicity) is viewable by subscription only.
The professor’s inaugural speech from 2012 is a very interesting read (PhD in research methodology not required) and can be viewed at

Dangerous staffing levels defined as more than eight patients per nurse. Nursing Standard. Vol 27; 30; 5

Mortality higher in hospitals with more unregistered staff. Nusing Times. Vol 107; 12; 5
The following may also be of interest:

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