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Revealed!! Leaked Email Details how Hospital Bosses told to FIDDLE Nursing Numbers! (Allegedly).

June 16, 2013

From: XXXXXXX
To: All English Hospital Chief Executives.
Subject: In recent weeks, the Safe Staffing Alliance has gained increased visibility with demands for a minimum ratio of 1 trained nurse to 8 patients on acute wards. As a campaign, it will inevitably  attract popular support and be difficult to oppose because it is evidence-based. However, the current economic climate means that staffing at this density is undeliverable in the majority of cases. Below, are outlined a number of creative solutions as to how to meet these difficult challenges which do not involve employing more staff. In particular, your attention is drawn to item 8. It is important that nursing staff understand that there can be no evidence-based staffing without the attendant evidence, and that the group responsible for collecting this evidence will be nurses themselves. Therefore, patient assessment-type activities will inevitably increase. In order to ensure the appropriate skill mix, we are considering the introduction of mandatory Personal Nursing Requirement Portfolios (PNRP) (e.g. 25% trained nurse, 50% untrained nurse, 25% self care). These will be applicable to EVERY PATIENT and will need to updated at least daily BY NURSES.
Distribution: Highly Confidential. Not for discussion in public forums. Not for press release.

1. ‘Every Nurse Counts*’. Key Concept: Leveraging global potentiality. ‘Unscheduled’ nurses e.g. clinical specialists and practice educators are a statistically reliable presence on wards in their professional capacities for about 80% of normal office hours. Until now, they have represented a seriously underutilised resource as regards their contribution to total nurse availability, but new provisions will allow them to be included in ward staffing numbers for the duration of their presence on a ward. Therefore, in a ward environment where five trained staff are on duty, the presence of one ‘unscheduled’ personnel would contribute, for the duration of the visit, an extra 20% to ‘Total Local Trained Nurse Availability’ (TLTNA). Research suggests that averaged out over a whole week (7 days), and acknowledging that there are fewer ‘unscheduled’ visits at nights and weekends, using TLTNA as the standard basis for calculating ward staffing numbers could nevertheless add an extra 10% to the ‘official’ nursing establishment of any given ward. Duties undertaken by nurses on ‘unscheduled’ visits are varied and subject to local conditions, but are frequently helpful to ward staff. The unscheduled staff themselves are likely to be grateful for the recognition afforded to them by this initiative.
* towards total staffing figures.
2. Absent patients. Key concept: Exploiting emptiness. Inevitably, for some part of every day, any given ward will house numbers of beds which are Temporarily Unoccupied (TU) or ‘Nil Input Occupied’ (NIO) because patients have been discharged, have gone to theatre or to investigations outwith the ward environment or have regrettably deceased (= ‘nil input occupation’). Nationally, we estimate that about 5,000 Whole Bed Equivalents (WBEs) on wards will fall into this category at any given time. It will be for individual Trusts to decide how to calculate and average out actual numbers of TU/NIO beds in their jurisdiction but we recommend a realistic target of 1-2 WBEs per ward per 24 hour (1 day) period rounded up to nearest whole number. Once arrived at, this figure should be subtracted from ward bed numbers (i.e. a ward with 30 beds would be shown as having 28-29 WBEs).
3. Averaged staffing. Key Concept: The Holistic Day (24 hours). Acknowledging the fact that increased staff are available during ‘handover periods’, and given that these ‘handover periods’ can have an aggregated duration of up to five hours (300 minutes) per day on any given ward, The Holistic Day is a new toolkit which through leveraging synergies generated by larger team size, potentiates the actualisation of maximum staff productivity during better staffed periods. It has been trialled in a small number of hospitals and preliminary feedback is positive. A nurse at one pilot site stated that ‘In the ward environment, handover period used to be the time when we could relax a little, but now it’s go go go!’. With its proven track record of productivity gains, implementation of The Holistic Day can be used as the rationale for presenting staffing figures for any given ward in ‘Average Staffing over 24hrs (1 day)’ format: total staff rostered for the whole 24 hour (1 day) period divided by 24 (hours) to give average staff numbers for each 24hr (1 day) segment.
4. Look for loopholes. Key Concept: Attention to detail. The Safe Staffing Alliance manifesto (http://www.kcl.ac.uk/nursing/research/nnru/news/Alliance-Statement-May-2013.aspx) states (Point 4) that ‘Under no circumstances is it safe to care for patients in need of hospital treatment with a ratio of more than 8 patients per registered nurse during the day time on general acute wards including those specialising in care for older people’. This could be taken as meaning that any patient whose notes have been documented that they are ‘medically fit and ready for discharge’ (or equivalent wording) need not be counted in total patient numbers. Consideration could also be given to excluding patients who are self-caring.
5. ‘Notional staff’: Key Concept: Attribution management. Staff who are unavailable to be present in the ward environment when rostered to be on duty may still be counted in numbers on duty for the hours of duty for which they are implicated by the roster provided that their absence is not the Trust’s fault. We suggest that Trusts work at the local level to produce an appropriate attribution schedule, for which purpose it may be necessary to appoint a dedicated Attribution Manager. Reasons for attributing absences to individual team-members rather than the organisation as a whole might include sickness with less than 48 hours (two days) notice (or some other locally-agreed time frame); unfilled bank shifts; inappropriate rostering; acts of God (or equivalent deity).
6. Telestaffing. Key Concept: 24 hour (24 hour) responsibility. Staff can now be contacted with ease even when they are outwith the ward environment on days off. Mobile technology makes it happen. Nurses have a continuing responsibility to patients in their care. This conforms with Francis Report which stated that ‘Hospitals should review, with a view to reinstatement, the practice of identifying a…nurse who is in charge of each patient’s care, so that patients and families are clear who is in overall charge of that care’ (Executive Summary, Pt 1, para 21). ‘Overall charge’ is not implicit with co-terminosity in shift patterns, therefore it is admissible to contact nurses at any time for issues of clarification of patient care. If a nurse has communicated with the ward about any given patient during a shift, this intervention can be counted towards calculation of nursing numbers due to fact that nurse has contributed to patient welfare/progress. Nurses who are off-duty but contactable could count as a percentage (half?) a TNE (see below).
7. Trained Nurse Equivalence. Key Concept: The Snowball of Nursing. As a snowball rolls down a hill, its core becomes larger and its periphery more diffuse. Using this analogy, untrained staff (clinical/non-clinical) can be assigned a Trained Nurse Equivalence (TNE) if present in sufficient numbers. Therefore, if 2 Band 2 staff are on duty, this could be assigned the ‘Trained Nurse Equivalence’ of 0·8 of 1 Band 5 nurse. Exact equivalences should be formulated at local level in line with local conditions.
8. Reactive Staffing™: Key Concept: Workforce flexibility/focus/targetting. Reactive Staffing™ is a patented software algorithm from the United States that allows managers to track ward acuity and staffing requirements at the forensic level. On a shift-by-shift, or even hour-by-hour basis, staff feed real-time information on ward activity into a data stream which in turn is analysed by a team of ‘staff enforcers’ located in a central operations bunker. Using this information, the enforcers are empowered to deploy ‘rapid response teams’ of nurses around the hospital to ‘fire fight’ in areas showing signs of pressure. Alerts in key indicators (e.g. failure to complete drug round by scheduled time) trigger escalation. Intense bursts of highly targetted staffing interventions may actually lead to reductions in permanent staff requirement.

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5 Comments
  1. This represents a level of thinking which is so obtuse it is hard to believe. The underlying drive to describe such concepts & share them illustrates a management mentality which cares not a shit about the human race… I feel like vomitting!!!

    • Well, that’s public sector management for you – at least as seen by those on the shop floor. Perhaps someone who sits higher up the tree than I do would like to correct me?

  2. Reblogged this on decco64's Blog.

  3. Very funny and clever. Obviously it’s a satirical piece of writing but likely to be uncomfortably close to the real thing.

    • Thanks. I think the Safe Staffing Alliance should take note: if recent evidence is anything to go by, the contents of the post represent exactly the kind of thinking you are likely to be up against.

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