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A silk purse from a sow’s ear?

May 13, 2014

Poor old Institute for Health and Care Excellence (NICE). Talk about a silk purse from a sow’s ear – it would take a heart of stone not to feel their pain. Tasked by the Department of Health with setting out ‘authoritative, evidence-based guidance on safe staffing’ (Hard Truths, Vol 2, p29), the best they could come up with was a Safe Staffing Guideline hedged with a list, over two pages long, of all the things for which they could find no evidence whatsoever. The creative use of language, as they struggled for different ways to say the same thing over and over, could make the guideline a runner for inclusion in the new list of ‘A’ level set texts: ‘there is a lack of high quality studies…’; ‘there is a lack of appropriately designed experimental studies…’; ‘there is limited evidence…’; ‘no evidence was identified…’ (pp23-25). No wonder Professor Gillian Leng, Deputy Chief Executive of NICE, sounded distinctly cagey when she appeared on Radio 4’s Today Programme.

The aim of the guideline is to set out the standard on how to calculate numbers of nursing staff required on acute adult (general) wards. Named ‘toolkits’ for bringing this about will be endorsed by NICE at a later date, depending on their compliance with the standard. In the meantime, Trusts are advised that they must calculate patient acuity and staffing requirements on the basis of ‘a systematic approach…[that] include[s] the use of a staffing toolkit that is agreed locally to be consistent with the recommendations of this guideline’. This is where it all starts to get a bit confused.

What is ‘a staffing toolkit that is agreed locally to be consistent with the recommendations of this guideline’? One possible answer is that Trusts are being given the green light to raid their collective garages and chuck together their own toolkits from whatever they find lying around. But given the time constraints and the work involved, it seems unlikely that many will go down this route. A much more plausible scenario is that that Trusts are being gently prodded in the direction of the Safer Nursing Care Tool (SNCT) – the same one I discussed in my earlier post, Tell Us The Scores On The Doors.

Why do I think this? Well, firstly because it’s a readily available, relatively straightforward and free-to-use resource, developed by and for British hospitals. A common-sense choice, then. But more importantly, the whole ‘process for determining nursing staff requirements’ as set out in the guideline is transparently based on the SNCT: there are numerous obvious parallels including the processes involved in arriving at a figure, the twice-yearly intensive monitoring of patient acuity and the use of the ‘average nursing hours per patient day’ formula. What’s more, the signposting of  SNCT is clearly intentional.

The minutes of the Safe Staffing Committee’s two-day-long March meeting reveal that evidence was discussed in terms of its relationship to SNCT at several points – and no other toolkit was even mentioned. Highlights of Day One included a review of the evidence on nursing activities, skill mix and outcome, including ‘what outcomes are most closely linked with nurse staffing and how the findings relate to the Safer Nursing Care Tool’. On Day Two, the committee ‘were asked to consider and review the evidence in relation to patient acuity and dependency. They discussed the impact on nursing activities and outcomes and how these related to the Safer Nursing Care tool.’

For an organisation like NICE, whose entire raison d’être is the cool assessment of evidence, such faith in SNCT is rather surprising. The guideline is at pains to point out that amongst the many areas for which there is little or no evidence, ‘there is a lack of high quality studies exploring and quantifying the relationship between registered nurse and healthcare assistant staffing levels and skill mix and any outcomes related to patient safety, nursing care, quality and satisfaction’. And about SNCT specifically, it observes that ‘While dozens of studies explore workload measurement systems, they are primarily descriptive in nature…This also includes studies on well-known approaches like the AUKUH/Safer Nursing Care’. Ladies and gentlemen, this is policy born out of desperation. The evidence is weak, but there is simply nothing else.

Except that there might be. It’s a strange thing, but although the stated purpose of the guideline is merely to ‘recommend[ ] the factors that need to be systematically assessed at ward level when determining nursing staff requirements’, this is carried out at such length and in such detail, that what NICE has come up with is effectively a whole new toolkit of its own. It’s a toolkit that, as I have already said, is heavily indebted to the SNCT, but there are still enough subtle differences to make it possible to view what we might call ‘the NICE toolkit’ as a separate but related entity.

It’s difficult to know what to make of this. Is it a conscious (if not terribly convincing) attempt to disguise the SNCT and sneak it in under the wire, even though NICE has not yet officially endorsed any staffing toolkits? Or is it evidence of the committee’s frustrations with SNCT’s limitations? The guideline emphatically does not give its toolkit a name or even designate it a toolkit. But it when it enjoins Trusts to ‘consider using nursing care activities summarised in Tables 1 and 2 as a prompt to inform professional judgement of the nursing staff requirements’ – it seems perilously close to saying ‘here’s your toolkit’.

When you finally arrive at Tables 1 and 2, what do you find? They are lists of common nursing interventions together with the estimated time a nurse needs to perform each one. It’s by no means obvious who devised these tables or what their evidence-base is, but they do form the most striking point of divergence with the SNCT. Rather than estimating the time required to perform various atomised nursing activities, SNCT assigns patients to groups on the basis of how much nursing input they need, and calculates the number of nurses required by applying a multiplier.

So here’s where we’re at. There is very little reliable evidence about how factors related to staffing contribute to safe patient care. Consequently, there is very little reliable evidence about what elements a staffing toolkit should contain. Coming soon: endorsement of staffing toolkits – how do  they measure up against a standard formulated on the basis of very little reliable evidence? NICE must feel as if it’s been handed a poisoned chalice. I wouldn’t be surprised if there are people within that organisation who counsel walking away from the whole exercise on the grounds that it discredits their brand and makes them look stupid.

On the other hand, we clearly have to do something. For the longer term, the government could show it’s serious about this issue by funding more research. In the short term, we certainly do need routine collection of hard data about patient acuity and nursing workload. But going by what’s presented in the guideline, it seems to me that we might just as well confine ourselves to the Safe Staffing Alliance’s line that more than eight patients to one nurse should be regarded as a ‘never event’. It’s straightforward, it’s easy to understand, it’s simple to police and it’s backed up by just as much evidence as anything we’ve got here.

There will be a follow-up post on ‘red-flag’ events and nurse:patient ratios.

For the NICE Safe Staffing Draft Guideline, see:

For the minutes of the NICE Safe Staffing Committee’s March meeting, see:

For the Safer Nursing Care Tool implemenatation resource pack, see:

  1. junegirvin permalink

    An excellent analysis of the shortcomings of so-called staffing tools, and of the rock and hard place that NICE must surely find itself in.

  2. Thanks very much. An earlier draft of this piece contained the phrase ‘a rock and a hard place’. That’s exactly how I see it.

Trackbacks & Pingbacks

  1. Critique of NICE Guidelines on staffing | 4:1 Campaign
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