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Your Flexible Friend

May 20, 2014

It’s impossible to make sense of NICE’s Draft Safe Staffing Guideline without reference to its dual contexts of economic restraint and shortages of qualified staff. If Trusts could routinely fund – and then find – enough nurses to guarantee a ratio of one nurse to eight patients or  – better still – six or even four patients on general wards, it’s a document that would barely be needed. And while media interest around the time of its publication focused on the acknowledgement that it is ‘unlikely that safe staffing can be achieved when registered nurses [are] caring for more than 8 patients during the day time on a regular basis’, Trusts are likely to see it in a very different light. For them, the stand-out message is the green-light the guideline gives for a major rethink around the way nurses are employed.

What Trusts are looking for is a magic formula that will allow them to expand their staffing at the same time as they tighten their belts. What they’re likely to end up with is more like sleight of hand. It was this tension – between expectations and resources – that loomed unspoken over Professor Gillian Leng’s distinctly cagey performance on the Radio 4’s Today Programme on May 10th. Quizzed by James Naughtie, the Deputy Chief Executive of NICE hedged that “we have issued advice on how hospitals and nurses should assess the care requirements on any particular ward in a flexible way so that nurses are there to be tailored to the care requirements of any particular patient group”. The key word in that sentence? ‘Flexible’.

‘Flexibility’ is a concept viewed by employers as something of a Holy Grail. Inherent within it is the possibility to deploy staff in an economically-efficient way: target people where they’re needed, when they’re needed, and when the job’s done, swiftly redeploy them to the next emergent hot-spot. Not for them any standing around idle when times are slack. So though you’ll search the Draft Guideline in vain if you want it explicitly spelled out, it its pages are strategically peppered with hints that one option Trusts should certainly consider is setting up ‘rapid reaction’ teams: trouble-shooters to perform ‘surgical strikes’ on floundering wards. At the very least, much more movement of staff between wards – on a shift-by-shift or even hour-by-hour basis – should be the new normal.

An example of what I mean appears on page nine. Trusts are urged to ‘ensure procedures allow for flexibility in ward nursing staff, to meet unplanned variations in the total nursing requirement or the availability of nursing staff. These procedures should enable an increase or decrease in staffing for nursing care from the planned daily or shift allocation’ (my italics). On page forty-three meanwhile, we learn that ‘flexibility can be achieved by changing the geographical location of the work of nursing staff between different wards or clinical sites, as well as alterations in the contracted working patterns and hours’.

Same problem, slightly different solution: writing in last week’s Nursing Times about the dilemmas associated with e-rostering, Robert Drake revealed that software packages now in development offer the potential to predict staffing requirements at a granular level, and of ‘tailoring’ nursing shifts accordingly. He concluded that this ‘raises the prospect of future employment contracts comprising a specified number of hours that Trusts may call upon at short notice, where all nursing hours are on-call hours’.

But there’s something holding back this brave new world: the woefully inadequate state of information technology in the NHS. It’s laughable really. To estimate staffing requirements, the Draft Safe Staffing Guideline relies on clunky charts where time taken by each nursing activity is allocated some ballpark average, and chalkboard calculations (‘total nursing requirement = average nursing hours per patient day X average bed utilisation + additional workload in nursing hours per day’). The Safer Nursing Care Tool (SNCT), to whose insights the Guideline is heavily indebted, makes sympathetic noises about the laborious task of transcribing paper records to a database and helpfully suggests that ‘input from the Information Technology (IT) department with a nominated contact person may be able to support this aspect of the project’. Sorry, but have I been whisked to a parallel universe or something?

Without real-time information about actual conditions on wards, this ‘targeted’ model of staffing can never work. Nowhere is confirmation of this is more stark than where the Guideline talks about so-called ‘nursing red flag’ incidents. A ‘red flag’ should ‘prompt an immediate response [which] may include an urgent need for additional nursing staff to be allocated to the ward’. Situations that could trigger it include ‘unplanned omission in providing patient medications or delay of more than 30 minutes in providing planned pain relief…patient vital signs not assessed and recorded as outlined in the care plan’. How will we know when any of this has occurred? Because it ‘could be reported by any member of the nursing team, and by patients, relatives or carers’. So we have to wait until patients and are actually in pain and on the phone to some dedicated central hotline before we have a mandate for action? And when we write up the inevitable report, we have to ring round everyone who was there to see what time they thought it was in case medications were not a full thirty minutes late but only twenty-nine? Oh please!

Technology that can predict how much longer the drug round or observations round is going to take based on how long they have taken already; that can monitor how long call-bells are ringing before they are answered; that can track the precise location of individual nurses, individual patients, and how long it has been since a patient last interacted with a nurse – all this already exists. Systems were being trialled in British hospitals as far back as 2011.

Widespread implementation opens the door to an extremely unpopular corollary however: vastly increased opportunities for staff surveillance – not just how long you spend writing notes or doing drug round, but how long you have for break or even how many times you visit the toilet. There could be pluses too of course – the system would be aware of when nurses had missed breaks (tellingly, this is not recommended to be a ‘red flag’) or how long they had stayed behind after their shift had ended. But the potential to attribute this behaviour to individual failings such as ‘poor time management skills’ rather than institutional factors such as overwork still exists.

Publication of the Draft Safe Staffing Guideline is not a cause for celebration. While it is true that a guarded Professor Leng told James Naughtie that “What we have found from the evidence is there is an increased risk of harm on average if a nurse is caring for more than eight patients on a ward on a regular basis…but not always”, she also re-iterated both here and on other broadcast media that “the main point from this guideline is that care needs to be tailored to patients’ needs”. Against a background of economic retrenchment and staff shortages, that word ‘tailoring’ is the one many Trusts will hear loudest and clearest. But as any tailor will tell you, you’ll never get a perfect fit if you don’t first take meticulous measurements. In the context of the NHS, we’d better start asking what that might mean.

In other news on this subject:
Roy Lilley has tweeted/blogged that the Department of Health may be about to abandon its plan to get ward-by-ward nursing numbers on the web by July because the available technology is unable to support it.
Val Moore (Implementation Programme Directory at NICE) tweeted that last week and this week have seen NICE field testing the Draft Safe Staffing Guideline on 100 wards. This involves ‘Testing five days in each ward, how estimate of staff numbers made by an experienced nurse compares with an estimate based on the guideline and the Safer Nursing Care Tool to check what factors are important for assessing staff numbers and the practical presentation of the final guideline’. Surprising that they didn’t do this before they published the Guideline? And why use SNCT as a control when no toolkit has yet been endorsed and the Guideline itself acknowledges that its evidence-base is weak?

For the Draft Safe Staffing Guideline, see:

For the Robert Drake article in the Nursing Times, see:

  1. Looks good in theory. Would be a nightmare in practice. Looks like a formula for getting away with short-staffing. Cut staff to the bone then if there is an emergency haul them from wherever they are – but Sod’s law tells us that as soon as staff are removed from one area, they will be needed in the area they have just left. So what is going to be sacrificed? Critical care only but patients left to wait for pain relief, washing, toileting? Is the plan to roll the Staff. model countrywide? Savings can be made but not with front line services. Cut the bureaucrats to the bone and re-tender their jobs at a max of £50k. With open borders and a worldwide labour glut of highly educated people, the jobs will be filled easily. Too much public money wasted on providing sinecures for parasites.

  2. Thank you for commenting. The ideas in the post are only speculation of course, but I wouldn’t be surprised if some Trusts are already thinking along these lines. I think a more interesting question is how a task-orientated model based on a high level of staff mobility would impact on the government’s pledges to make nurses ‘more compassionate’. Any interaction between staff and patient, however brief, can still be compassionate; but where staff are constantly moved around, continuity of care and the trusting relationships that both staff and patients so value are that much harder to achieve. It boils down to what you think ‘safe staffing’ really is – pairs of hand and tasks ticked off on your to-do list? Or something more indefinable?

  3. Agreed. It is part of the pattern of extracting the most amount of work from the workforce. I think what is proposed is a really bad idea. Apart from emergencies who decides priorities? If Royalty go into hospital will they be left until more urgent cases are dealt with, or will we find their like is discreetly placed in wards apart adequately staffed. This would be bad for staff and patients. The staff will be run off their feet and the patients will not know when or if someone they perhaps have never seen before arrive to attend to them. Medical errors will certainly increase. Where did this bright idea come from. The third world? I believe even in third world countries nurses are treated with more respect. It has already happened that one lady was so concerned about the lack of care her mother was getting in hospital she employed a private nurse to stay with her. Is that the direction we are going? You can go to hospital but you can’t rely on nursing care unless you pay for it yourself?

  4. As I said, it’s just speculation around ideas for improving nurse to patient ratios at lowest possible cost. If it ever became reality, I imagine plenty of software companies would like to get their hands on the contract to develop and run it.

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