National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee / Y Pwyllgor Iechyd a Gofal Cymdeithasol

 

Safe Nurse Staffing Levels (Wales) Bill / Bil Lefelau Diogel Staff Nyrsio (Cymru)

Evidence from Royal College of Nursing – SNSL(Org) 05 / Tystiolaeth gan Coleg Nursio Brenhinol – SNSL(Org) 05

 

 

 

Inquiry into the Safe Nurse Staffing Levels Bill (Wales)

January 2015

 

 

 

Submission from the Royal College of Nursing, Wales
Presented to the National Assembly for Wales Health & Social Care Committee

 

 

 

 

ABOUT THE ROYAL COLLEGE OF NURSING (RCN)

 

The RCN is the world’s largest professional union of nurses, representing over 400,000 nurses, midwives, health visitors, nursing students and healthcare support workers, with over 25,000 members in Wales. The majority of RCN members work in the NHS with around a quarter working in the independent sector. The RCN works locally, nationally and internationally to promote standards of care and the interests of patients and nurses, and of nursing as a profession. The RCN is a UK-wide organisation, with its own National Boards for Wales, Scotland and Northern Ireland. The RCN is a major contributor to nursing practice, standards of care, and public policy as it affects health and nursing.

 

 

The RCN represents nurses and nursing, promotes excellence in practice and shapes health policies.                                                   

 

 

 

Written Evidence of the Royal College of Nursing in Wales in Response to the National Assembly for Wales Health and Social Care Committee Consultation on Safe Nurse Staffing Levels (Wales) Bill

 

 

1.            The Royal College of Nursing is the world’s largest professional organisation of nurses.  It represents over 420,000 nurses, midwives, health visitors, nursing students and healthcare support workers.  In Wales the Royal College has over 24,000 members. The majority of our members work in the NHS.  The Royal College of Nursing works locally, nationally and internationally to promote standards of care and the interests of patients and nurses, and of nursing as a profession.

 

The Royal College of Nursing is a UK-wide organisation with its own National Board in Wales.  It is a major contributor to nursing practice; standards of care and public policy as it affect health and nursing.

 

The Royal College of Nursing represents nurses and nursing, promotes excellence in nursing practice and care and shapes health policies.

 

The Royal College of Nursing welcomes the opportunity to respond to the Health and Social Care Committee’s consultation on the Safe Nurse Staffing Levels (Wales) Bill.

 

Response to General Consultation Questions

 

Is there a need for legislation to make provision about safe nurse staffing levels?

 

2.            The Royal College of Nursing in Wales believes that there is a need for legislation to make provision about Safe Nurse Staffing Levels.

 

International research clearly demonstrates that that the number of registered nurses and nursing staff on a ward makes a significant difference to successful patient outcomes including morbidity and mortality. In 2006 Professor Rafferty CBE surveyed nearly four thousand nurses and looked at 118,752 patient episodes of care in 30 hospital trusts in England. Her research found that wards with lower nurse to patient ratios had a 26% higher patient mortality rate. An international meta study in 2007 estimated that each additional full time nurse per patient day saved five lives per 1,000 medical patients, and six per 1,000 surgical patients (Kane et al 2007). Another study found that when a nurse is charged with more than seven patients per day the risk of the patient dying within 30 days increases by 7 per cent (Aiken et al, 2014).

 

Poor outcomes also associated with low levels of nursing care include adverse events after surgery; increased accident rates and that patient injuries; increased cross-infection rates; and higher rates of pneumonia.

 

3.            Despite these principles being well known within the nursing profession there has not been a commitment in the NHS to seeing Safe Nursing numbers in practice in wards. Paragraphs 10 to 12 of the Explanatory Memorandum reference the Francis Report (2013), the Keogh review (2013), the Berwick review (2013) and the Andrews Report (2014), all of which have drawn attention to the repeated failure of the NHS to sufficiently prioritise patient safety and the quality of care by safeguarding nursing numbers.

 

4.            In Wales even the All Wales Nurse Staffing Principles Guidance issued by the Chief Nursing Officer (CNO) in 2012 has failed to make a sufficient impact. Trusted To Care (2014) the independent review of the Princess of Wales Hospital and the Neath Port Talbot Hospital specifically refers to ‘lack of suitably qualified, educated and motivated staff particularly at night’ and comments: ‘The Review Team were also concerned about the way staffing levels in the medical wards were determined as this seemed unconnected to the level of dependency and need on a ward at a specific time.’ The report of the Older People’s Commissioner for Wales ‘Dignified Care: Two Years On’ (2013) states that ‘there is a clear link between staffing levels and the safety and quality of care on hospital wards.’ As a result, the Royal College of Nursing believes that legislation is the only way to ensure Safe Nurse Staffing Levels on adult in-patient wards. 

 

5.            The figures below are from a Royal College of Nursing Survey carried out in 2013. This was an online survey sent out to a stratified random sample of the Royal College membership. The survey achieved a total of 9,754 usable responses across the UK, with 1,365 usable responses from nurses working in Wales. It shows the patient to nurse ratios reported by members in Wales:

 

 

Patients per registered nurse

All

8.5

Older people

10.9

Mental health

8.2

Children and young people

4.4

Acute and urgent care

8.4

 

 

 

 

 

 

 

 

 

 

6.            The Royal College of Nursing also undertook a Freedom of Information request (table below) which asked the Local Health Boards (LHBs) about the number of patients per registered nurse per day and night and the Ratio of Registered Nurses to Healthcare Support Workers. Their responses show that with the exception of Cwm Taf UHB all the other LHBs are failing to follow this guidance. 

 

 

7.            The Royal College of Nursing believes that legislation by the National Assembly is necessary and will ensure that Health Boards place a greater priority on ensuring safe nursing levels on wards.

 

Are the provisions in the Bill the best way of achieving the Bill’s overall purpose (set out in Section 1 of the Bill)?

 

8.            The Royal College of Nursing believes the provisions laid out in the Bill are the best way of achieving the Bill’s purpose.  

 

9.            The duty on Health Boards to have regard to safe nurse staffing levels will ensure a Corporate level of accountability for the first time and increase the significance of the advice of the Nurse Director to the Board. Too often Board and Executive teams have consciously or unconsciously focused on financial and other strategic priorities at the expense of this key indicator of patient safety.

 

10.        The requirement on Health Boards to publish information demonstrating how they have met the guidance will allow effective scrutiny, evidence of impact and also increase accountability.

 

11.        In seeking to achieve the purpose of safe nursing levels the Bill does not set actual numbers but instead refers to the use to evidenced based and validated workforce planning tools, standards and guidelines of professional organisations and the role of professional judgment. The Royal College of Nursing views this as the sensible and sustainable approach 

 

What, if any, are the potential barriers to implementing the provisions of the Bill? Does the Bill take sufficient account of them?

 

12.        The Royal College of Nursing does not believe there are potential barriers to implementing the Bill.  All LHBs currently undertake workforce planning and have the tools available to them to ensure that this legislation can be implemented without delay. This Bill simply places a duty upon the LHBs to consider Safe Nurse Staffing when planning their workforce.

 

Are there any unintended consequences arising from the Bill?

 

13.        The Royal College of Nursing does not believe there will be any detrimental unintended consequences that can arise from this Bill. The experience of similar legislation in Victoria, Australia and California has been very positive (Serratt, 2013).

 

14.        The Royal College of Nursing has previously been asked whether this Bill might result in a sudden increased demand for nurses might cause instability in another sector. This has not been the experience elsewhere. Indeed there was an increase in the number of nurses wishing to return to practice in Australia. If there was an increased demand this could be dealt with by an increase in the number of student nurses places commissioned.

 

15.        A second fear expressed to us has been that costs could escalate as a result of employing more nurses. More detailed information and analysis is provided to the Committee in the Explanatory Memorandum but a summary of the Royal College’s response to this would be that expenditure on nursing demonstrates the most effective impact on patient outcomes (Bray et al, 2014)

 

16.        The regulatory Impact section of the Explanatory Memorandum references findings from the ‘perfectly resourced ward’ pilot conducted by Aneurin Bevan Health Board at the end of 2012. Over the three month period of the pilot, although nursing establishment costs were 6% higher than the preceding period, the considerable reductions in the costs of agency more than outweighed these increases. At the end of the three month period, the combined staffing costs of the two wards had not increased and in fact was marginally lower than the preceding period.

 

17.        The Welsh Government has not published figures for spending on agency nursing in 2014 but the Royal College of Nursing is aware that agency costs to the NHS have increased 43% compared to 2013 and is at its highest level for four years. The Royal College of Nursing would estimate the cost of non-medical agency payments as between £20 and £30m in 2014.   

 

A 2011 study (Hurst, 2011) found that hospital wards with temporary staff had poorer staffing levels, higher workloads, more sickness absence and lower ward quality scores than wards that were staffed by permanent nurses only.

 

18.        Much research has also shown the financial benefit of safe nurse staffing levels. For example in 2009 US research quantified benefits per additional nurse at $60,000 with an additional $10,300 for reduced patient mortality, and $1800 from faster recovery. In the UK in 2009 Dr Foster Intelligence published research showing shorter hospital stays in acute Trusts that had more nurses per bed.

 

19.        A final concern that has been raised with us is that other healthcare professions may feel disadvantaged by not being explicitly mentioned in this Bill. 

 

20.        The Royal College of Nursing has been delighted to receive support from BMA, RCP, the Diabetes National Specialist Advisory Group and UNISON Cymru.

 

21.        Healthcare requires a multidisciplinary team approach to achieve the best outcome for the patient. At different moments in the journey of the patient they may require care from a surgeon, a pharmacist, a speech and language therapist, a physiotherapist etc.

 

The weight of academic evidence demonstrating the significance of the nursing impact is not a testimony to the superiority of the nursing profession but merely a testimony to that fact that the nature of nursing is a 24/7 caring role by the side of patient encompassing the very fundamentals of care including nutrition, hydration, alleviating pain etc. A core part of the nursing role is continuous assessment of the acuity of the patient, as the patients’ needs change or escalate, nurses are responsible for referring onwards to other healthcare professionals.  

 

Nurses make up the largest staff group in the NHS because they are

needed by patient at all times – and their absence has a significant negative impact.

 

 

 

 

Response to Consultation Question on Provisions in the Bill

 

View on the fact that, in the first instance, the duty applies to adult in-patient wards in acute hospitals only?

 

22.        The vast majority of academic research demonstrating the value of safe nurse staffing levels has been carried out in adult in-patient wards in acute hospitals. Certainly, based on the information that we have provided in Paragraphs 3 to 5, the Royal College of Nursing believe that by starting on adult in-patient wards in acute hospitals this piece of legislation is aiming to focus where there is the most need. 

 

23.        The Royal College of Nursing welcomes the provision that Welsh Ministers may make provision for the duty to be extended to additional settings within the NHS in Wales ensuring that Registered Nurses have time to care in such a way that ensures the dignity of the patient as well as clinical effectiveness. The Royal College of Nursing believes the nursing in the community needs legal safeguards relating to Safe Nurse Staffing too.  Staffing levels are mandatory in care homes and other settings and the Royal College of Nursing would welcome the opportunity to work with regulatory and inspection agencies and with the Welsh Government to develop effective workforce tools for the community.

 

Views on the requirement of the Welsh Government to issue guidance in respect of the duty set out in section 10A(1)(b) inserted by section 2(1) of the Bill which sets out the methods which NHS organisations should use to ensure there is an appropriate level of safe staffing

 

24.        The Royal College of Nursing welcomes the requirement on the Welsh Government to issue guidance which sets out the methods which NHS organisations should use to ensure there is an appropriate level of safe staffing. There needs to be a consistent and professional appropriate approach across Wales. Through this mechanism the Welsh Government would achieve this.  

 

25.        The Royal College of Nursing believes that Nurses must be able to meet patients fundamental care needs and efficaciously play their part in the delivery of complex treatments and therapies. The description of the potential guidance in the Bill is extremely helpful as it strikes an appropriate balance between the need of the individual nurse to use, and have respected, her professional judgment on the needs the patients, along with organisational support in the form of professionally recognised workforce planning tools and corporate accountability for patient safety.

 

Views on Welsh Government guidance including provision to ensure minimum ratios are not applied as upper limit?

 

26.        The Royal College of Nursing strongly prefers to use the term ‘safe’. The ratios evidenced by academics and cited by the CNO in Wales are because they are deemed as the ‘safe ratio’.  That is, if the ratios on the wards fall below this number, the wards themselves become unsafe and mortality and morbidity rates increase. These numbers are evidenced based.

 

27.        However common sense and professional judgment both dictate that if the needs of patients are greater than normal then the safe number of nurses in duty will be higher. Professional standards and the nature of medicine itself can change safe practice. The Royal College of Nursing is pleased that the approach to guidance in this Bill recognises and allows for this.

 

28.        As the committee will be aware, similar legislation has also been enacted in other parts of the world and there is no evidence of minimum becoming a maximum/standard number.

 

Views on Welsh Government guidance setting out process of providing information to patients on the numbers and roles of the staff on duty?

 

29.        The Royal College of Nursing believes that this legislation will strengthen the accountability of relevant service planners and managers for the safety, quality and efficacy of their workforce planning and workforce management.  We believe that Nurse Staffing information should be published at all levels of the healthcare system.  This might include: placing information at ward level on notice boards for public consumption, in the LHBs annual report; during quarterly reviews between the Chief Executive of NHS Wales and in annual reports the this committee.  The information for Wales/LHBs could also be placed on StatsWales for a LHB/LHB comparison.

 

Views on Welsh Government guidance including protections for certain activities and particular roles when staffing levels are being determined

 

30.        The Royal College of Nursing believes that when decisions on Safe Nurse Staffing Levels are being made, some roles such as that of Ward Sister/Charge Nurse should be supernumerary.  The Nurses in these roles should not be considered when determining Safe Nurse Staffing Levels because their roles provide oversight for the ward and other members of the nursing team on the ward must be able to refer to their clinical judgment when necessary. This was a clear recommendation of the Welsh Government Free to lead Free to Care strategy (2008) to improve patient care by empowering the ward sister and yet is still remains unachieved.

 

Student Nurses should also be considered to be supernumerary.  Student Nurses are still undergoing training and should not be required to take the place of a Registered Nurse until they have completed their training and are then registered with the NMC. Including Student Nurses when workforce planning is unacceptable; puts patients at risk and places the Student Nurses in an unjust position.

 

 

Views on the requirement of the Welsh Government to consult before issuing guidance

 

31.        The Royal College of Nursing believes this is a sensible and appropriate requirement allowing for professional organisations and other stakeholders to comment.

 

Views on the requirement for Welsh Minister’s to review the operation and effectiveness of the Act

 

32.        With regards to Section 3 of the Bill the Royal College of Nursing agrees that Welsh Ministers should be required to review the operation and effectiveness of the Act once it has been enacted.  The only way the effectiveness of the Act can be discovered is via a reporting mechanism and as the Welsh Ministers are responsible for the NHS in Wales this appears to be an appropriate mechanism.  The first report would allow the Royal College as well as this Committee the opportunity to compare mortality rates and other indicators pre-legislation to those in the first year of the Act.

 

Views on the effectiveness and impact of the existing guidance

 

33.        As mentioned above, the Royal College of Nursing believes that the All Wales Nurse Staffing Principles Guidance issued by the CNO in 2012 has failed to have the desired impact and will continue to do so. We believe that the guidance lacks the ‘teeth’ that legislation and statutory instruments provide.  This legislation can be compared to the legislation to ban smoking in public and the ensure wearing of seatbelts in cars. In both of these cases knowledge about the benefits of not smoking and of wearing a seatbelt was widespread but the existence of legislation improved both the behaviour of individuals and that of organisations. This legislation will impact positively on public wellbeing and the patient experience.  

 

 

 

View on balance between what is included on the face of the Bill and what is left to subordinate legislation and guidance

 

34.        The Royal College of Nursing feels that the balance between what is included on the face of the Bill and what is left to subordinate legislation and guidance is appropriate.  By excluding specific numbers from the Primary legislation, Welsh Ministers are given the flexibility to increase the scope of the legislation, by making it applicable to more areas and to update the ratios if academic evidence shows the need for them to change.  This flexibility will save time and money and ensure that Wales is able to provide the Safe Nurse Staffing that patients in Wales deserve.