- Email: [email protected]
Outcomes of variation in hospital nurse staffing in English hospitals: A lesson for policy makers
ARTICLE IN PRESS
International Journal of Nursing Studies 44 (2007) 167–168 www.elsevier.com/locate/ijnurstu
Guest Editorial
Outcomes of variation in hospital nurse staffing in English hospitals: A lesson for policy makers Keywords: Workforce planning; Nursing outcomes; Nurse staffing
The manic-depressive pattern continues—and, amongst health care systems, the British National Health Service (NHS) is a prime sufferer. One moment the NHS is scouring the world for nurses. The next moment it is cutting back on posts and training places. A mood of optimism is replaced by a mood of pessimism. So it has been throughout the history of the NHS. Labour force planning, for both nurses and doctors, has been consistent only in being inconsistent, with sudden swings between expansion and retrenchment. However, the latest swing towards retrenchment has been unique in at least one respect: it has taken place at a time when money is pouring into the NHS as never before. A minor blip in the NHS’s finances—with the problem concentrated, as British Government Ministers kept on insisting, in a small minority of NHS health care provider organisations (Trusts)—produced a major fiscal panic. The spectacle of panic among plenty is, in itself, worrying. It is hardly calculated to enhance confidence in NHS management or to improve the morale of those working in the service. But worry is compounded when the effect of a temporary fiscal embarrassment is to put the future at risk: the predictable and inevitable result of cutting training places for nurses. The folly of such a manic depressive pattern of policymaking should be self-evident. But should there be any lingering doubts, these should be dispelled by the study reported by Rafferty and colleagues in this issue (Rafferty et al., 2007). This shows that there is indeed a direct, statistical link between nurse staffing levels and patient outcomes. Hospitals in England with the best staffing levels in the sample studied had the lowest mortality rates. In short, better staffing means fewer patients dying. Conversely, if unsurprisingly, lower staffing levels were associated with a high rate of job dissatisfaction and burn-out among nurses. In short, patients treated in hospitals with lower staffing levels not
only face higher risks of poor outcomes but also are likely to be looked after by disgruntled or demoralised nurses—not a recipe for maintaining high standards of patient care. These findings are a challenge to British policy makers and should command widespread attention amongst health care policy makers internationally. The study is distinguished by the rigour and sophistication of its methodology. It is part of an international collaborative research enterprise, where evidence from other countries sustains and reinforces the conclusions drawn from the English sample. Above all, it is ground-breaking in exploring the relationship between nursing staff levels and mortality. There is general acceptance that the quality of nursing is the key to the patient experience in hospital (Black, 2005). There is evidence, too, that the higher the proportion of qualified nurses, the higher is patient satisfaction and the better the performance on such quality of care indicators as the incidence of pressure ulcers (Healthcare Commission, 2005). There would probably also be agreement that it is better to be nursed by a contented, stable staff than by a revolving cast of agency nurses. But what has been lacking so far is hard-currency evidence about what matters most for patients like myself: the chances of surviving hospitalisation alive. This is what Rafferty and her colleagues have delivered. If staffing levels are cut, if training places are trimmed back, then British Government Ministers and managers can be challenged as to whether they have thought through the consequences of their actions in terms of the risks to patients, present and future. The politics of the debate on nursing numbers have therefore subtly changed: nurses, as well as doctors, now appear to have shrouds to wave. Care must, however, be taken when waving shrouds. The evidence presented by Rafferty and colleagues is strong. The implications, however, are not clear cut. Like all pioneering research, this study opens up a new
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.08.006
ARTICLE IN PRESS 168
Guest Editorial / International Journal of Nursing Studies 44 (2007) 167–168
agenda for debate, analysis and empirical work. In what follows, I discuss some of these questions prompted by the study from the perspective of someone whose interest is in policy analysis and the politics of the NHS but who cannot claim any expertise in the field of nursing. First, there is the economic question, central to all policy making in the NHS and other health care systems. Better nurse–patient ratios may—as the study shows—save lives. But at what cost? When making decisions about what drugs should be prescribed in the NHS, or what procedures should be introduced, the British National Institute for Health and Clinical Excellence looks at the cost per QALY (quality adjusted life years). At present the data required for this kind of analysis, as applied to nursing staffing levels, do not exist. In this case it may be possible to make a rough, back-of-the-envelope calculation about the implied cost of per life saved, on the basis of the figures collected by Rafferty and colleagues. But we know nothing about the quality—or length—of those lives: essential information if we are to move toward a QALY-based estimate, essential if we are to compare expenditure on improving nursing ratios with other, competing claims on the NHS’s resources. So here is one urgent cross-disciplinary research project waiting to be done: the nursing profession has to embrace economics. A similar argument can be made about another finding of the study: the relationship between staffing ratios and staff dissatisfaction and burn-out levels. Here it would seem reasonable to assume that high rates of dissatisfaction and burn-out are linked to high rates of staff turn-over. And high rates of staff turn-over carry costs—such as recruiting new nurses—quite apart from their effect on the quality of care for patients. So, again, it would seem important to test the assumption and to quantify the costs and benefits involved. To what extent do high staffing ratios pay for themselves, because they avoid the costs of staff churning? There is yet a further set of questions which, again from the perspective of a non-expert in the field of nursing, require addressing. These are prompted by what is a key sentence in the paper: ‘‘Shortage is not just about numbers but about how the health system functions to enable nurses to use their skills effectively’’. In other words, we need to know more—much more— about how nurses are deployed and how they apportion their time. How much of their time is spent on direct patient care, as distinct from administrative duties and engagement with their colleagues? Has the proportion of
time spent on direct patient care changed over time and in what direction, and how does it vary between hospitals and wards? Rafferty and colleagues have demonstrated that there is a strong statistical relationship between high staff ratios and improved outcomes, but does this effect hold for all hospitals? Are there individual hospitals in the top quartile of their sample which do not perform as well as might be expected and are there hospitals in the bottom quartile which achieve better than expected outcomes? If so, staff deployment—as distinct from staff levels—might emerge as a key variable. In the NHS, and other health systems internationally, variation in the use of resources is the norm. Nursing is no exception. And nursing is no exception in another respect as well: the NHS has been far too slow to use systematic research designed to see what can be learnt from those variations by studying their effects, costs and benefits. In terms of research funding, nursing has hitherto been short-changed. The funding does not reflect the share of the NHS’s budget spent on nursing and is small change when compared to the money flowing into medical research. In the past, parsimony could be rationalised—if not entirely justified—on the grounds that the nursing profession did not have the capability for conducting hard, scientific research. The paper by Rafferty and colleagues not only prompts a whole raft of research questions about nursing that urgently require an answer. But it also demonstrates that the nursing profession now has the intellectual skills and technical capacity to carry out the rigorous, high quality research required.
References Black, N., 2005. Rise and demise of the hospital: a reappraisal of nursing. British Medical Journal 331, 1394–1396. Healthcare Commission, 2005. Acute Hospital Portfolio Review: Ward Staffing. Healthcare Commission, London. Rafferty, A.M., Clarke, S.P., Coles, J., Ball, J., James, P., McKee, M., Aitken, L.H., 2007. Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. International Journal of Nursing Studies, in press, doi:10.1016/j.jnurstu. 2006.08.003
Rudolf Klein1 Visiting Professor to LSE and School of Hygiene, UK E-mail address: [email protected]
1 Visiting Prof. of London School of Economics and London School of Hygiene, UK.
International Journal of Nursing Studies 44 (2007) 167–168 www.elsevier.com/locate/ijnurstu
Guest Editorial
Outcomes of variation in hospital nurse staffing in English hospitals: A lesson for policy makers Keywords: Workforce planning; Nursing outcomes; Nurse staffing
The manic-depressive pattern continues—and, amongst health care systems, the British National Health Service (NHS) is a prime sufferer. One moment the NHS is scouring the world for nurses. The next moment it is cutting back on posts and training places. A mood of optimism is replaced by a mood of pessimism. So it has been throughout the history of the NHS. Labour force planning, for both nurses and doctors, has been consistent only in being inconsistent, with sudden swings between expansion and retrenchment. However, the latest swing towards retrenchment has been unique in at least one respect: it has taken place at a time when money is pouring into the NHS as never before. A minor blip in the NHS’s finances—with the problem concentrated, as British Government Ministers kept on insisting, in a small minority of NHS health care provider organisations (Trusts)—produced a major fiscal panic. The spectacle of panic among plenty is, in itself, worrying. It is hardly calculated to enhance confidence in NHS management or to improve the morale of those working in the service. But worry is compounded when the effect of a temporary fiscal embarrassment is to put the future at risk: the predictable and inevitable result of cutting training places for nurses. The folly of such a manic depressive pattern of policymaking should be self-evident. But should there be any lingering doubts, these should be dispelled by the study reported by Rafferty and colleagues in this issue (Rafferty et al., 2007). This shows that there is indeed a direct, statistical link between nurse staffing levels and patient outcomes. Hospitals in England with the best staffing levels in the sample studied had the lowest mortality rates. In short, better staffing means fewer patients dying. Conversely, if unsurprisingly, lower staffing levels were associated with a high rate of job dissatisfaction and burn-out among nurses. In short, patients treated in hospitals with lower staffing levels not
only face higher risks of poor outcomes but also are likely to be looked after by disgruntled or demoralised nurses—not a recipe for maintaining high standards of patient care. These findings are a challenge to British policy makers and should command widespread attention amongst health care policy makers internationally. The study is distinguished by the rigour and sophistication of its methodology. It is part of an international collaborative research enterprise, where evidence from other countries sustains and reinforces the conclusions drawn from the English sample. Above all, it is ground-breaking in exploring the relationship between nursing staff levels and mortality. There is general acceptance that the quality of nursing is the key to the patient experience in hospital (Black, 2005). There is evidence, too, that the higher the proportion of qualified nurses, the higher is patient satisfaction and the better the performance on such quality of care indicators as the incidence of pressure ulcers (Healthcare Commission, 2005). There would probably also be agreement that it is better to be nursed by a contented, stable staff than by a revolving cast of agency nurses. But what has been lacking so far is hard-currency evidence about what matters most for patients like myself: the chances of surviving hospitalisation alive. This is what Rafferty and her colleagues have delivered. If staffing levels are cut, if training places are trimmed back, then British Government Ministers and managers can be challenged as to whether they have thought through the consequences of their actions in terms of the risks to patients, present and future. The politics of the debate on nursing numbers have therefore subtly changed: nurses, as well as doctors, now appear to have shrouds to wave. Care must, however, be taken when waving shrouds. The evidence presented by Rafferty and colleagues is strong. The implications, however, are not clear cut. Like all pioneering research, this study opens up a new
0020-7489/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2006.08.006
ARTICLE IN PRESS 168
Guest Editorial / International Journal of Nursing Studies 44 (2007) 167–168
agenda for debate, analysis and empirical work. In what follows, I discuss some of these questions prompted by the study from the perspective of someone whose interest is in policy analysis and the politics of the NHS but who cannot claim any expertise in the field of nursing. First, there is the economic question, central to all policy making in the NHS and other health care systems. Better nurse–patient ratios may—as the study shows—save lives. But at what cost? When making decisions about what drugs should be prescribed in the NHS, or what procedures should be introduced, the British National Institute for Health and Clinical Excellence looks at the cost per QALY (quality adjusted life years). At present the data required for this kind of analysis, as applied to nursing staffing levels, do not exist. In this case it may be possible to make a rough, back-of-the-envelope calculation about the implied cost of per life saved, on the basis of the figures collected by Rafferty and colleagues. But we know nothing about the quality—or length—of those lives: essential information if we are to move toward a QALY-based estimate, essential if we are to compare expenditure on improving nursing ratios with other, competing claims on the NHS’s resources. So here is one urgent cross-disciplinary research project waiting to be done: the nursing profession has to embrace economics. A similar argument can be made about another finding of the study: the relationship between staffing ratios and staff dissatisfaction and burn-out levels. Here it would seem reasonable to assume that high rates of dissatisfaction and burn-out are linked to high rates of staff turn-over. And high rates of staff turn-over carry costs—such as recruiting new nurses—quite apart from their effect on the quality of care for patients. So, again, it would seem important to test the assumption and to quantify the costs and benefits involved. To what extent do high staffing ratios pay for themselves, because they avoid the costs of staff churning? There is yet a further set of questions which, again from the perspective of a non-expert in the field of nursing, require addressing. These are prompted by what is a key sentence in the paper: ‘‘Shortage is not just about numbers but about how the health system functions to enable nurses to use their skills effectively’’. In other words, we need to know more—much more— about how nurses are deployed and how they apportion their time. How much of their time is spent on direct patient care, as distinct from administrative duties and engagement with their colleagues? Has the proportion of
time spent on direct patient care changed over time and in what direction, and how does it vary between hospitals and wards? Rafferty and colleagues have demonstrated that there is a strong statistical relationship between high staff ratios and improved outcomes, but does this effect hold for all hospitals? Are there individual hospitals in the top quartile of their sample which do not perform as well as might be expected and are there hospitals in the bottom quartile which achieve better than expected outcomes? If so, staff deployment—as distinct from staff levels—might emerge as a key variable. In the NHS, and other health systems internationally, variation in the use of resources is the norm. Nursing is no exception. And nursing is no exception in another respect as well: the NHS has been far too slow to use systematic research designed to see what can be learnt from those variations by studying their effects, costs and benefits. In terms of research funding, nursing has hitherto been short-changed. The funding does not reflect the share of the NHS’s budget spent on nursing and is small change when compared to the money flowing into medical research. In the past, parsimony could be rationalised—if not entirely justified—on the grounds that the nursing profession did not have the capability for conducting hard, scientific research. The paper by Rafferty and colleagues not only prompts a whole raft of research questions about nursing that urgently require an answer. But it also demonstrates that the nursing profession now has the intellectual skills and technical capacity to carry out the rigorous, high quality research required.
References Black, N., 2005. Rise and demise of the hospital: a reappraisal of nursing. British Medical Journal 331, 1394–1396. Healthcare Commission, 2005. Acute Hospital Portfolio Review: Ward Staffing. Healthcare Commission, London. Rafferty, A.M., Clarke, S.P., Coles, J., Ball, J., James, P., McKee, M., Aitken, L.H., 2007. Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records. International Journal of Nursing Studies, in press, doi:10.1016/j.jnurstu. 2006.08.003
Rudolf Klein1 Visiting Professor to LSE and School of Hygiene, UK E-mail address: [email protected]
1 Visiting Prof. of London School of Economics and London School of Hygiene, UK.