Friday, 13 September 2019

Aligning Safe Staffing with Patient Safety: Is this Two Sides of the Same Coin?

Catherine Best
Queen’s Nurse
Chair RCN Yorkshire and Humber Regional Board

In the second of 2 articles Catherine Best critiques the importance of understanding Human Factors in ensuring the delivery of safe and effective care.

On 17th September 2019 we celebrate the very first World Patient Safety Day.

Research undertaken by Dr Linda Aiken and others has identified a strong link between, nursing skill mix and improved patient outcomes:

‘We find a nursing skill mix in hospitals with a higher proportion of professional nurses is associated with significantly lower mortality, higher patient ratings of their care and fewer adverse care outcomes’ (Aiken et al. 2016).

Nursing research has also identified an increased risk of patient mortality, during hospital admissions when nurse staffing levels are reduced and there is a reliance upon nursing support staff to cover the shortfall.

The Royal College of Nursing (RCN) report Nursing on the Brink makes their position clear:

‘Having the right number of registered nurses and nursing support staff with the right knowledge, skills and experience in the right place at the right time is critical to the delivery of safe and effective care for patients and clients’.

With Westminster demonstrating a lack of accountability in ensuring safe nurse staffing levels, many see this as a flagrant lack of commitment to a nursing workforce that is teetering on the edge. The RCN is calling on parliament, not only to ensure accountability for staffing becomes the domain of the Secretary of State for Health and Social Care but also that accountability for the health and care workforce is firmly enshrined in English law.

Encouragingly legislation has been passed in both Wales and Scotland, which goes some way to making safe staffing a reality, but What about England? What about Northern Ireland? Nurses who take the fight to the doorstep of Westminster, must be prepared to be in this for the long haul, for history demonstrates that what we do today, requires patience, resilience and a sense of determination to succeed. This understanding however, should not dampen the spirits of any nurse who finds themselves working in understaffed clinical areas, for every great achievement must begin by taking the very first step. In the meantime, while we campaign for safe staffing levels to be enshrined in English law, what can nurses do to reduce the significant challenge to maintaining patient safety?

Find your voice and speak up 
It is not simply the role of nurses to speak up, but all healthcare professionals. Freedom to speak up was introduced following a 2015 review into whistleblowing practices within the NHS, the aim of which was to create a culture shift in the way in which safety issues are addressed ultimately reducing the need to ‘whistle blow’.

Disappointingly the continued culture of blame in the NHS fails to consider the consequences of poor staffing levels, inadequate skill mix and continued lack of investment. With the RCN demonstrating the impact of the loss of the nursing bursary and the cumulative effect of 40,000 nursing vacancies in England alone, nurses are being increasingly challenged in their attempts to ensure the delivery of safe and effective care. And when mistakes do happen, the impact can be devastating, not only for patients, carers and families but also for those healthcare professionals involved. Creating a just culture in healthcare settings is as important as ensuring safe staffing is enshrined in legislation. Nurses should not fear the stigma of blame when things go wrong; instead they should be encouraged to speak up in order to reduce the associated impact and for valuable lessons to be learned. It is however important to note, that a just culture does not absolve nurses of their accountability to deliver safe and effective patient care, simply that a fair and honest approach is taken.

The significant shortage of nurses is now considered to be affecting patient care and threatening lives. One way in which nurses can find their voice is by contributing to the 100 voices campaign. By sharing experiences, reflections and actions, nurses can contribute not only to the educating of others but also in ensuring lessons learned are encased in policy and health care reform. 

Pursue Learning Opportunities When Jeremy Hunt the then Secretary of State for Health declared in the report Building a Knowledge enabled NHS for the Future that:

‘The world’s fifth largest organisation needs to become the world’s largest learning organisation’. 

he was absolutely right.

However, when crisis after crisis continues to plague the NHS, as evidenced in the recent Whorlton Hall abuse scandal it is a strong reminder of the polemic approach that governments take when responding to any crisis.

Improving patient safety through education and training is recognised as an essential requirement and in recent weeks the government has gone some way to improving funding for continuous professional development for nurses, but this is only skimming the surface. More commitment is needed to ensure the future of nursing is guaranteed, throughout all sectors and in all specialties. A lack of funding for pre-registration nurse education has been cited as a reason for the reduction in the number of students entering nurse training. If the government is to be congratulated for their commitment to ensuring high quality patient care, then investment in the nursing workforce is crucial.

Demonstrate Strong Leadership
Strong leadership in nursing is considered one of the most important aspects of ensuring safe and effective care. All nurses have the capacity to lead; crucially however nurses must also have the ability to reflect and act in dynamic situations, not only to ensure that patient safety is maintained but that risks are identified quickly and service delivery transformed.

Nurses have a unique role to play in encouraging other nurses to speak up when they have concerns. All nurses have both a duty of candour and a responsibility for ensuring continued patient care and this cannot be achieved by nurses who are afraid to speak up and act. Supporting individual nurses with a degree of compassion and understanding when things do go wrong can make the difference between someone returning to work or not, staying in the profession or leaving or in some severe cases even prevent nurses from taking their own life. Errors in general occur as a result of bad systems, not bad people. Whether you agree with this or not is a matter of personal belief, however what is clear is that mistakes occur as a result of a very complex chain of design, systems, inadequate training and human factors.

In today’s turbulent healthcare climate, the responsibilities placed on nurses, is overwhelming. Nurses are no longer able to guarantee the delivery of safe and effective care, perhaps we never could, but we can continue to raise awareness of the impact that poor staffing, poor levels of skill mix and a lack of appropriate education and training can have on patient care. To do this may instil a sense of hope that things can be different.

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