High quality nursing care: Staff numbers + Management + Complexity = Goat (Rabbit or Duck)?

When did someone last get your goat?

For me I owe a vote of thanks to Mr Harry Cayton in the (print) Health Service Journal, 2012

 The wrong answer to the wrong question. 

I know it's hard to believe, but I've been simmering for a year and a half; especially watching, listening and reading about the NHS and the state of nursing in the media.

The subtitle of this short opinion piece (p. 16-17) reads:  

"There is no direct link between staff numbers and care quality, 

so a minimum staff ratio is a fig leaf performance measure." 

Online it is: 15 March 2012 'Mandating staffing levels is not the answer to reducing poor care'
 - so you get the gist...?

As a nurse, the subtitle did its trick, it rubbed against the whole tree of experience, not just a branch or two.

It is a long time since I was a deputy charge nurse on what was then 'psychogeriatrics'. Relatives would arrive on the ward for the first time and start to weep. We had to reassure and demonstrate that we cared not just in words, but actions: nursing care. We got things wrong: teeth, clothing. ... A variety of 'lists' and books signified institutional care. That Victorian institution is no more, this is progress. The change has been amazing. It is also a long time since I was a charge nurse on acute female admission. The thing is numbers always counted. How many times did we, the team, wonder what we could have done with another two, or four hands? Within mental health care risk is a positive and negative companion to all our patient contacts. There may be confusion in numbers, but there is safety too.

You know that numbers do count.

As Mr Cayton points out - poor management is a primary factor in poor care. He quite rightly refers to the complexity that arises. As I have posted here several times, staff attitudes and skills are central to the quality of care that follows. Mr Cayton highlights the same.

If evidence based health care is so powerful why are we still deliberating upon this?

This isn't just complex, it's complex as in complexity science. In the late 70s - 80s and even today there is discussion of dependency and workload measures. There is a real illusion at work.

As a nurse in this context you recognised the limitations of know thyself. You have to know yourself, especially: can I delegate effectively? Am I a manager's manager? How can I balance the office and the ward?

The limitation is: do I know my team? Since the 1980s I wonder how well ward managers know their team. What is the impact of agency workers - nursing and medical? How has this workforce development influenced the work and performance of the FY1s (foundation - first year doctors)?

We ensured we had covered the 'basics' as comprehensively as we could. Everyone was safe, warm, clean, skin clean and intact, dressings completed, fed, watered, given a smile, (if possible) gave a smile and as much reassurance as could be provided. Any care outstanding was reported to the next shift to ensure it was completed as a priority.

Returning to the question of evidence and the illusory, chimeric character of this debate. There is a great post-grad student essay on the relative and normative dimensions of nursing staffing to be written. Health services must wrestle with standards, local responsiveness, person-centredness, outcomes and umpteen other requirements in care delivery. If funding (staffing!) results in nurses having an arm tied behind their back, perhaps mandated staffing levels does the same for managers?

There is undoubtedly much to consider in relation to the equations that abound in staffing numbers and quality of care. As we think of trees of knowledge,  experience and branches, let's remember the leaves; everyone unique.

Update: 24 Aug 2013
News, Health Service Journal, 23 August 2013, Minimum safe staffing work yet to begin, 123, 6364, p.7. 123

"We need tools that are relevant to the care environment; we need leadership locally that has the resources and responsibility to meet the levels the tools are demanding and we need some degree of professional responsibility and decision making at ward level."
(Prof. Jim Buchan)

Additional links:

Policy Unit. Royal College of Nursing (2010) Guidance on safe nurse staffing levels in the UK
http://www.rcn.org.uk/__data/assets/pdf_file/0005/353237/003860.pdf

Safe Staffing Alliance

Kay, J. (2013). Making the case for more nurses, Health Service Journal, 123, 6355, 30-31.

Donnelly L., Mulhern, M., NHS pays £1,600 a day for nurses as agency use soars, The Telegraph, 14 Jul 2012.

http://hodges-model.blogspot.co.uk/2013/03/bbc-horizon-ii-processes-step-this-way.html

26/02/2014:
New [Lancet] study shows degree level nursing education cuts unnecessary hospital deaths
http://www.councilofdeans.org.uk/2014/02/new-study-shows-degree-level-nursing-education-cuts-unnecessary-hospital-deaths/#comment-28