Costs of staffing for compassionate care

Nicky Hayes is Consultant Nurse for Older People, King’s College Hospital London, formerly RCN Older People’s Advisor 2011-12, author of Safe Staffing for Older People’s WardsNursingStaff

Nursing staffing issues, especially for hospital wards where older people are cared for, are complex and contentious and have not gone away since the RCN published Safe Staffing for Older People’s Wards and Improving Hospital Care for Older People – A Call for Action. These publications were the first to identify actual staffing levels specific to older people’s wards and to correlate these with nurses’ reports of whether satisfactory, safe care could be delivered during their most recently worked shift.

Contrary to criticism at the time, the Safe Staffing report did not recommend mandatory minimum staffing levels, but did identify the staffing threshold below which aspects of essential care could not be completed. Top of the list were comforting and communicating with patients, which was reported as compromised  by 78% of nurses. Focus-group work confirmed that many nurses are distressed at being unable to meet this need due to the pressure of tasks and lack of staff.

Comforting and communicating with patients and their families is a vital component of compassionate care, highly valued by patients and families and, as the government’s response to Francis reminds us is enshrined in the NHS Constitution:

“Compassion. We ensure that compassion is central to the care we provide and respond with humanity and kindness to each person’s pain, distress, anxiety or need. We search for the things we can do, however small, to give comfort and relieve suffering. We find time for patients, their families and carers, as well as those we work alongside. We do not wait to be asked, because we care.”

Unfortunately this promise is not always met. The recently published Clwyd and Hart report into NHS complaints  recognised lack of time as one of the contributing factors to dignity and compassion related problems:

“Many people said that staff frequently did not (or could not) make time to speak to patients in a friendly or concerned way. This was not what they expected from staff providing their care. As a result, minor needs or concerns that could have been resolved promptly or courteously, might be neglected until they turned into major problems or formal complaints.” (page 16)

Compassionate care is essential, and does not come free. It is an integral component of professional, skilled care, but remains under-recognised and is insufficiently resourced. There is a pressing challenge to find appropriate measures and evidence to support the cost of staffing our wards adequately to deliver it. The Government’s response to Francis fails to adequately address this, merely directing NICE to produce ‘independent and authoritative evidence based guidance on safe staffing, and (will) review and endorse associated tools for setting safe staffing levels in acute settings’. If the tools currently in use were fully effective in capturing the time needed to deliver care with compassion, that meets the expectations of patients and staff then there really would not be a problem to be addressed. It’s difficult to capture the subjective nature of patient experience and attempt to quantify the contribution of caring, compassionate communication aspects, but in order to cost out care and staff appropriately, we must develop measures that can rank alongside infection control, pressure sores and falls on hospital’s quality dashboards.

Mandatory staffing levels are not a complete solution and are indeed a blunt instrument, as many commentators have pointed out. The solution recommended in Safe Staffing for Older People’s Wards was one of flexible staffing, responsive to the peaks and troughs of demand, informed by empowered ward sisters/charge nurses, and underpinned by staffing that exceeds the threshold below which we know that care is left undone. Currently that threshold is 8 staff for 28 patients.

The Government’s proposal for publication of staffing levels, whilst welcome, will not capture the nuances of daily fluctuations in demand that face front line nurses nor their capacity to offer the levels of comfort and caring that patients value. The robustness of data is likely to be open to question, and there is a danger of it becoming another beaurocratic exercise.

If we want to do more than pay lip service to the issues around compassionate care, there must be a concerted attempt to define and quantify the value of compassionate and to staff our wards accordingly.

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