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 Unison Cymru Wales – SNSL(Org) 06 / Tystiolaeth gan Unison Cymru Wales – SNSL(Org) 06

Safe Nursing Staffing Levels Bill

UNISON Cymru Wales written evidence (January 2015)

Introduction

UNISON is the UK’s largest healthcare union with over 400,000 members working in the NHS.  In Wales, UNISON represents 35,000 members providing NHS services.  Our health members are nurses, student nurses, midwives, health visitors, healthcare assistants, paramedics, community care workers, cleaners, porters, catering staff, medical secretaries, clerical and administration staff and scientific and technical staff.

Unless there is a mandatory minimum, quality patient care will suffer.  Over 90% of respondents in UNISON’s 2013 staffing levels survey said they support mandatory minimum staffing levels, but it has to be acknowledged that quality is more important than quantity; staff numbers are only part of the problem.    We believe that compassionate care would not only benefit the patient but also the working lives of our members.

General

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

UNISON believes that there should be a legally enforceable minimum nurse to patient ratio.  We support and recognise the role which workforce planning tools have to play in helping organisations identify the right levels, but the use of these must be mandatory and, in the absence of this, the default position should be a legal minimum.

UNISON Cymru Wales has extensively sought the opinions of our members about the Bill, as we believe ongoing consultation with staff on the ground is crucial. Our Welsh members are overwhelmingly in favour of mandatory minimum nurse staffing ratios as they believe that this is the only way to provide a better quality of service for patients, increase staff morale and increase satisfaction in the workplace. For example, some of our members have described scenarios where they have had to oversee 26 patients in acute areas at one time. This is not only clinically for patients, but also a dangerous working environment for staff.

Our UNISON survey in 2013 found that an alarming 45% of nurses were caring for eight or more patients on their shifts which highlights the need for a safe staffing levels bill.  Validated workforce planning is effective in producing safe staffing levels as it is predictive, rather than retrospective and takes into account the fluctuations among the Local Health Boards.  It is known that hospitals are the busiest at the weekends and on Mondays, when they are dealing with the backlog of pressures from the weekend’s admittances.  A workforce planning tool would take into account these issues and therefore could weigh staffing levels differently at the weekend to during the week.  On the other hand a legislated ratio is static and does not take these factors into account.  UNISON welcomes the reference to validated workforce planning tools in the Bill under Clause (6), but argues that further work needs to be undertaken to decide whether they can be used further.

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

As highlighted in our original consultation response UNISON believe that, as the proposed application of safe staffing levels doesn’t apply to all staff in every health care setting, it detracts from the overall impact and purpose.  From our perspective, this is a signification omission and we are disappointed that the Bill does not develop the point further.  Extending application to all healthcare staff would allow our dedicated and hardworking members, in all pay bands and in all clinical areas, the time to provide the high level of care they desire, in a safe environment that engenders compassion.

We welcome that the Bill does make reference to healthcare support workers but this definition needs to be tightened up in several regards.  The application of ratios of health care workers, other than nurses, should be applied to safe staffing levels in adult care in acute hospitals and beyond. Our members have described situations in which nursing staff are drawn away from clinical duties to undertake basic cleaning duties.   Similarly, if inadequate numbers of clerical staff in medical records or wards are employed, nurses end up being diverted from their clinical tasks to clerical duties. 

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

The chief barrier to successful implementation of the Bill and consequential improvements in the Welsh health care system would be the adoption of unrealistic nurse staffing ratios. 

UNISON advocates a 1:4 nurse to patient ratio as we believe this will provide the best quality patient care at all times.  Studies have shown that there are better clinical outcomes with a ratio of 1:6 or lower and that harm starts to occur when nurses are caring for 8 patients or more, although, clearly, “one size does not fit all”.  Therefore, each ward/clinical area must be assessed for its particular appropriate staffing levels both in the day and at night. 

Moreover, by only applying a safe staffing ratio to nurses the Bill does not adequately consider the pressure on nurses’ duties that are the consequence of inadequate numbers of other healthcare workers, e.g. domestic and clerical staff as previously stated.

The Safe Staffing Alliance, of which UNISON is a member, recommends that nurses must at all times be supported by a sufficient number of healthcare assistants. Yet, the Bills’ priorities remain solely focussed on the employment of qualified nurses, often at the expense of Healthcare Assistants.  Whilst UNISON welcomed the additional £10 million given by Welsh Government to Health Boards for the employment of additional nursing staff, we have seen examples of Health Boards in Wales downgrading Healthcare Assistants’ posts to pay for additional qualified nurses.  This is not acceptable and means that qualified nurses are not getting the appropriate level of support to enable them to undertake their duties effectively.

Q: Are there any unintended consequences arising from the Bill?

On no account should the Bill lead to a ‘plug gap’ situation where staff are robbed from one unit and moved into the inpatient adult acute sector.  

The majority of our members believe that there should be a requirement in the legislation for “protected time”, for staff training and development built into nurse staffing ratios.  Currently there are too many incidences when staff are pulled off mandatory training days to cover sickness on the ward, leaving those staff without the training they need.  It should not be an unintended consequence that the Bill increases such situations.

Q: The duty on health service bodies to have regard to the importance of ensuring an appropriate level of nurse staffing wherever NHS nursing care is provided?

UNISON agrees with Clause 2.5 (b) ‘allow for the exercise of professional judgement’ as NHS employees are often in the best position to know when systems in the Service are working efficiently and therefore when an appropriate level of nurse staffing is provided. 

Education is a crucial force in the protection of both the patient and the worker.  Aiken et al. 2004 found that a 10% increase in employment of degree-level educated nurses led to a 7% reduction of an inpatient dying.   Increased staffing levels would also alleviate the pressures on practice placement settings, which would make it easier for nurses to dedicate time to support students.  This would also benefit the health community at large.