On this blog, we’ve attempted to highlight the issue of nurse: patient ratios, and the extent to which understaffing of hospital wards puts patients at risk.
One thing we highlighted was the increased risk of hospital-acquired infections when wards are understaffed. We pointed to the body of published research evidence that shows that higher the ratio patients to nurses, the more likely the risk was of patients developing a HAI.
This point has been shown dramatically – and tragically – in the 90 deaths that occurred in the Clostridium Difficile outbreak at Maidstone and Tunbridge Wells NHS Trust.
The Healthcare Comission’s report into the outbreak (PDF file) makes for pretty grim reading. It also shows how nurse understaffing contributes to the spread of HAIs. Although staffing was not the only issue, it is one that was singled out by the Healthcare Commission as one of the core reasons for the outbreak.
Information from nurses, other clinical staff, patients and families, and from reported incidents and complaints, indicated that shortages of nurses contributed to the spread of infection because they were too rushed to undertake hand hygiene, empty and clean commodes, clean mattresses and equipment properly, and wear aprons and gloves appropriately and consistently.
The effects appear to have been horrendous. To quote one passage:
when patients rang the call bell because they were in pain or needed to go to the toilet, it was not always answered, or not in time. A particularly distressing example reported to us was of nurses telling patients on some occasions to “go in the bed,” presumably because this was less time-consuming than helping a patient to the bathroom. Some patients were left, sometimes for hours, in wet or soiled sheets, putting them at increased risk of pressure sores. Families claimed that tablets or nutritional supplements were not given on time, if at all, or doses of medication were missed. Wards, bathrooms and commodes were not clean and patients had to share equipment such as zimmer frames which were not cleaned between use.
Reports of nurses telling patients to “go in the bed” rather than in the toilet really make for unpleasant reading, and as a nurse I can’t say it exactly makes me feel pride in my profession. However, before leaping to slam nurses I’d just like to highlight some of the pressures that have come about from a combination of the NHS targets culture and the freezing of nurse recruitment due to the budget deficits crisis.
Particularly, I’d like to draw attention to some comments made by Nurse Anne (author of the Militant Medical Nurse blog, which I really can’t recommend enough) on the comments thread to a post by NHS Blog Doctor.
My ward is 35 beds general surgery, general medical, high dependency as well as 10-15 care of the elderly beds. We get one nurse and one or 2 assistants anymore that it is. Five years ago it was 4 and 3 and all the patients were taken care of. Now I can’t even do a drug round without constant interruptions. If mulitple patients start going downhill there is no one else to see to the others.
Often I am alone with 12 feeds,10 confused patients who are fall risks and climbing out of the beds as well as people who are acutely ill….drug rounds, admissions, discharges, 20 calls per hour from relatives of all my patients. Targets have led us to not having a ward clerk anymore.
A drop from 4 RNs and 3 HCAs on the ward to one RN and 2 HCAs. It really doesn’t take much imagination to realise that such a dramatic reduction in staff will result in patients suffering. Quite likely, some of them will die unnecessarily.
This why standards of nursing care are deteriorating. Not because all the nurses are swanning off to become nurse practitioners. Not because student nurses learn too much sociology. Not because whatever is going to be next week’s trendy excuse for gratuitous nurse-bashing, but the simple mathematics of numbers of boots on the ground (or crocs on the ward floor if you prefer).
A number of trusts have slashed nurse recruitment in an attempt to reduce their deficits. Whether they will actually save any money from this is dubious. Not once you’ve factored in the additional financial costs of dealing with an increase in hospital-acquired infections because nurses don’t have time to clean, malnutrition because patients aren’t getting fed properly, pressure ulcers because patients aren’t turned regularly and are left to stew in their own body fluids, extra complications because nobody noticed that a patient was starting to deteriorate…and that’s before the enraged relatives starting suing the trust.
Oh, and apart from the financial issue there might be some trivial stuff about actual humans suffering and dying, but as we all know, that’s not nearly as important as the balance sheet.
My own trust, I’m happy to say, hasn’t been hit nearly as bad by the deficits crisis as some. One thing I’ve noticed as a result is a sharp increase in nurses moving to our area to work, because they can’t find work where they currently live. Moving around to work is de rigeur for doctors, but for nurses it’s not so usual as in the past it’s always been fairly straightforward for a nurse to find a job locally. That seems to have changed now.
So, the likes of Nurse Anne have to struggle with insane levels of understaffing, while on the other side of the hospital gates willing recruits have to move to other areas to find jobs. And in the meantime, patients continue to suffer.
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