A “nursing shortage” is having an impact on the care of elderly people, and nurses are “too busy” to help elderly patients with basic care, according to TV, radio and print news sources today. This news is based on a Royal College of Nursing (RCN) report on safe levels of nursing staff for older people’s wards.

The RCN report set out, for the first time, its recommended staffing levels; below which it said care becomes compromised on older people’s wards. The RCN said that most hospitals do not meet this safe level of care. Older people’s wards regularly have a shortage of nurses and healthcare assistants, and an inappropriate skill mix of these two types of staff, it found.

This report sheds light on discrepancies between the nursing care of older people and the care of children and younger adults and may set new expectations for hospital nursing care. As well as nursing staffing levels, other factors are also likely to contribute to influence the overall quality of the care of older people in hospital.


Where did the report come from?

These reports are based on guidance and recommendations issued today by the Royal College of Nursing (RCN). The guidance relates to the provision of good quality, compassionate and safe nursing care for older people in hospital. It was developed from different sources, including:

  • the results of a survey of nurses who work on older people’s wards
  • nurse focus groups
  • a panel of expert nurses from across the UK
  • consultation with stakeholders
  • a review of the literature.

The report identified the issues in caring for older people in hospital and sets out what is needed to meet the expectations of patients, nurses and the public.


What did the survey of nurses look at?

The RCN has not released details of the survey, but its press release said that the survey included almost 1,700 nurses, 240 of whom were working on wards for older people.


What staffing levels did the RCN find?

The RCN reported that their work has found that older people’s wards have a different skills mix to other wards, with fewer registered nurses per patient:

  • older people’s wards have between 9.1 and 10.3 patients per registered nurse
  • adult general, medical and surgical wards have 6.7 patients per registered nurse
  • children’s wards have 4.2 patients per registered nurse

Currently on older people’s wards there are:

  • a 50:50 mix of registered nurses to health care assistants
  • one member of staff per 4.6 patients
  • three registered nurses for a typical 28-bed ward
  • six nursing staff on duty for a typical 28-bed ward

The RCN also said that older people’s wards which have fewer registered nurses have more episodes of missed or compromised care reported.


What impact do these shortages have?

The RCN said that these findings means that caregiving may be being inappropriately delegated, with few registered nurses feeling that they have time to supervise health care assistants (HCAs) properly. It said that this means that there is not enough time and skill to provide activities such as comforting and talking with patients in a satisfactory way.

The RCN also asked nurses what effects lack of time had on patient care. The nurses reported a range of tasks not done or done inadequately in their last shift due to lack of time, including:

  • comforting or talking to patients: 78%
  • promoting mobility and self care: 59%
  • oral hygiene: 48%
  • falls prevention: 45%
  • sufficient change of patient’s position: 41%
  • information giving to patients and families: 38%
  • helping patients with food and/or drink: 34%
  • helping patients use the toilet or manage incontinence: 33%
  • preparing patients and families for discharge: 30%
  • skin care: 30%
  • pain management: 19%
  • care for dying patients: 17%


What recommendations does the report make about staffing levels and skills mix?

The RCN report did not recommend a universal minimum staffing level; preferring senior nurses in each ward to have the final say. It also noted that evidence relating to older people’s wards indicates that there is a threshold of staffing numbers, below which care is compromised. It went on to outline recommendations for the skills mix and staffing levels required for basic safe care, and also for ideal, good quality care in older people’s ward.

For basic safe care, the RCN recommended:

  • a 50:50 mix of registered nurses to health care assistants
  • at least one registered nurse per seven patients
  • at least one member of staff per 3.3 to 3.8 patients
  • at least four registered nurses for a typical 28-bed ward
  • at least eight nursing staff on duty for a typical 28-bed ward

The recommendations for ideal, good quality care are:

  • a 65:35 mix of registered nurses to health care assistants
  • at least one registered nurse for every five to seven patients
  • at least one member of staff per 3.3 to 3.8 patients
  • four to six registered nurses for a typical 28-bed ward
  • at least eight nursing staff on duty for a typical 28-bed ward

These numbers exclude the ward sister or senior charge nurse, who is in a supervisory role. The RCN also said that the ward sister or senior charge nurse must be the final arbiter of whether the staffing for that day is appropriate for the specific needs and case mix of patients on the ward.


What other recommendations does the report make?

The RCN’s report also recommended that:

  • Safe day-to-day staffing levels for older people’s wards should be determined locally, following principles that are set out in the 2010 RCN document, “Guidance on Safe Staffing Levels in the UK” but with specific considerations relating to the nature of care for older people with complex needs.
  • Strong nursing leadership for older people’s wards.
  • Wards should have sufficient professional staffing and support at patient meal times to ensure that all patients who need assistance with food and drink receive it.
  • Appropriate training in the knowledge and skills to care for older people must be available to all nurses at both pre- and post-registration levels, and to health care assistants and assistant practitioners, appropriate to role
  • The ward sisters or senior charge nurses must have both a determining influence in selecting staff for their teams, and adequate administrative and human resources support for nurse recruitment.
  • Healthcare measurements must recognise the “full nursing contribution”, including compassionate care, communication and its impact on patient experience and outcomes.


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