It has been a grim week for nursing in England. The long awaited Francis Inquiry into failures of care at Mid Staffordshire Foundation Trust (known as Mid Staffs) between 2005-2009 made swingeing criticisms of the whole of the NHS, drawing conclusions that patients were “routinely neglected by a Trust that was preoccupied with cost cutting, targets and processes”. The problems were found to be pervasive and systemic, and “that a chronic shortage of staff, particularly nursing staff was largely responsible for substandard care”.
This leaves me with feelings of deep shame, because it was nurses who failed so many patients with a callous disregard for fundamental needs such as basic hygiene and having enough to drink. Whatever the reasons whether it was poor leadership, or a management culture that prioritised financial performance over people, the reality is it should never have happened and nursing as a profession is left deeply humiliated and scarred. There will be countless challenges in the months to come exhorting nursing to care more and to study less, to do more with less, be better ward leaders with expanding armies of untrained and unregulated health care assistants. But the question that bothers me most is the apparent silent collusion and why nurses and others stood by?
Francis rightly points to the staff shortages and of course there is growing evidence that having the right staff in the right numbers is linked to patient care outcomes. Authoritative studies done by Linda Aiken and her team in the United States have contributed to building evidence that shows lower registered nurse staffing levels are associated with adverse outcomes for patients and that patients with high dependency needs increase workloads for nurses and doctors (Aiken et al 2002). Studies using similar approaches have been done in the UK and have shown that mortality rates were higher in hospitals with fewer nurses (Rafferty et al 2007), which builds on Jarman et al’s (1999) earlier work. Although this is useful research it raises questions as to whether you can isolate the impact of nurse staffing from that of the wider health care team and other factors such as case mix.
The gross neglect in the Mid Staffs scandal was found in wards with high proportions of older people. It is typically these areas in the NHS, which are poorly staffed with the least well trained in comparison to high end acute care such as intensive care or paediatrics. Nursing is demanding and difficult work requiring investment of emotions and energy. When nurses get to the end of their tether and feel no longer able to do the job properly they can withdraw and behave in negative and defensive ways, which leads to poor practice. This was described by Isabel Menzies Lyth (1988) who observed that organisations as social systems can create anxiety and feelings of fragmentation for nurses working within them, and this can lead to failures of care or as Francis (2013) calls it “loss of a moral compass”, which in turn compounds the distress associated with low job satisfaction and turnover (de Veer et al 2013).
While there are no excuses for what happened in Mid Staffs, I fear more failures of care will arise if we neglect the evidence that nursing numbers contribute to patient outcomes and if we overlook the importance of paying attention to nurses themselves and their emotional wellbeing as they deal with increasingly complex challenges in a rapidly changing health care system.
This week’s blog entry is written by:
Professor Fiona Ross, Dean of Faculty of Health, Social Care and Education, Kingston University and St George’s, University of London
Aiken L., Clarke S., Sloane D et al (2002) Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. Journal of the American Medical Association 288 (16) 1987-1993
De Veer A., Francke A., Stuijs A., Willems D., (2013) Determinants of moral distress in daily nursing practice: a cross sectional correlational questionnaire survey. International Journal of Nursing Studies 50 (1) 100-108
Francis Inquiry (2013) Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005-March 2009 (Chaired by Robert Francis) HMSO
Jarman B., Gault S., Alves B et al 1999 Explaining differences in English hospital death rates using routinely collected data. British Medical Journal 318, 7197 1515-1520
Menzies Lyth, Isabel. “The Functioning of Social Systems as a Defence against Anxiety”, in Containing Anxiety in Institutions, Free Associations, London, 1988. pp 43-85.
Rafferty AM, Clarke S, Coles J et al (2007) Outcomes of variation in hospital nurse staffing in English hospitals, cross sectional analysis of survey data and discharge records. International Journal of Nursing Studies 44 (2) 175-182