Tag: Management

Nurse -patient ratios – what is the evidence?

Peter Griffiths of Southampton University wrote on the researchgate site:

“…..this is an area with a massive literature. The positive association (between more nurses and better patient outcomes) has been demonstrated against a range of quality and safety measures – primarily safety. Linda Aiken is not the only researcher in the area but possibly the best known. 

Try : Kane, R.L., Shamliyan, T.A., Mueller, C., Duval, S., Wilt, T.J., 2007. The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis. Medical Care 45 (12), 1195-1204 1110.1097/MLR.1190b1013e3181468ca3181463.

…for a comprehensive if slightly dated overview of the safety literature.

Recent reports from the RN4CAST study show associations with other outcomes e.g.:

Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E., Griffiths, P., 2013. ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality & Safety.

Aiken, L.H., Sermeus, W., Van den Heede, K., Sloane, D.M., Busse, R., McKee, M., Bruyneel, L., Rafferty, A.M., Griffiths, P., Moreno-Casbas, M.T., Tishelman, C., Scott, A., Brzostek, T., Kinnunen, J., Schwendimann, R., Heinen, M., Zikos, D., Sjetne, I.S., Smith, H.L., Kutney-Lee, A., 2012. Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. British Medical Journal 344.

Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Sermeus, W., 2013. Nurses’ reports of working conditions and hospital quality of care in 12 countries in Europe. International Journal of Nursing Studies 50 (2), 143-153.

…although limited as they are all self report.

The translation of this to specific ratios is difficult – largely for the reasons highlighted above and the evidence on that policy is less clear cut. Try

McHugh, M.D., Brooks Carthon, M., Sloane, D.M., Wu, E., Kelly, L., Aiken, L.H., 2012. Impact of Nurse Staffing Mandates on Safety-Net Hospitals: Lessons from California. Milbank Quarterly 90 (1), 160-186.

For a favourable gloss.

Some of the limitations are covered in:

Griffiths, P., 2009. RN+RN=better care? What do we know about the association between the number of nurses and patient outcomes? International Journal of Nursing Studies 46 (10), 1289-1290.

…one issue that is very germane for many health sectors is the absence of medical staffing from this literature. See

Griffiths, P., Jones, S., Bottle, A., 2013. Is “failure to rescue” derived from administrative data in England a nurse sensitive patient safety indicator for surgical care? Observational study. International Journal of Nursing Studies 50 (2), 292.


I would add:

This question is rooted within a wider context – that of managerialist control of care environments (Traynor 1999, Lees 2013) in which efficiency, effectiveness and economy are to the fore. This approach can militate against the consideration of qualitative, non measurable, outcomes which make a real difference to patients’ experience (Tadd et al 2011, Dixon-Woods et al 2013, Hillman et al 2013). The reality is that many health and social care sectors, in the UK, are under such financial pressure and managerialist control,  that the quality of the care experience is squeezed. Given current narratives of austerity, female undervalued labour and ‘private = good public = bad’, UK society has accepted that for example long term care of older people, and mental health, have to fight their corner for government and personal funding. I suspect that funders (e.g. DoH and FTs) ignore evidence, in any case, of staff-patient ratios, viewing it as idealistic and costly. However, they will not frame it in this way – the response will be that ratios are a blunt tool and should not be set down in terms of basic minimums. While I think it is imperative that evidence comes forth on this topic, we might need to consider that the translational model of evidence to policy is flawed. In the context of climate science,  Pielke (2010) describes the actual relationship between public policy and scientific research as problematic; it is not a linear ‘evidence to policy’ model.  The translational model, or ‘knowledge translation’ (Kerr and Wood 2008), in which scientists come up with answers which are then put into practice by policy makers (Wynne 2010) is contextualised within political and ideological frameworks such as that of neoliberalism and its adjutant, managerialism.  Naively we may think that the job of scientists, and their allies, is to improve the process of knowledge translation so that policy makers, guided by clear evidence, can make the right decisions. Drugs policy research is another example of the failure of this model. In nursing, even if we had irrefutable evidence, there is no necessary link to this and health policy on nurse staffing. The UK’s NHS is a ‘highly politicized setting’ (Traynor 2013), staffing of wards is as much a political as an empirical question.

Dixon-Woods, M., Baker, R., Charles, K., et al (2013) Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study. BMJ Quality and Safety (published online) http://www.ncbi.nlm.nih.gov/pubmed/240195079th September 2013 accessed February 25th 2014
Hillman, A., Tadd, W., Calnan, S., Calnan, M., Bayer, A., and Read, S. (2013) Risk, Governance and the experience of Care. Sociology of Health and Illness. 35 (6) pp 939-955
Kerr, T., and Wood, E. (2008) Closing the gap between evidence and action: the need for knowledge translation in the field of drug policy. International Journal of Drug Policy 19 (3) pp 223-234
Lees, A., Meyer, E., and Rafferty, J. (2013) From Menzies Lyth to Munro: The problem of Manageralism. British Journal of Social Work. 43 (3) 542-558
Pielke, R. (2010) The Climate Fix. Basic Books. New York.
Tadd, W., Hillman, A., Calnan, S., Calnan, M., Bayer, T., and Read, S. (2011) Dignity in Practice: An exploration of the care of older adults in acute NHS Trusts. NIHR Service Delivery and Organisation Programme. Project 08/1819/218. NETSCC – SDO: Southampton
Traynor, M. (1999) Managerialism and Nursing: beyond profession and oppression. Routledge. London
Traynor, M. (2013) Nursing in Context. Policy, Politics, Profession. Palgrave Macmillan.
Wynne, B. (2010) Strange Weather, Again. Climate Science as political art. Theory Culture and Society 27 (2-3): 289-305

Nursing and the NHS – wtf is going on?

I cannot take credit for this, it is Roy Lilley, and although I was about to write about it,  I thought, nah, Roy has done it better: 


Talk to the DH and they will tell you there are more nurses than there are daffodils smiling in the spring sunshine.


An extra 2,400 hospital nurses have been hired since Francis and over 3,300 more nurses working on wards since May 2010.  The bit that is missing is; ‘more’ doesn’t mean ‘enough’ and enough doesn’t mean enough of the ‘right sort’.


The RCN says; The NHS has lost nearly 4,000 senior nursing posts since 2010.  The ‘missing’ nurses include ward sisters, community matrons and specialist nurses.  They’ve gone because they cost more; drop them and you save loadsamoney… quicker.


According to the latest data, November 2013; the NHS was short of 1,199 full time equivalent registered nurses compared with April 2010.  The RCN says; ‘… hidden within wider nursing workforce cuts is a significant loss and devaluation of skills and experience’… just under 4,000 FTE nursing staff working in senior positions.  Band 7 and 8 have been disproportionately targeted for workforce cuts.  It looks like nursing is being de-skilled. (Must look graph).


If the evidence of my in-box is to be believed nursing is not just being de-skilled, it is being denuded.  Time and time again I hear stories of nurse patient ratios of 9,10,11,12,even 18 and often quickly beefed up for the benefit of the CQC.


“Let each person tell the truth from their own experience.”  Florence Nightingale.


Funnily enough, I am writing this on a plane where the cabin-crew to passenger ratio is a matter of law.  I see no reason why the nurse to patient ratio shouldn’t be a matter of law.


The Chief Nurse doesn’t agree.  She’s faffing-about with her half-dozen C’s and ignores the risk that one nurse looking after a dozen or more vulnerable patients is a risk to the Six C’s.  She speaks, unthinking, with her master’s voice…  I hope she’s ready to explain the inevitable.. the next Mid-Staffs.


“The very first requirement in a hospital is that it should do the sick no harm.”  Flo Nightingale again.


There’s a wilful blindness to what’s going on; on the wards and at the ‘high-end’ of nursing; nurse specialists.  If the RCN is right (and this H&SCIC FoI confirms) it is a madness that their numbers are reducing.


Nurse Clinical Specialists are highly skilled and there is overwhelming evidence that better skilled nurses are better for patients, and reduce admissions, re-admissions and waiting times, free-up consultant’s, improve access to care, educate and share knowledge with other health and social care professionals and support patients in the community.


“Were there none who were discontented with what they have, the world would never reach anything better.”   

Fabulous Flo again.


Yup, I’m discontent Flo!  There are only 2 types of post-reg’ training programmes; Specialist Community Public Health Nurses and a Specialist Practice Qualification and for all practical purposes, degree entry-level.  We know they work (chronic heart failure for example and in Stoma nursing) so the default position should be; all patients, with long term conditions, should have access to a specialist nurse… but here we go again… there are not enough of them.


A new, free web-resource for Specialist Nurses caught my eye; help with job plans, annual reports and service summaries and I particularly liked the ‘Speaking up for my Service’ section.  I hope they and their managers do. 


“How little can be done under the spirit of fear.” More Flo truth-to-power-talk.


Nursing is the Swiss Army knife of the NHS; versatile, multi-purpose, portable, one-stop.  Nurses build, work and fix services, flex them and extend their reach and cover.  But, we patronise them and squabble over their numbers. 


“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” Yes, Flo again… in full flow!


It looks to me very like nursing is in a muddle, confused, a jumble.  No one seems to have a clue what is ‘the right thing’, the right numbers or the right training.  Nursing, the biggest group in the NHS workforce, lacks direction… leadership.  Buried in directorates, managed by administrators shoved around by everyone’s agenda.   A Chief Nursing Officer (Carbuncle) and a Director of Nursing (DH), all chiefs but what about the Indians.


Events, technology, finance, balance sheets, bed-sheets, need and resources pull nursing in different directions.  The profession needs to stop, catch its breath and think about its voice, role and purpose.

I wonder what Flo would say? 

Liderazgo y Gestion en Enfermeria – Leadership and Management in Nursing

Liderazgo y Gestion en Enfermeria – Leadership and Management in Nursing

Motivating our nurses – give them freedom.

What gets you up in the morning?

 An old myth about nursing is that is a vocation, a calling based on the desire to help and care for each other. Currently nurses are being criticised for being too educated to care, that they have lost their compassion. I don’t think these things are true. Nurses come to work for a variety of reasons, chief among them of course is paid employment. However, pay itself is not the issue either. Managers and governments need to address more fundamental issues if they want nurses in the NHS to fulfil their mission to provide high quality complex care.

 The first thing to do is to dump old ways of thinking regarding motivation. The theory that if you reward good performance then you will get more if it and the converse that punishment of poor performance reduces it, is flawed. Daniel Pink (2009) reviewed the science and based on a good deal of research in both private sector and public sector organisations, criticises the carrot and stick approach.

First the pay issue, the carrot and stick method works when the task is mechanical in nature needing little or no thought. Then rewards for good performance works. Tasks requiring more than rudimentary cognition are different. The globally replicated research indicates that staff who were extremely well remunerated actually performed poorly which might explain why the global finance sector crashed. High pay does not lead to high performance. Pay has to be set, though, to remove it from the table as an issue, so there is a baseline to be achieved where staff no longer worry about their salary. Beyond that level there are there are three other factors at work: Autonomy, Mastery and Purpose.

We need Autonomy to perform well and to be creative.  Second we like Mastery. It appears that we like to get better at things, we like to practice to master our skills and finally we need Purpose (or vision) over and above the profit motive. If profit (or cost cutting) is the only goal things go pear shaped. Successful organisations want to make a difference and they develop a transcendental purpose.

The lesson for the NHS is clear. Calls for more nursing leadership to address poor care will fail unless nurses are given or allowed to develop these three things: Autonomy, Mastery and Purpose…that is what will get the nurse leaders of tomorrow really making a difference. Are our organisations up to the task of setting staff free or will they not take the risk and do more of the same? Bureaucracy, managerialism and petty fogging quality processes will kill this initiative. Identify your key members of staff and then give them autonomy to be creative and to master their skills and knowledge, ‘sell’ to them a higher purpose, let them develop their own purpose, and if you don’t know what that is you have work to do. Hands up those of you who can clearly articulate that these three things are your daily experience?

Pink, D.  Drive. (2009) The surprising Truth about what motivates us. Canongate. Edinburgh.

leadership for the future

This paper is for spanish nurses on a leadership course but has general application:

“Considerable evidence suggests that neocolonialism, in the form of economic globalization as it has evolved since the 1980s, contributes significantly to the poverty and immense global burden of disease experienced by peoples of the developing world, as well as to escalating environmental degradation of alarming proportions. Nursing’s fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order”. (Falk-Rafael 2006)


The theories and issues so far covered in this module are focused on the individual (micro) and organisational (meso) level of analysis. Nurses are asked to examine their personal resources and the culture of the clinical setting and the hospital environment in which they work. The immediate focus is on patient outcomes: their safety, their recovery, their dignity and their comfort. Many of the policy drivers for critical care rightly ask us all to consider the patient’s journey, to see the issues from their perspectives as well as from our own.


You have been invited to consider whether transformational leadership is a style fit for clinical practice, you have been invited to consider how interpersonal and interprofessional relationships affect your work, you have been invited to consider how we add value in a public sector organisation, you have been invited to consider applying CQI as a process in your work.  


But you have not been invited to take the next step: The macro analysis.


A macro analysis asks you to see beyond the individual, the clinical unit and the hospital. It asks you to consider wider socio-political issues that impinge on public health and well being. Critical care rightly focuses on the seriously ill individual and the skills and competencies developed for nurses reflect that. However, Nursing is an ethical endeavour, your exercise of leadership reflects your ethical positions. The decisions you don’t take may be as important as the decisions you do.  The world view you ascribe to helps to create the world you live in. You have an opportunity for just a moment to raise your eyes above the bedside and think about your vision for the future.


A good deal of discussion in leadership theory is about vision, that leadership is a role, it is a process and can be exercised by anyone.  Being a ‘leader’ is a post holder (chosen, elected , appointed), but a formal post may or may not exercise leadership. So I wish to ask, what are you leading for, for you are all potential leaders regardless of the formal title or post you hold. What is your vision? What are your ethics? What do you care about?


Sarah Parkin (2010) argues that much of leadership education does not clearly see the impending crises of unsustainable economic, business and political practice, has failed to see the wider picture and has failed to ask what is leadership for?


We know we live in a messy world (Peccie 1982, Morrall 2009). The financial crisis that started in 2008 continues prompting the indignados movement.  Spain has a 46.2% under 25 unemployment rate where young educated people argue:


“juventud sin futero, sin casa, sin curro, sin pension, sin meido.” (The Economist 2011).


We know that economic inequality has direct health effects (Marmot 2010, Wilkinson and Pickett 2009). We know what the under 5 mortality rate in many countries is still far above the stated target of the Millennium Development Goals (MDG 4). The WHO (2008) supports the ‘social determinants of health’ approach which links social, political and environment issues with human health. Climate change is the biggest threat to public health and security in this century (Costello et al 2009, BMA 2008, 2011, Goodman and Richardson 2009, Goodman 2011).


These issues, Parkin argues, require leadership as “positive deviancy”. A positive deviant is:


“a person who does the right thing for sustainability, despite being surrounded by the wrong institutional structures, the wrong processes and stubbornly uncooperative people” (2010 p1).


There is an urgent need for healthcare professionals to address the sustainability of current politics, economics and social practices (Goodman 2011). The exact nature of that response is down to individuals. However, without some macro analysis we are in danger of leading ourselves into the dark. This then leads us to ask about out ethical responsibilities on a globalised world.


Nurses’ ethical responsibility in a globalised world?


Globalization results in large capital flows, labour movement and displacement and the increasing dominance of TransNational Corporations (TNCs) on economic, social and political life. The demise of state power for the public good and its alignment with finance capital (Harvey 2010, Crouch 2011) – results in its increasing withdrawal from public services in many European countries. The TNCs and ‘the markets’ are two voices guiding politics. The current Eurozone crisis illustrates how politicians have to create polices that the international financial institutions feel are acceptable to them.  Collier (2008) suggests that we have a bottom billion stuck in poverty, and the WHO acknowledges wide health inequalities. Even for the Rich, threats to survival are not domestic but global. Perspectives are changing from local to global, the ethics of healthcare thus need to be discussed in this context. The WHO’s Millennium Development Goals also set a global policy framework. There is thusa need for another voice to defend global public goods such as health.


Ethical practice (source Austin 2008):


Paul Ricoeur (1992) suggested that ethics are about “aiming at the good life”, and so if this is the case we ought to consider the good for all. If everyone has a right to the opportunity for a good life, what should the Nursing response be? 


Consider the codes of Ethics that govern nursing practice. Where are they and what do they say?


Professional ethics:


   http://www.icn.ch/about-icn/code-of-ethics-for-nurses/  International Council of Nurses. Code of Ethics for Nurses.


Acting Ethically as a nurse in a global community requires a need for transformative thinking and leadership as positive deviance. 



My frame of reference is that healthy lives depend on a healthy socio-economic and physical environment as outlined in the Social Determinants of Health approach (WHO 2008) which has as its outer layer in the model ‘general socioeconomic, cultural and environmental factors’, i.e. social and environmental structures. Thus, I largely agree with Peter Morrall (2009) who argues that patterns of illness and disease are largely determined by issues of social structure and increasingly physical environments. Social structures protect some while damning others to misery and poverty as evidenced in the inequalities in health literature. The affluent even in poor countries and difficult environmental conditions live in ‘safe’ enclaves where they can ensure clean water and a ready supply of food, even in famine stricken countries, money buys food. However, even the affluent will be affected by global changes in certain key environmental limits.


The key power relationships operating at present is the hegemonic stranglehold of advanced consumer capitalism in which the richest 2% own 50% of the world’s wealth (Davies et al 2006). Many do not understand or recognise the notions of limits, while others put undue faith on the resourcefulness of humanity to solve the problems but to do so within the frame of reference of ‘business as usual’ unaware that their selves are interconnected and interdependent within a much wider framework of meaning.


Thus there is a need to transform thinking. Currently leadership is the problem not the solution because we are not asking what we are leading for.


To encourage and transform leadership there is a need to engage in provocative pedagogy whereby we engage in intellectual critique through being challenged with provocative positions. We need a sociological imagination to connect personal troubles with public issues, to fully understand their personal biographies as related to wider social forces at this point in history.


Medical and nursing disciplines cannot be immune from this process. It is not enough to learn how the body works and what to do when it goes wrong. This is navel gazing of the worse kind. Many doctors and nurses have for a long time been pioneers for social action, acting on behalf of the poor, weak and vulnerable. That is their ethic. That has been their historic mission, the problems of this messy little world may not mean a hill of beans to many but without a reawakening of consciousness and a reconnection of self to others, which includes the biosphere, the future looks grim. Peter Morrall (2009) has argued that we as health professionals and/or academics have an ethical responsibility to take individual, collegiate, and organisational action with regard to the social ills which affect human health and happiness.


However, taking a stand is hard. Ethics is hard.Ethics requires thinking. We may be the only sentient being on the planet who can think and reflect on our existence and the search for ‘truth’  It may be that we have a special responsibility to think about our decisions and why we make them. Damon Horowitz has recently argued (2011):


Not only can we think,we must.Hannah Arendt said,“The sad truthis that most evil done in this worldis not done by peoplewho choose to be evil.It arises from not thinking.”That’s what she called the “banality of evil.”And the response to thatis that we demand the exercise of thinkingfrom every sane person


But this may lead to ‘Moral distress’ and Moral responsibility – by understanding the disparities in health if we have responsibility what does that mean? We may provoke moral distress, but then what?



Austin, W. Chapter 3 in Tschudin, V. and Davis, A. (eds) (2008) The Globalisation of Nursing. Radcliffe. Oxford.


British Medical Association (2008). ‘Health professionals taking action on climate change’, http://www.bma.org.uk/ap.nsf/Content/climatechange


British medical Association (2011). The health and security perspectives of climate change. October 17thhttp://climatechange.bmj.com/statement


Collier, P. (2008) The Bottom Billion, OUP. Oxford


Costello, A. et al  (2009). Managing the effects of Climate change. Available online at http://www.thelancet.com/climate-change


Crouch, C. (2011) The strange non death of neoliberalism. Polity Press


Davies, J.,  Sandstrom, S., Shorrocks, A., and Wolff, E. (2006) The world distribution of household wealth. December. UNU-WIDER http://www.wider.unu.edu/events/past-events/2006-events/en_GB/05-12-2006/


Economist, The. (2011). Left behind. September 10th. http://www.economist.com/node/21528614


Falk-Rafael, A. (2006) Globalization and Global Health: Toward Nursing Praxis in the Global Community. Advances in Nursing Science: January/March 2006  29 (1) p 2-14


Goodman B., Richardson J. Climate Change, Sustainability and Health in United Kingdom Higher Education: The Challenges for Nursing in: Jones P., Selby D., Sterling S (2009). Sustainability Education: Perspectives and Practice Across Higher Education. London, Earthscan.


Goodman, B. (2011). The need for a sustainability curriculum in nurse education. Nurse Education Today [online] http://www.nurseeducationtoday.com/article/S0260-6917(10)00262-5/abstract 14th January 2011


Harvey, D. (2010) The enigma of capital and the crises of capitalism.


Horowitz, D. (2011) Calls for a moral operating system. TED.com http://www.ted.com/talks/damon_horowitz.html?utm_source=newsletter_weekly_2011-06-07&utm_campaign=newsletter_weekly&utm_medium=email



Marmot, M. (2010) .Fair society, Healthy Lives. The Marmot Review. Strategic review of health inequalities in England post 2010. http://www.marmotreview.org


Morrall P (2009a). Sociology and Health. London: Routledge.


Parkin, S. (2010). The Positive deviant. Sustainability leadership in a perverse world. Earthscan . London.


Peccie, A. (1982). One Hundred Pages for the Future: Reflections of the President of the  Club of Rome. Futura books.


Ricoeur, P. (1992) in Austin (2008) op cit.


Tschudin, V. and Davis, A. (eds) (2008) The Globalisation of Nursing. Radcliffe. Oxford.


Wilkinson R and Pickett K (2009).  The Spirit level. Why equality is better for everyone. Penguin. London.


World Health Organisation (2008). Closing the gap in a generation. Health equity through action on the social determinants of health.  WHO.

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