The Stafford Hospital Inquiry
Stories of inadequate staffing within NHS have been on the daily headlines for a while now. Coupled with reports of fewer European Union-based nurses registering with the NMC, cases have been reported of nurses leaving the NHS. Similarly, industry commentaries have raised alarm over a significant drop in students applying for nursing courses despite an increasing rate of nursing vacancies in the English health sector. Could Britain drifting towards a staffing crisis?
In 2008, an inquiry was launched into the Stafford Hospital upon an alert by the Healthcare Commission over high mortality rate of emergency patients in the hospital. In what was like a shocking revelation in the history of Britain’s healthcare sector, the inquiry report suggested that the hospital was languishing in deep inadequacies and appalling conditions which might have contributed to the death of between 400 and 1200 patients in the period of 2005 to 2008 (Francis Report 2013). While the Stafford hospital report was criticized for fully attributing the deaths to the hospital’s inadequacies, details of this report have still remained an object of reference in today’s conversations about NHS’s failure in offering quality healthcare to the public.
The aim of this essay is to investigate and critically analyse current issues related to the field of nursing. Majorly, the essay will dwell on health policy and politics, with a specific focus on safe staffing levels of nurses and how it impacts on patient care. In doing so, the first part of the essay will be a criticism of the staffing situation at NHS, highlighting the issues that have emerged with regards to staffing while drawing attention to several health-based reports such as the Francis report, and making reference to various UK organizations such as the Royal College of Nursing and the UNISON. This will be aimed at identifying the acceptable staffing standards and comparing them with the current staffing situation at NHS. The second part of the essay will highlight health policy on staffing, giving attention to the problem at hand (understaffing) and its impact on service delivery to the UK citizens. On the same note, there will be a highlight on the government’s response to the staffing situation at hand, explaining how different actors have influenced the process of policy formulation and the various factors that are considered during the development of policy. Next, the essay will identify the impact of health staffing policy on the level of service delivery within the NHS. Ultimately, the essay will identify whether the policy implementation process has improved health outcomes or not.
Current Staffing Situation at NHS
An assertion that the NHS is at a crisis is not new to the UK citizens. Emanating from historical events such as the Winterbourne View scandal, news headlines have reported inadequate quality care characterized by the mass violation of ethical standards in nursing practice. In fact, according to Stone (2017), the events at Winterbourne wholesomely violated the principles of medical ethics as proposed by Beauchamp and Childress in 2013. For instance, patients were forced to sleep outside in the cold, a violation of the ethical principle of autonomy – which states that patients are supposed to make their individual choices. Similarly, the Winterbourne case was characterized by the harsh handling of patients by staff, a violation of the beneficence principle which requires that staff must act in the best interest of the patients (NMC 2015). Following the events at the Winterbourne, there was a general notion that similar occurrences could be replicating in other Hospitals within the NHS. This triggered the CQC to launch an investigation (Serious Case Review) which revealed massive shortfalls within the NHS. Key to the findings was that patients in most hospitals offered poor quality services, a serious deficit of nurses, abuse of power by health facility managers and massive financial deficits (RNC 2010). No doubt, these events have left an indelible mark of disappointment in the hearts of the families and friends of the victims involved.
Taking the perspective of the Francis Report (2013), there were serious shortfalls in the NHS that affected the general service delivery to the patients. For instance, the report revealed that there were serious staffing deficits in the whole of English healthcare sector which contributed to longer hours of patients waiting to be served as well as a poor level of service because of only a few nurses available to serve patients at a time. However, with the reported reduction in the English nursing workforce, it is not surprising that the report attributed the poor quality of healthcare to poor staffing.
The Francis inquiry seems not to be the only one that identifies the dire need for adequate nursing within the NHS. While the Royal College of Nursing has been quite explicit about the recommended number of nurses for delivery of cost-effective quality care to patients, a research they conducted in 2009 revealed that in Scotland, only one out of ten nurses believed that staffing levels are always adequate (RCN 2010). Similarly, the according to (RCN 2010), 27% of nurses in Scotland believed that the staffing levels were not ideal for proper nursing care. On the same note, the UNISON safe staffing report (2017) raised issues with the NHS nursing staff levels. Particularly, a survey they conducted in 2017 revealed that the registered number of a nurse per patient was too low across all settings within the NHS. In this regard, the UNISON (2017) documented that inadequate nursing staff could compromise the quality of care delivered to the patients, coupled with missed care for patients with adverse conditions. Furthermore, UNISON highlighted that inadequate staffing contributed to more workload for the available staff, leading to physical, emotional, and mental exhaustion together with low job satisfaction.
Health Policy on Staffing and its Impact on Service Delivery
Undoubtedly, these revelations point out to the staffing crisis that the NHS could be experiencing, as well as the poor level of service delivery to patients that has characterised the NHS for a while now. Nickitas (2016) explains this with specific reference to the UNISON report 2016 which indicated that many nurses with NHS believed that the service was understaffed and this affected their ability to provide quality care. In fact, out of the 409,000 respondents in the UNISON 2016 survey, 47% agreed that there were inadequate staffs in their respective organizations to enable them to execute their duties and responsibilities properly (Nickitas 2016).
Comparing the UNISON report of 2016 and UNISON (2017), there seems to be no change or minimal change in the staffing situation at NHS. In fact, according to Stone (2017), the NHS still needs more staff to ensure effective delivery of services. Even if an analysis is done to compare the Francis report, the RCN and the UNISON, a major problem emerges, which is understaffing (Stone 2017).
While several reports have highlighted the understaffing situation within NHS, Naylor et al (2015), acknowledges may have different opinions of what constitutes adequate staffing. According to the author, having a proper understanding of what is meant by safe staffing enables policymakers as well as policy influences to make accurate decisions on the number of staff to be allocated per number of patients. Herein, let us establish what adequate nursing is meant, based on research by professional bodies and UK government recognized institutions.
According to UNISON (2017), safe staffing is measured by the nurse-to-patient ratio, which sometimes is measured the number of nurses per ward. As per the National Health Service (NHS) constitution, safe staffing is defined as that number of nurses that guarantees quality and adequate patient-centred care as per the patient rights in the NHS constitution (UNISON 2017). Furthermore, according to NICE (2014), the level of adequacy should be that which enables proper response to the patient’s individual preferences and needs.
According to RCN (2010), NHS has a duty and responsibility to quality care through adequate staffing levels. This means that patients have a right to receive care from experienced and qualified nursing staff as part of providing care in a safe environment. Similarly, the NHS Act 1999 bestows upon the NHS, the responsibility for accountability with regards to quality care through adequate staffing (Williamson et al 2010). Even if we referred to the Nursing and Midwifery Council guidelines, it is stipulated that safe staffing is a prerequisite for quality care delivery (NMC 2016). However, the daunting question is whether this is the case within the NHS. For instance, in the case of Mid-Staffordshire Hospital Disaster, there was a serious disobedience to the nationally set standards of care delivery such as the four-hour average waiting time for a patient to receive service at the emergency department; just because of inadequate staffing. According to The Francis Report (2013), the situation at Stafford Hospital was majorly contributed by the need for the hospital managers to meet the budgetary targets established by Foundation Trust Status, meaning they could not hire more staff as per their needs. Sadly, this was at the expense of the lives of patients who relied on quality care as the hope of livelihood. Indeed, this showed lack of accountability within the hospital management, which further endangered the lives of patients – even with the widely documented consequences of short staffing (Ansari et al 2018).
Impact of Health Staffing Policy on Service Delivery within the NHS
Upon witnessing the effects of short staffing in the Mid Staffordshire’s case, stakeholders as well as the public have sharply drawn their attention to the issue of safe staffing. According to Grady (2016), there is a public opinion that the events at Staffordshire should never repeat, creating a need to address the issue of understaffing at NHS. Biggs (2013) and Kossek et al (2016) also agree that addressing the issue of understaffing has a business case and can improve quality of care. For instance, Biggs argues that for the proposed efficiency and high impact actions to be implemented effectively, there is need to reduce the expenses associated by avoidable complication such as deep vein thrombosis; which can only be avoided by effective delivery of services by adequate nurses having the right skills of practice. Equally, Kossek and colleagues agree with Biggs’ assertions but add that adequate staffing reduces staff stress and promotes staff well-being, which further contributes to better and quality care delivery. To address these issues, RNC, UNISON and the Francis report have pointed to effective policy development on nursing staffing as the best remedy for the nursing shortfalls and their resultant effects. For instance, RNC (2010) proposes adequate staff planning both at national and local levels to prevent a shortfall of nurses. Similarly, UNISON (2017) opines that identifying the best nursing staff ratios and documenting them in policy documents is an appropriate way of dealing with the problem of inadequate nurse personnel within the NHS. However, what are the major factors influencing policy development in nursing? Are there service users, professionals, or organizations participating and influencing the development of these policies? Upon the development of these policies, what are their impacts on service delivery? These questions, together with other questions that emerge with regards to policy politics and nursing are the subject of discussion in the subsequent sections.
The political, social and economic contexts play a major role in shaping the process of policy development and implementation. According to Ansary et al (2018), the political aspirations and ambitions of those in power may lead them into developing policies in a certain area or department to promote better services or in response to public outcry. Similarly, Grady (2016) agrees that priorities and openness to public influence by political powers are a good influence to policy in sectors of health and public finance especially in terms of how the government responds to issues raised by public organizations, service users, health professionals and the general public.
Defining Safe Staffing Levels
This explains the role of political and philosophical principles influencing policy formulation. According to Gardener (2016), political and philosophical principles refer to the values, beliefs, and intentions of politicians which dictate their policy formulation strategies and how such policies resonate with their campaign promises and objectives. The case of Winterbourne View Hospital presents a good example. In this case, a video leaked of how adults under a care facility (Winterbourne View Hospital) were exposed to mistreatment and torture by their caregivers. Consequently, the Association of Supported Living (ASL) made a press release to all parliamentarians requesting a change of adult care from institutional services to community-based supported living services Gardener (2016). This led to a series of actions by the government against the perpetrators, and a change in the policy of how adult care was approached in the country. According to Grogan (2012), these changes were made with an immediate effect partly because the revelation could depict the government as weak in protecting public health and every citizen’s right to quality care and protection.
Further examples of the political and philosophical influence in policy formulation include the enactment of the Health and Social Care Act of 2012. There are several aspects of this bill that reveals the political and philosophical influence of the government on policy formulation. For instance, according to Leipert et al (2015), the proposal of these acts was not a subject of any discussion during the general election year, neither was it part of an agenda in the Liberal Democratic-conservative coalition agreement; despite featuring in the 2010 manifesto of the Conservative party. However, within two months after the general election, the Bill was tabled at the House of Commons before it was given a royal assent in March 2012. According to Andree-Anne et al (2013), this shows that the Conservative Party was keen to maintain its political and philosophical aspirations by seeing to it that what was part of their manifesto was acted upon.
The medial also has a huge influence in policy. For instance, in reaction to the Winterbourne expose, the Daily Mail wrote that the incidences at the Winterbourne was ‘a tip of the iceberg’ of what may have been occurring in several other English hospitals (Gardener 2015). The public outcry generated after the media publicised the matter was a major contributor to the government’s action against the perpetrators. This action was in largely in terms of commissions of inquiry which made proposals that later formed part of policies enshrined within the Health and Social Care Act of 2012 (Grady 2016). This illustrates the role of media in influencing policy because according to Fafard (2015), the agitations of Daily Mail and other media houses such as the BBC and the Daily Telegraph played a major role in promoting policy change.
The Business Case for Addressing Understaffing
Reinhard (2012) and Blaauw et al (2015) mention that the availability of economic resources to favour the implementation of policy as another major factor influencing policy formulation. For instance, if there are inadequate finances to facilitate the recruitment of more nursing staff, it would be difficult for the government to ratify policies that support the process (Blaauw et al 2015). These assertions are supported by Reinhard (2012) who adds that social factors and international influences such as immigration and global recession have an impact on policy formulation process. For instance, during the global economic downturn of 2008, most jurisdictions, Britain included, were slow at supporting policies that could inflate their budgets – such as additional staffing (Bayer et al 2017).
In the case of inadequate staffing within the NHS, there has been a continuous agitation from various professional bodies, associations and other institutions towards better adequate staffing within the NHS. Similarly, according to Gagnon et al (2017), the healthcare consumers have emerged to be key drivers of policy both directly and indirectly. For instance, El-Jardali et al (2014) acknowledge that the continuous agitation for a reduction in death cases among patients as a result of inadequate nursing staff has amplified the need for policy formulation. Lukens (2014) also supports this assertion but adds that from an indirect perspective, patients and their families have agitated for adequate staffing through campaigns and registered complaints on a case by case basis. However, Maass et al (2017) raise questions on the extent to which these registered complaints are acted upon.
Organizations such as the Royal College of Nursing, professional associations such as the Association of the Supported Living and the UNISON have a major role in influencing policy formulation on issues such as staffing. RNC has sponsored numerous studies and reports which forms the basis of knowledge for policy formulation. For example, the RCN (2010) report was majorly aimed at providing guidance to health care manages on safe nurse staffing levels. According to Busari et al (2016), such reports are important sources of information for policy formulators who rely on comprehensive and professionally compiled information for better policymaking. However, as He et al (2016) argue, some of these reports are never taken into serious consideration during policy formulation. This amplifies the need for nurses to actively be involved in policy formulation processes because when that happens, they are able to ensure that their problems, as documented in the reports, are considered for full implementation (Bowbils & Ghattas 2017). Therefore, what is the role of nurses in influencing policy?
Conclusion
sing, being the largest medical profession globally have the potentiality of influencing policy and politics both globally and locally. In fact, as Jaeger et al (2018) say, a commitment by nurses to influence policy has a potentiality of enhancing service delivery and promoting the quality of care to patients. Unfortunately, as Bae (2012) puts it, there has been little involvement by nurses in the formulation of policies that affect their service delivery.
Biggs (2013), Kossek et al (2016), Stone (2017) and NICE (2014) illustrate several reasons why nurses may not be involved in policy formulation. For instance, Biggs (2013) opines that they may face time and resources limitations as obstacles to their engagement in policy formulation. Equally, Kossek et al (2016) support the argument that they lack the needed support for generating useful evidence in influencing healthcare policy. Could this mean that health institutions such as the RCN need more resources to facilitate research and development? Stone (2017) dwells on this issue by illustrating that government support is a key aspect of developing the nursing profession. When government support is part of policy, the support becomes mandatory and therefore the institutions have an opportunity to conduct more research that can improve service delivery and job satisfaction among practitioners (NICE 2014).
Challenges notwithstanding, Ansary et al (2018) propose that engaging nurses in the process of redesigning health care systems through collaboration and partnership with other stakeholders in the medical profession is one of the best ways through which nurses can have an influence on policy formulation. For example, to ensure adequate staffing levels within the nursing profession, nurses can influence policy by making suggestions on best way to balance duties and responsibilities between nurses and physicians to ensure quality care amid nurses’ shortage (Gardener 2016). However, Grogan (2012) claims that lack of interdisciplinary teamwork and skills have been a major impediment to participating in policy formulation through collaboration between them and other industry stakeholders. Therefore, there is a need for capacity building and training for nurses to empower them and give them the intellectual capacity needed for participation in policy formulation.
The inclusion of nurses in policy formulation processes is only part of a whole process of establishing and operationalizing safe staffing policies. According to Leipert et al (2015), a penultimate step in proper policy formulation is the assessment of whether the policy has achieved its desired outcomes. For instance, in the case of the Winterbourne view, the policies that resulted from the incident could be assessed by having the opinion of patients on how they were being treated at the care centre, in if the facility had not been shut down. All in all, it is expected that a policy on increasing staff levels for better adult care would transform the nature of care through fastening process of pain relief care, enhancing the process of regular checks on patients and improve the morale of nurses through a lesser burden of work (Grady 2016). Nevertheless, according to Grogan (2012), these expected outcomes may not materialise due to several challenges such as inadequate funds for proper and full implementation, lack of proper skills for the implementation process, and other external factors such as lack of political will.
In conclusion, to address the challenge of understaffing and to involve nurses in policy formulation, nurses can be trained on the procedures for policy implementation, besides availing adequate funds for the same. After implementing the policies on safe staffing, It is important to monitor and evaluate the impacts of the policies through quality check metrics or by observing the emergence of any red flags such as delay of pain relieving services, poor or lack of regular checks executed on patients per day, or poor quality of person-centred care offered to patients.
References
Andrée-Anne, B, Audrey, F, Clémence, D, Elizabeth, B, Julie, B, & Sophie, P 2013, ‘Politics in nursing: an essential learning for postgraduate students / Políticas em enfermagem: um aprendizado essencial para estudantes de pós-graduação / Políticas en enfermería: un aprendizaje esencial para alumnos de posgrado’, Cogitare Enfermagem, 4, p. 803.
Ansari, M, Rassouli, M, Akbari, M, Abbaszadeh, A, & Akbarisari, A 2018, ‘Palliative Care Policy Analysis in Iran: A Conceptual Model’, Indian Journal Of Palliative Care, 24, 1, p. 51.
Busari, J, Burghgraef, J, & Faverey, L 2016, ‘The workload Intens-o-meteR: A novel instrument designed to determine workload intensity and adequacy of nurse staffing in a pediatric ward’, International Journal Of Healthcare Management, 9, 3, pp. 149-154.
Bowblis, J, & Ghattas, A 2017, ‘The Impact of Minimum Quality Standard Regulations on Nursing Home Staffing, Quality, and Exit Decisions’, Review Of Industrial Organization, 50, 1, pp. 43-68.
Bae, S 2012, ‘Nursing Overtime: Why, How Much, and Under What Working Conditions?’, Nursing Economic$, 30, 2, pp. 60-72.
Biggs, C 2013, ‘UNDERSTAFFING IS THE REASON WHY SOME NURSING APPEARS ‘VERY BAD”, Nursing Standard, 27, 18, p. 3.
Bayer, C, Smith, L, Volny Darko, R, McKool, M, Yan, F, & Heiman, H 2017, ‘Understanding health policy leaders’ training needs’, Plos ONE, 12, 3, p. 1.
Blaauw, D, Ditlopo, P, & Rispel, L 2015, ‘Nursing education reform in South Africa — lessons from a policy analysis study’, Global Health Action, 8, p. 1.
Daud-Gallotti, R, Costa, S, Guimarães, T, Padilha, K, Inoue, E, Vasconcelos, T, Rodrigues, F, Barbosa, E, Figueiredo, W, & Levin, A 2012, ‘Nursing Workload as a Risk Factor for Healthcare Associated Infections in ICU: A Prospective Study’, Plos ONE, 7, 12, pp. 1-6
El-Jardali, F, Hammoud, R, Younan, L, Nuwayhid, H, Abdallah, N, Alameddine, M, Bou-Karroum, L, & Salman, L 2014, ‘The making of nursing practice Law in Lebanon: a policy analysis case study’, Health Research Policy.
Fafard, P 2015, ‘Policy capacity meets politics: comment on ‘Health reform requires policy capacity”, International Journal Of Health Policy And Management, 10, p. 707.
Gardner, DB 2016, ‘Health Policy and Politics. Election 2016: Where Are We with the Affordable Care Act?’, Nursing Economic$, 34, 5, p. 251.
Grady, C 2016, ‘Cultivating Synergy in Nursing, Bioethics, and Policy’, Hastings Center Report, 46, p. S5.
Grogan, CM 2012, ‘The Murky Relationship between Ideology and the Role of Government in Health Policy’, Journal Of Health Politics, Policy & Law, 37, 3, p. 361
Gagnon, F, Bergeron, P, Clavier, C, Fafard, P, Martin, E, & Blouin, C 2017, ‘Why and How Political Science Can Contribute to Public Health? Proposals for Collaborative Research Avenues’, International Journal Of Health Policy & Management, 6, 9, p. 495.
Gardner, DB 2015, ‘Health Policy and Politics. Reframing Political Differences: One Conversation at a Time’, Nursing Economic$, 33, 3, p. 179.
He, J, Staggs, V, Bergquist-Beringer, S, & Dunton, N 2016, ‘Nurse staffing and patient outcomes: a longitudinal study on trend and seasonality’, BMC Nursing, 1.
Jaeger, F, Bechir, M, Harouna, M, Moto, D, & Utzinger, J 2018, ‘Challenges and opportunities for healthcare workers in a rural district of Chad’, BMC Health Services Research, 18, pp. 1-11.
Kossek, E, Piszczek, M, McAlpine, K, Hammer, L, & Burke, L 2016, ‘Filling the Holes’, ILR Review, 69, 4, pp. 961-990.
Leipert, B, Regan, S, & Plunkett, R 2015, ‘Working through and around: exploring rural public health nursing practices and policies to promote rural women’s health’, Online Journal Of Rural Nursing & Health Care, 1, p. 74.
Lukens, G 2014, ‘State Variation in Health Care Spending and the Politics of State Medicaid Policy’, Journal Of Health Politics, Policy & Law, 39, 6, p. 1213.
Maass, K, Liu, B, Daskin, M, Duck, M, Wang, Z, Mwenesi, R, Schapiro, H, Maass, K, & Daskin, M 2017, ‘Incorporating nurse absenteeism into staffing with demand uncertainty’, Health Care Management Science, 20, 1, pp. 141-155.
Martin, CJ 2015, ‘The Effects of Nurse Staffing on Quality of Care’, MEDSURG Nursing, 24, 2, pp. 4-6.
Naylor, M, Kurtzman, E, Miller, E, Nadash, P, & Fitzgerald, P 2015, ‘An Assessment of State-Led Reform of Long-Term Services and Supports’, Journal Of Health Politics, Policy & Law, 40, 3, p. 531.
NICE(2014) Safe staffing for nursing in adult inpatient wards in acute hospital
Nickitas, DM 2016, ‘Policy, Politics, and the Presidential Campaign: What’s at Stake for Nursing?’, Nursing Economic.
Reinhard, SC 2012, ‘Health Policy and Politics. AARP: National Champions of Nursing for Consumers’, Nursing Economic$, 30, 6, p. 359.
Royal College of Nursing 2010 https://www.weds.wales.nhs.uk/sitesplus/documents/1076/rcn%20safe%20staffing%20levels.pdf [Retrieved on 3/22/2018]
Stone, PW 2017, ‘Health Policy and Politics. Changing of the Guard: What’s in Store for Healthcare Policy?’, Nursing Economic$, 35, 1, p. 48.
Snow, T 2013, ‘Professional leaders grilled by MPs over understaffing in NHS hospitals’, Nursing Standard, 27, 22, p. 7.
NMC 2016 https://www.nmc.org.uk/globalassets/siteDocuments/Press/Safe-staffing-position-statement.pdf
The Francis Report 2013 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/279124/0947.pdf [Retrieved on 3/22/2018]
UNISON 2017 https://www.unison.org.uk/content/uploads/2017/04/Rationotrationing.pdf [Retrieved on 3/22/2018]
WILLIAMSON, G.R., JENKINSON T. &, PROCTORCHILDS T. 2010, ‘Contexts of Contemporary Nursing . 2nd edn. London: Learning Matters
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