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How does staffing differ between wards that provide high and low quality care? Keith Hurst finds out
Stark differences have emerged between wards that provide high quality patient care and those that underperform.
Nursing indicators reveal that wards providing low quality care employ half as many staff as those providing high quality care.
In addition, low quality wards have more dilute skill mixes, while staff spend less time with patients and are more likely to have time off sick.
In contrast, ward managers providing high-end patient services spend 51 per cent more money on ward staffing and are more visible leaders, spending 4 per cent more time at the bedside.
Data was extracted from Skills for Health's healthcare workforce portal , which holds information on almost 1,800 randomly selected wards, collected by independent observers who measure nursing care and test up to 1,000 quality standards in each ward.
Standards, converted into quality scores (Table 1), were collected across 1,000 general wards, and the top and bottom 10 per cent of performers were compared. A league table of best and worst performers emerged, with 63 high quality wards and 65 low quality wards identified.
Table 1 shows a marked contrast in performance: there is a 38 per cent difference between high and low performers. Staff in high quality wards consistently score highly in all five quality categories.
Staff in low quality wards are less likely to record assessment, planning and evaluation of patient care - legally important documentation. They also work in inferior ward environments (72 per cent versus 93 per cent), implying under-investment.
Workload analysis shows that low quality wards have tougher workloads, typically dealing with more patients, which means their workload, measured by a workload index, is high - 3.72 compared with 3.37.
Despite greater workloads, low quality wards have half the number of staff found in high quality wards. Table 2 shows low quality wards having significantly fewer staff per bed (1.29 versus 2.56). They also employ proportionally more band 1 to 3 staff - that is, they have a more 'dilute' staff mix (62:38 versus 69:31 nurse to support worker ratio).
Unsurprisingly, the analysis shows that staff in low quality wards (with higher workloads and fewer staff) take more sick leave. Almost one in four staff in low quality wards are away at any time - a significant loss. This contrasts with 22 per cent in high quality wards. For every 100 workers, low performing wards will lose an additional two staff compared with their high quality counterparts.
Do low quality ward managers make up for this by employing more temporary staff? Table 3 shows they do not (0.12 versus 0.23 full time equivalents per bed).
Consequently, high quality ward managers spend twice as much on ward staffing than low quality ward managers (£180 versus £88 per bed each day), which reflects low quality ward understaffing and failure to employ temporary staff cover.
Independent observers spent 50 hours recording staff activity in each high and low quality ward. They recorded precisely what each staff member was doing every ten minutes.
Table 4a summarises 38 ward activities as time spent in four main activities. Results show that staff in high and low quality wards spent 71 per cent and 68 per cent of their time, respectively, in patient-related care. A striking feature, though, is that low quality ward staff are 4 per cent less productive (13% versus 9%) than their high quality ward counterparts, which implies leadership may be lacking in low quality wards.
Interestingly, ward manager activity shows that they are less visible to patients and bedside staff in low quality wards because they spend 4 per cent less time at the bedside than their counterparts on high quality wards (Table 4b). Most 'missing' time is spent unproductively, which does not exemplify good leadership.
Similarly, staff nurses follow their leaders. Those in low quality wards spend 6 per cent less time in direct patient care, and are unproductive more of the time. In short, from 100 staff nurses employed in all low quality wards, 53 never give hands-on care (Table 4c).
We saw in Table 2 that support workers (total senior, intermediate and junior support workers) make up 38 per cent of the team in low quality wards. Table 4d shows they spend 3 per cent more time in bedside care than their high quality ward counterparts, thereby showing that they are main carers. However, they are less productive overall (14 per cent versus 10 per cent) - a common theme in low quality wards.
In conclusion, low quality ward characteristics are worrying; their high workload, lower staffing and substantially lower investment appear to influence negatively staff morale and nursing quality.
Nursing Standard :: vol 26 no 10 :: November 9 - 15, 2011
Keith Hurst is an independent researcher and analyst
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