Are busy nurses being forced to ration patient care?

7 August 2013

Nurses were under the spotlight again last week with an article in the Times reporting on a recent study carried out by the Florence Nightingale Institute of Nursing and Midwifery, which found that nurses are so busy that they are forced to ration care.

This study adds to a growing body of evidence that care suffers when staff are required to look after large numbers of patients.

The study looked at thirteen fundamental elements of care including comforting patients, patient education and patient monitoring, and concluded that a massive 86% of nurses were unable to perform at least one of these tasks.

These results echo a 2009 study published by the RCN which demonstrated that, where each registered nurse had eight or more patients, care was compromised on almost every shift.  In the Nightingale Institute study, the average nurse cared for 7.8 patients during the day and 10.9 at night.

The problem with averages is that they don’t tell the whole story.  What these figures mean is that half the nurses in the study were caring for more than 7.8 patients on their day shifts, which means that those patients were almost guaranteed poor care and those nurses were guaranteed to go home physically and emotionally exhausted.

Nurses prioritising care is nothing new.  When I trained as a nurse we gave priority to the tasks that we felt were most likely to hurt our patients if left undone.  Patients needed to be made ready for surgery, medication administered and wound dressings changed.  Extra cups of tea, cosy chats and bedbaths unfortunately had to wait.  This was a great shame because it is these caring and very personal aspects of nursing that many nurses enjoy the most and which are highly valued by patients.  The ability to prioritise effectively was seen as the mark of a good nurse and we always coped.  Didn’t we?

Possibly not.  Whilst nurses juggling the rapidly changing priorities of an acute ward is old news, there is an increasing focus on the impact of under-resourcing on the quality of care.  A survey carried out by Unison in the wake of the Mid Staffs scandal has shown that nurses are increasingly concerned about the quality of care they are able to give.  Common failures in care reported by nurses include patients being left in excrement or not being fed.

The need for this sort of rationing produces the kind of ‘toxic’ environment seen at Mid Staffs.  What nurse wouldn’t become disillusioned and jaded if he or she had to choose between giving a blood transfusion and helping someone who is sitting helplessly in excrement?  Sadly, if the figures coming out of these studies are to be believed, then this is the rule rather than the exception.

Many people remain unconvinced by the idea that nurses are too busy to provide compassionate care and blame the rise of degree-educated nurses and the demise of old fashioned matrons for the fall in standards.

The truth is that healthcare is very different from how it was fifty or so years ago when nurses not only had time to sit and talk to patients but also to maintain their impossibly starchy uniforms and elaborately folded hats.  I'm being slightly tongue in cheek of course, nursing was as serious then as it is today but along with attitudes and behaviours, priorities have changed.  Patients are different, they are sicker.  Many of those who would then have died are now surviving but with ever more complex needs.  Treatments are different and nurses need increasing theoretical knowledge to be able to deliver and monitor them safely.

Here is a recent example.  When I was in clinical practice I regularly cared for patients who had been left open after surgery.  They were fascinating to students as the intestine and omentum were often clearly visible. We used absorbent pads several times a day to soak up the exudate and hope that an infection didn’t get in.  Unsurprisingly the mortality rate was pretty high.  Things have now changed for the better. Modern nurses know how to apply a vacuum assisted closure device which sucks "gubbins" into a hygienic little pot and hugely reduces the risk of infection.  The downside to this is that it takes two people more than half an hour to apply it and during this time the rest of your patients are vomiting, spilling drinks and colostomy bags and pulling out feeding tubes.  Even matron might struggle to cope.

The evidence speaks for itself.  Better-educated and properly resourced nurses provide better care and save lives but they can only do this when they have the appropriate resources.  Patients need a health service in which nurses do not have to choose between bathing and feeding or monitoring and washing.  The Francis report highlighted an acceptance of poor standards as a problem within the NHS. This is an inevitable consequence of staffing levels that compromise care on a daily basis.  Both the RCN and the Francis report have called for safe minimum staffing levels to be set, as they have been in some parts of the United States and Australia.  However, the recommendation has not been adopted.  If we are to create a health service in which patients’ needs are truly at the heart of care, then there needs to be a shift away from management by numbers and cost saving rather than further attempts to squeeze ever greater efficiency from an already pressured workforce.


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