Hospital nursing levels and care of older people

Behind the Headlines

Tuesday March 20 2012

Nurses say they don't have time to comfort older patients

A “nursing shortage” is having an impact on the care of elderly people, and nurses are “too busy” to help elderly patients with basic care, according to TV, radio and print news sources today. This news is based on a Royal College of Nursing (RCN) report on safe levels of nursing staff for older people’s wards.

For the first time, the RCN report set out its recommended staffing levels; below which it said care becomes compromised on older people’s wards. The RCN said that most hospitals do not meet this safe level of care. Older people’s wards regularly have a shortage of nurses and healthcare assistants, and an inappropriate skill mix of these two types of staff, it found.

This report sheds light on discrepancies between the nursing care of older people and the care of children and younger adults and may set new expectations for hospital nursing care. As well as nursing staff levels, other factors are also likely to influence the overall quality of the care of older people in hospital.


Where did the report come from?

These reports are based on guidance and recommendations issued today by the Royal College of Nursing (RCN). The guidance relates to the provision of good quality, compassionate and safe nursing care for older people in hospital. It was developed from different sources, including:

  • the results of a survey of nurses who work on older people’s wards
  • nurse focus groups
  • a panel of expert nurses from across the UK
  • consultation with stakeholders
  • a review of the literature

The report identified the issues in caring for older people in hospital and sets out what is needed to meet the expectations of patients, nurses and the public.


What did the survey of nurses look at?

The RCN has not released details of the survey, but its press release said that the survey included almost 1,700 nurses, 240 of whom were working on wards for older people.


What staffing levels did the RCN find?

The RCN reported finding that older people’s wards have a different skills mix from other wards, with fewer registered nurses per patient:

  • Older people’s wards have between 9.1 and 10.3 patients per registered nurse.
  • Adult general, medical and surgical wards have 6.7 patients per registered nurse.
  • Children’s wards have 4.2 patients per registered nurse.

Currently on older people’s wards there are:

  • a 50:50 mix of registered nurses to health care assistants
  • one member of staff per 4.6 patients
  • three registered nurses for a typical 28-bed ward
  • six nursing staff on duty for a typical 28-bed ward

The RCN also said that older people’s wards which have fewer registered nurses have more episodes of missed or compromised care reported.


What impact do these shortages have?

The RCN said that these findings means that caregiving may be being inappropriately delegated, with few registered nurses feeling that they have time to supervise health care assistants (HCAs) properly. It said that this means that there is not enough time and skill to provide activities such as comforting and talking to patients in a satisfactory way.

The RCN also asked nurses what effects lack of time had on patient care. The nurses reported a range of tasks not done or done inadequately in their last shift due to lack of time, including:

  • comforting or talking to patients: 78%
  • promoting mobility and self care: 59%
  • oral hygiene: 48%
  • falls prevention: 45%
  • sufficient change of patient’s position: 41%
  • information giving to patients and families: 38%
  • helping patients with food or drink: 34%
  • helping patients use the toilet or manage incontinence: 33%
  • preparing patients and families for discharge: 30%
  • skin care: 30%
  • pain management: 19%
  • care for dying patients: 17%


What recommendations does the report make about staffing levels and skills mix?

The RCN report did not recommend a universal minimum staffing level; preferring senior nurses in each ward to have the final say. It also noted that evidence relating to older people’s wards indicates that there is a threshold of staffing numbers, below which care is compromised. It went on to outline recommendations for the skills mix and staffing levels required for basic safe care, and also for ideal, good quality care in older people’s wards.

For basic safe care, the RCN recommended:

  • a 50:50 mix of registered nurses to health care assistants
  • at least one registered nurse per seven patients
  • at least one member of staff per 3.3 to 3.8 patients
  • at least four registered nurses for a typical 28-bed ward
  • at least eight nursing staff on duty for a typical 28-bed ward

The recommendations for ideal, good quality care are:

  • a 65:35 mix of registered nurses to health care assistants
  • at least one registered nurse for every five to seven patients
  • at least one member of staff per 3.3 to 3.8 patients
  • four to six registered nurses for a typical 28-bed ward
  • at least eight nursing staff on duty for a typical 28-bed ward

These numbers exclude the ward sister or senior charge nurse, who is in a supervisory role. The RCN also said that the ward sister or senior charge nurse must be the final arbiter of whether the staffing for that day is appropriate for the specific needs and case mix of patients on the ward.


What other recommendations does the report make?

The RCN’s report also recommended that:

  • Safe day-to-day staffing levels for older people’s wards should be determined locally, following principles that are set out in the 2010 RCN document, “Guidance on safe nurse staffing levels in the UK” but with specific considerations relating to the nature of care for older people with complex needs.
  • There should be strong nursing leadership for older people’s wards.
  • Wards should have sufficient professional staffing and support at patient meal times to ensure that all patients who need assistance with food and drink receive it.
  • Appropriate training in the knowledge and skills to care for older people must be available to all nurses at both pre- and post-registration levels, and to healthcare assistants and assistant practitioners, appropriate to role
  • The ward sisters or senior charge nurses must have both a determining influence in selecting staff for their teams, and adequate administrative and human resources support for nurse recruitment.
  • Healthcare measurements must recognise the “full nursing contribution”, including compassionate care, communication and its impact on patient experience and outcomes.


How can I give feedback on my care or a relative's care?

You can rate and comment on hospital services on the NHS Choices website.

Analysis by Bazian

Edited by NHS Choices

Links to the science

Nurses 'too busy' to help elderly patients with basic care. The Daily Telegraph, March 20 2012

Nursing numbers a third lower on elderly wards. The Independent, March 20 2012

Low staffing levels 'harms elderly care'. BBC News, March 20 2012

Older patients let down by shortage of nurses, says Royal College of Nursing. The Guardian, March 20 2012

Staff shortages on wards ‘hits care of elderly’. Daily Express, March 20 2012

Nurses 'have no time to talk to older patients' because shortage of qualified staff is 'compromising care' on wards. Daily Mail, March 20 2012

Further reading

Policy briefings

Royal College of Nursing: Safe staffing for older people’s wards: RCN summary guidance and recommendations. Published March 20 2012

Press release

Royal College of Nursing: Care of older people let down by low staffing levels. March 20 2012.


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