NATIONAL STROKE NURSING FORUM NURSE STAFFING OF STROKE SERVICES POSITION STATEMENT FOR NATIONAL STROKE STRATEGY

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1 NATIONAL STROKE NURSING FORUM NURSE STAFFING OF STROKE SERVICES POSITION STATEMENT FOR NATIONAL STROKE STRATEGY Preamble The National Stroke Nursing Forum is pleased to be able to contribute to the development of a National Stroke Strategy for England, and in particular to submit guidance on the constitution of the stroke nursing workforce. Guidance has been prepared drawing on research evidence that identifies the link between nurse staffing and skill mix ratios, and service and patient outcomes. The Forum acknowledges that, as for most professional groups contributing to stroke services, evidence about appropriate staffing levels does not relate directly to stroke care. General evidence has therefore been supplemented with expert consensus of lead stroke nurses across the United Kingdom, the nursing profiles of international flag ship stroke services (Indredavik 2006), an analysis of imminent demands on the nursing workforce to facilitate the delivery of best practice such as thrombolysis throughout the United Kingdom, and a detailed analysis of the nursing requirements of stroke patients in the immediate post-stroke period (Watkins 2007, see Appendix 1). Our aim is to provide recommendations or general guidance on institutional nurse staffing in the form of principles of best practice. In many situations, the evidence does not support a definitive statement. However our position statement has been produced diligently, using the consensus of experts within the nursing profession, and evidence where it is available. It is essential therefore that significant variations from the principles of best practice in either the National Stroke Strategy, or its implementation within health service organisations, are, in the absence of our expert consensus, underpinned by evidence. We strongly advocate for, and would wish to provide the nursing contribution to, programmes of work that seek to examine the relationship between service staffing, and the delivery of clinical and cost effective stroke care. We do not believe that there is a satisfactory workload model or tools are underpinned by an understanding of the nursing contribution to stroke care. Background The National Stroke Sentinel Audit (Royal College of Physicians 2004) presents a bleak view of nurse staffing with wide variation in staffing levels, and low skillmix. For example, the median number of nurses per ten beds at 10 am was 3.3 (range ), with proportionally more support staff to qualified nurses. There is substantial evidence that higher nurse staffing and skill mix ratios are important in reducing patient mortality, failure to rescue, acquisition of health care associated infections, patient falls and in improving the general quality of

2 care (Aiken et al. 2002, Stanton & Rutherford 2004, Sheldon 2005, Rafferty et al. 2006). These ratios are also important in improving job satisfaction, recruitment and retention rates. There is no reason to suggest this situation would be any different in stroke services. There are also additional stroke related factors which reinforce the need for investment in the stroke nursing workforce, as follows pressure to improve the rates for thrombolysis, which are currently less than 1% of stroke admissions (National Audit Office, 2005) pressure to implement rapid assessment and early discharge care strategies, and the need to adhere to best practice in the monitoring and control of physiological variables in acute stroke. Position statement Our recommendation is that a minimum establishment of 12.5 WTE nurses for every ten beds 1 is required to meet the demands of the nursing contribution to stroke patient care. This ratio should not include the nurse-in-charge. Shift patterns should reflect patients waking hours as much as possible. The National Stroke Nursing Forum endorses the recommendation of the Royal College of Nursing (2006) that for general health care services, the appropriate skill mix ratio is 65% registered nurse to 35% health care assistants. We feel this is a realistic reference skill mix for stroke services, but this will vary according to the type of stroke service (acute stroke unit, stroke rehabilitation unit, combined stroke unit etc.). International expertise would suggest that a high-dependency model of nurse staffing for stroke patients in the first 36 hours after stroke. Where a stroke unit has combined acute and rehabilitation beds, the nursing staffing establishment should be increased to ensure that during every shift, 2 hyperacute patients are cared for by one registered nurse. This recommendation reflects the requirement for the intensive monitoring of patients, the potential for thrombolysis, the increased risk of stroke progression, and the profile of interventions required to deliver an appropriate standard of care (Appendix 1). Variation from the general principles Rehabilitation services It may be argued that patients in the rehabilitation phase do not require such intensive intervention and that the nurse:patient ratio could be reduced for nonacute stroke patients. We do not believe that there is evidence to support a dilution of this ratio in this situation. As stroke services become more proactive in patient management with the implementation of early mobilisation and early discharge and high patient throughput, an adequately staffed rehabilitation service is essential. The use of competency frameworks The National Stroke Nursing Forum has been keen to actively contribute to the development of competency frameworks in stroke care to drive forward workforce 1 This corresponds to 3.5 nurses on an early shift, 3 nurses on an evening shift and 2 nurses on a night shift for every ten beds. Please note these figures do not include the nurse-in-charge.

3 and service development. We believe however that relying solely on the demonstration of competency to justify variations in skill-mix is inappropriate, and runs the risk of diluting patient and family access to professional nursing knowledge, skill, expertise and experience. Collaboration between Nurses and Allied Health Professionals The impact of variations in the way in which nurses and therapists work together on the requirement needs consideration. Collaboration between therapists and nurses can include the situation where therapists work with patients in dedicated therapy sessions away from the patient s bedside. Other examples of collaboration include the joint provision of all care and rehabilitation for the patient on the stroke unit. It is worth noting that those international flagship stroke units (e.g. Trondheim, Norway) who demonstrate this level of collaboration (and good patient outcomes) have higher nurse:patient ratio than our proposed ratio. We do not believe therefore that collaboration between nurses and therapists can be used to justify a decrease in the proposed ratio in the United Kingdom. Weekends and nights In the United Kingdom, the provision of therapist-led rehabilitation at the weekends is variable. In services where therapists do not provide a weekend service (and where there are no plans to do so), it is highly likely that an increase in the nurse:patient ratio is required at weekends to maintain a seven-day rehabilitation service. This is an essential pre-requisite in developing and maintaining early discharge and high levels of patient throughput. Nursing interventions for hyper-acute stroke patients do not vary according to the time of day. Whilst rehabilitation continues throughout the entire 24 hour period as patients continue to mobilise and participate in other activities of living, there may be capacity to reduce the recommended skill mix during the night. Where this occurs, nurses should ensure that the culture of rehabilitation is maintained in interventions with patients during the night. Other principles The National Stroke Nursing Forum believes that good inter-professional teamwork, and the development of nurse-patient and family relationships are essential for the delivery of high quality and effective stroke care. The Forum does not, therefore, support the use of agency, locum or other temporary nursing staff, except in extreme or unavoidable circumstances. Dr Jane Williams Chair, National Stroke Nursing Forum January 2007 Project Team: Drs. Chris Burton 1, Michael Leathley 2, Jane Williams 1 & Professor Caroline Watkins 1. 1 National Stroke Nursing Forum 2 University of Central Lancashire

4 References Stanton M.W. & Rutherford M.K. (2004) Hospital nurse staffing and quality of care. Research in Action Issue 14. (AHRQ Pub. No ). Agency for Healthcare Research and Quality, Rockville (MD). Aiken L.H., Clarke S.P., Sloane D.M., Sochalski J. & Silber J.H. (2002) Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. Journal of the American Medical Association 288: Indredavik B. (2006) Stroke Unit Trondheim Nursing Staff September Personal Communication. Royal College of Physicians (2004) National Stroke Sentinel Audit Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London. National Audit Office (2005) Reducing Brain Damage: Faster access to better stroke care. Stationery Office, London. Rafferty A.M., Clarke S.P., Coles J., Ball J., James P., McKee M. & Aiken L.H. (2006) Outcomes of variation in hospital nurse staffing in English hospitals: Cross-sectional analysis of survey data and discharge records. International Journal of Nursing Studies (Article in Press), doi: /j.ijnurstu Royal College of Nursing (2006) Setting Appropriate Ward Nurse Staffing Levels in NHS Acute Trusts. Royal College of Nursing (Policy Unit), London. Sheldon T (2005) Workforce and Health Outcomes a scoping exercise (A Report to the NHS Research and Development Service Delivery and Organisation Programme). Available at

5 Appendix 1 Estimate of Nursing Time Requirements for 1 stroke patient during the first 24 hours after stroke. Activity Time (minutes) N per shift Total time Anti-embolic stockings (putting on) Anti-embolic stockings (checking) Bathing / shower Washing / grooming Tissue viability / pressure damage risk Toileting Oral hygiene Initial assessment (below*) medical history* social history* previous functional state* (m&h risk assessment) previous and current mood status* previous & current nutritional status* current neurological assessment (NIHSS)* Neurological assessment (SNOBS) Blood Pressure Oxygen saturation Pulse - rate and rhythm Temperature Respiration Meal time / Feeding / NG tube Swallowing ability Blood Sugar Fluid balance chart (include IV fluid) Weighing Monitoring for depression Medication Mobilisation & positioning Ward Rounds Relative - discussions patient - discussions CT scanning (one third to account for 3 shifts) Investigations / tests Handover & Report writing Breaks Total time (minutes) Please note this overview does not include time for any of the following activities: mentoring and staff training; management of complex disabilities, falls, incontinence and dementia/agitation; provision of palliative care, pain and other symptom control; thrombolysis/drug trial monitoring/documentation; participation in multi-disciplinary team working; bed management and advising on care of outliers; telephone referrals; working with translators. For further information on this analysis, please contact Professor Caroline Watkins, Professor of Stroke and Older People s Care, University of Central Lancashire, Preston, PR1 2HE (Tel: ; clwatkins@uclan.ac.uk).