Support workers and patient safety

That safety is paramount in healthcare goes without saying. There are though variations in patient outcomes between hospitals that cannot be explained by different population characteristics. Based on aggregate staffing data, a number of studies have shown that skill mix can be a factor accounting for these variations – essentially the higher the ratio of unregistered staff to registered staff the greater the incidence of adverse outcomes including mortality rates, (although some reviews have been more positive in their findings, whilst case studies demonstrate mixed results with some showing, for example, that failure to delegate tasks to support workers results in missed care).

An issue with large scale studies based on aggregate staffing data is, due to the poor data collection in the NHS, that they cannot, for example, be sensitive to the extent to which support staff have or have not had access to appropriate education, supervision, or managerial processes such as appraisals. These things matter. Whilst there are variations in hospital mortality rates, there are also variations between hospitals (and even within them) in how support staff are deployed, managed, invested in and developed. Camilla Cavendish captured this difference when she spoke of support workers being often used as “an extra pair of hands”, when they should be “an extra pair of eyes and ears”. My colleague at King’s College London, Professor Ian Kessler has shown that in many settings support staff are the key ‘bedside’ presence; often providing the bulk of face-to-face contact with patients and their families [1].

We know the factors that can underpin safe care. They include - appropriate numbers of registered staff, absolutely, but also, from the perspective of support staff - quality supervision, a clearly defined scope of practice linked to competences and occupationally relevant learning, acceptance as full team members so they feel they have a ‘voice’ when they see something that they think is not right, up-to-date governance policies and processes that reflect current models of care and, perhaps less regularly considered, so-called ‘good work’ practices like well-designed job descriptions, effective appraisals and clear career pathways. There is evidence that delivering ‘good work’ in the NHS, results in higher patient satisfaction.

Get these factors right and all staff are clear about the tasks that can and cannot be delegated and support staff will have the training and support they need to provide the necessary care to patients. ?The good news is that in a growing number of areas the features needed to underpin safe care, such as competency frameworks, now exist [2]. The Chartered Society of Physiotherapy has recently announced that they feel, following discussions with members, that the ratio of physiotherapy assistants could increase from its current proportion of 1:5 on average to 1:3. This is in the context of projected growth in staffing numbers at all levels. It is worth noting that the Allied Health Professions have probably the most resources and guidance for their support workforce.

There is a pressing gap in the research that rapidly needs to be filled and that is the extent to which the way support staff roles are designed, treated, managed, and developed impacts on safety (and also other measures including productivity). This is something, as far as I am aware, the aggregate studies have not been able to take account of. This has, I feel, let to a view sometimes that support staff per se are a safety issue, rather than their lack of development opportunities, valuing and investment [3].

Patient safety is a multi-faceted, complex issue at the core of which must be ensuring services have the right numbers of staff with the right skills. Support staff are key members of most clinical teams. Historically they have been neglected by policy makers and local employers, as Robert Frances, Cavendish and Lord Willis all pointed out. This is changing, although more needs to be done. It cannot be right, can it, that funding for CPD is based only on registered staff numbers? In a safety critical sector all staff should be funded so they can access the learning they need to do their job effectively and safely.

The debate on skill mix and patient safety, rightly, continues. The truth is that there is a dearth of research that looks, in detail, at the conditions in which support staff work and how these affect outcomes such as patient safety. That needs to change.

Notes

[1] See - Ian Kessler, Paul Heron and Sue Dopson (2012), The Modernising of the Nursing Workforce Oxford University Press

[2]. Most of the aggregate studies are based on data prior to the development of these resources. This is not the whole story, however. Whilst a number of safe staffing tools, such as the Safer Nursing Care Tool and Birthrate Plus exist to support professional judgement on safe staffing levels, there is the need to consider how acuity and activity impacts on safety in other clinical areas and the relationship between these tools and professional judgement. (Disclaimer – I am a Director of Birthrate Plus)

[3] One recent study defined support staff as “unregistered care staff (without nursing qualifications)”. Such a definition will include staff with literally no qualifications, those with NVQs probably acquired some considerable time ago, some who have recently completed the new Diploma linked to relevant apprenticeships or those who have achieved foundation degrees. It would seem reasonable to suggest that - (a) the contribution to care of each of these will be different, all other things being equal, (b) that all staff, at whatever level of practice, should have access to up-to-date learning and (c) research needs to be sensitive to these differences. (Quote from: Griffiths R, Ball J, Murrells T, Jones S, Rafferty AM (2016) Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study. BMJ Open https://dx.doi.org/10.1136/bmjopen-2015-008751 )