Royal College of Nursing submission (CCF0051)

1.0              Introduction

1.1               With a membership of more than 410,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets, the Royal College of Nursing (RCN) is the voice of nursing across the UK and the largest professional union of nursing staff in the world.  RCN members work in a variety of hospital and community settings in the NHS and the independent sector. The RCN promotes patient and nursing interests on a wide range of issues by working closely with the Government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

1.2              The RCN believes that much more can be done to reduce avoidable harm in health care[1]. We are currently focusing efforts on, but not limited to,  the following key areas:

• safe staffing levels
• growing safety conscious organisational cultures
• designing for reliability
• human factors as standard in education and training.

1,3              We appreciate the opportunity, therefore, to provide our views based on our experiences representing members that have been referred to the Nursing and Midwifery Council (NMC), as well as: a) the effectiveness of the NHS’s current approach to investigating and addressing untoward medical incidents, and b) how lessons about best practice, procedures and human factors should be learned and disseminated.

2.0              Safe staffing levels

2.1              The RCN believes that of the factors that lead to poor care, few are more tangible or pronounced than safe staffing levels. Evidence from extensive studies and experience of investigations into patient safety such as the Francis, Keogh and Berwick reports, show a strong correlation between inadequate staffing levels and poor quality of care, and, therefore, complaints. Not only should there be the right numbers of staff for the number of patients, but health care settings must have staff in place with the right mix of skills to support the specific needs of the patients in that setting.

2.2              The RCN supports the use of evidence based staffing tools to determine the right numbers of staff to keep care safe. However, while the NHS experiences the biggest financial squeeze in its history, the nursing workforce has not seen significant expansion since 2010 and the demand for nursing continues to grow due to an expanding, ageing population with increasingly complex care needs.

2.3              Safe staffing is a persistent issue across the NHS and too often financial pressures take precedence over workforce planning that is based on long-term service need. Failure to tackle the significant issue of recruitment and retention of nurses in the long term and a shortage of registered nurses on wards for care to be safe, will no doubt contribute to the numbers of incidents and complaints.

3.0              Patient safety in the NHS

3.1              The RCN defines patient safety as the prevention of avoidable errors and adverse effects to patients associated with health care. Staff practise patient safety when they apply safety science methods, such as the human factors approach, towards the goal of developing reliable systems of care. In so doing patient safety becomes both a characteristic of a health care system and a means through which quality of care is improved.[2]

3.2              The RCN concurs with the points made by Carl Macrae and Charles Vincent in their paper “Learning from failure: the need for independent safety investigation in healthcare” that the NHS has no consistent approach to investigating safety issues. The fragmented nature of current safety investigations in the NHS limits the opportunities for actionable learning.[3]

3.3              Different forms of investigation exist and are carried out by different agencies addressing different perspectives of the investigation. It is unsurprising, therefore, that we lack a coherent picture of the wider systemic factors leading to failures of care. Fragmentation and inconsistency limit meaningful understanding of challenges and hinder ability to learn from these and to develop a culture that openly learns from mistakes.

4.0              Managing patient safety incidents in the NHS

4.1              A significant study by Dr Rachel Murray (cited by Stone et al 2011[4]) looked at a survey of nurse suspensions known to the RCN in England during 2002, an audit of over 600 sets of RCN Counselling Service data and analysis of individual interview and focus group data of participants who had experienced suspension. The study found an inconsistent approach to the use of suspensions. It also showed that the length of suspension varied from 2 weeks to over 6 months and that the experience of being suspended was a significant traumatic event for the individuals concerned. With relatively few dismissals, Murray questioned the need for suspension due to its attendant psychological and financial cost.

4.2              Data from the Nursing and Midwifery Council (NMC) also highlights that managers are continuing to use punitive forms of performance management to deter poor performance. The Investigating Committee of the NMC assesses whether cases referred to them warrant further investigation or not. An increasing number are deemed as having “no case to answer”. This figure has risen from 1,270 cases in 2012-13 (37% of cases) to 1,404  cases in 2013-14 (just under 50% of cases). This would suggest that referrals are being made inappropriately with little or no impact on the underlying causes[5].

The RCN is also concerned that the NMC guidance on referring nurses to when an incident occurs has led to ‘over-referral’, particularly in the independent sector, where we often encounter the view from employers that the Care Quality Commission (CQC) would expect them to refer nurses to the NMC when an incident occurs. 

4.3              The RCN is also a concerned that learning tools such as the Incident Decision Tree (IDT)[6], published by the National Patient Safety Agency[7] in 2005, a flow chart designed to help managers and clinicians understand an individual’s actions, motives and behaviour at the time of an incident, are under-utilised by those making referrals. Consistent application of the IDT could help reduce the numbers of cases unnecessarily referred to the NMC and move attention from person-based, to system-based weaknesses. An independent agency would be able to shed light on the types of factors contributing to these figures too.

5.0              Conclusion

5.1              The RCN believes we urgently need ways of transferring the principles of independent investigation and investigation methodologies from other safety-critical industries to the NHS and that adoption of these by the NHS is long overdue. We would welcome an independent agency that has the expertise and the authority to undertake such work . This aligns with our goals of growing as a safety conscious organisations and designing reliable systems which take into account human factors.

5.2              We would especially welcome the emphasis on learning and improving the system of care. The NHS is lagging behind high risk industries in both attitude and systematic management of patient risks (Hudson 2003[8]). Such an agency would be augmenting the infrastructure provided by the Patient Safety Collaboratives and the cohort of “patient safety fellows” already announced. Together they can provide the means to share and apply sound human factors approaches across the NHS.