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Nursing skill mix in acute mental health in-patient environments. Jane Sayer, Programme Director (Nursing Excellence) Richard M Jones, Specialist Nurse Researcher. Why is skill mix important?. Current financial climate

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Nursing skill mix in acute mental health in-patient environments

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Nursing skill mix in acute mental health in patient environments

Nursing skill mix in acute mental health in-patient environments

Jane Sayer, Programme Director (Nursing Excellence)

Richard M Jones, Specialist Nurse Researcher

Why is skill mix important

Why is skill mix important?

  • Current financial climate

  • 1 in 10 patients report that there were rarely or never enough nurses available on in-patient units (CQC, 2010)

  • Positive effect on outcome supported by evidence

Mhmds report on 2010

MHMDS report on 2010

  • 5.1% increase in use of inpatient facilities (8.5% of total MH users)

  • 30.1% rise in number of people detained under MHA (lower level of 17.5% possible)

  • Number of voluntary patients falling for 4 years

  • Number of women detained via courts or prison saw an 85% rise last year

  • NHS mental hospitals are increasingly being used to care for and contain people who pose a risk to themselves or others (MHMDS, 2010, Bowers & Flood 2008)

The effect on outcomes

The effect on outcomes

  • 26% higher mortality in hospitals with poorer nursing levels

  • Higher burnout rates

  • Twice as likely to be dissatisfied in their job

  • More likely to report low/ deteriorating quality of care on their wards

  • Rafferty 2007

  • MH environments: higher staffing levels = lower re-admission rates. Substantially better outcomes achieved when attention patients received from staff was taken into account

  • Coleman & Paul 2001

  • 9% of suicides could have been prevented by increasing staff numbers and 6% by increasing beds and services

  • Appleby et al 2006

The cost of in patient care

The cost of in-patient care

  • Fivefold cost variance between UK MH trusts (£4.3 to £24.6 million)

  • Associations between nursing cost per bed and performance indicators were found

  • Bowers & Flood 2008

  • Conflict and containment in in-patient mental health settings in England estimated at £178.5 million per year

  • Flood et al 2008

Nnru 2009

‘whilst low registered nurse staffing levels should be considered a risk factor for poor quality care, increasing nurse staffing may not be a sufficient solution’

NNRU (2009)

Addressing grades

Addressing grades

  • RN- LPN- HCA- NA

  • Higher levels of RN= lower rates of adverse outcomes

  • Needleman el at (2002)

  • Higher RN levels = less likely to die in hospital. Higher levels of LPN more likely to die

  • Person et al (2004)

  • Violence associated with discrepancy between acuity and available staff

  • Higher skill mix and BSc qualified nurses associated with fewer incidents of violence

  • Roche et al (2010)

Nursing skill mix in acute mental health in patient environments

  • Higher LPN investment = more pressure ulcers, and wage saving more than offset by additional treatment costs

  • Hendrix and Foreman (2001)

  • Mental health environments in the UK are mostly staffed by the most junior, least qualified workforce, yet they care for the most acutely (and increasingly so) unwell patients

Needleman 2006 3 options

Needleman (2006) 3 options

  • Increase proportion of RN hours but not total nursing hours

  • Increase total number of hours of RNS and LPNs without changing proportion

  • Increase proportion of RN hours and total number of nursing hours of both groups



  • Appleby, L. Shaw, J. and Kapur, N. (2006) Avoidable deaths: five year report of the national confidential inquiry into suicide and homicide by people with mental illness. University of Manchester.

  • Bowers, l. and Flood, C. (2008) Nurse staffing, bed numbers and the cost of acute psychiatric care in England. Journal of Psychiatric and mental health nursing. 15 630-637.

  • Coleman, J.C and Paul, G.L (2001) Relationship between staffing ratios and effectiveness of inpatient units. Psychiatric Services. 52, 1374-1379.

  • CQC (2010) Supporting briefing note: issues highlighted by the 2009 survey of patients in NHS hospitals in England.

  • Flood, C. Bowers, L. Parkin, D. (2008) Estimating the costs of conflict and containment on adult inpatient psychiatric wards. Nursing Economics. 26, (5).

  • Hendrix, t. and Foreman, s. (2001) Optimal long term care nurse staffing levels. Nursing economics. 19 (4) 164-175.

  • MHMDS (2010) the information centre for health and social care. In-patients formally detained in hospital under the MHA 1983 and patients subject to SCT. Annual figure. England 09/10- October 2010.

  • Needleman, J. et al (2002). Nurse staffing levels and the quality of care in hospitals. New England Journal of medicine. 346 (22) 1715-1722.

  • Needleman, J. (2006) Nurse staffing in hospital: is there a business case for quality? Health affairs. 25 (1) 204-211.

  • Person, S. et al (2004). Nurse staffing and mortality for medicare patients with acute myocardial infarction. Medical care 42 (1) 4-12.

  • Policy+ (2009) Is there a case for the UK nursing workforce to include grades of qualified nurse other than the registered nurse? (21) October.

  • Rafferty, AM. Et al (2007) Outcomes of variation in hospital nurse staffing in English hospitals: cross sectional analysis of survey data and discharge records. Int. Journal of Nursing studies, 44 (2) 175-182.

  • Roche et al (2010) Violence toward nurses, the work environment, and patient outcomes. The Journal of Nursing Scholarship. 42 (1) 13-22

Average staffing and patient data nhs wards by speciality all shifts rcn 2009

Average staffing and patient data- NHS wards by speciality (all shifts), (RCN 2009)

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