inpatient care
Nursing
establishments
within acute
inpatient mental
health units:
the need for clarity
T
Staffing levels and skill he role and function of acute inpatient units
(AIUs) have developed and changed since
mixes have not kept the mid-1990s, with the introduction and
implementation of numerous policy and practice
pace with the increased guidance documents. There has been a recogni-
tion that acute inpatient care has failed service
demands made on users and carers, and at the same time failed
staff. Despite the increased attention and priority
modern acute care that inpatient care has received, one issue that
has not been explicitly addressed is the need to
settings. Now, with a develop robust staffing models and policies for
AIUs. As a consequence, staffing levels over the
steady stream of skilled past 20 to 30 years have remained essentially
unchanged, although the expectations of service
nurses leaving acute users and carers have increased, along with the
clinical and managerial demands upon nurses
inpatient units, Patrick
working within these areas.
McKee and colleagues This paper explores the policy and professional
drivers behind these changes, while highlight-
feel it is time to debate
Alamy
ing the continuing challenges and apparent
contradictions that provide the backdrop to the
the true cost of delivering growing expectation that AIUs continue to be
a core element of high quality mental health more recent guideline and policy publications are
this vital service services. The authors explore the issues related the National Occupational Standards in Mental
to nursing establishments, role development Health (Skills for Health 2003), Mental Health
and skill mix within an acute inpatient service Services Workforce Design and Development
within one mental health trust, although many (DH 2003) and A Mental Health Workforce for
keywords
of the issues and problems discussed will be of the Future: A Planner’s Guide (Sainsbury Centre
> staffing levels relevance to other areas of the mental health for Mental Health 2003), all of which address the
> s kill mix service. issue of workforce design and planning.
> health economics The Healthcare Commission (2005) recently
Professional and policy context completed a review of staffing issues within non-
These keywords are based Recent policy guidance has informed the debate mental health acute care settings and highlights
on the subject headings regarding staffing levels within AIUs and guide- the correlation between appropriate staffing
from the British Nursing
Index. This article has been
lines on workforce issues have reinforced the and levels of patient satisfaction. Additionally,
subject to a double-blind need to develop systematic processes relating the Royal College of Psychiatrists (2001) has
review. to workforce planning. Most significant among identified the importance of addressing staffing
18 mental health practice may 2006 vol 9 no 8
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inpatient care
Box 1. Factors that need to be considered
when planning and developing staffing
models for acute inpatient units
n New services, such as intensive home treatment
teams, may lead to fewer individuals requiring
inpatient admission, but those who do may be
more acutely unwell and require more intensive
individual nursing
‘Very few nursing staff n Legal and professional requirements relating to
individuals detained under the Mental Health Act
move back into the – e.g. the need for escorted leave, administrative
requirements relating to Section 117 aftercare
inpatient setting once planning. Between four and five hours of escorted
they have developed skills leave are required on a typical AIU on any given day
(Sainsbury Centre for Mental Health 2005)
and experience in other n Impact of increased levels of special and
parts of the service’ intensive nursing observations and the need to
supplement staffing levels accordingly (Barre and
Evans 2002)
n Shorter inpatient stays resulting in more time
having to be allocated to liaison with community
and home treatment teams and pre-discharge
planning
n Time spent on clerical and administrative tasks
– some nurses now spend 40 per cent more time
on ‘office duties’ when compared to inpatient
nurses in the 1980s (Hurst et al 1999)
n Whether the AIU is a ‘stand-alone’ unit, or part
of a multi-unit site – e.g. district general hospital or
dedicated mental health unit
n Impact of time that needs to be allocated to
statutory training (e.g. National Patient Safety
Agency requirements, child protection, basic life
support) and professional development activity
– calculated locally as requiring up to 11 days
annually for each member of staff; increased
levels of annual leave for staff following the
implementation of Agenda for Change
levels in its evaluation of violence in mental health are to be decided in the future. Given the rapid for the mental health workforce, in whichever
settings. Each document focuses on the need to pace of change within mental health services setting staff practice.
establish clear rationales and evidence for the and the development of new teams and roles, Despite the recent raft of policy and profes-
development of a skilled and competent mental it has never been more important to address sional guidance on the need to improve inpatient
health workforce, and nowhere is this more the issue in a systematic way. care, alongside the recognition that adequate
desirable than within inpatient mental health All of the above documents highlight issues of and appropriate staffing levels are essential,
units. However, one of the problems inherent concern with regard to staffing levels on AIUs, there has been no guidance relating to nation-
in effective workforce design, particularly in identifying the following key issues: ally agreed standards for minimum staffing on
relation to ensuring adequate nursing staffing n poor data regarding numbers, types of staff, AIUs. It is disappointing that the responsibility
levels, is the lack of a clear model or framework skill mix and client need for deciding staffing establishments and devel-
for the planning, implementation and evaluation n lack of strategic planning regarding staffing oping appropriate skill mix has been left almost
of staffing levels on AIUs (Golden et al 2004, levels and skill mix at national and local levels entirely to local commissioners and trusts to
O’Dowd 2005). As a result, it is often unclear n the negative impact of historical approaches to decide (O’Dowd 2005), with little in the way of
as to exactly how staffing levels have been defining staffing levels and identifying needs positive central guidance on how to plan and
determined and more importantly, how they n the need to ensure appropriate competencies develop staffing models that meet the needs of
may 2006 vol 9 no 8 mental health practice 19
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inpatient care
service users and carers receiving 21st century 2002), while, on the other hand, responding to ‘lost’ to the new community teams and services
mental health care. There is an expectation that the centrally driven expectation to develop new (Sainsbury Centre for Mental Health 2005). Many
within each trust Acute Care Forums should be crisis and intensive home treatment teams (DH of these individuals are those with the most
the local mechanism whereby the planning and 2001). While both are important aspirations and experience of caring for service users who are
service design should occur in relation to AIUs goals for NHS organisations, a tension has been acutely unwell, display high levels of disturbed
(DH 2002). However, there is little evidence created for mental health professionals and health behaviour and who require the most intensive
that such groups have been actively involved in planners and commissioners in attempting to levels of nursing and therapeutic support, yet
the review and redevelopment of new staffing achieve both targets at the same time. once they leave the inpatient setting, they are
models for acute units. highly unlikely to return to this area of practice
There appears to be a disparity between the ‘Lack of appropriately qualified in the future (Ryan et al 2004).
heavy emphasis placed on the need to deal with, There is no doubt that crisis and home treat-
or ‘do something’ about the issue, while at the
staff and poor attention to skill ment teams are often seen as more acceptable
same time a lack of direction and consensus as mix within clinical areas is a to both service users and carers, offering as
to what an appropriate staffing model for AIUs they do a practical and needs-led alternative
major stumbling block when it
should look like and how it can be implemented. to hospital admission; although this in itself has
One reason suggested for this is that if national comes to the delivery of effective the potential to generate additional problems
guidance on staffing levels were to be provided, nursing care’ due to an increase in the acute nature of the
AIUs that are staffed in excess of recommended problems experienced by those service users
numbers would come under pressure to reduce who do require inpatient care (Sainsbury Centre
staffing to the minimum levels (Sainsbury Centre The impact of these tensions becomes apparent for Mental Health 2005). The impact on both
for Mental Health 2005). when six years on from the Standing Nursing the type of service that can be provided and the
and Midwifery Advisory Committee’s (1999) quality of the care available within AIUs is likely
Understanding the problem report on acute inpatient care, both anecdotal to be influenced by a number of factors, many
In discussing the reasons for the generally poor and evaluative evidence (King’s Fund 2003, of which have not been taken into consideration
standard of inpatient care within mental health Sainsbury Centre for Mental Health 2005) when addressing staffing and skill mix within
units, the Sainsbury Centre for Mental Health highlights the continuing problems in improving inpatient units (Box 1).
(1998) identified the impact that inadequate staff- standards of care within AIUs. Added to this is Improving the experience of care within AIUs
ing levels have on the quality of care, as well as the growing awareness that appropriate skill mix is rightly seen as an urgent priority for health
how this can be a predisposing factor for violent and increased numbers of registered nurses can trusts, yet relatively little has been done to address
incidents (McGeorge and Lindow 2000). Overall, both lead to improvements in care and levels of the problems caused by the need to have highly
there has been a general acceptance that most patient satisfaction (Parish 2005). skilled and experienced staff working in the new
AIUs do not have enough staff to operate safe, Within our own organisation, inpatient nursing community services, while at the same time
effective and therapeutic ward environments. staff describe a link between the establishment ensuring that acute units remain professionally
Many AIUs remain overly dependent upon the of new teams and the ongoing problems of attractive and rewarding places to work.
use of bank and agency staff, with the average recruitment and retention within AIUs. Nation- Lack of appropriately qualified staff and poor
use per ward equating to 152 hours each; in ally, over a third of inpatient staff have been attention to skill mix within clinical areas is a
terms of numbers of staff, this is the equivalent major stumbling block when it comes to the
of four full-time nurses for each ward (Sainsbury Box 2. Critical factors required as part delivery of effective nursing care (Adams and
Centre for Mental Health 2005). of a robust inpatient staffing model Bond 2003). Despite the apparent need to develop
One of the major challenges in maintaining guidelines and policy relating to staffing numbers,
adequate staffing levels has been the appar- professional roles and skill mix, there has been
n reliable and realistic financial models that
ent drain of staff from inpatient areas to the little guidance for health managers in setting
accurately reflect the true costs of inpatient
growing number of additional services, such and benchmarking ward establishments in this
staffing
as crisis and home treatment teams, assertive area (Ryan et al 2004). For the most part there is
outreach teams and expanded community n identification of core tasks, roles and an adherence to historical methods of deciding
mental health teams. responsibilities of clinical staff within the unit the issue, and when data has been gathered
The Royal College of Psychiatrists highlighted – e.g. the need to ‘factor-in’ extraneous activity
regarding how ward staffing levels have been
the impact of this problem when commenting on decided, this is often based on tradition and
such as escorting detained patients, Section
the high numbers of newly qualified and bank arbitrary criteria (Waters 2003). If staffing levels
117 aftercare meetings, many of which have
and agency staff who are often left to run AIUs. are ever to properly reflect the clinical needs of
There are ‘insufficient numbers of experienced never been formally considered when planning patients, then all these factors need to be taken
senior staff to act as role models for the new staffing levels into account when setting baselines for nursing
members of the team, insufficient trained staff n explicit recognition of the impact of establishments and deciding on skill mix.
and constant changes within a short period
additional administration requirements
of staff becoming trained’ (Royal College of Strategies for improvement
Psychiatrists 2001). Very few nursing staff move n the need to respond to service user and carer The outdated staffing models identified above and
back into the inpatient setting once they have need for dedicated therapeutic time with staff the continuing need to improve the experience
developed skills and experience in other parts of – e.g. one-to-one contact with named nurses, of inpatient care need to be used as the focus
the service. Indeed, AIUs are frequently seen as providing specific therapeutic interventions such for developing more meaningful and realistic
stepping stones following initial registration and approaches to nursing establishments and skill
as cognitive behavioural therapy, recognising
preceptorship, a situation that militates against mix. Within our own organisation we have
the therapeutic nature of the processes of
the development of dynamic and user-led acute attempted to identify the most significant factors
nursing assessment and evaluation
inpatient care. that we think should be taken into consideration
A key issue for mental health professionals n realistic recognition of the impact of factors when developing a model for inpatient staffing
and NHS trusts is the apparent dilemma gener- such as unfilled staff vacancies, sickness, and that properly reflects the needs of service users,
ated by the need, on the one hand, to address initiatives such as Improving Working Lives
carers and staff (Box 2). For us, one of the most
the issue of improved staffing levels, skill mix significant elements to our work on addressing
and the physical environment within AIUs (DH the issue of realistic staffing has been a focus
20 mental health practice may 2006 vol 9 no 8
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inpatient care
Table 1. Replacement costs for inpatient nursing staff across the trust Conclusion
% Current models for staffing AIUs are inadequate
Factor and ineffective when seen in the context of
allowance
the drive to improve the standard of care and
Paid leave – based on the mean annual leave and special leave (e.g. maternity leave
address issues of recruitment and retention.
and bank holidays) entitlement following the implementation of Agenda for Change 17.00
The demands on, and expectations of, acute
of 37.66 days annually
care continue to grow, yet our approach to
Training and professional development – incorporates time for statutory training ensuring adequate staffing and appropriate
(10 days per year) and clinical supervision (1.6 days per year) 5.10 skill mix within inpatient units continues to be
informed by tradition and history, with limited
Sickness – figure set at 13 days per year, based on national sickness absence rates 5.00 recognition of the more complex nature of care
Clinical governance and related activity – e.g. quality improvement, practice and treatment in this setting.
development, clinical audit, research – 3.74 hours per month 2.30 While the development of new services is to be
welcomed, these appear to us to have occurred at
Total 29.40 the expense of inpatient care, with a steady drift
of skilled nursing staff from this setting to new
teams. Added to this is the ever-growing call for
on the issue of replacement costs for inpatient whole range of acute care provision becoming additional training and awareness around issues
establishments. Replacement cost refers to a the remit of our seven locality-based acute care such as cultural sensitivity, child protection, the
percentage allowance, in financial terms, that forums. It is only in this way that the solutions prevention of violence and aggression, clinical
is made to cover the costs associated with an can be developed that link the issue of staffing governance and service user involvement, all of
individual member of the nursing team being and skill mix with the broader agenda and aim which are important, yet, as we have shown,
absent from the ward. of improving the experience of inpatient care continue to struggle to be implemented due to
Collaborating with our acute care forums (DH for both service users and staff. a lack of appropriate skilled and experienced
2002), a realistic model highlighting replacement A further development has been the organisa- staff within AIUs.
costs has been developed (Cox 2005) and is cur- tion’s commitment to the development of new In this paper we have attempted to identify the
rently the subject of evaluation in partnership roles across a range of settings, including AIUs. need to fundamentally change our approach to
with the South West Development Centre of the Using Agenda for Change (AfC) as an opportunity the issues of staffing and skill mix within acute
National Institute for Mental Health in England. to reconsider the issue of skill mix, a pilot project is inpatient care. In order to achieve this there needs
Prior to the work described here, there was a currently underway within the trust to reconfigure to be an open and honest debate regarding
wide variation in the percentage allowance for the workforce within one inpatient area (Hayes the true cost of delivering care in this setting,
replacement costs across the trust, ranging from 2005). The AfC bandings and role profiles were as without this it will not be possible to deliver
16 to 23 per cent, with no logical reasons for used to review the skill mix and overall establish- the high standards of care and treatment that
the disparity between units. ment within the ward, resulting in additional staff service users and carers rightly expect n
Our current model has been developed by in bands three, four and six.
taking into account real data, such as up-to-date To support this development new roles were Patrick McKee, nurse director,
annual leave entitlements, internal and external created for existing healthcare support workers. Avon & Wiltshire Mental Health
sickness rates and the Nursing and Midwifery This has resulted in the creation of an associate Partnership NHS Trust;
Council’s PREP requirements for continual pro- practitioner role and a generic mental health
fessional development (Table 1). worker, both of which are underpinned by existing Anthony Harrison, consultant nurse
There is an urgent need for local Acute Care NVQ programmes and a dedicated educational (liaison psychiatry) and research
Forums to become engaged in the process of programme within the local university. The overall fellow, Faculty of Health & Social Care,
review and planning of new staffing models aim of this initiative is to improve the recruitment University of the West of England,
for acute care, with benchmarking and com- and retention of staff within the inpatient area Bristol;
mon standards needing to be developed across and develop the skills set of key members of
strategic health authorities. Within our organisa- the nursing team as a means of addressing the Gina Smith, consultant nurse and director of
tion, this process has begun to take place, with increased expectations of acute care by both studies (mental health), School for Health,
the channelling of issues concerned with the service users and central government. University of Bath
Golden M et al (2004) Workforce planning: is there a budgeted expenditure in acute mental health wards:
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