Over 60 people joined us to discuss the issue of safe staffing, and the role of skill mixes and observations as an indicator for safe staff levels.

Starting off discussing on the mixof HCA and RNs, there were few hard numbers presented (50:50 to 70:30 HCA:RN,one RN to 4 patients or 1 to 7). The discussion quickly moved on to who is best suited to do observations. There was no consensus on who, but the clear message was that there needs to be systems in place for abnormal observations to be escalated. With the role of HCA being helpful and practical, training was raised as important to help people make sure obs are done properly and escalated when appropriate. Delegating responsibility for completion of obsstill lies with nurses, as does follow-up.

While focusing on observations,it became clear that the quality of obs done is important, as opposed to itjust being a tick box exercise. One individual noted that “I can tell more about my patient by doing a bed bath than the obs”, and another that “having 100% compliance doesn’t mean it is done well”. The notion of a complete or incomplete set of obs was also raised.

Electronic obs systems were discussed, and whilst they can help measuring and monitoring, there were points raised about complacency and not interacting with the patient, and getting the full picture of them whilst distracted by a tablet.

The scope of the chat focused on obs because of the remit of the research by the CLARHC Wessex team, but the wider components of safe staff were raised – “caring safely for someone is not just about obs”.

The question that prompted the most activity was about what level of obs it was safe to miss or delay. There was a strong feeling that 100% compliance is needed, because you can’t be sure a patient won’t deteriorate, “we don’t accept 90% compliance with drugs for example, there is evidence, and it’s deemed to be needed so needs to be done”.Interestingly, one individual noted that obs were most likely to be missed or late on those patients who were the most ill. But the practical dilemma was summed up by one tweet; “We were scolded for missing obs – but the alternative was leaving a 20yr old covered in faeces. Not defined by %”

Furthermore, with a target of 100%, one person noted that “risk hitting the target, but missing the point”.