Developing, testing and applying instruments for measuring rising dependency-acuity's impact on ward staffing and quality

Strategic workforce planning in health and social care - an international perspective: A scoping review

Effective strategic workforce planning for integrated and co-ordinated health and social care is essential if future services are to be resourced such that skill mix, clinical practice and productivity meet population health and social care needs in timely, safe and accessible ways globally. This review presents international literature to illustrate how strategic workforce planning in health and social care has been undertaken around the world with examples of planning frameworks, models and modelling approaches. The databases Business Source Premier, CINAHL, Embase, Health Management Information Consortium, Medline and Scopus were searched for full texts, from 2005 to 2022, detailing empirical research, models or methodologies to explain how strategic workforce planning (with at least a one-year horizon) in health and/or social care has been undertaken, yielding ultimately 101 included references. The supply/demand of a differentiated medical workforce was discussed in 25 references. Nursing and midwifery were characterised as undifferentiated labour, requiring urgent growth to meet demand. Unregistered workers were poorly represented as was the social care workforce. One reference considered planning for health and social care workers. Workforce modelling was illustrated in 66 references with predilection for quantifiable projections. Increasingly needs-based approaches were called for to better consider demography and epidemiological impacts. This review's findings advocate for whole-system needs-based approaches that consider the ecology of a co-produced health and social care workforce.

Performance of the Safer Nursing Care Tool to measure nurse staffing requirements in acute hospitals: a multicentre observational study

OBJECTIVES

The best way to determine nurse staffing requirements on hospital wards is unclear. This study explores the precision of estimates of nurse staffing requirements made using the Safer Nursing Care Tool (SNCT) patient classification system for different sample sizes and investigates whether recommended staff levels correspond with professional judgements of adequate staffing.

DESIGN

Observational study linking datasets of staffing requirements (estimated using a tool) to professional judgements of adequate staffing. Multilevel logistic regression modelling.

SETTING

81 medical/surgical units in four acute care hospitals.

PARTICIPANTS

22 364 unit days where staffing levels and SNCT ratings were linked to nurse reports of "enough staff for quality".

PRIMARY OUTCOME MEASURES

SNCT-estimated staffing requirements and nurses' assessments of staffing adequacy.

RESULTS

The recommended minimum sample of 20 days allowed the required number to employ (the establishment) to be estimated with a mean precision (defined as half the width of the CI as a percentage of the mean) of 4.1%. For most units, much larger samples were required to estimate establishments within ±1 whole time equivalent staff member. When staffing was lower than that required according to the SNCT, for each hour per patient day of registered nurse staffing below the required staffing level, the odds of nurses reporting that there were enough staff to provide quality care were reduced by 11%. Correspondingly, the odds of nurses reporting that necessary nursing care was left undone were increased by 14%. No threshold indicating an optimal staffing level was observed. Surgical specialty, patient turnover and more single rooms were associated with lower odds of staffing adequacy.

CONCLUSIONS

The SNCT can provide reliable estimates of the number of nurses to employ on a unit, but larger samples than the recommended minimum are usually required. The SNCT provides a measure of nursing workload that correlates with professional judgements, but the recommended staffing levels may not be optimal. Some important sources of systematic variations in staffing requirements for some units are not accounted for. SNCT measurements are a potentially useful adjunct to professional judgement but cannot replace it.

TRIAL REGISTRATION NUMBER

ISRCTN12307968.

The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study

Background

The Safer Nursing Care Tool is a system designed to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). The Safer Nursing Care Tool is widely used in English hospitals but there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing the staffing levels needed for safe and quality patient care.

Objectives

To determine whether or not the Safer Nursing Care Tool corresponds to professional judgement, to assess a range of options for using the Safer Nursing Care Tool and to model the costs and consequences of various ward staffing policies based on Safer Nursing Care Tool acuity/dependency measure.

Design

This was an observational study on medical/surgical wards in four NHS hospital trusts using regression, computer simulations and economic modelling. We compared the effects and costs of a ‘high’ establishment (set to meet demand on 90% of days), the ‘standard’ (mean-based) establishment and a ‘flexible (low)’ establishment (80% of the mean) providing a core staff group that would be sufficient on days of low demand, with flexible staff re-deployed/hired to meet fluctuations in demand.

Setting

Medical/surgical wards in four NHS hospital trusts.

Main outcome measures

The main outcome measures were professional judgement of staffing adequacy and reports of omissions in care, shifts staffed more than 15% below the measured requirement, cost per patient-day and cost per life saved.

Data sources

The data sources were hospital administrative systems, staff reports and national reference costs.

Results

In total, 81 wards participated (85% response rate), with data linking Safer Nursing Care Tool ratings and staffing levels for 26,362 wards × days (96% response rate). According to Safer Nursing Care Tool measures, 26% of all ward-days were understaffed by ≥ 15%. Nurses reported that they had enough staff to provide quality care on 78% of shifts. When using the Safer Nursing Care Tool to set establishments, on average 60 days of observation would be needed for a 95% confidence interval spanning 1 whole-time equivalent either side of the mean. Staffing levels below the daily requirement estimated using the Safer Nursing Care Tool were associated with lower odds of nurses reporting ‘enough staff for quality’ and more reports of missed nursing care. However, the relationship was effectively linear, with staffing above the recommended level associated with further improvements. In simulation experiments, ‘flexible (low)’ establishments led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. Cost savings were small when high temporary staff availability was assumed. ‘High’ establishments were associated with substantial reductions in understaffing and improved outcomes but higher costs, although, under most assumptions, the cost per life saved was considerably less than £30,000.

Limitations

This was an observational study. Outcomes of staffing establishments are simulated.

Conclusions

Understanding the effect on wards of variability of workload is important when planning staffing levels. The Safer Nursing Care Tool correlates with professional judgement but does not identify optimal staffing levels. Employing more permanent staff than recommended by the Safer Nursing Care Tool guidelines, meeting demand most days, could be cost-effective. Apparent cost savings from ‘flexible (low)’ establishments are achieved largely by below-adequate staffing. Cost savings are eroded under the conditions of high temporary staff availability that are required to make such policies function.

Future work

Research is needed to identify cut-off points for required staffing. Prospective studies measuring patient outcomes and comparing the results of different systems are feasible.

Trial registration

Current Controlled Trials ISRCTN12307968.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 8, No. 16. See the NIHR Journals Library website for further project information.

Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion

Background

The importance of nurse staffing levels in acute hospital wards is widely recognised but evidence for tools to determine staffing requirements although extensive, has been reported to be weak. Building on a review of reviews undertaken in 2014, we set out to give an overview of the major approaches to assessing nurse staffing requirements and identify recent evidence in order to address unanswered questions including the accuracy and effectiveness of tools.

Methods

We undertook a systematic scoping review. Searches of Medline, the Cochrane Library and CINAHL were used to identify recent primary research, which was reviewed in the context of conclusions from existing reviews.

Results

The published literature is extensive and describes a variety of uses for tools including establishment setting, daily deployment and retrospective review. There are a variety of approaches including professional judgement, simple volume-based methods (such as patient-to-nurse ratios), patient prototype/classification and timed-task approaches. Tools generally attempt to match staffing to a mean average demand or time requirement despite evidence of skewed demand distributions. The largest group of recent studies reported the evaluation of (mainly new) tools and systems, but provides little evidence of impacts on patient care and none on costs. Benefits of staffing levels set using the tools appear to be linked to increased staffing with no evidence of tools providing a more efficient or effective use of a given staff resource. Although there is evidence that staffing assessments made using tools may correlate with other assessments, different systems lead to dramatically different estimates of staffing requirements. While it is evident that there are many sources of variation in demand, the extent to which systems can deliver staffing levels to meet such demand is unclear. The assumption that staffing to meet average need is the optimal response to varying demand is untested and may be incorrect.

Conclusions

Despite the importance of the question and the large volume of publication evidence about nurse staffing methods remains highly limited. There is no evidence to support the choice of any particular tool. Future research should focus on learning more about the use of existing tools rather than simply developing new ones. Priority research questions include how best to use tools to identify the required staffing level to meet varying patient need and the costs and consequences of using tools.

Tweetable abstract

Decades of research on tools to determine nurse staffing requirements is largely uninformative. Little is known about the costs or consequences of widely used tools.

Using workload measurement tools in diverse care contexts: the experience of staff in mental health and learning disability inpatient settings

ACCESSIBLE SUMMARY

What is known on the subject? Difficulties with the recruitment and retention of qualified nursing staff have resulted in nursing shortages worldwide with a consequential impact on the quality of care. It is increasingly recommended that evidence-based staffing levels are central to the development of workforce plans. Due to a paucity of empirical research in mental health and learning disability services the staffing needs and requirements for these settings are undefined and the availability of tools to aid staffing decisions is limited. What this paper adds to existing knowledge? This paper provides a valuable insight into the practical uses of these tools as perceived by staff members with day-to-day experience of the requirements of mental health and learning disability wards. It reveals that while workload measurement tools are considered a valuable aid for the development of workforce plans, they are limited in their ability to capture all aspects of care provision in these settings. It further emphasizes the inapplicability of a one-shoe-fits-all approach for determining nurse staffing levels and the need for individual and customized workforce plans. What are the implications for practice? This study demonstrates that the development of tools for use in mental health and learning disability services is in its infancy, yet no tool that has been validated as such. It highlights the potential for workload measurement tools to aid staffing decisions; however, a more holistic approach that considers additional factors is needed to ensure robust workforce planning models are developed for these services.

INTRODUCTION

The critical challenge of determining the correct level and skill mix of nursing staff required to deliver safe and effective health care has become an international concern. It is recommended that evidence-based staffing decisions are central to the development of future workforce plans. Workforce planning in mental health and learning disability nursing is largely under-researched with few tools available to aid the development of evidence-based staffing levels in these environments.

AIM

It was the aim of this study to explore the experience of staff using the Safer Nursing Care Tool and the Mental Health and Learning Disability Workload Tool in mental health and learning disability environments.

METHOD

Following a 4-week trial period of both tools, a survey was distributed via Qualtrics online survey software to staff members who used the tools during this time.

RESULTS

The results of the survey revealed that the tools were considered a useful resource to aid staffing decisions; however, specific criticisms were highlighted regarding their suitability to psychiatric intensive care units and learning disability wards.

DISCUSSION

This study highlights that further development of workload measurement tools is required to support the implementation of effective workforce planning strategies within mental health and learning disability services.

IMPLICATIONS FOR PRACTICE

With increasing fiscal pressures, the need to provide cost-effective care is paramount within the services of the National Health Service. Evidence-based workforce planning is therefore necessary to ensure that appropriate levels of staff are determined. This is of particular importance within mental health and learning disability services due to the reduction in the number of available beds and an increasing focus on purposeful admission and discharge.

Nursing care complexity in a psychiatric setting: results of an observational study

For nurses working in mental health service settings, it is a priority to perform patient assessments to identify patients' general and behavioural risks and nursing care complexity using objective criteria, to meet the demand for care and to improve the quality of service by reducing health threat conditions to the patients' selves or to others (adverse events). This study highlights that there is a relationship between the complexity of psychiatric patient care, which was assigned a numerical value after the nursing assessment, and the occurrence of psychiatric adverse events in the recent histories of the patients. The results suggest that nursing supervision should be enhanced for patients with high care complexity scores.