COMPLETED: Safer Nursing Care Tool and nurse staffing requirements
What did we learn
We found that for some wards using the Safer Nursing Care Tool (SNCT) gives a good estimate of the number of nursing staff needed. However, for other wards, relying on the estimate provided by this tool without further thought could lead to unsafe staffing levels for different reasons. For example, the current guidance recommends setting staffing levels to meet the average requirement, but following this logic, 18 wards in the three Trusts would often have been short-staffed. Also, a quarter of wards needed a sample of over 182 days to estimate the number of staff needed precisely, when the current recommendation is 20 days. Nursing workforce leaders at the three Trusts suggested characteristics of wards where the tool performed least well, for instance, high patient throughput and differences in workload between mornings and evenings.
What difference can this new knowledge make?
• This project and the previous related project (NIHR-funded study https://doi.org/10.3310/hsdr08160) led to a direct collaboration with NHS England and NHS Improvement and an invitation to work with them to further develop and update the guidance on using the Safer Nursing Care Tool.
• The team have spoken about the research findings and implications at a series of NHS Improvement safe staffing fellows training events.
• They have developed a set of resources to help nurses plan staffing: a professional guidance framework and a series of videos.
• Impact has been achieved through this research shaping revised guidelines published by NHS England and NHS Improvement on using the SNCT in combination with professional judgement to determine nurse staffing requirements.
Why is this important?
• The professional judgement framework we developed as a result of these projects will benefit nurses, who use this tool nationally, by giving them concrete guidance on issues to consider when deciding staffing levels.
• It will benefit patients admitted to inpatient wards, through better matching of staffing levels to demand. Having too few nursing staff is related to adverse effects for patients (more deaths, more falls, longer stays in hospital), staff (turnover, sickness) and organisations (higher costs from temporary staff to fill gaps).
Diagram 1
We presented the list of wards which were flagged as having overall poor fit to three nursing workforce leaders
Some of the common factors they suggested as potential reasons for poor fit are shown here above.
They highlighted wards with large morning-evening differences in staffing requirements (based on acuity-dependency ratings) may be among those where the tool fits least well.
For wards that are particularly small or large, it is possible that the number generated by the SNCT is less likely to be sufficient to maintain minimum registered nurse levels when rostering staff to shifts.
They highlighted some ward characteristics that mean the SNCT multipliers, as they are applied, may underestimate the true workload. These were
high patient turnover,
older patient population,
cancer infusion/device activity.
a high proportion of patients requiring one-to-one care AKA enhanced care/specialling.
The factors suggested are on the whole congruent with published evidence
What next?
Our next step is applying for funding to conduct research around predicting demand for nursing staff which we plan will also lead to tools and resources to guide decision-making around staffing.
Research team:
• Professor Peter Griffiths, Chair of Health Services, University of Southampton
• Rosemary Chable, Deputy Director of Nursing, Education & Workforce, University Hospital Southampton NHS Foundation Trust
• Nicky Sinden, Head of Nursing Workforce, Portsmouth Hospitals NHS Trust
• Tracy Moran, Lead Nurse for Nursing Workforce, Education & Practice, Poole Hospital NHS Trust
Project partners:
• University of Southampton
• University Hospital Southampton NHS Foundation Trust
• Portsmouth Hospitals NHS Trust
• Poole Hospital NHS Trust
More information
Evidence Brief Publication
Publications:
Saville, Christina and Griffiths, Peter (2021) Ward staffing guided by a patient classification system: A multi-criteria analysis of “fit” in three acute hospitals. Journal of Nursing Management, 29 (7), 2260-2269. (doi:10.1111/jonm.13341).
Saville C, Griffiths P, Casey A, Chable R, Chapman H, Radford M, and Watts N (2023) Professional Judgement Framework, doi: 10.5258/SOTON/P1102 University of Southampton (https://doi.org/10.5258/SOTON/P1102)
The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study (nihr.ac.uk)
Video:
Computer simulation what and why? https://sho.co/1E34T
The importance of professional judgement in nurse staffing decisions
Here is the orginal research outline
Identifying wards for which the Safer Nursing Care Tool is appropriate for assessing nurse staffing requirements
Principal Investigator: Dr Christina Saville
Team members: Dr Christina Saville (Research Fellow, University of Southampton) Professor Peter Griffiths (Chair of Health Services Research, School of Health Sciences, University of Southampton), Rosemary Chable RN (Deputy Director of Nursing, Education & Workforce, University Hospital Southampton NHS Foundation Trust) Ms Nicky Sinden (Head of Nursing Workforce at Portsmouth Hospitals NHS Trust), Tracy Moran (Lead Nurse for Nursing Workforce, Education & Practice, Poole Hospital NHS Foundation Trust)
Start: 1 December 2019 Ends: 1 August 2020
Partners:
University of Southampton, Portsmouth Hospitals NHS Trust, Poole Hospital NHS Foundation Trust
Lay summary
It is important to have enough qualified (registered) nurses looking after patients staying on hospital wards, because having too few is associated with worse patient care and more patient deaths. On the other hand, there are extreme shortages of nurses, so having “too many” on a ward could be considered a waste. The Safer Nursing Care Tool is used in many hospital wards in England to work out the number of nursing staff (including nursing assistants) needed. However, a recent study showed that it is more suitable on some wards than on others. For example, we found that factors not accounted for in the tool, e.g. whether a ward is surgical or medical, and the proportion of single rooms, also affected professional judgement of whether staffing was adequate.
Aim
This study aims to understand which ward characteristics mean that the Safer Nursing Care Tool gives a good estimate of the nursing staff required, and which ward characteristics mean that the number might need to be adjusted or further considered by taking into account the expertise of ward leaders. It also aims, if possible, to provide some general rules or an add-on tool to help nursing managers with setting staffing levels.
Methods
We will analyse the data that were collected for a previous study in a different way. This time we will focus on differences between wards rather than hospitals. We will use analytical techniques for finding patterns in data to identify similar wards. In our team we have experienced leaders in nursing who will provide expert professional insights into ward characteristics.
Patient, public and community involvement and sharing results
We will involve nursing managers in the study because they are the potential users of any rules or tools we develop. We plan to develop a resource (rules or a tool) for nursing ward managers and to run a workshop to test use of this resource. We plan to write one academic paper about what we find out. We also can share the plans for this with lay members from the PPI group as appropriate. We are developing a smaller user group across Workforce and Frailty and Older People teams.