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Research project: Identifying nurse-staffing requirements using the Safer Nursing Care Tool. Modelling the costs and consequences of real world application to address variation in patient need on hospital wards

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The National Institute for Health and Care Excellence (NICE) recently issued guidance on setting safe nurse staffing levels for hospitals. This is partly in response to reports into failures in the NHS (including the Mid Staffordshire inquiries) and research showing the importance of having the right numbers of nurses on wards to ensure safe care. NICE recommends a systematic approach to setting staffing levels. NICE endorsed a tool (The Safer Nursing Care Tool or SNCT) that estimates staff requirements by assigning patients to one of five categories, based on how ill they are and the typical time taken to care for similar patients (known as acuity/dependency). The standard approach to using the SNCT sets staffing to meet the average needs of a sample of patients. There is little evidence that shows how often this means there are enough nurses on the ward to meet patient need or whether other approaches might give better results.

The quality of nursing care and the potential for inadequate nursing to harm patients has emerged as a factor in many reports on failings in NHS hospitals. Reports often cite inadequate nurse staffing as a causal factor in these failures. NICE has recently issued guidance on determining safe staffing for hospital wards, which endorsed using the Safer Nursing Care Tool (SNCT) to indicate the number of nurses required on a ward to meet patient need, based on a patient acuity/dependency measure. Our review for NICE found little evidence about the costs or consequences of tools used to determine staffing levels based on assessed patient need, or the extent to which different staffing policies, based on using the tools are affordable, effective or feasible.

This study examines how patients’ needs for nursing care, as measured by the SNCT, vary from day to day. This will allow us to determine how often staffing shortfalls occur, whether there may be excess staff on other wards who could make up a shortfall, and to model the costs and consequences of different strategies for using the tool and deploying nursing staff to meet varying need. We will collect data on ward nurse staffing, validated nurse reported measures of staffing adequacy, and SNCT measures of patient acuity/dependency from all adult medical / surgical wards of three general and one specialist hospitals daily over a period of 1 year. We will compare daily nursing hours (RN, HCA, all nurses) available per patient to:

  • the required nursing hours (derived from daily SNCT acuity/ dependency assessment)
  • planned staffing for that day and
  • professional judgment of staffing adequacy

We will assess the association between periods of understaffing identified by the tool and nurse reported staffing adequacy and use computer modelling techniques that account for variability in patient acuity, length of stay, admissions and workforce availability, to compare the recommended strategy (staffing based on mean patient acuity/dependency) with:

  • a maximum staffing strategy (staffing set to meet maximum patient acuity dependency)
  • a flexible staffing strategy (regular staffing set to meet minimum patient acuity/dependency with shortfall met by redeployment from other wards or bank/agency staffing)
  • other staffing policies, as determined by an expert reference group

For each strategy, we will assess the proportion of shifts with a critical shortfall of nurses using criteria derived from NICE guidance. We will model the staffing costs and consequences of each strategy with varying approaches to filling critical shortfalls. Costs will include costs of any ward nursing staff and bank / agency staff deployed to meet shortfalls. Consequences will be modelled using regression coefficients from robust studies showing the association between nurse staffing and outcomes. Feasibility of flexible strategies will be assessed by examining data to identify when staffing shortfalls can be met by surplus on other wards and the required availability of bank/agency staff. The study will provide evidence for the usefulness and accuracy of the SNCT, which is widely used in the NHS. The results of the study will give guidance on the feasibility and relative costs and consequences of a variety of staffing policies aimed at addressing fluctuations in demand, including flexible staffing. To our knowledge this will be the first substantial study conducted using the SNCT other than those by its developers and the only study to have modelled the costs and consequences of using it to guide flexible staffing policies.


Project Team

PI: Professor Peter Griffiths, University of Southampton

Dr Jane Ball, University of Southampton

Dr Jeremy Jones, University of Southampton

Dr Antonello Maruotti, University of Southampton

Dr Tom Monks, University of Southampton

Dr Alex Recio Saucedo, University of Southampton

Miss Christina Saville

Ms Clare Aspden, University Hospitals Southampton NHS Trust

Ms Rosemary Chable, University Hospitals Southampton NHS Trust

Mr Andy Dimech, The Royal Marsden NHS Trust

Ms Shirley Hunter, Poole Hospitals NHS Trust

Ms Yvonne Jeffrey, Poole Hospitals NHS Trust

Ms Natalie Pattison, The Royal Marsden NHS Trust

Ms Nicola Sinden (Portsmouth Hospitals NHS Trust)

Ms Tracy Cassar (Portsmouth Hospitals NHS Trust)

Project Funder

NIHR HS&DR Programme


Associated research themes

Workforce, Patient Safety

Related research groups

Health Work and Systems

Affiliate Research Group

CLAHRC Wessex Fundamental Care Theme

Conferences and events associated with this project:

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