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.
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.
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