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Research project: Implementation, impact and costs of policies for safe staffing in acute trusts

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Having enough staff, with the right skills, is essential for patient safety. Research demonstrates a link between the number of registered nurses on duty and the risk of a patient dying whilst in hospital. An inquiry (led by Sir Robert Francis) highlighted that many decisions about nurse staffing in hospitals had been made without using evidence. Changing nurse staffing without considering the effect on patient care had led to poor care and higher than expected death rates at The Mid-Staffordshire NHS Trust. He recommended that research evidence was used to ensure hospitals are staffed safely. NICE (The National Institute for Health and Care Excellence) were asked to develop guidelines for different nursing areas, starting with acute hospital wards. They also endorsed a tool to help hospitals plan nurse staffing: the Safer Nursing Care Tool (SNCT). This study aims to identify the costs and consequences of implementing safe staffing policies in NHS acute hospitals in England. It will also look at the factors that have made a difference to how the policies have been implemented: what has worked well for whom, and in which situations. We will focus on two safe staffing policies that came out of the government response to the Francis Inquiry: Guidance launched by the National Quality Board (NQB) and Chief Nursing Officer in November 2013, which set out ten expectations of NHS Trusts in relation to staffing. National Institute for Health and Care Excellence (NICE) guidance on safe staffing for nursing in adult inpatient wards in acute hospitals, published in June 2014, and accompanied by endorsement of the Safer Nursing Care Tool (SNCT).  

The NHS needs to know how safe staffing policies have been implemented, how this varies across the country and what has been the costs and effects of implementation. Understanding what worked where and for who, can help inform future guidance provided to the NHS.

Research demonstrates a link between nurse staffing levels and higher rates of hospital related death. The Francis Inquiry highlighted the lack of evidence-based decisions on nurse staffing as a factor contributing to poor care and higher death rates at Mid-Staffordshire. Francis recommended that evidence on nurse staffing be used to develop guidance on nurse staffing levels. The CNO and NQB set out ten expectations that Trusts should meet to ensure adequate staffing. NICE were asked to develop guidelines, starting with acute hospital wards. They endorsed the Safer Nursing Care Tool as a method to help Trusts plan nurses staffing. However, we know little about the effectiveness or cost-effectiveness of approaches to plan, review and monitor staffing.

This study will use a mixed methods approach to identify the costs and consequences of implementing safe staffing policies in acute hospitals following the Francis Inquiry and to describe factors that have influenced implementation.

The approach is made up of the following elements:

  1. National survey of 155 acute Trusts using online / paper administration to understand how trusts have responded to safe staffing initiatives, including uptake and implementation of the SNCT.
  2. Analysis of national secondary datasets to explore changes in staffing over time within acute trusts and to identify shifts between acute trusts and other sectors.
  3. Case studies involving 
  • in-depth qualitative study of implementation using a realistic evaluation
  • quantitative and economic assessment of impact in 4 acute trusts.

The qualitative case studies, based on interviews with key informants and documentary analysis will: investigate the context of the organisational response to safe staffing policies in four NHS organisations; identify and track safe staffing policy implementation mechanisms and processes; determine what has shaped how safe staffing policy has been implemented and identify both the intended and unintended consequences of safe staffing policy implementation.

We will develop a comprehensive description of the resource implications for each of the four Trusts in planning and providing safe nursing care. We will identify financial costs to the organisation in terms of the costs for additional staff requirement (as identified by the staffing tool), costs of administration and costs of technical support for implementation of the staff planning process. We will collate data drawn from the SNCT itself, e-rostering, and HR workforce data in addition to key informant interviews, to examine the associated costs and consequences of changes made.

In the current financial context, using resources wisely to minimise the risks of hospital care and maximise the benefits to patients is essential; understanding the costs and consequences of implementing safe staffing policy is key to this.

Project Team

University of Southampton team

Jane Ball

Dr Jeremy Jones

Prof Peter Griffiths

Jane Lawless

Hannah Barker

Bangor University team

Prof Chris Burton

Prof Jo Rycroft-Malone

Project Funder

Department of Health’s Policy Research Programme

Associated research themes

Nurse staffing, Workforce, Policy, Francis Inquiry, Patient safety

Related research groups

Health Work and Systems

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