Safe Staffing in Acute Hospitals

Elaine Inglesby-Burke

Executive Nurse Director, Salford Royal NHS Foundation Trust

Helen Thomson

Chief Nurse, Calderdale and Huddersfield NHS Foundation Trust

Pippa Hart

Chief Nurse, Epsom and St Helier University Hospitals NHS Trust

US Research: Nurse staffing & mortality

• Surgical patients in hospitals with better nurse work environments have 13% lower odds on dying;

• Patients in hospitals with better staffing (two fewer patients per nurse) have 11% lower odds on dying;

• Patients in hospitals with better educated nurses (20% more BSNs) have 8% lower odds on dying.

Surgical patients in hospitals that are better on all three have roughly 30% lower odds on dying.

Source: Aiken et al., JONA, 2008

Kane (2007) systematic review

96 studies

Increased RN staffing was associated with lower hospital related mortality in:

• intensive care units (OR 0.91 CI 0.86–0.96)

• surgical units (OR, 0.84; 95% CI, 0.80–0.89),

• medical patients (OR, 0.94; 95% CI, 0.94–0.95)

- per additional full time equivalent nurse per patient day.

Kane et al (2007) Medical Care 45 (12), 1195-1204

Previous research – patient: RN ratios

UK Nursing outcome study: effect of nurse patient ratio - odds ratios for patient and nurse outcomes

1.92

1.78

1.71

1.26

1

1.5

2

<8.3patients per

nurse

8.6-10patients per

nurses

10.1-12patients per

nurse

>12patients per

nurse

Nurse patient ratio (quartile)

Fair/poor qualitycare

High emotionalexhaustion

Jobdissatisfaction

Mortality

Source data: Rafferty, A. M., S. P. Clarke, et al. (2007). Int J Nurs Stud. 44, 2

‘Care is compromised by short staffing’ by patients per RN (on NHS hospital wards)

Source: Employment Research/RCN 2009

2

4

6

8

10

12

Never Rarely Several times amonth

Once or twice aweek

On most shifts On every shift

Frequency patient care is compromised by short staffing

Me

an

no

. o

f p

ati

en

ts p

er

RN

An unsafe ratio….

Based on the research evidence:

A ratio of more than 8 patients per RN significantly increases the risk of harm and constitutes a breach in patient safety.

Under no circumstances is it safe to care for patients in need of hospital treatment with a ratio of more than 8 patients per registered nurse during the day time on general acute wards (including those specialising in care for older people).

Staffing levels : Pt/RN ratio (day)

23 10 18 30 6 19 22 1 26 13 20 9 31 12 17 15 29 14 16 28 2 7 24 11 3 8 32 21 25 5 27.0

2.0

4.0

6.0

8.0

10.0

12.0

Patients per RN

Source: Ball J, Griffiths P & Rafferty A M (2012) RN4Cast

StaffingStaffing levels should be:• Consistent with the scientific

evidence• Adjusted to patient acuity and local

context• Made public and easily accessible

to patients and carers

NICE will produce definitive guidance on safe and efficient staffing levels in a range of NHS settings

Staffing Expectations1. Boards take full responsibility2. Processes are in place to enable staffing establishments3. Evidence-based tools4. Culture where staff feel able to raise concerns5. Multi-professional approach6. Sufficient time to fulfil responsibilities7. Boards receive monthly updates on workforce information8. Clearly display information about staff present on each

ward/department9. Providers secure staff in line with their workforce requirements10. Commissioners get assurance that the right people, with the right

skills, are in the right place at the right time

Planned staffing (Full budgeted establishment)

Employed staff in post (Establishment minus vacancies)

Available staff (staff in post minus absent staff)

Planned staff for each shift (off-duty)

Actual staff per shift

(Planned minus unfilled gaps)

Ratios – of what to what? Staff erosion – from plans to reality

What can you do?

• What’s your role in ensuring staffing levels are safe? Have you got it right in your organisation?

• What tools are being used to plan staffing to match patient need and workload?

• Do you know the RN:pt ratios where you work?

• How do they compare to elsewhere?

• Are professional guidelines (eg. in to ITU, neonates) followed?

• Would normative staffing help?

• How do you know when you've got it right...or wrong?

• How is quality being measured? Is it being related to differences in staffing?

Safe staffing is your smoke detector for safe care and

improved performance

Know your business