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Dissemination Centre

Staffing on Wards: Slides and Discussion

Date: 05 April 2019

NIHR Dissemination Centre launched its themed review Staffing on Wards on 26th March at Hammersmith Hospital. An invited audience of 80 people listened to presentation about the evidence and held table discussions about the implications of the research evidence.

Below, we present a summary of those conversations and recommendations here and invite comments about the next steps needed to translate the findings into practice.

View the slides from the day:

Tara Slide Jill Slide Peter Slide Mark Slide

“As a Director of Nursing achieving good quality outcomes for patients is my main priority. In the complex times we work in it’s vital that we understand what the evidence tells us in relation to nurse staffing and quality of care. As the professional advisor to my Board this review helps me to advise the Board, with certainty, what staff we need to assure high quality care. One of the most interesting findings was the important relationship between registered and unregistered staff and the ratios that lead to the best outcomes.”

Juliette Cosgrove, Director of Nursing, Midwifery and Therapies at Southport and Ormskirk Hospital NHS Trust

“The NIHR Themed Staffing Review was an extremely insightful and stimulating event, providing useful evidence to inform and assist nursing leaders reflect on workforce challenges and maximise current staffing resources and practices more effectively.”

Heather Finlay, Nursing Officer at the Department of Health Northern Ireland

Table discussions Summarised:

Strength of the evidence

The meeting felt that the science around ward staffing is imperfect (although significantly better than for any other part of the workforce) although there was an understanding that RCTs would not be possible for many workforce questions.  However, there are strong and consistent messages in the review that should form the basis for policy and action unless and until more evidence emerges.

The challenge is to ensure the research is well understood from ward to board. The research clearly identifies a ‘sweet spot’ for registered nurse hours but there are many intervening variables, including the ward climate and the way nurses are deployed and managed and the changing shape of multi professional teams. These vary significantly between wards and between hospitals. 

It is not clear whether a universal minimum number of registered nurses for all wards can be determined from the evidence, and some fear such a figure becoming the norm rather than a safety net.  The research does not present a binary choice of safe/unsafe. There is a focus on tasks completed and harms rather than assessment and decision making to promote excellent care. Understanding the degrees of risk should inform actions when the best practice is not possible due to lack of funding or lack of supply of staff.

Research joining up the numbers and the conditions is needed. For example, is it better to fill an absence on the roster with an HCA who knows the ward well and is part of a well-functioning team or to employ an Agency or Bank Registered Nurse who has not worked on the ward before? The most surprising evidence for many of the delegates was the U shaped relationship between the number of HCAs and patient harms which was described as ‘counter intuitive’. For others, the most surprising evidence was the clear impact of the ward environment and staff welfare on patient as well and staff satisfaction.

Increase research literacy and dissemination

Staffing on wards is complex and utilising the evidence well requires a degree of research literacy. It was suggested that Nurse Directors need to role model reflection on research findings. This includes translation of the research and its application to local needs, including the different types of wards within a hospital. Practice development teams could be well placed to disseminate research findings. There was support for dedicated dissemination resources for Chief Nurses and a suggestion that research be presented as problem solving, using a ‘You asked, we discovered’ campaign.

Governance and assurance

The strong messages in the evidence need to be embedded in each organisation’s governance and assurance systems, starting with commissioners’ of services. There was a call for workforce requirements to be transparent in contracts, with contingencies for the workforce required for additional work. For governance and assurance, the evidence needs to be presented in ways that make risk and consequence more explicit and it was felt that NHS England/Improvement could have a role in developing a nursing assurance toolkit which could be used by commissioners, regulators and providers ( as they have with Friends and Family test, MRSA reporting etc). Such an assurance tool would be required to join the dots between fill rates, harms, retention of staff and ward climate and patient experience. 

Analytics

One of the challenges of acting on the evidence base is the lack of local analysis of real time data. The evidence can be used to make optimal decisions if providers can model different staffing configurations based on demand and staff availability. Local cost modelling with predicted risks could inform both Board decision making and managing the daily flux of supply and demand. The existing available data could inform decision but staff will need coaching on how to use it.

Board accountability

Most Boards currently receive monthly reports of ward staffing fill rates without wider indicators. It was felt that Boards understand the financial spend without a full understanding of risks and benefits and that there needs to be greater transparency in the Boards’ accountability. It was perceived that ward staffing was determined from the allocated funding rather than from an understanding and acceptance of the level of risk.

Leadership

Leadership at all levels of organisations was seen to be key to translating the evidence into useful operational guidance. This was felt to require investment in nurse leadership development, both for determining and managing the shape of the ward team and for creating and maintaining good ward climates. This would include writing and presenting business cases, using local data to understand the impact of day to day flux as well as creating supportive environments and managing staff. 

Systems and team thinking

Some delegates encouraged colleagues to think about wards staffing as part of a wider system, both within a hospital and across an integrated care system. The lack of evidence outside hospital wards should not mean that these areas are overlooked and resources focused on hospitals. The evidence on registered nurse and HCAs should not prevent integration with other professions where it is safe to do so. This requires clarity about the role and value of registered nurses in multidisciplinary teams. Unregistered staff and volunteers have a role to play but should be deployed in line with the evidence and have clear boundaries with registered practitioners.

The evidence on the importance of team work was welcomed but delegates cautioned that it cannot compensate for structural problems (including staff shortages). Considering the staffing needs across multi professional teams can be challenged by operational silos and separate budgets. More understanding of professional overlaps and interdependencies is required. Evidence is needed on the impact of new support roles such as Nursing Associates, particularly how this interfaces with the evidence on registered nurse requirements.

Creating the environment for maximising staff effectiveness

The strength of the evidence around managing emotional labour was new to some and delegates wanted to consider practical actions that increase the resilience of both teams and individuals. Some suggested that there is a vicious circle that when there is inadequate staffing, maintaining staff welfare and ward climate becomes more challenging. Some delegates thought that the evidence on teamwork suggests that moving the available staff to different wards may be counterproductive and lead to more stress and more staff leaving. Where teams having changing membership, team leaders need help to develop skills to manage them well.

The evidence around lack of time and physical space (for example, the loss of staff rooms) for reflection and team building resonated with delegates, who thought time for reflection and supervision should be built into calculation of staffing hours. 

Staff Supply

The discussion focused around the supply for registered nurses. It was felt that the evidence around staffing requirement for safe and effective care had not been used to inform strategic workforce planning, which had been based on historic patterns. Current campaigns to attract more people to study nursing should use the evidence on the impact registered nurses have on outcomes and safety and not focus on caring alone.

Recruiting more entrants without retaining more staff is self-defeating and organisations should be required to report on how they are using the evidence to improve ward climates and retain staff. Delegates felt that sabbaticals after a fixed number of years would help to retain more experienced staff.

Using local data, organisations can predict their own short and medium term supply requirements and should over recruit when students graduate to ensure they do not incur long term vacancies.

Building on the evidence around staff welfare, organisations should create a new range of career pathways where nurses can combine clinical practice with either managerial or academic responsibilities. Technology should be explored to enhance nursing care but is unlike to replace nurses.

Conclusion 

Participants found the research stimulating and helped them to reflect on current practices and challenges. While supply issues dominate day to day work, many good ideas emerged during the discussion that could enhance staff retention and create safe and supportive environments. There was interest and demand for research and delegates expressed a need for time to absorb and make sense of evidence and best practice. 

They was an appetite for resources to help staff at all levels to understand and share the evidence. This might include a slide deck for sharing the findings of our review and a nursing assurance toolkit. Please let us know your thoughts on this and on any part of the discussion.

  • Summary:

    NIHR Dissemination Centre launched its themed review Staffing on Wards on 26th March at Hammersmith Hospital. An invited audience of 80 people listened to presentation about the evidence and held table discussions about the implications of the research evidence.

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