Nurse staffing levels, missed vital signs observations and mortality in hospital wards: modelling the consequences and costs of variations in nurse staffing and skill mix. Retrospective observational study using routinely collected data.
Published, 2018, Principal Investigator Griffiths P
This study examined how registered nurse and healthcare assistant staffing levels relate to missed or delayed observations of vital signs (including patients’ blood pressure, pulse and breathing) and to death in hospital, adverse event (death, cardiac arrest or unplanned intensive care admission) and length of stay. It looked at data routinely collected by 32 general adult wards of an acute NHS hospital on staffing levels and electronically recorded patient observations and outcomes, involving 138,133 admissions from 2012 to 2015. Researchers found that higher registered nurse staffing levels were associated with fewer missed observations, reduced length of stay and less adverse events, including mortality. Patients who spent time on wards with fewer than the usual number of registered nurses were more likely to die, or to stay in hospital for longer. The relationship between registered nurse staffing levels and patient mortality appeared to be linear. By contrast, the effect of healthcare assistant levels was less clear, with the hazard of death increasing when patients experienced either above- or below-average healthcare assistant staffing. Although missed observations explained some of the links between nurse staffing levels and hospital death rates, there are other causal pathways so these records cannot guide staffing decisions. The authors noted that healthcare assistants are unlikely to make up for a shortfall of qualified nurses. More evidence is required to confirm approaches to setting staffing levels.
Griffiths P, Maruotti A, Recio Saucedo A, Redfern OC, Ball JE, Briggs J et al. Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. BMJ Quality & Safety 2018. Published Online First: 04 December 2018.
Griffiths P, Ball J, Bloor K, Böhning D, Briggs J, Dall’Ora C, et al. Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study. Health Serv Deliv Res 2018;6(38)
Published, 2017, Principal Investigator Doran T
This study explored the higher risk of death of people admitted to hospital during out-of-hours periods. Researchers looked at emergency admissions data for all 140 non-specialist acute hospital trusts in England between April 2013 and February 2014 (n=over 12 million accident and emergency attendances and 4.5 million emergency admissions). They also analysed emergency admissions between April 2004 and March 2014 for one large acute NHS trust (n=240,000 admissions). They compared deaths within 30 days of attendance or admission for normal working hours and out-of-hours periods (weekends and nights). Nationally, after taking account of how sick patients were, the risk of death was no higher for patients admitted outside normal working hours, with the exception of Sunday daytimes. In one acute stroke unit, having more, and registered, nurses present during the first hours of admission was associated with increased patient survival in the first week, but not over longer periods. The researchers concluded that it is likely to be more cost-effective to extend services for key specialities over critical periods than to implement seven-day services. Future research could identify these key specialities and times.
Han L, Meacock R, Anselmi L, Kristensen SR, Sutton M, Doran T, et al. Variations in mortality across the week following emergency admission to hospital: linked retrospective observational analyses of hospital episode data in England, 2004/5 to 2013/14. Health Serv Deliv Res 2017;5(30)
Published, 2010, Principal Investigator Kessler I
This three-year study examined the role of support workers in hospitals, particularly healthcare assistants. Senior staff were interviewed in nine NHS trusts in the south, midlands and north. Case studies of four trusts (one in each region and London) involved interviews with healthcare assistants, registered nurses and managers (n=273), observations of healthcare assistants, ward housekeepers and registered nurses (n=275 hours) and focus groups with former patients (n=94). Surveys in each trust included healthcare assistants (n=746), registered nurses (n=689) and former patients (n=1651). Findings indicated that senior managers considered healthcare assistants partly as a substitute to achieve cost efficiencies, but also as a way of relieving registered nurses of certain routine tasks. Healthcare assistants’ roles varied, with differences between trusts. Most commonly, they delivered routine technical tasks, traditionally the preserve of registered nurses. Some healthcare assistants had extended their role significantly, but were often paid at Band 2 rather than 3. Healthcare assistants were generally satisfied with their jobs. Many aspired to be nurses, but trusts did not tend to address this. Registered nurses valued healthcare assistants, although they sometimes had concerns about the delegation of tasks to them, and their accountability for them. Patients could often relate to healthcare assistants more easily than to registered nurses. Patients could not easily distinguish healthcare assistants from registered nurses but, when they could, their care experience was more likely to be positive.
Kessler I, Heron P, Dopson S, Magee H, Swain D. Nature and Consequences of Support Workers in a Hospital Setting. Final report. NIHR Service Delivery and Organisation programme; 2010.
Published, 2010, Principal Investigator Spilsbury K
This mixed methods study investigated the role of assistant practitioners in acute NHS Trusts in England. Assistant practitioners are workers who have undertaken a formal qualification, for example a national vocational qualification or foundation degree. Researchers undertook case studies at three trusts, involving 13 wards. Data collection included analysis of assistant practitioner job descriptions (n=22), observations of staff activity (n=15,355) and interactions with patients (n=17,543), questionnaires (270 returned, response rate 52%), interviews (n=105) and focus groups (n=31 participants) with registered nurses, assistant practitioners and healthcare assistants. A national survey of 40 acute trusts (381 responses overall, response rate 35%), and a literature review, added context. Results indicated that organisations were developing assistant practitioner roles with little national policy guidance. Confusion about whether assistant practitioners were ‘assistants’ or ‘substitutes’ for registered nurses was compounded by inconsistency in job titles, training and pay bands. Assistant practitioners’ responsibilities fluctuated. Registered nurses were reluctant to delegate tasks due to concerns about accountability. Assistant practitioners were generally valued for contributing to patient care, providing leadership to healthcare assistants, and supporting new nurses. Opportunities for career progression seemed limited. Assistant practitioners felt that registration and regulation were important for future development of the role. Further research could evaluate the role in varying contexts, its impact on patient outcomes and its cost-effectiveness.
Spilsbury K, Adamson J, Atkin K, Bartlett C, Bloor K, Borglin G et al. Evaluation of the Development and Impact of Assistant Practitioners Supporting the Work of Ward-Based Registered Nurses in Acute NHS (Hospital) Trusts in England. Final report. NIHR Service Delivery and Organisation programme; 2010.
Published, 2015, Principal Investigator Baczynska AM
This study explored the views of older people about the involvement of volunteers and family in the delivery of fundamental care in hospital. Ninety-two older people (aged 60-99 years, 74% female) were surveyed at lunch clubs (n=32 clients and 10 volunteers), a nursing home (n=11 residents) and acute medical wards in a hospital (n=38 in-patients and one relative). Forty-one respondents had experience of hospital volunteers and rated this highly. Most thought volunteers, with appropriate training, could help with meals and walking. Other tasks that some thought suitable for volunteers were: companionship and talking (n=19), tidying the bedside (n=16), and personal care (n=12) including washing, escorting to the toilet and cutting nails. Reservations included appropriate training, potential clashes with paid staff, and overcrowding on the wards. Over half of respondents would choose to regularly help paid staff in caring for a relative in hospital. Overall, the concept of volunteers and family members contributing to fundamental care in hospital was acceptable to the respondents.
Baczynska AM, Blogg H, Haskins M, Aihie Sayer A, Roberts HC. Acceptability of use of volunteers for fundamental care of older inpatients. Age and Ageing 2015 Apr; 44(suppl_1): i1.
Published, 2014, Principal Investigator Roberts HC
This study investigated the feasibility and acceptability of volunteers assisting older patients on an acute female medical ward with weekday lunches, over one year (February 2011 to January 2012). A volunteer training programme was developed and researchers conducted interviews and focus groups with volunteers (n=12), patients (n=9) and nursing and support staff (n=17). Of 59 potential volunteers, 38 attended a training session developed by the hospital speech and language therapist and dietitian. Volunteers were observed providing mealtime assistance, and their competency was assessed against set criteria. Twenty-nine volunteers went on to deliver mealtime assistance, including feeding, and 17 were still volunteering at the end of the year. In all, 3911 patients received assistance over the year. The authors noted that including the volunteers within the ward team was crucial. The volunteers were positive about their training and ongoing support. Patients and ward staff valued the volunteers highly. A subsequent study, from August 2014-December 2015, evaluated the wider implementation of the mealtime assistance programme in nine wards in one hospital (across Medicine for Older People, Acute Medical Unit, Trauma and Orthopaedics and Adult Medicine departments). Volunteers were trained to help patients aged 70 or over at weekday lunchtime and evening meals. Sixty-five volunteers helped at 846 meals over 15 months. A researcher interviewed patients (n=8) and staff (n=7), and conducted a focus group with volunteers (n=9). Patients and nurses universally valued the volunteers, who were skilled at encouraging reluctant eaters. Volunteers, patients and staff all saw training as essential. Cost analysis suggested that the programme released valuable clinical time. Limitations included the study being single-site.
Roberts HC, De Wet S, Porter K, Rood G, Diaper N, Robison J et al. The feasibility and acceptability of training volunteer mealtime assistants to help older acute hospital inpatients: the Southampton Mealtime Assistance Study. Journal of Clinical Nursing 2014; 23(21-22):3240-9.
Howson FFA, Robinson SM, Lin SX, Orlando R, Cooper C, Sayer AA, Roberts HC. Can trained volunteers improve the mealtime care of older hospital patients? An implementation study in one English hospital. BMJ Open 2018;8:e022285. doi:10.1136/bmjopen-2018-022285.
Interim publications, 2018, Principal Investigator Roberts HC
This study evaluated the feasibility and acceptability of using trained volunteers to increase the physical activity of older people in hospital. Low mobility of older people in hospital is associated with poor health outcomes. Volunteers were trained to encourage older inpatients to keep active for two 15 minutes sessions per day. Activity involved walking or chair based exercises. Outcomes measured were patient activity levels, cognition, mood and quality of life. Seventeen volunteers were recruited, and 12 retained (71% retention). 310 sessions were offered, of which 230 were delivered (74% adherence). The intervention was well-received by patients and staff. Researchers noted an improvement in physical activity levels, and concluded that it was feasible and safe to train volunteers to mobilise patients. This programme, together with the mealtime assistance programme, has since been adopted by the University Hospital Southampton NHS Foundation Trust as part of its ‘eat, drink, move’ initiative for patients. From autumn 2017, volunteer mealtime and mobility assistants have been embedded in clinical services and teams, and trained and supported by University Hospital Southampton staff. Future work may include a multicentre controlled trial.
Lim SER, Dodds R, Bacon D, Sayer AA, Roberts HC. Physical activity among hospitalised older people: insights from upper and lower limb accelerometry. Aging Clin Exp Res 2018; 30(11): 1363–1369. Published online 2018 Mar 14.
Published, 2017, Principal Investigator O’Hara J
This study explored the feasibility and acceptability of hospital volunteers collecting patient feedback about the safety of their care, using the Patient Reporting and Action for a Safe Environment (PRASE) Intervention. The intervention involves a facilitated discussion at the patient’s bedside, and was previously explored in a randomised controlled trial. The pilot phase of the study, involving two acute NHS trusts from July 2014-November 2015, comprised five focus groups with hospital volunteers (n=15), and interviews with voluntary services and patient experience staff (n=3) and ward staff (n=4). All stakeholders were positive about the intervention, and the use of volunteers. Volunteers identified the need for appropriate training and support, while staff concentrated on the necessary infrastructure for implementation, and raised concerns about sustainability in practice. This pilot did not collect patient views. These findings informed the roll-out of the PRASE intervention to multiple wards across three NHS trusts. Researchers will evaluate this roll-out and whether the patient feedback collected by volunteers led to patient safety improvements. Louch G, O’Hara J, Mohammed MA. A qualitative formative evaluation of a patient-centred patient safety intervention delivered in collaboration with hospital volunteers. Health Expectations 2017;20(5):1143-1153.
Published, 2013, Principal Investigator Reeves S, Corresponding author Zwarenstein M
This updated systematic review added nine new studies to the six studies from a previous update in 2008. The 15 studies comprised eight randomised controlled trials, five controlled before and after studies, and two interrupted time series studies. The authors graded the quality of the evidence low to very low. All the studies measured the effectiveness of interprofessional education interventions, where members of different social and/or health care professions learn together, interactively, with the aim of improving collaboration or patient health, or both. These interventions were compared to no educational intervention. Seven studies reported positive outcomes for healthcare processes or patient outcomes, or both, four studies reported mixed outcomes (positive and neutral) and four reported no effects. The authors noted that the small number of studies, their varying design and outcome measures, and the fact that none of them compared interprofessional with profession-specific education interventions, meant that they could not draw clear conclusions about the effects of interprofessional interventions. The evidence base has grown, but further research is needed to address these gaps.
Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2013; 3:CD002213.
Published, 2004, Principal Investigator Sheldon T
This scoping study comprised a review of research evidence and policy (including from outside the UK), and 19 semistructured interviews with heads of UK health-related organisations. It assessed evidence about the impact of different mixes of medical and nursing staff on quality, clinical effectiveness, health outcomes and length of hospital stay. The policy documents and interviews suggested that the NHS, at that time, was making staffing decisions based on activity, rather than outcomes. Most of the included studies reported that better health outcomes were associated with higher doctor:patient and/or nurse:patient ratios, but the study methods had some weaknesses. Most studies suggested that patient outcomes changed little in some areas where nurses substituted for doctors, but these studies were limited in scope. Length of stay and patient satisfaction tended to improve with greater staff collaboration. Evidence on skill mix and wellbeing was limited. Overall, the variations in the methods of the studies, and poor quality evidence in some areas, made combining their results and drawing firm conclusions difficult. The authors concluded that more comprehensive research was needed to evaluate the relationship between staffing levels, skill mix and outcomes.
Hewitt C, Lankshear A, Kazanjian A, Maynard A, Sheldon T and Smith K. Health Service Workforce and Health Outcomes: A Scoping Study. Report for the National Coordinating Centre for NHS Service Delivery and Organisation.
Interim publications, 2018-2019, Principal Investigator Drennan VM This mixed methods study investigated the physician associates contribution to hospital medical teams. Physical associates are trained, following entry with a first degree (usually in biomedical science), at a post-graduate level in the medical model to undertake medical histories, physical examinations, investigations, diagnosis and treatment within their scope of practice as agreed with their supervising doctor. At the time of the study physician associates were not a regulated profession although this will change soon. This multi-phase study included: a systematic review, policy review, national surveys of medical directors and physician associates, case studies within six hospitals utilising physician associates in England and a pragmatic retrospective record review of patients in the emergency department attended by physician associates and foundation year two doctors. The surveys found a small but growing number of hospitals employed physician associates. From the case study element it was found that medical and surgical teams mainly used physician associates to provide continuity to the inpatient wards. Their continuous presence contributed to: smoothing patient flow, accessibility for patients and nurses in communicating with the doctors and releasing doctors’ (of all grades) time for more complex patients and attending patients in clinic and theatre settings and patient safety. Physician associates undertook significant amounts of ward-based clinical administration related to the patients’ care. The lack of authority to prescribe or order ionising radiation (as a non-regulated profession) restricted the extent physician associates assisted with the doctors’ workload. This study was unable to quantify the impact on service delivery or patient outcomes of one, relatively new and small, professional group within complex multi-team acute care systems and service delivery. Physician associates can provide a flexible advanced clinical practitioner addition to the secondary care without drawing from existing professions such as nurses.
Halter M, Wheeler C, Pelone F, Gage H, de Lusignan S, Parle J et al. Contribution of physician assistants/associates to secondary care: a systematic review. BMJ Open 2018;8:e019573
Drennan VM, Halter M, Wheeler C, Nice L, Brearley S, Ennis J et al. What is the contribution of physician associates in hospital care in England? A mixed methods, multiple case study. BMJ Open. 2019 Jan 30;9(1):e027012.
Published, 2013, Principal Investigator Harris R
This mixed methods study examined interprofessional team working across the stroke care pathway. Evidence suggested that stroke patients cared for by interprofessional teams had better outcomes. Existing literature was analysed and research conducted with five stroke teams: two acute, one inpatient rehabilitation and two community teams. Researchers initially interviewed senior staff (n=19). They interviewed patients (n=50) and carers (n=33) two or three times along their care pathway, and staff (n=56) across the five teams. They surveyed all team members (n=263) about team characteristics (response rate=69%) and quality of life at work (response rate=56%), and observed team meetings. The study concluded that patients and carers do not necessarily notice interprofessional working despite its importance in their care; communication with staff is what they value highly. Staff noticed team working far more. Large teams made it harder for everyone to get involved, and had more conflict over leadership. Clear leadership was strongly associated with staff perceptions of better team performance, which in turn was associated with work related quality of life. Nursing staff seemed least involved in the interprofessional team despite having the most contact with patients and carers. Performance targets for single professional groups were a disincentive to collaborative working.
Harris R, Sims S, Hewitt G, Joy M, Brearley S, Cloud G et al. Interprofessional teamwork across stroke care pathways: outcomes and patient and carer experience. Final report. NIHR Service Delivery and Organisation programme; 2013.
Published, 2011, Principal Investigator Butler M
This systematic review included 15 studies about the effect of hospital nurse staffing models on patient and/or staffrelated outcomes. The studies were conducted in the UK, Netherlands, United States, Canada and Australia, published from 1977-2007. The quality of evidence overall was very limited. Many studies judged to have an inadequate design were excluded. The 15 included studies comprised randomised controlled trials (n=8), controlled clinical trials (n=2) and controlled before and after studies (n=5). Findings suggested that the addition of specialist nursing and specialist support roles to the nursing workforce may improve some patient outcomes. The authors found no evidence that the addition of specialist nurses reduces patient death rates, attendance at the emergency department, or readmission rates, but it is likely to result in shorter patient hospital stays and reductions in pressure ulcers. Specialist support staff, such as dietary assistants, may have an important impact on patient outcomes. The introduction of “primary nursing” and “self-scheduling” may reduce staff turnover. The authors concluded that, due to the limited evidence, the findings should be treated extremely cautiously. No suitable studies of interventions relating to nurse staffing levels, education mix, or grade mix were identified. The authors noted the need for larger, controlled studies.
Butler M, Collins R, Drennan J, Halligan P, O’Mathúna DP, Schultz TJ et al. Hospital nurse staffing models and patient and staff-related outcomes. Cochrane Database Syst Rev 2011; 7:CD007019.
Published, 2012, Principal Investigator West M
This mixed methods study aimed to identify the main factors in effective multi-professional team working in community mental health teams. The study had three stages. First, researchers held 10 workshops with service providers, users and carers (n=157 total participants), from 13 mental health trusts across England. These workshops informed the development of a questionnaire about team effectiveness. Second, researchers surveyed 135 community-based adult mental health teams across 11 NHS trusts, using this questionnaire and a team performance inventory (n=1500 team members responded, 67% response rate). Teams included those working with older adults, rehabilitation and recovery, early intervention, and generic teams. Third, researchers conducted in-depth studies of 19 teams, including observations of team meetings and interviews with staff (n=114), service users (n=31) and carers (n=13). Predictors of community mental health team effectiveness included: practical support for innovative approaches, team participation in decision making, regular meetings, trust, safety and support among team members, good team leadership, the right skills mix, effort, clarity of purpose and team objectives, promotion of carer involvement, organisational support and resources available, particularly staff availability. Limitations included service restructuring taking place during the research, and the questionnaire stage relying on data that team members self-reported.
West M, Alimo-Metcalfe B, Dawson J, El Ansari W, Glasby J, Hardy G et al. Effectiveness of Multi-Professional Team Working (MPTW) in mental health care. Final report. NIHR Service Delivery and Organisation programme; 2012.
Published, 2015, Principal Investigator Bailey K
This study reviewed existing evidence about staff engagement to find out whether people perform better at work and/or experience higher levels of wellbeing when they are engaged, and which workplace factors increase engagement. Researchers found 172 articles, published in peer-reviewed journals since 1990, that met their quality standards. They also evaluated 38 literature reviews and various practitioner materials. Overall, the evidence suggested that when people are engaged they tend to perform better, help colleagues more, and be more satisfied with their work and life in general. The researchers identified six factors linked to this: certain psychological states (such as resilience, self-efficacy and personal resources); people having the resources and tools needed to do their jobs; positive leadership; feeling supported by the organisation; working in a team with other engaged people; and taking part in training which boosts individuals’ coping strategies. However, the evidence was mixed; few studies focused on the healthcare sector, most used self-report surveys and only two took place in the UK. The term ‘engagement’ had many different meanings. The researchers concluded that there is a gap in knowledge about how engagement works in practice, and that further research is needed, particularly in the healthcare sector.
Bailey C, Madden A, Alfes K, Fletcher L, Robinson D, Holmes J et al. Evaluating the evidence on employee engagement and its potential benefits to NHS staff: a narrative synthesis of the literature. Health Serv Deliv Res 2015;3(26)
Published, 2012, Principal Investigator Maben J
This three-year mixed methods study explored links between patients’ experiences of healthcare, and the motivation, feelings and wellbeing of staff. Researchers conducted two patient focus groups, and interviewed 55 senior managers from two acute and two community NHS trusts in England. They selected two teams, wards or clinical units within each trust, in different care settings. They surveyed staff (n=427) and patients (n=498), interviewed staff (n=86) and patients (n=106), and observed day-to-day interactions, across the eight areas. They found that patient experiences were generally better when staff felt part of a good local team, experienced job satisfaction and a positive organisational climate, had low emotional exhaustion, and had support from co-workers, supervisors and the organisation. Ward/ team leaders played a critical role in setting expectations. Emotionally exhausting and demanding working environments, such as accident and emergency, negatively impacted on staff even when they were performing well. The researchers concluded that enhancing staff wellbeing is important both in its own right and for the quality of patient experiences. Recommendations included supporting staff to engage with patients on a meaningful personal level, regularly monitoring patient experience and staff wellbeing to target resources to problem areas, and disseminating good practice from highperforming teams.
Maben J, Peccei R, Adams M, Robert G, Richardson A, Murrells T et al. Patients’ experiences of care and the influence of staff motivation, affect and well-being. Final report. NIHR Service Delivery and Organisation programme; 2012
Published, 2018, Principal Investigator Maben
J Schwartz Center Rounds® aim to support healthcare staff to deliver compassionate care. They involve monthly group meetings where staff can safely reflect on the emotional, social and ethical challenges of care. This mixed methods study investigated how participation in Rounds affects staff wellbeing and patient care. Researchers mapped 77 Rounds providers in England in September 2014, rising to 115 by July 2015, of which three quarters were NHS trusts. Healthcare staff within 10 sites were surveyed before attending Rounds and eight months later. In all, 500 people responded at both time points, including regular attenders (n=51), irregular attenders (n=205) and non-attenders (n=233). In-depth case studies of nine organisations involved observations and 177 interviews. The survey found no change in engagement but a significant reduction in poor psychological wellbeing in regular Rounds attenders (25% to 12%) compared with nonattenders (37% to 34%). The authors identified a cumulative impact of Rounds. Reported outcomes included increased empathy and compassion for colleagues and patients, support for staff and changes in practice. Frontline staff could find it difficult to attend, and organisational support was required to sustain Rounds. Study limitations included outcomes relying on self-report and fewer regular attenders being recruited than desired.
Maben J, Taylor C, Dawson J, Leamy M, McCarthy I, Reynolds E, et al. A realist informed mixed methods evaluation of Schwartz Center Rounds® in England. Health Serv Deliv Res 2018;6(37)
Protocol published, 2016, Principal Investigator Griffiths P
The Safer Nursing Care Tool, widely used in the NHS, indicates the number of nurses required on a ward to meet patient need. This observational study will provide evidence for its usefulness and accuracy, and will model the costs and consequences of different staffing strategies aimed at addressing fluctuations in patients’ needs. The study will include all adult medical/surgical wards of one specialist and three general hospitals (n= 75 wards, over 1700 beds). Data on ward nurse staffing, validated nurse reported measures of staffing adequacy, and Safer Nursing Care Tool measures of patient needs, will be collected daily over a one-year period.
Published, 2018, Principal Investigator Burton CR
This study investigated how NHS managers’ use of workforce planning and deployment technologies impacts on nursing staffing and patient care, and what works, for whom, how and in what circumstances. Such tools can help with the complex task of allocating staff effectively, complying with patient safety standards, forecasting demand, and communicating transparently about staffing. The tools rely on correct inputting and updating of data. The study comprised four phases. First, NHS managers, patient and public representatives and policy experts developed a theory about how the tools work in different contexts. Second, researchers reviewed existing evidence, guided by the theory. Third, interviews with NHS managers (n=11), a nurses’ Twitter chat, and an advisory group, helped refine the theory. Fourth, practical recommendations for managers were developed. The tools had a positive impact when they clearly combined data on needs and resources, when there was technical and leadership support, and when they were part of a collaborative process. Managers needed to combine local knowledge and professional judgement with data from the tools for effective staffing decisions. Study limitations included a lack of detailed evidence about how managers apply professional judgement. Most available evidence related to adult acute settings.
Burton CR, Rycroft-Malone J, Williams L, Davies S, McBride A, Hall B, et al. NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis. Health Serv Deliv Res 2018;6(36)
Pilot study of a randomised trial of a guided e-learning health promotion intervention for managers based on management standards for the improvement of employee well-being and reduction of sickness absence
Published, 2015, Principal Investigator Stansfeld SA
This pilot study tested the feasibility and acceptability of conducting a trial of an online learning program for managers to improve employee wellbeing and reduce sickness absence. It comprised a pilot cluster randomised controlled trial within a mental health NHS trust, in which three groups of employees and their managers were randomly allocated to receive the e-learning intervention and a fourth group did not. In-depth interviews, focus groups and observations accompanied the trial. Managers completed the e-learning program over 10 weeks, with a facilitator and two face-toface meetings. Outcome measures included recruitment and participation of employees and managers; acceptability of the intervention and trial; employee well-being; employee sickness absence data. In total, 424 employees and 41 managers were recruited. Employees completed work and health questionnaires before the intervention (n=350) and after (n=291). Only half of the managers (n=21) adhered to the intervention, completing at least three of six modules. Some managers reported insufficient time. The authors concluded that the intervention and trial were feasible to participants. The economic assessment was also feasible. A future trial might need to gain more support from senior managers, encourage managers to complete the intervention, strengthen the online program, and allow longer for it to work.
Stansfeld SA, Berney L, Bhui K, Chandola T, Costelloe C, Hounsome N et al. Pilot study of a randomised trial of a guided e-learning health promotion intervention for managers based on management standards for the improvement of employee wellbeing and reduction of sickness absence: The GEM Study (Guided E-learning for Managers). Public Health Res 2015;3(9)
Protocol published, 2017, Principal Investigator Robert G
This study investigated the 10-year impact of the ‘Productive Ward: Releasing Time to Care’ programme, introduced in 2007 to improve ward efficiency, and free nurse time for direct patient care. Informed by earlier research about initial take-up, the researchers surveyed all NHS acute trusts in England, and studied two wards in each of six acute trusts. They compared three earlier and three later adopters of the programme, and included medical, surgical and care of the elderly wards. Researchers analysed trust documents and data, conducted observations, and interviewed staff at all levels, patient representatives, and those who led the initial implementation.
Interim publications, 2017-2018, Principal Investigator Harris R
Intentional rounding is a structured process whereby nurses conduct regular checks, usually hourly, with every patient using a standardised protocol. Most trusts in England introduced intentional rounding from 2012. This mixed methods study investigated the impact and effectiveness of intentional rounding in hospital wards on the organisation, delivery and experience of care. It explored the perspective of patients, their family members and staff. It examined this at three levels: national, service provider organisation, and individual ward/ unit. The study had four phases. First, a review of academic and policy literature with stakeholder consultation. Second, a national survey of all non-specialist NHS acute trusts in England. Third, in-depth case studies of six wards within three hospitals in England involving interviews with staff, patients and relatives, observations, and analysis of routinely collected ward outcome data and costs. Fourth, combining the study findings with input from stakeholders. Findings from the first phase literature review (n=44 papers) suggested a lack of clarity about the purpose of intentional rounding, and limited evidence of how it works in practice.
Sims S, Leamy M, Davies N, Schnitzler K, Levenson R, Mayer F et al. Realist synthesis of intentional rounding in hospital wards: exploring the evidence of what works, for whom, in what circumstances and why. BMJ Quality & Safety 2018;27(9):743- 757.
Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH (2002) Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 288:1987–93.
Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E. and McHugh, M.D. (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet 383(9931), pp.1824-1830.
Aiken, L.H., Sloane, D.M., Ball, J., Bruyneel, L., Rafferty, A.M. and Griffiths, P. (2018) Patient satisfaction with hospital care and nurses in England: an observational study BMJ Open 8(1), p.e019189.
American Nurses Association’s National Database of Nursing Quality Indicators The National Database of Nursing Quality Indicators: http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx
American Nurses’ Credentialing Center ANCC Magnet Recognition Program: https://www.nursingworld.org/organizational-programs/ magnet/
Ball. J.E., Pike, G., Griffiths, P., Rafferty, A.M and Murrells, T. (2012) RN4Cast Nurse Survey in England National Nursing Research Unit Report: https://www.kcl.ac.uk/nursing/research/nnru/publications/Reports/RN4Cast-Nurse-survey-report-27-6-12-FINAL.pdf
Ball, J.E., Murrells, T., Rafferty, A.M., Morrow, E. and Griffiths, P. (2014) ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Qual Saf 23(2), pp.116-125.
Ball, J. E., Bryuneel, L., Aiken, L. H., Sermeus, W., Sloane, D. M., Rafferty, A. M., Lindqvist, R., Tishelman, C., Griffiths, P. & Consortium, R. C. (2017) Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study. International Journal of Nursing Studies.
Bruyneel, L., Li, B., Ausserhofer, D., Lesaffre, E., Dumitrescu, I., Smith, H.L., Sloane, D.M., Aiken, L.H. and Sermeus, W. (2015) Organization of hospital nursing, provision of nursing care, and patient experiences with care in Europe Medical Care Research and Review 72(6), pp.643-664.
Buchan, J., Seccombe, I., Gershlick, B, and Charlesworth, A (2017) In short supply: pay policy and nurse numbers London: The Health Foundation.
Carter, P. (2016) Operational productivity and performance in English NHS acute hospitals: Unwarranted variations: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/499229/Operational_productivity_A.pdf
Cookson, G., Jones., S., van Vlymen, J., and Laliotis, I. (2014) The Cost-Effectiveness of Midwifery Staffing and Skill Mix on Maternity Outcomes: https://www.nice.org.uk/guidance/ng4/evidence/economicevaluation- report-5277277
Department of Health, Social Services and Public Services (DHSSPS) (2014) Delivering Care: Nurse Staffing in Northern Ireland: https://www.publichealth.hscni.net/sites/default/files/dc-section1%20FINAL%20PDF_0.pdf
Dixon, J., Street, A. and Allwood, D., 2018. Productivity in the NHS: why it matters and what to do next. BMJ 363, p.k4301.
Doyle, C., Lennox, L. and Bell, D., 2013. A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ open, 3(1), p.e001570.
Fitzsimons B, Goodrich J, Bennett L and Buck D (2014). Evaluation of King’s College Hospital Volunteering service Final report: https://media.nesta.org.uk/documents/kings_fund_evaluation_of_kch_impact_volunteering.pdf
Galletta, M., Portoghese, I., Battistelli, A. and Leiter, M.P. (2013) The roles of unit leadership and nurse–physician collaboration on nursing turnover intention. Journal of Advanced Nursing, 69(8), pp.1771-1784.
Griffiths, P., Ball, J., Drennan, J., James, L., Jones, J., Recio, A., and Simon,. (2014) The association between patient safety outcomes and nurse/healthcare assistant skill mix and staffing levels and factors that may influence staffing requirements Southampton, GB. University of Southampton.
Griffiths, P., Recio-Saucedo, A., Dall’Ora, C., Briggs, J., Maruotti, A., Meredith, P., Smith, G.B., Ball, J. and Missed Care Study Group (2018) The association between nurse staffing and omissions in nursing care: a systematic review Journal of Advanced Nursing 74(7):1474-1487.
Halter M., Boiko, O., Pelone, F., Beighton, C., Harris, R., Gale, J., Gourlay, S and Drennan, V. (2017a) The determinants and consequences of adult nursing staff turnover: a systematic review of systematic reviews BMC Health Services Research 17:824.
Halter, M., Pelone, F., Boiko, O., Beighton, C., Harris, R., Gale, J., Gourlay, S., and Drennan, V. (2017b) Interventions to reduce adult nursing turnover: a systematic review of systematic reviews The Open Nursing Journal 11 (2017b): 108.
Hayward, D., Bungay, V., Wolff, A.C. and MacDonald, V. (2016) A qualitative study of experienced nurses’ voluntary turnover: learning from their perspectives. Journal of clinical nursing, 25(9-10), pp.1336-1345.
Heinen, M.M., van Achterberg, T., Schwendimann, R., Zander, B., Matthews, A., Kózka, M., Ensio, A., Sjetne, I.S., Casbas, T.M., Ball, J. and Schoonhoven, L. (2013) Nurses’ intention to leave their profession: a cross sectional observational study in 10 European countries. International Journal of Nursing Studies 50(2), pp.174-184.
Hoffart, N. and Woods, C.Q. (1996) Elements of a nursing professional practice model. Journal of professional nursing 12(6), pp.354-364.
Jarman, B., Gault, S., Alves, B., Hider, A., Dolan, S., Cook, A., Hurwitz, B. and Iezzoni, L.I. (1999). Explaining differences in English hospital death rates using routinely collected data. BMJ 318(7197), pp.1515-1520.
Kitson, A. L., Wiechula, R. J., Conroy, T. A., MuntlinAthlin, A., & Whitaker, N. L. (2013). The future shape of the nursing workforce: a synthesis of the evidence of factors that impact on quality nursing care: https://digital.library.adelaide.edu.au/dspace/bitstream/2440/77059/1/hdl_77059.pdf
Lalfond S, Charlesworth A. (2017) A year of plenty? London: The Health Foundation.
Maben, J., Morrow, E., Ball, J., Robert, G., and Griffiths, P. High Quality Care Metrics for Nursing (2012) National Nursing Research Unit, King’s College London: https://eprints.soton.ac.uk/346019/1/High-Quality-Care-Metrics-for-Nursing----Nov-2012.pdf
Mid Staffordshire NHS Foundation Trust Public Inquiry (2013). Report of the Mid Staffordshire NHS Foundation Trust public inquiry—Executive summary: https://webarchive.nationalarchives.gov.uk/20150407084231/http://www.midstaffspublicinquiry.com/report
NHS Digital (2018a) NHS Workforce Statistics March 2018: https://files.digital.nhs.uk/EF/316A87/NHS%20Workforce%20Statistics%2C%20March%202018%20Bulletin.pdf
NHS Digital (2018b) NHS Workforce Statistics - September 2018: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-workforce-statistics/september-2018#keyfacts
National Quality Board (2014) How to ensure the right people, with the right skills, are in the right place at the right time: https://www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to-guid.pdf
National Quality Board (2016) Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time: https://www.england.nhs.uk/wp-content/uploads/2013/04/nqb-guidance.pdf
National Institute for Health and Care Excellence (2014) Safe staffing for nursing in adult inpatient wards in acute hospitals: https://www.nice.org.uk/guidance/sg1/chapter/3-Gaps-in-theevidence
Needleman, J., Buerhaus, P., Mattke, S., Stewart, M. and Zelevinsky, K. (2002) Nurse-staffing levels and the quality of care in hospitals New England Journal of Medicine 346(22) p.1715-1722.
Nursing and Midwifery Council (2019) Nursing Associates: https://www.nmc.org.uk/standards/nursing-associates/
Nursing Commission’s Report (1932) The Lancet 219: 5660 pp409.
Office of National Statistics (2016) UK Health Accounts: 2016: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthcaresystem/bulletins/ukhealthaccounts/2016#total-current-healthcare-expenditure-in-the-uk
Petit, O.P. and Regnaux, J.P. (2015) Do Magnet accredited hospitals show improvements in nurse and patient outcomes compared to non-Magnet hospitals: a systematic review. JBI database of systematic reviews and implementation reports, 13(6), pp.168-219.
Porter, J., Ottrey, E. and Huggins, C.E. (2017) Protected Mealtimes in hospitals and nutritional intake: Systematic review and meta-analyses. International Journal of Nursing Studies, 65, pp.62-69.
Ross, S., Fenney, D., Ward, D. and Buck, D. (2018) The role of volunteers in the NHS: Views from the front line London: The King’s Fund: https://www.kingsfund.org.uk/publications/role-volunteers-nhs-views-front-line
Royal College of Nursing (2018) Fund our future nurses – Cost effective options to support nursing students and grow the nursing workforce in England London: RCN.
Twigg, D., Myers, H., Duffield, C., Pugh, J., Gelder,L. and Roche, M. The impact of adding assistants in nursing to acute care hospital ward nurse staffing on adverse patient outcomes: An analysis of administrative health data. International Journal of Nursing Studies 63 (2016): 189-200.
UKCC (1986) Project 2000: A new preparation for practice London: UKCC.
Welsh Government (2016) Nurse Staffing Levels (Wales) Act 2016 Statutory Guidance: https://gweddill.gov.wales/docs/phhs/publications/171102nurse-staffingen.pdf
Westbrook, J.I., Li, L., Hooper, T.D., Raban, M.Z., Middleton, S. and Lehnbom, E.C. (2017) Effectiveness of a ‘Do not interrupt’ bundled intervention to reduce interruptions during medication administration: a cluster randomised controlled feasibility study BMJ Qual Saf 26:734-742.
Wood, V.J., Vindrola-Padros, C., Swart, N., McIntosh, M., Crowe, S., Moris, S. and Fulop, N.J. (2018) One to one specialling and sitters in acute care hospitals: A scoping review. International Journal of Nursing Studies 84:61-77.
World Health Organisation (2018) Nursing and Midwifery Fact Sheet: https://www.who.int/mediacentre/factsheets/nursing-midwifery/en/
Acuity: Acuity is the degree to which a patient has severe and recent onset symptoms which need prompt medical attention
Assistant Practitioner: Assistant practitioners (sometimes known as associate practitioners) have skills and experience in a particular area of clinical practice. Although they are not registered professionals they have a high level of skill through their experience and training (usually a Foundation Degree)
Healthcare Assistant: Healthcare assistants work under the guidance of a qualified healthcare professional, usually a nurse. Sometimes staff working in HCA roles are known as nursing assistants, nursing auxiliaries or auxiliary nurses
Intentional Rounding: Intentional rounding is a structured approach whereby nurses conduct checks on patients at set times to assess and manage their fundamental care needs
Lean management: A system for developing process improvement that focuses on reducing and eliminating waste
Licensed Practical Nurse: Licensed Practical Nurse is a regulated role in many countries (although not the UK). They undertake training of one or two years and are responsible for providing fundamental nursing care and usually work under the supervision of registered nurses
Nursing Associate: A nursing associate is a role in the UK that will provide care and support for patients and service users. It is intended to address a skills gap between health and care assistants and registered nurses
Observational studies: Studies which are not experimental, but where individuals and populations are observed and associations made between different variables
Physician Associates: Physician Associates are graduates who have undertaken post-graduate training and work under the supervision of a medical practitioner
Registered Nurse: A Registered Nurse is a nurse who has met the criteria for a nursing license defined by their country’s statute. They are independently accountable for their decisions and actions
Roster: A list or plan showing turns of duty or leave for individuals
Schwartz Round: Schwartz rounds are a forum for hospital staff from all backgrounds to come together to talk about the emotional and social challenges of caring for patients. The aim is to offer staff a safe environment in which to share their stories and offer support to one another
Specialling: One-to-one observation to reduce the risk and incidence of harm to the patient
Ward Climate: The ward climate is the sense, feeling or atmosphere people get on a day-to-day basis. It differs from culture which is defined as the (often unconscious) pattern of shared basic assumptions that direct the way the ward works
Workforce planning and deployment technologies: Tools to assist workforce planning and help make better decisions about cost effective numbers and mixes of staff. Usually derived from statistical analysis of past staffing and/or benchmarking
Work processes: Work processes are the set of steps or tasks used in the ward to achieve a specific goal
This report was written by Elaine Maxwell, with Katharine Hanss and Tara Lamont of the NIHR Dissemination Centre.
Expert input was provided by a steering group consisting of: