The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study

Abstract

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. Limitations This was an observational study. Outcomes of staffing establishments are simulated. 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. Future work Research is needed to identify cut-off points for required staffing. Prospective studies measuring patient outcomes and comparing the results of different systems are feasible. Trial registration Current Controlled Trials ISRCTN12307968. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 16. See the NIHR Journals Library website for further project information.

The association between 12-hour shifts and nurses-in-charge's perceptions of missed care and staffing adequacy: a retrospective cross-sectional observational study

“…In case any patients were omitted from the reports, we multiplied this by the total patient count derived from patient administration systems at 7am/1pm. There was close correspondence between the overall numbers of patients reported using the SNCT and the patient counts derived from patient administration systems, with under-reporting of one patient on average ( Griffiths et al, 2020 a). Since the multipliers are designed to provide an estimate of the required number of staff to employ, we converted this to the implied hours for the daytime from 7am – 7pm.…”

“…This sample of wards represents 74% of the beds across the four hospitals. We previously used this same sample to investigate whether there was an association between staffing deficits as measured by the Safer Nursing Care Tool and nurses-in-charge's perceptions of staffing adequacy, ( Griffiths et al, 2020 a, Griffiths et al, 2020 b) and for developing a simulation to assess the costs and consequences of different staffing levels ( Griffiths et al, 2020 a, Saville et al, 2020 ).…”

“…The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. This paper draws on research and data reported in the NIHR Journals Library Health Services and Delivery Journal ( Griffiths et al, 2020 ). Data are available from the corresponding author on reasonable request.…”

Beyond ratios - flexible and resilient nurse staffing options to deliver cost-effective hospital care and address staff shortages: a simulation and economic modelling study

“…Using data from an observational study in general inpatient units (wards) of acute care hospitals, we developed a simulation model of demand for unit based inpatient nursing. We used this to test various staffing plans guided by the Safer Nursing Care Tool (Griffiths et al, 2020b, Saville et al, 2020a), simulating the staffing levels achieved on each unit and for each shift in the face of variable demand and variable supply of staff. We then estimated the costs and consequences of the resulting staffing levels in an economic model, including cost per life saved with estimates of the effects of low staffing on length of stay and risk of death derived from a recent study (Griffiths et al, 2018).…”

“…Reproduced with permission from: Appendix 1 Griffiths, P., Saville, C., Ball, J.E., Chable, R., Dimech, A., Jones, J., Jeffrey, Y., Pattison, N., Saucedo, A.R., Sinden, N., Monks, T., 2020. The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study.…”