British Journal of Nursing - Staffing is not just a numbers game

Abstract

Sam Foster, Chief Nurse, Oxford University Hospitals, considers a newly published review of the evidence and areas for further reflection when it comes to questions about staff on the wards

I was so pleased to see the launch in March of the National Institute for Health Research (NIHR) themed review on ward staffing. I was involved in this as a member of the expert group. We aimed to provide a narrative by considering the most significant studies, along with emerging research; we also sought to identify the unanswered questions that will need further research. The document is a superb reference text that can be used from ward to board and is one that I have shared with our ward leaders, colleagues in human resources, and all board colleagues to support our decision making. It will enable a strengthened mutual understanding of the current evidence, which will generate more informed debate and collective ownership of our decisions.

The background context to the review reminds readers that over 40% of NHS spending is on nurses, midwives and support workers. The current national position, with more than 40 000 nurse vacancies, requires us to consider new roles to care for a changing population—this is the main area where further work is required. Changes in skill mix, the impact of digital records and the contribution of carers and volunteers are also areas of interest for future research.

The report essentially reviewed the available evidence in two key areas:

Shaping the ward workforce—size and mix

Managing the team and the ward.

In summary, the review of the evidence when considering the shape of the ward team acknowledged that decision making about the ideal ward establishment is complex, and that there is no ideal model. However, the review did highlight that there is a large body of evidence that demonstrates a positive relationship between a higher number of registered nurses and patient safety. A number of studies have also considered support roles, including the use of volunteers, and identified a lack of clarity around role boundaries, which has led to reflection on how work should be delegated to maintain patient safety. On review of the evidence, which was undertaken using a range of research methods, the key messages for reflection include:

Higher nurse staffing levels are associated with fewer missed observations, reduced length of stay and fewer adverse events, including mortality

There may be a U-shaped relationship with increased harm when there are both too few and too many support staff

There is an optimum number of registered nurses that is not affected by the number of support workers

Lack of clarity of scope and role boundaries can cause confusion and prevent uptake of new roles

Volunteers may be acceptable, but their impact and cost-effectiveness is unknown, The review considered a number of key areas in relation to managing the team on the ward. It concluded that ward leadership was not simply a ‘numbers game’. It acknowledged the way in which teams were organised had significant impact on efficiency, and that the use of roster-planning tools was important. It also identified that the practice environment, and its impact on patient satisfaction, is heavily influenced by ward manager skills in relation to staff retention and staff wellbeing. Again, a range of types of evidence were considered, with the key findings being:

Factors relating to retention tend to be multifactorial and include non-pay rewards and local ward climate—an example is Yeovil District Hospital, where a retention programme focused on culture and leadership, health and wellbeing and personal and career development, reduced the staff turnover rate by 3.3%

Evaluation of interventions such as Schwartz Rounds shows the value of initiatives to help staff deal with the emotional burden of care

Patient experience is affected by staff wellbeing and local ward climate

Nurse managers need time and training to manage staff absence and use workforce planning tools well

Interventions to improve ward care, from protected time for meals or drug rounds to intentional rounds, are often poorly evaluated and may have unintended consequences.

The ward leader role was shown as key both in providing high-quality care and in attracting and retaining staff. Ward leadership shapes how staff are deployed, sets standards for staff to follow and is key to creating a safe and healthy climate for both staff and patients. The review called for investment to develop the skills of ward leaders, and protection of time to enable delivery of the role. Ron Capes, the lead governor for Basildon and Thurrock University Hospitals NHS Trust, is quoted:

‘My own ward observations support the findings of this report regarding the importance of high quality leadership within wards and the value of a systematic team environment.’

This review is a welcome text. It acknowledges that decisions about ward staffing are complex—this area is not an exact science, nor is there an algorithm to know exactly what the safe or optimal level or skill mix is for individual wards. The review does, however, guide us more towards the consideration of the available evidence to balance the risks and the potential quality impact of any changes to skill mix, although more work on metrics—how to quantify this impact—needs to be undertaken.