Title: Identifying nurse-staffing requirements using the Safer Nursing Care Tool. Modelling the costs and consequences of real world application to address variation in patient need on hospital wards
Funder: Department of Health and Social Care

Abstract: The quality of nursing care and the potential for inadequate nursing to harm patients has emerged as a factor in many reports on failings in NHS hospitals. Reports often cite inadequate nurse staffing as a causal factor in these failures. NICE has recently issued guidance on determining safe staffing for hospital wards which endorsed using the Safer Nursing Care Tool (SNCT) to indicate the number of nurses required on a ward to meet patient need, based on a patient acuity/dependency measure. Our review for NICE found little evidence about the costs or consequences of tools used to determine staffing levels based on assessed patient need, or the extent to which different staffing policies, based on using the tools are affordable, effective or feasible. [6] Our proposed study examines how patients’ needs for nursing care, as measured by the SNCT, vary from day to day. This will allow us to determine how often staffing shortfalls occur, whether there may be excess staff on other wards who could make up a shortfall, and to model the costs and consequences of different strategies for using the tool and deploying nursing staff to meet varying need. We will collect data on ward nurse staffing, validated nurse reported measures of staffing adequacy, and SNCT measures of patient acuity/dependency from all adult medical / surgical wards of three general and one specialist hospitals daily over a period of 1 year. The daily nursing hours (RN, HCA, all nurses) available per patient will be compared to: • the required nursing hours (derived from daily SNCT acuity/ dependency assessment) • planned staffing for that day and professional judgment of staffing adequacy. We will assess the association between periods of understaffing identified by the tool and nurse reported staffing adequacy and use computer modelling techniques that account for variability in patient acuity, length of stay, admissions and workforce availability to compare the recommended strategy (staffing based on mean patient acuity/dependency) with: • a maximum staffing strategy (staffing set to meet maximum patient acuity dependency) • a flexible staffing strategy (regular staffing set to meet minimum patient acuity/dependency with shortfall met by redeployment from other wards or bank/agency staffing) • other staffing policies, as determined by an expert reference group. For each strategy, we will assess the proportion of shifts with a critical shortfall of nurses, using criteria derived from NICE guidance. We will model the staffing costs and consequences of each strategy with varying approaches to filling critical staffing shortfalls. Costs will include costs of any ward nursing staff and bank/agency staff deployed to meet shortfalls. Consequences will be modeled using regression coefficients from robust studies showing the association between nurse staffing and outcomes. Feasibility of flexible strategies will be assessed by examining data to identify when staffing shortfalls can be met by surplus on other wards and the required availability of bank/agency staff. The study will provide evidence for the usefulness and accuracy of the SNCT, which is widely used in the NHS. It will be the only study to have explored costs and consequences of the SNCT. The results of the study will give guidance on the feasibility and relative costs and consequences of a variety of staffing policies aimed at addressing fluctuations in demand, including flexible staffing

Lay abstract: The National Institute for Health and Care Excellence (NICE) recently issued guidance on setting safe nurse staffing levels for hospitals. This is partly in response to reports into failures in the NHS (including the Mid Staffordshire inquiries) and research showing the importance of having the right numbers of nurses on wards to ensure safe care. NICE recommends a systematic approach to setting staffing levels. NICE endorsed a tool that estimates staff requirements by assigning patients to one of five categories, based on how ill they are and the typical time taken to care for similar patients (known as acuity/dependency). This tool is the Safer Nursing Care Tool (SNCT). The standard approach to using the SNCT sets staffing to meet the average needs of a sample of patients. There is little evidence that shows how often this means there are enough nurses on the ward to meet patient need or whether other approaches might give better results. For example, if wards often have patients with far higher need for nursing care than average, staffing will often be too low unless the hospital can employ extra staff through an agency (which might be expensive) or move staff within the hospital from wards with “excess” staff. It might be more cost effective to routinely employ more staff. On the other hand, using the tool this way could mean that there are often too many nurses on some wards. It might be better to plan lower regular staffing, with extra nurses sent to a ward when needed. Our study will examine how patients’ need for nursing care, as measured by the SNCT, varies from day to day. This will allow us to see how often staffing shortfalls or excess occur, and to explore the costs and consequences of different ways of using the tool and deploying nurses. We will collect information on ward nurse staffing, nurses’ assessment of whether they have adequate staff and the SNCT measures of patient acuity/dependency in 4 hospitals every day for 1 year. We will compare the daily nursing hours available for each ward to the required hours as calculated by the SNCT, and nurses’ judgment of the number of staff needed. Using this information, we will develop computer simulation models that consider variability in patient need and availability of nurses to explore scenarios where nurse staffing is based on different approaches to using the SNCT. For example, we will compare the recommended approach with a scenario where regular staffing is set to meet the maximum requirement for nursing care that is likely to occur and a flexible staffing scenario, where routine staffing is set to meet minimum requirement with any additional need met by temporary staff. For each scenario we will estimate costs and how often critical shortfalls of nurses happen, putting patients at risk. We will consider whether staff are likely to be available to fill any shortfalls by looking at the numbers of wards with more staff than required. We will estimate the impact on patient outcomes using results from other studies showing the increased risk of poor outcomes, including death, for patients who experience low nurse staff levels in hospital. The study will provide evidence for the usefulness and accuracy of the SNCT, which is widely used in the NHS. The results of the study will give guidance on the best way of using tools like the SNCT and the costs to the NHS and consequences for patients of different approaches to meet daily change in demand for nursing.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE