Title: Implementation, Impact and Costs of Policies for Safe Staffing In Acute Trusts
Funder: Department of Health and Social Care

Abstract: Background: Research demonstrates a link between nurse staffing levels and higher rates of hospital related death. The Francis Inquiry highlighted the lack of evidence-based decisions on nurse staffing as a factor contributing to poor care and higher death rates at Mid-Staffordshire. Francis recommended that evidence on nurse staffing be used to develop guidance on nurse staffing levels. The CNO and NQB set out ten expectations that Trusts should meet to ensure adequate staffing. NICE were asked to develop guidelines, starting with acute hospital wards. They endorsed the Safer Nursing Care Tool as a method to help Trusts plan nurses staffing. However, we know little about the effectiveness or cost-effectiveness of approaches to plan, review and monitor staffing. Aims: This study aims to identify the costs and consequences of implementing safe staffing policies in acute hospitals following the Francis Inquiry and to describe factors that have influenced implementation. Research plan and methods of investigation: A mixed methods study using: National survey of 155 acute Trusts using online / paper administration to understand how trusts have responded to safe staffing initiatives, including uptake and implementation of the SNCT. Analysis of national secondary datasets to explore changes in staffing over time within acute trusts and to identify shifts between acute trusts and other sectors. Case studies involving in-depth qualitative study of implementation using a realistic evaluation, quantitative and economic assessment of impact in 4 acute trusts. Qualitative case studies, based on interviews with key informants and documentary analysis will: investigate the context of the organisational response to safe staffing policies in four NHS organisations; identify and track safe staffing policy implementation mechanisms and processes; determine what has shaped how safe staffing policy has been implemented and identify both the intended and unintended consequences of safe staffing policy implementation. We will develop a comprehensive description of the resource implications for each of the four Trusts in planning and providing safe nursing care. We will identify financial costs to the organisation in terms of the costs for additional staff requirement (as identified by the staffing tool), costs of administration and costs of technical support for implementation of the staff planning process. Using data drawn from the SNCT itself, e-rostering, and HR workforce data in addition to key informant interviews, we will collate data on: the level of nurse staffing for wards as determined by the SNCT achieved level of nurse staffing (and how changed over time) trends in the match or mismatch between the planned and achieved levels changes in the incidence of shortfall in staffing (relative to SNCT) recruitment of staff routine safety outcomes (safety thermometer) and staff outcomes (turnover, sickness, absence) We will examine the impact of changes on patient and staff outcomes using multi-level regression models to estimate difference in difference and / or discontinuities in time series analyses. Research team: This study builds on two studies on safe staffing commissioned by the NIHR HS&DR programme, led by teams with expertise in workforce (Southampton) and implementation (Bangor). Potential impact/influence on policy, users and wider stakeholders: The NHS needs to know how safe staffing policies have been implemented, how this varies across the country and what has been the costs and effects of implementation. Understanding what worked where and for who, can help inform future guidance provided to the NHS. In the current financial context, using resources wisely to minimise the risks of hospital care and maximise the benefits to patients is essential; understanding the costs and consequences of implementing safe staffing policy is key to this.

Lay abstract: Aims: This study aims to identify the costs and consequences of implementing safe staffing policies following the Francis Inquiry and describe factors that shape implementation. Background: Having enough staff with the right skills is key to patient safety. Research demonstrates a clear link between nurse staffing levels and hospital related death. The Francis Inquiry highlighted the lack of evidence-based decisions on nurse staffing as a factor contributing to poor care and higher death rates at Mid-Staffordshire. He recommended that the research evidence be used to develop guidance on nurse staffing levels. NICE were asked to develop guidelines for different specialities, starting with acute hospital wards. They also endorsed a tool to help Trusts plan nurses staffing: the Safer Nursing Care Tool. A report from the Chief Nurse and National Quality Board set out ten expectations that Trusts should meet to ensure adequate staffing is in place. However, we know little about the effectiveness or cost-effectiveness of approaches to plan, review and monitor staffing. The NHS needs to know how safe staffing policies have been implemented, how this varies across the country, and the costs and consequences. Understanding what worked where and for who, can help inform future guidance provided to the NHS. In the current financial context, using resources (staffing is the biggest element) wisely to minimise the risks of hospital care and maximise the benefits to patients is essential; understanding the costs and consequences of implementing safe staffing policy is key to this. Design and methods: A mixed methods study using: 1) national scoping survey; 2) analysis of existing national datasets 3) case studies using qualitative, quantitative and economic approaches assessment policy implementation and impact. Patient and public involvement: at a stakeholder workshop in October involving 23 members of the public and patients, nurse staffing ranked first as a topic for research to improve care in hospitals. Two advisers to the study will be recruited from the many who expressed an interest in our consultation survey. Dissemination: Findings will be disseminated to different audiences at key points during the study and on completion.

Research activity codes: 8.3 POLICY, ETHICS AND RESEARCH GOVERNANCE;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: GENERIC HEALTH RELEVANCE