After Francis: making a difference - Health Committee Contents

Appendix 2: Implementing Safe Nurse Staffing in an NHS organisation: briefing note from the Salford Royal NHS Foundation Trust

Case Study Overview

The review of nursing establishments is complex and any method of determining staffing has limitations. There is no one solution to determining safe staffing and therefore triangulation of methods is essential. Using the combination of approach will provide greater confidence in the decisions taken. The setting of establishments should triangulate from three different sources:

·  Workload measurement based information (acuity/dependency & activity) using a validated tool.

·  Benchmarking with other organisations

·  Professional consultation

We use a national model to determine our nursing establishments and assure ourselves that staffing numbers are adequate to deliver safe quality care. The model applied is the Association of United Kingdom University Hospitals (AUKUH). The AUKUH Acuity and Dependency Tool was developed to help NHS hospitals measure patient acuity and/or dependency to inform evidence-based decision making on staffing and workforce. The tool will also offer nurses a reliable method against which to deliver evidence-based workforce plans to support existing services or the development of new services.

The AUKUH Acuity/Dependency tool is based upon the classification of levels of care of critical care patients (Comprehensive Critical Care, DH 2000). These classifications have been adapted to support measurement across a range of wards/specialties.

We have until recently only completed part of the model where the identified number of beds for each ward, the WTE budgeted staffing numbers determine the nurse to bed ratio and this has been expected to be 1.1 or higher. This is based upon professional judgement and the numbers of qualified and unqualified nurses required to care for a designated number of beds. Currently all wards within SRFT go beyond 1:1 and meet this criteria in addition to the ratio of 1 registered nurse to 8 patients

Ratio of 1 RN to 8 patients

The Safe Staffing Alliance whose members are senior expert nurses issued an unprecedented warning in May 2013 that patient care is unsafe on wards where each nurse is looking after more than 8 patients. The 1:8 figure is based on evidence from Southampton University, Kings College London and National Nursing Research Unit. At SRFT we meet this figure as a minimum on all our wards during the day and in addition there is a co-ordinator. All our sub speciality wards have a higher nurse to patient ratio than this, e.g. neuro.

We never have less than 2 registered nurses on a night shift and if such a rare occurrence should happen then the Executive on Call is notified. We are currently looking at a piece of work to consider 3 registered nurses on a night shift.

During June/July 2013 we conducted an acuity audit where each ward collected data based on the classification of levels of care at the same point each day for a period of 21 days in order to ensure a consistent approach. Some areas with high patient turnover collected data at three points during a twenty four hour period such as ICU, HCU, EAU etc. The collected data is then calculated using the model and it identifies the nursing numbers and skill mix required to provide care to this level of acuity/dependency of patient.

This audit will be conducted twice yearly (January and June) and it is anticipated that this acuity and dependency measurement will enable identification of trends across seasons and in response to changing demographics and healthcare needs. We envisage that this evidence base will support workforce plans for nursing and should accurately predict and enable resources to be identified to support nursing establishments.

12 Hour Shift Working

12 hour shift working has now been implemented in all areas of the hospital since July 2013. The liberated time from the implementation of this shift working is to ensure that all ward manager/matron are in a supervisory role to allow them to have overview of the ward and provide support to patients, families and staff. The supervisory ward manager role is encouraged on all wards, but when staffing numbers are reduced due to short term sickness or absence they are included in the establishment providing direct patient care.

These areas of work underpin our approach to ensure that establishments are set and that wards are staffed to provide safe care.

Safe Staffing Steering Group/Staffing Boards

To support this piece of work a Safe Staffing Steering Group is in place with membership consisting of senior nurses, quality improvement facilitator and workforce to address initially the use of the AUKUH staffing model. The group considers how we share with our patients and families in an open and transparent way the numbers of nursing staff on our wards at each shift by the introduction of staffing boards on every ward.

The board identifies the coordinator for the area and the numbers of registered and unregistered nurses that the ward should have and the numbers they actually have for the shift. Initially staff were concerned about the difficult questions that patients/families may ask if the number of staff actually on the shift was not the same as expected. This hasn't caused a problem. Early feedback from the use of the boards demonstrates they are extremely useful for patients and families and staff believe they are a good idea. A mock up board has been designed following early feedback and the design has been agreed and they are currently being produced. (Figure 1) The board will be displayed at the entrance to every ward and visible to all patients/family and carers.

We are working with our Quality Improvement Team to measure the reliability of the data so that we can determine how many days the actual staffing numbers present on the shift represented the planned numbers. We aim to demonstrate 95% reliability.
Figure 1: prototype of a proposed safe staffing board

Daily Safe Staffing Teleconference/Daily Rotas

Each morning at 8.30 am a teleconference is held with senior nurses across the clinical divisions, chaired by Deputy Director of Nursing to determine any nurse staffing concerns within their wards/departments. This looks at the morning, late and night shift and presents a true picture of what the nurse staffing actual is at that moment in time and therefore as up to date as possible. This allows a helicopter view and we can assess areas of concern and implement immediate actions to address the situation. The teleconference is an opportunity to assess areas of concern that may affect the clinical divisions.

To support this, a daily nursing rota is produced from all the clinical divisions. Nurse staffing is discussed at capacity meetings held four times daily. Senior nurse cover is provided 7 days a week and weekend rotas are discussed at the teleconference on Friday morning so a suitable plan can be put in place.


To implement safe nurse staffing requires commitment from all staff and not just senior nurse leaders. The Board need to be supportive and receive assurance of the staffing implications within the organisation. Involvement from the Finance Director is of real benefit to demonstrate corporate oversight of the advantages to efficiency and productivity as well as quality and safety.

We would recommend testing any change such as the staffing boards before a whole organisation spread so that amendments can be made.

We will expand the project to look at our staffing with community nursing teams, an area that hasn't produced much work nationally on minimum safe staffing.

To implement safe nurse staffing will be a continuous initiative that requires continual focus and leadership.

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Prepared 18 September 2013