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 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
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
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
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.