Safe Staffing in Acute Hospitals

1. Safe Staffing in Acute Hospitals Elaine Inglesby-Burke Executive Nurse Director, Salford Royal NHS Foundation Trust Helen Thomson Chief Nurse, Calderdale and Huddersfield NHS Foundation Trust Pippa Hart Chief Nurse, Epsom and St Helier University Hospitals NHS Trust

3. US Research: Nurse staffing & mortality • Surgical patients in hospitals with better nurse work environments have 13% lower odds on dying; • Patients in hospitals with better staffing (two fewer patients per nurse) have 11% lower odds on dying; • Patients in hospitals with better educated nurses (20% more BSNs) have 8% lower odds on dying. Surgical patients in hospitals that are better on all three have roughly 30% lower odds on dying. Source: Aiken et al., JONA, 2008

4. Kane (2007) systematic review 96 studies Increased RN staffing was associated with lower hospital related mortality in: • intensive care units (OR 0.91 CI 0.86–0.96) • surgical units (OR, 0.84; 95% CI, 0.80–0.89), • medical patients (OR, 0.94; 95% CI, 0.94–0.95) • per additional full time equivalent nurse per patient day. Kane et al (2007) Medical Care 45 (12), 1195-1204

5. Previous research – patient: RN ratios Source data: Rafferty, A. M., S. P. Clarke, et al. (2007). Int J Nurs Stud. 44, 2

6. 12 10 8 6 Mean no. of patients per RN 4 2 Never Rarely Several times a Once or twice a On most shifts On every shift month week Frequency patient care is compromised by short staffing ‘Care is compromised by short staffing’ by patients per RN (on NHS hospital wards) Source: Employment Research/RCN 2009

7. An unsafe ratio…. Based on the research evidence: A ratio of more than 8 patients per RN significantly increases the risk of harm and constitutes a breach in patient safety. Under no circumstances is it safe to care for patients in need of hospital treatment with a ratio of more than 8 patients per registered nurse during the day time on general acute wards (including those specialising in care for older people).

8. Staffing levels : Pt/RN ratio (day) Source: Ball J, Griffiths P & Rafferty A M (2012) RN4Cast

9. Staffing Staffing levels should be: • Consistent with the scientific evidence • Adjusted to patient acuity and local context • Made public and easily accessible to patients and carers NICE will produce definitive guidance on safe and efficient staffing levels in a range of NHS settings

10. Boards take full responsibility • Processes are in place to enable staffing establishments • Evidence-based tools • Culture where staff feel able to raise concerns • Multi-professional approach • Sufficient time to fulfil responsibilities • Boards receive monthly updates on workforce information • Clearly display information about staff present on each ward/department • Providers secure staff in line with their workforce requirements • Commissioners get assurance that the right people, with the right skills, are in the right place at the right time Staffing Expectations

12. Ratios – of what to what? Staff erosion – from plans to reality Planned staffing (Full budgetedestablishment) Employed staff in post (Establishment minus vacancies) Available staff (staff in post minus absent staff) Planned staff for each shift (off-duty) Actual staff per shift (Planned minus unfilled gaps)

13. What can you do? • What’s your role in ensuring staffing levels are safe? Have you got it right in your organisation? • What tools are being used to plan staffing to match patient need and workload? • Do you know the RN:pt ratios where you work? • How do they compare to elsewhere? • Are professional guidelines (eg. in to ITU, neonates) followed? • Would normative staffing help? • How do you know when you've got it right...or wrong? • How is quality being measured? Is it being related to differences in staffing?

14. Safe staffing is your smoke detector for safe care and improved performance Know your business