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Does research help deliver safer care?

The Clinical Adviser at the National Institute for Health Research (NIHR) Dissemination Centre looks at evidence from a review of UK research on hospital ward staffing:

The debate about what constitutes safe staffing and how to determine it has always taxed healthcare providers.

Traditionally based on professional judgement, there have been increasing moves toward a more explicit methodology. The Telford formula (Determining nursing establishments Health Services Manpower Review /Telford, W.A. (1979)) was one of the first standardised tools to be used in the UK and has since been followed by a number of others. But can tools on their own provide an answer and what does the research say?

The NIHR Dissemination Centre recently undertook a review of UK research on ward staffing. It was limited to ward staffing as very little research has been undertaken in other settings.  NIHR has funded quite a few studies in this area recently.   Our review concludes that staffing is complex and cannot be reduced to a simple formula.

There is strong UK and international research showing a relationship between the number of registered nurses and patient harms, including death. What is not clear from the evidence is the point at which the number of registered nurses becomes ‘safe’ or ‘unsafe’. This is because different wards and indeed different patients have different needs.

Our current knowledge is based on averages and cannot provide a precise number for each individual patient. But this does not mean the evidence has no use. Safe staffing requires evidence informed practice, where managers undertake a risk assessment, using the evidence and layering professional opinion derived from knowledge of the local context.  This process needs to be transparent and managers must be held to account for these local decisions through a formal assurance process.

But safe staffing is more than just a numbers game.  We have clear evidence that safety comes from what nurses actually do and how well they work in teams. Our review showed the relationship between registered nurses (RNs) and patient harm is one directional – the harms increase as the number of RN hours reduce. While unregistered staff provide immense benefit for patients, they cannot replace the role of RNs in patient vigilance. Unlike RNs, emerging evidence suggests that harms increase with both too many and too few healthcare assistants.

The picture is changing with new roles and skill mix in the team.  As the impact of Nursing Associates has yet to be evaluated, it is unclear what impact their numbers will have. It’s also unclear what impact other ward-based health professionals – from ward pharmacist to physician associate – have on safe staffing.

What is clear is that good ward leadership is pivotal.  Good ward leaders make the best use of the staff available, through creating professional practice environments that allow staff to practise to the best of their abilities, while managing the fluctuating workload against known patient needs. The evidence suggests an effective route to safe staffing would be to focus on ward leader education and development.

Safe staffing is not straightforward, and expertise is required to apply the research to local contexts. Our review highlights that whilst tools for calculating the number of staff needed are helpful, leaders need to take account of a broad range of factors.  The new NHS Improvement Safe Staffing fellows programme is a welcome policy development and will ensure Trusts are able to develop evidence-based approaches to effective staffing that take into account all the elements that contribute to safe, effective care and great patient experience.

Dr Elaine Maxwell

Dr Elaine Maxwell is Clinical Adviser at the National Institute for Health Research (NIHR) Dissemination Centre, working to provide clear, accessible, actionable summaries of research that helps decision making in health and social care.

Elaine has previously worked as an Associate Professor and prior to that as an executive director of Nursing and a non-executive director of a number of NHS Trusts in England.

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