Objectives The best way to determine nurse staffing requirements on hospital wards is unclear. This study explores the precision of estimates of nurse staffing requirements made using the Safer Nursing Care Tool (SNCT) patient classification system for different sample sizes and investigates whether recommended staff levels correspond with professional judgements of adequate staffing.
Design Observational study linking datasets of staffing requirements (estimated using a tool) to professional judgements of adequate staffing. Multilevel logistic regression modelling.
Setting 81 medical/surgical units in four acute care hospitals.
Participants 22 364 unit days where staffing levels and SNCT ratings were linked to nurse reports of "enough staff for quality".
Primary outcome measures SNCT-estimated staffing requirements and nurses’ assessments of staffing adequacy.
Results The recommended minimum sample of 20 days allowed the required number to employ (the establishment) to be estimated with a mean precision (defined as half the width of the CI as a percentage of the mean) of 4.1%. For most units, much larger samples were required to estimate establishments within ±1 whole time equivalent staff member. When staffing was lower than that required according to the SNCT, for each hour per patient day of registered nurse staffing below the required staffing level, the odds of nurses reporting that there were enough staff to provide quality care were reduced by 11%. Correspondingly, the odds of nurses reporting that necessary nursing care was left undone were increased by 14%. No threshold indicating an optimal staffing level was observed. Surgical specialty, patient turnover and more single rooms were associated with lower odds of staffing adequacy.
Conclusions The SNCT can provide reliable estimates of the number of nurses to employ on a unit, but larger samples than the recommended minimum are usually required. The SNCT provides a measure of nursing workload that correlates with professional judgements, but the recommended staffing levels may not be optimal. Some important sources of systematic variations in staffing requirements for some units are not accounted for. SNCT measurements are a potentially useful adjunct to professional judgement but cannot replace it.
Trial registration number ISRCTN12307968.
- quality in health care
- human resource management
- health services administration & management
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Contributors PG (professor, health services research): principal investigator, original conceptualisation of the study and study design, secured funding, oversaw acquisition of the data, data analysis, interpretation of results and drafted article. CS (research fellow, operational research): undertook descriptive and regression analyses and contributed to critical revision of the article. JB (professor, health services research): contributed to study design, acquisition of funding, interpretation of results and critical revision of the article. DC (senior medical statistician): provided statistical advice, contributed to interpretation of results and critical revision of the article. NP (clinical professor, nursing): contributed to study design, acquisition of funding, acquisition of the data, interpretation of results and critical revision of the article. TM (principal research fellow, operational research and data science) contributed to study design, acquisition of funding, oversaw acquisition of the data, data analysis, interpretation of results and critical revision of the article.
Funding This report presents independent research funded by the UK’s National Institute for Health Research (NIHR) Health Services and Delivery Research Programme number 14/194/21. JB, NP, PG and TM were award holders.
Disclaimer The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the PHR programme or the Department of Health and Social Care.
Competing interests PG is a member of the National Health Service Improvement safe staffing faculty steering group. The safe staffing faculty programme is intended to ensure that knowledge of the Safer Nursing Care Tool (SNCT), its development and its operational application is consistently applied across the NHS.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Patient consent for publication Not required.
Ethics approval The study was approved by the Health Research Authority through the integrated research application system (IRAS) approval number 190 548. Ethical approval was granted by the University of Southampton Ethics committee (reference 18809).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available in a public, open access repository. All data supporting this article are openly available from the University of Southampton repository at https://doi.org/10.5258/SOTON/D1134.
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