Meeting of the Trust Board

4 May 2016

Report title: / Safer Nurse Staffing Review / Agenda item:
Executive Director:
Authors: / Nina Fraser
Tracey Brigstock
Adam Brown / Title: Director of Nursing &Patient
Services
Deputy Director of Nursing
Associate Director of Nursing (Workforce)
Report summary / This report details the findings of the sixth Safer Nurse Staffing Review of adult in-patient wards, undertaken in January / February 2016.
Related Trust Objective /
CQC Domain / Safe
Effective
Caring
Responsive
Well-Led
Action
(tick one box only) / Information / Approval / Assurance / Decision
Recommendation / The Trust Board is asked note the contents of this report and action plan.

Impact Assessments – None identified for this paper

Equalities / Human Rights / N/A
Patient & Public Involvement / N/A
Legal / Regulatory / CQC Regulations
Nursing Quality Board, 2013 ; RCN, 2013
NICE, 2014
Financial / Recommendations identified within the report.
Risk / High risk – if safe staffing standards are not met
Jargon Buster: Please detail acronyms used in the report / SNCT - Safer Nursing Care Tool
RCN - Royal College of Nursing
OSCE - Observation of Simulation Clinical Exercise
RN - Registered Nurse
RSCN - Registered Sick Childrens Nurse
CSW - Clinical Support Worker
CQC - Care Quality Commission
CNS - Clinical Nurse Specialist
CaMH - Community and Mental Health

Executive Summary

This report details the findings of the sixth Safer Nurse Staffing Review of adult in-patient wards, undertaken in January and February 2016, (6-monthly).

The aim of this report is to provide assurance to the Trust Board that safe staffing levels are being maintained. .

There are a number of tools available to determine safe staffing levels, each having their own strengths and weaknesses. The tools applied here are Skill Mix review, Safer Nursing Care Tool (SNCT) and Nurse to Patient Ratio. Professional judgement has also been applied by Matrons (skill mix and numbers of staff per shift). This data has been triangulated and reviewed with nurse sensitive indicators (Safety Thermometer, Pressure Ulcers and Falls incidence).

Care Contact Time has been reviewed in line with NICE Guidance, 2014.

Separate reviews of A&E and Paediatrics have been conducted, with Paediatrics reported in further detail in Appendix 1. A staffing review in Maternity is planned to take place in April 2016, with Outpatients Department scheduled for review in 2016/17

Findings

The monthly staffing fill rate over the last 6 months has consistently been above 95%.

Ward staffing levels are safe with the following considerations. Pilgrim Ward has consistently demonstrated an increase in acuity and demand, whilst Reginald Hart Ward continues to have additional beds due to increasing admissions. Both issues will be addressed through budget setting for 2016/17. Shuttleworth Ward requires a review of the service delivery model giving consideration to reducing capacity to ensure consistency in care delivery standards.

Methods for managing specialist individual care (1:1 nursing) need to be more fully explored across Harpur and Elizabeth Wards, together with further review of stroke services (Howard Ward).The additional capacity (3 beds) on Shand ward need to be stepped down.

The Safer Nursing Care Tool shows a wide variation in results, however, triangulation indicates a general shift in patient demand.

Action Plan

  • Establish funding of substantive posts in accordance with the projected out-turn (2015/16) for Pilgrim and Reginald Hart wards..
  • Findings from reviews currently in progress are to be considered and actioned, as available
  • Alternative methods for managing specials (1:1 nursing)to be considered and implemented
  • A tracking document to be developed in year predict the impact of changes in capacity and

demand (together with HR / finance teams)

  • Continue to monitor and escalate nurse staffing requirements through three times daily quality operational meetings (Matrons and Divisional Lead Nurses).

Recommendations

The Trust Board are asked to note this Report and Action Plan.

Summary Table

Ward/Department / Current Funded Beds / Current Funded WTE's / Skill Mix Ratio RN:CSW / SNCT Variance (for open beds) / Nurse to Patient Ratio
(for open beds)
over 24hrs / Overall Result
AA Unit / 25 + 3 Trolleys / 42.9 / 68:32 / 1:5 / 
Arnold Whitchurch* / 15 / 23.54 / 53:47 / - 1.56 / 1:6 / 
CCU / 16 / 21.52 / 73:26 / - 3.98 / 1:7 / 
Elizabeth * / 23 (4) / 33.55 / 58:41 / - 8.95 / 1:8
Godber / 18 / 23.94 / 56:44 / +1.84 / 1:8 / 
Harpur * / 25 / 33.55 / 58:42 / - 8.95 / 1:8
Howard (Stroke)** / 20 / 29.09 / 48:52 / - 2.41 / 1:8
Orchard Gynae / 11 / 11.51 / 89:11 / +2.11 / 1:6 / 
Pilgrim** / 30 / 39.06 / 62:38 / - 6.04 / 1:6
Reginald Hart* / 24 (6) / 32.99 / 54:46 / - 6.02 / 1:8
Richard Wells / 27 / 30.15 / 64:36 / +1.35 / 1:7 / 
Russell* / (15) / 0 / 53:47 / - 25.1 / 1:6 / 
Shand / 29 (3) / 35.63 / 62:38 / - 8.47 / 1:8
Shuttleworth / 32 / 35.04 / 62:38 / - 8.76 / 1:9
Whitbread / 26 (1) / 34.02 / 65:35 / - 2.58 / 1:7 / 

Notes:

* Elderly care wards requiring 1:6 ratios

** Pilgrim Ward has 30 Acute Respiratory beds, including 2 specialist Non Invasive Ventilation (NIV) beds and

Howard Ward has 20 Stroke beds, including 2 High Observation beds.

Unfunded beds are shown in brackets (total 29).

Unsafe staffing level
Action required
 / Satisfactory

Safe Staffing Review (January 2016)

  1. Introduction

All NHS Trusts are required to review their nurse staffing levels on a six monthly basis using nationally recognised evidence based tools (NQB, 2013; NICE, 2014; Hard Truths, 2014). This report details the findings of the sixth Safe Staffing Review across all adult inpatient ‘core’ wards at Bedford Hospital NHS Trust (BHT) conducted in January/February 2016.

  1. Aims and Objectives

The aim of this report is to:

  • Provide a credible objective review of nurse staffing levels
  • Assure the Trust Board that safe staffing levels are being maintained.

The objectives of this report are to:

  • Apply evidence based tools and review the output from each
  • Review quality indicators
  • Triangulate the evidence
  • Determine next steps.
  1. Evidence Based Tools (Methodology)

There are a number of tools available to determine safe staffing levels, each having their own strengths and weaknesses. Experts recommend that none should be used without triangulation with other approaches and sources of information. The evidence based tools selected are Skill Mix, Safer Nursing Care Tool (SNCT) and Nurse to Patient Ratio. Care Contact Time has also been reviewed. Additional quality indicators will also be considered for example, Safety Thermometer, Pressure Ulcer Incidence and Falls Incidence.

Skill Mix

The definition of skill mix is the number of RNs to CSWs allocated to ward areas and expressed as a ratio. Typically this would be 65:35 (RCN, 2010; Francis, 2013; NICE 2014). Skill mix may vary by setting. This must not fall below 55:45 for acute in-patient wards (Keogh, 2013).

Safer Nursing Care Tool

This tool has been updated (NHSI, 2014). The multipliers for calculating patient demand have been revised and developed to reflect the increasing patient care demand seen nationally and to reflect the higher turnover of patients seen in some areas, for example, medical assessment units and short stay surgical units. Within this review, ward staff collected data throughout January and February 2016 (4 weeks) which was entered into a central database for analysis. The data collection has been verified by Matrons. However this tool has a degree of subjectivity and must not be viewed insolation

Nurse to Patient Ratios

Nurse to Patient Ratios have been applied to reflect RCN Guidance. It is recommended that all elderly care wards adopt one Registered Nurse for every six patients (1:6). It is also recommended that all other acute in-patient wards apply 1:8 as a guiding principle. There is no published guidance for nurse staffing ratios at night. A ratio of 1:10 has been adopted. This reflects peers (Kettering General Hospital, Luton & Dunstable Hospital). However, it is noted that Lister Hospital has 1:7 ratio at night. Ratios are variable.

Care Contact Time

NICE guidance recommends that all Trusts conduct a review of Care Contact Time within 12 months of their recommendation (NICE, July 2014). It is important that as well as providing direct care, such as assistance with patient hygiene, there is a balance with indirect patient care. This includes attendance at multi-disciplinary ward rounds or liaising with families to plan discharge, as well as other activities, such as supporting and mentoring students and newly qualified nurses and midwives. Studies have shown that it is possible to increase direct care contact time from 53% to 78% by ward-led modifications in practice – as well as reducing length of stay and discharging patients earlier in the day.

Fill Rate Data – January 2016

The overall fill rate for staff was 98.1 %. This rate comprises of 93.8% fill and 4.3% by special individual nursing (1:1). Howard Ward has a lower fill rate with a higher rate of specials fill, this is some RN and but largely CSW staff.

Exclusions from the Safer Care Review

A&E has had a separate review to include ‘streaming’ of patients to the most appropriate parts of the service and the introduction of a Clinical Decisions Unit. Investment is to be afforded by bringing forward winter plan investment in partnership with CCG. The Maternity review is in progress (April 2016). The Paediatric in-patient areas have been benchmarked against Royal College of Nursing (2014) staffing criteria (Appendix 1).

  1. Findings

a) Skill Mix

Arnold Whitchurch and Russell Wards are designated to take low risk elderly frail patients, primarily delayed in the discharge process and a higher than average ratio of CSW staff is appropriate here. Howard Ward flags for urgent review where this tool is considered in isolation however, there is a ward based CNS that is not included and a higher ward presence of therapy staff. This model is under review. Reginald Hart Ward skill mix indicates that investment is required for the additional 6 beds that remain open and this will be addressed within the budget setting process.

b) Safer Nursing Care Tool

The table below presents the results of the staffing review according to the outcome from the safer nursing care tool completed in January 2016 (Fig 1).

Ward/Department / Current funded WTE's / Actual used WTE / Current funded Beds / Safer Nursing Care Tool / Beds open at validation / Variance
WTE for beds open at Validation
AA Unit / 42.9 / 42.9 / 25 + 3 Trolleys / 25 + 3 Trolleys
Arnold Whitchurch Ward / 23.54 / 23.54 / 15 / 25.1 / 15 / -1.56
CCU / 21.52 / 21.52 / 16 / 25.5 / 16 / -3.98
Elizabeth / 33.55 / 35.75 / 23 / 44.7 / 27 / -8.95
Godber / 23.94 / 23.94 / 18 / 22.1 / 18 / +1.84
Harpur / 33.55 / 33.55 / 24 / 42.5 / 24 / -8.95
Howard / 29.09 / 29.09 / 20 / 31.5 / 20 / -2.41
Orchard Gynae / 11.51 / 11.51 / 10 / 9.4 / 10 / +2.11
Pilgrim / 39.06 / 39.06 / 30 / 45.1 / 30 / -6.04
Reginald Hart W / 32.99 / 39.28 / 24 / 45.3 / 30 / -6.02
Richard Wells OWH / 30.15 / 30.15 / 27 / 28.8 / 27 / +1.35
Russell / 0 / 0 / 15 / 25.1 / 15 / - 25.1
Shand / 35.63 / 35.63 / 29 / 44.1 / 31 / -8.47
Shuttleworth / 35.04 / 35.04 / 32 / 43.8 / 32 / -8.76
Whitbread / 34.02 / 34.02 / 26 / 36.6 / 26 / -2.58

Figure 1

Discussion by Exception

The SNCT shows a comparison of the ‘Current Funded WTEs’ and a recommended establishment (SNCT column) based on the data analysis. There are eight ward areas with a gap of more than 3 WTEs using this model however, there are reasons why this may be the case at this time rather than this being a consistent picture. Four wards have scored higher than the last review in June 2015.

Elizabeth Ward had 27 beds open (escalation) throughout the time period and is funded for 23 beds demonstrating a shortfall and reliance on temporary staffing to meet demand.

Harpur Ward had a higher than usual number of patients requiring special 1:1 nursing during this period, managed by cohorting 2 -4 patients at any one time.

Reginald Hart Ward (30 beds, Surgery) became a 24 bedded Medical Ward in August 2015, changing core specialty with plans to reduce capacity. However, all 30 beds have remained open. In November 2015, a review of the SNCT was undertaken demonstrating 41.8 WTE establishment was needed should these beds remain open (= 8.81 WTE).

Shuttleworth and Shand Wards also have elevated SNCT scores compared to those recorded in June 2015. Russell Ward remains unfunded (winter pressures ward).

c) Nurse to Patient Ratios

Ward/Department / Current funded WTE's / Current funded Beds / Current RN to Bed Ratio
Day / Current RN to Bed Ratio
Night / Current WTE Template / Variance WTE (ie currently used and funded/ unfunded) / Ratio for 24 period ave (open beds)
AA Unit / 42.9 / 25 + 3 Trolleys / 1:5 / 1:5 / 42.9 / 0 / 1:5
Arnold Whitchurch Ward* / 23.54 / 15 / 1:5 / 1:8 / 23.54 / 0 / 1:6
CCU / 21.52 / 16 / N/A / N/A / 21.52 / 0 / 1:7
Elizabeth* / 33.55 / 23 / 1:6 / 1:7 / 34.61 / 1.06 / 1:8
Godber / 23.94 / 18 / 1:6 / 1:9 / 23.94 / 0 / 1:8
Harpur* / 33.55 / 25 / 1:6 / 1:9 / 33.55 / 0 / 1:8
Howard* / 29.09 / 20 / 1:7 / 1:10 / 29.09 / 0 / 1:8
Orchard Gynae / 11.51 / 10 / 1:6 / 1:6 / 11.51 / 0 / 1:6
Pilgrim** / 39.06 / 30 / 1:5 / 1:8 / 39.06 / 0 / 1:6
Reginald Hart* / 32.99 / 24 / 1:6 / 1:10 / 39.28 / 6.29 / 1:8
Richard Wells OWH / 30.15 / 27 / 1:6 / 1:8 / 30.15 / 0 / 1:7
Russell* / 0 / 15 / 1:5 / 1:8 / 26.16 / 26.16 / 1:6
Shand / 35.63 / 29 / 1:6 / 1:10 / 35.63 / 0 / 1:8
Shuttleworth / 35.04 / 32 / 1:6 / 1:10 / 35.04 / 0 / 1:9
Whitbread / 34.02 / 26 / 1:6 / 1:9 / 34.02 / 0 / 1:7

The table below (Fig 2) presents the results of the staffing review according to ‘Nurse to Bed’ ratios, identified within RCN Guidance for Staffing for Older Peoples Wards (1:6) and NICE guidance (1:8).

Figure 2

Notes:

* Elderly care wards requiring 1:6 ratios

** Pilgrim ward has 30 acute respiratory beds including 2 specialist Non Invasive Ventilation (NIV) beds and

Howard Ward has 20 stroke beds including 2 high observation beds.

Discussion by Exception

All wards meet the recommended Nurse to Patient ratio during the day show wider variation at night. This is locally determined.

d) Care Contact Time

This is the second time that the Care Contact Time tool has been utilised as part of the bi-annual staffing review (Fig 3). In essence, this has been a time and motion study over a 2 week period on each ward. The graph below shows the breakdown of how different grade types spend their time on day and night shifts across all wards. The ward by ward data shows a very similar picture.

Figure 3

Discussion

The measurement and understanding of care contact time can be used to drive local improvement, support the determinant of a robust nursing and midwifery establishment and the effective deployment of staff. The appropriate balance of nursing activities will vary according to the specialty of the ward or unit, the dependency and acuity of its patients, as well as other factors.

RN’s on day shifts spend 58% of their time involved in direct patient care as a baseline. As expected CSW’s spend most of their time involved in direct patient care during the day with an increased amount of time at night being spent undertaking indirect patient care activities (re-stocking/tidying etc.).

  1. Additional Shift Usage - Specials

At times it is necessary for ward templates to have additional duties added in order to provide increased care for single or multiple high risk patients or to meet increased operational pressure by staffing non-funded/non-operational beds. The table below (Fig 4) illustrates the number of hours’ worth of additional hours required by each ward over the four weeks of the data collection and the whole time equivalent per week that this equates to.

Additional Shift Usage

Wards / Total Hours used for Specials / WTE / Comments
AAU / 23.50 / 0.16
AWW / 0.00 / 0.00
CCC / 0.00 / 0.00
CCU / 0.00 / 0.00
Elizabeth / 347.50 / 2.32 / additional beds open plus cohorting of patients requiring 1:1 care
Godber / 0.00 / 0.00
Harpur / 508.00 / 3.39 / increase in special requirements
Howard / 600.50 / 4.00
Maternity / 0.00 / 0.00
Meadowbank / 0.00 / 0.00
Orchard / 0.00 / 0.00
Pilgrim / 1345.00 / 8.97 / One WTE RN 24/7 for tracheostomy patient – 5 wks
RGH / 226.00 / 1.51
Riverbank / 63.75 / 0.43
Russell / 63.50 / 0.42 / Nightingale style ward
RWW / 0.00 / 0.00
Shand / 25.50 / 0.17
SWW / 259.00 / 1.73
Whitbread / 216.00 / 1.44
Total / 3678.25 / 24.52

Figure 4

Discussion

It is important to note that there is an anomaly linked to the E-Rostering System whereby ‘special’ shifts can be filled without the baseline ward template being covered. This means that a number of wards may achieve a 95% fill rate with the inclusion of specials. This implies that once vacancies have been filled, the demand for specials will reduce.

It has been noted that there are on average 6 patients each day/night that require one to one care. The average number of patients requiring Deprivation of Liberty safeguarding order in place was on average 18 patients for January 2016 (average usually 10–12 patients). The majority of these patients were on Elizabeth, Russell, Harpur and Howard Wards.

All requests for specials authorised through a risk assessment process and signed off by divisional lead nurse or above and reviewed daily.

  1. Quality Indicators

a) Safety Thermometer

The data from the Safety Thermometer shows that patient safety is being maintained across all wards and this is a testament to the hard work of the staff and the safety culture that has been embedded. Part of this however this is the use of additional staff to maintain safety and quality when demand rises. The overall Harm Free care score for the month of January 2016 is 96.06%.

b) Pressure Ulcer Incidence

In the current year there have been three Category 3 and three Category 2 Hospital Acquired Avoidable pressure ulcers. In January 2016, there was one Category 3 pressure ulcer reported for the whole of the Trust (Fig 5). Excellent progress has been made in trust wide pressure ulcer assessment and prevention.

Tissue Damage All Adult Wards January 2016 / AAU / AWW / CCU / Elizabeth / Godber / Harpur / Howard / Orchard Gynae / Pilgrim / Reginald Hart / Richard Wells / Russell / Shand / Shuttleworth / Whitbread
New Cat 2 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0
New Cat 3 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 1 / 0 / 0 / 0 / 0 / 0
New Cat 4 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0 / 0

Figure 5

c) Patient Falls Incidence

The falls data reported in January 2016 (Fig 6) shows that 84% of all falls resulted in no harm, this group includes patients who had a fall whilst walking with staff and were guided to the floor (i.e., a managed fall or supported when collapsed). The remaining 16% of falls resulted in minor harm. There were no moderate or severe harm falls.

Falls for All Adult Wards in January 2016 / AAU / AWW / CCU / Elizabeth / Godber / Harpur / Howard / Orchard Gynae / Pilgrim / Reginald Hart / Richard Wells / Russell / Shand / Shuttleworth / Whitbread
No Harm / 8 / 2 / 1 / 13 / 4 / 4 / 3 / 0 / 2 / 3 / 6 / 6 / 6 / 0 / 4
Harm / 1 / 1 / 0 / 1 / 0 / 0 / 1 / 0 / 0 / 1 / 1 / 0 / 3 / 2 / 1

Figure 6

Targeted work to reduce the number of falls is being undertaken through the Patient Safety Programme. It is noted that Elizabeth Ward has the highest number of reported falls in month.