Review and Publication of Hospital Inpatient Staffing Levels
Produced by
Tracy Luckett
Director of Nursing & Allied Health Professions
Board of Directors Meeting
26th June 2014
1.0 Publication of nurse staffing requirements for inpatient wards
A key recommendation from the Francis report (2009) suggested that the government request that hospitals review and publish staffing levels, making staffing ratios transparent to boards and the public. The driver for change is a consequence of low staffing levels on some inpatient wards at the Mid Staffordshire Trust which resulted in an unacceptable standard of care.
In March 2013 Trusts received further guidance from NHS England, outlining expectations of all Trusts to implement a series of actions borne out of the Hard Truths –Putting Patients First publication (volume 1 of the Government Response to the Mid Staffs Inquiry).
The guidance, in the first phase sets out a number of milestones that Trusts are expected to achieve by the end of June 2014. Currently, this guidance is only applicable to inpatient areas although it is anticipated that all clinical areas will be included eventually.
Included in the guidance letter was an endorsement by the Care Quality Commission stating that they will be looking for compliance with the requirements set out in the guidance as part of their ongoing inspection regime.
Similarly, Monitor have also endorsed the guidance stating that they expect Foundation Trusts to have the right staff in the right place at the right time
The milestones are as follows:
1)The Board receives a report every six months on staffing capacity which has involved the use of evidence- based tool (where available).
2)The Trust clearly displays information about nurses and care staff present on each shift.
3)The board receives a monthly workforce update of actual and planned staffing on a shift by shift basis. The report should be published on the Trust’s website and NHS Choices.
2.0 Background to staffing requirements
The key challenge for Moorfields is to ensure that the staffing requirements and the subsequent reporting of any variation is representative of the model of care delivery in an ambulatory ophthalmic care setting.
Many of the established staffing models in the UK are based on an acute care setting and staffing levels are set against the acuity and dependency of the patient. There is very little information available in the UK to benchmark against and a recent review of other ophthalmic units in the country confirmed this. There is no approved model for ophthalmic nursing and most staffing levels are based on a professional judgment model.
3.0National Staffing Ratios
There is currently much debate on whether there should be a national mandate on staffing levels. For many years the acceptable ratio for registered nurse to patient care has been set at 1:8 (1 registered nurse caring for 8 patients) although many believe this is too low. The ratio for qualified versus support staff is also a topic for debate and in 2010 the Royal College of Nursing reported that the skill mix had become more dilute with a ward typically having 65% of registered nurses per shift. The accepted ratio is 70/30 split although this may differ in clinical areas where the care requirements demand more support staff or technicians.
As part of the Hard Truths commitment to safer staffing NICE have also produced draft guidance on safe staffing for nursing in adult inpatient wards in acute hospitals. The guidance, currently out to consultation, focuses on staffing requirements based on a 24 acute care ward. It is anticipated that further guidance will be produced in 2015 that will incorporate other care settings such as community and day care settings.
4.0 Reporting current staffing levels for inpatient wards
As of June 2014 the trust is required to submit planned and actual staffing levels via the Unify data collection system (the information will be presented in aggregated hours over a month). The data collection is intended to identify shortfalls in staffing levels, highlighting deficits between required staffing and actual staffing levels per shift. The data collection will be included in the monthly operational report and will be presented at the trust board.
The Director of Nursing will update the board twice yearly on specific challenges with staffing levels and highlight areas of work to rectify these challenges. The model adopted by Moorfields, as in many other hospitals, is based on the ‘professional judgment’ model of care. This historical model is calculated by applying a competency-based approach to define staffing requirements.
For example, there is a requirement that an experienced ophthalmic nurse, banded at band 7 or 6 would lead the team of nurses on each shift. To date, this this approach has been applied with some success and current ward establishments demonstrate that required staffing numbers fall within acceptable levels of nurse to patient ratio (see below). The staffing ratios are calculated based on service demand which differs between weekday, night and weekend shifts.
4.1 Staff to patient ratios (planned) - inpatient areas
Ward / Number of beds / Staffing ratio - RN / Support staffDuke Elder / 6 / Weekday 1:3
Saturday 1:3
Sunday 1:3
Night shift 1:6 / 2
1
1
2
Observation Bay / 6 / Weekday 1:6
Nights and weekends 1:3 / 1
Cumberlege / 12 / Weekday 1:4
Weekend 1:3
Night shift 1:6 / 2
2
1
4.2 Planned v Actual staffing- Unify Submission
Below is the staffing hours worked during May. The data demonstrates that all three inpatient wards reported sufficient staffing levels per shift. The trust has provisionally RAG rated this indicator as green pending national guidance.
Day / Night / Day / NightWard/Dept name / Registered nurse/midwife / Care staff / Registered nurse/midwife / Care Staff / Average fill rate -registered nurse/
midwife (%) / Average fill rate -care staff (%) / Average fill rate - registered nurse/
midwife (%) / Average fill rate - care staff (%)
P* / A* / P / A / P / A / P / A
CR –Observation Unit / 728 / 729 / 268 / 262 / 440 / 430 / 180 / 180 / 100% / 98% / 98% / 100%
SG – St.George’s
Duke Elder Ward / 1004 / 1056 / 105 / 133 / 310 / 310 / 310 / 310 / 105% / 127% / 100% / 100%
CR – CumberlegeWg / 1324 / 1320 / 400 / 429 / 442 / 421 / 0 / 10 / 100% / 107% / 95%
P = Planned
A = Actual
4.3 Variances in staffing levels
Variations to the planned staffing requirements are common in clinical areas, this usually occurs because of vacancies, sickness and other types of leave. Whenever possible predicted shortfalls are managed in advance by booking temporary staff in advance of the shift. Staff rotas are also utilized to ensure maximum coverage. Temporary staff are provided by Pulse Bank Partners and the overall fill rate per month is 98% which is a very good performance. The majority of additional shifts are worked by Moorfields’ nurses although we continue to recruit additional non-substantive staff and now offer a programme of basic ophthalmic training at induction.
At times there are difficulties in covering shifts, mainly because of short term sickness as short notice cover is often difficult to find, this is especially challenging in a specialist hospital were the skill set, in certain areas, is quite unique. Daily reports are sent to the Director of Nursing outlining unfilled temporary staffing shifts and when necessary this is discussed with the relevant senior nurse.
In recent months there has been an increase in temporary staffing requests associated with activity growth. The use of temporary staff to fill additional posts is viewed as a short term solution and the trust has launched a national recruitment campaign to fill the vacancies.
4.4 Quality and staffing levels
As of 1st June 2014, all inpatient wards and the day case wards within the trust,display daily staffing numbers displayed on a quality board situated at the entrance of the ward. The board states who is the nurse in charge of each shift and how many registered nurses and support staff are on each shift. The board also includes other quality information such as infection control audits and ‘friends and family’ ‘you said – we did comments’.
The risk and safety team received 4 incident reports pertaining to staffing levels in Q1 of this year. The incidents related to the unavailability of health care support workers in one particular clinical area. As noted in paragraph 4.3 acquiring staff at short notice can be a problem and the trust is currently exploring ways to address this particular problem. The introduction of a ‘pool’ of health care support workers and an ‘on call’ system for nurses are two of the options that are currently being explored.
5. Future reporting
In addition to the monthly reporting of staffing levels in the operational report, the Board will receive a six monthly update on the wider staffing situation. Future reports will include an update on the success of the national recruitment campaign and the implementation and impact of new ways of working to provide cover for short notice vacancies, staff pool etc. The Board will also be briefed on any changes to the nursing and technicians workforce as highlighted in the nursing strategy.
The Board is asked to note the contents of this report.
Tracy Luckett
Director of Nursing & Allied Health Professions
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