Published:25/04/2002, Volume II2, No. 5802, Page 24 25
One of the most challenging and emotive subjects for any hospital is effective staffing on wards. At Bedford Hospital trust, the increased acuity of patient care and a rise in emergency admissions over the past two years had a marked impact on nurses'workload, potentially affecting the quality of care.
Historically, the trust had relied on computerised workload software to recommend changes on wards, but it became clear that many wards and departments were still working with fewer nurses than needed. This led to a review of methodologies for staffing and skill-mix reviews.
We set up a 'safe staffing group' to prioritise the cases of need for improved staffing levels in wards, improve risk assessment and link staffing to the trust's clinical governance agenda.
The trust first started to examine workload versus nurse staffing in 1996 using a program called the nursing information systems for change management (NISCM).
1This shows where the greatest demand on staff is at any time and measures workload against staff availability.
The trust pledged to review staffing levels according to the results of the study and five wards received an additional 22 staff. But many wards still showed a shortfall. The trust could not continue to meet its pledge, and financial constraints required a fresh approach.
Information was also sparse about the quality of care provided. This was seen as particularly important in view of the statutory duties of chief executives for finance and quality outlined in the NHS plan.
An assessment in summer 2001 identified the need to streamline recruitment and retention, which were being handled by a number of different groups.
The safe staffing group was set up in July 2001 to ensure the most effective provision of a safe level of nursing/midwifery and therapeutic care to patients, within available resources. It was also charged with finding a systematic way to identify which wards and departments most needed any available funding for staff.
At first, members of the group included the health and safety adviser, all the senior nurses, the therapies manager, human resource and financial advisers. Once the terms of reference and systems were in place, this was cut down to seven members, including senior nurses, a human resources manager and a finance manager. Others are co-opted as required.
The NISCM package provides a quality tool, which had been piloted on a ward at the trust in1998. The results showed that the tool was somewhat subjective and open to misinterpretation.
So in September last year we piloted the quality pointers tool, which measures the ability to provide a variety of aspects of care for each shift.
2The measurements are input into a computer package, which produces a graph showing the quality of care given, ranging from excellent to dangerous. At the same time, nurses' judgement of the quality of care given is compared to the computerised data. The system was launched on 13 wards.
After piloting it on two wards together with the NISCM data, it was possible to compare staffing levels and quality on a graph. This showed some correlation between staffing levels and quality, indicating that an adequately staffed ward can provide a higher quality of care.
A ward profile was devised to examine each area in terms of overall level of care: ward routine; staff deployment; success in completing paperwork, stock ordering, supervision and teaching; care planning and assessment; and communication with patients.
The profile also includes health and safety issues, clinical incidents and risks, the number of hospital-acquired pressure sores, staffing changes complaints and use of bank and agency nurses. Each ward is entered on a rolling eight-week programme, where workload and quality are measured.
These reports are presented to the safe staffing group and submitted to the trust-wide clinical governance committee with recommendations for improvement.
So far seven wards have completed full reports on staffing levels, care quality and risk. The results showed good care in three wards, adequate care in another three, and less than adequate in one.Most wards were slightly understaffed. One ward was overstaffed by one nurse post.
A total of 10.5 whole-time equivalent nurses have been appointed as a result. The human resources department is tackling sickness absence, and senior nurses' study leave is being reduced in wards with high absence levels.
The review has also led to increased use of pre-operative assessment clinics and faster thrombolysis treatment for heart attack patients.
Several wards are working on environmental improvements, such as providing private consulting areas.
The surgical ward where care was less than adequate had 30 beds. There were low staffing levels on all shifts and several reports of clinical risks, including a high number of falls by patients. Staff sickness - including long-term absence - was high.
Some senior staff had been seconded to other areas to help cover maternity and other leave. Action has been taken to remedy the problems.
In contrast, a 19-bed ward caring for elderly patients had enough staff, but sometimes they were rostered inappropriately, leaving gaps in service on some shifts and slight overstaffing on others. The quality of care was good to adequate and other criteria such as clinical risks and falls were very low.
A medical ward where additional staffing had been put in after a 2001 review was deemed to have slightly more staff than needed for the workload.
But this included using three whole-time equivalents of bank and agency staff.The template, when completed, showed two broad findings; while there were several clinical incidents over the period, delayed discharges had been minimised.
These results are seen as important in identifying areas where there is a possible risk to patients and making changes to correct areas of concern.This might not necessarily involve increasing staff levels, but can be tackled by addressing other issues such as time lost through study and sick leave.
The development of measurable criteria, applied in a systematic way, to address ward and department staffing has benefited the management of these issues as well as patient care.
The evidence collected shows that some wards are offering better care than others, and that staffing levels influence the quality of care that can be offered. In addition, the studies have highlighted areas for improving staffing levels by addressing clinical risk factors.
The safe staffing group has therefore provided a framework for measuring risk, prioritising the wards most in need and addressing clinical governance issues related to staffing levels.
Bedford Hospital trust now has robust data covering the last five years.Our next step is to consider whether this level of data collection should be ongoing or whether intermittent gathering of data would be enough to complement what we already know. l REFERENCES 1MacIntosh JD. Nursing Information Systems for Change Management. JDM Management Services, September 1996.
2 York Health Economics Consortium. Quality Pointers Questionnaire for General Medical and General Surgical Wards. 1993.