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Hospital staff managing staffing levels

NIHR Signal NHS managers need support to use tools to ensure safe nurse staffing levels

Published on 5 February 2019

doi: 10.3310/signal-000724

Workforce planning technologies can help NHS managers plan for safe nurse staffing levels, but only with proper support and tools that are designed with good understanding of local needs. Tools also need to give easy access to standardised information such as staff availability and costs. NHS Trusts need to be open to information sharing and system integration.

Adequate nurse staffing is linked with improved patient outcomes and quality of care, making this an NHS priority. Technologies are available to help NHS managers plan the workforce, but there is little understanding of how these are used. This theory-driven research involved literature review, stakeholder workshops and interviews with managers to explore the use of tools and any barriers to successful implementation.

The study identified seven key explanations for why tools may work in given situations. The findings may help NHS leaders to ensure that tools and technologies for workforce planning are used efficiently.

Share your views on the research.

Why was this study needed?

Safe staffing levels can have major impact not just on patients’ experience of care, but on clinical outcomes. A recent review of international studies found that important aspects of care are missed when there are fewer registered nurses available. NICE was asked to develop evidence-based guidelines on safe nurse staffing in the wake of a series of critical reports, including the 2013 Francis Report on Mid Staffordshire NHS Trust and Keogh review into quality of care at 14 hospital trusts.

NICE endorses various tools that are in line with guideline recommendations and have been developed to help managers plan for safe staffing. However, their use and usefulness may be affected by various factors, such as changing patient needs and staff availability. Studies are in progress to assess costs and outcomes from real-world application of such tools.

This study aimed to find out what helps NHS managers use these tools effectively.

What did this study do?

This realist review had several phases. It started with a literature review to develop theories around how workforce planning and deployment tools and technologies work in context and any barriers or facilitators to implementation. This theoretical understanding was developed in workshops involving NHS staff, patient and public representatives.

This was followed by 10 telephone interviews with NHS managers, including ward managers and team leaders in hospital and community settings. A further 11 interviews were conducted at a later phase to refine their theories.

The information was used to draw up seven principles, ‘context-mechanism-outcome’ conditions. These were agreed might help NHS managers use workforce planning tools effectively and enhance safe nurse staffing.

The research focuses on acute adult care.

What did it find?

The principles linking context, mechanism and outcome were:

  • When a staffing system can respond to real-time demands (such as flexibility of staff working patterns) this can uphold the organisation’s reputation and enhance recruitment, so creating a positive cycle where nurses can be matched to demand.
  • NHS managers can use workforce planning tools to bring about necessary changes when the Trust's organisational strategies (e.g. professional, financial) are aligned with patient safety.
  • When NHS managers have the necessary training, skills and support, workplace planning tools can empower managers by allowing them to make use of complex data to make safe staffing decisions.
  • NHS managers are most likely to be successful in their use of these tools when they have leadership skills (e.g. being a visible presence and having good communication skills) and good knowledge of their staff.
  • When the culture within the organisation is supportive (for example, helping managers thrive in complex roles) and values evaluation, NHS managers can work together using standardised data to achieve safe staffing outcomes. Managers are more likely to use tools and technology when they see them as fit for purpose, and when they have been involved in designing them.
  • Workforce planning tools can increase patients/families’ confidence in care when the NHS Trust is open and clear about staffing levels.

What does current guidance say on this issue?

NICE 2014 guidelines on safe staffing levels make recommendations about organisational strategy, principles for determining nurse staffing requirements (such as establishing the skill mix and shift allocation), ongoing monitoring and evaluation. The guidelines state “The nurse in charge on individual shifts should make the on-the-day assessments of nursing staff requirements, which could be facilitated by using a NICE-endorsed decision support toolkit.” NICE list several endorsed tools, such as The Safer Nursing Care Tool.

The Royal College of Nurses issued a 2018 report that outlines a set of principles for safe and effective staffing. These include workforce plans developed at national, regional and local levels to ensure the right skill mix is available in the right place at the right time.

What are the implications?

The research shows that various conditions influence the ability of managers to make effective use of workplace planning tools. Several messages emerge. Managers need to understand the organisational system within which they work, such as legislation and policy. 

Strong leadership, collaboration at different levels within and across organisation and a standardised approach seem essential.  It’s also vital that NHS managers have support and training to develop their skills in use of available tools for workplace planning.

Notably, the research highlighted a lack of information on whether staffing levels are communicated to patients and carers. This seems important given the high-profile reports linking quality and safety in staffing and was a priority of public stakeholders.

Citation and Funding

Burton CR, Rycroft-Malone J, Williams L et al. NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis. Health Serv Deliv Res. 2018;6(36).

The study was funded by the National Institute for Health Research as part of the Health Services and Delivery Research (HS&DR) programme.

Bibliography

NICE. Safe staffing for nursing in adult inpatient wards in acute hospitals. SG1. London: National Institute for Health and Care Excellence; 2014.

RCN. Staffing for safe and effective care: nursing on the brink. London: Royal College of Nursing; 2018.

Why was this study needed?

Safe staffing levels can have major impact not just on patients’ experience of care, but on clinical outcomes. A recent review of international studies found that important aspects of care are missed when there are fewer registered nurses available. NICE was asked to develop evidence-based guidelines on safe nurse staffing in the wake of a series of critical reports, including the 2013 Francis Report on Mid Staffordshire NHS Trust and Keogh review into quality of care at 14 hospital trusts.

NICE endorses various tools that are in line with guideline recommendations and have been developed to help managers plan for safe staffing. However, their use and usefulness may be affected by various factors, such as changing patient needs and staff availability. Studies are in progress to assess costs and outcomes from real-world application of such tools.

This study aimed to find out what helps NHS managers use these tools effectively.

What did this study do?

This realist review had several phases. It started with a literature review to develop theories around how workforce planning and deployment tools and technologies work in context and any barriers or facilitators to implementation. This theoretical understanding was developed in workshops involving NHS staff, patient and public representatives.

This was followed by 10 telephone interviews with NHS managers, including ward managers and team leaders in hospital and community settings. A further 11 interviews were conducted at a later phase to refine their theories.

The information was used to draw up seven principles, ‘context-mechanism-outcome’ conditions. These were agreed might help NHS managers use workforce planning tools effectively and enhance safe nurse staffing.

The research focuses on acute adult care.

What did it find?

The principles linking context, mechanism and outcome were:

  • When a staffing system can respond to real-time demands (such as flexibility of staff working patterns) this can uphold the organisation’s reputation and enhance recruitment, so creating a positive cycle where nurses can be matched to demand.
  • NHS managers can use workforce planning tools to bring about necessary changes when the Trust's organisational strategies (e.g. professional, financial) are aligned with patient safety.
  • When NHS managers have the necessary training, skills and support, workplace planning tools can empower managers by allowing them to make use of complex data to make safe staffing decisions.
  • NHS managers are most likely to be successful in their use of these tools when they have leadership skills (e.g. being a visible presence and having good communication skills) and good knowledge of their staff.
  • When the culture within the organisation is supportive (for example, helping managers thrive in complex roles) and values evaluation, NHS managers can work together using standardised data to achieve safe staffing outcomes. Managers are more likely to use tools and technology when they see them as fit for purpose, and when they have been involved in designing them.
  • Workforce planning tools can increase patients/families’ confidence in care when the NHS Trust is open and clear about staffing levels.

What does current guidance say on this issue?

NICE 2014 guidelines on safe staffing levels make recommendations about organisational strategy, principles for determining nurse staffing requirements (such as establishing the skill mix and shift allocation), ongoing monitoring and evaluation. The guidelines state “The nurse in charge on individual shifts should make the on-the-day assessments of nursing staff requirements, which could be facilitated by using a NICE-endorsed decision support toolkit.” NICE list several endorsed tools, such as The Safer Nursing Care Tool.

The Royal College of Nurses issued a 2018 report that outlines a set of principles for safe and effective staffing. These include workforce plans developed at national, regional and local levels to ensure the right skill mix is available in the right place at the right time.

What are the implications?

The research shows that various conditions influence the ability of managers to make effective use of workplace planning tools. Several messages emerge. Managers need to understand the organisational system within which they work, such as legislation and policy. 

Strong leadership, collaboration at different levels within and across organisation and a standardised approach seem essential.  It’s also vital that NHS managers have support and training to develop their skills in use of available tools for workplace planning.

Notably, the research highlighted a lack of information on whether staffing levels are communicated to patients and carers. This seems important given the high-profile reports linking quality and safety in staffing and was a priority of public stakeholders.

Citation and Funding

Burton CR, Rycroft-Malone J, Williams L et al. NHS managers’ use of nursing workforce planning and deployment technologies: a realist synthesis. Health Serv Deliv Res. 2018;6(36).

The study was funded by the National Institute for Health Research as part of the Health Services and Delivery Research (HS&DR) programme.

Bibliography

NICE. Safe staffing for nursing in adult inpatient wards in acute hospitals. SG1. London: National Institute for Health and Care Excellence; 2014.

RCN. Staffing for safe and effective care: nursing on the brink. London: Royal College of Nursing; 2018.

NHS managers' use of nursing workforce planning and deployment technologies: a realist synthesis

Published on 15 November 2018

Burton C R, Rycroft-Malone J, Williams L, Davies S, McBride A, Hall B, Rowlands A, Jones A, Fisher D, Jones M & Caulfield M.

Health Services and Delivery Research Volume 6 Issue 36 , 2018

Background Policy and reviews of health-care safety and quality emphasise the role of NHS managers in ensuring safe, good-quality patient care through effective staffing. Guidance requires that NHS managers combine professional judgement with evidence-based workforce planning and deployment tools and technologies (WPTs). Evidence has focused on the effectiveness of WPTs, but little is known about supporting their implementation, or the impact of using WPTs across settings. Objectives The review answered the following question: ‘NHS managers’ use of workforce planning and deployment technologies and their impacts on nursing staffing and patient care: what works, for whom, how and in what circumstances?’. Design A realist synthesis was conducted. A programme theory was formulated and expressed as hypotheses in the form of context, mechanisms and outcomes; this considered how, through using WPTs, particular conditions produced responses to generate outcomes. There were four phases: (1) development of a theoretical territory to understand nurse workforce planning and deployment complexity, resulting in an initial programme theory; (2) retrieval, review and synthesis of evidence, guided by the programme theory; (3) testing and refinement of the programme theory for practical application; and (4) actionable recommendations to support NHS managers in the implementation of WPTs for safe staffing. Participants NHS managers, patient and public representatives and policy experts informed the programme theory in phase 1, which was validated in interviews with 10 NHS managers. In phase 3, 11 NHS managers were interviewed to refine the programme theory. Results Workforce planning and deployment tools and technologies can be characterised functionally by their ability to summarise and aggregate staffing information, communicate about staffing, allocate staff and facilitate compliance with standards and quality assurance. NHS managers need to combine local knowledge and professional judgement with data from WPTs for effective staffing decisions. WPTs are used in a complex workforce system in which proximal factors (e.g. the workforce satisfaction with staffing) can influence distal factors (e.g. organisational reputation and potential staff recruitment). The system comprises multiple organisational strategies (e.g. professional and financial), which may (or may not) align around effective staffing. The positive impact of WPTs can include ensuring that staff are allocated effectively, promoting the patient safety agenda within an organisation, learning through comparison about ‘what works’ in effective staffing and having greater influence in staffing work. WPTs appear to have a positive impact when they visibly integrate data on needs and resources and when there is technical and leadership support. A collaborative process appears to be best for developing and implementing WPTs, so that they are fit for purpose. Limitations The evidence, predominantly from acute care, often lacked detail on how managers applied professional judgement to WPTs for staffing decisions. The evidence lacked specificity about how managers develop skills on communicating staffing decisions to patients and the public. Conclusions and recommendations The synthesis produced initial explanations of the use and impact of WPTs for decision-making and what works to support NHS managers to use these effectively. It is suggested that future research should further evaluate the programme theory. Funding The National Institute for Health Research Health Services and Delivery Research programme.

Expert commentary

The findings from this study are clearly valuable for better understanding how nurse and other NHS managers, and indeed managers in non-NHS settings, can be supported to make best use of workforce planning and deployment tools. Tools are seen alongside professional judgement and latest evidence on staffing and skill mix.

In the context of significant nursing vacancies, and a diminishing numbers of new workforce entrants, it is of particular interest to note the finding that tools are best used when aligned with organisation strategies. 

Their use and the data they generate can drive organisational change, and to promote patient safety.

Antonia Borneo, Head of Policy & Public Affairs (UK & International), Royal College of Nursing