Safe staffing guidance still elusive – three years on from Mid Staffs

Evidence reviews into safe nurse staffing that reveal gaps in available information have led to calls for urgent progress to be made on the issue.

The National Institute for Health and Care Excellence published four evidence reviews last month. It looked at safe nurse staffing in inpatient mental health services, adult services in the community and in accident and emergency. NICE also reviewed management and organisational approaches that support safe nurse and midwife staffing.

These reports had been intended to inform subsequent guidelines on safe nurse staffing, but NICE was told last summer by NHS England to suspend the work it had been doing on safe staffing.

Patient outcomes

A theme that runs through the reviews is the lack of reliable evidence about how staffing levels affect patient outcomes and the need for further research (see box).

Some of the gaps in the evidence

NICE’s evidence review on safe nurse staffing in inpatient mental health care included studies pointing to the effect of environmental factors.

These included ward configuration and single-gender units, when setting nurse establishments.

It found ten low-quality studies that described the associations between nurse staffing levels and outcomes including episodes of conflict, for example assaults or refusal of medication.

NICE concluded the 29 papers reviewed provided only moderate or low-quality evidence.

The authors of the evidence review on adult nursing care in the community said it was impossible to draw firm conclusions about the approaches that are effective for assessing and determining nursing staffing and/or skill mix.

The accident and emergency review identified a number of outcomes that appear to be associated with nurse staffing levels in emergency departments, although it included the caveat that most of the studies were only carried out at single sites.

Outcomes included patients leaving without being seen and patient satisfaction with nursing care.

It said there are a number of factors that have not been studied that might influence nurse staffing requirements in the emergency department, including unit layout, patient acuity, overcrowding and time of day and the day of week.

The gaps in the evidence for the management and organisational review present several areas for research, according to the authors, including how management systems may support safe staffing for nurses and midwives.

The community nursing review stated ‘it was not possible to draw firm conclusions about what approaches for assessing and determining nursing staffing and/or skill mix are effective’.

Picture credit: Daniel Mitchell

The paucity of information for the reviews begs the question ‘what happens now?’. It is three years since the care scandal at Mid Staffordshire NHS Foundation Trust made safe nurse staffing a politically as well as clinically sensitive issue.

NHS Improvement and England’s chief nurse Jane Cummings are now charged with drawing up guidance in the areas on which NICE was working.

The Safe Staffing Alliance has been leading the campaign for clarity on nurse to patient ratios since Sir Robert Francis’s 2013 Mid Staffs report.

Alliance chair Susan Osborne was glad the NICE reviews were finally published because they had initially been blocked. But she says there is still a lack of focus on safe staffing. She says: ‘The government keeps calling for more studies and more research, but this is a delaying tactic. Evidence of the dangers caused by severe nurse shortages should be plain for all to see. Someone needs to show some leadership.’

Fellow alliance member Jane Ball, principal research fellow at University of Southampton faculty of health sciences, says very little on safe staffing has been produced since the Francis report.

She agrees there are gaps in the evidence and is concerned that NHS Improvement and the chief nurse will carry on NICE’s work without sufficiently robust evidence.

She says: ‘The concern is that since NHS Improvement is conducting its safe staffing investigation as we speak, is it also struggling with the gaps in the evidence?’

Ms Ball worked with colleagues including Southampton research fellow Alejandra Saucedo on studies that helped inform NICE’s 2014 safe nurse staffing guideline for adult inpatient wards in acute hospitals.

Dr Saucedo says, in the past, patient and hospital data were not always readily available to researchers. She says methods for recording data and the IT systems used in the UK have varied too widely in the past but insists things have improved recently.

She adds: ‘We are now able to collect and analyse data in much more reliable ways.’

She says she hopes officials at NHS Improvement will be reading a University of Southampton study into emergency department nurse staffing.

‘Dangers of a staffing shortage are plain to see – someone needs to show leadership’

This was not published until after NICE’s work was suspended.

Dr Saucedo believes NHS Improvement will face the same lack of information as seen by NICE.

She says: ‘I say it because all the evidence needed isn’t there yet.

‘I know it is frustrating but nurses have got to be patient. I can assure them researchers are going as fast as we can.’

RCN head of policy Howard Catton, shares Ms Osborne’s sense of impatience. He points out there have been calls for safe staffing guidance for a decade and the time has come for analysts to accept existing research. He acknowledges much of the evidence NICE considered in its reviews comes from overseas.

However, he says: ‘The findings still show the impact of nurse ratios on aspects like patient outcomes, stress and human error, and mortality rates mirror very closely what happens in the UK.

‘I have seen policy adopted based on far thinner evidence. If you wait for “the perfect evidence” to come along, you will never issue guidance on anything. Nurses need this safe staffing guidance and eventually the political will to see it published has to be found.’

An NHS Improvement spokesperson confirms it intends to publish its safe staffing guidance later this year. He adds that this will include looking at care hours per patient, ‘so that staffing arrangements remain safe across a range of times and situations’.

‘We will be developing further safe staffing guidance for NHS commissioners and provider boards that will help them improve efficiency, and ensure that staffing decisions take account of the local context and interprofessional teams’.

Read the NICE guidance reviews here: (mental health) (community) (A&E) (management)

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