9 Safe nursing indicators

Safe nursing indicator: Adequacy of meeting patients' nursing care needs

Data collection

Local collection could use the following National Inpatient Survey questions developed by the Picker Institute which contains a number of questions where patients' experience of care could be affected by the number of available nursing staff:

Patients' experience of nursing care on hospital inpatient wards

Q.23 Did you get enough help from staff to eat your meals?

Q.30 In your opinion, were there enough nurses on duty to care for you in hospital?

Q.40 How many minutes after you used the call button did it usually take before you got the help you needed?

Patients' experience of nursing care on hospital inpatient wards

Q.39 Do you think the hospital staff did everything they could to help control your pain?

Patients' experience of communication with nursing staff on hospital inpatient wards

Q.27 When you had important questions to ask a nurse, did you get answers that you could understand?

Q.34 Did you find someone on the hospital staff to talk to about your worries and fears?

Q.35 Do you feel you got enough emotional support from hospital staff during your stay?

Local collection of patient experience could use these questions to provide a more frequent view of performance than possible through annual surveys alone, but please note NHS Surveys' request that local patient surveys are mindful of avoiding overlap with national patient surveys.

Outcome measures

Responsiveness to inpatients' personal needs.

Data analysis and interpretation

The annual national survey results for your hospital can be compared with previous results from the same hospital and with data from other hospitals (but be aware that comparison between hospitals is subject to variation in expectations of care between different populations). Data from more frequent local data collection, where available, can be compared with previous results from the same ward and with data from other wards in your hospital.

Safe nursing indicator: falls

People falling whilst admitted to hospital

Definition

A fall is defined as an unplanned or unintentional descent to the floor, with or without injury, regardless of cause (slip, trip, fall from a bed or chair, whether assisted or unassisted). Patients 'found on the floor' should be assumed as having fallen, unless confirmed as an intentional act.

Record any fall that a patient has experienced. The severity of the fall could be further defined in accordance with National Reporting and Learning System categories: no harm; low harm; moderate harm; severe harm; death:

  • No harm – fall occurred but with no harm to the patient.

  • Low harm – patient required first aid, minor treatment, extra observation or medication.

  • Moderate harm – likely to require outpatient treatment, admission to hospital, surgery or a longer stay in hospital.

  • Severe harm – permanent harm, such as brain damage or disability, was likely to result.

  • Death – where death was the direct result of the fall.

Data collection

Proportion of people admitted to a ward who fall while in hospital.

Numerator: the number of reported falls for the ward.

Denominator: the number of occupied bed days for the ward.

Data source : Local incident reporting systems.

Outcome measures

Reported falls per 1,000 occupied bed days.

Data analysis and interpretation

Rates of falls should be compared with previous results from the same ward with caution, as not all falls will be recognised and reported, and because frequency at ward level may be too small for significant increases or decreases in these to be apparent. Rates of falls should not be compared with data from other wards or hospitals, because of differences in patient case mix and clinical specialties of the wards. Incident reporting systems may be affected by under-reporting. Periodic local collection of data on whether falls are going unreported will identify if changes in reported falls rates are true changes in actual falls rates or are affected by changes in completeness of reporting.

Although falls may be sensitive to the number of available nursing staff, falls prevention requires a multidisciplinary approach, and falls rates will also be affected by:

  • availability of physiotherapy, occupational therapy, pharmacy and medical staff

  • knowledge and skills of all healthcare professionals and support staff

  • safety of the environment, furniture and fittings

  • access to mobility aids and falls prevention equipment.

Safe nursing indicator: pressure ulcers

People acquiring pressure ulcers while in hospital

Definition

A pressure ulcer is a localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Record any pressure ulcer developed or worsened 72 hours or more after admission to an organisation. The patient's worst pressure ulcer could be categorised as 2, 3 or 4 according to the European Pressure Ulcer Scale (Defloor T et al. Statement of the European Pressure Ulcer Advisory Panel - pressure ulcer classification. J Wound Ostomy Continence Nurs 2005;32:302-6).

Data collection

Proportion of people admitted to a ward who develop a pressure ulcer (or have an existing pressure ulcer that worsens) while in hospital.

Numerator: the number of reported new or worsened pressure ulcers for the ward.

Denominator: the number of occupied bed days for the ward.

Data source : Local incident reporting systems.

Data on the number of patients in hospital with a pressure ulcer greater than category 2 (irrespective of location of origin) will also be collected for the NHS Outcomes Framework 2014/15 indicator 5.3: Proportion of patients with category 2, 3 and 4 pressure ulcers.

Outcome measures

Reported hospital-acquired pressure ulcers per 1,000 bed days.

Data analysis and interpretation

Rates of pressure ulcers should be compared with previous results from the same ward with caution, as not all pressure ulcers will be recognised and reported (distinguishing pressure ulcers from other skin lesions and grading them correctly is not always straightforward). In addition the frequency of pressure ulcers at ward level may be too small for significant increases or decreases to be apparent. Rates of pressure ulcers should not be compared with data from other wards or hospitals, because of differences in patient case mix and clinical specialties of the wards. Incident reporting systems may be affected by under-reporting. Periodic local data collection by specialist nurses/matrons visiting wards to carry out skin inspections can be used to cross-check with incident reports and Safety Thermometer data to assess if pressure ulcers are being correctly identified, graded and reported.

Although pressure ulcers may be sensitive to the number of available nursing staff, pressure ulcers prevention requires a multidisciplinary approach, and pressure ulcers rates will also be affected by:

  • access to pressure ulcer prevention equipment and mobility aids

  • availability of physiotherapy, occupational therapy, pharmacy and medical staff

  • knowledge and skills of all healthcare professionals and support staff. 

Safe nursing indicator: medication administration errors

People receiving the wrong medications whilst in hospital

Definition

A medication administration error is any error in the administration, omission or preparation of medication by nursing staff. This could include deviation from prescriptions, manufacturer medication information instructions or recommended local pharmacy procedures. The severity of the medication error should be recorded,

Data collection

Proportion of people admitted to hospital who experience a medication error while in hospital.

Numerator: the number of reported medication errors for the ward.

Denominator: the number of occupied bed days for the ward.

Data source : local incident reporting systems.

Outcome measures

Reported medication errors per 1,000 bed days.

Data analysis and interpretation

Rates of medication errors should be compared with previous results from the same ward with caution, as not all medication errors will be recognised and reported. In addition the frequency of medication errors at ward level may be too small for significant increases or decreases to be apparent. Reported medication administration errors should not be used as an indication of actual harm from medication error as wards with the most knowledgeable and vigilant nursing staff may be more likely to detect and report medication errors. Incident reporting systems may be affected by under-reporting. Periodic local collection of data on whether medication errors are going unreported will identify if changes in reported medication error rates are true changes in actual medication error rates or are affected by changes in completeness of reporting.

Although medication errors may be sensitive to the number of available nursing staff, medication errors prevention requires a multidisciplinary approach, and medication error rates will also be affected by:

  • knowledge and skills of all healthcare professionals and support staff

  • involvement of pharmacy and medical staff.

Safe nursing indicator: missed breaks

Nursing staff unable to take scheduled breaks

Definition

A missed break occurs when a nurse is unable to take any scheduled break due to lack of time.

Data collection

Proportion of expected breaks for registered nurses and healthcare assistants working on inpatient hospital wards that were unable to be taken.

Numerator: the number of breaks in the denominator that were unable to be taken.

Denominator: the number of expected breaks for registered nurses and healthcare assistants on inpatient hospital wards.

Data source : Local data collection.

Outcome measures

Proportion of missed breaks due to lack of time amongst nursing staff.

Safe nursing indicator: nursing overtime

Nursing staff working extra hours

Definition

Nursing overtime includes any extra hours (both paid and unpaid) that a nurse is required to work beyond their contracted hours at either end of their shift.

Data collection

a) Proportion of registered nurses and healthcare assistants on inpatient hospital wards working overtime.

Numerator: the number of registered nurses and healthcare assistants in the denominator working overtime.

Denominator: the number of registered nurses and healthcare assistants on inpatient hospital wards.

b) Proportion of nursing hours worked on hospital inpatient wards that are overtime.

Numerator: the number of nursing hours in the denominator that are overtime.

Denominator: the number of nursing hours worked on hospital inpatient wards.

Data source : Local data collection. Data are also collected nationally on the number of staff working extra hours (paid and unpaid) in the NHS National Staff Survey by the Picker Institute.

Outcome measures

Staff experience.

Safe nursing indicator: planned, required and available nurses for each shift

The number of planned, required and available nursing hours on hospital inpatient wards in relation to bed utilisation

Definition

The number of nursing hours which were planned in advance, deemed to be required during that shift and that were actually available and bed utilisation during this period.

Bed utilisation is defined as the number of patients that the ward nursing team is responsible for during each 24-hour period. This includes patients who are discharged or transferred to another ward during the 24-hour period.

Data collection

a) Proportion of total nursing hours for each shift that were planned in advance and that were actually available

Numerator: the number of nursing hours for each shift that were actually available and the actual bed utilisation.

Denominator: the number of nursing hours for each shift that were planned in advance and the expected bed utilisation.

b) Proportion of total nursing hours for each shift that were deemed to be required on-the-day and that were actually available

Numerator: the number of nursing hours for each shift that were actually available and the actual bed utilisation.

Denominator: the number of nursing hours for each shift that were deemed to be required on-the-day (calculated by following the recommendations of this guideline) and the actual bed utilisation.

Data source : local data collection, which could include data collected for the NHS England and the Care Quality Commission joint guidance to Trusts on the delivery of the 'Hard Truths' commitments on publishing staffing data regarding nursing, midwifery and care staff levels and more detailed data collection advice since provided by NHS England.

Outcome measures

Deviation between planned and available nursing staff; deviation between required and available nursing staff in relation to bed utilisation.

Safe nursing indicator: high levels and/or ongoing reliance on temporary nursing

Temporary nursing staff on hospital inpatient wards

Definition

Registered nurses and healthcare assistants who are working on adult inpatient wards who are not contracted with the hospital.

Data collection

a) Proportion of registered nurses and healthcare assistants working on adult inpatient wards who are on bank contracts.

Numerator: the number of registered nurse and healthcare assistant shifts in the denominator who are employed on bank contracts.

Denominator: the number of registered nurse and healthcare assistant shifts per calendar month to work on adult inpatient wards.

Data source : local data collection.

b) Proportion of registered nurses and healthcare assistants working on adult inpatient wards who are on agency contracts.

Numerator: the number of registered nurse and healthcare assistant shifts in the denominator who are employed on agency contracts.

Denominator: the number of registered nurse and healthcare assistant shifts per calendar month to work on adult inpatient wards.

Data source : local data collection.

Outcome measures

Expenditure (£) on bank and agency staff per inpatient bed.  

Safe nursing indicator: compliance with any mandatory training

Compliance of ward nursing staff with any mandatory training in accordance with local policy

Definition

Nurses who are working on adult inpatient wards who are compliant with the mandatory training that has been agreed in line with local policy.

Data collection

Proportion of registered nurses and healthcare assistants working on inpatient hospital wards who are compliant with all mandatory training.

Numerator: the number of registered nurses and healthcare assistants in the ward nursing staff establishment who are compliant with all mandatory training.

Denominator: the number of registered nurses and healthcare assistants in the ward nursing staff establishment.

Data source : local data collection.

Outcome measures

% compliance with all mandatory training.