Development of a Safe Staffing App

The aim of the project was to develop a transparent assurance mechanism to monitor nurse staffing levels from ward to board.  The Trust wanted to engage ward nurses with the new development to ensure that any new tool was user friendly, highlighted the necessary areas of concern, provided a platform for professional judgement to be utilised and incorporated an escalation process.

Nottingham University Hospitals NHS Trust (NUH) is the fourth largest acute trust in England and provides services to more than 2.5 million residents of Nottingham and its surrounding communities. The trust also provides specialist services to between 3 and 4 million people from neighbouring communities. The Trust is based in the centre of Nottingham across three sites; Queen’s Medical Centre (QMC), Nottingham City Hospital and Ropewalk House. NUH has 87 inpatient wards across both QMC and City campuses. The trust has 14,500 staff of which circa 4400 are RN’s and 1800 are HCA’s.

The ability to provide safe nurse staffing levels has been an ongoing priority at NUH but not having visibility of an accurate live staffing position was a risk and challenge we were keen to overcome.  Historically senior teams relied on manual collation of nurse staffing levels at key points in the day. This data was not visible to the whole trust and failed to provide information and signal where resource or support might be available from elsewhere across the organisation. NUH had historically collated nurse staffing data via a manual system on each inpatient site which was circulated to a number of staff twice a day. This was felt to be inadequate for a number of reasons including:

• The data was not visible from ward to board
• There was not an easy method to view the staffing position in between the times this data was circulated
• Effective deployment of staffing resource  to provide support to areas that required it was difficult

The Deputy Chief Nurse met with the Senior Nurse Lead in ICT to discuss the potential of a live nurse staffing monitoring system and discussed some key requirements of the new system:

• The system had to be easy and quick to complete
• A number of risks areas needed to have automatic alerts (skill mix, % temporary staffing etc)
• The system  needed to allow the professional judgement of the nurse in charge of the shift, in relation to determining safe staffing levels, to be captured
• Red flag process needed to be incorporated into the system
• Nurse staffing levels needed to be visible form ward to board

The project was a joint initiative between nursing and ICT that commenced in June 2015. Once the ICT were aware of the requirements of the new system they designed a staffing app that incorporated the elements requested. It was important that the staffing app captured relevant best practice guidance advised within the NICE guidance:

• planned staffing levels determined via the bi-yearly establishment review which used multiple benchmarks including SG1 guidance. The latest review saw investment to HCA numbers to facilitate cohorting needs across the Trust
• process to capture Red Flag incidents as recommended in NICE guidance SC1 (section 1.4)
• professional judgement of the nurse in charge as to whether they assessed staffing levels as adequate to deliver care to the high standards they strived to achieve
• capture of reasons why staffing was not deemed as adequate as this allowed a mechanism to capture the cause and response to variations in nurse staffing requirements

The app was designed to function on either a tablet or IPAD rather than the hand held devices the staff had access to as the user experience of the app was much better. Regular meetings between the Deputy Chief Nurse and the ICT nursing lead allowed changes to the app to be made until we were happy we had a version ready to be tested by ward teams. At this point a number of stroke wards offered to test the app and they in turn offered helpful suggestions to improve the new app design. By August 2015 we had version 1 of the staffing app that was ready to roll out across the inpatient wards. Prior to rollout the planned staffing for every ward had to be locked into the system and a standard operating procedure was developed and circulated.

A roll out programme was devised and training sessions were made available for staff at ward level. Communication with nursing teams was key pre and during the roll out as the app posed a significant change to how nurse staffing data was captured and put responsibility at ward level for providing the data. A variety of methods was used to achieve this including face to face meetings. Another challenge was ensuring that wards received an appropriate and timely response if staffing shortfalls were highlighted. A workshop was held with different grades of nursing staff to find out if the app was achieving this response. The workshop highlighted that responses had varied at times although in the main staff felt supported.

During the rollout period the ICT developed the reporting element of the app and made this available on the Trust intranet so that all related reports were able to be seen from ward to board. The reports were designed to be user friendly for those staff that would use them and so are available at ward, directorate, division, site and trust level.

The staffing app was developed ‘in house’ by the NUH ICT team. The cost of the development was circa £9k if all developer time and support time was taken into account. The project was supported at Board level and therefore no bidding process for funds was required.

At handover the nurse in charge inputs actual staffing numbers and relevant information into the ward mobile device. The app reports fill rate skill mix and would immediately flag any issues such as high numbers of bank or agency staff or skill mix. Professional judgement is applied as the nurse in charge assesses and inputs whether the ward or department is safely staffed.

Any staffing changes during the shift are updated to maintain a live accurate position.  The app generates a report that can be viewed at Trust, site, divisional, directorate and ward level, allowing rapid response and action to be taken to remedy the situation. The app is supported by a training package, a standard operating procedure and a red flag escalation process which guide staff to take appropriate action.

The staffing app completion was monitored daily to ensure the process was embedded across the Trust and this is still being embedded in some areas especially for weekend shifts.

The Trust now has a live staffing position available from ward to board. The wards are able to add commentary to support the professional judgement made in relation to determining if  ward staffing felt to be safe or not. The project team found that staff, especially less experienced shift leaders, sometimes found it difficult to assess what safe staffing was with a heavy reliance on whether planned staffing numbers were achieved. The project team and senior nurses found that discussing the rationale for any areas deemed not to have safe staffing levels allowed nurses to share experience and assess staffing requirements against the current patient dependency rather than rely on planned staffing numbers alone. The project team felt this was a crucial learning opportunity as shift leaders needed to recognise both when they may not require planned staffing numbers but also when planned staffing levels were achieved but did not match the acuity/dependency of the current caseload of patients.

Red flag completion was monitored by the Red Flag project group and compared to the staffing app information. There was an increase in red flag completion following the roll out of the app and this was not surprising as the app specifically informs the nurse in charge to complete a red flag if they report ward staffing  as not safe.

The site management team were spending at least 2 hours/site/day collating the staffing data manually and this time was released to focus on hospital flow and effective deployment of staff when needed,

Information relating to red flag data and wards that declare they do not feel staffing levels are adequate are reported monthly to Board members, by the Chief Nurse, at the Quality Assurance Committee meetings.

Summary of benefits:

• The staffing app provides live, real time planned and actual staffing levels in relation to staffing numbers, skill mix, bank and agency percentage of staff on duty
• The nurse staffing position is visible to all staff within the Trust from ward to board
• The staffing app information ensures that everyone is aware whether or not the organisation has the right number and skill mix of staff on duty for the patients being cared for.
• Allows staff to be focused where the patient need is greatest supporting the delivery of safe care. Areas have seen significant reduction in spend ; an example of this is the Stroke Directorate which has seen a £60k reduction in spend since Sept ember 2015 and a reduction in the cost/hr of temporary staffing costs
• Captures in real time the professional judgement of the nurses responsible for giving care
• Allows staff to raise concerns  - using red flags if they have staffing concerns
• Internal staff deployment is the first response,  rather than  resorting to  booking bank or agency staff, which has the potential to reduce temporary staffing expenditure
• Potential patient harm is closely monitored and the Trust continues to make good progress in reducing harm incidences. We have seen a 25% reduction in falls incidences and a 16% reduction in the number of medication incidents

• Work collaboratively engage widely to ensure the design will be fit for purpose
• Test the idea, work in phases before rolling out widely
• Recognise that there will be  variation in how nurses assess safe staffing  levels , due to complexity and nature of different clinical specialties and environments
• Develop an education and training package to support the introduction of the tool