The Trust has introduced a planned programme of detailed adult in-patient ward level staffing reviews in accordance with NICE guidance SG1. The reviews engage the professional judgement of the Ward Manager, Financial Accountant, Operational Manager, Matron and the Executive Director of Nursing. An evidence based tool is used to inform the review but the focus is on local ward level engagement of the ward teams; achievements, current challenges and concerns and the quality of care delivered through monitoring nurse sensitive indicators linked with staffing levels. The programme also includes training for all Ward Managers, Ward Sisters, Charge Nurses and Matrons participating in the staffing reviews.
Aims and objectives
The aim was to establish a programme across the Trust for adult in-patient ward staffing reviews based around the requirements outlined in NICE guidance SG1. The programme would incorporate training with the aim to raise awareness, understanding and knowledge for senior nurses on the national staffing requirements.
The difference in our approach to a general staffing review was; incorporating training on national staffing literature; ward level engagement and using the review to provide a detailed report for each ward in the programme covering staffing levels, staffing recommendations, quality metrics, achievements, current challenges, ward activity and finance. No evidence based workforce tool can cover all factors and therefore triangulation with identified nurse sensitive indicators (NSI’s) and ward activity were imperative in our objectives for making recommendations for optimal staffing levels. Variables in terms of geographical layout of the ward, patient visibility and the number of side rooms do have an impact on the number of nurses required to staff a ward but this is not reflected in an evidenced based workforce tool and was a clear objective to be considered at ward level.
Professional judgement and local intelligence was included and applied to increase confidence in the process for recommendation of staffing levels and to provide further assurance to the Trust Board.
Reasons for implementing your project
Prior to the project, no detailed staffing reviews were established across the whole organisation which combined professional judgement and an evidence based dependency tool. Local reviews had been undertaken but not using an evidence based tool nor with the engagement of the ward sister/charge nurse. The plan was agreed and supported by the Trust Board in line with NICE guidance (Safer Staffing NICE guidance, SG1).
Forty wards were included in the reviews across our ten hospital sites over a large geographical area. The reviews were done in stages and the first review in all wards provided the baseline assessment. Patients were not directly involved in the review programme but our stakeholders through our Governors were informed of the programme. Our staff side representatives were informed of the programme and of the stage one outcomes. The benefits from putting the NICE guidance into practice were reported from; individual staff, ward teams, finance, Operational Managers and Trust Board Directors.
From a ward teams’ perspective the benefits related to recognition of work the ward teams undertook daily, quality of care and the openness and opportunity to discuss current challenges. Having individual ward quality metrics, with financial and ward activity data supported detailed triangulation. The information in the individual ward reports provided detailed information for clinical, non-clinical staff and the Board of Directors and supported triangulation of quality metrics, ward activity, professional judgement and staffing levels.
How did you implement the project
The NICE guidance and nurse staffing literature were all considered, and discussion with the senior team of the outcomes to be achieved was agreed. The proposals were discussed with the Executive Management Team and Trust Board. A three stage approach was used and a scoping exercise for how the data would be collected, collated and evaluated was planned. The training needs were identified and all staff involved attended training prior to commencing the ward staffing reviews. The main problem encountered was with the data collection and data submission from wards to the Trust’s Information Department.
Due to timescales and IT available we had to use a paper based system. We needed staff to be fully engaged in the process and with increasing demands on ward nurses’ time, we wanted to keep this to a minimum. The Ward Managers along with two identified senior ward staff (Ward Sister, Charge Nurse or Staff Nurse) undertook the daily acuity data collection and provided their ward descriptions. The Trust’s Information Team collated the results and provided the acuity, quality metrics and ward activity data. The Business Unit Financial Accountants provided information on the wards WTE current and actual budgets and costing’s for the recommendations following the ward review meetings.
The Matrons and Chief Matrons completed the daily quality control process and reviewed the patients and level of care descriptors data. The Associate Nurse Director evaluated the data and prepared the final report. The Executive Director of Nursing chaired the individual ward meetings with the Ward Manager, Chief Matron, Matron, Business Unit Accountant, Operational Service Managers and General Manager. The meeting format entailed reviewing each wards SNCT data, staffing levels, quality metrics, ward activity, good practice and current challenges. We addressed the problem of a paper based system by having all paperwork readily available for staff. All master copies of the data collection forms were retained on the ward and the data was then sent to the Trust’s Information Team.
We did not discontinue any services however as part of the options identified bed numbers were reduced in one clinical area and the outcome monitored with improved occupancy levels and decreased length of stay. The project had no identified budget and additional costs incurred were less than £500.
From a ward teams’ perspective the benefits related to recognition of the work the ward teams undertook daily, the quality of care and the openness and opportunity to discuss current challenges. We had ward level data and were able to demonstrate the staffing requirements and patient dependency.
Areas of excellent delivery of quality care were identified that had been maintained for over 18 months in some wards and the recognition of this was appreciated by the team. Areas were also identified where the quality metrics required further review and immediate action and support was required. Having individual ward quality metrics, with financial and ward activity data supported detailed triangulation.
Progress was monitored through daily reporting, quality control measures and weekly overview reports. The outcomes were measured on outstanding vacancies, professional judgement and quality metrics. The results met expectations and identified areas where additional resources were required. The response from staff involved was very positive.
Key learning points
• Set clear expectations and timescales for all staff.
• Identify the key staff involved and ensure they complete the training.
• Provide additional support and training during the data collection phase.
• Have an agreed quality control process for the data collection and ensure this is followed.
• Allow appropriate time for the final staffing recommendation meetings and ensure that key staff attend. If they cannot attend then do not go ahead despite tight timescales.
• Try to hold the review meetings on the ward or hospital site as this was appreciated by the ward manager and allowed other non-clinical members of staff the opportunity to see the ward’s layout and location.
• Have clear lines of communication planned from ward to board and board to ward.
• Do not underestimate the detail required and time for the individual ward reports. The reports were beneficial to both the ward team, Board of Directors and Business Units.
• Timely feedback to the ward team of all data is essential.
• The individual meetings provided the opportunity to identify achievements of the ward and current challenges.
• Hold a pre-meet prior to the wards review meeting. This was undertaken with the lead nurse for the programme and ensured that the ward manager was fully prepared. Use this opportunity to check all ward data as we picked up some discrepancies which could then be addressed prior to review meetings. The pre-meetings were also a good development opportunity for ward managers and matrons.
• Do not underestimate the power of data and how this can engage staff.
• Identify other sources of support to provide the data.
• Avoid too many staff involved in the process so continuity can be maintained.
• Ensure reminders and prompts are provided so no data is missing.