Evidence

The Committee considered the following commissioned reports.

Evidence review 1: Griffiths P, Ball J, Drennan J, Jones J, Reccio-Saucedo A, Simon M (2014) The association between patient safety outcomes and nurse/healthcare assistant skill mix and staffing levels and factors that may influence staffing requirements. University of Southampton.
Evidence review 2: Simon M, Ball J, Drennan J, Jones J, Reccio-Saucedo A, Griffiths P (2014) Effectiveness of management approaches and organisational factors on nurse sensitive outcomes. University of Southampton.
Economic analysis: Cookson G, McGovern A (2014) The cost effectiveness of nurse staffing and skill mix on nurse sensitive outcomes. University of Surrey.

The Committee also considered the following:

Expert paper 1: Expert testimony presented to the Safe Staffing Advisory Committee.
Expert paper 2: Patient testimony presented to the Safe Staffing Advisory Committee.
Expert paper 3: Report from the Safe Staffing Advisory Committee sub-group meeting 11 April 2014.
Report on field testing of the draft guideline

The evidence reviews, economic analysis and expert papers are available on the evidence reviews, economic analysis and expert papers are available on the NICE website.

Evidence review 1 focused on ward-level activities and considered the following review questions:

What patient safety outcomes are associated with nurse and healthcare assistant staffing levels and skill mix?
- Which outcomes should be used as indicators of safe staffing?
- What outcomes are associated with tasks undertaken by registered nurses, healthcare assistants and other staff?
Which patient factors affect nurse and healthcare assistant staffing requirements at different times during the day? These include:
- patient dependency and acuity assessment and grading
- patient turnover.
How does the ward environment, including physical layout and diversity of clinical disciplines, affect safe staffing requirements?

Evidence review 2 focused on ward-level managerial activities and organisational level factors and considered the following review questions:

What management approaches affect nurse and healthcare assistant staffing requirements?
- What nursing staff supervisory and/or team management approaches are required?
- What approaches for identifying required nurse staffing levels and skill mix are effective, and how frequently should they be used?
What organisational factors influence safe staffing at a ward level? These include:
- management structures and approaches
- organisational culture
- organisational policies and procedures, including staff training.

The economic analysis used the best available evidence and data from the UK to determine the relationship between nursing and skill mix and nursing sensitive outcomes. The cost effectiveness of altering staffing or skill mix was also assessed.

Expert paper 1 presented testimony from the topic specialist member on the experience of safe staffing in the New Zealand public health system.

Expert paper 2 presented testimony from the topic specialist lay member of the Committee.

Expert paper 3 presented a summary of a subgroup meeting of the Committee to explore the key patient factors and nursing needs that must be considered when calculating nursing care requirements, and aspects of nursing missed care that could be monitored as red flag nurse staffing indicators.

The Report on field testing of the draft guideline presented results of testing the use of the draft guideline with nursing staff.

Gaps in the evidence

The Safe Staffing Advisory Committee identified a number of gaps in the available evidence and expert comment related to the topics being considered. These are summarised below.

There is a lack of high-quality studies exploring and quantifying the relationship between registered nurse and healthcare assistant staffing levels and skill mix and any outcomes related to patient safety, nursing care, quality and satisfaction. All of the identified studies were observational and the majority were not for UK populations. Where evidence was available it tended to be associational with limitations due to confounding factors that affected the outcome.
There is a lack of appropriately designed interventional studies relating to the outcomes of interest with appropriate control for confounding variables, such as studies designed to identify the outcomes associated with increasing numbers of available nursing staff. The outcomes identified generally report on failures of care rather than the more positive aspects of quality of care. There is also a lack of research on measures of missed care that could be routinely monitored and therefore easily collected and investigated.
There is a lack of evidence from UK data that allows the effects of actual nursing staff that are present (as opposed to variations in nursing staff) to be readily determined.
There is a lack of good quality research on the:
- effect of different patient factors and patients' nursing care needs on the nursing staff requirement
- indicators that are most sensitive to numbers of available registered nurses
- impact of healthcare assistants (and the different levels of healthcare assistants) on the outcomes of interest
- effect of ward layout and ward size on nursing staff requirements
- relationship between time of day and patient-related outcomes
- impact of ward-level team leadership and management (including supervisory roles and models of organising nursing care) on nursing staff requirements
- influence of training approaches set at an organisational level.
There is a lack of research that assesses the effectiveness of using defined approaches or toolkits to determine nursing staff requirements and skill mix. Only 1 study, which assessed 1 particular approach, was identified and this did not assess the frequency of its use. No evidence relating to other approaches was found.
There is limited evidence about the effectiveness of management structures and organisational culture. There is some evidence from studies assessing the American Nurses Credentialing Center Magnet Programme, and the transferability of the principles and practices in this programme warrants further exploration.
No evidence was found relating to organisational policies and procedures and nursing staff or nursing-sensitive outcomes in acute adult wards. Studies evaluating 'lean'-type approaches, such as the 'productive ward' and the elimination of non-productive care activities in order to help release more time for nursing care, were also not identified.
There is a lack of economic studies exploring ward nursing staff establishments, requirements and skill mix. Any evidence identified is derived from countries with very different contexts and cost bases to the UK and therefore is of limited relevance to NHS decision-making.
No economic evidence relating to ward environment, patient factors and their effect on nursing staff requirements was identified. No economic evidence was found that explored the relationship between ward-based management approaches (including the use of toolkits) and organisational factors and nursing staff requirements.
There is a lack of data collection in relation to the wide variety of outcome variables at a ward level that would allow a detailed economic analysis of patient outcomes in relation to ward nursing staff establishments or requirements in the NHS. Patient level costing data were also limited, which hampered a clearer understanding of the cost implications of nursing staff changes and skill mix.