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Lyn McIntyre MBE, UK Director of Healthcare, writes:

Clinical teams and leaders continue to strive towards the ultimate safe staffing goal – to achieve the right number of staff and mix of skills to meet the patient demand and care needs.

But across the world, the reality is that we’re living with the ongoing challenge of health and social care recruitment and retention. At present, we stand at a global shortage of more than seven million health workers, and the World Health Organisation estimates that this number could rise to nearly 13 million by 2035.

This doesn’t remove the need to do all we can to staff safely; in fact, it makes it more important than ever. So what can nurse leaders do to help achieve and maintain the right balance?

Here are my top 5 considerations for improving safe staffing levels.

Keep to a 6-week roster approval

Firstly, all approved rosters must be safe, efficient, and fair. Additionally, they should be approved in sufficient time to prevent negative impacts on safety, wellbeing and efficiency.

Work with organisations at both a national level in England as part of the Lord Carter reviews and with Allocate Improvement Collaboratives has found that those clinical areas who do not approve rosters at least 4 weeks in advance have a 50% greater chance of needing agency staff.

Further feedback provided by the staff has highlighted that when it gets busy clinically, especially recently when managing pandemic workloads, 6-week approvals can be one of the lost practices. However, it is recognised that being late in approving rosters can also cause more pressure on staff due to teams not knowing what and when they are working, and on senior staff from not knowing if bank shifts will get filled, often leading to red flags on staffing levels.

Over the years, I’ve witnessed several good practices that may help you keep to this timeframe. This includes roster approvals forming part of ‘Check and Challenge’ meetings, clinical teams using rostering approval checklists and the use of team-based rostering to significantly reduce time to develop the roster, increase approval timescales and increase staff satisfaction.

Understanding and reporting care or nursing hours per patient per day (N/CHPPD)

In 2016 in England, the Lord Carter report (2016) identified that one of the obstacles to eliminating unwarranted variation in the deployment of nursing and healthcare support workers was the absence of a single means of recording and reporting how staff are deployed.

Care hours per patient day (CHPPD) is the total number of hours worked on the roster (clinical staff), divided by the bed state captured at 23.59 each day. For reporting, this is aggregated into a monthly position. CHPPD is now the principal measure of nursing, midwifery and health care support worker deployment across all sectors in England.

However, CHPPD and nurse hours per patient day (NHPPD – internationally recognised resourcing metric) alone does not acknowledge the complexity of the care provided. It should, therefore, be considered alongside other measures of quality and safety.

In England, nurse to patient ratios stand at 1:8, whilst in Wales, the current number of patients to nurse ratio should not exceed 1:7 by day and 1:11 at night. Comparing how international safe staffing metrics can differ, across Australia, the ratio is 1:4. In Germany, nurses need to care for more patients than in other countries, with the ratio standing at 1:13.

Despite such measures, the limitations of CHPPD and NHPPD, along with other safety metrics such as ratios, is that alone it doesn’t consider wider factors including acuity or geography of wards. Therefore, professional judgment and the environment must be taken into account to ensure there’s the correct number of staff to match patient care needs.

As a final point, workforce technology can help calculate the metrics for N/CHPPD and provide additional sources of data for a wider view on whether the care is safe, effective and responsive – therefore helping with the much needed professional judgment.

Leadership and reporting KPIs from ward to board – done in silo it won’t work

It is important to have strong and effective governance in place so that everyone from ward to board can be assured that their workforce decisions will promote patient safety, enabling compliance with the ‘triangulated approach’ to deciding staffing requirements.

This approach combines evidence-based tools, professional judgment and outcomes to ensure that the right staff with the right skills are in the right place at the right time. It is based on patients’ needs, acuity and dependency plus risks, and trusts should monitor it from ward to Board.

Boards review workforce metrics, quality and outcome indicators, and productivity measures monthly – as a whole and not in isolation from each other. They also check that there is evidence of continuous improvements across all areas. This is recognised in England by the ‘Levels of Attainment and Meaningful Use Standards’, where it is an essential requirement for Level 2.

Regular assessments or re-setting of the nursing establishment

To understand the organisation establishment and starting place, organisations must undertake a regular (at least twice yearly) assessment or re-setting of the nursing establishment and skill mix by ward or service (based on acuity and dependency data and using an evidence-based toolkit where available) linked to professional judgement and patient outcomes.

Deploying/re-deploying staff effectively highlights the importance of reviewing workforce metrics, quality and outcome indicators and productivity measures monthly. Needing such insights emphasises the importance of using e-rostering systems to support efficient and effective staff deployment using acuity and dependency tools.

Workforce planning through e-rostering

Effective workforce planning is crucial to ensuring appropriate staff levels and skills are available to deliver safe and high-quality care to patients.

Workforce planning should include patient acuity and dependency using an evidence-based tool; patient activity levels; seasonal variation in demand; planned service developments or changes; staff supply; vacancies; where temporary staff have been required above the set planned establishment; patient and staff outcome measures and staff experience.

E-rostering systems provide evidence-to-detail workforce utilisation, including leave trends and types of staff utilised (bank, agency, substantive), providing valuable evidence that can be used to plan workforce needs in the future. It also highlights areas of skill-mix deficit and supports new roles, particularly as we move into integrated care systems within the UK.

Longer-term, accurate plans will help predict the numbers of healthcare workers required to meet future demand and supply.

How do you manage and report your safe staffing?

Safe care standards and policies can differ across countries. If you would like to discuss how you can improve safe staffing practices in your area, please contact [email protected].

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