Hospital staffing and patient safety

 In response to the Francis Inquiry, the government commissioned the National Institute for Health and Care Excellence (NICE), to develop guidelines on safe staffing levels on hospital wards. As the UK’s leading researcher in this area, Professor Peter Griffiths, Chair of Health Services Research at Southampton, presented a review of the evidence which informed these NICE guidelines.

Why is it important to have NICE guidelines on safe staffing levels on hospital wards?

In the past, it seemed that some hospitals looked at nursing as the icing on the cake of patient care, and acted as if nothing detrimental would happen if it was reduced. Clearly, following the Francis Inquiry, there has been a lot of attention focused on the nursing profession and it has been recognised that this is not true. Although it seems as though we have learned a lesson from mid-Staffordshire that we will never forget, it’s inevitable that without some tangible guidelines in place, changes will not last. Having NICE guidelines on safe staffing levels will shape the way that we move on from the Francis Report. It will put forward evidence from a significant research base, delivered by a very influential body that cannot be ignored in the way that it has been in the past. This puts nurse staffing levels on the agenda in a way that is more permanent – it’s a very important piece of work which has been a long time coming. Southampton is an excellent place to continue to develop this area because of its recognised eminence in health sciences, nursing in particular, and the opportunities it presents to develop interdisciplinary collaborations.

What does optimised care on hospital wards look like to you?

It’s a very good question. Optimal care is often defined by the absence of a number of bad things. We go into hospital because we are sick or need treatment and go from a situation where we are in charge of our daily lives, to one where we are vulnerable and forced to place a lot of power into other people’s hands.

To expect that nursing care can protect people from harm at the most basic level is not unreasonable. It should protect you from being harmed by the treatment you are undergoing, as well as the things that are consequential to your illness, such as pressure sores. Avoiding those negatives is a very positive contribution.

How have you compiled this review of the evidence?

One of the key datasets we looked at was death rates on hospital wards. This is due to the self-evident importance of these figures, but also, because it’s one of the clear things you can find in the statistics; it’s quantitative data that there is no ambiguity about. Many of the other things we are interested in, such as the development of pressure ulcers and the overall patient experience don’t have valid and reliable data so readily available. However, the problem with using death rates is that what it tells us about the quality of care the patient received is really very indirect. The main thing that actually determines whether you live or die is why you were in hospital in the first place, not the quality of the care you receive. Similarly, we have to consider the other things that were wrong with the patient aside from what they were being treated for, like their age and socio-economic background.

The effect of anything the healthcare system does to people is quite easy to lose in among that, which is a challenge we have to tackle.

How is your work linked to the National Institute for Health Research’s (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) within the Wessex region?

A key focus of this important collaborative group is fundamental care in hospital, which I lead on, linking this work about the structural characteristics of the hospital workforce, to the actual delivery of fundamental care, such as vital signs observations, nutrition, and emotional support. It seems clear that we need to consider both the workforce numbers and the type of work being done in tandem. Our work in the CLAHRC aims to design nursing interventions coupled with appreciation of the basic requirements for the workforce to support successful implementation. The NIHR CLAHRC Wessex really helps to provide a core focus, to create better networks between local NHS trusts.

What else have you worked on that is having an impact on patient care?

We have recently conducted research for a report on single bedrooms in hospitals, which is specifically in relation to patient safety. In terms of infection control, we found no evidence that single rooms had any benefit in comparison to standard hospital ward settings; the spread of infection is actually controlled better in other ways. However, there was a clear preference from patients that they would prefer a single bedroom, and as such, hospitals are broadly engaging with our research and adapting. There is however an impact to be considered for monitoring acutely ill patients. We found that when a patient was at risk of falling, the single room model didn’t improve this risk.

What will be the focus of your work going forward?

The first set of guidelines we contributed to on nursing numbers and patient safety is having a significant impact on the focus of the NHS. We have recently compiled a second evidence review, to contribute to NICE guidelines on nurse staffing in emergency departments. We have also delivered evidence to the Welsh Assembly Health and Social Care Committee who were considering a bill on mandatory nurse staffing levels.

In terms of workforce numbers, we require much more detail on wards. The research indicates that we need more nursing staff, but how many is the optimum number? We are considering ways of measuring workload, linking this with outcomes, to establish what this optimum number looks like. We have just secured a grant from the NIHR to explore the relationship between nurse staffing levels, timely vital signs observations and patient mortality at the level of the hospital ward. This will allow us to come much closer to the actual work done by nurses and get a better idea of what is happening at the level of the hospital ward, where in patient nursing care is delivered.

We are also working on another grant looking at workforce development, to support nurses and care workers in compassionate care.

Do you feel that the work that you are currently involved with is the culmination of your many years spent working on safe staffing levels?

Research that I have been involved in over the past years has put me in a good position to undertake this research, pulling together a large volume of international studies including my own for NICE and moving forward to undertake much more detailed analysis. Any research like this leads to additional questions, and new focuses for study, so I don’t see this as a culmination, but rather the beginning of the next chapter in this crucial body of research.