Paper 07
Russell Hardy  4358
Chairman
BOARD OF DIRECTORS
27TH MARCH 2014
Subject/Title
Nursing Staffing Review
Executive Responsible
Paper prepared by (if different
from above)
Jayne Downey, Director of Nursing
Jayne Downey, Director of Nursing
Nature of Report
For Information
For Discussion
For Approval
Category of Item
Context
Executive Summary
Strategic Direction and
Development
Performance and Governance
Previous Board discussion
Link to National Policy
Link to Trust’s Strategic
Objectives
Risk if no action taken






As a result of recent national reports including Francis, Berwick and
Keogh and reported incidents identified internally a full review of
the adult ward staffing skill mix and ratios have been undertaken to
ensure that the needs of the patient and the quality of care
provided is maintained at the highest standard and in line with the
Chief Nursing Officer’s expectations and Royal College of Nursing
recommendations
Received or approved by
Legal Implications
Recommendation
The Board of Directors are asked to approve the contents of the
Report.
Acronyms and Abbreviations
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Russell Hardy  4358
Chairman
BOARD OF DIRECTORS
27TH MARCH 2014
NURSE STAFFING REVIEW
1.0 Introduction
The senior nursing team including ward managers have recently undertaken a review of all adult ward
staffing levels across the organisation as a result of the Government’s response to the Francis inquiry
(2013). The key drivers for this review and the subsequent proposed investment are the
recommendations from the following reports and information:
The Francis Inquiry
The Keogh Reviews
The Berwick Report
The Chief Nursing Officer’s (CNO) Expectations
Internal intelligence through incident reporting, complaints and acuity measurement
The process did not incorporate paediatrics (Alice Ward) or the High Dependency Unit (HDU) as
these areas have specifically defined staffing standards which the trust is currently meeting
The review has been undertaken in line with recommendations from the Royal College of Nursing and
the expectations set by the CNO that reviewing staffing levels should be undertaken in full
consultation with ward managers and senior nurses. The proposed increase to the levels of staff have
been agreed at ward, divisional and corporate nursing level and will be continually monitored and
reviewed in line with the recent government and NHS England recommendations. Staffing
establishments will be reported to the Board of Directors at least six monthly and displayed in wards
on a shift by shift basis
2.0 Evidence
Staffing levels have always been an issue within the NHS. Evidence over recent years has shown a
direct association between higher rates of registered nurses and lower mortality rates and adverse
events. Although the incident rate and mortality rate is at a lower level at the Robert Jones and Agnes
Hunt Orthopaedic Hospital than most other larger organisations there are still incidents of harm or
potential harm identified such as falls , medication errors and pressure ulcers.
Along with patient complaints, again although low they do identify issues relating to the quality of care
provided such as waiting for care to be delivered or waiting to be discharged and attitude of staff,
which could be correlated to numbers of staff available at that time and how stressed the nurse may
be feeling within the environment due to workload.
Evidence has shown that sickness levels and the reliance on the use of temporary or bank staff can
have a detrimental effect on the quality of care provided. Increased complaints and low staff morale
are also indicators of poor quality care and possibly inappropriate staffing levels.
The ratio of one registered nurse to eight patients and a 65/35 registered to unregistered nurse skill
mix plus the nurse in charge have been identified as substantially improving the safety of patient care
within acute ward areas. These recommendations have been made within a wide range of research
literature and recently within specific reports including:
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the Royal College of Nursing (2010)
Berwick (2013)
This ratio is by no means to be interpreted as an ideal or sufficient standard, higher acuity and
dependency of patient needs will require additional staffing within areas such as acute spinal injuries,
immediate post-operative patients with complex needs and care of the elderly wards.
Guidance is that staffing establishments should be developed utilising a wide range of tools and
professional knowledge and judgement. Don Berwick in his recommendations identified that:
‘Staffing levels should be consistent with the scientific evidence on safe staffing, adjusted to patient
acuity and the local context. (This includes, but is not limited to, nurse-to-patient staffing ratios, skill
mixes between registered and unregistered staff...)
Unlike other countries including Australia, Wales and states in the USA that have stipulated and in
some cases legislated minimum staffing levels required for wards, the Chief Nursing officer in her
‘Expectations’ has identified that:
‘As part of a wider assessment of workforce requirements, evidence-based tools, in conjunction with
professional judgement and scrutiny, are used to inform staffing requirements, including numbers and
skill mix. Senior nursing and midwifery staff and managers actively seek out data that informs staffing
decisions, and they are appropriately trained in the use of evidence-based tools and interpretation of
their outputs. Staff use professional judgement and scrutiny to triangulate the results of tools with
their local knowledge of what is required to achieve better outcomes for their patients.’
Therefore the literature supports that professional judgement is backed by the use of analytical tools
such as acuity scores and the use of nursing indicators such as:
Incidents/harms
Complaints
Sickness levels
Staff morale
Stipulated staffing levels can be constrictive and are often used as the maximum requirement with no
flexibility when situations change either short term or long term. Effective review and escalation
processes along with strong ward leaders and Matrons to ensure staff are used efficiently and
effectively, with Board support when changes are required due to capacity, changes in service or
increases in dependency will ensure staffing levels are appropriate at all times both on a daily basis
and within defined establishments
3.0 Proposed staffing
Over the past 18 months the senior nursing team have been working to review and understand the
staffing needs across the organisation and to ensure that the nursing skill mix is appropriate in order
to meet the needs of the patients in all adult ward areas.
Specific focus during this time had been within the Spinal Injuries Unit and Sheldon ward in which the
acuity of the patients were identified as being higher than in other areas of the trust. Alternative ways
of working and utilising resources more effectively have already been implemented and the
introduction of the 12 hour shift patterns across the organisation had provided more flexible working
opportunities for staff and the Ward Managers when completing off duty rotas
In conjunction with the internal work that had already commenced and the changes made to existing
staffing levels, a further review was required following the publication of the high profile national
reports, which included analysis of local intelligence such as incident reports and complaints and the
wider professional judgement from the senior nursing team including all Ward Managers.
In line with the recommendations and expectations consideration has been given to the 65/35
registered nurse to unregistered nurse skill mix split, the acuity of the patients on each ward,
occupancy levels and the 1:8 registered nurse to patient ratio for safe daytime care and the 1:11
registered nurse ratio for safe night time care
.
In developing the recommended establishments consideration to the supervisory status for Ward
Managers which is a requirement as defined within the CNO Expectations has also been included for
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3 days per week providing time and opportunities for the Ward Managers to engage more fully in the
Quality Improvement initiatives and development of their ward areas and staff.
This supervisory status also provides an opportunity to review the senior level structures and
alternative ways of working within the senior management and nursing teams across the organisation
to ensure efficiencies are gained and resources used effectively and appropriately in meeting the
trust’s objective of delivering Outstanding Patient Care to every patient every day.
The Trust has purchased an electronic acuity system which incorporates the ‘Safer Nursing Care tool’
which is recommended as one of the evidence based tools within the literature. The Safer Nursing
Care Tool enables nurses to assess patient acuity and dependency on a daily basis and over an
accumulative period ensure nursing establishments reflect patient need in each ward. It is
recommended that the tool is used in conjunction with nursing indicators such as adverse incidents,
harms and complaints, patient flow including occupancy levels, ward attenders, transfers, admissions
and discharges. The tool will ensure effective use of nurse resource across all wards when demand in
one area may be higher than another utilising our own staff as efficiently as possible and with the
anticipation of a reduction in bank usage.
With the introduction of the 12 hour shift patterns and the proposed up lift in staffing establishments
across each ward this should provide the organisation with a more flexible work force, utilising our
own staff instead of bank staff and providing greater opportunity to complete relevant and appropriate
training requirements.
Giving ward managers supervisory status along with their presence on the ward Monday to Friday for
the majority of the time should support the delivery of the trust’s Quality Strategy such as focusing on
gaining and sustaining the highest level of ‘STAR’ status and providing opportunities to introduce
different ways of working which are efficient and effective and support the drive for quality including
delivery of the Productive Ward-releasing time to care project and review of incidents more regularly
with opportunities to provide support and training as necessary.
The trust currently has clear escalation processes for when short term staff are required and
management of bank usage through Matron scrutiny. Within the proposed investment clear strong
leadership will be required to ensure staff are being utilised effectively and efficiently across all ward
areas using data to support decisions such as sickness levels, incident data, complaints and acuity.
Ward managers must ensure that resources reflect need with continuous review essential to maintain
services in the future. This will be further enhanced by having appropriate allocated time to
undertake these duties.
4.0 Finance
In line with the evidence, the table in Appendix 1 provides full details of the changes to the staffing
establishments across the adult wards and the proposed investment in to meeting the national and
local requirements for safe staffing levels at the Robert Jones and Agnes Hunt Orthopaedic Hospital.
The table shows the current staffing establishment, the proposed staffing establishment and the
registered to unregistered nurse split both current and proposed as well as the supervisory status of
the Ward Manager for 3 days per week and 21% uplift for annual leave, sickness and training.
As a result of the review and in line with the need to increase registered nurses across the adult
wards the following whole time equivalent (WTE) changes are proposed
Increase 17.4 WTE registered nurses
Reduction 5.46 WTE unregistered nurses
The cost of implementing the proposed investment is:
Registered nursing staff = £579,874
Unregistered nursing staff= -£115,996
Total investment= £463,877
There are a total of 1.87 WTE unregistered nurses that are not assigned a ward on night duty which
currently float between wards and support break cover. With the increase of establishments on night
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duty it is envisaged that these staff will be allocated to a ward area utilising £49,600 in to the total
proposed investment.
Total investment required= £414,277
Movement of staff will be required from those areas in which there has been a reduction of
unregistered nurses to those areas that have seen an increase.
The specialised services contract for spinal injuries would have shown a reduction in 2014/15 due to
reduced through put and deflation. However, commissioners have recognised the investment
required in staffing for the spinal injury wards and have therefore maintained funding at current levels.
5.0 Risks
As part of the process risks have been identified if the proposed investment is not agreed and
implemented these include:
In ability to sustain and deliver Outstanding Patient Care
Failure in clinical quality or safety controls
Possible impact to the trust’s Monitor Governance rating
Non-compliance with Monitor’s terms of licence
Non-compliance with Care Quality Commission (CQC) standards affecting licence to deliver
services
Impact on reputation
Poor patient experience
6.0 Conclusion
The total proposed investment across all adult wards is £414,277, a figure which has been derived
from open discussion with the senior nursing team using their professional knowledge and judgement
and internal intelligence.
The national expectations from the Chief Nurse, evidence based literature and the recommendations
from 3 key national reports, Francis, Keogh and Berwick have all identified the need to ensure safe
staffing levels in line with recommended ratios, skill mix and professional judgement, at least until
NICE provide further evidence based assessment tools.
With the introduction of the electronic Safer Nursing Care tool this will allow for the continued review
and assessment of nurse staffing levels based upon acuity and dependency of the patient’s need and
will be included as part of the regular 1:1 meetings with senior nurses and changes made as
appropriate.
The Board of Directors are asked to review the content of the report and approve the proposed
investment in to nurse staffing levels across all adult wards.
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Appendix 1
Ward Staffing Review
Band 7
(rota'd)
Current WTE
Ludlow
58.38%
41.62%
9.82
8.57
£392,445
£189,431
Proposed WTE
Proposes £
0.4
£22,972
1.20
£47,438
11.56
£462,174
9.10
£201,128
60.00%
£58,039
40.00%
£11,250
62.62%
37.38%
0.6
£34,459
1
1.00
13.28
9.12
Current £
£54,851
£50,771
£492,754
£211,179
Proposed WTE
Proposes £
0.4
£21,940
1.00
£50,771
15.80
£586,189
9.49
£219,663
65.00%
£83,763
35.00%
£7,789
62.30%
37.70%
0.6
£32,911
1
1.80
12.47
9.24
Current £
£54,851
£79,328
£458,245
£224,300
Proposed WTE
Proposes £
0.4
£21,940
1.80
£79,328
15.00
£551,148
9.49
£230,281
65.00%
£84,096
35.00%
£5,238
60.07%
39.93%
0.6
£32,911
1
1.00
13.99
10.63
Current £
£54,510
£42,546
£524,725
£231,954
Proposed WTE
Proposes £
0.4
£21,804
1.00
£42,546
16.02
£601,015
9.29
£202,775
65.00%
£67,659
35.00%
-£28,426
65.19%
34.81%
0.6
£32,706
1
2.00
14.43
9.31
Current £
£44,080
£88,863
£528,135
£241,983
Proposed WTE
Proposes £
0.4
£17,632
2.00
£88,863
16.38
£599,475
9.45
£245,808
70.00%
£64,838
30.00%
£3,128
48.70%
51.30%
0.6
£26,448
1
2.85
11.88
16.57
Current £
£48,118
£116,579
£437,213
£430,007
Proposed WTE
Proposes £
0.4
£19,247
2.85
£116,579
13.91
£512,027
13.10
£339,964
60.00%
£67,621
40.00%
-£73,760
57.74%
42.26%
70.00%
£153,857
30.00%
-£41,215
£579,874
-£115,996
Grand Total
£463,877
1.87
£49,600
Current WTE
Sheldon
Skillmix unregistered
1.20
Current WTE
Gladstone
Skillmix Registered
£47,438
Current WTE
Wrekin
HCA
1
Current WTE
Kenyon
Band 5
£57,431
Current WTE
Powys
Band 6
Current £
Current WTE
Clwyd
Band 7
(Supervisory)
0.6
£28,871
1
1.00
11.76
10.07
Current £
£38,643
£46,407
£461,068
£239,989
Proposed WTE
Proposes £
0.2
£7,729
1.00
£46,407
16.39
£642,411
8.13
£193,783
0.6
£23,186
Floating HCA's
Investment Required
£414,277
Appendix 2
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References
RCN (2010) Guidance on safe nurse staffing levels in the UK. London: RCN www.rcn.org.uk
RCN (2010b) RCN policy position: evidence based nurse staffing levels. Available at:
http://www.rcn.org.uk/__data/assets/pdf_file/0007/353239/003870.pdf
RCN (2012a) Safe staffing for older people’s wards: RCN full report and recommendations.
Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0009/476379/004280.pdf
Department of Health (2013) Report of the Mid Staffordshire NHS Foundation Trust Public
Inquiry. London: The Stationary Office. www.midstaffspublicinquiry.com
Department of Health (2013) A promise to Learn-a commitment to act-National Advisory Group
on the Safety of Patients in England. Berwick Report. London: The Stationary Office.
www.gov.uk/goverment-berwick-review-into-patient-safety
Department of Health (2013) Hard Truths: The Journey to Putting Patients First
The Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry2,
Volume 1 and 2 London: The Stationary Office
Department of Health (2013) Hard Truths: The Journey to Putting Patients First
The Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry2,
Volume 1 and 2 London: The Stationary Office
NHS England (2013) How to ensure the right people, with the right skills,
are in the right place at the right time A guide to nursing, midwifery and care staffing capacity
and capability
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