The Safer Nursing Care Tool (SNCT) is a system implemented across numerous English hospitals to inform critical decisions regarding nurse staffing levels on hospital wards, specifically in determining the necessary number of nurses to ensure adequate staff establishment. Despite its widespread adoption, substantial evidence is still lacking to confirm the effectiveness and cost-efficiency of nurse staffing tools, like the SNCT, in consistently delivering staffing levels that guarantee safe and high-quality patient care.
A recent observational study was conducted across four NHS hospital trusts to investigate the SNCT’s alignment with professional nursing judgment and to evaluate different approaches for its application. The research also aimed to model the financial implications and patient care outcomes associated with various ward staffing policies derived from the SNCT acuity/dependency measure.
This study employed a multifaceted approach, including regression analysis, computer simulations, and economic modeling within medical and surgical wards. Researchers compared three staffing establishment models: a ‘high’ establishment designed to meet staffing needs on 90% of days, a ‘standard’ establishment based on mean demand, and a ‘flexible (low)’ establishment (80% of the mean) intended to use a core staff supplemented by redeployed or newly hired staff to accommodate demand fluctuations.
The core outcome measures assessed in this research were professional evaluations of staffing adequacy, reported instances of omitted patient care, shifts staffed more than 15% below the SNCT-measured requirement, cost per patient-day, and cost per life saved. Data was gathered from hospital administrative systems, staff reports, and national reference costs, encompassing 81 wards with a high participation rate (85%) and linking SNCT ratings with staffing levels across 26,362 ward-days (96% response rate).
The findings indicated that according to SNCT measurements, 26% of ward-days were understaffed by 15% or more. Interestingly, nurses reported feeling adequately staffed to provide quality care on 78% of shifts, suggesting a discrepancy between SNCT metrics and perceived staffing adequacy. Statistical analysis revealed that using SNCT for staffing establishment required approximately 60 days of observation to achieve a 95% confidence interval within one whole-time equivalent nurse above or below the mean.
Furthermore, the study established a clear correlation between staffing levels below the SNCT-estimated daily requirement and negative outcomes. Lower staffing was associated with decreased nurse-reported perceptions of ‘enough staff for quality care’ and an increased frequency of reported missed nursing care tasks. Crucially, the relationship was found to be linear, indicating that staffing levels exceeding SNCT recommendations were linked to further improvements in care quality and reduced omissions.
Simulation experiments provided valuable insights into the implications of different staffing models. ‘Flexible (low)’ establishments, even with the assumption of readily available temporary staff, resulted in high rates of understaffing and adverse patient outcomes. The anticipated cost savings from such models were minimal when considering the necessity for high temporary staff availability to maintain functionality. In contrast, ‘high’ establishments were associated with significant reductions in understaffing and improved patient outcomes. While these models incurred higher costs, the study suggests that under most conditions, the cost per life saved was considerably less than £30,000, indicating potential cost-effectiveness when considering patient safety and quality of care.
It is important to acknowledge the limitations of this study, primarily its observational design and the simulated nature of staffing establishment outcomes. However, the research underscores the critical importance of understanding workload variability when planning nurse staffing levels. While the Safer Nursing Care Tool Snct demonstrates a correlation with professional judgment, it should not be seen as defining optimal staffing levels in isolation. The study concludes that employing more permanent staff than strictly recommended by SNCT guidelines, aiming to meet demand on most days, could be a cost-effective strategy for hospitals. The apparent cost savings associated with ‘flexible (low)’ staffing models are largely achieved by operating with potentially inadequate staffing levels, and these savings diminish significantly when factoring in the practical requirements of high temporary staff availability needed to support such policies.
Future research is essential to pinpoint definitive cut-off points for required staffing levels and to conduct prospective studies that directly measure patient outcomes, comparing the effectiveness of different staffing systems and tools like the Safer Nursing Care Tool SNCT.
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme. Trial registration: Current Controlled Trials ISRCTN12307968.
