Workforce & Health Systems publications

Remmington C, Camporota L, McKenzie CA, Hanks F, Sanderson B, Rose L

Changes in sedation and pain medication levels throughout the day may affect how well patients recover. But so far, there hasn’t been any research looking at how these changes happen in patients who are on ECMO, a machine that supports the heart and lungs.

This study aimed to compare how sedation and pain medication levels vary during the day in two groups of critically ill adults: those on a ventilator and those on ECMO.

10.1016/j.iccn.2025.104056

April 2025

Hurley-Wallace AL, Defty J, Richardson A, Wagland R.

Patients with oncological emergencies require immediate specialist cancer care to ensure optimum outcomes. This is often a stressful, time-sensitive situation for patients and their families who describe having to navigate complex care pathways to access urgent treatment. Acute oncology was established as a subspecialty in the UK in 2009, with the goal to streamline emergency cancer care. Patient experiences of urgent care in acute oncology contexts have not specifically been explored; hence, it is unknown whether patient experiences of emergency cancer care have improved. This may be due to lack of a patient-reported experience measure for this purpose.

https://doi.org/10.1007/s00520-025-09245-8

February 2025

Simons G, Klepacz N, Baldwin DS

Doctors globally are increasingly experiencing high workloads and challenging working conditions and, consequently, are reporting high levels of stress, anxiety, depression,1 emotional distress, burn-out risk and suicidal feelings. This negatively impacts patient care quality, safety and satisfaction and leads to declining job satisfaction and doctors leaving the workforce. In a UK context, the 2023 National Health Service (NHS) staff survey found that 44% of doctors felt unwell in the previous 12 months because of work-related stress, and 38% often or always found their work emotionally exhausting. Emphasis is often placed on doctors to be more resilient, with stigma and a fear of potential repercussions preventing doctors from speaking up about their well-being. However, there is an emerging consensus that some aspects of doctors’ training, working conditions and organisational support negatively impact well-being. The well-being of doctors significantly impacts workforce planning, cost, healthcare quality and patient outcomes. Dissatisfaction with role/place of work or NHS culture was cited as the top reason for leaving the workforce in a General Medical Council survey, with burn-out/work-related stress as the third most cited reason behind retirement. Poor mental well-being of staff is estimated to cost the NHS at least £12.1 billion per year; tackling poor mental well-being and reducing the number of staff leaving the NHS could save up to £1 billion. The UK’s health system prioritises patient care—often over staff well-being—but long-term patient care and safety depend on staff well-being.

The need to address doctor well-being is well recognised, with government and industry reports highlighting the need for improvement. While recognising the urgent need to address doctors’ well-being, these reports often fail to operationalise well-being or specify the outcome or measurement tools required to gauge the success of their recommendations. For example, the ‘NHS Long Term Plan’ aims to make the NHS ‘the best place to work’ but provides little detail on implementation or how success will be captured or measured. The NHS Long Term Workforce Plan commits to implementing actions from the NHS People Plan to ensure that staff have access to well-being services and support; however, the British Medical Association has questioned how this ambition will be made a reality. Many employers and education deaneries now provide well-being programmes for doctors and implement the NHS health and well-being framework. However, evidence of the success of these (and similar) programmes—often aimed at individual coping strategies, resilience and productivity—suggests limited effect. The lack of consensus on what doctor well-being is and how it should be measured means that the monitoring and evaluation of these strategies are inconsistent.

The ongoing and accurate measurement of doctors’ well-being is necessary to understand local and specific needs and ensure the effective delivery of staff services. It is, therefore, vital for both research and governance to take a consistent data-driven and evidence-based approach to doctors’ well-being, taking account of the many dimensions (ie, social, cultural, environmental and economic) and levels (ie, individual, organisational and societal) that comprise this complex issue. However, work has not yet been undertaken to standardise the definition and measurement of doctor well-being. In addition, ‘well-being’ has often been used interchangeably with, or to describe, mental health, with previous research focusing largely on ‘pathologies’ such as depression, anxiety and burnout rather than positive measures of well-being. Consequently, workplace well-being has become a measure of the absence of mental health disorders. A salutogenic approach that measures positive determinants, context, mechanisms and individual and group well-being should be preferred when considering doctor well-being. A salutogenic approach is a positive approach that looks prospectively at how to create, enhance and improve well-being; as opposed to a pathogenic approach that looks retrospectively at the disease burden of doctors (usually mental health diagnoses).

Our systematic review found well-being outcomes and measurement tools used in doctor well-being research were heterogeneous, demonstrating the need for a core outcome set (COS). COSs are consensus minimum groups of outcomes with recommended reliable and valid measurement tools. Reaching agreement among stakeholders—including NHS doctors—ensures a consistent and comprehensive focus, facilitating comparison between organisations through the generation of ‘big data’, and in doing so, provides decision-makers with the evidence needed to inform future workforce strategies, interventions and actions. We used a salutogenic and consensus-based approach to develop a COS to capture and report on the well-being of doctors in the NHS. To our knowledge, this study represents the first time a non-pathological concept—well-being—has been applied to the COS-STAndards for Development (COS-STAD) guidance.

https://doi.org/10.1136/bmjopen-2024-094973

May 2025

Saville C, Jones J, Meredith P, Dall'Ora C, Griffiths P

Understaffing by nursing staff in hospitals is linked to patients coming to harm and dying unnecessarily. There is a vicious cycle whereby poor work conditions, including understaffing, can lead to nursing vacancies, which in turn leads to further understaffing. Is hospital investment in nursing staff, to eliminate understaffing on wards, cost-effective?

This longitudinal observational study analysed data on 185 adult acute units in four hospital Trusts in England over a 5-year period. We modelled the association between a patient's exposure to ward nurse understaffing (days where staffing was below the ward mean) over the first 5 days of stay and risk of death, risk of readmission and length of stay, using survival analysis and linear mixed models. We estimated the incremental cost-effectiveness of eliminating understaffing by registered nurses (RN) and nursing support (NS) staff, estimating net costs per quality-adjusted life year (QALY). We took a hospital cost perspective.

https://doi.org/10.1136/bmjqs-2024-018138

April 2025

Fogg C, King P, Parsons V, Dunbar N, Woutersen M, Branson J, Pocock H, Jadzinski P, Lofthouse-Jones C, Walsh B, Smith D

Ambulance trusts across the UK serve vast and varied regions, impacting equitable healthcare access, especially for older patients facing urgent, non-life-threatening conditions. Detailed variation in demand and service provision across these regions remains unexplored but is crucial for shaping effective care policies and organisation. Geospatial mapping techniques have the potential to improve understanding of variation across a region, with benefits for service design.

The aim of this project was to explore the feasibility of using geospatial techniques to map emergency 999 calls and outcomes for older adults within an academic-healthcare collaboration framework.

https://doi.org/10.1136/bmjoq-2024-002977

April 2025

Dall'Ora C, Meredith P, Saville C, Jones J, Griffiths P

Rates of work-related stress and sickness absence are high among nurses. The consequences of sickness absence are severe for health systems' efficiency and productivity.

Our objective is to examine the association between nurse staffing configurations and sickness absence in hospital inpatient unit nursing teams.

 This retrospective longitudinal case-control study using routinely collected hospital data among 4 general acute care hospitals in England examined 18 674 registered nurses (RNs) and nursing support (NS) staff working in 116 hospital units. Data were analyzed from April 1, 2015, to February 29, 2020.

https://doi.org/10.1001/jamanetworkopen.2025.5946

April 2025

El Asmar ML, Mortagy M, White B, Burns D, Ramage J

Neuroendocrine neoplasms (NEN) are a group of rare cancers predominantly found in the
bronchopulmonary and gastrointestinal systems. NEN incidence has been increasing globally
(White, Rous et al. 2022). NEN can be categorised into well-differentiated neuroendocrine
tumours (NET) and poorly differentiated, high-grade neuroendocrine carcinomas (NEC) (Rindi,
Klimstra et al. 2018).

Gastroenteropancreatic NEN (GEPNEN) characteristically present between the ages 50 and 60
(Horton, Kamel et al. 2004), and can be difficult to diagnose, as they either present
asymptomatically and are diagnosed incidentally (e.g. post-appendicectomy), as non-specific
bowel symptoms causing delays in diagnosis or with symptoms resulting from mass effect of the
tumour within the abdomen (Oronsky, Ma et al. 2017, Tadman, Davies et al. 2019).

Research suggests that the time from the onset of symptoms to the diagnosis of NEN averages 5 to 7 years (Modlin, Kidd et al. 2005). This process often involves several visits to the GP and frequent misdiagnoses such as
irritable bowel syndrome (IBS) or gastritis. Lung NEN may present with cough, wheeze, shortness
of breath, chest pain, or haemoptysis, depending on tumour aggressiveness and location, or may
be found incidentally on imaging (Ramage, Davies et al. 2005, Tadman, Davies et al. 2019).

Route to diagnosis is recorded for patients with NEN within England’s National Cancer Registry
and Analysis Service (NCRAS) database. The emergency pathway for the diagnosis and initial
treatment of NEN can be regarded as a proxy for a delayed diagnosis, as it suggests that the case
has not undergone diagnostic evaluation at an earlier phase of symptom presentation. Disease
stage at presentation may also reflect delays in diagnosis. The factors in NEN associated with
emergency presentations or late presentation are unclear

Knowledge of factors leading to NEN presentation helps health commissioners target populations at higher risk to reduce delays to diagnosis. Addressing delays and inequity in the timely diagnosis of NEN aligns with targets set
by the NHS Long Term Plan and the UK Rare Diseases Framework (UK 2021).

This article aims to assess factors associated with emergency versus routine presentation at the
time of diagnosis of NEN, to assess factors associated with late presentation (higher stage) at
diagnosis of NEN, and to correlate these with overall survival.

http://dx.doi.org/10.1530/EO-25-0012

April 2025

Svensson I, Bridges J, Ellis J, Brady N, Dello S, Hooft J, Kleine J, Kohnen D, Lehane E, Lindqvist R, Maier CB, Mc Carthy VJC, Strømseng Sjetne I, Eriksson LE, Smeds Alenius L

Magnet hospitals, a concept developed in the U.S., have been associated with improved nurse recruitment and retention, and better patient outcomes. Magnet principles may be useful to address workforce challenges in European hospitals, but they have not been implemented or evaluated on a large scale in the European hospital context.

This study aims to explore the initial phase of implementing Magnet principles in 11 acute care hospitals in six European countries. The specific objectives of the study were to investigate the type of work that characterises the early phase of implementation and how implementation leaders engage with their context.

https://doi.org/10.1016/j.ijnurstu.2024.104754

June 2024

Hope J, Dall'Ora C, Redfern O, Darbyshire JL, Griffiths P

Vital signs monitoring is key to identifying deteriorating hospital patients. However, adherence to monitoring protocols is limited, with observations frequently missed or delayed. Previous studies of interruptions and delays to vital signs observations have been descriptive, with none attempting to conceptualise the types of tasks that are prioritised over vital signs observations.

This paper aims to explore how nursing teams perform vital sign observations on acute hospital wards and conceptualises which types of work delay or interrupt them.

https://doi.org/10.1016/j.ijnurstu.2025.105018

February 2025

Stalpers D, Schoonhoven L, Dall'Ora C, Ball J, Griffiths P

In nursing, achieving adequate staffing levels to ensure high quality of care is a worldwide problem. The existing nursing shortages and the continuously increasing demand for highly skilled nurses lead to higher workloads for the already overburdened nursing workforce (Dall'Ora et al., 2022; Haddad et al., 2023). These challenges in the nursing field have driven a call for rigorous rethinking and redesigning of nursing care delivery (Griffiths and Dall'Ora, 2023; Geltmeyer et al., 2024).

In organising nursing care, currently the leading principle is to primarily consider nursing work a job that consists of a multitude of tasks that can be divided between staff (Sasso et al., 2017). However, this way of thinking partly ignores what nursing work entails; it does not fully acknowledge its multi-layered, holistic and therefore complex character.

In this paper, we aim to explore the potential of a new and less simplistic model for dividing nursing labour. We believe that, to capture the comprehensiveness of nursing work and its corresponding complexity, it is necessary to recognise that care delivery is not only about performing a discrete set of tasks. A defining factor in the daily work of nurses is the ‘entanglement’ of care activities. This refers to the fact that the work does not simply concern a series of tasks occurring in parallel, but that these activities are intertwined and bundled together. These activities are linked and cannot be separated without changing the nature of all activities involved.

https://doi.org/10.1016/j.ijnurstu.2025.104995

January 2025

Campling N, Turnbull J, Richardson A, Voss S, Scott-Green J, Logan S, Latter S

Global demand for care during the last year of life (end-of-life) is rising and with shortfalls in community healthcare services, paramedics are increasingly called on to deliver this.

 Despite this growing demand on the paramedic workforce, little large-scale or detailed empirical research has evaluated current practice and paramedic experiences of attending this patient group. Therefore, as part of a wider study evaluating paramedic delivery of end-of-life care, a large-scale survey in England describing paramedics' current practice and experiences providing end-of-life care was undertaken.

https://doi.org/10.1186/s12904-024-01629-7

December 2024

Meredith P, Turner L, Saville C, Griffiths P

Nurses play a crucial role in maintaining the safety of surgical patients. Few nurse staffing studies have looked specifically at surgical patients to examine the impact of exposure to low staffing on patient outcomes.

A longitudinal patient analysis was conducted in four organizations in England using routine data from 213 910 admissions to all surgical specialties. Patients' staffing exposures were modelled as counts of understaffed registered nurse and nurse assistant days in the first 5 inpatient days. Understaffing was identified when staffing per patient-day was below the mean for the ward. Cox models were used to examine mortality within 30 days of admission and readmission within 30 days of discharge. Generalized linear models were used to investigate duration of hospital stay and occurrence of hospital-acquired conditions.

https://doi.org/10.1093/bjs/znae215

August 2024