Workforce & Health Systems publications

Nwanosike   E, Griffiths P, Dall'Ora C, Monks T, Pattison N, Yapa TD, Saville C

Intensive care units (ICUs) are high-stakes environments where patient outcomes are heavily influenced by the quality and quantity of nursing care. The increased risk of mortality has been widely studied in terms of relationships with RN staffing, but other important outcomes, including length of stay (LoS), unit-acquired infections, and readmissions much less so. The risk of poor patient outcomes, including unit-acquired infections in ICUs, is high, with prevalence rates reaching up to 20 % in some hospitals. Also, patient readmissions to the ICU are another important outcome, with rates as high as 25 % in some hospitals. The importance of nurses being involved in management has been shown indirectly through studies of Magnet hospital accreditation.

A recent systematic review of longitudinal studies including ICU settings reported mixed findings on the association between RN staffing levels and LoS, infections and readmissions. The reviewed studies have a serious risk of bias due to inadequate risk-adjustment. This means that any detected association between staffing levels and patient outcomes might be at least partly explained by high patient acuity and existing co-morbidities. In addition, the COVID-19 pandemic introduced unprecedented challenges, including surges in patient acuity, resource constraints, and rapid changes in care protocols, which may have altered these relationships beyond the pandemic period. Although prior research has examined RN-to-patient ratios, limited evidence exists regarding how RN team composition (e.g. RN skill-mix and presence of nurse managers) influences ICU outcomes such as the development of unit-acquired infections, increased LoS and readmissions to the ICU.

Therefore, this study aims to fill these gaps by exploring longitudinal associations between RN staffing, skill mix, and patient outcomes in English ICUs over almost four years, encompassing the pre-pandemic, pandemic, and post-pandemic periods. By providing insights into the impact of staffing on ICU outcomes prior to, during and after the pandemic, this study offers valuable evidence for optimising ICU staffing strategies in both crisis and non-crisis settings.

https://doi.org/10.1016/j.iccn.2025.104314

December 2025

Crowe S, Grieco L, Monks T, Keogh B, Penn M, Clancy M, Elkhodair S, Vindrola-Padros C, Fulop NJ, Utley M

Overcrowding affects hospital emergency departments (ED) worldwide. Most OR studies addressing overcrowding develop bespoke models to explore potential improvements but ignore the organisational context in which they would be implemented, and few influence practice. There is interest in whether reusable models, for ED crowding and in healthcare generally, could have more impact. We developed a configurable approach for tackling ED overcrowding. 

A reusable queuing model for exploring drivers of ED performance was augmented by a qualitative approach for exploring the implementation context and a generic framework for assessing the likely compatibility of interventions with a given organisation. At the hospital where the approach was developed it directly informed strategy. 

We describe reuse of the approach at three hospitals. The primary contribution of this work is its novelty in considering, alongside quantitative modelling, evidence-based interventions to overcrowding and qualitative assessment of a hospital’s aptitude and capability to adopt different interventions. A secondary contribution is to further the debate on model reuse, particularly by introducing more complex, modelling-centred approaches that acknowledge how models must relate to tangible interventions with reasonable prospects of being adopted locally.

https://doi.org/10.1080/01605682.2023.2199094

July 2023

Fox S, Dall'Ora C, Young M

Occupational fatigue among healthcare professionals is a complex, multifaceted issue associated with increased likelihood of medical error, compromised patient safety and negative impacts on staff mental and physical health. While safety-critical sectors such as aviation and rail have implemented formal systems to manage fatigue-related risks, it remains unclear whether similarly structured approaches exist or operate effectively within healthcare.

This scoping literature review aimed to examine the current state of knowledge regarding fatigue risk management strategies and countermeasures in healthcare and explore the barriers and facilitators to their implementation. This review sought to highlight gaps and provide insights into advancing fatigue risk management practices within the healthcare context

https://doi.org/10.1016/j.ijnurstu.2025.105282

November 2025

Nwanosike E, Dall'Ora C, Griffiths P, Saville C, Monks T, Pattison N et al

Staff wellbeing in intensive care units is essential for quality patient care, and nurse staffing configurations can impact nurse sickness absence. The COVID-19 pandemic imposed additional strain on nurses, potentially affecting sickness absence rates.

The objective of this study is to examine the association between registered nurse staffing levels, skill mix, and staff sickness absence in intensive care units spanning prepandemic (01/19–02/20), early pandemic (03/20–02/21), later pandemic (03/21–02/22), and post-pandemic (03/22–12/22).

https://doi.org/10.1016/j.ijnsa.2025.100451

November 2025

Reula   M, Parreño-Torres C, Lamas-Fernandez C, Martinez-Sykora A

In the health and social care sectors it is common for some specialized teams to travel to patients homes to provide care. These teams are typically made up of by a number of staff members with varying skills, starting locations and working hours. Patients require different types of care, during specific time windows, and may have special requirements, such as needing two staff members, or multiple visits with some sort of temporal dependency between them. Since teams need to decide which staff member will visit each patient, as well as the routes they will take to do so, this kind of planning problem is known in the literature as the Home Health Care Routing and Scheduling Problem (HHCRSP). 

We introduce a new mixed integer linear programming formulation for the HHCRSP that extends previous models. Our formulation can readily be adapted to address more specific variants in the scientific literature, proving a larger number of optimal solutions and stronger lower bounds on benchmark instances using the same computational framework. We further propose an instance generator for producing scenarios that closely resemble those of the National Health Service in the United Kingdom.

https://doi.org/10.1016/j.ejor.2025.05.055

November 2025

Dylag JJ, Zlatev Z, Boniface M

In clinical research, there is a strong drive to leverage big data from population cohort studies and routine electronic healthcare records to design new interventions, improve health outcomes and increase the efficiency of healthcare delivery. However, realising these potential demands requires substantial efforts in harmonising source datasets and curating study data, which currently relies on costly, time-consuming and labour-intensive methods. We explore and assess the use of natural language processing (NLP) and unsupervised machine learning (ML) to address the challenges of big data semantic harmonisation and curation.

https://doi.org/10.1186/s12911-025-03055-y

October 2025

Bhat S,   Gavin J, Warner M, Myall M

Musculoskeletal disorders remain a leading occupational health challenge in physically demanding sectors such as healthcare, social care, and industry. Exoskeletons – wearable devices designed to mitigate physical strain are increasingly explored as potential solutions; however, factors affecting their adoption in real-world settings remain underexplored. This novel scoping review systematically maps the existing evidence on the application of commercially available exoskeletons within real and simulated work environments, focusing on usage patterns, user experiences, and factors influencing implementation.

https://doi.org/10.1017/wtc.2025.10033

November 2025

Tavares N, Jarrett N

Studying for final exams is often regarded as difficult for nursing students, therefore, activities using game-based learning methods may increase student satisfaction. Therefore, this study aimed to understand the feasibility of a game-based learning activity on nursing students' learning and revision processes. A one-group pre and post-questionnaire design was undertaken to evaluate the effectiveness of a game-based learning activity. 

All nursing students found the game-based learning activity valuable when preparing for written exams. The learning activity increased the levels of knowledge retention and the final grades. Although two students found the activity somewhat distracting, most students believed that game-based learning should be embedded into the nursing curriculum. The game-based learning activity was well-accepted when revising for written exams in nursing. However, research at a larger scale is required to confirm the effectiveness of the activity on students' knowledge, grades and long-term retention.

https://doi.org/10.1371/journal.pdig.0001043

October 2025

Reula M, Parreno-Torres C, Lamas-Fernandez C, Martinez-Sykora A

 In the health and social care sectors it is common for some specialized teams to travel to patients homes to provide care. These teams are typically made up of by a number of staff members with varying skills, starting locations and working hours. 

Patients require different types of care, during specific time windows, and may have special requirements, such as needing two staff members, or multiple visits with some sort of temporal dependency between them. Since teams need to decide which staff member will visit each patient, as well as the routes they will take to do so, this kind of planning problem is known in the literature as the Home Health Care Routing and Scheduling Problem (HHCRSP).

We introduce a new mixed integer linear programming formulation for the HHCRSP that extends previous models. Our formulation can readily be adapted to address more specific variants in the scientific literature, proving a larger number of optimal solutions and stronger lower bounds on benchmark instances using the same computational framework. We further propose an instance generator for producing scenarios that closely resemble those of the National Health Service in the United Kingdom.

https://doi.org/10.1016/j.ejor.2025.05.055

September 2025

Barker HR, Griffiths P, Dall'Ora C

The nursing workforce globally faces significant challenges, including burnout, stress, and absenteeism, exacerbated by unsafe staffing levels and suboptimal working conditions. In England, many nursing staff express intentions to leave their roles, driven by work-life imbalance. 

This study explores how the preferences and constraints of nursing staff, nurse managers, and hospital directors interact to influence shift scheduling decisions within the NHS, aiming to identify strategies that reconcile individual wellbeing with organisational imperatives.

https://doi.org/10.1186/s12912-025-03705-6

August 2025

Meredith   P, Saville C, Dall'Ora C, Weeks T, Wierzbicki S, Griffiths P

Managing nurse staffing is complex due to fluctuating demand based on ward occupancy, patient acuity, and dependency. Monitoring staffing adequacy in real time has the potential to inform safe and efficient deployment of staff. Patient classification systems (PCSs) are being used for per shift workload measurement, but they add a frequent administrative task for ward nursing staff.

https://doi.org/10.2196/71666

July 2025

Griffiths P, Saville C, Ball J, Culliford D, Jones J, Lambert F, Meredith P, Rubbo B, Turner L, Dall'Ora C

Staffing shortages are a major concern for the National Health Service. A lot of research shows that low nurse staffing in hospital is correlated with worse patient outcomes, including an increased risk of death. However, a lot of this research has only looked at hospital average staffing and has not considered other staff, such as doctors and allied health professionals, so it is hard to be sure if improving nurse staffing on wards leads to better outcomes. It is also hard to know the most cost-effective approach to addressing staff shortages. 

Our study used existing data from national reports and daily staffing data from hospital wards to answer some of the main uncertainties from past research. Using data from national reports, we found low staffing levels from doctors and allied health professionals were linked to increased risk of death. Nurse staffing levels were linked to important aspects of patient experience and staff well-being, but to properly understand the effects of nurse staffing we needed to know the staffing patients experience when on hospital wards. 

Our study included 626,313 patients in 4 hospitals. We found that when patients spent time on wards with fewer-than-expected registered nurses or nursing assistants, they were more likely to die and their stay in hospital was longer. Low registered nurse staffing was also associated with more re-admissions. We looked at the cost of avoiding low staffing and the cost of gaining the equivalent of 1 year of healthy life. We compared these ‘cost-effectiveness’ estimates for different ways of avoiding low staffing and for different patient groups.

Overall, we concluded that a focus on avoiding low registered nurse staffing gave more benefits than using assistants to fill any gaps, and should be the priority, although it is still not clear what the best level of staff is.

https://doi.org/10.3310/zbar9152

July 2025