Reports, toolkits and support

Maternity staffing is variable from day to day and between organisations; there are also fluctuations in the demand for care. This evidence brief outlines the quantitative evidence on the relationship between staffing levels and the quality of maternity care, including four new studies based on existing NHS data in England. Maternity services need to provide safe, effective and person-centred care for women and families. When staffing is below expected or workload is high, it is important to understand the consequences across a wide range of patient outcomes.

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The Ockenden review of maternity services at the Shrewsbury and Telford NHS Trust highlighted the urgent need to ensure adequate staffing levels in maternity care and called for a review of the feasibility and accuracy of the Birthrate Plus tool and associated methodologies. Birthrate Plus® is a system that is used to guide workforce planning for midwifery, informing decisions about the number of midwives to employ in order to maintain safe and high quality care (establishment setting). In this review we consider the available evidence to support the use of Birthrate Plus based on a recently published systematic scoping review.

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Many health care systems, including the NHS, use online services to support the delivery of care, a trend which was accelerated by the COVID-19 pandemic. Patients are increasingly encouraged to access and use online health services such as the NHS 111 online urgent care service, which assesses, triages and signposts users to other health services where necessary. Services like NHS 111 online require people to have sufficient motivation, knowledge of health and of services, and to be able to use digital technologies (‘eHealth literacy’). Whilst digital technologies may seem almost ubiquitous in many aspects of daily life, it is estimated that many millions in the UK do not go online or lack the skills to use the Internet effectively.

The push towards accessing care online may exacerbate health inequalities due to variations in peoples’ level of eHealth literacy. However, the relationship between eHealth literacy and the use of urgent online services such as NHS 111 online is not clear. This Evidence Brief describes the findings of a two-year study undertaken by the University of Oxford and the University of Southampton. It summarises the findings of a survey that measured eHealth literacy and preferences of users and non-users of NHS 111 online.

Frailty is an aging-related syndrome of physiological decline, which results in reduced ability of a person to recover from minor health problems. It is common in older adults and increases the likelihood of hospital admissions and a move to residential care. Services supporting older patients with moderate or severe frailty have been developed across the healthcare sector. However, there is a lack of research describing how frailty evolves within the whole adult population and its impact on health services.

In 2017, NHS England introduced routine frailty identification for patients aged 65 and over in General Practice, using tools such as electronic Frailty Index (eFI). As well as improving patient care, use of the eFI enables large-scale population studies to explore the epidemiology of frailty and inform future health service provision. This Evidence Brief describes the results of research that analysed a large primary care dataset of adults in England to understand how common frailty is in adults aged 50 and older, how quickly it progresses and the consequent impact on the use of health services.

Currently the National Health Service (NHS), in common with many health systems around the world, faces shortages of registered nurses. Common sense and a huge body of evidence suggest this is far from ideal to deliver high-quality patient care. In acute general hospitals, when there are fewer registered nurses, more patient care is missed, quality is reduced and patient outcomes are worse. But fixing the problem is likely to be expensive and it is important to ask if this is the best way to spend money in a resource-limited system. Are there alternatives to using registered nurses? In this Evidence Brief, we summarise a recent systematic review answering whether investing in registered nurses represents value for money, and considers whether using support staff with lower qualification levels might provide a more cost-effective solution to nurse shortages.

Working out how many nursing staff are needed to provide safe care on a hospital ward is complicated, as many factors affect the amount of work. Many tools are available to help estimate the work and the staff needed, but no single tool captures everything, meaning that using professional judgement remains important.

Nonetheless, numbers of nursing staff generated by tools may be trusted more than decisions based on professional judgement, which can be seen as too subjective. Providing a framework to help guide new managers in using professional judgement and to help experienced managers justify their thinking may help overcome this challenge.

This Evidence Brief describes the development of a Professional Judgement Framework to guide nurse staffing decisions, based on our safe staffing research and nurse workforce expert guidance.

How do long shifts, overtime, and higher patient load influence activities that support good nursing practice?

Nursing workforce factors like shift length, workload, and use of overtime are known to influence care quality and staff wellbeing. But to what extent do these factors influence other aspects of nursing work - such as care coordination and continuous professional development? We used data from a large national survey of nurses to see if working long shifts, overtime, and having higher patient loads influenced nurses’ opportunities for completing activities that support good practice.

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What makes it difficult for patients to ask for help in hospital?

Failures in fundamental care of hospital patients can have serious consequences, including patients dying unnecessarily. NHS policy and nursing theory emphasise shared decision making by staff and patients. However they do not consider what prevents nurses providing care as they would wish, nor the difficulties patients can face in alerting staff to missed care.

Researchers from the University of Southampton interviewed 20 patients and six focus group members about their experiences of involvement in fundamental care decisions in hospitals, including whether they raised missed care with staff and if not, why not. This evidence brief presents our findings, taken from our recent paper.

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Are poor experiences on postnatal wards linked to staffing levels?

Experts are growing increasingly concerned about the sustainability of the midwifery workforce, with unfilled vacancies in the thousands, an ageing workforce with many taking early retirement, and difficulty retaining newly qualified midwives. Staffing studies have focussed on the quality of care in labour, with fewer studies looking at staffing levels in relation to postnatal care.

This Evidence Brief describes a cross-sectional analysis of women’s responses to the Maternity Survey 2018 linked to midwifery staffing levels in each Trust. Researchers at the University of Southampton aimed to understand whether the experience of care on postnatal wards varies according to the number of midwives available. They have focused on experiences of postnatal care while in hospital, as this is an area where families have expressed dissatisfaction.

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How long do nurses take to measure patients’ vital signs, and does it matter?

Patients in hospital may be at risk of unexpected deterioration. Monitoring patients’ vital signs, for example blood pressure and heart rate, ensures that any deterioration can be spotted early. This means that monitoring patients’ vital signs is an important part of safe patient care, and, if carried out effectively, has the potential to save many patients’ lives. However, previous studies have been unable to specify the workload this monitoring activity generates for nursing staff. This makes it difficult to plan how many staff are needed to monitor patients.

Researchers at the University Of Southampton, University of Portsmouth and University of Oxford have teamed up to measure and estimate the time and workload associated with measuring patients’ vital signs, and this evidence brief reports what they found.

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What keeps nurses in nursing?

There is a shortage of registered nurses across the world, including in the UK. As demand for care increases, we need to find ways of recruiting more nurses and retaining those already in the workforce. But what makes some nurses decide to leave their jobs, or the profession altogether, and others stay? Understanding workplace factors that influence these decisions could help employers and policymakers to create the conditions needed to keep nurses in the profession.

In this Evidence Brief, we bring together the key findings from a scoping review of reports and research papers to summarise what is known about factors that influence nurse retention, and consider what more needs to be done to develop effective retention strategies.

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Staffing levels have been implicated in cases of adverse maternity events, near misses and sub-optimal outcomes such as unwell new-borns or still births. Care that is missed due to high workload can affect the detection of deterioration in mothers and babies, and delay appropriate management. A national shortage of midwives has resulted in increased reliance on support workers but the possible effect of skill-mix changes on outcomes has not been assessed.

This Evidence Brief describes a systematic scoping review to explore evidence on the association between inpatient midwifery staffing levels, skill mix and outcomes for mothers and babies. Researchers at the University of Southampton aimed to understand the amount and strength of the available evidence, the direction of relationships established, and to highlight gaps for future research.

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Automated planning using Operational Research methods can save both planning and travelling time. Researchers at the Universities of Southampton and Exeter are working to close the gap between these methods and the practicalities of home care planning. This Evidence Brief draws attention to the difficulty of finding the best route and schedule.

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Burnout in Nursing: what have we learnt and what do we still need to know?

Recent health workforce crises, exacerbated by the COVID-19 pandemic, have meant that burnout has often become a ‘buzzword’ to represent stress, extreme tiredness, and a willingness to quit one’s job. Several studies in nursing focus on burnout as an indicator of adverse work environments or staff characteristics. Nonetheless, what burnout is - what aspects contribute to its development and what the effect is for nurses, healthcare organisations, or their patients - is often overlooked.

This evidence brief describes a review, undertaken by researchers at the University of Southampton, of the research examining relationships between burnout and work-related variables. We sought to determine what is known (and not known) about the causes and consequences of burnout in nursing, and whether these relationships confirm or dispute Maslach’s theory of burnout.

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Many studies of registered nurse staffing in hospitals have shown an association between higher levels and better patient outcomes and care quality. Systems for determining the number of nursing staff needed on wards exist in abundance. However, research

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Urgent care typically describes healthcare for non-life threatening conditions requiring prompt attention (‘same day’ or within 24 hours). In England, urgent care services have proliferated partly to divert people from attending overcrowded emergency departments but also to address policy concerns of patient choice and improved access to care.

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Job-related stress and burnout are prevalent amongst healthcare staff; in particular, nurses in the UK have one of the highest levels of burnout in any country in Europe. Tackling this problem is a high priority in the UK and in other countries where shortages of healthcare professionals are affecting healthcare delivery.

‘Magnet’ hospitals are reputed to attract and retain staff, and to achieve better outcomes for patients. But what do we know about whether Magnet hospitals are ‘better’ places for staff to work, and whether they improve staff wellbeing?

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The Francis inquiries in 2010 and 2013 highlighted nurse staffing as a patient safety factor contributing to the care failings identified at Mid Staffordshire NHS Trust. The reports and government response led to the development of national ‘safe staffing’ policy.

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