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Each Health Board/Trust in Wales must calculate the number of nurses - and those staff undertaking nursing duties under the supervision of or delegated to by a registered nurse - required to provide patient centred care and to meet the holistic needs of patients, in every adult acute medical and surgical ward.
The triangulated approach is used for this calculation, utilising three sources of information to determine the required nurse staffing level. In this situation the information triangulated is both qualitative and quantitative in nature. The triangulated approach should include:
The designated person is required to draw on evidence, using the triangulated approach, to determine the nurse staffing level.
The Nurse Staffing Level (Wales) Act 2016 became law in Wales in March 2016. The Act requires health service bodies to make provision for an appropriate nurse staffing level wherever nursing services are provided, and to ensure that they are providing sufficient nurses to allow them time to care for patients sensitively. This requirement extends to anywhere NHS Wales provides or commissions a third party to provide nurses.
The Act consists of five sections:
Part of the triangulated approach involves considering those quality indicators that are particularly sensitive to care provided by a nurse. To reduce the burden of measurement, quality indicators that have an established data source should be used and the Act advises the designated person to consider the following quality indicators as these have been shown to have an association with low staffing levels:
In addition to the quality indicators listed above, other quality indicators that are sensitive to the nurse staffing level may be deemed appropriate. The statutory guidance suggests that: patient feedback; unmet care needs; failure to respond to patient deterioration; staff wellbeing; staff ability to take annual leave; staff compliance with mandatory training; and staff compliance with performance development reviews can all be considered as potentially relevant.
All the information collected should be reviewed independently and then interpreted together to arrive at an informed decision on the nurse staffing level for each ward.
First, apply a sense check to the information outlined in the triangulation.
What is the information saying?
What is the significance of the results?
The nurse staffing level is to be determined using three sources of information: professional judgement; patient acuity; and quality indicators.
The calculation should be informed by the registered nurses within the ward along with staff within the nurse management structure for the ward.
The designated person must be provided with the rationale behind the calculation, must confirm the calculation based on the prioritisation that has been given to the information, and make a recommendation to the Board regarding the nurse staffing level for each adult acute medical and surgical ward.
As of April 2018, section 25B of the Act applies to adult acute medical and surgical inpatient wards. The Welsh Government has the power to make regulations to extend the duty to calculate nurse staffing levels to other areas in the future.
The statutory guidance provides broad definitions of adult acute medical inpatient ward and adult acute surgical wards. These are as follows:
A list of the types of wards which are excluded is available within the statutory guidance.
Health Boards/Trusts are required to use the statutory guidance and their professional judgement to determine which wards are defined as section 25B wards. The outcome and rationale of this decision making process should be recorded and the decisions regarding which wards are included and excluded should be presented to the Board.
In cases where uncertainty exists, to focus on the ‘primary purpose’ of the ward provides a helpful approach to determining whether a ward meets the inclusion criteria.
The designated person will calculate the nurse staffing level every six months as a minimum and more frequently if the use of the ward changes which alters the nurse staffing level, or if the designated person deems it necessary.
The evidence and rationale used to determine the nurse staffing level must be recorded. The level for each ward will be presented to the Board annually, along with an annual report outlining the Board’s position and planned actions in relation to the Act.
Written reports will be provided if there is a change of use/service that has resulted in a change to the nurse staffing level for the ward.
The All Wales Nurse Staffing Programme takes direction from Executive Nurse Directors and the Chief Nursing Officer who will advise on when new workstreams will be added to the programme.
NHS Wales is committed to developing evidence based workforce planning tools for other areas of speciality and work is underway to identify other workstreams to join the programme.
The programme has devised a range of information and education materials to educate and support staff in participating in the audit these include a ‘how to guide’, operational guidance and training sessions.
For more information, please contact the operational lead within your organisation or the Nurse Staffing Programme Team.
Each Health Board/Trust should put systems in place through which they can review and record every time the number of deployed nursing staff varies from the planned roster. These systems should include the reasonable steps taken to maintain the nurse staffing level and a mechanism for recording the use of temporary staff, including bank and agency staff; and the occasions when nursing staff are temporarily moved from other clinical areas/duties within the organisation in order to support the nurse staffing level within a ward.
On occasions the planned roster may be appropriately varied in response to an assessment of the patient acuity across the system and the professional judgement of the ward sister/charge nurse. As part of the record, a rationale is required to determine whether this variation has impacted, either positively or negatively on, for example, the patient experience or the prudent use of resources.
The record should be used as part of the evidence to support the routine six monthly recalculation of the nurse staffing level, and will also provide evidence to support the need to recalculate the nurse staffing level at other periods if required. In addition, the conclusions drawn from these records will inform the reports to the Board and the Welsh Government.
Health Boards/Trusts should ensure all reasonable steps are taken to maintain the nurse staffing level for each adult acute medical and surgical inpatient ward on both a shift by shift and on a long term basis.
Reasonable steps which should be taken at national, strategic corporate (Health Board/NHS Trust) and operational levels to maintain the nurse staffing levels are as follows.
Strategic corporate steps:
It is acknowledged that on occasions, the planned roster might be appropriately varied in response to an assessment of the patient acuity across the Health Board/Trust. In such circumstances, the ward sister/charge nurse and senior nurse should continuously assess the situation and each Health Board/Trust should develop a system for keeping the designated person formally appraised. This will enable the designated person to consider whether a recalculation of the nurse staffing level is required. In this situation, a record should be made and the circumstances reviewed.
Under section 25A of the Act there is a duty placed upon Health Boards/Trusts to provide sufficient nurses to allow them time to care for patients sensitively wherever nursing services are provided or commissioned. Therefore, this overarching responsibility should guide decision making on the allocation of nursing staff across all nursing services within the organisation.
Section 25A of the Nurse Staffing Levels (Wales) Act states:
In line with the requirements of the Act and the statutory guidance, each Health Board/Trust is required to inform patients of the nurse staffing level by displaying the nurse staffing level for the ward and should also inform patients of the date the level was presented to their Board.
National work has been undertaken to develop a template which, if used to display the information specific to each adult acute medical and surgical in-patient ward, would enable each Health Board/Trust to meet the requirements of paragraphs 20-25 of the statutory guidance. Each Health Board/Trust is expected to determine how the information displayed on the template will be updated locally and it would be appropriate for the process agreed to be included within the operating framework. In addition, each Health Board/Trust is required to ensure that the information provided to patients is also made available in Welsh to comply with the Welsh Language Standards.
National work has also been undertaken to support each Health Board/Trust to adopt a once-for-Wales approach by devising an information sheet listing frequently asked questions to assist staff to provide patients with accurate information about the Act.
Some adult medical and surgical inpatient wards may choose to provide additional information about the nurse staffing level, over and above the core information requirements which are specified within the Act and the statutory guidance. This might be particularly appropriate, for example, when it will help patients and visitors to understand the broader multi-disciplinary nature.
The All Wales Nurse Staffing Programme has a comprehensive publication and communication strategy which all work streams and Health Boards and Trusts are signed up to. The programme is committed to ensuring that stakeholders are engaged and kept updated on the progress of the work through a variety of means ranging from local and national events to newsletters, websites and social media.
The Nurse Staffing Levels (Wales) Act applies to every Health Board and Trust in Wales. The primary purpose of the All Wales Nurse Staffing Programme is to ensure Health Boards and Trusts follow the Once for Wales approach to ensure consistency and unity amongst these organisations.
The purpose of the interim nurse staffing principles is to provide Health Boards and Trusts with guidance to assist them with workforce planning. These principles are to be used on an interim basis while the evidence-based workforce planning tool is being devised. The ultimate goal of the principles is to prepare areas of speciality for eventual extension of the Nurse Staffing Levels (Wales) Act and at that time the interim nurse staffing principles will be superseded by the Act.
Interim nurse staffing principles have already been devised and introduced for district nursing services and paediatric inpatients. Work is underway to develop interim nurse staffing principles for health visiting and mental health.
Evidence-based workforce planning tools help managers determine what demand there will be for services. This enables them to calculate what level of staff is required to deliver that service. In healthcare, it is difficult to predict demand, but tools have been developed to measure patients’ levels of acuity which gives an indication of how much care is required to meet their reasonable care requirements. This information will form part of the evidence that is used to calculate the nurse staffing level.
Under the responsibilities outlined within the Act, each Health Board/Trust has been informed by the office of the Chief Nursing Officer that the evidence-based workforce planning tool to be used is the Welsh Levels of Care. Since 2014 work has been undertaken to develop and test the Welsh Levels of Care to enable it to be used within adult acute medical and surgical inpatient wards to assess patient acuity.
The capture of acuity data across all adult acute medical and surgical in-patient wards in NHS Wales takes place bi-annually in January and June as directed by NHS Executive Directors of Nursing. It is anticipated that this acuity measurement will identify seasonal trends in response to changing demographics and healthcare needs. This information when used as part of a triangulated approach alongside the use of quality indicators and professional judgement will determine the nurse staffing level for the ward.
The designated person is required to exercise professional judgement when calculating the nurse staffing level for any given ward area.
The statutory guidance describes some of the key considerations that may be taken into account when exercising their professional judgement, as listed below. In addition, the designated person is required to consider relevant expert professional nurse staffing guidance, principles, research and current best practice standards to inform their decisions. The following 11 factors should be considered as a minimum, but other factors relating to professional judgement would also need to be considered according to the area of speciality.
1) The qualifications, competencies, skills and experience of the nurses providing care to patients.
This is a crucial component that influences staffing numbers. Such skills, knowledge and competencies may in turn be guided by best practice standards as explained above, with the aim of the nurses within the establishment being equipped with the requisite skills to care for patients sensitively and meet the specific clinical care needs of their patients. Workforce planning and required establishments should take account of the need to provide a workforce with an appropriate level of clinically focussed professional and practical skills and knowledge. The guidance also recognises the need to ensure the required establishments enable the workforce to achieve the mandated levels of organisational training requirements. This means structured and detailed workforce planning and calculation of the necessary resource to achieve the required levels of competencies, as well as compliance with mandatory and statutory training should be taken into account.
2) The effect of temporary staff on the nurse staffing level.
The level of familiarity that staff members have with ward/organisational systems and processes may impact upon the efficiency with which they can undertake their work and deliver continuous care to patients. Vacancy levels and recent historical patterns relating to the use of temporary staff will therefore need to be considered when calculating the nurse staffing level. As this is a potentially fluid position, this may also need to be a consideration for prompting an establishment review outside of the normal bi-annual cycle.
3) The effect of a nurse’s considerations of a patient’s cultural needs.
Responding to specific cultural and religious practices (e.g. when providing end of life care) can take significant time. If there are significant numbers of patients with higher levels of holistic nursing needs being cared for on a particular ward, then the designated person will need to be able to demonstrate how they have considered these specific needs in calculating the nurse staffing level so that the team can provide sensitive care to all its patients.
4) Conditions of a multi-professional team dynamic.
Complex care needs, requiring a multi-disciplinary team approach, may require the nursing team to be involved in a significant amount of indirect care coordination work. This work is vital in order to ensure that there are shared goals; and effective and sensitive provision of care by each multi-disciplinary team member, delivered in a timely manner. This indirect care coordination work can be challenging to quantify but often requires skilled and expert decision making and can be time consuming. As such, it will need to be carefully considered by the designated person.
5) The potential impact on nursing care of a ward’s physical condition and layout.
The layout and other physical features of a clinical area will impact on the efficiency of use of the nursing hours available at any time. For example, whether patients are cared for in single rooms or in multiple bedded-bays may influence the number of patients who can be observed and kept safe by one staff member. The location of treatment, medication, storage and sluice rooms within the clinical area can influence the non-productive time if staff members have to walk long distances repeatedly to obtain essential supplies or prepare medications.
6) The turnover of patients receiving care and the overall bed occupancy.
Most adult acute medical and surgical inpatient wards deliver inpatient care to a frequently changing group of patients. The level of variation in both the nature and the type of activity that is additional to the delivery of care sensitively to the patients who are actually in the bed can be immense and is often dependent on the nature of the specialty. Some wards will have high numbers of patients who return to the ward for a post-discharge check, thus avoiding an elongated stay in hospital whilst retaining clinical contact/open door for the patient for a short period after discharge. Some will undertake procedures on the ward as a more efficient approach to care than arranging a planned admission. In other wards the numbers of patients admitted and discharged in a single day - representing a time of intense care management and communication with the patient and often, between health care professionals – can be particularly high.
Though reflected to some extent through the Welsh Levels of Care acuity audit findings, such variations in the nature and type of activity may not be fully captured and thus may need to be reflected in the professional judgement applied by the designated person.
7) Care provided to patients by other staff or health professionals, such as health care support workers.
The nature of the care needs of the patients in each clinical area will influence both the numbers and the skill mix - including the knowledge, skills and competencies - of the nurse staffing level. In addition, the role responsibilities of staff from other teams within the hospital workforce (e.g. hotel facilities, porters, medical records) can impact upon the duties that the ward nursing team is required to undertake in order to ensure the provision of sensitive care. This can also then impact the nurse staffing level the designated person will calculate.
8) Any requirements set by a regulator to support students and learners.
Ensuring a robust learning environment for commissioned health care professional students is a priority responsibility of the NHS in Wales. It is through this route that the care provided in the future will be delivered by appropriately trained, educated and skilled nurses who will be available in sufficient numbers to meet the NHS Wales workforce requirements. This highlights the importance of creating a learning environment where time can be allocated to teaching, supervising and mentoring students. The numbers of student placements allocated within each clinical area should form an important consideration when calculating the nurse staffing levels, to ensure that each student can be adequately supported in practice.
9) The extent to which nurses providing care are required to undertake administrative functions.
As with Section 7 above, the scope of the responsibilities that sit within the nursing team will influence the number and skill mix of the required establishment. Importantly the designated person will consider skill mix and prudent healthcare delivery principles when calculating the roles a team requires within their required establishment.
10) The complexity of the patients’ needs in addition to their medical or surgical nursing needs, such as patients with learning disabilities.
The designated person must take account of the individual holistic needs of patients in addition to their presenting medical or surgical condition would indicate. This means that the specific additional care needs of patients, for example, with mobility difficulties, cognitive impairment or learning difficulties must be taken into consideration when calculating the nurse staffing level.
11) Delivering the active offer of providing a service in Welsh without someone having to ask for it.
When calculating the nurse staffing level, the designated person will be required to demonstrate that specific consideration has been given to the provision of care delivered through the medium of Welsh, as part of the Welsh Government’s More than Just Words strategic framework requirements. In particular this may impact on the deployment of the staff establishment to ensure that the availability of the Welsh language skills among the staff on duty at any time can reflect the predictable needs of the patients within a given clinical area.
Part of the triangulation approach involves considering the data available which links to the above aspects of professional judgement. For example, compliance with mandatory training, vacancy and sickness rates, use of temporary staff, bed occupancy and/or student feedback.
The ward sister/charge nurse is responsible for ensuring that the social, psychological, spiritual and physical care needs are assessed and classified using the Welsh Levels of Care descriptors.
The Welsh Levels of Care consists of five levels of acuity ranging from level 1 where the patient’s condition is stable and predictable requiring routine nursing care, to level 5 where the patient is highly unstable and at risk requiring an intense level of continuous nursing care on a 1:1 basis.
The Welsh Levels of Care are summarised as:
|Level 5||One to one care - the patient requires at least one-to-one continuous nursing supervision and observation for 24 hours a day.|
|Level 4||Urgent care - the patient is in a highly unstable and unpredictable condition either related to their primary problem or an exacerbation of other related factors.|
|Level 3||Complex care - the patient may have a number of identified problems, some of which interact, making it more difficult to predict the outcome of any individual treatment.|
|Level 2||Care pathways - the patient has a clearly defined problem but there may be a small number of additional factors that affect how treatment is provided.|
|Level 1||Routine care - the patient has a clearly identified problem, with minimal other complicating factors.|
Further information on how to measure patient acuity and dependency using the Welsh Levels of Care can be found in the Welsh Level of Care (edition 1) document.
Each Health Board/Trust should develop systems for recording the evidence used and the rationale applied when calculating the nurse staffing level for each adult acute medical and surgical in-patient ward.
A national checklist of the factors, which must be considered, provides a template for recording calculating and the decision making process undertaken during the calculation process.
Health Boards/Trusts are required to record the outcome of the calculation and evidence the decision making process.
The following list of factors has been agreed by the All Wales Nurse Staffing Group as reasons to prompt Health Boards/Trusts to consider whether to recalculate nurse staffing levels outside the routine bi-annual calculation process. This is not an exhaustive list and other factors may also be considered: