Nursing Workforce

Background

Questions about the relationship between nursing skill mix and outcomes for the workforce and patients had been prevalent within the nursing research literature and policy conversations in the period leading into the SRA. Initially the programme focused upon scoping those aspects of the literature associated with skill mix. The Working Group then focused on questions concerning ‘missed nursing care’, as well as the impact of workload pressures upon retention and work satisfaction.

Design

A range of methods were used within this work stream, including scoping review, rapid review, systematic review, narrative review, secondary data analysis, survey and semi-structured interviews. The work was broad in scope in relation to setting and was undertaken in acute, primary, community and mental health environments. The final elements were as follows:

●        In 2018, a scoping review was undertaken to identify what patient safety outcomes were associated with nursing skill mix interventions and to explore how these compared across acute and primary care settings. In the course of the review, we were also able to explore those conceptual frameworks that had been used to characterise nursing skill mix.

●        A systematic review explored how the factors associated with the concept of missed care relate to safety outcomes in primary, community and nursing home settings. This review (2019) comprised a synthesis of primary research and a review of relevant conceptual frameworks for missed care.

●        In 2020, a secondary analysis of a large RCN dataset was undertaken. The analysis focused upon quality of care, workload, missed nursing care and skill mix across acute and community settings. The work was extended in 2021 to include mental health in-patient settings.

●        A rapid review was undertaken in 2020 to identify what patient safety outcomes were associated with nursing skill mix interventions within in-patient mental health environments.

●        A large-scale survey of 550 District and Community nurses across the UK was undertaken in 2021, focusing on missed nursing care, quality of care, job satisfaction and intention to leave.

●        A qualitative study of District and Community nurses was carried out in 2021. Thirty nurses across the UK were interviewed to add to the survey undertaken (above).

●        In 2021, a meta-synthesis of the qualitative literature was completed to understand more about the nursing contribution during respiratory pandemics.

●        The workforce stream includes the SRA Consensus Development Project (see section 5).

Key Findings

Registered nurse safe staffing compromised across care environments.

Our work indicated pressure upon safe staffing levels across a range of environments. In the community, just under four-fifths indicated at least one vacancy in our survey of district and community nurses. Those teams indicating at least one vacancy had, on average, low RN staffing capacity. The mean proportion of vacancies per team showed that teams with posts unfilled were functioning at an average capacity of 60%. Because of increased numbers of patients following Covid, those responding to the survey also indicated increased caseload due to reduced availability of RNs.

Secondary analysis of acute adult environments revealed that just under two-fifths reported having a full complement of RN staff. However, additional analysis revealed that where full complement did exist, the shortfall in permanent staff was bridged using temporary (bank or agency) staff in around one-third of cases. Even in cases where bank and agency staff were being utilised, one third of all shifts reported being more than 25% below the RN full complement. One of the reviews submitted as part of the CDP identified a range of UK and international evidence pointing to associations between nurse staffing levels in acute environments and poor patient outcomes. Reports of declining quality of care, dissatisfaction with work and exhaustion were also associated with lower RN presence. Our meta-synthesis of qualitative research relating to nursing contribution during pandemic conditions revealed evidence of nursing staff managing depleted resources and working often as the single lone profession ‘on the frontline’. Nurses working extra shifts to address staff shortages was a common strategy employed by health care systems across the globe.

Our rapid review on the relationship between nursing skill mix, safe staffing and inpatient outcomes in mental health environments was inconclusive. The notion of skill mix, nurse staffing and outcomes was poorly conceptualised at the time, leading to evidence in the field being inconsistent and contradictory. Primary research focusing on the relationship between registered mental health nurse resources and outcomes is required.

Missed nursing care is prevalent across settings, has consequences for care quality and is the result of staffing decisions made within health care organisations.

In the community, evidence rated ‘moderate’ identified missed nursing care as a common feature within the literature. Missed nursing care in the community was related to health promotion, optimising health care and well-being, as well as patient monitoring and surveillance. Causes of missed care were related to increased acuity of patients in the community, increasing complexity of care, and unexpected volume of workload. SRA primary research was able to add to the existing evidence base in our 2021 survey, where DNs and CNs identified prevalence of self-reported missed care as high (60% of respondents). Highly cited forms of missed care included: health promotion, report writing, screening, educational interventions and liaising with other professionals. Statistically significant predictors of missed care were, proportion of permanent staff capacity, active caseload size (additional caseload), number of RNs on the team and amount of overtime worked. Secondary analysis of an existing RCN dataset revealed a high prevalence of reported missed care, highest in Emergency Departments (48%). Missed nursing care is prevalent when there is sub-optimal RN staffing. However, on shifts with a full quota of nursing staff the odds of a ‘care left undone’ event is 10% more with the proportion of temporary nursing staff at 50%, compared to shifts with modest understaffing of 25% or less with no temporary nursing staff. A review submitted as part of the CDP identified a range of international evidence highlighting the presence of missed care in both hospital and care home settings. The review cited a number of studies indicating a relationship between missed care and poor outcomes but stopped short of confirming causation.

RN demoralisation, poor job satisfaction and intention to leave (ILL) is prevalent across a range of care environments.

The high prevalence of demoralised nursing staff in SRA studies is noted as a recurrent theme. Of those nurses working in acute environments and included in our secondary analysis, 60% admitted to feeling demoralised. Statistically significant factors in determining demoralisation were observing missed care, poor leadership (limited support and failure to respond to raised concerns), workload (taking a break and overtime and understaffing). The huge personal cost to nurses is also identified through SRA qualitative data.

Over half of respondents to our 2021 survey of DNs and CNs reported having no job satisfaction and two-fifths indicated ILL. Fewer members of permanent staff in the team, working overtime and poor leadership were all statistically significant factors in determining ILL for DNs and CNs.

Our qualitative synthesis of nurse experiences in pandemic conditions also revealed insights into aspects of work satisfaction. The personal contribution made by nurses across the world was revealed to include compromised personal lives, fear, emotional distress, stigma and rejection. These outcomes can be understood in the context of adaptation to increased responsibility and versatility, compensating for organisational failure, and pressure to work under compromised and unpredictable conditions.

Publications

Sworn, K. Booth, A. (2020) A systematic review of the impact of ‘missed care’ in primary, community and nursing home settings. Journal of Nursing Management. https://doi.org/10.1111/jonm.12969 

Senek, M., Robertson, S., Ryan, T., King, R., Wood, E., Tod, A. (2020) The Association between Care Left Undone and Temporary Nursing Staff ratios in Acute Settings: A cross- sectional survey of registered nurses. BMC Health Services Research, 20(1), 1-8. 10.1186/s12913-020-05493-y  

Senek, M., Robertson, S., Ryan, T., Sworn, K., King, R., Wood, E., Tod, A. (2020) Nursing care left undone in community settings: results from a UK cross-sectional survey. Journal of Nursing Management, 28(8): 1968-1974 https://doi.org/10.1111/jonm.12995 

Senek, M., Robertson, S., Ryan, T., Sworn, K., King, R., Wood, E., Taylor, B., Tod, A. (2020) Determinants of Nurse Job Dissatisfaction and Intention to Leave- Findings from a Cross-sectional Survey Analysis in the UK. BMC Nursing, 19(1): 1-10. https://doi.org/10.1186/s12912-020-00481-3 

Senek, M., Robertson, S., Ryan, T., Sworn, K., King, R., Wood, E., Tod, A. (2021) Missed Care in Community and Primary Care. Primary Health Care, 31(2) doi: 10.7748/phc.2021.e1692  

Senek, M., Robertson, S., Ryan, T., King, R., Wood, E., Tod, A. (2021) Consequences of understaffing on frequency and type of rationed community care- a cross-sectional study. International Nursing Studies Accepted 8th March 2022 https://doi.org/10.1016/j.ijnsa.2022.100075 

Ryan, T. Talpur, A., Robertson, S. (2023) Nurses contribution during pandemic conditions: A synthesis of qualitative literature. Journal of Clinical Nursing, 32(9-10), 1738-1747. DOI: 10.1111/jocn.16203 

Senek, M., Robertson, S., King, R., Wood, E., & Ryan, T. (2023). Should I stay or should I go? Why nurses are leaving community nursing in the UK. BMC Health Services Research, 23(1), 164. https://doi.org/10.1186/s12913-023-09163-7  

Robertson, S., Ryan, T., Talpur, A. (2024) Rapid Review Report: Nurse and patient experiences of overcrowding, boarding and corridor care. University of Sheffield, Sheffield. 

Robertson, S., Ryan, T., Talpur, A. (2024) Media Review Report: Nurse and patient experiences of overcrowding, boarding and corridor care. University of Sheffield, Sheffield.