Background: Emergency departments are experiencing crowding and delays in care, which are associated with poorer patient outcomes. Nurse staffing is a key determinant of patient throughput and outcomes, but much of the existing research relies on indicators such as average nurse-to-patient ratios that do not account for daily variation in patient acuity. Acuity-adjusted measures of staffing that reflect the balance between available nursing hours and patient care requirements may provide a more accurate understanding of how nurse staffing affects emergency department performance.Objective: To examine the association between nurse staffing, adjusted for daily case-mix acuity, and patient processes and outcomes. Design: Retrospective longitudinal study.Setting: Emergency department of a university hospital. Participants: Administrative data from 67,010 patients corresponding to 115,078 adult visits over 787 consecutive days.Methods: Routinely collected emergency department data from January 2018 to February 2020 were analysed, with each 24-hour period as the unit of analysis. Actual nursing hours were taken from rosters. Required nursing hours were estimated by linking each patient’s Manchester Triage System category to a pre-determined nursing care time. A staffing deficit was defined as actual minus required hours. Process measures were time to triage, and wait to be seen; outcome measures were patient experience time, and leaving without being seen. Models were run unadjusted and adjusted for potential confounders.Results: On average, 85% of visits were triaged as urgent or very urgent. On 88% of days, actual nursing hours were below the estimated requirement. Median times were 21 minutes to triage, 2.1 hours to be seen, and a median of 7.0 hours total patient experience time. Staffing deficits were associated with poorer patient processes and outcomes (p < 0.001). Each 5-hour deficit (versus no deficit) in nurse staffing was associated with a 21% increase in time to triage (RGM 1.21; 95% CI 1.19 to 1.23), a 12% increase in wait to be seen (RGM 1.12; 95% CI 1.09 to 1.14), a 7% increase in patient experience time (RGM 1.07; 95% CI 1.05 to 1.09), and 16% higher odds of a patient leaving without being seen (OR 1.16; 95% CI 1.11 to 1.22). Conclusions: Lower nurse staffing relative to patient acuity was associated with delays across all stages of care and more patients leaving without being seen. An acuity-adjusted staffing metric provides a more accurate relationship between staffing and patient need than simple nurse-to-patient ratios supporting its use in determining safe emergency department staffing.

Background Frailty is a common condition in older adults which becomes more prevalent and more severe with age. Health and care services designed to meet the needs of older adults living with frailty are expanding in number and scope, but information on the workforce needed to deliver services both now and in the future is lacking.Objectives To understand the service design and staffing configurations for frailty services through gathering data on the setting and purpose of services; target population; referral methods into the service; specific activities delivered; frailty assessment tools; key service and patient outcomes; staff involved; future service priorities and anticipated future workforce requirements.Design National survey, circulated electronically via national networks and organisations involved in the care of patients with frailty (n=26).Setting England health and care settings.Participants Health and care professionals delivering services for people living with frailty.Results There were 93 survey responses from frailty services across England, of which 82 contained usable information. Respondents included clinicians and managers in a range of health and care sectors and the voluntary sector. Frailty services across settings commonly prioritised reducing frailty-associated risks but few focused on prevention. Staff teams included representation across professions, with specialists in older people’s care (eg, geriatricians, advanced practitioners) present in most teams, but non-specialist team members (eg, therapists, social workers and care co-ordinators) comprised a large proportion of the total workforce. All respondents identified similar priorities for their service in future, including reducing frailty progression, and specified needs for additional staff which broadly reflected the current team configurations. However, staff vacancies or unmet patient need due to low capacity was highlighted, and all respondents identified the need for additional staff in future.Conclusions Services designed to identify and manage people with frailty are complex and require a workforce with specialist training to assess, plan and deliver care. Current services are understaffed with insufficient capability to prevent frailty onset or slow progression, thereby failing to address unmet need. Workforce planning and resourcing to address frailty-related needs is urgently required.

Conflict and containment are the most frequently reported incidents in acute mental health care settings. This systematic review seeks to examine and synthesise existing evidence on the association between nurse staffing levels, nursing skill-mix and the occurrence of these incidents in acute mental health wards. Systematic review of quantitative studies examining nurse staffing levels and skill-mix (proportion of nursing shift that are registered or experience levels). Searches were undertaken in CINAHL, Cochrane, Embase, MEDLINE, PsycINFO, SCOPUS and Web of Science. Thirty-five observational studies were reviewed, including 32 on staffing levels (44 analyses) and 12 on skill-mix (14 analyses). Nine analyses found that higher staffing levels were associated with a reduction in reported conflict and containment incidents, while nine found lower staffing levels were associated with reduced incidents. Twenty-six studies found no significant association. For skill-mix, six analyses found that higher skill-mix was associated with a reduction in incidents, seven found no significant association, while one analysis showed reduced skill-mix was associated with a reduction in incidents. The results from analyses are mixed, with no clear conclusions on the relationship of staffing on incident rates. Studies often rely on routine or staff-reported data that are prone to measurement and observer bias, where most analyses did not control for important factors, e.g., patient case-mix or other patient-related factors which could have influenced the results. Although higher staffing levels are sometimes associated with increased incident reporting, this may reflect greater interaction and reporting, or residual (unmeasured) confounding and/or lack of control for mediators and effect modifiers. The review highlights the need for better risk adjustment in observational studies, more refined methodologies and clearer definitions of outcomes to guide workforce planning and policy. Further large-scale research is necessary to understand the complex relationships between staffing, skill-mix and safety in mental health care. There is a major staffing crisis in mental health nursing, but evidence to understand the impact of this on patient outcomes and to guide staffing policies is missing, with several significant limitations in the existing evidence that need to be resolved. Identified evidence on mental health nurse staffing levels and skill-mix is mixed and inconclusive; therefore, no clear implications for workforce planning or deployment can be recommended. However, this prompts debate on the nature and efficacy of routinely collected patient outcomes in clinical practice.

Background:The National Health Service faces significant challenges in recruiting and retaining registered nurses. Recruiting unregistered staff is often adopted as a solution to the registered nurse shortage, but recent research found lower registered nurse staffing levels increase hospital mortality with no evidence that higher levels of assistant staff reduced risk. Objectives:To estimate the consequences, costs and cost-effectiveness of variation in the size and composition of the staff on acute hospital wards in England. To determine if results are likely to be sensitive to staff groups such as doctors and therapists, who are not on ward rosters, associations between staffing and outcomes for multiple staff groups, including medical, are explored at hospital level. Design:A national cross-sectional panel study and a patient-level longitudinal observational study using routine data. Setting:All English acute hospital Trusts and a subsample of four Trusts for the patient-level study. Interventions:Naturally occurring variation in the size and composition of the workforce. Participants:Patients experiencing a hospital admission with an overnight stay and nursing staff providing care on inpatient wards. Outcomes:Death, patient and staff experience, length of stay, re-admission, adverse events, incidents (Datix), staff sickness, costs and quality-adjusted life-years. Data sources:Publicly available records of hospital activity, staffing and outcomes (cross-sectional study) and hospital administrative systems (longitudinal study). Results:In the cross-sectional study, lower staffing levels from doctors and allied health professionals were associated with increased risk of death. Higher nurse staffing levels were associated with better patient experience and staff well-being. In the longitudinal study, for adult inpatients, exposure to days with lower-than-expected registered nurses or nursing assistant staff was associated with increased hazard of death (adjusted hazard ratio 1.08/1.07, 95% confidence interval 1.07 to 1.09/1.06 to 1.08) and longer hospital stays. Low registered nurse staffing was also associated with increased hazard of re-admission (adjusted hazard ratio 1.01, 95% confidence interval 1.01 to 1.02). Eliminating low staffing cost £2778 per quality-adjusted life-years gained. Avoidance of registered nurse understaffing gave more benefits and was more cost-effective for highly acute patients. Although high bank or agency staffing was associated with increased hazard of death, avoiding low staffing using temporary staff still reduced mortality but was more costly and less effective than using permanent staff. If costs of avoided hospital stays are included, avoiding low staffing generates a net cost saving. Exploration of thresholds for low staffing indicated a greater beneficial effect from registered nurse staffing higher than current norms. Limitations:This is an observational study. Causal inferences cannot be made from these results in isolation. Quality-adjusted life-years gains were estimated, although conclusions are not sensitive to assumptions or discount rates. We used current ward norms as reference for low staffing. Conclusions:Our results show the adverse effects of low nurse staffing but also show that medical and allied health professional staffing are important considerations for patient safety. Eliminating low registered nurse staffing gave more benefits than eliminating assistant staffing. Future work:Research is needed to validate methods to determine nurse staffing requirements, and the interaction between registered nurse and assistant staffing needs further exploration. Study registration:This study is registered as Current Controlled Trials ClinicalTrials.gov NCT04374812. Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128056) and is published in full in Health and Social Care Delivery Research; Vol. 13, No. 25. See the NIHR Funding and Awards website for further award information.

BACKGROUND:Descriptive studies have documented high hospital nurse burnout and turnover but there are few, if any, large-scale evaluations of organizational interventions to improve clinician retention. The Magnet model is an organizational hospital intervention associated with better clinician and patient outcomes but there is insufficient evidence as to whether the Magnet model based on structural empowerment of clinicians results in better outcomes or rewards hospitals with good work environments, and whether the Magnet model can be implemented at scale outside the United States. OBJECTIVE:To evaluate whether Magnet4Europe-a multiyear organizational intervention of European hospitals-could be implemented and would result in improvements in nurse well-being, care quality, and patient safety. DESIGN:Quasi-experimental longitudinal evaluation of 56 European intervention hospitals in 6 countries. Hospital-level implementation of the intervention measured by changes (from baseline to follow-up) in 77 Magnet model intervention targets. Outcome measures (eg, nurse burnout, intent to leave, quality of care, patient safety) were derived from surveys of nurses (4546 nurses at baseline; 3171 at follow-up). FINDINGS:Hospitals that implemented intervention targets during the study period observed reductions in nurse burnout, nurses' intentions to leave their jobs, and unfavorable care quality. Each 10-percentage-point increase in intervention target implementation was associated with 2.7%-point reduction in nurses who intend to leave (β -2.66; 95% CI: -4.74, -0.58, P <0.05). Hospitals which implemented more than 25% of intervention targets observed 6.3%-point reduction in nurse burnout, 7.6%-point reduction in intent to leave, 6.4%-point reduction in unfavorable care quality, and 3.7%-point reduction in unfavorable patient safety. Improvements in hospital percentages of nurses reporting staffing adequacy were associated with reductions in burnout, intentions to leave, unfavorable care quality, and patient safety. CONCLUSION:Successful implementation of Magnet4Europe demonstrates promise for international adoption at scale of Magnet as an organizational intervention for improving clinician well-being, care quality, and patient safety.

INTRODUCTION:Job satisfaction and intention to leave have been consistently linked to the working environment. However, there are few studies of interventions for improving the environment or staff outcomes. AIM:To determine the impact of implementing a framework for safe nurse staffing on the environment and staff outcomes. This involved an assessment of required nursing hours per patient day, supernumerary nurse in charge and minimum 80:20 skill-mix, with intentional changes in staffing if required. DESIGN:A pre-post observational design. METHODS:This was a prospective observational study in six medical and/or surgical wards across three acute hospitals in Ireland. The outcomes were measured pre- and post-implementation, and included the environment, using the Practice Environment Scale of the Nursing Work Index; and job satisfaction and intention to leave using a dichotomised 4-point scale. OUTCOMES:Changes in staffing levels, adjustments to skill-mix and the supervisory role of the ward leader were seen following the implementation. A multilevel model found significant increases over time on three of the five Nursing Work Index subscales: Staffing and Resource Adequacy, Collegial Nurse-Physician Relations, and Nurse Participation in Hospital Affairs. Job satisfaction increased and intention to leave decreased, although the differences were not statistically significant. Increased job satisfaction was significantly associated with Staffing and Resource Adequacy, Collegial Nurse Physician Relations and Nurse Manager, Leadership and Support. A decreased odds of intention to leave was associated with increased job satisfaction. CONCLUSION:There were significant improvements in the environment following the implementation of the Framework. Three of the practice environment subscales were significantly associated with job satisfaction, while job satisfaction is a predictor of intention to stay. This study indicates that intentional changes to staffing can result in improvements to working environments which may in turn have an impact on job satisfaction and furthermore, on intention to stay. IMPACT:This study investigated intentional changes to nurse staffing in medical and surgical wards, examining the impact pre- and post-implementation. This study underlined that when staffing is based on a systematic approach, based on a Framework for Safe Nurse Staffing, a subsequent improvement can be seen in staff's perceptions of the work environment, along with improvements in staff outcomes. This research will impact on staff working in acute settings as a means of determining staffing and improving outcomes using a Framework for Safe Nurse Staffing. REPORTING METHOD:STROBE checklist. PATIENT OR PUBLIC CONTRIBUTION:No patient or public contribution.

AIM:To examine burnout levels, nurse perceptions of the work environment, job satisfaction, intention to stay and quality of care for nurses working in emergency departments before and following a planned change to nurse staffing levels. DESIGN:A pre-post observational design. METHODS:A systematic approach (Nursing Hours per Patient Presentation) was introduced to determine nurse staffing levels based on patient presentations resulting in adjustments to nurse staffing. Data on burnout, the work environment, intention to stay, job satisfaction and quality of care were collected from three emergency departments prior to and following the adjustments to nurse staffing. RESULTS:An adjustment to nurse staffing levels was made to all three emergency departments. Mean emotional exhaustion scores were significantly lower, and quality of work environment scores and levels of job satisfaction were significantly higher for nurses following staffing adjustments. There was an increase to the proportion of nurses who perceived an improvement in quality of care delivered. In general, the results indicated improvements in outcomes following adjustments to nurse staffing levels. CONCLUSION:A more holistic organisational approach is required to address staffing in emergency departments. Initiatives that involve frontline nurses in resource planning facilitating a bottom-up approach to allow for improved work environments would be beneficial. IMPACT:This study addressed a planned change to nurse staffing levels in emergency departments and staff outcomes pre and post changes to staffing levels. This study highlighted that staffing an emergency department, based on nursing hours per patient presentation, was associated with improvements in staff outcomes. The research will impact on nurses working in emergency departments as outcomes from this research were used to develop a Framework for Safe Nurse Staffing and Skill Mix in Emergency Care Settings. REPORTING METHOD:STROBE and SQUIRE checklist. PATIENT OR PUBLIC CONTRIBUTION:No Patient or Public Contribution.

Background: Nursing shortages are detrimental to healthcare services due to the loss of skills and experience in patient care. In England, the retention of NHS nurses in their early- and late-career stages is of particular interest because they have the highest leaver rates. Aim: To explore in detail what early- and late-career NHS nurses value and expect from their employers to retain them in their jobs and the profession. Insights from nurses at two ends of the career spectrum could offer a new perspective and shed light on seemingly persistent and detrimental factors for retention. Methods: Semistructured focus groups and interviews, using Microsoft Teams, were conducted between April 2023 and February 2024 with early-career nurses (i.e., first registration between 2019 and 2024) and late-career nurses (i.e., 55 years and over). We also analysed open-text comments from a related survey (2023), which explored nurses' working lives and retention. Results: 27 nurses participated in the qualitative study, and 784 nurses provided open-text comments from the cross-sectional survey. Except for tailored support when entering the profession and adequate remuneration when leaving nursing, the organisational factors cited by nurses as key to their retention were similar for both groups. Some of these 'persistent' factors potentially detrimental to retention across both groups included a negative work culture, lack of adequate resources and limited opportunities for career development. Perceived inadequate remuneration should not be underestimated either. Conclusion: Support from the leadership team and/or colleagues seems to partially alleviate the stress of working in strenuous environments. However, addressing 'persistent' and detrimental organisational factors throughout nurses' careers should continue to be a priority to retain them, safeguard their well-being and enable them to deliver the standard of care they aspire to. Nursing Management Implications: The findings have significant implications for improving the retention of early- and late-career NHS nurses.

Ongoing challenges in the provision of care, driven by growing care complexity and nursing shortages, prompt us to reconsider the basis for efficient division of nursing labour. In organising nursing work, traditionally the focus has been on identifying nursing tasks that can be delegated to other less expensive and less highly educated staff, in order to make best use of scarce resources. We argue that nursing care activities are connected and intertwined. As such ‘entanglement’ is a hallmark of nursing work, it needs to be understood to identify optimal and sustainable options for division of labour in nursing.We elaborate the value of entanglement as a theoretical proposition to shift the focus away from old models of task-oriented nursing and put forward a model of labour division that acknowledges the importance of entangled nursing care activities. We build on the work of Jackson, Anderson, and Maben (2021) in which nursing work was conceptualised as a combination of cognitive, emotional, organisational, and physical labour. We assert that just allocating labour based on the type of work will not do the trick. The complexity of nursing work also needs to be considered. This is commonly framed as the combination of care activities required in the interest of patients and the complexity of each of these activities (‘task complexity’). Integrating the concept of entanglement brings to light that even ‘simple’ care activities contribute to the complexity of work, as activities are potentially bound up with other activities (‘entangled care activities’). That is to say, nursing work is not simply a function of the tasks undertaken. Based on our conceptualisation, we propose that the existence and nature of entangled care activities (‘task entanglement’) should be taken into account, to express what is needed in dividing the labour (‘labour complexity’). This should in turn underpin future staffing and skill mix decisions.In the pursuit of guaranteeing high quality of care, further research on ‘ideal’ mixes of skills and optimal team compositions in various health care contexts is necessary. For nursing practice, our theoretical proposition can be used to explicate the complexity of daily work. Hereby, giving nurses something to demonstrate their added value in providing the best care to patients.Tweetable abstractNursing work is more than the accumulation of care activities; to comprehend its complexity care entanglement (intertwining) should be acknowledged.

Descriptive studies have documented high hospital nurse burnout and turnover but there are few, if any, large-scale evaluations of organizational interventions to improve clinician retention. The Magnet model is an organizational hospital intervention associated with better clinician and patient outcomes but there is insufficient evidence as to whether the Magnet model based on structural empowerment of clinicians results in better outcomes or rewards hospitals with good work environments, and whether the Magnet model can be implemented at scale outside the United States. To evaluate whether Magnet4Europe—a multiyear organizational intervention of European hospitals—could be implemented and would result in improvements in nurse well-being, care quality, and patient safety. Quasi-experimental longitudinal evaluation of 56 European intervention hospitals in 6 countries. Hospital-level implementation of the intervention measured by changes (from baseline to follow-up) in 77 Magnet model intervention targets. Outcome measures (eg, nurse burnout, intent to leave, quality of care, patient safety) were derived from surveys of nurses (4546 nurses at baseline; 3171 at follow-up). Hospitals that implemented intervention targets during the study period observed reductions in nurse burnout, nurses’ intentions to leave their jobs, and unfavorable care quality. Each 10-percentage-point increase in intervention target implementation was associated with 2.7%-point reduction in nurses who intend to leave (β −2.66; 95% CI: −4.74, −0.58, P <0.05). Hospitals which implemented more than 25% of intervention targets observed 6.3%-point reduction in nurse burnout, 7.6%-point reduction in intent to leave, 6.4%-point reduction in unfavorable care quality, and 3.7%-point reduction in unfavorable patient safety. Improvements in hospital percentages of nurses reporting staffing adequacy were associated with reductions in burnout, intentions to leave, unfavorable care quality, and patient safety. Successful implementation of Magnet4Europe demonstrates promise for international adoption at scale of Magnet as an organizational intervention for improving clinician well-being, care quality, and patient safety.

Background Independent inquiries have identified that appropriate staffing in maternity units is key to enabling quality care and minimising harm, but optimal staffing levels can be difficult to achieve when there is a shortage of midwives. The services provided and how they are staffed (total staffing, skill-mix and deployment) have been changing, and the effects of workforce changes on care quality and outcomes have not been assessed. This study aims to explore the association between daily midwifery staffing levels and the rate of reported harmful incidents affecting mothers and babies.Methods We conducted a cross-sectional analysis of daily reports of clinical incidents in maternity inpatient areas matched with inpatient staffing levels for three maternity services in England, using data from April 2015 to February 2020. Incidents resulting in harm to mothers or babies was the primary outcome measure. Staffing levels were calculated from daily staffing rosters, quantified in Hours Per Patient Day (HPPD) for midwives and maternity assistants. Understaffing was defined as staffing below the mean for the service. A negative binomial hierarchical model was used to assess the relationship between exposure to low staffing and reported incidents involving harm.Results The sample covered 106,904 maternal admissions over 46 months. The rate of harmful incidents in each of the three services ranged from 2.1 to 3.0 per 100 admissions across the study period. Understaffing by registered midwives was associated with an 11% increase in harmful incidents (adjusted IRR 1.110, 95% CI 1.002,1.229). Understaffing by maternity assistants was not associated with an increase in harmful incidents (adjusted IRR 0.919, 95% 0.813,1.039). Analysis of specific types of incidents showed no statistically significant associations, but most of the point estimates were in the direction of increased incidents when services were understaffed.Conclusion When there is understaffing by registered midwives, more harmful incidents are reported but understaffing by maternity assistants is not associated with higher risk of harms. Adequate registered midwife staffing levels are crucial for maintaining safety. Changes in the profile of maternity service workforces need to be carefully scrutinised to prevent mothers and babies being put at risk of avoidable harm.

Importance Many studies show the adverse consequences of insufficient nurse staffing in hospitals, but safe and effective staffing is unlikely to be just about staff numbers. There are considerable areas of uncertainty, including whether temporary staff can safely make up shortfalls in permanent staff and whether using experienced staff can mitigate the effect of staff shortages. Objective To explore the association of the composition of the nursing team with the risk of patient deaths. Design, Setting, and Participants This patient-level longitudinal observational study was conducted in 185 wards in 4 acute hospital trusts in England between April 2015 and March 2020. Eligible participants were patients with an overnight stay and nursing staff on adult inpatient wards. Data analysis was conducted from month April 2022 to June 2023. Exposure Naturally occurring variation during the first 5 days of hospital admission in exposure to days of low staffing from registered nurses (RNs) and nursing support (NS) staff, the proportion of RNs, proportion of senior staff, and proportion of hospital-employed (bank) and agency temporary staff. Main Outcomes and Measures The primary outcome was death within 30 days of admission. Mixed-effect Cox proportional hazards survival models were used. Results Data from 626 313 admissions (319 518 aged ≥65 years [51.0%]; 348 464 female [55.6%]) were included. Risk of death was increased when patients were exposed to low staffing from RNs (adjusted hazard ratio [aHR], 1.08; 95% CI 1.07-1.09) and NS staff (aHR, 1.07; 95% CI, 1.06-1.08). A 10% increase in the proportion of temporary RNs was associated with a 2.3% increase in the risk of death, with no difference between agency (aHR, 1.023; 95% CI, 1.01-1.04) and bank staff (aHR, 1.02; 95% CI, 1.01-1.04). A 10% increase in the proportion of agency NS was associated with a 4% increase in risk of death (aHR, 1.04; 95% CI, 1.02-1.06). Evidence on the seniority of staff was mixed. Model coefficients were used to estimate the association of using temporary staff to avoid low staffing and found that risk was reduced but remained elevated compared with baseline. Conclusions and Relevance This cohort study found that having senior nurses in the nursing team did not mitigate the adverse outcomes associated with low nurse staffing. These findings indicate that while the benefits of avoiding low staffing may be greater than the harms associated with using temporary staff, particularly for RNs, risk remains elevated if temporary staff are used to fill staffing shortages, which challenges the assumption that temporary staff are a cost-effective long-term solution to maintaining patient safety.

BackgroundThe relationship between nurse staffing, skill-mix and quality of care has been well-established in medical and surgical settings, however, there is relatively limited evidence of this relationship in emergency departments. Those that have been published identified that lower nurse staffing levels in emergency departments are generally associated with worse outcomes with the conclusion that the evidence in emergency settings was, at best, weak.MethodsWe searched thirteen electronic databases for potentially eligible papers published in English up to December 2023. Studies were included if they reported on patient outcomes associated with nurse staffing within emergency departments. Observational, cross-sectional, prospective, retrospective, interrupted time-series designs, difference-in-difference, randomised control trials or quasi-experimental studies and controlled before and after studies study designs were considered for inclusion. Team members independently screened titles and abstracts. Data was synthesised using a narrative approach.ResultsWe identified 16 papers for inclusion; the majority of the studies (n = 10/16) were observational. The evidence reviewed identified that poorer staffing levels within emergency departments are associated with increased patient wait times, a higher proportion of patients who leave without being seen and an increased length of stay. Lower levels of nurse staffing are also associated with an increase in time to medications and therapeutic interventions, and increased risk of cardiac arrest within the emergency department.ConclusionOverall, there remains limited high-quality empirical evidence addressing the association between emergency department nurse staffing and patient outcomes. However, it is evident that lower levels of nurse staffing are associated with adverse events that can result in delays to the provision of care and serious outcomes for patients. There is a need for longitudinal studies coupled with research that considers the relationship with skill-mix, other staffing grades and patient outcomes as well as a wider range of geographical settings.Tweetable abstractLower levels of nurse staffing in emergency departments are associated with delays in patients receiving treatments and poor quality care including an increase in leaving without being seen, delay in accessing treatments and medications and cardiac arrest.

Background Preventing readmission to hospital after giving birth is a key priority, as rates have been rising along with associated costs. There are many contributing factors to readmission, and some are thought to be preventable. Nurse and midwife understaffing has been linked to deficits in care quality. This study explores the relationship between staffing levels and readmission rates in maternity settings.Methods We conducted a retrospective longitudinal study using routinely collected individual patient data in three maternity services in England from 2015 to 2020. Data on admissions, discharges and case-mix were extracted from hospital administration systems. Staffing and workload were calculated in Hours Per Patient day per shift in the first two 12-hour shifts of the index (birth) admission. Postpartum readmissions and staffing exposures for all birthing admissions were entered into a hierarchical multivariable logistic regression model to estimate the odds of readmission when staffing was below the mean level for the maternity service.Results 64 250 maternal admissions resulted in birth and 2903 mothers were readmitted within 30 days of discharge (4.5%). Absolute levels of staffing ranged between 2.3 and 4.1 individuals per midwife in the three services. Below average midwifery staffing was associated with higher rates of postpartum readmissions within 7 days of discharge (adjusted OR (aOR) 1.108, 95% CI 1.003 to 1.223). The effect was smaller and not statistically significant for readmissions within 30 days of discharge (aOR 1.080, 95% CI 0.994 to 1.174). Below average maternity assistant staffing was associated with lower rates of postpartum readmissions (7 days, aOR 0.957, 95% CI 0.867 to 1.057; 30 days aOR 0.965, 95% CI 0.887 to 1.049, both not statistically significant).Conclusion We found evidence that lower than expected midwifery staffing levels is associated with more postpartum readmissions. The nature of the relationship requires further investigation including examining potential mediating factors and reasons for readmission in maternity populations.

Background Shortages of nurses are one of the biggest challenges healthcare systems face around the world. Given the wide range of contexts and individuals working in nursing, a ‘one-size-fits-all’ retention strategy is unlikely to be effective. Knowing what matters most to nurses at different career stages would help employers and policy-makers who want to enhance nurse retention to design tailored strategies. Objective To review and synthesise findings from recently published literature on the push-pull factors influencing nurses' decisions at the micro level, to enter and stay (or leave) at key career stages (i.e. pre-career, training, early-, mid- and late-career, and return to practice). Methods We undertook a set of structured searches of the literature and a narrative synthesis to explore factors that motivate individuals to enter the nursing profession and the push-pull factors influencing nurse retention at different career stages. Electronic databases CINAHL, Medline, Scopus and Embase were searched in December 2022 (and updated in November 2023) for English language publications. Additional health workforce sources, such as King's Fund and Nuffield Trust, were also searched. Results 227 articles met the criteria for inclusion in the narrative review. Some push-pull factors were common to nurses across all career stages, including workplace support, flexible schedule patterns, opportunities for career advancement, fair treatment and salaries. In contrast, some challenges and push-pull factors were unique to each career stage. Students experienced difficulty in adjusting and balancing education and life; early-career nurses experienced transition shocks; mid-career nurses were frustrated by the lack of career advancement; late-career nurses desired more recognition; nurses returning to practice were discouraged by their lack of confidence and the cost of return-to-practice courses. Conclusion Our findings reinforce the view that factors influencing nurses' choices about whether to enter, continue or leave nursing jobs are multi-factorial and multi-dimensional. Policy and employment practices should be informed by research that has a more nuanced insight into what matters most to whom and at what career stage. Tweetable abstract Nuanced insight into motivations is needed to attract and retain a mix of nurse throughout their careers @ZEjebu @julia_philippou @JaneEball.

Background/Aims Demand for mental health services is high, but so are vacancy levels for registered nurses in mental health. To effectively address the workforce disparity, we need to engage with nurses to understand better the rewards and challenges of being part of the UK's mental health nursing workforce. The aim of the study set out in this protocol will be to identify modifiable workplace factors impacting nurses' work lives and wellbeing. Methods A protocol for an online cross-sectional survey exploring the work lives and wellbeing of registered nurses working in mental health in the UK. Implications This survey will provide an understanding of the daily challenges and rewards of mental health nursing. In understanding the modifiable workplace factors impacting nurses, the authors will provide the evidence and recommendations necessary to develop and implement workplace policies and interventions supporting nurse retention, recruitment and wellbeing.

Introduction Like many countries, England has a national shortage of registered nurses. Employers strive to retain existing staff, to ease supply pressures. Disproportionate numbers of nurses leave the National Health Services (NHS) both early in their careers, and later, as they near retirement age. Research is needed to understand the job preferences of early-career and late-career nurses working in the NHS, so tailored policies can be developed to better retain these two groups.Methods and analysis We will collect job preference data for early-career and late-career NHS nurses, respectively using two separate discrete choice experiments (DCEs). Findings from the literature, focus groups, academic experts and stakeholder discussions will be used to identify and select the DCE attributes (ie, job features) and levels. We will generate an orthogonal, fractional factorial design using the experimental software Ngene. The DCEs will be administered through online surveys distributed by the regulator Nursing and Midwifery Council. For each group, we expect to achieve a final sample of 2500 registered NHS nurses working in England. For early-career nurses, eligible participants will be registered nurses who graduated in the preceding 5 years (ie, 2019–2023). Eligible participants for the late-career survey will be registered nurses aged 55 years and above. We will use conditional and mixed logit models to analyse the data. Specifically, study 1 will estimate the job preferences of early-career nurses and the possible trade-offs. Study 2 will estimate the retirement preferences of late-career NHS nurses and the potential trade-offs.Ethics and dissemination The research protocol was reviewed and approved by the host research organisation Ethics Committees Research Governance (University of Southampton, number 80610) (https://www.southampton.ac.uk/about/governance/regulations-policies/policies/ethics). The results will be disseminated via conference presentations, publications in peer-reviewed journals and annual reports to key stakeholders, the Department of Health and Social Care, and NHS England/Improvement retention leaders.Registration details Registration on OSF http://doi.org/10.17605/OSF.IO/RDN9G.

This Element reviews the evidence for three workplace conditions that matter for improving quality and safety in healthcare: staffing; psychological safety, teamwork, and speaking up; and staff health and well-being at work. The authors propose that these are environmental prerequisites for improvement. They examine the relationship between staff numbers and skills in delivering care and the attainment of quality of care and the ability to improve it. They present evidence for the importance of psychological safety, teamwork, and speaking up, noting that these are interrelated and critical for healthcare improvement. They present evidence of associations between staff well-being at work and patient outcomes. Finally, they suggest healthcare improvement should be embedded into the day-to-day work of frontline staff; adequate time and resources must be provided, with quality as the mainstay of professionals' work. Every day at every level, the working context must support the question 'how could we do this better?' This title is also available as Open Access on Cambridge Core.