Peter Griffiths

The purpose of this study was to identify the treatment-associated problems that most impact on patients undergoing cancer chemotherapy, how problems relate to experiences of supportive care and variations in experience between cancer treatment centres. A survey administered to patients at six cancer centres in England explored variations of prevalence of 17 cancer chemotherapy-associated problems and associated supportive care. Problem items were identified as the most frequently experienced and severe when experienced in a scoping and consensus exercise. A health-related quality of life (HRQoL) measure, the EQ5D, was included to measure impact of problems. A total of 363 completed questionnaires were returned (response rate 43 %, median 61 %). The most prevalent problem was 'tiredness/fatigued' (90 %), followed by 'changes in taste & smell' (69 %) and 'difficulty managing everyday tasks' (61 %). Significant variations in problem prevalence existed between c...

To inform healthcare workforce policy decisions by showing how patient perceptions of hospital care are associated with confidence in nurses and doctors, nurse staffing levels and hospital work environments. Cross-sectional surveys of 66 348 hospital patients and 2963 inpatient nurses. Patients surveyed were discharged in 2010 from 161 National Health Service (NHS) trusts in England. Inpatient nurses were surveyed in 2010 in a sample of 46 hospitals in 31 of the same 161 trusts. The 2010 NHS Survey of Inpatients obtained information from 50% of all patients discharged between June and August. The 2010 RN4CAST England Nurse Survey gathered information from inpatient medical and surgical nurses. Patient ratings of their hospital care, their confidence in nurses and doctors and other indicators of their satisfaction. Missed nursing care was treated as both an outcome measure and explanatory factor. Patients' perceptions of care are significantly eroded by lack of confidence in eith...

To explore why adherence to vital signs observations scheduled by an Early Warning Score protocol reduces at night. Regular vital signs observations can reduce avoidable deterioration in hospital. Early Warning Score protocols set the frequency of these observations by the severity of a patient's condition. Vital signs observations are taken less frequently at night, even with an Early Warning Score in place, but no literature has explored why. A qualitative interpretative design informed this study. Seventeen semi-structured interviews with nursing staff working on wards with varying levels of adherence to scheduled vital signs observations. A thematic analysis approach was used. At night, nursing teams found it difficult to balance the competing care goals of supporting sleep with taking vital signs observations. The night-time frequency of these observations was determined by clinical judgement, ward-level expectations of observation timing and the risk of disturbing other pa...

To provide an overview of the evidence base on the effectiveness of workforce interventions for improving the outcomes for older people with cancer, as well as analysing key features of the workforce associated with those improvements. Systematic review. Relevant databases were searched for primary research, published in English, reporting on older people and cancer and the outcomes of interventions to improve workforce knowledge, attitudes or skills; involving a change in workforce composition and/or skill mix; and/or requiring significant workforce reconfiguration or new roles. Studies were also sought on associations between the composition and characteristics of the cancer care workforce and older people's outcomes. A narrative synthesis was conducted and supported by tabulation of key study data. Studies (n=24) included 4555 patients aged 60+ from targeted cancer screening to end of life care. Interventions were diverse and two-thirds of the studies were assessed as low qua...

Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital wards and in nursing homes. A considerable body of evidence support the hypothesis that lower levels of registered nurses on duty increases the likelihood of patients dying on hospital wards, and the risk of many aspects of care being either delayed or left undone (missed). However, the direct consequence of missed care remains unclear. Systematic review. We searched Medline (via Ovid), CINAHL (EBSCOhost) and Scopus for studies examining the association of missed nursing care and at least one patient outcome. Studies regarding registered nurses, healthcare assistants/support workers/nurses' aides were retained. Only adult settings were included. Because of the nature of the review, qualitative studies, editorials, letters and commentaries were excluded. PRISMA guidelines were followed in reporting the review. Fourteen studies reported associations between missed care and patient outco...

Research into relational care in hospitals will be facilitated by a focus on staff-patient interactions. The Quality of Interactions Schedule (QuIS) uses independent observers to measure the number of staff-patient interactions within a healthcare context, and to rate these interactions as 'positive social'; 'positive care'; 'neutral'; 'negative protective'; or 'negative restrictive'. QuIS was developed as a research instrument in long term care settings and has since been used for quality improvement in acute care. Prior to this study, its use had not been standardised, and reliability and validity in acute care had not been established. In 2014 and 2015 a three - phase study was undertaken to develop and test protocols for the use of QuIS across three acute wards within one NHS trust in England. The phases were: (1) A pilot of 16 h observation which developed implementation strategies for QuIS in this context; (2) training two observers and ...

older people with dementia admitted to hospital for acute illness have higher mortality and longer hospital stays compared to those without dementia. Cognitive impairment (CI) is common in older people, and they may also be at increased risk of poor outcomes. retrospective observational study of unscheduled admissions aged ≥75 years. Admission characteristics, mortality rates and discharge outcomes were compared between three groups: (i) known dementia diagnosis (DD), (ii) CI but no diagnosis of dementia and (iii) no CI. of 19,269 admissions (13,652 patients), 19.8% had a DD, 11.6% had CI and 68.6% had neither. Admissions with CI or DD were older and had more females than those with no CI, and were more likely to be admitted through the Emergency Department (88.4% and 90.7%, versus 82.0%) and to medical wards (89.4% and 84.4%, versus 76.8%). Acuity levels at admission were similar between the groups. Patients with CI or DD had more admissions at 'high risk' from malnutrition...

Recent studies of the quality of in-hospital care have used the Quality of Interaction Schedule (QuIS) to rate interactions observed between staff and inpatients in a variety of ward conditions. The QuIS was developed and evaluated in nursing and residential care. We set out to develop methodology for summarising information from inter-rater reliability studies of the QuIS in the acute hospital setting. Staff-inpatient interactions were rated by trained staff observing care delivered during two-hour observation periods. Anticipating the possibility of the quality of care varying depending on ward conditions, we selected wards and times of day to reflect the variety of daytime care delivered to patients. We estimated inter-rater reliability using weighted kappa, κ w , combined over observation periods to produce an overall, summary estimate, [Formula: see text]. Weighting schemes putting different emphasis on the severity of misclassification between QuIS categories were compared, as...

Variation in post-operative mortality rates has been associated with differences in registered nurse staffing levels. When nurse staffing levels are lower there is also a higher incidence of necessary but missed nursing care. Missed nursing care may be a significant predictor of patient mortality following surgery. Examine if missed nursing care mediates the observed association between nurse staffing levels and mortality. Data from the RN4CAST study (2009-2011) combined routinely collected data on 422,730 surgical patients from 300 general acute hospitals in 9 countries, with survey data from 26,516 registered nurses, to examine associations between nurses' staffing, missed care and 30-day in-patient mortality. Staffing and missed care measures were derived from the nurse survey. A generalized estimation approach was used to examine the relationship between first staffing, and then missed care, on mortality. Bayesian methods were used to test for mediation. Nurse staffing and m...

Objective: The aim of this paper is to examine the costs of introducing a nursing-led ward program together with examining the impact this may have on patients' outcomes.Methods: The study had a sample size of 177 patients with a mean age of 77, and randomized to either a treatment group (care on a nursing-led ward, n = 97) or a control group (standard care usually on a consultant-led acute ward, n = 80). Resource use data including length of stay, tests and investigations performed, and multidisciplinary involvement in care were collected.Results: There were no significant differences in outcome between the two groups. The inpatient costs for the treatment group were significantly higher, due to the longer length of stay in this group. However, the postdischarge costs were significantly lower for the treatment group.Conclusions: The provision of nursing-led intermediate care units has been proposed as a solution to inappropriate use of acute medical wards by patients who requir...

The Department of Health (DH) once had lofty aspirations for reform of the healthcare workforce. Its document A Health Service of All The Talents (HSAT) advocated patient-led planning with a workforce of 'teams... rather than different professional tribes' (DH 2000) (see box page 63 ).

This paper discusses research evidence about changes in the size and composi-tion of the health care workforce. Much of it concerns ''skill mix'' – a term often used to describe the mix of posts, grades or occupations in an organization or the combinations of activities or skills need-ed for each "job" within the organization (Buchan and Dal Puz 2002). It is, on the face of it, a dry subject: remote from the day to day concerns and drama of clinical care. A rarefied pursuit and, perhaps, an example of researchers preoccupied with research that has little application 'to practice'. On the other hand, workforce research is a surprisingly emotive subject because it raises questions about the fun-damental value of what people: health care workers, actually do, how they spend their working lives and, ultimately, their ability to make a living. For users of health services it raises questions about the quality of the care they receive and, ultimately, of ...

Increasing numbers of the population are living with long-term life-limiting conditions with a significant proportion characterised by multimorbidity. Patients with these conditions often experience high volumes of clinical interaction involving them, their caregivers and healthcare providers in complex patterns of organising, coordinating, negotiating and managing care. A better understanding of the sources of experienced complexity and multimorbidity, from the patient perspective is paramount to improve capacity and manage workload to promote improved experience of illness, more effective healthcare utilisation and improved healthcare outcomes. To better understand the sources of complexity we will undertake an evidence synthesis of qualitative studies of patient and informal carer experiences of three common long-term life-limiting conditions. We will investigate what is known about these diseases at different stages in disease progression, treatment regimens and places of care. ...

Despite concerns as to whether nurses can perform reliably and effectively when working longer shifts, a pattern of two 12- to 13-hour shifts per day is becoming common in many hospitals to reduce shift to shift handovers, staffing overlap, and hence costs. To describe shift patterns of European nurses and investigate whether shift length and working beyond contracted hours (overtime) is associated with nurse-reported care quality, safety, and care left undone. Cross-sectional survey of 31,627 registered nurses in general medical/surgical units within 488 hospitals across 12 European countries. A total of 50% of nurses worked shifts of ≤ 8 hours, but 15% worked ≥ 12 hours. Typical shift length varied between countries and within some countries. Nurses working for ≥ 12 hours were more likely to report poor or failing patient safety [odds ratio (OR)=1.41; 95% confidence interval (CI), 1.13-1.76], poor/fair quality of care (OR=1.30; 95% CI, 1.10-1.53), and more care activities left und...

Nursing research is a diverse discipline which draws on methods and methodologies from across the social, behavioural and biomedical sciences. Few if any of the approaches to research used within nursing are unique; however, their application within the complex milieu of nursing care has frequently raised distinctive challenges and generated novel applications. Nursing Research Methods brings together seminal sources that illustrate both the origins and the state of the art of research in nursing. The editors draw on ...

Objectives: To assess whether variation in the provision of cancer specialist nurses is associated with the experiences of care for patients undergoing treatment for cancer. Methods: This is a cross-sectional study using routinely collected national survey data in 158 acute hospital National Health Service (NHS) Trusts in England. Patients with a primary diagnosis of cancer who attended hospital as inpatients or day cases in the first three months of 2010 responded to a national survey ( n = 67,713, response rate 67%). Patient perceptions of coordination of care, quality of information provision, emotional support and support for symptom management were studied. Results: Patients in Trusts that had the fewest patients per specialist nurse were more likely to report that people treating and caring for them worked well together (adjusted odds ratio 1.08, 95% confidence interval 1.01–1.15; p = 0.02) and provided enough emotional support during ambulatory treatment (1.15, 1.01–1.32; p =...

Background:'Failure to rescue'-death after a treatable complication-is used as a nursing sensitive quality indicator in the USA. It is associated with the size of the nursing workforce relative to patient load, for example patient to nurse ratio, although assessments of nurse sensitivity have not previously considered other staff groups. This study aims to assess the potential to derive failure to rescue and a proxy measure, based on long length of stay, from English hospital administrative data. By exploring change in coding practice ...

Background “Failure to rescue” refers to a failure to prevent a clinically important deterioration resulting from a complication of an underlying illness (eg cardiac arrest in a patient with acute myocardial infarction) or a complication of medical care (eg major haemorrhage after surgery). Rates of failure to rescue are widely recognized and used as patient safety indicators but have not been widely used in the NHS. Recently they have received renewed attention after the National Institute for Health and Clinical Excellence ( ...

There is little strong evidence relating to the impact of single-room accommodation on healthcare quality and safety. We explore the impact of all single rooms on staff and patient experience; safety outcomes; and costs. Mixed methods pre/post 'move' comparison within four nested case study wards in a single acute hospital with 100% single rooms; quasi-experimental before-and-after study with two control hospitals; analysis of capital and operational costs associated with single rooms. Two-thirds of patients expressed a preference for single rooms with comfort and control outweighing any disadvantages (sense of isolation) felt by some. Patients appreciated privacy, confidentiality and flexibility for visitors afforded by single rooms. Staff perceived improvements (patient comfort and confidentiality), but single rooms were worse for visibility, surveillance, teamwork, monitoring and keeping patients safe. Staff walking distances increased significantly post move. A temporary...

Background Health care professionals worldwide attend courses and workshops to learn evidence-based medicine (EBM), but evidence regarding the impact of these educational interventions is conflicting and of low methodologic quality and lacks generalizability. Furthermore, little is known about determinants of success. We sought to measure the effect of EBM short courses and workshops on knowledge and to identify course and learner characteristics associated with knowledge acquisition. Methods Health care professionals with varying expertise in EBM participated in an international, multicentre before–after study. The intervention consisted of short courses and workshops on EBM offered in diverse settings, formats and intensities. The primary outcome measure was the score on the Berlin Questionnaire, a validated instrument measuring EBM knowledge that the participants completed before and after the course. Results A total of 15 centres participated in the study and 420 learners from N...

To summarise and synthesise published qualitative studies to characterise factors that shape patient and caregiver experiences of chronic heart failure (CHF), chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD). Meta-review of qualitative systematic reviews and metasyntheses. Papers analysed using content analysis. CINAHL, EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science were searched from January 2000 to April 2015. Systematic reviews and qualitative metasyntheses where the participants were patients, caregivers and which described experiences of care for CHF, COPD and CKD in primary and secondary care who were aged ≥18 years. Searches identified 5420 articles, 53 of which met inclusion criteria. Reviews showed that patients' and caregivers' help seeking and decision-making were shaped by their degree of structural advantage (socioeconomic status, spatial location, health service quality); their degree of interactional advantage (cognitive adv...

Background Discharge from critical care to a general care unit is a difficult period, and more effective information is needed to support patients and their families at this time. Objectives This study sought the views of patients, relatives and health care staff on (1) the most effective methods of delivering critical care discharge information, (2) the required information content of any proposed strategies, (3) the benefits and limitations of any existing strategies, and (4) potential resource implications. Methods In this qualitative focus group study, 11 adult patients, 8 family members, and 23 health care staff in Eng-land took part in 8 focus group interviews at 2 hospitals. The computer software program NVIVO7 was used for thematic analysis of the data. Results Three key themes were identified from the data: (1) considerations related to effective discharge information, (2) goals of critical care discharge information, and (3) resource implications. Conclusions This focus gr...

Chapter 4, by Sarah Hean and colleagues, highlights the importance of theory development in making the concept useful to the practice of public health. The authors present an innovative way of thinking about the different facets of social capital, describe the development of a survey instrument that attempts to make explicit the inputs and outputs of social capital and describe how these can be operationalised in a practice setting. The survey tool takes account of the dynamic nature of social capital and offers a useful way of ...

Abstract: This report explores evidence to identify the potential benefits and to inform the implementation of dementia specialist nursing roles to support people with dementia during admission to hospital. It shows a business case exists for developing a dementia specialist nurse role in the United Kingdom. The evidence suggests that a properly trained and educated dementia specialist nurse, undertaking a clearly defined role, and working directly with people with dementia and their carers for a significant proportion of the time, could benefit people with dementia in hospitals. If these benefits addressed only a fraction of the excess stays experienced by people with dementia, a significant return on investment could be obtained. A reduction in hospital stay by one day on average could achieve an annual return on investment of 37%, with a net saving of nearly £11,000,000 nationally.

In April 2012 the Chief Nursing Officer Designate, Jane Cummings, requested
the establishment of a Task and Finish Group to look at measuring the quality of
nursing care in the National Health Service (NHS). To inform the work of the
Group the National Nursing Research Unit (NNRU) at King’s College London
was asked to undertake a rapid appraisal (June-July 2012) of the evidence to date
on nursing measures.
The overall purpose of the resulting High Quality Care Metrics for Nursing
report is to bring together the evidence and theory in a useful way to inform
recommendations that will be put forward by the Task and Finish Group. In
particular it aims to:
• Review current knowledge and issues in defining and using nursing metrics
as part of a national architecture for measuring the quality of healthcare that
enables: accountability, quality improvement and transparency (the three
dimensions identified in the NHS Outcomes Framework).
• Build on the 2008 National Nursing Research Unit report State of the Art
Metrics (Griffiths et al. 2008) to further identify the nursing metrics that are
currently in operation, and explore any major trends, both nationally and
internationally.
The wider context of this work is a need to:
• Establish a (small) set of clearly defined key indicators of high quality nursing.
• Consider these alongside broader factors that underpin high quality healthcare.
• Align nursing metrics with ‘what matters most’ to patients in terms of their
experiences.
• Demonstrate the broader contribution of nursing to high quality care.
• Design and implement an infrastructure that enables national consistency and
benchmarking between organisations.
This report looks at UK initiatives and international developments in the
measurement of nursing quality. Advances since our 2008 report include: more
international healthcare systems using nursing metrics, the development of metrics
for quality improvement and transparency in the UK, specialty-specific metrics
(e.g. mental health nursing) and metrics in NHS accountability systems (e.g.
clinical dashboards).
High quality care metrics for nursing
2
Key findings of this report are that:
• There are a number of widely recognised indicators of nursing care quality.
These include:
· Healthcare associated infection
· Pressure ulcers
· Falls
· Drug administration errors
· Patient complaints
• It is unclear the extent to which all of these are sensitive to variation in nursing
quality but they are plausible and, as such, widely supported.
• There are numerous contextual variables that impact upon the quality of
nursing care which can be regarded as wider structural indicators. These
include:
· Workforce e.g. staffing levels, skill mix, sickness absence
· Staff experiences e.g. perception of the practice environment
· Systems e.g. admissions, discharge, handover
• Many NHS trusts are measuring some or all of these indicators in a structured
way at a local level, including the use of quality dashboards.
• There is considerable overlap between approaches to quality measurement but
little standardisation of indicators.
• As a result, many current systems of measurement do not permit benchmarking
between organisations at the ward/unit level.
• There is some degree of standardisation around specific nursing quality
indicators for patient safety, including measures for falls and pressure sores
(the NHS Safety Thermometer, and through the North West Transparency
project).
• We do not have good risk adjustment for measures such as falls and pressure
ulcers to ensure valid comparisons between organisations.
• Few if any UK systems appear to have the sophistication of the ‘state of the art’
represented by the United States and Canadian systems, although we have not
been able to review them in depth here.
High quality care metrics for nursing
3
Lessons from international systems are that:
• Systems that collect patient level data can be risk adjusted, to ensure
meaningful comparison across the system (i.e. benchmarking between matched
comparators, or for specific specialties).
• Systems and infrastructure need to be put in place and tested to enable
consistent definition, collection and interpretation of information.
• Commitment and investment is needed to develop and secure the required
infrastructure
• It is essential to have sufficient resourcing including for example the right
informatics systems, information technology and expertise in place.
• Professional learning networks specifically focusing on the contribution of
nursing to achieving high quality care can support implementation.
Whilst there has been considerable interest and some notable successes in
measuring nursing quality in the UK, further work is needed to:
• Coordinate a consistent and standardised approach to the collection, analysis,
and interpretation of a core minimum dataset.
• Identify a wider range of metrics and indicators that relate to effective and
compassionate care, not just safety.
• Develop metrics and systems that reflect the wider structural factors that
underpin nursing quality, such as staffing, skill mix and staff experiences and
link to other care quality metrics such as patient experience.
• Create or adapt local infrastructure (e.g. information systems and technologies)
to minimise the burden of measurement on staff.
• Gain an informed understanding of what aspects of nursing quality are being
measured by any new system, and what is not - or cannot - be measured (but is
still important) and how this fits with the ‘whole picture’ of nursing quality.
• Explore the potential for patient level data to be risk adjusted, to ensure
meaningful comparison across the system (i.e. benchmarking between matched
comparators, or for specific specialties).
• Develop and secure support from national and regional leads for a national
system of measurement and reporting before rolling-out any future
measurement initiative to healthcare provider organisations.
• Support professional learning networks which focus on the contribution of
nursing to achieving high quality care.

This scoping review sought evidence about organisational and management factors affecting infection control in general hospital settings. A literature search yielded a wide range of studies, systematic reviews and reports, but high quality direct evidence was scant. The majority of studies were observational and the standard of reporting was not always good.

Positive leadership at ward level and above appears to be a prerequisite for effective action to control infection, although the benefits of good clinical leadership are diffused by supervision of large numbers of staff.  Senior clinical leaders need a highly visible presence and clear role boundaries and responsibilities. Team stability and morale are linked to improved patient outcomes. Organisational mechanisms for supporting training, appraisal and clinical governance are important determinants of effective practice and successful change.  Rates of infection have been linked to workload, in terms of nurse staffing, bed occupancy and patient turnover.

The organisational characteristics identified in the review should be considered risk factors for infection. They cannot always be eliminated or avoided completely, but appropriate assessment will enable targeted action to protect patients.

Background: There is long standing interest in identifying patient outcomes that are sensitive to nursing care and an increasing number of systems that include outcomes in order to demonstrate or monitor the quality of nursing care.
Objective: We undertook scoping reviews of the literature in order to identify patient outcomes sensitive to the quality of nursing services in ambulatory cancer chemotherapy settings to guide the development of an outcomes based quality measurement system.
Methods: A 2 stage scoping review to identify potential outcome areas which were subsequently assessed for their sensitivity to nursing. Data sources included the Cochrane Library, Medline, Embase, the British Nursing Index, Google and Google scholar
Results: We identified a broad range of outcomes potentially sensitive to nursing. Individual trials support many nursing interventions but we found relatively little clear evidence of effect on outcomes derived from a systematic reviews and no evidence associating characteristics of nursing services with outcomes.
Conclusion: The purpose of identifying a set of outcomes as specifically nurse-sensitive for quality measurement is to give clear responsibility and create an expectation of strong clinical leadership by nurses in terms of monitoring and acting on results. It is important to select those outcomes that nurses have most impact upon. .Patient experience, nausea and vomiting, mucositis and safe medication administration were outcome areas most likely to yield sensitive measures of nursing service quality in ambulatory cancer chemotherapy.

Nursing research is a diverse discipline which draws on methods and methodologies from across the social, behavioural and biomedical sciences. Few if any of the approaches to research used within nursing are unique; however, their application within the complex milieu of nursing care has frequently raised distinctive challenges and generated novel applications. Nursing Research Methods brings together seminal sources that illustrate both the origins and the state of the art of research in nursing. The editors draw on methodological sources from outside the discipline that are influential and have shaped nursing research as well as discussions and debates about the application of particular methods within the field.

The text is organised around a selection of 8-10 seminal studies which have been selected based on their significance and ability to represent the broad scope of the discipline. Studies are selected to provide a vehicle to cover key methods for nursing research and to represent some of the diversity of the research topics that constitute the discipline. Because of the wide international audience, the editors take a broad view of the 'family' of nursing to include health visiting, public health nursing and midwifery and nurse midwifery.

This scoping review was commissioned by the Nursing and Midwifery Council of the United Kingdom in view of growing concerns that healthcare support workers are increasingly extending their role to undertake tasks previously undertaken by registered professionals but remain an unregulated workforce.

Lack of regulation has meant that there is little control over entry to employment and little standardization of roles, competencies and education. A wide range of proposals currently exists for taking regulation of this workforce forwards, but with diverse approaches to choice of regulator and level of regulation required.


The review had three objectives:

Assess the evidence of risks presented to public protection from an unregulated healthcare support workforce and the evidence of benefits of regulation.

Identify and consider key questions to be addressed in developing models of regulation.

Make recommendations for further work required in taking healthcare support worker regulation forwards.

Increasingly, public services are asked to explicitly demonstrate performance, in order to improve public accountability and increase quality. The recent Next Stage Review of the NHS outlined a number of initiatives designed to improve the measurement and monitoring of quality within the NHS. Public concern about the quality of nursing care, coupled with a professional desire to demonstrate contributions and improve quality, have led to an increased interest in measures of nursing. By making the contribution of nursing explicit in performance measures it is hoped that quality can be maintained and enhanced rather than neglected in the drive to meet other performance targets2.

However, developing indicators to properly represent the functioning of such a complex service is not without its pitfalls. 

The evidence

We populated a list of possible indicators for nursing from a number of sources: Doran’s review of the “State of the Science” of nurse sensitive indicators3, recent systematic reviews of the link between the ward environment, nurse staffing and patient outcomes4-7 and a number of indicator systems8-10. Most sources focussed on acute care and we concentrate on these here.
There is a degree of consistency in identifying failure to rescue (death among patients with treatable complications); healthcare associated infection (HCAI); pressure sores and staffing variables as outcome indicators of nursing quality. A systematic review found that falls and pressure sores are not consistently associated with nurse staffing. The amount of variation in the other outcomes associated with nurse staffing is  relatively low4. The invisibility of some nursing indicators in the research may be because they are often not recorded in administrative databases4 Staffing variables, such as workforce planning, staff satisfaction, perceived quality of the practice environment and staffing levels are also supported as structural indicators of nursing quality based on reviews and individual studies which link these factors with mortality and other outcomes in countries including the UK4-7 ,11. Positive contributions of nursing to patient experience and patient outcomes such as measures of wellbeing function or recovery do not consistently appear in the sources we used although they are clearly important.
There is a danger in focussing on a few narrowly defined indicators  in that perverse incentives may be created12 resulting in gaming, whereby maximising performance on the indicators detracts from overall performance or changes performance in relation to the indicator in a way that invalidates it13. The selection of indicators must consider the potential for gaming and seek to minimise the potential. Experience of gaming in relation to NHS targets suggests that process type indicators (where completion of activities is recorded) seem particularly vulnerable. One notable example was the 48 hour target for GP appointments leading to practices refusing to offer appointments more than 48 hours in advance13.
Indicators must be important, scientifically sound, useable and feasible14 ,15. Risk adjustment, to adjust for differences in patient groups and their relative vulnerability, is necessary if comparisons are made between institutions on outcomes. Indicators adopted must fall in the sphere of responsibility of nursing and be recognised as doing so by nurses, other professionals, and hospital managers in order for them to facilitate positive change and accountability. Minimising the burden of data collection is important but this consideration must be balanced with known problems in the quality of data in administrative data sets.


Summary & conclusions
• There are several proposed ‘nurse sensitive’ indicator sets aiming to demonstrate and measure the quality of nursing care. Work so far is dominated by indicators and research related to acute hospital care, primarily in North America.
• There is considerable disagreement between the different sources as to the key indicators for nursing
• Evidence from systematic reviews of the association between nurse staffing and patient outcomes consistently supports, “failure to rescue” and healthcare associated infection (especially pneumonia) as nurse sensitive outcomes. 
• Evidence for other widely advocated outcomes such as falls and pressure sores an association with nurse staffing variables is less consistent but these are strongly supported by the profession and by theoretical links.
• Staffing variables such as workforce planning, staff satisfaction, perceived quality of the practice environment and staffing levels are also supported as structural indicators of nursing quality.
• Positive contributions of nursing to patient experience and patient outcomes such as measures of wellbeing function or recovery do not consistently appear in the sources we used, but need to be considered if indicators sets are to be properly representative of the goals of nursing.
• Measures of care structure and processes are particularly vulnerable to ’gaming’ and token compliance. Patient and staff reported measures are less vulnerable.
• The scope for using administrative data to generate indicators is limited and the ‘audit’ burden may be high.  Areas to prioritise are those where most benefit can be derived and data can be collected efficiently
• Failure to rescue, hospital acquired pneumonia, pressure sores, falls and workforce planning and patient and staff experience seem the most promising areas for indicator development in acute care

This report was commissioned by the Chief Nursing Officer for England and was undertaken in the spring and early summer of 2008 to support and inform the nursing contribution to Lord Darzi's NHS next Stage Review. The work was guided by a task and finish group and supported by an evidence gathering exercise. The stimulus for the report was the sense that nursing had lost its way; that there was unacceptable variation in the quality of care. While the standard of nursing is generally high, when it falls short it has a marked impact on how patients experience the whole of their contact with the health service. The report defines what patients and nurses want in terms of good quality care in all healthcare settings and identifies a series of proposals to improve the quality of patient care in the NHS in England.

Nurse staffing matters: first findings from research addressing the associations between nurse staffing and patient safety and quality of care with guest speakers

Professor Anne Marie Rafferty, Head of the Florence Nightingale School of Nursing & Midwifery, King’s College London and

Professor Peter Griffiths, Chair of Health Services Research, University of Southampton.

RN4cast is the largest ever research study to explore the associations between nurse staffing and patient outcomes. The study aims to get a more accurate idea of the nursing workforce required (in terms of number & qualifications) to ensure safe patient care and a healthy work environment for nurses.

The study is in its 3rd and final year and the England study co-directors (Professor Anne Marie Rafferty and Professor Peter Griffiths) will present findings from the nurse survey that explore the relationship between staffing variables and measures of patient safety and quality of care.