Safe staffing: what forces make a shift safe or unsafe?

August 2016 Vol. 16 (4)

Nurses driving home from work probably know whether a shift felt ‘safe’ or ‘unsafe’. PhD researcher RHONDA McKELVIE wants to talk to nurses about the forces influencing safe, or unsafe, staffing.

Imagine a nurse, we’ll call her Sandra, leaving an afternoon shift at 11.20pm.

She’s late leaving her shift. She’s had one break of 12 minutes in in her ‘eight-hour’ shift. Her dinner is still in the staff fridge. She might get time to eat it tomorrow night….

Sandra knows her colleagues had similar length breaks and, when they did cross paths that evening, all agreed that there was way more work to be done than they could possibly achieve. Each nurse was looking after five to seven patients. At 5.17pm there was a drug error; at 7.10pm one of the patients fell in the bathroom sustaining significant bruising but no fractures or skin tears.

During this particular shift only three of the 32 patients received all of the care requirements mapped out in their clinical care pathways and progress notes.. All of the nurses worked 45 to 75 minutes after their shift ended, a similar shift pattern for the previous few weeks.

Sandra gets home just after midnight. After a hot drink and some TV – to try and quieten her frantic mind – she falls into bed at 12.45am. She wakes at 1.45am panicking about whether she had charted the volume of the wound drain she’d emptied on her way out the door; she calls the ward to check, and of course she had.

She then lies awake for several hours processing her distress at not being able to provide all the care her patients required. She’d had to do a number of patient care activities for junior colleagues without PCA (patient controlled analgesia) or epidural skills. There just hadn’t been enough time for to get everything done, and some needed equipment and meds that weren’t available or were hard to find.

As a result, Sandra feels, patients were put at risk through lack of resources, fatigue-related errors and insufficient staff for surveillance of all patients at risk of falling. Reflecting on the shift, Sandra believes it was unsafe for both patients and staff – and tomorrow night’s shift could well be exactly the same.

What factors and forces shape safe staffing?

Rhonda McKelvieScenarios like the one above are the motivation behind my doctoral research into the factors affecting safe staffing.

Despite abundant research evidence from highly credible researchers, such as US researcher Linda Aiken’s work on nurse staffing, burnout and patient mortality, and widespread and comprehensive evidence-based strategies, safe staffing for nurses remains an unresolved conundrum in
New Zealand and abroad.

This is because nursing safe staffing is not, and cannot be, a magic fixed number. Patients’ care requirements are dynamic, they fluctuate and surge, and, though predicting these requirements is increasingly sophisticated, meeting them safely every hour of every day in every unit is a challenge that few, if any, healthcare providers achieve and sustain long term. And where the requirements are not met safely every hour of every day, patients are at risk of harm. Harm to patients, as a result of unsafe staffing, is an untenable outcome of care for nurses.

New Zealand’s evidence-based safe staffing strategies for nursing combine the best of overseas evidence and experience with homegrown initiatives and on-the-ground testing, including the acuity-based Care Capacity Demand Management (CCDM) system developed by the joint union and district health board Safe Staffing Healthy Workplaces Unit.

There have been some significant gains from these strategies, but to date it appears their scale and penetration into DHBs falls short of what was hoped for. This seems to be the result of the complexity of the healthcare environment, including competing priorities and tensions between a safe and socially-just standard of care, constrained funding and the ever-present drive for productivity and efficiency.

Can you help?

My doctoral research project aims to uncover some of the factors and forces that result in shifts like the Sandra scenario above, while acknowledging that these same factors and forces are also present when shifts are safely staffed and the nursing team leaves feeling satisfied with the care provided.

Some of the project findings are likely to reflect the complexity and tensions of the healthcare environment, but where do these complexities and tensions originate? And how do they have such a powerful effect on how a shift actually plays out?

This study aims to begin with a small group of nurses describing their everyday experience of ‘safe staffing’ and ‘unsafe staffing’ shifts in public hospitals and will then investigate, on their behalf, how their shifts are organised to occur as they do.

This research will not evaluate individuals or organisations or speculate on whether organising factors and forces are right or wrong – it is concerned with what these factors and forces are and how they affect everyday work. It is not concerned with who or why.

I want to interview DHB registered nurses working in direct patient care in clinical areas such as surgery, paediatrics, medicine, maternity, mental health, acute planning and emergency and outpatient departments.

I would also like to interview a small number of clinical nurse managers and duty nurse managers. Your contributions will be anonymous and confidential. Nurses’ contributions will be anonymous and confidential.

Your experiences and perceptions will form the basis for the study, which will go on to examine the wider safe staffing context, including legislation, policy formation and implementation and local documents and practices. :

If you are interested in being interviewed and describing your on-the-ground, everyday experience of safe staffing, please contact me at

AUTHOR: Rhonda McKelvie is a registered nurse and PhD scholarship student. She currently works (very much part-time) as a programme consultant for the Safe Staffing Healthy Workplaces Unit. 


1. Aiken L, Clarke S, Sloane D, Sochalski J, Silber J (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. Journal of the American Medical Association 288(16).  

2. Griffiths P, Ball J, Drennan J, Dall’Ora C, Jones J, Maruotti A, Pope C, Recio-Saucedo A, Simon M (2016). Manuscript accepted for publication in press. Nurse staffing and patient outcomes: strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence Safe Staffing guideline development: International Journal of Nursing Studies

3. Report of the Safe Staffing Healthy Workplaces Committee of Inquiry (2006), Wellington, NZ.

4. Rathert C, May D, Chung H (2016). Nurse moral distress: A survey identifying predictors and potential interventions. International Journal of Nursing Studies 53, 39-49.


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