PRO-JUDGE: Nurses’ Professional Judgement in Nurse Staffing Systems in England and Wales

Every day in healthcare settings across the world, decisions are made about whether enough nurses are available to meet patient needs. How are these decisions arrived at?

Investigations into failures of care in hospital settings have identified the need to develop better systems to support decision-making about levels of nurse staffing.

What was the Pro-Judge study about?

Ensuring enough nurses are available to care for patients is an important policy concern in many countries. Research has shown a relationship between lower nurse staffing levels and poorer patient outcomes. Many different systems exist internationally to support workforce planning and staff deployment. These typically include rostering technologies, formal workload assessment tools, data on patient outcomes, and professional judgment.

There is a substantial body of research on the formal tools deployed in staffing systems, but we know very little about the role of professional judgment and its impacts on decision-making. Pro-Judge aimed to address this gap in understanding.

What did we do?

Between January 2021 and March 2023, the study focused on three National Health Service Trusts in England and three University Health Boards in Wales.

Interviews were conducted with key individuals involved in the nurse staffing systems, staffing meetings were observed, and formal documents, tools and technologies were analysed. A limited number of observations in clinical areas were also conducted to gain insights. These data were combined to analyse the role of professional judgement in staffing systems in each case.

What did we find?

At the time of the study, none of the cases had sufficient staff to fulfil planned rosters. It was the professional judgements of clinical nurses and senior nurse managers, rather than formal systems, that were central to operational decisions to manage risk and ensure safe care.

Staffing levels required for the routine operation of clinical areas were reviewed twice a year. In routine reviews of staffing levels, efficiency, safety, and ‘hard’ data were given considerable weight in decision-making. Nurses considered that the data did not capture important aspects of care quality and staff well-being. As a result, nurses found it challenging to articulate their professional judgments and influence decision-making at the board level.

What does this mean?

The study highlights that while nurses are relied upon to use professional judgment to manage risks during staff shortages, their judgments do not carry the same weight when it comes to agreeing on staffing levels at the board level.

This may result in safe but not necessarily high-quality patient care, which could impact nurse retention and perpetuate staff shortages. The following actions are indicated to address this:

equipping nurses with a vocabulary to articulate their professional judgment for strategic decision-making,
healthcare organisations being more inclusive of expert nursing clinical knowledge
refining measurement systems to better capture the complexity of care