Papers by Peter Griffiths
Background Women have consistently reported lower satisfaction with postnatal care compared with ... more Background Women have consistently reported lower satisfaction with postnatal care compared with antenatal and labour care. The aim of this research was to examine whether women's experience of inpatient postnatal care in England is associated with variation in midwifery staffing levels. Methods Analysis of data from the National Maternity Survey in 2018 including 17,611 women from 129 organisations. This was linked to hospital midwifery staffing numbers from the National Health Service (NHS) Workforce Statistics and the number of births from Hospital Episode Statistics. A two-level logistic regression model was created to examine the association of midwifery staffing levels and experiences in post-natal care. Results The median full time equivalent midwives per 100 births was 3.55 (interquartile range 3.26 to 3.78). Higher staffing levels were associated with less likelihood of women reporting delay in discharge (adjusted odds ratio [aOR] 0.849, 95% CI 0.753 to 0.959, p=0.008),...
International journal of nursing studies, Jan 18, 2015
It comprises guidance for reporting randomised controlled trials and a checklist, specifying the ... more It comprises guidance for reporting randomised controlled trials and a checklist, specifying the essential content for a report of a randomised controlled trial. The original CONSORT Statement referred to individually randomised trials but subsequently other guidelines were developed covering, for example, cluster randomised studies . The rationale for the development of the CONSORT Statement was that in order to practice evidence based medicine it is necessary to determine the quality of the research providing that evidence. Randomised, controlled trials, when appropriately designed, conducted, and reported, represent the gold standard in evaluating health care interventions. However, randomised trials can yield biased results if they lack methodological rigor (1). To assess a trial accurately, readers of a published report need complete, clear, and transparent information on its methodology and findings. (Schulz et al., 2010p 726).
How good is the evidence for using risk assessment to prevent pressure ulcers?
Nursing times
Nurses may assume that carrying out risk assessment and auditing such care processes result in be... more Nurses may assume that carrying out risk assessment and auditing such care processes result in better outcomes. However, it is vital to examine the evidence on care processes before using them to demonstrate quality of care. This article analyses the evidence supporting risk assessment for pressure ulcer prevention, which has been adopted as one of the eight high impact actions for nursing and midwifery. The issues raised are equally relevant to any clinical area where processes such as risk assessment are used to demonstrate evidence of quality care.
Interventions for reducing the use of baby walkers
Reviews, 2005
Executive summary This review has been commissioned by the Nursing and Midwifery Council (NMC) as... more Executive summary This review has been commissioned by the Nursing and Midwifery Council (NMC) as part of their review of pre-registration midwifery education. The review examines evidence from the published and unpublished literature, from key informants in midwifery and other professions in the UK and midwifery in other selected countries (see appendix 1) about the relationship between the number of midwife teacher and the quality of education delivered. In particular the review focuses on the role of a mandated ratio ...
A randomised controlled trial to assess the effect of performance feedback on tracheal suctioning knowledge and skills
Journal of Advanced Nursing, 2009
Aim. This paper is a report of a study to determine whether individualized performance feedback i... more Aim. This paper is a report of a study to determine whether individualized performance feedback improved nurses' and physiotherapists' knowledge and practice of tracheal suctioning. Background. Nurses' knowledge and practice of tracheal suctioning is often deficient. Whilst teaching has been shown to improve suctioning knowledge and practice, this is not sustained over time. Method. Ninety-five qualified healthcare professionals (nurses and physiotherapists) in two acute hospitals were randomly allocated to receive ...
Efficacité des soins intermédiaires dans les unités de soins dirigées par des infirmiers
Les patients atteints d'une maladie aiguë sont souvent hospitalisés dans une unité de soins ... more Les patients atteints d'une maladie aiguë sont souvent hospitalisés dans une unité de soins actifs fournissant de nombreux services. Au cours de leur convalescence, ils n'ont pas forcément besoin de ces services intensifs et doivent au contraire préparer leur sortie. Les unités de soins dirigées par des infirmiers (plutôt que par des médecins) ont été conçues pour préparer les patients à leur sortie d'hôpital. Dix études portant sur plus de 1 800 patients ont été analysées en vue de déterminer si les patients envoyés dans une unité de ...
MRSA Origins-A study to identify and determine the significance of attributional bias in the control and prevention of meticillin-resistant Staphylococcus aureus (MRSA) in healthcare settings
This work was commissioned and supported by the Hospital Infection Society in England as part of ... more This work was commissioned and supported by the Hospital Infection Society in England as part of its Major Grants Programme. It commenced 1 March 2008 for 18 months. The work was led by the National Nursing Research Unit, which receives funding from the Department of Health. The views expressed here are those of the authors, not of the Department of Health.
Scoping review: Moving to an all-graduate nursing profession: assessing potential effects on workforce profile and quality of care
1.2 Method The research team, working in conjunction with the project steering group, developed k... more 1.2 Method The research team, working in conjunction with the project steering group, developed key questions arising from the literature and current policy concerns in relation to workforce profile and quality of care; these are set out in Sections 2 and 3. Our brief was not to undertake a full systematic review of every study undertaken on the subject but rather to: review contemporary studies with most relevance to current debates; take into account conclusions of reviews of earlier studies; and consider the implications of the evidence for ...
Approaches to specialist training at pre-registration level: an international comparison
National Nursing Research Unit, King’s College London, Nov 1, 2007
Executive Summary Many countries are in the throes of debate about the structure and content of p... more Executive Summary Many countries are in the throes of debate about the structure and content of preregistration nurse education. This report considers international evidence available on the outcomes of forms of pre-registration educational preparation for mental health and learning disability nursing which differ from that in the UK.
London: National Nursing Research Unit, King's College London, Mar 1, 2009
Preceptorship is currently high on the policy agenda with recommendations for a mandatory period ... more Preceptorship is currently high on the policy agenda with recommendations for a mandatory period of preceptorship for nurses emanating from the Next stage review of the NHS (DH 2008) and from the Nursing and Midwifery Council's consultation on pre-registration education (NMC 2008, 9). It is heralded as a means of improving patient care by assisting new practitioners in developing clinical skills and encouraging workforce retention by supporting students in the transition to registered practitioner.
American Journal of Infection Control, 2011
Background: Meticillin-resistant Staphylococcus aureus (MRSA) is endemic within the United Kingdo... more Background: Meticillin-resistant Staphylococcus aureus (MRSA) is endemic within the United Kingdom health care sector. Recent campaigns to reduce health care-associated infection have rested on increasing staff accountability and ownership of the problem and its solutions. However, the existence of reservoirs of colonization in the community now creates ambiguity about sources, which may undermine preventative strategies. Methods: The theoretical framework of causal attribution was applied to explore staff biases in perceptions and effects on infection control behaviors on both sides of the hospital/care home interface. Forty-four staff from 1 acute care hospital and 53 staff from 6 care homes estimated prevalence, risk, and sources of MRSA. Focus groups (6 care home and 8 hospital) were used to elicit group perceptions. Results: Staff tended to attribute the causes of MRSA to external (not self) human factors including patient risk factors and poor infection control practices of others. Teams tend to attribute their ''successes'' in infection control to dispositional attributions (good team policy and performance) and attribute ''lapses'' to situational factors (client group, patient movement, work pressures). Conclusion: Variations in information needs, ownership, and infection control practices could be addressed by better interorganizational working and support for staff teams to assess their own responses to the problem.
Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, Dec 27, 2016
The purpose of this study was to identify the treatment-associated problems that most impact on p... more 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...
Nursing Research Methods: Mixed Methods, Integration and Synthesis
Nursing Research Methods: Quantitative Approaches
BMJ open, Jan 11, 2018
To inform healthcare workforce policy decisions by showing how patient perceptions of hospital ca... more 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...
Journal of clinical nursing, Jan 21, 2017
To explore why adherence to vital signs observations scheduled by an Early Warning Score protocol... more 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...
BMJ open, Jan 31, 2017
To provide an overview of the evidence base on the effectiveness of workforce interventions for i... more 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...
Journal of clinical nursing, Jan 31, 2017
Systematic review of the impact of missed nursing care on outcomes in adults, on acute hospital w... more 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...
BMC health services research, May 31, 2017
Research into relational care in hospitals will be facilitated by a focus on staff-patient intera... more 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 ...
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Papers by Peter Griffiths
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.
Objectives: This study aims to assess the potential for deriving 2 mortality based failure to rescue indicators and a proxy measure, based on exceptionally long length of stay, from English hospital administrative data by exploring change in coding practice over time and measuring associations between failure to rescue and factors which would suggest indicators derived from these data are valid.
Design: Cross sectional observational study of routinely collected administrative data.
Setting: 146 general acute hospital trusts in England
Participants: Discharge data from 66,100,672 surgical admissions (1997 to 2009)
Results: Median percentage of surgical admissions with at least one secondary diagnosis recorded increased from 26% in 1997/8 to 40% in 2008/9. The failure to rescue rate for a hospital appears to be relatively stable over time: inter-year correlations between 2007/8 and 2008/9 were r=0.92 to r=0.94. No failure to rescue indicator was significantly correlated with average number of secondary diagnoses coded per hospital. Regression analyses showed that failure to rescue was significantly associated (p<0.05) with several hospital characteristics previously associated with quality including staffing levels. Higher medical staffing (doctors + nurses) per bed and more doctors relative to the number of nurses were associated with lower failure to rescue.
Conclusion: Coding practice has improved, and failure to rescue can be derived from English administrative data. The suggestion that it is particularly sensitive to nursing is not clearly supported. Although the patient population is more homogenous than for other mortality measures, risk adjustment is still required.
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.
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.
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.
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.
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
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.