The Scottish Safe Staffing Act at Baseline: Quantitative Findings

Amid a global nurse staffing crisis, in 2019 Scotland legislated the Health and Care (Staffing) (Scotland) Act to address health care workforce challenges. Instead of requiring patient-to-nurse ratios as legislated elsewhere, this act requires staffing decisions according to guiding principles, duties, and a common staffing method. Measuring variation in hospitals' adherence to the act's provisions at baseline is important for policymakers to evaluate fulfillment of the act's requirements and goals. Results will inform policymakers about which provisions are achieved at baseline and which require support for employers to achieve. The purpose of the study was to establish the baseline of nurse staffing standards in Scotland at April 2024 implementation of the Act. Nurse reports of quality, safety, and their intent to leave were measured to complement assessment of the implementation status.

A cross-sectional study design was used. A convenience sample of registered nurses and nursing support workers was recruited through professional organizations and trade unions. Nurses were invited to complete an online survey between May 1 and July 31, 2024. The survey content included demographic and professional characteristics, international nursing metrics, the Act's provisions, and job intentions. Descriptive statistics were calculated to describe the sample, act's provisions, and nurses' job intentions.

The sample comprised 1870 nurses, of whom 93% were registered nurses, from all regions with characteristics reflecting the Scottish nursing workforce. Regarding the act's provisions, 9% reported that nursing staffing is appropriate to provide safe, high-quality care every shift. Similarly, few nurses reported that the quality of care was excellent (17%) or graded safety an A (10%). Most nurses disagreed that current staffing levels met the eight guiding principles. Most nurses reported that the common staffing method and duties regarding real-time staffing decisions were followed at best occasionally. Nearly half of nurses (45%) intend to stay in their current job over the next year. Among those intending to leave their current job, about half plan to leave the profession through retirement or another unspecified job change. The other half plan to seek another similar nursing job or promotion.

Few nurses report that the act's overarching goal is being met at the point of implementation. Although most nurses see nursing as a long-term career, workforce disruption is anticipated through routine turnover, promotion, or retirement, requiring workforce retention policies. Whether the act's complex provisions can be achieved and its goals fulfilled may not reverse the trend of exiting nurses. The complexity of the approach will be a challenge to achieving the objective of safe staffing. Therefore, this approach to achieving safe staffing may be too complex to be recommended widely. These remain urgent questions for Scottish policymakers, nurse leaders, and researchers.