Using the NNAP measure for neonatal nurse staffing to support benchmarking, oversight of safe staffing and quality improvement

This QI project reviewed nurse staffing data to drive forward improvements in: shift leadership, QIS nursing ratios and skill mixing for safer staffing and inform recruitment, workforce planning and investment via budget setting in each Trust.

Publication date: 12 October 2023


Across the Herts and West Essex Local Maternity and Neonatal System (HWE LMNS).

Jacki Dopran, HWE LMNS Neonatal Project Manger, Husnara Begum, Neonatal Manager, Princess Alexandra Hospital, Elvira Baker, Neonatal Matron, & Linda Queijo, Neonatal Ward Manager, Watford General Hospital, Laura Kelly, Neonatal Matron, Lister Hospital, ENHT.


 Nursing workforce is a key element in the Neonatal Critical Care Transformation Review (NCCR) national action plan in England. The HWE LMNS local NCCR project plan undertakes bi-monthly nursing workforce meetings, to support quality improvement (QI) and system-working for the three local neonatal units’ matron and nursing leads. The objective of this forum is ‘to support safety, benchmark nurse staffing and to develop shared approaches to safer nurse staffing in the neonatal environment.’

The BadgerNet nurse staffing data and the NNAP measure for neonatal nursing workforce support: this forum, the project workstream and allows benchmarking across the HWE system and the region that supports a driver for improvement, and provides a safer staffing oversight and trend.


The neonatal nursing workforce faces many challenges. Some trusts have processes and tools for oversight of safer staffing in the neonatal environment. However, these tools often do not reflect activity in the NNU, qualified in specialty (QIS) nursing staff and skill mixing that is reflective of the activity. The three Trusts in the HWE do not have safer staffing tools that provide this level of detail and assurance of safer neonatal staffing. There are no other available tools with activity and British Association of Perinatal Medicine (BAPM) quality standard ratios.


 To support QI in neonatal nursing by reviewing nurse staffing data to drive forward improvements in: shift leadership, QIS nursing ratios and skill mixing for safer staffing and inform recruitment, workforce planning and investment via budget setting in each Trust.


Neonatal teams and their Trusts, HWE LMNS, NCCR project stakeholders


  • Plan: Identification of a tool or approach that allows benchmarking and comparison for neonatal nurse staffing to other LNU services.
  • Do: Utilisation of the BadgerNet data reports and wider oversight of nurse staffing from the NNAP measure.
  • Study: Review as a workforce working group how the different resources support benchmarking, drive quality improvement and support safe nurse staffing oversight and assurance.
  • Act: At each workforce meeting the BadgerNet data and NNAP measure are shared, for the system to ensure a regular benchmark for each of the units. Identification of gaps in data, and improvements in these gaps, to inform the overall picture of staffing.

Process for meeting forum

  • For each meeting, data is downloaded from the BadgerNet system for each LNU’s nurse staffing.
  • This data is presented in a RAG rated table that allows comparison of the 3 LNUs in terms of BAPM compliance and regional comparisons for the shifts for nurse staffing.
  • The NNAP measure outcome data is then included in this benchmark, to support a wider view across similar units both in and out of the region.

For each service, this approach supports wider Trust sharing of the nursing workforce in the unit, highlighting areas where there is a variance from the benchmark that may impact on safe care. The BadgerNet reports and NNAP measure also allows a record of day to day and wider trend nursing skill mix and numbers in relation to activity. The data can also support responses to clinical incidents, investigations and provide assurance of mitigation, in relation to the use of bank nursing hours when this is required to bring the safe cover up to a higher rate of compliance.

Outcome data

By undertaking a peer review of the data, the following factors were identified.

  • Some data fields were not always completed by each unit.
  • Rates of increased bank staffing use interface well to a rise in the activity trend. This demonstrates good oversight of safer staffing and patient need.
  • QIS cover for shifts is variable across the system. The outcome data supports drives for improvement in planning for specialised training and clinical placement for training in each service.
  • Improvement in the compliance to local and national benchmarking can be demonstrated.
  • Support for unit managers and matrons in utilising oversight of safer nurse staffing in many of their workstreams; safety, workforce planning, budget requirements.

Challenges and learning

  • In LNUs workforce planning can be challenging due to: geographical location, proximity to London and timelines to increase the QIS position, by cultivating and training your own QIS nurses can be long.
  • An improvement in data entry quality can quickly demonstrate increases in assurance relating to supernumerary shift leadership and use of bank nurses, to fill rota gaps and therefore, improve safety.
  • Understanding of the local, regional and national oversight to compliance with BAPM nursing ratios for teams and Trusts. This information is not available via any sources other than the NNAP measure.

Suggestions for further implementation

The approach used by the HWE LMNS to support system awareness and local comparison is a valuable tool as part of the NCCR project work, and an action that could be shared widely across the other LMNSs in the ICB footprints across England.

An overview of staffing is shared in the HWE LMNS System Partnership Board forum, as an escalation within the context of a NCCR project dashboard, that support extensive ICB oversight of neonatal nurse staffing and ongoing drivers for improvement.

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