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NICE sets out guidance on safe nurse staffing levels for hospitals

Fewer than two registered nurses present on a ward during any shift, day or night, represents a patient safety “red flag”, according to major guidelines for the NHS.  

In addition, nurse managers must check staffing levels are safe on hospital wards where each registered nurse is caring for more than eight patients during day shifts.

The National Institute for Health and Care Excellence has today published the final version of its much-anticipated guidance on safe staffing levels for acute inpatient wards – the first of a series covering a range of healthcare settings.

“The NHS cannot afford to be unsafe – neither morally nor financially”

Gillian Leng

Much of the final guideline remains unchanged from an earlier version that was published in May for consultation.

The guidelines state that nurses in charge of shifts should monitor for the occurrence of “nursing red flag events” during each 24-hour period. Where one occurs, it should “prompt an immediate escalation response”, such as allocating additional nursing staff to the ward.

The red flags set out by NICE include patients missing planned medication, delays of more than 30 minutes in providing pain relief and a lack of planned vital signs checks.

Another red flag situation cited by NICE is where there is a shortfall of more than eight hours or 25% – whichever is reached first – of registered nurse time available compared with the actual requirement for the shift. For example, if a shift requires 40 hours of registered nurse time, a red flag event would occur if less than 32 hours of registered nurse time is available for that shift.

However, in a change from the draft version, NICE has added a red flag for when there are less than two registered nurses present on a ward during any shift.

The draft version of the guideline caused some controversy when it was widely miss-reported that the institute was backing a mandatory minimum ratio of one nurse for every eight patients.

In the final version of the guideline, NICE has stated there is “no single” nursing staff-to-patient ratio that can be applied across all acute inpatient wards, which will disappoint those campaigning for the introduction of minimum ratios like those used in California and parts of Australia.

However, NICE noted there was evidence of increased harm associated with a registered nurse caring for more than eight patients during day shifts, and suggested that where this occurred it could indicate the risk of a red flag occurring.

It stated that if registered nurses for a particular ward – excluding the sister or charge nurse – were caring for more than eight patients, matrons or senior nursing managers should closely monitor for red flag events and safe nursing indictors, and take action where necessary.

The guidelines set out recommendations on staffing requirements at three levels of responsibility – trust boards and senior managers, senior nurses that set ward establishments and ward and shift managers.  

NICE called on trust boards and senior management to develop procedures to ensure ward staffing establishments were “sufficient to provide safe care to each patient at all times”. It also called on managers to involve nursing staff when drawing up trust staffing policies, such as escalation and contingency plans.

When agreeing skill mix for establishments, NICE told trusts and senior nurses to take into account evidence showing patient outcomes were better when care was delivered by registered nurses.

Meanwhile, those responsible for setting ward establishments should routinely measure the average amount of nursing time required throughout a 24-hour period for each of the ward’s patients, NICE said.

It also hinted strongly that this should be expressed as nursing hours per patient, rather than a nurse-to-patient ratio – arguing that this type of measurement enabled individual patient needs and different shift durations to be taken into account more easily.

Much of the guideline was based on two reviews commissioned from the University of Southampton and the University of Surrey. However, NICE highlighted a “number of gaps” in available evidence and expert comment relating to staffing levels and patient safety.

It called for more studies across the topic, noting in particular that “research is needed to compare outcomes from acute adult inpatient wards that use different staff numbers, skill mix, and shift patterns”.

Professor Gillian Leng, deputy chief executive and director of health and social care at NICE, said: “The NHS cannot afford to be unsafe – neither morally nor financially.”

Gillian Leng

The development of NICE guidance on staffing was recommended by Robert Francis QC in his report on care failings at Mid Staffordshire Foundation Trust. It was also recommended last August by Professor Don Berwick in his report for the government on patient safety.

The government announced it would ask NICE to develop guidance on staffing levels in March 2013 and subsequently referred the work to the institute in November.

As well as the work by NICE, NHS England told trusts to put new staffing transparency systems in place by the end of June as a further response to the Francis report.

Trusts are now required to display the number of staff on each shift outside all inpatient wards, publish monthly updates on staffing, and perform an establishment review every six months.

The first datasets from these monthly updates were published on the NHS Choices website at the end of last month. Analysis of these figures by Nursing Times suggested nearly one in 10 hospitals in England had a fill rate for nursing shifts of less than 90% during May.


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Readers' comments (16)

  • Less than three RN's on a shift on most wards is not safe for goodness sake!

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  • "A red flag should .... "prompt an immediate escalation response”, such as allocating additional nursing staff to the ward....."
    Where do they get these extra staff from - other wards = other red flags.

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  • What about skill mix, patient dependency - Two inexperienced nurses - That is detrimental to both the patient and the nurses. How would the public know what a safe level of staffing is ? Appears like another tick box exercise. "Trusts are now required to display the number of staff on each shift outside all inpatient wards, publish monthly updates on staffing, and perform an establishment review every six months " . What about the band/ level of experince( skill mix) of staff, it's not just about numbers.

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  • What about theatres, do they not count?

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  • Again, unrealistic guidelines from decision makers who have no clue about the real world. Regularly, i have to spend my shift caring for an acute surgical admission that needs a one to one, which results in me having to almost ignore the rest of the patients in my care and relying on the goodwill of the other qualified nurse on shift with me to help out. Red flagging this only gets the same reply each time. ' Sorry, everyone is in the same boat'. Every shift is an accident waiting to happen yet there is always money available for an assistant to the assistant for a management post. I have spoken out many a time about unsafe practice and this has resulted in me being almost taken to disciplinary by my lead nurse for being threatening. All you decision makers out there, please get the know the real world that we constantly struggle in every day. I am posting this anonymously much against my grain , but I know what whistleblowing results in.

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  • Agree with last comment - red flagging does not appear to get results. Such a shame that you feel threatened by highlighting risks and resultant unsafe practice. NICE recommendations will not change the current situation however, nurses need to stand up and be counted and put their experiences and views forward regarding this situation.

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  • Totally agree with
    "' Sorry, everyone is in the same boat'. Every shift is an accident waiting to happen yet there is always money available for an assistant to the assistant for a management post. I have spoken out many a time about unsafe practice and this has resulted in me being almost taken to disciplinary by my lead nurse for being threatening."
    This is how our lead nurse works also.
    I made a complaint against unsafe practice and I have now had investigatory meetings against me,..... If you speak out or up for yourself you are seen as a trouble maker... The culture from lead nurses is ingrained in the NHS and they get away with being able to control whatever way the ward including staffing runs (safe or not) Money and saving money is their main priority.

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  • This does not take account of heavy wards with patients that are immobile and have to be hoisted or have dementia. Too often there is no special to watch a patient who is a serious risk to themselves. How can a nurse do her job if she is specialling a patient, helping to cover low staffing and hoisting all her patients in and out of bed. In addition, we are constantly starting the shift with a full compliment of staff who are taken to cover low staffing elsewhere and after several hours some came back to cover again, in the meantime leaving us struggling with 12 patients each. Does this staff movement get represented properly on the boards and figues that are shown to the officials. Or is that if you look closely there is one member of staff in two places at the same time. I would prefer not to give my name at this time.

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  • This recommendation will give Trusts a licence to just have 2 trained staff on each shift and save them loads of money. Patients are going to be much worse off, not to mention to poor ol' staff. Any nurse will tell you this. You are going to need one trained nurse per shift to deal with all the work 'red flagging' going on, by the sound of it. Like some other posts have highlighted, on these recommendations where are the extra staff going to come from. Another exercise taking nurses away from patient care. Who are these people who come up with these unrealistic, not to mention stupid ideas? (That isn't really a question).

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  • Yet again its only the wards that get mentioned with regard to unsafe staffing levels.I work in operating theatres and we have had long running issues with understaffing of anaesthetic nurses and recovery nurses and there have been several serious incidents in both these related areas.I am really beginning to wonder what the NMC and NICE have been doing all this time ?

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  • If there was three RGN's on at night the patient care would improve immensely. I see such a difference when we occasionally have three RGN's on. But in less every ward had this it would be pointless as nurses would be coming in and being moved to unfamiliar wards every night which wouldn't be fair.

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  • I agree with all above comments and want to add.
    How can the NMC represent nurses when they cannot run their own business?
    Nursing research has an abundance of papers dealing with safe levels of nursing and skill mix to deliver quality of care both in this and other countries, particularly the USA. that look at ACUITY levels for staffing,
    California is the first to lawfully implement these.
    Required ratios vary by unit, ranging from 1:1 in operating rooms to 1:6 on psychiatric units.
    California's mandate improved staffing for all hospitals, including safety-net hospitals. Furthermore, improvement did not come at the cost of a reduced skill mix, as was feared.
    Get a grip NICE and NMC lets look at this from the ground up not ivory bloody towers down.

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  • michael stone

    This was being discussed on BBC Radio 4 as soon as the guidance came out: there was a fairly common view that if this guidance is followed, it will require an increase in nursing numbers, and that will effectively bankrupt the NHS within a few years (to be more accurate, the prediction is that very quickly, all hospitals would be running deficits).

    I would HATE such an outcome, being used by any Goverment, as 'another lever with which to tear apart our free-at-the-point-of-use and paid for out of general taxation [i.e. decent healthcare for everyone, irrespective of their wealth] NHS.

    But it is obvious that when nursing numbers fall below a certain level, over-stretched nurses cannot provide 'good and decent' care: reduce staffing numbers even more, and at some point the nurses would be unavle to even provide 'safe' care.

    So this has to be a move in the right direction - IF it isn't used as yet another excuse to destroy the NHS !

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  • I totally agree with all previous posts, i wonder though what the staffing levels are for night shift? Where i work as with all other wards our workload has increased, but some people still think nothing ever happens at night! If only...

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  • The numbers should be based on RNs who deliver direct patient care, not just any RNs on shift.
    Ratios could potentially change from 1 RN to 5 Patients, to 1 RN to 9 patients.
    On top of that RNs are expected to complete all the administrative tasks, which takes them away from patient care, otherwise if its 'not written, its not done'.
    Then when one or two people's acuity rises; how quickly can you expect to find another RN to help the ward out?

    Even with 1RN to 8 patients, a frequent situation people could find themselves in is: 3 patients wanting to go to toilet together, 2 confused and 2 at higher risk of falling and maybe 1 asleep (or may have deteriorated quietly) and all happening in the middle of the night.

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  • andy wecome to the real world we have wores wehave one/two RN one/two and may have three csw depending on the 12 patience to bearing in mind 95% of them or dependent all care spinepatience too csw are at witts end yes when one or to need toilet at the same time then another fells iland the lunch trolly comes round to serve meals then you have vomiting then feeding patience on a raio 4/5 this has happened in one shift we have confussed pt too that need observing and nights you still have more staff then a good many? and under the work load colleages have to go home sick,the is people leaving because they have had enough yes red flags do go unoticed

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