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More than eight patients per nurse 'risks harm' to patients, warns NICE

More than eight patients per nurse on a “regular basis” can increase the risk of harm in adult hospital wards, according to ground-breaking new guidelines on safe staffing levels in the NHS.

The National Institute for Health and Care Excellence will publish draft recommendations on Monday about nursing workforce levels in adult inpatient wards in acute hospitals – the first of a series of guidelines on safe staffing in different healthcare settings.

On individual wards, the draft guideline highlights the importance of the nursing team’s awareness of patient needs and “red flag events”, which signal that an immediate response is needed, such as an urgent need for additional nurses.

These “red flag events” include patients not being provided with basic care requirements, such as help with visits to the bathroom, being asked about pain levels or delays in providing medicines.

“Assessing patient needs is paramount when making decisions about the number of nursing staff”

Gillian Leng

The lead nurse should consider any “red flag events” as indicators of the ward becoming in danger of being understaffed and, therefore, tailor the number of available nursing staff as needed.

The draft guideline highlights that if each registered nurse is caring for more than eight patients during the day time on a regular basis, there is an increased risk of harm. It stresses the importance of checking if patient needs are adequately being met in these situations.

However, a NICE spokeswoman stressed that eight to one was not a minimum ratio, but rather a point where senior nurses needed to check and assess their nurse staffing numbers.

“There is no floor or ceiling number on the required number of nursing staff that can be applied across the whole of the NHS,” added Professor Gillian Leng, deputy chief executive and director of health and social care at NICE.”

Gillian Leng

She said: “What the [NICE] safe staffing advisory committee concluded was that assessing patient needs was paramount when making decisions about the number of nursing staff and planning should allow for flexibility on a day-to-day or shift-by-shift basis.”

The government has consistently rejected the idea of setting a single minimum staffing level, despite increasing support for a ratio of one nurse for every eight patients on acute wards.

A one-to-eight ratio is favoured by the Safe Staffing Alliance, which was formed in summer 2012 and is supported by a range of nursing organisations and senior nurses.

Their campaign is based on evidence from the National Nursing Research Unit showing that care becomes unsafe and can lead to patients dying unnecessarily when numbers of patients per registered nurse falls below certain levels.

The draft NICE guideline also calls for hospital boards and senior management to take greater responsibility, and includes step-by-step guidance on how to determine the number of nursing staff that should be funded.

The evidence shows that providing a higher proportion of registered nurses in the skill mix contributes to better outcomes for patients, the draft guidance stated.

The development of guidance on staffing for different services by NICE was a key recommendation made by Robert Francis QC in his seminal 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 its initial response to the Francis report in March 2013. It subsequently referred the work to the institute in November.

“This guideline is an important step forward in addressing the issues of having adequate numbers of nursing staff within the NHS”

Gillian Leng

To support use of the guideline in hospitals, NICE said it would be assessing a range of practical toolkits designed to assist in estimating staffing requirements.

Staffing toolkits which comply with guideline recommendations and meet specified criteria will be given the NICE endorsement.

Professor Leng said: “Following on from the Francis and Berwick reports, the Department of Health and NHS England asked NICE to develop evidence-based guidelines to advise the NHS about safe staffing.

“Our first draft recommendations… focus on wards that provide overnight care for adult patients in acute hospitals,” she said. “This guideline is an important step forward in addressing the issues of having adequate numbers of nursing staff within the NHS.”

She called on nurses to take part in the consultation on the guidance, highlighting that it was “vital that we have the views of relevant stakeholders”.

Responding to the publication by NICE of the first set of guidance for staffing levels on adult inpatient wards, Royal College of Nursing said it was “encouraged” by the creation of the guidelines.

“Too often, staffing levels are allowed to yo-yo because of finances, and this puts staff under strain and patients at risk”

Peter Carter

RCN chief executive and general secretary Peter Carter said: “They underline what we already know, that a registered nurse caring for more than eight patients under these circumstances is a cause for concern – in many cases, considerably more nurses will be needed. The skill mix is also vital – to allow for supervision from ward sisters and other senior staff.

Peter Carter

“These guidelines will be very important when hospitals come to determine how many staff they need. In conjunction with the influence and experience of senior nurses, wards should be able to fully assess their needs and adjust them to suit demand.”

He added: “It is also crucial that needs are not only assessed, but also met, and resources are made available to keep care safe. Too often, staffing levels are allowed to yo-yo because of finances, and this puts staff under strain and patients at risk.”

The RCN, which contributed to the draft NICE guidance, said it would be responding to them “in detail as part of the consultation”.

Gail Adams, head of nursing at Unison, said: “We do welcome NICE’s recognition of the link between caring for eight patients or more and the increase in risk to patients, but it is a shame that it falls short of calling for a national mandatory minimum.”

“There is safety in numbers when it comes to caring for patients and that means legal staff patient ratios,” she added. 

Gail Adams

She noted that a recent survey by the union found 45% of nurses were caring for eight or more patients so action is needed now.”

Unison expressed disappointment that the consultation was limited to those registered with NICE, which it said missed an opportunity to engage with nurses, patients and students.

As previously reported by Nursing Times, as well as the work by NICE, NHS England and the Care Quality Commission have told trusts to put new staffing transparency systems in place by the end of June – as a further response to the Francis report.

The number of staff on each shift must be displayed outside all inpatient wards, monthly updates on staffing given to the trust’s board and published online, and there must be an establishment review every six months.

The NICE document – published to coincide with International Nurses’ Day on 12 May – follows a warning last week that most frontline nurses feel they remain severely understaffed.

In a joint survey of over 1,800 nurses by Nursing Times and ITV’s Good Morning Britain programme, 82% of respondents said they did not have sufficient time to give patients adequate care.

Latest official workforce figures show hospitals were employing around 2,400 more nurses on acute, elderly and general wards in October 2013 than they were when the Francis report was published in February.

Despite the creation of some extra posts, which have been welcomed by ministers, the survey results suggested further recruitment was vital.  

The public consultation for the draft NICE guideline will begin on 12 May and closes on 10 June 2014. Visit the NICE website to take part.

Readers' comments (43)

  • Totally agree that we MUST have safe staffing levels all to often we are told there is not evidence to support minimum staffing levels or what does in fact constitute what these levels should be there is an opportunity here for nurses to respond in large numbers to convince NICE just what the real situation is Let's give the evidence

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  • We must make sure 1.8 is not the ceiling otherwise 1000s of nurses to go - acuity and support workers need to factor in

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  • This is a significant move by NICE.

    It is now up to Nurses to ensure that this guidance is implemented.

    No longer will "nurse managers" be able to ignore the plight of patients or treat the advice of clinical nurses with contempt.

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  • tinkerbell

    Hooray and about bloody time, not like this hasn't been going on for years and years and managers didn't know. Are we at last going to be given the tools to do the job safely? Incompetent management who do not/have not listened to staff concerns should be made accountable for the state we're in.

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  • michael stone

    I foresee the next row over this one, hinging on questions about how 'a nurse on the ward' is being measured (in other words, when these staffing ratios are being published, will all of the staff being counted actually be available for 'direct' patient care/response).

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  • tinkerbell

    probably not, most will have passed away from exhaustion.

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  • so glad I was never expected to go to work in my pyjamas, or is this some model from 'Grey's Anatomy' in the photo?

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  • Totally agree this is a step in the right direction us as nurses have worked for too long under uneccsary pressure, we are run off our feet trying to provide the care to our patients on a daily basis and maintain standards, when in fact we ourselves often go without breaks and fluids so we can care for the people under our care. In the end it catches up with us because we become worn out. At the end of the day we must provide quality care at all times to our patients, so a bit of help in this direction can only be positive.

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  • cheryl leese | 11-May-2014 10:52 am

    as a nurses you should understand the dangers of going without fluids. if you can't take responsibility for your own health you could end up as a further burden on the NHS and the taxpayer!

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  • Ward staff have been told at the trust at which I work that they are to satisfy their fluid requirements for the whole 12.5 hour shift during the 2 X 15 minute breaks they have during the day. They also have to eat enough food to give them the energy to work.
    Managers can sit at their desk and eat and drink during their 8 hour day. They do not appreciate how difficult it is to provide care for patients, usually more like 12 per qualified nurse whilst ensuring that they are suitably refueled and rested during their short breaks.
    More qualified nurses means more expenditure. What will be lost in order to provide more available nurses for direct patient care.

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  • Anonymous | 11-May-2014 3:02 pm

    nobody can tell you when to satisfy your fluid requirements except your own body clock! It is total nonsense to be persuaded otherwise.

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  • I remember a school friend of mine who left nursing, shortly after qualifying in 1980 because "she couldn't spend time with patients, as she wanted and they needed".
    It seems that nothing has changed in over 30 years. It's not rocket science is it?

    As a member of the public, 4:1 seems a sensible ratio - then at least you have the resources to care for everyone during an emergency.

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  • 8:1 ratio is unsafe any shift. Nurses and their patients deserve adequate time to for the nurse to assess, review the patients chart, labs, tests, educate the patient, provide time for toileting, walking in the hallways, treatments etc. Although it has always been the plan to staff according to acuity level, it always seems that in the end you get the amount of patients your floor has deemed as a safe level. Four patients with the max of five depending on acuity would mostly be doable. More then six patients on night shifts is too much.
    Adequate help of aides to assist the nurses is always a problem too. They have no limit to amount of patients, so too few nurses and too few aides mean long wait times for the patient needing help. Patients are people not the bottom line.

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  • 8:1 ration is better I am looking after 12 patients in an acute setting very frustrating, sometimes you do not feel you want to go to work hope the top ones will comply with he decision

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  • I don't work in an acute/general setting and havement done so for 20 years or more, but looking around the country at all the acute trusts who are in financial difficulties and who are still expected to cough up their share of the billions that the Govt want back out of the NHS - how exactly are they going to pay for any increase in registered nurses in their clinical teams?

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  • somebody needs to spell out precisely all that a nurse does for each of her patients on a shift as those who has never done the job and dictate what patients and nurses need to do a safe and good job don't have a clue.

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  • I work in Acute admissions and while I welcome looking at minimum staffing levels I would urge there to be consideration of acuity.When I trained in the 1980s we had to complete acuity charts to be given to the nursing managers.
    I appreciate acuity is fluid, especially in my own environment & others similar but the admission process which is so long winded, albeit mostly necessary, is primarily undertaken at the front door in addition to the patient being at their most unstable make it very difficult for prediction and preplanning staffing levels on a regular basis.
    The publication of nursing staff numbers outside the ward is totally meaningless.It would be a shame is relatives gain reassurance from these numbers.
    Amazing that money has been found to produce boards and time found to complete these. How long before jobs are created to provide the reports and sort out the establishment reviews???
    With regards to keeping hydrated on the ward....has anyone asked relatives if they preferred their nurses having a drink at their desk (if they are lucky enough to have one as ours have been largely removed) or the same nurse disappearing out of view and therefore not watching their patients while they grabbed a drink!

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  • I recently had to look after 6 patients with the help of a Carer, It was one heavy shift, only by being there would one fully understand how difficult the work was.
    -One patient was EMI and a big falls risk, can only feed herself needed help with everything else, had an obsession with needing the toilet.
    -One was end of life.
    -One had dementia and spat in your face when helping with her care, also pinch and dig her nails into your arm, this lady needed all care, also needed a hoist to move her.
    -One was critical and needed all care plus regular BP, P, etc taken, IVs and other regular medication.
    -One had dementia and wanted to leave the ward, mobility good,can feed herself but needed help with every thingh else, constant monitoring on her whereabouts required.
    -One was a falls risk, can feed herself needed help with every thingh else. Very nice lady wanted to help the next patient which put her as a massive falls risk, she kept getting up to walk over.
    I can go on and on about that shift.
    Just giving basic care took so long. I had to clean so many dentures, I did so much caring that I did not feel as I was a nurse.
    I still had to do the nursing jobs that the carer could not help me with.
    Please measure Dependancy.
    A nurse can have 6 patients and still be under staffed.

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  • Though this is a welcome move, i fear that it has only partially solved the problem. Until it is a Mandatory and Legal minimum staffing level, management and the NHS will get around the guidline and fudge the issue. Put this guidline into Law.

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  • As an Australian nurse following this debate, I am unsure what a 1:8 ratio means. Does this ratio mean that, in an acute care setting 1 nurse is responsible for total care of 8 patients? I work in a public hospital that has a mandated 1:4 nurse:patient ratio, where that one nurse provides total care to those four patients.

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