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Exclusive: Trusts will need to find more nurses

Many trusts will need to increase their nurse numbers to comply with new national guidance on setting safe staffing levels in England, Nursing Times has been told. Meanwhile, latest workforce data shows huge variation between hospitals.

Guidance from the chief nursing officer for England and the NHS National Quality Board was announced last week as part of the government’s full response to the Francis report.

It said, from April, all hospitals would have to publish staffing levels on a ward-by-ward basis together with the percentage of shifts meeting safe staffing guidelines. This would be mandatory and done on a monthly basis.

By the end of next year this will be done using models approved independently by the National Institute for Health and Care Excellence, it added.

It is widely expected to lead to trusts identifying shortfalls in their staffing establishments.

There is no official estimate of how many extra nurses might be needed to meet requirements such as cover for unplanned leave among staff.

However, the Royal College of Nursing recently estimated there were at least 20,000 vacancies for registered nurses, while the Centre for Workforce Intelligence has predicted a shortfall of 47,500 nurses by 2016.

Meanwhile, Nursing Times has obtained data suggesting a big variation in nursing ratios between hospitals which gives further indication that the shortfall will be significant.

Data from June, compiled by analytics company Methods and shared with Nursing Times, shows the ratio of available nurse staff days to occupied bed days for every NHS acute hospital.

The ratio among acute trusts varies from 1.33 at Tameside Hospital Foundation Trust to 2.59 at University College London Hospitals Trust. Among trusts that provide both acute and community services, the ratio ranges from 1.52 at Croydon Health Services Trust to 3.34 at Guys and St Thomas’ Foundation Trust.

Even when the varying size of organisations is taken in account, some organisations currently appear to have one and half times more nursing availability than others.

The data must be treated with caution as it includes nurses who are not in patient facing roles and excludes day cases.  

Both Croydon and Tameside have been subject to much public scrutiny due to concerns about quality and staffing levels, and are planning to increase their numbers of registered nurses. In total, seven of the 10 acute trusts with the lowest ratios are among those that the CQC has highlighted concerns about. 

Ruth May, NHS England’s director of nursing for Midlands and the East, led the development of the new guidance for boards on staffing.

Ruth May

Ruth May

She told Nursing Times the first step for boards was to make sure they knew what their establishment should be.

“To begin with people will be surprised to see they have got a shortfall, but as the weeks and months go on, organisations will get better at aligning their staffing levels,” she said. “It’s likely we will see trusts increasing establishments as well as more focus on rostering correctly to maximise staff they have got.”

Dr May said the idea was for staffing levels to be reported in a similar manner to how wards report how many days they have been free of a pressure ulcer or an MRSA infection.

She stressed the guidance applied to community and mental health providers just as much as acute trusts.

Although additional nursing recruitment is likely to be welcomed by the profession, there is widespread concern among hospital managers about whether it is affordable in the long term. An additional 8,000 band 5 nurses would cost the NHS about £320m.

A Nursing Times investigation earlier this year found 73 acute trusts had increased their nursing establishment in 2012-13 by a total of 4,321. Last week Health Education England revealed trusts are planning to employ an additional 3,700 nurses during the current financial year.

Royal College of Nursing head of policy Howard Catton told Nursing Times it was encouraging that the government seemed to be finally recognizing the existence of a nursing shortage.

“There is a question mark about what the extent of that shortage would be. The work that’s going to flow from this new guidance will put us in a much better place.”


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Readers' comments (28)

  • Most hospital Trusts have an abundance of qualified staff: visit any critical care, theatre or endoscopy suite and you will find large concentrations of nurses not necessarily making best use of their registrations. This isn't a dig at these particular specialities, it is just an observation and in these austere times, it makes sense to redeploy this untapped resource.

    I think many Trusts will be revisiting their vastly swelled ranks of 'specialist nurses' and looking to reassigning them - even for just one shift a week - to a ward-based setting.

    I welcome this new thinking as I believe ward-based staff have become very deskilled in a number of key areas as virtually every process now has some specialist nurse attached to it. I think having specialists working on wards will help with staff training and the promotion of best practice.

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  • Skills4nurses a Scottish organisation have been over to Portugal, Spain, Greece and Italy in the past recent months and have recruited over 300 nurses for UK NHS Trusts. I know that are returning in January again on behalf of a northern NHS Trust, it seems that the shortage of nurses is not only confined to down south.

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  • michael stone

    How do we know - as opposed to suspect - that there are note nough nurses, when the 'metric' has not yet been settled ?

    Personally, I still see this working in a cause-and-effect fashion. If different hospitals publish staffing numbers AND 'patient outcomes', then it should soon become clear both:

    1) if there is a 'critical ratio' below which bad things happen, and

    2) if some places have got 'bad things happening' even if they apparently have got enough staff.

    So if you properly collect and publish the ratios and outcomes, you can then work out from the figures 'what is needed as a minimum level' (from 1) and also 'which operational set-ups seem to work well and which badly' (from 2).

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  • michael stone

    'not enough nurses' !

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  • Currently to plug gaps, recruitment drives are being done from other countries. Though this should only be a short term fix, and will not solve long term shortages of nurses in this country.
    The emphasis on nurturing home grown staff and the improvement of retention of staff is very much lacking from what I've heard.

    It seems there is only retention premia for the most difficult to fill vacancies, where staff don't stay for long.

    Nurses work bank shifts for extra money to make ends meet; paid at similar rates to normal rates. However as they are meeting service requirements, they should really be paid overtime rates (especially if there is lack of staff or increased numbers of patients or complexity of care).

    Due to lack of retention, staff leave more readily, either to work elsewhere or to leave the profession entirely. This then adds to the cost of employers of advertising and recruiting new staff, time and costs to cover senior staffs for interviewing, training costs of new staff, allied costs associated with recruitment - DBS checks, references, occupational health screening.

    Staff and resources are directed towards specialist areas such as Emergency Departments, Intensive Care, Hyper-Acute Stroke Units, etc; as they are high profile areas; however this then leaves massive gaps in care of the Elderly and those with long-term conditions, as resources aren't being put into those areas.

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  • Anonymous | 27-Nov-2013 10:46 am

    I don't know anywhere with an "abundance of qualified staff" or "vastly swelled ranks of "specialist nurses"".

    The specialist nurses in my hospital work throughout the breadth of their specialties. (In wards, clinics, patients' homes, etc). They are also required to work ward shifts, not "to help with staff training and the promotion of best practice.", but to make up the numbers and avoid recruiting adequate levels of staff. Their patient caseloads (which ward based nurses don't carry) do not decrease whilst they are working in the wards and their teaching and research duties need to be fulfilled in addition to their main role.

    Most patients are not found in bed, yet 'nurses at the bedside' is peddled endlessly as the answer to all problems. Neither is any consideration given to career choices and ambitions of individuals. The ignorance and lack of aspiration in this type of thinking is damaging. It isn't the solution to chronic understaffing and should never be punted as such.

    I think you will also find that the vast majority of ward-based staff are well educated, trained and skilled individuals who might take exception to being portrayed as "deskilled". In an increasingly complex patient environment, they are required to possess many more skills than ever before.

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  • Where are these nurses going to come from? we know that there is a nurse shortage, what happens if they can't find extra staff?

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  • Does this mean the end to supernumerary ward managers - will they be out on the wards helping patients, same with the senior nurse managers, bed managers etc. etc. - is this the end of these jobs being given to nurses.

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  • Not all patients are on the ward. Most are not.

    Regardless, the organisation of a ward can't be done by nurses if every nurse is carrying out 'bedside care' for every minute of every shift. Those who constantly argue for ward managers to spend all their time 'out in the ward', are completely unaware of the requirements of the job, (and never seem to put themselves up for these jobs).

    If all nurses regardless of training, experience, qualifications, specialist interest and ambition are to be placed 'at the bedside', how can nursing ever progress? We might as well just let everyone walk over us and do as we are told. Mind you that is pretty much what goes on at the moment.

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  • Anonymous | 28-Nov-2013 12:05 pm

    All of your specialist nurses may well be filling in and covering shifts on wards, but that certainly isn't the case in my patch, indeed there are droves of very qualified people in non-jobs wandering the corridors and populating the coffee shops and restaurants of hospitals.

    We have so many 'teams' involving themselves - viscerally - in patient care that it is almost impossible to admit, correct and discharge a patient without some team or specialist having to be informed or involving themselves. It's crazy, the NHS is effectively bust, we need to make changes!

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  • Anonymous | 28-Nov-2013 12:47 pm

    Perhaps you didn't understand my point. The purpose of a specialist nurse is NOT to "be filling in and covering shifts on wards"!

    As for, " very qualified people in non-jobs wandering the corridors and populating the coffee shops and restaurants of hospitals."; I often see comments which describe ward nurses as rude, feckless and much more interested in sitting around the Nurses' Station avoiding eye contact with everyone, not answering call bells and bitching about how busy they are whilst everyone else swans about. I don't give much credence to them either.

    It's crazy, we work in the NHS and still so many don't actually understand that it is a health service, not one big In Patient ward where every health professional must work. With regard to making changes? Broadening your mind would be a good place to start.

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  • More Nurses! Yes. Working the wards delivering direct patient care. Nurses know the drill.
    Nurses of every grade/band on the floor. Feeding, bathing, assessing, caring, documenting and planning care.
    Patient centred? Let the leaders take the lead and inspire by example.
    Ask the patients and relatives how they would feel about the above. I have often heard that 'Nurses' are not taken seriously. Why? Because even a senior Doctor shows up on the ward from time-to-time. How embarrassing is that?
    Nursing is the only profession whereby you start as a 'Professional' and end up a 'title'. Good job though, but not behind a desk or bleeper.

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  • Nursing Standard

    Volume 28, Issue 12, 20 November 2013


    Half of Portuguese nursing school graduates leave to work abroad

    Full-text HTML

    Jennifer Sprinks Lisbon

    Nursing Standard. 28, 12, 14-14.

    Published in print: 20 November 2013


    "Portugal is losing too many nurses to countries such as the UK at a time when its workforce needs to increase to care for an ageing population, Lisbon’s nursing school president has warned."

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  • I didn't realise that the Daily Mail had taken to flooding these threads with comments.

    "Nurses of every grade/band on the floor. Feeding, bathing, assessing, caring, documenting and planning care." = (Daily Mail) Daft, backward thinking based in the belief that all nurses should be in a ward, at a bedside, regardless of the needs of patients anywhere else. Tick.

    "Patient centred? Let the leaders take the lead and inspire by example." = (Daily Mail) As we suspected, a bog standard staff nurse is incapable of carrying out patient care without a Matron's hand on their shoulder. (It's these degree nurses you know. They haven't a clue. They don't need education. Just two arms, two legs and the ability to carry out orders. No need for all that thinking malarkey). Tick.

    Or you could train and employ enough nurses to staff all areas where they are needed. Where they are able to work in areas that are appropriate to their training, interest and qualifications. Where their own aspirations are fostered and they are able to flourish and improve patient care with confident, nurse led care, instead of dragging them from all the other areas where they are needed. Nah, that would involve motivation, effort and forward thinking, and it would improve patient care.

    Much better to moan endlessly and carry on in the belief that all patients are 'in a ward' and that everyone else should work there. Beats actually doing anything to change things for the better, doesn't it? Yeah, that's Daily Fail readers for you. Fag packet solutions!

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  • to the nurse or nurses who think that those who don't work in the wards are doing nothing jobs:

    after 28 years in frontline nursing, my career in nursing almost came to an end through a physical illness (not caused by my work) which meant that i was unable to go back to my ward. yet i couldn't see myself as anything other than a nurse. long story short, i had to change direction completely and went into research or leave nursing. the training for each study (i work on around a half dozen at a time and need to know every aspect of each one) is constant and the learning curve has been steep. i work in a small, busy team. we are carrying out studies involving new treatments, drugs, procedures, medical devices, etc. which will have direct impact on outcomes for our patients and the way we prevent and treat disease. i have never been busier (i worked in busy wards for most of my career) and it is not a nothing job. my contribution to patient care is every bit as valuable as yours. if you had your way and i was forced back into a ward situation, i would have to leave nursing. all my skills, my experience, my knowledge and my love of my job would leave with me. i am sad to say that, in the course of my work, the people i find the most difficult and obstructive, are usually ward nurses! when i had to be a patient myself, i can assure you that i was very grateful for the support and expertise of the specialist nurse whom i saw mainly in the out patient clinic and in my home, not a hospital ward.
    we are short staffed everywhere, not just in hospital wards. the solution is to recruit staff who are suitably qualified to work there, not steal them from elsewhere. the role of the nurse is much more varied than ward work. nurses are found everywhere in the NHS and they need to be.

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  • I agree with the above comment. And simultaneously to the (6:26pm) above. Where and when was the 'Daily Mail' mentioned in the latter comment?
    Nurses of all grades, aspirations and qualifications should have direct patient contact. Is that wrong?
    Changes have to and will be made. Less Nurses will be around to do it. Hard times ahead for patients. Not too worry, there is a myriad of 'fag packet' solutions from the Daily Mail.
    Nurses that do not work directly with patients should rescind their registration. I'm a Nurse and that is common sense. Care and be credible.

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  • Anonymous | 28-Nov-2013 11:39 pm
    I think that anon 28 nov 10.36pm was being facetious and I have to say that I agree. Some of the solutions offered by anon 28 nov 6.26pm are found in the comments sections of the daily mail by those who think that nurses should shut up and just do what they are told to do by doctors. There is too much small mindedness in nursing and a lack of understanding about the variety in our profession. Direct patient contact shouldn't be defined as 'Feeding, bathing, assessing, caring, documenting and planning care.' As pointed out by anon 28 nov 11.12pm, there is a lot more to patient contact than that. It would be beneficial for nurses of all jobs and grades to have an opportunity to understand each other's roles. But that is not realistic. I don't want my senior manager getting in my way. I want her to listen and act upon our concerns and make sure that we have the right amount of staff and resources to do our job. If everybody just did their job, then life would be easier for us all. I work in the community. A couple of years ago a new manager joined our team and insisted that she would be hands on and had a caseload. Things started to go wrong very quickly and she soon realised that the demands of her new job meant she could not hold a caseload. We were actually relieved when she got down to managing the team and taking care of all the necessary business which to the rest of us is deathly boring. I wouldn't want her job, but it has to be done so that I can get on with mine. So when you talk about direct patient contact, be careful how that is defined. It isn't a one size fits all.

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  • I did some agency work recently in a Urology Clinic. The clinic was well staffed, but really busy. Every friday the specialist nurse was not available to patients with a variety of needs, particularly those who were at various stages of their journey through the diagnosis and treatment of prostatic ca. When she was at the clinic, she was incredibly busy. If a patient phoned on a friday she would make arrangements to call them back during her breaks and would return to outpatients every friday evening to prepare her caseload for the following week. What was she doing on a friday? She was made to work a day a week in a ward she had left two years earlier. She had been there for years, did further studying in her own time and became a specialist nurse because she felt she could develop her role and offer more to patients. She was busier and had much more responsibility in her specialist role. She gave up her 12 hour shifts and compressed working week which suited her home life and swapped it for a 5 day week, which didn't fit in so well. But she felt that on the whole it was worth it to have the opportunity in her specialist role. The one day a week in the ward that people seem to think is such a great idea, takes this nurse away from her patients where she can do the best job.

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  • Anonymous | 29-Nov-2013 9:50 am

    admirable story and i am sure there are thousands like it. obviously your final argument is totally correct but I can't help thinking of all the benefits this nurse, with all her experience, is bringing to the patients on the ward even though it is not really concomitant with continuity in care and seems something of ? an organizational/management failure (putting this before the needs of individuals - patients and staff) and a very hefty workload for one individual whose wellbeing, health and private life must also be taken into consideration.

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  • Anonymous | 29-Nov-2013 10:14 am

    If there are perfectly competent registered nurses already on the ward (and there are), how can that be measured against the out patients who lost out, are of equal importance and whose needs are not being catered for? Not all nurses should be made to work in wards! Our patients are everywhere.

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