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NICE recommends minimum safe nurse staffing levels for A&E


There should be a minimum of one nurse per four cubicles in accident and emergency departments, according to new draft guidance on safe staffing levels.

The National Institute for Health and Care Excellence has today issued a draft guideline to advise A&E departments on safe staffing levels of nursing staff.

The new draft A&E sets out actions needed to ensure enough registered nurses and non-registered nursing staff to provide safe care “at all times to patients attending A&E”.

For the first time, NICE has recommended minimum ratios to be considered by trusts when planning their nursing establishments or for use on a shift-by-shift basis.

It has recommended one registered nurse to four cubicles in either “majors” or “minors”, one registered nurse to one cubicle in triage and one nurse to two cubicles in the resuscitation area.

“We want to ensure that each and every A&E department across the country is clear on how to get nurse staffing right”

Mark Baker

Senior nurses should check there is enough capacity to meet ratios for certain situations, such as two registered nurses to one patient in cases of major trauma or cardiac arrest, and one to one for priority ambulance calls and for family liaison.

There must be one band 7 nurse, or equivalent, included on every shift at all times to lead, supervise and oversee the shift.

It also includes making sure departments have the capacity to provide all necessary emergency care, as well as specialist input for children, older people or those with mental health needs.

For example, it states there should be a registered children’s nurse on each shift or, where the level of service provided does not warrant this, at least one A&E nurse with education, training and competency in children’s nursing.

NICE said the guidance, which comes at a time of unprecedented pressure for A&E departments across the country, will help hospitals to plan safe staffing levels and best meet patient demand.

Professor Mark Baker, director of clinical practice at NICE, said: “Nursing staff are often among the first to see patients. Ensuring there are enough available nursing staff, with the right skills, helps to make sure people in need of immediate medical help, will get safe care, whatever the time of day or night.”

The draft guideline also recommended that, when planning establishments, departments should allow for enough nursing staff to care for higher than the average number of patients who attend the department on a daily basis.


A&E ratios backed by NICE draft guidance:

1 registered nurse to 1 cubicle in triage

1 registered nurse to 4 cubicles in minors and majors

1 registered nurse to 2 cubicles in the resuscitation area

1 band 7 (or equivalent) registered nurse on every shift at all times

  • major trauma (2 registered nurses to 1 patient)
  • cardiac arrest (2 registered nurses to 1 patient)
  • priority ambulance calls (1 registered nurse to 1 patient)
  • family liaison (1 registered nurse to 1 patient’s family/carers)


By increasing weekly nursing staff hours to cover above average attendance numbers, staff could deal with unexpected peaks in the demand for A&E services and be moved around the department flexibly to respond to changing situations, it added.

The recommendations also sets out a series of “red flags” that may indicate there are insufficient nursing staff on a shift. These include patients falling or leaving the department without being seen. These should be reported immediately to the nurse in charge.

Trusts should also publicise “red flags” to patients – via notice boards in waiting rooms – to ensure they are able to report incidents, such as untreated pain or delays receiving food and drink.

In addition, it calls on managers to review the A&E nursing staff establishment at board level at least every six months and more often if warranted by factors such as increasing staff absenteeism or frequent overcrowding.

The draft guideline will now be the subject of a consultation exercise until 12 February, after which a final version will be published.

Professor Baker said: “We want to ensure that each and every A&E department across the country is clear on how to get nurse staffing right and is able to provide safe care to the millions of patients who walk through the door.

“We now need feedback from nursing staff and all other healthcare professionals working in emergency care, hospitals trusts and also members of the public to help us ensure all relevant views are considered for the final guideline.”

“Setting the minimum number for a given department is a step in the right direction but minimums should never become maximums”

Peter Carter

However, speaking on BBC Radio 4’s Today programme this morning, Professor Baker acknowledged that NICE was “not absolutely sure” how many departments were currently meeting the ratios suggested in the guidelines.

He added that NICE was now going to “field test” the ratios to see how close they were to present situation in A&E departments before it published the final version of the guidance.

An A&E nurse, who wished to remain anonymous, said the guidelines were “surprisingly similar” to the pre-existing staffing levels in his department. However, he said he was concerned the guidelines could encourage trusts to meet “a bare minimum” of staffing.

“A&E departments are very fluid environments with patients moving constantly,” he said. “One issue we have is who takes responsibility for the patients in the waiting room, on the corridors, and the patients in other waiting areas? I feel there should be a designated nurse for these patients.”

He suggested there should be more nurses in a “floating” role, who were not assigned to specific areas and could help alleviate pressures, for example, by taking blood tests in waiting rooms so they were back from the lab by the time the patient reached a cubicle.

Peter Carter, RCN chief executive and general secretary, said: “A&E departments are at breaking point. NICE have recognised that this is not just a winter crisis and that only long term planning can tackle staffing issues.

“For years now, many A&E departments have been understaffed, or staffed with temporary or less experienced nursing staff,” he said. “Safe care cannot be delivered without safe nurse staffing levels.

“Setting the minimum number for a given department is a step in the right direction but minimums should never become maximums,” he added.

A Department of Health spokesman said welcomed NICE’s work as a “major step forward”.

He claimed the nursing ratios in the guidance were “typical of current practice in A&E” and that there were 1,366 more nurses working in A&E than in May 2010.

“This NICE guidance will give the NHS evidence to make sure it has the right number of staff, improving patient care,” he added.

Sir Mike Richards, chief inspector of hospitals at the Care Quality Commission, said: “The inspections we have carried out during the last year found widespread evidence of the impact of staffing issues on patients.

“Our initial analysis has shown that there are fewer staffing problems in departments where there are clear staffing recommendations, such as intensive care and maternity, and therefore we welcome guidance in this area,” he said.

“Hospitals will now have to look carefully at the NICE guidance in relation to A&E staffing and we will need to assess whether they are meeting it,” he added.

The guideline was commissioned by the Department of Health and NHS England in November 2013, as part of a series on safe staffing following the Francis report into care failings at the former Mid Staffordshire NHS Foundation Trust.

NICE has already published guidance for nurse staffing levels on adult inpatient wards in acute hospitals and for midwifery.

The inpatient guidance, finalised in July, stepped back from setting a minimum ratio NICE, but noted there was evidence of increased harm associated with a registered nurse caring for more than eight patients during day shifts, and suggested this could indicate the risk of a “red flag”.

The midwifery guidance, published in October, said any occasion when one midwife was not able to provide continuous 1:1 support to women during established labour represented a “red flag”.


Readers' comments (8)

  • Well NICE can recommend all they like but it ain't going to happen! Are they on Planet Earth?

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  • Where are they going to get the nurses to fulfill these guidelines?!?
    Have they forgotten that there are consultations going on about restructuring pay ... Who is going to work under so much pressure for less pay if they succeed in unsocial pay reductions etc??
    Then of course there is the training issue for nurses ... will 'Shape for Care' help of hinder the training of new nurses and HCAs, many universities are already re-thinking having nurse training on the prospectus.
    We want to give high quality care ... when is someone going to realise that without enough staff and investment we can't!!!

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  • michael stone

    I heard a chap from NICE talking about this on Radio 4 this morning. I think the most interesting of his points, was the statement that [employed - i.e. not 'agency'] staffing numbers should not be set for 'average demand', but instead should be set at a level 'where the number of staff on duty could cope with 6 days out of every 7 without drafting in extra cover'.

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  • Anonymous | 16-Jan-2015 10:45 am

    Why the cynicism ?

    If the guideline is adopted then NHS Trusts will be judged, by the CQC and others, by that standard. Failure to meet the standard would imply that Trusts were not offering safe care. Not offering safe care will attract criticism and the possibility of "warnings" or other means of enforcement.

    Such guidelines should be welcomed as they restrict "managements" ability to ignore staffing issues.

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  • the chap from nice said nurses work long hours and it is at great cost financially failed to mention all the unpaid hours done, another mandarin from NHSE with no clue

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  • The trusts will use the minimum as their maximum....the numbers will never reach maximum staffing levels. What they should be thinking about is looking at the root cause of the problems ie. more beds in the hospitals, better systems throughout the hospitals to allow better flow through A&E. With the increasing number as of people coming to this country it's hardly surprising that there is no infrastructure to support it and it'll only get worse when staff will be looking for 9-5 jobs elsewhere when the unsocial hours pay etc is cut. However it's good to have standards but the management out there won't change!!

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  • why did NICE not include safe staffing levels for operating theatres after all these patients are unconscious.
    As an anaesthetic nurse I routinely have to deal with two unconscious patients at the same time and the managers are aware of it and so are the clinical directors and they choose to ignore it year in year out.
    As for NICE they really are not a credible organisation at all.

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  • What staffing ratio do they recommend for the ambulances queuing up outside AED with acutely ill or injured people, when all the cubicles are occupied by patients waiting to be seen or for a bed on the wards?

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