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Staffing levels: who’s counting?

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With news of growing staff shortages and cuts to training places, nursing feels increasingly understaffed and under pressure. How are nurses faring on the wards, and is anybody listening?


With the Keogh review highlighting the link between low staffing levels and outcomes, patient to nurse ratios are again in the spotlight. Hospital nurses experience care at the sharp end and report that staffing levels are a concern. However, this issue of staffing and outcomes is more complex than instigating ratios would suggest.

A survey of more than 500 nurses by Nursing Times and Allocate Software, echoes the sentiment in the Keogh review and has found that understaffing is already a serious concern at the frontline with 42% saying their ward was understaffed more than once a week and another 33% saying this happened every day.

Nurse dissatisfaction

Our survey showed that understaffing on wards is affecting nurse job satisfaction.

“Staffing levels have been reduced to a level where nursing is no longer enjoyable as I don’t feel I’m doing my job properly,” one respondent told us.

Another one nurse felt her situation was irretrievable: “Night staffing on our ward is totally unacceptable. Because of this I am moving to New Zealand.”

On the move

The survey reflects that relocation can help address the short-term spikes but does not address fundamental shortages. It also highlights how relocation is delicate and can impact morale.

Respondents felt staff relocations due to low staffing fed into their low morale. Most said that staff were relocated one to five times a quarter due to cancelled theatre or clinic sessions.

“Being moved from your base ward to a new place to cover absence is stressful, dangerous and damages morale and goodwill,” said one nurse.

Others agreed. “Staff relocation does not address shortages on a day-to-day basis, it just provides a temporary gap filler.”

The responses demonstrate that it is important to have agreed systems and processes in place to ensure that staff are appropriately skilled and that relocation it is fairly distributed.

Patient care suffering

As the Keogh review suggests, there is a link with quality of care. Some 42% of nurse respondents said that low staffing negatively

impacted on daily safe admission and patient discharge.

Others felt distressed by the level of the care they were able to give. “It’s becoming more and more difficult to provide the high standard of care I aspire to. I often go home knowing the care I have given is substandard and that is gut wrenching,” said one nurse.

All about the data

And yet our survey found that nurses feel they are measuring staffing level data and reporting it, but understaffing seems to carry on regardless.

Some 30% said they take a staffing level census once per shift and a quarter of respondents said they took one per day.

Nurses are taking a comprehensive look at their wards. Most nurses examined patient acuity and patient dependency data. And a quarter of respondents also triangulated acuity, dependency and staffing levels against the safety thermometer.

Is anybody listening?

Despite these efforts on the floor to capture and report staffing level data, our survey showed that faith in management putting the information to good use diminished up the chain.

While nearly half of nurses felt ward management put census data to good use, only 27% thought nursing directors did the same. Some 12% felt the board listened and only 5% and 7% had faith in the Department of Health and regulators using their staffing level data.

“It doesn’t make a difference what we report, staffing levels remain the same,” said one nurse.

“Although we know what safe levels are, no formal view is taken, ever,” agreed another.

Nurses felt that staff censuses were a paper exercise culminating in little change, with management only showing an interest if staffing was at extreme unsafe levels.

Others were more hopeful, post Francis. “Management have known about low staffing levels for a long time and have done very little to improve the situation. In the light of Mid Staffs things are starting to change.”

But most felt it was out of their control. “Everyone is bound by budgetary constraints so can only plan for what finances dictate, not what gathered information suggests.”

The survey demonstrates that even where organisations are trying to do the right thing with evidence-based workforce tools, there appears to be variation on how well tools and workforce planning are executed locally, resulting in a disconnect between the board and the ward.

How do most nurses capture staffing level data?

  • Nurses tended to take staffing level census at the start of the day
  • The most popular census tool was paper and pen, followed by a spreadsheet
  • AUKUH and Telford acuity model tools were the most used on the ward

What needs to change?

Aside from recruiting additional staff, nurses voted that better morale would have the biggest impact on improving staffing levels.

Others cited speeding up the recruitment process, better staff retention, reducing sickness absence and planning multidisciplinary team’s time in tandem. Many felt that staff needed better tools to examine staffing levels and the impact on patient experience in order to help the board engage with their data.

One nurse said: “The best solution would be to increase the number of staff using a workforce planning tool. Management need to understand the differing needs of patient specialties.”

“Documentation needs streamlining, it takes up far too much of my time in relation to patient contact,” said one respondent.

Others felt more predictive tools were needed: “We need planning tools to predict need and capacity; this would lead to better morale and lower sickness rates.”

To the future

What with nursing numbers continuing to fall and the impact on staff morale and patient care being clear, it’s certain that change is needed as soon as possible.

One nurse said: “I hope something can be done urgently. I see staff beaking down every day because of staffing levels and I think of changing my career daily. My patients deserve better care.”




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