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More than seven patients per nurse risks missing vital care


Wards should have seven patients or less per registered nurse to avoid missing vital care, according to latest UK nursing research by leading academics.  

They found the number of patients per nurse on duty was significantly linked with the incidence of unfinished care by nurses, or “missed care”, and called for it to be used as an early warning for potential patient safety concerns and unnecessary deaths.

The study, by the National Nursing Research Unit at King’s College London, found more than eight out of 10 hospital nurses had to leave care undone on their last shift because of staffing shortages.

It also revealed that when number of patients per registered nurse was over seven significantly more care deemed vital by nurses to patient safety was missed.

In May this year the Safe Staffing Alliance, which includes the Royal College of Nursing, Unison and the Florence Nightingale Foundation, said one nurse should look after an absolute maximum of eight patients.

The NNRU findings come as senior nurses are set to warn hospital regulators that they should monitor staffing levels and latest workforce figures revealing a drop of 1,000 NHS nurses in England in one month.

The researchers argue that hospitals could use a nurse-rated assessment of “missed care” as an early warning measure to identify wards with inadequate nurse staffing, rather than relying on mortality indicators that reveal problems after they have happened.

“Missed care is a more direct indicator of quality deficiencies with a clear pathway to adverse patient outcomes and experience,” they said this week in the journal BMJ Quality & Safety.

“As the inquiry into excess mortality at Mid Staffordshire Foundation Trust critically shows the consequences of poorly informed experiments to improve the efficiency of the nursing workforce can be disastrous,” they added.

The study, carried out between January and September 2010, involved 46 acute trusts in England.

Researchers, led by the NNRU’s deputy director Jane Ball, surveyed 2,917 registered nurses working in 401 general medical and surgical wards.

Nurses were given a list of 13 care activities, with 86% reporting one or more had been left undone due to lack of time on their last shift.  

Most frequently left undone activities were comforting or talking with patients, educating patients and developing or updating care plans. Pain management, and treatment and procedures were the least likely to be missed.

More care was left undone on day and afternoon shifts than night shifts.

The study also revealed nursing workforce levels. The average number of patients cared for per nurse during a day shift was 7.8, compared with 8.8 in the afternoon or evening, and 10.9 at night.

Fewer elements of care were missed and the odds of missing any care were significantly lower when nurses were caring for the fewest patients – six per nurse or less – compared with when nurses caring for the most – around 12 or more patients per nurse.

The practice environment, as rated by nurses, was also significantly associated with missed care. There were fewer missed activities on wards where the environment was rated as positive in terms of factors like support from management and nurse-doctor relations.  

“Our findings clearly show that nurses are more likely to report care being left undone when they are working on shifts with high numbers of patients per registered nurse,” the authors said.

“For NHS hospitals to significantly reduce the amount of care left undone would require a change to a daytime shift average of just over seven or fewer patients per registered nurse providing care.”

But they add: “Our findings raise difficult questions for hospitals in a climate where many are looking to reduce—not increase – their expenditure on nurse staffing.”

A report published last week showed that hospital foundation trusts in England were looking to cut their nursing workforce by 4% across 2014-16, following a short-term increase this year in response to the Francis report and the Keogh review.

The level of the challenge for some hospitals is also demonstrated by the ratio of 14 patients per nurse recently identified by the Keogh review on the largest ward at The Dudley Group Foundation Trust.

Lead study author Ms Ball told Nursing Times: “As we saw in the Keogh review, this study demonstrates the importance of registered nurse staffing levels to the quality and outcomes of patient care.”

“By looking at ‘care left undone’ due to lack of time, we can understand more about the association previously found between nurse staffing levels and patient mortality,” she said. “The study provides an indication of the scale of the staffing problems we face.” 

She pointed out that only the top 40% of hospital wards in the study had nurse staffing levels sufficient to significantly reduce the chances of care being left undone. The majority had staffing levels that were insufficient to meet patient needs on every shift.

“Having data on the actual numbers of patients per registered nurse on duty, as opposed to the number of posts per bed, is essential to robustly assess and monitor staffing levels, and ensure they are sufficient to meet patient needs and provide care safely,” she told Nursing Times.

Peter Carter, chief executive and general secretary of the Royal College of Nursing, said: “These are depressing findings and unfortunately not surprising.

“When nurses are overloaded with tasks, and have extremely limited time to complete them, something has to give. Without enough staff on the ground it’s vital care such as having the time to talk with, and reassure, patients that suffers,” he said.

“We need to prevent poor care by making sure wards are well staffed, not just use poor care as an early warning sign. We urge all employers to make use of this research.”


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Readers' comments (48)

  • A Registered Nurse used to look after a whole ward and the care was ten times better than today. The Enrolled Nurses where the main carers and where eccellent at their job-big mistake to upgrade them to do paper work and computer records. RG are now trained as managers, not nurses, Sisters time taken up with money allocation for bathrooms etc, audit and Personel work to counsel "overworked" nurses. Lets get back to organised routine, where ths Sister knows what everyone is expected to do or be doing at any given time. From a die-hard disciplinarian!

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  • all these investigations by academics and civil servants on what nurses have been warning for years, and have already predicted a serious crisis, seem useless. by the time they come to be considered for any action and the situation has deteriorated even further a new and further inquiry will be called for instead of implementing any improvements.

    it is so much easier for those not directly involved in delivering care just to observe, ask questions, tick boxes and push paper than it is to make any decisions and ensuring meaningful action is taken and then continue to monitor its effectiveness.

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  • Oh for Godness sakes!!! We all know this and have been verbalising this for years. It now taks a "Study" to reiterate what we, the people who have to care for the patients, already knew.....but still nothing will be done about it.

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  • My tears drool down, oh! NHS what's going to happen, the forcing work load on nurses!
    Poor HCA are have to carry out the more physical exerting part, patients care mostly performed by HCAs, one HCA to 8 to 10 patients. nurses have no time to work together with HCA to deliver safe and quality care to vulnerable patients, Nurses take ample time to serve medication, no matter howmany years of work experience, they take time as newly qualified nurse. Continuity of work equip an individual's efficiency, it seem this category is continuing same speed and same manner which eat time and more of the work and interaction with patients are done by HCA,PLEASE not all one out of ten find real nightingal

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  • Well well well, what a waste of valuable resources. Not rocket science and shouldn't have needed a study to reinforce it. The fact of the matter is...... there aren't enough nurses on the wards. Just look at how Australian nurses work, 1:4, perfect ! I don't know of any Aussie nurse who doesn't love her job and feels she's providing quality care, plus goes home with enough energy to enjoy the rest of her day instead of feeling stressed and exhausted.
    Such a pity that something as blatantly obvious as staffing levels needs to be discussed continually. Rationing care certainly isn't the answer !!

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  • and the tories answer.....CUT more nursing posts...brilliant

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  • Well, nothing new here is there really? Its not the Tories cutting nursing staff numbers, its the individual Trusts who decide who to hire and fire and most - it would seem - would rather hire media consultant, IT consultants and a host of other non-job people rather than retain those who work directly with patients.

    However, the number of specialist nurses and modern matrons and project nurses etc wandering around aimlessly where I work is unbelievable!

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  • We all knew this for years but nobody is listening to us instead we are been subject to scrutiny. No one values our hard work and dedication. Managers should come out to their offices and get their hands dirty because we all know that shortage of staff will continue because of this so called money saving.

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  • It is not difficult to see why there is only one Nursing research facility in this country.

    Anonymous | 30-Jul-2013 1:24 pm

    "Just look at how Australian nurses work, 1:4, perfect ! I don't know of any Aussie nurse who doesn't love her job and feels she's providing quality care, plus goes home with enough energy to enjoy the rest of her day instead of feeling stressed and exhausted."

    And do you know why that is? Because Aussie nurses didn't sit around blaming everyone else for their lot. They got off their backsides, took to the streets, took on the government and had the courage to co-ordinate and carry out effective industrial action. And won.

    So what are you going to do with this latest evidence? Are you going to use it to back up the case for action, rally your colleagues and come out fighting for statutory ratios? Or are you going to moan about those who added to the evidence supporting your cause? I guess the answer is already obvious.

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  • Anonymous 5.17pm - have you ANY idea what a specialist nurse does? We do not need to be griping at fellow nurses, it's fairly clear you don't yet know much about the roles. Which nurses in particular wander around aimlessly - is it the orthopaedic practitioners, the A&E specialists, the diabetes nurse, the vulnerable adults and child protection nurses? Or maybe the continence, tissue viability, medicines management, transplantation, respiratory, epilepsy, parkinsons nurses? What are the projects that the project nurses are working on? Have you asked, and if so, do you think the projects are valid or useful, and if not have you made that known and explained why you think that? I'm sure any of them would welcome you spending a day with them to help advise them on their performance, and then together you could approach management to resolve any issues you find. You may be surprised at what you see, and I hope you'll learn not to criticise until you really know the full extent of somebody else's role.

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