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Unions call NICE guidance on safe staffing a ‘positive step’


Health unions, regulators and other nursing organisations have largely welcomed the publication of safe staffing advice for nursing care on adult inpatient wards in acute hospitals.

The National Institute for Health and Care Excellence has today published the final version of its much-anticipated guidance on safe staffing levels for acute inpatient wards.

The guidelines state that nurses in charge of shifts should monitor for the occurrence of “nursing red flag events” during each 24-hour period. Where one occurs, it should “prompt an immediate escalation response”.

“The needs of patients should be the only thing determining staffing levels”

Peter Carter

The red flags set out by NICE include having less than two registered nurses present on a ward during any shift, day or night, also represents a patient safety “red flag”. Where there is a shortfall of more than eight hours or 25% – whichever is reached first – of registered nurse time available compared with the actual requirement for the shift is another red flag, according to NICE.

In addition, NICE said nurse managers must check staffing levels are safe on hospital wards where each registered nurse is caring for more than eight patients during day shifts – though it was keen to point out that this ratio was not a red flag by itself.

The Royal College of Nursing described the NICE guidance as a “positive step” forward for the NHS.  

Peter Carter

Peter Carter, RCN chief executive and general secretary, said: “These guidelines are based on best evidence and managers should be using this evidence alongside the expertise of nursing staff.

He added that the red flags set out in the guidance “must not be ignored” by trusts.

“Nursing staff have long recognized the importance of safe staffing levels and consistently provided evidence of the danger to patients where there are too few staff,” he said. “It is good to see that this is now being recognised across the NHS.”

“The NHS can’t carry on like this. Ministers must intervene to ensure safe staffing levels”

Andy Burnham

Mr Carter also warned trusts not to save money by cutting staff, which had been the case in the recent recession and helped drive the widespread staff shortages that many trusts are now seeking to address with overseas recruitment.

“The needs of patients should be the only thing determining staffing levels – not finances. Patient care must not be compromised because of short term financial cuts and a minimum safe staffing level should not become a default staffing level,” he said.

Gail Adams, Unison’s head of nursing, also described the NICE guidelines as a “step in the right direction”, but repeated the union’s call for nurse to patient ratios to be made mandatory.  

“A ratio of one registered nurse per eight patients across the health service should be the absolute minimum and in many circumstances this will need to be higher,” she said.


Gail Adams

“By not introducing mandatory safe staffing levels the government is putting patient safety at risk and without any additional funding the NHS will struggle to implement the guidance,” she said.

“Having staff working through their breaks and beyond their hours is not sustainable. It is bad for patients and bad for staff whose morale has already hit rock bottom,” she added.

The Care Quality Commission’s chief inspector of hospitals also welcomed the guidance, saying he supported the principle that ward staffing “should be based on the needs of patients”.

“Staffing isn’t just about numbers. Under our new approach to hospital inspections, we assess whether staffing levels and the skills and training of staff are appropriate in each of the services we inspect,” said Professor Sir Mike Richards.

Sir Mike Richards

Sir Mike Richards

“We know that staffing levels impact both on safety and on patients’ experience of care,” he said. “If we judge that staffing levels are impacting adversely on the quality of care, we expect to see improvements.”

Michael Adams, associate head of the school of nursing, midwifery and social work at Birmingham City University, also backed the NICE recommendations, noting that the responsibility still remained with trusts to protect patients and staff with safe staffing levels. 

“I think this is a good step forward and there are some interesting points made inthe guidance published,” he said.

“NICE haven’t gone as far as to state a minimum staffing at all times in all environments and have still left it to organisations to monitor and decide on appropriate staffing levels – the responsibility still remains with NHS trusts to protect patients and staff with safe staffing levels,” he added.

“A ratio of one registered nurse per eight patients across the health service should be the absolute minimum”

Gail Adams

The development of NICE guidance on staffing was recommended by the Francis report on care failings at Mid Staffordshire Foundation Trust.

As well as the work by NICE, the new commissioning body NHS England has told trusts to put new staffing transparency systems in place by the end of June as a further response to the Francis report.

But Labour shadow health secretary Andy Burnham called on ministers to “intervene” directly to ensure safe staffing levels.


Andy Burnham

“Hospitals across England are operating way beyond recommended capacity levels and, because of this, too many do not have enough staff to provide safe care,” he said in response to the NICE guidance on staffing.

“The government has trapped the NHS in a vicious circle,” he said. “Huge cuts to nurse training have left the NHS relying on agency staff but that in turn has deepened financial problems.

“Last year, trusts spent £2.6bn on agency staff – this short-sighted policy amounts to nothing less than gross mismanagement of the NHS,” he added.

  • Unions call NICE guidance on safe staffing a ‘positive step’


Readers' comments (2)

  • If we really want to improve standards the ratio needs to be more like 1:6 as a minimum. Clearly there is a huge spectrum of scale in terms of patient's needs. The issue needs to be looked at in a lot more detail. Scoring systems needs to be devised (relating to need/dependencies), so a ward can be overseen at any time, by senior nurse on for the unit and staff moved accordingly. The dependency list for each shift would back up red flag system proposed and hilight trends. I apologise if this type of system operates as I have not worked in acute setting for some time. But I have been on the other side as a visitor, to close relatives and felt ashamed of how my profession seems to have gone backwards judging by some of the shambles we have experienced. I do however understand that it is clearly very difficult given the numbers of staff versus the high dependency of the patients. In my day many of those patients would have been 'specialised'/in ITU! Nurses need to be more vocal and clearly demonstrate the evidence why more staff are needed.

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  • And what about the minimum qualified staffing levels in private nursing homes? I am often the only nurse to meet the clinical needs of 28-30 highly dependent residents, or if on a night shift, that can be 40 residents over two floors (the only nurse in the home). Profit over safety is often the only arbiter of staffing levels in this situation and the legislation seems to only cover the NHS.

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