It’s a misconception that NICE has recommended 1:8 as a minimum ratio, says Jane Ball
On the recent International Nurses’ day I was asked what I thought of a 1:8 registered nurse-to-patient ratio and whether it is enough. My response was: “It’s the wrong question.”
Why? Well, when we hear registered nurse-to-patient ratios being discussed, we think of “mandated minimums”, as in California and Australia. And when 1:8 is referred to in the National Institute for Health and Care Excellence guidance regarding increasing the risk of harm, you may conclude that NICE is recommending a minimum of one registered nurse for every eight patients on a daytime shift. A natural conclusion to reach, but it’s wrong on two counts.
“What I think is excellent about NICE referring to a ratio as a potential “hazard zone”, is that they have given an actual number - something concrete that can be easily understood by anybody”
First, the 1:8 ratio is not an acceptable minimum. It comes from a review of the research on nurse staffing and patient outcomes, which shows as staffing levels fall, the risk of harm to patients increases. The most recent findings from our EU-funded RN4Cast study (published in The Lancet) shows that for each additional patient per RN, there is a 7% increased risk of death following common surgery. Last year, we reported that care is more likely to be complete on acute wards with one RN per six patients or fewer. So is 1:8 enough? Absolutely not - it is a “danger zone”, not a safe minimum.
Second, it is a misconception that NICE has recommended 1:8 as a minimum ratio. What it has said is that hospitals should plan their staffing based on patient need, and they should use “red-flags” to highlight unmet needs.
The guidance states: “There is no single nursing staff-to-patient ratio that can be applied across the wide range of wards to safely or adequately meet the nursing care needs of patients.” But they advise that, like a “red-flag” indicator, 1:8 is recognised as a level that may pose increased risk of harm to patients.
But what I think is excellent about NICE referring to a ratio as a potential “hazard zone”, is that they have given an actual number - something concrete that can be easily understood by anybody. Not a relative term such as “sufficient staffing” or “safe staffing levels”; nor simply how planned staffing compares with actual staffing. But a number of registered nurses relative to patients. And it’s the “relative to patients” part that is key.
In the last 20 years we’ve had various guidance on planning nurse staffing, and dozens of tools to assist in that process. We have trusted hospitals to plan their own nurse staffing without holding them to account, and without systems in place to monitor the effects - on achieved ratios and quality of care provided.
Our research suggests that this trust has been misplaced. In 2010, 43% of the 406 NHS medical and surgical wards we surveyed were in the “high-risk” zone, with an average of more than eight patients per RN during the day; 86% of nurses said they had left necessary care undone on their last shift, due to lack of time.
Something has to change and I am hopeful that the NICE guidelines (informed by the research evidence) herald the start of that change. Will it make a difference? To find out if there really has been a “Francis effect” on the NHS, trusts must follow the NICE lead, and publish RN to patient ratios achieved. Not just the numbers on duty compared with numbers planned. Maybe once we have consistent national data on RN to patient ratios, and tackle those environments that have high-risk levels, England will no longer be one of the worst countries for nurse burnout. That really would be a cause for celebration on the next International Nurses’ day.
Jane Ball is deputy director of the National Nursing Research Unit at the Florence Nightingale School of Nursing and Midwifery, King’s College London