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Jane Ball: 'Staffing ratios of 1:8 indicate "danger", not a safe minimum'


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


Readers' comments (7)

  • I agree with you Jane.
    I feel that Staff to Patient ratio should not be as simple as pulling out some ratio from a box of limited rationales.
    Also I have been advocating the need for an intelligent computerised tool for national use in the aid of getting the right number of staff for any particular group of patients under any care system in he UK.

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  • Anonymous | 29-May-2014 8:18 am

    for the authorities it is just a question of logic and yet another box ticking exercise!

    done that, what is next?

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  • It does feel like numbers chosen for 'safe' staffing will become the ceiling. How can this be safe?
    I agree it's a minimum. As soon as a couple patients ask for help and assistance, have anxieties, maybe need toileting, feeding, medication, a fall, deteriorating, etc acuity levels changes on a ward, but staffing numbers don't. Then potentially the rest of the ward's patients are unattended at best, which could be unsafe / dangerous depending on how things develop. Still it's not nice having to wait a long time while staff are busy elsewhere.

    We would like excellent staffing numbers to deliver excellent care, not just adequate staffing for barely safe care.
    Also would like to see a cross party group of MPs work a full fortnight, during their long recess period and donate the difference of what they earn vs Care assistants to charity.
    I imagine both will not happen.

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  • Nurses are quite vulnerable to pressures from their employers and other authorities. Menzies demonstrated that the nursing responses were quite dysfunctional and led to depersonalised care. Any nurse trying to deliver individualised care in today's hospitals is painfully aware of this!

    The work of Hilda Steppe on nurses' contributions to the 'euthanasia' programmes of the third reich in Germany is less well known, but I think it's relevant to the abuse of patients today, especially those who are less valued by our society, such as the frail elderly people & learning disabled adults.

    Already these patients are relegated from free NHS care to means tested new Poor Law provision in the social care sector. We see them treated as 'bed blockers' and skill mixes in elderly care and learning disability settings are even more impoverished than in acute care. These people almost seen as a nuisance in A&E and acute care settings.

    Nurses themselves are marginalised from health policy. Look what has happened to the nursing advisors in DH, nurses in Trust boards, etc. Consider the implications of the tabloid hate campaigns and the disparagement & underfunding of nursing education. The profession seems barely able to answer Mid Staffs critics, let alone lead actions to remedy the problems highlighted.

    The professional values nursing used to represent are no longer taken seriously and all that remains is individual humanity versus the values of health care policymakers. In this perspective, nurses and some groups of patients have a low value.

    Nursing whistleblowers are persecuted, but while there's no formal state extermination of vulnerable patients, freeing blocked beds and reducing costs by employing unqualified staff with no professional ethical constraints are both highly valued and rewarded. I'd argue that some of the effects are not very different!

    It's a toxic mix & we need to consider Menzies' and Steppe's evidence about the effects on staff & vulnerable patients.

    The Steppe abstract & source are:

    >>West J Nurs Res. 1992 Dec;14(6):744-53.
    Nursing in Nazi Germany.
    Steppe H.

    German nursing did indeed change during the Nazi period. There were external changes, in terms of the improved social status of nursing, the tightening and unification of professional nursing organizations, the laws affecting nursing, and the politicization of the profession. Articles written by nurses at the time and more recent interviews suggest that there were internal changes as well. It appears that at least a portion of German nurses accepted the National Socialism reinterpretation of professional nursing ethics and humanitarian principles in the assumption that through their obedience they were doing good. This historical research points to clear lessons for contemporary nurses. Nurses in Nazi Germany were under the illusion that they were remaining true to their professional ethics, unaffected by the social change around them. This apolitical professional consciousness made it possible for the profession to be subsumed as a part of the larger political system. I believe that we must be clear that nursing never takes place in a value-free, neutral context; it is always a socially significant force. This means that we cannot simply observe what is taking place around us but must take a stand and get involved, helping to shape sociopolitical developments. I also believe that we must deal with the history of our profession, especially its darkest hours, so that we may remain sensitive to any signs of inhumanity. We must call into question traditional principles, such as obedience, and replace them with professional competence, professionalism, and creative self-consciousness. And not least, we have a moral obligation to the millions of victims of National Socialism, even if it only means that, through historical research, we assure that they are not forgotten. By taking responsibility for this part of our history, we can become more sensitive for the future, with eyes and ears open for all social injustices.<<

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  • Forester | 29-May-2014 10:39 am

    excellent and informative post. thanks for bringing this to readers' attention.

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  • tinkerbell

    until nurses become politically aware they will remain ignorant about how governments are shaping their profession rather than clinicians shaping the profession as practitioners in their own right who want to promote moral/ethical practice rather than become puppets for any particular master.

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  • tinkerbell

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