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New draft staffing guidance keeps NICE ratio and promotes evidence-based tools


Staff on hospital wards can continue to use the ratio of one nurse to more than eight patients as evidence of the point at which there is increased risk of harm during day shifts, according to a draft version of new national workforce guidance that also promotes evidence-based tools to calculate staffing.

However, the draft acute adult inpatient guidance, published today by the regulator NHS Improvement, stressed that nurses should also note that no single nursing staff-to-patient ratio could be applied across all wards of the same type, as per previous guidelines.

“The biggest safeguard we have got to have to ensure great quality of care is the registered nurse”

Ruth May

Specifically, the document recommends staffing levels should be calculated by using an evidence-based workforce tool, as well as by comparing against other similar wards and organisations, and also by using professional judgement – though warning that individual opinion should not be relied upon solely.

Today’s draft guidance for acute settings was produced after revisiting staffing guidelines already completed by the National Institute for Health and Care Excellence two years ago.

NICE’s work on safe staffing across a range of settings was controversially suspended in 2015 by NHS England and the Department of Health, just as the research body was on the brink of publishing documents recommending minimum nurse ratios in accident and emergency departments.

Today’s document states: “While NICE guidance identified evidence of ’increased risk of harm associated with a registered nurse caring for more than eight patients during the day shifts’, they clearly stated there is ‘no single nursing staff-to-patient ratio that can be applied across all acute adult inpatient wards’. We have found no new evidence to inform a change to this statement.”

It also stressed that decisions about how many nurses work on hospital wards cannot be left to individual judgements but need to be evidence based.

The document warned trusts not to rely solely on professional judgements, which it said were “considered subjective and may not be transparent”, adding that “a triangulated approach” was needed.

As a result, it said trusts should “triangulate” information such as the rate of falls, pressure ulcers and other ward data, including complaints and staff sickness using evidence based acuity tools to calculate staff numbers.

Organisations should only use professional judgement to address specific local issues, stated the draft guidance – titled Safe, sustainable and productive staffing: An improvement resource for adult inpatient wards in acute hospitals.

In addition, the document said staffing levels should include uplifts for issues such as study leave and sickness, and trusts should have “float” nurses who can be moved to different wards during times of peak demand.

nurse with clipboard

Although it made reference to the importance of multi-disciplinary staff, it accepted “there is little workforce modelling or planning evidence on how this has been successfully achieved”.

Trusts are also advised to benchmark themselves against other organisations using a new staffing metric – known as the care hours per patient day (CHPPD) measure – which shows the average hours of care provided per patient by nurses and healthcare assistants in a 24-hour period.

While also acknowledging the involvement of non-registered nursing care staff, it makes clear “the registered nurse hours must always be considered in any benchmarking alongside quality care metrics in order to assess the impact on patient outcomes”.

Alongside the guidance, NHS Improvement has published summaries of existing evidence on nurse safe staffing to help inform local decisions.

One of the summaries, prepared by Southampton University, said: “While the odds of adverse outcomes were generally increased when average staffing fell below the 1:8 threshold, better outcomes were often associated with higher staffing levels and ratios of 1:7 and lower.

“For some services, significant increases in risk occurred well below this threshold. While not giving a clear ‘safe’ staffing level this evidence reinforces that a 1:8 threshold represents a level at which risk is known to be increased, not an optimal, safe staffing level,” it noted.

Hilary Chapman

Hilary Chapman

Hilary Chapman

The guidance was produced by an independent committee for NHS Improvement, which was chaired by Hilary Chapman, chief nurse at Sheffield Teaching Hospitals NHS Foundation Trust.

“The evidence is clear that the 1:8 ratio is not a ‘target’ staffing level for all circumstances and therefore should be triangulated with local assessments and professional judgement to determine what is required,” she told Nursing Times.

Today’s draft guidance is one of seven safe staffing resources due to be published by the regulator for consultation in coming months.

Ruth May, NHS Improvement’s executive director of nursing, told Nursing Times that the regulator was developing safeguards to ensure organisations complied with the recommendations laid out in the staffing resources.

“But the biggest safeguard we have got to have to ensure great quality of care for patients is the registered nurse, wherever they are – whether that’s on the board or in a clinical setting. We will, though, be developing safeguards prior to the final publication,” she added.

Queen's Nursing Institute

Nurse staffing shortage is ‘top priority’ for regulator

Ruth May

NHS Improvement has also published today draft guidance for safe staffing in learning disability settings. A consultation on the adult acute and learning disabilty settings documents will run until 3 February.

Meanwhile, it has also published a separate joint consultation with the Care Quality Commission on future checks on the “effective use of resources” by acute trusts, which includes workforce factors such as agency spend, skill mix, rostering technology, turnover and sickness.







Readers' comments (8)

  • This is NOT applicable for all areas e.g.: AMU the ratio should be at least 1:5 to ensure patient safety!

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  • Obeid AlRashoud

    I'm so pleased to an account and an access to website

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  • This 1 to 8 is ill thought out it needs to be linked to different types of situation. General Surgery and Geriatrics are totally different
    Wake up UK no more substandard policies

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  • Keep going Shaun I believe your on the right tracks, now look up why average time spent is arguably a terrible metric, This might not go down well if you point it out hard enough. I suspect the pressure is now on NHS Improvement and thus the gov. A question to ask is whether EBP is itself subjective where care is so dynamic? and if so then the issue is arguably management control that may lead to negation of other variables or what is known as a method associated care deletism.

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  • Common sense suggests more front - line Registered staff is needed for today's sicker and older patients thus the ration should be 1:4 to achieve basic standard care. Why is resources found to do these investigations by NICE and NHS Improvement rather than resources to pay for nurses? The plethora of these gov't quango's and their unlimited funds could pay for the Registered Nurses that are needed. After all the elderly have paid for their care with their taxes and should be duly care for by qualified staff. Resources should not be directed to non-clinical staff who do not know how to care for an elderly or acute patient.It is utter madness on what is happening in the health service. It is led by inadequate nursing leader's and 'CEO's of 'failing Foundation Trusts' who would not be employed by the Private sector due to their woeful incompetence in the current and worsening healthcare system which is no longer fit for purpose. "Lions (frontline staff) led by donkey's (NHS Management"

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  • NHS Improvement and Mark Radford as someone who spoke up on such associated issues of safer staffing it is terrifying you would potentially promote NHS MH managers who are all for average time metrics. Mental health doesn't come in neat boxes and defies Carter approaches and methods such as lean. Such environments are dynamic and fluid and any hint of metric is not collaboration it is in my view arguably indirect compliance. I know of cases where for example nurses on acute MH wards have wanted to get out as quick as they can due to less nursing numbers and whilst this might be great for other skill professions attempting diversion and activity it can not replace nursing care. The cost of NHS Improvement gov ideology to some is leaving wards thread bare. Once more it's even more worrying if CQC inspectors are if true too close to trust management/ associations (seen as potentially bias) if right via social media links and unconscious where or if bias is involved in their inspections. The frontline are seeing through you.

    Average metrics and Carter approaches will turn MH units nurses into call centre staff. It's not why I came into it. And cheaper labour care forces create frontline internal battles taking heat off management. The use of fixed variables creates illusions and scripted work. MH Care doesn't fit fixed variable, scripts or QI where it can create false red flags based on going off script or infinite care possibilities. In such circumstances QI potentially becomes a behavioural tool to punish staff where they demand extra need and false bell curves of performance should your metrics not work.

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  • We all know people are living longer.Less sick patients are in theory nursed at home.So sicker older patients with multiple illnesses and co-morbidity come to hospital.To summarise 1:8 is no longer safe,given the average age of patients being admitted and the severity of their illnesses.In order to be professional and get paperwork completed nurses rarely take breaks stay on late, in order to keep their registrations.
    It is near impossible to get everything completed in your shift.The stress levels in trying to do so are extremely high.
    No one listens when we say we need more staff instead we are accused of poor time management .

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  • What about nights

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