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‘Nursing isn’t just about safety – it’s also about effective care’

Juliette Cosgrove
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Like many nurses up and down the country, I recognise the concerns highlighted in a recently published report on safe staffing

( It emerges from a two-year research project conducted at the University of Southampton and Bangor University, and commissioned by the National Institute for Health Research. The overall assessment is that progress in improving staffing levels since the Francis report has not been sustained. 

The report identifies some significant improvements, such as transparency and visibility of the nurse staffing agenda and ward-to-board ownership of safe staffing. However, what comes across very powerfully is that trusts are responsible for ensuring safe staffing but lack the resources to do so – budgets are limited and nurse numbers insufficient. 

It has always been my view that the person who is best able to assess whether a ward is safely staffed is the nurse in charge of that ward. However, when that nurse’s views about safe staffing are not followed, because of financial or supply constraints, what happens? One thing that happens is that registered nurses (RNs) are substituted with healthcare assistants (HCAs). Indeed, some staff interviewed for the report felt it might be better to have an HCA who is familiar with the ward than an RN who is not. 

I am concerned that, with this type of approach, nursing care is being reduced

to tasks and the key role of RNs in

coordinating patient care is receding. There is strong evidence linking RN staffing levels and some clinical outcomes such as patient mortality. And, although numbers are important, focusing solely on them puts us at risk of missing the fundamental point – achieving good outcomes for our patients. 

But nursing isn’t just about avoiding harm, it is also about giving patients care when they need it. What exactly do we ration in a chronic situation of insufficient staffing? Are there delays in medicine administration? Omissions of medicines? Lack of assessment and planning by RNs? Undue responsibility placed upon HCAs and students? Some of the concerns that were described in the Francis report must still be in evidence today in hospital wards that are chronically understaffed. 

We also need to understand and articulate the difference between ‘safe’ staffing and ‘effective’ staffing. Past guidance from the National Quality Board ( refers to “safe, sustainable and productive” staffing, but today we only talk about safe staffing; this, in itself, may pose a risk. Worryingly, what the report demonstrates is that staffing levels are planned to fall below the expected level, as there is a consistent failure to achieve more than a 93% fill rate. What is the safety valve? We could reduce activity to maintain safety, but the report identifies that temporary ward closures because of safety concerns are rare. 

The key message for me as a director of nursing is that I need to gain a better understanding of staffing requirements beyond numbers, so I can report to the board and we can build the transparency and ownership identified in the report. We need to assess the impact of chronic staffing shortages on RN and HCA decision making at ward level to ensure we don’t ration safety-critical activities and to find measures that demonstrate whether nursing care is delivered both safely and effectively.

Juliette Cosgrove is director of nursing, midwifery and therapies, Southport and Ormskirk Hospital Trust

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