Fewer than two registered nurses present on a ward during any shift, day or night, represents a patient safety “red flag”, according to major guidelines for the NHS.
In addition, 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.
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 first of a series covering a range of healthcare settings.
“The NHS cannot afford to be unsafe – neither morally nor financially”
Much of the final guideline remains unchanged from an earlier version that was published in May for consultation.
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”, such as allocating additional nursing staff to the ward.
The red flags set out by NICE include patients missing planned medication, delays of more than 30 minutes in providing pain relief and a lack of planned vital signs checks.
Another red flag situation cited by NICE is 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. For example, if a shift requires 40 hours of registered nurse time, a red flag event would occur if less than 32 hours of registered nurse time is available for that shift.
However, in a change from the draft version, NICE has added a red flag for when there are less than two registered nurses present on a ward during any shift.
The draft version of the guideline caused some controversy when it was widely miss-reported that the institute was backing a mandatory minimum ratio of one nurse for every eight patients.
In the final version of the guideline, NICE has stated there is “no single” nursing staff-to-patient ratio that can be applied across all acute inpatient wards, which will disappoint those campaigning for the introduction of minimum ratios like those used in California and parts of Australia.
However, NICE noted there was evidence of increased harm associated with a registered nurse caring for more than eight patients during day shifts, and suggested that where this occurred it could indicate the risk of a red flag occurring.
It stated that if registered nurses for a particular ward – excluding the sister or charge nurse – were caring for more than eight patients, matrons or senior nursing managers should closely monitor for red flag events and safe nursing indictors, and take action where necessary.
The guidelines set out recommendations on staffing requirements at three levels of responsibility – trust boards and senior managers, senior nurses that set ward establishments and ward and shift managers.
NICE called on trust boards and senior management to develop procedures to ensure ward staffing establishments were “sufficient to provide safe care to each patient at all times”. It also called on managers to involve nursing staff when drawing up trust staffing policies, such as escalation and contingency plans.
When agreeing skill mix for establishments, NICE told trusts and senior nurses to take into account evidence showing patient outcomes were better when care was delivered by registered nurses.
Meanwhile, those responsible for setting ward establishments should routinely measure the average amount of nursing time required throughout a 24-hour period for each of the ward’s patients, NICE said.
It also hinted strongly that this should be expressed as nursing hours per patient, rather than a nurse-to-patient ratio – arguing that this type of measurement enabled individual patient needs and different shift durations to be taken into account more easily.
Much of the guideline was based on two reviews commissioned from the University of Southampton and the University of Surrey. However, NICE highlighted a “number of gaps” in available evidence and expert comment relating to staffing levels and patient safety.
It called for more studies across the topic, noting in particular that “research is needed to compare outcomes from acute adult inpatient wards that use different staff numbers, skill mix, and shift patterns”.
Professor Gillian Leng, deputy chief executive and director of health and social care at NICE, said: “The NHS cannot afford to be unsafe – neither morally nor financially.”
The development of NICE guidance on staffing was recommended by Robert Francis QC in his report on care failings at Mid Staffordshire Foundation Trust. It was also recommended last August by Professor Don Berwick in his report for the government on patient safety.
The government announced it would ask NICE to develop guidance on staffing levels in March 2013 and subsequently referred the work to the institute in November.
As well as the work by NICE, NHS England told trusts to put new staffing transparency systems in place by the end of June as a further response to the Francis report.
Trusts are now required to display the number of staff on each shift outside all inpatient wards, publish monthly updates on staffing, and perform an establishment review every six months.
The first datasets from these monthly updates were published on the NHS Choices website at the end of last month. Analysis of these figures by Nursing Times suggested nearly one in 10 hospitals in England had a fill rate for nursing shifts of less than 90% during May.
- Read the NICE guidelines: Safe staffing for nursing in adult inpatient wards in acute hospitals
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