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Nurse staffing guidance: 10 expectations


New staffing guidance emphasises the need for a culture of transparency and openness in healthcare organisations


Recent reviews of patient care have identified the link between inadequate staffing and poor care. The National Quality Board has produced new staffing guidance for nursing, midwifery and care staff. This article summarises the 10 expectations laid out in the guidance.

Citation: May R (2013) Nurse staffing guidance: 10 expectations. Nursing Times; 109: 47, 20-21.

Author: Ruth May is chief nurse Midlands and East, NHS England and member of the Nursing and Care Quality Forum.


Recent changes in the NHS have presented new challenges for providers of NHS-funded health services and there is a need for guidance on staffing levels and skill mix. In addition, the findings of the Francis inquiry (Francis, 2013), the Keogh review (Keogh, 2013) and the Berwick report (Berwick, 2013) all highlight the negative impact of inadequate staffing on patient care.

Leading this work is a real opportunity to work with other key organisations within the health and care system to bring some clarity to what is a highly complex process. It is also critical to the delivery of safe and high-quality compassionate care.

In my role as panel chair for three of the Keogh reviews I saw clearly that when nurse staffing levels and skill mix are sufficient, outcomes for patients improve. There are many examples of high-quality care being achieved when the right staff balance is in place; this good practice needs to be shared.

Staffing guidance

The reviews mentioned above have provided evidence to underpin the National Quality Board (2013) staffing guidance published last week. Working closely with organisations, including the National Institute for Health and Care Excellence, Care Quality Commission, Monitor and the NHS Trust Development Authority, we have produced guidance to support commissioners and providers to:

  • Review their staffing levels;
  • Review systems and processes they use to set and monitor staffing and ensure they are fit for purpose;
  • Take steps to address any shortfall.

The guidance sets out 10 clear expectations that aim to support organisations to:

  • Establish appropriate staffing levels;
  • Create a culture where issues and concerns about staffing can be raised;
  • Establish clear accountability for ensuring this is achieved with openness and transparency.

We have been careful to make explicit the difference and the links between capacity and capability when we are talking about nursing, midwifery and care staffing levels. We know about numbers of staff (capacity) and the skills and experience of the staff, so capability is of equal importance. We have set out 10 clear expectations in relation to this.

1. Accountability

Boards must take full responsibility for the quality of patient care. They must ensure they are operating with safe, high-quality staffing levels based on robust systems and procedures, and be able to account publically for staffing decisions. They must not move the problem or cost saving to another part of the workforce, causing a detrimental effect elsewhere within the system.

2. Shift-to-shift staffing

Boards should provide systems and processes that ensure safe and high-quality care is delivered through appropriate staffing levels on a shift-by-shift basis. This requires real-time monitoring to take account of annual leave, absence, unplanned activities and a change in skill mix as a result of using bank and agency staff to meet any immediate shortfall. Systems for escalating concerns need to be in place so staff know how and when to raise and escalate issues relating to staffing shortages.

3. Using evidence-based tools

Evidence-based tools must be used to inform decisions about, and monitor actual, staffing levels. Staff responsible for setting and monitoring staffing levels must be trained to use these tools in conjunction with available data and soft intelligence to support their decision making.

4. Supporting staff to raise concerns

Clinical and managerial leaders must foster a professional and responsive culture so employees feel able to raise staffing concerns. Leaders must create an environment where staff feel genuinely supported and able to speak out safely without fear of reprisal if they feel they cannot deliver the level of care that is expected by patients or if they see poor practice as a result of this.

5. Using a multiprofessional approach

A multiprofessional approach should be taken when setting staffing levels. This involves collaboration with other parts of the organisation to make sure the whole staffing picture is considered and reviewed. The aim is to make best use of available resources and provide the best possible experience and outcome for patients.

6. Time for additional duties

Nurses, midwives and care staff should have time to fulfil responsibilities that are additional to their direct caring duties including mentorship, continuing professional development, supervision and supervisory roles. Those setting staffing levels must proactively plan for these indirect but essential tasks and factor them in when determining shift-by-shift requirements.

7. Board reporting

Boards should receive monthly updates on workforce information; these should be discussed at a public board meeting at least every six months. This builds on expectation 1 but specifically focuses on the need for transparency. In addition to taking collective responsibility for knowing their required and actual staffing levels, boards must review and publish this data every six months on their website, discuss it at a public board meeting and be able to account for any deviation from their evidence-based requirement at that meeting.

8. Displaying staffing information

This continues the openness and transparency theme, with organisations required to show very clearly in each ward or unit their current staffing levels and key points of contact for patients and visitors.

9. Recruitment and retention

The board and the organisation should take an active role in recruiting, training and retaining good staff while making every effort to meet requirements and manage any shortfall. They need to work closely with their local education and training board, regulators and local commissioning groups to develop a future workforce planning forecast to support their strategy for ongoing recruitment.

10. Role of commissioners

Commissioners have an important role in assuring providers are actively trying to recruit, develop and retain good staff, and are proactive in the management of any staffing shortfall. They must satisfy themselves that providers are working with the appropriate staffing numbers and skill mix to ensure they have the capacity and capability to deliver high-quality care.

Making staffing decisions

There is no “one-size-fits-all” approach to establishing nursing, midwifery and care staffing capacity and capability. This guide does not prescribe a single approach or recommend a minimum nurse to patient ratio as staffing needs will vary in relation to each clinical setting and the complexity of care provided. Provider organisations must make decisions about nursing, midwifery and care staffing requirements, working in partnership with their commissioners, based on the evidence, their patients’ needs, their expertise and their knowledge of the local context.

Board members must watch closely to ensure there are no unintended consequences arising from staffing-level changes. Ensuring appropriate staffing levels in nursing, midwifery and care staff must not negatively impact other areas of the workforce such as allied health professionals or administrative and support staff. We must be extremely careful that in fixing one problem, we do not create another for the leaders of tomorrow.

Media attention has focused on the impact of poor staffing levels within acute settings but we have been careful when producing this guidance to consider the impact in all environments where care and support is delivered. As we now know from the Winterbourne inquiry (Department of Health, 2012), the impact of poor staffing levels and inappropriate staffing skill mix had a significant impact on care failings. This clearly demonstrates that it is just as important to ensure the right staff are in the right place at the right time in a learning disabilities unit or community-based setting as in a large teaching or district hospital.

The future

The guidance has been developed in collaboration with quality regulators and will be used by them when assessing the quality of care and support delivered by NHS providers and NHS-funded services. Following publication of this guidance, NICE has agreed to take the work forward.

I would urge every board member to read the guidance and take it to your next board meeting for discussion. I recommend it is brought to a public board meeting, along with open and transparent information about current staffing levels and shortfalls between agreed and actual shift-by-shift numbers and skill mix, together with plans to address your findings.

I witness many examples of excellent nursing, midwifery and care staff providing outstanding care to patients. This guidance aims to ensure we have sufficient capacity with the right capability. I am keen to find examples of where this has been achieved already and where you can demonstrate the positive impact of your staffing model on patient outcomes. Please share your success stories with us so we can disseminate good practice.

Key points

  • New staffing guidance has set 10 staffing expectations for NHS commissioners and providers
  • Boards must ensure they are operating with safe, high-quality staffing levels
  • Staffing levels should be monitored on a shift-by-shift basis
  • A multi-professional approach should be taken when setting staffing establishments for nurses, midwives and care staff
  • Staffing levels should be displayed on wards

Readers' comments (2)

  • 23 November 2013, Saturday

    This nurse staffing guidance is good in paper only. Unless someone from the top board member takes initiative in implementing this guidance its only "paperweight" and a lot of wasted lives.

    A lot was said about culture change. I say understanding the work environment psychology that lead to the Mid Stafford Crisis is the way forward. Please refer to the article of, "Exclusive: Increase in nurses quitting register", 22 November 2013 - Comments.

    It would be more helpful and decisive to set up a minimum staffing level to acute hospitals who are struggling to resolve the staffing crisis in real time as in "NOW". Instead of assessing, monitoring, making lots, lots, more of statistical data that would be worthless if nobody will analyze quickly the situation, undecided or got stuck to a workable plan by the BOARD members, until its very too late THEY had to sit on the minimum staffing level for so many years. They have decided to bury the minimum staffing level, stick their heads under the sand and hope everything has been forgotten..... until another Mid Stafford Crisis happens again.

    Its a vicious cycle. Its very frustrating that the nursing profession is bashed by the politicians, the media, NMC, Employers and patient's relative association. There is nobody to defend and support the NURSES. It demoralizes and shames an individual registered nurse, who takes care the patient.

    Is it the budget and targets that dictates the minimum staffing levels or the patient clinical outcomes leading to improve in the care and better health condition upon discharge of the patient from the acute hospital?


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  • Hear, Hear! I completely agree with anon above. You have said everything i would have written. Lots of recommendations, protocols, guidance.....None of these are really implemented! Resources and time are always wasted to put things together but no action follows.
    Whose responsiblitity is it for such recommendations to be put into practice??? Why not now? Especially with staffing levels? Why wait till April 2014? Or till anothr midstaff occurs as anon stated? They should take time, go to the wards unannounced and see things for themselves.This is UK, a developed country not a struggling developing country!

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