Nurses safety critical but ‘no simple algorithm’ for ward staffing

They said determining the size and shape of the inpatient ward team “cannot be reduced to a simple algorithm” and requires consideration of the best available evidence to weigh up the risks.

“We do not know exactly what is a safe level or the optimal skill mix”


However, they said they found “strong evidence” showing a link between registered nurse numbers and patient harms and deaths. Nurse staffing was also considered key to patient satisfaction.

The observations were made by experts in a new report (see attached) from the National Institute for Health Research (NIHR) who have carried out a review of recent studies on hospital ward healthcare staffing.

“The evidence demonstrates that making decisions about ward staffing is complex,” their report concluded.

“We know that there is a relationship between the level of nurse staffing and patient outcomes, but we do not know exactly what is a safe level or the optimal skill mix of a team for individual wards,” it added.

“Determining the right number of staff and mix of education and skills is not a precise science and requires a risk assessment based on the best available evidence,” said the report, called Staffing on Wards.

“Using research evidence to make sure we make the right decisions about ward staffing is key”

Ruth May 

It found a larger body work showing a relationship between the number of registered nurse and safety, effectiveness and patient experience, which was stronger than for any other staff group.

However, it highlighted a gap in the literature in how nurses depended upon other professions on the ward and said the role of support workers “needs further exploration”.

“Evidence is needed on where the boundaries with registered nurse work should be drawn, together with ways of supporting delegation and the flow and transfer of information relevant to patient care across the ward team,” said the report.

Chief nursing officer

Ruth May

Source: NHS England

Ruth May

The review found that there may be a “U-shaped relationship” between support worker staffing and patient harms, with rates rising when there were both too few and too many on shift.

It called for “close attention” to be paid on how the introduction of the new nursing associate role impacted on the work of registered nurses.

Evidence showed there were aspects of the workload that may be better undertaken by registered nurses in order to “prevent avoidable patient harms” including direct observation of patients. 

Therefore, the review recommended that registered nurse hours should be considered separately from those of assistant and support workers.

Calculations of registered nurse hours should also factor in sufficient time to supervise lesser trained staff, it added.

The evidence presented in the report should be used by ward managers to assist their workforce decisions alongside their professional judgement and resources available to them, the report said.

It added that the need for “good local, real time intelligence” to respond to fluctuating need on a ward was “clear”.

“Deciding exactly how many nursing staff are needed on wards is highly complex”

Donna Kinnair 

Ward managers were also found to be “pivotal” in creating a good working environment for staff, which in turn helped retention and recruitment.

It called for investment in developing the skills of ward leaders and to ensure they had protected time to carry out management duties.

Dr Ruth May, chief nursing officer for England, will speak at a launch event for the report today.

She said: “Using research evidence to make sure we make the right decisions about ward staffing, and that we create work environment where nursing and care staff can thrive is key to achieving a sustainable NHS and improving the experience and outcomes of care for patients and service users.”

Donna Kinnair

Dame Donna Kinnair

Donna Kinnair

Responding to the report, Dame Donna Kinnair, acting chief executive and general secretary of the Royal College of Nursing, said: “The NIHR’s review adds to the important body of existing evidence that too few registered nurses on wards can lead to patient harm, and even death.

“The report is right to recognise that deciding exactly how many nursing staff are needed on wards is highly complex, and will vary according to the type of ward and how sick its patients are,” she said.

The RCN is campaigning for safe staffing laws to cover the whole of the UK. Wales introduced legislation in 2016 and Scotland is in the process of doing so.