Safe staffing - better care: NICE guidance for today's nurses

Posted on Thursday 15th May 2014

On 12 May, International Nurses’ Day, the National Institute for Health and Care Excellence (NICE) – the body that is responsible for promoting improvement in the health service – released draft guidelines on safe staffing levels for nursing on adult in-patient wards in acute hospitals. The guidelines were written by a team of experts that included Kay Fawcett, former Executive Director of Nursing at University Hospitals Birmingham NHS Foundation Trust and a member of the Nursing Strategic Oversight Group at the University of Birmingham.  

In response to a number of recent publications, such as the Francis Report on Mid-Staffordshire; the guidelines draw on available evidence on safe and effective staffing. They indicate that registered nurses should not be expected to care for more than eight patients during the daytime on a regular basis because of the increased risk of harm to patients.  

Importantly, the guidelines indicate that there is no single staff-to-patient ratio that can be applied across all wards. Therefore, they advise that a range of factors need to be rigorously assessed in each ward to determine appropriate registered nurse staffing levels, using the care needs of individual patients as the main driver. Thus, an advanced level of professional judgement is needed to make an informed assessment of patient need and nursing staff requirements. Such decisions clearly need to be taken by nurses who have the ability to assess a range of indicative factors, judge the supporting evidence and use sophisticated decision-making skills to determine appropriate staffing levels. Hence, if nurses are to make safe decisions about required staffing levels, they need to be prepared appropriately and supported adequately within care provider environments.  

Moreover, as patients’ care needs become more diverse and unpredictable, nurses need to be knowledgeable, skilled and flexible practitioners who are able to respond to complex patient demands and work in a range of healthcare situations. In recognition of the level of expertise needed by nurses in the current healthcare climate, nursing is moving to an all-degree workforce and nurses now enter the profession with a degree qualification. This is not new to the University of Birmingham, where nurses have studied at degree level since 1990 and have developed technical, cognitive and interpersonal skills that prepare them to work in a range of settings and with patients with differing health care needs.  

The move to a graduate profession in 2011 has the support of Dr Peter Carter, Chief Executive and General Secretary of the Royal College of Nursing (RCN), and an Alumnus of Birmingham. He stated that: ‘Compassion and caring will always be at the heart of nursing practice and nurse training. However, the demands of modern health care mean that this must be backed up by a higher level of education so that patients, who often have complex needs, receive skilled and compassionate care.’ The RCN has also welcomed the NICE safe staffing guidelines, which it believes respond to the consistent evidence of the danger to patients where there are too few nursing staff.  

At the Heart of England Foundation Trust (HEFT), a partner of the University; senior nurses have developed a sophisticated process to monitor planned versus actual nurse staffing levels each day, in every ward over a 24-hour period. The model combines the measurement of patient needs together with the application of professional judgement to ensure that required staffing levels are set appropriately and met consistently. In recognition of this innovative work, the team has been approached by the journal, Nursing Management to write up this work for publication and I will support them in writing this paper.  

As a mark of the level of importance that HEFT places on innovative, nurse-led practice and in recognition of the strong relationship between the University of Birmingham and HEFT, the Florence Nightingale Foundation has made a commitment to fund a prestigious new Chair of Clinical Nursing Research at Birmingham, working specifically with the Heart of England NHS Trust. This is a wonderful opportunity for the two organisations to add to the valuable research that focuses on advancing the nursing contribution to improved patient care; and is an opportunity for further work to be undertaken to explore the impact that the HEFT nurse staffing model is making on patient safety.  

Professor Fiona Irvine  
Head of Nursing, University of Birmingham