Read the Nursing Workforce Standards

Executive nurse - a registered nurse who has executive responsibility on the corporate board and is ordinarily responsible for assuring the board in nursing workforce issues. Executive nurses have a pivotal and transformational role in an organisation. They navigate a complex set of stakeholders and partners in the service of organisational values and must use their influence at board level to guide nursing priorities for their organisation.

Registered nurse lead - focus on setting and upholding standards. Their role is to fulfil the organisation's vision, mission, and long-term plan. The registered nurse lead will have operational responsibility for ensuring there are enough nursing staff to run a service. This function may be fulfilled by registered nurses holding different titles, but the requirement of the role is set out in the descriptor for Standard 5: each clinical team or service that provides nursing care will have a registered nurse lead.

Staffing for safe and effective care - having the right number of registered nurses and nursing support workers with the right knowledge, skills and experience in the right place at the right time is critical to the delivery of safe and effective care for all those who use health and care services. 

Nursing support workers - support the registered nurse in the provision of nursing care. This term encompasses a wide range of roles and titles which may include nursing associate, assistant practitioner, health care assistant, health care support worker and nursing assistant. 

Corporate board - the body with the ultimate governance responsibility for any organisation providing health and care services.

People who use services - in these standards, this phrase refers to those who use or are affected by the services of professionals within the nursing workforce. This umbrella term also covers client, service user, resident, child, patient and other common terms.

Standard 1

Executive nurses are responsible for setting nursing workforce establishment and staffing levels. All members of the corporate board of any organisation are accountable for the decisions they make and the action they do or do not take to ensure the safety and effectiveness of service provision.

Description

a) Leaders responsible for contracting or commissioning services have a duty to ensure there is a nurse at executive level within an organisation’s governance structure. The executive nurse provides professional, strategic and operational assurance to corporate boards and commissioners on nurse staffing. This is in order to ensure that the board fully understands the nursing workforce demands and are accountable for the decisions they make and the actions they take, as well as providing assurance on the provision of staffing for safe and effective care.

b) Due to their size, some organisations such as general practices, care homes, charities and other third sector organisations may not have an executive nurse. This exception should be recognised within the documented organisational structure. They must use and evidence the use of the nursing expertise of their commissioning body/partner organisation to confirm that nurse staffing is optimal. They should have an identified registered nurse lead with operational responsibility for ensuring the nursing workforce can provide safe and effective care. This person would be responsible for reporting and escalating to the board/ senior management who are accountable for safe staffing.

c) Decisions and accountability relating to the nurse staffing level rests with the corporate board. Executive nurses are responsible for the information and advice they provide to the board. Other board members or members of a senior management team such as HR Directors may share this responsibility in some organisations. The board collectively is accountable for the decisions they make and the action they do or do not take in response to this information and advice. The board should collectively agree the operating framework for these decisions to include actions to be taken, and by whom, and how these will be visibly and actively monitored.

d) The nursing workforce establishment should be determined by the demand for services and the need to provide safe and effective care. (See Standard 2d)

e) Setting the nursing workforce establishment should explicitly inform the organisation’s financial planning and be funded by revenue allocation rather than fitting a prescribed financial envelope.

f) In setting the nursing establishment workforce planning and decision making should be underpinned by professional nursing knowledge and experience. The responsibility for setting nursing establishments remains with the executive nurse; where this is shared for example, with directors of human resources/finance directors, the nursing establishment must always be signed off by the executive nurse.

g) Nurse leaders are integral to contracting and commissioning care in order to distinguish between nursing specific workload and that of the wider multi-professional workforce.

h) Decisions on nurse staffing must be recorded. Discussions must detail the workforce requirements of the organisation/service in order to provide staffing for safe and effective care. Nurse staffing should be a standing item for scrutiny and discussion at every board meeting.

i) Each organisation should have a board-approved risk management and escalation process in place to enable real-time nurse staffing risk escalation and mitigation with clear and transparent procedure to address severe and recurrent risks.

Standard 2

Registered nurse and nursing support workers establishments should be set based on service demand and the needs of people using services. This should be reviewed and reported regularly and at least annually. This requires corporate board level accountability.

Description

a) The nursing workforce will be a standing item for discussion at the board or accountable body for decision making in any organisation providing nursing services. 

b) Workforce data should be reviewed at least monthly and ‘red flags’ such as high rates of sickness or turnover investigated with transparency. 

c) A framework should be in place that enables regular review and decisions about service provision and workforce resourcing. This framework should include additional trigger points when a review should take place, for example, when serious concerns have been raised about quality of care or when there is a change in service provision, or the opportunity to consider such a change. This allows further scrutiny of nurse staffing, risk escalation and timely management. 

d) A continuous quality improvement approach to staffing should be taken. A triangulated approach is required and will include:

• professional judgement
• patient-dependency/acuity workload tools
• clinical quality indicators
• nationally agreed standards
• peer reviewed published evidence
• benchmark data from matched comparators who can evidence the delivery of high-quality person-centred services and/or data linkage to care quality indicators.

e) Once any review is completed, the findings and any recommendations must be presented to the corporate board accountable for decision-making on resourcing service provision and workforce. An action plan should be created to address any issues identified.

f) Where there are nurses rostered within a multi-professional workforce rota, they cannot be counted twice. For example, an advanced nurse practitioner rostered on the acute medical rota could not also then be counted as part of the nursing workforce for that acute medical unit.

g) Staff who support the workforce, such as clerical, housekeeping and catering staff, should not be considered within nursing workforce numbers when determining the nursing establishment to meet clinical need.

h) All nursing students must be supernumerary when in training. 

Standard 3

Up-to-date business continuity plans must be in place to enable staffing for safe and effective care during critical incidents or events.

Description

a) Business continuity plans need to be developed with nursing leadership taking into consideration:

• the ability to manage and react to critical incidents
• the way in which critical incidents or events may impact on staffing, for example, redeployment
• the established nursing workforce and their roles, skills and responsibilities
• current and future workforce challenges and their impact on current and future service delivery models
• contingency plans for situations in which the nursing workforce is compromised, understaffed or redeployed. These contingency plans should align to the safe staffing escalation process

b) These plans should be reviewed and tested at least annually and if any serious concerns have been raised over quality of care.

c) Staff-side/recognised trade union engagement in the principles, development and outcomes of business continuity reviews is vital to accurately reflect nursing, foster collaboration and build trans-organisational cohesion.

Standard 4

The nursing workforce should be recognised and valued through fair pay, terms and conditions.

Description

a) Employment terms and working conditions should reflect levels of skills, knowledge, competence and responsibilities required. Recognised fair and equitable pay structures should reflect the Real Living Wage as a minimum and must support nursing advancement and role development. Employment terms and working conditions should support health, safety and wellbeing, equality at work as set out in Standard 8b. Nursing staff should be supported through fair workplace procedures as well as access to clinical supervision, continuous professional development and opportunities for career progression.

b) Fair and equitable pay, terms and working conditions are achieved by engaging directly with the nursing workforce, through the RCN and any other recognised trade unions/professional organisations.

Standard 5

Each clinical team or service that provides nursing care will have a registered nurse lead.

Description

a) Any service which has nurses working within it must have a registered nurse as part of the leadership team. This individual will have the authority and the responsibility to identify the nursing workforce required to meet the clinical need. They will identify mitigating action when real time and recurrent risks are identified. If risk mitigation such as reducing caseloads or bed closures cannot be achieved, risk escalation must take place and be responded to. This individual’s reporting line will feed into the executive nurse. If there is no executive nurse in the organisation they should report to an identified member of the board or senior management team.

b) Where nurses practise within a wider multi-disciplinary team and have a direct line manager who is not a registered nurse, a clear professional line to clinical nursing leadership must be available. 

Standard 6

A registered nurse lead must receive sufficient dedicated time and resources to undertake activities to ensure the delivery of safe and effective care.

Description

a) In the majority of large organisations this registered nurse lead will be supervisory and not rostered as part of the nursing workforce allocation. If there is exception to this, clear rationale must be documented, agreed by the board and highlighted to commissioners / regulators.

b) Resources and time are required for:

• leading and management of the team
• improving and monitoring the quality of care experienced by people who use a service
• workforce planning, monitoring and associated activity
• budget management
• clinical audit and regulatory audit
• initiating quality improvement programmes
• research
• clinical supervision and staff development
• monitoring health and safety data for adverse incidents involving staff and people who use services.

c) Their role in the leadership team must be reflected and incorporated into job descriptions to ensure the additional workload and time management are included.

Standard 7

The time needed for all elements of practice development must be taken into consideration when defining the nursing workforce and calculating the nursing requirements and skill mix within the team.

Description

a) Practice development encompasses clinical supervision, assessment, supervision and teaching, Continuing Professional Development (CPD), revalidation and lifelong learning. Practice development must align to the needs of people who use services.

b) Comprehensive workforce planning should be undertaken and include a workforce learning needs analysis, commissioning and provision of training and education. Facilities for regular professional reflection and clinical supervision should also be in place to support ongoing learning and best practice development.

c) As a minimum, all inductions must include explanation of the governance structure within the team and organisation, and the routes of escalation of nursing issues such as nursing workload, nursing workforce and safety concerns.

Standard 8

When calculating the nursing workforce Whole-Time Equivalent (WTE) an uplift will be applied that allows for the management of planned and unplanned leave and absence. 

Description

a) Realistic uplift enables recognition of planned and unplanned leave. Underestimation of either or both planned and unplanned leave will result in an establishment that cannot meet day to day staffing requirements, and over reliance on supplementary staffing such as bank and agency staff, will impact on overall costs and quality of care. The uplift percentage agreed should not compromise service delivery, safety and quality of care.

b) Approved nursing workforce establishment tools are recommended when calculating uplift which must consider each of the following:

• annual leave
• sickness / absence – derived from organisational monitoring of sick leave
• study leave – this must meet or exceed the statutory requirements for registrants
• leave for parents
• other leave – this includes carers leave, compassionate leave etc.

c) Professional judgement considerations for nursing workforce establishment / uplift should include:

• Environmental issues, for example, single rooms
• Geographical issues, for example, travel requirements for community-based staff
• shift patterns / working day
• flexible working
• acuity, complexity and dependency
• professional regulatory requirements
• time required to support/mentor learners in the workplace. 

Standard 9

If the substantive nursing workforce falls below 80% for a department/team this should be an exception and should be escalated and reported to the board / senior management.

Description

a) Bank and agency work provides both services and nursing staff with flexibility on both an individual and an organisational level. Over reliance on a temporary workforce such as bank or agency staff:

• has an effect on care provision in the range of activities temporary staff are able to undertake, accountability and delegation and continuity of care for people who use services
• is associated with increased clinical risks due to factors such as variable clinical ability, limited relevant experience and unfamiliarity with the specialty and/or the local geography / population
• is associated with financial risk for the service / organisation.

b) When using nursing staff from bank or agency, the service must be assured that they are competent to work in the role or setting to which they are allocated. Staff skill should be matched to acuity and dependency of people who use services, within approved guidelines. The bank or agency must follow approved employment practices and clearance.

c) All staff from bank / agency will be provided with orientation and local induction which must include incident reporting and how to escalate concerns. 

Standard 10

Registered nurses and nursing support workers must be appropriately prepared and work within their scope of practice for the people who use the services, their families and the population they are working with.

Description

a) This includes access to CPD, education, support and development to ensure the nursing workforce has the knowledge, skills and competencies required to deliver evidence based, safe, person-centred care that is of high-quality. As a minimum this needs to include:

• safeguarding
• mental capacity
• consent
• record keeping
• basic life support
• competency frameworks specific to the area of specialty
• the principles of accountability and delegation
• raising concerns
• health and safety related training including moving and handling, infection prevention and control and fire training.

b) The registered nurse lead will ensure that:

• individuals appointed to the nursing workforce, including those in management roles, are allocated a period of supernumerary induction /preceptorship
• individuals with no previous experience should have a preceptorship period which includes structured induction and close supervision until specialty competence and confidence are achieved
• for more senior/experienced staff taking on additional or different roles, a preceptorship period is still needed until competence and confidence are achieved.

c) For staff who are lone workers, there must be clear access to advice, supervision and support at all times as well as compliance with necessary health and safety requirements. 

d) Fostering leadership capability is integral to all members of the nursing workforce throughout their career to embed a psychologically safe culture and strengthen the nursing voice.

Standard 11

Rostering patterns for the nursing workforce will take into account best practice on safe shift working. Rostering patterns should be agreed in consultation with staff and their representatives.

Description

a) Longer shifts are preferred by some individuals, such as those with caring responsibilities or those who travel long distances to work. However, fatigue at the end of a long shift can result in clinical error. Cumulative fatigue can result in health problems for staff and even ‘burnout’. Careful rostering and internal rotation are strategies that are supportive and clear policies and procedures need to be in place.

b) Where staff work long shifts, employers should offer appropriate support with respect to their health and wellbeing, and their ability to provide safe and effective patient care. Opportunities should be offered to move to shorter shift times where this is preferred. Other options for wellbeing include self-rostering and team rostering.

c) The Health and Safety Executive recommend the avoidance of shifts that are longer than eight hours where the work is safety critical and physically demanding. They recommend that where 12-hour shifts are implemented there should be adequate rest breaks and that 12-hour night shifts should be limited to two or a maximum of three in a row to ensure compliance with working time regulations.

Standard 12

The nursing workforce should be treated with dignity, respect, and enabled to raise concerns without fear of detriment, and to have these concerns responded to.

Description

a) The nursing workforce is a highly differentiated body of practitioners who bring their own unique skills and qualities to make up a diverse workforce. Employment policies, practices, processes and cultures as well as leadership styles must intentionally support and nurture inclusion and psychological safety as well as create environments that are free from discrimination, bullying and health inequalities.

b) To treat someone with dignity is to treat them as being of worth, in a way that is respectful to their diversity. Treating people who use services with dignity is essential in nursing practice, but in order to do this effectively, nursing staff must themselves be treated with dignity by their employers, managers and colleagues.

c) Encouraging and valuing diversity within the workforce is shown to have positive effects for a more motivated, harmonious, willing and loyal workforce.

d) Encouraging staff to report near misses and incidents and ensuring appropriate follow up by accountable managers creates psychologically safe environments and a learning culture.

Standard 13

The nursing workforce is entitled to work in healthy and safe environments.

Description

a) Risks to health and safety should be properly controlled and all legal requirements complied with. This includes robust procedures for prevention of and dealing with:

• violence and aggression
• back and musculoskeletal disorders
• work-related stress
• infection.

b) There is a legal requirement for the provision of adequate welfare and safety facilities, for example, breaks, changing facilities and personal lockers, access to sufficient, well maintained and high-quality resources (eg PPE, moving and handling equipment) and utilising the working environment as a place for promoting health and wellbeing is vital to enable a healthy and safe workforce.

c) Members of the nursing workforce working in people’s homes or community settings should carry out dynamic risk assessments. For staff who are lone workers, there must be clear access to advice, supervision, and means of raising the alarm and support at all times and individual risk assessment.

d) Health, safety and wellbeing is more than just the absence of work-related disease or injury rather, an emphasis on achieving good physical and mental health amongst the nursing workforce. As well as complying with the legal requirements of health and safety laws, nursing leaders have a professional responsibility to create healthy environments that improve the health and wellbeing of others.

Standard 14

The nursing workforce is supported to practice self-care and given opportunities at work to look after themselves.

Description

a) The health and wellbeing of nurses is fundamental to the quality of care they can provide. Supporting the nursing workforce to practice self-care will help improve recruitment to the profession as well as support retention of the current workforce. Inherent within the Nursing & Midwifery Council Code is the need for individual practitioners to look after their own health and wellbeing in order to care effectively for others and employers must ensure they are able to do this.

b) Access to healthy eating options at work, opportunities to participate in wellbeing initiatives and access to proactive sessions on promoting physical and mental health all support employee health and wellbeing. This is alongside providing access to occupational health support and all recommended occupational health vaccines.

Safe staffing means having enough nursing staff with the right skills and knowledge, in the right place, at the right time. Without safe staffing levels in place, nursing staff are struggling to provide patients with the safe and effective care they would like to, and which patients deserve.

We're calling for safe and effective care to be enshrined in law in each UK country. 

Find out what is happening in England.

Safe staffing means having enough nursing staff with the right skills and knowledge, in the right place, at the right time. Without safe staffing levels in place, nursing staff are struggling to provide patients with the safe and effective care they would like to, and which patients deserve.

We're calling for safe and effective care to be enshrined in law in each UK country. 

Find out what is happening in Northern Ireland.

Safe staffing means having enough nursing staff with the right skills and knowledge, in the right place, at the right time. Without safe staffing levels in place, nursing staff are struggling to provide patients with the safe and effective care they would like to, and which patients deserve.

We're calling for safe and effective care to be enshrined in law in each UK country. 

Find out what is happening in Scotland.

Safe staffing means having enough nursing staff with the right skills and knowledge, in the right place, at the right time. Without safe staffing levels in place, nursing staff are struggling to provide patients with the safe and effective care they would like to, and which patients deserve.

We're calling for safe and effective care to be enshrined in law in each UK country. 

Find out what is happening in Wales.

These resources are set out by practice area.

Intensive care

• Faculty of Intensive Care Medicine (2019) Guidelines for the Provision of Intensive Care Services (GPICS) V2. GPICS (2019) can be used as the definitive reference source for planning and delivery of UK Intensive Care Services
• Paediatric Critical Care Society (PICS) Quality Standards for the Care of Critically Ill Children 

Perioperative 

• Faculty of Intensive Care Medicine & Centre for Perioperative Care (2020) Guidance for Establishing and Delivering Enhanced Perioperative Care Services (England only)  

Neonatal nurse staffing

• British Association of Perinatal Medicine (2019) Calculating Unit Cot numbers and Nurse Staffing Establishment and Determining Cot Capacity
• British Association of Perinatal Medicine (2010) Service standards for hospitals providing neonatal care

Nursing associates

• National Quality Board (2019) Safe, sustainable and productive staffing. An improvement resource for the deployment of nursing associates in secondary care
• National Quality Board (2019) Response to feedback on safe, sustainable and productive staffing
• National Quality Board (2016) Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time
• NMC (2018) Standards of proficiency for registered nursing associates 

Learning disability 

• NHS England. The Learning Disability Improvement Standards for NHS Trusts 
• HEE & Capital Nurse (2020) Learning Disability Nursing Workforce Best Practice Guide 
• NHS England and NHS Improvement (2019) Performance against the learning disability improvement standards Findings from the benchmarking exercise

Education 

• NMC. Principles of preceptorship
• NMC (2018) Standards of proficiency for registered nurses 
• RCN. Practice Based Learning - professional resources

CPD principles

The principles are designed to guide individuals, employers and wider systems to create a culture of continuous improvement, workforce development and improve outcomes for service users. People working in the health and social care workforce operate in a changing, challenging and complex environment. Practicing safely and effectively, now and in the future is essential. 

The five principles are that CPD and Lifelong Learning should:

• be each person’s responsibility and be made possible and supported by your employer
• benefit the service users
• improve the quality of service delivery
• be balanced and relevant to each person’s area of practice or employment
• be recorded and show the effect on each person’s area of practice.

See: Principles for CPD and Lifelong Learning

See also:

• England. Health Education England 
• NI: Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC) 
• Scotland: NHS Education for Scotland

Maternity Services

• Heath Education England (2019) Maternity Workforce Strategy – Transforming the Maternity Workforce Phase 1: Delivering the Five Year Forward View for Maternity
• Heath Education England (2022) Advanced Clinical Practice (ACP) in Midwifery
• NHSE Maternity Toolkit (2022) Continuity of Carer – Workplace Toolkit 
• Royal College of Midwives (2016) Getting the Midwifery Workforce Right
• Royal College of Midwives (2016) RCM guidance on implementing the NICE safe staffing guideline on midwifery staffing in maternity settings.

Absences - Agreed and non-agreed non-attendance at a workplace. Absenteeism is habitual absence from work. 

Direct care - Care provided personally by a member of staff. May involve any aspect of health care including treatments, counselling and education regarding people who use services. 

Indirect care - Nursing interventions that are performed to benefit people who use services but do not involve direct contact with these individuals and communities.

Independent employer - Any independent contractor, employer organisations that may or may not be commissioned by the public sector. This will include private health care providers, most social care providers; GP practices; out of hours/call centres; social enterprises and community interest companies; charities, private surgical, mental health and learning disability hospitals; independent treatment centres; public/private schools; private industry.

Missed care - Required care for people who use or need services that is omitted in part or fully, or care that is delayed. 

Nurse-patient/staff ratios - Number of people who need or use services assigned to an individual or team of nurses; based upon the acuity and/or dependency of the service user for nursing care.

Nurse retention - A strategy which focuses on preventing nurse turnover and keeping nurses in an organisation's employment.

Nursing establishment - The total number of staff to provide sufficient resource to deploy a planned roster that will enable nurses to provide care to people who need or use services that meets all reasonable requirements in the relevant situation. This includes: a resource to cover all staff absences, and other staff functions that reduce the time available to care for people who need services. Supernumerary persons such as students and sisters/charge nurses/managers should not be included in the planned roster.

Nurse staffing - Rota and whole time equivalent (WTE) for a nursing team. The nurse staffing level refers to both the required establishment and the actual staffing level per shift/allocated workday. The maintenance of the nurse staffing level should be funded from the organisation’s revenue allocation. 

Nursing workforce - The total number of nursing staff – of all levels of experience and qualification – currently working within an organisation, sector or country. 

Patient acuity - Acuity can be defined as the measurement of the intensity of nursing care that is required by a person in need of service. An acuity-based staffing system regulates the number of nurses on a shift according to the individual's needs and not according to numbers of people who use or need services.

Patient/client dependency - Measuring the differing reliance of individual people who use services on nursing staff, a means to classify patients in order to predict staffing needs.

Patient safety - Patient safety is the prevention of errors and adverse effects to patients associated with health care. It is closely correlated to safe staffing levels.

Public sector - Refers to employers that are publicly provided – either as an arm’s length body of the department of health and social care, or via another government department or directorate such as education, home office, and criminal justice. Examples include local authorities, statutory agencies such as inspectorates and regulators.

Seasonal variation in nursing workload - Variations and fluctuations in demands for care by people who need or use services, such as differing attendance rates.

Shift patterns - Is the organising of shifts to ensure patients have continued access to nursing care whatever the day or time of day. The shifts could be rotational between day, night and weekend working, or fixed or a continuous working pattern. 

Skill mix - Percentage of different health care personnel involved in provision of care, for example between registered nurses and nursing support workers, or between different health care professions.

Social care - Is 60% publicly funded by local authorities. However, most UK residential and domiciliary care and employment is provided by independent employers, which include private care home companies, domiciliary care agencies, charities, private care management companies. 

Staff rosters/schedules - A list of staff and associated information such as working times, responsibilities and locations for a given time period. 

Staffing levels - To ensure effective staffing there needs to be the right numbers of the right people, in the right place at the right time. It is not just a matter of having enough staff, but also ensuring they have suitable knowledge and experience.

Substantive position - An employee's permanent position of employment.

Team - A group of staff brought together to achieve a common goal. Often associated with a multidisciplinary approach to care for people who use services.

Understaffing - A situation where there are insufficient numbers of staff to operate effectively, such as to impact upon service user safety.

Uplift - Adding an allowance when calculating staff numbers for planned and unplanned staff absence. 

Vacancies - Paid posts which are newly created, unoccupied, or about to become vacant and the employer is actively searching for suitable staff. Temporary staff may be able to fulfil posts during the recruitment of permanent staff. 

Whole-time equivalent - This is a standardised measure of the workload of an employee. 

Workforce planning – The process of analysing the current workforce and determining future needs, including identifying any gaps between current and future provision.