A guide for RCN members on nurse staffing levels.
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Staffing levels have always been an issue for healthcare staff. 'What is the optimal level and mix of nursing staff required to deliver quality care as cost-effectively as possible?' is a continual question.
We believe that mandatory standards for nurse staffing levels and skill mix standards would help prevent staffing levels being set too low in the first place, and we will continue to campaign for such standards as an important way of guaranteeing patient safety.
In the UK at present, nurse staffing levels are set locally by individual health providers. The Department of Health and professional organisations such as the RCN have recommended staffing levels for some care settings but there is currently no compliance regime or compulsion for providers to follow these when planning services.
Our Guidance on Safe Nurse Staffing Levels in the UK sets out the range of different factors that influence the total demand for staff and highlights the variety of methods for planning or reviewing staffing levels.
Read more about the Nurse Staffing Levels (Wales) Act 2016.
We make a number of recommendations regarding staffing levels and skill mix in general NHS wards. Nurses and workforce planners should see the RCN document Setting Appropriate Ward Nurse Staffing levels in NHS Acute Trusts for the full set of principles and their context.Back to contents
The ‘gold standard’ ratio of one registered nurse to one patient was set in 1967. This continued to be the standard for decades, until revised guidance, Standards for Nurse Staffing in Critical Care (2009) was produced jointly by the British Association of Critical Care Nurses (BACCN) and the RCN. This guidance highlights the complexity of teams and the need for staffing to be planned to map local variation (in patient mix, unit/bed layout and team mix).Back to contents
The RCN publication Defining Staffing Levels for Children and Young People’s Services (2013) outlines our specific guidance for this area.
All staff working with babies, children and young people must comply with Safeguarding Children and Young People: every nurse's responsibility (2014).
The Paediatric Intensive Care Society (PICS) Standards for the Care of Critically Ill Children are now widely used during workforce planning in critical care, and the Appendices to Standards for the Care of Critically Ill Children also give useful guidance in this area (see section 13 – nurse workforce planning).Back to contents
The Royal College of Psychiatrists (RCPsych) has developed Quality Standards for Liaison Psychiatry Services covering minimum staffing levels/skill mixes for psychiatry liaison teams serving different functions. The College states that these minimum staffing levels will need to vary to accommodate different deployment patterns or levels of need.
In 1998, RCPsych stated that “It is unlikely that a ward of 15 acute patients could be safely managed with less than three registered nurses per shift during the day and two at night, irrespective of other staff available”. More up-to-date guidance on numbers has not been produced but principles around appropriate staffing levels are contained in a number of the RCPsych’s standards.
Ultimately, safe day-to-day staffing levels for older people’s wards should be determined locally, with specific considerations relating to the nature of care for older people with complex needs.
Please see the following guidance:Back to contents
We have long been concerned about a lack of national guidance on staffing levels, nurse:patient ratios and skill mix in care homes. In the briefing Persistent Challenges to Providing Quality Care, we called for 'national guidance on staffing levels and ratios for care homes, determined and applied locally according to the dependency and needs of residents in a home’s care and to the demands of the home’s day (early and late) and night time shifts'.
In the absence of national guidance and ratios, the RCN’s Guidance on Safe Nurse Staffing Levels in the UK provides general principles for appropriate staffing that can be used in care homes across the UK.
The document includes some guidance questions that should be used when considering concerns about staffing levels in care homes. Once you have considered all these questions you will have a better idea of whether the needs of the patients are being met. Contact us for help in preparing a clear and objective statement of concerns to put to your employer.
Different regulators also set guidance/minimum standards for nursing and care homes across England, Northern Ireland, Scotland and Wales:
Nursing and care homes in England are regulated by the Care Quality Commission (CQC). CQC is the independent regulator of all health and adult social care in England provided by the NHS, local authorities, private companies or voluntary organisations. Providers must meet the 28 regulatory outcomes and essential standards as part of the registration process.
Standards are set by the Department of Health.
The Regulation and Quality Improvement Authority (RQIA) regulates independent health care providers, residential care homes and nursing homes.
RQIA has produced a range of standards which include guidance around staffing levels.
The Care Inspectorate registers services who must continuously meet the requirements of The Public Services Reform (Scotland) Act 2010, the National Care Standards, and any other legislation relevant to that service.
The Care and Social Services Inspectorate for Wales (CSSIW) regulate care homes for adults – including care homes which provide nursing care. CSSIW inspects against national minimum standards for care homes for older people and care homes for younger adults, which are available from the CSSIW website.Back to contents
We understand that raising concerns can be very difficult - that’s why the RCN has developed a guide to make it easier for you to assess whether a situation you’ve witnessed or experienced should be raised as a concern. Please read the information in this section alongside the guide Raising Concerns: a Guide for RCN Members. Contact us if you remain concerned on 0345 772 6100.
As a registered nurse or midwife, under The Nursing and Midwifery Council (NMC) Code you have a number of responsibilities to act on concerns where you believe actions or situations are putting people at potential or actual risk. The NMC has produced a publication Raising Concerns: Guidance for Nurses and Midwives (2013). Although health care assistants and assistant practitioners do not work under The Code, the RCN would support any health care assistant who wished to raise concerns regarding staffing levels.Back to contents