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Staffing for Safe and Effective Care

Use this guide to find information resources and evidence about nursing staffing levels for safe and effective care including RCN publications, key resources and journal articles.

Last updated: 20/07/2020

RCN Publications

Royal College of Nursing (2020) Staffing for Safe and Effective Care in the UK 2019 report: Reviewing the progress of health and care systems against our principles. London: RCN. Royal College of Nursing (2020) Staffing for safe and effective care in the UK 2019 report: reviewing the progress of health and care systems against our principles. London: RCN.
Royal College of Nursing (2020) A safety representative's resource staffing for safe and effective care, London: RCN. Royal College of Nursing (2020) A safety representative's resource staffing for safe and effective care, London: RCN.
Royal College of Nursing (2019) Staffing for safe and effective care in England. Member briefing. London: RCN. Royal College of Nursing (2019) Staffing for safe and effective care in England. Member briefing. London: RCN.
Borneo A and Hadden C (2019) Standing up for patient and public safety: England policy report, London: RCN. Borneo A and Hadden C (2019) Standing up for patient and public safety: England policy report, London: RCN.
Borneo A, Cackett R, Fry O, Kiely S, Knape J, Maynard E, Oorthuysen-Dunne J and Turnbull L (2019) Staffing for safe and effective care: RCN member campaigning in the UK. Policy report, London: RCN. Borneo A, Cackett R, Fry O, Kiely S, Knape J, Maynard E, Oorthuysen-Dunne J and Turnbull L (2019) Staffing for safe and effective care: RCN member campaigning in the UK. Policy report, London: RCN.
Royal College of Nursing (2017) Safe and effective staffing: nursing against the odds, London: RCN. Royal College of Nursing (2017) Safe and effective staffing: nursing against the odds, London: RCN.
Royal College of Nursing (2017) Safe and effective staffing: the real picture. UK policy report, London: RCN. Royal College of Nursing (2017) Safe and effective staffing: the real picture. UK policy report, London: RCN.
Royal College of Nursing (2015) Registered nurses and health care support workers: a summary of RCN policy positions, London: RCN. Royal College of Nursing (2015) Registered nurses and health care support workers: a summary of RCN policy positions, London: RCN.
Royal College of Nursing Policy and International Department (2012) Mandatory nurse staffing levels, (Policy briefing 03/12), London: RCN. Royal College of Nursing Policy and International Department (2012) Mandatory nurse staffing levels, (Policy briefing 03/12), London: RCN.
Royal College of Nursing Policy Unit (2006) Setting appropriate nurse staffing levels in NHS Acute Trusts (Policy guidance 15/2006), London: RCN. Royal College of Nursing Policy Unit (2006) Setting appropriate nurse staffing levels in NHS Acute Trusts (Policy guidance 15/2006), London: RCN.

Legislation and guidance

RCN (2020) Budget submission to HM Treasury. February 2020. London: RCN.
  • The RCN has written to the Treasury ahead of the budget on 11 March 2020 outlining what investment is needed to tackle nursing workforce shortages across the UK.
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Scottish Government: Health and Care (Staffing) (Scotland) Act 2019
Royal College of Nursing Wales (2019) Progress and challenge: the implementation of the Nurse Staffing Levels (Wales) Act 2016. RCN Wales Report, Cardiff: RCN.
Royal College of Nursing Wales (2018) An act of compassion: the story of the RCN Wales campaign for the first nurse staffing law in Europe, Cardiff: RCN Wales.
  • Free on request to all RCN members. Please contact Policy & Public Affairs Wales for your copy. Email: policy.publicaffairs.wales@rcn.org.uk
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NHS Wales 1000 Lives Improvement: National nurse staffing programme
National Institute for Health and Care Excellence (2014) Safe staffing for nursing in adult inpatient wards in acute hospitals: safe staffing guideline SG1, London: NICE.
  • NICE guidance is officially England only.
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National Institute for Health and Care Excellence (2015) Safe midwifery staffing for maternity settings: NICE guideline NG4, London: NICE.
  • NICE guidance is officially England only.
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Northern Ireland Practice and Education Council for Nursing and Midwifery (NIPEC): Delivering care: nurse staffing in NI
NHS Education for Scotland (2013) Nursing and midwifery workload and workforce planning learning toolkit (second edition), Edinburgh: NES.

Reviews and reports

These reviews and reports discuss standards of care and staffing levels.
Griffiths P, Saville C, Ball J E, Chable R, Dimech A, Jones J, Jeffrey Y, Pattison N, Saucedo A R, Sinden N and Monks T (2020) The Safer Nursing Care Tool as a guide to nurse staffing requirements on hospital wards: observational and modelling study. Southampton: NIHR Journals Library.
Ball J, Barker H, Burton C, Crouch R, Griffith P, Jones J, Lawless J, Rycroft Malone J (2019) Implementation, impact and costs of policies for safe staffing in acute trusts, (no place): University of Southampton.
Griffiths P, Ball J, Bloor K, Böhning D, Briggs J, Dall’Ora C, and others (2018) Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study, Health Services and Delivery Research, 6(38).
Francis R (Chair) (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry: final report, London: Stationery Office.
Andrews J and Butler M (2014) Trusted to care: an independent review of the Princess of Wales Hospital and Neath Port Talbot Hospital at Abertawe Bro Morgannwg University Health Board. Cardiff: Welsh Government.
Berwick D and National Advisory Group on the Safety of Patients in England (2013) A promise to learn: a commitment to act. Improving the safety of patients in England, London: Department of Health.
Cookson G and McGovern A (2014) The cost-effectiveness of nurse staffing and skill mix on nurse sensitive outcomes. A report for the National Institute for Health and Care Excellence, (no place) University of Surrey.
Keogh B (2013) Review into the quality of care and treatment provided by 14 hospital trusts in England; London: NICE.
Older People's Commissioner for Wales (2011) Dignified care? The experiences of older people in hospital in Wales, Cardiff: Older People's Commissioner for Wales.
Older People's Commissioner for Wales (2013) Dignified care: two years on: the experiences of older people in hospital in Wales, Cardiff: Older People's Commissioner for Wales.

Journal articles

These resources provide evidence and research findings around nursing staffing levels.
Emmanuel T, Dall’Ora C, Ewings S and Griffiths P (2020) Are long shifts, overtime and staffing levels associated with nurses’ opportunity for educational activities, communication and continuity of care assignments? A cross-sectional study, International Journal of Nursing Studies Advances. p. 100002.
Griffiths P, Saville C, Ball J, Jones J, Pattison N and Monks T (2020) Nursing workload, nurse staffing methodologies and tools: A systematic scoping review and discussion. International Journal of Nursing Studies, 103, p. 103487
Griffiths P, Saville C, Ball J, Culliford D, Pattison N and Monks T (2020) Performance of the Safer Nursing Care Tool to measure nurse staffing requirements in acute hospitals: a multicentre observational study, BMJ Open, 10(5), p. e035828.
Griffiths P, Maruotti A, Recio Saucedo A, Redfern O C, Ball J E, Briggs J, Dall’Ora C, Schmidt P E, Smith G B and Missed Care Study Group (2019) Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study, BMJ Quality and Safety, 28(8), pp. 609–617.
Saville C E, Griffiths P, Ball J E and Monks T (2019) How many nurses do we need? A review and discussion of operational research techniques applied to nurse staffing, International Journal of Nursing Studies. pp. 7–13.
Aiken LH, Sloane DM, Ball J, Bruyneel L, Rafferty AM, Griffiths P (2018) Patient satisfaction with hospital care and nurses in England: an observational study, BMJ Open, 8.
Ball JE, Bruyneel L, Aiken LH and others (2017) Post-operative mortality, missed care and nurse staffing in nine countries: a cross-sectional study, International Journal of Nursing Studies.
Ball JE (2017) Nurse staffing levels, care left undone and patient mortality in acute hospitals, PhD thesis, Department of Learning, Informatics, Management and Ethics, Karolinksa Institutet.
Aiken LH, Sloane D, Griffiths P and others (2016) Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care, BMJ Quality and Safety, Published online first: 15 November 2016.
Griffiths P, Ball J, Drennan J, Dall’ora C, Jones J, Maruotti A, Pope C, Recio Saucedo A and Simon M (2016) Nurse staffing and patient outcomes: strengths and limitations of the evidence to inform policy and practice. A review and discussion paper based on evidence reviewed for the National Institute for Health and Care Excellence safe staffing guideline development, International Journal of Nursing Studies, 63, pp. 213–225.
Griffiths P, Ball J, Murrells T, Jones S and Rafferty A (2016) Registered nurse, healthcare support worker, medical staffing levels and mortality in English hospital trusts: a cross-sectional study, BMJ Open, 6.
Aiken LH, Sloane DM, Bruyneel L, van dH, Griffiths P, Busse R and others (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study, Lancet, 383 (9931), pp.1824-30.
Ball JE, Murrells T, Rafferty AM, Morrow E and Griffiths P (2014) 'Care left undone’ during nursing shifts: associations with workload and perceived quality of care, BMJ Quality and Safety, 23, pp.116-125.
Barton N (2013) Acuity-based staffing: balance cost, satisfaction, quality, and outcomes, Nurse Leader, 11(6), pp. 47-50, 64.
North N, Leung W, Ashton T, Rasmussen E, Hughes F and Finlayson M (2013) Nurse turnover in New Zealand: costs and relationships with staffing practises and patient outcomes, Journal of Nursing Management, 21(3), pp.419-428.
Hurst K and Smith A (2011) Temporary nursing staff: cost and quality issues, Journal of Advanced Nursing, 67(2), pp.287-296.
Needleman J, Buerhaus P, Pankratz VS, Leibson CL, Stevens SR and Harris M (2011) Nurse staffing and inpatient hospital mortality, New England Journal of Medicine, 364 (11), pp.1037-1045.
Dall TM, Chen YK, Seifert RF, Maddox, PJ and Hogan PF (2009) The economic value of professional nursing, Medical Care, 47(1), pp.97-104.
Newbold D (2008) The production economics of nursing: a discussion paper, International Journal of Nursing Studies, 45(1), pp.120-128.
Unruh L (2008) Nurse staffing and patient, nurse, and financial outcomes, American Journal of Nursing, 108(1), pp.62-72
Kane RL, Shamliyan TA, Mueller C, Duval S, and Wilt TJ (2007) The association of registered nurse staffing levels and patient outcomes: Systematic review and meta-analysis, Medical Care, 45 (12), pp.1195-1204.
Rafferty AM, Clarke SP, Coles J, Ball J, James P, McKee M and Aiken LH (2007) Outcomes of variation in hospital nurse staffing in English hospitals: cross-sectional analysis of survey data and discharge records, International Journal of Nursing Studies, 44 (2), pp.175-182.
Needleman J, Buerhaus, PI, Stewart M Zelevinsky K and Mattke S (2006) Nurse staffing in hospitals: is there a business case for quality? Health Affairs, 25(1), pp.204-211.
Pearson A, Pallas, L O, Thomson D, Doucette E, Tucker D, Wiechula R, Long L, Porrit, K and Jordan Z (2006) Systematic review of evidence on the impact of nursing workload and staffing on establishing healthy work environments, International Journal of Evidence-Based Healthcare, 4, pp.337–384.
Spetz J (2005) The cost and cost-effectiveness of nursing services in health care. Nursing Outlook, 53(6), pp.305-309.
Cho S, Ketefian S, Barkauskas VH, and Smith DG (2003) The effects of nurse staffing on adverse events, morbidity, mortality, and medical costs, Nursing Research, 52(2), pp.71-79.
Aiken LH, Clarke SP, Sloane DM, Sochalski J and Silber JH (2002) Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction, JAMA, 288 (16) pp.1987-1993.
Needleman J, Buerhaus P, Mattke S, Stewart M and Zelevinsky K (2002) Nurse-staffing levels and the quality of care in hospitals, New England Journal of Medicine, 346 (22), pp.1715-1722.

Videos

An act of compassion. RCN Wales' campaign for safe staffing (short version)
An act of compassion. RCN Wales' campaign for safe staffing (full version)
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Page last updated - 20/07/2020