Staffing for Safe and Effective Care
Find information resources about Staffing for Safe and Effective Care. This guide is for RCN members including nursing students, nursing support workers, and registered nurses.
Last updated:
29/05/2026
RCN Publications
Dall'ora C and Griffiths P (2025) Safe staffing: evaluating the evidence for mandatory nurse-to-patient ratios. London: RCN.
Ball J (2025) Registered nurse staffing levels for patient safety, care quality and cost effectiveness. London: RCN.
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RCN position statement.
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Royal College of Nursing (2025) Nursing workforce standards: supporting a safe and effective nursing workforce . London: RCN.
Royal College of Nursing (2026) The nursing workforce in Scotland 2026. RCN: Edinburgh.
Royal College of Nursing (2025) On the frontline of the UK’s corridor care crisis. London: RCN.
Royal College of Nursing (2025) A practical guide to raising concerns for registered nurses. London: RCN.
RCN: Raising concerns toolkit
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This guide is to help nurses, nursing associates, students and health care support workers based in the NHS and independent sector. It includes a decision making tree to help nursing staff and students decide whether to raise a concern and when to escalate a concern.
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Royal College of Nursing (2025) State of the profession report: RCN employment survey 2025. London: RCN.
Hadden C and Tse J (2024) Corridor care: unsafe, undignified, unacceptable: the impact on patients and staff of providing care in corridors and other inappropriate areas. London: RCN.
RCN: Safety critical nurse-to-patient ratios
RCN: Unsustainable pressures
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This resource is designed to support RCN members both in delivering safe and effective care and with the difficult decisions they make every day. These decisions often relate to the type of care provided, how it is provided and who it is provided to, and can have wider implications on the delivery of health and social care services.
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RCN: The RCN's position on registered nurse substitution.
Royal College of Nursing (2024) Staffing for safe and effective care: a health and safety representative’s resource.
Research by Design (2023) Last shift survey 2022: qualitative report prepared for the Royal College of Nursing.
Tamburello H (2023) Impact of staffing levels on safe and effective patient care: literature review. London: RCN.
Castro-Ayala A, Borneo A, Hayford E, Holden J, Maynard E, Stainton R, Taylor E and Tse J (2022) Investing in patient safety and outcomes: health and care nursing workforce and supply in England. London: RCN.
Royal College of Nursing (2022) UK staffing for safe and effective care: state of the nation's nursing labour market: RCN biannual report February 2022. London: RCN.
Castro-Ayala A, Borneo A, Hayford E, Holden J, Maynard E, Stainton R, Taylor E and Tse J (2022) UK nursing under unsustainable pressures: staffing for safe and effective care in the UK. London: RCN.
Royal College of Nursing Wales (2022) Position paper. Ward manager project: the importance of being supernumerary. Cardiff: RCN.
Royal College of Physicians, Royal College of Nursing, Royal Pharmaceutical Society, the Chartered Society of Physiotherapy and NHS England (2021) Modern ward rounds.
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.
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 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.
Legislation and Standards
Scottish Government: Health and Care (Staffing) (Scotland) Act 2019
- View the Act
- Overview
- RCN: Staffing for safe and effective care in Scotland
- RCN briefing for MSPs on Stage 3 amendments to the Health and Care (Staffing) (Scotland) Bill
- RCN briefing to MSPs on the case for non-caseload holding senior charge nurses and their equivalents in the community
- RCN briefing to MSPs on the role of registered nurses in care homes
National Assembly for Wales (2016) Nurse staffing levels (Wales) Act 2016, Cardiff: NAW.
Royal College of Nursing Wales (2022) Progress and challenge in delivering safe and effective care 2022: how NHS Wales has implemented the nurse staffing levels (Wales) Act 2016. 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.
Department of Health Northern Ireland (2024) Safe and effective staffing legislation in Northern Ireland: consultation document, July 2024.
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The consultation is closed.
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National Institute for Health and Care Excellence (2014) Safe staffing for nursing in adult inpatient wards in acute hospitals [safe staffing guideline SG1].
NHS England: Safer staffing: nursing and midwifery.
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Information and resources to support and enable NHS providers to make decisions on safer staffing
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Key Resources
World Health Organization Regional Office for Europe (2026) Policies and approaches to promote safe nurse staffing.
Dall’ora C, Emmanuel T, Griffiths P, Saville C and Turner L (2026) What is the impact of implementing mandatory minimum nurse-patient ratios in general acute care hospitals? Evidence brief 33. University of Southampton.
European Federation of Nurses Associations (2025) EFN policy brief: Safe staffing levels nursing action: a WHO-led project funded by the European Commission.
Maben J, Ball J and Edmondson A C (2023) Workplace conditions. Cambridge: Cambridge University Press (Elements of Improving Quality and Safety in Healthcare).
Buchan J, Ball J, Shembavnekar N, Charlesworth A (2020) Building the NHS nursing workforce in England. London: The Health Foundation.
Cordeiro R, Kirwan M, Harvey C, Rengel-Diaz C, Fuster Linares M and Riklikiene O (2020) Promoting patient safety through minimising missed nursing care: a recommended good practice guidance for nurse managers. Cost Action RANCARE.
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.
Sworn K and Booth A (2019) Scoping review: patient safety outcomes and nursing skill mix interventions. Sheffield: ScHARR, University of Sheffield.
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A scoping review emerging from the RCN strategic alliance with the University of Sheffield.
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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.
Saudi Patient Safety Center and International Council of Nurses (2019) Nurse staffing levels for patient safety and workforce safety. SPSC and ICN White Paper. Riyadh.
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.
International Council of Nurses (2009) Evidence-based safe nurse staffing.
Journal articles
Nwanosike E, Griffiths P, Dall’Ora C, Monks T, Pattison N, Yapa T D and Saville C (2026) ICU staffing and patient outcomes in English hospital Trusts: a longitudinal observational study examining ICU length of stay, re-admission and infection rates, Intensive and Critical Care Nursing, 94, article number 104314.
Saville C, Jones J, Meredith P, Dall’Ora C and Griffiths P (2026) Cost-effectiveness of eliminating hospital understaffing by nursing staff: a retrospective longitudinal study and economic evaluation, BMJ Quality & Safety, 35(1), pp. 8–17.
Drennan J, Murphy A, McCarthy V J C, Ball J, Duffield C, Crouch R, Kelly G, Loughnane C, Murphy A, Hegarty J, Brady N, Scott A and Griffiths P (2024) The association between nurse staffing and quality of care in emergency departments: A systematic review, International Journal of Nursing Studies, 153, 104706.
Griffiths P, Saville C, Ball J, Dall’Ora C, Meredith P, Turner L and Jones J (2023) Costs and cost-effectiveness of improved nurse staffing levels and skill mix in acute hospitals: A systematic review, International Journal of Nursing Studies, 147, 104601.
Zaranko B, Sanford N J, Kelly E, Rafferty A M, Bird J, Mercuri L, Sigsworth J, Wells M and Propper C (2023) Nurse staffing and inpatient mortality in the English National Health Service: a retrospective longitudinal study, BMJ Quality & Safety, 32(5), pp. 254–263.
Ball J E and Griffiths P (2022) Consensus Development Project (CDP): An overview of staffing for safe and effective nursing care, Nursing Open, 9(2), pp. 872–879.
Dall’Ora C, Saville C, Rubbo B, Turner L, Jones J and Griffiths P (2022) Nurse staffing levels and patient outcomes: A systematic review of longitudinal studies, International Journal of Nursing Studies, 134, p. 104311.
Dierkes A, Do D, Morin H, Rochman M, Sloane D and McHugh M (2022) The impact of California’s staffing mandate and the economic recession on registered nurse staffing levels: A longitudinal analysis, Nursing Outlook, 70(2), pp. 219–227.
Senek M, Robertson S, Taylor B, Wood E, King R and Ryan T (2022) Consequences of understaffing on type of missed community care- a cross-sectional study, International Journal of Nursing Studies Advances, 4, 100075.
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The project was funded by the Royal College of Nursing (RCN) as part of the Strategic Research Alliance (SRA) between the RCN and the University of Sheffield.
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McHugh M D, Aiken L H, Sloane D M, Windsor C, Douglas C and Yates P (2021) Effects of nurse-to-patient ratio legislation on nurse staffing and patient mortality, readmissions, and length of stay: a prospective study in a panel of hospitals, The Lancet, 397(10288), pp. 1905–1913.
Blatter C, Hamilton P, Bachnick S, Zúñiga F, Ausserhofer D, Simon M and Consortium for the R (2021) Strengthening tRansparent reporting of reseArch on uNfinished nursing CARE: The RANCARE guideline, Research in Nursing and Health, 44(2), pp. 344–352.
Clemens S, Wodchis W, McGilton K, McGrail K and McMahon M (2021) The relationship between quality and staffing in long-term care: A systematic review of the literature 2008–2020, International Journal of Nursing Studies, 122, 104036.
Senek M, Robertson S, Ryan T, Tod A, King R, Wood E and Taylor B (2021) Missed care in community and primary care, Primary Health Care, 31(3), pp. 20–23.
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The project was funded by the Royal College of Nursing (RCN) as part of the Strategic Research Alliance (SRA) between the RCN and the University of Sheffield.
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Musy S N, Endrich O, Leichtle A B, Griffiths P, Nakas C T and Simon M (2021) The association between nurse staffing and inpatient mortality: A shift-level retrospective longitudinal study, International Journal of Nursing Studies, 12, 103950.
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
Senek M, Robertson S, Ryan T, Sworn K, King R, Wood E and Tod A (2020) Nursing care left undone in community settings: results from a UK cross‐sectional survey, Journal of Nursing Management, 28(8), pp. 1968–1974.
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The project was funded by the Royal College of Nursing (RCN) as part of the Strategic Research Alliance (SRA) between the RCN and the University of Sheffield.
View article (open access)
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.
Sworn K and Booth A (2020) A systematic review of the impact of ‘missed care’ in primary, community and nursing home settings, Journal of Nursing Management, 28(8), pp. 1805–1829.
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The project was funded by the Royal College of Nursing (RCN) as part of the Strategic Research Alliance between the RCN and the University of Sheffield
View article (open access)
Senek M, Robertson Steven, Ryan T, King R, Wood E, Taylor B and Tod A (2020) Determinants of nurse job dissatisfaction - findings from a cross-sectional survey analysis in the UK, BMC Nursing, 19(1), p. 88.
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The project was funded by the Royal College of Nursing (RCN) as part of the Strategic Research Alliance (SRA) between the RCN and the University of Sheffield.
View article (open access)
Senek M, Robertson Steve, Ryan T, King R, Wood E and Tod A (2020) The association between care left undone and temporary nursing staff ratios in acute settings: a cross- sectional survey of registered nurses, BMC Health Services Research, 20(1), p. 637.
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The project was funded by the Royal College of Nursing (RCN) as part of the Strategic Research Alliance (SRA) between the RCN and the University of Sheffield.
View article (open access)
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 J E, Bruyneel L, Aiken L H, Sermeus W, Sloane D M, Rafferty A M, Lindqvist R, Tishelman C and Griffiths P (2018) Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study, International Journal of Nursing Studies, 78, pp. 10–15.
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).
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.
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Caroline Lynch
Editor of this guide
RCN Library and Museum
Page last updated - 29/05/2026
