If you, or someone you love needs care in hospital or a community setting, you would hope that there would be enough nurses to keep them safe. But public polling commissioned by RCN Scotland shows that most people do not believe this likely; 78% think there are not enough nursing staff to provide safe and effective care to patients and care home residents in Scotland.

They’re right to be concerned, despite nursing staff across Scotland going above and beyond every day to provide the best care they can.

At no point has the NHS in Scotland employed the number of nursing staff it says it needs. Scotland’s safe staffing legislation came into force in 2024, but nursing vacancies remain stubbornly high, with over 2,700 NHS posts unfilled. Care homes also report significant retention and recruitment challenges.

Last summer more than 500 RCN members in Scotland answered questions about the safe delivery of care. 27% of respondents said their work setting rarely or never has enough registered nursing staff, with the right skills, to care for patients safely. 61% said the number of nursing staff working during their last shift was insufficient to meet the needs of patients.  In a recent report from the Nursing and Midwifery Council (NMC), 37% of nurses and midwives in Scotland said they witnessed a patient safety incident in the last year.

Decades of research from the UK and around the world consistently shows that when nurse‑to‑patient ratios drop, the risk of harm rises, from preventable complications and falls to higher death rates. A recent observational study in NHS England found that increasing permanent staff to avoid low staffing reduced the hazard of death by 7.7%.

Meanwhile, nursing staff are also harmed, through increased pressure, stress, and risk of burnout. The NMC reported that more than a quarter (30%) of professionals from Scotland were ‘struggling’ with their workload, with 27% of registered nurses at high risk of burnout.

The evidence is clear and compelling: safe nurse staffing saves lives, protects exhausted staff and strengthens health and care services.

Too often, nurse staffing decisions are based on affordability rather than need. This is a false economy. There’s increasing evidence that, as well as improving safety, ensuring adequate levels of registered nurse staffing is cost effective. Recent economic analysis in the NHS suggests that investing in better nurse to patient ratios is likely to be highly cost effective and may lead to net cost savings due to reduced length of hospital stay and readmissions, as well as reduced staff sickness.

Delivering safe staffing is also vital for improving retention of experienced nurses and attracting new individuals into the profession. Both are key for securing a sustainable nursing workforce able to meet the increasing needs of Scotland’s ageing population.

Scotland’s safe staffing legislation, which came into force in April 2024, places a legal duty on NHS and care providers to make sure there are always suitably qualified staff working in the right numbers to maintain safe and effective care. However, a study by Penn Nursing’s Centre for Health Outcomes and Policy Research and Edinburgh Napier University found that at the point of implementation the Act’s goal of ensuring safe staffing was not being met. Their research found that only 9% of nurses believed that staffing levels on every shift were adequate.[4]

RCN Scotland’s manifesto includes a call for the introduction of mandatory minimum nurse-to-patient ratios for all health and care settings, a policy that is supported by 86% of those surveyed in our recent public polling. Without safe nurse to patient ratios, people are being put at risk.

Funding our health and social care services is a political decision. Yes, budgets are tight, and we recognise the severe financial challenges facing health and care services. Change is necessary, services need to transform and opportunities to do things differently, including a better understanding of how digital infrastructure can support service delivery, need to be embraced. Nursing needs to be at the heart of these decisions and engaged in shaping the future, and all of this must be built on staffing levels that are safe.

The costs of not investing in nursing are significant both in terms of the long-term impact on service delivery, and the very real risk of harm to patients and residents being cared for today. Population health is pivotal to the wider goals of government, including economic growth, ensuring children and young people thrive in education and keeping people in employment. The right investment now will release wide-ranging benefits.

Not investing in nursing is the financially unsustainable choice. That’s why, ahead of this Scottish parliament election, we’re calling for nursing to be recognised as an asset, rather than viewed as a cost.

It’s time to value nursing properly, because Scotland’s health depends on it. 

Blog first published on Enlighten - Scotland's independent think tank.