1 Recommendations

This guideline begins with recommendations for the responsibilities and actions at an organisational level to support safe staffing for nursing in individual acute adult inpatient wards.

There is no single nursing staff-to-patient ratio that can be applied across the whole range of wards to safely meet patients' nursing needs. Each ward has to determine its nursing staff requirements to ensure safe patient care. This guideline therefore makes recommendations about the factors that should be systematically assessed at ward level to determine the nursing staff establishment. It then recommends on-the-day assessments of nursing staff requirements to ensure that the nursing needs of individual patients are met throughout a 24-hour period.

The guideline also makes recommendations for monitoring and taking action according to whether nursing staff requirements are being met and, most importantly, to ensure patients are receiving the nursing care and contact time they need on the day. The emphasis should be on safe patient care not the number of available staff. This includes recommendations to review the nursing staff establishment for the ward and adjust it if required.

1.1 Organisational strategy

These recommendations are for hospital boards, senior management and commissioners. They should be read alongside the National Quality Board's guide to nursing, midwifery and care staffing capacity and capability .

Focus on patient care

1.1.1 Ensure patients receive the nursing care they need, including specialist nursing, regardless of the ward to which they are allocated, the time of the day or the day of the week. This includes planning to locate patients where their clinical needs can best be met.

Accountability for ward nursing staff establishments

1.1.2 Develop procedures to ensure that ward nursing staff establishments (the number of registered nurse and healthcare assistant posts that are funded to work in particular wards) are sufficient to provide safe nursing care to each patient at all times.

1.1.3 Ensure that the final ward nursing staff establishments are developed with the registered nurses who are responsible for determining nursing staff requirements at a ward level and approved by the chief nurse (or delegated accountable staff). The board should retain organisational responsibility. (See section 1.3 for recommendations on setting ward nursing staff establishments.) This includes when the ward establishment and budget are set.

1.1.4 Ensure senior nursing managers are accountable for the nursing staff roster that is developed from the ward nursing staff establishment.

1.1.5 When agreeing the ward nursing staff establishment, ensure it is sufficient to provide planned nursing staff requirements at all times. This should include capacity to deal with planned and predictable variations in nursing staff available, such as annual, maternity, paternity and study leave (commonly known as uplift). Consider adjusting the uplift for individual wards where there is evidence of variation in planned or unplanned absence at a ward level.

1.1.6 When agreeing the ward nursing staff establishment, ensure capacity to deal with fluctuations in patients' nursing needs (such as seasonal variations indicated by historical records of nursing staff requirements) and staff unplanned leave or absences.

1.1.7 When agreeing the skill mix of the ward nursing staff establishment, this should be appropriate to patient needs and take into account evidence that shows improved patient outcomes are associated with care delivered by registered nurses (see recommendation 1.3.6).

Responsiveness to unplanned changes

1.1.8 Ensure that there are procedures to identify differences between on-the-day nursing staff requirements and the nursing staff available on a ward.

1.1.9 Hospitals need to have a system in place for nursing red flag events (see section 1.4) to be reported by any member of the nursing team, patients, relatives or carers to the registered nurse in charge of the ward or shift.

1.1.10 Ensure there are procedures for effective responses to unplanned variations in predicted patients' nursing needs or the availability of nursing staff at any time during the day and night. These procedures should include prompt action to enable an increase or decrease in nursing staff.

1.1.11 Action to respond to nursing staff deficits on a ward should not compromise staff nursing on other wards.

1.1.12 Ensure there is a separate organisational contingency plan and response for patients who require the continuous presence of a member of the nursing team (often referred to as 'specialing' care).

1.1.13 Consider implementing approaches to support flexibility, such as adapting nursing shifts, nursing skill mix, assigned location and employment contract arrangements.

Monitor adequacy of ward nursing staff establishments

1.1.14 Ensure that there are procedures for systematic ongoing monitoring of safe nursing indicators (see section 1.5) and formal review of nursing staff establishments of individual wards at a board level at least twice a year (and more often if there are significant changes such as ward patient characteristics). These procedures should include periodic analysis of reported nursing red flag events and the safe nursing indicators (see section 1.5).

1.1.15 Make appropriate changes to the ward nursing staff establishment in response to the outcome of the review.

Promote staff training and education

1.1.16 Enable nursing staff to have the appropriate training for the care they are required to provide.

1.1.17 Ensure that there are sufficient designated registered nurses who are experienced and trained to determine on-the-day nursing staff requirements over a 24-hour period.

1.1.18 The organisation should encourage and enable nursing staff to take part in programmes that assure the quality of nursing care and nursing standards to maximise the effectiveness of the nursing care provided and the productivity of the nursing team.

1.1.19 Involve nursing staff in developing and maintaining hospital policies and governance about nursing staff requirements, such as escalation policies and contingency plans.

1.2 Principles for determining nursing staff requirements

These recommendations are for registered nurses in charge of individual wards or shifts who should be responsible for assessing the various factors used to determine nursing staff requirements.

1.2.1 Use a systematic approach that takes into account the patient, ward and staffing factors in box 1 to determine nursing staff requirements both when setting the ward nursing staff establishment and when making on-the-day assessments.

1.2.2 Use a decision support toolkit endorsed by NICE to facilitate the systematic approach to determining the nursing staff requirements (see the details of the process for assessing toolkits).

1.2.3 Use informed professional judgement to make a final assessment of nursing staff requirements. This should take account of the local circumstances, variability of patients' nursing needs, and previously reported nursing red flag events (see section 1.4).

1.2.4 Consider using the nursing care activities summarised in tables 1 and 2 as a prompt to help inform professional judgement of the nursing staff requirements. Tables 1 and 2 may help to identify where patients' nursing needs are not fully accounted for by any decision support toolkit that is being used.

Box 1: Factors to determine nursing staff requirements

Patient factors

  • Use individual patient's nursing needs as the main factor for calculating the nursing staff requirements for a ward. (The term patient nursing needs is used throughout this guideline to include both patient acuity and patient dependency.)

  • Make a holistic assessment of each patient's nursing needs and take account of specific nursing requirements and disabilities, as well as other patient factors that may increase nursing staff requirements, such as:

    • difficulties with cognition or confusion (such as those associated with learning difficulties, mental health problems or dementia)

    • end-of-life care

    • increased risk of clinical deterioration

    • need for the continuous presence of a member of the nursing team (often referred to as 'specialing' care).

Ward factors

  • Expected patient turnover in the ward during a 24-hour period (including both planned and unscheduled admissions, discharges and transfers).

  • Ward layout and size (including the need to ensure the safety of patients who cannot be easily observed, and the distance needed to travel to access resources within the ward).

Nursing staff factors

  • Nursing activities and responsibilities, other than direct patient care. These include:

    • communicating with relatives and carers

    • managing the nursing team and the ward

    • professional supervision and mentoring of nursing staff. Student nurses are considered supernumerary

    • communicating with and providing nursing clinical support to all healthcare staff involved with the care of patients on the ward

    • undertaking audit, and staff appraisal and performance reviews.

These activities and responsibilities may be carried out by more than one member of the nursing team.

  • Support from non-nursing staff such as the medical team, allied health professionals and administrative staff.

Table 1: Ongoing nursing care activities that affect nursing staff requirements

Routine nursing care needs

Additional nursing care needs (about 20‑30 minutes per activity)

Significant nursing care needs (more than 30 minutes per activity)

Care planning

Simple condition and care plan

Complex condition or care plan (such as multiple comorbidities)

Attending multidisciplinary meetings

Direct contact and communication

Providing information and support to patients, including all emotional and spiritual needs

Complex multiple health needs

Difficulties with communication including sensory impairment or language difficulties

Eating and drinking

Ensuring food and drink provided and consumed

Assistance with eating and drinking

Parenteral nutrition

Fluid management

8‑hourly IV fluids

IV fluids more frequently than 8 hourly or blood components

Complex fluid management (such as hourly or requiring monitoring in millilitres)

Management of equipment

Simple intermittent (such as catheters, IV access)

Central lines, drains, stomas

Multiple lines, drains, ventilator support

Medication

Regular oral medication

IV medication or frequent PRN medication

Medication requiring complex preparation or administration, or 2 nursing staff

Mobilisation

No assistance needed

Assistance needed (such as post‑op or during out of hours periods)

Mobilisation with assistance of 2 nursing staff

Observations

4–6 hourly

2–4 hourly

More frequent than 2 hourly

Oral care

No assistance needed

Assistance needed

Intensive mouth care needed (such as patient receiving chemotherapy)

Skin and pressure area care

Less frequent than 4 hourly

2–4 hourly

More frequent than 2 hourly or requiring 2 nursing staff

Toileting needs

No assistance needed

Assistance needed

Frequent assistance or 2 nursing staff needed

Washing or bathing and dressing

Minimal assistance with washing, dressing and grooming

Assistance with some hygiene needs by 1 member of the nursing staff

Assistance with all hygiene needs, or needing 2 nursing staff

Abbreviations: IV, intravenous; PRN medication, medication administered as needed

Note: these activities are only a guide and there may be other ongoing activities that could be considered

Table 2: One‑off nursing care activities that affect nursing staff requirements

Routine nursing care needs

Additional nursing care needs (about 20‑30 minutes per activity)

Significant nursing care needs (more than 30 minutes per activity)

Admission

Admission assessment

Complex admission assessment

Care after death

Arrangements after the death of a patient, including support for relatives and carers

Discharge planning

Simple follow‑up and transfer home

Coordination of different services

Organising complex services, support or equipment

Patient and relative education and support

Routine teaching about condition, routine post‑op care

Teaching about a significant new condition (such as diabetes, heart disease or cancer)

Teaching about a new complex or self‑managed condition (such as dialysis, colostomies), or to patient or their carers or relatives who have difficulties with communication including sensory impairment or language difficulties

Patient escorts

Routine escorts or transfers for procedures

Escorting a patient off a ward for 20‑30 minutes

Escorting a patient off a ward for more than 30 minutes

Procedures and treatments

Simple wound dressings, specimen collection

Catheterisation, nasogastric tube insertion, multiple wound dressings

Complex wound dressings (such as vacuum-assisted closure), tracheostomy care

Note: these activities are only a guide and there may be other one-off activities that also could be considered

1.3 Setting the ward nursing staff establishment

These recommendations are for senior registered nurses who are responsible for determining nursing staff requirements or those involved in setting the nursing staff establishment of a particular ward.

1.3.1 Set ward nursing staff establishments using the stages outlined in recommendations 1.3.2–1.3.8. This should involve the designated senior registered nurses at a ward level who are experienced and trained in determining nursing staff requirements. This process could be facilitated by the use of a NICE‑endorsed decision support toolkit.

Stage 1: Calculate the average nursing staff requirement throughout a 24-hour period

1.3.2 Routinely measure the average amount of nursing time required throughout a 24‑hour period for each of the ward's patients. The measurement should take into account the patient factors and nursing care activities outlined in section 1.2. It could be expressed as nursing hours per patient to ensure ward nursing staff establishments are derived from individual patient's needs. (A measurement of nursing hours per patient enables the nursing needs of individual patients and different shift durations of the nursing staff to be more easily taken into account than with a nurse-to-patient ratio. See the glossary for more information.)

1.3.3 Formally analyse the average nursing hours required per patient at least twice a year when reviewing the ward nursing staff establishment.

1.3.4 Multiply the average number of nursing hours per patient by the average daily bed utilisation (the number of patients that a ward nursing team is responsible for during each 24-hour period). Using bed utilisation rather than bed occupancy will ensure that the nursing care needs of patients who are discharged or transferred to another ward during a 24-hour period are also accounted for.

1.3.5 Add an allowance for additional nursing workload based on the relevant ward factors such as average patient turnover, layout and size, and staff factors such as nursing activities and responsibilities other than direct patient care (see recommendations section 1.2, box 1).

Stage 2: Determine required nursing skill mix and shift allocation

1.3.6 Identify the appropriate knowledge and nursing skill mix required in the team to meet the nursing needs of the ward's patients, with registered nurses remaining accountable for the overall care of patients. Base the nursing staff requirements on registered nurse hours, and consider which activities can safely be delegated to trained and competent healthcare assistants. Take into account:

  • the level of knowledge, skill and competence of the healthcare assistants in relation to the care that needs to be given

  • the requirement for registered nurses to support and supervise healthcare assistants

  • that improved patient outcomes are associated with a higher proportion of registered nurses in the ward nursing staff establishment.

1.3.7 Use average patients' nursing needs and the estimated time of day or night when care will be required to:

  • design the staffing roster

  • allocate nursing staff to care for specific patients during shifts.

1.3.8 Take account of the following factors (commonly known as 'uplift' and likely to be set at an organisational level, see recommendation 1.1.5):

  • planned absence (for example, for professional development, mandatory training, entitlement for annual, maternity or paternity leave)

  • unplanned absence (such as sickness absence).

    The following diagram summarises the process of setting nursing staff establishments for an individual ward:

Summary of the process of setting ward nursing staff establishments

1. Average nursing staff requirement throughout a 24‑hour period

Average nursing hours per patient

Use results of a systematic approach

x

Average daily bed utilisation

The average number of patients cared for in a ward per day

+

Additional workload in nursing hours per day

This should take into account:

  • average patient turnover

  • ward layout and size

  • nursing activities and responsibilities, other than direct patient care

2. Determine required ward nursing staff establishment and shift allocation

Use the care needs of patients and the time when care will be required together with professional judgement to determine:

  • nursing skill mix

  • allocation of nursing staff during shifts

Add an allowance for planned and unplanned absence (commonly known as uplift)

Note: This process of setting ward nursing staff establishments could be facilitated by using a decision support toolkit

1.4 Assessing if nursing staff available on the day meet patients' nursing needs

These recommendations are for the registered nurses on wards who are in charge of shifts.

1.4.1 Systematically assess that the available nursing staff for each shift or at least each 24-hour period is adequate to meet the actual nursing needs of patients currently on the ward. The nurse in charge on individual shifts should make the on-the-day assessments of nursing staff requirements, which could be facilitated by using a NICE-endorsed decision support toolkit. Also take into account the patient factors outlined in section 1.2, box 1 and tables 1 and 2.

1.4.2 Monitor the occurrence of the nursing red flag events shown in box 2 throughout each 24-hour period. Monitoring of other events may be agreed locally.

1.4.3 If a nursing red flag event occurs, it should prompt an immediate escalation response by the registered nurse in charge. An appropriate response may be to allocate additional nursing staff to the ward.

1.4.4 Keep records of the on-the-day assessments of actual nursing staff requirements and reported red flag events so that they can be used to inform future planning of ward nursing staff establishments or other appropriate action.

Box 2: Nursing red flags

  • Unplanned omission in providing patient medications.

  • Delay of more than 30 minutes in providing pain relief.

  • Patient vital signs not assessed or recorded as outlined in the care plan.

  • Delay or omission of regular checks on patients to ensure that their fundamental care needs are met as outlined in the care plan. Carrying out these checks is often referred to as 'intentional rounding' and covers aspects of care such as:

    • Pain: asking patients to describe their level of pain level using the local pain assessment tool.

    • Personal needs: such as scheduling patient visits to the toilet or bathroom to avoid risk of falls and providing hydration.

    • Placement: making sure that the items a patient needs are within easy reach.

    • Positioning: making sure that the patient is comfortable and the risk of pressure ulcers is assessed and minimised.

  • A shortfall of more than 8 hours or 25% (whichever is reached first) of registered nurse time available compared with the actual requirement for the shift. For example, if a shift requires 40 hours of registered nurse time, a red flag event would occur if less than 32 hours of registered nurse time is available for that shift. If a shift requires 15 hours of registered nurse time, a red flag event would occur if 11 hours or less of registered nurse time is available for that shift (which is the loss of more than 25% of the required registered nurse time).

  • Less than 2 registered nurses present on a ward during any shift.

Note: other red flag events may be agreed locally.



There is an example on the NICE website to illustrate the use of recommendations in sections 1.3 and 1.4.

1.5 Monitor and evaluate ward nursing staff establishments

These recommendations are for senior management and nursing managers or matrons to support safe staffing for nursing at a ward level.

1.5.1 Monitor whether the ward nursing staff establishment adequately meets patients' nursing needs using the safe nursing indicators in box 3. These are indicators that evidence shows to be sensitive to the number of available nursing staff and skill mix. Consider continuous data collection of these safe nursing indicators (using data already routinely collected locally where available) and regularly analyse the results. (Section 9 gives further guidance on data collection for the safe nursing indicators.)

1.5.2 Compare the results of the safe nursing indicators with previous results from the same ward at least every 6 months. The comparisons should also take into account the specific ward and patient characteristics (such as patient risk factors and ward speciality). Reported nursing red flag events (see section 1.4, box 2) should also be reviewed when undertaking this monitoring and prompt an earlier examination of the adequacy of the ward nursing staff establishment.

1.5.3 There is no single nursing staff-to-patient ratio that can be applied across all acute adult inpatient wards. However, take into account that there is evidence of increased risk of harm associated with a registered nurse caring for more than 8 patients during the day shifts. Therefore if the available registered nurses for a particular ward (excluding the nurse in charge) are caring for more than 8 patients during the day shifts, the senior management and nursing managers or matrons should:

  • closely monitor nursing red flag events (see section 1.4, box 2)

  • perform early analysis of safe nursing indicator results (see section 1.5, box 3)

  • take action to ensure staffing is adequate to meet the patients' nursing needs if indicated by the analysis of nursing red flag events and safe nursing indicators.

    In many cases, patients' nursing needs, as determined by implementing the recommendations in this guideline, will require registered nurses to care for fewer than 8 patients.

Box 3: Safe nursing indicators (please see section 9 for further information)

Patient reported outcome measure

Data can be collected for the following indicators from the National Inpatient Survey:

  • Adequacy of meeting patients' nursing care needs.

  • Adequacy of provided pain management.

  • Adequacy of communication with nursing team.

Safety outcome measures

  • Falls: record any fall that a patient has experienced. The severity of the fall could be further defined in accordance with National Reporting and Learning System categories: no harm; low harm; moderate harm; severe harm; death.

  • Pressure ulcers: record pressure ulcers developed or worsened 72 hours or more after admission to an organisation. The patient's worst new pressure ulcer could be categorised as grade 2, 3 or 4.

  • Medication administration errors: record any error in the preparation, administration or omission of medication by nursing staff. The severity of the error should also be recorded.

Staff reported measures

  • Missed breaks: record the proportion of expected breaks that were unable to be taken by nursing staff working on inpatient hospital wards.

  • Nursing overtime: record the proportion of nursing staff on inpatient hospital wards working extra hours (both paid and unpaid).

Ward nursing staff establishment measures

Data can be collected for some of the following indicators from the NHS England and Care Quality Commission joint guidance to NHS trusts on the delivery of the 'Hard Truths' commitments on publishing staffing data regarding nursing, midwifery and care staff levels and more detailed data collection advice since provided by NHS England.

  • Planned, required and available nursing staff for each shift: record the total nursing hours for each shift that were planned in advance, were deemed to be required on the day of the shift, and that were actually available, plus the bed utilisation during the same period.

  • High levels and/or ongoing reliance on temporary nursing: record the proportion of nursing hours provided by bank and agency nursing staff on inpatient hospital wards. (The agreed acceptable levels should be established locally.)

  • Compliance with any mandatory training in accordance with local policy (this is an indicator of the adequacy of the size of the ward nursing staff establishment).

Note: other safe nursing indicators may be agreed locally.