But upper limit of eight patients per nurse to trigger safety vigilance

The NHS will not face specific patient-to-nurse ratios but an upper limit of eight patients per nurse will trigger a heightened state of vigilance to check patients are not at risk, the National Institute for Health and Care Excellence (NICE) has said.

In its final advice for the health service, NICE confirmed it would not call for a specific staffing ratio saying there was, “no single staff number that can be safely and adequately applied” across the organisation.

However, it has set an upper threshold of eight patients to one nurse, which will prompt senior managers and nurses to take a closer look at “red flag” events and act where appropriate. “Red flag” events include a failure to provide basic care such as pain relief or help to go to the toilet and if they occurred nurses would be expected to act immediately to ensure there are enough staff to fulfil these needs.

Professor Gillian Leng, deputy chief executive and director of health and social care at NICE, said: “Safe staffing is more complex than setting a single ratio. The emphasis should not just be on the available number of staff, it should be on delivering safe patient care and making sure that hospital management and nursing staff are absolutely clear on best practice to do this.”

The final advice from NICE said patient needs must come first when mangers make decisions about safe staffing on acute wards. It also outlined ‘safe nursing indicators’ for managers which means monitoring the frequency of incidents affecting patient safety such as falls and pressure ulcers or staff reported outcomes such as missed breaks and overtime.

“Acute wards see a variety of patients, from appendicitis to broken bones, from young to very old, and each individual has very different needs,” said Miles Scott, chief executive officer at St George’s Healthcare NHS Trust. “The [NICE] guideline clearly sets out the factors that must be taken in to account to work out what is the adequate skill level and number of nursing staff required on that particular ward. Safe staffing needs to be about ensuring you have the right staff, in the right place, at the right time, to give patients the care they need and deserve.”

However, Sue Covill, director of employment services at the NHS Employers organisation, warned that the message that simple ratio numbers were not the answer to safer care was too subtle, meaning the NHS could get “a nurse ratio by default”.

She said: “All the national organisations we speak to including NICE say they don't believe a crude nationally mandated nurse ratio is desirable. They always agree safer staffing is about more than simple numbers. Yet these continued nuanced reports that don't make that explicit mean we seem to be getting a nurse ratio by default. We should be alert to the unintended consequences of this when a figure based on limited evidence becomes a proxy for a minimum.

“We know there is a link between safe staffing and good care but the focus on one professional group - nurse ratios - disregards the contribution and effectiveness of the whole health care team including dieticians, occupational therapists, physiotherapists and support staff.”

Covill said there was strong evidence that staff values, employer culture, quality of supervision and leadership were key components of safe care.

Leng added that prior to the final advice from NICE, many NHS trusts had already made staffing changes to ensure patient safety following the Robert Francis report recommendations.

Between March 2013 and February 2014, registered nurse numbers increased by about 3 per cent (full time equivalents, FTEs) and healthcare assistant numbers also rose by around 7 per cent (FTEs).