Demanding safe staffing levels to ensure quality nursing care

A nursing alliance with a firm and simple message: numbers matter

Senior figures have joined forces as part of Nursing Standard's Care campaign to demand minimum staffing levels that ensure quality care. Janet Snell reports.

Download PDF

This article was first published in Nursing Standard, Vol 27 No 18, January 2 2013

Download PDF

As nursing braces itself for the imminent publication of the Francis report into failings at Mid Staffordshire NHS Foundation Trust, a group of the profession’s key leaders have come together to take a stand on the issue of staffing levels.

They have launched Safe and Sound – the Safe Staffing Alliance, to grab a ‘once in a generation opportunity’ to demand minimum registered nurse staffing levels that will guarantee patient safety.

The alliance emerged from a summit organised by Nursing Standard as part of our Care campaign. It has a clear message: numbers matter. Members believe that registered nurse/patient ratios should be viewed as an indicator equal in importance to surgeons’ mortality rates.

Issuing their five new year wishes for nursing, the alliance warns that getting registered nurse staffing wrong leads to early deaths and slow or poor recovery. In addition, it is expensive.

Safe and Sound: five new year wishes for nursing

1 Minimum registered nurse staffing levels – there is clear evidence linking numbers of registered nurses and patient safety. In the light of this, statutory minimum staffing levels should be set. These must be respected as a fl oor not a ceiling, and falling below the minimum should be reported and action taken.

2 Information for patients on registered nurse numbers – patients should have access to information on registered nurse staffing as well as other quality indicators, such as waiting times, clinical performance and the friends and family test, when making choices about where to go for health care.

3 An annual review of nurse staffing – the board of every healthcare organisation should receive an annual review of nurse staffing from the director of nursing that uses evidence-based tools and takes account of changes in need, activity and dependency.

4 More power for clinical nurse leaders – ward sisters, charge nurses and senior community nurses are accountable for care standards and should be given control of staffing and other key resources.

5 New research on registered nurse staffing – the Department of Health should fund research into the continuing effects of staffing on safety and quality, and invest in the development of tools that link nursing inputs to safety and quality.

How these wishes fit in with our campaign The campaign calls for healthcare providers to guarantee that:

  • Staff communicate compassionately.
  • Patients are assisted with toileting, ensuring dignity.
  • Pain is relieved effectively.
  • Adequate nutrition is encouraged.

Nurses tell us repeatedly that a lack of staff is the biggest single barrier to achieving these aims.

‘If tools are mandatory in Scotland then why not England?’ asked Unison’s head of nursing Gail Adams. ‘The past three years have seen a fall in nurse numbers and a drop in morale.’

London South Bank University dean Judith Ellis said it was important to make clear that if a set nurse/patient ratio was put in place it must remain a minimum and not be allowed to become a maximum. ‘It could also be dangerous to put set staffing levels in place without looking at patient acuity. We need to be careful here,’ she added.

Nurse on ward

National Nursing Research Unit deputy director Jane Ball said she understood the unease, but pointed out that where there are agreed safe minimum guidelines, these have become accepted and have proven effective in ensuring staffing in those areas does not fall below that minimum. ‘On general medical and surgical wards we see huge variations – from five patients per nurse to 11. Yet the dependency of patients varies very little,’ said Dr Ball.

She added that a new study from the National Nursing Research Unit showed that nurses on medical and surgical wards with fewer than seven patients were less likely to say care is left undone on each shift due to lack of time.


‘We know registered nurses are essential yet there is a huge variability in numbers,’ Dr Ball said. ‘Everyone deserves to know if they are in one of the worst staffed wards or worst staffed community services. Nursing is too important to be an experiment. Don’t chop and change staffing when you do not know what the effect will be.’

Hearts and minds

RCN head of policy Howard Catton told the meeting: ‘There is a critical point below which you are virtually guaranteed poor care. Numbers matter for nurses and for patients.’

Evidence that links staffing levels to quality is coming in from across the globe. Figures from the United States military nursing outcomes database project presents clear evidence that inadequately staffed shifts can increase the likelihood of adverse events.

Yet the meeting was told that some senior civil servants were continuing to peddle the myth that evidence linking registered nurse numbers and quality was lacking.

Health Foundation strategic lead for patient safety Elaine Maxwell said: ‘We still have a long way to go before we win the hearts and minds of the policymakers. We need to change the culture from “we cannot afford more staff” to “you cannot afford not to employ sufficient nurses”.’

Several members argued that the alliance should make links with other clinical professionals and finance colleagues. ‘We need to have this conversation outside of nursing, as well as within it,’ said Elaine Inglesby, Salford Royal NHS Foundation Trust’s director of nursing and a member of the prime minister’s care quality forum.

‘Staffing levels are going to stay at the top of the agenda for the forum as there is no point in doing anything if you do not get the staffing right’.

Supporters: organisations


In addition to these organisations, the Safe Staffing Alliance also has the support of a number of individuals. Find out about them.

Supporters: individuals

Jane Ball, deputy director, National Nursing Research Unit;

Judith Ellis, dean, London South Bank University faculty of health and social care;

Baroness Audrey Emerton, nurse member of the House of Lords;

Ruth Holt, chief nurse, Leeds Teaching Hospitals NHS Trust;

Keith Hurst, senior lecturer, University of Leeds health sciences institute;

Elaine Inglesby, nurse director, Salford Royal NHS Foundation Trust and member, prime minister’s nursing and care quality forum;

Lis Jones, nurse director, The Tavistock and Portman NHS Foundation Trust;

Alison Leary, independent healthcare consultant and research analyst;

Trish Morris-Thompson, chief nurse, NHS London;

Jenny Kay, director of quality, Merton Clinical Comissioning Group;

Eiri Jones, interim director of nursing, United Linconshire Hospitals NHS Trust;

Cathy Winfield, director of patient experience & chief nurse, Derby Hospitals NHS Foundation Trust;

Claire Johnston, director of nursing and people, Camden and Islington NHS Foundation Trust;

Elisabeth Jelfs, director of policy, Council of Deans of Health;

Elizabeth Robb, chief executive, The Florence Nightingale Foundation;

Fiona Nolan, Camden & Islington NHS Trust;

Gwen Collins, chief nurse & lead director for clinical governance, Bupa;

Helen Morgan, acting chief nurse, University Hospitals Bristol NHS Foundation Trust;

Helen Thomson, director of nursing/ deputy CEO), Calderdale & Huddersfield NHS Foundation Trust;

Pippa Hart, director of nursing standards & quality assurance, Epsom & St Helier University Hospitals NHS Trust;

Sarah Amani, manager of Early Intervention in Psychosis Service & Youth Mental Health Network Lead for NHS South of England (East);

Susan Osborne, healthcare consultant;

Yvonne Sawbridge, senior fellow, Health Services Management Centre, University of Birmingham;

Professor Jennifer Hunt; retired;

Katherine Fenton OBE, chief nurse, University College London NHS Foundation Trust and professor of nursing leadership, City and Southbank Universities;

Libby McManus, executive director of nursing and quality, Chelsea and Westminster Hospital NHS Foundation Trust;

Mandie Sunderland, chief nurse, Pennine Acute Hospitals NHS Trust;

Mike Wright, executive director of nursing, County Durham and Darlington NHS Foundation Trust

About the Alliance

Alliance panel

The Alliance is made up of nurse leaders who came together as part of the Nursing Standard / Patients Association Care campaign.

Find out about our organisation and the arguments for safe staffing levels.

Find out more


About safe staffing

The Safe Staffing Alliance has brought together some of the vast body of evidence that staffing levels are linked to quality.

Find out more

Read our response to NICE



If you would like to be kept informed of what's happening please leave your email details here.

Register now

Contact us

We would like to hear what's going on in your area so we have an up-to-date picture of the staffing situation nationally.

Get in touch