Nurses raise concerns about shelved safe staffing guidance

Suppressed safe staffing guidance calling for minimum nurse-to-patient ratios in NHS emergency departments (EDs) was leaked to the media at the end of last month

Suppressed safe staffing guidance calling for minimum nurse-to-patient ratios in NHS emergency departments (EDs) was leaked to the media at the end of last month.

The unofficial document, produced by the National Institute for Health and Care Excellence (NICE) in the summer, shows an intention to recommend minimum staffing ratios for EDs, including two registered nurses to one major trauma patient, two registered nurses to one cardiac arrest patient, and one registered nurse to four cubicles in majors.

The ratios would be:

  • One registered nurse to one cubicle in triage
  • One registered nurse to four cubicles in majors
  • One registered nurse to two cubicles in resuscitation
  • Two registered nurses to one major trauma patient
  • Two registered nurses to one cardiac arrest patient
  • One registered nurse to one priority ambulance patient
  • Every shift should have a registered children’s nurse, or at least a nurse trained in caring for children
  • Each shift should have a band 7 nurse

The advice, which has not been endorsed by NICE or the Department of Health (DH), follows draft guidance published in January last year as part of the institute’s work on safe staffing levels undertaken in the wake of the Mid Staffordshire NHS Foundation Trust inquiry

In his final report on the inquiry, published in February 2013, Sir Robert Francis linked care failings at Stafford Hospital to chronic understaffing, and urged NICE to develop guidelines for minimum staff numbers and skill mix.


But just as the final guidance for EDs was due to be published in June last year, it was announced that all NICE’s work on safe staffing was being suspended and taken over by new body NHS Improvement, in conjunction with NHS England.

This was met with dismay from the nursing profession at the time, with thousands of nurses who attended RCN Congress that month backing a call to push for a reversal of the decision.

Following the leaking of the guidance in January, senior emergency nurses have reiterated their call for NICE to continue its safe staffing work, and for the guidance to be implemented in EDs.


Somerset Partnership NHS Foundation Trust consultant nurse Mike Paynter says DH officials ignore the expert advice of senior emergency nurses ‘at their peril’.

Mr Paynter adds: ‘The government says it is investing in the emergency care workforce but, as a front line clinician, I am not seeing this.

‘Moving safe staffing work from NICE to NHS Improvement is just stalling and delaying the production of anything definitive. I cannot see any reason why this guidance should not be implemented, other than the fact that there will be a clear cost implication.’

Agency staff

University of York lecturer in emergency, acute and critical care nursing Mike Parker thinks implementing the guidance would help reduce an over-reliance on expensive agency staff.

‘Specialist agency nurses can clear up to £800 a shift on a bank holiday, which is far from cost effective,’ he says. ‘If they are not regular staff, they would likely be placed in minors. So, not only are you not getting value for money, but regular staff are being flogged to death because they are always in majors or resus and never get a chance to rotate around the department.

‘This guidance makes total sense. But if it is not backed by NICE, where do senior nurses in charge of emergency departments stand on implementing it? There is a worry about reprisals from management and trust financiers.’

Evidence reviews

The leaking of the unofficial guidance coincided with the release by NICE of four previously unpublished evidence reviews on safe staffing, including one for EDs.

The documents had been withheld to allow NHS Improvement to assess them as part of an ongoing review of safe staffing. But after an internal review by NICE, in which a panel of board members assessed the decision, it was suggested that the disclosure of the documents was in the public interest.

RCN director of nursing, policy and practice Dame Donna Kinnair says the evidence reviews ‘found a clear relationship between the number of registered nurses and patient care’.

She adds: ‘Evidence for the importance of having the right number of nurses, and the right ratio of nurses to healthcare assistants, would have led to new recommendations and guidance on safe staffing levels for nurses.’

Official guidance

Meanwhile, NHS Improvement has been asked by the National Quality Board to update official safe staffing guidance, which includes emergency care, and plans to publish its work later this year.

RCN Emergency Care Association (ECA) chair Janet Youd agrees that any safe staffing guidance must take skill mix and competencies of staff, as well as patient acuity, into account.

‘I have reservations about minimum nurse numbers becoming maximum nurse numbers, and matching nurses to cubicles,’ says Ms Youd. ‘As we know from this winter, there are huge numbers of patients in corridors or waiting areas, which the guidance does not address.’

Staffing tool

She recommends using the ECA staffing tool, which looks at the competencies and skill mix of nurses looking after patients in EDs, and the dependency and number of patients as they arrive at a department.

She agrees with the NICE guidance that every shift should have a band 7 nurse and a registered children’s nurse but says that, rather than focusing on bandings, the competencies of these nurses must be assessed. ‘Just because you are a registered children’s nurse does not mean you are an emergency children’s nurse,’ she says.

The Patients Association (PA) has also expressed concern about the suppression of the NICE guidelines, which suggest that some EDs could be understaffed as much as 50% of the time.

PA chief executive Katherine Murphy says: ‘NICE’s advice would have exposed shortages in nursing levels, while highlighting the need for additional finance to provide correct levels of front line staff. Having enough skilled and experienced staff to treat patients is fundamental to ensuring safety.’

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