EXCLUSIVE: ‘You can't comply with safe staffing law on some wards by robbing others’

Chief nurse's message to managers struggling to fill gaps and protect skill mix amid staff shortages 
Jean White

Chief nurse's message to managers struggling to fill gaps and protect skill mix amid staff shortages 

Welsh chief nursing officer Jean White. Picture: David Gee

Band 4 healthcare workers cannot replace or act as substitutes for registered nurses, the chief nursing officer (CNO) for Wales said.

Speaking exclusively to Nursing Standard, Jean White said the Nurse Staffing Levels (Wales) Act prohibits such skills dilution but also places responsibility on senior nurses to ensure they are not ‘robbing Peter to pay Paul’ when planning staffing for wards not yet covered by the law.

Wales was the first part of the UK to enact staffing legislation in April this year, following on from statutory guidance issued last autumn.


The act requires Welsh hospitals to display figures on public boards in all adult acute medical and surgical wards showing how many staff should be on duty – and how many actually are.

Crucially, the act also describes ‘a broader duty to consider how many nurses are necessary to provide care for patients sensitively in all settings’.

But the transition has not been easy thanks to a difficult winter, Professor White admitted.

She said some areas had struggled with seasonal pressures and staff shortages, leaving senior nurses having to decide between ‘complying with a piece of paper’ or ensuring they look after patients ‘safely and well’.

Robbing Peter to pay Paul

The chief nurse continued: ‘The first part of the act, introduced in the autumn, was to stop us from asset-stripping from other parts of the hospital.

‘What the senior nurse has to say is, looking at the whole of the hospital, will somebody come to more harm if I take a nurse from the emergency department or medical assessment unit to prop up what is an okay, but not ideal, mix on another ward?

‘That is their responsibility because they have to make sure patients stay safe. It’s a whole-system approach and that’s what the first part was for – to stop us robbing Peter to pay Paul.’

She said the legislation provided a ‘very strong platform’ to match the workforce with patient need and a first reflection on the implementation will take place this autumn.

Extent of bank nurse use

‘Is it perfect? No, of course it is not. It is new, and Wales – as with other parts of the UK – does have challenges around the numbers of staff available, so we are still having to use some bank and agency staff to balance our vacancy rate,’ the CNO said.

The use of costly agency staff is something Professor White said health boards must be prepared to address. She said each health board had agreed it could deliver the right staffing under the funding deal and therefore had no excuse for not complying with the new law.

Support staff no substitute for registrants

Asked if immediate staff shortages could lead to nursing associates being introduced in Wales, Professor White said she would monitor the new role in England, but added: ‘The Nurse Staffing Levels (Wales) Act, and algorithm in the tool, has set particular ratios. So you cannot substitute a band 4 support worker, whatever you call them, or however you regulate them.

‘They are not a registered nurse and so cannot be a replacement.’

She said she hoped this would reassure the public, with influential nurse researchers such as US academic Linda Aiken raising concerns over diluted skill mix on hospital wards.

Professor White added: ‘As chief nursing officer here, I took the research deeply to heart and try to set policy around it. Support staff absolutely have a role, but it has to be at the right level and under supervision of a registrant.’

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