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Safe staffing: train senior nurses to make complex decisions on numbers, review urges

National Institute for Health Research says ward leaders are key to patient safety

National Institute for Health Research says ward leaders are key to patient safety


Picture: John Houlihan

Senior nurses need training in risk-based decision-making to make complex decisions on how to safely staff each ward, a review has urged. 

The National Institute for Health Research (NIHR) review examined evidence from more than 20 nursing and staff-related studies on hospital ward staffing, ranging from the relationship between staffing levels and patient outcomes to issues of leadership.

Assessing risk

The research highlights that staffing is a complex issue. The review’s authors say determining the right number and skill mix of staff is not a precise science and requires a risk assessment based on the best available evidence.

The review’s findings include:

  • Ward leadership shapes how staff are deployed, sets standards for staff to follow, and is key to creating a ‘safe and healthy’ climate
  • The way staff are managed and how ward work is organised is key to good outcomes and experience for patients and staff
  • The number of registered nurses on a ward is directly linked to the level of patient satisfaction and patient harm, including death
  • Involving carers and volunteers in ward work can be beneficial but requires clarity on boundaries between professional and lay work
  • Developing the skills of ward leaders is central to providing high-quality care and attracting and retaining staff

The review also highlights a lack of available evidence on how the contribution of other professions, such as healthcare support staff, can influence the number and mix of nursing and support staff required.


Howard Catton.
Picture: Barney Newman

Patient safety

International Council of Nurses chief executive Howard Catton, who was a member of the review steering group, said: ‘We see health systems around the world struggling with increasing demand and challenges in workforce supply.

‘Patient safety has moved to the centre of policy and operational decision-making, and that means significant attention is being paid to safe nurse staffing.

‘There are some striking core findings from across the evidence that all countries should consider, in particular the importance of nurse leadership.’

Safe staffing around the UK

  • England has no legislation related to nurse staffing, with the RCN campaigning for a law to be introduced 
  • Wales introduced safe staffing legislation in 2017, covering all adult acute medical and surgical inpatient wards, while Scotland is currently debating a bill on the issue
  • While Northern Ireland does not have a safe staffing law, in 2014 the country’s Department of Health published a framework of expected ranges of nurse staffing in specific specialties


Further information

Read the Staffing Wards review


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