Ensuring you have the right staff, in the right place, at the right time

The Francis Inquiry into the care provided by the Mid-Staffordshire NHS Foundation Trust, together with the Berwick report, outlined ways in which the NHS can improve care by ensuring there is the right number and mix of staff available to look after patients.

We published our first guidance on staffing levels in July 2014 focusing on nursing in hospital wards. The guidance sets out a series of ‘red flag events’ which warn when nurses in charge of shifts must act immediately to ensure they have enough staff to meet the needs of patients on that ward.

‘Red flag events’ include patients not being provided with basic care such as pain relief or help to visit the bathroom. An appropriate response could be to provide more skilled nurses or increase numbers of staff.

As patients’ needs differ from day to day, there is no single staff number that can be safely and adequately applied across the wide range of wards in the NHS. The guidance committee concluded that when each registered nurse is caring for more than 8 patients this is a signal to check that patients are not at risk of harm. At this point senior management and nursing managers should closely monitor red flag events, analyse safe nursing indicator data and take action if required. No action may be required if patient needs are being adequately met.

More complex than setting a single ratio

“Safe staffing is more complex than setting a single ratio,” said Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE.

“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.”

Miles Scott, Chief Executive Officer, St George’s Healthcare NHS Trust and Chair of the Guideline Development Group, said: “Acute wards see a variety of patients, from appendicitis to broken bones, from young to very old, and each individual has very different needs.

“This guidance has been trialled in over 100 hospital wards in 14 different hospitals and 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.”

One to one care for women in labour

In February 2015, we published our second safe staffing guideline which advises on midwifery safe staffing levels for women and their babies in whatever setting they choose.

The guideline recommends that maternity services should have the capacity to provide women in established labour with supportive one-to-one care. This is because birth can be associated with serious safety issues, and can help ensure that a woman has a safe experience of giving birth.

The recommendations for midwifery staffing are split into four sections and set out the responsibilities of senior managers, actions organisations should consider as part of their midwifery staff planning, and how registered midwives on a shift should monitor whether there are sufficient staff to provide care.

NICE says that commissioners, trust boards and senior management should focus on the needs of each woman and baby, and ensure there are enough midwives employed to provide safe care, regardless of the time of day or the day of the week.

Escalation plans should be developed to respond to unexpected changes in demand. These should include sourcing extra staff, redistributing midwives’ workload to other competent staff or rescheduling non-urgent work. The guidance stresses that any action taken must not be at a detriment to other areas and that service closures should only be considered as a last resort.

Professor Gillian Leng said: “From planning to have a baby, to giving birth and the days after, the care provided by midwives has a lasting impact on a woman’s wellbeing , and on the health of her baby.

“This guideline provides evidence-based advice to the NHS on how to ensure midwifery staffing is safe in whichever setting a woman may choose, be it at home, in the community or in hospital.”