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Safe staffing for nursing in adult inpatient wards in acute hospitals

About

What is covered

This pathway covers safe staffing for nursing in adult inpatient wards in acute hospitals, based on the best available evidence.
The pathway focuses on wards that provide overnight care for adult patients in acute hospitals. It does not cover intensive care, high dependency, maternity, mental health, acute admission or assessment units or wards, or inpatient wards in community hospitals.
In this guideline, nursing staff refers to registered nurses and healthcare assistants unless otherwise specified.
The pathway identifies organisational and managerial factors that are required to support safe staffing for nursing, and indicators that should be used to provide information on whether safe nursing care is being provided in adult inpatient wards in acute hospitals.

Updates

Updates to this pathway

23 June 2015 Link to NICE pathway on workplace health: policy and management practices added.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on safe staffing for nursing in adult inpatient wards in acute hospitals in an interactive flowchart

What is covered

This pathway covers safe staffing for nursing in adult inpatient wards in acute hospitals, based on the best available evidence.
The pathway focuses on wards that provide overnight care for adult patients in acute hospitals. It does not cover intensive care, high dependency, maternity, mental health, acute admission or assessment units or wards, or inpatient wards in community hospitals.
In this guideline, nursing staff refers to registered nurses and healthcare assistants unless otherwise specified.
The pathway identifies organisational and managerial factors that are required to support safe staffing for nursing, and indicators that should be used to provide information on whether safe nursing care is being provided in adult inpatient wards in acute hospitals.

Updates

Updates to this pathway

23 June 2015 Link to NICE pathway on workplace health: policy and management practices added.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Nursing red flag events

  • Unplanned omission in providing patient medications.
  • Delay of more than 30 minutes in providing pain relief.
  • Patient vital signs not assessed or recorded as outlined in the care plan.
  • Regular checks on patients to ensure that their fundamental care needs are met as outlined in the care plan. This is often referred to as 'intentional rounding' and involves checks on aspects of care such as the following:
    • Pain: asking patients to describe their level of pain level using the local pain assessment tool.
    • Personal needs: such as scheduling patient visits to the toilet or bathroom to avoid risk of falls and providing hydration.
    • Placement: making sure that the items a patient needs are within easy reach.
    • Positioning: making sure that the patient is comfortable and the risk of pressure ulcers is assessed and minimised.
  • Fewer than 2 registered nurses present on a ward during any shift
  • A shortfall of more than 8 hours or 25% (whichever is reached first) of registered nurse time available compared with the actual requirement for the shift. For example, if a shift requires 40 hours of registered nurse time, a red flag event would occur if less than 32 hours of registered nurse time is available for that shift. If a shift requires 15 hours of registered nurse time, a red flag event would occur if 11 hours or less of registered nurse time is available for that shift (which is the loss of more than 25% of the required registered nurse time).
Note: other red flag events may be greed locally.
NICE has produced pathways on falls in older people and pressure ulcers.

Safe nursing indicators

Please see the guideline for further information on safe nursing indicators.

Patient reported outcome measure

Data can be collected for the following indicators from the National Inpatient Survey:
  • Adequacy of meeting patients' nursing care needs.
  • Adequacy of provided pain management.
  • Adequacy of communication with nursing team.

Safety outcome measures

Falls: record any fall that a patient has experienced. The severity of the fall could be further defined in accordance with National Reporting and Learning System categories: no harm; low harm; moderate harm; severe harm; death.
Pressure ulcers: record pressure ulcers developed or worsened 72 hours or more after admission to an organisation. The patient's worst new pressure ulcer could be categorised as grade 2, 3 or 4.
Medication administration errors: record any error in the preparation, administration or omission of medication by nursing staff. The severity of the error should also be recorded.

Staff reported measures

Missed breaks: record the proportion of expected breaks that were unable to be taken by nursing staff working on inpatient hospital wards.
Nursing overtime: record the proportion of nursing staff on inpatient hospital wards working extra hours (both paid and unpaid).

Ward nursing staff establishment measures

Data can be collected for some of the following indicators from the NHS England and Care Quality Commission joint guidance to NHS trusts on the delivery of the 'Hard Truths' commitments on publishing staffing data regarding nursing, midwifery and care staff levels and more detailed data collection advice since provided by NHS England.
  • Planned, required and available nursing staff for each shift: record the total nursing hours for each shift that were planned in advance, were deemed to be required on the day of the shift, and that were actually available, plus the bed utilisation during the same period.
  • High levels and/or ongoing reliance on temporary nursing: record the proportion of nursing hours provided by bank and agency nursing staff on inpatient hospital wards. (The agreed acceptable levels should be established locally.)
  • Compliance with any mandatory training in accordance with local policy (this is an indicator of the adequacy of the size of the ward nursing staff establishment).
Note: other safe nursing indicators may be agreed locally.
NICE has produced pathways on falls in older people and pressure ulcers.

One-off nursing care activities that affect nursing staff requirements

Routine nursing care needs
Additional nursing care needs (about 20–30 minutes per activity)
Significant nursing care needs (more than 30 minutes per activity)
Admission
Admission assessment
Complex admission assessment
Care after death
Arrangements after the death of a patient, including support for relatives and carers
Discharge planning
Simple follow-up and transfer home
Coordination of different services
Organising complex services, support or equipment
Patient and relative education and support
Routine teaching about condition, routine post-op care
Teaching about a significant new condition (such as diabetes, heart disease or cancer)
Teaching about a new complex or self-managed condition (such as dialysis, colostomies), or to patient or their carers or relatives who have difficulties with communication including sensory impairment or language difficulties
Patient escorts
Routine escorts or transfers for procedures
Escorting a patient off a ward for 20–30 minutes
Escorting a patient off a ward for more than 30 minutes
Procedures and treatments
Simple wound dressings, specimen collection
Catheterisation, nasogastric tube insertion, multiple wound dressings
Complex wound dressings (such as vacuum-assisted closure), tracheostomy care
Note: these activities are only a guide and there may be other one-off activities that could be considered.

Ongoing nursing care activities that affect nursing staff requirements

Routine nursing care needs
Additional nursing care needs (about 20–30 minutes per activity)
Significant nursing care needs (more than 30 minutes per activity)
Care planning
Simple condition and care plan
Complex condition or care plan (such as multiple comorbidities)
Attending multidisciplinary meetings
Direct contact and communication
Providing information and support to patients, including all emotional and spiritual needs
Complex multiple health needs
Difficulties with communication including sensory impairment or language difficulties
Eating and drinking
Ensuring food and drink provided and consumed
Assistance with eating and drinking
Parenteral nutrition
Fluid management
8-hourly IV fluids
IV fluids more frequently than 8 hourly or blood components
Complex fluid management (such as hourly or requiring monitoring in millilitres)
Management of equipment
Simple intermittent (such as catheters, IV access)
Central lines, drains, stomas
Multiple lines, drains, ventilator support
Medication
Regular oral medication
IV medication or frequent PRN medication
Medication requiring complex preparation or administration, or 2 nursing staff
Mobilisation
No assistance needed
Assistance needed (such as post-op or during out of hours periods)
Mobilisation with assistance of 2 nursing staff
Observations
4–6 hourly
2–4 hourly
More frequent than 2 hourly
Oral care
No assistance needed
Assistance needed
Intensive mouth care needed (such as patient receiving chemotherapy)
Skin and pressure area care
Less frequent than 4 hourly
2–4 hourly
More frequent than 2 hourly or requiring 2 nursing staff
Toileting needs
No assistance needed
Assistance needed
Frequent assistance or 2 nursing staff needed
Washing or bathing and dressing
Minimal assistance with washing, dressing and grooming
Assistance with some hygiene needs by 1 member of the nursing staff
Assistance with all hygiene needs, or needing 2 nursing staff
Abbreviations: IV, intravenous; PRN medication, medication administered as needed.
Note: these activities are only a guide and there may be other ongoing activities that could be considered.

Glossary

the number of patients that the ward nursing team is responsible for during each 24-hour period. This includes patients who are discharged or transferred to another ward during the 24-hour period
the number of registered nurses and healthcare assistants funded to work in a particular ward, department or hospital. This includes all nursing staff in post, as well as unfilled vacancies or vacancies being covered by temporary staff. Ward nursing staff establishments are usually expressed in number of whole time equivalents
this is how the measure of nursing staff requirements could be expressed. It represents the number of hours of nursing time (for both direct patient care and other nursing activities) provided by registered nurses and healthcare assistants per patient over a defined period. This is an alternative to expressing nursing time as a ratio of how many patients each nurse cares for. The 2 measurements are interchangeable. For example, a registered nurse or healthcare assistant working an 8-hour shift (after accounting for breaks) can contribute 8 hours of nursing time that day, which includes direct patient care as well as other necessary nursing activities
events that prompt an immediate response by the registered nurse in charge of the ward. The response may include allocating additional nursing staff to the ward or other appropriate responses
the nursing staff required by each ward. This should take into account all nursing care needs of patients, ward factors and staff factors including nursing activities other than direct patient care. This can be expressed as number of nursing hours
this refers to registered nurses and healthcare assistants, unless otherwise specified
the daily staffing schedule for registered nurses and healthcare assistants to work on an individual ward
the composition of the nursing team in terms of qualification and experience. This is typically expressed as a percentage of registered nurses to healthcare assistants. Nursing skill mix should also encompass individual clinical competencies and different areas of expertise and grades of registered nurses healthcare assistants
the total nursing care needed by each patient on an individual ward that has been assigned to the nursing profession. This term includes both patient acuity (how ill the patient is, their increased risk of clinical deterioration and how complex their care needs are; this term is sometimes used interchangeably with the terms 'patient complexity' and 'nursing intensity') and patient dependency (the level to which the patient is dependent on nursing care to support their physical and psychological needs and activities of daily living, such as eating and drinking, personal care and hygiene, mobilisation)
a practical resource to facilitate the process of calculating the nursing staff requirements for wards or organisations. It may be electronic or paper-based
healthcare assistants are all unregistered clinical staff working in hospital or community settings under the guidance and supervision of a registered healthcare professional. They may have a variety of titles such as healthcare support worker, nursing auxiliary and nursing assistant. In this pathway, the term healthcare assistants also includes assistant practitioners. The responsibilities of healthcare assistants vary, depending upon the healthcare setting and their level of training and competence
the NICE endorsement programme assures users that an endorsed decision support toolkit estimates nurse staffing requirements in line with the relevant NICE recommendations. NICE awards an endorsement mark, which is a seal of approval, to toolkits that meet the endorsement criteria

Paths in this pathway

Pathway created: July 2014 Last updated: February 2017

© NICE 2017

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