Navigating nurse safe staffing approaches in the UK

Election campaigns often see the different political parties outbidding each other on promises to employ more nurses. But ‘more’ nurses at national level also needs to translate into the ‘right’ number of nurses locally to provide safe care. This requires consistent application of staffing methods and tools to determine local nurse numbers, deliver safe care to patients, and offer opportunities to increase productivity through improved efficiencies.

How are nurse staffing levels currently set in England?

At the moment, the approach to determining nurse staffing levels in England relies primarily on loose national guidance and cost-constrained local management decisions. This approach is clearly not working. National nursing shortages are long term and pervasive. At the end of March 2024, the reported vacancy rate for NHS England registered nurses was 7.5%. This equates to 31,000 vacant posts, with other vacancies being covered by expensive agency staff. The 2023 NHS England staffing survey highlighted that only 29% of registered nurse and midwives agreed or strongly agreed that ‘there are enough staff at this organisation for me to do my job properly’. The situation is worrying.

UK alternatives

So, what are the options for nurse safe staffing? Policymakers in England don’t need to look far for examples of new approaches. On 1 April 2024, Scotland introduced national safe staffing legislation to cover the NHS and social care systems. Scotland joins NHS Wales in implementing a standardised national approach to nurse safe staffing, underpinned by legislation. In both countries, the legislation emphasises the employer’s duty of care to apply mandated safe staffing tools, and accountability through regular reporting (Box 1).

The Scottish approach is too recent to offer evidence of impact, and also faces the unresolved issue of a lack of validated staffing tools for some care environments (eg some areas of social and community care, and mental health). In Wales, the legislation currently only covers nursing staff in adult acute medical and surgical wards, and children’s wards. It’s therefore unclear whether these approaches offer genuinely valuable alternatives.

A certain ratio?

Another safe staffing option is the system-wide use of legally enforceable nurse-to-patient ratios. The Royal College of Nursing has long called for safety-critical nurse-to-patient ratios in all care settings, and this remains one of the top priorities in its pre-election manifesto published in early June. 

Legislated ratios are based on predetermined system-wide standard nurse-to-patient ratios calibrated for different care environments. First implemented in California and Victoria (Australia) more than 20 years ago, they have become more widely used since the COVID-19 pandemic. System-wide nurse-to-patient ratios now apply (or will be implemented soon) in many states/provinces across Australia (eg South Australia, New South Wales, Australian Capital Territory, Queensland) and North America (eg Oregon in the US and British Columbia in Canada).

Evidence on the impact of nurse-to-patient ratios includes studies reporting a positive impact on staffing levels and patient outcomes (eg lower mortality). Nurses – and their unions – who work in jurisdictions using state-level mandated ratios reportedly like the certainty and legislative underpinning that comes with them. Such ratios offer a transparent and easily understood staff metric, and can make it easier to hold governments to account for any political commitments on safe staffing levels.

Though they are sometimes criticised as a ‘blunt instrument’ creating local inflexibility, closer examination shows that, in some contexts at least, ratios have been adjusted over time, tailored to different care environments, and have some local flexibility. In the nursing home sector, the Australian federal government has implemented nationwide mandatory minimum nursing hours per resident, and the US federal government is aiming for a similar nationwide regulated minimum nurse staffing standard.

Safety in numbers

The NHS in England has some catching up to do to tackle understaffing in nursing. There is no perfect solution, but there are options to assess. Learning lessons from various system-wide nurse staffing approaches already used in similar care contexts could help identify how best to standardise and improve local nurse safe staffing in England. This could enable greater policy alignment between delivering local safe staffing levels and the national nurse supply projections in the NHS England Long Term Workforce Plan. It would also help identify where increased funding is most urgently required to sustain nursing workforce growth, and ultimately, it would improve patient care.