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Good nurse leadership linked to safer outcomes

Patient harm associated with understaffing

Jo Carlowe

Wednesday, 27 March 2019

Correct staffing levels and strong ward leadership is key to creating safer healthcare.

This is the conclusion from a major new review of ward staffing published this week by the National Institute for Health Research (NIHR).


The review looks at the evidence around how many staff are needed on wards and how managing them is key to the safety and efficiency of hospitals. Staffing on Wards brings together more than 20 nursing and staff-related studies funded by the NIHR, which examine hospital ward staffing. These range from studies looking at the relationship between staffing levels and outcome, the way in which support staff are deployed and wider issues of ward culture and leadership.

The evidence coming out of the review highlights that deciding the number of staff needed for individual wards is complex and staff at all levels (from commissioners to ward leaders) need training in risk-based decision making to achieve best possible outcomes given available resources.

Key findings from the review include:

  • Ward leadership shapes how staff are deployed, sets standards for staff to follow, and is key to creating a safe and healthy climate for both staff and patients. 
  • There is a gap in the evidence on the way in which the contribution of other professions at ward level affects the number and mix of nursing and support staff needed.
  • The way staff are managed and the way ward work is organised is key to good outcomes and experience for both patients and staff. 
  • There is evidence that the number of registered nurses is related to the level of patient satisfaction and patient harms (including death).
  • Involving carers and volunteers in ward work can be beneficial but expectations need to be explicit with clarity around the boundaries between professional and lay work.
  • Investment in developing the skills of ward leaders and ensuring they have protected time to deliver has been shown to be key in providing high quality care as well as attracting and retaining staff.

Commenting on the findings, Ruth May, chief nursing officer for England, said: “Using research evidence to make sure we make the right decisions about ward staffing, and that we create work environment where nursing and care staff can thrive is key to achieving a sustainable NHS and improving the experience and outcomes of care for patients and service users.”

The review highlights that determining the right number of staff and mix of education and skills is not a precise science and requires a risk assessment based on the best available evidence. It further shows that nurse staffing has been shown to be associated with patient satisfaction as well as physical outcomes, and that when staff are pressed for time they are most likely to miss activities such as ‘comforting, talking with and educating patients’.

Case studies in the review show a link between the level of missed care and patient experience as well as outcomes, with good patient experience positively associated with clinical effectiveness and patient safety.

Dame Donna Kinnair, acting chief executive and general secretary of the Royal College of Nursing, said the NIHR’s review adds to the important body of existing evidence that "too few registered nurses on wards can lead to patient harm, and even death."

She added: “The report is right to recognise that deciding exactly how many nursing staff are needed on wards is highly complex, and will vary according to the type of ward and how sick its patients are. The RCN is campaigning for laws ensuring safe and effective staffing in countries within the UK”.

A separate nursing poll released today reveals that nine out of 10 nurses say understaffing affects the quality of patient care.

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