Safe and Effective Staffing: Nursing Against The Odds

Safe and Effective Staffing:
Nursing Against the Odds
UK POLICY REPORT
“ Staffing levels, skill mix, sickness,

unprecedented demands, patient numbers,
lack of resources and capacity have left me
”
fearing for a profession I once loved.
SAFE AND EFFECTIVE STAFFING
Contents
Foreword 1
Executive summary 2
1. What is safe and effective staffing? 4
2. The impact of staffing levels on patient care 6
3. Approaches to safe and effective staffing across the UK 11
4. What urgent action is needed 18
Appendix 1: Survey method and respondents 20
Appendix 2: Survey findings by country 24
Appendix 3: A sample of experiences from nursing staff across the UK 31
Appendix 4: RCN UK Safe and Effective Staffing Group members 37
References 38
Acknowledgements
This report was authored by Antonia Borneo, Claire Helm and Julian Russell.
Significant thanks to the RCN UK Safe and Effective Staffing Group who have led this work.
They are identified in Appendix 4.
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ROYAL COLLEGE OF NURSING
Foreword
The debate around health and care staffing can On the back of this work and all the studies that
at times feel at risk of stagnation. The professions support it, the Royal College of Nursing wants to
warn about falling numbers; the governments see – enshrined in law – guarantees on safe and
find a new way to present the figures; the effective nurse staffing in each country of the
experts raise unprecedented safety concerns; UK. The ambiguity and uncertainty that exists
again governments say it is under control. These for our nurses and patients cannot continue.
conflicting messages can leave the public and the A good day should not be a rare or chance event.
profession more than a little confused.
Legislation alone will not improve patient
But when thirty thousand professionals give you safety but it would give clear accountability and
an account of their own last shift, they cannot be responsibility for workforce strategy, policy and
overlooked. These are personal experiences – too planning. Ministers across the UK must have
often desperately sad – and their truth will have responsibility for it if patient safety is to receive
its own power in driving the debate forward. the prominence it deserves. But they must also
increase the funding so that health and care
Over half told us that their shift was not staffed to services can meet the real demand and nurses’
the level planned and that care was compromised. pay can be increased to keep people feeling
One-third report having to leave elements of patient valued and in post.
care undone due to a lack of time, while two-thirds
are working extra time – on average another hour Political leaders, policymakers and employers
per shift, for which they are hardly ever paid. who read this report will get a genuine frontline
perspective from the people they can ill-afford
This report adds these figures to the growing to lose. Their voices punctuate every page and,
expert evidence, but we expect the use of if heard, they will frame the policy debate that
testimonies will have equal impact on policy- follows.
makers, regulators and academics.
Janet Davies
It is the personal details in these accounts that RCN Chief Executive & General Secretary
matter. They range from the seemingly minor
complaints of missed tea breaks – a situation
I remember well – to those saying that some
patients are no longer afforded enough dignity,
even dying alone.
“
One nurse told us they drove home “sobbing” at
Today was an unusual
how the shortage of staff was impacting on the
care their patients were getting. Another nurse,
occasion to be fully staffed,
a single mum, said she feels she doesn’t have the but the difference it makes
energy after the late-running shift to support her to patient care and morale
son as he starts secondary school. Others told is immeasurable. In contrast,
us about colleagues who have burned out and the week before I worked
have become sick themselves, unable to come to a 15.25-hour shift, having
work; many question their future in nursing and to stay late with no break
are contemplating leaving the profession. Large in a different mental health
numbers said they had raised concerns about the unit. I left exhausted, upset
impact of the staff shortage on patients or their that I could not offer more
discomfort at handing over to junior staff, only to to patients due to workload
feel ignored.
and unsure of how long
Survey response number 9,504 put the need for working at this pace was
fixed staffing levels most clearly. The nurse, who sustainable. Sadly, days like
”
works in a mental health setting, said her last these are far too common.
shift had been a one-off – it was fully-staffed
and the difference to patient care and morale had Mental health nurse
been “immeasurable”.
1
Executive summary
Having the right number of appropriately lack of staffing actively preventing them from
qualified, competent and experienced nurses doing work they love, to the standard patients,
protects both the public and the nursing families and carers deserve. They report that
profession. The right number of registered nurses they are regularly working additional unplanned
leads to improved patient outcomes, reduced time, usually unpaid. It is clear that our
mortality rates and increased productivity. But health and care workforce are personally and
insufficient numbers of registered nurses has professionally plugging the gap between missing
potentially life-threatening consequences for staff and the demand for care, because of factors
patients – and when care is left “undone” there beyond their control.
is a greater risk of death. Yet despite decades of
research there is clear evidence of a shortage of In 2009, the proportion of registered nurses
registered nurses in the UK. This is mostly down within the nursing team in adult general wards
to factors that could – and should – have been was 62% – it is now at 58%. Having more support
anticipated and addressed by policymakers. staff does not safely or adequately compensate
for having too few nurses in terms of quality,
For the first time in years there are now more outcomes or mortality rates.
nurses and midwives leaving the NMC register
than joining. The impact of the EU referendum Our findings show that the majority of shifts
appears to be driving EEA nationals away. reported were short of staff and, more often
UK-trained nurses and midwives are also leaving than not, nursing staff stated that care was
the register, before retirement. compromised. In some circumstances, poor
staffing levels meant that staff had to leave
One in three nurses are due to retire within necessary care undone.
the next ten years. International recruitment is
plateauing, and there are significant unresolved The vast majority of shifts (96%) captured in
challenges in recruiting and retaining a this survey were worked during May 2017. This
domestically trained workforce. Without urgent suggests that the pressures we have come to
action by policymakers, these combined factors expect in winter are now experienced in most
pose a significant risk of sustained long-term health and care services throughout the year.
decline in the supply of registered nurses. The
“
implications for patient safety and patients’
experiences are extremely worrying.
I was supposed to finish at
This report provides further evidence of the 19.15pm to collect my son. I
shortage of registered nurses, and describes did not finish until 19.55pm
the impact this is having on patient care and on so I was late. I was mentally
nursing staff. and physically exhausted
The Royal College of Nursing (RCN) is calling for
and unable to engage
legislation in each UK country that guarantees with my family when I got
safe and effective staffing levels, for all providers home. Relationships were
across health and care settings. strained again because my
family believe that I always
Following the publication of our report Safe and put work first, which I do.
Effective Staffing - the Real Picture in May 2017, I could not sleep due to
we launched a survey of nursing and midwifery
the worry of not meeting
staff in the UK. We asked people about their last
all the care demands and
shift or day worked in health or social care. In just
two weeks we received over 30,000 responses. The feeling that I’ve failed my
message was clear and unified: when there is a patients, colleagues and
now my family. I cried all
”
shortfall of staff, patient care suffers.
the way home.
Nursing staff describe harrowing experiences at
work. They say that safe and effective staffing Adult acute nurse
is the exception, not the rule. They describe a
2
Key findings in our new survey data are that:
• 55% of respondents reported a shortfall

in planned staffing of one or more
registered nurses on their last shift
(58% for NHS providers and 25% for
“ I always go above and
beyond for my patients –
we all do as nurses – but
independent providers) that is to the detriment of
myself, minimal breaks,
• 41% of all shifts were short of one or more not drinking enough fluid,
health care support workers holding on for the toilet.
Even doing this I don’t feel
• 20% of the registered nurses across the
30,000 shifts were temporary staff. 28% I have enough time for
of health care support workers were my patients. I was trained
temporary staff to provide holistic care,
and often, because of the
”
• the skill mix of the nursing workforce pressures we face, we are
(proportion of registered to non-registered not able to do that.
nurses) in acute settings has been diluted
over the past seven years Practice nurse
• 36% of all respondents said that due to a lack

of time they had to leave necessary patient
care undone Nursing voices are united in saying that too
often poor staffing levels are preventing nursing
• over half (53%) said care was compromised staff from doing the work they joined the
on their last shift profession to do. Patients and nursing staff are
suffering the consequences of a lack of clarity
• 53% felt “upset/sad” that they could not
about accountability for workforce planning –
provide the level of care they wanted
politically, nationally and locally. The boards
• 44% said no action was taken when they of all health and social care providers have a
raised concerns about staffing levels duty to ensure patient safety and should provide
assurance to the public that services are safe.
• 65% of all respondents said they worked Governments must respond when health and
additional time, on average almost one hour care workers say that patients are being let down
extra (53 minutes) and that they are at risk of harm – the time has
come for nurse staffing law.
• 93% of nursing staff who worked extra
unplanned time for NHS providers were not The RCN calls on providers of health and care
paid for this. For non-NHS providers, the services across the UK to urgently review nurse
figure is 76% staffing levels and assure their boards that
services are safe for patients.
• based on our survey findings, our conservative
estimate is that the additional unpaid time
worked by registered nurses in the NHS across
the UK equates to £396 million annually.
Our findings demonstrate the damaging impact

policy decisions are having on patients and
nursing staff. Governments across the UK should
be making every effort to retain the existing
workforce and recruit new skilled workers.
3
1. What is safe and effective

staffing?
Appropriate nursing staffing levels are critical ongoing nursing shortage impacting domestic
to the delivery of safe and effective care. The and international workforce supply. These
planning and delivery of safe and effective care include short-sighted cost-control measures,
is complex, and is dependent on the constantly including recruitment freezes, cuts to nurse
changing circumstances of patients’ diagnosis student commissions and reduced post-
and treatment when they access any type of registration education programmes. A global
health and care service. When we refer to “safe shortage of nursing staff has reduced the supply
and effective staffing”, we mean that health and of nurses from overseas, as has the UK’s decision
care services have: to leave the EU.
• the right numbers We set out a range of areas which need attention
from all UK governments so that systemic issues
• with the right skills contributing to the nursing staff shortage at
national levels can be properly addressed:
• in the right place
• legislation for the accountable provision of
• at the right time.
staffing levels
Having the right number of appropriately
• increased funding with political
qualified, competent and experienced nurses
accountability for safe staffing of health
protects the public and nursing alike. The evidence
and care services
is clear: sufficient numbers of registered nurses
lead to improved patient outcomes, reduced • credible and robust workforce strategies
mortality rates and increased productivity. A
range of studies clearly warn that diluting the skill • scrutiny, transparency, openness and
mix by increasing the proportion of health care accountability.
support workers has potentially life-threatening
consequences for patients. To emphasise the sheer scale of the nursing
shortage across the UK we demonstrated how
In May 2017, we published Safe and Effective the number of vacancies across the UK has
Staffing – the Real Picture. The report explored risen in the past three years, with our research
the many interdependent factors driving the showing 40,000 nursing vacancies in the NHS
in England alone.
“
Following our report, the NMC published data
I work hard to provide showing that there are now more nurses and
a high standard of care; midwives leaving the register than joining,
however, when I can’t do my leading to a reduction in the number of nurses
job due to staffing issues, I and midwives registered to work in the UK. The
feel my profession is being data also shows that the number leaving the
register under retirement age has increased.
undervalued. I expect
When considering people who did not cite
to provide exceptional
reitrement as their reason for leaving, the NMC
care every day, not just data showed the average age of leaving the
sometimes. All my patients register has fallen from 55 in 2013 to 51 in 2017.
deserve the best care I For these respondents, “Working conditions – for
can provide; unfortunately example, staffing levels, workload” was the top
this is not always the reason for leaving the profession.
case, which is something I
”
struggle with. Alongside the challenge of insufficient numbers
of registered nurses in the UK labour market,
Older people’s nurse this report shows the very real, day-to-day
struggle of ensuring there are enough nursing
4
staff on each shift to provide safe and effective
“
care. We wanted to reflect the lived experience
of nurses and health care support workers,
I feel like I’m spinning
which illustrates the real impact of the national plates, except the plates
shortage at a local level. are patients – that to me
is the worst feeling. A
feeling of having no control.
Going from crisis to crisis
Our survey of nursing staff continuously is so incredibly
In May 2017, we asked nursing and midwifery stressful. Frontline staff
staff across the UK to tell us about the experience feel like they are working
of staffing during their last day or night at work. on a battlefield; we don’t
For ease, throughout the report we refer to this know who to go to first. We
as “last shift”, whilst recognising that this term are constantly having to
is not used across all the different places where prioritise, but some patients
nursing and midwifery staff work.
need your help just as
The survey aimed to cover all health and care urgently as the next.
settings, and the call was made to those working Frontline nurses are moved
in and outside the NHS. Unless stated otherwise,
around different wards,
our findings are inclusive of all shifts and as a
which is also very stressful.
result cover the whole of the UK and all clinical
settings and types of providers, the NHS and We can start a shift with an
primary care and other providers including acceptable amount of staff
care homes, prisons, hospices, independent but we are always moved to
providers and charities. A detailed breakdown of other wards. So we go from
respondents can be found in Appendix 1. having 8 patients to working
on a ward we are unfamiliar
We had over 30,000 responses to the survey, with, often with 12 or more
providing us with insight into staff experiences
patients. Something big has
and staffing levels for over 30,000 shifts in
the UK. A full methodology can be found in
to change or I’m leaving – or
Appendix 1. may not even go back for my
next shift. I am, as so many
”
As well as providing a crucial insight into local are, at breaking point.
staffing levels across 30,000 shifts, our findings
provide a strong voice from nursing staff, clearly Adult acute nurse
describing the impact that poor staffing has on
both patient care and their own wellbeing.
Throughout the report we include some of the

experiences and stories shared with us via
the survey. A wider selection can be found in
Appendix 3. Some of the stories are stark and
include moving descriptions of profoundly
difficult personal experiences which illustrate
the consequences of understaffing. We intend
to develop our understanding of the experiences
described, through further engagement with
our members and the public.
5
2. The impact of staffing levels

on patient care
The survey data from over 30,000 shifts shows
“
that a shortfall in planned staffing levels is present
I drove home from work
across the UK, and spans the full range of clinical
settings and providers – both NHS and non-NHS. sobbing today, knowing that
the patients that I cared for
Across the UK, 55% of respondents reported that did not get even a fraction
there was a shortfall of one or more registered of the level of care that I
nurses on their last shift. A quarter of staff would consider “acceptable”.
in non-NHS providers reported a shortfall, I would be devastated if my
compared to 58% in NHS services. family or friends were in the
Survey respondents also reported a shortfall hospital I work in, as there
in health care support workers, with 41% of all are just not enough staff to
shifts being short of one or more health care go around and whilst we do
our best, it’s not enough.
”
support workers.
In addition to asking nursing staff about the Registered nurse

staffing levels on their last shift, we also asked
them several questions about the quality of care
that was provided. Only 40% of respondents said However, there was significant variation in how
they were able to provide the quality of care they respondents rated the quality of care on their
would like to receive as a patient; 42% said they shift by clinical setting.
were not able to provide this.
Broadly, those working across the range of services
When rating the overall quality of care across all in the community rated the quality of care more
health and care settings; 68% of respondents said highly than those working across hospital settings
that the quality of care on their last shift was good such as adult acute inpatient health wards, A&E,
or very good. 23% said it was neither good nor older people’s wards and inpatient mental health
poor and 9% said it was poor or very poor. services. In 14% of A&E shifts, quality of care was
rated as poor or very poor. It is worth noting that
There was no difference in the rating of 96% of the shifts reported took place in May, not
quality between NHS and non-NHS services. during winter months when demand is greater.
Figure 1: Average number of patients per one registered nurse by quality

of care
Mean number of patients
per registered nurse
Very good Good Neither good Poor Very poor

nor poor
6
Respondents who worked in services such as • ensure patients’ oral hygiene is attended to
intensive care/high dependency units, neonatal,
theatre and outpatients rated the quality of care • provide information and comfort to patients
more highly, with at least 80% of the nurses in and their families
these services rating the care as good or very
• complete nursing care records
good. The quality of care was rated most poorly
in prisons, albeit with a much smaller sample of • develop nurse care pathways.
183 respondents.
The inability of nursing staff to provide essential
Figure 1 shows that, taking the data from over nursing care presents the risk of complications
30,000 shifts, there is a clear trend: nursing staff which adversely affect quality of life for people
rate the quality of care more highly when there receiving care, their families and carers, as well
are fewer patients for every one registered nurse. as the risk of causing harm.
Importantly, this finding is supported by the
existing research evidence. 54% of respondents said too much of their time
was spent on “non-nursing duties”, with non-
“
nursing administration a recurring theme in our
Some patients need one- qualitative analysis.
to-one care but there aren’t
enough staff to provide
this so they are in danger. Care compromised
A patient recently had a
fall because there were not When care is left undone, patient care is
”
enough staff to stay with compromised. To further understand the impact
of care being left undone due to staff shortages,
him all the time.
we asked whether care being provided to patients
Health care support worker was compromised. Over half (53%) of survey
respondents said that care was compromised
on their last shift, 41% said that it was not
compromised and 6% said “don’t know”.
Care left undone The numbers who reported that care was
compromised were broadly consistent across the
Only 31% of respondents agreed that they had
UK. However, there was a difference in whether
the time to provide the care they would like. 36%
care was compromised between those working
said that due to a lack of time they had to leave
in NHS services (54%) and those in non-NHS
necessary care undone.
providers (46%).
Research has shown that there is a causal link
There was variation between settings, with 67%
between nurse staffing levels – in particular the
of respondents in A&E/urgent and emergency
number of registered nurses – the amount of care
care and 64% of those working in prisons saying
left undone, and patient mortality rates (Ball 2017).
that care was compromised. Settings that
Examples of care left undone, or “missed care” as reported lower rates included GP practices (31%),
it is sometimes referred to, include when nursing hospices (35%) and theatres (35%).
staff are unable to:
The most common reasons given for
• administer medication to patients on time compromised care were:
• help manage pain experienced by patients • not enough registered nurses (69%)
effectively
• not enough health care support workers
• frequently change a patient’s position for (51%)
safety and comfort
• increased patient acuity and/or dependency
• ensure effective skin care (49%).
7
Reliance on temporary staff Raising concerns

43% of the shifts we examined had at least one When staffing levels are low and care is
bank or agency nurse. Good workforce planning compromised, nurses have an obligation to raise
dictates there is access to a contingent temporary concerns in accordance with the NMC Code.
workforce to manage shortages. This must be The RCN has produced guidance for registered
carefully managed, as temporary staff require nurses on raising concerns.
a level of orientation and supervision that
substantive staff – already under pressure – may 72% of respondents said that when there
find difficult to provide. When the proportion of are not enough staff or when patient care is
temporary staff becomes too great, this impacts compromised they feel they have been able
the quality of care provided. to raise a concern. However, only 37% of
respondents reported action being taken when
Our findings show that the proportion of they raised their concern, 44% said no action was
permanent registered nurses to bank/agency taken and 19% said they did not know if anything
registered nurses was 4 to 1 (20% temporary happened as a result of raising their concern.
staff). This clearly signifies a heavy reliance on
temporary staff. This issue was not unique to
registered nurses: 28% of support workers were
also temporary staff.
Impact on nursing staff
More than half (55%) of survey respondents
These findings indicate a shift from temporary
reported a shortfall in planned numbers of
staff being deployed to cover unplanned
registered nursing staff on their last shift/day
situations, to the planned deployment of
worked, with around two-thirds having worked
agency and bank staff as an integral part of the
unplanned extra time.
workforce. Shifts are sometimes booked months
in advance to fill longstanding vacancies in When nursing staff are overstretched due
nursing rotas. This demonstrates an over- to insufficient staffing, they often suffer the
reliance on temporary staffing. consequences personally. Not being able to stay
hydrated, eat, or use the toilet impacts on their
“
physical and emotional wellbeing, especially
I go home from shifts over prolonged periods of time. Taking a break at
worrying about the patients work is not a luxury but a basic right protected by
I have handed over to junior employment law.
staff/bank staff/agency
59% of survey respondents said they did not get
staff. I constantly worry to take sufficient breaks on their last shift. This is
about my registration & the more pronounced in community settings, where
”
lack of care I am providing 69% of nursing staff did not take sufficient breaks,
for my patients. compared to 56% of those working in hospitals.
Adult acute nurse This is particularly worrying when 50% of the
shifts reported were 12 or more hours long. There
was little variation in the number of nursing staff
who were unable to take sufficient breaks between
“
NHS (58%) and non-NHS (63%) organisations.
I have just started this role...I
We asked nursing staff to rate how they felt about
raised concerns about
their last shift/day worked. The results highlight
poor staffing, burnout, etc.
just what they are dealing with day in, day out.
in my previous role and
subsequently resigned due • 57% of respondents said they had been too
”
to lack of support. busy to provide the care they would like.
Registered nurse • 53% felt “upset/sad” that they could not
provide the level of care they wanted.
8
• 46% said they felt exhausted and felt
“
negative.
I am a single mother of a
• 45% said they felt demoralised. 12-year-old boy and he has
recently transitioned to
• Only 26% of respondents said they felt
secondary school. I cannot
fulfilled after their last shift.
remember the last time I
• Only 43% said they felt satisfied with the care finished a shift on time, nor
they provided and the job they had done. can I remember the last time
I finished and had the energy
• Only 37% said they felt positively challenged.
to give my son the positive
”
• Only 40% said they felt exhausted but positive. attention he deserves.
Registered nurse
Extra time worked

Of those who worked additional time, 91%
Respondents were asked if they had worked
reported this was unpaid, which means 59%
additional time on their last shift, and if so, how
of all respondents worked unpaid additional
many minutes, and whether this was paid or
time. There was little variation in additional
unpaid. 65% of all respondents said they worked
time worked between NHS and non-NHS
additional time, for an average of 53 minutes.
organisations. 93% of those working additional
25% of respondents worked an additional hour or
time in the NHS were unpaid, while 76% were
more on their last shift.
unpaid in non-NHS organisations.
57% of respondents 53% felt upset/sad 46% said they felt 45% said they
said they were too that they could not exhausted and felt demoralised.
busy to provide the provide the level of negative.
care they would like. care they wanted.
Only 26% of Only 43% said they felt Only 37% said Only 40% said
respondents said satisfied with the care they felt positively they felt exhausted
they felt fulfilled they provided and the challenged. but positive.
after their last shift. job they had done.
9
Requiring staff to work additional time can have
“
an adverse impact on patient safety, particularly
when the member of staff has already worked
When we are understaffed
a long shift, so analysis was carried out to it takes a toll on everyone,
understand whether this was prevalent in our raising stress levels and
survey data. For all respondents, the average making it difficult to cope
intended length of shift was 10.2 hours, with with the rising demand
35% working a shift of eight hours or less (short), of a population with
55% working a shift of 9-12 hours (medium), varying health needs. It’s
and 9% working a shift longer than 12 hours demoralising when you
(long). For those working short shifts, 70% cannot give the care you
reported working extra time for an average of are trained to give. A lot of
64 minutes. For those working medium-length shifts are covered by the
shifts, 63% worked additional time, for an
goodwill of staff who agree
average of 46 minutes. For those working long
shifts, 61% worked additional time for an average
to stay on for a few more
of 44 minutes. While responses indicate those hours despite being tired
working short shifts were slightly more likely to and run down. Inevitably,
work additional time, and for slightly longer, it is this leads to burnout. On
clear that significant numbers of those working the other hand, when we
medium and long shifts were also working are well staffed we are able
additional time. to give the care we want to
give. It restores our faith in
72% of respondents working in community
the profession we chose.
settings and 71% in care homes worked
additional time, which was slightly higher than The staff are happier, and
the women and families in
”
in hospital settings (63%). This trend is similar to
that seen when looking at the numbers unable to our care are happier.
take breaks in those same settings. Midwife
There is some variation across the UK, with 69%
of respondents in Northern Ireland saying they
worked additional time, 65% in England and 61% The stories submitted to our survey paint a bleak
in both Scotland and Wales. picture of widespread burnout and frustration,
while also demonstrating the commitment of
In the research we published in May this year, nursing teams to pull together and shoulder these
82% of Directors of Nursing said that their difficult working conditions.
services are running on the goodwill of staff.
This report reveals the extent of the unpaid Based on our survey findings we have scaled up
additional hours worked by nursing staff, and the cost of the additional unpaid time nurses
demonstrates just how much services depend are working in the NHS across the whole of the
upon this goodwill. UK. We calculate the cost to be £396 million
of unpaid work in the NHS per year. This
As in many other professions, nursing staff are estimation uses the salary of a Band 5 registered
happy to go the extra mile, especially when it nurse (first band upon registration) for the entire
means providing the level of care they know their NHS nursing workforce in the UK, providing the
patients deserve. However, it is unacceptable for most conservative method of costing.
nursing staff to feel they have no other option
than to work additional unpaid time for sustained
periods to make up for the staffing shortages
caused by short-sighted national policy decisions.
10
3. Approaches to safe and

effective staffing across the UK
We are clear that safe and effective staffing Guidance
levels should not be understood as one fixed
number or ratio. Instead, it is essential to ensure Some health care systems in the UK have
that a systematic approach is in place which national guidance developed to offer support.
triangulates the use of a planning tool alongside Where this exists, it tends to cover a limited
guidance for different settings, and used with number of settings – usually hospital adult
the professional judgement of registered nurses. general wards. This is often based on a
This can then take into account the changing staff:patient ratio approach. Whilst there is no
needs of a particular local population, severity of one fixed nurse:patient ratio that is appropriate
illness and patient needs within specific services, all of the time, the measurement can be a useful
among other factors. and helpful indication of the quality of care.
Planning tools Legislation
Planning tools should be used locally by Having a law related to nurse staffing is the
registered nurses to help determine safe and only way to put a legal duty on governments,
effective staffing levels. Planning tools can vary agencies and providers to ensure local and
significantly depending on clinical setting. national accountability for safe and effective
staffing. Wales introduced the Nurse Staffing
Levels (Wales) Act in 2016. Following a period
“
of consultation, implementation guidance is
I continue to look for due later this year. The Welsh Government
alternative, potentially has committed to extending the legislation to
non-NHS work. My job is further settings.
exhausting both mentally
Following its consultation on a proposed Safe and
and physically. I will look
Effective Staffing Bill, the Scottish Government
at reducing my hours if I
has confirmed it is intending to bring forward
don’t find anything else. legislation on staffing. The RCN submitted a
My colleagues are comprehensive response to the consultation,
wonderful people and calling for robust legislation which ensures
so are the patients, but I staffing for safe and effective care. However
will not carry on working at the time of writing, the scope of the Bill is
”
in this environment in the unclear.
long term.
Northern Ireland and England have no
Critical care nurse legislation relating to nurse staffing levels.
11
Staffing levels reported

across settings
As well as asking respondents to tell us about the
actual staffing level on their last shift, we also
“ On a night shift when
you’re down to two staff
nurses and have to look
after 32 medically unwell
asked how many patients were on their ward,
people, if just one of those
or how many patients they cared for that day,
patients becomes acutely
depending on which clinical setting they worked
in. This enables analysis on key staffing level unwell overnight you
cannot effectively look
”
measures such as the nurse:patient ratio and skill
mix. after everyone else.
There is existing RCN guidance related to setting Adult acute nurse

staffing levels and skill mix across a range
of clinical settings. In support of our call for
legislation, we are committed to strengthening The key to using ratios set out in guidance is to
and expanding the range of guidance we have implement them appropriately and sensibly. They
available for nursing staff. In this report, we should not be used as blunt instruments to justify
compare our survey findings to any staffing an inflexible minimum staffing level that does
levels set out in national policies within the not respond to changes in workload and capacity,
different UK countries. Existing policies are the numbers of patients and fluctuations in the
very limited and focus on acute adult settings. dependency and acuity of patients.
We have also chosen to highlight a selection of
settings which have no staffing levels set out in In Wales, the Chief Nursing Officer’s guidance
governmental or other national health policies, in recommends a ratio of one registered nurse to
order to provide a wider picture. seven patients, cared for on medical and surgical
wards. Secondary reference is made to a ratio
For day shifts in inpatient settings we have of 1:11 at night. Along with other categories,
excluded one nurse when calculating the our survey asked about staffing in acute adult
nurse:patient ratio. This accounts for the ward settings, which includes adult medical and
sister/senior charge nurse who should be acting surgical wards. The responses indicate an
in a supervisory capacity, and therefore should average of 9.7 patients to one registered nurse
not be counted in the staffing numbers providing on day shifts in Wales. 85% of the respondents
clinical care. In addition, we explore the survey reported more than seven patients to one
findings specifically relating to the role of the registered nurse. There were an average of 15.7
supervisory ward sister/senior charge nurse. patients to one registered nurse on night shifts in
Wales. 78% of night shifts reported more than 11
patients to one registered nurse.
Acute adult wards
In Northern Ireland, the Delivering Care
In England, the 2014 NICE guidelines for adult
programme guidance for medical and surgical
wards state that when the nurse:patient ratio
wards is unique in that it provides a staffing level
reaches eight patients to one nurse, this should
range between one nurse to four patients and
act as a red flag that care is potentially at risk of
one nurse to eight patients, allowing for varying
becoming unsafe. In our data for day shifts in
severity of illness and dependency of patients.
England, 71% of respondents reported that their
The average ratio reported from our survey data
last shift had eight or more patients to each nurse
for acute adult wards in Northern Ireland was
and therefore would be a red flag for unsafe care.
6.4 patients per registered nurse, with 27% of
26% of respondents (1,200) in England reported
day shifts having more than eight patients to one
staffing levels with 14 or more patients to one
registered nurse.
registered nurse. On average, there were 9.1
patients to one registered nurse.
12
“
Critical care
The dependency in elderly
Critical care, which covers both Intensive Care care is higher than ever due
Units (ICU) and High Dependency Units (HDU),
to community support not
”
is often staffed with greater recognition of
patient acuity and patient safety. These areas
being available.
have had established guidance on nurse staffing Older people’s nurse
levels for the past 15 years. In 2015, the previous
guidance was superseded by UK-wide guidelines
issued by the Faculty of Intensive Care Medicine, Older people’s acute wards
which generally suggest a minimum overall
Data from over 1,420 day shifts in older people’s
nurse:patient ratio of 1:2 for HDU patients and
wards across the UK showed that:
1:1 for ICU on all shifts.
• 47% had a shortfall of one or more
In our survey, data from 2,000 ICU/HDU shifts
registered nurses
found an average of 1.5 patients per registered
nurse. 27% of ICU/HDU respondents reported • 44% of shifts were short of one or more
more than two patients to one registered nurse. health care support workers
• 28% of nurses were temporary staff (bank
“
or agency).
On shifts where we are
short staffed we have to Accident and emergency/urgent and
prioritise all the essential emergency care
tasks. For example, I have
had shifts where parents There is currently no national guidance or policy
have complained that across the UK for emergency and urgent care. In
their child was waiting for England, work led by NICE to develop guidance
for this setting was decommissioned by the
feeds because I was busy
Department of Health, despite draft guidance that
doing IVs. It isn’t fair on the included ratios being published. However, the RCN
family/child and also makes
”
has produced the Baseline Emergency Staffing Tool
me feel stressed/rushed. designed to measure a patient’s dependency in order
Inpatient children’s nurse to assist with setting local staffing levels in A&E.
Data from over 2,200 shifts in A&E across the

UK showed that:
• 71% had a shortfall of one or more

Acute children’s wards
registered nurses
Data from over 1,320 shifts in acute children’s
• 52% of shifts were short of one or more
wards across the UK showed that:
health care support workers; this was also
• 62% had a shortfall of one or more registered the setting with the highest shortfall for this
nurses staffing group
• 34% of shifts were short of one or more • 29% of nurses were temporary staff (bank
health care support workers or agency)
• 17% of nurses were temporary staff (bank • 44% of those working on A&E shifts reported
or agency). that they had to leave necessary care undone
• only 26% said they had the time to support

the relatives or those important to the
patient, which is a key part of communication
and the effective running of A&E services.
13
“
Those taking part in the survey paint a bleak
picture of the working conditions in emergency We all really struggled to
care settings. On nearly every measure relating get through the day today.
to quality of care and staff wellbeing, those in I am applying for work
”
A&E fell well below the average. outside of the NHS.
A&E nurse
Mental health inpatient settings
Data from over 1,300 shifts from inpatient Community nursing services
mental health wards showed that:
Community nursing refers to a diverse range
• 34% of shifts in inpatient mental health of nurses and support workers who work in the
wards had a shortfall of registered nurses community, and can include district nurses,
• a shortfall of 41% of health care support intermediate care nurses, community matrons,
workers was also reported hospital-at-home nurses, and other health care
professionals.
or agency) There is a specialist post-registration
qualification for district nurses working in the
• nearly half of the health care support workers community. District nurses usually lead much
in mental health inpatient settings were larger nursing teams to provide care across a
temporary staff. This is considerably higher geographical area, and demonstrate a particular
than most other settings. set of expertise, knowledge and leadership.
Staffing levels in this setting are driven by
“
caseloads, which vary in size and complexity.
In a mental health unit Community nursing is diverse with the treatment
where patients are under and care varying hugely from patient to patient.
the Mental Health Act, Predicting the length and complexity of each
visit can be difficult, and as our data has already
patients frequently go
”
shown, community nurses are less likely to
several days without being
take breaks and the vast majority are regularly
able to leave the hospital staying at work longer than their contracted
due to poor staffing levels. hours to get through their caseloads.
This frustrates the patients
(understandably!) and leads Data from over 2,200 community nursing shifts
to an increase in incidents of showed that:
aggression and violence. • 68% had a shortfall of one or more registered
Inpatient mental health nurse nurses; this was one of the highest shortfalls
of registered nurses across all settings

health care support workers
• despite having a high rate of staffing

shortfalls, community teams are less likely
to fill these gaps with temporary staff – 15%
of nurses and 11% of health care support
workers were bank or agency staff
• 62% of community nursing staff say they

spend too much time on “non-nursing duties”,
which is higher than most other settings.
14
“
For many years there has been a widely held
policy ambition to increase treatment and care When I told my manager I
in people’s homes and communities, yet this
was the only nurse on a shift
has not been consistently followed up with
with 44 residents I was just
increased funding or training, or an expansion
of community nursing roles. Instead, for told that’s how it’s going
example, we have seen a huge reduction in the to be. There should be
number of specialist district nurses in many adequate qualified nurses
parts of the UK. on night shifts. We should
not be reduced to one nurse
Care homes just because it’s supposed
to be quieter at night
”
Data from over 1,829 shifts from care homes
according to managers.
showed that:
Nurse in a care home
• 18% of shifts had a shortfall of one or more
registered nurses
“
health care support workers

Residents having to wait
or agency) too long to go to the
toilet (to the point of real
• 20% of health care support workers were distress), get pain meds, get
temporary staff (bank or agency) assistance with food/drink,
• 71% of people working in care homes across
personal care issues...
the UK said they did not take sufficient No breaks for staff... One
breaks. carer has been given a
”
rota for nine days of this...
There are differences in how care homes are Unhappy relatives...
funded and provided, often by the independent
sector, which will require particular Nurse in a care home
consideration when developing legislation and
other policy levers.
15
Skill mix
Beyond staffing numbers, we also need to know
the spread of skills across the nursing team as
well as the balance between registered nurses
“ I feel panic on shifts when
faced with poor skill mix,
reduced staff numbers,
acutely sick patients and no
”
and health care support workers. These are all beds available.
referred to as the “skill mix”. As with temporary
staffing, skill mix is another example of where Adult acute nurse
“who” is just as important a consideration as
“how many”. The education level, practical
training, skills and experience that nursing staff nurses delegate and supervise activities and
hold need to be considered when determining interventions to health care support workers,
how many staff are needed, and when setting the they retain responsibility and accountability for
skill mix. patient outcomes.
Skill mix within the registered nurse workforce is We are concerned that this widespread dilution
also important. Following registration, nurses will is in fact a response to short-sighted cost-saving
develop different knowledge and skills, depending measures. This trend cannot continue unchecked
on the setting in which they work and the range since the evidence demonstrates that higher
of experiences to which they are exposed. In staffing levels of registered nurses, educated
addition, nurses undertake continued professional to degree level, reduce patient mortality and
development. These factors mean that registered improve both the clinical outcomes of patients
nurses are not simply interchangeable between and the patients’ experience.
health and care settings.
Respondents identified a threat to securing Supervisory nursing role

appropriate skill mix in ward settings, as a
result of staff being moved between wards to The RCN recommends that there should be a
fill staff shortages in other areas. This practice supervisory nursing role – which is not included
undermines any previous planning undertaken, in the numbers of nursing staff available to
in both the area they are taken from and the area directly provide care and treatment – in all
they are moved to. inpatient and community health and care
settings across the UK.
Compared with data we collected for a similar
survey in 2009, these latest findings suggest This supervisory role must have oversight of
increased dilution of skills within teams. The the clinical setting and use their knowledge and
proportion of registered nurses within the experience to make key clinical decisions. This
nursing team in adult general wards was 62% includes having the time to use professional
in 2009, and is now at 58%. In children’s acute judgement to make meaningful decisions on
wards, the proportion has dropped from 83% to staffing. Protecting the supervisory status of
79%. This data shows a wide-ranging dilution this role ensures that professional judgement is
of skill mix across a range of inpatient settings. used to monitor changes in patient flow, severity
There are risks to patient care when the skill mix of illness and patient dependency, and the
becomes too diluted, with research showing that deployment of staff, which are all key factors to
mortality rates are lower in areas with higher safe and effective staffing.
proportions of registered nurses. Our findings demonstrate that more often
As more and more personal care is now provided than not the senior nurse in charge did not
by health care support workers, the argument have the protected supervisory status required
for regulation of health care support workers throughout a shift. We know that when nursing
is strengthened – we have been calling for this rosters are short-staffed, nurses and midwives
for many years. Expansion of the health care in supervisory roles are used to fill the shortfall.
support worker workforce has a direct impact on The figures show that this is so widespread the
the registered nurse workforce. While registered practice appears to be normalised.
16
Table 2: Supervisory ward sister/charge nurse across settings - UK
Supervisory ward sister/ Number of

No Yes Don't know
charge nurse respondents
A&E/urgent and emergency 63% 28% 9% 2,220

care
Adult acute ward 70% 23% 7% 8,356
Community children and 67% 23% 10% 236

young people’s service
Community mental health 52% 36% 12% 504

service
Community nursing care 69% 23% 8% 2,276
Inpatient children and young 75% 20% 5% 1,331

people’s ward
Inpatient learning disabilities 68% 26% 7% 176

ward
Inpatient mental health ward 66% 27% 6% 1,586
Intensive care unit/high 44% 52% 5% 1,933

dependency
Maternity 63% 27% 9% 201
Neonatal 64% 32% 4% 232
Older people’s ward 70% 22% 9% 1,948
Outpatient services 66% 25% 8% 1,388
Public health services (health 58% 29% 13% 389

visiting, school nurses, sexual
health)
Theatre 59% 32% 9% 857
Supernumerary status of students

All students undertaking pre-registration
nursing and midwifery programmes are required
to have supernumerary status while on clinical
“ Poor staffing also leads to
burn-out of registered staff,
meaning that your mentor
practice placements. This means that they must may be off sick for long
be additional to the workforce requirement and periods of time and so your
staff on duty on each shift. We are concerned learning needs are not met.
”
that many students who completed the survey
said that this supernumerary status is often Student nurse
compromised. As a result of staffing shortages
students are often having to assist nurses and
health care support workers when they are
supposed to be actively learning.
17
4. What urgent action is needed

The boards of all health and social care providers
have a duty to ensure patient safety and should
Increased funding with
provide assurance to the public that services are political accountability for
safe. Governments must respond when health safe staffing of health and
and care workers say that patients are being let care services
down and that they are at risk of harm – the time
has come for nurse staffing law. Short-sighted cost-saving measures and lack of
funding have been demonstrated to be significant
The RCN calls on providers of health and care factors in the issues described – an increase in
services across the UK to urgently review nurse funding will grow both “pools” of posts to meet
staffing levels and assure their boards that actual demand and numbers of qualified staff
services are safe for patients. needed. It will also lessen the pressures on the
system so that patients can be put first again,
In order to ensure patient safety, we are calling for
with staff enabled to both deliver high-quality
each country in the UK to have:
care and maintain their own wellbeing. This will
1. legislation for the accountable provision of improve retention rates and ultimately decrease
safe staffing levels the cost of agency and bank spend.
2. increased funding, with political It is critical that responsibility for a workforce

accountability for safe staffing strategy lies at ministerial level, to give patient safety
the accountability and prominence it deserves.
3. credible and robust workforce strategies
4. scrutiny, transparency, openness and

accountability. Credible and robust
Some progress has been made on aspects of these
workforce strategy
in some UK countries. It is crucial that governments across the UK resolve
the historical lack of workforce strategy through a
planning and development model that determines
Legislation for the and provides adequate supply for each health and
accountable provision of care system. This must be underpinned by the
development of education and training models
staffing levels that maintain an adequate supply of appropriately
educated, skilled, competent and motivated nurses
While legislation alone won’t guarantee patient
to meet the needs of their population.
safety, it is a critical building block in clarifying
roles and responsibilities for the workforce – Progress on developing workforce strategy has
both crucial components of a health and care been made in Wales.
system. We need to know who is accountable and
responsible for workforce strategy, policy and The Scottish Government has produced part
planning at every level – politically, nationally and one of its health and social care workforce plan,
locally. This must include the commissioning of with parts two and three due to be published
pre-registration nursing places, post-registration by the end of the year. However, Audit Scotland
professional development and preparation for has highlighted the responsibility for NHS
specialist and advanced practice. workforce planning across national, regional
and local levels is confused and that the Scottish
Government has not yet adequately estimated
the impact that increasing and changing demand
could have on the workforce and skills required.
In Northern Ireland, responsibility for regional

workforce planning for health and social care
and commissioning of pre and post-registration
education sits with the Department of Health in
Northern Ireland.
18
In England, the Department of Health is
“
ultimately accountable for securing value for
money on training and employing nurses. While I feel guilty leaving work
in principle Health Education England oversees two hours late knowing
national workforce strategy for health care, and the staffing levels are
this is a locally driven process, in light of the inadequate, sometimes
changes to student funding arrangements it is leaving just two trained
no longer clear which organisational body is nurses to care for 24 acute
responsible for addressing the national shortage patients. I often go home
of nurses. This must change. in tears. I love being a
nurse – 28 years – yet I feel
I am unable to do my job
Scrutiny, transparency, properly. Instead of being
openness and thanked for the million and
accountability one things you have done,
you get berated for the one
Whilst legislative interventions help provide that you haven’t. The only
additional data, to be fully successful robust saving grace is that when
workforce data must be collected and published in we talk to patients, the vast
each country and intelligence generated from it. majority are happy with
This will help ensure there is full accountability the care they receive. I just
for the staffing of services serving our population
”
know it could and should
and enable delivery of workforce strategy by
be better.
providing a sound evidence base. Importantly,
data collection must cover the entire health and Acute adult nurse
care system irrespective of provider.
19
Appendix 1: Survey method and

respondents
The RCN conducted an online survey from Sunday Table 2: Breakdown by day and
14 May to Wednesday 31 May 2017. The survey night shift
was launched at the RCN annual Congress.
The link to the survey was sent to every Day/night shift Count %
RCN member via email. It was also listed on
Day 24,064 78%
our website and promoted via social media
throughout the time the survey was open. Night (any time after 8pm) 6,728 22%
The survey was open to members and non- Total 30,792 100%
members across all health and care settings, to
enable us to get the best response. The survey
was open to nurses, midwives and health care Table 3: Breakdown of month of
support workers delivering patient care.
last shift*
We had 30,865 responses, which included
sufficient data on staffing to be analysed. Date of last shift Count %
The survey focused on the respondent’s last Jan-17 91 0%
shift. The survey asked for self-reported staffing
levels data and asked the respondent a range of Feb-17 122 0%
perception questions and questions about their Mar-17 268 1%
wellbeing. The majority of questions were closed
quantitative questions with two supplementary Apr-17 682 2%
open-text questions. May-17 29,702 96%
In each table in Appendices 1 and 2 we have Total 30,865 100%
included the count of respondents to the
question, to show the base number as well as *We excluded any shifts that predated January
percentages. Questions may have a different 2017 or were reported as being in the future from
base because not all questions were mandatory the analysis.
or applicable.
Table 4: Breakdown by organisation type

Table 1: Breakdown by country
Organisation type Count %
Country Count %
For the NHS (including 27,430 89%
England 24,381 79% GP practices)
Scotland 3,323 11% Outside the NHS 3,435 11%
Wales 1,762 6% Total 30,865 100%
Northern Ireland 1,212 4%
Outside UK* 159 1%
Total 30,837 100%
*To account for nurses working in the Isle of Man

and the Channel Islands in our membership.
20
Table 5: Breakdown of non-NHS Tables 6a – 6f: Breakdown by

organisation type clinical area
6a: hospital settings
Non-NHS
Count %
organisation type
a hospital Count %
Independent/private 1,983 58%
health care – for profit A&E/urgent and 2,301 10%
emergency care
Independent/private 509 15%
health care – non-profit Adult acute ward 8,600 37%
Local government 108 3% Inpatient children and 1,375 6%

young people’s ward
Other (please specify) 156 5%
Inpatient learning 181 1%
Social care 216 6% disabilities ward
Social enterprise 67 2% Inpatient mental health 1,613 7%
Voluntary/charity/third 386 11% ward
sector Intensive care unit/ 1,999 9%
Total 3,425 100% high dependency
Maternity 209 1%
Neonatal 240 1%
Table 6: Breakdown by setting
Older people’s ward 1,993 9%
Setting Count % Outpatient services 1,481 6%
a hospital 22,949 74% Theatre 910 4%
the community 5,004 16% Other 2,047 9%
a care home 1,829 6% Total 22,949 100%
urgent and emergency 423 1%
care (non-hospital)
prison/police custody 225 1%
Other (please specify) 435 1%
Total 30,865 100%
21
6b: community settings 6e: Prison and policy custody settings
the community Count % prison/police custody Count %

Community children and 247 5% Police custody 32 14%
young people’s service
Prison 191 85%
Community learning 89 2%
Other 2 1%
disabilities service
Total 225 100%
Community maternity 27 1%
care
Community mental 527 11% 6f: other settings

health service
Other (please specify) Count %
Community nursing care 2,347 47%
Total 435 100%
GP practice 643 13%
Hospice 252 5%
Outpatient services 2 0% Table 7: Breakdown by registered and

Public health services 405 8% unregistered staff
(e.g. health visiting, school
nurses, sexual health) Role Count %
Other 465 9% Registered workforce 26,089 87%
Total 5,004 100% Unregistered 2,426 8%
Student 1,531 5%
6c: care home Total 30,046 100%
a care home Count %

Total 1,829 100%
6d: urgent and emergency care

(non-hospital) settings
urgent and emergency

Count %
care (non-hospital)
Call centre 62 15%
Home visits 103 24%
Walk-in centre/ 197 47%

face-to-face
Other 61 14%
Total 423 100%
22
Table 8: Breakdown by role (detailed)

Role Count %
Advanced nurse practitioner 166 1%
Associate director 15 0%
Chief nurse/director of nursing 14 0%
Clinical nurse specialist/consultant nurse/advanced nurse practitioner/ 1,288 4%
adviser/specialist
Clinical nurse specialist/consultant nurse/nurse practitioner/adviser/ 560 2%
specialist
Community learning disabilities nurse 72 0%
Community psychiatric nurse 363 1%
Community staff nurse 1,378 5%
District nurse 505 2%
Health visitor 169 1%
In reach nurse 12 0%
Lead nurse 25 0%
Liaison and diversion role 13 0%
Manager 187 1%
Matron 27 0%
Mental health nurse/learning disabilities nurse/children and young 26 0%
people nurse/midwife
Midwife 148 0%
Nurse clinical adviser 82 0%
Nursing manager 14 0%
Occupational health nurse 5 0%
Other (please specify): 569 2%
Practice nurse 415 1%
Primary care nurse 83 0%
School nurse 105 0%
Senior nurse/matron/nurse manager 1,080 4%
Sister/charge nurse/service manager/team leader 431 1%
Sister/charge nurse/ward manager/senior charge nurse 4,424 15%
Specialist community public health nurse 88 0%
Specialist nurse 20 0%
Specialist nurse/practice educator/quality lead 37 0%
Staff nurse 13,722 46%
Team leader 46 0%
Health care assistant/health care support worker/assistant practitioner/ 2,426 8%
associate practitioner/trainee nursing associate
Student 1,531 5%
Total 30,046 100%
23
Appendix 2: Survey findings

by country
Table 1: Shifts that are short by one or Table 3: Shifts with one or more bank
more registered nurse by country or agency registered nurse
Shifts short Shifts with 1

Total Total
Country by 1 or Country or more bank
(count) (count)
more RN or agency RN
England 56% 23,784 England 45% 24,381
Scotland 51% 3,255 Scotland 38% 3,323
Wales 46% 1,725 Wales 40% 1,762

Northern Ireland 50% 1,212
Table 4: Shifts with one or more bank

Table 2: Shifts that are short by one or agency health care support worker
or more health care support worker
by country Shifts with 1 or
Total
Country more bank or
(count)
Shifts short agency HCSW
Total
Country by 1 or more
(count) England 45% 24,381
HCSW
Scotland 40% 3,323
England 42% 22,453
Wales 40% 1,762
Scotland 38% 3,086
Wales 40% 1,637
Table 5: Proportion of registered nurse temporary staff by country
Temporary staffing Permanent staff Bank/agency staff Total (count)

England 79% 21% 22,696
Scotland 88% 12% 3,071
Wales 85% 15% 1,635
Northern Ireland 82% 18% 1,124
Table 6: Proportion of health care support worker temporary staff by country
Temporary staffing Permanent staff Bank/agency staff Total (count)

England 71% 29% 20,785
Scotland 76% 24% 2,857
Wales 73% 27% 1,485
Northern Ireland 71% 29% 20,785
24
Table 7: Quality of care by country
Very Neither good Very

Quality of care Good Poor Total
good nor poor poor
England 20% 48% 23% 8% 1% 23,384
Scotland 20% 48% 23% 9% 1% 3,206
Wales 22% 46% 23% 7% 2% 1,690
Northern Ireland 23% 49% 20% 6% 1% 1,164
Table 8: Care compromised by country
Care compromised Yes No Don't know Total (count)

England 53% 40% 6% 23,288
Scotland 53% 41% 5% 3,198
Wales 51% 42% 7% 1,676
Northern Ireland 48% 43% 9% 1,159
Table 9: Able to raise concerns by country
Raising concerns Yes No Not applicable Total (count)

England 73% 19% 7% 21,275
Scotland 67% 26% 8% 2,871
Wales 68% 24% 7% 1,509
Table 10: Concerns raised were dealt with by country
Concerns raised
Yes Don't know No Total (count)
were dealt with
England 37% 19% 43% 15,429
Scotland 33% 18% 49% 1,904
Wales 36% 18% 46% 1,019
Northern Ireland 36% 20% 43% 715
Table 11: Able to take sufficient breaks by country
Able to take
Yes No Don't know Total (count)
sufficient breaks
England 40% 59% 1% 21,797
Scotland 43% 56% 1% 2,947
Wales 44% 56% 0% 1,546
25
Table 12: Additional minutes worked by country
Additional minutes No Yes Don't know Total (count)
England 34% 65% 1% 21,797

Scotland 38% 61% 1% 2,947
Wales 39% 61% 1% 1,546
Table 13: Average minutes worked by country
Average minutes worked Additional minutes Total (count)

England 53.8 13,921
Scotland 46.5 1,760
Wales 49.9 927
Northern Ireland 49.5 739
Table 14: Supervisory status of ward sister/charge nurse
Supervisory status Yes No Don't know Total (count)

England 26% 66% 8% 21,035
Scotland 26% 66% 8% 2,875
Wales 26% 65% 9% 1,534
Tables 15a – 15j: Staff perception questions of last shift

15a: I had enough time to provide the level of care I would like
Strongly Neither agree Strongly Total

Agree Disagree
agree nor disagree disagree (count)
England 8% 23% 16% 39% 14% 21,831
Scotland 7% 24% 15% 40% 14% 2,956
Wales 9% 23% 17% 38% 13% 1,554
15b: I felt satisfied with the quality of care I was able to provide

Agree Disagree
England 11% 34% 20% 28% 7% 21,776
Scotland 9% 33% 19% 30% 8% 2,952
Wales 12% 33% 22% 27% 7% 1,547
26
15c: I was concerned about the skill mix

Agree Disagree
England 15% 30% 23% 25% 7% 21,743
Scotland 16% 28% 22% 28% 7% 2,951
Wales 14% 30% 22% 26% 8% 1,550
15d: I was able to provide the quality of care that I would want to receive as a patient

Agree Disagree
England 10% 30% 19% 32% 10% 21,761
Scotland 9% 27% 18% 35% 11% 2,939
Wales 10% 30% 19% 31% 9% 1,552
15e: Due to the lack of time, I had to leave necessary care undone

Agree Disagree
England 7% 29% 19% 34% 10% 21,773
Scotland 7% 27% 18% 38% 10% 2,940
Wales 6% 27% 21% 35% 11% 1,550
15f: I was too busy to provide the care I would like

Agree Disagree
England 17% 40% 14% 21% 7% 21,726
Scotland 17% 39% 14% 22% 7% 2,944
Wales 18% 38% 15% 21% 8% 1,545
15g: Too much of my time was spent on non-nursing duties

Agree Disagree
England 17% 36% 23% 19% 5% 21,768
Scotland 20% 37% 21% 19% 3% 2,944
Wales 17% 35% 24% 19% 5% 1,552
27
15h: I was concerned that support staff were being expected to perform the duties of
registered staff without appropriate supervision

Agree Disagree
England 7% 20% 22% 38% 14% 21,677
Scotland 7% 19% 20% 39% 14% 2,937
Wales 6% 19% 21% 39% 15% 1,542
15i: I was provided with the appropriate supervision and support

Agree Disagree
England 7% 28% 30% 25% 10% 21,709
Scotland 6% 25% 32% 27% 11% 2,937
Wales 8% 26% 31% 23% 11% 1,545
15j: I had the time to support relatives and those of importance to the patient

Agree Disagree
England 7% 26% 28% 31% 8% 21,728
Scotland 5% 24% 29% 33% 9% 2,939
Wales 6% 25% 30% 30% 8% 1,544
28
Tables 16a to 16g: Staff wellbeing questions after last shift

16a: I felt fulfilled

Agree Disagree
England 5% 22% 25% 35% 13% 21,197
Scotland 4% 18% 24% 40% 14% 2,869
Wales 4% 20% 25% 37% 14% 1,508
16b: I felt positively challenged

Agree Disagree
England 7% 31% 24% 29% 9% 21,128
Scotland 6% 26% 23% 34% 11% 2,847
Wales 7% 30% 24% 29% 10% 1,499
16c: I felt satisfied with the care I had provided and the job I had done

Agree Disagree
England 8% 35% 21% 27% 8% 21,171
Scotland 7% 33% 22% 29% 9% 2,861
Wales 8% 35% 23% 26% 8% 1,505
16d: I felt exhausted, but I felt positive

Agree Disagree
England 9% 32% 23% 28% 7% 21,159
Scotland 7% 26% 23% 35% 9% 2,859
Wales 8% 29% 26% 29% 8% 1,508
16e: I felt exhausted, and I felt negative

Agree Disagree
England 15% 30% 18% 29% 8% 21,069
Scotland 18% 33% 16% 25% 7% 2,855
Wales 16% 29% 19% 26% 9% 1,505
29
16f: I felt demoralised

Agree Disagree
England 15% 29% 22% 26% 8% 21,126
Scotland 17% 30% 23% 23% 7% 2,862
Wales 16% 30% 20% 24% 9% 1,503
16g: I felt upset/sad that I could not provide the level of care I had wanted

Agree Disagree
England 21% 33% 18% 21% 8% 21,202
Scotland 22% 32% 17% 21% 7% 2,864
Wales 21% 31% 20% 20% 9% 1,512
30
Appendix 3: Illustrative quotes

from survey
Included in the 30,000 responses are thousands of personal experiences from nursing and midwifery
staff. We intend to develop our understanding of these experiences through further analysis of the
responses and continued engagement with our members.
Below are a handful of the responses from staff across all of the UK:
“I feel that I am totally burnt out. Don’t think “I feel so exhausted, demoralised and do not
that I can continue to work at this pace. I have want to go back for another shift.”
resorted to antidepressant medication. I am Neonatal nurse
seriously thinking of retiring next year as I will
be 60 after 44 years in the NHS.” “We are overworked and underpaid. No nurse
Practice nurse does this job for the money; however, it is not
unfair to ask for the pay level we are entitled to.
“In primary care we are stretched just as much We see politicians take pay rises year in, year out
as secondary care. Our appointment times are and they are able to stop us having the pay rises
10 mins for HCAs and 15 mins for nurses. As we deserve, nothing more than that.”
an HCA, I have 15 mins for dressings, which is Inpatient children’s inpatient nurse
such a struggle. I feel totally drained at the end of
the day and am totally fed up with my job at the “I have just had 12 weeks off work due to stress
moment.” from the high demands of my case load and
Health care support worker in a GP practice administration responsibilities. During this
period I realised just how much the career I
“I always go above and beyond for my patients – have chosen has been consuming my life. I have
we all do as nurses – but that is to the detriment actually had time for myself, my children and my
of myself, minimal breaks, not drinking enough grandchildren. I love being a nurse but feel that
fluid, holding on for the toilet. Even doing this I the demands placed on us are unsafe. This has
don’t feel I have enough time for my patients. I been going on for too long and action needs to
was trained to provide holistic care, and often, be taken. This job has affected my health and if
because of the pressures we face, we are not able something is not done the NHS will be in major
to do that.” crisis.”
Practice nurse Community nurse
“The NHS is surviving on the goodwill of those “I’m constantly stressed. Emotionally shut down.
that work within it. The majority of staff work I’m going through the motions just to get through
over and beyond on a routine basis. Studying the day. After 33 years of being a registered
and performing mandatory training in their own nurse, it’s time to go. So sad.”
time. Personally I am currently studying in my Community nurse
own time. But to be able to do this I have to put
my son in childcare one day a week. At a cost “We do this job because we care for people
of £38 a day. This would not be expected in any but the Government does not care for us. We
other profession.” regularly miss breaks, go 14 hours without a
Registered nurse drink – to the point where one of my colleagues
has developed kidney stones. I stay late basically
“I seriously question my career as a nurse, I love every night, I take work home with me and
my job but the pressures are ever increasing. receive no emotional support for an extremely
A family member works in retail and is on draining and impacting job. Something needs to
approximately £7k more a year than me. We change. I often feel as though I cannot do my job
are registered professionals but our pay and fully because I spend my day putting out various
conditions do not reflect this.” fires or completing tick box exercises rather than
Adult nurse actually caring for my patients.”
Community nurse
31
“I started nursing to look after and care for people, “Staff are working late without pay or claiming
but poor staffing levels mean that I struggle to time back. The department runs largely on the
give the best care due to the stress and strain goodwill of its staff. We feel rushed and stressed
put on staff. Most days I feel low and completely due to the fact we are not able to provide the
demoralised. I would like to believe things can level of care the patients are entitled to. Staff
change but feel this may never happen.” have become demoralised and have left to take
Practice nurse up posts elsewhere. We don’t feel our opinions
count, even though we are on the frontline.”
“Every day I feel my registration is being Midwife
compromised, as is the quality of care we provide
due to the lack of nurses. We are pushed to “Patients are not receiving the care they deserve,
exhaustion and no one wants to listen to our which upsets us as nurses and midwives. There
concerns. Every day I question why I became a are not enough staff and no support. Our patients
nurse as I feel my health is deteriorating. I am frequently suffer delays in their care. While
not able to drink enough on shift or even go to they are understanding, it becomes frustrating
the toilet when I need to.” and eventually they and their families become
Older people’s nurse hostile and aggressive. I am actively looking for
a job out of the NHS. I don’t want a different job,
“Each shift, I feel drained, broken and but I can’t take working in such an oppressive,
inadequate from never having enough time unsupportive and stressful environment any
to give the care that patients and families longer. We don’t have a break, so for 12 hours we
deserved. I only qualified in 2014, and yet I was don’t eat or drink. I didn’t become a midwife to
already considering leaving nursing. It wasn’t go home feeling down and upset, nor to see my
until I moved department that I remembered colleagues crumbling and our management not
how much I loved to nurse. Across the NHS, we care as long as they look good.”
need more staff.” Midwife
A&E nurse
“Nurses are telling everyone not to join the
“I feel guilty leaving work two hours late knowing profession as it is the most degrading job, good
the staffing levels are inadequate, sometimes hardworking people being taken advantage
leaving just two trained nurses to care for 24 of. Nurses should take strike action and stop
acute patients. I often go home in tears. I love being walked over. We should stand up for our
being a nurse – 28 years – yet I feel I am unable profession and pave the way for the future.”
to do my job properly. Instead of being thanked Registered nurse
for the million and one things you have done,
you get berated for the one that you haven’t. “Lots of staff are leaving to work in other areas.
The only saving grace is that when we talk to Nurses are crying on duty as they are unable to
patients, the vast majority are happy with the provide quality care. It’s difficult to support my
care they receive. I just know it could and should colleagues as I cannot see how it will improve in
be better.” the future.”
Acute adult nurse A&E nurse
“We are only able to fire fight. Patients that are “Short staffing has left me feeling stressed,
not presenting with an acute need fade into anxious, unsafe, under-supported and ready to
the background and often don’t get to speak to give up on my career. I feel burnt out and worry
staff. We are carrying four WTE qualified nurse about my mental health if conditions like this
vacancies and two WTE health care support are to continue in the future. I have cried during
worker vacancies. We rely on bank staff to plug the and after so many shifts. As a newly qualified
gaps every day. I’ve never known it to be so bad.” nurse, this isn’t what I expected to feel like so
Inpatient mental health nurse soon into my career. I am considering moving
overseas or giving up on my dream of being a
nurse altogether.”
Critical care nurse
32
“I am a staff nurse who recently left their job “Being a student, the staffing levels have
to move to Australia in hope of better working detrimentally impacted my supernumerary
conditions. I have only been qualified for two status, as I am often counted in the numbers
years and I am already questioning my choice without this being discussed with me. I often
of career. I am so passionate about nursing and find I am left to develop my skills alone through
I love my job, but I can’t do it properly with practice, with no constructive feedback.”
the poor staffing levels and increased patient Student nurse
demand. Elderly patients are waiting for hours
on end by themselves, and then when they’re “Our trust sends nurses from certain specialities
admitted they don’t even get a bed. I get so fed up (like cardiology) to other wards when they are
with patients’ disappointment in the service and short of staff. The nurses from the cardiac ward
now I’m wondering if I will ever go back to the do not have experience of caring for patients on
NHS. It’s such a shame.” wards such as a stroke unit. This compromises
A&E nurse patient care and it causes a lot of stress for the
staff. When the decision is made that our staff
“It’s unsafe practice to utilise staff from other have to go to another ward, there is no discussion
wards to cover the staff gaps. Very irritating about it. As staff, we are not able to comment on
when you’re just a number.” it and our concerns are not considered.”
Acute adult nurse Acute adult nurse
“I no longer wish to be a nurse. I’m not able “I am lucky and blessed to work in a very safe,
to provide my patients with even the basics of effective, caring unit, which the vast majority
nursing care due to the constant lack of staff of staff are proud to work on. I am very aware
and any support from management. When I’m this is not the case everywhere and I think
the only nurse on a locked unit I don’t get the both patients’ experience and staff satisfaction
30-minute break I’m entitled to.” are in jeopardy if nothing is done regarding
Older people’s nurse staffing levels in the NHS. We love to care for
our patients. Nursing is more than just our job:
“I just feel like a number, having to send staff to it is our passion. But we are running the risk of
unfamiliar wards that they didn’t apply for a job letting nurses live in despair at the prospect of
on. I find it dangerous.” their next shift, their next pay slip, their next bill.
Critical care nurse Can anyone else see this problem?! Please let us
do what we do best, in a dignified and dignifying
“When it is very overcrowded everyone way. Together we care!”
pulls together. Because we are constantly Critical care nurse
overcrowded we regularly have no space to
see patients, which impacts on waiting times. “We are not able to provide the care the CQC
Majors regularly have numerous corridor and NMC expect of us with these numbers of
patients and blocked minor cubicles.” RNs. We believe that they should spend a day
A&E nurse in our shoes, doing the work that we do, before
demanding that we give more and more with
“When I started the team was very well established fewer staff and fewer resources. Expectations are
and few people left. In the last 12 months over half far too high and its time that it is recognised by
the team has left, losing a lot of knowledge and the CQC and NMC that we cannot give any more.
creating a very junior team. Management are not I am thankful that I work with a fantastic team
interested when people say they are not happy or who support each other, but nurses will continue
are thinking about leaving. They only care about to leave if we are treated this way and I for one
numbers. Staff do not feel cared for, there is never am planning on leaving as soon as I can.”
good feedback given, lack of communication, and Older people's nurse
empty promises. We are constantly being moved to
other wards or another hospital, dividing the team
and causing people to leave.”
Critical care nurse
33
“Working in a forensic setting, low staffing levels “When we advertise for staff we have very few
not only compromise the quality of care given applicants and many who apply do not turn up
but also the safety of both staff and patients. for interview. There are no experienced staff
Early warning signs are missed because staff are out there to apply for job vacancies. Supporting
stretched across too many duties and too many newly qualified staff all the time is exhausting
patients, so incidents occur.” for senior staff and many of these new staff then
Health care support worker leave after a year, leaving us in the same situation
year after year. Most of our experienced staff are
“As a newly qualified nurse, I feel like I have over 45 and do not want to stay past 55, which
been left to figure things out on my own. I have will be a massive crisis in our area.”
learned more from my mistakes than from any Neonatal nurse
support I have received from senior staff. This is
a hugely negative and stressful way of learning. I “Every day, we prison nurses struggle, and I
feel that if staffing levels were better, more time mean struggle, to cope with the lack of staff and
would be available to give this support. I have clear direction. We also continually deal with
suffered from anxiety when I have been asked above-normal aggression and at a level of pay
to help other wards when they are short-staffed. that is a disgrace for the work we do. Hence why
Having only ever experienced working on a ward we continually lose staff.”
for the elderly, I was asked to move to A&E to Prison nurse
cover a shift there. I felt useless, unsafe and out
of my depth. I now worry every time I drive into “I feel panic on shifts when faced with poor skill
work that I will be moved. This happens so often mix, reduced staff numbers, acutely sick patients
now that I don’t want to go to work.” and no beds available. As the nurse in charge
Older people's nurse when working nights I dread this situation as
patients and relatives get upset, which often
“Staffing levels, skill mix, sickness, results in them becoming verbally aggressive
unprecedented demands, patient numbers, lack towards nursing staff. Staffing levels are
of resources and capacity have left me fearing for continually low but it’s now considered normal.
a profession I once loved. I end a shift exhausted, I experience stress, palpitations and worry when
stressed, dehydrated and with little if any job the agency nurse is not knowledgeable of our
satisfaction. I’m paid around £5,000 less than a area, because I end up overseeing the care of
comparable professional with a massive level of their patients as well as mine. Qualified nurses
responsibility and accountability – for patients’ are scared their registration number is at risk.”
lives. After 29 years I am considering leaving Adult acute nurse
nursing due to lack of job satisfaction, being
treated with utter contempt by managers and the “I consistently work double my contracted hours.
government, and five years of pay restraint.” As a senior nurse, I am prevented from providing
A&E nurse clinical care as I have to support a wide team.
My employers are incredibly supportive but are
“On a night shift when you’re down to two staff constantly held to account by national bodies for
nurses and have to look after 32 medically unwell putting funds towards specialist nursing resources.
people, if just one of those patients becomes acutely I choose to work over my hours to support my team,
unwell overnight you cannot effectively look after who are doing an incredible job with poor pay and
everyone else. Patients are unhappy that their long working hours. It is not sustainable and it is
medicines are late. Patients’ families are unhappy not the fault of our employers, it is central policy.”
because you cannot update them on how their Nurse manager
relatives are. Your line manager is unhappy because
patients’ families have complained that you haven’t “I have recently dropped my hours from full time
done your night time cleaning duties because to 28 hours per week, as the reduced staffing
there were only limited staff. The pressure from levels and the drop in experience level have made
managers, patients and families is taking its toll. work so much more demanding. I needed all my
Staff are stretched to the limit and we can’t possibly days off just to recover from work and had lost
do our best under these circumstances.” quality of life.”
Adult acute nurse Theatre nurse
34
“Working in a care home for an agency, it is "I feel like I’m spinning plates, except the plates
not unusual to be responsible for 30+ residents are patients – that to me is the worst feeling. A
on a typical shift. On some night shifts I have feeling of having no control. Going from crisis
been the only professional nurse responsible to crisis continuously is so incredibly stressful.
for anywhere between 50-100 residents. I feel Frontline staff feel like they are working on a
that this is totally unacceptable and “senior battlefield; we don’t know who to go to first.
carers” are being used to fill the gaps, despite the We are constantly having to prioritise, but
fact that they are not nurses and are unable to some patients need your help just as urgently
function as such.” as the next. Frontline nurses are moved around
Nurse in a care home different wards, which is also very stressful. We
can start a shift with an acceptable amount of
"Today was an unusual occasion to be fully staff but we are always moved to other wards.
staffed, but the difference it makes to patient care So we go from having 8 patients to working on
and morale is immeasurable. In contrast, the week a ward we are unfamiliar with, often with 12 or
before I worked a 15.25-hour shift, having to stay more patients. Something big has to change or
late with no break in a different mental health I’m leaving – or may not even go back for my next
unit. I left exhausted, upset that I could not offer shift. I am, as so many are, at breaking point."
more to patients due to workload and unsure of Adult acute nurse
how long working at this pace was sustainable.
Sadly, days like these are far too common." "I drove home from work sobbing today, knowing
Registered nurse that the patients that I cared for did not get
even a fraction of the level of care that I would
"I was supposed to finish at 19.15pm to collect consider “acceptable”. I would be devastated if
my son. I did not finish until 19.55pm so I was my family or friends were in the hospital I work
late. I was mentally and physically exhausted in, as there are just not enough staff to go around
and unable to engage with my family when I got and whilst we do our best, it’s not enough."
home. Relationships were strained again because Registered nurse
my family believe that I always put work first,
which I do. I could not sleep due to the worry of "Some patients need one-to-one care but there
not meeting all the care demands and feeling that aren’t enough staff to provide this so they are in
I’ve failed my patients, colleagues and now my danger. A patient recently had a fall because there
family. I cried all the way home." were not enough staff to stay with him all the time."
Adult acute nurse Health care support worker
"I always go above and beyond for my patients – "I go home from shifts worrying about the
we all do as nurses – but that is to the detriment patients I have handed over to junior staff/bank
of myself, minimal breaks, not drinking enough staff/agency staff. I constantly worry about my
fluid, holding on for the toilet. Even doing this I registration & the lack of care I am providing for
don’t feel I have enough time for my patients. I my patients."
was trained to provide holistic care, and often, Adult acute nurse
because of the pressures we face, we are not able
to do that." "I have just started this role...I raised concerns about
Practice nurse poor staffing, burnout, etc. in my previous role and
subsequently resigned due to lack of support."
"I work hard to provide a high standard of care; Registered nurse
however, when I can’t do my job due to staffing
issues, I feel my profession is being undervalued. "I am a single mother of a 12-year-old boy and
I expect to provide exceptional care every day, not he has recently transitioned to secondary school.
just sometimes. All my patients deserve the best I cannot remember the last time I finished a
care I can provide; unfortunately this is not always shift on time, nor can I remember the last time
the case, which is something I struggle with." I finished and had the energy to give my son the
Older people’s nurse positive attention he deserves."
Registered nurse
35
"When we are understaffed it takes a toll on "When I told my manager I was the only nurse
everyone, raising stress levels and making it on a shift with 44 residents I was just told that’s
difficult to cope with the rising demand of how it’s going to be. There should be adequate
a population with varying health needs. It’s qualified nurses on night shifts. We should not be
demoralising when you cannot give the care you reduced to one nurse just because it’s supposed to
are trained to give. A lot of shifts are covered be quieter at night according to managers."
by the goodwill of staff who agree to stay on for Nurse in a care home
a few more hours despite being tired and run
down. Inevitably, this leads to burnout. On the "Residents having to wait too long to go to the
other hand, when we are well staffed we are able toilet (to the point of real distress), get pain
to give the care we want to give. It restores our meds, get assistance with food/drink, personal
faith in the profession we chose. The staff are care issues...
happier, and the women and families in our care No breaks for staff... One carer has been given a
are happier." rota for nine days of this... Unhappy relatives..."
Midwife Nurse in a care home
"I continue to look for alternative, potentially "Poor staffing also leads to burn-out of registered
non-NHS work. My job is exhausting both staff, meaning that your mentor may be off sick
mentally and physically. I will look for long periods of time and so your learning
at reducing my hours if I don’t find anything else. needs are not met."
My colleagues are wonderful people and Student nurse
so are the patients, but I will not carry on
working in this environment in the long term." "Patient care is seriously compromised when
Critical care nurse there are not enough staff. Patients at the end
of life have no one to sit with them. It is very
"On shifts where we are short staffed we have to upsetting when they have no family. Too many
prioritise all the essential tasks. For example, I patients are dying alone."
have had shifts where parents have complained Acute adult nurse
that their child was waiting for feeds because I
was busy doing IVs. It isn’t fair on the family/ "Being unable to attend to a dying patient as
child and also makes me feel stressed/rushed." quickly as they need is soul destroying."
Inpatient children’s nurse Acute adult nurse
"The dependency in elderly care is higher

than ever due to community support not
being available."
Older people’s nurse
"In a mental health unit where patients are

under the Mental Health Act, patients frequently
go several days without being able to leave
the hospital due to poor staffing levels. This
frustrates the patients (understandably!) and
leads to an increase in incidents of aggression
and violence."
Inpatient mental health nurse
"We all really struggled to get through the

day today. I am applying for work outside of
the NHS."
A&E nurse
36
Appendix 4: RCN UK Safe and

Effective Staffing Group members
Stephanie Aiken, Deputy Director of Nursing
Androniki Bayliss, Research and Innovation Manager
Antonia Borneo, Head of Policy and Public Affairs (UK and International)
Lara Carmona, Associate Director, Policy and Public Affairs (UK and International)
Anna Crossley, Professional Lead for Acute, Emergency and Critical Care
Alison Davies, Associate Director (Professional Practice)
Lizzie Dowd, Public Affairs Manager
Mirka Ferdosian, Directorate Project Manager
Claire Helm, Policy Advisor
Sian Kiely, Knowledge and Research Manager
Gerry O’Dwyer, Senior Employment Relations Adviser
Wendy Preston, Head of Nursing Practice
Rosie Raison, Policy and Public Affairs Officer
Emma Selim, Member Engagement, Campaigns and Digital Manager
Janice Smyth, Director, RCN Northern Ireland
Maria Trewern, RCN Council Member
Glenn Turp, Regional Director, Northern Region
37
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vii
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inpatient wards in acute hospitals,
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viii
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assembly.wales/documents/s37198/HSC4-07-
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[Reference only, full text not available online]
38
ix
National Assembly for Wales Research Service
(2015), National Assembly for Wales Bill
Summary, www.assembly.wales/Research%20
Documents/The%20Safe%20Nurse%20
Staffing%20Levels%20%28Wales%29%20
Bill/15-005.pdf (accessed 21/9/2017)
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uk/sites/default/files/publications/dhssps/
normative-staffing-ranges-section1.pdf
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Faculty of Intensive Care Medicine (2015),

xi
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Services, www.ficm.ac.uk/sites/default/files/
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(accessed 20/9/2017)
Aiken LH, Sloane DM, Bruyneel L and others

xii
(2014) Nurse staffing and education and

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xiv
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february/pub-003312.pdf
39
The RCN represents nurses and nursing, promotes
excellence in practice and shapes health policies
RCN Online
www.rcn.org.uk
RCN Direct
www.rcn.org.uk/direct
0345 772 6100
Published by the Royal College of Nursing

20 Cavendish Square
London
W1G 0RN
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September 2017
Publication code 006 415
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Safe and Effective Staffing: Nursing Against The Odds

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Safe and Effective Staffing:

Nursing Against the Odds

“ Staffing levels, skill mix, sickness,

1. What is safe and effective staffing? 4

2. The impact of staffing levels on patient care 6

3. Approaches to safe and effective staffing across the UK 11

4. What urgent action is needed 18

Appendix 1: Survey method and respondents 20

Appendix 2: Survey findings by country 24

Appendix 3: A sample of experiences from nursing staff across the UK 31

Appendix 4: RCN UK Safe and Effective Staffing Group members 37

RCN Legal Disclaimer

Key findings in our new survey data are that:

• 55% of respondents reported a shortfall

• 36% of all respondents said that due to a lack

Our findings demonstrate the damaging impact

1. What is safe and effective

staff on each shift to provide safe and effective

Throughout the report we include some of the

2. The impact of staffing levels

In addition to asking nursing staff about the Registered nurse

Figure 1: Average number of patients per one registered nurse by quality

Very good Good Neither good Poor Very poor

Reliance on temporary staff Raising concerns

• 46% said they felt exhausted and felt

Extra time worked

Requiring staff to work additional time can have

3. Approaches to safe and

Planning tools Legislation

Staffing levels reported

There is existing RCN guidance related to setting Adult acute nurse

• 28% of nurses were temporary staff (bank

Data from over 2,200 shifts in A&E across the

• 71% had a shortfall of one or more

• only 26% said they had the time to support

Staffing levels in this setting are driven by

• 42% of shifts were short of one or more

• despite having a high rate of staffing

• 62% of community nursing staff say they

• 47% of shifts were short of one or more

• 24% of nurses were temporary staff (bank

Respondents identified a threat to securing Supervisory nursing role

Table 2: Supervisory ward sister/charge nurse across settings - UK

Supervisory ward sister/ Number of

A&E/urgent and emergency 63% 28% 9% 2,220

Adult acute ward 70% 23% 7% 8,356

Community children and 67% 23% 10% 236

Community mental health 52% 36% 12% 504

Community nursing care 69% 23% 8% 2,276

Inpatient children and young 75% 20% 5% 1,331

Inpatient learning disabilities 68% 26% 7% 176

Inpatient mental health ward 66% 27% 6% 1,586

Intensive care unit/high 44% 52% 5% 1,933

Maternity 63% 27% 9% 201

Neonatal 64% 32% 4% 232

Older people’s ward 70% 22% 9% 1,948

Outpatient services 66% 25% 8% 1,388