• National Institute for Health Research report cautions use of HCAs can lead to poor care
  • Review emphasises link between registered nurses and patient safety
  • Managers setting staffing levels need training to ensure they can do it effectively, it adds

A new review of safe staffing evidence has warned increasing the proportion of healthcare assistants on wards can raise the risk of poor care.

The review, Staffing on Wards by the National Institute for Health Research, will be published today and underlines the importance of registered nurses to patient outcomes and satisfaction. It makes clear the numbers of registered nurses and numbers of healthcare assistants on wards should be counted separately.

The review also highlights the need to invest in ward-level leadership and emphasises the need to consider other professionals’ presence on wards when hospitals set safe staffing levels.

The report said staff who are responsible for setting safe staffing levels need training to do so effectively.

It added: “The decision about the planned numbers of workers for each ward is a pragmatic decision… People making these decisions need education and training and provider organisation boards should articulate the levels of risk that they can tolerate.”

More than 20 separate nursing and staff-related studies funded by the NIHR were examined for the report.

Its author Elaine Maxwell, a clinical advisor at the NIHR and former director of nursing, told HSJ: “The relationship between the number of nurses and good patient outcomes is dependent on numerous local contextual factors, including the number of practitioners of different professions.

“Organisations should use a risk-based assessment when determining the number of registered nurses needed. The relationship between HCAs and harms is different from the relationship between nurses and harms. The two should be considered separately and the evidence suggests it is the number of registered nurse hours at the bedside that avoids patient harms.”

Dr Maxwell added: “Safe and effective ward staffing is not just a numbers game. Having a ward environment that supports professional practice and good staff experience are prerequisites for good patient experience and outcomes.”

The review will be published today at a launch event organised by NIHR where chief nursing officer Ruth May will deliver her own response to the report.

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

NHS Improvement has produced a range of safe staffing guidance for different clinical settings with an emphasis on staff using their professional judgement alongside assessing the evidence from their own wards around incidents and other metrics.

As well as looking at existing research, the review also identified gaps where more work was needed. It said: “Most of the evidence fails to consider the contribution of other health professionals. There is a need for evidence that considers models with different levels of other healthcare professionals’ hours at ward level. The role of temporary and agency staff on the ward is also under-examined.

“Evidence is needed on where the boundaries with registered nurse work should be drawn, together with ways of supporting delegation and the flow and transfer of information relevant to patient care across the ward team.”

The Royal College of Nursing has said it will campaign for new safe staffing legislation in England, while both Scotland and Wales are pursuing legally mandated safe staffing laws requiring hospitals to determine what is safe and to follow guidance on determining staffing levels.

Dame Donna Kinnair, acting RCN chief executive, said: ”The NIHR’s review adds to the important body of existing evidence that too few registered nurses on wards can lead to patient harm, and even death.

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

Hospitals in Northern Ireland use ranges of safe staffing levels for particular settings.

Following the Mid Staffs care scandal, the numbers of registered nurses in the NHS has hit record levels. However, the demand from the NHS for registered nurses means that, despite this record recruitment, there are still 42,000 vacant posts in the health service.