Search the hub

Understaffing by nursing staff in hospitals is linked to patients coming to harm and dying unnecessarily. There is a vicious cycle whereby poor work conditions, including understaffing, can lead to nursing vacancies, which in turn leads to further understaffing. Is hospital investment in nursing staff, to eliminate understaffing on wards, cost-effective? This longitudinal observational study analysed data on 185 adult acute units in four hospital Trusts in England over a 5-year period. The study found that exposure to registered nurse understaffing is associated with increased hazard of death, increased chance of readmission and increased length of stay, while exposure to nursing support understaffing is associated with smaller increases in hazard of death and length of stay but reduced readmissions. Rectifying understaffing on inpatient wards is crucial to reduce length of stay, readmissions and deaths. According to the National Institute for Health and Care Excellence £10 000 per QALY threshold, it is cost-effective to eliminate understaffing by nursing staff. This research points towards investing in registered nurses over nursing support staff and permanent over temporary workers. Targeting particular patient groups would benefit fewer patients and is less cost-effective.

The fundamental importance of having enough registered nurses present to deliver care is well supported by evidence. Lower registered nurse staffing levels are associated with higher risks to patients and poorer quality care.  The Royal College of Nursing has issued their position statement on registered nurse staffing levels for patient safety, care quality and cost effectiveness. The RCN has a duty to uphold standards in nursing, support all members of the nursing team and lead the way towards safe and effective care. In relation to safe staffing, the RCN Nursing Workforce Academy (launched as part of the RCN Institute of Nursing Excellence) is leading the way by: Launching refreshed nursing workforce standards, making explicit what we see as the fundamentals needed to underpin safe and effective care delivery. Sharing the evidence on safe staffing (this article has highlighted some key references, but a more formal summary of the evidence is being produced). Bringing together the nurse staffing guidance that exists for each specialty and making explicit where there are recommended registered nurse to patient ratios. Taking forward the RCN’s commitment to ‘safety critical redlines’ – minimum nurse to patient ratios to protect patients and staff from harm caused by low registered nurse staffing levels. Our forthcoming ‘nest’ community platform will offer all relevant resources, latest publications and networking opportunities.

Each year since May 2023 the Sands & Tommy’s Joint Policy Unit have published an annual report setting out the extent of pregnancy and baby deaths across the UK. This year’s report argues that progress made to date falls short of what is needed to stop babies dying every day in the UK, and that unacceptable inequalities in pregnancy and baby loss persist despite continued calls for change. It estimates that at least 2,500 fewer babies – the equivalent of around 100 primary school classrooms - would have died since 2018 if the government had achieved its ambition of halving the 2010 rates of stillbirth, neonatal and maternal deaths in England. The report draws on the latest data from MBRRACE-UK, which shows that the gap continues to grow between neonatal death rates in the most deprived areas and those in the least deprived areas of the UK. It highlights that the stillbirth rate among babies of Asian ethnicity has risen sharply, and Black babies are still twice as likely as White babies to be stillborn. It includes 10 key actions for policymakers Renew commitments to save babies’ lives. Specifically, a stillbirth rate of 2.0 stillbirths, and a neonatal mortality rate of 0.5 neonatal deaths for babies born at 24 weeks’ gestation and over (per 1,000 live births). A preterm birth rate of 6.0%. Count miscarriages in the UK. The number and rate of miscarriages are not reported across the UK or for any individual nation. All UK governments should set up routine data collection on miscarriage. Take coordinated and meaningful action to eliminate inequalities. There are a range of policy areas where specific action is needed, including: understanding whether current efforts to reduce inequalities are working, and a comprehensive review of translation and interpreting services in maternity and neonatal care. Strengthen national leadership to make progress on the safety of maternity and neonatal services. Clarify the workforce needed to deliver safe care. Future development of the workforce must move away from a binary debate focussed on whether we do or don’t have enough staff and focus on the staffing requirements needed to deliver safe care, in line with nationally-agreed standards. Put the resources needed in place to deliver safe care. More investment is needed to improve the safety and quality of services if the government is going to deliver on its commitments to reduce rates of stillbirth and neonatal death and eliminate inequalities. Make informed choice a reality. Everyone should receive personalised care, know what they are entitled to, such as their birth choices, and services need the resources and operational capacity to provide this. Address unwarranted variation in care. Too often babies are dying because of care that is not in line with nationally-agreed standards. We need clarity on how national guidance is applied and clear national standards to improve the consistency of service provision. Ensure lessons are learned when babies die. The NHS is still not properly learning lessons when babies die or listening to the experiences of bereaved families to improve care in the future. There must be more robust oversight of the implementation of actions that are identified by reviews and investigations. Prioritise pregnancy and baby loss in research. This requires a broad range of research topics, the involvement of bereaved parents and communities, and a strong connection with policy and practice.

The fundamental importance of having enough registered nurses present to deliver care is well supported by evidence. Lower registered nurse staffing levels are associated with higher risks to patients and poorer quality care. Here is the Royal College of Nursing's position statement on registered nurse staffing levels for patient safety.

In June 2023 the Secretary of State for Health and Social Care announced that HSSIB would undertake a series of investigations focused on mental health inpatient settings. This overarching report brings together and explores cross-cutting patient safety risks across five individual investigations. The aim of this report is to examine patient safety risks identified across the following HSSIB investigations: Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of suicide risk and safety planning (12 September 2024) Creating conditions for the delivery of safe and therapeutic care to adults in mental health inpatient settings (24 October 2024) Mental health inpatient settings: out of area placements (21 November 2024) Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s mental health services to adult mental health services (12 December 2024) Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services and when patients die within 30 days of discharge (30 January 2025) Findings Safety, investigation, and learning culture There remains a fear of blame in mental health settings when safety events happen. This contributes to a more defensive culture despite staff actively wanting to learn. Many recommendations to support learning for improvements in mental health care do not lead to implemented actions. Reasons for this include a lack of impact assessment resulting in unintended consequences, no clear recipient involved in the development of recommendations, and duplicated recommendations across organisations. System integration and accountability The integration of health and social care within an integrated care system currently relies on relationships, with an expectation and hope that they will work well. However, where this is not the case, a lack of clear accountability can result in poor outcomes for people with mental illness and severe mental illness. The delivery of care for people with mental illness and severe mental illness is challenging because health and social care services are not always integrated and their goals are not always aligned. Physical health of patients in mental health inpatient settings There are gaps in the provision of physical health care for people with severe mental illness, including inconsistent health checks, poor emergency responses, and misattribution of physical symptoms to mental illness. The misattribution of physical symptoms to patients’ mental health was observed and had the potential to contribute to worsened patient outcomes. National reports, strategies and research have made recommendations to improve the physical health of people with severe mental illness. However, there is evidence that recommendations are delayed in implementation and people continue to die prematurely. Integrated care boards lack the required data and the necessary analytical capability to assess disparities in access, experience and outcomes related to the physical health needs of people with severe mental illness. There is variation in how the physical health checks are carried out on mental health inpatient wards, with limitations in processes for following up on patients’ physical health needs. There is variation in the knowledge, skills and experience of staff who undertake physical health checks and in the environments in which these checks take place. Patients may not always be supported in terms of health education about their physical health risks and modifiable risk factors, for example smoking, dietary advice and physical activity. Caring for people in the community Integrated care boards cannot consistently draw reliable insights from data at national, system or local level, to optimise and improve services, patient care, and outcomes across mental health pathways of care. This results in variability in service provision which does not always meet the needs of individual patients or local populations. Inpatient ‘bed days’ are taken up by people who no longer need them, because people who are clinically fit for discharge are delayed in being transferred to their home or a suitable residence (appropriate placement). Reasons for delayed discharges include issues with housing support and establishing suitable accommodation. This means patients are not always in the right place of care. Barriers to discharge affect patient flow and may result in delays in admission for people with severe mental illness. This means they have to be cared for in a community setting while waiting for an inpatient bed. There is variation across the country in how drug and alcohol services are provided. The variation does not allow for fair and equitable treatment for all patients. Community services are vital to support people to stay as well as possible and to prevent hospital admissions. However, there is variation in community service provision across the country. Staffing and resourcing Staffing and resource constraints in inpatient and community mental health settings impact their ability to provide safe and therapeutic care. In inpatient settings, constraints contribute to mental health wards aiming to staff for ‘safety’ but not always for ‘therapy’. Challenges for staff include the emotionally demanding nature of their work; this can lead to staff burnout and sickness, and further strain on services. There are gaps in mental health workforce planning, particularly in community services where there is no evidence based workforce planning tool to support a standardised staffing establishment setting model. Digital support for safe and therapeutic care A lack of interoperability or integration between digital systems affects the provision of care across mental health, acute and community providers. Challenges in securing appropriate funding impacts on the ability of hospitals to integrate and update their digital services and infrastructure. Electronic patient record functionality is often not available or does not meet staff needs, and so it is not used. Examples include absent functions for food and fluid balance monitoring and risk assessment of venous thromboembolism (blood clots). Challenges in providing and maintaining patient-facing technology, for example televisions and payphones, impacts on the therapeutic environment and the ability of patients to maintain contact with families and loved ones. Where technology for monitoring patients had been introduced, implementation has required considerations to ensure it is used appropriately, is patient-centred, maintains therapeutic engagement, and supports patients to feel safe. Suicide risk and safety assessment ‘Doing’ tasks, like ‘ticking’ checklists, overshadow meaningful, empathetic ‘being’ interactions with patients. Open, compassionate conversations that build trust and therapeutic relationships, enabling patients to own their risk while feeling supported, can help mitigate this. Investigation processes can contribute to a fear of blame, and subsequently contribute to defensive practices such as checklists and a ‘tick box’ culture. This inhibits open and honest conversations and the ability to put the patient, as their authentic self, at the heart of them. Safety recommendations HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are reviewed. This work should consider the mechanisms that supported or hindered the implementation of actions from these recommendations. This may help the Department of Health and Social Care understand what has worked when implementing actions from recommendations and enable learning about why some recommendations have not achieved their intention. HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management of patient safety risks and issues that span integrated care systems. Safety observation National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and therapeutic care.

Between August 2020 and April 2024, US hospitals were mandated to report weekly occupancy to the Department of Health and Human Services as part of Covid-19 data tracking efforts, providing unprecedented insight into mean daily census and inpatient bed supply across nearly all hospitals nationwide. In this report, the authors repurposed this Covid-19 dashboard to describe several possible US hospital bed occupancy scenarios arising from an aging US population over the next decade, while varying hospitalisation rates and staffed hospital bed supply. The study found that the US has achieved a new postpandemic hospital occupancy steady state 11 percentage points higher than it was prepandemic. This persistently elevated occupancy appears to be driven by a 16% reduction in the number of staffed US hospital beds rather than by a change in the number of hospitalisations. Experts in developed countries have posited that a national hospital occupancy of 85% constitutes a hospital bed shortage (a conservative estimate); these findings show that the US could reach this dangerous threshold as soon as 2032, with some states at much higher risk than others. These scenarios suggest that an increase in the staffed hospital bed supply by 10%, reduction in the hospitalisation rate by 10%, or some combination of the two would offset the aging-associated increase in hospitalizations over the next decade.

The phenomenon of a 'weekend effect' refers to a higher potential for adverse outcomes in patients receiving care over the weekend. Few prior studies have comprehensively investigated the effects of postoperative weekend care on surgical outcomes in a generalisable cohort. The aim of this study was to examine differences in short-term and long-term postoperative outcomes of patients undergoing surgical procedures immediately before vs after the weekend. In a cohort study involving 429 691 patients undergoing 25 common surgical procedures in Ontario, Canada, those who underwent surgery immediately before the weekend experienced a statistically significant increase in the composite outcome of death, complications, and readmissions at 30 days, 90 days, and 1 year compared with those treated after the weekend. These findings suggest that patients treated before the weekend are at increased risk of complications, emphasising the need for further investigation into processes of surgical care to ensure consistent high-quality care and patient outcomes. It is important for healthcare systems to assess how this phenomenon may impact their practices to ensure that patients receive excellent care irrespective of the day.

A new global survey of care workers reveals a deepening staffing crisis in the health and care sectors, with nearly 70% of workers frequently understaffed and over a third (36.4%) saying they are always working short-handed. Released on the fifth anniversary of the WHO’s Covid-19 pandemic declaration, the UNI Global Union report—based on responses from 11,233 workers across 63 countries—exposes a care system still in freefall. Despite being hailed as heroes, care workers face chronic understaffing, poverty wages, and surging workplace violence, driving many out of the profession and leaving patients at risk. Workers without union protections are affected by this trend even more intensely. The same failures that cost tens of thousands of lives during the pandemic remain dangerously ignored. UNI warns that these conditions are driving workers away from the sector, exacerbating a crisis that governments and employers have failed to address. The survey shows that union membership and collective bargaining significantly improve worker retention and satisfaction. Safe staffing levels are essential for high-quality care and safer work environments, but chronic shortages in hospitals and care homes undermine patient health – even causing preventable deaths. For care workers, understaffing leads to poor morale, increased workplace violence and injury rates, and high turnover. “Five years after the pandemic, care workers are still being overworked, underpaid and exposed to dangerous conditions,” said Christy Hoffman, General Secretary of UNI Global Union. “This report is a wake-up call. Without immediate action to raise wages, improve staffing levels, and combat workplace violence, care systems will collapse.”

This systematic review in JAMA Network Open aimed to assess the magnitude and moderators of the association between nurse burnout and healthcare quality and safety. The meta-analysis covered 85 studies which included 288, 581 nurses. The results show that nurse burnout was associated with: a lower patient safety climate and patient safety grade more nosocomial infections, patient falls, medication errors and adverse events lower patient satisfaction ratings lower nurse-assessed quality of care. The associations were consistent across nurse age, sex, work experience and geography. Based on these findings, the authors of the study suggest that systems-level interventions for nurse burnout may improve patient outcomes.

Previous research suggests that survival of patients may be associated with hospital organisational culture. Organisational factors such as culture, staffing, and retention of staff are crucial to patient safety. In a linked study covering nine years of monthly data from all NHS acute trusts in England, Moscelli and colleagues showed that a high turnover of senior doctors (hospital consultants and specialty associated doctors) and nurses in hospitals is associated with increased mortality for patients admitted for emergencies. For the 30 day mortality risk, a 1 standard deviation increase in the monthly turnover rate of nurses was associated with a 0.052 percentage point increase and of senior doctors was a 0.019 percentage point increase. Turnover rates among nurses showed a stronger association with mortality than turnover rates among doctors. One potential explanation is that while doctors usually meet patients one to one, nurses more often work in teams, which may be disrupted by high turnover rates.No significant association was reported between staff turnover and mortality for elective patients. As the authors suggest, this difference may be explained by the fact that elective patients have a lower mortality risk than patients in emergency departments. It should also be noted that well practiced processes are especially important in emergency settings where time is crucial. Decisions must be taken quickly and under stress. Therefore, patients in the emergency departments might be particularly susceptible to when the staff is less experienced or not well settled into their team.

Nurses play a crucial role in maintaining the safety of surgical patients. Few nurse staffing studies have looked specifically at surgical patients to examine the impact of exposure to low staffing on patient outcomes. The study, published in the British Journal of Surgery and conducted by University of Southampton researchers, analysed data from 213,910 NHS hospital admissions of surgical patients between April 2015 and February 2020, to see the relationship between nurse staffing and adverse outcomes. According to the research, the relative risk of a surgical patient dying was increased by 9% for each day where registered nursing shortages were reported. This additional risk increased to 10% when the shortage was of nursing support staff. Risks for specific hospital-related conditions also increased when nurse shortages were reported. The study found evidence that registered nursing shortages correlated with 5% increased risk of deep vein thrombosis, 6% for pneumonia and 6% for pressure ulcers. Too few nursing assistants also increased the risk of these conditions.

The Trade Unions Congress (TUC) is proposing a new care workforce strategy for England, developed with trade unions and informed by the voice and experiences of care workers. This strategy document sets out the critical building blocks to ensure care workers are valued and supported, as a key means of addressing the current staffing crisis and improving access to and quality of social and childcare services. The strategy proposes four key focus areas for the national care workforce strategy: Worker voices heard and valued including through sectoral collective bargaining arrangements and through the creation of National Partnership Forums in social care and childcare. Decent pay and conditions for all care workers through a collectively bargained sectoral agreement on fair pay and decent working conditions, a new sectoral minimum wage of £15 per hour, sick pay, secure contracts and full payment for all time worked, as well as access to efficient labour market enforcement mechanisms. Skills, training, and progression pathways with nationally negotiated training frameworks to ensure consistency and quality. These should be aligned with national pay structures to make sure staff are fairly renumerated and can progress as they acquire new skills and knowledge. Training must be accredited and qualifications recognised and transferrable to new employers. Protect health, safety, and wellbeing including ensuring that staffing levels are based on care and education needs and not arbitrary ratios. And a zero-tolerance approach to workplace abuse with comprehensive safeguarding and support, notably for staff who may be at increased risk of experiencing abuse and harassment including Black and migrant workers.

This study in Intensive and Critical Care Nursing examined the association between safety attitudes, quality of care, missed care, nurse staffing levels and the rate of healthcare-associated infection (HAI) in adult intensive care units (ICUs). The authors concluded that positive safety culture and better nurse staffing levels can lower the rates of HAIs in ICUs. Improvements to nurse staffing will reduce nursing workloads, which may reduce missed care, increase job satisfaction, and, ultimately, reduce HAIs. Key findings ICUs with strong job satisfaction had lower incidence and nurse-reported frequency of CLABSI, CAUTI, and VAP. Missed care was common, with 73.11% of nurses reporting missing at least one required care activity on their last shift. The mean patient-to-nurse ratio was 1.95. Increased missed care and higher workload were associated with higher HAIs. Nurses’ perceptions of CLABSI and VAP frequency were positively associated with the actual occurrence of CLABSI and VAP in participating units.

Georgia Stevenson discusses NHS England’s Long Term Workforce Plan, evaluating its potential to alleviate staffing shortages, enhance training routes, and ultimately improve care quality in maternity and neonatal services.

The presentation was held following the inaugural William Rathbone X Lecture, given by Professor Alison Leary, who spoke on the highly topical subject, ‘Thinking differently about nursing workforce challenges.’ The presentation can be watched from The Queen's Nursing Institute website.

This report assesses why NHS hospitals are failing to deliver higher activity despite higher spending on the service and higher levels of staffing over the last couple of years. It argues that politicians need to urgently focus on capital investment, staff retention and boosting management capacity, and sets out key questions for policy makers to address if they want to solve the NHS crisis. The NHS has been on a longer-term negative trajectory: most of the challenges identified in the report existed before the pandemic and have been exacerbated since.

This is the 15th annual clinical radiology census report by The Royal College of Radiologists. The census received a 100% response rate, meaning this report presents a comprehensive picture of the clinical radiology workforce in the UK as it stood in October 2022.   Key findings The workforce is not keeping pace with demand for services. In 2022, the clinical radiology workforce grew by just 3%. In comparison, demand for diagnostic activity is rising by over 5% annually, and by around 4% for interventional radiology services.  The UK now has a 29% shortfall of clinical radiologists, which will rise to 40% in five years without action. By 2027, an additional 3,365 clinical radiologists will be needed to keep up with demand for services.   This will have an inevitable impact on the quality-of-care consultants are able to provide. Only 24% of clinical directors believe they had sufficient radiologists to deliver safe and effective patient care.   Interventional radiologists are still limited with the care they can provide. Nearly half (48%) of trusts and health boards have inadequate IR services, and only 1/3 (34%) of clinical directors felt they had enough interventional radiologists to deliver safe and effective patient care.   Stress and burnout are increasingly common among healthcare professionals, risking an exodus of experienced staff. 100% of clinical directors (CDs) are concerned about staff morale and burnout in their department. 76% of consultants (WTE) who left in 2022 were under 60.  We are seeing increasing trends that the workforce is simply not able to manage the increase in demand for services. 99% of departments were unable to manage their reporting demand without incurring additional costs.   Across the UK, health systems spent £223 million on managing excess reporting demand in 2022, equivalent to 2,309 full-time consultant positions. Access the full census report here Related content: The benefits of a nursing led Vascular Access Service Team: A White Paper to outline a standardised structure and approach for the NHS to deliver vascular access services in every hospital (27 June 2022)  

In this opinion piece for the BMJ, Partha Kar looks at the current debate surrounding the role of medical associate professionals (MAPs) in the NHS. He highlights the concerns raised by many that MAPs are “doctors on the cheap” and outlines the reasons for friction between junior doctors and MAPs, which include the issues of pay, training and regulation. He also outlines issues facing locally employed doctors (LEDs), international medical graduates (IMGs) and specialist, associate specialists (SASs) including lack of access to training, supervision and career progression. He makes five suggestions to improve the situation and calls for a pause to consider how these different roles can interact and work together, for the good of both staff and the health service.