National Assembly for Wales / Cynulliad Cenedlaethol Cymru
Health and Social Care Committee / Y Pwyllgor Iechyd a Gofal Cymdeithasol


Safe Nurse Staffing Levels (Wales) Bill / Bil Lefelau Diogel Staff Nyrsio (Cymru)

Evidence from National Institute for Health and Care Excellence – SNSL(Org) 27 / Tystiolaeth gan Y Sefydliad Cenedlaethol dros Ragoriaeth mewn Iechyd a Gofal – SNSL(Org) 27




NICE Safe Staffing Programme




1.    NICE was identified as a lead organisation in the development of advice on NHS staffing levels in the Francis report[1] on Mid Staffordshire, and in the Berwick report[2], Improving the safety of patients in England. The Berwick report stated: 


‘NICE should interrogate the available evidence for establishing what all types of NHS services require in terms of staff numbers and skill mix to assure safe, high quality care for patients’. 


2.    Following these reports, the National Quality Board (NQB) set out the immediate expectations of NHS providers in providing safe staffing levels. Their document, Expectations relating to Nursing, Midwifery and Care Staffing Levels[3], brings together the best of all the currently available material as a practical guide to help NHS providers. 


3.    To build on this work, in 2013 NICE was asked by the Department of Health (DH) to conduct a comprehensive review of the evidence relating to staffing levels, and to produce definitive guidelines on safe and effective staffing in a range of settings.

Scope of NICE safe staffing programme

4.    NICE was asked by the DH to develop evidence-based guidelines setting out safe staffing levels for the NHS, and to review and endorse any associated tools (for example, software or other decision-support tools that aid decision-making and setting staffing levels).  NICE was not asked to set minimum staffing levels.  The guidelines developed for the programme are primarily for use within NHS provider organisations, but are also relevant to non-NHS bodies that provide care for NHS patients.


5.    The main focus of the NICE safe staffing programme is on nursing and midwifery staffing levels, including nursing support staff, to ensure an appropriate balance of skill-mix across the whole team on wards and in other settings. Other elements of the healthcare team may also need to be included, particularly in future areas of work such as in mental health.


6.    The topic areas for our safe staffing programme have been prioritised according to areas covered by existing tools, which is where the most research is already available. 

7.    The first guideline topic we worked on was safe staffing in adult inpatient wards[4], which was published in July 2014.

8.    Work is well underway to develop and publish guidelines for the following topics.


·         Accident and emergency settings, including medical, children and surgical assessment units

·         High dependency and intensive care

·         Maternity wards

·         Care of the older people ward

·         Acute in-patient paediatric and neonatal wards

·         Neonatal intensive care and special care baby unit

·         Mental health in-patient settings

·         Learning disabilities in-patient setting

·         Mental health community setting

·         Learning disabilities in the community

·         Community nursing care settings

·         Operating theatres


9.    The principal output for our safe staffing programme is evidence-based guidelines[5] on cost-effective, safe staffing levels to support local decisions at ward and team level.  These guidelines are also used to help third parties update any tools they have produced to support safe staffing levels.


10.As part of the safe staffing programme NICE also provides formal quality assurance of existing safe staffing tools to confirm that they are compliant with the relevant NICE guideline.  This assurance process covers commercial and non-commercial tools. Where no tools are available, NICE engages with third party organisations to determine whether existing tools could be adapted for new settings.  In cases where this approach may not work, NHS England or the Department of Health could decide to directly commission a new tool.



11. The overall approach NICE uses to develop safe staffing guidance is in line with established NICE processes and methods for guideline development.  In brief, this entails setting out an initial scope that defines the parameters of the work, carrying out a comprehensive evidence review for consideration by an independent advisory committee, and the development of recommendations that are subject to open consultation. 

12. We also undertake targeted engagement with key stakeholder organisations for each topic area before we start evidence reviews.  This helps to inform stakeholders of the process, confirm the scope of work is appropriate, and to understand the breadth of evidence that might need to be considered.

13. A comprehensive search of published literature in the field is undertaken and all sources identified in the search are systematically reviewed. The evidence review considers which measures of safety are most closely linked to staffing levels, and any evidence comparing the role of nurses with support staff is taken into account.  The exact questions to be considered by the literature review are discussed and agreed with the independent advisory committee.

14. We identified early on that the evidence base for safe staffing in adult inpatient wards is unlikely to be complete; therefore scenario modelling was an important part of our assessment work.  This helped the NICE team and the independent advisory committee to model different staffing levels, and types of staff, against agreed safety outcomes to provide an impact analysis, which included resulting costs.

15. During the consultation phase for the first guideline, NICE employed a field testing approach to obtain more practical feedback on the product.  This is a useful method in relation to staffing guidance, to test assumptions prior to publication, subject to time constraints.

Independent Staffing Levels Advisory Committee

16. To help us with the evidence review and to develop the guidance we established an independent staffing levels advisory committee (SLAC). SLAC’s role is to consider the evidence and draft guidance, and provide general advice on the evidence base.  The committee may also signal the need for changes to existing tools, where the evidence clearly indicates that there is an urgent need for them to be updated.  The SLAC comprises of:

·       Chair (NHS Trust Chief Executive)                      1

·       Directors of nursing                                                 2

·       Senior nurses                                                           3

·       Nursing assistant/ assistance advocate              1

·       Lay members/patients                                             2

·       Local commissioner                                                            1

·       Allied Health Professional                                                 1

·       Medical director                                                        1

·       Hospital consultant                                                 1

·       Operations director                                                  1

·       Health economist                                                     1

·       External workforce experts                                     3


17. The membership of SLAC reflects the skills and expertise in core areas relevant to effective and safe staffing, as well as representatives from patients and carers.  The Committee also has capacity for expert advisors to be co-opted for specific topics such as maternity care and mental health services.







Further information:


NICE guideline: Safe staffing for nursing in adult inpatient wards in acute hospitals


Example scenario to illustrate the process of setting ward nursing staff requirements:

Frequently asked questions about SG1:


NICE safe staffing guidelines currently in development:



February 2015