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The University of Southampton
Health Sciences

Influencing changes to nurse staffing legislation, policy and practice to improve patient safety in hospitals in the UK and internationally

Following a damning enquiry into failing nursing care at an NHS trust, research by the School of Health Sciences’ Health Work Research Group has shaped the ensuing public debate around safe nurse staffing which subsequently informed clinical guidelines and legislation in the UK. Their influence has reached global levels through reports from WHO and the International Council of Nursing.


The Francis Inquiry (2013) into the care scandal at Mid Staffordshire NHS Trust found that some patients had gone without essential nursing care with fatal consequences. Nurse staffing levels were identified as a contributory factor and the inquiry recommended that evidence-based national policy and guidance on safe staffing be developed.

This was backed up by the findings of a global consortium, RN4Cast, whose research in the UK was led by the UoS team. They found that each additional patient per nurse was associated with an average 7% increase in the odds of patient death.

Research challenge

Professor Peter Griffiths, Professor Jane Ball and Dr Jeremy Jones addressed important gaps in the evidence base, explaining how nurse staffing impacted upon patient mortality and elucidating specific levels associated with harm.

Previous studies had rarely considered other staff groups, including doctors, and thus were largely unable to demonstrate that the nurse staffing effect was not confounded with general hospital resources or address the potential substitution between staff groups – a crucial policy issue in the face of staff shortages.

Influencing public policy debates over safe staffing levels for nurses

The UoS team’s findings on missed care and nurse staffing levels – in particular that 86% of nurses left necessary care undone, and that this was related to nurse staffing levels – caused a public outcry.

The widespread and sustained public debate contributed to a change in discourse among policymakers and health practitioners, including the Safe Staffing Alliance, and was supported by organisations like Royal College of Nursing and UNISON, who campaigned for a legal minimum nurse:patient ratio of 1:8, which was the ‘warning level’ identified at UoS.

Shaping new polices, clinical guidelines and legislation on safe staffing in the UK

The National Institute for Health and Care Excellence (NICE) commissioned the UoS team to review the evidence, and the 1:8 warning level was included in the 2014 NICE guideline, Safe staffing for nursing in adult inpatient wards in acute hospitals.

The warning level was widely cited in key guidance published by NHS Improvement between 2016 and 2019 to ensure safe staffing levels. Griffiths acted as scientific advisor to NHS Improvement’s ‘Safe & Sustainable Staffing’ panel.

Shaping new polices and clinical guidelines on safe staffing internationally

The UoS finding that important omissions in care were associated with low staffing has led to its use by the Irish Government as an indicator of staffing insufficiency; they noted that the UoS research “has provided an important outcome indicator, capable of measurement at ward level, and incorporation into Government Policy for system-wide implementation.”

Globally, the research continues to raise awareness of the need for ‘safer staffing’ and prompt action to change policy and practice. It has been cited in authoritative reports including those by the WHO, the American Nurses Association and Australia’s Department of Health.

Key Publications

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