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Using evidence to make decisions: does this apply to the government?
  1. Alison Twycross
  1. Department of Children's Nursing, Faculty of Health and Social Care, London South Bank University, London, UK
  1. Correspondence to: Dr Alison Twycross, Department of Children's Nursing, Faculty of Health and Social Care, London South Bank University, London SE1 0AA, UK; a.twycross{at}

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In my May contribution to the EBN Blog ( I sent a message to Jeremy Hunt, the English Secretary for Health, about nurse staffing levels. Despite compelling evidence supporting the conjecture that patient safety is inextricably linked to registered nurse-to-patient ratios, the Government continue to pronounce that decisions need to be taken at a local level and refuse to set minimum staffing levels. A study published in 2011 suggests missed nursing care may explain, at least in part, the relationship between staffing levels and patient outcomes in the USA.1 Similar findings are emerging in the UK with 86% of nurses in one study reporting that one or more care activity had been missed on their last shift due to a lack of time.2 This is perhaps a no brainer—if there are not enough staff on duty with the right skill mix it is going to be almost impossible to ensure all nursing care is carried out. Mandatory staffing levels work in other countries—so why not in the UK?

As the editor of EBN I, perhaps unsurprisingly, believe it is important that nurses use the best available evidence when making healthcare decisions. I also believe politicians should do the same when deciding on policy. There are a plethora of examples where they have failed to do this even when the results of pilot studies indicate there are likely to be unintended consequences if policies are implemented across the board. Take, for example, recent changes to housing benefit in the UK which is now paid directly to the tenants rather than landlords. In pilot studies the incidence of rent arrears went up. Despite this Government is implementing the policy across the UK. (This begs the question of why they bothered with the pilot study in the first place.) The Government appears to be taking a similar approach to setting mandatory staffing levels—that is, ignoring the evidence.

Some trusts in the north of England have taken matters into their own hands and under an initiative called Transparency in Care are taking the laudable step of publishing data on patient safety incidents. The reported data is likely to include information about the number of incidents and the severity of harm, and the staffing levels and skill mix at the time the incident took place. Such transparency is integral to the 6Cs Compassion in Practice Action Plan (for more information see: Publishing this data is a good starting point but I think we need to go a step further and explore how it can be used to ensure practice improves. One way is to use root cause analysis. Root cause analysis looks at an incident from several vantage points with the aim of identifying the root cause(s).3 ,4 Given the complexity of healthcare, adopting this approach would enable a clearer evidence-base for planning improvements. Any guesses on the number of times staffing levels and skill mix would emerge as a key issue?

At the start of 2014 we should perhaps revisit the New Year wishes for nursing put forward by the Safe Staff Alliance ( in January 2013.

  • Statutory minimum staffing levels should be set.

  • Information should be available for patients on registered nurse numbers.

  • The board of every healthcare organisation should receive an annual review of nurse staffing from the Director of Nursing.

  • Ward sisters and community nurse leaders should be given control of staffing and other key resources.

  • New research should be carried out on registered nurse staffing funded by the Department of Health.

A year on there is clearly more work to be done but what is apparent is that the nursing profession needs to take a stand on safe staffing levels and campaign to ensure the Government takes decisions based on the best available evidence.

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  • Competing interests None.

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