Supplementary written evidence submitted by the Nursing and Midwifery Council (WBR0080)


1           Following our letter of 2 September 2020 to the Committee Chair regarding this inquiry and the subsequent extension of the inquiry deadline, we would like to take this opportunity to submit additional NMC evidence and point to other external sources of data that demonstrate the impact of low staffing numbers on safety and workforce resilience.

2           In our previous evidence, we stressed the importance of the whole health and social care system joining together to address the challenges of workforce shortages and the impact this could have on burnout. The letter included a summary of our annual leavers survey data which saw pressure and its impact on mental health as the second most common reason given for leaving the nursing and midwifery professions.

Further evidence on the impact of staffing levels on care

3           Our Future Nurse and Future Midwife standards emphasise the importance of understanding the relationship between safe staffing levels, appropriate skills mix, and safety and quality of care. We use a variety of surveys and other opportunities, internal and external to the NMC, to evaluate the experiences of the professionals on our register and to help us to continually improve.

4           There is strong evidence linking the number of registered nurses to the rate of patient harms, including mortality.[1] Existing research shows that low staffing levels can lead to more instances of ‘missed care.’ For example, this could cause a lack of follow-up care and health monitoring and relational care, which in turn negatively impacts patient safety.[2]

5           Other research shows how staff shortages can be linked to higher levels of nurse burnout and lower levels of nurses’ wellbeing. This in turn results in poor patient safety outcomes, such as medical errors.[3] In contrast, hospitals with higher levels of nurse staffing have better patient outcomes including lower rates of mortality, reduced patient falls and lower rates of pressure ulcers.[4]

6           Whilst important as measures of safety, people are more than just their illnesses. The way care is delivered by the professionals on our register influences people’s experience of care, as well as clinical outcomes. Care should involve a person-centred approach that sees the person as a whole. Nurse staffing has been shown to be associated with patient satisfaction as well as physical health outcomes.[5] [6] One study found that when staff were pressed for time, they were most likely to miss activities such as supporting and comforting, listening to and educating patients.[7] A study of general acute hospitals in 12 European countries found a link between the level of missed care and patient experience[8] as well as outcomes.[9] Good patient experience is positively associated with clinical effectiveness and patient safety.[10]

7           Burnout is not a new issue and has been explored in studies and surveys generally for a while, including the regular RCN members survey and a recent study in midwifery. However, staff shortage and the impact of Covid-19 bring this into sharper focus. There are many studies underway in relation to this, including calls for evidence and reflections from the Royal College of Nursing and the Royal College of Midwives.

8           There are good resources available for nurses and midwives to support them with welling being and self-care including guidance for nurses developed by the RCN and the resources developed by the RCM as part of their Caring for you campaign that has been in place since 2016.

9           The NMC contributed to the Kings Fund report ‘The Courage of Compassion: supporting nurses and midwives to deliver high quality care,’ published on 23 September 2020. The report looks at how the Covid-19 pandemic has exacerbated the excessive demands on professionals who were already at risk of burnout. It also considers the impact of ‘moral distress,’ burnout and dissatisfaction on staff turnover. Attrition can impact nursing and midwifery students, even before they qualify, causing further issues with workforce planning. The report highlights the negative effect a lack of robust workforce analytics in the health and social care sector has had on workforce planning and the need for this to be urgently addressed.

10      As outlined in our recent submission to your inquiry on social care, when care teams are understaffed they are less able to deliver high quality, dignified, safe, and person-centred care. Recent evidence from the CQC indicates that chronic workforce shortages have an impact on record keeping, information handover, infection control, management and support of care needs, and the capacity for staff to take essential training.[11] In such conditions mistakes can happen and quality can suffer.

11      A 2017 evidence review found a consistent and significant relationship between nurse staffing levels in the NHS and outcomes including mortality, staff burnout and incomplete nursing care.[12] It seems reasonable to assume that similar synergies exist between nurse staffing levels and outcomes for people using services in the social care sector too.

Next steps

12      Both NMC evidence and wider studies illustrate the impact of vacancies and low staffing levels on patient safety and staff resilience. Effective and sustainable  workforce planning, making sure we have enough nurses available to meet demand over the long term, is therefore essential for addressing these problems.

13      In order to achieve the intended benefits, any workforce plan needs to be fully comprehensive in covering the entire health and social care system. Both sectors are crucial and if we fail to account for the future needs of any part of the system, this will inevitably lead to gaps that will severely undermine the success of the whole.

14      Recent increases in the numbers of nurses and midwives have depended upon international recruitment. While there are positive benefits for learning and exchange of ideas, we cannot rely on this supply in the future. Earlier this year the International Council of Nurses reported a global shortage of nurses of almost 6 million.[13] In a global shortage of nurses we must make sure we are not taking nurses away from those countries already struggling with their own supply.

15      We are committed to playing our part in supporting the development of future workforce plans - from sharing our registration data, to ensuring that our registration processes are simple and proportionate and that our fitness to practise processes are fair and reflect the importance of just culture.

16      During the Covid-19 pandemic, many registrants who had moved away from the profession answered our call to return. Our survey of professionals on our Covid-19 temporary register highlighted that almost half would consider rejoining the profession permanently. If we want to keep them we have to be able to offer them an environment in which they can deliver the sort of care they can take pride in.

17      Key to success is that all parts of the system, across the UK, join together to collaborate in transparent and long term workforce planning.

About us

18      Our vision is safe, effective and kind nursing and midwifery practice that improves everyone’s health and wellbeing. As the professional regulator of more than 700,000 nursing and midwifery professionals, we have an important role to play in making this a reality.

19      Our core role is to regulate. First, we promote high professional standards for nurses and midwives across the UK and nursing associates in England. Second, we maintain the register of professionals eligible to practise. Third, we investigate concerns about nurses, midwives or nursing associates – something that affects less than one percent of the professionals on our register each year. We determine whether their knowledge, skills, education or behaviour fall below the standards needed to deliver safe, effective and kind care. We believe in giving professionals the chance to address concerns, but we’ll always take action when needed.

20      To regulate well, we support our professions and the public. We create resources and guidance that are useful throughout people’s careers, helping them to deliver our standards in practice and address new challenges. We also support people involved in our investigations, and we’re increasing our visibility so people feel engaged and empowered to shape our work.

21      Regulating and supporting our professions allows us to influence health and social care. We share intelligence from our regulatory activities and work with our partners to support workforce planning and sector-wide decision making. We use our voice to speak up for a healthy and inclusive working environment for our professions.



September 2020


[1] National Institute for Health Research (2019) Staffing on Wards. Thematic review. NIHR Dissemination Centre. doi 10.3310/themedreview-03553

[2] Sworn, K & Booth, A (2019) Systematic review: ‘missed care’ and the impact on safety in primary, community and nursing home settings. Journal of Nursing Management. DOI:

[3] Hall L, Johnson J, Watt I, Tsipa A & O’Connor D (2016) Healthcare staff wellbeing, burnout and patient safety: A systematic review. PLoS One 11(7): e0159015

[4] Griffiths P, Ball J, Drennan J, James L, Jones J, Recio-Saucedo A & Simon M (2014) The association between patient safety outcomes and nurse/healthcare assistant skill mix and staffing levels and factors that may influence staffing requirements. University of Southampton report for the National Institute of Health and Care Excellence (NICE)

[5]Aiken L, Sloane D, Bruyneel L, Van den Heede K, Griffiths P, Busse R, Diomidous M, Kinnunen J, Kózka M, Lesaffre E & McHugh M (2014) Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. The Lancet 383(9931): 1824-1830

[6] Griffiths P, Recio-Saucedo A, Dall’Ora C, Briggs J, Maruotti A, Meredith P, Smith G, Ball J & Missed Care Study Group (2018) The association between nurse staffing and omissions in nursing care: a systematic review Journal of Advanced Nursing 74(7):1474-1487

[7]Ball J, Murrells T, Rafferty A.M, Morrow E & Griffiths P (2014) ‘Care left undone’ during nursing shifts: associations with workload and perceived quality of care. BMJ Quality and Safety 23(2): 116-125.

[8]Bruyneel L, Li B, Ausserhofer D, Lesaffre E, Dumitrescu I, Smith H, Sloane D, Aiken L & Sermeus W (2015) Organization of hospital nursing, provision of nursing care, and patient experiences with care in Europe Medical Care Research and Review 72(6): 643-664

[9]Ball J, Bryuneel L, Aiken L, Sermeus W, Sloane D, Rafferty A.M, Lindqvist R, Tishelman C, Griffiths P & Consortium R (2017) Post-operative mortality, missed care and nurse staffing in nine countries: A cross-sectional study. International Journal of Nursing Studies

[10]Doyle C, Lennox L & Bell D (2013) A systematic review of evidence on the links between patient experience and clinical safety and effectiveness. BMJ open, 3(1): 001570.

[11] House of Commons Health Committee (2018) The nurses workforce, written evidence provided by CQC

[12] Griffiths et al (2017) Nurse staffing levels, quality and outcomes of care in NHS hospital wards: what does the evidence say?