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Our practical guide explains how and in what circumstances to use ‘red flags’ to raise nurse staffing gaps, whether you’re a ward manager or leader, or a staff nurse
Feeling safe to raise concerns in the knowledge that any issues will be listened to and acted on is essential to our well-being at work. Whether about patient safety or staffing levels, we must have the courage to raise and escalate our concerns using the tools and support available, such as a red flag system.
Nursing Standard. 39, 1, 30-31. doi: 10.7748/ns.39.1.30.s16
Published: 03 January 2024
In 2014, the National Institute for Health and Care Excellence (NICE) published guidance on safe staffing levels on hospital wards. This followed the 2013 publications of the Francis Inquiry report into poor care at Mid Staffordshire NHS Foundation Trust and the Berwick report on patient safety – both of which identified that inadequate staffing levels contributed to poor quality care.
The NICE guidance recommended the use of ‘red flags’ for safe staffing – a system that warns the nurse in charge that there may not be enough nursing staff to meet the needs of patients on that shift, so that immediate action can be taken.
From students and support workers to the most senior nurses in an organisation, everybody has a role in raising concerns about safe staffing.
The level of responsibility for acting on these concerns depends on your role and level of experience, but if you have any concerns about staffing levels as a nursing student, healthcare support worker or newly registered nurse, raise these with the nurse in charge of the shift as soon as you can.
Nurses at band 5 should also raise any concerns with the nurse in charge. For example, if there is only one registered nurse on the ward who can administer intravenous (IV) medications and the majority of patients require IVs, raise this with the nurse in charge so they can help.
The responsibilities of those at band 6 include assessing staffing, discussing it with the nurse in charge and supporting them in coming up with solutions or mitigations. The nurse in charge is responsible for assessing staffing against bed occupancy and patient acuity and dependency, so listening to colleagues’ concerns is vital.
This cycle of communication is essential when raising, reviewing and resolving red flags. It reassures staff that any concerns raised are being listened to and acted on promptly, improving staff well-being while ensuring patient safety.
» The nurse in charge assesses staffing levels for the day at the earliest opportunity – ideally during or immediately after handover – then compares their findings to the types of red flags set out by the organisation
» If the assessment of staffing triggers a red flag, the nurse in charge creates a red flag via the system used by the organisation. This triggers an auto-alert to senior nursing colleagues – usually nurses at band 8a and above, such as matrons – to respond to the alert
» Senior nurse reviews the red flag at the earliest opportunity during the same shift period, looking at staffing levels and implementing mitigations where possible and appropriate. An example is weighing whether a staff member can be redeployed to another area for part of the shift, to avoid the use of bank or agency staff
» The decision-making process and resolution of the red flag is then documented, with the senior nurse providing feedback on actions taken to the nurse in charge
Many factors can affect safe staffing levels during a shift, such as increases in patient acuity or someone going home sick.
Red flag systems enable real-time monitoring during the course of a shift, giving senior nurses continuous oversight of staffing levels and patient acuity, allowing them to determine whether the staffing level is safe enough to meet patient demand. Either the nurse in charge or the ward manager should raise a red flag. This ensures continuity and eliminates the risk of power struggles between colleagues.
The nurse in charge of any shift should have access to software for raising a red flag. At University Hospitals of Leicester NHS Trust, red flags are raised electronically using Allocate SafeCare, which provides live visibility of staffing levels in relation to patient demand.
Technology is key to safe staffing. Although red flags can be raised in person – at staff meetings, for example, or if the ward manager or nurse in charge speaks directly to the matron – an automated escalation system enables senior colleagues to respond quickly as soon as a red flag is raised, so that a timely solution can be found.
Organisational oversight of staffing is essential for senior nurses’ daily operational management. SafeCare uses a traffic light system, with red, amber or green status allocated depending on the staff required versus the staffing hours actually available.
The system also highlights areas where red flags have been raised, allowing the data to be analysed so any themes or patterns can be identified. For example, if the data show most of the red flags for one area or specialty are being raised on a Monday long day shift, senior nursing staff can examine what is happening during that shift and how can they respond.
The monitoring and analysis of trends is critical to enabling continuous improvement of services and response to patient need.
The core nursing red flags in the NICE guidance are:
» Planned medicine administration is missed
» More than 30 minutes’ delay in providing someone with pain relief
» Failure to record or assess a patient’s vital signs in line with the person’s care plan
» Delayed or missed regular checks on patients to ensure fundamental care needs are being met, such as pain assessment, meeting hydration needs, ensuring patients are comfortable and assessment and monitoring of pressure ulcer risk
» Fewer than two registered nurses being present on a ward during a shift
» A shortfall of more than eight hours, or 25% (whichever is reached first) in the registered nurse time available, compared with the actual requirement for the shift. For example, if a shift requires 40 hours of registered nurse time, a red flag event would occur if fewer than 32 hours of registered nurse time was available for that shift
The NICE guidance says red flags can also be agreed locally – not having enough staff to provide continuous patient observation, for example, could be an additional red flag.
It is essential red flags are not neglected or disregarded, with safe staffing guidance from the National Quality Board highlighting the importance of a ‘triangulated approach’ to safe staffing. This combines patient outcomes, evidence-based tools and professional judgement to ensure we have the right staff with the right skills in the right place at the right time.
As well as enabling staffing concerns to be identified and acted on quickly, a red flag system improves communication, team work and nurses’ problem solving skills, and ensures staff are listened to when they raise concerns.
Safe staffing is everybody’s business and should be monitored from ward to board. This promotes a transparent culture and positive working relationships that make it possible to deliver high-quality patient care.
Letby: the safeguarding support nurses need to raise concerns rcni.com/Letby-safeguarding-support
NICE (2014) Safe staffing for nursing in adult inpatient wards in acute hospitals
National Quality Board (2016) Supporting NHS providers to deliver the right staff, with the right skills, in the right place at the right time
