Patients who receive poor standards of nursing care while in hospital should be able to prompt an investigation into whether or not there are enough staff on their ward, new NHS guidance suggests.
Hospital patients in England who are given sub-standard care should be able to alert ward managers which should prompt a probe into whether or not there are a safe number of staff working on the ward, according to the National Institute for Health And Care Excellence (Nice).
Nice has identified a number of "red flags" which indicate that care could be compromised. When these are identified by a patient or a member of staff action should be taken immediately, it's new advice to the NHS states.
These include patients not being helped on a visit to the bathroom, patients not receiving their medication or delays of 30 minutes or more in providing pain relief.
Missing regular checks on patients to ensure that their fundamental care needs are being met - including having enough to drink and ensuring that they are not at risk of bed sores - should also be treated as a smoke alarm to indicate that there may not be enough nurses on the ward.
Having fewer than two registered nurses on a ward at any time or if there is a shortfall of 25% of the number of nurses required for the shift should also act as a warning sign.
If these red flag events are highlighted by a patient or staff member then the nurse in charge of the ward should act "immediately" to ensure that there are enough staff on the ward, Nice said.
Nurses could then be drafted in from other wards or agency staff brought in to address the shortfall urgently.
But in the longer term these red flags would be reported and considered in the management of staffing levels throughout the hospital - which Nice says should be an ongoing process .
"The key point of a red flag is that additional staff are required pretty urgently on the ward to make sure that those key things are delivered," said Professor Gillian Leng, deputy chief executive at Nice.
But the organisation would not be drawn on setting a nurse-to-patient ratio, despite calls for the health service to have a minimum of one nurse caring for eight patients.
Nice did say that if a nurse is "routinely" caring for more than eight patients at a time it should be seen as an "amber flag" and investigated.
Prof Leng said: "Safe staffing is more complex than setting a single ratio. The emphasis should not just be on the available number of staff, it should be on delivering safe patient care and making sure that hospital management and nursing staff are absolutely clear on best practice to do this.
"The reason why there is no single one-to-eight figure is because that will be seen as the figure that should be applied across all wards where we know that one to eight is not going to be enough in many scenarios. A single figure is not appropriate if we want to deliver the right level of care for patients.
"It's an amber flag, it's a signal about safety that should be taken into account and investigated.
"If there is a nurse routinely caring for more than eight patients during a day shift the matron in charge should take a look at whether care is actually being delivered appropriately and it may be that it is but it may be that more staff are required."
In its new safe staffing advice Nice sets out how NHS organisations should set out, and routinely review, nursing staffing requirements to ensure safe patient care on adult inpatient wards in acute hospitals.
"This is about assessing patient needs and and getting the staffing levels right," Prof Leng said. "We need to be smarter than a minimum number."
The guide sets out how managers can determine whether staffing is meeting expected standards.
If a ward is seeing large numbers of patients with pressure ulcers or falls or staff are not getting appropriate breaks these are signs that a ward is not staffed well enough, Nice said.
Nice said that it could cost as much as £200 million to implement the changes across the health service in England but it couldn't say where the cost estimate has come from.
The current cost for nursing staff in acute wards is estimated to be around £4 billion.
Prof Leng added: "The NHS cannot afford to be unsafe - neither morally nor financially. The benefits of better care, such as cost savings that could be achieved from dealing with fewer infections, falls or pressure ulcers, will go a long way to helping hospitals balance limited budgets."
Dr Peter Carter, chief executive and general secretary of the Royal College of Nursing, said: "Nursing staff have long recognised the importance of safe staffing levels and consistently provided evidence of the danger to patients where there are too few staff. It is good to see that this is now being recognised across the NHS.
"The needs of patients should be the only thing determining staffing levels - not finances. Patient care must not be compromised because of short-term financial cuts and a minimum safe staffing level should not become a default staffing level.
"The guidelines identify a number of red flags which would indicate care is being compromised. These must not be ignored and action should be taken immediately to avoid harm to patients."
Health Secretary Jeremy Hunt said: "This is a major step forward for NHS safety. As a result of this new guidance the NHS will be able to give safer care and patients can have confidence that the right number of nursing staff are on duty. It will also help hospitals to balance their books - for every fall avoided because a nurse was on hand to help, Nice estimates another £1,400 is saved.
"Recent years have seen a big jump in nursing numbers in hospital wards, with 6,200 more nurses since 2010. Today's guidance will help the NHS use staff as effectively as possible."
Labour's shadow health secretary Andy Burnham said: "Hospitals across England are operating way beyond recommended capacity levels and, because of this, too many do not have enough staff to provide safe care. In the last year, inspectors failed one in six hospitals for not having adequate numbers of staff.
"Worryingly, this problem looks set to get worse as the NHS is planning to cut thousands more nurses in the coming years as financial problems deepen.
"The Government has trapped the NHS in a vicious circle. Huge cuts to nurse training have left the NHS relying on agency staff but that in turn has deepened financial problems."
A spokesman for NHS England said: "There are more NHS nursing staff than ever before with over 5,000 more than last year.
"Every ward is different and needs the right team of staff to provide high quality, compassionate care for their patients' individual needs.
"This means looking at the evidence, using clinical judgment and regularly monitoring staffing, with the flexibility to quickly adapt to changing circumstances."