Level of safety staffing in mental health wards based on evidence: No such thing
How many caregivers should you have in your mental health ward to achieve the best results for your service users? This is a very important issue and needs to be taken apart a lot. What are we talking about? A decrease in negative outcomes such as self-harm and aggressiveness or improvement in positive outcomes, such as increased well-being or less readmissions or both? Recently, some negative experiences in mental health wards have been discussed here. Then, what caregivers (registered nurses, nursing partners, medical assistants) means we mean the best?
Some countries and jurisdictions, including Scotland, Wales, Victoria (Australia) and California (USA), legally require mandatory minimum staffing (e.g., van den Heede et al., 2020). Some have also called for this in England, but many of these policy decisions are based on studies on general and surgical wards (P. Griffiths et al., 2023). Is this study related to mental health? What happens when a hospital fails to meet legal restrictions? They usually get a fine, and a hospital that is already struggling with employee numbers is unlikely to make things better. As we discussed earlier, we have already had problems with retaining staff (Karpusheff, 2023; Long et al., 2023), and although understaffed wards can help, it is not the only problem.
Many UK hospitals use clinical judgment-based staffing guidelines that can be changed based on the number of service users in the ward and their severe illness (sensitivity), but even this is problematic. For example, “clinical judgment” will vary from one clinician to another.
A recent study published by Woodnut and colleagues (Woodnutt et al., 2025) brings together research literature on staffing in mental health wards to see the evidence we currently have and whether more evidence-based suggestions can be made.
Do we know the best staff portfolio for mental health wards?
method
Woodnutt et al.’s study is a systematic review of existing research Staffing level and violence in acute mental health wards. The purpose is just to look at the result. Therefore, it is relatively narrow, but is better defined and better represented in the literature than some other results. The search criteria are clear and seem to be suitable for research questions, and a large number of research databases have been searched, which suggests that all relevant published papers will be captured.
Due to the widespread differences in the literature, a narrative synthesis approach is adopted that prioritizes the analysis and discovery based on the quality of the paper. Overall, the authors pay great attention to the quality of the research. This is important because much of the evidence is of low quality and it is difficult to draw confident conclusions.
The relationship between staffing and violence and aggression on the ward is complex and the guidelines are unclear.
result
Thirty-five studies were included in a systematic review, all of which were observational, i.e. they did not include randomization of participants. There are large differences between the types of research. These include:
- International Comparison (2)
- Those who have reviewed national data (14)
- Ward-based comments (17)
All included studies were based on high-income countries. Most studies have low to moderate quality and are only evaluated as high quality.
The main finding of this review is that the relationship between staffing level and violence is complex. For example, Some studies found an association between staffing level and reduced violence, while others found the opposite effect (The improvement in staffing level is related to the increase in violence).
Some studies have shown that increasing staff reduces violence, but others again show the exact opposite, while others have no relationship at all.
have More positive evidence around skill setsStudies either show that the increase in the rate of registered nurses (compared to assistants or assistants) reduces violence or does not make any difference. Results on registered nurse levels in the ward were similarly mixed with studies that found positive and negative correlations with levels of violence.
This general level of inconsistency in the data may not be as shocked as a clinician or a former resident. However, it is still important to evaluate the status of the current literature so that nuances can be addressed in future research.
The results on the relationship between staffing and violence are far from clear.
in conclusion
The author concluded:
The current staffing crisis in mental health care emphasizes the urgent need for strong evidence to guide policies and improve patient outcomes. However, existing studies on the relationship between staffing, skill sets, and conflict/containment outcomes are limited by inconsistent findings, poor study design and under-adjusted confounders.
Advantages and limitations
This is a good review; the search strategy is likely to capture the most relevant and significant published studies. Quality assessments are thorough and candid about the shortcomings of the included study. This is woven through analysis.
As the authors point out, this was done as part of a PhD, with the first author doing most of the work in isolation. This may lead to the introduction of some bias, but the team does try to address this.
The review cannot draw a definite conclusion or make any recommendations on staffing level. However, this is because the current evidence is low quality. This is an important discovery in itself, not a criticism of the comments. This type of systematic review is important not only for summarizing and comprehensive research knowledge, but also for highlighting the serious shortcomings of the current evidence base.
The authors’ honesty about these limitations is honest, including lack of ambiguity (the types of events that occur in the study and including the types of events that are in the study). They have made recommendations for future work and research in the field. However, I personally would like to see more discussions about acuity and how to define “violence.”
Systematic evaluation plays an important role in highlighting uncertainties and gaps in the evidence base.
Impact on practice
The predecessors of violent behavior in mental health settings were diverse. Staffing may have some impact due to the interpersonal nature of mental health care. However, this is much more complicated than the number of people in the ward. Further, better research is urgently needed to take into account the nuances of this topic, including levels of acuity, employee experience and broader safety outcomes.
At this time, the level of the mental health ward equipped by the safety staff is not, nor is it based on evidence, which is detrimental to both employees and service users. Therefore, this review plays an important role in expressing an inconsistent and weak evidence base in areas of very important mental health practices.
The main implication of this work is that the current research on the level of staffing in mental health is simply not good enough. This review cannot make recommendations about the best approach to reducing violence because the evidence does not exist. This is a symptom of a lack of attention and respect for mental health services. In 2015, Nice began providing safety staffing guidelines for mental health services in England and stopped without publication. Ten years later, we don’t seem to be closer to the best approach to understanding the mental health department that benefits service users and employees. This results in poor retention rates in the mental health sector among NHS and service users, reporting repetitive experiences at best and actively traumatized in the worst case.
Given the severity of the topic and the impact of violence on employees and patients, substantial investment in high-quality research on mental health staffing is needed. We urgently need:
- Increase research funding for research for mental health personnel.
- High-quality researchers’ research level and skill set and impact on the safety of mental health environment. This should include hospitalization and community settings.
It’s a complex area, much more complex than healthcare in general, and it’s one of the reasons why it doesn’t get much attention. However, the interpersonal nature of mental health therapy means that this is crucial to achieving positive results for service users. As governments increasingly encourage new roles such as nursing partners, understanding the needs of staffing and skill sets has become even more important.
The level of security staffing on the ward is not, nor is it based on evidence, because we do not have enough research. This is a damage to all participants.
Link
Main paper
Woodnut (S.) The association between nurse staffing and conflict and containment in acute psychological care: a systematic review. International Journal of Mental Health Care34 (2), E70039.
Other references
Cost and cost-effectiveness of nurse staffing level and skill sets in acute hospitals: a systematic review. International Journal of Nursing Research147.
Karpusheff, J. (2023). What is missing from the NHS workforce program?. Health Foundation.
Long, J., Ohlsen, S., Senek, M., Booth, A., Weich, S. and Wood, E. (2023). The synthesis of realists, factors that affect the retention of personnel of adult mental health service personnel in the UK. BMJ opens13 (5), E070953.
Vanden Hyde (K. Safety Nurse Staffing Policy for Hospitals in England, Ireland, California, Victoria and Queensland: Discussion Documents. Health Policy124 (10), 1064–1073.
