Editorial: Enough Now: Mental Health Wards Must Be Adequately Staffed

The UK trade union Unison's Only Enough is Enough safe staffing campaign undertakes an annual survey of practising nurses' experiences and views (Tuckwood et al. 2024). The survey is administered through the union's extensive network of branches. Overall, across all domains of care, a worrying degree of staff shortages is reported alongside disappointing management responses and a disinclination amongst practitioners to bother escalating concerns. Broader research evidence has cumulatively painted the same picture. For instance, a systematic review focused on the relationship between omissions in nursing care (rationed care, care left undone, or missed care) and staffing levels showed 75% of nurses reporting some degree of missed care, and these care omissions were significantly associated with low staffing levels and seemed impervious to workforce substitution of nurses with support workers (Griffiths et al. 2018). Mental health problems also contribute to staffing pressures in wider NHS settings, including accident and emergency units and general hospital wards, leading to poorer outcomes (Foye et al. 2020). There is less research on staffing levels and ratios in the mental health context. With a specific focus on inpatient mental health settings, a systematic review found an unclear relationship between low staffing, ward conflict and use of containment measures, though nine studies did show higher staffing levels associated with reductions in conflict and containment (Woodnutt et al. 2025). Another more recent systematic review has demonstrated a positive relationship between quality of mental health nursing care and a range of important outcomes, including manifestations of aggression, instances of self-harm and rates of use of various restrictive interventions (Ngune et al. 2023). Interestingly, low staffing levels can impede quality improvement interventions within inpatient services, such as those aimed at minimising restrictive interventions (McKeown et al. 2019). There would seem to be an intuitive association between quality of nursing care or prevalence of critical incidents and staffing levels, but previous research has failed to conclusively demonstrate this in the mental health context (Woodnutt et al. 2025). More and better designed research is needed to explore relationships between nurse staffing levels, care quality and outcomes in mental health services; including a need to take account of vagaries in standard reporting and recording of ward incidents and outcomes. Commentary on previous iterations of this survey have highlighted these matters, drawing attention to a perceived normalisation of inadequate and unsafe staffing levels, whereby nurses and hospital managers have reached the point of taking it for granted that staffing is insufficient (Tuckwood and Griffiths 2025). Indeed, Robert Francis, who led the most notable inquiry into service failings associated with poor staffing, has remarked recently how an ongoing crisis amounts to a replication of the Mid Staffs deficiencies across the NHS with fatal results (Francis and Power 2023). This editorial focuses on the mental health data contained within the wider survey. 9 UNISON branches located in acute, community and mental health trusts and health boards in various regions of England and Wales took part in the survey. Members of UNISON who worked in mental health inpatient settings in these employers, including clinical staff (registered and non-registered) and non-clinical staff, were asked to complete a short anonymised online survey about their last shift as often as possible during October and November 2025. Members were sent several emails with a link to the online survey; promotional materials were shared in workplaces; and branch activists discussed the campaign and survey with colleagues. Data was collected from 164 shifts in mental health in-patient settings in October and November 2025. Respondents were asked to identify whether the shift was safely or unsafely staffed. The survey results show that 73% of mental health in-patient shifts were reported as having unsafe staffing levels. Specific red flag events occurred on 77% of all mental health in-patient shifts. They occurred on 89% of unsafely staffed shifts compared to 42% of safely staffed shifts. Particular red flag events included: 4% of shifts where preceptorship nurses (newly qualified) were working without a second RN; 22% of shifts where there were insufficient staff of the appropriate gender to ensure privacy and dignity; and 20% of shifts where there were fewer than two registered nurses on duty. The most commonly occurring red flag event was a reported insufficiency of staff with required safety critical skills (i.e., managing aggression and violence skills or Immediate Life support (ILS) competency) which occurred on 60% of unsafely staffed shifts. Important tasks were delayed or not performed on 79% of all relevant mental health in-patient shifts. Although tasks were delayed or not performed even if the shift was safely staffed, this happened on 91% of unsafely staffed shifts compared to only 35% of safely staffed shifts. The most common task subject to deficit on mental health in-patient shifts was ‘regular therapeutic ward activities’ which were delayed or not performed on 69% of unsafely staffed shifts, compared with 28% of the shifts deemed to be safely staffed. This substantial detriment to necessary activities chimes in with multiple published criticisms of the denuded or impoverished character of standard inpatient ward mental health care (e.g., Thompson et al. 2024). Other delayed or missed tasks included: supporting prescribed care such as planned escorted leave or ward activities (22% of safely staffed shifts and 59% of unsafely staffed shifts); carrying out required welfare checks (11% of safely staffed shifts and 22% of unsafely staffed shifts); environmental safety checks as indicated in patient care plans (11% of safely staffed shifts and 37% of unsafely staffed shifts); administering medication as prescribed (8% of safely staffed shifts and 15% of unsafely staffed shifts); supporting planned visits or appointments (11% of safely staffed shifts and 38% of unsafely staffed shifts). We're constantly under staffed, we're told we're not a priority as we're mental health. (health care support worker) We are always understaffed causing burnout and risk of been attacked by aggressive patients. (health care support worker) Protected Time for mental health nurses and healthcare support workers on inpatient wards is usually just lip service. We need time to be prioritised for us to have meaningful supervision, appraisals, reflective practice, being involved in QI projects, personal and professional training and development opportunities like it is the norm in community and all other disciplines with who we work with in the MDT, and an effective working environment for both patients and staff. (Registered Nurse) There continues to be a significant shortage of staff, which is placing considerable strain on service delivery and staff wellbeing. As bank staff, we are frequently required to provide continuous observation back-to-back, with little opportunity to rest outside of our scheduled break. This ongoing pressure is unsustainable and increases the risk of fatigue, stress, and reduced quality of care. (healthcare support worker) Adequate staffing levels and improved workforce planning are urgently needed to ensure a safe, supportive, and effective working environment for both patients and staff. (healthcare support worker) Overall, 56% of respondents on mental health in-patient shifts escalated a safety or staffing concern, an increase from 38% in 2024. Despite a seemingly healthy overall proportion of registrants escalating their concerns, there is worrying evidence that these are not always acted upon and that this can breed a reluctance to speak out. The survey asked the 68 respondents who escalated their concerns whether their employer took action to enable the delivery of safe patient care. Only 12% of these respondents were satisfied that their employer took action which enabled the delivery of safe patient care. An additional 35% of respondents didn't know if their employer took action or not. When they did take action, employers were most likely to bring in NHS bank or agency cover (75%). On 6% of occasions, the response was to reduce service activity, for example, closing beds or admissions. The survey also explored the reasoning of the 54 respondents who did not report their concerns. These respondents were most likely to say they did not have confidence that their employer would act on their concerns, or they didn't have enough time (each 44% of respondents). A further 11% were afraid of the consequences of escalating concerns and 13% stated they did not know how to escalate a concern, which suggests a substantial organisational deficiency. 4% said somebody else raised the issue, and a further 6% gave a range of other reasons. Taken together there is a concerning lack of consensus on the value of raising and escalating concerns regarding safe staffing and a worrying lack of professional courage and autonomy to do so in the face of perceived organisational antipathies. In a context of uncertainties over NHS funding and an ongoing workforce crisis, concerns over safe staffing levels within inpatient mental health services are legitimate. The Unison survey provides a degree of evidence to bolster campaigning and bargaining in the workforce context. A deterioration of service quality is with us, and nurses are discouraged from raising concerns about appropriate staffing and safety. This needs immediate policy and organisational attention to avoid further detriment to quality of care and safety. Even though a need for more rigorous research to examine the details of putative causative relationships would be welcome, this should not be the tail that wags the dog of urgent remedy. We would like to thank all the unison branches that took part in the survey and Professor Peter Griffiths at the University of Southampton who helped design earlier iterations of this survey. McKeown is an associate editor of the journal. The other authors declare no conflicts of interest. The data that support the arguments made in this editorial are available in a report to be published by Unison at [https://www.unison.org.uk/our-campaigns/only-enough-is-enough/].