Analysis

Does your emergency department match up to the new nursing workforce standards?

Meeting the RCN and Royal College of Emergency Medicine’s standards for Type 1 EDs might prove challenging, warn leading ED nurses

Meeting the RCN and Royal College of Emergency Medicines standards for Type 1 EDs might prove challenging, warn leading ED nurses

  • 27 nursing workforce standards address patient safety and care in the emergency department
  • A minimum of one registered nurse to each patient in the resuscitation area is recommended
  • Emergency departments should have a lead nurse manager, a matron and at least one emergency nurse consultant

Rigorous new standards for the number and skill mix of nurses in major emergency departments (EDs) will

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Meeting the RCN and Royal College of Emergency Medicine’s standards for Type 1 EDs might prove challenging, warn leading ED nurses

  • 27 nursing workforce standards address patient safety and care in the emergency department
  • A minimum of one registered nurse to each patient in the resuscitation area is recommended
  • Emergency departments should have a lead nurse manager, a matron and at least one emergency nurse consultant
The RCN and Royal College of Emergency Medicine guidelines say that there should be at least two registered nurses to one patient during the resuscitative phase of illness or injury. Picture: iStock

Rigorous new standards for the number and skill mix of nurses in major emergency departments (EDs) will be challenging to meet for most hospitals, leading emergency nurses warn.

Joint workforce standards from the RCN and the Royal College of Emergency Medicine (RCEM) contain 27 specific recommendations on the make-up of the nursing workforce in Type 1 EDs for patient safety and quality of care.

There were 183 Type 1 EDs in England in 2018, which include facilities such as a consultant-led 24-hour service with full resuscitation facilities, as well as designated accommodation for the reception of ED patients.

The workforce standards stipulate that there should be a minimum of one registered nurse to each patient in the resuscitation area, and a minimum of one registered nurse to three cubicles where moderate and high-dependency patients are nursed.

‘Unacceptable’ to nurse patients in corridors and non-clinical areas

The RCN and RCEM’s standards also state that nursing patients in corridors and non-clinical areas is ‘unacceptable’.

183

Type 1 emergency departments in England in 2018

Source: Royal College of Emergency Medicine

‘When this is unavoidable, a risk assessment must be completed to ensure that the area used has the necessary equipment and resources to minimise patient safety risks.’

Each ED should have a lead nurse manager, a matron and at least one emergency nurse consultant.

The nursing workforce should comprise a minimum of 80% registered nurses, and at least half of these should have academic post-registration training in emergency nursing.

Seven key standards for Type 1 emergency departments

  1. There will be a minimum of one registered nurse to each patient in the resuscitation area. This ratio will be at least two registered nurses to one patient during the resuscitative phase of illness or injury, such as cardiac arrest and the initial assessment of major trauma
  2. The emergency department (ED) nursing workforce will be determined by triangulating professional judgement and nursing workload, which is calculated using the RCN Emergency Care Association Baseline Emergency Staffing Tool or by using another appropriate ED nursing workload tool benchmarked with appropriately selected and comparable peers
  3. No greater than 20% of individuals on any given shift will be from bank or agency. The use of temporary, bank, overtime and agency staff is associated with increased clinical risks due to factors, such as variable clinical ability, limited relevant experience and unfamiliarity with the specialty and the local geography of the ED
  4. A minimum of 50% of registered nurses will be in possession of an academic post-registration award in emergency nursing
  5. Where EDs receive children there will be at least two registered children’s emergency nurses on shift
  6. The nursing workforce on shift will be sufficient to accommodate staff breaks without compromising patient safety and quality of care
  7. When calculating the nursing workforce whole time equivalent, a minimum uplift of 27% will be applied to cover planned leave, unplanned leave, mandatory training and specialty specific training, without compromising patient safety

Source: RCN and RCEM (2020)

Previous attempts to set safe staffing ratios in emergency departments have stalled

Meeting the 27 recommendations set out in the standards will be challenging for most EDs, emergency nurses warn.

Previous attempts to set standards for ED staffing struggled.

Draft guidance on safe staffing for nursing from the National Institute for Health and Care Excellence ground to a halt following a consultation in 2015, and was handed over to NHS Improvement.

This handover resulted in a set of recommendations from the National Quality Board in 2017, with no mention of minimum staffing ratios.

Janet Youd

Co-author of the new standards, and emergency nurse consultant and former chair of the RCN Emergency Care Association (ECA) Janet Youd says the standards are a much-needed push to increase the numbers of staff with specialist knowledge in emergency care around the UK.

It is well known that many EDs are struggling with the volume of patients.

Pre-lockdown, the number of ED visits was generally increasing, more patients were being cared for in corridors, and waiting times were growing.

Overcrowding and corridor nursing care had become the norm last winter

According to a Care Quality Commission (CQC) report published earlier this year, urgent and emergency services receive the lowest CQC ratings of core hospital services, with more than half being rated as ‘inadequate’ or ‘requires improvement’.

Picture: Charles Milligan

The CQC reported that overcrowding and corridor nursing care had become the norm in EDs last winter.

As Dr Youd says: ‘The RCN and the RCEM decided that we needed these standards.

‘There is so much disparity around the country between skill mix and the number of nurses in different EDs, and it is about the quality and safety of care.

‘These standards are a line in the sand saying this is what is needed.’

The CQC report was inspired by the British Association of Critical Care Nurses’ (BACCN) influential workforce standards that state each ventilated patient should have one-to-one nursing care, and every patient in a critical care unit should have ‘immediate’ access to a nurse with a post-registration qualification in the specialty.

‘We need emergency nurses working in emergency departments. It is not just about numbers of staff. It is how many registered nurses we need, and the level of skill they have’

Janet Youd, emergency nurse consultant and co-author of the RCN and Royal College of Emergency Medicine workforce standards

The BACCN guidance calls for an overall skill mix of 30% emergency charge nurses; 40% emergency nurses; 10% foundation staff nurses; and 20% nursing associates or clinical support workers.

Education and skill level of nurses is critical

According to the BACCN: ‘This skill mix ensures sufficient emergency charge nurses or emergency nurses to deliver safe clinical care, while providing appropriate supervision of foundation staff nurses, student nurses, nursing associates and clinical support workers.’

20%

Maximum amount of bank or agency staff on any given Type 1 emergency department shift

Source: RCN and Royal College of Emergency Medicine (2020)

Education and skill level of the nurses is critical: ‘We need emergency nurses working in EDs. It is not just about numbers of staff. It is how many registered nurses we need, and the level of skill they have,’ says Dr Youd.

‘Patients deserve to be nursed by people who are familiar with and skilled in the specialty, which we don’t always provide at the moment.

‘We have deliberately mapped it to the competency framework of the RCN Emergency Care Association.’

Most departments will be some way off meeting the standards currently, she adds.

‘There will be some work to do to meet these for most places, and a lot to do in some places.’

Patients in resus should receive one-to-one nursing care

One of the recommendations that is likely to be considered more controversial – and a long way from what is offered in many EDs – is the call for patients in the resus area to receive one-to-one nursing care.

‘The one-to-one care is a minimum, sometimes a patient will need two or three nurses,’ Dr Youd says. ‘But sometimes you find one nurse trying desperately to care for four patients in resus, trying to do observations and draw down bloods.

‘You just cannot give safe, good quality care in these circumstances. We are talking about the most seriously unwell patients here.’

Safe rostering patterns will reduce long shifts and staff burnout

Long shifts should be kept to a minimum when emergency departments (EDs) are planning their rosters, the RCN and Royal College of Emergency Medicine’s Nursing Workforce Standards for Type 1 Emergency Departments guidance says.

It calls for rostering patterns for emergency departments (EDs) to take into account best practice on safe shift working, minimising the use of long shifts where appropriate and using them in consultation with staff.

This is a difficult issue for nurses, as long shifts can be popular, especially with those with caring responsibilities or long commutes.

Clinical errors and staff exhaustion

But, according to the standards, it can lead to higher rates of clinical errors at the end of a long shift and, over time, it can lead to exhaustion and burnout for staff.

In a 2019 Nursing Standard survey, nurses were divided in their views on 12-hour shifts.

Of the 2,243 UK nurses who responded, 40% were against 12-hour shifts; 35% were for them; and 25% were undecided.

The standards state: ‘Where staff work long shifts, employers should offer appropriate support with respect to their health and well-being, and their ability to provide safe and effective patient care at the end of their shifts.

‘Opportunities should be offered to move to shorter shift times where this is preferred.’

Co-author of the new standards and emergency nurse consultant Janet Youd says: ‘Shift length is a difficult one.

‘Long shifts can lead to burn out and fatigue for nurses and affect the quality of patient care.’

According to the workforce guidelines there should be a minimum of 27% uplift applied for holiday, sickness absence and to cover training.

There should also be sufficient staff for everyone to be able to safely take their breaks.

Nurses should not be working alone in areas out of sight and sound of the rest of the department, it states.

‘About 80% of emergency departments are probably meeting only 50% of these standards. So many departments just scrape by day by day with staffing, living dangerously and robbing staff from tomorrow to get by today’

David Smith, RCN Emergency Care Association chair

There should be at least two nurses, unless there is a reliable way to bring immediate help.

‘This is for the safety of nurses and patients,’ Dr Youd adds.

27%

Minimum uplift applied to staffing to cover breaks, holidays, sickness and training

Source: RCN and Royal College of Emergency Medicine (2020)

RCN ECA chair David Smith agrees many departments are considerably adrift from these staffing levels.

‘About 80% of EDs are probably meeting only 50% of these standards,’ he says. ‘So many departments just scrape by day by day with staffing, living dangerously and robbing staff from tomorrow to get by today.

‘I’m pleased we have the one-to-one nursing in resus in there, but it will be difficult to meet.’

Mr Smith says that the standard of only 20% of staff coming from bank and agency will also be incredibly challenging to meet.

‘I have worked in departments where more than half of staffing on that day will be agency or bank,’ he says.

David Smith

‘A lot of EDs are running at 50 to 60% vacancy rates for nurses. Something has to change.’

Standards could be used to drive up numbers of skilled staff

Driving out corridor nursing is also laudable, but has become the norm in many places, Mr Smith adds.

‘A couple of years ago it would have been recorded as a never event, now it is so routine that a “corridor nurse” is on lots of rotas.’

The hope is that the workforce standards can be used as a lever for those planning, commissioning and delivering emergency nursing workforce models to drive up numbers of skilled staff.

Nursing leaders in EDs can use the document to work out where they are and what they need, and build an effective case to take their managers.

It will also involve universities and NHS trusts working together to ensure nurses, nursing associates and healthcare support workers are having the chance to access the emergency care training they need, Mr Smith says.

Standards could help drive the emergency department staffing debate forward

While not mandatory, the RCN and RCEM hope the standards will carry sufficient influence to boost the numbers of staff in EDs across the UK.

Dr Youd hopes that EDs will see the standards as an aspiration to work towards over the next few years.

‘I’m hopeful it will be critical to the discussion that brings change, that it will drive that debate forward,’ she says.

Find out more


Erin Dean is a health journalist

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