Analysis

Mounting pressures put nurses off working in EDs

Nurse are being deterred from working in pressured emergency departments (EDs) because of the associated stress, MPs have warned.
Nurses are leaving EDs

Nurses are being deterred from working in pressured emergency departments (EDs) because of the associated stress, MPs have warned.

A report by the Commons health committee on winter pressures in emergency care says poor performance has become the norm for some NHS trusts, due to increasing demand for services, insufficient staff numbers and bed-blocking.

It also highlights that the NHS in England could face a substantially more difficult winter this year.

A seminar for NHS trust leaders, held as part of the committees research, heard that the limited supply of nurses relative to demand means they can be more selective about where they work and they are not opting for EDs because of the related pressures.

88%

Percentage of major EDs which met government target

...

Nurses are being deterred from working in pressured emergency departments (EDs) because of the associated stress, MPs have warned.

A report by the Commons health committee on winter pressures in emergency care says poor performance has ‘become the norm’ for some NHS trusts, due to increasing demand for services, insufficient staff numbers and bed-blocking.

Nurses are leaving EDs
Nurses are leaving EDs in favour of other areas of practice. Picture: Getty Images

It also highlights that the NHS in England could face a ‘substantially more difficult’ winter this year.

A seminar for NHS trust leaders, held as part of the committee’s research, heard that the limited supply of nurses relative to demand means they can be more selective about where they work – and they are not opting for EDs because of the related pressures.

88%

Percentage of major EDs which met government target of admitting, transferring or discharging patients within four hours in 2015-2016

RCN emergency care association chair Janet Youd says attrition in the specialty is higher than ever.

‘In emergency nursing across the country, we have seen attrition from the specialty we have never seen before. 

‘Emergency medicine used to be a place where people wanted to work. It was exciting, cutting-edge and different every day. Now it’s seen as hard work. It’s frustrating when you feel you cannot deliver the care you feel is needed.’

Greater investment

Ms Youd called for greater investment in education and training and says the RCN plans to publish a structure showing the various career options for nurses working in EDs and the competencies required.

The college has been working on a proposed new career and competency framework that sets out clinical, academic and management career pathways for emergency nurses, which is due to be completed soon. 

'There is still a worrying lack of workforce strategy nationally'

Anna Crossley

Her comments are echoed in evidence given to the committee by the RCN, which highlighted how EDs in England are buckling under rising demand and a drastic shortage of nurses.

RCN professional lead for acute, emergency and critical care Anna Crossley says: ‘EDs are not only coping with a lack of staff and resources, but also feeling the impact of pressures and delays elsewhere in the health and social care system. 

‘There is still a worrying lack of workforce strategy nationally to improve staffing levels and reduce these pressures.

‘It is time the government had a serious look at how long health and social care services can continue to function when they are consistently under-funded and under-staffed.’

Consultant nurse at Somerset Partnership NHS Foundation Trust Mike Paynter says good quality emergency nurse practitioners (ENPs) are being poached by primary care settings, which is compounding the problem.

‘There is an unprecedented haemorrhage of emergency nurse practitioners from emergency departments and community urgent care services,’ he says. ‘One of the prime reasons is that good quality ENPs are being actively poached to support primary care, which is under intense pressure due to the lack of GPs.

‘The incentives for these staff to leave is usually a financial increase to band 8a or equivalent, the opportunity to work regular hours, Monday to Friday, with no out-of-hours work, structured CPD and an organised working day that incorporates breaks.’ 

The attraction for nurses and ENPs to leave the NHS and work for specialist agencies is also a significant factor, he says, with nurses being able earn the same or more working three days for an agency instead of five for the NHS.

Poor access to social care

Health Committee MPs recommended the shortfall in social care provision is addressed to reduce avoidable admission and delayed hospital discharges. They pointed out that ED pressures are now felt all year round, peaking during winter.

10%-20%

Vacancy rates at some emergency departments

Ms Youd says in her experience most ED attendees are not inappropriate users but older and frail people. A simple action to ease problems this winter would be to invest in extra blankets and pillows, she says.

‘We know we are going to have patients on trolley beds. Let’s make sure they can be as comfortable as possible, let’s have blankets and pillows and allow nurses to take breaks.’

Mr Paynter adds: ‘The NHS is competing for an ever diminishing group of specialist clinicians; when will there be a collective realisation that to help retain staff appropriate funding is essential?

‘The alternative is the short-term use of specialist agency ED staff just to keep services “ticking over”, which is a genuine false economy.’

Figures show that for major EDs in 2015-16, only 88% of patients were admitted, transferred or discharged within four hours. The government standard is 95%.

What the RCN told the Commons health committee inquiry into planning for winter pressures

‘Across England, the acute sector is buckling under the strain of financial pressures and increased demand for services. It is clear that the pressure is affecting the whole system, however, [emergency departments] are often the place where the effects are most visible.’

  • Staff shortages: recruitment and retention of nurses in the ED is poor – some operating on vacancy rates of between 10% and 20%.
  • Insufficient skill mix: with experienced nurses being replaced by lower band nurses.
  • Substantial financial investment in primary, community, social care and public health needed to ease pressure in EDs.
  • Action needed to support and improve workplace health and safety for ED nurses.
How emergency care services are being advised to cope this winter
  • Place health staff in EDs, such as specialist nurses, geriatricians and GPs, to screen patients coming in the ‘front door’ and divert them where appropriate.
  • Increase the number of NHS 111 calls dealt with by clinicians, such as nurses. The goal is to increase the number by 50% although it is acknowledged that will not be reached this winter.
  • Look into using ‘discharge to assess’, freeing up hospital beds more quickly.
  • Extend the ‘dispatch on disposition’ pilot to all areas giving call centres up to an extra three minutes to triage calls – does not cover the most serious red 1 calls.
  • Improve ED waiting time performance against the four-hour target in line with the trajectories set out by regulators in July – each trust has its own individual target. To help, fines for missing the 95% mark have been scrapped.

Source NHS England and NHS Improvement


Find out more

The House of Commons health committee: Winter Pressure in Accident and Emergency Departments report

 

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