Policy briefing

Ensuring safe staffing in emergency departments

Guidelines to help hospitals with workforce planning and staff deployment

Guidelines to help hospitals with workforce planning and staff deployment

Picture: iStock

Essential information

Safe staffing means having enough nursing staff with the right skills and knowledge, in the right place, at the right time. Concerns about inadequate staffing levels have affected all services in the NHS, including increasingly over-stretched emergency departments (EDs).

Last September, the RCN published the results of a survey of 30,000 members of staff which found that 58% reported a shortfall by at least one nurse on their last NHS shift.

While Wales has introduced some safe staffing legislation, and Scotland has started this process, it does not apply to EDs. England and Northern Ireland have no plans for legislation.

What’s new?

Safe staffing guidance for urgent and emergency care services in England has been published by NHS Improvement.

The guidelines call for NHS trust leaders to use professional judgement, a workforce planning tool and comparison with peers when calculating staffing needs.

Among the recommendations is for a workforce review to be undertaken annually, and for nurse numbers to take into account how demand in emergency services can fluctuate throughout 24 hours and over seven days a week.

NHS Improvement recommends EDs have action plans to address local recruitment and retention priorities as concerns about filling vacancies continue.

The publication, which is not mandatory, is one of a number covering different areas including maternity, children’s services, adult inpatient and district nursing services.

NHS Improvement says there is no evidence to support a specific ratio of staff to patients in EDs, and that further research is needed to better understand the impact of staffing in urgent and emergency care settings on outcomes for patients. While it calls for an evidence-based tool to be used, it does not state which one.

Its publication comes after the National Institute for Health and Care Excellence was told to stop its work on ED safe staffing guidance in 2015. The draft guidance, which had already been published, had included some staffing ratios.

The RCN says that the failure of NHS Improvement to recommend specific tools has been criticised by members.

Implications for nurses

  • Staffing should take into account the considerable variation between acuity and dependency in different urgent and emergency care settings, says NHS Improvement 
  • Flexible employment options and efficient deployment of staff should be used to limit the use of agency staff
  • There should be sufficient uplift added to staffing numbers to allow for planned and unplanned leave
  • The wide variety of roles in EDs, including advanced nursing roles, should be considered when workforce planning

Expert comment

RCN professional lead for acute, emergency and critical care Anna Crossley

‘Staffing in EDs remains a challenge. Many experienced staff have suffered burnout and are leaving the specialism. Recruitment and retention remains critical. 

‘The inclusion of professional judgement as part of the approach is very welcome, as is the recognition of the need to factor in sickness absence, annual leave and study leave. 

‘Including this uplift will be essential to provide time for emergency nurses to undergo training, for example to expand their knowledge and skills.

‘We welcome that the guidance stresses the importance of the recruitment and retention of staff. While we know there is a paucity of evidence surrounding safe staffing and EDs, we also know that the higher nurse numbers are, the safer and more effective patient care is. 

‘Despite not being fully validated, ED-specific tools are available to assist with staffing, and it would therefore have been helpful if the guidance could have recommended some.’


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Erin Dean is a freelance health writer

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