Safe and sustainable staffing
In September the RCN published a survey of 30,000 UK nurses, of whom 55% said shifts did not have the planned level of nursing staff, while 53% warned that staff shortages were compromising care.
Last month NHS Improvement (NHSI) produced a resource covering England called Safe, Sustainable and Productive Staffing in Urgent and Emergency Care.
In the draft resource, which is out for consultation until 22 December, NHSI does not recommend specific overall nurse-to-patient ratios. Instead it sets out recommendations for developing models of care, and planning and monitoring tools, as well as action to take if staffing resources are not meeting patient need.
The NHSI resource states that the interdependence of the roles in the multi-professional team has a direct influence on the number and skill mix of the team’s required nursing component.
It also warns that this makes it ‘inappropriate to prescribe definitive nurse-to-patient ratios’, but adds that in workforce planning and review, the required ‘nursing establishment’ does need to be calculated.
NHSI defines the ‘nursing establishment’ as the number of registered nurses and healthcare support workers who work in a particular department or team.
It cautions about comparing skill mixes in different emergency departments that include a substantial contribution from new roles such as assistant practitioners. Such roles are likely to be used differently by different employers and care should be taken to compare like with like.
However, the resource does state that professional consensus guidance for nurse staffing in critical care could be useful for resuscitation areas, whereby level 3 patients require a nurse-to-patient ratio of one to one and level 2 patients a ratio of one to two to deliver direct care during the resuscitation phase of care.
The National Quality Board (NQB) published guidance in 2016 outlining its expectations and a framework where decisions on safe and sustainable staffing should be made.
The NHSI improvement resource on nurse staffing in urgent and emergency care settings is one of a number of specialty resources underpinning the overarching NQB staffing guidance.
Implication for nurses
NHS boards should carry out strategic staffing reviews at least annually and consider a staffing review whenever local evidence suggests patient safety might be at risk due to staffing issues, according to the NHSI resource.
It sets out 13 recommendations for decision-making in determining nurse staffing requirements for urgent and emergency care settings.
The recommendations stress that safe staffing requirements and workforce productivity should be considered integral to the operational planning process. They acknowledge that demand in urgent and emergency care settings fluctuates over 24 hours, during the week and over the seasons so workforce planning should allow for these variations and reflect trends in activity. Contingency plans should enable flexibility of staffing to meet unexpected demand.
Workforce planning should allow for role development and expansion, and new ways of working while ensuring that fundamental care remains a priority. The consultation document also advises that nursing associates could have an important future role, and states that the impact of the role in EDs should be considered.
Organisations should ensure they have an appropriate escalation process in case staffing is inadequate, and all organisations should investigate staffing-related incidents and the outcomes for patients and staff, ensuring action and feedback.
RCN deputy director of nursing Stephanie Aiken
‘Our research shows that across hospital settings, the shortfall of nursing staff is greatest in emergency departments (EDs). This demonstrates that there is a clear need for guidance on staffing ED areas safely. However, we’re concerned that this new resource from NHS Improvement on staffing in urgent and emergency care only has the status of advice, rather than being a binding requirement.
‘We will now consult members working in these areas as soon as possible on this issue, and their views will form the basis of our response to NHSI’s consultation. The RCN is calling for a legal duty that makes ministers across the UK accountable for safe staffing levels across all settings.’