ANALYSIS
Nursing leaders warn that without an increase in nurse numbers NICE recommended staffing levels in A&E will not be met. Katie Osborne reports
Controversial safe staffing guidance is necessary but ‘unrealistic’
The publication of draft guidance on safe staffing in A&E departments has prompted widespread debate among nurses. Some have welcomed the National Institute for Health and Care Excellence (NICE) guidance, published last week for consultation, while others say it is unrealistic given the nursing shortage. According to NICE, the recommendations in the 54-page document aim to help A&E departments ensure there are enough nursing staff to provide safe care at all times. It says trusts should determine nurse staffing levels at least every six months, using data on A&E demand over the past two years. But critics argue that unless steps are taken to address the national shortage of nurses, there is no prospect of trusts complying with the recommendations. The guidance calls on nurses, patients, family members and carers to report ‘red flags’, which might indicate something is wrong, to the nurse in charge on the shift. These
NICE A&E recommendations One registered nurse to four cubicles in ‘majors’ and ‘minors’ One registered nurse to one cubicle in triage One registered nurse to two cubicles in resuscitation One band 7 registered nurse on every shift at all times Two registered nurses to one major trauma patient Two registered nurses to one cardiac arrest patient One registered nurse to one priority ambulance patient One family liaison registered nurse to one patient’s family One children’s nurse on every shift include missed care, crowding in the department, a patient going missing or a shortfall of more than 25 per cent in registered nurse time available compared with the requirement for the shift.
Jim Bethel, a University of Wolverhampton senior lecturer and nurse practitioner at Sandwell and West Birmingham Hospitals NHS Trust, argues that the NICE recommendations are unachievable because of the shortage of nurses. He adds that the document makes no mention of healthcare assistants or allied health professionals, a vital support to registered nurses. ‘Nurses will view these recommendations with a degree of cynicism and will be concerned that they have not made more of other professions’ roles,’ he says. ‘There are just not enough nurses to achieve these visions and I do not see that changing in the near future.’ Susan Osborne, chair of the Safe Staffing Alliance, which campaigns for nurse-to-patient ratios to be enshrined in law, says she is ‘delighted’ that NICE has set levels for A&E departments (see box, left). ‘One of the most positive things in this guidance is that the chief
NURSES’ COMMENTS FROM OUR FACEBOOK PAGE Ross Truscott, charge nurse on an acute inpatient unit: ‘Where, may I ask, is anything to do with mental health? Should there not be at least one registered mental health nurse to advise patients in crisis? Yet again mental health is forgotten.’ Maxine O’Brien, matron in an acute mental health trust: ‘I think that measuring how many times breaks are not taken, as well as the amount of unpaid overtime, would make interesting reading. Could the NHS survive if we didn’t do this? I think not.’ Sandi Waters-Lewis: ‘Make nurse-to-patient ratios mandatory.’ Amreen Mahroof: ‘In the A&E I work in, it is two nurses to about 18 to 24 cubicles, and if we are really lucky we have
three nurses or a healthcare assistant. It is pointless making recommendations that can never be reinforced.’ Karen Greenland: ‘So again it is just a recommendation. Nothing will change and it’s not worth the paper it’s written on. If it is not compulsory it is hardly worth doing.’ Bev Syson: ‘It is not just A&E they ought to be giving guidelines to. The ward I work on is frequently understaffed, with staff more often than not going without breaks and staying after time to catch up with paperwork. We need bank or agency staff but paradoxically that is what can cause the budget crisis.’ Mary Easton: ‘Are the people who put this recommendation together professionals who work in the A&E department? If you don’t work there how does one know?’
14 january 28 ::from vol 29 no 22 ::by 2015 STANDARD Downloaded RCNi.com ${individualUser.displayName} on Nov 28, 2015. For personal use only. NoNURSING other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
ANALYSIS
Nurse-to-patient ratios recommended by guidance NICE in draft guidance Ratios recommended by NICE in draft urse to atient ratios in cu ic es
Minors and majors
Triage
:
Resuscitation area
:
:
urse to atient ratios in ot er situations
Major trauma
Cardiac arrest
:
:
Priority ambulance calls
: nurse will be expected to sign off the staffing levels,’ she says. ‘This should be happening across every department. ‘In the short-term these recommendations may not be immediately achievable, but it is marvellous that NICE has set these levels. It is something for everyone to aim for. We have unsafe care in this country and that needs to be addressed.’
Major incidents
In England alone, there were 400,000 more visits to A&E in 2014 compared with the previous year. These pressures led to at least 15 acute trusts declaring ‘major incidents’ earlier this month as front line staff struggled to cope with unprecedented demand in emergency departments. Major incidents are typically declared when there is a large-scale emergency such as a train crash. They allow managers
Fami
iason
: to bring in extra staff and postpone non-urgent procedures. Health Education England recently announced that it will commission an extra 827 pre-registration nurse training places for 2015/16, but the RCN maintains that this is not nearly enough to tackle the scale of the current shortage or rising patient demand. With hospitals forced to rely on overseas and agency staff to fill thousands of vacant nursing posts, much more needs to be done to address the shortage, the college says. Commenting on the guidelines, RCN general secretary Peter Carter said: ‘For years now, many A&E departments have been understaffed or staffed with temporary or less experienced nursing staff.’ In its response to the 2013 Francis report into care failings at Mid Staffordshire NHS Foundation Trust, which linked chronic understaffing with
poor care, the RCN said its own research showed that almost 90 per cent of nurses do not think staffing levels are always adequate to provide safe patient care. The college estimates there is a 10 per cent nurse shortage. RCN adviser on acute, emergency and critical care JP Nolan says we need a review of the current A&E nursing workforce. NICE recommends that the nurse in charge of a shift monitors the number of staff who are missing breaks and working unpaid overtime, as well as overall staff morale.
Extra tasks
It says additional time needs to be factored in for patients who have extra nursing care needs, for example 20-30 minutes more is needed for activities such as help with eating, drinking, toileting and administering medication. Nurse leaders maintain that this will not be possible given the pressures on nurses. There are also fears that if the guidance is breached, trusts will do poorly in Care Quality Commission inspections. Comments on Nursing Standard’s Facebook page in response to the recommendations reflect a widespread unease among nurses, with many having little faith that anything will change (see box). Ross Truscott, a charge nurse on an acute inpatient unit, said he was disappointed that the recommendations did not provide for a registered mental health nurse in A&E. His concerns were echoed by Andrew Timms, who said: ‘For too long mental health has been secondary or even further down the priority order. This is something that needs addressing urgently.’ A NICE spokesperson said that, while the organisation is unable to comment on individual concerns, it welcomes feedback via stakeholder organisations as part of the consultation, which runs until February 12 NS
NURSING january 28other :: voluses 29 without no 22 ::permission. 2015 15 DownloadedSTANDARD from RCNi.com by ${individualUser.displayName} on Nov 28, 2015. For personal use only. No Copyright © 2015 RCNi Ltd. All rights reserved.
Nursing leaders warn that without an increase in nurse numbers NICE recommended staffing levels in A&E will not be met. Katie Osborne reports
Controversial safe staffing guidance is necessary but ‘unrealistic’
The publication of draft guidance on safe staffing in A&E departments has prompted widespread debate among nurses. Some have welcomed the National Institute for Health and Care Excellence (NICE) guidance, published last week for consultation, while others say it is unrealistic given the nursing shortage. According to NICE, the recommendations in the 54-page document aim to help A&E departments ensure there are enough nursing staff to provide safe care at all times. It says trusts should determine nurse staffing levels at least every six months, using data on A&E demand over the past two years. But critics argue that unless steps are taken to address the national shortage of nurses, there is no prospect of trusts complying with the recommendations. The guidance calls on nurses, patients, family members and carers to report ‘red flags’, which might indicate something is wrong, to the nurse in charge on the shift. These
NICE A&E recommendations One registered nurse to four cubicles in ‘majors’ and ‘minors’ One registered nurse to one cubicle in triage One registered nurse to two cubicles in resuscitation One band 7 registered nurse on every shift at all times Two registered nurses to one major trauma patient Two registered nurses to one cardiac arrest patient One registered nurse to one priority ambulance patient One family liaison registered nurse to one patient’s family One children’s nurse on every shift include missed care, crowding in the department, a patient going missing or a shortfall of more than 25 per cent in registered nurse time available compared with the requirement for the shift.
Jim Bethel, a University of Wolverhampton senior lecturer and nurse practitioner at Sandwell and West Birmingham Hospitals NHS Trust, argues that the NICE recommendations are unachievable because of the shortage of nurses. He adds that the document makes no mention of healthcare assistants or allied health professionals, a vital support to registered nurses. ‘Nurses will view these recommendations with a degree of cynicism and will be concerned that they have not made more of other professions’ roles,’ he says. ‘There are just not enough nurses to achieve these visions and I do not see that changing in the near future.’ Susan Osborne, chair of the Safe Staffing Alliance, which campaigns for nurse-to-patient ratios to be enshrined in law, says she is ‘delighted’ that NICE has set levels for A&E departments (see box, left). ‘One of the most positive things in this guidance is that the chief
NURSES’ COMMENTS FROM OUR FACEBOOK PAGE Ross Truscott, charge nurse on an acute inpatient unit: ‘Where, may I ask, is anything to do with mental health? Should there not be at least one registered mental health nurse to advise patients in crisis? Yet again mental health is forgotten.’ Maxine O’Brien, matron in an acute mental health trust: ‘I think that measuring how many times breaks are not taken, as well as the amount of unpaid overtime, would make interesting reading. Could the NHS survive if we didn’t do this? I think not.’ Sandi Waters-Lewis: ‘Make nurse-to-patient ratios mandatory.’ Amreen Mahroof: ‘In the A&E I work in, it is two nurses to about 18 to 24 cubicles, and if we are really lucky we have
three nurses or a healthcare assistant. It is pointless making recommendations that can never be reinforced.’ Karen Greenland: ‘So again it is just a recommendation. Nothing will change and it’s not worth the paper it’s written on. If it is not compulsory it is hardly worth doing.’ Bev Syson: ‘It is not just A&E they ought to be giving guidelines to. The ward I work on is frequently understaffed, with staff more often than not going without breaks and staying after time to catch up with paperwork. We need bank or agency staff but paradoxically that is what can cause the budget crisis.’ Mary Easton: ‘Are the people who put this recommendation together professionals who work in the A&E department? If you don’t work there how does one know?’
14 january 28 ::from vol 29 no 22 ::by 2015 STANDARD Downloaded RCNi.com ${individualUser.displayName} on Nov 28, 2015. For personal use only. NoNURSING other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
ANALYSIS
Nurse-to-patient ratios recommended by guidance NICE in draft guidance Ratios recommended by NICE in draft urse to atient ratios in cu ic es
Minors and majors
Triage
:
Resuscitation area
:
:
urse to atient ratios in ot er situations
Major trauma
Cardiac arrest
:
:
Priority ambulance calls
: nurse will be expected to sign off the staffing levels,’ she says. ‘This should be happening across every department. ‘In the short-term these recommendations may not be immediately achievable, but it is marvellous that NICE has set these levels. It is something for everyone to aim for. We have unsafe care in this country and that needs to be addressed.’
Major incidents
In England alone, there were 400,000 more visits to A&E in 2014 compared with the previous year. These pressures led to at least 15 acute trusts declaring ‘major incidents’ earlier this month as front line staff struggled to cope with unprecedented demand in emergency departments. Major incidents are typically declared when there is a large-scale emergency such as a train crash. They allow managers
Fami
iason
: to bring in extra staff and postpone non-urgent procedures. Health Education England recently announced that it will commission an extra 827 pre-registration nurse training places for 2015/16, but the RCN maintains that this is not nearly enough to tackle the scale of the current shortage or rising patient demand. With hospitals forced to rely on overseas and agency staff to fill thousands of vacant nursing posts, much more needs to be done to address the shortage, the college says. Commenting on the guidelines, RCN general secretary Peter Carter said: ‘For years now, many A&E departments have been understaffed or staffed with temporary or less experienced nursing staff.’ In its response to the 2013 Francis report into care failings at Mid Staffordshire NHS Foundation Trust, which linked chronic understaffing with
poor care, the RCN said its own research showed that almost 90 per cent of nurses do not think staffing levels are always adequate to provide safe patient care. The college estimates there is a 10 per cent nurse shortage. RCN adviser on acute, emergency and critical care JP Nolan says we need a review of the current A&E nursing workforce. NICE recommends that the nurse in charge of a shift monitors the number of staff who are missing breaks and working unpaid overtime, as well as overall staff morale.
Extra tasks
It says additional time needs to be factored in for patients who have extra nursing care needs, for example 20-30 minutes more is needed for activities such as help with eating, drinking, toileting and administering medication. Nurse leaders maintain that this will not be possible given the pressures on nurses. There are also fears that if the guidance is breached, trusts will do poorly in Care Quality Commission inspections. Comments on Nursing Standard’s Facebook page in response to the recommendations reflect a widespread unease among nurses, with many having little faith that anything will change (see box). Ross Truscott, a charge nurse on an acute inpatient unit, said he was disappointed that the recommendations did not provide for a registered mental health nurse in A&E. His concerns were echoed by Andrew Timms, who said: ‘For too long mental health has been secondary or even further down the priority order. This is something that needs addressing urgently.’ A NICE spokesperson said that, while the organisation is unable to comment on individual concerns, it welcomes feedback via stakeholder organisations as part of the consultation, which runs until February 12 NS
NURSING january 28other :: voluses 29 without no 22 ::permission. 2015 15 DownloadedSTANDARD from RCNi.com by ${individualUser.displayName} on Nov 28, 2015. For personal use only. No Copyright © 2015 RCNi Ltd. All rights reserved.
