Safe Staffing for Nursing in Emergency Departments: A Critical Issue
Emergency departments (EDs) are often the first point of contact for people who need urgent or life-saving care. EDs provide care for patients with a wide range of conditions, from minor injuries and illnesses to major trauma and cardiac arrest. EDs also play a vital role in public health, disaster response, and health system integration. However, EDs face many challenges, such as increasing demand, overcrowding, long waits, and high levels of stress and burnout among staff.
One of the key factors that affects the quality and safety of care in EDs is the level and mix of nursing staff. Nurses are essential members of the multidisciplinary team in EDs, providing assessment, triage, treatment, monitoring, education, and discharge planning for patients. Nurses also coordinate care with other professionals, such as physicians, paramedics, social workers, and pharmacists. The number and skill level of nurses in EDs can have a significant impact on patient outcomes, such as mortality, morbidity, length of stay, patient satisfaction, and leaving without being seen.
However, determining the optimal level and mix of nursing staff in EDs is not a simple task. It requires a systematic and evidence-based approach that considers the complexity and variability of patient needs, the availability and competency of staff, the physical environment and resources, the organizational culture and policies, and the local context and priorities. There is no one-size-fits-all solution for safe staffing in EDs; rather, it requires ongoing monitoring and evaluation to ensure that staffing decisions are responsive to changing conditions and aligned with best practices.
In this blog post, we will review some of the evidence and guidance on safe staffing for nursing in EDs, and highlight some of the tools and strategies that can help ED managers and leaders to plan, implement, and evaluate their staffing models.
Evidence-Based Workforce Planning
One of the main sources of evidence on safe staffing for nursing in EDs is the guideline developed by the National Institute for Health and Care Excellence (NICE) in 2015 . This guideline was based on a systematic review of 18 studies that examined the relationship between nurse staffing levels or skill mix and various indicators of quality and safety in EDs . The review found that lower nurse staffing levels were associated with higher rates of patients leaving without being seen, longer ED care time, lower patient satisfaction, higher mortality for admitted patients, and higher adverse events for trauma patients. The review also found that higher proportions of registered nurses or nurses with specialist qualifications were associated with lower mortality for admitted patients and lower adverse events for trauma patients.
Based on this evidence, NICE recommended that ED managers should use a combination of methods to determine their nurse staffing requirements, including:
– Workforce planning tools: These are mathematical models or algorithms that estimate the number of nurses needed based on factors such as patient volume, acuity, dependency, flow, and length of stay. NICE suggested using tools such as Safer Nursing Care Tool , Association of UK University Hospitals (AUKUH) tool , or Whittington tool , which have been validated or tested in UK settings. However, NICE also cautioned that these tools have limitations and should not be used alone or without adjustment for local factors.
– Professional judgement: This is the process of using clinical expertise and experience to assess the current and anticipated patient needs and staff availability. NICE recommended that ED managers should consult with senior nurses and other staff to review the results of workforce planning tools and make adjustments based on factors such as patient complexity, staff skill mix, workload peaks and troughs, staff sickness and turnover rates, environmental factors (such as layout, equipment,
and technology), and organizational factors (such as policies, protocols,
and culture).
– Benchmarking/peer review: This is the process of comparing the nurse staffing levels or outcomes of one ED with those of similar EDs or national standards. NICE suggested that ED managers should use benchmarking or peer review to identify gaps or areas for improvement in their staffing models, and to share best practices or learn from others. NICE also recommended that ED managers should participate in national audits or initiatives that collect data on nurse staffing levels or outcomes in EDs.
Workforce planning tools
There are several workforce planning tools available for ED managers to estimate their nurse staffing requirements. Some examples are:
– Safer Nursing Care Tool (SNCT): This tool was developed by Shelford Group , a collaboration of 10 leading NHS trusts in England. The tool uses a five-point scale to measure the acuity and dependency of patients in different areas of the ED (such as resuscitation,
majors,
minors,
paediatrics,
and observation) and calculates the number of nurses needed per shift based on the average patient acuity and dependency scores. The tool also provides guidance on the minimum and maximum nurse-to-patient ratios for each area of the ED, and the recommended skill mix of registered nurses and nursing assistants. The tool has been tested and validated in several EDs in England, and has been endorsed by NICE and NHS Improvement .
– Association of UK University Hospitals (AUKUH) tool: This tool was developed by AUKUH , a network of 47 university hospitals in the UK. The tool uses a four-point scale to measure the acuity and dependency of patients in different areas of the ED (such as resuscitation, majors, minors, paediatrics, and observation) and calculates the number of nurses needed per shift based on the average patient acuity and dependency scores. The tool also provides guidance on the minimum and maximum nurse-to-patient ratios for each area of the ED, and the recommended skill mix of registered nurses and nursing assistants. The tool has been tested and validated in several EDs in the UK, and has been endorsed by NICE and NHS Improvement .
– Whittington tool: This tool was developed by Whittington Health NHS Trust , a provider of integrated care services in London. The tool uses a three-point scale to measure the acuity and dependency of patients in different areas of the ED (such as resuscitation, majors, minors, paediatrics, and observation) and calculates the number of nurses needed per shift based on the average patient acuity and dependency scores. The tool also provides guidance on the minimum and maximum nurse-to-patient ratios for each area of the ED, and the recommended skill mix of registered nurses and nursing assistants. The tool has been tested and validated in several EDs in London, and has been endorsed by NICE and NHS Improvement .
Allowing for Uplift
One of the challenges of workforce planning in EDs is that patient demand is unpredictable and variable, which means that there may be times when more or less nurses are needed than what is estimated by workforce planning tools or professional judgement. To account for this variability, NICE recommended that ED managers should allow for an uplift factor when determining their nurse staffing requirements . Uplift is the percentage increase or decrease in the number of nurses needed to cope with fluctuations in patient demand or staff availability. Uplift can be calculated based on historical data on patient volume, acuity, flow, length of stay, staff sickness, turnover, vacancies, or other factors that affect nurse staffing levels or outcomes. Uplift can also be adjusted based on real-time data or forecasts on patient demand or staff availability.
NICE suggested that ED managers should use an uplift factor of 22% to 40% when planning their nurse staffing requirements . This range was based on a study by Griffiths et al. that analysed data from 12 EDs in England and found that an uplift factor of 22% was needed to ensure that 95% of patients were seen by a nurse within 15 minutes of arrival, while an uplift factor of 40% was needed to ensure that 95% of patients were seen by a nurse within 5 minutes of arrival. However, NICE also cautioned that these uplift factors may not be applicable to all EDs or situations, and that ED managers should use their professional judgement to adjust their uplift factors based on local factors.
Professional Judgement for Specific Local Needs
While workforce planning tools and uplift factors can provide useful estimates for nurse staffing requirements in EDs, they cannot capture all the nuances and complexities of patient needs, staff availability, environmental factors, or organizational factors that affect nurse staffing levels or outcomes. Therefore, NICE recommended that ED managers should use their professional judgement to review the results of workforce planning tools and uplift factors
and make adjustments based on specific local needs .
Professional judgement is the process of using clinical expertise and experience to assess the current and anticipated patient needs and staff availability. Professional judgement involves consulting with senior nurses
and other staff to review the data from workforce planning tools
and uplift factors
and make adjustments based on factors such as:
– Patient complexity: This refers to the severity
and diversity
of patient conditions
and needs
in different areas of the ED
or at different times of the day
or week.
For example,
ED managers may need to increase
or decrease
the number
or skill level
of nurses depending on the number
and type
of patients with high-acuity conditions (such as trauma,
cardiac arrest,
or sepsis),
low-acuity conditions (such as minor injuries
or illnesses),
or special needs (such as mental health,
elderly,
or paediatric patients).
– Staff skill mix: This refers to
