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Concerns over nursing skill mix and recruitment in A&E

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Accident and emergency departments are failing to reach the nurse staffing levels they have planned for, according to new data that indicates nurses are under increasing pressure and at risk of burnout.

A snapshot survey of 33 major and single speciality A&E departments across England and Scotland has found that trusts are experiencing problems filling posts across all bands of nursing.

“There may be issues around dilution, substitution and replacement”

Howard Catton

Band 5 nurse posts have proved particularly difficult to fill, with an average 23% shortfall between the budgeted and actual number of whole-time equivalents. Band 7 vacancies were also hard to recruit for. On average there were 15% less WTE nurses available in a week than were budgeted for.

The survey, of A&Es in both rural and city locations, showed trusts were using temporary staff to try and plug the gaps, but this was still not always enough to reach safe levels.

The research, which saw trusts use a safe-staffing tool to identify recommended nurse levels, also identified skill mix concerns. It comes amid the increasing pressure being placed on the health service’s already creaking urgent and emergency services.

Royal College of Nursing head of policy Howard Catton said the data was likely to reflect the situation nationally, claiming it showed emergency services were running at “full capacity” and, as consequence, risking staff “burnout”.

The data also revealed problems around a lack of appropriate skill mix within A&E departments. It showed trusts were budgeting for more band 5 and 6 nurses than the required safe level, while planning for fewer band 7 and 8 nurses than the recommended amount.

Mr Catton suggested this meant the nursing skill mix was a “too dilute” and that lower band nursing staff were being used to substitute more senior staff.  “It may be that we are looking at trying to use band 5s to replace more senior grades. So there may be issues around dilution, substitution and replacement,” he said.

“It is not just the number of nurses that are related to patient experience and outcomes”

Howard Catton

Similarly, the data showed trusts were on average exceeding the planned number of band 1-3 healthcare assistants, which Mr Catton said could also indicate substitution of lower band registrants with support workers.

“This may be a consequence of a shortage of registered nurses – we can’t automatically say that is a cost-cutting exercise,” he noted.

He added that while trusts were making great efforts to employ additional staff, for example through overseas recruitment drives, senior posts in particular were more difficult to fill in this way.

“It’s not that trusts don’t want to recruit those more senior grades, but they are just struggling to do that and are therefore using band 5s,” he said.

He said that while increasing nurse training commissions was part of the solution, trusts needed to do more to provide career development for their existing nurses so they could progress to higher bands.

“It is not just the number of nurses that are related to patient experience and outcomes, but the skill set and mix of those nurses as well,” he told Nursing Times.

“I’d be much more confident in the service if the managers funded to the recommend staffing level”

Keith Hurst

Independent researcher and analyst Dr Keith Hurst collated the data for the RCN. It forms part of a larger, ongoing study on staffing levels from 2012-14.

At some of the 33 departments taking part – representing 18% of A&E services in England and Scotland – there was a “phenomenal gap” between both the budgeted and actual number of nurses in post, he told Nursing Times.

He also warned that the trusts had largely based their planned levels of nurse staffing on historical patterns, rather than safe staffing recommendations.

“The recommended staffing levels are empirically based – based on patient throughput, dependency and acuity data – and are probably what the budgeted staffing should be,” he said.

“I’d be much more confident in the service if the managers funded to the recommend staffing level and made that their aspirational figures.”

An NHS England spokeswoman said: “NHS trusts are responsible for recruiting and planning their workforce, but it is of course vital that we are able to attract the right of numbers of staff to the healthcare system. 

“This is why we’re working with Health Education England on robust training and recruitment plans that will lead to more permanent doctors, nurses and paramedics in the NHS,” she said.

Mr Catton was due to present the data on Monday at a conference on A&E nurse staffing levels and skill mix in London (see top-right for presentation slides).

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