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Safe staffing guidance issued on children’s hospital wards, neonatal settings and urgent care

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All children and young people in hospital should have 24 hour access to a registered children’s nurse, new guidance from the English NHS regulator says.

The NHS Improvement resource is the first published guidance directly focused on safe staffing levels for children and young people’s wards.

“We have worked with clinicians, leading academics, and stakeholders to create these resources”

Ruth May

The document – Safe, sustainable and productive staffing: An improvement resource for children and young people’s inpatient wards in acute hospitals – is aimed at all those involved in staffing from the ward manager, sister and charge nurse, right up to the board of directors.

Around the clock access to a registered children’s nurse is particularly important in acute trusts and district general hospitals where the children’s services are a small department, the guidance stated.

Because children’s nurses tend to be younger than the general workforce hospitals should consider their specific needs, the resource said. For example, they should offer more flexible employment to limit the use of temporary staff, it said. There are 13 main recommendations, including:

  • Trusts need to adopt a systematic approach using “an evidence based decision support tool, triangulated with professional judgement and comparison with peers”
  • A strategic staffing review should take place every year or more frequently in the event of service changes
  • The impact on parents and carers should be considered when making staffing decisions

The document builds on recommendations from the Royal College of Nursing’s 2013 publication – titled Defining staffing levels for children’s and young people’s services – as well as guidance from representative bodies for paediatrics, paediatric intensive care, and the Care Quality Commission.

A set of safe staffing guidance from the National Institute for Health and Excellence was controversially halted in 2015, before the task was handed to NHS Improvement. But a specific guideline on children’s wards was not part of the programme at the time of its cancellation.

The new resource from NHS Improvement noted that children and young people’s services are complex.

It states: “An organisation’s senior nurse leadership must be strong, visible and effective to ensure children and young people’s needs are recognised, articulated and listened to, especially when the service is part of a large general hospital.”

“Children’s services are falling short of expected standards due to staff shortages and safeguarding failures”

Janet Davies

Staffing requirements for children and young people’s inpatient services will vary according to demand and specialism, the document said.

It quotes existing RCN guidance that states that each ward should always have at least two registered children’s nurses on duty irrespective of its size or layout.

The resource suggests that all children and young people’s wards should be led by a supervisory and supernumerary band 7 (minimum) sister/charge nurse.

The document considers “uplift” – the extra capacity needed to cover staff sickness, holidays and parenting leave.

NHS Improvement has also published setting specific safe staffing resources for trusts covering neonatal and urgent and emergency care services.


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Ruth May

The neonatal resource supports NICE’s 2010 minimum standards for nurse staffing, which were published before the rest of its workforce programme was suspended.

For neonatal intensive care, NHS Improvement said staffing should be 1:1 nursing for all babies. For neonatal high dependency care, it said the ratio should be 2:1 nursing for all babies, while for neonatal special care it should be 4:1 nursing for all babies.

However, the new urgent and emergency care guidance said there was “no evidence base to support a specific ratio”. Instead, staffing needs should be decided using a range of factors such as patient acuity data and the skills and experience of the wider team.

Further research was needed to better understand the impact of staffing in urgent and emergency care settings on patient outcomes, it said.

NICE’s guidance on accident and emergency care was never officially published by a leaked draft version was reported on by the media, including Nursing Times.

Ruth May, executive director of nursing at NHS Improvement, said safe staffing was an essential requirement for trusts.

“We have worked with clinicians, leading academics, and stakeholders to create these resources, in the expectation that they will support local NHS leaders and their staff deliver compassionate, effective, safe, sustainable high quality patient care,” she said.

The regulator’s urgent and emergency care sub group had concluded that workforce, staffing advice and support were “vital”, she said.

janet davies

janet davies

Janet Davies

“The professional judgement of the group was that the evidence base was insufficient in some areas to support staffing requirements such as ratios which do not recognise the diverse nature of departments geography, demand profile or complexity. (They) recognised that in resus and high dependency areas, the models of care and staffing by the Intensive Care Society could be applied,” she said.

“NHS Improvement is working with the Emergency Care Improvement Programme and other stakeholders to develop further work in this area, notably in the dynamic workforce models,” she added.

The Royal College of Nursing’s chief executive and general secretary, Janet Davies, welcomed the new guidance.

“These resources in conjunction with RCN guidance will help nursing staff to make informed decisions to meet the needs of patients and provide them with safe and effective care,” she said. However, action was needed to make safe staffing law, she noted.

“Earlier this year, it was revealed that children’s services are falling short of expected standards due to staff shortages and safeguarding failures,” she said, citing a report published in April.

“All good intentions to provide safe patient care will be wasted if there isn’t the staff available to fill posts,” she said. “Only by enshrining safe staffing in legislation can patient safety be assured.”

She added: “More work and evidence is clearly needed to fill the existing knowledge gap by defining what safe and effective staffing levels should be for urgent and emergency care.”

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