24 September 2021

UKCCNA Position Statement: Critical Care Nurse Staffing during Surge

The UKCCNA acknowledges the sustained pressure critical care nurses (and other staff) continue to experience. We understand the significant negative impact this is having on nurses’ physical and mental health and wellbeing.

Nurse-patient ratios
We set out our position on surge bedside nurse: patient ratios in our November 2020 and January 2021 position statements (1,2). During times of surge, the UKCCNA firmly believe patient safety and staff wellbeing is best secured if ratios are maintained at a minimum of one trained critical care nurse (TCCN)* and one registered healthcare professional** for two level 3 patients (compared with the normal 1:1 ratio (3,4), and one TCCN with one registered healthcare professional for every four level 2 patients (compared to the normal 1:2 ratio (3,4)) as set out in National pandemic workforce guidance documents, such as that published by NHSE (5). Other support staff*** should also be available to assist with delivering patient care.

The UKCCNA position from 14 January 2021(1) remains unchanged. Further dilution of bedside nurse : patient ratios outside the guidance given in November 2020 should only happen in exceptional circumstances where there is a need to expand capacity despite escalation to regional and national critical care networks and when all local and regional mutual aid options, including inter-regional assistance, have been exhausted. Ratios beyond 1 TCCN : 2 patients should only be used to facilitate emergency admissions. If surge models are used to facilitate elective surgery, then extra nursing support must be in place. Ongoing work is exploring additions to the substantive establishment including Nursing Associates and Operating Department Practitioners, examining how they will interface into the current workforce model.

Ratios must be returned to normal as soon as practicable as these staffing levels are unsustainable for nurses’ wellbeing and for patient safety. After episodes of surge, until further evidence is available, we must see a return to GPICS2 staffing model (3).

The UKCCNA requests that the four Nations provide further guidance on how to manage the increased workforce requirements associated with additional expansion of critical care capacity. Data on adverse patient and staff outcomes should be collected.

Redeployment of staff
Surge ratios should be achieved through the redeployment of staff from outside critical care who should have received critical care surge training. Staff are encouraged to make use of the online training resources, such as those produced by the London Transformation and Learning Collaborative - Critical Care (LTLC) - e-Learning for Healthcare (e-lfh.org.uk)  and the RCN – Introducing Critical Care https://www.rcn.org.uk/professional-development/professional- services/introducing-critical-care .

Redeployment of staff, either within their own NHS organisation or between organisations is not always viable. This is due to multiple factors including staff sickness, pressures related to covering ward beds and the need for inter-hospital transfers. In addition, many staff redeployed during surge have been unable maintain their skills after return to their substantive posts and future redeployed staff may not be the same people.

This problem is compounded by the bureaucratic challenges faced by some nurses who do not currently work for the NHS (for example academics and retired staff) which prevent or delay them from being able to work. Unnecessary restrictions and administrative hurdles must be removed, and a common-sense approach taken to facilitate the timely availability of staff and the maintenance of fundamental critical care knowledge and skills, necessary for periods of surge, using resources such as the digital skills passport.

Paediatric patients
During an unseasonable Respiratory Syncytial Virus (RSV) surge (6), critically ill older paediatric patients may, on occasion, need to be cared for in adult ITU settings. Guidance around staffing requirements, ratios, education, and safeguarding can be found at: https://pccsociety.uk/wp-content/uploads/2016/05/PICS_standards_2015.pdf . Educational resources for Respiratory Surge in Children produced in collaboration with PCCS and HEE are also available on the e-Learning for Healthcare website.

Nurse wellbeing
The UKCCNA acknowledges the significant negative impact on nurses’ physical and mental health and wellbeing. Professional Nurse Advocates should be given protected time to enable them to provide nurses with the much-needed support they require during and after experiencing unrelenting pressure to meet demands.

We strongly encourage nurses to take full advantage of available support resources such as the regional resilience hubs funded by NHSE. Asking for help is not a sign of weakness. Links to wellbeing resources are available via our member organisation websites: Intensive Care Society - wellbeing hub , British Association of Critical Care Nurses ( BACCN) , Royal College of NursingCoronavirus Resources & Guidance (cc3n.org.uk) . We also recommend that research exploring how best to support nurses’ wellbeing is prioritised.

Definition of terms
*Trained critical care nurses (TCCN): Whilst specialist training based on Steps competencies (7) is usually required to become a TCCN, in this exceptional situation TCCNs are defined as those who have completed their step 1 competencies (or have been deemed competent to care for a critically ill patient) and who normally work in critical care plus TCCNs who have left the specialty within the last 12 months.

**Registered health care professionals: A registered nurse (including nurse associates) or other relevant health care professionals (ideally with IV competence and some preparatory critical care training) working in the capacity of a bedside nurse. This will include nurses with critical care experience longer than 12 months ago.

***Other support staff: Healthcare support workers and non-nursing support workers, including students, dentists and doctors working in bedside care support roles.

The joint statement on developing immediate critical care nursing capacity remains current (8).

  1. UKCCNA position statement (January 2021): https://www.ficm.ac.uk/sites/default/files/ukccna_position_final_13.01.2021_.pdf
  2. UKCCNA position statement (November 2020): https://www.ficm.ac.uk/uk-critical-care-nursing-alliance-ukccna/ukccna-workforce-news-and-statements
  3. The Intensive Care Society and Faculty of Intensive Care Medicine, Guidelines for the Provision of Intensive Care Services: https://www.ics.ac.uk/ICS/ICS/GuidelinesAndStandards/GPICS_2nd_Edition.aspx
  4. https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-d/d05/
  5. https://www.england.nhs.uk/coronavirus/publication/advice-on-acute-sector-workforce- models-during-covid-19/
  6. The Intensive Care Society and Paediatric Critical Care Society joint position statement on paediatric RSV surge (June 2021):  https://www.ics.ac.uk/Society/Society/Policy_and_Communications/Articles/ICS_PCCS_RSV_Surge_Statement.aspx    
  7. https://www.cc3n.org.uk/uploads/9/8/4/2/98425184/01_new_step_1_final1_.pdf
  8. https://www.england.nhs.uk/coronavirus/publication/joint-statement-on-developing- immediate-critical-care-nursing-capacity/