Defining staffing levels for children’s and young people’s ...

Defining staffing levelsfor children’sand youngpeople’sservices

RCN guidance for clinicalprofessionals and servicemanagers

Acknowledgements

The RCN Children's Leadership and ManagementForum would like to thank the following members forundertaking the Delphi study into Nurse Staffing inChildren's Wards and Departments during 2002:

✦ Alison Arnfield

✦ Kathy Hale

✦ Judith Hunter

✦ Deborah Oughtibridge

✦ Fay Valentine

Particular thanks need to be made to Fiona Smith,Adviser in Children's Nursing, for drafting thisguidance on behalf of the Forum Steering Committee.

Fay ValentineChair

The RCN Children’s Leadership and ManagementForum (previously known as the Paediatric NurseManagers Forum) has produced this guidance.The forum exists to support all nurses workingwith children and young people in a supervisory or managerial capacity and is particularly aimed at those G grade (or equivalent) or above withcontinuing responsibility for care.

Contents

1. Introduction 1

2. The policy and professional context of care provision 1

3. Nurse staffing and the quality of care 2

4. Neonatal services 3

5. Designated children’s intensive care and children’s high dependency services 4

6. General children’s wards and departments 5

7. Specialist children’s wards and departments 7

8. Time to review? 8

9. References 9

Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN

© 2003 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers or a licence permitting restrictedcopying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. This publication may not be lent, resold, hired out or otherwisedisposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers.

Defining staffing levels for children’s andyoung people’s servicesRCN guidance for clinical professionals and service managers

R O Y A L C O L L E G E O F N U R S I N G

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IntroductionThis document follows on from the 1999 RCNpublication Skill-mix and staffing in children’s wardsand departments. This provided a checklist to assistpractitioners and managers when considering thestaffing requirements for paediatric care areas. Definingstaffing levels gives further information and specificguidance on staffing levels based on the outcome of aDelphi study undertaken by the RCN’s Paediatric NurseManagers Forum during 2002. The guidance relates toneonatal and paediatric intensive care services, as wellas the average general children’s ward.

The policyand professionalcontext of careprovisionRecent policy initiatives, including nursing andworkforce strategies in the four countries (DH, 1991a;DH, 2000) have important implications for thedevelopment of the nursing workforce and future skill-mix and staffing levels. Other initiatives arising fromthe NHS plan include the development of nationalservice standards and frameworks. They indicate amore targeted and multidisciplinary team approach toplanning future workforce requirements (DH, 2002b).

The focus on clinical governance, clinical riskmanagement and continuing professional developmentare other factors affecting skill-mix and staffing levelrequirements in all clinical areas (RCN, 2001). Theimpact of the European Working Time Directive andthe subsequent reduction in junior doctors’ hours,along with the UKCC/NMC Scope of professionalpractice (UKCC, 1992) has influenced the expansion of the nursing role. It has also blurred the boundariesbetween different professional groups. As a result, nursepractitioner, nurse specialist and nurse consultant roleshave developed to meet local service needs.

All nurses are bound by the NMC Code of professionalconduct (NMC, 2002) to promote and protect the rightsand best interests of their patients. Children and youngpeople1 are frequent users of all types of health carecompared to adults (DH, 2003a). In any one year, one in15 children/young people are admitted to hospital. Themajority of admissions are unplanned, with changes inpatterns of service provision and care delivery affectingstaffing and skill-mix requirements.

1 The term ‘children and young people’ in this documentrefers to infants (neonates), children and young people up to the age of 18 or the point at which the individual’stransition to adult health care is completed.

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D E F I N I N G S T A F F I N G L E V E L S

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The Delphi study undertaken by the RCN PaediatricNurse Managers Forum in 2002 found that:

✦ it is generally acknowledged that those children andyoung people admitted to hospital today are moreacutely ill and require greater nursing intervention

✦ shorter lengths of stay, increasing throughput andbed occupancy place greater pressure on nursingresources

✦ nurses’ roles are expanding to encompass manyaspects of care and treatment undertaken by otherprofessional groups

✦ the provision of education and support toparents/carers to facilitate partnership in careand/or preparation for care at home is intensifying

✦ marked seasonal variations no longer exist in mostchildren’s wards and departments

✦ there is an increase in the number of student nursesand others requiring supervision and support inclinical environments.

The children’s national service framework (England)(DH, 2003a) emphasises that children and youngpeople should receive high quality, evidence-based carethat is appropriate to meet their specific needs anddelivered by staff who have the right knowledge base,expertise and skills. The Bristol Royal Infirmaryinquiry report (Kennedy, 2001) clarified that childrenand young people should always be cared for by healthcare professionals who hold a recognised qualificationin caring for children. From a nursing perspective thespecific requirements are clearly outlined in Preparingnurses to care for children and young people (RCN,2003b). Reference should also be made to the RCNPaediatric Nurse Managers Forum position statements,A modern matron role for paediatrics and Nurseconsultants in children’s services (see www.rcn.org.uk).

Nurse staffingand the qualityof careResearch indicates that the quality of care isinextricably linked to the availability of care providedby registered nurses (Carr-Hill et al, 1992). A higherproportion of nursing care provided by registerednurses, and a greater number of hours of care byregistered nurses per day, are associated with betterpatient outcomes (Needleman et al, 2002). Care by staffwho have received specific training to meet the needsof the client group undoubtedly influences the qualityof care received (RCN, 2003a).

Children’s psychological needs differ from those ofadults, and the considerable time spent by nursesteaching and supporting parents to provide care totheir child needs to be taken into account in decisionsrelated to staffing (DH, 1991b; Kennedy, 2001). A Delphistudy by the RCN Paediatric Nurse Managers Forum2002 supported the view that children need a greaternumber and ratio of registered nurses2 than adultpatients because of the need for closer monitoring andobservation. The same study reported that the numberof beds occupied/patient numbers are poor indicatorsof the number or skill-mix of nurses required, with anysuch baseline needing to be quantified by the use of apatient dependency tool.

2 The term registered nurse in the context of children's andyoung people's care refers to a registered children's nurseon part 8 of part 15 of the NMC register.


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Neonatal services

Nursing establishmentThe Department of Health (England) Report of theneonatal intensive care services review group (2003b)concludes that the nursing establishment for a neonatalunit should be based on the level of clinical care eachbaby requires. These have been defined as special care,high dependency care and intensive care, with the ratioof registered nurse to infants in each clinical category:

✦ special care 1:4

✦ high dependency 1:2

✦ intensive care 1:1

On a day-to-day basis, nurse staffing should reflect theneeds of infants and families in the unit, rather thanthe pre-determined cot numbers in designated clinicalcategories.

In addition to the requirements for clinical nursingcare, the nursing establishment should allow for a shiftsupervisor, who will co-ordinate the operational andclinical management of the ward alongside caredelivery to a small case load.

A 25 per cent time allowance should be incorporatedinto the nursing establishment to allow for staffabsences (sickness, annual leave and training anddevelopment) (RCN Paediatric Nurse Managers Forum,2002).

NB Staffing requirements for neonatal transportservices should be separate from the clinical in-patient service so that care of babies is notcompromised by unpredictable staffingrequirements (DH, 2003b).

Nursing skill-mixThe skills and competencies of the nursing team shouldreflect the infant clinical care requirements. In neonatalintensive care environments 70 per cent of the nursingestablishment should demonstrate knowledge, skill andcompetency attained via specialist post-registrationeducation in neonatal nursing care.

Nurses undertaking neonatal nurse practitioner orneonatal nurse specialist roles should have completedan externally validated, knowledge, skill andcompetency-based education programme for thisspecific purpose.

NB Nurse practitioner and nurse specialist postsshould be in addition to the required nursingestablishment to provide bedside nursing care inthe unit/department. The fact that these rolesinclude role expansion with responsibility fortechnical aspects of care or care enhancement willinevitably frequently take them away from bedsidecare. Although they would be expected to have alarge clinical component in their role, they wouldalso be expected to have, for example, input intoeducation programmes, research, qualityinitiatives, clinical governance and riskmanagement.

Nursery nurses and health care assistants, who areeducated to the level of S/NVQ 3 with additionalspecific skill and competency-based training, are ableto provide support to registered nurses as part of thenursing team in special care areas. Considerationshould be given to the other support worker roles thatmay be required to address the needs of the baby andtheir family. Examples include family support workersand lactation/breast feeding specialists.

The number of student nurses in any clinicalenvironment should not exceed the number stated inthe clinical placement’s educational audit, which shouldbe updated on an annual basis. This is negotiatedbetween the clinical practice area and the link tutorfrom the local university. This should take intoconsideration the standards and guidelines establishedin several key educational documents (ENB & DH,2001a; ENB & DH, 2001b; UKCC, 1999; RCN 2002).

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Designatedchildren’sintensive care and children’shigh dependencyservices

Nursing establishmentThe Department of Health (NHSE, 1997a; NHSE,1997b) states that the nursing establishment forchildren’s intensive care and high dependency careshould be based on the level of clinical care eachchild/young person needs. These have been defined aslevel 3, level 2 and level 1, with the following ratio ofregistered nurse to children/young people in eachclinical category:

✦ level 3 2:1

✦ level 2 1:1

✦ level 1 1:2

(NB Level 1 is equated to high dependency carerequirements.)

On a day-to-day basis, nurse staffing should reflect theneeds of children/young people and families in theunit, rather than the pre-determined bed numbers indesignated clinical categories.

In addition to the requirements for clinical nursing carethe nursing establishment should allow for a shiftsupervisor to co-ordinate the operational and clinicalmanagement of the ward alongside care delivery to asmall case load.


NB Staffing requirements for paediatric intensivecare retrieval/transport services should be separatefrom the clinical in-patient service so that care ofchildren and young people is not compromised byunpredictable staffing requirements.

Nursing skill-mixThe skills and competencies of the nursing team shouldreflect the child/young person’s clinical carerequirements. In paediatric intensive careenvironments 70 per cent of the nursing establishmentshould demonstrate knowledge, skill and competencyattained via specialist post-registration education inpaediatric intensive care. In high dependencyenvironments, at least one member of staff on eachshift should be trained to Advanced Paediatric LifeSupport level and demonstrate knowledge, skill andcompetencies in high dependency care attained viaspecialist post-registration education (DH, 2002a).The number of staff with appropriate skills andcompetencies will need to be adjusted in light of thelevel and type of high dependency provision, and thelocation of the nearest paediatric intensive care facility.

Nurses undertaking paediatric intensive care (PIC),nurse practitioner or PIC nurse specialist roles shouldhave completed an externally validated, knowledge,skill and competency-based education programme forthis specific purpose.

NB Nurse practitioner and nurse specialist postsshould be in addition to the required nursingestablishment to provide bedside nursing care inthe unit/department. The fact that these rolesinclude role expansion with responsibility fortechnical aspects of care or care enhancement willinevitably frequently take them away from bedsidecare. Although they would be expected to have alarge clinical component in their role, they wouldalso be expected to have, for example, input intoeducation programmes, research, qualityinitiatives, clinical governance and riskmanagement.


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Consideration should be made to supporting roles toaddress the needs of children, young people and theirfamilies, as well as student nurses. Examples includethe employment of lecturer practitioners, playspecialists, family support workers and interpretingservices.

The number of student nurses in any clinicalenvironment should not exceed the number indicatedin the clinical placement’s educational audit, whichshould be updated on an annual basis. This isnegotiated between the clinical practice area and thelink tutor from the local university. This should takeinto consideration the standards and guidelinesestablished in several key educational documents (ENB & DH, 2001a; ENB & DH, 2001b; UKCC, 1999;RCN 2002).

Generalchildren’s wardsand departments

Nursing establishmentIn 1991, the Department of Health (1991b) stated that aminimum of two registered children’s nurses should beon duty 24 hours a day in all children’s wards anddepartments. The RCN Paediatric Nurse ManagersForum 2002 Delphi study highlights that this minimumis now insufficient to meet the clinical care needs ofchildren and young people on any average generalchildren’s ward. Ward nursing establishments should bebased on the level of clinical care each child/youngperson needs as determined by a patient dependencytool (RCN, 1999). The following provides an indicativebaseline ratio of registered nurses to children/youngpeople taking into account the distinct carerequirements linked to age and development:

✦ under 2 years 1:3

For other age ranges:

✦ during the day 1:4

✦ during the night 1:5

On a day-to-day basis, nurse staffing should reflect theneeds of children/young people and families in theward or department.

In addition to the requirements for clinical nursing carethe nursing establishment should allow for a shiftsupervisor, who will co-ordinate the operational andclinical management of the ward alongside caredelivery to a small case load.


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NB. If a children’s ambulatory or assessment unit isadjacent to or part of a children’s ward the nursingestablishments should be distinct and separate foreach area.

Nursing skill-mixThe acute hospital standard of the Children’s NationalService Framework (DH, 2003a) reinforces thatchildren and young people should be cared for by staffwho have the right knowledge base, expertise and skillsto meet their needs. All nurses who provide care tochildren and young people should therefore have aspecific qualification in the nursing care of childrenand young people (RCN, 2003b).

Each children’s ward/department3 nursingestablishment should encompass a minimum of1 WTE G grade (or equivalent) post to provide overallleadership, supported by a minimum of 2 WTE F grade(or equivalent) (RCN Paediatric Nurse ManagersForum, 2002).

Health care assistants educated to the level of S/NVQ 3with additional specific skill and competency-basedtraining are able to provide support to registerednurses as part of the nursing team.

The ratio of qualified to unqualified staff in children’sareas will depend on the clinical care requirements ofthe children and young people but in most generalchildren’s wards will be well above the absoluteminimum of 70 per cent qualified: 30 per centunqualified.

Nurses undertaking paediatric nurse practitioner orpaediatric nurse specialist roles should have completedan externally validated, knowledge, skill andcompetency based education programme for thisspecific purpose (RCN, 2000).

3 The figures stated relate to a ward/department functioningon a 24 hour/7 day basis

NB. Nurse practitioner and nurse specialist postsshould be in addition to the required nursingestablishment to provide bedside nursing carewithin the unit/department. The fact that theseroles include role expansion with responsibility fortechnical aspects of care or care enhancement willinevitably frequently take them away from bedsidecare whilst undertaking, for example, nurse-ledclinics, home visits or cross-boundary working.Although they would be expected to have a largeclinical component within their role they wouldalso be expected to have, for example, input intoeducation programmes, research, qualityinitiatives, clinical governance and riskmanagement.


The number of student nurses within any clinicalenvironment should not exceed the number citedwithin the clinical placement’s educational audit, whichshould be updated on an annual basis. This isnegotiated between the clinical practice area and theirlink tutor from the local university. This should takeinto consideration standards and guidelines establishedin several key educational documents (ENB & DH,2001a; ENB & DH, 2001b; UKCC, 1999; RCN 2002).


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Specialistchildren’s wardsand departments

Nursing establishmentThe nursing establishment within specialist areasshould reflect the child’s/young person’s clinical careneeds, the type and number of clinical interventionsand the parent/families need for support. For examplein children’s oncology units, 1/3rd of the patients canbe classed as requiring high dependency care, with the remaining patients requiring a ratio of 1:3 (UKChildren’s Cancer Study Group, 1997a & 1997b; RCP,1996).

On a day-to-day basis, nurse staffing should reflect theneeds of children/young people and families within theward or department.

In addition to the requirements for clinical nursing carethe nursing establishment should allow for a shiftsupervisor, who will co-ordinate the operational andclinical management of the ward alongside caredelivery to a small case load.


Nursing skill-mixThe skills and competencies of the nursing team shouldreflect the child/young person’s clinical carerequirements. For example, in children’s oncology 70per cent of the nursing establishment shoulddemonstrate knowledge, skill and competency attainedvia specialist post-registration education in paediatriconcology.

Nurses undertaking paediatric nurse practitioner orpaediatric nurse specialist roles should have completedan externally validated, knowledge, skill andcompetency-based education programme for thisspecific purpose.

NB. Nurse practitioner and nurse specialist postsshould be in addition to the required nursingestablishment to provide bedside nursing carewithin the unit/department. The fact that theseroles include role expansion with responsibility fortechnical aspects of care or care enhancement willinevitably frequently take them away from bedsidecare whilst undertaking, for example, nurse-ledclinics, home visits or cross-boundary working.Although they would be expected to have a largeclinical component within their role they wouldalso be expected to have, for example, input intoeducation programmes, research, qualityinitiatives, clinical governance and riskmanagement.


The number of student nurses within any clinicalenvironment should not exceed the number citedwithin the clinical placement’s educational audit, whichshould be updated on an annual basis. This isnegotiated between the clinical practice area and theirlink tutor from the local university. This should takeinto consideration standards and guidelines establishedin several key educational documents (ENB & DH,2001a; ENB & DH, 2001b; UKCC, 1999; RCN 2002).

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Time to review?‘The 1991 standards for the numbers of paediatricallyqualified nurses required at any one time should serveas the minimum standard’ (Kennedy, 2001). The BRIinquiry report has called for an urgent review of theseminimum levels in light of changing patterns of careprovision for children and young people across hospitalsettings. However, although minimum levels can be setat a national level it is critical that their applicability tolocal settings is substantiated in light of regular patientdependency studies (RCN, 1999; Smith & Valentine,1999). Factors indicating that a review of nurse staffingshould be undertaken include:

✦ an increase in the number of complaints andcritical incidents, including drug errors

✦ an increase in the rate of hospital-acquiredinfections

✦ falling standards of care and non-adherence toprotocols and policies

✦ an increase in staff turnover

✦ poor evaluation of placement areas from students

✦ low staff morale

✦ failure to meet statutory training and education ofstaff

✦ a lack of staff time available to enhance or developpractice

✦ change in model of care delivery

✦ change in bed occupancy /dependency levels

✦ change in local/ national standards

The RCN fully supports members in appropriatelyraising concerns in relation to the care of childrenand young people, and the protection of their rightsas individuals. RCN members can seek specificadvice if required by contacting RCN Direct on0845 772 6100 or by contacting their local RCNOffice (contact numbers can be found in the RCNMembers’ guide to services and benefits).

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ReferencesCarr-Hill R, Dixon P, Gibbs I, Griffiths M, McCaughlan Dand Wright K (1992) Skill-mix and the effectiveness ofnursing care. York: Centre for Health Economics,University of York

Department of Health (1991a) Making a difference.London: The Stationery Office

Department of Health (1991b) Welfare of children andyoung people in hospital. London: HMSO

Department of Health (2000) A health service of alltalents. London: The Stationery Office

Department of Health (2002a) High dependency care forchildren - report of an expert advisory group. London: DH.www.doh.gov.uk/nsf/hdchildren.pdf

Department of Health (2002b) Liberating the talents:helping primary care trusts and nurses to deliver the NHSplan. London: The Stationery Office

Department of Health (2003a) Getting the right start:national service framework for children standard forhospital services. London: DH,www.doh/gov.uk/nsf/children/standardhospserviceindex.htm

Department of Health (2003b) Report of the NeonatalIntensive Care Services Review Group. London: DH.www.doh.gov.uk/nsf/neonatal.htm

English National Board and Department of Health(2001a) Placements in focus. London: ENB and DH

English National Board and Department of Health(2001b) Preparation of mentors and teachers - a newframework of guidance. London: ENB and DH

Kennedy I (2001) Learning from Bristol. The report of thepublic inquiry into children’s heart surgery at the BristolRoyal Infirmary 1984-1995. London: The Stationery Office

Needleman J, Buerhaus P, Mattke S, Stewart M andZelevinsky K (2002) Nurse-staffing levels and the qualityof care in hospitals. New England Journal of Medicine 346,1715-1722

NHS Executive (1997a) Paediatric intensive care: aframework for the future. London: DH.www.doh.gov.uk/pubs/docs/doh/paedsum.pdf

NHS Executive (1997b) A bridge to the future: nursingstandards, education and workforce planning in paediatricintensive care. London: DH.www.doh.gov.uk/pubs/docs/doh/bridge.pdf

Nursing and Midwifery Council (2002) Code ofprofessional conduct. London: NMC

RCN Paediatric Nurse Managers Forum (2002) Nursestaffing in children’s wards and departments – results of aDelphi study (unpublished report)

Royal College of Nursing (1999) Skill-mix and staffing inchildren’s wards and departments. London: RCN.Publication code 001 054

Royal College of Nursing (2000) A framework fordeveloping practice in paediatric oncology nursing.London: RCN. Publication Code 001 062

Royal College of Nursing (2001) Developing an effectiveclinical governance framework for children’s acute healthcare services. London: RCN. Publication code 001 390

Royal College of Nursing (2002) Helping students get thebest from their practice placements: an RCN toolkit.London: RCN. Publication Code 001 815

Royal College of Nursing (2003a) Children and youngpeople’s services: pre-registration nursing education.London: RCN. Publication code 001 996.

Royal College of Nursing (2003b) Preparing nurses in thecare of children and young people: summary positionstatement by the RCN children and young people field ofpractice. London: RCN. Publication code 001 997

Royal College of Pathologists (1996) Standards of care forchildren with leukaemia. London: RCP

Smith F M and Valentine F (1999) Value added decisions.Nursing Management 6 (3): 6-7

United Kingdom Central Council (1992) Scope ofprofessional practice. London: UKCC

United Kingdom Central Council (1999) Fitness forpractice (The Peach report): the UKCC commission fornursing and midwifery education. London: UKCC

United Kingdom Children’s Cancer Study Group (1997a)Guidance for services for children and young people withbrain and spinal tumours. London: Royal College ofPaediatrics and Child Health

United Kingdom Children’s Cancer Study Group (1997b)The resources and requirements of a UKCCSF treatmentcentre (unpublished report), as cited in United KingdomChildren’s Cancer Study Group (1997) Guidance forservices for children and young people with brain andspinal tumours. London: Royal College of Paediatrics andChild Health

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September 2003

Published by the Royal College of Nursing20 Cavendish SquareLondonWIG ORN

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The RCN represents nurses andnursing, promotes excellence inpractice and shapes health policies.

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