1 INTRODUCTION

Critical care is at the heart of every acute hospital.1 A previous survey highlighted the state of the critical care nursing workforce across significant areas of the National Health Service (NHS) in Great Britain.2 Workforce planning, informed by representative data, is essential to providing care that is safe, high quality, sustainable, cost-effective, flexible, and delivered at all times of every day by appropriately trained and highly skilled nursing staff. Staff shortages and poor skill mix limit the availability of trained critical care nurses for the patients who need them. They also have a negative impact on the well-being of nurses and, as a result, the standards of care they deliver.1 This and other issues highlighted in this paper are evident in the literature and affect critical care nursing internationally.3 However, the NHS has many standards against which critical care services are delivered and evaluated. The standards that form the basis for the areas explored in this survey are aimed at the NHS and differ significantly from those in other countries and health care systems.

This survey was conducted to inform decision-making and workforce planning for the future of critical care nursing in the NHS. The study was conducted by the Critical Care National Network Nurse Leads Forum (CC3N) representing the operational delivery networks (ODNs) across England Northern Ireland, and Wales. ODNs comprise groups of critical care units that are within a geographical area and collaborate in service provision and evaluation.

The results give a picture of critical care nurse staffing in large areas of the NHS, highlighting great diversity, strengths, and the challenges to be addressed. It builds on the first national survey undertaken in 2015,2 highlighting areas of stability and change.

2 BACKGROUND AND CONTEXT

Nursing turnover and shortages are worldwide issues.3, 4 These affect critical care in the United Kingdom,2 where in 2017, for the first time, attrition from the professional register exceeded new registrants.5 There were also concurrent reports of dilution of the nursing skill mix.6 Consequently, substitutions with non-registered staff, vacancy rates, and retention have become significant issues.

The NHS plan sets out an ambitious agenda for the future of the NHS based on adequate staffing.7 The current 100 000 staffing shortfall is estimated to grow to 250 000 by 2030 but could reach 350 000 if attrition is not addressed.8

Workforce remains the single most important and challenging element in the provision of safe, high-quality clinical services in the NHS, as well as internationally.3 Issues previously identified2 include high vacancy and turnover rates, reliance on agency nurses, and overseas recruitment. This may impact safety standards such as nurse: patient ratios and the ability of senior staff to oversee and supervise the workforce. A shortage of clinical educators to support learners and limited access to specialist training in some areas were also evident.

In 2015, two national groups who advise the NHS on the provision of critical care, the Adult Critical Care Clinical Reference Group (ACCCRG) and the Clinical Leadership Forum (CLF), commissioned CC3N to provide an overview of the non-medical workforce supporting critical care services across England, Northern Ireland, and Wales. This was the first time workforce data had been collected on a national basis to determine the profile of nursing within critical care services. The response rate was 70% of the 270 critical care services.

This follow-up survey provided insight into where progress has been made since 2015 and also identified challenges faced by critical care nursing in the areas represented.

3 AIMS

The aims of this study were to measure key aspects of the critical care nursing workforce across the NHS and compare these with recommended standards where they exist.

4 METHODOLOGY

The intent was to collect data from all the NHS critical care units in England, Northern Ireland, Wales, and Scotland. A survey design was chosen as an inexpensive and practical approach to quickly gather a large amount of valid and reliable data that could be compared with future surveys.

A stakeholder-driven consensus development approach was adopted to design an initial workforce survey in 2015 by members of CC3N. Based on the report from that survey2 and subsequent stakeholder events, the survey was redesigned in 2017. Lessons such as lack of clarity and misinterpretation of questions informed the revision of the survey. The key stakeholders were senior expert nurses from the clinical networks for critical care across England, Northern Ireland, and Wales. Their expertise helped to ensure validity in the questions being asked. The survey was reviewed in electronic form via email by all members, and revisions were agreed upon through consensus at quarterly group meetings. A key strategy to enhance reliability was the inclusion of definitions for each question in the electronic survey.

Data were collected between 1 September and 31 October 2017. The survey, a pre-formatted spreadsheet, was emailed to lead nurses for each clinical network and subsequently cascaded to nurse managers in each critical care unit in their area. A letter of explanation and support from the respective chairs of the ACCCRG and CLF accompanied the survey. Anonymity was assured to individual units. It was acknowledged that data relating to specific networks and countries would be described in the final report but that individual units would not be identified. Ethics committee approval was not sought as Medical Research Council advice was that it was not needed. Approval from the ACCRG, CLF, and CC3N and consent from clinical networks were obtained.

The midlands critical care and major trauma network received and analysed completed surveys. Initial data analysis was undertaken using Microsoft Excel. This generated descriptive statistics. An initial report was published,9 but further analysis and omission of Scotland and Wales because of insufficient survey returns meant that data in this report differ from those initially reported.

5 RESULTS

Summary results are presented here. A full description of all data are reported elsewhere.9 At the time of the survey, there were 272 critical care units in England and Northern Ireland. Data were submitted from 240 units, at a return rate of 88%, an increase from 70% in the previous survey.2 Some datasets were incomplete, meaning denominator numbers vary in the sections below. The differences in the sample and response rate between the two surveys meant valid comparisons between the two surveys was not always possible.

Because of low response rates in Scotland (21%) and Wales (20%) and the skewing effect this would have had on national figures, Wales and Scotland data were excluded.

5.1 Critical care capacity and configuration

Combined levels 2 (high dependency) and 3 (intensive care) general units were most prevalent (65.5%); 7.9% were cardiothoracic units, 7.1% were general level 2 units, 7.1% were general level 3 units, 3.8% were combined general and neurosurgical units, 3.3% were neurosurgical units, and 1.3% were combined general and cardiothoracic units. Other units (burns, gynaecology, and obstetric) were 0.4% each. A category of “Other” was included in the survey, which 2.5% of respondents selected as the descriptor of their unit.

Larger units (≥10beds) were most prevalent (69%), most commonly 11 to 20 beds (42.9%). There were 3222 funded/commissioned beds (3461 bed spaces). There were 1017 single rooms. The proportion of single rooms varied significantly between units.

5.2 Registered nurses

In the NHS, nurses are organized and paid according to “clinical band.” Staff nurses are band 5, progressing through to Sisters/Charge Nurses in band 6 or 7 and more senior and specialist nurses at bands 8a, 8b, and 8c.

There were 17 615 whole-time equivalent (WTE) nurses in the 240 units who returned data; 11 428 were band 5, 4343 were band 6, 1243 were band 7, 445 were lead band 8 nurses, 292 were educators, 68 were research nurses, and 22 were consultant nurses. Comparison of the data between 2015 and 2017 shows small changes. Staff at band 5 decreased by 1.5%, with a corresponding 1.5% rise in band 6 staff. Consultant nurses fell from 0.2% to 0.1%.

5.3 Nursing support staff

Of the total workforce, 1742, 9% were unregistered clinical support staff in bands 2 to 4. This was unchanged from the 2015 survey.2

5.4 Nurse-to-patient ratios

The nurse staffing ratios required according to GPICS9 and the adult critical care service specification10 at the time of the survey were as follows:

Level 3 patients (level guided by ICS levels of care) require a registered nurse: patient ratio of a minimum 1:1 to deliver direct care

Level 2 patients (level guided by ICS levels of care) require a registered nurse: patient ratio of a minimum 1:2 to deliver direct care

Overall, 100% reported compliance with this for level 3 patients. This was an increase from 93% in the 2015 survey.2 A total of 99.5% reported compliance with this for level 2 patients. Fourteen units described including unregistered staff in the ratios of nurse: patient reported in the survey.

5.5 Nursing leadership

Professional nursing leadership was provided by a range of staff—including Matron (51%), Lead nurse (21%), Unit manager (12%), or another named senior nurse or nurse manager (16%). Among the nurse leaders, time dedicated to leadership of the unit ranged from 100% of the time (58% of units), to 51% to 99% (24% of units), 25% to 50% (10% of units), and to less than 25% (7% of units).

5.6 Supernumerary clinical co-ordinator The standards9, 11 state:

There will be a supernumerary clinical co-ordinator (sister/charge nurse bands 6/7) on duty 24/7 in critical care units (for units >10 beds)

The term “supernumerary” indicates that they are not allocated to care for a specific patient during their shift but rather perform a supervisory, leadership, and co-ordinating role. Achievement of this standard had increased significantly since 2015.2 Compliance varied with size of unit and time of day. Daytime shifts in larger units (>21 beds) had the highest compliance (around 97%). In smaller units (11-20 beds), at night, this was lower at around 87%. The smallest units (<10 beds) had an average of 44% of shifts with a supernumerary co-ordinator.

5.7 Registered nurse staff over 50 years of age

The average number fell slightly from 12.9% in 20152 to 12.0%. Four networks (shaded in Table 1) previously had over 20% over 50 years of age.

TABLE 1. Nursing workforce over 50 years of age by operational delivery network Network % Cheshire and Mersey 19.7 South East Coast 16.5 North Yorkshire and Humberside 16.4 Birmingham Black Country 15.3 Northern Ireland 15.1 North of England 13.9 Lancashire and South Cumbria 13.2 Central England 12.3 West Yorkshire 11.8 Greater Manchester 11.6 North Trent 11.4 Mid Trent 11.2 Thames Valley and Wessex 10.8 East of England 10.6 London—North West 10.3 South West 10.2 North West Midlands 8.4 London—South 7.8 London—North Central and East 3.1 Average 12.0 5.8 Vacancies

There were 1447 (8.3%) vacant nursing posts. The rates were: band 8: 1.8%, band 7: 5.5%, band 6: 9.9%, band 5: 8.2%, and support staff bands 2 to 4: 11.5%. Vacancies across all bands have all reduced slightly since the previous survey.2 The areas with the highest vacancies (9.3%-15.9%) are located in North Central and East London, South East Coast, and the South West.

5.9 Turnover

A slight reduction in average staff turnover from 11% to 9.9% was reported, with fewer units (n = 18) reporting an annual turnover of >20% compared with 20151 (n = 23). Turnover rates vary considerably between networks (range: 4.4%-15.1%), with the highest individual unit turnover reported as 42%.

5.10 Overseas recruitment

In the 2015 survey,2 57 units of 188 (30%) had actively recruited staff from outside the United Kingdom. In the 2017 survey, the question differentiated between European Union (EU) and non-EU recruitment. A total of 208 units returned data on this question. Fifty units (24.3%) had recruited from the EU, and 65 (31.7%) had recruited from non-EU countries.

The results (Table 2) show a diverse picture with total overseas workers ranging from 3.2% in North Trent to 76.5% in North Central and East London. Overall, the non-EU workers constitute a higher proportion of the workforce than EU workers.

TABLE 2. Overseas EU and non-EU registered nurses' (bands 5-8) average percentage of headcount by network Network EU % of headcount Non-EU overseas % of headcount Total (rank order) London—North Central and East 31.1 45.4 76.5 London—North West 14.7 44.1 58.8 East of England 14.4 33.1 47.5 London—South 21.2 22.8 44 Thames Valley and Wessex 21.5 19.4 40.9 South East Coast 19.0 20.8 39.8 Central England 8.2 15.6 23.8 Mid Trent 7.6 14.7 22.3 Lancashire and South Cumbria 4.7 14.7 19.4 West Yorkshire 5.8 13.1 18.9 South West 9.8 8.6 18.4 Greater Manchester 5.1 13.0 18.1 Northern Ireland 0.7 10.2 17.2 Birmingham Black Country 2.8 13.6 16.4 North Yorkshire and Humberside 4.6 10.0 14.6 Cheshire and Mersey 4.0 9.5 13.5 North West Midlands 3.8 6.8 10.6 North of England 1.0 7.3 8.3 North Trent 1.9 1.3 3.2 5.11 Sickness

The average sickness rate was 4.9%. It was 5.1% in 2015.2 There was an inverse relationship between size of unit and sickness rate. Units with 12 or fewer beds had an average of 5.1%. Units with between 13 and 30 beds had an average of 4.8%. Units with 31 to 40 beds had an average of 4.7%. The largest units with >40 beds had an average of 3.7%.

5.12 Agency staff GPICS11 states that units:

Must not utilise > 20% of registered nurse from bank /agency on any one shift when they are NOT their own staff

Of those responders who answered the question (n = 181), 23 (12.7%) stated that they exceeded 20%. This was a significant reduction from 46% in 2015.2

5.13 Clinical educators

Recommendations in GPICS9 require critical care units to have one WTE clinical educator for every 75 nurses; 57% of responders met this standard. This was a slight reduction from 61% in 2015.1 A total of 80% of critical care units (n = 167) had at least one educator, an increase of 11% from 20152; 43 units had no educator.

5.14 Adoption of national critical care nurse competency framework

The national critical care competency framework12 for the NHS includes three steps: Step 1 for new and novice nurses and steps 2 and 3 for higher levels of knowledge and skill development as part of academic education programmes. Of 205 respondents, 134 (65%) were using all levels of the framework, an improvement from 48% in 2015.2 A total of 198 (97%) were using at least one part of the framework.

5.15 Critical care trained nurses

Current standards10, 11 require 50% of critical care nurses in each unit to hold a specialist academic qualification in critical care nursing. Overall, 48.8% held the qualification. There was significant diversity between the units. The reported range was between 0% and 100%.

A total of 151 (73%) reported that they allocated the minimum requirement9 of a 6-week supernumerary period for new nurses. The range reported overall was between 0 and >10 weeks.

5.16 Advanced critical care practitioners in critical care units

Inclusion of trainee and qualified advanced critical care practitioners (ACCPs) increased from 11.6% of units in 20152 to 23% in 2017. There were 116 trainee ACCPs and 93 qualified ACCPs. The majority were at band 7 during training and band 8a on qualification.

5.17 Clinical data reporting

A total of 59% indicated that Intensive Care National Audit and Research Centre (ICNARC) data were entered by an audit clerk. Other answers included other “Healthcare Professional” (31%), “Ward Clerk” (4.3%), and no answer (5.7%).

5.18 Critical care outreach teams

Of the units, 94% had an outreach service compared with 86% in 2015.1 An expanded report on outreach services is reported elsewhere.9

6 DISCUSSION

There has been transformation of critical care services in the NHS since the Audit Commission report of 199913 when stand-alone ICUs (level 3 units) predominated. Most in the NHS are now combined levels 2 and 3 units, resulting in significant flexibility and efficiency of resource use. However, this requires a broader competence base among the nursing workforce. The question of whether combined units are most clinically beneficial for patients requires further research. The answer may be nuanced and context specific based on factors such as the size and case mix of a unit or geographical remoteness.14

A total of 70% of units have 10 or more beds, indicating a growing centralization of critical care services within hospitals. This may lead to improved standards and outcomes in specialities.14 The benefits of providing general intensive care services at a local level, for smaller or geographically remote areas, has also been acknowledged.14 Such units are seen as more challenging to sustain.14 It has been argued that clinical support from neighbouring units and professional integration with surrounding centres and professional societies is essential.14 This organization of NHS critical care units around clinical networks obviously differs significantly from other countries, where clinical support and professional integration may be less structured and consistent.

There appeared to be no significant historical differences in the percentage of staff in bands 5 to 7. This is not unexpected as demands for bedside nurses (band 5) and supervisory staff (bands 6 and 7) have not changed. Greater relative differences appeared in the more senior bands. The differences between the two surveys in the senior groups were susceptible to a statistical effect because of the small numbers involved. Overall, there appeared to be stability in the workforce.

Significant improvements were seen in two important national standards of nurse: patient ratio and supernumerary “nurse in charge.” The nursing leadership of units is further strengthened by the role of the lead nurse who, in 82% of units, spent at least half of their time dedicated to the unit.

The number of nurses approaching retirement age may threaten future workforce numbers in the NHS. As a “special class,” nurses in the NHS can currently retire and receive their pension at 55 years of age. Recent changes to the NHS pension mean this will be less financially beneficial in future, and nurses are likely to retire at an older age. On average, 12% of staff were over 50 years of age. In some areas, this was as high as 20%. These staff were within 5 years of eligible retirement. The age of staff was not measured, and some staff may have been at or beyond the NHS retirement age of 55 years. When staff in this age group retire, there is a significant loss of experience and skill. Ways of retaining more experienced staff in appropriate roles is clearly an area requiring further work.

Many units reported actively recruiting from the EU (24.3% of units) and non-EU countries (31.7% of units). Overall, UK Nursing and Midwifery Council registrants from overseas continue to grow in number, comprising 5.5% (EU) and 9.7% (non-EU) of total nurse registrants in 2017.5 There is a very wide variation in the proportion of overseas staff in critical care units in the NHS. Those units with the highest rates face the greatest challenges if future immigration policy affects migrants seeking work in the NHS as nurses. In some areas of the South East, for example, London, services would be completely unsustainable without overseas nurses. The continuation of arrangements that support nurses from overseas to register and work within the NHS is vital to critical care services. There may have been some issues of clarity and interpretation or accuracy relating to the term “overseas” in the survey. Knowing the birthplace, nationality, or visa status of employees was clearly essential to accurate reporting in the survey. Further work refining this element of the survey in future may be beneficial.

Turnover was stable since the previous survey.2 Networks with the highest turnover rates, up to 42%, were in a very challenged position. A limitation of the survey was that it did not investigate the reasons for attrition or the most common reasons for sickness and absence. Sickness in this survey was unchanged from the previous survey at around 5% on average. According to national NHS statistics,15 between October and December 2016, the average sickness absence rate for the NHS in England was 4.44%, a slight increase from the same period in 2015. Interestingly, in this survey, sickness was inversely proportional to the size of the unit. Further investigation is needed to understand whether this is a statistical effect or in some way reflects a healthier workforce in larger units. The cause of staff ill health and absenteeism is of critical importance. There is increasing evidence that mental ill health is a major cause of sickness in critical care nurses.16 This may be one of the most important areas for future work that could impact not only the numbers of nurses attending work and remaining in their jobs but also the quality of their care, health care outcomes, and costs.17

The NHS aspires to a standard that agency staff should not exceed 20% of the complement of staff on duty.10, 11 The number of units who exceeded 20% had fallen from 46% in 20151 to only 12.7%. This could be in response to the published standards on safe agency levels18 along with constraints introduced to reduce agency expenditure across the NHS. As nurse-patient ratios have improved, and vacancy rates and sickness were broadly similar, the question arises of how nursing ratios have been sustained with significant reductions in agency staff use. As there was no collection or analysis of workload statistics, such as occupancy rates, it was not possible to draw meaningful conclusions from the survey data about service demands vs nurse availability.

A total of 73% of respondents reported that newly appointed critical care nurses received 6 weeks of supernumerary induction in line with national standards.11 The increase in adoption of levels 1 to 3 of the national step competencies12 from 48% of units in 20151 to 65% is a significant improvement. There were only 3% of units not using any part of the national framework, a significant improvement from 23% in 2015.2 This means staff and employers have greater transferable evidence and assurance of competence. The recent development of step 4 competencies19 will further enhance the structure of competence acquisition for more senior and advanced nurses working in critical care. Exploring the uptake of these higher-level competencies in future surveys would increase understanding in this area.

It is expected that staff will progress to gain an academically accredited qualification in critical care nursing and that 50% of staff in each unit should hold such a qualification10, 11; 48.8% of nurses had attained this qualification at the time of the survey, but the proportion of staff within units varied widely between 0% and 100%. Funding for post-registration nurse education has seen substantial cuts, which has impacted access to academic programmes and retention.20 Of critical care units, 57% had the recommended number of clinical educators (one WTE per 75 nurses).10, 11 This was a reduction from 61% in the 2015 survey. Of WTEs, 1.7% were educators, increasing from 1.3% in 2015.1 While the number meeting the national standard may have reduced, the overall proportion of educators had increased. These differences could be explained by some units increasing in size without increasing educator numbers, while other units, which previously did not have educators, employed them. The changes could also be explained by the different samples and response rates between the two surveys.

While intensive care medicine continues to face challenges in recruiting adequate numbers of doctors,2 ACCPs continue to grow in numbers. In 2017, there were 93 qualified and 116 trainee ACCPs in 23% of the units surveyed—a significant rise from 11% in 2015.2 ACCP posts are an additional career pathway for critical care nurses. This retains their experience and developing skill within the service.

Critical care outreach is essential in the critical care patient pathway, preventing and identifying critical illness and facilitating recovery. A total of 94% had a critical care outreach service, an increase from 86% in 20152; 64% of units had 24/7 outreach cover, up from 56% in 2015.1

While improvements have been seen in many areas, some challenges lie ahead. The strengths of this study include the high response rate, improved from the previous survey.1 The broader question set allows deeper insight than the previous survey while allowing some historical comparison.

There were some key limitations in this study. First, the data give a time-limited snapshot. The exclusion of Wales and Scotland data means that it was not representative of the whole NHS. The differences in sample and response rates mean that valid comparisons were not possible in all areas of the survey. As discussed above, there are key areas in which a future repetition of the survey could be enhanced.

At the time of initial submission of this manuscript, critical care services in the NHS had not experienced surges in activity because of COVID-19. This has significantly changed future possibilities and what is needed from the critical care nursing workforce. The frame of reference for the survey and discussion of results was largely “business as usual.” Ensuring a stable and solid foundation, as well as the ability to adapt to surge, will be important in the future. The critical care nursing workforce will, in future, include redeployed staff. The training, support, and management of these will bring a new set of challenges and learning.

7 CONCLUSION

Critical care services provide life-sustaining care for the very sickest patients. Their support enables complex surgery to be performed and treatment of life-threatening emergencies, including those emanating from major incidents. Standards and frameworks describe the human resource requirements and structure of services in the NHS. This survey has illuminated compliance levels with these and future challenges.

The most salient themes challenging critical care provision are the recruitment, retention, well-being, support, and development of the clinical workforce. To address these, engaged clinical leadership and clinical and professional networks are key to informing future policy and resource allocation at the local and national levels.

Trusts and ODNs should review their own critical care workforce data in conjunction with the information contained within this report to inform local and regional reviews of their own teams.

Further work is needed to understand the personal challenge and demands of the clinical role in critical care and the burden it places on staff. Upon this should be built a national strategy for staff well-being. A further workforce survey is currently being planned and will be conducted by CC3N across the NHS.

ACKNOWLEDGEMENTS

Angela Himsworth—Former Lead Nurse, The Midlands critical Care Network. Julie Platten—Network Manager, The North of England Critical Care Network. Chris Hill—Senior Clinical Practice Educator, Royal Free Hospital. Steve Littleson—Data Analyst, The Midlands Critical Care Network. Network lead nurses nationally and all staff who submitted data.