Opinion

Letter Staffing ratios DEMAND FOR urgent care clinical services is unprecedentedly high so it is not surprising that meeting the demand with a limited workforce is difficult. There is, for example, a scarcity of experienced emergency nurse practitioners (ENPs), and acute and community care providers are chasing the same small group of skilled clinicians. Various general emergency department skill-mix tools are available and, of course, there is the College of Emergency Medicine’s (2011) guideline that one full-time ENP working 37.5 hours a week should see between 2,500 and 3,000 patients a year. However, these figures relate to minor injury-type presentations of the kind seen in the old A&Es rather than the more complex

Board’s eye view acute cases commonly managed in the minor injury and urgent care units that are replacing them. Delivering a high quality, safe clinical service is paramount, which is why a review of the skill mix in minor injury and urgent care units in the UK is overdue. I would be interested in hearing from anyone working in minor injury and urgent care services in which a benchmark ratio of ENP to mixed-patient acuity has been established. You can email me at michael.paynter@ sompar.nhs.uk or call +44 (0)1278 436716. Mike Paynter a consultant nurse at Somerset Partnership NHS Foundation Trust, Bridgwater Reference College of Emergency Medicine (2011) The Way Ahead 2011. tinyurl.com/okfvf6j (Last accessed: May 14 2014.)

The bigger picture

Keep snacks out of sight BOXES OF chocolates, bottles of fizzy drink and cups of coffee are often scattered around emergency departments (EDs) as nurses refuel themselves to get through their busy shifts. When people are hungry or thirsty, their abilities to make decisions can suffer, so it is right that managers encourage staff to eat regularly and stay hydrated. But snacking and drinking should be confined to staff rooms and break times, for several reasons. First, by eating or drinking in public areas of a department, staff put their health at risk. Sick people in EDs often sneeze and cough, and anything left uncovered can be showered in a wide range of exotic germs that nurses may end up ingesting. Second, there is a risk of damage to patient care equipment when food and drink are nearby. Computers that are wet can short out, patient notes can absorb spilled coffee, and fingers that have just picked up a chocolate from an enormous box left by a grateful patient may leave sticky fingerprints on the buttons of an electrocardiograph. In short, eating and drinking on the shop floor is bad for clinical equipment. EMERGENCY NURSE

Third, snacking in sight of patients is unprofessional. How would we feel if a dentist sipped a latté during examinations or if the person behind a supermarket till nibbled biscuits while scanning our weekly shop? Few of us would, yet we sometimes sip high-energy drinks while writing notes, or pop sweets in our mouths while on the phone to a ward. Patients who see staff eating and drinking can perceive that they are more interested in their own needs than those of patients. When reading through patient complaints about waiting times, I frequently see some or other variation of: ‘I waited three hours for my X-ray (or pain medication or discharge instructions), yet the staff had time for a coffee at the nurses’ station.’ The nurses were undoubtedly busy, but did not appear to be so because they had combined snacking with their work. Staff must not go hungry or thirsty at work, but they also need to separate the times when they care for themselves from those when they care for others by confining their eating and drinking to break times away from the shop floor. Sara Morgan is a committee member of the RCN Emergency Care Association

Parallel assessments I RECENTLY attended a conference on parity of esteem for mental health. Our chief subject of debate was ensuring that the treatment of patients’ mental health problems is given equal priority to that of their physical health conditions. The keynote speaker was comedian, actor, writer and mental health campaigner Ruby Wax, who spoke eloquently about her experiences. She challenged the audience to identify what good services look like and to push for them to be developed. Emergency departments (EDs) are often the first places that people with mental health problems seek care, perhaps because there are too few alternative services they can access directly, especially out of hours. But is the ED the best place for people with mental health problems to attend? In some circumstances, it is. It is the ‘normal’ place for people in crisis, whether they have physical or emotional problems. It can also be the appropriate place to go for people who do not recognise that they are mentally unwell or who fear they would be admitted if they presented directly at mental health services. If such patients are to attend EDs first, mental health staff must be on site to assess them, irrespective of the patients’ ages or presenting complaints, and help to refer them to the appropriate services. This system would work especially well if mental health services were co-located in EDs to enable parallel assessment of people with both physical and emotional concerns. It must be remembered, however, that EDs can be over-stimulating and noisy, and are full of opportunities for self-harm. To achieve a good service, therefore, we must assess risk and escalate concern for those who are especially vulnerable so that they can be moved to more appropriate environments as soon as possible. Shelley Cummings is a senior sister A&E at the Royal Surrey County Hospital and a member of the Emergency Nurse editorial advisory board June 2014 | Volume 22 | Number 3 13

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