Purpose
Enhanced therapeutic observations and care (ETOC) demand can fluctuate. To meet this demand, organisations frequently rely on reactive, short-term solutions, including the use of unfunded temporary staff.
This guidance supports organisations in undertaking ETOC workforce planning within the existing National Quality Board’s (NQB’s) guidance on safe staffing and Developing workforce safeguards (DWS) guidance. It also outlines 3 potential deployment models that organisations can use or adapt for the delivery of ETOC:
- a centralised dedicated ETOC team
- integrating ETOC requirements into ward staffing
- budgeted temporary staffing models
More ETOC information and resources are available on our website.
Considerations for ETOC workforce deployment
The following questions may help organisations when planning ETOC staffing as part of their nursing establishment and workforce review processes.
What tools and processes can support ETOC workforce planning?
ETOC workforce planning is most effective when carried out as part of the biannual establishment setting process as outlined in the NQB and DWS guidance and when considered through existing nursing workforce governance arrangements.
It is also important to align ETOC planning with organisational budget setting to ensure that sufficient funding is available to meet anticipated demand.
When considering changes to ETOC staffing models, skill mix, adding new roles or changing existing roles, organisations should complete a quality impact assessment to support safe decision‑making and understand any potential effects on patient care.
How can local data and evidence be used to inform decisions?
Analysing local ETOC activity, acuity and trends over time helps organisations ensure that funded staffing levels reflect clinical need. This also reduces the need for routine reliance on unbudgeted temporary staffing. This analysis is an integral part of establishment reviews over a reporting period.
Where appropriate and available, organisations can use workforce planning evidence-based tools to support this work including:
How can organisations build an agile approach to deployment and escalation?
Given that ETOC demand can fluctuate, deployment arrangements need sufficient flexibility to respond. Local leaders may choose a single model or a combination of deployment models to suit their local context.
Regular review of ETOC demand, including through daily staffing reviews, will support responsive allocation of resources. Where demand is close to exceeding capacity, the organisation’s escalation and safety processes should be implemented.
This supports local decision‑making and helps ensure ETOC provision remains safe and effective during periods of pressure.
How can staff be supported to deliver ETOC safely?
All staff delivering ETOC should have the appropriate skills, training and competencies, as suggested in the ETOC training and education guide.
This includes ensuring staff:
- receive a full handover and local induction
- have access to patient records, care plans and safety plans
- are trained and supported to complete relevant ETOC documentation
- have regular breaks and are frequently rotated
ETOC deployment models
Local organisations can use a deployment model or combined approaches, based on context, workforce and clinical need.
Workforce planning evidence-based tools such as the Safer nursing care tool can generate area-specific resource requirements which can then be used to shape the models described below.
Centralised dedicated ETOC team
A centralised team consists of staff trained to deliver consistent ETOC across an organisation’s inpatient settings. Factors to consider before adopting this model include:
- consistency and quality – consolidating assessment, decision-making principles, processes and training into 1 team can make it easier to maintain consistent standards of care, which can be audited and monitored over time
- geography – covering a large footprint may be difficult, although this can be managed by creating several sub-teams located across the sites
- capacity – centralised teams are often small, and unplanned absences can have a substantial impact on available capacity
- person-centred care – centralised staff may not always know the patient or ward environment, so co-ordination with ward teams is important for maintaining personalised care
Local example: a dedicated ETOC team
In 2022, the Shrewsbury and Telford Hospital NHS Trust reviewed its ETOC staffing as part of its establishment review. This identified rising temporary staffing costs and inconsistencies in ETOC delivery.
Using this insight, the trust created an ETOC team made up of an ETOC clinical lead and enhanced care healthcare support workers. The team received training in therapeutic interventions, including preventing deconditioning, communication and de-escalation.
Since introducing the team, falls have decreased by 28%. The team also works closely with ward staff to develop a person-centred approach to ETOC. This includes using a support document to capture patient preferences and key information.
Total temporary and agency spend has reduced significantly:
- agency spend decreased from £203,740 in 2023 to £12,462 by June 2024
- agency spend for healthcare support workers delivering ETOC ceased in August 2024 and has remained at zero.
Integrating ETOC requirements into ward staffing
In this model, ETOC provision is built into a ward’s planned staffing to meet the immediate needs of patients. Factors to consider before adopting this mode include:
- a shared knowledge base – creating a single integrated workforce can reduce the risk of burnout and deskilling, as all ward staff involved in ETOC are trained and responsibility is shared across the team
- consistency – ETOC becomes a standardised clinical intervention and a core function of the ward
- continuity – patients receive ETOC from staff who already know them, which can result in a more consistent and personalised approach
Local example: integrated ETOC team
Sandwell and West Birmingham NHS Foundation Trust recognised that high complexity in older people’s inpatient services created a constant, unmet demand for ETOC. To address this, the trust was relying heavily on temporary staffing, which impacted both the cost and continuity of care.
To move away from this reactive staffing approach, the trust moved to a model that embedded ETOC capacity directly into their funded establishment. They used the Safer nursing care tool to model demand and secure the necessary investment to enable effective skill mix.
This shift eliminated reliance on ad-hoc staffing, resulting in a resilient, flexible workforce meeting patients’ complex needs consistently and within budget.
Budgeted temporary staffing models
In some circumstances, using a budgeted temporary bank staffing resource may be a more efficient and cost-effective way to meet ETOC demand safely.
Factors to consider before adopting this model include:
- responsiveness – a pre-allocated resource can help organisations respond more quickly and flexibly to changes in demand, and it allows use to be monitored regularly, with action taken when needed
- training and induction – temporary staff should ideally have equivalent training and the same local induction as the substantive team. Whilst they may be deployed to support areas with ETOC demand, they may not be the most appropriate staff member to deliver ETOC or may not have sufficient training. In these instances, they can be allocated to support core ward duties to allow staff with an established patient relationship and relevant training to deliver ETOC
Local example: developing a temporary staffing model
Sheffield Teaching Hospitals NHS Foundation Trust faced a surge in unbudgeted enhanced observations, resulting in up to 10,000 hours of temporary staffing per month. Without a formal process, ETOC delivery was inconsistent and financially unsustainable.
Instead of filling shifts ad-hoc, the trust introduced a central, budgeted approach that brought together:
- data-led modelling – using the Safer nursing care tool to identify actual demand during the twice-yearly data collection, which informed the biannual workforce reviews
- robust governance – embedding a multidisciplinary approval process at ward, department and board levels
- daily validation – implementing 24-hour shift reviews within existing processes and updating standard operating procedures to ensure every additional hour was clinically justified
This shift resulted in operational efficiency, reduced temporary staffing by 2,000 hours per month and ensured consistent care delivery and financial assurance.
Publication reference: PRN01862_v