Nursing and Midwifery Workforce and Safe Care · 2020-05-14 · of between £5000 and £8000 per year for all students in nursing or midwifery from September 2020. This significant

Sharing how we careDoncaster and Bassetlaw

Teaching HospitalsNHS Foundation Trust

Sister

MatronHead of Nursing

SeniorSister/ACP/ Specialist Nurse

Sta� Nurse

HealthcareAssistant

AssistantPractitioner

Nurse Associate

HouseKeeper

Service Assistant

Service Assistant

WardClerk

Sister

MatronHead of Nursing

SeniorSister/ACP/ Specialist Nurse

Sta� Nurse

HealthcareAssistant

AssistantPractitioner

Nurse Associate

HouseKeeper

Service Assistant

Service Assistant

WardClerkSister

MatronHead of Nursing

SeniorSister/ACP/ Specialist Nurse

Sta� Nurse

HealthcareAssistant

AssistantPractitioner

Nurse Associate

HouseKeeper

Service Assistant

Service Assistant

WardClerk

We know that the nature of patient needs and ward activity is changing. Inpatients tend to be more ill than they used to be, many with complex needs often arising from multiple long-term conditions. At the same time, all hospitals in the NHS face the challenges of a shortage and high turnover of registered nurses and midwives.

Issue 1: January 2020 Nursing and Midwifery Workforce and Safe Care

Making decisions about optimal ward staffing is complex. Most inpatient areas have their establishment, skill mix and hands per shift planned on the average acuity and dependency of patients. This means that at times of increased patient activity, acuity and dependency, these areas can seem busy places with not enough staff.

While planning the shape of the team is critical, managing wards well is not just a numbers game. Managers need time and training to manage staff and to use roster planning tools well. Evidence is emerging that patient experience is affected by staff wellbeing and local ward culture. Teamwork, clear role design and good local leadership all contribute to positive ward environments.

NHS Improvement reported registered nurse vacancies as 41,772 in June 2018 out of 317,884 posts (NHS Digital 2018b). The Royal College of Nursing’s analysis show that, far from filling this gap, the supply of registered nurses will decrease over the next five years (RCN 2018). These challenges are not unique to the UK. The World Health Organisation (WHO) estimates that nurses and midwives represent more than 50% of the current shortage in health workers globally and that the world will need an additional 9 million nurses and midwives by the year 2030 (WHO 2018).

Planning the Teams

Leadership

Vacancy rates

What are we doing?2020 is Florence Nightingale’s bicentennial year, designated by World Health Organisation as the first ever global Year of the Nurse and Midwife. Nurses and midwives make up the largest numbers of the NHS workforce and are being recognised as highly skilled, multi-faceted professionals from a host of backgrounds, representing our diverse communities.2020 is our time to reflect on these skills, the commitment and expert clinical care you bring, and the impact you make on the lives of so many. This year is also an opportunity to say thank you to the professions; to showcase your diverse talents and expertise; and to promote nursing and midwifery as careers with a great deal to offer.

Nursing and Midwifery Workforce and Safe Care

January 2020

The CNO has vowed to foster greater positivity about the nursing profession and to promote a contemporary image of nurses and midwives by stamping out old stereotypes. The new CNO uniforms are designed to tackle outdated stereotypes and encourage conversations with young people on how rewarding and varied careers in the profession can be.

Sam Fawkes, acting matron for children’s services ordered some of the CNO future nurse uniforms for children’s outpatient areas, which was also published in the nursing times.

If you would like to order the mini-nurse uniforms, you can use this link. Please share your future nurse pictures with the #teamCNO.

In December 2019, the Chief Nursing Officer (CNO) for England, Ruth May announced a new investment of between £5000 and £8000 per year for all students in nursing or midwifery from September 2020. This significant news was positive in showing the professional voice being heard. It is hoped that this news will see an increase in students applying for their nurse or midwifery training to support the future workforce.

The ‘We are the NHS’ campaign has returned aiming to highlight the valuable and varied nursing roles available across the NHS.

There is also a new applicant support system which guides prospective nursing candidates through their UCAS applications and beyond. You can watch and share the 90 second video here.

While recruiting on a regular basis for all areas with vacancy, we have a proactive and consistent approach to recruiting our newly qualified nurses and midwives at each intake. This is also complimented with a generous preceptorship offer to support newly qualified RN and RM in the transition from student to registered practitioner. We are always looking for volunteers to help woth the open days and assessment events. For more information or to help with the recruitment of newly qualified nurses please contact [email protected] or [email protected] more information on recruitment in maternity, please contact [email protected]

Retention of staff is a key issue for the NHS and is a crucial factor in securing a skilled and sustainable workforce for the future.Last year, we joined the NHS improvement retention of nurse’s programme to learn how to ensure new and existing staff are supported and encouraged to remain in the NHSIn 2019, we asked our Nurses and Midwives what were the most important factors when looking for a new role and what were the most important factors to stay within a current role. You can see the results below (and also print off for your area).

CNO future nurse uniforms

Nurse Training

Retention

We are the NHS

Recruitment

How can I find out about and share opportunities for development? We have developed this infographic and the one on the following page, to help highlight the variety of career options available for registered nurses and midwives at DBTH. Print off for use in your area. Download and print

your own copy

Download and print

your own copy

Download and print

your own copy

We also want to be able to offer career development for health care assistants, should they wish to persue these options. The infographic below helps to demonstrate what is available. For more information on carer development for health care assistants please contact [email protected]

Download and print

your own copy

Download and print

your own copy

The NICE guidance on safe staffing for nursing in adult inpatient wards in acute hospitals was published in July 2014. This identifies organisational and managerial factors needed to support safe nurse staffing, and set out a series of indicators or ‘red flags’ to assess whether the level of nurse staffing is sufficient to meet patient needs safely, and provide a warning of potential insufficiency.

The guidance was accompanied by the endorsement of the Safer Nursing Care Tool (SNCT), to help Trusts review nurse staffing in adult inpatient care.

This is a simple-to-use, evidence based digital tool that calculates nurse staffing requirements based on the acuity and dependency of the patients on a ward. It is linked to nurse sensitive outcome indicators. This can help nurse leaders in setting ward staffing levels rigorously and objectively, although of course it remains challenging to recruit to those optimal levels in the current environment.

During summer 2019, we signed the licence for us to use the Safer Nursing Care Tool at DBTH, thanks to an innovative partnership between the Shelford Group and Imperial Innovations, in collaboration with NHS Improvement and the Chief Nursing Officer.

Every month, the wards collect the hours of planned nursing time, versus the actual nursing time worked. This is then triangulated with patient safety outcomes and quality improvement accreditations. The Hard Truths quality metrics is presented to the Trust Clinical Governance Committee (CGC) each month and shared with all wards managers, matrons and associate directors of nursing. In addition the information is shared with the local Clinical Commissioning Group (CCG) as well as the Quality and Effectiveness Committee (QEC), which is a sub-group of the Board of Directors.

Planning establishments What is the NICE guidance?

The Safer Nursing Care Tool

Hard Truths Quality Metrics

The SNCT works by all adult and paediatric inpatient areas undertaking the Safer Nursing Care Tool data collection:1. Data is to be collected at 3pm each day 2. Data is to be collected Monday to Friday for a period of 4 weeks, twice a year. No data is required on weekends.

The Safer Nursing Care Tool can be accessed here:• Adult inpatient areas• Adult assessment areas• Children and Young People inpatient wards

How will the SNCT work? This data will be collected in January and June from 2020 – the results will then be available for the Associate Directors of Nursing to complete their annual workforce reviews in September. The Director of Nursing, Midwifery and AHPs will then review workforce plans and present to the Board of Directors.

Where will this be published?The results will be published by the Board of Directors and available for all staff on the Quality and Safety page on the Hive.

What other data is published? Care Hours per patient day (CHPPD) has been collected since May 2016. The planned versus actual hours collected for the hard truths quality metrics are also published on the model hospital site so we can see how we benchmark against other Trusts.

CHPPD data can tell us the total care hours per patient per day (nursing, midwifery and AHP staff)

CHPPD for registered nurses and midwives

CHPPD for healthcare assistants.

From September 2019, we have also submitted CHPPD for trainee nursing associates and nursing associates. Where AHPs are integrated into ward establishments, this should also be included. We currently don’t have any AHPs integrated into ward establishments. You can read about CHPPD and how this is published here.

BEST is a workforce planning tool for use in the Emergency Department (ED) the tool highlights if there is a difference between nursing workload and staffing. BEST has been designed to estimate ED’s nursing staffing requirements based on a combination of the number of patients attending the department, and a measure of the patients’ nursing dependency –not their acuity.

A patient may be very sick, but not actually require much nursing input. Their acuity would be high, but their nursing dependency low.

There may be another patient who is not actually very ill, but because of other factors, (perhaps incontinence, coupled with confusion), will have a low acuity, but very high dependency. They require significant nursing input, despite not being critically ill.

Please contact Kate Carville, Associate Director of Nursing in Medicine for more information regarding BEST.

Birthrate Plus is a method for assessing the needs of women for midwifery care throughout pregnancy, labour and the postnatal period in both hospital and community settings. From that data it is possible to calculate the required numbers of midwives to meet all of those needs in relation to defined standards and models of care and to assess local workforce planning needs.

The Birthrate Plus Workforce Planning system provides each maternity service with a detailed breakdown of the number of midwives required for each area of service in both hospital and community. It also provides each service with its own individual ratios of hospital births per whole time equivalent (WTE) midwife and the number of cases and home births per WTE community midwife.

The Birthrate Plus Intrapartum Classification system is based upon clinical indicators of need during labour, birth and post-delivery. Each indicator is given a score and the total score is used to place the mother and infant(s) into one of five distinct categories. The birth outcome category also predicts the postnatal care needs for mother and infant. A further classification is used for other women who require care in the delivery area but do not give birth at that time. It is based upon an understanding of the total midwifery time required to care for women based on a

minimum standard of providing one-to-one midwifery care throughout established labour. The principles underpinning the Birthrate Plus methodology are consistent with the recommendations in the NICE safe staffing guideline for midwives in maternity settings, and have been endorsed by the Royal College of Midwives and Royal College of Obstetricians & Gynaecologists. Birthrate plus is based on the total activity, not just the number of births per unit, needed to meet the needs of women including:

• All antenatal and postnatal care• Antenatal outpatient activity• Antenatal inpatient activity and ward attenders.• Delivery in all settings.• All postnatal care in hospital.

Please contact Lois Mellor, Head of Midwifery for more information regarding Birthrate Plus.

Baseline Emergency Staffing Tool (BEST)

Maternity Birthrate Plus

It is this measure of the patient dependency load in the Emergency Department that the BEST tool seeks to measure. This measure will most accurately reflect the number of nurses required to care for the mix of dependencies present in individual units. The tool allows you to:

Analyse the volume and pattern of nursing workload in ED

Track this against your rostered staffing level

Calculate the whole time equivalent workforce and skill mix which would be required to provide the nursing care needed in the department during the audit period.

The tool does not produce recommended staffing levels but will allow EDs to work locally to reduce any gaps between workload and staffing. This can be achieved for example by improving patient’s pathways, departmental and hospital processes, roster designs and actual staffing.

The BEST calculation requires data to be collected and input for a seven-day period on an hour-by-hour basis. The calculations work by using nurse-to-patient ratios in the various dependency categories. It is important that these ratios reflect how care is actually delivered in your department, if they do not then the outputs from the tool will not be accurate.

We know that sickness absence rates in the NHS are higher than other industries. NHS staff sickness rose from 3.8% in April 2018 to 4.1% in April 2019. This is the highest level at that time of year for more than a decade and represents 1.4 million full time days lost in one month alone (Kings Fund 2019)

Long hours and difficult shift patterns can affect your health and wellbeing. However, increasing sickness absence creates a negative spiral that increases pressure on those still at work.

Clearly we need to improve the workplace environment and one way is to help you prioritise your own health and wellbeing. This could be as simple as using your 4 requests a month. Ensuring you have rest days between long days or night shifts or reducing the amount of additional shifts you have picked up to support your area. There is also a flexible working policy of you feel this may benefit you for a period of time.

Other help and advice to support your mental, physical and financial wellbeing can be found here on the Hive.

The responsibility of the nurse in charge of the ward is to ensure it is safely staffed and concerns escalated to the appropriate person. If someone has rung in sick at short notice, the first action is to try and cover this with your own staff. Putting the shift on NHS P will also increase the chances of the shift being picked up and filled. If this hasn’t happened, the bleep holder or matron for that area should be informed to look at the available options within the division. If this can’t be resolved, this should then be escalated to the duty matron or clinical site manager. Sometimes staff are moved between wards and departments to try and make the clinical areas as safe as possible. This isn’t just about numbers. Consideration on the acuity and dependency of patients, escalation, closed beds or even empty beds must be assessed before any decision is made. We also know that moving staff can cause increased worry for the staff member being moved. If you are the ward where staff have been sent to help you, please try and ensure they are welcomed and supported in your area.

There is opportunity for all Trust staff to have their say in the annual staff survey. This helps us compare what our staff think about working at this Trust against other Trusts in the NHS. The overall results are published and made available to the regulators like the Care Quality Commission (CQC).

The Freedom to Speak Up (FTSU) Guardian works alongside the Trust’s leadership teams to support the organisation in becoming a more open and transparent place to work, where all staff are actively encouraged and enabled to speak up.

If you want more information about Freedom to Speak Up, click through to the FTSU page on the Hive.

Sickness and absence

Escalating unsafe staffing

Reporting unsafe staffingIf you still feel you have worked in a clinical area, where patient safety was compromised, we want you to report this. The National Reporting and Learning System (NRLS) is a central database of patient safety incident reports and every incident reported via Datix Web is exported to the NRLS. From October 2018 to March 2019, lack of suitable trained/skilled staff accounted for 8.5% of all incidents reported at DBTH.

While there may be many reasons for unsafe staffing (for example - it may not have been possible to cover sickness absence at short notice), it is vital to capture the facts of the incident reported. How many staff should have been on shift, why the shift was unsafe, who this was escalated to and what action was taken? This helps to build a picture of the themes around unsafe staffing in our hospitals for us to help make it better.

Staff Survey

Freedom to speak up