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Nursing and Midwifery review – January 2014
Overview
In the national strategy for nursing and midwifery (DH and NHSCB, 2012) clear expectations of Directors of Nursing are set out around presentation and discussion of nursing metrics at Board meetings held in public at least twice a year. It goes on to state that any proposed changes to nursing and midwifery skill mix required to reflect service redesign should be discussed at Board level.
This paper seeks to update the Board on:
Evaluation against the 10 expectations set out in the paper published by the National Quality Board ‘How to ensure the right people, with the right skills, are in the right place at the right time’
Key Points for Decision and Discussion
The following key points are requested for discussion:
1 Progress in the implementation of the dependency and acuity tool
2 Note that a further paper will be presented to compare agreed appropriate staffing levels (including staffing to patient ratios including skill mix issues) with the data collected through the acuity and dependency monitoring exercise in progress through January 2014.
Presented for: Discussion
Presented by: Chris Wilkinson, Director of Care Quality and Chief Nurse
Strategic objective:
Excellent Patient Care - Patient Safety
Date: 28/01/14
Regulatory relevance:
CQC
Registration:
Quality and Management Outcome 16
CQC Registration Staffing Outcome 13
NHS LA Risk Mgt:
Competent Capable Workforce
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Nursing and Midwifery review
1. Introduction
This paper builds on the information provided in the report submitted to the Board in June 2013. Nursing and midwifery staff comprise a significant component of the total Trust workforce. It is essential that Trusts are clear that such employees are deployed appropriately in terms of staffing levels and skill mix and that the nurses and midwives are clear about their role and contribution to providing the Trust’s business. Patient care requirements continue to develop and it is therefore essential to have strong nursing and midwifery leadership and management, with access to and uptake of sound professional learning and development for all the registered and unregistered staff.
High profile national inquiries and reviews published in the professional and national media over recent years including the Francis Inquiry (2010) have been critical about nursing care, leadership and management. The national strategy for nursing and midwifery (DH and NHSCB, 2012) set clear expectations of Directors of Nursing around presentation and discussion of nursing metrics at Board meetings held in public at least twice a year. It goes on to state that any proposed changes to nursing and midwifery skill mix required to reflect service redesign should be discussed at Board level. In 2013 the National Quality Board (NQB) published the document entitled ‘How to ensure the right people, with the right skills, are in the right place at the right time: a guide to nursing, midwifery and care staffing capacity and capability’. It sets out 10 expectations of providers and commissioners across themes of accountability and responsibility, evidence based decision making, supporting and fostering a professional environment, openness and transparency, planning for future workforce requirements, and the role of commissioning.
This paper seeks to provide the Board with:
An evaluation against the 10 expectations set out in the paper published by the National Quality Board ‘How to ensure the right people, with the right skills, are in the right place at the right time’
The paper will not repeat details provided in the June 2013 report regarding nursing and midwifery leadership and management infrastructure, key roles clarification around roles and responsibilities or governance around nursing and midwifery performance and behaviours.
Board members are asked to note that a future paper will be presented to compare agreed appropriate staffing levels (including staffing to patient ratios including skill mix issues) with the data collected through the acuity and dependency monitoring exercise in progress through January 2014 once the analysis has been completed.
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2. Evaluation of the Trust’s position against the NQB’s 10 expectations 2.1 Accountability and responsibility
Expectation 1: Boards take full responsibility for the quality of care provided to patients, and as a key determinant of quality, take full and collective responsibility for nursing, midwifery and care staffing capacity and capability.
Ensuring the appropriate staffing levels and skill mix are available for nursing and midwifery is a key function for the board in fulfilling its responsibilities for the quality of care provided and for the outcomes achieved. Several reports published recently have reiterated the relationship between staffing levels and skill mix and mortality rates. The paper outlines expectations of Board level scrutiny and engagement in assuring themselves about staffing levels, skill mix, capacity and capability. The following expectations detail the information that should be provided to Board members for review together with an update of the Trust’s progress against regular reporting provision.
Expectation 2: Processes are in place to enable staffing establishments to be met on a shift-to-shift basis.
The Appropriate Staffing Policy includes sections relating to the systems used to date to assure appropriate staffing levels and skill mix. It also details the processes in place for staff to escalate concerns around gaps between planned and actual staffing levels on a day to day basis. This includes the actions required to use temporary staff to cover vacant shifts or to provide one to one care for patient safety requirements. Monitoring of performance against planned staffing levels and quality of care outcomes is undertaken at the Matron’s Forum when any emerging trends are identified and actions planned. Any significant concerns identified are recorded on the Trust risk register and escalated to the Quality Assurance Committee.
An electronic rostering system is in place for the majority of nursing and midwifery teams. Work continues to realise the benefits offered by such systems and the policy directing its implementation is currently under review.
2.2 Evidence-based decision making
Expectation 3: Evidence-based tools are used to inform nursing, midwifery and care staffing capacity and capability.
The AUKUH tool was revised by the Shelford Group during 2013. The result was the Safer Nursing Care Tool (SNCT). The aim of using this process in the Trust is to establish that the new and increased nurse staffing levels are appropriate for all areas and utilise the patient acuity and dependency scores to look at trends and changes in patient requirements over time. The SNCT does have some limitations for example in areas of rapid turnover such as ESS and those with a high acuity such as CCS; however it was felt that all areas should be involved in the initial data collection. A data collection sheet suitable for our Trust was designed and piloted on four inpatient areas during December. The pilot appeared to give relevant data when compared with the funded establishment figures. Although only a snapshot, only one of the four wards showed a slight under establishment of one WTE thus supporting
4 the work already completed however a greater information set is necessary to assess and review the new nurse staffing levels.
More information was required regarding staff RAG rating and patient’s needing one to one care, so the collection sheet was altered and an electronic version was developed to begin the twenty day data collection process beginning on the 6th January 2014. This involves a limited number of senior nurses on the wards, usually the ward manager and deputies, recording patient flow, staffing levels and acuity and dependency scores. This is carried out once a day at 14.00. Once completed this will be allied to other key data regarding Nurse Sensitive Indicators such as complaints and falls. It is anticipated that once all the data has been collated it will support the present nurse staffing levels and enable future planning as the process is repeated up to four times a year to match establishment levels with patient’s needs.
Future development during 2014 will be to formulate an electronic system sensitive enough to suit all areas where patients are nursed within the Trust which is easy to use but gives live data to those trying to manage the patient/bed and nurse staffing status within the Trust.
In using the data collected around patient dependency and acuity, it will also be important to consider other key elements that have an impact on staffing requirements, for example:
The design of the in-patient spaces, especially the high proportion of single room accommodation
Other support roles in place within the extended ward team (housekeepers, ward clerks, ward hostesses, ward manager assistants)
The use of technology in aiding nursing and midwifery capacity and capability
The activity levels and patient throughput in each ward area.
2.3 Supporting and fostering a professional environment
Expectation 4: Clinical and managerial leaders foster a culture of professionalism and responsiveness, where staff feel able to raise concerns.
The Trust policy ‘Raising concerns in a safe environment’ has recently been revised, endorsed and published in light of new national requirements and learning from the Francis Report. This outlines how staff can raise concerns about patient care and Trust issues if they feel that the day to day mechanisms are inappropriate or have been exhausted (for example, the adverse event reporting system). It is essential that staff are aware of this policy and how to use it in reinforcing our culture of patient safety and in meeting the requirements of registrants’ professional codes of conduct. A briefing factsheet is under design to highlight the key points within the revised policy and to direct staff to the full document. This area of practice is also supported by the Duty of Candour Policy which has replaced the preceding ‘Being Open’ policy. It is clear from several reporting systems that the Trust has a good reporting culture and that staff are clear about how to report and that they would report adverse events or issues of concern. A less positive outcome is the confidence recorded by our staff that concerns raised will be addressed within the Trust. This is a key area for further development and is being monitored through the quarterly staff cultural barometer work ked by the Organisational Development team. A new system has been in place
5 for the past two months following the inaugural staff barometer exercise whereby a slide is presented at each Team Brief meeting of actions taken in response to concerns raised.
Work is underway to refresh the Nursing and Midwifery Strategy to align it with the national strategy entitled ‘Compassion in Practice’ and which introduced the key values known as the 6 Cs (that is, care, compassion, competence, communication, courage and commitment).
An area for further development and learning from the Francis Report is to ensure good lines of communication are in place between Trust staff and staff side representatives about care quality and any areas of concern. This will build on the already well established Trust Joint Consultative Committee’s work.
Expectation 5: A multi-professional approach is taken when setting nursing, midwifery and care staffing establishments.
Work outlined in the previous report showed the involvement of ward managers, operational management teams and executive directors in agreeing appropriate staffing levels and funded establishment. A similar process will be run again once the data from the dependency and acuity monitoring exercise has been collated and analysed to check for any differences between agreed levels and those indicated as necessary using the evidence based tool. Work is underway to develop further the monthly reporting received from the Director of Workforce and Organisational Development on workforce KPIs. This will include monthly reports of appropriate and actual staffing levels for in-patient areas.
The requirement to triangulate staffing levels, capacity and capability with key quality indicators is undertaken within directorates and then collectively at the Matron’s Forum. This forum reviews each directorate’s Matron’s Balanced Scorecard and the performance in month, identifying any trends or concerns emerging over time or in month. Where concerns emerge, these are escalated within the appropriate clinical directorate for action, examples of which have recently been the development of a new role within the surgery directorate for co-ordinating capacity management activities across the wards leaving the ward staff free to remain in their ward setting and fulfilling their role as part of the appropriate staffing levels. Also, a concerted effort around substantive recruitment and temporary staff assistance for one ward has been overseen by the Chief Executive and Chief Nurse after a cluster of complaints and PALS concerns emerged.
Expectation 6: Nurses, midwives and care staff have sufficient time to fulfil responsibilities that are additional to their direct caring duties
A consistent uplift to the funded establishment for in-patient areas has been agreed enabling time for continuing professional development and for fulfilling roles such as mentorship and supervision. This uplift also enables appropriate staffing levels to be maintained despite absences from the wards due to sickness and training.
The Ward Manager role has been determined as supervisory (i.e. not part of the appropriate staffing levels for shifts). However this is not always possible to enact while the Trust is actively seeking to recruit to vacant nursing posts. Work is
6 underway with the ward managers to identify the key performance indicators that they can be performance managed against when working in their supervisory role.
2.4 Openness and transparency
Expectation 7: Boards receive monthly updates on workforce information, and staffing capacity and capability is discussed at a public Board meeting at least every six months on the basis of a full nursing and midwifery establishment review.
Please see above regarding further developmental work underway for monthly reporting of staffing capacity and capability. The NQB document states that these should be available on the Trust’s website for optimal transparency and that there should be evidence of the Trust triangulating the data with quality outcomes (e.g. infection control, pressure ulcers, complaints, Friends and Family test results).
Expectation 8: NHS providers clearly display information about the nurses, midwives and care staff present on each ward, clinical setting, department or service on each shift.
Following on from the 15 Steps Challenge there is work underway with the Matrons and Ward Managers to review what is displayed in public within the ward areas. Part of this work includes display of the ward staffing levels available on the day compared with the establishment agreed as appropriate. We will also enhance the information available within the ward areas regarding uniforms and key roles with some information about the contribution made by each of the role holders.
2.5 Planning for future workforce requirements
Expectation 9: Providers of NHS services take an active role in securing staff in line with their workforce requirements.
The Trust is engaged with the Local Education and Training Board around workforce planning which then feeds in to the national work led by Health Education England. Nationally there has been an increase in the number of registered nurses required for many Trusts and as a consequence many trusts (including ours) are looking to source recruits from overseas as demand is exceeding supply. A taskforce is leading a strong emphasis on recruitment activity including being more proactive in securing employment of student nurses in their last year of training and running well publicised recruitment roadshows. A recruitment and retention strategy is in preparation to address these issues.
2.6 THE ROLE OF COMMISSIONING
Expectation 10: Commissioners actively seek assurance that the right people, with the right skills, are in the right place at the right time within the providers with whom they contract.
Regular performance management meetings are held with our commissioners when we are monitored against the indicators set out in the quality schedule of our contracts. This includes looking at workforce indicators and triangulating these with key quality performance indicators.
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3. Recommendations
Board members are asked to note the evaluation against the NQB’s 10 expectations around nursing and midwifery capacity and capability, specifically:
Appropriate staffing levels review underway incorporating evidence based data from the dependency and acuity data collection exercise
The challenges for the Trust in recruiting substantive staff and the actions underway to address these
The publication of the Appropriate Staffing Levels Policy and the processes included in this to maintain staffing capacity
Assurance that wards noted to be challenged and/or not meeting key performance indicators are identified and actions put in place.
A further paper will be presented to the Board to compare agreed appropriate staffing levels (including staffing to patient ratios including skill mix issues) with the data collected through the acuity and dependency monitoring exercise in progress through January 2014.
4. References
Department of Health and NHS Commissioning Board (2012) Compassion in Practice: Nursing, midwifery and care staff; our vision and strategy. Gateway ref. 18479
Francis, R (2010) Independent Inquiry into care provided by Mid Staffordshire NHSFT January 2005-2009
Francis, R (2013) The Mid Staffordshire NHSFT Public Inquiry
National Quality Board (2013) How to ensure the right people, with the right skills, are in the right place at the right time: A guide to nursing, midwifery and care staffing capacity and capability.
Wilkinson, C (2013) Nursing and Midwifery Review – paper to the Board meeting. PSHFT
