Nursing
Establishment Review
(Safer Staffing)
July 2014
1.0 National Context
1.1 This is the second nursing establishment review since the current Director of Nursing took up post in March 2013. Following the ‘Hard Truths’ publication and in line with the National Quality Board recommendations ‘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’. One of the expectations of this document is that a nurse staffing review will take place twice yearly as a minimum. This is to ensure the Board receives assurance that patient safety is being maintained with regards to ward staffing numbers and skills.
1.2 The report is also to provide an assurance both internally and externally, that ward establishments are safe and that staff are able to provide appropriate levels of care to patients with a level of care that reflects the Trust values and the 6Cs of both the National Nursing Strategy (2012) and the Trust’s Nursing & Midwifery Strategy. This is particularly important in light of key recommendations made in the Francis Report (2013) and the Berwick Report (2013).
1.3 The report also supports the Care Quality Commission requirements under the Essential Standards of Quality & Safety, including outcomes 13 (staffing) and 14 (supporting staff).
2.0 Background
2.1 The Trust has a duty to ensure that ward staffing levels are adequate and that patients are cared for safely by appropriately qualified and experienced staff. This is incorporated within the NHS Constitution (2013) and the Health and Social Care Act (2012).
2.2 The evidence suggests that appropriate staffing levels and skill mix influences patient outcomes, for example:
• Reducing mortality
• Reducing 30 day readmissions
• Reducing failure to rescue
• Reducing pressure ulcer incidence
• Reducing adverse incidents, particularly related to medication errors and falls
• Improves the patient experience
3.0 Summary of key actions implemented from the 2013 establishment review:
3.1 The reviews from 2013 and Spring 2014 supported a nurse staffing investment of approximately £1 million. Investments were made in the following areas:
· To support implementation of Supervisory Ward Manager role
· Increased staffing establishments to the following wards:
Ø 34 and 43 - Older Persons
Ø Ellesmere Port Hospital - to ensure 2 Registered Nurses on night duty
Ø Emergency Department
Ø Intensive Care Unit
Ø A number of smaller areas in a phased approach
3.2 Staffing numbers are without doubt an important factor. The senior nursing team and ward managers have also addressed a number other areas regarding the capability of its Registered and Non Registered nursing staff:
· Implementation of recruitment to values
· Review of Nursing Induction
· Review and further development of Nursing Preceptorship
· Review of training for Nursing Assistants to reflect the ‘Cavendish Report’
· Agreement of Ward Manager Key Performance Indicators
4.0 Methodology for 2014 Establishment Review
4.1 A literature review was undertaken prior to commencement of the establishment review in order to incorporate the latest evidence to inform the methodology and the recommendations.
4.2 It is an important factor to incorporate the professional judgment of the senior nurses. Their views are then supported objectively by the use of the following information:
· Establishments were compared to 2013
· Patient Acuity using the Safer Nursing Care Tool (SNCT) as per national guidance
· National standards for specialty wards e.g. Intensive Care
· Review of Registered to unregistered nurse ratios
· Review of staff to bed ratios in line with national guidance
· Utilisation of Number of beds and bed occupancy
· The nursing quality indicators and key safety and outcome measures were used to inform the recommendations
· Role of the Supervisory Ward Manager
4.3 The review covers the general wards on both sites as well as Emergency Department and Intensive Care Unit.
5.0 Establishments were compared to 2013 (Appendix 1)
The investment in nursing has seen an increase of the nursing establishment by 42.44 WTE. Appendix 1 demonstrates which wards have had an increase of their nursing establishments.
6.0 Cover
Establishments are agreed and have the following cover built in to the budget often referred to or known as ‘headroom’
· 14.5% for annual leave (mid -range for A4C, built into establishment)
· 3.65% sickness (Trust target)
· 1.5% training (equates to 4 days per person)
7.0 Role of the Supervisory Ward Manager
7.1 One of the Francis Report (2013) recommendations was that Trusts should make all ward managers supervisory, this means supplementary to the rostered workforce. As part of the 2013 review a comprehensive diary exercise of the ward manager role was undertaken to assess the current supervisory allocation. The diary exercise demonstrated variation by ward in the supervisory allowance, and following the 2013 establishment review it was recommended that each ward manager should have a minimum of 15 hours supervisory allowance. This is in addition to the hours they already have. This has now been realised and will be operationalised when the vacancies are fully recruited to.
8.0 Acuity using the Safer Nursing Care Tool (SNCT) as per national guidance
8.1 Throughout May 2014 an acuity review of patients in the Trust was carried out using the SCNT tool. However, use of the scoring tool was misinterpreted by some of the wards, therefore the information cannot be fully relied upon. This will need to be repeated following a further education session. The Deputy Director of Nursing has agreed to take this forward with the Divisions to enable the wards to use this on a regular basis
8.2 More in depth training will take place, together with closer monitoring of the tool’s use prior to the next review. The National Institute of Clinical Excellence (NICE) is also likely to report back in the Autumn and recommend an agreed staffing tool as well as endorsing national guidance for the ratios.
9.0 National standards for wards
9.1 There are no national minimum standards for the general wards, however there is RCN guidance – this is 1:8 Registered Nurse to patient ratio. The recent review does demonstrate that this is achieved with the current establishments on day shifts. The exception is on night duty on most of the general wards. The ratio for night shift on these areas is 1:14 as a maximum. It is accepted in most hospitals that this is the case
9.2 If the ratio was to be realised the 1:8 ratio during the night shift then a further investment would be required to skill mix the current staffing on most general wards form 2/2 to 3/1. This would give a RN patient ratio of 1:9. The financial cost of achieving this would be in the region of £320K.
9.3 However there are some areas e.g. Acute Medical Unit (AMU), Respiratory -Ward 51 and Coronary Care Unit where there is an agreed higher establishment for Registered Nurses complement on night duty. In the main, this is usually achieved. However this is compromised when short term sickness occurs (as demonstrated in the tables), and this cannot be achieved. This is due to staff from these areas being moved at short notice to support other wards.
9.4 A recommendation going forward is for the Trust to build on its existing nursing ’pool’. The current pool is comprised of Nursing Assistants who are rostered on night shifts, covering 7 nights a week. This has been very successful. Adding a number of Registered Nurses or changing the pool from Nursing Assistants to Registered Nurses (RN) will, we believe stop the need for RNs to be moved from areas where they are needed, to cover general wards. It would also support the wards that may encounter increased acuity at short notice. There may be a small cost pressure for the Trust, as there may be times no gaps for the pool to cover or an RN may be covering a Nursing Assistant shift.
10.0 Midwifery
10.1 This review has focused on adult general wards. However in November 2013 an external review of the midwifery service took place, by means of a desk top exercise. This looked at the current workforce position using ‘Birthrate Plus’ which is a nationally recognised tool.
10.2 The result of this exercise suggested that the level of staffing currently in post ‘is broadly in line with recommended levels’. This said, the review team did consider that midwives in some areas were challenged in managing their workload.
10.3 It was suggested that a detailed review of staff allocation in the workforce is undertaken. A recommandation was also made to ensure the midwifery workforce is assigned to meet the needs of the service. Consideration should be given to evaluation of 90/10 skill mix to support midwives in postnatal care. More detailed work is now underway with the Head of Midwifery to determine future staffing levels in line with future service plans and Commissioner intentions.
11.0 Paediatrics
Paediatrics are currently using paediatric patient acuity tool ‘System To Escalate And Monitor’ (STEAM). The information will enable the Director of Nursing to make informed decision regarding staffing as the occupancy is at times low, however the dependency of the patients may be high . This work is not yet complete and will be reported back at the next review.
11.1 Neonatal Unit - The Head of Nursing in Urgent care is supporting the Lead Nurse in Paediatrics, to review the establishment within the unit in line with national guidance and determine if it meets the requirements and dependency of the babies in their care. This work is likely to take some months, however the unit does have a robust escalation process and utilises the flexibility within its nursing teams at times of peak/demand.
12.0 Adult Critical Care
The new adult Intensive Care Unit has seen progression towards full achievement of the Core Nurse Staffing Standards for Intensive Care Units (Intensive Care Society, 2013)
There are now only two remaining standards which have not been fully met. A plan is in place to achieve this:
• Through flexibility of resources a supernumerary shift co-ordinator is in place on most shifts.
• All senior Band 6 Registered Nurses hold a post registration qualification in Intensive Care nursing; this is now being extended to the Band 5 Nurses.
13.0 The nursing quality indicators and key safety and outcome measures were used to inform the recommendations
13.1 Much work has been done to improve the nurse sensitive indicators. The most recent report for May 2014 detailed the following:
· Hospital acquired pressure ulcers = 9 (first time ever in single figures)
· In hospital falls = 68 (lowest ever). Of those, none resulted in moderate or serious harm
· Safety Thermometer - over 95% (May 2014)
· Care Metrics: Audits continue whilst the revised ward metrics are being finalised
14.0 Results
14.1 The Deputy Director of Nursing has met with each Ward Managers within the inpatient general ward areas and discussed their individual results with each of them. Valuing their professional judgment is the most important part of this review. In the main, the Ward Managers believe that the staffing is sufficient to meet the needs of their patient group. However there are times that this will peak and the use of the bank and additional hours are needed, based in the main on patient need and short notice staff sickness/absence.
14.2 Following these meetings, the following areas have been identified as requiring further work in order to provide assurance to the Board
· Ward 50 - Diabetes, Haematology and General Medicine - The ward is reporting a high number of staffing incidents. In year, the Urgent Care Division has supported the investment of an additional Nursing Assistant. This was following the closure of Ward 48 causing the dependency of the patients on ward 50 to increase.
More recently there has been an increase of acute Haematology patients. Although this increase in activity can come in peaks and troughs it is the Ward Managers professional opinion that the activity has been increasing for a number of months and she believes that a further review in 3 months will be able to determine if any further investment is needed. This approach is supported by the Matron and the Head of Nursing for Urgent Care.
· Coronary Care Unit - The unit has logged a number of staffing incidents. This usually relates to Registered Nurses being moved from CCU to cover staffing gaps elsewhere in the Trust. This is confirmed by the Ward Manager of the unit. Establishing a pool of Registered Nurse should reduce the need for staff to be moved from this area.
· Ruby ward – has logged a number of falls where there was no or low harm to patients. However work is taking place in the Trust to look at falls management. There is recognition that rehabilitation wards by their definition may have a higher number of falls, however a comparative piece of work is needed in order to provide assurance.
· Ward 51- Ward Manager’s professional judgment is that a skill mix of Nursing Assistants to Registered Nurses is required, as she is struggling to operationalise her supervisory role. The Deputy Director of Nursing has met with the Ward Manager and agreed a short piece of work to determine whether the base line is correct. This will help to identify any potential gap.
15.0 Going forward
15.1 The Trust is now publishing its staffing hours both Registered and Unregistered -planned versus actual, in line with the National Quality Board (NQB) guidance. This is published externally on NHS Choices with a link to the Trust’s own website.
15.2 There will also be a monthly report that adheres to the national guidance and reports by exception to the Board of Directors.
It will contain the following indicators:
· Sickness % per wards
· Vacancy per ward
· Shifts - planned versus actual
16.0 Recommendations
16.1 The previous investment from the Board in 13/14 has not yet reached its full effect due the recruitment problems. Intensive recruitment has taken place locally, nationally and internationally. With the imminent closure of Sapphire Ward, some staff will be moved to support the gaps identified.