Poole Hospital NHS Foundation Trust
REPORT TO THE BOARD OF DIRECTORS – JUNE 2016
NURSING AND MIDWIFERY ESTABLISHMENT REVIEW JUNE 2016
1.
INTRODUCTION
In 2013 the Francis report brought into the spot light the importance of ensuring safe staffing
levels on inpatient ward areas. The findings of the report indicated how poor staffing levels
and skill mix can lead to the delivery of unacceptable standards of care to patients.
Therefore one of the key recommendations was to ensure that NHS Trust Boards receive biannual reviews of staffing levels in their inpatient ward areas. The main purposes of these
reviews are to assure Boards that there are safe staffing numbers in their organisations and
the correct skill mix of nurses to provide good standards of care.
2.
BACKGROUND
Much debate and research has been reported over many years on the tools and methods of
setting and agreeing safe staffing numbers and skill mix. In July 2014 NICE published ‘Safe
staffing for nursing in adult inpatient wards in acute hospitals’ SG1, to ensure that all NHS
organisations could use the most evidence based tools and methodologies. In August 2015
it was announced by NHS England that a new body, NHS Improvement, would be taking
forwards developments on safe staffing led by the Chief Nurse for England working
alongside the National Institute for Clinical Excellence (NICE). All published guidance
remains valid for adult and maternity.
A recommendation in the NICE guideline is the assessment and review of staffing levels
based on average nursing hours per patient. Subsequently this has emerged as a key
recommendation from the Carter report (Operational productivity and performance in
English NHS acute hospitals: Unwarranted variations, February 2016) described as Care
Hours Per Patient Day (CHPPD).
To provide a single consistent way of recording and reporting deployment of staff working
on inpatient wards/units Care Hours Per Patient Day (CHPPD) can be used to describe
both the staff required and staff available in relation to the number of patients. It is
calculated by adding the hours of registered nurses to the hours of healthcare support
workers and dividing the total by every 24 hours of in-patient admissions.
Fig. 1
This is not a methodology used previously within PHFT and the approach has been piloted
for this review and will be adopted more fully in subsequent reviews. The implementation of
1
the Safer Nursing Care Tool ( SNCT) will enable assessment of average patient hours
requirements mapped against acuity / dependency.
This paper provides the Board of Directors with the nursing and midwifery establishment
review for June 2016. The review has utilised April 2016 data. The review was conducted
utilising NICE 2014 guidance. It begins by providing an update of the actions agreed at the
last review in December 2015. It then describes the methodology used for the review, the
findings and recommendations.
2.1
Summary of key recommendations and actions from the December 2015
nursing and midwifery establishment review




Recruitment
Continue to actively recruit to current vacancies of both registered nurses,
midwives and unregistered staff (Health Care Assistants, HCAs).
Workforce efficiency
Continued implementation and monitoring of the electronic rostering system to
it’s full potential.
Acuity and dependency measurement
Commence implementation of the Safer Nursing Care Tool (SNCT) to guide
patient acuity and dependency measurement.
DME establishment increase
Consider an increase of staffing on four medicine for elderly wards.
Update of the actions agreed at the last review in December 2015
2.2
Recruitment
In partnership with Human Resources detailed work continues on a range of
retention and recruitment initiatives to increase substantive staffing and reduce the
baseline vacancies. A full summary of Nurse Recruitment can be seen in appendix 1.
Current initiatives include;
 EU recruitment
 International recruitment
 Initiatives to support student nurses recruitment
 Support of return to nursing for registered nurses
 Opportunities for registered nurse training through open university courses
 Increasing temporary staffing (PHFT bank service)
 Use of website & promotional material
 International English Language Testing System (IELTS) project; A bid of £40k
was successfully secured from Health Education Wessex to support 20
HCA’s who are registered nurses in their own country to obtain their NMC
registration and subsequently work as registered nurses.
 Events/promotion of nursing as a career
2
Summary of registered nurses recruited since November 2014 (total 115):
50
45
40
35
30
25
20
15
10
5
0
47
30
Overseas:
recruitment
agencies
20
18
Overseas: friends
referrals
Nurse bank
Newly Qualified
HCA recruitment
Since March 2015, HCA recruitment has adopted a values-based approach and
recruited 99 successful candidates for substantive positions on in-patient wards
and 55 for the HCA bank.
2.3
Workforce efficiency – E Rostering
The Lord Carter Interim report on workforce efficiency in the NHS recommends the
use of an electronic rostering system to not only maximise workforce efficiency but
also to ensure safe staffing levels meet patient acuity and dependency.
The Allocate electronic rostering system is now successfully used on all inpatient
areas.
Key Performance Indicators (KPI’s) have been agreed for ward leaders to ensure
that there is continuous progress towards meeting the efficiencies. Monthly
‘challenge’ meetings are held between the ward lead, Assistant Director of Nursing
(Workforce) and the e Roster lead to ensure clinical staff understand expectations
and are supported in triangulating their staffing budget with appropriate skill mix and
quality of care. The KPIs are reported monthly at the nursing workforce meeting.
2.4
Acuity and dependency measurement
NICE recommends that Trusts use a validated tool to measure and analyse the
acuity and dependency of patients to ensure that there are not only sufficient nurses
on duty to provide care, but also that the nurses have the right skills to match the
care needs of the patient group.
The Implementation of eRostering and the rollout of the ‘Safe Care’ module
provides functionality to review patient acuity/dependency routinely as part of
workforce resource management and allocation.
3
A pilot of the acuity/dependency reviews (using the Safer Nursing Care Tool
SNCT) has been completed and the figures used as part of the ward
establishment review methodology.
2.5
DME establishment increase
The recommendation to increase staffing on four medicine for elderly wards;
Kimmeridge, Lilliput, Lulworth and Lytchett was agreed and implemented. This
means there is now an extra unregistered nurse (Health Care Assistant) on night
duty on each of the four wards to give a total of two registered nurses and two health
care assistant on night duty seven days a week. In addition the re allocation of the
six hour shift from18.00 – 24.00 to 07.00 - 13.00 supports personal care delivery.
3.
METHODOLOGY USED FOR THE REVIEW
The review focused on ward based staff on inpatient wards only.
departments were included in the review.
No other
For each inpatient area the staffing template was set to reflect the speciality of each
area and any specific issues that may impact on staffing needs.
These templates were agreed between the matron, ward sister / charge nurse,
finance, human resources and the Assistant Director of Nursing and used to provide
challenge and scrutiny into decision making on the ward establishment structure.
The aim being to provide safe, competent and fit for purpose staffing to deliver
efficient, effective and high quality care.
Key methods used to analyse staffing were;
 The speciality of each ward and number of beds.
 The total staff to bed ratio on each ward.
 The total numbers of registered and unregistered staff required for each
shift with the breakdown of day and night duty.
 The registered nurse: patient ratio.
 The % split of registered and unregistered staff on each shift.
 The % of headroom for each ward.
 Review of quality metrics, such as incidents of patient falls, pressure
ulcers and medication errors.
Appendix 2 provides further explanation and presentation of the findings.
4.
ANALYSIS OF FINDINGS
The Trust continues to be under significant and sustained capacity/activity pressures
in both emergency departments and inpatient wards at various points since
Christmas 2015. This includes requiring extra bedded capacity open in both medical
and surgical wards.
This has placed the Trust in the challenging position of having to balance patient
care needs, scheduled and unscheduled care activity, rising and complex patient
acuity alongside securing safe staffing levels for its inpatient areas and emergency
4
departments. This is all with the ultimate priority requirement to deliver safe and
high quality patient care.
4.2.1. Department of Medicine for Elderly
The overall established staffing levels are appropriate for the level and acuity of
patients with previous investments.
The area continues to expand the health care assistant role in the medicine for older
people wards to provide a higher total nurse to patient ratio.
It should be noted that whilst the establishment levels achieve the recommended
registered/unregistered ratios – ongoing challenges with recruitment impact on the
ability to achieve these ratios fully on a shift by shift basis.
For RACE, the Rapid Assessment and Consultant Evaluation unit for elderly medical
patients further work needs to be undertaken to ensure the skill mix is correct for this
area.
4.2.2
Medical Care Group
The overall established staffing levels are appropriate for the level and acuity of
patients with previous investments with the exception of A4 Arne ward during the
night shift.
A4 Arne is a 28 bedded acute medical ward that specialises in respiratory medicine
and provides non-invasive ventilation for patients suffering from respiratory illness.
Since the last review the number of patients requiring non-invasive ventilation has
increased meaning the acuity and dependency on this ward has increased.
A4 Arne is highlighted in this review as an outlier in the reported quality metrics of
falls, pressure ulcers and medicine incidents which raised two red flags during April.
The acuity and dependency audit SNCT on Allocate Health roster has highlighted
that patients on Arne ward require increased nursing time due to the acuity of their
conditions, required medications and complexity of their discharges.
Staffing ratios at night are 1:14 registered nurse to patient, with unregistered (HCA)
care the nurse to patient ratio increases to 1:7.
The recommendation from this review is a phased increase in staffing to enable
measurement of impact
 Increase band 2 unregistered (HCA) shift from 3 to 4 for the 11.30 – 19.30 shift
during the week
 Increase band 5 registered nurse by 2.64 wte for 7 nights a week
Funding for the band 2 unregistered (HCA) shift has been identified in the current
budget.
Funding for 1.0 wte band 5 registered nurse has been identified by the matron for
surgery and trauma in the current surgical care group establishment budget.
5
The matron for the medical care group is currently reviewing the care group budget
with the finance department for opportunities to fund the further 1.64 wte band 5
registered nurse.
4.2.3
Surgical and Oncology Care Group
Surgery and Trauma : The overall established staffing levels are appropriate for
the level and acuity of patients on all wards.
Surgical Assessment Unit (SAU) : Prior to the commissioning of the SAU monies
from ward B2 were used to fund escalation beds. Therefore it was unknown if this
funding was still required once SAU was established and fully functioning. The SAU
has now been fully operational for over 6 months and the funding for B2 has not been
required. After discussion with the matron and careful review of the B2 staffing
budget it has been agreed that 1.0 wte band 5 registered nurse could be transferred
to ward A4 Arne.
Oncology : The overall established staffing levels are appropriate for the level and
acuity of patients. Due to its location a charitable investment has been received to
support the Forest Holme hospice to increase the unregistered (HCA) establishment
to 1.0 wte at night. This was not a recommendation of the establishment review but
offered by the hospice charity.
Critical Care (CC) : The overall established staffing levels are appropriate for the
level and acuity of patients. This is a specialised unit needing staff with specific
skills. Staffing within this area has been challenged due to current funded maternity
leave and long term sickness. Changes to rosters are made to ensure the correct
skill mix meets the patient need.
4.2.4
Women and Children’s Care Group
Children’s unit: The overall established staffing levels are appropriate for the level
and acuity of patients. Due to service expansion, the recent CQC inspection,
subsequent feedback and recent clinical service review (CSR) a review of the
nursing staff levels on the children’s wards has been undertaken before this review.
Recommendations to increase the staffing levels have already been made and
accepted by the Trust Board.
The recommendations have taken into consideration the RCN guidance and the
professional judgement of the senior nursing team.
Funding has been agreed to support the proposal to;
 Increase band 6 registered nurse by 4.27 wte
 Increase band 5 registered nurse by 2.75 wte
 Increase band 2 unregistered (HCA) by 1.89 wte
This provides band 6 nurse leadership 24 hours a day 7 days a week and additional
registered nurses will increase the ratio of registered nurses available to deliver care.
Maternity : The overall established staffing levels are appropriate for the level and
acuity of patients. Maternity services use the tool “birth-rate-plus” which supports
6
decisions on the total numbers of midwives required, based on the pattern of activity
experienced. At Poole local demographics identify a need for a ratio of 1: 31 (1
midwife to 31 women) which is in keeping with the national standards and provides
assurance of safe midwifery staffing at the time of the review.
Due to concerns raised as part of the CQC inspection a further detailed review of
“birth-rate-plus” has been commissioned. The outcome of this review will be included
in the January 2017 Establishment review.
5.
SUMMARY
5.1
This paper provides the six monthly establishment review for the Board of Directors.
It presents an appraisal of the Trust’s current status for the provision of nurse and
midwifery staffing levels, and provides the Board with assurance of the work in
progress to monitor and manage safe staffing levels of nursing and midwifery staff
across the trust.
5.2
As outlined in this review much has been done to ensure the staffing levels reflect the
acuity of patients. Recruitment continues with the focus on retention of staff.
5.3
To support future establishment reviews the Safer Nursing Care Tool used with
quality indicators and workforce metrics, will be used to support dependency and
acuity measurement and inform optimal staffing levels.
5.4
The agreed establishments are set to enable safe, quality care and will be reviewed
using a similar process in six months.
6.
RECOMMENDATIONS
The Board of Directors are asked to support the following recommendations arising
from the establishment review;




Increase of staffing for A4 Arne ward through re allocation of existing nursing
establishment funds.
It is suggested that the night shift is increased by one additional registered nurse
at band 5 (2.64 wte). Funded through; 1.0 wte from the surgical care group and
1.64 wte re allocated from the existing medical care group budget.
Continue to actively recruit to current vacancies of both registered nurses,
midwives and unregistered (health care assistants).
Effective monitoring of the electronic rostering system to ensure the system is
used to it’s full benefit. This includes the Safer Nursing Care Tool (SNCT) and
Care Hours Per Patient Day (CHPPD) to guide measurement of patient acuity
and dependency.
To receive a review of nurse/midwife staffing; the next Nursing and Midwifery
Establishment Review will be reported to the board in January 2017.
Yvonne Jeffrey
Assistant Director of Nursing (Workforce)
June 2016
7
Appendix 1
Nurse Recruitment
Summary: November 2014-April 2016
BACKGROUND
The NHS Employers NHS Registered Nurse Supply and Demand Survey Findings
(December 2015) determined that 93 per cent (137) of trusts reported registered nurse
supply shortages. Poole Hospital was among 31 per cent of trusts that had between 1 and
60 fulltime equivalent vacancies (whilst 27 per cent (40 trusts) had between 61 – 120 FTE
vacancies, 24 per cent (35 trusts) between 121 – 300 FTE vacancies and three trusts
reported more than 300 FTE vacancies.)
The nurse recruitment role aimed to reduce vacancies and resulting agency nurse spend by
concentrating on seven initiatives:
Short Term
1.
EU recruitment
Using three recruitment agencies, 29 nurses have been appointed from within the EU/EEA.
On commencing their employment, these nurses have been encouraged to refer their friends
to work here and to-date 21 nurses have arrived saving an approximate cost of £65k in
recruitment agency fees. Since December 2014 (the arrival date of the first cohort), only 3
nurses have left employment resulting in a remarkable 94% retention rate. A summary of
the countries recruited from, and areas of work are displayed in the following charts:
EU/EAA nurses: by
2%
4% 2%
country
Spain (25)
Portugal (6)
30%
Romania (2)
Bulgariaby
(1)
EU/EAA nurses:
Greece (1)
area of work
12%
4%
Italy (15)
50%
10%
DME (36)
14%
Trauma (7)
Surgery (2)
Medicine (5)
72%
8
The appointment of three practice educators has been vital to the success of overseas
recruitment; providing dedicated support for both the wards and the nurses to adjust to
working in the UK. Overseas nurses have also been invited to attend the preceptorship
programme and English courses via LearnDirect have assisted improvements in language
skills.
2.
International recruitment
In January 2015, over 40 Filipino nurses were interviewed (via Skype) resulting in 15
provisional job offers. Unfortunately the monthly limit on restricted certificates of sponsorship
(RCoS) was reached for consecutive months from June 2015 so visas were unable to be
secured for these nurses. This is because the salary thresholds used to allocate certificates
when the limit has been reached are beyond the entry salary for a registered nurse in the
NHS. Nurses have since been added to the Shortage Occupation List but by this time, 14 of
the original candidates had withdrawn from the process. The remaining nurse arrived in
March 2016 and is due to take the OSCE (the final step in the NMC process) in July 2016.
3.
Student nurses
The recruitment nurse role has established a single point of contact for student nurses.
Attending Bournemouth and Southampton Universities’ careers fairs has promoted the trust
as a place for students to start their career and this experience has shown that a good
preceptorship course is a vital element of requisites students are looking for in a place of
work. It is important therefore that this is continued to be provided at a high standard. In
total, 47 student nurses have been appointed since September 2015.
4.
Temporary staffing
There is now a rolling advert for bank staff nurses and applicants are shortlisted within two
days of applying. Since September 2015, 18 staff nurses have been appointed; some are
relocating to the area, some have been previous employees of the trust and are returning,
and some are making the transition from agencies. A new advert has been created for
student nurses to apply for bank HCA roles – this gives the opportunity for students who are
not on placements within Poole Hospital to gain experience of working at the trust with the
aim that they will return once they have qualified.
5.
Website & promotional material
Using a design agency in conjunction with the communications department, A4 booklets
were designed providing interested nurses and students with necessary information on
working at PHFT (see appendix A) and two display stands and a larger exhibition stand were
purchased enabling an eye-catching display at any external events. The website ’nursing in
Poole’ has been added to the trust’s website; it follows the theme of the promotional material
and includes information on specialities, temporary staffing, preceptorship, return to practice
and who to contact for further information. A promotional recruitment video was filmed using
our own staff and this is located on the website also.
Medium term
6.
IELTS project
The trust has approximately 20 healthcare assistants who are registered nurses in their
home countries. A bid of £40k was successfully secured from Health Education Wessex to
support these HCA’s obtain their NMC registration and subsequently work as band 5 nurses.
The first requirement is achieving level 7.0 in the International English Language Testing
System (IELTS) followed by taking a Computer Based Test (CBT) and an Objective
Structured Clinical Examination (OSCE) as part of the NMC requirements. An IELTS
preparation course run by Bournemouth and Poole College starts in June 2016 and it is
anticipated that registration may be gained for successful candidates by the beginning of
2017.
9
Long term
7.
Events/promotion of nursing as a career
Although a long-term investment, attending schools and colleges to advise and promote
nursing as a career to students has been a vital part of the role. Booklets produced by NHS
careers are given to interested students and work experience, volunteering and working as a
healthcare assistant is promoted as appropriate.
Summary of registered nurses recruited (total 115):
50
45
40
35
30
25
20
15
10
5
0
47
30
Overseas:
recruitment
agencies
20
18
Overseas: friends
referrals
Nurse bank
Newly Qualified
HCA recruitment
Since March 2015, HCA recruitment has adopted a values-based approach and recruited 99
successful candidates for substantive positions on in-patient wards and 55 for the HCA
bank. Candidates now apply to a generic advert which is posted every 4-6 weeks and up to
30 applicants are short-listed and invited to attend the recruitment session. The session
includes a visit to the clinical skills suite where demonstrations and information is given on
the role. Candidates are also observed during a group exercise where their values and
beliefs are tested. The numeracy and literacy tests have been re-written and ward
leads/matrons are invited to be part of the interview panels. This has resulted in a more
streamlined and responsive process for wards (shorter time period between leavers and new
starters), an improvement in the quality of HCA’s and improved retention rate as candidates
are more aware of the job role.
HCA recruitment
March 2015 - April 2016 (total 154)
60
40
20
0
Trauma
DME
Surgery
Bank
10
Medicine
Appendix A
Images on A4 booklets, stands and website:
11
Critical Care
11
1
62.78
90% : 10%
1:1.2
3
Kimmeridge
20
14
37.15
36% : 64%
1:5.0
7
Lilliput
20
0
24.75
50% : 50%
1:6.7
4
Lulworth
20
0
24.75
50% : 50%
1:6.7
6
Lytchett
20
0
24.75
50% : 50%
1:6.7
1
RACE
24
0
48.22
70% : 30%
1:3.4
Stroke Care Unit (Acute & Rehab)
44
0
63.92
43% : 57%
1:7.3
Ansty
30
8
60.97
58% : 42%
1:4.3
C4
6
5
10.56
50% : 50%
1:6.0
CCU
8
0
20.20
75% : 25%
1:2.7
0
2
N/A
N/A
6
0
0
3
60.00%
100.00%
5.20
6.18
1
3
0
1
95.80%
100.00%
5.40
6.85
1
4
0
0
68.40%
92.30%
6.99
6.72
4
0
0
53.80%
92.90%
5.35
6.74
7
0
0
8
4.90%
88.90%
16
0
1
3
81.80%
91.70%
1
0
0
3
22.60%
62.00%
7.84
4.89
1
0
0
2
9.00%
66.70%
0
0
1
85.70%
100.00%
7.74
5.75
51.80%
96.60%
4.94
6.70
6.63
6.30
5.66
5.81
5.06
5.96
6
2
1
2
28
0
35.03
50% : 50%
1:7.0
3
4
0
0
2
Avonbourne A5
23
0
32.31
63% : 38%
1:4.6
1
4
0
0
1
42.90%
95.20%
Portland
12
2
24.42
60% : 40%
1:4.0
1
0
0
1
5.90%
100.00%
0
0
1
88.10%
100.00%
0
0
28.60%
100.00%
0
0
2
58.10%
98.00%
0
0
7
N/A
N/A
17
3
23.28
60% : 40%
1:5.7
Forest Holme
12
0
17.76
60% : 40%
1:4.0
Sandbanks
20
0
25.41
50% : 50%
1:6.7
Children's Unit
26
6
67.87
70% : 30%
1:3.7
2
1
1
12
*Required CHPPD
0
Arne A4
Durlston
*Actual CHPPD
FFT Score
FFT Response Rate %
Red Flag incidents
Medication Incidents
C-difficile Infections (PHFT
Acquired)
MRSA Bacteraemia (PHFT
Acquired)
Falls
Urinary Catheter Infections
(New)
Wte Total
Unfunded beds
Funded beds
Inpatient areas
PU Grade 2 or above (New)
Poole Hospital NHS
Foundation Trust
April 2016
CHPPD
1 week
data (pilot)
Nurse sensitive indicators
Ratio of registered nurse to
patients (Early shift)
Workforce
Ratio of registered nurse to
unregistered %
Appendix 2
1
NICU
20
0
43.28
88% : 13%
1:2.9
0
0
Antenatal Ward only
12
0
23.93
75% : 25%
1:4.0
0
0
Postnatal & TCU
33
0
36.66
56% : 44%
0
0
Delivery Suite
9
0
23.05
0
Haven Birth Centre
5
0
11.00
B2
27
0
42.46
60% : 40%
SSAU
12
0
19.18
50% : 50%
B4
B3
30
26
0
4
38.93
37.35
56% : 44%
56% : 44%
1:4.5
1
2
1:5.2
19
0
34.02
43% : 57%
1:6.3
TAU Red E3
24
0
32.96
57% : 43%
1:6.0
N/A
2
6.70%
100.00%
2
14.60%
96.80%
0
37.70%
95.90%
0
0
25.50%
91.70%
0
0
1
31.90%
98.60%
0
0
1
N/A
N/A
6
0
0
3
56.40%
97.80%
4
0
0
1
17.20%
100.00%
83.30%
97.10%
28.40%
100.00%
1
1:6.0
TAU Green C3
N/A
3
2
* Actual CHPPD
* Required CHPPD
13
1
1
0
0
5
1
4
0
0
4
2
6.39
5.22
6.52
6.71
5.00
6.75