Cliff EvansConsultant Nurse Emergency Medicine

Medway Foundation Trust

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Case Study:Recruiting and Retaining

Urgent and Emergency Care Staff

The National Picture

• Oct 2018, estimated 41,000 nursing vacancies across England

• Nursing degree applicants fell by 23% in wake of bursary loss

• 8% of shifts remain uncovered, increasing workplace

• Vacancies vary widely by region:

Nursing vacancy rates 8% in the North - 15% in London

• West Midland Ambulance Service has no paramedic vacancies

• National average 33%

• Staff turnover or retention rates can be equally varied

Why is it hard to recruit?

• NHS staff have “never worked harder” than over the past 5 years “They’ve never had to deal with so much pressure on the front line”.

• Physical assaults on NHS staff increased by nearly 9.7% last year

Our Case Study

September 2015: 65% nursing vacancy rate within ED

• Ineffective leadership – a failure to undertake appraisals

• Only 12% of nurses had received an appraisal

• Years of under investment in staff CPD

• Ineffective working processes

• A blame focused culture

• Poor working conditions - Workforce hopelessness - Burnout

• No students

• Organisation placed in Special Measures 2-years previously

”felt like a punishment rather than help with improvement”

Creating a Sustainable Solution

Our Strategy (Summary)

• Creating a vision of improvement through visible leadership

• Establishing clear lines of communication

• Standardising career development pathways for all nurses

• Reclaiming Emergency Care as a specialism

• Taking complete ownership of the recruitment process

• Developing display boards to visually demonstrate ownership

• Investing in staff through appraisals and CPD

• Sharing resources (collaborations)

NHS Improvement(Improving Staff Retention, 2018)

• Know your local workforce data and construct a strategy based on evidence, including findings from exit interviews

• Support new starters, delivering preceptorship programmes and supervised support from experienced staff

• Offer a range of flexible working options

• Innovative employment practices such as one stop recruitment events

• Effective staff engagement, acknowledge and reward good practice

• Visualise career pathways, promoting roles and opportunities

• https://improvement.nhs.uk/resources/improving-staff-retention/

• https://www.hee.nhs.uk/our-work/workforce-strategy

February 2016 – Progress Begins

Visual Display of Traditional Nursing Workforce

New Roles – New Ways of ‘Doing’

• Having a workforce strategy

• Review of long-term vacancies

• Empowering workforce to undertake new roles

• Existing medical resources could be better utilised

• Benefit to patient groups:

• Minor Injures

• Rapid Assessment, STREAMing and turnaround of acute arrivals

• Ambulant Majors patients

Support Roles

• 60% of care provided by supporting roles (Willis, 2015)

• Knowing your workforce

• Investing in existing individuals

• Associate Practitioners and Nursing Associates

• Historically easier to recruit into support roles

• A staggered approach.

Real Progress

Visual Display of Traditional Nursing Workforce

Can New Staff Groups Improve Care?

The Financial Cost & Cost to PatientsPeriod October

2015October

2016October

2017October

2018

EDNursing Vacancy

Rate 65% 30% 18% 4%

Turnover Rate 24% 12% 8% 7%

Financial CostAgency:

Bank:

Total Cost:

£258,726

£ 19,564

£278,290

£198,959

£ 40,300

£239,260

£115,287

£ 70,264

£185,552

£71.231

£61,883

£133,115

Serious Incidentsinvolving

patient outcomes 7 2 2 1

Period 2016 2017 2018

Total Year Emergency Department

Attendances

105,527

(+6)

114,730

(+9%)

121,531

(+6%)

Nurses completing specialist training

12(Total 12)

12(Total 24)

14(Total 38)

Senior Decision Making

Patients STREAMed to Primary Care

Patients turned around at front door

Per Month

2076 (22%)

70

Per Month

2372 (23%)

126

Per Month

2908 (28%)

274

Rapid Assessment Practitioner(Referred to GP/other)

Per Year0.55%

575

Per Year1.081238

Per Year2.64%3288

Percentage of Total ED Attenders Seen by Emergency Physicians

46% 44% 34%

Key learning

• What are your main recruitment constraints?

• Is your key issue recruiting or retaining staff?

• Why are your staff leaving?

• Forums and communication

• Are you communicating a positive vision?

• Are you family friendly?

• Have you reviewed where, and who delivers care?

• Have you invested in your senior staff?

• Challenge long-term vacancies; patient focused solutions

• Wider workforce understanding of new roles

• Factoring in training and increased rates of uplift.

Budget & Skill Mix(Historic Approach)

• 49 Band 5 Staff Nurses

• Reality 18

Service Improvement ProgrammeNovember 8th 2018

Phase I of new Workforce Strategy commences 8th November

➢ October 1st: Nurse Practitioners compliment Middle Grade rota to cover ‘Majors Lite’ for pre-determined

group of patients

➢ October 16th first Nursing Associates (NAs) commence training

➢ October 30th Support Worker interview day to begin ‘production line’ of new nursing workforce

➢ Phase I: 08/11 new Nursing skill-mix model commences = reduction in Band 7,6,5 roles (as vacancies exist

the result will be realised through a reduction in temporary shift cover)

➢ 12th December NAs formally rostered to new positions

Cost saving MG to NP rota: per shift £237.19 x 80 days service provided = £18,975Full year cost saving accumulating by end of Phase I: = £865.7kFull year investment accumulating by end of Phase II: = (631.6k)Full year cost saving accumulating by end of Phase III: = £ 81.4kTotal accumulated savings (Phase I to the end of Phase III): = £315.6k

Benefits of Workforce Investment

STREAMing

November 2016

STREAMing

November 2017

STREAMing

November 2018