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Safe Staffing Report – Maintaining Optimum Establishments 1.0 Background The focus on nursing, midwifery and care staffing as a key determinant of the quality of care experienced by patients has become increasingly prominent over recent years. Several high profile public inquiries have highlighted the importance of ensuring appropriate nurse staffing capacity and capability, and outlined the need for further work in this area. In November 2013 the National Quality Board (NQB) published the ‘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’. www.england.nhs.uk/wp-content/uploads/2013/11/nqb-how-to.pdf. Research demonstrates that staffing levels are linked to the safety of care and that staff short falls increase the risks of patient harm and poor quality care. This report provides an overview of the expectations of the NQB and details the work being undertaken to ensure that the Royal United Hospital Bath NHS Trust (RUH) meets the requirements of these expectations. 1.1 Introduction The impact of nursing, midwifery and care staffing capacity and capability on the quality of care experienced by patients, and on patient outcomes and experience has been well documented, with multiple studies linking low staffing levels to poorer patient outcomes, and to increased mortality rates. Nursing staff are the primary deliverers of 24/7 health-care within the multidisciplinary team in the majority of clinical settings and clinical specialities. There are currently no nationally agreed standards or guidelines for the number of nurses required to deliver care safely, to meet fundamental care needs, to prevent complications, to avoid unnecessary deaths and to deliver care to a recognised level of quality (except in a few specialist areas such as intensive care). In December 2010 the Royal College of Nursing (RCN) released two publications: ‘Guidance on safe nurse staffing levels in the UK (RCN, 2010)’; and a policy position titled ‘Evidence-based nurse staffing levels’ (RCN, 2010). These publications do not set targets for nurse staffing per bed, but they do set out the essential elements for planning and reviewing nurse staffing. NHS England and the Care Quality Commission (CQC) have issued joint guidance to trusts on the delivery of Hard Truths, the Government’s response to Francis in 2013, and commitments associated with publishing staffing data regarding nursing, midwifery and care staff. They have identified essential standards that providers must meet in order to be compliant with CQC regulation. As such monitoring appropriate staffing levels will be a core requirement of all future CQC reviews. Enforcing a quality agenda that demands that the effects of short staffing witnessed at NHS hospitals such as Mid Staffordshire should not be allowed to happen again. Author: Maria Wallen, Lead Nurse, Workforce Planning and Education Document Approved by: Helen Blanchard, Director of Nursing

Date: 16 April 2014 Version: 3.0

Agenda Item: 10 of 23

Compassion in Practice (NHS Commissioning Board 2012) emphasises the need for:

• Achieving evidence-based, patient need-driven staffing levels in all care settings

• A twice yearly public Board level discussion to ratify and agree nurse staffing levels

• Monthly reports to the Trust Board • Supervisory 0.4 WTE Ward Manager/Team Leader time as a minimum. • Planned and actual staffing displayed on clinical ward areas

Demonstrating sufficient staffing is one of the essential standards that all health care providers must meet in order to be compliant with CQC requirements and will be required to publish staffing data from April 2014 in the following ways:

• A Board report describing the staffing capacity and capability, following an establishment review, using evidence based tools where possible is to be presented to the Board every six months

• Information about the nurses, midwives and care staff deployed for each shift compared to what has been planned is to be displayed at ward level.

• A Board report containing details of planned and actual staffing on a shift by-shift basis at ward level for the previous month. To be presented to the Board every month

• The monthly report must also be published on the Trust’s website, and Trusts will expected to link or upload the report to the relevant hospital(s) Web page on NHS Choices

• Boards must, at any point in time, be able to demonstrate to their commissioners that robust systems and processes are in place to assure themselves that the nursing, midwifery and care staffing capacity and capability in their organisation is sufficient to provide safe care. All NHS Trusts are accountable to the NHS Trust Development Agency (TDA) and, as stated in the Accountability Framework 2014-15, will be expected to provide the NHS TDA with assurance that they are implementing the NQB staffing guidance and that, where there are risks to quality of care due to staffing, actions are taken to minimise the risk

This paper is the start of that journey for the RUH and provides information on the evaluated nurse staffing establishments for the medical and surgical adult in-patient wards at the RUH. Theatres, Emergency Care Departments, and Paediatrics were not part of the review as the tool used to assess acuity and dependency of patients is unsuitable for use in those areas. ITU has not been included in the this particular report, as their establishment was increased more recently as part of a separate review. Author: Maria Wallen, Lead Nurse, Workforce Planning and Education Document Approved by: Helen Blanchard, Director of Nursing



1.2 General Factors Influencing Nurse Staffing The national picture influencing the increased requirement for healthcare and therefore nurses is well documented and includes:

• The ageing population’s impact on inpatient dependency and acuity. • Rapid throughput and shorter patient-stays; but of a greater complexity and

acuity. Patients with low acuity are no longer found within our acute wards • Decreasing Registered Nurse (RN) direct-care time and the corresponding

rise in support worker direct care time • New roles within the workplace; e.g. Band 4 Assistant Practitioner positions • Change in the nursing skill mix • The Francis report • New technologies and treatments • Changes to pathway delivery i.e. integrated care models • Changing commissions • National Performance measures and CQUIN • Public expectations regarding quality • Financial position

2.0 National Changes, Nurse Staffing and Regulation In England, demonstrating sufficient staffing is one of the essential standards that all health care providers (both within and outside of the NHS) must meet to comply with Care Quality Commission (CQC) regulation. Whilst Boards of organisations have always been responsible for the quality of care they provide, and for the outcomes they achieve, this has never been so overt as is currently the case following the Mid Staffordshire NHS Foundation Trust Public Inquiry (2013), and the subsequent reviews by Professor Sir Bruce Keogh into 14 trusts with elevated mortality rates, Don Berwick’s review (2013), into patient safety, and the Cavendish review into the role of healthcare assistants and support workers (2013). This building body of evidence, led the Safe Staffing Alliance, whose members are senior expert nurses, to issue a statement in May 2013 that patient care is unsafe on wards where each nurse is looking after more than 8 patients. This is also the figure that is being cited by various patient groups, although not endorsed by NHS England in light of so many variables influencing what is safe staffing. 2.1 Nurse Staffing and Nurse Outcomes The impact of nursing, midwifery and care staffing capacity and capability on the quality of care experienced by patients, and on patient outcomes and experience has been well documented, with studies linking low staffing levels to poorer patient outcomes, and increased mortality rates. Recent reviews by Sir Bruce Keogh and Don Berwick reinforced this by the examples witnessed where poor outcomes have been linked to poor nurse to patient ratios, for example in Professor Sir Bruce Keogh’s review, a positive correlation was found between inpatient to staff ratios and higher hospital standardised mortality ratios (HSMRs), (Keogh, 2013). Author: Maria Wallen, Lead Nurse, Workforce Planning and Education Document Approved by: Helen Blanchard, Director of Nursing



There is a wealth of evidence that shows the effect that inadequate staffing levels have on nurses and nursing. Having insufficient nursing staff relative to the nursing workload to be delivered leads to increased pressure, stress, higher levels of burnout, lower job satisfaction, high turnover which is costly. 3.0 National Quality Board (NQB) Expectations The NQB guidance identified ten expectations which NHS organisations should consider and seek to support in making the right decisions to create a supportive environment where staff are able to provide compassionate care. The purpose of the expectations is to ensure that high quality care can be delivered and the best outcomes can be achieved for patients. All but one expectation (Expectation 10) is targeted at healthcare providers and there is overlap between some of the expectations:

National Quality Board 10 Expectations

Accountability and Responsibility 1. The Board 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. 2. Processes are in place to enable staffing establishments to be met on a shift by shift basis

Evidence Based Decision Making 3. Evidence based tools are used to inform staffing capacity and capability

Supporting & Fostering a Professional Environment 4. Clinical & Managerial Leaders foster a culture of professionalism and responsiveness, where staff feel able to raise concerns 5. A multi professional approach is taken when setting nursing, midwifery and care staffing establishments 6. Nurses and midwives and care staff have sufficient time to fulfil responsibilities that are additional to their direct caring duties.

Openness & Transparency 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 & midwifery establishment review. 8. NHS providers clearly display information about the nurse’s midwives and care staff present on every ward, department or service on each shift.

Planning for Future Workforce Requirements 9. Providers of NHS services take an active role in securing staff in line with their workforce requirements

The Role of Commissioners 10. Commissioners actively seek assurance that the right people, with the right skills, are in the right place at the right time. (Figure 1. National Quality Board expectations) Author: Maria Wallen, Lead Nurse, Workforce Planning and Education Document Approved by: Helen Blanchard, Director of Nursing



3.1 Meeting the NQB Expectations Accountability & Responsibility Key actions that are being progressed at the RUH are as follows:

• We are systematically reviewing the staffing level capacity and capability requirements for each ward, on a shift by shift basis Systems for monthly assurance and reporting of ward standards are in place.

• A staffing establishment review will be undertaken for consideration by Trust Board on a six monthly basis

• Standardised systems are being developed to assist in decision- making regarding care staffing levels, capacity and capability in all clinical areas, on shift by shift basis, to ensure that safe staffing levels are met and high quality, compassionate care can be realistically delivered

3.2 Evidence Based Decision Making Key actions that are being progressed at the RUH are as follows:

• Use of evidence based tools to determine staffing levels is part of the staffing establishment review

• Scrutiny /Triangulation of results of tools is used in conjunction with professional judgement and local knowledge.

• Daily reviews of actual staff available in comparison to planned staffing levels is reviewed through E-rostering which is being further developed to enable more immediate capacity planning and monthly reporting on the variance between planned and actual capacity, allowing for changing fluctuations in staffing level demand on a shift by shift basis.

3.3 Supporting & Fostering a Professional Environment Key actions that are being progressed at the RUH are as follows:

• Ensuring that the organisational culture supports staff and ensures that staff are able to raise concerns/ speak up (Whistle blowing policies)

• The incident reporting system is in use to support escalation of concerns and facilitate risk management

• Regular analysis of incident data to identify and respond to trends in relation to safe staffing

• Consideration by Lead Nurse for Workforce Planning, and Assistant Directors of Nursing, of how establishments reflect the impact on staffing requirements for professional training, supervision, mentoring needs and the supervisory status of leaders. This will be reported through the Trust establishment review

3.4 Openness and Transparency. Key actions that are being progressed at the RUH from April 20914 are as follows:

• Monthly updates on inpatient staffing to be considered in public • Staffing establishment review is considered by Trust Board on a six monthly

basis Author: Maria Wallen, Lead Nurse, Workforce Planning and Education Document Approved by: Helen Blanchard, Director of Nursing



• Information about the nurses and care staff working on each shift is displayed and accessible to the public

3.5 Planning for future workforce requirements A plan to recruit the staff required to fill current vacancies, to manage turnover, and to recruit the staff that will result from the investment is in place and is actively being managed. The numbers of staff to be recruited is a realistic objective but will be challenging as competition for staff is significant. The Recruitment Plan includes the following activities for 2014/2015:

• Targeted recruitment to attracting potential Bristol/Gloucestershire based practitioners (widening boundaries).

• Open Days to be run on a quarterly basis, with interview panels • Aiming a recruitment campaign to attract nurses who's registration may have

lapsed or wish to return to Acute Care • Increase capacity to support Return to Nursing Practice Students from UWE • Attend undergraduate recruitment days • Overseas recruitment • Development of Band 1-4 strategy • Increase opportunities for apprenticeships • Introduce Return to Acute Care Programme • Retention strategies

3.6 The Role of Commissioners The guidance sets out clear and specific expectations of commissioners for pro-actively seeking assurance that providers have sufficient nursing and care staffing capacity and capability to deliver the outcomes and quality standards they require for their patient populations. Currently the quality schedule with our commissioners details the reporting in relation to workforce and we maintain a constant dialogue with providers about any issues relating to safety and staffing levels. We have in place processes to ensure cost improvement programmes proposed are assessed for impact on quality. 4.0 Patient Acuity and Dependency Monitoring The range and nature of services provided across the RUH means that there is no single ratio or formula that can be used to determine the right staffing levels for a particular clinical area. Decision making in this area requires the use of local knowledge of particular clinical environments, evidence-based tools, professional judgement and a multi-professional approach. A review of the literature confirms that there are advantages and disadvantages to using either workload measurement tools or professional judgement methods to determine skill mix. On a national basis, plans by NICE to review the evidence and accredit evidence based tools to further support decision making on staffing will take place in the near future. Author: Maria Wallen, Lead Nurse, Workforce Planning and Education Document Approved by: Helen Blanchard, Director of Nursing



4.1 SAFER NURSING CARE TOOL

The AUKUH Acuity and Dependency Tool - Renamed Safer Nursing Care Tool (SNCT), was developed to help NHS hospitals measure patient acuity and/or dependency to inform evidence-based decision making on staffing and workforce. The tool, when allied to Nurse Sensitive Indicators (NSIs), offers nurses a reliable method against which to deliver evidence-based workforce plans to support existing services or the development of new services. The Safer Nursing Care Tool (SNCT) is one method that can be used to assist Senior Nurses to determine optimal nurse staffing levels.

Trusts collect data at the same time to enable benchmarking across participating organisations. It is recommended that Acuity and dependency measurement takes place twice yearly (January and June). Over time, it is anticipated that this acuity and dependency measurement will enable identification of trends across seasons and in response to changing demographics and healthcare needs. Ultimately, this evidence base will support workforce plans for nursing that should accurately predict and enable resources to be identified to support nursing establishments that meet patient and service needs.

Nurse Sensitive Indicators (NSIs)

Nurse Sensitive Indicators are quality indicators linked to nursing care. They inform nurses of good and poor patient outcomes enabling sharing of good practice and review of potential reasons for poor quality. Evidence in literature links low staffing levels and skill mix ratios to adverse patient outcomes.

NSI’s refer to quality indicators that can be linked to nurse staffing issues, including leadership, establishment levels, skill-mix and training and development of staff. This information can be used to further support ward staffing requirements identified through acuity and dependency measurement. The NSIs used within this project have been identified as indicators of quality of care, with specific sensitivity to nursing intervention or lack of. Monitoring (NSIs) such as infection rates, complaints, pressure ulcers and falls is therefore recommended to ensure that staffing levels determined in the ways described above, deliver the patient outcomes that we aim to achieve. Within the SNCT this data is converted into a rate per 1,000 occupied bed days, thus allowing consistent comparison across wards and Trusts to help ensure optimum staffing levels.

Author: Maria Wallen, Lead Nurse, Workforce Planning and Education Document Approved by: Helen Blanchard, Director of Nursing



Nurse Sensitive Indicators Official Complaints (OC) Official complaints about nursing/midwifery care/staff received identifying the 3 areas of:

• Communication • Clinical Care • Attitude

Data relating to complaints was not collected during this study as often complaints are received several months after the period – this data needs to be reviewed in 3 months’ time Drug Errors (DE)

• Actual drug errors where nursing was the primary cause, not including near misses.

Infection • Incidence rates of MRSA bacteraemia per 10,000 occupied bed days and

Clostridium Difficile. Slips, Trips & Falls

• Number of slips, trips or falls caused primarily by nursing error. Pressure Ulcers

• Incidence of hospital acquired pressure ulcers. Nutrition

• Number of patients having had nutritional screening.( Average MUST scores )

Patient Flow Patient Flow information is collected to enable nurses responsible for nursing workforce reviews to consider issues such as throughput, including numbers of admissions, discharges, transfers, ward attendees, deaths and transfers away from the ward/department, levels of occupancy and staffing levels. The multipliers account for normal patient-flow levels; however when there is a high throughput of patients, an additional staffing uplift may be considered appropriate. Nurse Sensitive Indicators and patient flow allied to acuity and dependency support professional judgement and enable agreement of nursing establishment appropriate to meet the needs of each department.

The following values have been used to calculate the required ward establishment based on the acuity and dependency data:

• Level 0 patient =0.99 Nurse to patient :Patient receiving standard ward care Level

• Level 1a patient =1.39 Nurse to patient : acute care (unstable patient • Level 1b patient =1.72 Nurse to patient : Basic nursing care (significantly

dependant • Level 2 patient =1.97 Nurse to patient : HDU level unstable patients • Level 3 patient =5.96 Nurse to patient :ITU level ventilated patients

These multipliers allow 22% uplift for annual leave / study leave etc. The uplift contains no allowance for maternity leave. Author: Maria Wallen, Lead Nurse, Workforce Planning and Education Document Approved by: Helen Blanchard, Director of Nursing



4.2 Skill Mix Review The RUH last undertook a nurse staffing and skill mix review in September 2011 using an evidence-based patient acuity/dependency tool (AUKUH) to inform decisions about the nursing workforce required for all adult inpatient wards. Recommendations were made following this review to adjust staffing in a number of areas, and the actions were taken by the Assistant Directors of Nursing to address key priority areas within the Medical and Surgical Divisions. The patient acuity/dependency review recognised a high number of ‘dependant’ patients, particularly on the older person’s wards and that this reflected the needs of an older population. A more recent patient acuity/dependency review was undertaken in February 2014, and information from this current review will be used as a benchmark to inform future reviews that will be undertaken on a regular basis and this information will be reported to the Board as a minimum of twice yearly. 4.3 Methodology and key findings from the 2014 Review

• All Adult Inpatient ward areas participated in the tool over a period of 20 days in February/March 2014

• To ensure consistency data was collected at the same time during the same period at 1500hrs Monday to Friday. This enabled nursing staff to understand not only the levels of patients on the ward, but also enabled this information to be allied to other key data

• Ward staff were well prepared and trained to undertake the scoring • Quality control was undertaken by the Staffing Solutions team and Matrons to

ensure that the tool was applied consistently across all wards • It should be noted that ASU failed to collect the data for 7 days and an

average score was taken on those days. The Older people’s wards reported a significant amount of level 1b patients




4.4 Older Persons Unit

Ward Levels

0 1a 1b 2 3 ACE 141 224 203 0 0 ASU 147 43 333 0 0 Helena 116 28 131 59 0 Midford 2 8 564 0 0 Pultney 190 153 216 0 0 Combe 158 8 351 0 0 Totals 754 464 1798 59 0

Funded and Required Establishment Figures

Nurse Sensitive Indicators OC DE

MRSA bac C-diff Falls

Pressure Nutrition

Helena 0 2 0 1 3 1 96% ACE 0 2 0 1 7 0 90% ASU 0 2 0 1 4 1 86% Midford 0 0 0 0 11 1 91% Combe 0 0 0 0 4 0 94% Pultney 0 0 0 0 10 1 83% Helena 0 2 0 1 3 1 96% ACE 0 2 0 1 7 0 90% ASU 0 2 0 1 4 1 86% Midford 0 0 0 0 11 1 91%

It should be noted that ASU failed to collect the data for 7 days and an average score was taken on those days. The Older people’s wards reported a significant amount of level 1b patients.The data indicates there are some ward areas with an apparent excess of staff. Helena ward and ACE swapped locations in 2013 and the results suggest that their establishments should be amended to reflect this. ACE ward also has a distinct Annex area to the ward making the staffing requirements higher in order to safely manage the patient’s.

Ward funded Est. Req Est.

Deficit

Combe 38.97 38.56 +0.41

Midford 38.97 49.159 -

10.189 Pultney 38.97 38.6 +0.37 ASU 46.53 38.93 +7.6 ACE 24.52 40 -15.8 Helena 40.5 24.76 +15.74 Totals 228.46 230.009 -1.549




Midford ward scored a significant higher numbers of level 1b patients than its sister wards of Pultney and Combe – The ward did care for a high level of dependent patients during the period of the study. Their NSI data reflects this – reporting a higher than average level of patient falls in this period. In conclusion the required establishment across the OPU wards, ASU and Helena is only 1.5 WTE more than actually funded. The results suggest that in some cases the funding is not in the right place. 4.5 Medicine and Oncology Levels Ward 0 1a 1b 2 3 MAU 159 301 175 54 1 MSS 185 92 61 7 0 Haygarth 107 232 195 6 0 Parry 218 5 319 0 0 Cheselden 110 4 201 0 0 Resp 111 196 260 60 0 Cardiac 644 31 7 1 0 CCU 5 29 3 119 3 W/ Budd 78 103 242 1 0 Totals 1617 993 1463 248 4 Funded and Required Establishment Figures: Ward Funded Est. Req Est Deficit MAU 61.34 49.45 11.89 MSS 24.35 21.487 2.863 Haygarth 34.06 38.78 -4.72 Parry 38 38.572 -0.572 Cheselden 22.13 23.009 -0.879 Resp 42.72 47.38 -4.66 Cardiac 43.92 34.73 9.19 CCU 19.3 15.136 4.164 W/Budd 28.27 31.93 -3.66 Totals 314.09 300.47 13.616






Pressure

Nutrition

Resp 0 2 0 0 6 1 95% W/Budd 0 0 0 0 4 3 94% MSS 0 2 0 0 3 0 95% MAU 0 8 0 0 1 1 88% CCU 0 0 0 0 0 0 100% Cardiac 0 0 0 0 2 0 96% Haygarth 0 0 0 0 2 0 98% Parry 0 0 0 0 3 0 100% Cheselden 0 0 0 0 4 0 95%

Sample of Activity data

Medicine and Oncology care for a wider range of patients than the OPU wards – scoring high in both level 0 and 1b patients. Additionally they see a far higher amount of Level 2 patients.

It should be noted that Cardiac ward and MSS failed to collect the data for 5 days MAU failed on 4 days and an average score was taken.

MAU‘s activity is as expected very high and this should be considered when reviewing their required funded establishment and not based solely on the acuity scoring only. The Cardiac ward they appear significantly over established. However since the opening of medical therapies this area is constantly operating at maximum occupancy. Consideration should be given to small ward areas such as CCU whose acuity figures give a number of staff that would render the ward unworkable.

Ward

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Esco

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Resp 2 67 0 1 64 16 6 0

W/Budd 20 33 15 4 52 9 0 0

MAU 420 41 0 4 146 367 1 0




4.6 Surgery and Orthopaedics

Levels Ward 0 1a 1b 2 3 SSW 469 20 23 0 0 SAU 337 105 97 0 0 RS 270 68 222 0 0 Charlotte 205 77 153 0 0 Whouse 221 38 288 6 1 FB 229 54 816 23 0 PY 323 69 89 2 0

totals 2054 431 1688 31 1

Ward funded Est.

Req Est deficit

SSW 17.97 26.58 -8.61 SAU 43.19 32.32 10.87 RS 37.55 37.188 0.362 Charlotte 26.78 28.657 -1.877 Whouse 39.69 39.23 0.46 FB 79.05 87.53 -8.48 PY 33 28.635 4.365 Totals 277.23 280.14 -_2.91



Pressure Nutrition

Robin Smith 0 0 0 1 5 1 89% Waterhouse 0 1 0 0 2 0 95% Charlotte 0 2 0 0 0 0 75% SAU 0 0 0 0 1 0 88% SSW 0 0 0 0 1 0 83% PY 0 0 0 0 1 0 100% FB 0 3 0 1 10 1 97%

Sample of Activity data

Ward Admissions

Transfers in

Ward Attenders

Escorts on site

Discharges

Transfers out Deaths

Escort off site

SAU 178 70 123 0 94 134 6 0

SSW 592 42 0 12 444 5 0 0




Surgery has wards with high activity level such as Surgical Admissions Unit who in addition to the in-patients manage a large level of ward attenders, additionally surgical short stay ward has a very high activity, and both these levels of activity and patient through put must influence their agreed nursing establishments.

Trust Totals

Total Funded Est.

Req Est.

Deficit

819.74 810.61 8.39

NB. None of the funded or required figures take into account the supervisory role of the band 7 senior sisters, additional activity or geographical layout of individual ward areas.

5.0 Managing Temporary Workforce

The use of temporary staff has historically been essential in helping the Trust meet variations in activity levels, cover vacancies and short term staff absences, and to bring in specific skills for short periods of time.

Properly managed, temporary staff play an important part in helping the Trust achieve flexibility. However it has been suggested that high levels of poorly managed temporary staff can be costly and may adversely affect patient safety. A more robust plan is being developed, and monthly information is now available showing usage and expenditure on Bank and agency by ward.

In 2013/14 the trust spent £3.147m on Bank and £2.044m on agency staff. An average of £432,583 per month. There is an expectation that the use of non- framework agency will cease by June 2014. Reliance on other agencies and bank staff will reduce throughout the year with trajectories. Achievement of this is hugely dependant on recruitment and retention of the nursing workforce.

5.1 Current Recruitment Activity

• A recruitment action plan has been developed • Recruitment sub group meets on a monthly basis • A 4 - 6 months targeted recruitment campaign is to be introduced immediately

to address the current shortfall in nursing establishments. • Plan to recruit overseas registered nurses from Spain, Portugal and Greece

2014/2015 • The existing programme of regular recruitment needs to be maintained

alongside the above programme. • A budget is available to support the recruitment campaign • Two Band 6 Practice Development/Support Nurses will be recruited for a 6

month period in Medicine to support the newly appointed staff in practice and support them in achieving their clinical skills and competencies. The




outcomes of these roles will be evaluated and overseen by the Nursing Workforce Planning Group.

• Availability of on- site accommodation for new recruits Risks

• Lack of suitable recruits will impact on our ability to maintain safe levels of staffing.

• Mitigation will be continued use of temporary staff (bank and agency). • Potential inability to reduce bank and agency costs due to lack of recruitment. • Mitigation will be a further paper to Trust Board if the required numbers of

nurses are not recruited. • Problems securing on-site accommodation for new recruits

The Trust does already fulfil many good practice standard recommendations to reduce and control the volume of its temporary staff by having in place:

• Centralised booking of temporary staff • Clear booking controls. • Robust sickness reporting systems • Escalation processes • E-rostering of all wards nursing rosters. • Agency framework agreements. • Consortiums across local Trusts that increase cost effectiveness of agency

spending • Policy for the use of temporary staff and rostering • Managers that take responsibility for local budgets • Monthly and weekly data supplied by unit to understand activity.

6.0 Supervisory Ward Sister Role Supervisory status has been strongly advocated in all recent national reviews with a minimum base of 0.4 WTE but to be truly effective the RUH are planning a 1.0 WTE (with the exception of CCU where staffing and patient ratios are less) The benefits of supervisory leadership are well articulated in the recent national reviews. This role will lead to the beneficial effect on staff engagement, and therefore on patient satisfaction and improved patient safety and patient outcomes. Effective Leadership will achieve:

• Measurable improvement in the key Nurse Sensitive Indicators • Delivery of consistently safe and high standards of quality care on all wards • Time to lead, and support staff in their clinical role and ensure patients are

having a good experience of care. • Improved and effective decision making • Time to listen to staff in effective forums and allow individuals to feel

acknowledged, and part of the decision making process • Effective appraisal systems




• Free up senior nurse time, to develop and engage more junior members of the ward team, by delegating appropriate tasks, thereby promoting ownership and sustainability.

It is also important to recognise that the supervisory role is not intuitive to all in Ward Leader positions and many will need support and development to achieve this.

7.0 Nursing investment

Investment in nursing 2013/2014 was £975K.

For 2014/15 an additional £2.885m has been made available. The breakdown can be seen in Appendix 1.

The investment into nursing for 2014/15, has allowed for the Senior Sisters of all adult in patient areas to become supervisory five days per week, with the exception of CCU where the Senior Sister is supervisory for three days per week due to the size of the unit.

The above investment includes investment into some of surgical and medical base wards; these include Robin Smith, Forrester Brown and the Older Peoples Unit (OPU) and Respiratory wards.

£153k was allocated to ACE OPU to bring their base staffing levels in line with the other OPU wards.

The dependency tool has indicated that a number of ward areas have the correct amount of staff, whilst some are over and some or under. Philip Yeoman, Waterhouse and Robin Smith Ward were showing the correct amount of staff but in regards to Robin Smith ward this doesn’t take into account the layout of the ward and the difficulty in observing patients in all but one bay. Surgical Admission Unit is reported to not need all the staff allocated to the Unit but this doesn’t take account the function of the department.

• Surgical Short Stay Unit is showing that there are insufficient staff. The department was funded for 6 ½ days per week with a maximum of twelve patients over night and on Saturday mornings. Investment has been made which will match the activity on the Unit, i.e. that the department is open seven days per week and frequently has up to 22 patients

• Combe and Midford ward were showing the correct amount of staff for those areas. However, Pulteney Ward identified an under establishment during this period. The case load for these three areas can fluctuate with different wards at a time having increased acuity. The proposal for these areas is to use the allocated investment but in a more flexible way to enable staff to work where the demand is at the time. Other areas within the medical division that have shown a shortfall in the required staffing levels are Haygarth, William Budd and Respiratory wards

• Shifts on all areas are being reviewed collaboratively by the Senior Sisters/Charge Nurses, Matron and Assistant Directors of Nursing for each Division to ensure a more standardised approach to rostering as well as ensuring that the needs of the service is maintained. See Tables 1 & 2




• The investment achieves a 60:40 ratio of registered to unregistered staff across the medical and surgical inpatient ward areas

• On a shift by shift basis the average bed to nurse ratio is: Early shift - 5 beds per registered nurse Late Shift - 6 beds per registered nurse Night shift – 8 beds per registered nurse

A comprehensive breakdown of funded beds, numbers of registered and unregistered nurses per ward and nurse: bed ratios is available in Appendix 2.

Surgical Division Shift Times (Table 1)

Ward / Dept. Day Shift Early Shift Late Shift Night Shift

Robin Smith 07.30 - 20.00

07.30 – 15.30

12.00 – 20.00

19.30 – 08.00

Waterhouse 07.30 - 20.00

07.30 – 15.30

12.00 – 20.00

19.30 – 08.00

Surgical Admission Unit

07.30 - 20.00

07.30 – 15.30

12.00 – 20.00

19.30 – 08.00

Forrester Brown 07.00 -19.30 07.00– 15.00

13.00 -21.00

19.00- 07.30

Philip Yeoman 07.00– 20.00

07.00– 15.00

13.00 -21.00

19.45-07.15

Surgical Short Stay 07.00-17.30

07.00-15.00 10.00-20.30 20.15 – 07.15

Critical Care Services 07.30-15.30 13.30-21.30 21.00-08.00

Charlotte 07.30 – 15.30

13.30 – 21.30

21.00 – 08.00

Children’s 07.30-20.00 07.30 – 15.30 12.00 – 20.00 19.30 – 08.00

Neonatal Unit 07.30-20.00

07.30 – 15.30

12.00 – 20.00

19.30 – 08.00

Medical Division Shift Times (Table 2).




Ward / Dept. Long Day

Early Shift Late Shift Night Shift

ACE OPU 07.30-21.30

07.30 – 15.30

13.30b- 21.30

21.00- 08.00

ASU 07.30 -21.30

07.30 – 15.30

13.30b- 21.30

21.00 -08.00

Cardiac 07.30 -21.30

07.30 – 15.30

13.30b- 21.30

21.00- 08.00

CCU 07.30 -21.30

07.30 – 15.30

13.30b- 21.30

21.00- 08.00

Cheseldon 07.30 -21.30

07.30 –15.30

13.30b21.30 21.00- 08.00

Combe 07.30 -21.30

07.30 – 15.30

13.30b- 21.30

21.00 – 08.00

There are a number of tools and methods available for assessing patient dependency, and the above tool has been previously used in the Trust. Whilst there is no specific tool recommended above others, all of them when used in combination with other staffing information including, nurse to bed and trained to untrained ratio they provide evidence to ensure that staffing levels and patient outcomes are correlated. NICE intends to review the evidence based tools to further support the decision making, and some recommendations may then follow.

8.0 Incidents

The majority of incidents regarding staffing across the Trust concern unfilled bank and agency shifts, these are mainly short notice sickness shifts; however currently the medical division is carrying a number of trained nurse vacancies which is also having an impact on the number of unfilled shift.

Datix are also completed when staff are moved to cover an unfilled area; this would be following an assessment of the whole division and mitigating the risk. When staffing is not at the optimal numbers for the wards areas staff report that they have been unable to provide safe care, they have been unable to complete all the documentation/ risk assessments and at times that they have been unable to provide 1:1 care for patients with challenging behaviours. For example, there has recently been an incident where due to decreased staffing numbers two patients fell at the same time, with one fall resulting in a fracture. This particular ward was one member of staff short.




9.0 Monthly reporting From April 2014, all wards will record monthly staffing levels on a ward-by-ward basis together with the percentage of shifts meeting safe staffing guidelines. This information will be reported to the trust board from May, showing the levels of safe staffing within all inpatient areas, specifically highlighting the areas of concern where pre-agreed staffing metrics have not been met. This reporting format aims to identify when specific ward areas are developing the potential to become problematic therefore avoiding issues by prompt intervention and also allows for cross- cutting themes to be easily identified. The report utilises the current available data, the format has been presented at the Nursing Workforce Group and will be used for on-going reporting. Both Medical and Surgical divisions have identified baseline information on agreed skill mix per shift, and identified a system that highlights when areas are running below these figures, identifying hot spots that will require immediate action. An example from Surgery is outlined in Appendix 3. 9.1 Next Steps

• Systems for monitoring and reporting regularly on staffing levels to the Trust

Board and the Public will continue to be developed and reviewed over the next 12 months using staff and patient feedback as well as any national drivers that may be published. In order to monitor compliance with all the expectations in the guidance produced by the Chief Nursing Officer and the National Quality Board (September 2014 and March 2015).

• Six monthly review reports and monthly updates will be submitted to assure the Board that the nursing and care staffing capacity and capability in the Trust is sufficient and that where it is deemed insufficient, measures are put in place to address any shortfalls, to ensure that patient safety and quality of care are not compromised.

• Assistant Directors of Nursing to feedback and work with matrons to review findings of the February /March 2014 Patient Dependency/Acuity audit.

• Ward Sister job description to be reviewed and updated to reflect the supervisory' requirements of the role and a development pathway introduced to facilitate and support the delivery and sustainability of this role.

• Investment and support for practice development framework, to facilitate mentoring, supervision and coaching opportunities in practice that all nursing staff can access.

• Develop a framework to support nurse leadership at all levels within the organisation.

9.2 Additional Activity

• Assistant Directors of Nursing to work in partnership with the Lead Nurse for Workforce Planning to identify strategies to sustain and support current and future workforce planning initiatives.

• Supervisory Sister role to be implemented fully by September 2014. • Nursing Strategy to be agreed and implemented by September 2014.




• Nursing Workforce strategy being developed - June 2014. • Band 1-4 Strategy being developed and will be presented at Nursing

Workforce Group in June 2014 10 Summary The areas for investment have been prioritised and are largely based on an assessment that includes professional judgement, knowledge of the ward specialities and environments and the output from the SNCT. The quality benefits from the investment will be closely monitored and reported to the Board. Financial controls will be robust to ensure the nursing resource is used effectively.




Appendix 1 RUH Bath NHS Trust

Trust Investments 2012/13 - 2014/15 Division Pay/Non pay Reason 2012/

13 2013/14

2014/15

Nursing Corporate Areas

Pay Trust wide Safeguarding Nurses and Admin support Mental Health

73

Medicine Pay ACE OPU in line with other OPU wards

153

Medicine Pay Cheselden unregistered nurses 20 Medicine Pay Combe registered nurses 122 Medicine Pay Haygarth Ward unregistered nurses 85 Medicine Pay HCAs 151 Medicine Pay Midford registered nurses 127 Medicine Pay Parry unregistered nurses -14 Medicine Pay Pulteney registered nurses 127 Medicine Pay Safer Staffing 404 Medicine Pay Supervisory Sister 133 236 Surgery Pay Charlotte additional 8 beds 250 Surgery Pay R Smith registered nurses -21 Surgery Pay R Smith unregistered nurses 33 Surgery Pay Safer Staffing 155 Surgery Pay SAU unregistered nurses -21 Surgery Pay SSU registered nurses -20 Surgery Pay Supervisory Sister 102 152 Surgery Pay Waterhouse registered nurses -21 Total Nursing 151 975 1,100 ECIST Medicine Pay ACE Nurse Practitioner 61 Medicine Pay ED / MAU Nurse Practitioners and

EDAs 357

Surgery Pay Direct access clinics SAU Nursing and HCA

63

Surgery Pay Urology Specialist nurses 95 Front Door

Medicine Pay and Non-pay

ED Staffing - Nurses and EDAs 367

Business cases

Medicine Pay Gastroenterology Specialist Nurses, Nursing and HCAs

103

Other Corporate Pay Senior nursing roles 92 Medicine Pay ACE - Nursing and discharge co-

ordinators 254

Medicine Pay End of Life Care nursing 50 Surgery Pay Critical Care Outreach 90 Surgery Pay and Non-

pay ITU skill mix 11 beds 253

GRAND TOTAL 151 975 2,885




Appendix 2

Division Specialty/Ward Fund

ed B

eds

Fund

ed S

uper

viso

ry

Fund

ed R

eg N

urse

Fund

ed U

n Re

g N

urse

Tota

l Fun

ded

Bed

To R

eg N

urse

Bed

to U

n-Re

g N

urse

Beds

Per

Nur

se

Reg

to U

n Re

g Ra

tio

Fund

ed R

eg N

urse

Fund

ed U

n Re

g N

urse

Tota

l Fun

ded

Bed

To R

eg N

urse

Un-

Reg

Nur

se R

atio

Nur

ses

Per B

ed

Reg

to U

n Re

g Ra

tio

Fund

ed R

eg N

urse

Fund

ed U

n Re

g N

urse

Tota

l Fun

ded

Reg

Nur

se R

atio

Un-

Reg

Nur

se R

atio

Nur

ses

Per B

ed

Reg

to U

n Re

g Ra

tio

MEDICAL DIVISION ACUTE MEDICINE 52 3.0 14 7 21.0 3.7 7.4 2.5 66.7 13 7 20 4.0 7.4 2.6 65.0 12 5 17 4.3 10.4 3.1 70.6

CHESELDEN WARD MEDICINE 16 1.0 3 2 5.0 5.3 8.0 3.2 60.0 2 2 4 8.0 8.0 4.0 50.0 2 1 4 8.0 16.0 4.0 50.0

MAU 34 1.0 8 3 11.0 4.3 11.3 3.1 72.7 8 3 11 4.3 11.3 3.1 72.7 8 3 11 4.3 11.3 3.1 72.7

MED SHORT STAY 18 1.0 3 2 5.0 6.0 9.0 3.6 60.0 3 2 5 6.0 9.0 3.6 60.0 2 1 3 9.0 18.0 6.0 66.7

CARDIOLOGY 44 2.0 9 4 13.0 4.9 11.0 3.4 69.2 8 3 11 5.5 14.7 4.0 72.7 6 3 9 7.3 14.7 4.9 66.7

CARDIOLOGY WARD 36 1.0 6 3 9.0 6.0 12.0 4.0 66.7 5 3 8 7.2 12.0 4.5 62.5 4 2 6 9.0 18.0 6.0 66.7

CORONARY CARE UNIT 8 1.0 3 1 4.0 2.7 8.0 2.0 75.0 3 0 3 2.7 0.0 2.7 100.0 2 1 3 4.0 8.0 2.7 66.7

CARE OF THE ELDERLY 129 5.0 24 19 43.0 5.4 6.8 3.0 55.8 20 15 35 6.5 8.6 3.7 57.1 16 11 27 8.1 11.7 4.8 59.3

COMBE WARD (3) 26 1.0 5 4 9.0 5.2 6.5 2.9 55.6 4 3 6 6.5 8.7 4.3 66.7 3 2 5 8.7 13.0 5.2 60.0

HELENA WARD 17 1.0 3 3 6.0 5.7 5.7 2.8 50.0 3 2 5 5.7 8.5 3.4 60.0 3 2 5 5.7 8.5 3.4 60.0

MIDFORD WARD (9) 28 1.0 5 4 9.0 5.6 7.0 3.1 55.6 4 3 6 7.0 9.3 4.7 66.7 3 2 5 9.3 14.0 5.6 60.0

PULTENEY WARD (4) 28 1.0 5 4 9.0 5.6 7.0 3.1 55.6 4 3 6 7.0 9.3 4.7 66.7 3 2 5 9.3 14.0 5.6 60.0

ACE OPU 28 1.0 6 4 10.0 4.7 7.0 2.8 60.0 5 4 9 5.6 7.0 3.1 55.6 4 3 7 7.0 9.3 4.0 57.1

ENDOCRINOLOGY 28 1.0 4 4 8.0 7.0 7.0 3.5 50.0 4 4 8 7.0 7.0 3.5 50.0 2 3 5 14.0 9.3 5.6 40.0

PARRY WARD 28 1.0 4 4 8.0 7.0 7.0 3.5 50.0 4 4 7 7.0 7.0 4.0 57.1 2 3 5 14.0 9.3 5.6 40.0

GASTROENTEROLOGY 43 1.0 4 3 7.0 10.8 14.3 6.1 57.1 4 2 6 10.8 21.5 7.2 66.7 3 3 6 14.3 14.3 7.2 50.0

HAYGARTH WARD 27 1.0 4 3 7.0 6.8 9.0 3.9 57.1 4 2 6 6.8 13.5 4.5 66.7 3 3 5 9.0 9.0 5.4 60.0

ONCOLOGY 22 1.0 4 2 6.0 5.5 11.0 3.7 66.7 3 2 5 7.3 11.0 4.4 60.0 2 2 4 11.0 11.0 5.5 50.0

W BUDD CANCER UNIT 22 1.0 4 2 6.0 5.5 11.0 3.7 66.7 3 2 5 7.3 11.0 4.4 60.0 2 2 4 11.0 11.0 5.5 50.0

RESPIRATORY 33 1.0 6 3 9.0 5.5 11.0 3.7 66.7 5 3 8 6.6 11.0 4.1 62.5 4 2 6 8.3 16.5 5.5 66.7

RESPIRATORY UNIT 33 1.0 6 3 9.0 5.5 11.0 3.7 66.7 5 3 8 6.6 11.0 4.1 62.5 4 2 6 8.3 16.5 5.5 66.7

STROKE 26 1.0 5 5 10.0 5.2 5.2 2.6 50.0 4 5 9 6.5 5.2 2.9 44.4 3 3 6 8.7 8.7 4.3 50.0

ACUTE STROKE UNIT 26 1.0 5 5 10.0 5.2 5.2 2.6 50.0 4 5 9 6.5 5.2 2.9 44.4 3 3 6 8.7 8.7 4.3 50.0

SURGICAL DIVISION GENERAL & VASCULAR SURGERY 83 3.0 18 11 29.0 4.6 7.5 2.9 62.1 13 9 22 6.4 9.2 3.8 59.1 10 8 18 8.3 10.4 4.6 55.6

ROBIN SMITH WARD 28 1.0 6 4 10.0 4.7 7.0 2.8 60.0 4 3 7 7.0 9.3 4.0 57.1 3 3 5 9.3 9.3 5.6 60.0

SAU 27 1.0 6 3 9.0 4.5 9.0 3.0 66.7 5 3 8 5.4 9.0 3.4 62.5 4 2 6 6.8 13.5 4.5 66.7

WATERHOUSE 28 1.0 6 4 10.0 4.7 7.0 2.8 60.0 4 3 7 7.0 9.3 4.0 57.1 3 3 5 9.3 9.3 5.6 60.0

GYNAECOLOGY 14 1.0 5 2 7.0 2.8 7.0 2.0 71.4 3 2 5 4.7 7.0 2.8 60.0 2 2 4 7.0 7.0 3.5 50.0

CHARLOTTE WARD 22 1.0 5 2 7.0 4.4 11.0 3.1 71.4 3 2 3 7.3 11.0 7.3 100.0 2 2 4 11.0 11.0 5.5 50.0

THEATRES 12 1.0 6 2 8.0 2.0 6.0 1.5 75.0 4 2 6 3.0 6.0 2.0 66.7 2 1 3 6.0 12.0 4.0 66.7

SSU 12 1.0 6 2 8.0 2.0 6.0 1.5 75.0 4 2 5 3.0 6.0 2.4 80.0 2 1 2 6.0 12.0 6.0 100.0

TRAUMA & ORTHOPAEDICS 83 2.0 16 10 26.0 5.2 8.3 3.2 61.5 13 9 22 6.4 9.2 3.8 59.1 9 7 16 9.2 11.9 5.2 56.3

FORRESTER BROWN 56 1.0 11 8 19.0 5.1 7.0 2.9 57.9 9 7 16 6.2 8.0 3.5 56.3 6 5 10 9.3 11.2 5.6 60.0

P.YEOMAN/RECOVERY 27 1.0 5 2 7.0 5.4 13.5 3.9 71.4 4 2 3 6.8 13.5 9.0 133.3 3 2 3 9.0 13.5 9.0 100.0

569 22.0 115 72 187.0 4.9 7.9 3.0 61.5 94 63 157 6.1 9.0 3.6 59.9 71 50 121 8.0 11.4 4.7 58.7

Early Late Night

TotalAuthor: Maria Wallen, Lead Nurse, Workforce Planning and Education Document Approved by: Helen Blanchard, Director of Nursing



SURGICAL DIVISION STAFFING STATUS REPORT

Early Late Night

G

reen

Am

ber

Red

Gre

en

Am

ber

Red

Gre

en

Am

ber

Red

Charlotte Mon-Fri 3/3 3/2 2/3 3/2 3/1 2/2 2/2 - 2/1

Surgical Short Stay /Admission Suite Mon-Fri Nt No’s = 12 patients Sat

7/1 6/1 5/1 5/1 5/0 4/1 1/1 - -

1/1

- -

Forrester Brown Mon-sun Weekend

10/8 9/8 8/8 9/7 8/7 8/6 6/4 5/4 5/3

9/7 9/6 8/7 9/7 9/6 8/7 6/4 5/4 5/3

Philip Yeoman Mon-Fri Weekend Dependant on number of patients

4/2 3/2 2/2 4/2 3/2 2/2 2/2 2/1 2/0

Sat 3/2 Sun2/2

2/2 2/1

2/1 2/0 2/2 2/1

2/0 2/2 2/1 2/0

Robin Smith Mon-Fri Weekend

5/4

4/3 3/2 4/3 3/3

3/1 3/2 3/1 2/2

4/4 4/3 3/2 4/3 3/3 3/1 3/2 3/1 2/2 Waterhouse Mon-Sun Weekend

5/4

4/3 3/2 4/3 3/3

3/1 3/2 3/1 2/2

4/4 4/3 3/2 4/3 3/3 3/1 3/2 3/1 2/2

SAU 27 beds 5/3

4/2 3/2 5/3 4/2 3/2 4/2 3/2 3/1

CCS (ITU & HDU) (11 beds) Dependant of number and level of patients

10/1

9/1

9/1

Eye Unit 1/1

1/1

1/1

Appendix 3




safe staffing report – maintaining optimum establishments ...€¦ · 1.2 general factors...

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