Agenda item: 9.3, Public Board meeting Date: Title: Nursing & Midwifery Establishment Review Six Monthly Report Prepared by: Presented by: Bernadette George, Head of Safety, Risk & Patient Experience, Tracey Reeves, Deputy Chief Nurse / Midwife Em Wilkinson-Brice, Deputy Chief Executive / Chief Nurse Responsible Executive: Em Wilkinson-Brice, Deputy Chief Executive / Chief Nurse Summary: This paper provides the findings of the Trust s six monthly nursing and midwifery establishment review Actions required: Status (*): History: Link to strategy/ Assurance framework: The Board of Directors is asked to receive and note the report and proposed action. Decision Approval Discussion Information x x Nursing and Midwifery Establishment Review six monthly report July 2015 Nursing and Midwifery Establishment Review six monthly report January 2015 Safe Staffing At Night Establishment Review May 2014 In-Patient Ward Establishment Review May 2013 The issues discussed are key to the Trust achieving its strategic objectives. Monitoring Information Please specify CQC standard numbers and tick other boxes as appropriate Care Quality Commission Standards Outcomes Monitor Finance x Service Development Strategy Performance Management x Local Delivery Plan x Business Planning Assurance Framework Complaints Equality, diversity, human rights implications assessed Other (please specify) 1 of 5
1. Purpose of paper 1.1 The purpose of the paper is to present to the Board of Directors the findings of the November 2015 nursing and midwifery establishment review and the action taken. 2. Background 2.1 Within the Trust and nationally it is established good practice for all Trusts to regularly review nursing and midwifery establishments, ensuring that the workforce is sufficient in both skill and number to meet patient demand. In addition, in 2014 it became a policy requirement for acute Trusts to review their nursing and midwifery establishments every 6 months and for Board of Directors to assure themselves that safe nurse / midwife staffing is in place. 2.2 Organisational Context Since the last establishment review in May 2015 the following actions and changes have occurred: The change in skill mix to provide additional band 6 establishments to two ward areas has been incorporated into baseline budgets and recruited to. The additional requirement to enhance the registered nurse establishment on late shifts and weekday night shifts in one ward area has been incorporated into baseline budgets and recruited to. The continued focus on local and international recruitment to support the nursing workforce resource plan has resulted in the lowest number of registered nursing vacancies for over three years. There have been 168.6 WTE registered nurses commencing employment since 1 ST June 2015 until the end of November 2015. The successful recruitment into the ward establishments has resulted in an overall reduction in the overall specialling requirements across the trust. There has been a reduction in the reliance on temporary staff, reflected in the overall reduction in bank expenditure and nursing overspend. To support the financial position the Matrons have had reduced supervisory time from 3 to 2 days per week. In addition the Senior Nurses are working clinically rostered shifts to help provide cover up until the end of March 2016. The revised Transition Programme continues for our overseas recruits alongside a team of Practice Educators to support the cultural adaptation to the English registered nurse role in practice. This is currently funded until the end of March 2016. Options to cover the cost recurrently are being explored. Evaluation of the team has included demonstrable improvement in sickness levels ( for nursing reduced to 1.52% versus 4.26% for other staff groups). Staff feedback has been extremely positive and the stability index has also improved, demonstrating effective retention. The metrics are being monitored through the Trust s Nursing, Midwifery and Therapy Workforce Group. 2 of 5
Statutory Supervision of Midwives will be discontinued from April 2017. Midwifery supervision is there to provide support and development of Midwives with an emphasis on continuous quality improvement. National proposals for changing midwifery supervision are being reviewed and the new system will be employer led with the emphasis on a professional model for all registrants. Practice educators will need to work alongside supervision to provide assurance that registrants are fit to practice. Supervision has a fundamental role in supporting Midwives who practise autonomously and use the Supervisory framework particularly when working with women with complex needs. The Deputy Chief Executive/Chief Nurse has commissioned the Head of Midwifery to develop proposal for consideration to ensure on-going support for Midwives. There is still a requirement for Registered Mental Health nurse specialling which requires a documented recommendation by the Psychiatric Liaison Team and sign off by the relevant Assistant Director of Nursing / Head of Safety Risk and Patient Experience in hours and the Senior Nurse on call out of hours. Work is planned with the support of Devon Partnership Trust to enhance understanding of the requirements for RMN support, and to explore alternative models, potentially covering cross site and in a reciprocal capacity. Following Lord Carter s publication of the Review of Operational Productivity in NHS Providers; Interim Report published in June 2015 the Trust has been working with the cohort of 22 (now 32) Trusts to develop the Model Hospital. The nursing workforce component of this programme has been to develop an Nursing Hours Per Patient Day (NHPPD) metric. NHPPD is a simple calculation of dividing the number of actual nursing hours by the number of patients. It therefore represents the number of nursing hours that are available to each patient. It is widely used as a nursing indicator in South Africa, America, New Zealand and Australia. We are expecting publication of our data and next steps for the Carter review work shortly. In theory this metric could replace that currently used within the Trust. The use of the ongoing Safe Staffing Thermometer reveals a constant level of patients with a dependency of level 3 or 4, (with 1 being the lowest and 4 the highest level of dependency). 2.3 Nursing and Midwifery Establishment Review Scope and Methodology The establishment review has taken account of all adult and paediatric inpatient ward areas, the Neonatal Unit, the Emergency Department, the Intensive Care Unit and the Midwifery Service. In addition safe staffing dashboards have been developed for the pre-assessment areas and main outpatient areas within the Trust. This will continue to be developed over the next 6-12 months. There is currently no national acuity or dependency tool for these areas so the professional judgement model has been used by the relevant Assistant Director of Nursing and subject to peer challenge and scrutiny through the Star Chamber process. The approach and principles agreed by the Board in May 2014 have been followed including incorporation of individual ward / department dashboards, based on a combination of benchmarking, outcomes analysis and professional judgement, together with 2 3 of 5
Star Chambers led by the Deputy Chief Nurse / Midwife, and finally the Deputy Chief Executive / Chief Nurse. 3. Analysis 3.1 Key Findings No ward or department is over established with their nurse / midwife staffing levels. One ward area in Specialist Services has seen a decrease in acuity / dependency since the last review which if sustained may require some disinvestment in the ward establishment at the next establishment review period. This is initially believed to be due to a greater number of ambulatory patients being cared for during this time. However, to assess whether this is a longer term trend, the nursing establishment on the ward will be re-assessed again in February 2016. Paediatric Services and the Neonatal Unit nurse staffing levels are safe when there are normal levels of activity and acuity. The Paediatric Assessment Unit appears to be receiving a greater number of referrals. Work will be undertaken to review and re-consider the emergency paediatric pathway. Maternity Services staffing levels are safe. The Emergency Department has temporarily uplifted it s nursing establishment over the winter period to cater for increased activity, funded as part of the winter plan. This will be reviewed during March 2016. The Intensive Care Unit staffing levels are safe. The Acute Stroke Unit is having increased practice facilitation time over the next three months to provide enhanced leadership and skills development at ward level. A ward buddying system with another experienced Matron will also provide additional leadership support to the team. All adult in-patient areas meet the NICE 2014 recommendations of a nurse to patient ratio of 1:8 for the early and late shifts: this is also the professionally supported ratio. The RCN benchmark of 1:10.9 average is not reached for night duty in 2 ward areas and professional judgement supports this in both those areas. The Assessment & Outpatient areas are safe. The Outpatient Transformation Programme will support the review of the future workforce model and will link into future nursing and midwifery establishment reviews. The Deputy Chief Nurse / Midwife, Head of Midwifery, Assistant Directors of Nursing and the Head of Safety, Risk and Patient Experience have reviewed the data and applied their professional judgement and concluded that there are no adult ward areas that require uplifting in this establishment review. The Deputy Chief Executive / Chief Nurse has reviewed the data and concludes that it is her professional view that current nurse / midwife staffing is sufficient to provide safe, compassionate care. A review of the specialling 1:1 data has concluded that four ward areas within the Medical Services Division still have requirements for 1:1 specialling. There is a 60:40 split to night day specialling requirements within these areas. 4 of 5
Further work will be completed to consider how the day can be structured for patients with cognitive impairment to explore how this could be covered in a more therapeutic way for the patient and reduce the requirement for night time specialling. The specific requirement where the Psychiatric Liaison team request mental health specialling will be explored in more detail to see whether any alternative options can be considered, in conjunction with Devon Partnership Trust. 4. Resource/legal/financial/reputation implications 4.1 Financial implications None 4.2 Legal implications None identified. 4.3 Reputation implications Failure to secure safe staffing establishment may lead to regulatory action by the Care Quality Commission or Monitor and have a negative impact on patient outcomes and reputation. 5. Link to BAF/Key risks BAF risk 14 There is a risk due to increased demand and an increasingly more competitive recruitment market that the supply of skilled and available workforce will not meet service needs. This risk appears to have been mitigated with the successful recruitment and retention. 6. Proposals The Board of Directors is asked to note the findings of the establishment review and the proposed action. 5 of 5