WORKFORCE COMMITTEE – COVER SHEET

Meeting Date: 22 June 2015

Agenda Item: Paper No:

Title: / Nursing and Midwifery EstablishmentReview June 2015
Purpose: / To provide the workforce committee with a review of the current Nursing and Midwifery Establishment.
Summary: / In 2013 the Francis report brought into the spot light the importance of ensuring safe staffing levels on inpatient wards.
This paper provides the Trust nursing and midwifery review for June 2015 and has utilised data available in March 2015.
The review was conducted utilising NICE 2014 guidance and shows that the overall picture of nurse and midwifery staffing at Poole Hospital NHS Foundation Trust is compliant with the available national guidance (NICE 2014).
It begins by providing an update of the actions agreed at the last review in November 2014. It then describes the methodology used for the June 2015 review, the findings, and asks support for the following recommendations;
  • Continue to actively recruit to current vacancies of both registered nurses, midwives and unregistered (health care assistants).
  • The continued implementation of the electronic rostering system to ensure it is used to its maximum benefit.
  • In line with the NICE (2014) recommendations the Safer Nursing Care Tool will be implemented to support acuity and dependency measurement information and trends.
  • Continue to receive a six monthly review of nurse/midwife staffing; the next Nursing and Midwifery Establishment Reviewwill be reported to the board in January 2016.

Recommendation: / For discussion and review of recommendations.
Prepared by: / Yvonne Jeffrey
Assistant Director of Nursing (Workforce) / Presented by: / Tracey Nutter
Director of Nursing

This report is relevant to: (Please tick relevant box)

Assurance Framework / X / Risk Register I/D No.
Healthcare Standards:
Please specify which standard / Financial implications NO
Monitor compliance / X / Human Resources implications YES
Internal monitoring / X / Legal implications NO

Poole Hospital NHS Foundation Trust

Report to the Board of Directors – 29th July 2015

NURSING AND MIDWIFERY ESTABLISHMENT REVIEW JUNE 2015

  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 bi-annual reviews of staffing levels in their inpatient ward areas. The main purposes of these reviews are to assure the Boards that there are safe staffing numbers in their organisations and the correct skill mix of nurses to provide care.

1.1Much debate and research has been reported over many years on the tools and methods of setting and agreeing staffing numbers and skill mix. In 2014 NICE published guidance to ensure that all NHS organisations are utilising the most evidence based tools and methodologies.

1.2This paper provides the Trust nursing and midwifery review for June 2015. The review has utilised data available in March 2015. The review was conducted utilising NICE 2014 guidance. It begins by providing an update of the actions agreed at the last review in November 2014. It then describes the methodology used for the June 2015 review, the findings and recommendations.

  1. Summary of key recommendations and actions from the November 2014 Nursing and Midwifery Establishment review

The November 2014 review recommended to the Board of Directors the following in order to provide further assurance;

  • Continue to actively recruit to current vacancies of registered nurses, midwives and unregistered staff (health care assistants).
  • Implementation of the electronic rostering system (Allocate Healthroster)
  • Agree the number of substantive staff required to manage all escalation beds.
  • Continue to review and understand the roles of individuals engaged in supervisory/supernumerary time
  • Continue to receive a six monthly review of nurse/midwife staffing

2.1Recruitment

The Assistant Director of Nursing (Workforce) leads a monthly ‘Nursing and Midwifery Staffing Working Group’ which focuses on ‘Recruitment and Retention’ of registered nurses, midwives and unregistered staff, she is supported by a recruitment nurse post which provides additional focus.A variety of recruitmentinitiatives have been successfully deployedlinked to staff retention.Since January 2015 67 registered

nurses and 68 health care assistants have been recruited.

Data from the inpatient wards demonstrate that there are currently;

  • 43.7 whole time equivalent (wte) unfilled registered nurse posts
  • 1.6 wte unfilled registered midwife posts
  • 34.04 wte unfilled unregistered staff (health care assistants).

2.2Electronic rostering system (Allocate Healthroster)

Led by the Assistant Director of Nursing (Workforce) the Trust is currently implementing a new electronic rostering system,‘Allocate Healthroster’ across wards and departments. This project commenced 16th February 2015 and will replace the current SMART system for electronic rostering. Allocate Healthrosterwill provide clear reports and improved intelligence on workforce reporting to ensure effective use of workforce resources.The inpatient nursing resources account for £33,885,800 of the total £148,175,973 staffing cost for the Trust. It is essential that this resource is effectively managed.

2.3Substantive staff required to manage all escalation beds.

The demand for patients to be admitted has increased, extra beds have been opened to support the increase, these patients are usually cared for by the registered nursesand unregistered staffemployed by the organisation and any shortfall backfilled by bank and agency staff. Kimmeridge has now been funded to provide a further 20 beds and DSAU funded to provide a further 12 beds to the Trust bed complement. Substantive staff are currently being recruited to these areas.

2.4Review of individuals engaged in supervisory/ supernumerary time.

All in patient wards have an identified Band 7 ward sister / charge nurse who is allocated a minimum of 0.2 whole time equivalent (wte) within their funded establishment, to be supernumerary for one day a week. They are supported by both administration and housekeeping roles. A number of wards haveidentified administrator hours to support the ward sister / charge nurse which includes elements of human resource management which are funded from the ward establishment budget.

3Methodology

The scope of the nursing and midwifery establishment review focused on ward based staff on inpatient wards only. No other departments were included in the review.

3.1As part of the establishment review each ward staffing template was reviewed with the matron, ward sister / charge nurse and Assistant Director of Nursing to provide challenge and scrutiny into decision making on the ward establishment structure.

3.2The budgeted establishments were compared with the staffing requirements for each area as provided by the ward sister / charge nurse. Discussion took place around the actual levels of staffing required for each area taking into account the speciality of each area and any specific issues that may impact on staffing needs. At the time of this review there was no system for measuring patient acuity in the Trust.

3.3The 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 nightduty.
  • The registered nurse: patient ratio.
  • The % split of registered and unregistered staff on each shift.
  • Review of ‘Care Contact Time’, the actual time a nurse provides direct care to patients.
  • Review of quality metrics, such as incidents of patient falls, pressure ulcers and medication errors.

3.4In addition nursing and midwifery teams have worked alongside finance colleagues to ensure there is a shared understanding of nursing and midwifery budgeted establishments.

3.5Registered nurse : patient ratio.

Nice published the guidance for “Safe staffing for nursing in adult inpatient wards in acute hospitals” in July 2014. There is no single nursing staff-to-patient ratio that can be applied across the whole range of wards to safely meet patients nursing needs. However recent NICE guidance made reference to but stopped short of mandating a

1 : 8 registered nurse to patient ratio on day shifts. Each ward has to determine its

nursing staff requirements to ensure safe patient care. This guideline therefore makes recommendations about the factors that should be systematically assessed at ward level to determine the nursing staff establishment. It then recommends on-the-day assessments of nursing staff requirements to ensure that the nursing needs of individual patients are met throughout a 24-hour period.

3.6i Although the staff to patient ratio is key, it is important that it is considered alongside number of other indicators and in particular alongside patient dependency, acuity and the skill mix (registered nurse: unregistered).

3.6ii In virtually all wards across the Trust the registered nurse:patient ratio during the day time is no greater than 1 : 8.

3.6iiiAt night time some wards demonstrate the nurse patient ratio has increased above the 1: 8. Additional unregistered staff (health care assistants) have been added to these wards to reflect the specific care needs of these patients.

Appendix A Registered nurse: patient ratio.

3.7Nurse to patient % split byregistered to unregistered staff

Consideration has been given to the % split of registered nurses to unregistered staff during the day and night shift patterns. The Royal College of Nursing recommends that there is a 65% / 35% split of registered nurses to unregistered on wards in order to provide safe levels of nursing care.

3.7iWards that demonstrate a 50% / 50% split of registered nurses to unregistered staff have included additional health care assistants in the establishmentto meet the care requirements of the patients on that ward.

3.7iiIn this review most of the wards have met this recommendation.

Appendix B Nurse to patient split by registered to unregistered staff.

3.7iiiIt should be noted that roles such as ward housekeeper, ward administrators and wards clerks are not included in the ratios. In addition the ward sister / charge nurse is not included in these ratios when supervisory / supernumerary.

3.8Nurse to patient direct care contact time

A key new recommendation in the NICE guidelines (2014) is the review of staffing levels based on average nursing care hours required per patient. This is not a methodology previously used within PHFT. For this review the approach was to measurethe actual time a nurse gave 1:1 personal care to a patient, termed ‘care contact time’. The planned implementation of Allocate e rostering will providethe Trust with the automatic functionality to assess average patient hours.

3.8iFor this review the care contact time has been calculated using the ‘activity follow’ data collection tool from the Productive Ward programme. On 23rd April, a registered nurse on Lilliput was observed during a 12 hour period from 7am to 7pm and her activity was recorded every minute.

3.8iiThrough this one 12 hour period (snapshot) a breakdown of the direct patient care (1:1 personal care)delivered was recorded at 46%, against the other ward based clinical activity the nurse undertook in that time period. The aim being to achieve a higher level of direct contact patient care. The implementation of the Safer Nursing Care Tool will monitor this achievement.


Diagram to represent 'nurse to patient’ direct care contact time on one ward

3.9Safer Nursing Care ToolThrough Allocate Healthroster the Trust is implementing an acuity / dependency tool known as Safer Nursing Care Tool (SNCT). This tool will enable nurses to record the assessment of patient acuity and dependency. Astaffing multiplier is then electronically activated to guide the required nurse to patient ratios for each adult inpatient area. Thisdata will be validated against quality metrics such as, incidents of patient falls, pressure ulcers and medicine errors. Professional judgement will assure that the levels set are appropriate for the speciality and the number of patients.

3.10Headroom

Through this review it was demonstrated that all areas have 23% funding allocated to allow for additional headroom requirements arising from non-direct care time;

  • 17.0% for annual leave
  • 3.0% sickness
  • 3.0 % training

There is no allowance built in to establishments to allow for maternity leave, or other leave including compassionate or carers’ leave.

3.11Review of quality metrics

The NICE 2014 guidance outlines some key quality metrics that should be considered as part ofthe staffing reviews. The qualitymetrics defined are; patient falls, pressure ulcers andmedicine errors. These are already monitored through our internal Patient SafetyThermometer (PST) and are considered as part of the professional judgement methodology.

3.12The reported falls and pressure ulcer incidents have had a RCA undertaken and actionsimplemented as identified. The medicine reported incidents have been reviewed through theTrust Medicine Incident Review Group and identified actions addressed on the Trust incident reporting system datix. No trends were identified.

Appendix CReview of quality metrics

4Findings

This review shows that the overall picture of nurse and midwifery staffing at Poole Hospital NHS Foundation Trust is compliant with the available national guidance (NICE 2014).

4.1In comparison to the nursing and midwifery establishment of November 2014, there has been a slight increase in staff funded for extra capacity wards. This has resulted in 2015 / 16 establishment increase for staffing on Kimmeridge, Surgery and the Emergency Department.

4.2Medical Care Group : Overall establishment staffing levels are appropriate for the level and acuity of the patient. To enable the delivery of care, some wards demonstrate the ratio of registered nurses to unregistered as 50 : 50 split, due to the nature of the patient caseload, particularly in Medicine for Elderly this is considered appropriate.

4.3NICE 2014have also issued draft guidance for consultation on safe staffing in the emergency department, PHFT has reviewed these guidelines and provided feedback on the consultation. A full action plan against compliance will be developed when the guidelines are issued.

4.4Surgical and Oncology Care Group : Overall establishment staffing levels are appropriate for the level and acuity of the patient. Wards in surgery are currently involved in reconfiguration to increase the Trust bed establishment. Wards in this care group are continuing to refine their staffing levels and rostering patterns to meet the speciality demands.

4.5Women and Children’s Care Group :Overall establishment staffing levels are appropriate for the level and acuity of the patients. It should be noted that in the absence of any formal validated acuity / dependency tool for children, professional judgement and benchmarking have been used as the methodology for the review.

4.6For this review maternity services used the tool “birth-rate-plus” which supports 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. The next review will reflect the NICE midwifery staffing guidance published in February 2015.

4.7As outlined in this review much has been done to ensure the staffing levels reflect the acuity of the patient. Recruitment continues with the focus on retention of staff.

4.8Assurance has been provided from the indicators and methodology used that the levels of staffing are appropriate.

4.9The Safer Nursing Care Tool will support acuity measurement and inform optimal staffing levels. This tool together with quality indicators and workforce metrics will support future staffing establishment reviews.

5Recommendations

The Board of Directors are asked to support the following recommendations arising from this most recent Nursing and Midwifery establishment review;

5.1Continue to actively recruit to current vacancies of both registered nurses, midwives and unregistered (health care assistants).

5.2The continued implementation of the electronic rostering system to ensure it is used to its maximum benefit.

5.3In line with the NICE (2014) recommendations the Safer Nursing Care Tool will be implemented to support acuity and dependency measurement information and trends.

5.4Continue to receive a six monthly review of nurse/midwife staffing; the next Nursing and Midwifery Establishment Reviewwill be reported to the board in January 2016.

Yvonne Jeffrey

Assistant Director of Nursing (Workforce)

11.06.15

Appendix ARegistered nurse : patient ratio (March 2015)

Wards/department / Registered Nurses per bed (EARLY shift) / Registered Nurses per bed (LATE shift) / Registered Nurses per bed (NIGHT shift)
Nurses / No. beds / Nurses / No beds / Nurses / No beds
Critical Care / 1 / 1.2 / 1 / 1.2 / 1 / 1.2
Kimmeridge / 1 / 5.0 / 1 / 6.7 / 1 / 6.7
Lilliput / 1 / 6.7 / 1 / 10.0 / 1 / 10.0
Lulworth / 1 / 6.7 / 1 / 10.0 / 1 / 10.0
Lytchett / 1 / 6.7 / 1 / 8.0 / 1 / 10.0
RACE / 1 / 5.0 / 1 / 6.3 / 1 / 8.3
Stroke Care Unit (Acute & Rehab) / 1 / 7.3 / 1 / 7.3 / 1 / 8.8
Ansty / 1 / 5.0 / 1 / 5.0 / 1 / 6.0
CCU / 1 / 2.7 / 1 / 2.7 / 1 / 4.0
Arne A4 / 1 / 7.0 / 1 / 9.3 / 1 / 14.0
Avonbourne A5 / 1 / 5.8 / 1 / 7.7 / 1 / 11.5
Portland / 1 / 4.0 / 1 / 6.0 / 1 / 6.0
Durlston / 1 / 4.7 / 1 / 4.7 / 1 / 7.0
Forest Holme / 1 / 6.0 / 1 / 6.0 / 1 / 6.0
Sandbanks / 1 / 5.3 / 1 / 5.3 / 1 / 8.0
Children's Unit / 1 / 3.7 / 1 / 3.7 / 1 / 3.7
NICU / 1 / 3.3 / 1 / 3.3 / 1 / 4.0
B2 / 1 / 3.9 / 1 / 5.4 / 1 / 9.0
B4 / 1 / 6.0 / 1 / 7.5 / 1 / 10.0
B3 / 1 / 5.2 / 1 / 6.5 / 1 / 13.0
TAU Green C3 / 1 / 6.3 / 1 / 6.3 / 1 / 9.5
TAU Red E3 / 1 / 6.0 / 1 / 6.0 / 1 / 12.0

Appendix B Nurse to patient split by registered to unregistered staff (health care assistants) (March 2015)

Wards/department / Funded Beds / Registered Nurse relative to Unregistered (EARLY/LONG day shift) / Registered Nurse relative to Unregistered (LATE shift) / Registered Nurse relative to Unregistered (NIGHT shift)
Registered % / Unregistered % / Registered % / Unregistered % / Registered % / Unregistered %
Critical Care / 11 / 90% / 10% / 90% / 10% / 90% / 10%
Kimmeridge / 20 / 40% / 60% / 38% / 63% / 50% / 50%
Lilliput / 20 / 50% / 50% / 44% / 56% / 57% / 43%
Lulworth / 20 / 50% / 50% / 44% / 56% / 57% / 43%
Lytchett / 20 / 43% / 57% / 42% / 58% / 57% / 43%
RACE / 25 / 50% / 50% / 44% / 56% / 50% / 50%
Stroke Care Unit (Acute & Rehab) / 44 / 43% / 57% / 46% / 54% / 56% / 44%
Ansty / 30 / 55% / 45% / 52% / 48% / 77% / 23%
CCU / 8 / 75% / 25% / 75% / 25% / 100% / 0%
Arne A4 / 28 / 50% / 50% / 50% / 50% / 50% / 50%
Avonbourne A5 / 23 / 57% / 43% / 60% / 40% / 50% / 50%
Portland / 12 / 60% / 40% / 50% / 50% / 50% / 50%
Durlston / 14 / 60% / 40% / 60% / 40% / 67% / 33%
Forest Holme / 12 / 50% / 50% / 50% / 50% / 100% / 0%
Sandbanks / 16 / 60% / 40% / 52% / 48% / 62% / 38%
Children's Unit / 26 / 64% / 36% / 64% / 36% / 70% / 30%
NICU / 20 / 86% / 14% / 86% / 14% / 83% / 17%
Ante & Post Natal,Central Delivery Suite, Transitional Care & Haven Birthing Suite / 63 / 67% / 33% / 67% / 33% / 67% / 33%
B2 / 27 / 64% / 36% / 63% / 38% / 60% / 40%
B4 / 30 / 56% / 44% / 57% / 43% / 60% / 40%
B3 / 26 / 56% / 44% / 57% / 43% / 40% / 60%
TAU Green C3 / 19 / 43% / 57% / 43% / 57% / 50% / 50%
TAU Red E3 / 24 / 57% / 43% / 67% / 33% / 50% / 50%

Appendix CReview of quality metrics(March 2015)