CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

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1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Agenda Item 9.6 Report of: Paper prepared by: Chief Nurse - Cheryl Lenney Acting Director of Nursing Dawn Pike Date of paper: September Subject: Purpose of Report: To provide the bi annual report on nurse staffing to the Board of Directors in accordance with the requirements of the National Quality Board. Indicate which by Information to note Support Resolution Approval Consideration of Risk against Key Priorities (Impact of report on key priorities and risks to give assurance to the Board that its decisions are effectively delivering the Trust s strategy in a risk aware manner) 1. Patient Safety 2. Patient experience 3. Productivity and Efficiency Recommendations Contact To note the work that is being undertaken to mitigate the number of registered nursing vacancies Dawn Pike Acting Director of Nursing

2 Executive Summary 1. Introduction 1.1. This is the bi-annual, comprehensive report provided to the Board of Directors on nursing staffing based on the Trust position against the requirement of the National Quality Board (NQB) Safer Staffing Guidance and the National Institute for Health and Care Excellence (NICE) guidance issued in July 2014 for adult in patient wards The previous report was received by the Board of Directors in March 2. Current Position 2.1. The Board of Directors has previously received reports on nurse staffing outlining nurse staffing numbers, establishments and the Trust plans to achieve the NICE requirements for adult wards against a background of a national shortage of registered nurses. The purpose of this paper is to provide the Board with the actual position, the actions taken to mitigate the impact on patient experience and patient care and the forward plans Modelling by the Centre for Workforce Intelligence 1 predicts an overall decline in the registered nurse headcount with a likely reduction of between 0.6 per cent and 11 per cent depending on assumptions on net emigration of UK trained nurses, numbers of newly qualified nurses exiting training programmes and forecast retirements As of the end of July, there are a total of wte vacant qualified nursing posts across the Trust. The majority of vacancies, wte, are at Staff Nurse (band 5) level wte offers of employment have been made to registered nurses with 78% of these staff commencing in post in September and October upon completion of training programmes and 54 wte international nurses are expected to be in post by December In order to address the lack of UK registered nurses the Board previously approved a recruitment plan 2 for international, European and UK nurses. In addition as outlined in previous papers a focused retention strategy has been launched and commenced to reduce the turnover rate of registered nurses by 12.5% with a plan to reduce turnover further in 2016/17 by at least 25% A modelling exercise has been undertaken to predict and plan for the number of nurses in post for the period September March 2016 for the Manchester Royal Infirmary (MRI); as this hospital has the highest number of vacancies. This modelling has taken a cautious view of the current position, factored in the bed numbers based on the service transformation plans and also the current impact on nurse sensitive indicators (patient outcomes) and patient feedback Report of the Chief Nurse, March safer Staffing and midwifery Workforce Page 6 Section 7 paragraph Nursing and Midwifery Retention Strategy /18 Published: August Author: Dawn Pike Page 2 of 15

3 2.7. The planned reduction of beds through the agreed transformation programme, alongside a pragmatic assessment of the increase in the nursing workforce and anticipated turnover will ensure that by March 2016 staff in post to bed ratio s will have improved, reducing the need for expensive agency cover. Additionally if the international recruitment numbers are fully achieved workforce will match capacity in March 2016 using this model The associated triangulation of nurse sensitive indicators 4 suggests that there is currently no evidence of a deterioration on nurse sensitive indicators, specifically, pressure ulcers, falls with harm and infections and overall patient experience. However, it is accepted that there are unquantifiable measures of overall patient experience that are not captured in these measures and the Trust is committed to continuing to recruit to the required numbers of registered nurses. It is also accepted that the impact on staff as a result of ensuring that patient outcomes are maintained is reflected in high turnover rates (appendix 2) A further exercise is being undertaken to assess the impact of nursing and midwifery vacancies for the Royal Manchester Children s hospital (RMCH), Trafford and Saint Mary s The Trust has reported a static position on the planned vs actual numbers on NHS Choices which reflects the vacancies in registered nurse numbers (Appendix 1) The Trust is working towards achieving the NICE recommendations on safe staffing and has plans in place to mitigate the number of registered nurse vacancies The Trust has invested in an e-rostering system and the associated software to identify red flags and has long standing escalation plans in place to manage staffing shortages The Trust uses a recognised acuity and dependency tool to inform nurse staffing and nursing establishments. This is also used to inform divisional integrated business plans The Trust recognises the hard work and dedication of the nurses and midwives in ensuring that patient outcomes have not deteriorated during this challenging period. The work and commitment of the staff is acknowledged and the Chief Nurse will continue to lead and oversee the recruitment and retention plans including alternative ways of working to support front line nurses and midwives with the Executive Director of Human and Corporate Resources. 4 The impact of nurse staffing on quality and performance, Report to Quality and Performance Scrutiny Committee, September Page 3 of 15

4 1. Introduction 1.1. This is the biannual comprehensive report provided to the Board of Directors on nursing staffing based on the Trust position against the requirement of the National Quality Board (NQB) Safer Staffing Guidance and the National Institute for Health and Care Excellence (NICE) guidance issued in July 2014 for adult in patient wards The previous report was received by the Board of Directors in March. 2. Current Position 2.1. The Board of Directors have previously received reports on nurse staffing outlining nurse staffing numbers, establishments and the Trust plans to achieve the NICE requirements for adult wards against a background of a national shortage of registered nurses. The purpose of this paper is to provide the Board with the actual position, the actions taken to mitigate the impact on patient experience and patient care and the forward plans The detailed position on acuity and dependency and achievement against NICE guidance is provided in appendix Modelling by the Centre for Workforce Intelligence 5 predicts an overall decline in the registered nurse headcount with a likely reduction of between 0.6 per cent and 11 per cent depending on assumptions on net emigration of UK trained nurses, numbers of newly qualified nurses exiting training programmes and forecast retirements As of the end of July, there are a total of wte vacant qualified nursing posts across the Trust. The majority of vacancies ( wte) are at Staff Nurse (band 5) wte offers of employment have been made to registered nurses with 78% of these staff commencing in post in September and October upon completion of training programmes. A further 54 wte international nurses are expected to be in post by December In order to address the lack of UK registered nurses the Board previously approved a recruitment plan 6 for international, European and UK nurses. In addition as outlined in previous papers a focused retention strategy 7 has been launched and commenced to reduce the turnover rate of registered nurses by 12.5% with a plan to reduce turnover further in 16/17 by at least 25% A modelling exercise has been undertaken to predict and plan for the number of nurses in post for the period September March 2016 for the Manchester Royal Infirmary (MRI); as this hospital has the highest number of vacancies. This modelling has taken a cautious view of the current position, factored in the bed numbers based on the service transformation plans and also the current impact on nurse sensitive indicators (patient outcomes) and patient feedback Report of the Chief Nurse, March safer Staffing and midwifery Workforce Page 6 Section 7 paragraph Nursing and Midwifery Retention Strategy /18 Published :August Author: Dawn Pike Page 4 of 15

5 2.8. The modelling and analysis of nurse sensitive quality indicators 8 suggests that there is no evidence of a deterioration on nurse sensitive indicators, specifically, pressure ulcers, falls with harm, infections and overall patient experience. However, it is accepted that there are unquantifiable measures of overall patient experience that are not captured in these measures and the Trust is committed to continuing to recruit to the required numbers of registered nurses. It is also accepted that the impact on staff that results from ensuring that patient outcomes are maintained is reflected in high turnover rates (appendix 2) A further exercise is being undertaken to assess the impact of nursing and midwifery vacancies for the Royal Manchester Children s hospital (RMCH), Trafford Hospital and Saint Mary s The Trust recognises the hard work and dedication of the nurses and midwives in ensuring that patient outcomes have not deteriorated during this challenging period. The Chief Nurse will continue to lead and oversee the recruitment and retention plans including alternative ways of working to support front line nurses and midwives with the Executive Director of Human and Corporate Resources 3. National Quality Board Requirements (NQB) 3.1. In order to provide a level of assurance in regards to safer staffing and safer care for patients, there are a number core requirements for Trusts to respond to, based on NQB requirements. Planned versus Actual staff on duty 3.2. The Trust has published on a monthly basis since June 2014 information on the Trust website and through a Unify submission to the NHS Choices site, data in relation to nurse staffing Tables 1 and 2, below, show the number of wards from a total of 55, that are achieving 90% planned versus actual staffing levels from April to July. This position is similar to that reported in the March Board report and reflects a static position in terms of reducing vacancies despite the programmes of work that are in place. Table 1: Number of wards achieving 90% planned versus actual registered nurses/midwives (April July ). Registered Nurses/Midwives Days and Nights April May June July Days > 90% Night > 90% Days < 89% Night < 89% 8 The impact of nurse staffing on quality and performance, Report to Quality and Performance Scrutiny Committee, September Page 5 of 15

6 Table 2: Number of wards achieving 90% planned versus actual Nursing Assistants (April July ) Nurse Assistants Days and Nights Days > 90% Days < 89% Night < 89% 0 April May June July 3.4 Analysis of the data shows that the wards achieved over 90% of their planned Registered Nurse/Midwife levels between 44% and 61% of the time, with higher levels of compliance at night time. Planned levels of Nursing Assistants were achieved between 50% and 90% of the time, with night time compliance ranging from 87% to 90% of the time. 3.5 All wards display the planned versus actual staff on duty for each shift at the entrance to ward areas. This data is updated manually by the ward team and is presented alongside a number of quality nursing indicates that patients have told us they want to know about when they come into hospital. 4. NICE Requirements The following core requirements are stipulated by the NICE guidance. 9 Red Flags 4.1. The guidance sets out a number of red flag events which signify when nurses in charge of shifts must act immediately to ensure that they have sufficient staff to meet the needs of patients on that ward. The implementation of Allocate Safecare software in June, as part of the e- rostering project, now provides a mechanism to record red flag events and the actions taken in response July was the first full month that all ward areas had access to the Allocate SafeCare system and during July 24 red flags have been raised, with the majority (21) being recorded as shortfall in RN time. Red flag events are escalated through existing senior nurse routes. Acuity and Dependency 4.3. 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 for the patients, but also that the nurses have the right skills to match the care needs of the patient group. 9 Page 6 of 15

7 4.4. Forty two ward areas have been monitored on three census periods since February 2014, using the validated Safer Nursing Care Tool (SNCT). 10 Evidence suggests that a minimum of three census periods are required for each area before the information regarding recommended workforce establishments that is provided by the SNCT can be considered valid. The tool also requires that there are no significant changes in ward environment or patient case mix between census periods, as either of these factors impact the validity of the census outcomes Implementation of the Allocate Safecare software now allows matrons, lead nurse and Heads of Nursing to review all ward areas for a specific shift highlighting where staffing does not match acuity and dependency and enables action to be taken in real time. This software enables a review of the acuity and dependency needs of the area to be undertaken at any time and is not dependent on waiting for the next census period The information provided is used at divisional level to monitor any shortfall against planned staffing levels and to implement plans, aligned to corporate support strategies, to bridge the gap. This information in intended to be used by the Divisions to support any proposed changes to nursing establishments. Acuity and Dependency Exception Report 4.7. Valid acuity and dependency establishment recommendation data is currently available for ten of the forty two wards monitored using the SNCT Of these 10 ward areas, one area has subsequently significantly changed the patient case mix since the February census and therefore will require 3 further census periods to be undertaken. The data for the remaining 9 areas demonstrates the following: 2 areas are appropriately established 1 area is over-established by 3 wte 6 areas are under-established by approximately 8% which equates to 27.26wte. This information has been shared with Divisions to enable establishments to be realigned and reviewed accordingly as part of the business planning processes within each area Further data collection is required for 20 wards, to obtain valid recommendations regarding establishments, as a result of changes to patient case mix, bed numbers, significant differences in the results compared to previous census periods and ambiguities within the data. One ward has now closed and a further twelve areas have been identified as not suitable for application of the tool due to low bed numbers, daycase activity or high patient flow. In these areas professional judgement is used to agree nursing establishments. The Board is reminded that professional judgement must always be the default position if any conflicts arise from the application of acuity and dependency tools The data entered for July has not yet been fully analysed but initial review suggests that patient acuity is increasing, which will impact nurse staffing requirements. This position will continue to be monitored and nursing resources allocated accordingly Page 7 of 15

8 4.11. Analysis of the census data also highlights continued differences in the uplift assigned across nursing establishments across the Trust. The current recommended uplift (NHS Employers/RCN) is 25% 11. This uplift is to cover annual leave, sickness, absence and statutory and mandatory training. There is no provision for absence due to maternity leave within the uplift, however, it is noteworthy that over a year an average of 200 staff, are unavailable for work due to maternity leave. The majority of this number are staff nurses. Care Contact Time The Board is aware from previous papers that the Trust has undertaken monitoring of care contact time as part of the Improving Quality Programme. Data from this twice yearly exercise has been used to inform local improvement work The Trust supported NHS England (NHSE) to further develop this work in response to the Chief Nursing Officer s (CNO England) requirement to review care contact time as part of establishment and skill mix reviews This work is intended to support Trust Boards when assessing the impact of nurse staffing on the quality of patient care and cannot be used in isolation but as a local measure to assess the effectiveness of care delivery and change to nursing models. There is currently no national evidence or benchmark data as to what is the correct percentage and ratio of direct or indirect care time The Trust data demonstrates a range of direct care time for registered staff from 48-60%. Whilst it is widely assumed that more registered nursing input equals improved patient care; 12 a lower level should not be assumed to require improvement as it may be that this ratio is the most effective use of the registered nurse skills in this area. Equally a high level may indicate inefficient use of a highly skilled nurse The Chief Nurse is intending to pilot a small study looking at a different ward model of care which will be brought to the Board when fully worked up and will incorporate a number of measures for assessing the quality of nursing care and patient satisfaction as well as clinical outcomes. 5. Update on Recruitment and Retention 5.1. In November 2014 the Board of Directors approved a business case to support a large scale international recruitment project for 300 nurses and a domestic recruitment campaign under the banner proud to care launched in March A nursing and midwifery retention strategy was launched in August and there has been a focus through the Trust workforce recovery programme on reducing sickness and absence levels. 11 RCN Policy Position: evidence-based nurse staffing levels 12 Guidance on safe staffing levels in the UK. data/assets/pdf_file/0005/353237/ pdf Page 8 of 15

9 International Recruitment 5.3. The Trust commenced a programme of international recruitment in April. 275 candidates from India have been interviewed and offered conditional posts with the Trust. The certificates of sponsorship which are required to gain entry into the UK expire after 12 weeks of issue. There have been some difficulties in managing the immigration and pre-employment/registration process in India to this timetable; therefore the Trust has had to reapply for the certificates of sponsorship which has impacted in progressing the project within the anticipated timescales Members of the Board are reminded that a risk identified at the onset of this programme of work was the Nursing and Midwifery (NMC) process to approve candidates on the first phase to join the register. The average duration of this process is minimum of 60 days, but individual experiences can mean the process takes up to 90 days. The process is not transparent and information from the NMC international recruitment team is limited about individual candidates The project management structure for this programme of work includes weekly update conference calls with our partner agency in order to gain assurance that progress on the stages of the process is made to the agreed timescales The Trust is exploring a number of other options to recruit qualified nursing staff. Each of these options will be form the basis of an options appraisal and only those that we are confident will realise a supply of suitable nurses will be progressed: 15 nurses from Portugal have commenced in post in July as part of partnership working with NHS Professionals Agreed EU recruitment from Italy in September with NHS Professionals. Work with NHS Professionals to establish a rolling programme of EU recruitment over the next 4 months in order to provide a supply of nurses via this route. Meeting in September with Dutch University and recruitment providers as a short term supply (12 months) of newly qualified nurses will be available from early The feasibility of recruiting in other international markets, primarily Australia, New Zealand and Canada The Trust proud to care nursing recruitment campaign was launched in March. The campaign has resulted in an increase in applicants, compared to similar periods in previous years wte conditional job offers are currently being managed through the pre-employment checks phase of the recruitment process. The majority of these staff (78%) are new registrants who will commence in post during September and October upon completion of their programme of education. Retention 5.8. The first phase of the retention strategy is to focus on the retention of the staff nurse (band 5) workforce. As of end of July the rolling 12 months turnover rate within this group of staff for the Trust was 22.79%. This means that an average of 37 wte staff nurses leave the Trust each month The aim is to reduce turnover by 25% however an immediate reduction of 12.5% is the focus on the work programme within the divisions supported by corporate services from September March The strategy has a number of detailed Trust wide actions, and will be supported by local delivery plans within each Division. The strategy has been developed around 5 evidence based themes: Page 9 of 15

10 Supporting staff (such as wellbeing/work life balance) Effective use of resources Understand why staff leave and why staff stay and take action Workforce development/redesign Career pathways and commitments from the Trust as an employer Retention remains an on-going focus for the Trust with delivery of the key actions being monitored on a monthly basis by the Director of Nursing. 6. Workforce efficiency - E Rostering 6.1. The Lord Carter Interim report 13 on workforce efficiency in the NHS recommends the use of an electronic rostering system to not only maximise workforce efficiency but also ensure safe staffing levels meet patient acuity and dependency The Allocate system was implemented for the nursing and midwifery workforce in 2014 and completed in July. As a result, all nursing and midwifery staff rotas and payroll are managed through the system. The system provides a platform through which ward managers can create rosters based on standards for creating rosters detailed within the Trust Policy. Now that the system is fully implemented a new rota policy is required to ensure that the functionality and reporting provided by the system are embedded in our processes The system also manages all temporary staffing requests to NHSP; the Trust s temporary staffing provider, which are aligned to the establishment and provide a shift by shift overview of safe staffing. As part of the final phase of the project over the next 4 months a review of each area using the system will be undertaken to ensure that the system is being used to the maximum effectiveness In June the SafeCare software was implemented as the final phase of the e- roster project. This software combined with the health-roster system affords a number of benefits including: Recording of real time attendance at the start and end of each shift to inform accurate payroll Recording of acuity and dependency data alongside the staff attendance data which provides an immediate analysis of ward requirements. This allows ward, divisional and Trust views on a shift by shift basis allowing the reallocation of resources to meet the identified needs. The system will replace the previous manual acuity and dependency process and negate the need for nurses and midwives to input planned and actual data on a shift by shift basis as this will be generated automatically. Supports improved staff experience as staff can access their roster from home via their employee on line account Page 10 of 15

11 7. Key Risks 7.1. The information detailed in this paper sets out the numerous actions being undertaken to enable the Trust to reduce the number of vacancies within the nursing and midwifery workforce This risk has been registered on the Trust risk register as a high level risk and will be reviewed monthly and reported to the risk management committee, as the strategies described in this paper impact on reducing vacancy rates. 8. Conclusion 8.1. The Board are asked to: Note the significant programmes of work that are being undertaken to address the nursing vacancies. Note the Trust position against NQB and NICE requirements which will improve when nursing vacancies are reduced. Commend the work undertaken by nurses and midwives across the Trust to maintain quality and safety whilst managing with a high number of vacancies. Page 11 of 15

12 APPENDIX 1 WARD NURSE STAFFING FIGURES Board of Directors Agenda Item 9.6 Division Ward Bed s Funded WTE July In Post (WTE) from ESR Variance In Post (WTE) from ESR (July ) Qualified Unqualified Qualified Unqualified Qualified Unqualified A&D Recommended WTE (Feb ) 14 % Average Turnover last 12 months From ESR % sickness (JUNE) from ESR Temp Staff wte July Qualified Unqualified July % of temp staff hours used (funded est) 15 NICE RN to Pt ratio based on establishment Day Comments Medicine & Community AM1 28 AM % % % % NQ appointments expected September NQ appointments expected September NQ appointments expected September % % % OMU % % % SCNT tool does not capture high volume of patient admission and transfer activity 1 TO 8 A&D data not collected Feb-change to ward to become isolation area. Acute Medical Unit % N/A SCNT tool does not capture high volume of patient admission and transfer activity Specialist Medicine 3 & % 1 TO 5 Significant number of additional shifts from bank to cover cohort nursing 14 BOLD text details wards where 3 valid census periods have given consistent results 15 Temporary Staffing Percentage - it should be noted that most temporary staffing cover is provided by trust staff undertaking additional shifts (i.e. over 65% for RN shifts) therefore high temporary staffing usage does not necessarily indicate staff who are unfamiliar with patient group/area are being used. Page 12 of 15

13 AM % Agenda Item 9.6 AM % % 1 TO % 1 To Acute Cardiac Unit 16 CSITU 12 REH 54 & % % % % 1 To 5 Change in ward use to cohort ward indicates high number of bank shifts whilst staffing realigned to patient mix 1 TO 3.3 SCNT tool not suitable for patient case mix SCNT tool not valid in critical care setting 1 TO 5 SCNT tool not suitable for patient case mix due to mix of daycase and inpatients. Ophthalmolog y Day Case % SCNT tool not suitable for patient case mix Surgery &12 28 Emergency Surgical Unit Elective Treatment Centre & RMCH (ETC) % % % % % % % % % Page 13 of 15 1 TO 6 NQ appointments expected September 1 TO 6 NQ appointments expected September 1 TO 6 NQ appointments expected September 1 TO 6 Change to case mix and use of day case unit as escalation area during winter indicates high bank use 1 TO 6 NQ appointments expected September 1 TO 6 NQ appointments expected September SCNT tool not suitable for patient case mix due to mix of daycase and inpatients.

14 (Burns Unit) (BMTU) PICU Trafford INRU 30 MAU % % % % % % % % % Agenda Item 9.6 SCNT not valid in areas with less than 16 beds. SCNT not valid in areas with less than 16 beds SCNT not valid in areas with less than 16 beds SCNT tool not valid in critical care setting 1 TO 8 Unable to collect A&D census in Feb due to ward reconfigurations 1 TO 6 SCNT tool does not capture high volume of patient admission and transfer activity Orthopaedic Unit % 1 TO 6 SCNT tool not suitable for patient case mix due to mix of daycase and inpatients. Seymour Stroke Unit % 1 TO 8 Unable to collect A&D census in Feb due to ward reconfigurations Surgical Unit (Day Case) % 1 TO 8 SCNT tool not suitable for patient case mix % % % 1 TO 5 Ward now closed 1 TO 6 1 TO 6 Clinical & Scientific ITU & HDU % SCNT tool not valid in critical care setting St Mary's % 1 TO 6 SCNT tool not suitable for patient case mix due to mix of daycase and inpatients. Page 14 of 15

15 NICU Delivery unit Salford Birth Centre % % % % % Agenda Item 9.6 SCNT tool not valid in critical care setting SCNT tool not valid in maternity care setting Page 15 of 15