1 Introduction
The purpose of this paper is to present a six-month review of nursing[1] establishment and outcomes to the Board. The Board received a review of nurse staffing in April 2013, at which time it supported recommendations for a £1.7 million investment in nursing services. Nurse staffing within the Trust is kept under constant review with the aim of getting the right staff in the right place at the right time, and therefore, ensure the provision of excellent nursing care. There is a direct link between patient outcomes and appropriate staffing numbers and skills, with the risks to patients when these are not achieved being evident in the Mid-Staffordshire NHS Foundation Trust inquiry and the Keogh mortality review. This paper includes:
2 Evaluation of Nursing Establishment Changes 2013/14
In April 2013 the Trust Board supported four main changes in nursing establishments:
Existing nursing establishments were increased by 31 whole time equivalent (WTE) in April 2013. Initially these increased posts were filled by the use of temporary staffing. The successful recruitment of 39 overseas nurses in June 2013 has ensured that the additional nursing personnel are now permanent members of staff. The impact of this increased staffing has supported a 56% reduction in pressure ulcers between April and September 2013 and the achievement of the falls reduction target since June 2013.
It was not possible to recruit mental health nurses to support patients with challenging behaviours as planned. To address the continued need for this support, recruitment is currently underway for a Band 6 nurse who will support the Lead Nurse for Adult Safeguarding and provide support and training for staff to manage patients with challenging behaviours. The additional funding that was supplied in 2012/13 has been allocated to offset some additional costs associated with enhanced supervision for patients in the Emergency and Urgent Care Division.
The supervisory status of the Ward Sisters had enabled them to provide clear leadership in all ward areas. The Divisional Heads of Nursing are monitoring the effectiveness of this leadership through performance measures agreed with the Sisters. The impact of the Sisters’ leadership was noted by the Care Quality Commission during their inspection in July 2013.
“At this inspection we observed ward sisters and nursing staff were much more visible on the wards. This had a beneficial impact on the standard of care experienced by patients”
In addition to the 31 nurses for existing wards, the Trust Board supported the provision of a permanent nursing workforce for an additional temporary capacity ward (currently Uphill). Although it was not intended for this ward to be in use during summer additional beds have been open for all but six days since April 2013. The appointment of a permanent sister to this ward has ensured that patients receive the required standard of care even though temporary staffing has been used for this area.
At a visit in April 2013 the Care Quality Commission noted the actions the Trust has put in place to review and increase nurse staffing levels and declared the Trust to be non-compliant until posts had been filled through the recruitment plans. At their return visit on 12th and 13th November 2013 the Care Quality Commission found the Trust to be compliant to staffing and stated the following in relation to nurse staffing:
One patient said "No problem, staffing levels are about right". Other patients said there were occasionally too few nurses, but only at certain times and only for a short period. A patient who had previously been admitted to the hospital said "Staffing is much better than 6 months ago".
A ward sister said "Staffing numbers have improved, the new nurses are brilliant and patients love them". A nursing assistant said "We rarely need agency or bank staff now".
The Care Quality Commission has asked the Trust to note their comment regarding the number of nursing assistants on the Medical Admission Unit and this has been considered in the six month review of staffing numbers.
3 Nurse Staffing Metrics and Nurse Sensitive Outcome Indicators
3.1 Workforce Metrics
In this section nurse staffing metrics are reviewed against nurse sensitive outcome indicators for the period April to October 2013. The overall Trust metrics are within the body of the paper with individual ward metrics shown in Appendix I.
Table 1 - Nurse Staffing metrics WAHT April 2013-September 2013
Month
Apr 13
May 13
Jun 13
Jul 13
Aug 13
Sept 13
Sickness rate
5.44%
3.58%
4.13%
4.29%
4.59%
4.77%
Bank usage
91.13
85.42
72.62
80.70
82.08
77.87
Agency usage (wte)
50.21
17.17
22.33
31.80
32.49
25.56
Vacancies (wte)
116.26
115.30
110.30
86.53
75.98
57.92
Band 6-8 leavers (wte)
1.10
0.40
1.80
2.35
1.00
Band 5 leavers (wte)
1.37
3.40
3.48
5.67
1.59
Band 2-4 leavers (wte)
0.80
2.40
1.93
0.61
2.00
0.96
Although the rate of sickness for nurses has been above the Trust average for the six months April to September 2013, it is comparable to the national average sickness for qualified nursing staff which was 4.72% in 2012/13.
Bank usage has remained relatively stable and is the preferred usage for temporary staff as opposed to agency staff that is not as likely to be familiar with Trust policies, procedures and ways of working. The agency usage has fluctuated by month but has continued to reduce post September 2013 as a result of the successful international recruitment campaign.
The number of nurses leaving the Trust peaked in June and July and August but has since decreased, with the number of recruits per month now outnumbering the number of leavers.
The number of actual nurses against the planned numbers and skill mix has been monitored from 1st November 2013 and will be included in ongoing reporting to the Board. For November 2013 88% of the 652 shifts monitored had the Registered Nurse complement planned. When there is a shortage of a Registered Nurse, most wards actively replace a Registered Nurse with a permanent and experienced Nursing Assistant or Assistant Practitioner as opposed to obtaining an agency Registered Nurse who may have little experience of the hospital. This is reflected in the percentage of shifts where the number of staff achieved the planned staffing numbers, being 92% for the November shifts monitored. At present this monitoring represents a rudimentary monitoring of numbers agreed in the April 2013 staffing review and does not identify where wards are below numbers for planned reasons, for example, bed closures. There is currently no national benchmark against which to assess Weston’s staffing numbers compliance, however at the Chief Nursing Officer’s November 2013 conference, the Director of Nursing for Salford NHS Trust reported that compliance to planned staffing had been achieved 86% of this time in her Trust.
Staff are encouraged to report nursing staff shortages that could impact on patient care via the Datix system. For April to September 2013 a total of 25 incidents have been reported across 11 ward or department areas.
Table 2 – Number of nurse staffing incidents reported through Datix April 2013-September 2013
Apr
May
Jun
Jul
Aug
Sep
Emergency Department
0
1
Ashcombe Ward
Day Case Unit
Harptree East
3
Harptree Highcare
Harptree West
Hutton Ward
Kewstoke
2
Medical Assessment Unit
5
Steepholm Ward
Waterside
Totals:
6
7
None of these reported incidents led to actual patient harm. A number of the reported incidents above relate to inability to fill shifts when short term sickness occurs and failure of agency staff to attend for booked shifts. As these data relate back to April and May, there are a number of reports for Hartpree/Medical Assessment Unit which occurred before the staffing complement was increased and recruitment complete. Kewstoke Ward staffing was increased in October in response to patient safety concerns related to increased patient dependency. The Nursing Resource Council is monitoring and addressing the number and type of incidents monthly.
The ability of Ward Sisters to retain their supervisory status for the majority of shifts has been monitored since November 2013 with four supervisory shifts for Sisters being converted to direct patient care shifts during the month.
3.2 Nurse Sensitive Outcome Indicators
The nurse sensitive outcome indicators presented in this report cover those areas where nurses will have direct impact on patient outcomes i.e. safety of care and quality of experience. This is information that is collected, reported and addressed on a monthly basis through Divisional governance structures. The overall nurse sensitive indicators are given in the body of the report with individual ward data shown in appendix I.
Table 3 - Nurse Sensitive Outcome Indicators WAHT April 2013-September 2013 with national comparators where available
*Pressure ulcers
WAHT
3.37%
4.42%
2.24%
0.98%
1.90%
1.19%
National
1.33%
1.23%
1.17%
1.16%
1.08%
1.09%
MRSA BSI[2] rate
0%
15.57%
Regional
0.87%
1.26%
0.84%
0.42%
1.30%
C difficile infection rate
15.07%
30.14%
14.76%
18.07%
16.38%
14.28%
15.19%
*Catheter Associated
UTI[3]
2.01%
0.45%
0.48%
0.79%
0.93%
0.96%
0.95%
0.97%
*Falls with harm
5.99%
5.83%
2.44%
1.43%
4.74%
0.01%
Net promoter
62
72
50
70
67
71
Satisfied with nursing care
97.1%
95.6%
84.3%
91.8%
96.6%
96.7%
Treated with dignity and respect
89.2%
96%
91.5%
92.9%
95.7%
94.8%
Complaints
19
11
14
17
21
12
* National Patient Safety Thermometer data which is a prevalence survey completed once a month for all inpatients
The rate of pressure ulcers has been reducing since April 2013 and has continued the decreasing trend after September 2013.
There has been one patient who acquired a hospital MRSA blood stream infection and this was the first case for over 2 ½ years. The rate of C. difficile infection has been above the regional rate in individual months, however, across the six-months the rate for Weston is below the regional average. This is also the case for catheter associated urinary tract infections. There is continued focus on nursing practice to prevent infection with the Infection Control Nurses having a presence on the wards daily.
The falls with harm measure includes patients who may have fallen in the preceding 72 hours which if they occurred in the community are only included if the patient was on a Community Nurse current case load. To ensure that the correct definition is used, close scrutiny of the safety thermometer data is undertaken to validate this figure as it was identified in April and June that cases were reported that do not meet this definition.
The Net Promoter score is the test of whether patients would recommend the Trust to their friends or family. In the commercial sector it is used as a test of brand loyalty with any positive score being considered good and a score of 50+ being considered excellent. The Net Promoter for individual wards is reviewed monthly and work undertaken with individual wards where needed. As part of the patient feedback cards satisfaction with nursing care and being treated with dignity and respect are surveyed alongside the Net Promoter score. Overall satisfaction with nursing care and privacy and dignity is acceptable, although improvements are still being made in these areas. The complaints number given above includes those complaints where nursing care was mentioned. Each complaint is individually investigated and the feedback and actions approved by the Head of Nursing.
4 Methodology for Reviewing Staffing Levels
The workforce metrics and nurse sensitive outcome indicators were used alongside the professional judgement of Ward Sisters, Matrons, Heads of Nursing and Director of Nursing as the primary tool for this six month review. This was augmented by a proactive assessment of acuity and dependency of patients in August and September 2013 using the national recommended Safer Nursing Care Tool and application of the Skills for Health Nursing Workforce planning tool. These latter tools were used to benchmark professional judgement.
Table 4 sets out the results of the three methodologies for each ward area with comparison to the 2013/14 staffing numbers.
Table 4 – outcome of six-month nurse staffing review WAHT September 2013
Ward
Beds
2013/14 (WTE)
Skills for Health (WTE)
Safer Nursing Care Tool (WTE)
Berrow
28
36.36
33.10
49.70
31.96
30.20
36.58
Stroke
20
25.07
21.40
28.56
Uphill
24
25.90
25.74
Rehabilitation
27.22
33.80
23.80
Medical Admission Unit
27
41.56
40.20
35.00
Harptree
36.55
33.60
N/A
Cheddar
25.97
26.70
23.55
Hutton
32.86
34.30
34.93
Steepholm
22
30.27
28.00
22.72
12.99
17.10
13.27
Based on professional judgement, the following changes have been made to nursing establishments since April 2013:
Winter funding has also enabled the appointment of additional Ward Clerks and Patient Flow facilitators to support non-clinical delivery of care, releasing more time for direct care by existing nursing staff until end of March 2014.
5 Benchmarking
Table 5 demonstrates the position against recommendations for skill mix of 60/40, Registered Nurse to patients of 1:7 for day-time shifts and nurse to patient ratio of 1:3.8 for days and nights[4] for the six months April to October 2013 and the planned staffing to end of March 2014.
Table 5 – Compliance to recommended skill mix and Registered Nurse to patient ratio In-patient wards Weston General Hospital agreed staffing 2013/14 (benchmark given in brackets)
Skill mix (60% Registered Nurses days)
RN to patient ratio (1:7 days)
Nurse to patient ratio (1:3.8 days and nights)
Early
Late
Night
Apr-Sept
50%
1:7
1:9.3
1:3.5
1:4.6
Current
38%
40%
1:14
1:4.7
1:5.6
60%
1:6.7
1:10
1:3.3
1:4
1:5
Rehabilitation*
(Rowan)
33%
67%
1:12
1:4.8
Extra capacity*
(Uphill)
43%
1:8
1:3.4
1:6
75%
71%
1:4.5
1:5.4
1:3.9
63%
1:3.6
Harptree and High Care
62%
66%
1:6.8
1:7.3
100%
1:3
* Rehabilitation ward and fit for discharge wards with lower nurse to bed and Registered Nurse requirements than general wards
Although some wards are below the 60% skill mix benchmark, the majority of wards are achieving the 1:7 Registered Nurse to patient ratio recommended by the Royal College of Nursing. In addition, the Ward Sister is present in the day Monday to Friday and is not included in these numbers.
The NHS Trust Development Authority dashboard enables benchmarking against a cohort of Trusts that are classified as small acute Trusts. Table 6 below shows the number of WTE nurses and beds and gives a ratio of nurses to beds for the year from September 2012 to August 2013. This benchmarking demonstrates that WAHT is mid-range in nurses to bed ratio.
Table 6 – Nurse benchmarking data from NHS Trust Development Authority Dashboard for small acute Trusts (September 2012 to August 2013)
Trust
WTE nurses
Nurses to bed ratio
Trust A (FT)
438
370
1.18
Trust B
448
324
1.38
Trust C
572
364
1.57
Trust D FT
534
335
1.60
Weston Area Health Trust
359
223
1.63
Trust E FT
597
995
1.67
Trust F
813
427
1.91
Trust G FT
678
336
2.02
Trust H
837
410
2.04
6 Emergency Department[5] Staffing Review
Validated tools to review Emergency Department staffing are not currently available. The review of staffing in this unit was carried out using professional judgement of the Matron, supported by the input of a local Nurse Consultant Emergency Care. Staffing changes have been implemented in acknowledgement of the Royal College of Paediatrics and Child Health review, and to address changes in patient pathways, designed to improve efficiency and experience for emergency patients.
The following changes have been made in the Emergency Department staffing based on the review and effective use of winter planning funding:
7 Summary and Next Steps
The investment in nurse staffing and subsequent recruitment activity has supported improvements in patient care and has reduced the overall requirement for temporary staff, particularly agency staff. Nurse sensitive outcome indicators demonstrate that progress has been made to improve patient care, with further improvement still needed to align Trust performance to better than the national average. The Care Quality Commission has confirmed that the Trust is meeting their standard for staffing at a visit in November 2013. The six-month review of nurse staffing was carried out in line with the November 2013 recommendations of the National Quality Board. This review demonstrated that in most areas, the nurse staffing plans for 2013/14 met the patient acuity and dependency needs. There were some areas where staffing changes were indicated, and these have been implemented where current budgets supported the changes, or where patient safety and quality of care was demonstrably compromised. The ward skill mix and nurse to patient ratios are broadly in line with recommended practice, and benchmarking against small acute Trusts has shown the Nurses to bed ratio to be around the midline. Changes have been made to the Emergency Department staffing to reflect a changed patient pathway and to provide additional paediatric cover.
The following actions will be taken to ensure a continued high level of management of nurse staffing:
8 Recommendations
The Board is recommended to:
Appendix I
Nurse Staffing Metrics and Nurse Sensitive Outcome Indicators by Ward
Apr-13
May-13
Jun-13
Jul-13
Aug-13
Sep-13
Vacancies
-22.39%
-16.75%
-18.86%
-16.01%
-13.59%
-14.06%
Sickness
1.51%
0.00%
0.69%
2.06%
4.35%
3.75%
Bank use Expenditure - In month £'000
13.77
15.53
18.55
19.79
17.51
13.35
Agency use - In month £'000
12.16
5.46
9.25
12.87
23.91
15.11
Unsafe staffing reports
New Pressure ulcers
Catheter associated urinary tract infections
Falls causing significant harm
MRSA and C diff
Serious incidents
57
40
-24.90%
-18.65%
-18.80%
-16.16%
-5.60%
-8.14%
8.13%
5.30%
3.63%
1.63%
1.73%
14.27
18.51
18.39
19.30
15.34
14.48
17.96
7.86
18.65
19.16
43.08
7.32
43
46
44
36
48
54.37
50.59
45.13
41.70
31.85
48.41
34.40
20.95
19.28
19.24
30.68
27.43
4
86
74
Stroke Unit
-4.63%
-1.34%
1.49%
1.55%
1.32%
1.50%
3.45
3.24
3.64
5.84
5.92
2.99
3.35
5.52
3.07
4.23
7.16
4.22
MAU Harptree West
-22.43%
-20.11%
-19.99%
-7.00%
-5.27%
9.76%
10.63%
14.67%
10.78%
11.42%
0.24
12.37
21.17
28.57
28.99
24.16
63.73
19.64
32.60
56.98
38.45
63
68
Harptree East and High Care
-18.89%
-15.27%
-12.64%
-9.34%
-7.63%
-10.70%
9.60%
5.86%
5.07%
1.37%
1.01%
0.53%
39.05
16.36
11.83
17.80
18.32
15.49
0.00
36.87
25.64
16.88
21.25
9.19
56
47
54
-23.62%
-14.20%
-13.86%
-11.07%
-5.49%
-13.43%
4.53%
6.49%
1.99%
7.22%
3.98%
3.65%
17.13
11.01
12.91
16.68
13.60
6.68
6.98
3.00
4.40
7.12
9.21
81
89
88
100
Cheddar Ward
-13.74%
-11.59%
-7.70%
-1.50%
-7.77%
7.50%
0.40%
8.06%
7.41%
6.20%
12.84
13.83
8.68
12.63
11.03
6.94
2.81
5.85
6.42
10.34
8
83
82
33
-20.72%
-12.62%
-9.45%
-13.91%
-10.61%
-11.25%
2.31%
8.77%
1.07%
2.60%
2.67%
11.22
15.74
14.40
11.30
14.55
13.90
9.26
1.85
15.69
22.58
16.87
73
59
Waterside Suite
9.69%
5.56%
-6.43%
-3.40%
-12.88%
3.12%
5.37%
9.51%
1.69%
1.14%
6.35
2.55
4.98
6.86
6.90
4.10
4.73
1.35
0.44
1.75
5.93
2.15
41
92
ITU
-9.32%
-8.81%
-7.71%
-6.59%
-5.78%
4.49%
3.82%
8.66%
7.33%
7.55%
6.31%
1.07
3.53
3.59
3.96
6.10
7.73
1.98
1.23
1.24
Rowan Rehab Unit
-26.97%
-28.10%
-25.44%
-19.24%
-14.63%
-19.11%
5.51%
4.72%
7.21%
3.11%
4.68%
9.54
10.21
8.45
8.10
3.33
3.89
7.27
8.28
13.21
5.15
3.87
5.38
60
78
[1] For the purpose of this paper, the term nursing is used to denote nurses, midwives and care staff
[2] Blood Stream Infection
[3] Catheter associated urinary tract infections
[4] Royal College of Nursing (2006) Setting Appropriate Ward Nurse Staffing Levels in NHS Acute Trusts; Royal College of Nursing (2010) Safe staffing for older people’s wards; George Alberti (2009) Mid Staffordshire NHS Foundation Trust: A review of procedures for emergency admissions and treatment.
[5] Department includes the Ambulatory Care Centre