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PART
AGENDA ITEM
PAPER
Title of Board paper
and link to specific
Nursing staffing review
corporate objective
Board meeting date 19th December 2103
Purpose
The purpose of this paper is to appraise the Board of Directors on the
current nurse staffing on the wards at UHSM and the future assurance
plans in relation to nurse staffing
Actions
Recommended
Discussion / Noting / Decision
Publication
This paper will be published in line with the UHSM Publication Scheme,
subject to redactions approved by the Board, within 3 weeks of the
meeting: http://www.uhsm.nhs.uk/AboutUs/Pages/ExecDirectors.aspx
Unusual acronyms
NCQ - National Quality Board
NICE - National Institute for Health Care and Excellence
HSMRs - Higher Hospital Standardized Mortality Ratios
AUKUH - Association United Kingdom University Hospitals
CQC – Care Quality Commission
Communications /
actions after the
meeting
Communication plan is outlined within the report
Report of
Chief Nurse
Paper prepared by
Deputy Chief Nurse
1. Introduction
1.1 The issue of whether there are sufficient nurses and midwives with the right skills has
been a topic of debate for decades. The intensity of the discussion has increased
recently following the publication of several high profile reports relating to quality and
patient safety: Francis, Keogh and Berwick and accumulating with the very recent
staffing guidance: ‘How to ensure the right people, with the right skills, are in the right
place at the right time’, (Chief Nursing Officer for England & National Quality Board
(NQB), November 2013). All these recent reports have led to both heightened public
awareness and greater media exposure relating to nurse staffing levels within ward
areas.
1.2 The Safer Staffing Alliance (senior national nursing and expert leads) have also
gathered evidence following the above recent reports and shown a direct link between
numbers of registered nurses and the quality of the care delivered to patients. The Safer
Staffing Alliance shows that the staffing ratio of one registered nurse to eight patients
(excluding the nurse in charge) is the level below which there is a significant risk of
harm. For example, a 24-bed ward must have at least three registered nurses on duty
plus a nurse in charge, and be supported by healthcare assistants. This does not
guarantee good care but anything less is known to increase the risk of poor care and
constitutes a safety hazard. In Prof. Sir Bruce Keogh’s review of 14 hospitals with
elevated mortality rates, he found a positive correlation between inpatient to staff ratios
and higher hospital standardized mortality ratios. (HSMRs)
1.3 There is no ‘one size fits all’ approach to establishing safe staffing capacity and
capability and the national guidance did not recommend a minimum staff to patient ratio
level. The review of staffing establishments are complex and any method of determine
staffing has limitations. Triangulation of methods are noted to be the best and therefore
we aim to use both an evidence based tool to determine safe staffing levels, with staff to
patient ratios and professional judgment.
2. Chief Nursing Officer for England & the National Quality Board guidance
(November 2013)
2.1 ‘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, describes
the established evidence and links between patient outcomes and whether
organizations have the right people, with the right skills in the right place and the right
time. This guidance sets out ten expectations relating to nursing, midwifery and care
staffing capacity and capability. This paper will briefly detail each expectation and
describe how the Chief Nurse, senior nursing team and Board of Directors will support
and action each expectation.
2.2 In the longer term, the guidance will be built upon by the work of National Institute for
Health and Care Excellence (NICE) who are reviewing nurse staffing with the aim of
establishing a senior committee in early 2014 and accrediting tools to support staffing
capacity and capacity. The expectations described in the Chief Nursing Officer for
England & National Quality Board report and ‘Hard Truths’ are to be achieved by April
2014.
3. Expectations
3.1 Accountability & Responsibility
Expectation 1: Boards take full responsibility for the quality of care provided to
patients, and as key determinant of quality, take full and collective responsibility for
nursing, midwifery and care staffing capacity and capability.
Action: The Board at UHSM will receive and monitor staffing capacity and capability
through regular and frequent reports on the actual staff on duty on a shift to shift basis,
versus planned staffing levels. The Board will receive a ‘staffing paper’ in the format on
Appendix One as detailed in the Chief Nursing Officer for England & National Quality
Board report and the staffing paper will also be published on the external intranet.
The Board of Directors will receive comprehensive staffing reviews twice a year and
monthly staffing reports considering actual staff on shifts monthly. Information and erostering systems will be required to support the monthly staffing reports. The roles and
responsibilities to the Board of Directors, Executive Team and senior nursing and
management team in relation to this expectation has been set out by the Chief Nursing
Officer for England & National Quality Board report. These will be circulated and
awareness sessions set up for the senior nursing team.
Lead: Deputy Chief Nurse.
Expectation 2: Processes are in place to enable staffing establishment to be met on a
shift-to shift basis.
Action: A daily Safe Staffing Huddle will take place from January 2014 every morning.
This Safe Staffing Huddle will comprise of a senior nurse representative (Matron or
above) from each of the Divisions and a senior nurse lead (Head of Nursing and / or
Deputy Chief Nurse). At the weekends this will be carried out by the Site Coordinator.
Full site staffing concerns will be discussed and addressed via actions at this huddle
and ‘actual’ staffing numbers reported. Where shortages are identified, the teams will
work together to seek a solution such as pooling of staff from other clinical areas or the
deployment of locum staff. A daily rota of senior staff attendance at this huddle will be
complied as will daily Divisional staffing rotas. Further safe staffing issues will be
discussed at the Bed Meetings throughout the 24 hour period as required. An escalation
procedure will be developed to support the clinical teams.
Lead: Interim Head of Nursing for Clinical Support Services & Deputy Chief Nurse.
A fully implemented e-rostering system will be required to support the above action,
however in the interim a paper based system will need to be used.
3.2 Evidence based decision making
Expectation 3: Evidenced-based tools are used to inform nursing, midwifery and are
staffing and capability.
Action: The AUKUH (Association United Kingdom University Hospitals) Acuity and
Dependency tool will be used to inform the evidence based decision making on safe
staffing at UHSM. The AUKUH tool is based upon the classification of levels of care of
critical care patients which have been adapted to support measurement across a range
of wards and specialties. AUKUH tool was applied to all ward staffing in 2011.
A full and comprehensive review and data collection is planned for March 2014 and
October 2104 which will be reported to the Board of Directors and Public Board. This is
a large scale project in which data is collected over a number of weeks and at different
times in the day. The project will be managed by the Matron for Quality and overseen by
the Deputy Chief Nurse. A review of the current staffing establishments took place in
the first week of December which can be seen in Appendix Two and is based on both
professional judgment and the acuity review of 2012. This review shows one area
within Scheduled Care and seven areas within Unscheduled Care where the
establishment does not support the basic patient to staff ratio. Immediate actions have
been taken which include review of potential staff that can move to long days to support
increased establishment and the use of bank staffing to ensure safe staffing levels. The
Matrons visit the wards daily to review staffing levels and discuss with the Heads of
Nursing for both areas daily. There are no areas of staffing concern within Clinical
Support Services.
Maternity Staffing ratios
New guidance related to Birth Rate plus was released in November 2014 and the Head of
Midwifery is currently working through this guidance. Staffing levels within the maternity
services are calculated following The Royal College of midwives Guidance Paper No 7
(May 2009) incorporating the Birthrate Plus® workforce tool (Ball JA, Washbrook M, 1996).
The guidance advises an overall staffing ration of 1:28 midwives to births which was
adopted as a standard by the Making It Better Manchester Re-configuration of Maternity
Services and Healthier Together.
The maternity unit is currently maintaining staffing levels at 1:28.7 exclusive of post
vacancies. Ratios are monitored by the Directorate on a monthly basis and form part of the
Maternity Dashboard.
A revised guidance document ‘Working with Birthrate Plus®’ (Ball JA, Washbrook M, 2013)
published in December 2013 is currently under review by the Directorate and will inform
future midwife to birth calculations.
Neonatal Staffing
Neonatal nurse staffing is calculated following British Association of Perinatal Medicine
Guidance (BAPM 3rd Edition, August 2012) based on the acuity of cots (Intensive Care,
High Dependency Care and Special Care). The Unit is compliant with BAPM standards for
commissioned Level 2 cots.
Lead: Deputy Chief Nurse, Head of Midwifery, Head of Nursing for Scheduled Care &
Matron for Quality.
3.3 Supporting and fostering a professional environment
Expectation 4: Clinical and managerial leaders foster a culture of professional and
responsiveness, where staff feel able to raise concerns. Staff work in well structured
teams and can practice effectively through the supporting infrastructure of the
organization i.e. IT, Ward Clerks and Housekeepers.
Action: The Staffing Escalation procedure is currently being developed in tandem with
the Safe Staffing Huddle and will be fully implemented in January 2014. The ward staff
are aware of the interim solution which is immediate escalation to the Matron and Site
Coordinator out of hours. As part of the implementation of the Ward Accreditation team,
(pilot April 2014) part of the assessment criteria will be based upon a ‘well structured
team’.
Lead for Staffing Escalation Process: Head of Nursing for Unscheduled Care & Deputy
Chief Nurse.
Expectation 5: A multi professional approach is taken when setting nurse staffing,
midwifery and care staffing establishments.
Action: As noted within in Expectation one, Action.
Expectation 6: Nurses, midwives and care staff have sufficient time to fulfill
responsibilities that are additional to their direct caring duties including the supervisory
status of the Ward Manager. This expectation also sits within the ‘Hard Truths’ Report.
(2013) which states:
Ward nurse managers should operate in a supervisory capacity, and not be office-bound or
expected to double up, except in emergencies as part of the nursing provision on the ward.
They should know about the care plans relating to every patient on his or her ward. They
should make themselves visible to patients and staff alike, and be available to discuss
concerns with all, including relatives. Critically, they should work alongside staff as a role
model and mentor, developing clinical competencies and leadership skills within the team.
As a corollary, they would monitor performance and deliver training and/or feedback as
appropriate, including a robust annual appraisal.
Action: A review of each Ward Managers supervisory capacity has taken place in
December 2013 which can be seen in Appendix Two. All Ward Managers have two
days as ‘supervisory’ which is of supernumerary status. (out of the shift numbers) A
further review to consider the specialty need and Ward Manager supervisory
requirements will take place in January 2014. A review of hospital members of the
AUKUH revealed that on average Ward Managers are supervisory between 3-5 days
often dependant on specialty. There may be some possibilities of increasing a small
percentage of wards within challenging areas (elderly care and complex health) with
review of long day shift status. The minimum time set for supervisory status of Ward
Managers according to Chief Nursing Officer for England & National Quality Board
report is two days per week and all wards at UHSM meet this minimum standard.
Lead: Head of Nursing for Unscheduled Care.
3.4 Openness and Transparency
Expectation 7: Boards receive monthly updates on workforce information, and staffing
capacity and capability is discussed at a pubic Board meeting at least every six months
on the basis of a full nursing and midwifery review.
Action: As described in Expectations One, the information presented to the Board of
Directors will include the number of actual staff on duty during the previous month,
compared to the planned staffing level and reasons for any gaps, including actions
taken to address the gaps. An electronic system will be required to support this
expectation. A template for Staffing Board papers can be seen in Appendix One.
Lead: Deputy Chief Nurse.
Expectation 8: NHS providers clearly display information about the nurses, midwifes
and care staff present on each ward, clinical setting, department or service on each
shift.
Action: A group has been set up which is led by the HoN for Scheduled Care and
Patient Experience Matron to discuss with staff and patients how best to represent
registered and unregistered staff on the wards. A mock board is being produced which
will be piloted to ensure patients can understand the ‘actual’ staff recorded plotted
beside should have (base establishment for the shift). Each ward will have a board and
a number of wards across different specialties will pilot the board in January 2014. In
addition as part of the Hard Truths recommendations all individual bedside areas /
behind the bed area will have details of the consultant in charge of the patients care and
the nurse name caring for the patient on each shift. This expectation also forms part of
the Open and Honest (former Transparency) Project that the Trust is part of.
Lead: Head of Nursing for Scheduled Care and Patient Experience Matron.
3.5 Planning for future workforce requirements
Expectation 9: Providers of NHS Services take an active role in securing staff in line
with their workforce requirements.
Action: A comprehensive recruitment strategy is being developed and an immediate
action plan in place.
Lead: OD Business Partner (Talent & resourcing), HoN’s and Deputy Chief Nurse.
3.6 The role of commissioning
Expectation 10: Commissioners actively seek assurance that the right people, with the
right skills, are in the right place at the right time within the providers with whom they
contract.
Action: The Deputy Chief Nurse will brief the Commissioning team regarding staffing via
the established Quality Monitoring Meetings in place.
Lead: Deputy Chief Nurse.
4. Update on Care Quality Commission (CQC) and Monitor in relation to staffing
4.1 Care Quality Commission
The CQC is currently developing a new approach to monitoring, inspecting and rating
providers. Staffing capacity and capability will be central to this new approach and the
expectations set out in the Chief Nursing Officer for England & National Quality Board
report will be used to inform the development of their new approach to inspections, and
subsequently, to inform their judgements and ratings. Three recent published inspection
reports available on the CQC website note the full review of staffing at hospital inspections.
4.2 Monitor
Monitor expects that NHS foundation trusts should have the right people, with the right
skills, in the right place at the right time. Monitor will act where the CQC identifies any
deficiencies in staffing levels for foundation trusts.
5. Conclusions
5.1 The work steams described above will be overseen by the Chief Nurse and led by the
Deputy Chief Nurse. Further staffing work streams resulting from the Recovery
Programme relating to implementation of the 12 hour shift which will liberate time from
baseline ward establishments will be linked into this programme of work to ensure safe
staffing across the organization. In addition, the ideal skill mix on older peoples ward
should aim to meet the RCN recommendations never exceeding 1:7 and the Head of
Nursing for Unscheduled Care is leading on this pieced of work in conjunction with the
review of 12 hour shifts across elderly and complex care.
5.2 This paper will be discussed at the Operational Board, Professional Forum and Matrons
meeting. The paper and actions will also be discussed through the divisional structures.
Actions will be monitored via the Professional Nursing & Midwifery Forum.
6. Recommendations
6.1 The Board of Directors are requested to: 

Note the expectations of the Chief Nursing Officer for England & National Quality Board
Report, November 2013, and
agree the current staffing levels and plan to increase the establishments on eight wards
and further actions to support full implementation of the Nursing Officer for England &
National Quality Board Report.
Deputy Chief Nurse
12/12/13
Appendix One
Papers to the Board on establishment reviews should aim to be relevant to all wards and
cover the following points:
 the difference between current establishment and recommendations following the
use of evidence based tool(s) (further detail provided under expectation 3);
 what allowance has been made in establishments for planned and unplanned
leave (further detail provided under expectation 6);
 demonstration of the use evidence based tool(s) (further detail provided under
expectation 3);
 details of any element of supervisory allowance that is included in establishments
for the lead sister / charge nurse or equivalent (further detail provided under
expectation 6);
 evidence of triangulation between the use of tools and professional judgement
and scrutiny (further detail provided under expectation 3);
 the skill mix ratio before the review, and recommendations for after the review
(further detail provided under expectation 3);
 details of any plans to finance any additional staff required (further detail provided
under expectation 9)
 the difference between the current staff in post and current establishment and
details of how this gap is being covered and resourced;
 details of workforce metrics - for example data on vacancies (short and long-term),
sickness / absence, staff turnover, use of temporary staffing solutions (split by
bank / agency / extra hours and over-time); and
 information against key quality and outcome measures - for example, data on:
safety thermometer or equivalent for non-acute settings, serious incidents,
healthcare associated infections (HCAIs), complaints, patient experience /
satisfaction and staff experience / satisfaction.
The paper should make clear recommendations to the Board, which would be
considered and discussed at a public Board meeting. Actions agreed by the Board should
be detailed in the minutes of the meeting, and evidence of sustained improvements