2 nd Global Nursing Management & Innovation forum: Berlin, Germany March 9 - 10, 2017 How to deal with the main challenges in Nursing recruitment: A practical case study Noel Scanlon Executive Director of Nursing County Durham & Darlington National Health Service Foundation Trust, UK www. cddft. nhs. uk
Objectives Workforce planning, Nursing shortages, increased demand for nursing services cost containment for temporary nursing labour – a perfect storm Nursing shortage: how to recruit into nursing profession? Nursing retention and better working conditions: What do we do to keep our nurses? Career possibilities for nurses Reward systems for nurses around the globe Protection of Nurses www. cddft. nhs. uk
Welcome to Co. Durham & Darlington NHS Foundation Trust, UK
Where is County Durham, in North East England County Durham www. cddft. nhs. uk
Offering the best care possible to the citizens of County Durham A large rural county in the North East of England The largest integrated Care provider in the North East Strong competition to recruit nurses and midwives from major tertiary care providers in larger cities on the coast Training schools are all beyond the County boundaries www. cddft. nhs. uk
County Durham & Darlington NHS Foundation Trust • Operates from 8 Hospital sites • • 2 Acute secondary hospitals, 800 beds 1 elective and Elderly care centre 5 Community hospitals, 120 beds 81 District Nurse bases 5 Urgent care centres 2 Emergency departments 2 Maternity departments • serving the needs of 650, 000 people • Providing services in hospitals, in the community and in people’s homes • This year is our 10 th anniversary as a Foundation Trust
County Durham & Darlington NHS Foundation Trust 7000 staff 3750 Nurses, Midwives, Health visitors & Support workers 2950 Registered Nurses, Midwives, Health visitors www. cddft. nhs. uk
Background of ill health and underlying deprivation v 23% 4 -5 year olds have excess weight – that’s over 1, 300 children (43 classrooms). v Just under one in ten (9. 3%) of County Durham children at reception are obese v 36% 10 -11 year olds have excess weight – that’s over 1, 800 children (60 classrooms) v Around one in five (21. 4%) of County Durham children at Year 6 are obese v 69% of adults are estimated to be of excess weight v Industrial diseases. An increasing number of patients now have diseases from working in industries such as Durham Mines, v Chronic obstructive airways disease v diseases related to high asbestos exposure. www. cddft. nhs. uk
You still don’t know where County Durham is ? Hogwarts in Harry Potter and the Philosophers Stone and Chamber of Secrets – Durham Cathedral www. cddft. nhs. uk Billy Elliot’s home in Billy Elliot – Easington Colliery in County Durham.
And the home of … Stan Laurel of Laurel and Hardy – lived in Bishop Auckland during childhood www. cddft. nhs. uk Rowan Atkinson – Mr Bean – attended school in Durham for 2 years Sir Anthony Eden – British Prime Minister 1955 -1957 – born in Bishop Auckland
A perfect storm Global shortages of registered Nurses 20, 000 Nursing posts unfilled in UK Static commissions for Pre Registration Nursing places At a time of increased demand for Registered Nursing labour Scandals at Mid Staffordshire, Maidstone & Tunbridge Wells, other places The real value of Nursing exposed where it has been least valued and patients suffered greatly as a consequence Mandatory monitoring of Staffing levels in UK Statutory controls in some parts of Australia, US Depressed Health care spend precipitated by the Banking crisis and reduced investment in public services Consequent downward pressure on Nursing costs especially temporary staff who fill the gap and reductions in Spending on Nursing education www. cddft. nhs. uk
Retention of Staff 2 way communication flexible working via the staff bank good preceptorship managers are approachable Exit Questionnaires & Interviews better still pre Exit intelligence Pro-active redeployment - Career all here Developing our current staff www. cddft. nhs. uk a Talent Management Framework Developing Valuing Diversity busy well supported cross site working rotation of staff Staff Involvement & Engagement Compassion Simulation training Shared governance Decision making Learning in action Awards & Reward schemes development opportunities Flexible Careers retirees post Maternity leave Students / Volunteers / Work Experience excellent support staff are friendly Developing a Flexible Workforce Flexible Working Temporary Workforce team working Corporate Retention Strategy
Protection of staff All nurses are protected by vicarious liability of the NHS trust which employs them All are required to take professional indemnity insurance as a condition for professional revalidation Standards of training and Clinical governance procedures and policies are such that medical errors are very rare if staff operate within their scope of practice and institutional policies Nursing Staff thus feel protected and are very rarely litigated against www. cddft. nhs. uk Employer sanctions tend toward retraining and supervision Dismissal and Referrals to the statutory body are extremely rare and tend toward individuals who are ill, momentarily reckless or who have failed to respond to management strategies over a prolonged period Result : Nurses take legal and professional protection by their employer and trade union for granted Retention is therefore relatively high and a sense of loyalty reciprocated
Improving the experience of Staff Improving the Staff Experience Self / Fair rostering Child care Flexible working Improve working conditions Environment Safety Stress European working time directive Staff Health and Well-being Gym, Occupational Health Weight watchers Mandatory, Statutory training & CPD Pay and conditions London weighting / premia by region Staff Non-Pay Benefits Car lease, Salary sacrifice – Bicycle, Computer, I-Pad Overseas recruits – free wi-fi Accommodation - Subsidised housing Developing Corporate Induction; Strategies for professional groups www. cddft. nhs. uk Delivery and Review
Enhancing the context for recruitment • • Retention activity Preceptorship – Internship, rotational posts – Nurse apprenticeship schemes – Job guarantees – Learning environment • Mentorship Internship – Temporary staffing / Agency / In house bank – Pay – Flexibility & Security Contextual factors – Accommodation – Transport links – Careers advice • Links with careers service, job centres • Website, Journals, Advertising • Careers material www. cddft. nhs. uk
Improving the recruitment process • Recruitment process – Application forms and literature on all wards and depts. – Recruit bank & agency staff to substantive contract – Job fairs – Recruitment events – Human resource (HR) process fill posts quickly • transparency • feedback loop to staff • regular policing points • agreed standard of HR performance, service compliance with time frames • Job descriptions, Advertisement text, Person specification – Innovative Recruitment Solutions – Improving the way we advertise – Targeted Recruitment Campaigns • Speciality specific – Understand labour market - Match it to your needs • hard to recruit / premium areas – Theatres, Emergency, Critical care – Paediatrics, Medicine, Older person care www. cddft. nhs. uk
Marketing the institution, building partnerships • • Attraction Strategy Develop the organisation as a socially inclusive employer Engaging the Local Community / labour market Engaging with Academic Institutions – Support worker Secondment to Nursing/Midwifery Degrees – Foundation Degrees • Access to Pre Registration programmes • Appenticeships – Get to ultimate and freshers years early – Integrate with university modules – All undergraduates are guaranteed a job – Graduate recruitment bureau plans September for January • Return to Practice – – • HENE RTP project- pilot site expand commissions Salary candidates Nurse refresher courses Better personal and pastoral support Student District Nurses and Health Visitors www. cddft. nhs. uk
Alternatives to local recruitment Italy 80 RNs notwithstanding IELTs, Language tuition Longer lead time to registration On boarding much quicker Hiring into RN vacancies at Band 3 Business case to Board July 27 Saving £ 580, 000 Philippines 15 -30 Theatres & Anaesthetic nurses notwithstanding IELTs, Language tuition as above NMC OSCE in Northampton 65% pass rate, 6 mo. re sit Salary thresholds immigration rules Migration levy Saving £ 100, 000 -200, 000 Elimination of locum Theatre technicians Division to work up business case Self funded / Trust funded bursary programmes Open University Teesside University Sunderland own School of Nursing model www. cddft. nhs. uk
Language support is essential, especially the patients • These nurses from Italy try to speak ‘Geordie’. • http: //www. chroniclelive. co. uk/news/north-east-news/watchitalian-nurses-trying-out-10944283 • All are screened in Italy • Subject to rigorous selection • Receive enhanced Induction • Social programme • Clinical practice acclimatisation • Language programme – 60 -120 hours - IELTs examination in country • Employed as support workers until they retain registration www. cddft. nhs. uk
Outcomes Taking account of recruitment under process 277 RN vacancies of which 163 under process 114 active RN vacancies 138 HCA vacancies of which 64 under process 74 active HCA vacancies Taking account of attrition (10. 7% turnover) our Vacancy rate overall is likely to remain unchanged at around 10% 30 -50 new graduates from Teeside University joined us in September 2016 and January 2017 Commissions for 2017/8 mean that we will have 50% more students on placement in 2017/18 than the Sept. 2016 intake ‘Brexit’ depressed interest but it has recovered Of the 80 Italian nurses on staff only 2 have returned home – sickness & bereavement – www. cddft. nhs. uk trust none have left the
Bank & Agency control plan 1. Retention of Staff 2. Enhancing the context for recruitment 3. Managing Nursing costs within available resources 4. Bank and Agency Nursing 5. Managing Demand Improving Efficiency 6. Assuring the Quality of Care 7. Keeping Costs Under Control 8. Monitoring outcomes 9. The Way Forward www. cddft. nhs. uk
Bank and Agency Nursing • Bank and agency nursing staff make an enormous contribution to patient care in the NHS, enabling trusts to maintain service delivery by – covering for staffing shortfalls and fluctuating workloads. • Major driver - Vacancies • Long term sickness – “HR process panders to game playing malingerers “ – Sickness policy fir for purpose » effectivess varies upon individual HR officer • • Maternity leave Cohorting / specialling vulnerable / at risk patients Preceptorship Unfunded activity – esp. out of hours – But there are concerns about the effects on patient care and rapidly rising costs. www. cddft. nhs. uk
Managing Nursing costs within available resources • Ward Srs should have the responsibility and authority to manage their resources effectively – Training – An appropriately structured budget – Matching the budget to the establishment – 'headroom' to cover sickness, annual leave and (NMC) required training (statutory, mandatory & CPD) – Backfill for Maternity leave – Discipline around roster management • Roster matches establishment – Real time monitoring of safe staffing levels • Three times a day www. cddft. nhs. uk
Managing Demand Improving Efficiency • • We should take action to stop any unnecessary use of bank and agency staff – improved recruitment processes • Recruitment plan for every vacancy • Monitored by Division & Nurse executive – better retention of experienced and newly qualified staff – fairer, more consistent rostering – electronic weighted fair request process and to minimise the time clinicians spend arranging cover. • Paperless E-Rostering • Technology to reassign staff in real time • timely, appropriate and effective escalation to Bank, Agency • Escalation process for authorisation by Ward Sr. , Matron, (Lead Nurse) Associate Director of Nursing, Exec Director of Nursing • Explicit Booking process within roster identifying clear reconciliation to both unmet supply and invoicing for payment This means having effective Management controls and Policy Adherence – Management supervision – Control, Support & Educate – Feedback and sanction A modern temporary staffing service that makes best use of information technology. – Staff Bank lead to book all temporary staff use – Disincentivised to use Agencies www. cddft. nhs. uk
Keeping Costs Under Control We reduced our expenditure on agency staff through improved contracting and by working in partnership. neighbouring trusts, NHS Supplies, procurement partners Create preferred provider / reduce number of framework agencies squeezed out higher cost suppliers understood relationship between rate of pay Controlled price reductions and Controls on commissions i. e. not about the nurse Nurture migrate to framework agencies mid cost framework agencies In-house Staff Bank auto-enrol permanent staff 'Grey bank' retire & return competitive rates of pay compete with agencies Consider moratorium on use of agency staff for HCAs from October 1, 2016 for RNs from January 1, 2017 subject to Bank being built up www. cddft. nhs. uk Vacancies being filled
Results: Bank & Agency cost trends www. cddft. nhs. uk
Bank & Agency cost trends December Bank Fill rate was 81% Agency shifts – less than 100 per week - approx. 80% fill rate by De Poel (our new neutral vendor) all General nurse bookings are now under Agency cap – Operating theatres is an outlier HCA agency bookings reduced to 20 per week, almost all short-term sickness and specialing overnight / at weekends Reduce Bank rates of pay to £ 19/h wef Feb. 1 tempered by introduction of a weekly payroll for Erostered areas Reduce Theatre agency rates by £ 10/h to £ 29/h wef Feb. 1 www. cddft. nhs. uk
Temporary staffing outcomes Nursing and HCAs: Demand for RN bookings has fallen by around 30% Bank Fill rate > 75% Agency shifts – approx. 80% filled by Neutral vendor / broker between NHS and agencies HCA agency bookings reduced to < 20 per week, almost all short-term sickness and specialing overnight / at weekends Italian nurses – 80 appointments Around 500 HCAs on the staff bank Over 1000 RNs, mainly Trust staff but over 100 from elsewhere www. cddft. nhs. uk
Monitoring Ward staffing levels – real time & monthly to board and Do. H Overall fill rates exceed safe thresholds High levels of substitution HCA for RNs Hot spot areas for Registered nurse day duty fill rates Stroke, Rehab. Orthopaedic Critical care Respiratory, Acute Medical assessment Emergency departments www. cddft. nhs. uk
Monitoring outcomes for patients • • Patient safety Patient experience Harm events Mandatory incident reporting of understaffing • Impacts upon – Staff sickness – Stress, Turnover, Retention – Error events • • • Medication Hand hygiene Infection rates Pressure ulcers Falls www. cddft. nhs. uk
Career possibilities for nurses Reward systems for nurses around the globe Nursing still provides an enriching career with clear opportunities for advancement irrespective of background Good career prospects Relatively good salary in Europe where Nursing shortages dictate demand for skilled labour Opportunities to work abroad with the right skill set, application and expectation www. cddft. nhs. uk
Summary • This local UK NHS case study has shown that through attention to Workforce planning, addressing Nursing shortages, increased demand for nursing services and cost containment for temporary nursing labour can avert a perfect storm • Critical is an holistic approach to job design, partnership building and sophisticated recruitment • Nursing retention and agreeable working conditions is however key to ensuring we can keep our nurses • This includes better protection for nurses • Career possibilities for nurses remain strong whilst • Reward systems for nurses around the globe centre on more than just remuneration although this is still very important • The importance of constantly managing every aspect of recruitment, retention, contracting, education and workforce management with rigor and attention to detail cannot be overstated www. cddft. nhs. uk
Questions www. cddft. nhs. uk
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