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Nursing & Midwifery: Workload & Workforce: Planning Project

chapter 5. Recommendations

The project reflects an extensive piece of work that offers a snapshot of the current situation in relation to nursing and midwifery workload and workforce planning in Scotland. It provides more detail than has been gathered in previous work, building a picture of practice and identifying areas of strength. Inevitably, however, discrepancies in the data that require attention have also arisen, and these are addressed in the recommendations.

With the exception of Recommendation 1, which is over-arching, the recommendations are set out under five broad headings: principles (which includes the need for flexibility in approaches); education and development (for key staff); systems (which concentrates on the use of particular nursing and midwifery workload and workforce development systems used in NHSScotland); allowances (focusing on the need for defined protected time and predictable absence allowances); and research (which provides pointers for future research activity in this area).

The recommendations are based on the project's outcomes and describe what NHS Boards and others should implement in the short and medium term. They also address needs for further work in specific areas. They must be considered within the wider context of the dynamic nature of health services. Patient acuity is a particularly strong driver of workload in clinical areas, but service planning, delivery and redesign, new nursing and midwifery roles and integrated workforce planning are also significant influences. For this reason, it is recommended that workforce planning methods (including patient dependency measures) should be reviewed on at least a three-yearly basis and more frequently when changing circumstances dictate.

NHS Boards will need to set out detailed, costed action plans to ensure these recommendations are implemented and reviewed on an ongoing basis. Responsibility within the Board for ensuring the action plan is open, transparent and delivered lies with the Nurse Director, ²³ and performance should be assessed as part of the Board's accountability review through the Performance Assessment Framework.

Principles

Many of the recommendations are aimed at ensuring consistency across Scotland in relation to tools and other key issues. Board action plans are necessary to tie these diverse strands together. In addition, plans should spell out how continuity of care can be improved through reducing use of agency staff where used and increasing permanent nursing and midwifery resources. This will assist in breaking the vicious cycle that can exist in some organisations if there is a high ongoing level of vacancies of permanent staff and continuous high and unplanned use of temporary staff.

While data will accumulate at local level to inform ongoing practice, it is also important that the national picture emerges. Data from individual NHS Boards should be collated, leading to the creation of a national dataset on nursing and midwifery workload and workforce planning. This process should involve relevant stakeholders, such as Regional Workforce Centres; one outcome of this may be to improve the quality of the information needed for the Student Nursing Intake Planning (SNIP) process.

Innovative and effective approaches to the use of flexible working are essential, particularly to maximise recruitment and retention of nursing and midwifery staff. The project gathered anecdotal evidence that NHSScotland organisations are using a variety of flexible working practices. There was less tangible evidence on how flexible working practices are contributing to effective use of current nursing and midwifery resources and maximising benefits for patients. Systems should be in place to ensure this information is transparent.

The project has demonstrated little consistency in the approach to nursing and midwifery workload and workforce planning across NHSScotland, with the exception of highly specialised areas such as theatres and ITU. A wide range of workload and workforce planning tools was found to be in use. While each may have individual benefits in reflecting local circumstances, there was a widespread view among respondents that systematic approaches to nursing and midwifery workload and workforce planning applicable across the whole of NHSScotland, within which adjustments could be made to reflect local needs, would enhance consistency and increase equity.

It is essential that any planning tool(s) recommended for use has/have the capacity to take account of the organisation of nursing and midwifery and the dynamic context in which care is delivered. A key criterion for recommending a tool or system at national level is that it is sufficiently flexible and adaptable to maintain its relevance and applicability in this changing context. Tools should be capable of taking account of the impact of developments in health technologies, shorter hospital stays and increased patient acuity, and should reflect emerging workload issues such as those presented by the consultant contract, junior doctors' hours, Level 1 patients (or equivalent), expanded/extended nursing roles, skill mix changes, the impact of healthcare support workers, flexible working and new patterns of work. Where necessary, tool(s) should be adapted to ensure these factors are reflected.

The use of workload and workforce systems is not resource-neutral, and several respondents commented on the resource-intensive nature of applying some tools. It is important to ensure that the benefits of using the tools are not negated by inadequate resources being made available.

Education and development

The project showed that very few users of the various systems had received anything other than cursory instruction in their use. While the project was unable to establish any concrete link between resource implications of using a system and the hours of training provided, good practice suggests that better training in use of tools is likely to improve users' competence, with consequent positive implications for time and resources.

The project demonstrated misunderstandings and lack of knowledge of establishments, budgets and resources among some respondents, which suggested a need for education and training to ensure that people involved in these processes are equipped with basic underpinning knowledge and competencies.

A variety of local and national education, training and development initiatives focusing on clinical leadership development are available to nurses and midwives at charge nurse/team leader level. These opportunities should be continued and developed to ensure efficient use of resources. Consideration also needs to be given to succession planning, so involvement of F and E-grade staff may be appropriate.

Systems

Professional judgement, explicit in the wide use of a 'Telford'-type method, was identified in the project as the current bedrock of nursing and midwifery workload and workforce planning. While the value of this approach is acknowledged, it is important that other tool(s) are used to validate findings. In this context, that means not relying exclusively on 'Telford' (or any single tool) as a stand-alone system.

Patient dependency measures offer a means of indicating changing patient acuity and associated workload, and should be used alongside other nursing and midwifery workforce planning systems.

Quality is a key part of nursing and midwifery workload and workforce planning. Looking at workforce planning in isolation does not provide the assurances that the numbers of nurses and midwives within an establishment are able to deliver optimum quality of care. It is therefore crucial that organisations are able to define quality, able to recognise it, and able to measure it.

There were ambiguities in how respondents interpreted 'quality systems', 'quality tools' and 'quality rating scales'. This resulted in the emergence of a mixed picture of how they were used, to what purpose, by whom and at what times. The project has nevertheless provided a better understanding of the range of information and data provided under quality measures. Clinical quality indicators for NHSScotland are currently being considered by a project within NHS QIS (see footnote 4, page 17). Until such times as the project issues its conclusions, a nationally recognised quality measure relevant to the area of practice should be used in conjunction with a workforce planning tool and patient dependency measure.

It was clear in the project that some workforce planning tools were being used more frequently and were reportedly working very well in particular areas, with broad-based interest expressed in standardising tools across the country. In adult acute areas, an 'Acuity Quality tool' was being used alongside a 'Telford'-type tool. In community hospitals, great interest was expressed in 'Acuity Quality tools', while 'Birthrate Plus' and 'Telford' were used in maternity settings.

It was noted in discussion with respondents, however, that the 'Telford' system was being interpreted differently in different areas. While some allowance for local differences is understandable, there would be clear benefits in ensuring the 'Telford' system was, at core, the same tool regardless of where it was used. A standardised 'Telford' system should be refined at national level and made available throughout NHSScotland in electronic format.

Respondents in some specialist areas showed interest in and expressed support for National Recommendations such as those applying to ITU, theatres and neonatal units. These tools need to be examined, monitored and reviewed to ensure their validity, resulting in underlying assumptions and ratios on a Scotland-wide basis.

Allowances

Senior charge nurses (and equivalents), ²⁵ who have overall leadership responsibility in the direct care area, have a wide range of responsibilities and make key contributions to management, clinical governance, education and research. These responsibilities consume significant amounts of their working time. There was widespread support in the project for an allocation of one day a week 'protected time' ²⁶ to enable them to develop their leadership, managerial and education roles, but a variable picture of current protected time allowances emerged, with different allocations across NHS Board areas. This variability should be addressed through the development of a national standard protected-time allowance.

Similar to other allowances (such as 'protected time'), predictable absence allowance (see page 17) was being applied inconsistently throughout the country. There was wide support for a national standard to guide practice.

The impact of Agenda for Change will need to be factored into the predictable absence allowance, which will have to be reviewed in the light of the planned full implementation of the agreement from October 2004.

Research

It is clear from data emerging from the project that further research and evaluation work is required in some specialty areas to obtain a clear picture of the current situation with regard to nursing and midwifery workload and workforce planning and to work towards developing tools appropriate to these specialties.

It should also be acknowledged that there is a balance to be achieved in terms of making progress with implementation of nursing and midwifery workload and workforce planning systems and refining the tools to be used.

Level 1 patients in adult acute areas (and equivalents in other areas) are presenting in increasing numbers, but the project showed a lack of consistent definitions, understandings and planning to meet their needs. This is putting considerable pressure on nursing establishments, and needs to be addressed with some urgency through further research.

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