Delivering Care: Nurse Staffing in Northern Ireland
WSCNTL 2014, Kings HallLeading Care, Leading Teams - Innovating and Supporting Person-Centred Care
Siobhan McIntyreRegional Lead Nurse Consultant PHA
Chair of Delivering Care Regional Working Group
Community Nursing Four key principles:
• Effectiveness: Timely access
• Integration: Collaborative multi-disciplinary working
• Efficiency: right person, right place, right time, right service, right outcome
• Expertise: Appropriately skilled
Mapping the Change in Service Direction
Reduction in inappropriate referral to hospital and NIAS
Reduction in unscheduled care admissions
Increased acute care delivery at home
Consider the needs of the over 65yrs and patient groups for community acute care teams/triage and see and treat protocols. Have an agreed directory of service
Expansion of 24 hour provision in primary care nursing
Developing the right interfaces / secondary + primary care inc diagnostics
Choice of preferred place of care for palliative patients
Nurse led clinics across primary and secondary services
Disease prevention and early intervention
Increased technological interventions
The Need to Transform • Safe, effective, person
centred care;• Increased demand for
efficiency and effectiveness;• Changing population
demographics;• Working closely with GPs;• Changing patterns of disease• eHealth / Telehealth;• Changing lifestyle;• Changing public expectations;• Inequalities in health;• Reconciliation in demand,
need & access.
Commissioning Framework • An integrated vision and framework will be developed and led by the
PHA which outlines how district nursing services will be modelled across each HSCT;
• The framework will seek out evidenced based and good practice examples for district nursing services to support the targeting of resources at local and regional level. This will take cognisance of population needs and enhance delivery closer to home and improve health and social care outcomes and productivity;
• The framework will seek to capture the importance of technology and to promote more effective mobile working practices to support care delivery;
• The framework will be based on the principles for core district nurse services aligned to Gps 24 hour provision and the management of acutely ill patients in primary care.
‘The planning, provision and evaluation of appropriate programmes of nursing care, particularly for people discharged from hospital and patients with complex needs; long-term conditions, those who have a disability, are frail or at the end of their life.”
(RCN, 2013)
• District nurses will be the key professionals involved in planning and providing this care within the following three care domains – Acute care at home – Complex care at home – End of life care at home
Workforce Planning in Nursing & Midwifery-what’s happening in Northern Ireland
1. Policy/Strategy recommendations2. DHSSPS Workforce Review 20143. Delivering care Regional Project for Normative Staffing4. Caseload analysis for Community Nursing & Health Visiting5. Clinical Nurse Specialist Job Plans6. Community Information Systems7. 92% female, 44% part time 8. 773.67 WTE district nursing staff across N.I.9. Caseloads > 29,000 patients as at Dec 201310. Largest professional workforce in HSC11. Responsible for continuous care provision12. Delegate care to unregulated care workforce 13. Learning and development requirements > post registration qualifications > uptake on courses to meet TYC requirements14. Professional and regulatory requirements
Regional Policy and Strategy• Transforming Your Care• Quality 20:20• The People’s Priorities• A Partnership for Care• Community indicators /caseload analysis• Commissioning directions • Integrated Care Partnerships.Evidence Base Related to Staffing Levels and Patient Outcomes• Link to patient outcomes http://www.rn4cast.eu/en/index.phpEvidence from Public Inquiries• Francis • Hine Inquiry• Health Committee House of Commons
Strategic Drivers
ContextHigh Quality
care in community
Improving and extending services
• To promote a shared understanding between professional, management, finance and human resources colleagues of the essential components to set and review nurse staffing establishments and when commissioning new services to provide safe, effective, person centred care.
• To support general and professional managers in presenting clearly the need for investment in nurse staffing, within changing service profiles, particularly in response to incremental service growth and TYC.
• As a reference document for the nurse staffing levels component within investment proposals.
Why?
Ref page 4, 2.10‘It is anticipated that on occasion nurse staffing may be outside the normal range. In such cases the Executive Director of Nursing must provide assurances about the quality of nursing care to these patients, and the efficient use of resources through internal and external professional and other assurance frameworks.’
Why Define a Range?• Reasonable starting point for ‘conversation.’
• Not as prescriptive as a ratio and for district nursing, it will be essential to consider cover and hours of service for the future model of service for an agreed population range.
Steering Group
Working Group
Additional expertise
as required
Project Structure
Who are the Partners?
Project Aim
• PHA• HSC Trusts• DHSSPS
• HSCB• HR Reps
• Staff side• PCC
To support the provision of quality care which is safe and effective in hospital and community settings
through the development of a tool to determine staffing ranges for the nursing and midwifery workforce in a
range of major specialities.
Phase 1 Acute Hospital Settings
Phase 2 Emergency Depts
Phase 3 District Nursing
Phase 4 Health Visiting
Phases
Underpinned by:• Communiqués• Literature reviews/searches• Interviews with HSC Trust Assistant Directors responsible
for nursing workforce• Data gathering of current workforce and caseloads • Gathering of international and national intelligence
around workforce planning in nursing• Development and production of Part 2 of a framework• External Critical Review• Engagement with stakeholders
Process
PROJECT OUTCOMES
Assumptions of the Framework
Staffing Ranges
Delivering Care, Part 1
Assumptions of the Framework
Key Performance Indicators
PUAA
Skill Mix
Management of Recruitment
Influencing Factors
Planned and Unplanned Absence Allowance
What is it? Periods of absence from work, which can be described as anticipated and, therefore, must be factored into the workforce planning process.
Comprises:• Annual leave• Sickness absence• Study leave
Evidence base:• Telford (1979)• Other professions: Consultant Contract
Framework (2003) , BASW, UK Supervision Policy (2011)
• Auditor General Scotland (2002)
Planned and Unplanned Absence Allowance
What has changed since 2002?Annual leave:• Overall net increase of 16% following Agenda for Change
Study Leave• 56% full time, 44% part time• Increased intensity and complexity of patient care – practice and
competence training needs significantly increased• Statutory/mandatory training• Professional/regulatory updates and training in relation to pre-
registration nursing and midwifery mentorship• Professional supervision
Planned and Unplanned Absence Allowance
Year Annual Leave:
Sick Leave: Study Leave:
Total Allowance
2012 15% 5% 4% 24%
So.......?
Year Annual Leave:
Sick Leave: Study Leave:
Total Allowance
2002 13.5% 5.5% 3% 22%
• Workforce
• Activity
• Environment and Support
• Professional Regulatory Activity
Influencing Factors• Competence skill set to work flexibly• Management of absenteeism• Constitution of district nursing teams
• Caseload activity• Referral rates• Visiting patterns• 24 hour services• Throughput• Acuity/Dependency• Seasonal Variations • Geographical areas
• Location of care• Population sizes• GP attachment• Skill mix
• Compliance with professional regulatory standards
• Supervision / Training• Accountability and governance
requirements
Key Issues
• Need to understand how the district nursing service has developed
• Review the integration of multi-disciplinary working
• Need to review the alignment of core district nurses to GP practices
• Requirement to enhance practice knowledge and specialist skills
• Develop workforce planning methods
Progress • Population and caseload management• Consistent Data/activity collection• Support and care for patients who are unwell, recovering at home• End of life/palliative care • 24 hour provision• Acute care at home • Support and care for independence• Promotion of technology and LTC• Peer Review / Expert Reference Groups• Users views of the service • Communication and Dissemination
Measuring Impact and Enhancing the Patient Experience
District nurses :• contributing to population health needs• leading care and contributing to healthy
communities• working in partnership with social care
enhancing the quality of care.• contributing to enhancing the patient
experience
Key Performance IndicatorsPhase 1Organisational: • absence rates within nursing and midwifery teams; • normative staffing ranges - including vacancy rates.Safe and Effective Care: • incidence of pressure ulcers • falls • omitted or delayed medicationsPatient Experience: • consistent delivery of nursing/midwifery care against
identified need• involvement of the person receiving care in decisions
made about their nursing/midwifery care• time spent by nurses and midwives with the patient
‘Should quality indicators begin to fall below the accepted level of achievement, staffing levels should be reviewed as one of the lines of enquiry of attributable causes.’
Process for Phase 3 To conduct an academic literature review on district nursing workforce
models; To build on the work already collated with HSCTs from Ecats; To build on the commissioning framework developed for district nursing
in Northern Ireland; To liaise with key partners re critical success factors for training and
development; To agree a regional workforce and caseload range for district nursing in
Northern Ireland; To agree the influencing factors as they relate to district nursing practice; To agree service definitions; To agree KPIs as they will relate to the workforce planning framework for
District Nursing; To set up user feedback forums for the project.
