Published: 7/11/2002, Volume II2, No. 5830 Page 28 29
Traditional ward rota systems need to be changed if money is to be saved and staff morale improved.Karen Hansed explains
Ward staffing is a key issue for acute trusts in meeting the government's NHS plan targets, as well as being the largest component of their budgets. It is also crucial to staff morale and the quality of patient care.Yet many hospitals are running with outdated manual rostering, inflexible working arrangements and poor skill-mix.
Hospitals are continually having to reassess their performance to achieve key national targets set out in the NHS plan; the most challenging, a maximum six-month wait for inpatient treatment to be in place by the end of 2005.Ward staffing arrangements must reflect the needs of the organisation, with staff being deployed efficiently and flexibly to respond to the demands of patients' changing dependencies and complexities during their stay. And as the single largest budgeted expenditure for any acute trust, ward staffing should demand the commitment of senior managers.
Reports from the Audit Commission have highlighted the scope for improvement and the wide variation in the amounts spent on ward staffing, and the quality of care provided.
Further research shows that only a limited number of hospitals have increased ward staff to accommodate new service developments and changes in patients' dependencies. It also suggests clear links between the management of ward staffing and the use of bank and agency staff.
3Yet hospitals that invest in employing more staff on wards can reduce their dependence on agency nurses.
Over recent years, ward staff have seen many changes that have affected their workload, including the introduction of Project 2000 nurse training, which requires students to spend more time in the classroom and less on the wards, and the reduction in junior doctors' hours. But ward establishments are often based on old patterns which lack flexibility and do not reflect current workloads or the required skill-mix.
When researching this area, we found little or no information available at a national level to assist trusts to evaluate, review and re-balance ward staffing establishments on formula-based methods.
We are aware of a number of computer systems available in trusts that can identify the staffing levels required, but many hospital staff regard these as out of date and time consuming. And the systems often over-estimate the level of staff required.
Our work in acute trusts in England has highlighted many obstacles that hospitals face in achieving the right ward staffing balance. These include the need to move away from the attitude of 'We have always done it this way', to real-time rostering that is flexible in its design and reflects patient activity throughout the week. Just as important is the need to improve the skills given to those who produce the ward rosters and remove the barriers to share staff with other wards when unpredictable demand outstrips planned capacity.
Our research found that ward staffing needs to be managed much more effectively so patient care and staff morale improve and absenteeism and reliance on agency staff is reduced.
Our work has shown that the majority of wards still operate a traditional three-shift pattern: early, late and night. These are often unable to meet the needs of day-to-day ward activity and are not flexible enough to cope with unexpected increases in demand. It is not the best model for providing employees with a good work-life balance.
The timing of shifts often does not meet the needs of staff who have children or carer responsibilities.
Variations in individuals' shift patterns from week to week can also make domestic arrangements difficult to manage. Even though the government's Improving Working Lives initiative has encouraged many trusts to set up staff nurseries, those working traditional shift patterns are often unable to use them because the opening hours are too restricted.
We are also finding that many wards do not routinely monitor patient dependencies, which are becoming increasingly complex because of medical advances and an increasingly aged population.
Reduced length of stays and increases in day surgery mean that throughput is rising rapidly.We also found that new service developments being introduced at ward level, such as telephone helplines and patients returning for follow-up treatment, do not appear to be supported by any increases in ward establishments. There is also a lack of correlation between shift patterns and patient dependencies. This is restricting the ability to deploy staff effectively and efficiently.Many ward rotas do not take account of elective admission patterns, operating days or emergency on-take arrangements.
Trusts need to recruit more part-time staff to maximise flexibility. Part-time staff working three or four hours per day can bring many benefits to the employer and employee. Productivity can be maximised as there are no interruptions for meal breaks, so staff tend to be more focused. Employing staff who work a limited number of hours per week reduces the trust's National Insurance bill and allows the individual to be more flexible to cover more shifts at a standard rate as opposed to premium rates, thereby helping the trust reduce its reliance on expensive agency staff.
Ward staff rostering is a complicated and timeconsuming exercise, involving significant manual effort.Many wards are still operating with monthly paper-based rotas which are ill-suited to accommodating changes.There is a real need for IT systems to be developed to help nurse managers roster staff more efficiently than at present.
The allocation of weekend work is also not fairly distributed across all ward staff.We found some ward staff working more weekend shifts than others, with bank or agency staff covering the gaps.
This can be an expensive way to use a hospital's permanent pool of staff, and the subsequent deployment of agency staff can cause resentment where individuals are perceived to earn more than their fair share of premium pay for weekend cover.
This can result in staff leaving to work for agencies in the hope of better pay and conditions.
The government's initiative to encourage actively international recruitment of nurses is also having a major effect on trusts' permanent staff. Some wards have up to eight different nationalities working on them. Increasing the number of nurses from overseas involves pressures on trusts who are responsible for supporting and monitoring these staff.Hospitals must make arrangements for accommodation and transport.
This needs sensitive handling to avoid resentment from other staff.Many trusts are now increasing the length of their induction programme to prepare these nurses better.
In the long term, it will be important for trusts to actively recruit the many UK nurses who are not currently employed by the NHS.Trusts should be encouraged to make direct contact with these individuals and with those who have left the trust in recent years to discuss the opportunities for nurses who return to practice.
We have also found other factors which affect the management of wards, such as the use of clerical staff.Typically, ward clerks are contracted to work 9am-5pm, Monday to Friday, and this does not meet the needs of wards.Trusts need to extend and redesign the roles of ward clerks to provide cover during weekends and evenings so nurses can be more effectively employed.At the moment, vast amounts of nurses' time is absorbed in administrative work.
Trusts should recognise the contribution their ward staff make to not only providing highquality patient care, but also to the smooth running of their organisation.
They are a highly valuable resource, but management techniques must now be brought up to date. It is important that detailed reviews of ward staffing arrangements are undertaken to get 'back to basics' and begin to develop ward staffing establishments that are based on the dependencies of patients, workload and activity throughout the week.
Until all of these factors are taken into consideration, ward staff will continue to be placed under significant pressure and struggle to meet key performance targets.That in turn could affect the quality of patient care and staff morale.
Ward staffing is the largest single component of acute trusts'budgets and should attract the attention of senior managers.
Many trusts have inflexible arrangements which do not take account of patient dependency and skill mix.
Trusts should consider employing more part-time staff and introducing more flexible working for ward clerks.
1Audit Commission. The virtue of patients: making the best use of ward nursing staff. Stationery Office, 1991.
2Audit Commission.Ward Staffing. Stationery Office, 2001.
3Audit Commission. Brief Encounters. Stationery Office, 2001.
Karen Hansed is performance audit manager, PricewaterhouseCoopers.