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Nurse staffing shortages are 'top priority' for new regulator's senior nurse

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Staffing is the main issue concerning the senior nurse at the newly-created regulator NHS Improvement, as well as being the “biggest challenge” facing community nursing, she has said.

Dr Ruth May, executive nursing director at NHS Improvement, said the body’s responsibility to help trust’s respond to nursing workforce shortages “scares me and excites me in equal measure”.

“I’m living breathing and sleeping around staffing – or not sleeping around staffing”

Ruth May

Underlining her workforce objectives, Dr May told delegates recently at a Queen’s Nursing Institute conference that she was focusing on “staffing, staffing and staffing”.

Dr May also highlighted that the QNI was leading a national workstream to develop safe staffing improvement resources for community settings, as previously announced in July.

As well as staffing, she defined her other three priority areas as quality of care, supporting excellence – which she described as the “how” – and future vision.

Regarding support, she told delegates the regulator wanted to move away from “dragging in” consultancy firms to advise struggling trusts and be more “about peer support and peer challenge”.

Returning to workforce issues and talking specifically about care outside hospitals, Dr May described staffing as the “biggest challenge” in community nursing.

“It’s going to be on all of us, whatever level we are, to make sure we safeguard the quality of care, particularly given the financial challenges that almost all organisations are facing,” she said at the event in London last month.

She said that, in her view, nursing as a registered profession must “make sure that we safeguard quality”.

“My concern is that we just do not have enough nurses who are trained in the community”

Gail Adams

She noted that NHS Improvement was going to be doing a “range of things” to professionally develop and support community nurses, highlighting in particular leadership.

For example, she said she wanted to support a “talent pool” of deputy nursing directors to become directors of nursing – but especially from community settings.

“I don’t think we’ve got sufficient, as yet, community deputy directors of nursing wanting to take on the challenge of big acute trusts,” she said. “I don’t believe you have to have grown up in an acute trust in order to become an acute director of nursing.

“I really want to see community nursing leaders across the whole spectrum of director of nursing leadership programmes,” added Dr May, who is also deputy chief nursing officer for England.

NHS Improvement

Nurse staffing shortage is ‘top priority’ for regulator

Source: Kate Stanworth

Panel session with Jean White, Charlotte McArdle and Ruth May

But, in the following panel session (see below for full transcripts), Unison head of nursing Gail Adams said she was “desperately worried” about both the current workforce pressures in the community and the impact that the loss of bursaries for student nurses would have on the sector.

Ms Adams also told delegates that she was concerned that the NHS and its leaders did not “always learn the lessons from history” regarding the need to increase capacity in the community before transferring services out of acute settings.

“I just wish for once we put workforce in the community before we started increasing care in community, because often what happens is we just get an increase in caseload,” she said.

“My concern is that we just do not have enough nurses who are trained in the community and we have an expectation of new graduates going into the community…but they need to be supported by very experienced community staff,” she added.

Ms Adams also argued that community staff were not sufficiently valued, respected or paid for the work the they did and also called for GPs to pay practice nurses “properly” to retain them.

“We can’t necessarily just train our way out of this quickly”

Jean White

In response, Dr May reiterated that her high level of concern about staffing problems in the community was the reason the QNI had been asked to advise NHS Improvement.

She noted that chief nursing officer Jane Cummings had recently acknowledged that there were unknown risks from the move from bursaries to loans for student nurses and midwives.

She also told delegates that community nursing needed to be part of the local sustainability and transformation plans being drawn up under NHS England’s Five-Year Forward View strategy.

However, she said there were “some fantastic” practice and community providers already hosting placements for students wanting to go straight into jobs in non-acute settings upon graduation.

“I think there’s hope for the future but I’m not underestimating where we are with community nurse staffing at all,” she said.

Meanwhile, chief nursing office for Wales Jean White said: “The workforce is the key to everything isn’t it, because without us the services don’t get done.”

But she cautioned that nurses must not be “slaves to the past” regarding models of care. “There are models out there that use our services much more efficiently,” she said, calling for more integration between acute and community sector staff.

“There are nuances within this that are not about numbers,” she stated. “It’s about skill mix, it’s about relationships between sectors, it’s about different ways of working, as much as the numbers.

“We can’t necessarily just train our way out of this quickly. We’ve got a couple of years where we’re going to have to think much more creatively about what we are doing and how we are shaping our services,” said Dr White.

“The difficulty we’ve got is that the caseloads that you [district nurses] all have are growing exponentially,” she said. “It’s the challenge of the day quite frankly.”

“More of the same, frankly it’s just not going to work”

Charlotte McArdle

Charlotte McArdle, CNO for Northern Ireland, added: “We all share in the concerns that have been articulated, but there is no quick-fix solution.

“It’s going to be a long journey,” she said. “Every country is concerned about the situation, every country is putting measures in place to support and help the [community] staff that we have there.

“We as a group need to show leadership because more of the same, frankly it’s just not going to work,” she said. “We really do need to look at different ways and different models in the future.”

She added that was vital, if nurses were to get investment in their services, to demonstrate the “impact that nursing, or the lack of it, has on the outcomes of the patients”.

“You’ve got to be able to describe what it is you are going to do with the extra investment and how it’s going to make a difference,” she warned delegates.

 

QNI annual conference: Q&A panel session on staffing in full

Gail Adams, Unison head of nursing

Question: “I am passionate about community services and passionate about nurses in the community. But I am desperately worried about the numbers. I am desperately worried about the impact that, in England in particular, the changes to education funding will have on staff.

Also what concerns me is that we don’t always learn the lessons from history. So, as a passionate advocate of community and community services, I just wish for once we put workforce in the community before we started increasing care in community, because often what happens is we just get an increase in caseload…

Adams_Gail.jpg

Gail Adams

My concern is that we just do not have enough nurses who are trained in the community and we have an expectation of new graduates going into the community, which I think is great, but they need to be supported by very experienced community staff and I just worry that we do not value, respect or pay community staff sufficiently for the work that they do… why the hell aren’t GPs properly paying practice nurses to retain them.

We are losing a number of GP practice nurses because they don’t always have comparable rates of pay. So I’m all for improving the service but one of the best ways we can do that and retain our staff is value them and valuing them in remuneration as well as in respecting and thanking them for the work they do.”

Ruth May, executive nursing director at NHS Improvement

Answer: “That’s why I put it up there as my main thing that I am concerned about. I am working hard with you all on this. Staffing, particularly in the community, that’s why we’ve got a separate workstream for community and that’s why we’ve asked the QNI – who I believe are the leading experts in this area, so they can lead on our behalf so they advise us.

Queen's Nursing Institute

Nurse staffing shortage is ‘top priority’ for regulator

Ruth May

But it isn’t just about one of the workstreams that we’ve got. You are right… I think Jane Cummings, the CNO, has said in Nursing Times that having the bursaries [go] at the same time, we don’t know what effect it’s effect it’s going to have. All I know is what we need to be doing is working with STPs – those strategic groups we’ve got in England now – and sure making sure community is certainly a part of that.

The other thing I’d say is that there are some fantastic practices and community services really hosting great graduate training places. And they’re doing really well and it’s really exciting to see some of our graduates or about to be graduate nurses wanting to do community. I think there’s hope for the future but I’m not underestimating where we are with community nurse staffing at all.”

Jean White, CNO for Wales

Answer: “I suppose I will hark back to what I said in my presentation, the workforce is the key to everything isn’t it, because without us the services don’t get done.

But we musn’t be – this is sort of a challenge back I suppose – slaves to the past and think models that we’ve always done we just need to keep doing more of that. I don’t think that will necessarily be the solution going forward.

I spent quite a bit of time over the summer going out and seeing for myself different ways of doing things, and there are models out there that use our services much more efficiently.

There has be to a better relationship, I think, between the acute sector workforce and the community sector workforce so we’ve seeing lots of in-reach/outreach type models going on. I think there’s a debate about where specialisation sits to support the excellent generalists, which are the district nurses, and I worry that if we start having too many specialists we will end up deskilling and disempowering the district nurses [audience murmurs yes].

Queen's Nursing Institute

Nurse staffing shortage is ‘top priority’ for regulator

Jean White

So there are nuances within this that are not about numbers. It’s about skill mix, it’s about relationships between sectors, it’s about different ways of working, as much as the numbers.

And let’s not kid ourselves, you can’t create a new nurse overnight, it takes years from the point of making a decision, to commissioning the training, to having the training completed and getting them to work competently in the community.

So we can’t necessarily just train our way out of this quickly. We’ve got a couple of years where we’re going to have to think much more creatively about what we are doing and how we are shaping our services. I think that’s where some of our debate has to be as much as what have we got exactly to deliver care.

And the difficulty we’ve got is that the caseloads that you all have are growing exponentially because we have this older, sicker population that we have to care for. It’s the challenge of the day quite frankly, as far as I’m concerned, to get this right. I wish I had a magic wand. I wish I had a bottom draw I could open up and say here you are, have a couple of hundred more nurses…”

Charlotte McArdle, CNO for Northern Ireland

Answer: “We’ve got here to the point where we’re at in relation to workforce and concerns.

We all share in the concerns that have been articulated, but there is no quick fix solution and that’s why we have a policy in Northern Ireland around delivering care that doesn’t focus on ratios of nurses to patients but it looks at scales and that’s why we’ve been doing the work around the caseload weighting and trying to find an evidence base which I think in community nursing is more difficult than in a hospital where you can look at the number of patients, the inputs, the outputs, the processes and come up with a safe staffing solution – it’s not just quite as easily done in the community.

In Northern Ireland there has been, during the comprehensive spending reviews, money taken out of district nursing and now it’s recognised that that money has to go back in and not only does it need to go back in but more needs to go on top of it, if we’re going to make the change happen that needs to happen, which is why we need them delivering the framework for district nursing

Queen's Nursing Institute

Nurse staffing shortage is ‘top priority’ for regulator

Charlotte McArdle

But I will say the one thing I think that we should focus on is articulating the value that nursing brings to the care experience and it’s only through that process of actually demonstrating the impact that nursing, or the lack of it has, on the outcomes of the patients, right down to very specifics, will people actually listen to the argument.

You’ve got to be able to describe what it is you are going to do with the extra investment and how it’s going to make a difference and as nurse leaders, all of us in this room – it’s not just the CNO from Northern Ireland, it’s not just Ruth’s role for improvement – everybody in this room needs to be saying the same message and we all need to show leadership to this debate.

Because even if tomorrow we all got, I don’t know, £100m for nursing we couldn’t actually use it then because we can’t get the workforce in the right place. So it’s going to be a long journey. I think every country is concerned about the situation, every country is putting measures in place to support and help the staff that we have there, and it will take time and we as a group need to show leadership because more of the same, frankly it’s just not going to work. We really do need to look at different ways and different models in the future.”

 

  • 6 Comments

Readers' comments (6)

  • Phil Dup

    I couldnt wait any longer for nurse staffing to get better - I have been qualified since 1996 and spent the last 18 years in A&E and have loved it mostly - however in the last year it has been bedlam with no space to treat the massive increase in patients. The ambulance corridor is now set up with mini 'curtains on rails' which have become a patient treatment area where people have everything from ecgs / bloods/ IV drugs and even bedpans, all within a few feet of each other. Regularly working nightshifts in a 4 bedded Resus Room on my own. New Staff leaving within a few months as its so hard. So at last I have lapsed my registration and although I have no job to go to I have fely a massive weight ease from my shoulders knowing I shall never Nurse again.

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  • Spot on Phil - these leaders and politicians create the problems by providing managerial solutions that further the issues.

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  • I feel so sad Phil that your career has ended in this way. I too started out full of enthusiasm in1984. I had what I consider to be a real vocation and I was so proud to be a nurse. I cannot say that today. I have had a similar experience but have not lapsed my registration as I cannot bring myself to do so. Not yet anyway!

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  • This report seems to be about general trained nurses but in mental health nursing we also have severe recruitment and retention problems in the community. We need to pay CPNs properly too.

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  • The whole staffing issue has become a political gameplay. The fact remains that we will always have the reliance on overseas workforce because we don't produce enough nurses of our own. Yet because of the pressures imposed by the general public on the government over immigration, the solution to the problem which is recruiting from overseas has been totally made almost impossible by the government. The new routes to nursing like the nursing associates and apprenticeships will not produce the nurses that we need now. Remove the bursaries and impose tuition fees to increase the number of nursing places at universities. Politicians say these are the long term solution. Perhaps. Perhaps not. Regardless, what we need is a solution now before many more nurses like Philip decide to hang their scrubs for good because they've had enough of short staffing and politicking.

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  • I too have retired from being a CPN after 30 years working in most mental health disciplines and I too feel a weight has been lifted from my shoulders. More and more worked being given to understaffed teams by managers who simply haven't a clue. Most of who have never worked on a ward or community team or if they have it was years ago. They don't realise the verbal abuse staff get and in many cases if it's bought to their attention do little or nothing citing their (the patients) illness as an excuse for such behaviour. In the community the dangers staff are put in through lone working.
    I woke up one morning and decided it wasn't a job I wanted to do any more. I just wasn't enjoying it any more. Bearing in mind I could have retired four years ago.
    I have lapsed my registration as after a time there is little choice as you cannot fulfil the requirement to do the 35 hours training needed to re-register

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