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Apprenticeships enhance patient safety and care

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Apprenticeships are a practical entry to healthcare and ensure literacy and numeracy


In this article…

  • Introducing a modern apprentice programme
  • Developing a patient safety culture
  • Measures to reduce staff errors



Sue Smith is executive director of nursing and patient safety and director of infection prevention and control, North Tees and Hartlepool Foundation Trust.


Smith S (2011) Apprenticeships enhance patient safety and care. Nursing Times; 107: 14, early online publication.

Poor standards of numeracy and literacy pose a danger to patient safety. Recruiting staff through the modern apprenticeship programme can address this.

Staff are tested for numeracy and literacy when they enter and complete the programme, and problems they may experience during their apprenticeship can be immediately addressed.

Training days and regular feedback from senior nurses to ward staff about audits of clinical care can also contribute to building a culture of safety at a trust.

Keywords: Modern apprentices, Patient safety, Staff Development

  • This article has been double-blind peer reviewed


5 key points

  • Poor literacy and numeracy is a serious threat to patient safety
  • The modern apprenticeship programme can ensure recruits understand the importance of procedures such as observations and early warning scores
  • Providing clinical placements in areas where staff are on maternity leave or long-term sickness absence gives apprentices stability and reduces agency staff use
  • Analysing case studies with staff can help them see how acts and omissions affect care
  • Senior nurses should be included in quality review panels and involved in assessing the environment, auditing evidence of care and asking patients for their views on care


After a number of incidents involving junior nursing staff occurred, our trust decided to develop a career path for recruiting and developing its unregistered nursing staff.

We had assumed that standards of literacy and numeracy were universally high in our organisation. A number of critical incidents recently uncovered problems that could have been serious threats to patient safety. These included patients who were nil by mouth being fed, and early warning scores being miscalculated.

Working with colleagues in training and development, we identified a lack of literacy and numeracy skills as a patient safety issue. In considering how to address this, we found a solution in line with the Skills for Health career framework. Modern apprenticeships were already in place at the trust for other staff groups, so this approach seemed an obvious solution.

We work closely with Stockton Riverside College. Apprentices are employed in the trust for two years, during which time they work towards a technical certificate in health and social care and national vocational qualification (NVQ) level 2, going on to obtain a level 3 NVQ in health in their second year.

Recruitment benefits

We decided we would no longer recruit healthcare assistants (HCAs) directly. Instead, we recruit modern apprentices whose literacy and numeracy is tested on entry and again when they have completed their apprenticeship. There is no age restriction on the programme.

If, after two years’ training, the apprentices have not attained adequate numeracy and literacy skills, they cannot become HCAs. This rarely happens because problems are identified as they arise and apprentices are given support.

The approach has numerous benefits. The modern apprentice programme introduces recruits into the culture of our trust, so we develop a group of people who understand their own role, can work effectively in a team and are able to support and challenge colleagues where necessary – all of which contribute to our safety culture.

Our HCAs can see exactly how their attitude, behaviour and practices affect the patients they care for, and some modern apprentices go on to undertake nurse training.

Skill development

We have recruited more than 70 staff through the programme.

Recruits are made aware of the importance of completing observations and calculating early warning scores (EWSs). Because apprentices are trained and assessed in practice, observations are
completed and EWSs are calculated accurately, and there is an audit trail to show the actions taken when a high score is triggered.

During training, apprentices are made aware that failing to take a temperature at 2.00am means colleagues are unable to accurately assess if a patient is deteriorating. This has reduced the number of patients who deteriorate and the number who go on to have a cardiac arrest.

Recruitment of modern apprentices is only one aspect of the trust’s patient safety work. Staff commitment to reducing opportunity for error or harm has helped to significantly reduce hospital mortality rates. In August 2008, we had the highest mortality ratio in the North East; this has declined by 15% a year, reducing our mortality to the lowest in the region.

We tend to provide clinical placements for modern apprentices in areas where staff are on maternity leave or long-term sickness absence. This has enabled us to offer longer placements, giving apprentices stability and enabling them to contribute to the nursing team. This has helped to eliminate reliance on agency staff and reduce our bank nurse use.

According to the Audit Commission (2010), temporary nursing staff costs as a proportion of the total varies from 1% to 28%: ours is 2%, so this approach has improved our financial position.

Other staff development initiatives

The trust’s modern apprentice scheme is part of a wider programme of staff development.

The trust has been developing band 4 associate practitioner posts for a number of years. These skilled, unregistered nurses support the nursing team by taking on roles previously carried out by registered staff. For example, they can oversee the care of specific groups of patients and administer some oral medications. Their training makes associate practitioners aware of when to refer or escalate to a nurse or a doctor. While nurses remain accountable for patients’ care, associate practitioners are responsible for working within protocols, working closely with their nurse lead.

Nurses also receive supervision and support. On alternate months, we run a one-day nurse development programme, which focuses on patient safety and experience. We teach nurses how to use the Global Trigger Tool, which enables them to evaluate the quality of clinical care provided. We give them real (anonymised) case studies to review where something went wrong, including occasions where this resulted in harm. By reviewing scenarios, nurses are able to evaluate the impact of acts and omissions on care. We are working with Teesside University to accredit the nurse development programme.

Senior nurses are included in quality review panels – a monthly half-day event that includes peer assessment of key quality standards in our clinical areas both in the community and in hospitals. We assess the quality of the environment, audit evidence of clinical care and ask for patient views on nursing care, compassion and overall experience. The senior nurses (band 7 and above) then report back the results of these meetings to the ward teams and, where necessary, give constructive feedback.

Examples of incidents discussed at review panels could be a missed medication without rationale, or a missed early warning trigger.

Ward teams then meet to share their observations and experience during the reviews to promptly identify and address any issues that arise. The visit is followed up by a letter from me, and I report back to our board on a regular basis. A large proportion of clinical areas regularly achieve 100% on all standards.

Incident reviews

As part of our drive to develop our patient safety culture, every Monday morning, the medical director and I meet the senior medical and nursing team where we review every incident and death from the previous week.

This has helped us to understand how we perform and events leading up to any incident. Because we review these as a team, we can discuss and debate how best to reduce risk and to support staff to improve processes and systems, or where necessary, to support individual clinicians who may be struggling.

One example of a cause for error or omission has been the fact that things
get missed when nurses write in one document and doctors in another. In response to this, our senior medical and nursing team agreed that we would all write in one document. This happened within six weeks and now all patient records are contemporaneous and contributed to by all professional healthcare staff.

These efforts help everyone at the trust to understand not only the importance of patient safety first, but also the positive impact that their individual practice can have on our organisation.

Case study: career change

Jacqui Hatherall, 45, applied for the apprenticeship scheme to change career.

She had joined the trust in 2007 as a ward clerk on the surgery and urology ward, but realised her ambition was to nurse patients. She is now on the way to completing a two-year advanced apprenticeship.

She says: “Although I enjoyed working as a ward clerk, I wanted a hands-on role caring for patients. The apprenticeship training has helped boost my confidence and made me realise my goals.

“I feel lucky that my placement is on the ward where I was working previously. On a typical day, my duties include taking patients’ blood pressure, helping them get washed and helping to feed them.

“I’d recommend an apprenticeship not just because you learn on the job, but because of the different experiences I have managed to observe.”

Sister Kimberly O’Brien says: “Apprentices bring with them energy and enthusiasm. Jacqui is very keen to learn. It’s brilliant to have the added support from the apprentices.”

Vocational training manager Angela McNeill says: “We see our apprenticeship scheme as being equally beneficial for the organisation and people in the local area. Places are offered not only to the traditional school leavers; existing NHS staff and anyone over the age of 16 can apply.”

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