Many wards employ temporary staff, costing the NHS up to £50m a year. Do they affect working styles or quality, and do they provide value for money?
In this article…
- An overview of temporary staffing on UK wards
- The impact of these staff on ward working styles, nursing quality and staffing costs
- What to monitor when using bank or agency staff
Keith Hurst is independent researcher and analyst, Nottinghamshire.
Hurst K (2011) Are temporary ward staff cost effective? Nursing Times; 107: 37, early online publication.
Background Temporary staff cost the NHS a significant amount, which is unlikely to fall in the near future. What is their effect on care and cost?
Aim To compare staff activity, cost and service quality in wards with and without temporary staff, and highlight issues that ward managers need to monitor.
Method Data on patient dependency, nursing activity, workload, staffing and quality was collected for 959 NHS wards; 659 wards had permanent staff only, while 300 had permanent, bank and agency staff.
Results Workloads and absence on wards with temporary staff were greater than on those with permanent staff only. Staffing levels on the former were lower, and working styles and quality scores differed.
Conclusion Ward managers should monitor temporary staffing, and its effect on ward staff activity and nursing quality.
Keywords: Temporary staff, Costs, Quality, Nursing activity
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article
5 key points
- More than half of UK nurses do temporary work
- Wards with permanent staff only have less sickness absence and are better staffed
- Wards with permanent and temporary staff have a greater workload than those with only permanent staff
- Permanent staff-only wards have higher ward quality scores than those that also have temporary staff
- Ward managers should monitor temporary staffing and its effects
More than half of UK nurses have undertaken temporary work and around 60% do unpaid overtime (National Audit Office, 2006; Royal College of Nursing, 2006; Healthcare Commission, 2005).
There are three main types of additional nursing staff employed in the NHS – bank, agency and permanent staff working overtime. At any one time, 4.8% of nurses and 6% of support workers are off sick (NHS
Information Centre, 2011). Unfilled and frozen posts also mean managers must use temporary staff (NAO, 2006; Buchan, 1992). This is costly; the average daily ward staffing cost per occupied bed is £189, of which 10.5% is temporary staffing (Skills for Health Workforce Projects Team, 2011).Agency staff are less familiar with wards, which can lead to lower patient satisfaction, more complaints and more drug errors. High-quality care depends on teamwork, and teams can be destabilised by temporary staff (NAO, 2006).
This study aimed to determine the effects of temporary staff on working styles, nursing quality and staffing costs.
The UK nursing database (Skills for Health, 2011) holds data on 1,145 UK wards. We extracted wards using permanent and temporary staff during our observations. After matching their specialties with permanent staff-only ward specialties, we had with 300 wards with permanent and temporary staff (P&T wards) and 659 with permanent staff only (P-only wards). Four main data sets were collected for each ward:
- Patient dependency: this helped to determine whether P&T wards and P-only wards had different case mixes;
- Nursing activity: categorised as direct care, indirect care, hotel-type work and personal time, this data helped to explore whether staff work differently in P&T and P-only wards;
- Nursing quality: around 800 quality standards were tested for each ward to determine whether nursing quality differs between the two ward types;
- Ward staffing and time out data: this helped compare P&T and P-only ward establishments and costs.
Four areas were analysed: the number of full-time-equivalent (FTE) staff per occupied bed, patient dependency and workload, ward staff activity, and quality scores.
FTE staff per occupied bed
The study findings show that P-only wards have 12% more staff than P&T wards, have a better skill mix and experience less staff absence (Table 1). Managers hiring temporary staff are more likely to employ support workers, diluting the skill mix. While P&T wards cost 18% less than P-only wards to run, the costs given here exclude P&T back-office activity and agency charges so P&T costs are likely to be higher than shown.
Patient dependency and workload
P&T wards had more medium-dependency (dependency 2 and 3) patients than P-only wards, so had a higher workload index (3.3 vs 2.6, Table 2). Workload, calculated using dependency mix and direct care time, is the equivalent number of dependency 1 (low dependency) patients in each bed. It seems that hiring temporary workers in P&T wards is justified.
Ward staff activity
Table 3 summarises P-only and P&T ward staff activity as a percentage of time spent on all activities. This indicates that P&T ward staff spend longer on indirect care than hotel-type work and personal time. Handover time with temporary staff takes longer on P&T wards than on P-only wards. This raises the question whether this makes the best use of expensive nurse time. On understaffed wards, workers have less “breathing time”.
Ward quality scores
Quality scores are consistently higher on P-only wards than on P&T wards (Table 4). However, while P&T wards had higher workloads and were less well staffed, they had the same quality score as P-only wards for hands-on care.
The main findings are not surprising; managers on understaffed wards with high workloads are more likely to hire temporary workers. Is this cost effective?
The consistently lower quality scores are worrying. Around four additional nursing interventions per 100 in P&T wards did not meet the required standard compared with P-only wards. This could be related to heavier workload, understaffing and a more diluted staff mix.
Since we did this analysis three years ago, the gap between P-only and P&T FTEs per occupied bed has widened significantly, so ward managers employing temporary workers need to be extra vigilant. NT
This article is a summary of Hurst K, Smith A (2011) Temporary nursing staff – cost and quality issues. Journal of Advanced Nursing; 67: 2, 287–296.
Buchan J (1992) Using agency nurses in the NHS. Nursing Standard; 6: 20, 29.
Healthcare Commission (2005) Ward Staffing. London: Healthcare Commission.
National Audit Office (2006) Improving the Use of Temporary Nursing Staff in NHS Acute and Foundation Trusts. London: The Stationery Office.
NHS Information Centre (2011) Sickness Absence Rates in the NHS: October-December 2010. Leeds: NHS Information Centre.
Royal College of Nursing (2006) Policy Guidance 15/2006. Setting Appropriate Ward Nursing Staffing Levels in NHS Acute Trusts. London: RCN.
Skills for Health Workforce Projects Team (2011) Nursing Workforce Planning Tool. Manchester: Skills for Health.