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Setting standards for planning off duty and audit of practice

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Linda Walker, MA, BSc, RNT, RGN, is head of nursing surgical services; Anne Minchin, MA, BA, DipN, RGN, is modern matron surgical services; Jane Pickard, BA, RGN, ITEC, DipN, is modern matron surgical services;all at University Hospital Leicester NHS Trust.


Drawing up the off duty is an essential management skill. However, because this tends to be passed from nurse to nurse, many nurses have not had formal training in off-duty planning. As a result some nurses may be unprepared for the impact of national policies such as Agenda for Change (Department of Health, 2005) and efficiency programmes on the way they manage off duty.

The off-duty (rostering) system is often used as a forward-planning tool but rarely as a monitoring and evaluation tool. This is where managers have lost a valuable opportunity to examine if they have rostered adequately and if there is room for improvement.

Off-duty standards

The following standards were agreed between all ward sisters/charge nurses, matrons and the head of nursing for the surgical services directorate to standardise the way off duties were managed.

In planning the off duty, it was felt that the following were important to the clinical (ward) areas:

- A minimum of four weeks’ off duty to be complete at any one time;

- There should be a date when the off duty is completed - this needs to be clearly recorded so that the above standard can be measured retrospectively;

- The off duty reflects the minimal acceptable staffing levels (agreed with the matron/head of nursing);

- The nurse in charge of a shift is clearly identified;

- Staff on annual leave, maternity leave and study leave are clearly identified - no ward should have more than 21% whole-time equivalent (WTE) staff off on these manageable absences at any one time. There may be circumstances where working within this limit may not be possible. Ward managers need to be mindful that AfC (DH, 2005) has increased annual leave requirements.

Staffing utilisation standards

Guidance for each trust is different. The accepted norm for staff absence in the UK prior to AfC was:

- Annual leave 13.5% (fixed);

- Maternity leave 1% (will vary);

- Sickness 5% (will vary);

- Study leave 1.5% (will vary);

- Total 21%.

AfC has had a significant impact. To keep the total absence percentage the same under AfC, some organisations have adjusted the amount of study leave (and budget) as follows:

- Annual leave 15.4% (fixed);

- Maternity leave 1% (will vary);

- Sickness 3.6% (will vary);

- Study leave 1% (will vary);

- Total 21%.

The only way to keep an element of study leave for mandatory training and professional development is to manage sickness. This brings benefits such as reducing the need for agency and bank nurses. However, it is acknowledged that some areas rely heavily on bank and agency staff and policy changes such as those described above will have a significant impact on the cost to the organisation (and ward budget) in ‘backfilling’ for this increase in annual leave entitlement.

A set of standards for off duty were agreed:

- The requests in a request book are just that - requests. The priority is to cover the ward and requests must be flexible;

- There should be a recognised system in place for the authorisation of annual leave and study leave to ensure all staff are treated equitably;

- Requests to the nurse bank office must follow trust policy. An accurate record of when bank requests are made and when shifts are filled should be kept at ward level;

- Records of nursing students’ off duty should be kept separately from the ward off duty as they are supernumerary and should not be counted in the ward numbers;

- The off duty should comply with the bleep-holding rota as this ensures that staff carrying the bleep for the unit are on duty;

- A copy of the off duty should be in the bleep folder to allow the person covering the unit easily to identify which staff are where;

- Copies of the off duty should be submitted to the matron as this allows the matron to identify any particular issues on a ward;

- Once the off duty has been completed, all changes/amendments should be authorised by the deputy sister/ward sister/charge nurse only. These changes are to be signed and dated;

- Sickness/absence should be clearly identified on the off duty entry and must be signed and dated recording the number of hours lost;

- The total number of hours taken in annual leave must be recorded on the off duty against the staff member taking the leave;

- The total number of hours taken in any type of leave must be recorded on the off duty against the staff member who has taken the leave;

- Weekly sickness and vacancy reports should be sent to the head of nursing.

It was decided to audit the off duty against these standards every three months. A tool was devised (Table 1) to achieve this.


After the standards were drawn up, ward sisters became responsible for auditing their wards’ off duty. Following a few incidents of staff shortages suggesting that standards were possibly not being adhered to, it was agreed that matrons would carry out a snapshot audit of the off duties using the tool.


The audit was carried out across 21 surgical wards across three hospital sites - Leicester Royal Infirmary (LRI), Leicester General Hospital (LGH) and Glenfield General Hospital (GGH) - on 20 and 23 May 2005. The off-duty standards audit tool was used to evaluate compliance with the standards and highlight areas for improvement or development.


The results are shown in Table 2. It was decided that the following questions would not be audited:

- Within the identified desirable staffing level for the ward, are there sufficient staff to meet this requirement over a one week period?

- If not, where are the total number of shifts that are not covered adequately and how many shifts show a shortfall?

- Is there a clearly defined reason for this shortfall?

- Do the number of staff exceed the identified desirable staffing level?

- If so, how many shifts show excess staff?

- Is there a clearly defined reason for this excess?

- Do the manageable staff absences (study/maternity/annual leave) on any shift exceed 21%?

- If so, is there a clearly defined reason for this?

It was felt that due to the complexity of some of the clinical areas, this part of the audit needed to be the responsibility of the ward sister/charge nurse to work with their own matron, as each ward would have its own numbers and skill-mix requirements.


Overall, it was concluded that the completion of the off duty was not well managed and there were areas for improvement. These included:

- Dating and signing amendments to rotas;

- Identifying the nurse in charge;

- Recording sickness and absence not only in red ink but also in hours;

- Totalling all absence.

It was disappointing and worrying to find that it was difficult for a manager/matron from one clinical area to look at an off duty rota from outside their own ward areas and work out what was happening without asking. Many wards presented their off duty in different ways and used their own abbreviations and codes or symbols.


Even though off-duty standards were developed for the surgical services directorate, it was clear from the audit that those standards were not always adhered to.

The most worrying finding was that amendments to the off duty were not dated and signed, which would make it very difficult should the records need to be scrutinised in the future, for example to see who was on duty at the time an adverse event occurred.

Further work needs to be carried out with the ward sisters/charge nurses to address some of the shortfalls identified by this audit.

This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see

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