Filling the gaps in a nurse practitioner workforce
James Bird describes a project using innovative approaches to provide a service in an urgent care centre
Using an innovative approach to provide a service in an urgent care centre, and the significant cost improvement this provided.
The recruitment of senior, experienced staff in emergency nursing is challenging for organisations across the UK. Frequently, there are insufficient numbers of suitable candidates to fill senior posts, and sometimes experienced senior nurse practitioners are unwilling to return to substantive employment when agency working offers greater flexibility and remuneration.
This article describes an approach taken to tackle a significant gap in the practitioner workforce in an urgent care centre (UCC). UCC nursing staff were provided by an external provider, but with vacancies it could not fill and an escalating agency bill of around £170,000 a month, the provider withdrew from the contract.
This left the trust with a 100% vacancy rate in the UCC, with 18 whole time equivalent emergency nurse practitioner (ENP) posts unfilled. Because of this, the trust provided the UCC service through ably qualified and experienced agency locum practitioners, while attempting to recruit permanent staff. However, recruitment was unsuccessful and, with the locum costs projected to reach £900,000 over the financial year, an alternative strategy was required.
The trust decided to look at training its own workforce. Traditional ENP training involves completing a six-month university course to learn minor injury management and a further six months at university to learn minor illness management. During this time learners cannot practise independently so the trust would have had to continue to employ locum staff to run the UCC. Only a few staff could be trained through the traditional route while maintaining the service, due to cost, and it would have taken between four and six years to achieve full staffing.
The trust employs two nurse consultants in emergency nursing: both are experienced ENPs and one is a widely-published author with a focus on minor injury and illness management. The trust also had an employee who had been the module leader on the minor injury course at the local university. This combined knowledge allowed the trust to design an in-house practitioner programme, that met the same standards as the external academic provider. The programme was based on a work-based learning approach, in collaboration with the local university, which provided credit on completion of a piece of academic work.
Developing a practitioner workforce required upfront investment, on an ‘invest to save’ model. The total cost for the work-based learning through the university was £6,750, a saving of £30,650 from the cost of training everyone on university courses. The cost of employing trainees for the three-week course totalled £43,697.
After completion, the practitioners worked under supervision in the UCC, so locum staff were not required on these shifts, but continued to cover night and weekend shifts. This also made a cost saving, but it was only when the objective structured clinical examinations (OSCEs) were complete and the practitioners became fully qualified that a significant improvement in agency costs was seen. An average monthly saving of between £80,000 and £100,000 was achieved after the practitioners qualified. Since then locums have been used only to cover sickness and the cost savings have continued.
Identifying the potential workforce
It was decided that to qualify for interview, potential trainee practitioners would require between two and three years’ experience of undertaking acute patient assessments, with non-differentiated and undiagnosed conditions, in an emergency department (ED), although those with other clinical backgrounds, such as pre-hospital care, were also considered. In addition to nursing staff, the training programme was open to paramedics, and physiotherapists who specialised in musculoskeletal practice. This acknowledged the range of professional backgrounds suitable for working as an emergency practitioner. For this reason, the title ‘nurse’ was removed from the job description, and the requirement for professional registration was expanded to the Health Care Professions Council. From this point, the workforce was described as emergency practitioners.
External recruitment was undertaken through NHS Jobs, and a social media campaign across London and the South East. 127 people applied for 17 training posts, and 16 of these candidates were selected. Staff from the trust’s EDs also applied, and they were accepted on the condition that they would work 50% of the time in the UCC, and 50% in the main ED. This ensured that no clinical area was depleted of staff, and maintained the seniority of staff in the ED. Finally, the UCC workforce comprised eight paramedics and eight nurses; a physiotherapist has since also joined the team.
The training consisted of four phases. First, an intensive, three-week lecture period, during which trainees were taught the theory of a range of minor injury, and minor health-related presentations. Lecturers included qualified ENPs, nurse consultants, and GPs.
The second phase involved between two and three months’ supervised practice in the UCC. During this time, trainees managed their own patients, who were then reviewed by senior staff before discharge. The trainees also completed a practice log book, which detailed the number patients with particular clinical conditions they were required to manage under supervision.
The third phase was a clinical OSCE, during which trainees were presented with two unknown case studies, one an illness and one an injury, and their examination and management techniques were observed against marking criteria. External examiners were used for this element, to ensure assessment was objective and so that quality was maintained, and two healthcare assistants from the main ED acted as the patients.
The fourth phase was an academic work-based learning component through one of the trust’s partner universities. This has given the trainees academic credit that they can use for further study, such as through a master's degree, if they want. The credits provided by the university ensure that their training is equivalent to that of other UCC practitioners.
Sustaining the workforce
Once a workforce is qualified to manage patients independently, there is a temptation to stop development, and consider the job done. However, this could lead to disengagement and ultimately staff might leave the service, so development of the emergency practitioner workforce is ongoing. The trust’s nursing rotas include a percentage of study leave and, in the UCC, this time is used to build up the new practitioners’ skills, consolidate their learning and slowly expand their scope of practice. There is also a monthly study day attended by half the staff, during which patients they have managed are discussed and training is provided.
Novel approaches to recruitment can bring positive results, in terms of developing and maintaining a skilled, engaged workforce, which consequently improves patient care, and makes costs savings. The skills the UCC practitioner team has learned are transferable to other urgent or primary care services across the healthcare spectrum, so this may prove an attractive method of training staff in the future.
Other care providers could implement similar training programmes; the main element required is a senior nurse consultant practitioner who can provide teaching. Investment in the senior workforce, who can educate and lead practitioner services, is part of an ‘invest to save model’, and ultimately can result in cost savings and better patient care.