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Tomorrow’s nurse: how other staff might fill gaps in the roster

A director of nursing sparked controversy by suggesting she may substitute nurses with other staff because her NHS trust is struggling to recruit. Does she have a point and what other options do managers have?

A director of nursing sparked controversy by suggesting she may substitute nurses with other staff because her NHS trust is struggling to recruit. Does she have a point and what other options do managers have?

Nurse substitute©Daniel Mitchell
Picture: Daniel Mitchell

A trust struggling to recruit nurses sparked a heated debate after revealing it may use a range of other professionals and support staff to fill gaps in nursing rosters.

Julie Smith, chief nurse at University Hospitals of Leicester NHS Trust, said she was considering role substitution as the trust remains unable to fill 500 nursing vacancies.

The trust has set up a project called Tomorrow’s Ward to consider whether other staff, including health professionals such as pharmacists and therapists, could fill some of the posts.

Julie Smith
Julie Smith, whose trust has set up
the Tomorrow’s Ward project.

After facing criticism over the plans, Ms Smith said in a statement in October: ‘To be clear, this is not an exercise to save costs and we will not undermine the need for registered nurses on our wards, but there just are not enough registered nurses, and every trust is finding this a challenge.

‘Some of our registered nurses are doing tasks they don’t need to do, like cleaning bed spaces and giving out drinks – things other people can be trained to do.’

Among the difficulties the trust has faced is the high retirement rate among an ageing nursing workforce and the loss of more than half of its 440 European nurses.

‘Nurses are doing tasks like cleaning bed spaces and giving out drinks – things others can be trained to do’

Julie Smith, chief nurse at University Hospitals of Leicester NHS Trust

An international recruitment process has identified 200 nurses willing to travel from India and the Philippines, but the trust says they are struggling to achieve the strict English language standards set by the Nursing and Midwifery Council.

Many nurses discussing the issue on Nursing Standard’s Facebook page were unhappy about a potential dilution of nursing skills due to role substitution. But some said other staff such as pharmacists could bring valuable skills to the caring team.

Impact of nurse shortage

The discussion ignited by Leicester Hospitals is likely to be watched closely by managers in other organisations as they attempt to respond to the nursing shortage.

In May, the RCN said there were 40,000 nursing vacancies in England alone, while in July the NMC said that for the first time more nurses were leaving the register than joining it. The number of EU nurses seeking registration has plummeted since the Brexit vote in June 2016, but the main factor in the downward trend is the number of UK nurses and midwives leaving the profession.

Staff shortages have been reported around the country, including in Care Quality Commission reports. Stockport NHS Foundation Trust was strongly criticised by the care watchdog in October and instructed to ‘ensure there is an adequate skills mix on all medical wards and that staff have the right level of competence to effectively nurse the patients’.

For nurses working in overstretched and understaffed settings, the impact of too few staff is likely to include exhaustion, stress and unsafe care. But employers find themselves struggling to find a solution.

‘The best organisations will speak to staff on the front line as they will have a good grasp of how things might be organised differently’

RCN head of employment relations Josie Irwin

RCN head of employment relations Josie Irwin says she has some sympathy with trusts trying to recruit more nurses. But organisations need to react in the right way rather than seeing it as an opportunity to increase numbers of cheaper, unregistered staff, she says.

Josie_Irwin©BN
RCN head of employment relations
Josie Irwin. Picture: Barney Newman

‘The best organisations will speak to staff on the front line as they will have a good grasp of how things might be organised differently in a way that isn’t going to mean role substitution, but a more effective way of doing things,’ Ms Irwin says.

‘However, not all organisations are doing things the right way. Some are turning to different roles and starting to look at ways they can recruit people to do things more cheaply and ensure that they have bums on seats, rather than the right balance of registered and unregistered staff.’

At the Conservative party conference in October, health secretary Jeremy Hunt announced a 25% boost in funded placements for nursing students and said an additional 5,500 nursing associates will be trained each year by 2019 at the Conservative party conference in October. This band 4 support role, of which 2,000 were due to start training in 2017, will be regulated by the NMC.

Scale of the shortage

This role is intended to bridge the gap between healthcare assistants and nurses. Nursing associates will have two years of training, including on the job and at universities and colleges. But the first cohort is not due to qualify until January 2019, and they will not be trained to the same level as a nurse. In any case, their numbers are dwarfed by the scale of the nursing shortage.

Research points to the importance of having enough registered staff on the front line. A large European study by the University of Pennsylvania, King’s College London and the University of Southampton, published in 2017, showed that replacing professional nurses with nursing assistants was linked to a heightened risk of deaths.

The study, published in BMJ Open, found that for every 25 patients substitution of just one nurse was associated with a 21% rise in the odds of dying in a hospital with average nurse staffing levels and skill mix.

‘Diluting skill mix can negatively impact quality of care, patient outcomes and nursing productivity’

King’s College London professor of nursing policy Anne Marie Rafferty

It said the nursing skill mix in England varies from 79% registered nurses to 47%, with an average of 57% – one of the lowest in Europe.

King’s College London professor of nursing policy Anne Marie Rafferty, who was involved in the study, says it’s hard to know where role substitution is taking place. ‘Evidence indicates that diluting skill mix by whatever means can negatively impact quality of care, patient outcomes and nursing productivity,’ she says.

Anne-Marie_Rafferty©JB
King’s College London professor ​​​​of
nursing policy Anne Marie Rafferty.
Picture: John Behets

‘I am not sure how pervasive direct role substitution might be because it is difficult to ascertain, but we do know that there are high levels of registered nurse vacancies across the NHS, so it is possible that trusts are recruiting nursing associates where registered nurse recruitment and retention is particularly pressured.’

Skill mix

There is a debate among employers about whether the new nursing associate role should be included on the nursing side of the skill mix ratio. Skill mix is often broken down into registered and non-registered staff, and it is unclear where the regulated nursing associate will fit in.

Cardiff and Vale University Health Board executive director of nursing Ruth Walker says its large acute and community organisation is running a campaign aimed at filling 95% of band 5 roles with permanent staff. It currently has just over 90% of band 5 posts filled.

‘We are probably in a better position than many, and having a workforce plan that is clear about what is required is crucial, so we can be clear about what our commissioning numbers are,’ Ms Walker says.

‘If the registered nurse workforce isn’t there, we need to think where we most need to deploy them’

Cardiff and Vale University Health Board executive director of nursing Ruth Walker

But even with such a focus, recruitment is undoubtedly a challenge for the health board and many others, and employers will have to use their workforce differently in the future, she says.

The nursing associate role is not being introduced in Wales, and a legal requirement from next April for safe nursing levels on some adult wards is likely to add to staffing challenges, according to senior nurses and RCN Wales.

‘It is about looking at ways that we deliver services, and we have spent a lot of time trying to prevent older, frail patients coming into hospital as they can quickly lose their independence,’ Ms Walker says. ‘If the registered nurse workforce isn’t there, we need to think where we most need to deploy them.’

What nurses revealed about their last shift

An RCN survey asked 30,000 nurses about their last shift and published the results in a report called Safe and Effective Staffing: Nursing Against the Odds. The findings included the following:

  • 55% of respondents reported a shortfall of registered nurses.
  • 41% of shifts were short of healthcare support workers.
  • 20% of registered nurses were temporary staff.
  • The skill mix in acute settings has been diluted over the past seven years.
  • More than half (53%) said care was compromised on their last shift.
  • 36% said they had to leave care incomplete due to lack of time.
  • 44% said no action was taken when they raised concern about staffing levels.

To read the report click here


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