THE UK PICU STAFFING STUDY Funded by NIHR Service Delivery and Organisation SDO Workforce Programme

1. 1 THE UK PICU STAFFING STUDY Funded by NIHR Service Delivery and Organisation (SDO) Workforce Programme Dr Janet Tucker

2. 2 Project Investigators Janet Tucker (PI) ] Lorna McKee ] University of Aberdeen Diane Skatun ] Liz Draper ] University of Leicester Nicky Davey ] Gareth Parry ] IHI, Boston, USA Mark Darowski ] Leeds Teaching Hospital Trust Research Fellows: Namita Srivastava, Dawn Coleby, Clare Jackson and Divine Ikenwilo

3. 3 Background NHS workforce with essential skillmix and competencies is central to quality of care Policy goals in 2006 Meet challenging workforce / medical labour market context New ways of working / extended nursing roles

4. *Hewitt et al (2003) NCCSDO Review 4 Background Little evidence to date About how new nursing roles arise About the impact of extended nursing roles on staff and users* Staff views and wellbeing Direct patient care Patient outcomes / user views

5. 5 Aim The study aims to explore the impact of different workforce patterns and skillmix on staff practice and patient outcomes in UK PICUs

6. 6 Objectives Identify extended nursing roles In units with vs without the extended role Compare impact on STAFF Context and HR support for change Staff views & wellbeing Staffing costs Compare impact on PATIENTS Direct care time adjusted outcomes and process of care indicators User views and satisfaction

7. 7 Study Design Mixed quantitative and qualitative methods 3 phases PHASE 1 at all 30 UK PICUs – staffing/skills census PHASE 2 at 12 units – site visits & non-participant observation PHASE 3 at 12 units – prospective comparative study (2007-8)

8. 8 PHASE 1 –staffing census Detailed Staffing Survey (2005/6) Information on extended nursing roles and nurses with additional clinical skills 24 clinical nurse tasks identified

9. 9 PHASE 1 -Skills Analysis Identified which units had nurses performing specific skills. *6 extended respiratory support tasks Altering ventilator settings Chest assessment NB BAL (broncheoalveolar lavage) Initiation of N/I ventilation Planned nurse led extubation End of life extubation Non-bronchoscopic broncheoalveolar lavage Non-bronchoscopic broncheoalveolar lavage

10. 10 PHASE 2: Unit profiles Stratified random sample of units Invite SIX of…..9 with higher extended nursing role Invite SIX of…..7 with lower extended nursing role

11. 11 Methods - Phase 3 Prospective comparative study at 12 PICUs 2007-8 (6 higher vs 6 lower extended nursing skills) Staff workforce, configuration and wellbeing Staff views (42 interviews: 21 nurses + 21 doctors) Staff postal questionnaire (700/1222 respondents (57%)) Patient outcomes and care process PICANet consecutive series - risk-adjusted regression models User satisfaction Parent views (19 interviews) Consultation with user groups for neonatal & adult IC

12. 12 Results: Impact on staff

13. 13 Impact on Staff I The Unit Profiles data / context (2006-7) Compared with lower units, those in the “higher” group tended: To be bigger To have more beds and more beds in cubicles To have fewer junior doctors and more middle grade doctors To report more fluctuations in occupancy/activity To have similar levels of specialist paediatric trained nurses (93%) and around 25% in senior nurse bands To report same or decreased pressures on staffing To report higher quality/recently refurbished facilities for staff and parents

14. 14 Impact on Staff II Staff wellbeing using NHS Staff Survey: (Adjusted for unit-level variation in professional group response) Compared with lower units, staff from higher units were significantly more likely to report: Working extra hours (paid and unpaid) (77% vs 66%) Suffering work-related stress (36% vs 24%) Having a higher mean work pressure score (3.13 vs 3.01) But conversely Recognised their management’s supportive approach to work-life balance (3.36 vs 3.23) No other differences in reported team working, job satisfaction or intention to leave

15. 15 Impact on Staff III Staff views from interviews Themes arising in both types of units included: good team working, poor skills in in-coming nurses and doctors, training, communication, perceptions of extended nursing roles & professional roles, local HR initiatives to support staff Many barriers to extended and advanced nursing roles Recruitment and retention difficulties re: highly skilled nurses Marked context and regional variation in workforce supply Widely different views held by staff within units about extended and advanced roles

16. 16 Demarcation boundaries between professional groups

17. 17 Results: Impact on patients/users

18. 18 Results: Impact on Patients I- Direct nursing care time Total observation time (min) 2585(lower) vs 2969(higher) Direct care time nurses 67% (lower) vs 71% (higher) OR 1.22 (0.65-2.3, p=0.53) Direct care time doctors 13% (lower) vs 9% (higher) OR 0.80 (0.32-1.99, p=0.62) NB: Wide variation between units within higher/lower gp

19. 19 Results: Impact on Patients IIClinical process of care indicators

20. 20 Results: Impact on Patients III- Parent/user views All parents interviewed in the units were very positive about the units, staff and care teams delivering the best care possible for their child. Roles of doctors and nurses ill-defined by parents. Only one account described nurse making changes to care: acceptable if minor and if nurse highly skilled and experienced. (Some PIC, NIC and adult IC users groups disagreed with nurse substitution and of blurring roles between nurses and HCAs) Parents hesitant to mention and tended to excuse any shortcomings No discernable differences in parents views when comparing interviews from higher or lower units

21. 21 Conclusions Impact on patients No significant impact of extended nursing roles on direct care time or processes of care tested Impact on staff Higher units enthusiastic about a tier of skilled nurses in substitution for trainee doctors Staff recognise many barriers: yet to achieve Widely differing staff views about professional roles Extended nursing roles may adversely affect staff wellbeing Policy and practice Training nurses and medical trainees Nationally agreed extended skillset for nurse workforce One model may not fit all local labour markets Impact on patients No significant impact of extended nursing roles on patient direct care time or care measures here – but caution about assuming equivalence Queries remain around acceptability to users Impact on staff Culture of higher units enthusiastic about a tier of skilled nurses in substitution for trainee doctors: but yet to achieve Widely differing staff views about professional roles and extended roles within units Extended nursing roles may adversely affect staff wellbeing Policy and practice Training nurses and medical trainees is key Nationally agreed extended skillset for nurse workforce skills development to avoid local professional demarcations that varyImpact on patients No significant impact of extended nursing roles on patient direct care time or care measures here – but caution about assuming equivalence Queries remain around acceptability to users Impact on staff Culture of higher units enthusiastic about a tier of skilled nurses in substitution for trainee doctors: but yet to achieve Widely differing staff views about professional roles and extended roles within units Extended nursing roles may adversely affect staff wellbeing Policy and practice Training nurses and medical trainees is key Nationally agreed extended skillset for nurse workforce skills development to avoid local professional demarcations that vary

22. 22 Acknowledgments All PICUs, and especially those collecting data in Phase 3: Birmingham, Manchester, St Georges, Leeds, Newcastle, Leicester Glenfield, Leicester Royal, Liverpool, Nottingham, St Mary’s, Kings, Edinburgh. Parents and User groups PICANet NHS Staff Survey Team (Aston University) Project advisory group PIC Nurse Managers group

23. 23 NIHR Service Delivery and Organisation (SDO) programme For Final Report see: http://www.sdo.nihr.ac.uk/sdo962005.html