Delivering Care: Nurse Staffing in Northern Ireland

1. Delivering Care: Nurse Staffing in Northern Ireland Siobhan McIntyre Regional Lead Nurse Consultant PHA Chair of Delivering Care Regional Working Group WSCNTL 2014, Kings Hall Leading Care, Leading Teams - Innovating and Supporting Person-Centred Care

2. Community Nursing Four key principles: • Effectiveness: Timely access • Integration: Collaborative multi-disciplinary working • Efficiency: right person, right place, right time, right service, right outcome • Expertise: Appropriately skilled

3. Mapping the Change in Service Direction • Reduction in inappropriate referral to hospital and NIAS • Reduction in unscheduled care admissions • Increased acute care delivery at home • Consider the needs of the over 65yrs and patient groups for community acute care teams/triage and see and treat protocols. Have an agreed directory of service • Expansion of 24 hour provision in primary care nursing • Developing the right interfaces / secondary + primary care inc diagnostics • Choice of preferred place of care for palliative patients • Nurse led clinics across primary and secondary services • Disease prevention and early intervention • Increased technological interventions

4. The Need to Transform • Safe, effective, person centred care; • Increased demand for efficiency and effectiveness; • Changing population demographics; • Working closely with GPs; • Changing patterns of disease • eHealth / Telehealth; • Changing lifestyle; • Changing public expectations; • Inequalities in health; • Reconciliation in demand, need & access.

5. Commissioning Framework • An integrated vision and framework will be developed and led by the PHA which outlines how district nursing services will be modelled across each HSCT; • The framework will seek out evidenced based and good practice examples for district nursing services to support the targeting of resources at local and regional level. This will take cognisance of population needs and enhance delivery closer to home and improve health and social care outcomes and productivity; • The framework will seek to capture the importance of technology and to promote more effective mobile working practices to support care delivery; • The framework will be based on the principles for core district nurse services aligned to Gps 24 hour provision and the management of acutely ill patients in primary care.

6. ‘The planning, provision and evaluation of appropriate programmes of nursing care, particularly for people discharged from hospital and patients with complex needs; long-term conditions, those who have a disability, are frail or at the end of their life.” (RCN, 2013) • District nurses will be the key professionals involved in planning and providing this care within the following three care domains • Acute care at home • Complex care at home • End of life care at home

8. Workforce Planning in Nursing & Midwifery-what’s happening in Northern Ireland • Policy/Strategy recommendations • DHSSPS Workforce Review 2014 • Delivering care Regional Project for Normative Staffing • Caseload analysis for Community Nursing & Health Visiting • Clinical Nurse Specialist Job Plans • Community Information Systems • 92% female, 44% part time • 773.67 WTE district nursing staff across N.I. • Caseloads > 29,000 patients as at Dec 2013 • Largest professional workforce in HSC • Responsible for continuous care provision • Delegate care to unregulated care workforce • Learning and development requirements > post registration qualifications > uptake on courses to meet TYC requirements • Professional and regulatory requirements

9. Strategic Drivers Regional Policy and Strategy • Transforming Your Care • Quality 20:20 • The People’s Priorities • A Partnership for Care • Community indicators /caseload analysis • Commissioning directions • Integrated Care Partnerships. Evidence Base Related to Staffing Levels and Patient Outcomes • Link to patient outcomes http://www.rn4cast.eu/en/index.php Evidence from Public Inquiries • Francis • Hine Inquiry • Health Committee House of Commons

10. Context

11. Why? • To promote a shared understanding between professional, management, finance and human resources colleagues of the essential components to set and review nurse staffing establishments and when commissioning new services to provide safe, effective, person centred care. • To support general and professional managers in presenting clearly the need for investment in nurse staffing, within changing service profiles, particularly in response to incremental service growth and TYC. • As a reference document for the nurse staffing levels component within investment proposals.

12. Why Define a Range? • Reasonable starting point for ‘conversation.’ • Not as prescriptive as a ratio and for district nursing, it will be essential to consider cover and hours of service for the future model of service for an agreed population range. Ref page 4, 2.10 ‘It is anticipated that on occasion nurse staffing may be outside the normal range. In such cases the Executive Director of Nursing must provide assurances about the quality of nursing care to these patients, and the efficient use of resources through internal and external professional and other assurance frameworks.’

13. Project Structure Steering Group Working Group Additional expertise as required

14. Who are the Partners? • HSCB • HR Reps • PHA • HSC Trusts • DHSSPS • Staff side • PCC Project Aim To support the provision of quality care which is safe and effective in hospital and community settings through the development of a tool to determine staffing ranges for the nursing and midwifery workforce in a range of major specialities.

15. Phases Phase 1 Acute Hospital Settings Phase 2 Emergency Depts Phase 3 District Nursing Phase 4 Health Visiting

17. Process Underpinned by: • Communiqués • Literature reviews/searches • Interviews with HSC Trust Assistant Directors responsible for nursing workforce • Data gathering of current workforce and caseloads • Gathering of international and national intelligence around workforce planning in nursing • Development and production of Part 2 of a framework • External Critical Review • Engagement with stakeholders

18. Project outcomes

20. Delivering Care, Part 1

21. Assumptions of the Framework

22. Planned and Unplanned Absence Allowance What is it? Periods of absence from work, which can be described as anticipated and, therefore, must be factored into the workforce planning process. • Evidence base: • Telford (1979) • Other professions: Consultant Contract Framework (2003) , BASW, UK Supervision Policy (2011) • Auditor General Scotland (2002) • Comprises: • Annual leave • Sickness absence • Study leave

23. Planned and Unplanned Absence Allowance • What has changed since 2002? • Annual leave: • Overall net increase of 16% following Agenda for Change • Study Leave • 56% full time, 44% part time • Increased intensity and complexity of patient care – practice and competence training needs significantly increased • Statutory/mandatory training • Professional/regulatory updates and training in relation to pre-registration nursing and midwifery mentorship • Professional supervision

24. Planned and Unplanned Absence Allowance So.......?

25. Influencing Factors • Competence skill set to work flexibly • Management of absenteeism • Constitution of district nursing teams • Workforce • Activity • Environment and Support • Professional Regulatory Activity • Caseload activity • Referral rates • Visiting patterns • 24 hour services • Throughput • Acuity/Dependency • Seasonal Variations • Geographical areas • Location of care • Population sizes • GP attachment • Skill mix • Compliance with professional regulatory standards • Supervision / Training • Accountability and governance requirements

26. Key Issues • Need to understand how the district nursing service has developed • Review the integration of multi-disciplinary working • Need to review the alignment of core district nurses to GP practices • Requirement to enhance practice knowledge and specialist skills • Develop workforce planning methods

27. Progress • Population and caseload management • Consistent Data/activity collection • Support and care for patients who are unwell, recovering at home • End of life/palliative care • 24 hour provision • Acute care at home • Support and care for independence • Promotion of technology and LTC • Peer Review / Expert Reference Groups • Users views of the service • Communication and Dissemination

28. Measuring Impact and Enhancing the Patient Experience District nurses : • contributing to population health needs • leading care and contributing to healthy communities • working in partnership with social care enhancing the quality of care. • contributing to enhancing the patient experience

29. Key Performance Indicators • Phase 1 • Organisational: • absence rates within nursing and midwifery teams; • normative staffing ranges - including vacancy rates. • Safe and Effective Care: • incidence of pressure ulcers • falls • omitted or delayed medications • Patient Experience: • consistent delivery of nursing/midwifery care against identified need • involvement of the person receiving care in decisions made about their nursing/midwifery care • time spent by nurses and midwives with the patient ‘Should quality indicators begin to fall below the accepted level of achievement, staffing levels should be reviewed as one of the lines of enquiry of attributable causes.’

30. Process for Phase 3 • To conduct an academic literature review on district nursing workforce models; • To build on the work already collated with HSCTs from Ecats; • To build on the commissioning framework developed for district nursing in Northern Ireland; • To liaise with key partners re critical success factors for training and development; • To agree a regional workforce and caseload range for district nursing in Northern Ireland; • To agree the influencing factors as they relate to district nursing practice; • To agree service definitions; • To agree KPIs as they will relate to the workforce planning framework for District Nursing; • To set up user feedback forums for the project.

33. Thank you Siobhan.mcintyre@hscni.net Telephone ; 02871860086 Mobile; 07818556161