Nursing Workforce Standards - case studies

Mark Butler is RCN West Midlands Regional Board Chair and has been a steward for more than 20 years.

"The RCN’s Nursing Workforce Standards are proving to be a fantastic resource and I’ve been able to use many of them in my work representing members. I recommend them to all RCN reps as part of their toolkit, as I think it’s one of the best documents we’ve ever produced.

I had one case involving a member who was a very experienced and dynamic ward sister. In the middle of the pandemic, she moved from a hospital setting to a very busy community-based team, where she was given a case load, but no support or help to settle in. In her new role, she followed a policy that applied in hospitals, but there was no equivalent in the community setting. This resulted in a complaint and my needing to represent her.

As her health was being adversely affected, I was able to cite Standard 13 which talks about how the nursing workforce is entitled to work in healthy and safe environments. Standard 10 was also useful, as it talks about how more senior staff, who are taking on additional or different roles, need a period of preceptorship until their competence and confidence are achieved. As a result of my intervention, managers decided there was no case to answer and she returned to work, receiving her back pay and a formal apology.

Another case involved a healthcare support worker, who worked night shifts on an acute mental health admissions unit. There was an incident where a fire alarm was activated as a prank, during a very busy time. She was disciplined over a complaint that she shouted at a patient, but it was to make herself heard above the noise of the alarm. The consequences of facing a disciplinary included losing such a large amount of her wages she was forced to start using food banks.

In my role representing her, I was able to talk about the qualities of good leadership, referring to the introduction in the standards document, which says: “Nursing leadership must embody compassion both in style and behaviour towards the staff they lead.” I also cited Standard 12, which talks about how leadership should support and nurture psychological safety and Standard 10, with its focus on staff working within their scope of practice. Eventually the case was dismissed and she returned to work, with the opportunity to have more training, helping her career pathway.

When I’m delivering preceptorship training, I also use Standard 8. We talk about how you manage a ward using staffing; how you judge that staffing; and how ward managers should build in enough practice time for mentors, preceptors, learners and students.

These standards are helping to create lasting change, with my trust working towards a new and improved system that is altering how we deal with a range of issues, including absence management, disciplinaries and performance. This has come about through my repeatedly asking managers to show how they are complying with these standards. We know they are studying them closely, especially those elements around responsibility, accountability, staffing and leadership.

I think it’s demonstrated to managers that the RCN’s approach is more robust than ever. This says: these are the standards we expect as a minimum. And as an employer, if you’re not meeting them, you need to be prepared to be challenged."

Which Nursing Workforce Standards did Mark used to help members?

• Standard 8: When calculating the nursing workforce whole-time equivalent (WTE), an uplift will be applied that allows for the management of planned and unplanned leave and absence. “Underestimation of either or both planned and unplanned leave will result in an establishment that cannot meet day to day staffing requirements,” says the standard. “…over reliance on supplementary staffing, such as bank and agency staff, will impact on overall costs and quality of care.”

• Standard 10: Registered nurses and nursing support workers must be appropriately prepared and work within their scope of practice for the people who use services, their families and the population they are working with.

• Standard 12: The nursing workforce should be treated with dignity, respect, and enabled to raise concerns without fear of detriment, and to have these concerns responded to.

• Standard 13: The nursing workforce is entitled to work in healthy and safe environments. “Health, safety and wellbeing is more than just the absence of work-related disease or injury rather, an emphasis on achieving good physical and mental health amongst the nursing workforce,” says the standard.

Lena Johnson manages a respiratory ward, where she has been caring for patients with COVID-19 since the pandemic began. 

I first heard about the RCN’s Nursing Workforce Standards when I was invited to a conference about safer staffing. For my nursing team, who have gone through two very difficult and demanding years, the section that talks about wellbeing is really important. I’m using these standards to help support staff, thinking about what we can offer to help them. 

Staff have been through a great deal of trauma that stays with them. At one point during the worst of one of the waves, we had 20 patients who were ventilated on our ward. I’ve never seen so many ill patients in one place. I still remember coming into work one day and losing six patients, one after another. On a ward like ours, you would usually have one patient die every couple of weeks. We need to acknowledge the impact all of this continues to have on the 50 nursing staff I manage. It has been very tough - but at least we can see a big contrast now, with vaccination driving down the numbers of those who become really sick.

I’ve always been passionate about staff wellbeing and seen it as highly important. But during the pandemic it became very obvious to me that, as ward manager, I needed to work on it from day one. At the beginning, every member of staff was in action mode, but I knew as soon as there was a lull, we would see a lot of cracks appearing, with staff starting to struggle. 

Over the last couple of years, people have become much more used to opening up about mental health, although in some cultures it can still be a taboo subject, with talking about it seen as a sign of failure. With their clear recommendations and focus on good practice, the RCN standards have really helped me to address this issue with my staff, who come from a variety of international backgrounds, validating what I’m trying to achieve. 

On our ward, we have a clinical psychologist providing face-to-face support once a week, with staff able to book time directly or via occupational health. We also offer care spaces, where four or five staff come together to discuss whatever might be worrying or stressing them, working towards finding solutions. In addition, professional coaching is helping small groups of staff manage their stress and learn from difficult experiences. Discussions around mental health and wellbeing have now become part of the norm and something we do every week. Knowing that you are not alone, and what you’re feeling is completely normal, is reassuring. 

Standard 11 talks about making sure rostering patterns take into account best practice. As I want as many people as possible to be able to come to our ‘Wellbeing Tuesday’ sessions, I enable staff to work half shifts, so they can attend either at the beginning or the end of their work. There is senior buy-in for this, including from the chief nurse. 

The standards give me ideas for things I can do better or begin to introduce. It also reassures me that I’m doing the right thing for my staff, which in turn has a positive impact on the care we can give to our patients. These standards are providing a blueprint of what we all need to be aspiring towards.

 

Which standards are helping Lena support her staff's wellbeing?

• Standard 11: Standard 11: Rostering patterns for the nursing workforce will take into account best practice on safe shift working. Rostering patterns should be agreed in consultation with staff and their representatives.

• Standard 14: Standard 14: The nursing workforce is supported to practice self-care and given opportunities at work to look after themselves. This says: “The health and wellbeing of nurses is fundamental to the quality of care they can provide.” 

Wendy Preston is the RCN’s Head of Nursing Practice. She is also an honorary consultant nurse at George Eliot Hospital in Warwickshire and an advanced nurse practitioner in 111/out-of-hours care for the independent sector.

Making sure that the RCN’s Nursing Workforce Standards are grounded in reality has been important to me from the very beginning. In my honorary role - as a consultant nurse in a district general hospital - I’m able to check in with nursing leaders and colleagues, explaining what we’re trying to do and seeking their views about what they think will work in practice.

From my first-hand experience, I can see the huge pressures that nursing staff are still facing, as the pandemic’s impact continues. The last thing we want to do is make that worse, by setting goals that feel unattainable. But it’s important the RCN sets standards based on what is needed, rather than what’s currently available.

For me, one of the crucial standards is the first one, which says that every organisation’s chief nurse should be at executive level, with any exceptions seen as outside the norm and documented. If organisations want to see real nurse leadership in action, with all the benefits that brings, this has to be what happens.

We’re the largest profession in the health and social care workforce. An organisation’s lead nurse must be sitting at the top table, so nursing is always on the agenda and their voice has equity and can be heard in vital discussions about the nursing workforce. How can you campaign and influence on behalf of nursing staff, if you’re not representing them at the highest level?

Another key standard is 6, which talks about how nurse leads should be supervisory, rather than rostered. I’ve witnessed examples of vast variation across countries, regions and settings. From nursing establishments that allow 100% supervisory nurse leadership, to nurses being expected to lead teams, while rostered as a registered nurse for the majority of their shifts.

While we know that good practice in leadership comes from having the time to do it properly, we also understand what a challenge this can be, especially on busy wards that face almost constant difficulties with staffing. But just because it’s hard to achieve, doesn’t mean it’s not right to aim for it.

Our standards must be both aspirational and realistic. Sometimes that means working towards a goal, a few steps forward at a time. In practice, what we’ve seen is nurse leaders - including ward managers - creating a business case towards achieving 50% of their time being spent as supervisory, eventually building towards 75% and then the whole time, enabling them to achieve standard 6.

So far, feedback has been very positive, with nursing staff understanding that these standards can drive real and positive changes locally, in all settings, using national standards and guidance. They support achieving staffing for safe and effective care.

For me, it’s like splashing a pebble into a pool of water, with the ripples slowly getting bigger. It’s a long journey, but we need to keep going, constantly sharing our progress.

Which Nursing Workforce Standards did Wendy used to help members?

• Standard 1: Executive nurses are responsible for setting nursing workforce establishment and staffing levels. All members of the corporate board of any organisation are accountable for the decisions they make and the action they do or do not take to ensure the safety and effectiveness of service provision. It says: “Leaders responsible for contracting or commissioning services have a duty to ensure there is a nurse at executive level within an organisation’s governance structure.”

• Standard 6: A registered nurse lead must receive sufficient dedicated time and resources to undertake activities to ensure the delivery of safe and effective care. “In the majority of large organisations this registered nurse lead will be supervisory and not rostered as part of the nursing workforce allocation,” says the guidance.