Experienced Nurse Rotation Scheme
Phase one evaluation

Section One
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Section One — Experienced Nurse Rotation Scheme

1.1 Introduction

This study is the first part of an ongoing evaluation of a recruiting and retention focused Work-Based Learning scheme (see 1.4) for Experienced Nurses, which is combined with one job rotation of one-year duration (for the development and progression of the rotation scheme see 4.5). The purposes of the scheme are to retain Experienced Nurses within the NHS; assure service provision for service users and carers; and develop career pathways through open learning packages and the creation of life-long learning environments.

The data were collected as the practitioners began the first module of the programme. The aim was to collect base line information relating to their reasons for joining the scheme; their expectations of what they would gain from it beyond a qualification and what they thought the Trust, colleagues and patients might also gain from the programme. The two main course tutors were also interviewed to obtain their expectations of the programme's outcomes, as was the Senior Nurse Advisor for Research who led the scheme for the Trusts concerned.

The study is itself part of a larger Action Research study (see 2.3) one of the main purposes of which is to establish and evaluate an overall scheme that will lead to the sustained recruitment and retention of Mental Health Nurses in hard to staff areas such as acute psychiatric in-patient areas, forensic services and elderly care in order to provide minimum number of staff and to improve both the quality and continuity of clinical care.

The Action Research study is being used to implement the schemes and thus to facilitate organisational change. It includes the Experienced Nurse Rotation Scheme as well as the Rotation Schemes for D/E grade nurses implemented earlier. At the same time the study is evaluating the schemes in order to identify the successes, minimise the difficulties and to share the learning from the scheme across professions and agencies.

It is anticipated by the stakeholders in the Experienced Nurse Scheme (see 2.4) that the scheme will assist competent and expert nurses to transfer knowledge, skills and experience across traditional boundaries and barriers; to develop new competencies; and to transfer evidence into practice.

It is also anticipated by the stakeholders that the nurses who join the scheme will act as role models for other Experienced Nurses who may be ambivalent about actively involving themselves in Continued Professional Development as part of the clinical governance, life-long learning and professional self-regulation targets (see 1.2)

1.2 The context

Britain is a signatory to the World Health Organisation’s initiatives ‘Health For All 2000’ and ‘Health For All 2020’ and to facilitate the first of those initiatives in this country the Document ‘Health of The Nation’ was introduced by the last Conservative government with a focus on finance and the use of market forces in the management of the Health Service. It committed the Health Service to a greater patient voice as well as to quality and economic efficiency. It also advocated devolution of responsibility in the service and it was during the administration of that government that the United Kingdom Central Council for Nursing Midwifery and Health Visiting (UKCC) published the documents ‘Code of Professional Conduct’ (1992) and ‘Scope of Professional Practice’ (1992) which, between them, emphasised that the development of competencies should be self-regulated. Together, all these initiatives implied a change of governance that would facilitate flexibility in nursing.

The present Labour government changed that focus somewhat when, in its white paper ‘The New NHS, Modern, Dependable’ (1997), it turned the spotlight on quality rather than finance and market forces. The document made it plain that for the new NHS to succeed, there would need to be involvement, flexibility, decentralisation, empowerment, and accountability. NHS staff would also need to be sufficiently flexible to work across, as well as within, boundaries and this should be aided by effective continuing professional development. Educational Consortia would need to balance personal and organisational development.

For their new policy a number of initiatives were undertaken such as clinical governance, the National Institute for Clinical Excellence and the ‘NHS Plan’. The ‘NHS Plan’ is concerned with the root and branch reorganisation of the Health Service to provide equality of treatment through evidence based care. To achieve this, reorganisation plans, known as National Service Frameworks, were developed for each major public health threat to determine what was going to be done about developing services. One such National Service Framework is for Mental Health.

Each ‘framework’ is underpinned by a number of strategies one of which is ‘The Workforce Plan’. This is concerned with recruiting, retaining and developing people for the NHS. It is in this context that the larger Action Research Study has been operationalised by two organisations, namely CNWL Mental Health Trust and West London Mental Health Trust, with the aim of contributing to ever-higher standards of care through the recruitment, retention and development of Mental Health Nurses (Coyne & Beadsmore (2001). This particular study is concerned with one particular part of that Action Research Study, namely, the ‘Experienced Nurse Rotation Scheme’.

For fear of confusion between the projects being undertaken e.g. the ‘Experienced Nurse Rotation Scheme’ and the wider Action Research being undertaken at any one point, it should be noted here that Action Research combines, at one and the same time, both the implementation of a project and the researching of that project. This will be discussed in more detail in the Methodology Section.

1.3 The Problems That Have Led To The Action Research Study

The result of the various initiatives discussed in 1.2 is an increase in service delivery needs in mental health care. However, there are a number of problems, which together, could militate against the success of that delivery.

Essentially there is a shortage of manpower in the NHS and in particular there is a shortage in certain areas of mental health. In part it is a problem of recruitment and, in relation to the two mental health Trusts involved in the Action Research study that is being dealt with by another part of that study.

A study by Buchan, J. Finlayson, B & Gough, P. (2002) helps to explain the general shortage of manpower in the NHS and the reasons for this. They noted that as well as problems with recruitment there are also problems with retention. In the past the NHS has paid more attention to recruitment than retention and one effect of this is what Buchan (1999) calls, ‘The ‘graying’ of the United Kingdom nursing workforce’. Just over 11% of nurses are over fifty and they are leaving the NHS in large numbers. They leave as early as they possibly can, many at fifty-five and some as early as fifty. Interviewed in focus groups, the reasons they gave included:

If the situation does not change then the problem will continue as each generation of the workforce finds itself in a position to retire.

There is a long-standing problem with staffing in London particularly in mental health care. The inner London in-patient units of both of the Trusts involved in this study have had vacancy rates of around 50% at times, with regular vacancy rates of 30% or more.

There is also an acknowledged difficulty finding ‘mental health leaders’, particularly in some clinical specialities (Buchan 1999).

This deficit has been covered to some extent by agency and bank nurses. However this leads to a lack of continuity, making the general care giving environments unstable and operating at minimum levels of staffing (Buchan 1999) If the number of experienced nurses leaving some clinical areas can be reduced, more stable care environments could be created, and the numbers of agency staff used could be substantially reduced.

However, there is also a need to encourage the ‘turn over’ of staff in some areas, to allow new ideas and practices to be brought in. This is especially the case where new clinical challenges are being faced e.g. dual diagnosis; forensic community care; continuing care and rehabilitation of the elderly.

Unfortunately, there are ‘barriers to entry’ (Johnson & Scholes 2002) for people who wish to provide health care. Skills are often seen as non-transferable with the result that Experienced Nurses who would like to move to a different speciality are often frustrated by demands for a specific diploma or at least two years experience. The alternative is to be down-graded in an already low paid occupation.

In the past there have been poorly developed career development pathways within mental health and social care with the result that opportunities for advanced practice education may have been restricted for many within the nursing workforce. Although the opportunities for education for older and more mature people are being generally expanded such opportunities have rarely been available to more experienced nurses other than under their own initiative.

If the present government’s initiatives are to work, these problems need to be rectified. The Action Research study of which this study is a part, is working towards that in the two Mental Health Trusts involved.

Specifically, and based on the partial success of a previous local rotation scheme in attracting D and E grade nurses, and on the development work of Gabrielle Atmorrow at Leeds Teaching Hospitals Trust, the two London Mental Health Trusts mentioned in 1.2 set about implementing an enhanced nurse rotation programme.

Brent Kensington & Chelsea and Westminster Mental Health Trust and Ealing, Hammersmith & Fulham Mental Health Trust set up the joint initiative in February 1999 to attract nurses and support and develop nurses already working in ‘hard to staff’ areas (Coyne and Beadsmore 2001; Coyne 2002)

A joint Trust committee consisting of the directors of nursing, senior managers and HR personnel designed the content of the rotation scheme and consulted local managers and staff in ‘hard to staff’ areas. The scheme, in its final form, with the support and investment from the Education Consortia (now the Workforce and Education Confederation) in West London, was launched in January 2000.

It should be noted that although the original concept paper for the D/E Rotation Scheme mentioned research, it did not include any reference to Action Research or to the Experienced Nurse scheme because they had not been thought of at that time. However, both were, included in two ‘Bids for London, West Sector Consortium Development Fund Allocation 2000/01’ submitted in April 2000 (www.nurserotation.com).

The research attached to the Experienced Nurse Rotation Scheme came about because the person who led the project (Patrick Coyne, the Senior Nurse Advisor) and stakeholders such as the Workforce and Education Confederation and the management teams wanted to evaluate the scheme and share results.

For the Action Research programme overall, the representatives of the stakeholder community were the Director of Nursing in what was then BKCW (now CNWL); the deputy Director of HR in BKCW; and the Executive Director of Nursing in Ealing Hammersmith and Fulham (now West London); and the Workforce and Education Confederation (formerly the Education Consortium). When plans were made for the Experienced Nurse Rotation Scheme, the same group of people agreed that an evaluation was appropriate and worth seeking funding for. The education provider (Middlesex University) was involved from the start of the D/E Rotation Scheme and agreed to participate in this project and it being researched. At that point, Dr Ricky Lucock was commissioned to do a pre and post evaluation.

As things progressed, a development group evolved which consisted of a collection of people who wished to initiate the project and develop it; wanted to know about its progress and what the outcome of it all would be. They were people who could influence the system to support the project. The key players were, and still are, the Workforce and Education Confederation; the two NHS Trusts- in particular the Directors of Nursing and the Directors of Human Resources; the local Managers; the University; the Experienced Nurses who are rotating while undertaking the course; Patrick Coyne as the Principle Investigator; and Dr Ricky Lucock as the person who has been commissioned to undertake the researching of the Experienced Nurse Rotation Scheme.

There are also individuals and groups who can be seen to be associated, in a slightly more tenuous way, with the Action Research programme for the rotation schemes because of other rotation schemes projects they are interested in. An even wider group is being developed through the rotation scheme web page (see 4.8)

So, there are different groups of stakeholders with different sorts of influence but the really key stakeholders in this part of the project, and perhaps in the Action Research study as a whole are the nurses on the Experienced Nurse Scheme itself. They are experienced and highly influential nurses who have the potential to introduce considerable change. This is discussed further in 4.2

1.4 Discussion of terms use in 1.1.

Four terms have been employed above which can be used and/or interpreted in different ways. The meaning given in this work to the terms ‘Work-Based Learning’ and ‘stakeholders’ and the meaning and use given to the term ‘rotation’ will be discussed in the introductory section but the meaning and use given to the term ‘evaluation’ will be not be discussed until the methodology section.

A fifth term, Recognition and Accreditation of Learning (RAL) will be explained as it is Middlesex University’s own version of what is usually named Accreditation of Prior Experiential Learning (APEL).

1.4.1 Work-Based Learning

The term Work-Based Learning refers to those university programmes which ‘…bring together universities and work organisations to create new learning opportunities in workplaces. Such programmes meet the needs of learners, contribute to the longer-term development of the organisation and are formally accredited as university courses.’ (Boud et al 2001)

Boud et al (2001) add that although the ‘mix of elements’ in this type of programme varies greatly from one university to another the programmes usually have six characteristics in common. The characteristics, as defined by Boud et al, refer to students but throughout the rest of this study the students are referred to as practitioners because this seems to be more in keeping with their status. The characteristics are as follows:

The Work-Based Learning programmes at Middlesex University, detailed in Appendix 2 (The Framework for Work Based Learning at Middlesex University) conform to the above framework. To begin with, in relation to the Experienced Nurse programme being discussed here, there is a partnership between the university and two organisations, namely CNWL Health Trust and West London Mental Health Trust. Furthermore, one or other of these Trusts employs the practitioners involved in the Experienced Nurse Scheme.

The programme run by Middlesex University is derived from the needs of the learner and the workplace and is not controlled by a professional or disciplinary curriculum.

The starting point for any student is, ‘…the learning that the individual has already developed’ (Osborne et al 1998). The first module the practitioners undertake has the title Recognition and Accreditation of Learning. It is an extremely demanding module that requires the practitioner to review his or her learning to date, identify his or her capabilities and think about where the future direction might lie (Doncaster 2000).

The practitioners will undertake learning projects in the workplace when they rotate (but see 4.5) and Middlesex University will assess the learning outcomes of the scheme and do so with respect to a transdisciplinary framework of standards and levels.

1.4.2 Stakeholders

Stakeholders are defined here as individuals or groups of people who can have influence over the project either supporting it or preventing it. This also includes people who could choose to support the ongoing development of the project or who could choose to cut it off at the roots i.e. they can influence the project’s sustainability.

1.4.3 Rotation Scheme

Research into rotation schemes has not taken place on a wide scale. In a report discussing such schemes MacLeod & Kennedy (1992) imply that most rotation schemes are different to those employed in this study. They argue that;

“The principle of job rotation is to alleviate physical fatigue and stress of a particular set of muscles and tendons by rotating employees among other jobs that use different muscle-tendon groups.”

For both the D/E and the Experienced Nurse Schemes, the idea could be muted for job rotation as a means to manage ‘psychological strain injury’ i.e. not very different to physical strain injury. In these schemes psychological strain injury could come from not being able to use your capabilities any more, or from being prevented from growing and developing and job rotation could fit nicely into that set of theories.

However this is speculation and in the Experienced Nurse Rotation Scheme discussed here rotation certainly serves a very different purpose. As already discussed in 1.1 (but see 4.5) there is only one job rotation the purpose of which is threefold. One aim is to retain Experienced Nurses by enabling them to experience a new area of work and to develop new competencies; the second is to transfer fresh ideas into ‘hard to staff’ areas and the third is to have fresh evidence introduced into those areas by way of the projects undertaken by the practitioners.

1.5 Conclusion

The aims of this study and the purpose of the larger Action Research study have been discussed. Section 2 will explain the philosophy underpinning both the Action Research and the evaluation of the Experienced Nurse Scheme. It will then discuss Action Research as an approach; the approach used in the evaluation of the Experienced Nurse Rotation Scheme; and the methods of data collection and analysis used in that evaluation. Section 3 provides the results and the discussion of those results. Section 4 discusses the development to date of the larger Action Research Study and Section 5 draws certain conclusions.