Experienced Nurse Job Rotation Scheme
Phase two final evaluation

Section One
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Section One — Experienced Nurse Job Rotation Scheme

1.1 Introduction

This study is the second and final part of an ongoing evaluation of a retention focused Work-Based Learning scheme (see 1.4) for Experienced Nurses, which is combined with one job rotation of one-year duration. The purposes of the scheme were 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 once the practitioners had completed the programme. The aim was to collect final information that would both compliment the data collected for the first study and provide evidence to demonstrate the success or lack of success of the scheme.

The study is itself part of a larger Action Research study one of the main purposes of which was 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 the minimum number of staff and to improve both the quality and continuity of clinical care.

The Action Research study was used to implement the schemes and thus to facilitate organisational change. It includes the job rotation schemes for D/E grade nurses implemented earlier. Two studies were carried out by the present authors in relation to those schemes. They are Lucock & Coyne (August 2006) ‘Perceptions of a job rotation scheme by a sample of cohort four rotation nurses’ and Lucock & Coyne (September 2006) ‘Perceptions of a job rotation scheme by a sample of supervisors’. A further related study was Buchan, J. & Ball, J. (2004) Nurse Rotation Scheme at CNWL/WLMHT.

The Action Research study also includes ‘Experienced Nurse Job Rotation Scheme: Phase one evaluation’ (Lucock & Coyne, 2003) to which this study is the successor.

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 was anticipated by the stakeholders in the Experienced Nurse Job Rotation Scheme (see 1.4.3) that the scheme would 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 hoped that the evidence provided in this report will justify that anticipation.

It was also anticipated by the stakeholders that the nurses who joined the scheme would 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). It is hoped that the evidence provided in this report will also justify that anticipation.

1.2 The context

Competency Frameworks

Britain is 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.

Flexible professional workforce

The present Labour government changed that focus somewhat when, in its white paper ‘The New NHS, Modern, Dependable’ (Department of Health 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.

National Frameworks

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.

Workforce planning

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 was 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 Job Rotation Scheme’.

Action Research: change and evaluation

For fear of confusion between the projects being undertaken e.g. the ‘Experienced Nurse Job 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 was discussed in more detail in the Methodology Section of phase one of the study (Lucock & Coyne 2003).

1.3 The Problems That Have Led To The Action Research Study

1.3.1 Shortages of staff

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 was a shortage of manpower in the NHS for some time and in particular there was a shortage in certain areas of mental health. In part this was a problem of recruitment and, in relation to the two mental health Trusts involved in the Action Research study, that was 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 have 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 (Forest 1997).

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.

1.3.2 Challenging institutionalisation through staff transfer

Paradoxically, 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, has worked 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 (Lucock & Coyne 2003; Lucock & Coyne August 2006; Lucock & Coyne September 2006; Buchan & Ball 2004).

1.3.3 Setting up the job rotation schemes

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).

1.3.4 The Action Research stakeholder community

The research attached to the Experienced Nurse Job 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 the results.

For the Action Research programme overall, the representatives of the stakeholder community were the Director of Nursing in what was 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 Job Rotation Scheme, the same group of people agreed that an evaluation was appropriate and worth seeking funding for. The education provider (Middlesex University) were involved from the start of the D/E Rotation Scheme and agreed to participate both in this project and in 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 to a certain extent 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 were rotating while undertaking the course; Patrick Coyne as the Principle Investigator; and Dr Ricky Lucock as the person who was commissioned to undertake the researching of the Experienced Nurse Job 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.

Consequently, 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 who were participants on the Experienced Nurse Scheme itself. They are experienced and highly influential nurses who have the potential to introduce considerable change.

1.4 Discussion of terms used in 1.1

Six 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’, ‘stakeholders’, ‘experienced nurse’, ‘job rotation’ and ‘hard to staff areas’ will be discussed in the introductory section. The meaning and use given to the term ‘evaluation’ was discussed in the methodology section of phase one of the initial study (Lucock & Coyne 2003). However, its operationalisation for this study is discussed below.

A seventh 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 this framework. To begin with, in relation to the Experienced Nurse programme being discussed here, there was 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.

1.4.2 RAL versus APEL

The starting point for any student is, ‘…the learning that the individual has already developed’ (Osborne et al 1998). The first module the practitioners undertook had the title Recognition and Accreditation of Learning. It is an extremely demanding module which requires the practitioner to identify four specific areas of expertise, work out the learning that went into developing that expertise and write a four thousand word essay to explain their findings.

The difference between APELing in its normal accreditation form and the RAL module is that the latter is accompanied by extensive personal as well as professional reflection culminating in a clear statement of intent for the development of specific work based capabilities. Furthermore, these form the basis for the subsequent programme planning module that will produce a specific action plan for self directed study that will result in the achievement of those capabilities.

As well as studying other modules related largely to research, the practitioners then undertook learning projects in the workplace when they rotated and Middlesex University assessed the learning outcomes of the scheme and did so with respect to a transdisciplinary framework of standards and levels.

1.4.3 Stakeholders

Stakeholders are defined here as individuals or groups of people who had influence over the project either supporting it or preventing it. This also includes people who could have chosen to support the ongoing development of the project or who could have chosen to cut it off at the roots i.e. they could influence the project’s sustainability (see Appendix 1).

1.4.4 Rotation Schemes and the evidence base for them

As with Work-Based Learning, there has been little research into rotation schemes. In a report discussing such schemes MacLeod & Kennedy (1993) 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 or from ‘burnout’. Job rotation could fit nicely into that set of theories.

However this is speculation and in the Experienced Nurse Job Rotation Scheme discussed here rotation certainly served a number of other clearly defined purposes. As already discussed in 1.1 there is only one job rotation the purpose of which was threefold. One aim was to retain Experienced Nurses by enabling them to experience a new area of work and to develop new competencies; the second was to transfer fresh ideas into ‘hard to staff’ areas and the third was to have fresh evidence introduced into those areas by way of the projects undertaken by the practitioners.

Whilst in this scheme job rotation has been used as a tool to address retention for hard to staff areas in these local health organisations, its use has been based more on anecdotal report and unresearched custom and practice than on a well developed body of research evidence. This is hardly surprising when we consider the limited knowledge base. The following sub section provides a short review of job rotation literature in order to describe a wide range of possible uses and demonstrates that there is still a very small research evidence base.

1.4.4.1 Literature review on job rotation

A variety of stakeholders have undertaken literature searches on ‘nurse rotation’ throughout the course of this research project. However, whilst they found a plethora of short opinion articles, and numerous advertisements by health organisations for nurses who might wish to join ‘nurse rotation schemes’ they identified few research articles. With persistent searching some pieces of ‘grey literature’ have been found that do contribute to an understanding about job rotation schemes for nurses (e.g. Gabrielle Atmarrow in Leeds and her developments of job rotation schemes, Eric Forest’s (1997) university assignment describing the setting up of the first formal job rotation scheme in Westminster; and Evan’s (2001) Master’s dissertation describing job rotation for children nurses in East London). One key American article (Default et al 1992) described issues to do with the development of a three placement rotation scheme, to recruit and retain nurses to a specialist area, and to fit them for the posts.

Nevertheless there were more research studies ‘out there’ but they remained hidden because of inconsistencies in terminology. It has become apparent to the researchers and managers of this scheme over the time of the study that a wide number of different terms are used to describe human resources staff development schemes which are similar to ‘nurse rotation’. Some examples are:

It has also become apparent that terms are sometime misleading e.g. nurse rotation — relating to shift working, and job rotation relating to reducing the potential for physical strain injury in factories.

In spite of these findings, it is still the case that there are few research studies in this field and this claim is supported by a recent review of the literature from Finland (Jarvi and Uusitalo 2004). Amongst research studies identified, Coggel and Miceli (1998) reviewed the extensive use of job rotation in Japan, identifying some of the claimed benefits, its role in innovative organisations, and the development of models. Huang (1999) reviewed literature on ‘job rotation’ including papers from the 1950s describing the tool as a developmental technique that has been widely used in Taiwan, and one that contributes to both job satisfaction and training. Oretega (2001) described the extensive use in the USA of job rotation for the purposes of ‘increasing human capital accumulation’ (i.e. learning within the organisation) and also for employee motivation, and suggested that a further purpose for job rotation was that of providing employers with information about the abilities and potential of employees. Claire et al (2002) in their evidence to the Australian government reviewed ‘transition programmes’ for nurses that seek to enable nursing students to take up their professional roles. They suggested that whilst they have been used, there is still an absence of evidence to support their cost effectiveness, or to demonstrate best practice models. From a much wider perspective Kaisa Kankaanpää-Lehtinen and Pasi Lahtinen (2001) reviewed models of job rotation across 14 European countries with the intention of describing their key characteristic in relation to opportunities within Europe.

Authors from this present study have provided ideas about the use of job rotation as mean of recruitment and retention (Coyne and Beadsmoore 2001), and as ideas for helping to provide career development opportunities in specialist areas e.g. substance misuse (Coyne 2002). The Kings Fund in the UK have made recommendations about the use of job rotation, using early data from the present project, for its use in recruitment and retention (Buchan, Finlayson and Gough 2002 p23; 2003 pp 38-9). Similarly, the Department of Health published their ‘Workforce Action Team for Mental Health’ (2002) recommending that job rotation schemes be included in local commissioning plans for NHS education and arguing that the schemes should include a research element to provide information for decision making. Clearly there is a substantial scope for further research.

1.4.5 Experienced Nurses

Experienced nurses (Lucock & Coyne 2003; Lucock & Coyne July 2006) as described here were generally nurses who had five or more years of post registration experience.

1.4.6 Hard to staff areas

In this study, ‘hard to staff areas’ refers to inpatient units and community teams which have ongoing difficulty recruiting to post. Generally this meant that there were vacancies from 30% to 50% of establishment over a substantial period of time (Forest 1997).

1.4.7 Evaluation

The main use of evaluation in this study was to establish the usefulness of job rotation as a means of retaining experienced nurses in ‘hard to staff areas’. Evaluation was also included to establish if other benefits accrued from the use of this job rotation scheme (e.g. quality of care, organisational learning, value of work based learning, career development and the development of an evidence base for the use of this job rotation model) The details of the evaluation can be found in section three.

1.5 Conclusion

The aims of this study and the purpose of the larger Action Research study have been discussed. For an explanation of the philosophy underpinning both the Action Research and the evaluation of this study, the reader is referred to the methodology section of phase one of the Experienced Nurse Job Rotation Scheme Report (Lucock & Coyne 2003). In the same report, Action Research is discussed as an approach as is the approach used in the evaluation of the Nurse Job Rotation Scheme.

The methods of data collection and analysis used in that evaluation are discussed in Section 2 of this report. Section 3 of this report provides the results and the discussion of those results. Section 4 draws certain conclusions and Section 5 provides recommendations.