Nurse Rotation Scheme at CNWL/WLMHT
Research Report

Section Six
Views
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6. Views of the scheme

Participants were presented with a list of 27 different features of the scheme and asked to rate each on a scale of 1 to 10, to indicate their satisfaction or dissatisfaction. A complete table showing the proportion reporting satisfaction (ie who rated each item 7-10) on each item for all of the surveys conducted for all of the cohorts is given in the appendix. Here the results are reviewed thematically, before concluding with an overview of how participants’ views have changed over time.

6.1 Education

At the start of the scheme, participants in the first cohort reported general satisfaction with the educational component. Three-quarters of the first cohort described it as either good or very good at the time of their first survey, although some commented (in focus groups) that they would have liked more information prior to the joining the scheme. By the middle of the scheme the majority were still well satisfied with the content of the course, standard of teaching and organisation of the educational element, and satisfaction continued through to the final survey.

The subsequent two cohorts were as satisfied or more so at the same stages. For example all of the respondents from cohort 2 rated the standard of teaching on study days as 7 (out of 10) or over on their first survey. Similarly the content of the education was highly rated by both Cohort 2 & 3 throughout the scheme. Learning opportunities on the placements was generally less well rated.

Although the first cohort were not generally satisfied with the information they received about the education component prior to starting work, this had improved for later cohorts. One in five of the first cohort were satisfied compared with about half of those starting Cohorts 2 & 3.

6.2 Clinical Placements

Across all cohorts and at each stage, participants were consistently positive about the specialty they were working in. After the educational aspect of the scheme, the opportunity to rotate to get different clinical experience was the second most frequently cited ‘best’ aspect of the scheme. Typical comments included:

‘Have been able to work in different wards, learning different skills……. meeting with staff from other parts of the Trust on the study day’ C1

‘Wide variety of clinical experience obtained’ C2

‘Newly qualified staff will have a wide level of practical experience, making them more aware of clinical changes within mental health services’ C3

However, one of the biggest sources of dissatisfaction for the first cohort early on in the scheme, was the degree of choice they had in selecting their specific placements. Many participants were frustrated by the lack of choice on offer and felt the range of options did not match their expectations. A comment from the first survey of cohort 1 was:

‘I felt rather duped by being shown around very pleasant wards, only to assume that the ward I would be likely to work on would be the much the same standard. This was not the case. There has to be more consistency in terms of what recruiters offer as placement opportunities’ C1

The survey results reflect this; less than a third reported satisfaction (score of 7 or over) with the degree of choice they had regarding their first or second placements. This was also seen to be one of the reasons why colleagues had left the scheme. ‘Rigidity in placement choice was very discouraging’ A higher proportion of those left on the scheme (just over half of the 8 respondents) reported that they were satisfied with the degree of choice for the third placement.

Level of choice over placements and the process for selecting and moving placements were the two aspects of their placements that Cohort 2 and Cohort 3 also felt most negative about. In contrast, the majority of staff in Cohort 1 and two were positive about the welcome they received at their placements. Cohort 3 rated this aspect less highly throughout their time on the scheme. Most participants (ie never less than 65%) were positive about the friendliness of their colleagues in general. Participants were asked about the ‘attitude of other staff to the rotation scheme’. Across all cohorts the lowest levels of satisfaction on this item were reported by the first cohort at the time of their first survey (35%). However in later surveys and for the next two cohorts generally at least half of participants rated this item positively. This may reflect a situation where staff became more acquainted with the scheme and more supportive. It appears that staff were not fully aware of the imperative for managers to secure nursing staff for clients in the ‘hard to staff’ and often less ‘attractive’ work areas.

Some of the improvements suggested by participants concerning placements and process of rotating between them were:

6.3 Information & Communication

One of the strongest themes that emerged early on in the scheme’s development was the need for more information and communication. Participants of the first cohort reported that they were keen to have more written information about the education course content and structure before starting work. Several months later the first cohort also pointed to problems in communication about scheme developments between scheme managers, supervisors and participants. This reflects the limitations of new and evolving projects, where detailed information becomes available as the scheme develops.

The survey results to the first surveys of Cohort 2 and Cohort 3 suggest that the information given prior to the scheme had been improved. Whereas roughly a quarter of the first cohort were satisfied (ie. gave 7 out of 10 or higher) with information before joining the scheme, in Cohort 2 two-thirds were. Similarly more of Cohort 2 were satisfied with their ability to get queries answered before the scheme — 61% compared with 25% of Cohort 1. Cohort 1 were particularly dissatisfied with early information about the education course (only 20% scored this item 7 or higher) but both the subsequent cohorts were more likely to be satisfied — more than half were in each case.

6.4 Supervision

Views in the first survey of the first cohort were polarised regarding the amount and quality of supervision. The discussion groups with Cohort 1 in June 2000 reinforced this finding. A picture was painted of supervision being ‘patchy’ — whilst some were very satisfied with the supervision they had had, it was apparent that others were not in receipt of supervision. In one case, a participant reported being unaware that they had a supervisor. Communication to supervisors emerged as a potential problem, with concern that not all supervisors were receiving the information needed to fulfil their roles.

Early on in the project, a plan of action was put forward in response to concerns voiced at the review day, to ensure that the supervisors role was clarified, so that both supervisor and scheme participants had a better idea of what to expect. Supervisors reported that they would like more support and the possibility of providing structured guidance/education for supervisors was reviewed.

On later surveys respondents from cohort 1 expressed greater levels of satisfaction with the support they received from their line managers and colleagues within the placement. There was however little change in their reported views of the quality of supervision and the satisfaction with the level of contact continued to fall during the course of the scheme. Cohort 2 were generally more satisfied with the support they received but Cohort 3 were less positive. In the final survey less than a fifth of cohort 3 were satisfied with the level of contact with their supervisor.

Part of the education component was the regular opportunity to meet with colleagues and experienced lecturer/practitioners to discuss the realities of nursing care in ‘hard to staff’ areas.

6.5 Trust Organisation and support

Eight items that respondents were asked to rate related to aspect of the scheme’s organisation and the Trust support. One asked respondents how satisfied they were with the ‘Commitment of the Trust to the rotation scheme’. The results form a clear pattern.

Within each cohort, the participants views are fairly positive at the start of the scheme but become progressively more negative as the scheme progresses. For example, of Cohort 1, three-quarters were satisfied to some or a great extent at the start of the scheme. By the end, the proportion satisfied had fallen to just a quarter. In Cohort 2 the proportion went from three-quarters to about a third. The same pattern is followed in response to the statement on ‘Terms and conditions of your post’.

At the beginning, middle and end, few of Cohort 1 (a quarter) were satisfied with the ‘Overall organisation of the scheme’. Some felt that it was this that had contributed to their colleagues leaving the scheme:

‘Almost a general dissatisfaction among colleagues in the way the scheme was run. What we were told before we started the scheme was different from what actually happened.’ C1

‘I think the Trust have shown almost a complete lack of commitment to the scheme, but because they have not appeared decisive and pulled out altogether, they only appear incompetent’ C1

Cohort 2 & 3 were both more satisfied than Cohort 1 at the start of the scheme (about half and two thirds respectively) but satisfaction with the overall organisation was less in the later surveys.

‘I enjoyed the academic side of it but the authorities in charge of co-ordinating the scheme have failed me and others…………’ C3.

The Trust support that was more consistently rated highly, was ‘Access to study leave’. Interestingly, for all three cohorts satisfaction with this feature of the scheme increased during the scheme. Difficulties combining work and study was seen as one of the possible reasons that staff may have left the scheme. Putting these two facts together it may be that that those who felt satisfied with the access to study leave are more likely to have stayed on the scheme to the end. Several of the participants (particularly in Cohort 2 and Cohort 3) suggested that the pressures of combing work with study was one of the main reasons that colleagues had left the scheme.

Satisfaction with the ‘Service provided by personnel/HR department’ plummeted for each successive cohort. Each cohort viewed HR fairly positively at the start, but by the end of the scheme the proportion who were satisfied was very small or none. Views were particularly negative at one of the Trusts:

‘We have less variety of placements, less supervisors involved, and no personnel support since the local co-ordinator left’ [and was not replaced]. ‘Ad hoc personnel support from staff from another trust is not sufficient.’ C1

6.6 Overview of the three cohorts views from start to end

At each stage of the scheme participants were asked how, on balance, they rated each of the three main elements — their current placement, the educational component and the scheme overall. A range of five possible responses were provided: ‘very good’, ‘good’, ‘satisfactory’, ‘poor’ and ‘very poor’. The average score for each cohort at each stage was calculated, where the highest score of 5 represents ‘very good’ and the lowest of 1 represents ‘very poor’. The results are presented in Figure 6.1 (the vertical axis represents the average score; high is positive).

In order to make sense of the findings, a natural tendency in longitudinal data of this sort needs to be understood. A key point to realise is that the number of people reporting on the scheme reduces from the first to the last survey, as some participants leave. It is likely that the leavers are likely to be less satisfied overall with the scheme than those individuals who have chosen to continue with it (although some may leave for other reasons unconnected to their work). Thus if the views of the individuals who remained on the scheme had stayed the same throughout, there would never the less have been an upward shift, as there would be reduced numbers of the less satisfied participants. Bearing this ‘survivor effect’ in mind, we would therefore expect to see that during the course of each cohort’s time on the scheme, satisfaction would gradually increase as dissatisfied nurses ‘vote with their feet’.

Figure 6.1

Three cohorts views at different stages

Employment Research 2003

Looking at the results for Cohort 1, the expected pattern is present — satisfaction with the education component, placements and the scheme in general increases steadily from the first survey through to the last. For the second and third cohorts, the same pattern is visible in terms of their views of their placements, but is not present in relation to their views on the educational component or the scheme in general.

Contrasting the cohorts with one another to see if there is any evidence of the scheme changing overtime, it would seem Cohort 2 and Cohort 3 were initially slightly more positive than the first cohort had been at the beginning of their time on the scheme. By the end of the two year scheme, the level of satisfaction was about the same in cohort 3 as it had been for survivors of the first cohort, whereas cohort 2 were less satisfied, most noticeably with the scheme overall.

Across all the cohorts and at almost every stage of the scheme, education emerges as the highest ranking aspect of the scheme, with it typically be regarded as being ‘good’ or ‘very good’.

Analysis was undertaken to look only at the results from the staff who had stayed on the course for all three placements (23 across all three cohorts), to remove the ‘survivor’ effect described previously. The results show that this group’s views of the education component remained fairly constant, with average scores of just under 4.5. (ie half way between good and very good). From start to end the views of placements also stayed fairly uniform at around 4, but with a slight dip to 3.7 on the second survey. Similarly scheme overall scored 4.1 at the start and 3.9 at the end but dipped to 3.5 in the middle.

The results suggest that the people who stayed on the scheme were no more satisfied at the end than at the start, but that they were the more satisfied group throughout.