8. Conclusions

The report is concluded by drawing together the survey findings and qualitative data to review the schemes strengths and weaknesses, and how the scheme could be improved, on the basis of the feedback from those involved, and an analysis of their responses.

Despite other recruitment and retention initiatives, this scheme did attract and retain nursing staff in ‘hard to staff’ areas. Overall, participants and stakeholders found the scheme appealing. It has successfully attracted new staff into the Trusts and also has kept recent recruits from leaving. The work-based learning programme leading to a degree appear to have been the biggest ‘hook’ at the outset and desire to get the degree the main driver in keeping participants on the scheme until the end. Having their education funded and supported by the Trust (through study days), and combining it with a chance to get a variety of clinical experience made the scheme even more attractive.

‘The rotation scheme has enabled me to develop professionally and the support I have from doing this has been a great help. The scheme has also provided an incentive for me to continue working at the Trust. It has definitely been a positive way of starting my career.’

‘For me the main benefit is the fact that it has given me further opportunity to continue working for the Trust as I was beginning to look for jobs elsewhere.’

However, based on the data available, the attrition rate is not low. Initially it was speculated that the 50% drop out rate for Cohort 1 was due to the newness of the scheme and the ‘teething problems’ encountered. But the survivor rates for Cohort 2 and Cohort 3 seem little better.³

After the first year of the scheme, the biggest potential for improving the scheme was felt to be through increasing the communication and information on offer, both directly to scheme participants and with supervisors and colleagues. A solution put forward was to have a scheme handbook to provide: an outline of the rotation scheme, a contact list, list of placement options, system for organising placements, university information and facilities available, course structure, nature of supervision, and competency framework for becoming an E grade. The handbook was to be customised by each Trust and distributed to everyone involved in the scheme both directly and indirectly. Unfortunately, changes in staff has meant that the handbook was never finalised and used.

However, although later cohorts have generally been more satisfied with the information given before joining the scheme, there are still some concerns about communication and information. Firstly concerns were expressed about the awareness of ward/unit staff about the scheme.

‘Ward staff seem to have less knowledge about the scheme’ C3.

Secondly, participants were not satisfied with the extent they were able to get queries about the scheme addressed. One of the key ingredients in the original scheme proposal, was the inclusion of a dedicated scheme co-ordinator, since lack of this role was believed to have been the undoing of previous rotation schemes at the Trust. Despite having a dedicated co-ordinator at the start of the scheme, the first cohort did not rate the overall scheme co-ordination very highly, although few made reference to this as one of the ‘worst features’ of the scheme. Cohort 1’s biggest bone of contention was the nature of the rotation — information about placements, the process of moving to different placements and the restricted range of options available.

Choice of placement remained a major source of dissatisfaction throughout the scheme. But later cohorts were also increasingly dissatisfied with the schemes organisation and communication more generally. Clearly the Trust reconfigurations and changes in personnel have had some impact on the scheme and the lack of dedicated co-ordinator was commented on. For example:

‘There should be an identified link person’ C3

‘The Trust should employ efficient co-ordinators who visit the clinical areas frequently to see how candidates are progressing’ C3

One of the conundrums of the scheme relates to non-rotation — how do the Trusts respond if a participant asks to not to rotate? On one level non-rotation does not diminish the success of the scheme since a new recruit has been brought in to a ‘hard to staff’ area. However, the scheme posts need to be kept open for the scheme to allow the flow of participants between placements to continue. Some interviewees pointed to the need to widen the choice of placements, as a way of reducing the likelihood of participants not wanting to rotate.

One of the strengths of the scheme in the eyes of many of the stakeholders interviewed, was its potential to improve staffing in ‘hard’ to fill’ areas, and thereby rejuvenate care standards. Some participants were conscious of having had a positive effect on standards within their placements, and one suggested that it would be a benefit to the scheme for the clinical impact to be monitored at ward level.

The down-side of ‘hard to staff’ areas for placements is that they do not necessarily provide a good learning experience. In a work based learning programme the quality of the work place is particularly important as learning is based on problem solving and creative thinking within the work place. But in some cases the approach clashes with the culture of the ward, hence the environment can become a barrier to learning.

‘Newly qualified/inexperienced nurses being put in areas that are poorly staffed with low standards of care.’ C1

‘I am not always able to share the information I acquire regarding best practice as colleagues are not always ready for change’ C1

Some felt that because rotation scheme staff stay for relatively short periods in areas that have staffing difficulties, they tend to be regarded as temporary staff, and are less fully accepted as permanent members of staff.

It is not just the way in which ward staff view participants that is an issue, but how they view themselves. Does the fact that many start the scheme soon after they have qualified and are embarking on a new phase of study mean that they still feel like students? Is there any conflict between their role as ‘learners’ and their status as paid members of staff. It seemed that this was an issue for a few, but not many of the participants. Feeling like a ‘student’ was a double edge sword, On the one hand the academic input offers support, but on the other hand, some felt that their ‘student’ image made it harder for them to be fully accepted by other staff on the wards.

‘Educational component means that feel safe that still a student’ C1

‘Not treated as member of staff on ward’. C1

Finally, offering more career planning and support (particularly in thinking about jobs at the end of the scheme) would not only enrich the scheme for participants, but would ensure that the Trusts are better placed to retain these highly qualified and experienced nurses within their employ. A nurse in cohort 3 finished her final questionnaire with this comment:

‘Please look after the rotation nurses who finish a very demanding 2 years and then feel like they are being put out to pasture’…… ‘I have been proactive and got a job back in the hospital but others, having been guided into thinking they may get an automatic F grade, are applying for these scant posts and getting disillusioned when they don’t get them’ C3.