Section Three — Findings and Discussion for the Supervisors of the Nurse Job Rotation Scheme Study (Continued)

3.4 What patients/clients can gain from the job rotation scheme

The comments on this theme showed a very similar pattern as those above on the theme of ‘benefit to yourself and the staff on the ward’ Analysis shows that Stuart had nothing to say but that could be down to researcher error if my lack of success with the previous theme meant that I failed to draw his attention to this one. Martin once again showed only a modicum of enthusiasm and Robert was quite negative.

3.4.1 Good feedback from clients and carers

From the point of view of the success of the scheme, the following quote from Karen is a very important one from a manager/supervisor. She made a further comment about a job rotation scheme nurse she had mentioned earlier, saying,

“From what I’ve heard from the clients and the carers about her… I had a meeting this morning and I had these two people talk about this because she is so good.”

But then Karen went on to speak about the job rotation scheme nurses in general. She said,

“But I certainly get good feedback from my clients about what they do; about the way the nurses are. We’ve never had any negative feedback and as far as I can see the clients are generally pleased with the type of caring that they get.”

3.4.2 Nurse to patient matching

But then Karen indicated that her team and the clients are, perhaps, also benefiting from the team’s own insights. She said,

“When the job rotation scheme nurses come here they’re not allocated a full case list, they’re allocated a manageable light case list of people who are deemed to be able to tolerate change and experience good vibes from someone new coming along. Certainly you wouldn’t give the rotation nurses clients who are full of inconsistency. We try to match the clients to the nurses.”

From one perspective, given much of what has been said, both in this study and the parallel study of the perceptions of job rotation scheme nurses, about supervision and the treatment of the job rotation scheme nurses Karen’s remarks are impressive. Not only is this very good management, it is also important in terms of demonstrating good preceptorship and mentorship.

3.4.3 Potential downside — envy

However, seen from another perspective, Karen’s comments about rotatees not being given a full case list provides a warning that, for a variety of reasons, being ‘considerate’ to the rotatees could have set them up for exposure to envy or jealousy.

3.4.4 Top notch assessment and care planning

Susan’s comment was brief but important in that she confirmed that, at least in her experience, there was planning and co-ordination based on good assessment. I had said to Susan,

“But so that’s the usefulness of the scheme for you and your colleagues but what about the clients?”

Susan responded,

“The clients were always well looked after by the rotation nurses. Things like care plan role was top notch, as you can imagine.”

3.4.5 Get to know regular staff

Mary’s response was also brief but useful in that she highlighted the benefits that accrue from having job rotation scheme nurses on the ward rather than bank and agency staff. She commented, “Well, it’s good for the patients because it’s helped our staffing levels; it’s helped our recruitment. We have regular nurses here who are an extra member of the team, who are part of the team and who get on very well with the patients. The patients obviously don’t know who’s who and whatever but I am sure the patients will benefit from the fact that there are regular members of staff around.”

3.4.6 Agents of change: government policy

Mark painted the picture of job rotation scheme nurses as agents of change, contributing to the government’s modernisation agenda through the National Service Framework and thus being responsible for direct improvements for clients He commented, in the context of discussing what the job rotation scheme nurses bring back from their studies,

“The patients benefit as well, of course. I mean, we’re making improvements for the better rather than sticking to the old type things that we were doing. I like changes and challenges.”

3.4.7 Right calibre

Jane had started to talk about the advantages or disadvantages to patients of the presence on the ward of job rotation scheme nurses but then went on to talk about one particular nurse. I tried to bring the interview back to a more general point by saying,

“So, if I can paraphrase what you’re saying there, you’re saying, ‘Yes, it’s a good idea… yes, it is rather helpful for the patients in ‘hard to staff areas’, providing it’s the right sort of person. So, it’s not necessarily going to be useful to them if the person concerned isn’t of the right calibre?”

Jane’s response was somewhat ambiguous. She said,

“If it was another pair of hands it would, I suppose, enhance staff areas, if it’s another pair of hands, but I think… I was in a hard to staff area which was very demanding; it was a very difficult place to work. The guy that we had was… I felt he was very skilled; it was a very difficult place to work in but from the day he walked in he ‘fitted to the T’, you don’t always find that.”

Jane’s comment underlines how important it is that rotatees should be capable of becoming team members as they rotate through the organisation.

3.4.8 A good all rounder — characteristics

To gain a clearer understanding of what Jane meant, I asked,

“Can you give me some examples?”

Jane’s reply referred to advantages for both staff and clients. She said,

“Well, he was very knowledgeable. He was a very good role model for the others staff nurses at the time. He was very professional, you know, professionalism throughout. He had a good rapport with his client group. One of his patients was a very difficult patient, difficult to manage and he stuck with that and he always appeared very confident when he was dealing with him. And there was good communication between the staff group with him and others and he was just a good all rounder. You know, he could put his hand… I mean, there were various tasks but he did whatever. He was a good all rounder and I think that helped in that particular area.”

3.4.9 Basic and advanced benefits

From her earlier remark it is clear that Jane appreciates the value of the job rotation scheme nurses even as the basic level of ‘another pair of hands’ in the absence of which, there are recruitment problems. When she described one particular nurse, who is hopefully, typical of those on the rotation scheme, she described an experienced nurse and provided the characteristics of a good nurse, namely knowledgeable, a role model, professional with good rapport with patients/clients and good communication with staff.

3.4.10 Education about administration and management — important

Reflecting on what the patients might get from the job rotation scheme nurses, Harry said,

“I think they get it indirectly because of the areas the job rotation scheme nurses are studying. They are studying at more of an administrative level so if that is being addressed it’s definitely going to have an impact on the patient because the rotation nurses are able to reflect and then improve their practice. So, if they’re getting that, although they are not going to ask patients direct questions, such as, ‘How are your relations with staff’, or whatever, they can say things indirectly, because they are getting the support and they are getting the development. They will be able to put in good practice and look at the quality of care as well. So indirectly, patients will benefit. Whatever we do, the end product is for the patient because they are at the heart of what the government is saying about the system.”

3.4.11 Leadership training

Harry’s notion of the job rotation scheme nurses as being trained in leadership and management is not one picked up directly by other supervisors although there is a hint, throughout the interviews that this is where they are heading.

3.4.12 No benefits — except more thorough CPA

Martin didn’t feel that the patients benefited at all, although he did make one very positive comment, saying,

“Well, they might have got more thorough CPA from start to finish.”

3.4.13 Costs and benefits compared to bank and agency

In response to a comment by Robert, I ventured,

“So, in a sense then, your feeling here is that you would rather have the staff who were going to stay than the job rotation scheme nurses who are going to move on?”

Robert responded,

“Yes! Because it’s a big chunk even to loose two people at once; two or three at once who all the patients know and they know the ward. And then I have to induct new ones and that’s actually quite hard going. And it is a shame when I’ve got a really good nurse and they move on because they want to go to a different place for a different experience.”

3.4.14 Dissatisfaction through wishful thinking?

This comment by Robert’s is another that can be looked at from more than one perspective. It can be argued that it shows the down side of having more than one job rotation scheme nurse on a ward at a time. If that is the case then perhaps there is a need to consider the type of ward involved before allowing there to be more than one job rotation scheme nurse there at any given time.

However, from another perspective it could be argued that this is an example of very concrete thinking that has led to an inability at times to see opportunities and to inspire others to see them.

3.4.15 Patients miss them when they rotate

Robert had been discussing the problems of loosing job rotation scheme nurses who all the patients know so I asked what that implied about the advantages of the scheme for patients. He responded,

“It’s not an advantage for the patients that are here for a long time. We’ve had patients who have been here for a year and they have one key worker who looked after them and if that person moved on, they’ve then had to get used to another one. And so, in that respect, no! A lot of the patients don’t know about them. They don’t know about the job rotation scheme and it’s not until, say, a week before the person is due to leave that they actually inform the patients that they are moving on. And then I have to go and find someone who is able to work with that particular person.”

This suggests that how to end work with clients and staff is something that needs to be addressed in the education and management of the rotation nurses.

I commented that what Robert had said suggested that it is really on acute wards that this is potentially a problem and he agreed.

3.4.16 Induction to the NHS from private sector

James’ comment about the advantages for patients also came from his perspective as a past job rotation scheme nurse. He said,

“Because I’d been on the job rotation scheme and had just come back to the national health from the private sector, it helped me. I had been out of the national health since 1995 and I came back and there were lots of things on the ward that weren’t… the standards were not satisfactory in my opinion, and it helped them put the standards secure really.”

This is an interesting perspective, suggesting that a possible benefit of the scheme is to introduce nurses from the private sector into the NHS. Perhaps it can apply also to nurses from abroad or specialists from other areas.

3.4.17 Inviting rotatees to come and take permanent jobs

I checked that that was the ward he was on now and then asked,

“Was that well received?”

James replied,

“Well, I think so. I never had any complaints because when I was leaving the manager said to me, ‘I know you don’t like the department but if ever you want to come back, do come back’.”

3.4.18 Selling and persuasion

This is an interesting comment about a manager being pleased with the performance and capability of a job rotation nurse despite it being clear that the area was not that nurse’s preference.

3.5 What the Trust can gain from the rotation scheme

The parallel study of the views of nurses on the job rotation scheme (Lucock & Coyne August 2006) produced very positive comments on the topic of what the Trust can gain from having the job rotation scheme nurses. This study was more disappointing in that respect. Not all the supervisors commented on the theme and, of those who did, only a few appeared to have considered the matter in any depth.

3.5.1 Differing perspectives

This is not really surprising as the extremely busy supervisors may be unaware of the organisation’s overall concerns but be highly aware of local and immediate concerns. Furthermore, for the most part the supervisors working in ‘hard to staff areas’, were keen to take advantage of the scheme because it would provide regular staff and they would no longer have to depend so much on bank and agency staff. Unlike the rotation nurses themselves, they were unlikely to give much thought to other aspects of the scheme and it is, therefore, rather reassuring that they have been able to reflect as deeply as they have on many of its aspects.

3.5.2 Cheap way of recruiting and filling gaps

In relation to the topic of the usefulness of the scheme to the Trust as a whole, Ursula’s first comment indicated that she considered the job rotation scheme to be effective and efficient but then she appeared to be complaining that it was being used in the very way that had been intended, to fill a gap in nursing. She said,

“I think, to start with, it’s a way of recruiting and it’s a cheap way of recruiting because they have this carrot dangling to try and use as an incentive and I also think that, in some cases, some of the rotation staff are being exploited. In a way, they are being used to fill a gap.”

She then started to say,

“In some places I’ve actually felt that…”

But then she stopped and said,

“But I can’t say it because I’m not in that working area.”

3.5.3 Exploitation or facilitation?

I expressed interest in what she was about to say, so Ursula continued,

“Too much pressure being put on them and too much chucked on them too fast. You know, you should give them a chance.”

3.5.4 A nurse for two years and much more

Stuart said,

“What the Trust gets from it is somebody for two years.”

I responded,

“And that’s the sum total?”

But Stuart responded by making a number of very relevant points which should be encouraging for those who organised the scheme. He replied,

“No, no, no! They get a member of staff. At least you know somebody’s on your ward for eight months. You’re going to get somebody to cover your work. I mean, that’s how the Trusts have been looking at it. Cut out on bank, cut out on agency! But from my point of view, what it brought to me is people who were learning things; bringing new things on the ward; were bringing research evidence and working with the elderly. Sometimes you’re working with unqualified staff quite a lot and they’re able to bring in these things and change practice.”

I asked,

“And so, even though it may appear that the Trust was only interested in having bodies in to do the work there’s more to it than that?”

3.5.5 More than filling gaps — developing the profession

Stuart’s reply was equally complimentary for the scheme. He said,

“I think there’s more to it. I mean, there’s also the development of the profession. It’s a catching up with what hospitals have to do because in time training has changed a bit at every level and it’s nice to see the Trust is supporting people like that. And I think, why people are thinking it’s bodies is because it was right at the beginning, when it was a hard to staff area; when they were needed for the hard to staff area. In other words, ‘We want to bring in bodies’, and that’s a negative connotation on its own.”

3.5.6 Reassurance that someone will know the patients

There were further positive remarks, albeit retrospectively from a rotation nurse’s perspective, from James as he contemplated what the Trust could gain. He said,

“I think for us, when we started, there was a problem getting people to work within the Trust and I think the Trust would get out of it, at least, having a permanent nurse for eight months instead of a different person every day. Saying that, people have left throughout the thing but at least you know that there’s somebody there for eight months who will know the patients.”

3.5.7 More proactive

James added,

“Maybe at the end of it you’d be educated to degree level so you’d be more dynamic, more proactive. I don’t say that the degree has made me competent because I was obviously competent because I had other interests. But it will make you more competent and more patient focused maybe and in a leadership role if that’s where you want to go because a bit of the assignment is on leadership. For your leadership you have to write about reflecting on your learning that was helpful. It makes you look back and see where you are and where you’re going.”

3.5.8 Retaining staff — but a lot do not stay

Robert said,

“My understanding was that it was a way of retaining staff but I think that at the end of it a lot of staff don’t stay. They leave the Trust; they move on, in particular if they want promotion and if they want an F Grade they’re not going to get a F Grade on the wards because those vacancies don’t come up very often. We’ve already filled all our F Grade posts. By the time they’ve finished the scheme they should be ready for an F Grade which means they would have to leave; either get one in the community or leave in order to get one, because there’s no vacancies here.”

I suggested,

“But they are staying within the NHS”

Robert said,

“I presume so yes.”

Robert appeared reluctant to reflect on this so I commented,

“I think the idea was hoping to keep them in the Trust but at least to keep them in nursing.”

I then asked,

“So, do you think it’s worth continuing with them?”

Robert replied,

“Mm! I think it’s worth it.”

3.5.9 Clinical governance — they are giving a lot to the organisation

Jane said,

“At this end of the Trust, it’s our first (cohort) and it’s a bit on hold at the moment because we don’t know when we’re going to have the next one or if we’ve made that decision to have the next cohort. But where it’s been that rolling programme, I think it has to be of benefit for the Trust because it has to… well it’s part of the clinical governance agenda anyway, you know; about supporting the person and developing and supervising staff. So, I can only ever see it as a benefit because they’re actually getting something but they’re also giving a lot to this organisation as well.”

Jane’s comment shows appreciation of the scheme but her remark about things being ‘a bit on hold’ need to be considered in context. At the time of the interviews the pilot scheme was running down and people were waiting for the Trust and the Education Confederation to decide whether or not to continue. In order for the Trust to continue with the nurse job rotation schemes there would need to be an agreement from government, in particular with reference to their work force development plans. And that decision depends, in turn, on the government’s Post Registration Education document from Department of Health.

3.5.10 Innovation

Harry’s comment contained suggestions that were innovative and comprehensive. He said,

“How it benefits the system as a whole? I think it’s difficult for me to say. It’s only when they come to the end of the placement when they will be able to choose a particular topic, like the one on supervision, and do their research on that and then that can be more productive. We can look overall at what difficulties they did or didn’t encounter and what benefits and how they want the system to change. So that will be for people who work on the placements initially. They do two assessments and then they look at what is in place and how things progress. I don’t think there were any thoughts in senior parts of the organisation about changes to make. I think the way to learn from that is, once they start making the assignments there is the issue of them identifying deficits. Then those recommendations should be forwarded to the ward… probably not a particular ward as such because of confidentiality. At the end of the placement you would have about half a dozen people who would submit assessments in a particular area so they can identify the different aspects and then put it out as a whole. It may not apply to here. Maybe somebody might say, ‘Oh well, here we don’t do this and that’. As long as it does not identify the person who identified those issues, management can then look at which area might be relevant to a particular locality.”

I commented,

“This doesn’t happen does it?”

Harry replied,

“In my experience of acting as a deputy, I don’t get any feed back in the sense of what people have said in their assessments about issues of deficit or things that could be improved.”

I continued,

“There are two possibilities and I’m trying to clarify them. Are you talking about all the job rotation scheme people in one cohort who come to this hospital?”

3.5.11 Whole group feedback to the organisation

Harry replied,

“I am saying in general; the whole group at college. I think it would be easier for the whole cohort to do it. It should be done at the organisational level for people who are organising the process as well, and also for service providers and also for us as well as service providers. I think it would be easier if they identify about ten different issues within that cohort and then they can say, ‘Ok, those are the issues that were identified that could be improved’. They don’t have to improve it, it’s just a suggestion from what people felt could be improved. And then here we can look at why people aren’t doing it if that is what they are supposed to be doing. When we do the auditing as well we can bear those issues in mind as well as saying, ‘Oh yes, someone has looked at that for me’, so I can make sure that is included in my audit form.”

This is an interesting and potentially useful suggestion about how the Trust could gain even greater benefit from any future scheme. However, it is a suggestion that would need careful consideration since it would require an on-going partnership between the management of the scheme, the Trust and the university and would possibly also require the involvement of the audit department.

3.5.12 Using literature reviews to improve standards and audits

Harry went on to say,

“I think it’s more about the development of those who learn as well. We’re running wards and we do auditing monthly; or we try to do it as often as possible and it’s sometimes longer than a month. Sometimes we may have these issues because we look at the general aspect of it but it’s useful when somebody has looked at specific issues in depth and also reflected on what they have found from what research has said and what other people have done in the past and also looked at what the policy is. So it is useful that they are looking at what research has been done and comparing it with the standards that have been set by the Trust and see whether all those are in balance. We try to minimise the gap and make sure that everything is within the standards that we want to achieve. So, somebody that has already done that for us, they may have done that here or they may have done it somewhere else, but the outcome comes to us so that we can say, ‘Oh yes, that was what was identified by the students’.”

3.5.13 Use the rotatees research within the organisation

He continued,

“And then that can be used. They can say, ‘Ok, we’ve had some people on courses as part of a rotation and we’re paying for them to do it and although we are getting benefit out of them from them from being on wards where there are difficulties in recruiting, at the same time we are getting something from the educational projects they are doing because they are bringing something back. Indirectly we can use the information from their research and see how best we can use it. Although it’s provisional on people looking at what is being done. Although the Trust is doing it, other people are doing it as well so we can compare the figures and say,’ Yes, people have done that. The questionnaires that they have done, the questions that they have asked, that was an outcome’, Then they can compare with the general trend around the Trust and see if it is consistent. And if it is consistent it shows people are not doing the work for their own benefit of for their own benefit; just writing a paper to get a pass mark.”

3.5.14 Rotatees who stay — good and bad

Martin, who had been a supervisor in his previous employment, identified what he saw as a disadvantage for the Trust, saying,

“And my experience, just before I left, was that we had two nurses on the job rotation scheme and one of them opted to come out of the scheme and actually wanted to stay on the ward with the same team to get some stability there so soon after qualifying, which was good for me because she’s an excellent nurse. But obviously it wasn’t very good for the Trust that somebody is dropping out. It was against the spirit of how she was appointed.”

3.5.15 CPA

Martin’s final comment on this topic was very useful through its reference to an organisational and client priority, namely, what is the care that is being received; who is providing it, when is it being reviewed, how are people contacted, and does everyone in the system know about this?

He remarked,

“And for the organisation, I suppose, it’s having staff who are up to date on things like the CPA which, because it has been going on for so long causes more problems than anything in terms of people being aware of the CPA policies and processes and things like that. So, it means more nurses have got more skills in that area. I’m not so sure whether it means that they’re more skilled as nurses. But in that particular area you’ve got nurses who are very much aware of the national/local context.”

3.6 — Usefulness or otherwise of the scheme for the rotation nurses