I am always slightly apprehensive before starting a bank shift. My mind races with questions: will the staff be friendly? Who will I be looking after? What is the ward routine?
But waiting to start a recent shift, my apprehension turned to dread as it quickly became apparent that I was one of four bank nurses working alongside only one permanent member of staff – she didn’t seem surprised.
It was a tough shift. Searching for equipment and navigating unfamiliar paperwork was particularly time consuming and, in the absence of close supervision, I felt added pressure to double and triple check all my work.
But perhaps the biggest challenge was to maintain the illusion of some continuity. I did my best to be tactful when talking to patients – trying to limit frustration caused by having to repeat themselves to a succession of temporary nurses. Come visiting time, the challenge was to inspire confidence when updating families who had (understandably) grown weary of hearing the “I’m only bank” excuse every day.
All things considered, it could have gone much worse. As a team, we communicated well and, by sheer luck, collectively had a complementary set of skills and experience. However, it could have been a different story, and worrying anecdotal evidence from my colleagues suggests that my experience is not uncommon.
The temporary workforce
Nurses employed by private agencies and NHS banks have long been used to fill rota gaps and accommodate fluctuating patient demand. However, in the wake of the 2013 Francis inquiry, nursing shortages and commitments to safe staffing prompted a surge in demand for this temporary workforce.
The resulting growth rate in expenditure was attributed to “extortionate” agency rates, which hit the headlines and inspired a wave of policy efforts. It’s worth noting that the National Audit Office said that rising demand was the biggest contributory factor to the increased spend. Nevertheless, hourly rate caps were introduced in 2015 and the NHS staff banks were promoted as a more cost-effective source of temporary workers. Given that agencies increased nurses’ hourly rates by close to 30% between 2012 and 2015, these measures were a reasonable starting place.
However, NHS Professionals report that demand for temporary nursing staff continues to rise year on year. Their analysis demonstrates that the number of nursing hours requested from nurse banks and agencies between October 2016 and September 2017 increased by 8.5% compared to the previous year. Perhaps unsurprising in the context of rising nurse vacancies.
In their draft Health and Care Workforce Strategy, the HEE estimate that there are currently 36,000 nurse vacancies – 92% of which are being filled by temporary nurses (both bank and agency).
What’s the problem?
We know that demand for temporary staff is rising and we know the overall proportion of vacancies filled by temporary staff is high, but what we don’t know is how this translates at ward level. The implications of these averages are therefore masked.
Monthly staffing reports go some way to illustrate staffing at ward level. Mandated after Francis, these reports disclose the number of planned nursing hours and the actual nursing hours that were delivered – generating an average ‘fill rate’ for each ward.
That tells us what percentage of nursing shifts is being filled so that shortages can be monitored. But because it doesn’t distinguish between permanent and temporary staff, it paints only a partial picture. My worry is that looking at the ‘fill rate’ on its own disguises permanent vacancies and doesn’t allow for scrutiny of skill mix.
For example, my recent bank shift would have achieved a 100% fill rate – a statistic that doesn’t reflect the skills and experience of the nurses on shift. Given the often ‘pot-luck’ allocation of temporary workers, ward managers have less control over the balance of skills and experience on shifts where temporary staff outnumber permanent staff – making the temporary-to-permanent ratio even more important.
Furthermore, relatively little is known about how the balance of permanent versus temporary staff could affect patient care. Of the few UK studies that have investigated this relationship, conflicting findings indicate that a higher proportion of temporary staff is associated with positive outcomes for deep-vein thrombosis and negative outcomes for sepsis.
From my own experience, because bank and agency staff work across a range of clinical settings they can often offer additional skills and expertise that could improve outcomes. However, relying solely on this resource to staff entire shifts can be stressful and dissatisfying for nurses (permanent and temporary alike) as well as patients and their families. Ultimately, temporary staff require a level of orientation and support that can’t always be provided if only one person knows the ward.
Until now, policy efforts have primarily focused on reducing agency expenditure. However, these policies have failed to recognise that the temporary nurse workforce is providing an increasingly valuable resource. As such, policy-makers need to turn their attention to strategies that will support permanent and temporary nurses to deliver safe and effective care.
To inform that thinking, more information is needed to better understand how temporary workers are being deployed. We need to know how many shifts are almost exclusively staffed by temporary nurses, and we need more research to explore how safety and continuity can be protected. If we can fill in these gaps with detailed and reliable data, the urgent and complex issue of workforce planning can be more effectively grappled with.
Louise is an acute medical nurse currently on an academic placement at the Nuffield Trust.
Taylor L (2018) "Temporary nursing: we’re banking on better information", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/temporary-nursing-we-re-banking-on-better-information