The NHS is the world's largest employer of highly skilled professionals (NHS England and NHS Improvement, 2019). However, despite the scale of its workforce, the NHS does not have enough staff to meet demand, with the highest number of advertised vacancies found in ‘nursing and midwifery’—at nearly 40 000 (Rolewicz and Palmer, 2019). It is estimated that 80% of nurse vacancies and 90% of doctor vacancies are being filled by temporary agency or bank staff (NHS Improvement, 2018), with spend on temporary staffing to plug clinical vacancies costing the NHS £1.3 billion in 2017 (Britnell, 2019). Although efforts have been made to manage the NHS temporary staffing pay bill, it is a huge drain on already overstretched NHS finances. Using temporary staff can also be disruptive to health services and reduce the ability to deliver continuity of care to patients.
In January 2019 NHS England published its long-term plan, with a chapter that sets out a number of specific workforce actions aiming to address the workforce challenges over the next 10 years (NHS England and NHS Improvement, 2019). These actions include increasing nursing student places, new routes into nursing, apprenticeships, nursing associates and increasing international nurse recruitment. The NHS Long Term Plan (NHS England and NHS Improvement, 2019) also sets out a number of actions to retain the current NHS workforce; with more flexible rostering to be become mandatory and funding for continuing professional development (CPD) to increase year on year.
This article describes the early success of the Nurse Clinical Fellowship Programme, a programme developed by The Royal Wolverhampton NHS Trust to both attract and retain its nursing workforce. The Trust was awarded ‘Best Recruitment Experience’ by the Nursing Times in 2018 and won the ‘Best Organisation for Learning and Development’ category at the 2019 Nursing Times awards.
The Royal Wolverhampton NHS Trust
The Royal Wolverhampton NHS Trust is the largest employer in Wolverhampton, employing around 9000 staff and is an NHS acute and community provider in the West Midlands, with more than 850 beds on the New Cross site, 56 rehabilitation beds at West Park Hospital and 54 beds at Cannock Chase Hospital. The Care Quality Commission (CQC) has rated the services provided by the Trust as ‘Good’ in its report published 27 June 2018.
In July 2018 the Trust had 300 registered and unregistered nursing vacancies, which despite numerous recruitment initiatives had remained static for 2 years. With the static number of vacancies, in addition to retirement predictions, the Trust needs to recruit around 450 additional registered nurses and healthcare assistants (HCAs) each year. To support the recruitment and retention of nursing staff, the Trust's nursing strategy set out a number of key nursing workforce objectives, one of which was to replicate the success of the Trust's Medical Clinical Fellowship Programme and develop the Nurse Clinical Fellowship Programme.
Medical Clinical Fellowship Programme
In March 2016 the Trust reported a cost pressure of around £8 million relating to spend on junior doctor temporary staffing. Struggling to fill junior doctor posts and relying heavily on locum doctors, the Trust initiated an innovative clinical fellowship programme to attract UK and overseas trainee-level doctors. The leadership at the Trust recognised that training needed to be tailored to the individual needs and expectations of doctors. Clinical fellows gain associate membership of the University of Wolverhampton and have access to a fully-funded Masters qualification in Clinical Medicine with bracketed routes in research, leadership and management, teaching and learning or a chosen clinical specialty.
From August 2016, the Trust has recruited over 220 doctors, attracting applicants from the UK and overseas (mainly South Asia, Nigeria, Egypt and Europe). This has helped to reduce significantly the rota gaps in a variety of clinical specialties. The programme supports the principles of global learning and knowledge exchange, and aims to help staff apply the learning from their time in the UK when they return to their home countries.
The Trust currently employs around 170 clinical fellows and has expanded the programme from trainee level up to and including consultant equivalent. The Trust recently appointed a care of the elderly consultant who spent 2 years as a senior clinical fellow with the Trust during his break from the Deanery training programme. This demonstrates that the Trust has been able to attract staff to return to the organisation, as a result of their experience while being employed with us as a Clinical Fellow. The programme has a well-established Certificate of Eligibility Specialist Register (CESR) scheme, with 26 doctors on track to becoming consultants. The Trust has five doctors who have recently successfully completed the CESR programme and are now working as consultants.
Nurse Clinical Fellowship Programme
Following the success of the Clinical Fellowship Programme for doctors, in late 2018 the Trust's executive team approved a business case to support the recruitment of 320 nurses to the Nurse Clinical Fellowship Programme over a period of 4 years. The programme is open to internal and external applicants. Lack of career progression is a source of great discontent, particularly for nurses (Britnell, 2019), therefore the internal programme is open to the Trust's current nursing workforce at all stages of their career. The external offering is open to band 5 registered nurses who want to join an organisation that invests in its employees and be part of an innovative programme of study. The internal offering is open to all bands of registered nurses who want to develop their career, or underpin it with further study at academic level 6 or 7. The Medical and Nursing Fellowship Programmes mirror one another in terms of their benefits, providing educational equity across staff groups and maximising multidisciplinary learning opportunities.
The Trust has worked in partnership with the University of Wolverhampton to develop an MSc in Clinical Nursing with bracketed routes in research, leadership and management, teaching and learning, or a chosen clinical specialty. The programme is also offered at BSc level. Both degrees are fully funded by the Trust. Access to CPD is a vital prerequisite for advanced practice of health professionals (Britnell, 2019).
The Nurse Clinical Fellowship Programme recruits both UK and international applicants without the need for an agency, providing an exciting development opportunity for nurses and promoting global learning through a well-managed ‘learn, earn and return’ scheme.
The two main aims of the programme are to recruit nurses to support the delivery of high-quality patient care, and retain the nursing workforce through access to fully funded CPD and career development support. The associated benefits of the programme are that the Trust is able to upskill the nursing workforce to bachelor's or master's degree level and in turn deliver higher quality of care to patients. Most studies have reported that higher levels (baccalaureate degree) of educational attainment by nurses are associated with lower levels of patient mortality (Mahfoud et al, 2018). In a study by Aiken et al (2014) patients in hospitals in which 60% of nurses had bachelor's degrees demonstrated lower patient mortality than those in which only 30% of nurses had bachelor's degrees.
Since establishing the programme, the Trust has been successful in recruiting 90 staff nurses to the programme. Alongside this the Trust also has a cohort of 10 internal nursing staff enrolled onto the programme completing either their BSc Nursing Studies (top-up) or Masters in Clinical Nursing with a second cohort of 60 internal nurses due to start in September 2019.
OSCE preparation programme
To complement the international offering of the Nurse Clinical Fellowship Programme the Trust has a well-established OSCE [objective structured clinical examination] preparation programme, run internally by the nurse education team. In 2014 the Nursing and Midwifery Council (NMC) introduced the test of competence (ToC) for overseas nurses and midwives, the purpose of which is to ensure safe and effective practice in the UK. All overseas nursing applicants must pass a ToC to be registered to work in the UK. The test is designed to assess candidates’ skills in both theory-based and practical settings. All candidates must be able to demonstrate that their skills, knowledge and behaviours are at the level required to meet the NMC preregistration nursing or midwifery standards for the UK. The breadth of skills, knowledge and behaviours that the ToC covers is derived from the NMC testing blueprint, which maps the NMC preregistration nursing and midwifery standards and competencies (NMC, 2016). The current method for the ToC is the OSCE, which is designed to test the performance of a candidate's clinical skills in a simulated clinical setting.
The nurse education team's aim was to proactively implement an educational programme to support and prepare international nurses for their OSCE. The Trust recognised the challenges for these staff and committed to developing and implementing the OSCE preparation programme to support staff with the final part of their NMC journey. The Trust recognised and appreciated that these staff join the Trust with a wide variety of knowledge and skills. The OSCE programme is designed to embrace and enhance candidates' existing knowledge and skills, while guiding staff in transferring these in line with UK and Trust policies and practices.
The programme runs over a 6-week period and consists of supervised clinical shifts to encourage staff to apply their acquired knowledge and skills into practice before their examination. This also allows candidates to identify strengths and areas of development before they undertake their examination. The team adapts the programme to facilitate time and extra time for staff who may require further support. Peer assessment is a core component of the practical elements of the programme, with staff reporting that this approach helps them to gain a more in-depth understanding and recognise areas of development. The staff are supernumerary during the programme to enable them to focus on preparation for their OSCE.
With an overall pass rate of 97.7% the programme has worked well and supported over 60 international nurses in gaining their UK nurse registration. The OSCE preparation programme is an ongoing journey of development, discovery and transition for staff both personally and professionally. The Trust is in the process of gaining university accreditation for the OSCE programme and will be offering access to the programme to other NHS Trusts.
Integration in UK practice: the preceptorship programme
The Trust recognises that the first year of a newly qualified nurse's career journey is exciting and rewarding but also comes with challenges as they make the transition from student to registered practitioner. It is crucial that newly registered nurses are given the right support during this fundamental stage in their professional journey to enhance their experience and patient care. Although the international nurses are not newly qualified, they are new to UK practice. In view of this the international nurses complete the Trust's multidisciplinary preceptorship programme, which continues to support their transition and integration into the nursing workforce while also completing their academic study.
Conclusion
The Trust is pleased with the progress to date of the Nurse Clinical Fellowship Programme and the OSCE preparation programme. The number of vacancies at the Trust has improved dramatically and is the lowest it has been for 2 years, with some wards and departments having waiting lists for staff to join them. The Trust cannot afford to be complacent with this success as the retirement profile is still showing an upward curve. As part of its nursing workforce strategy the Trust has chosen to enhance its pipeline into nursing by doubling undergraduate nursing student placements from 2019/20, offering both Nursing Associate and Registered Nurse apprenticeships and setting a target for zero HCA vacancies by July 2019.