nursing & midwifery rostering policy for nursing

Policy Manager Charlie Sinclair

Jenny Alexander

Policy Group Workforce Advisory Group

Nursing & Midwifery

Rostering Policy for Nursing & Midwifery Staff

Policy Established April 2013

Policy Review Period/Expiry April 2019

Last Updated June 2019

This policy does not apply to Medical/Dental Staff

UNCONTROLLED WHEN PRINTED

Document Control Document: Rostering Policy for Nursing & Midwifery Staff Version:4.0 Version Date: June 2019 Policy Manager: Charles Sinclair and Jenny Alexander Review Date: April 2023

Version Control

Version Number Purpose Change Author Date 1.0 Introduction of new

policy Eileen McKenna Jenny Alexander Vanessa Shand

April 2013

1.1 Rewording of section 4.4 bullet point 5 Removal of 4.5

Eileen McKenna Jenny Alexander Vanessa Shand

October 2013

1.2 Addition of paragraph 6.5 and Appendix 2

Eileen McKenna Jenny Alexander Vanessa Shand

April 2014

2.1 Rewording of Sections 3.1 and 4.9. Table 1 altered. Addition of Appendix 1 – audit tool. Addition of Appendix 2 – Policy Compliance Monitoring. Time out algorithm now appendix 3.

Eileen McKenna Jenny Alexander

April 2015

3.0 Section 3 - The responsibility for Heads of Nursing monitoring and improving duty rosters upon completion has been added as second level approvers.

Section 4 - We have

highlighted that it is possible to work a block of nights

The use of ‘time out’

(Annual Leave, Sickness Absence, Study, Maternity/Paternity and other leave) can be viewed with flexibility for slight variation at the discretion of the Senior Charge Nurse / Midwife / Community Team Leaders but must not rely on supplementary staffing

The inclusion of a weekend off before annual leave cannot be guaranteed.

Where staff are not actively requesting annual leave Senior Charge Nurse /

Charlie Sinclair Jenny Alexander

June 2018


Midwife / Community Team Leaders must meet with staff to reach agreement to ensure that staff entitlement is used within the financial year.

Changes have been

made to sections in relation to requests before and after roster publication including that annual leave requests that exceed the documented acceptable level for the department will not be approved.

There is now a specific

requirement to ensure that consideration and approval of requests or annual leave does not lead to a need for supplementary staffing.

Flexible working

requires adjustments to be formally agreed and reviewed.

Clarification that

requests should be for specific days off, only in exceptional circumstances will requests for specific shifts be considered.

4 Foreword Reference made to the

pending Health and Care (Staffing) (Scotland) Bill added

3.5.1 Addition of “... and reporting of compliance through Quality Performance Reviews or equivalent meetings. Non compliance should be recorded on HealthRoster (eRostering system). For areas not on HealthRoster, non compliance must be

Charlie Sinclair Jenny Alexander

April 2019


recorded using the tool in Appendix 1 to form a local record which will be available for audit purposes upon request.”

Page 6 - 2.1.4 bullet point 4 correction to refer to section 4.2 4.2 minimum of four weeks in advance made bold to emphasise standard 4.5 minimum of one weekend off per four week roster made bold for emphasis of standard 4.5 bullet points text made bold to highlight requirements (to support compliance with policy) 4.5 bullet 6 “(with day 1 of any 7 day period being the first day of a period of night duty)” removed to try to reduce ambiguity and different interpretation by readers. Wording change from “Any requirement for an individual member of staff to work days and nights in the same 7 day period must be supported by a clear service requirement and approved by Head of Nursing (or equivalent) to “Any requirement for an individual member of staff to work days and nights in the same 7 day period must be supported by a clear service requirement and documented in HealthRoster or using the tools in Appendix 1. ” Bullet 7 added text to read “In all cases 3


days off must follow the last night duty worked when changing from night to day duty. ” 4.7 Timeout Allowance changed to “Predicted Absence Allowance” to align with legislation and Excellence in care Terminology. Update of Appendix 1 Revised numbering of Appendices and changes to any references throughout the policy document


NHS TAYSIDE POLICY CORPORATE TEMPLATE

CONTENTS

Page Number

FOREWORD 7

1. PURPOSE AND SCOPE 8

2. STATEMENT OF POLICY 8-9

3. RESPONSIBILITIES 10-12

4. ORGANISATIONAL ARRANGEMENTS 12-17

5. KEY CONTACTS 17

APPENDIX 1: Audit Tool and Policy Compliance Monitoring 18-19

APPENDIX 2: Predicted Absence Allowance Algorithm 20

APPENDIX 3: Policy Approval Checklist 21 APPENDIX 4: Equality Impact Assessment 22-37


FOREWORD NHS Tayside recognises the value of its workforce and is committed to supporting staff to provide high quality patient care. Whilst acknowledging the need to balance the effective provision of service with supporting staff to achieve an appropriate work life balance, it is recognised that the Board needs to be able to respond to changing service requirements. A flexible, efficient and robust rostering system is the key to achieving this objective. This policy is for use by ALL Nursing and Midwifery areas within NHS Tayside and Health & Social Care Partnerships that require staff to be rostered over 24 hours to provide safe, effective services. To assure the provision of safe, effective and person centred care requires planning to ensure there are the right staff available, at the right time, in the right place and with the necessary skills and knowledge required. Safe and effective rostering relies on a number of key ingredients which include having the correct numbers and skill mix of staff recognised within the funded establishment. The funded establishment should be considered by applying the Nursing & Midwifery Workload & Workforce Planning (NMWWP) tools where applicable and should incorporate a triangulation approach as recommended in CEL 32 (2011)…. …..“For the nursing and midwifery workforce, professional validated workload measurement and workforce configuration tools should be used. NHS Boards should reference the national nursing and midwifery workload and workforce planning tools (as appropriate) used in deriving the nursing numbers for each clinical area (as appropriate). These tools should be used as part of the triangulated approach incorporating professional judgement with quality measures.” In 2013, all validated nursing workforce planning tools have been mandated for use within NHS Boards and form part of the planning and setting of nursing and midwifery establishments, planning future services, local delivery plans and inform the ongoing requirements for nurse and midwife training. The nationally validated and evidence based tools incorporate an allowance for staff absence of 22.5%. All tool outputs are considered using the CEL 32 recommended triangulated methodology i.e. funded establishment, actual staff in post, staff absence with consideration of quality measure outputs including reference to staff activity monitoring which forms part of the triangulated process. On Thursday 2 May 2019 the Scottish Parliament agreed that the Health and Care (Staffing) (Scotland) Bill – Stage 3: be passed. The enactment of the Bill will require NHS Boards to evidence how they have made decisions and involved staff in the process, to ensure the right workforce is in place to provide safe and high-quality services, taking account of the particular needs, abilities, characteristics and circumstances of different service users and ensuring the wellbeing of staff. This policy document aims to address gaps in unders tanding around effective rostering and will provide guidance for all nursing and midwifery staff and managers. This in turn will offer a consistent and fair mechanism for managing planned absence whilst ensuring there are the right numbers and skill mix on duty, at the right time to deliver care requirements and assure safe and effective services are delivered.


1. PURPOSE AND SCOPE

1.1 The purpose of this document is to determine the framework that managers and senior nurses and midwives will use to ensure efficient and effective use of nursing & midwifery staff across NHS Tayside and Health & Social Care Partnerships.

1.2 The policy scope specifically relates to nursing and midwifery teams who provide a twenty four hour/seven days per week service. The responsibility of preparing rosters that ensure the appropriate number of skilled staff are available to safely manage the care of the patient or client group, whilst maintaining a work-life balance for the staff can be a complex and time consuming process.

1.3 This document presents a Rostering Policy for the nursing and midwifery workforce of NHS Tayside. The policy aims to promote good practice in the preparation of rosters and to guide line managers and their staff on the principles of effective rostering and should be used in conjunction with the NHST Nursing/Midwifery Bank and Agency Policy .

1.4 Adherence to this document will ensure that good practice is consistent across NHS Tayside. It applies to all Heads of Nursing/Clinical/Service Managers, Nurses and Midwives working in clinical services and nurses and midwives registered with the Nurse Bank across NHS Tayside.

2. STATEMENT OF POLICY

2.1 General Principles of Duty Rostering

2.1.1 The nursing and midwifery workforce is a significant resource of the Board, which requires underlying principles to ensure effective utilisation through efficient and safe rostering. NHS Tayside recognises the value of its workforce and is committed to supporting staff to provide high quality, person centred patient care. Whilst acknowledging the need to balance the effective provision of clinical services with supporting staff to achieve an appropriate work life balance, it is recognised that the organisation needs to respond to changing service requirements. A flexible, efficient and robust rostering system is key to achieving this objective.

2.1.2 The purpose of this policy is to ensure that duty rosters are produced to an agreed standard, which is consistent for all Nurses and Midwives within NHS Tayside and Health & Social Care partnerships (H&SCPs).

2.1.3 To achieve this robust ward/team and department duty rotas are an essential aspect of any well managed area. Senior Charge Nurses/Heads of Nursing/Team Leaders are accountable for the effective management of duty rotas within their area including:

• Minimise clinical and non clinical risk by ensuring that the appropriate number and skill mix of staff is available to provide person centred, safe and effective patient care

• Ensure rosters are prepared using existing budgeted resources to safely meet clinical demand

• Ensuring appropriate leadership within the clinical environment at all times • Ensuring appropriate deployment of staff (see 4.2)


• Management of the standard of duty rotas within the area of responsibility ensuring that rosters are fair, consistent and fit for purpose and that no member of staff is disadvantaged through the workings of this policy

• Effective management of time out allowance added to establishments e.g. annual leave, study leave,

• Improving the monitoring and management of sickness and absence by department and/or individual, generating comparisons, identifying trends and priorities for action

• Enabling the legal requirements of the European Working Time Directive to be met whilst meeting the demands of the service

• Ensure staff feel valued as a resource by ensuring a fair and equitable system to manage working time

2.2 Associated Documents 2.2.1 Before compiling a roster this policy must be read in conjunction with the following

documents:-

• Agenda for Change Terms and Condition of Employment which includes guidance for annual leave

• NHS Tayside Promoting Attendance at Work Policy • NHS Tayside Maternity, Paternity and Adoption Leave Policy • NHS Tayside Mentorship Framework • NHS Tayside Secondment Policy • NHS Tayside Retirement Policy • NHS Tayside Employee Conduct Policy • NHS Tayside Management of Capability Policy • NHS Tayside Carer Leave Policy • NHS Tayside Compassionate & Bereavement Leave Policy • NHS Tayside Paternity, Parental & Shared Parental Leave Policy • NHS Tayside Facilities & Time off Policy • NHS Tayside Career Break Policy • NHS Tayside Recruitment & Selection Policy • NHS Tayside Professional Registration Policy • Any other relevant ward/unit documents • NHS Tayside Working Time Regulations Guidance Document • NHS Tayside Workforce Resourcing Toolkit

2.2.2 If following completion of a roster and there are gaps due to vacancies and a high

level of sickness/absence then refer to:-

• NHS Tayside Nursing/Midwifery Bank & Agency Policy • NHS Tayside Flexible Deployment Protocol

The above documents can be accessed through NHS Tayside Staffnet or by contacting the Human Resources Department (HR).

2.2.3 In conjunction with the European Working Time Directive (EWTD) the effective utilisation of the workforce in NHS Tayside wards, departments and community will support a fair and consistent roster and will provide a safe workforce level, which meets with service need and demand for ensuring delivery of safe, effective person centred care to patients and their families.

NHS Tayside supports the principles regarding work life balance, flexible working and family friendly working. However, this will be set against the optimisation of staff to ensure safe levels of staf fing and skill mix to maximise the quality of patient care and reduce cli nical and non-clinical


risk. The Board in line with public sector duty leg islation under the equality act will consider requests for flexible working but may decline them if this pattern does not support the requirements and needs of the service. All other factors are secondary to this, including requ ests, preferences, team coverage and study leave.

3 RESPONSIBILITIES 3.1 Nurse Director 3.1.1 NHS Tayside Nurse Director holds overall responsibility for ensuring all NHS

Tayside Board and Health & Social Care Partnerships clinical areas and teams are able to deliver safe, effective and person centred patient care with appropriately skilled nursing and midwifery staff.

3.2 Associate Nurse Directors 3.2.1 NHS Tayside Associate Nurse Directors hold responsibility for ensuring all

Directorates and Health & Social Care Partnerships within their sphere of responsibility are able to deliver safe, effective and person centred patient care with appropriately skilled nursing and midwifery staff.

3.2.2 Baseline budget and staffing establishments; Whole Time Equivalent (W.T.E.) ,

demand template levels and skill mix will be agreed between General Manager/Chief Operating Officer/H&SCP Chief Officer and Associate Nurse Director following use of nationally agreed workforce planning tools. Any variance from available resource and recommended staffing levels and skill mix will be escalated to NHS Tayside Directors.

3.3 General Managers / Chief Officers 3.3.1 Ensure compliance with the Policy in their clinical areas of responsibility. 3.4 Clinical Service Managers

3.4.1 Responsible for monitoring and reporting against Key Performance Indicators (KPIs), in conjunction with the Finance, Human Resources and Nursing and Midwifery Directorate Teams and reporting through Directorate/H&SCP performance mechanisms

3.4.2 Responsible for monitoring reports in staff demand profile and temporary staffing usage against unit establishments

3.4.3 Responsible for monitoring staff absence and ensuring that management teams following NHST Promoting Attendance at Work policy

3.4.4 Responsible for the implementation of an early intervention and recovery plan for wards/units/teams failing to meet KPIs.

3.5 Heads of Nursing/Lead Nurses/Senior Nurses and Operational Managers

3.5.1 Responsible for ensuring policy implementation and compliance within their area of responsibility and reporting of compliance through Quality Performance Reviews or equivalent meetings. Non compliance should be recorded on HealthRoster (eRostering system). For areas not on HealthRoster, non compliance must be recorded using the tool in Appendix 1 to form a local record which will be available for audit purposes upon request.


3.5.2 Responsible for monitoring and approving the ward/department/team duty roster on completion (For areas on HealthRoster this is Level 2 Approver). Alternative sign off arrangements should be in place in order to ensure rosters are approved and ready for publication to cover any absence. This includes:

• Approving all shifts including out of hours where supplementary staffing e.g.

bank, or escalated to agency as required • Approve all additional hours and duties according to the needs of service

safety • Produce analysis reports on staffing, expenditure and quality of patient care

and experience • Providing guidance and support to the Senior Charge

Nurse/Midwife/Community Team Leaders or designated other in the creation of duty rosters

• Regularly reviewing supplementary staffing levels, demand templates and additional duty hours, notifying where applicable the appropriate operational line manager of any additional hours or staffing levels agreed above the budgeted staffing resource

• Monitoring and management of staff absence 3.6 Senior Charge Nurse/Senior Charge Midwife/Com munity Team Leader 3.6.1 Responsible for adhering to the agreed nursing establishment Whole Time

Equivalent (W.T.E.) and demand template, escalating to line manager in a timely manner the requirement for any additional resource above this to ensure safe, effective person centred patient care. This includes ensuring that any changes to establishment e.g. changes to staff hours or new staff are communicated to the appropriate department i.e. Payroll and HealthRoster

3.6.2 Responsible for approving the roster (For areas on HealthRoster this is Level 1,

Approver). 3.6.3 Responsible for providing a completed and authorised roster to the clinical team

with a minimum of 4 weeks advanced notice prior to start of roster. 3.6.4 Responsible for the safe staffing of each clinical area lies with individual SCN /

SCM/ CTL in consultation with the Lead Nurse/Midwife/Senior Nurse/Service or Operational Manager/Professional Leads.

3.6.5 Responsible for rostering appropriate senior/experienced nursing/midwifery cover

to ensure clinical expertise and leadership is available at all times including times of peak activity, the weekend and out of hours.

3.6.6 Responsible for Roster Creation; ensuring rosters comply with the requirements

of the Working Time Directive and the principles detailed within this policy. Ensuring that a quality roster is produced, maintained and finalised in line with the Key Performance Indicators (KPI’s)

3.7 Nursing and Midwifery Staff are responsible for :-

• attending work as per their duty roster • adhering to the requirements set out by the roster policy • being reasonable and flexible with their roster requests and being considerate

to their colleagues within the rules set out by NHS Tayside • working their share of nights and weekend shifts where applicable (this will be

defined in each clinical area)


• notifying the Senior Charge Nurse or Deputy of required changes to a planned shift, informing SCN/Deputy as soon as possible in order to give sufficient notice in advance of the planned shift

• Once e-rostering is implemented in the department/ward all staff MUST use employee on-line for duty and annual leave requests. It is the responsibility of all staff to ensure they have completed the Employee Online eLearning and ensure they have account access.

• Responsibility for checking that requests have been authorised lies with the individual. Duty/off duty requests that have been authorised will appear on the published roster. Annual leave requests which have been authorised will appear with a tick indicating approval by the Senior Charge Nurse/Midwife/Community Team Leaders

• The balance of Annual Leave taken/remaining can be viewed in the individual’s Employee Online account

4 ORGANISATIONAL ARRANGEMENTS

4.1 Rostering Principles 4.1.1 For areas on HealthRoster the roster demand template (i.e. the planned number

of staff required on duty at any time) must: • Be in line with the available budgeted resources and agreed skill mix

requirements • Use approved staffing profile and shift patterns • Take account of the predicted absence allowance • Be responsive to known workload variations such as service provision or

seasonal fluctuations

4.1.2 To ensure that the roster reflects the current needs of the service the roster template must be reviewed by Senior Charge Nurse/Midwife/Community Team Leaders and Head of Nursing, supported by Senior Nurse Workforce Planning and approved by Associate Nurse Director and General Manager: • On an annual basis as a minimum • In advance of any significant service change • In response to the use of evidence based tools such as NHS Scotland

Nursing & Midwifery Workload & Workforce Planning Tools • Flexible working arrangements should be formalised in accordance with the

relevant PIN policy and reviewed as a minimum annually or in line with the initial agreement

• Requests for specific duties, annual leave or other leave must be managed within agreed parameters

4.2 For the majority of areas there will be thirteen, four week rosters per year,

commencing on a Monday and published a minimum of four weeks in advance . This will enable staff to better manage their personal arrangements and to afford the Nurse Bank Office sufficient time to fill vacant shifts.

4.3 All rosters should be composed to adequately cover twenty four hours (or agreed

set hours to meet clinical activity) utilising substantive staff1 proportionally across all shifts. The use of bank and agency should be used in line with the NHS Tayside Nursing/Midwifery Bank and Agency Policy.

1 This includes staff on temporary or fixed term contracts


4.4 If staff are working non–standard shifts such as late starts, this should be entered into Healthroster and SSTS to ensure accuracy of hours worked and avoid misinterpretation.

4.5 Staff must have a minimum of one weekend off per four week roster , in normal circumstances. Additional weekends off can be rostered if the departmental requirements allow.

• A week is defined as the period Monday to Sunday and in every week, a staff member should have two consecutive days off during this seven day period

• The number of consecutive standard day shifts for staff to work w ill not exceed seven 2.

• The number of consecutive twelve hour shifts for staff to work will not exceed four

• Night Duty MUST not exceed a maximum of four consecutive shifts . • Where clinically appropriate for service provision and needs of staff it is

possible to work blocks of nights. Full time staff SHOULD not normally work more than 4 blocks of nights in a roster period.

• Internal rotation between day duty and night duty is promoted within the organisation. Roster managers should ensure that employees do not work days and nights in any 7 day period. Any requirement for an individual member of staff to work days and nights in the same 7 day period must be supported by a clear service requirement and doc umented in HealthRoster or using the tool in Appendix 1.

• In all cases 3 days off must follow the last night duty worked w hen changing from night to day duty.

• It is good practice during a period of day duty practice to roster an early shift before days off and a late shift following days off

4.6 Pre Registration Student Nurses will be rostered with their mentors for a minimum of 40% of their shifts. All shifts are supernumerary therefore students will not be counted in the establishment or Safe Care calculation where used.

4.7 Predicted Absence Allowance

Within each Ward/Unit/Team the following timeout allowance is included in the unit/department budget to cover expected absence.

• Annual Leave – 15% (including Public Holidays) • Sickness - 4% • Study Leave – 2% • Maternity/Paternity Leave – 1% • Other paid leave – 0.5% • Total – 22.5%

Note: Smaller teams will need to calculate their specific levels of tolerance.

4.8 Public Holidays/Annual Leave The Senior Charge Nurse/Midwife/Community Team Leaders is responsible for

approving all annual leave. Each member of staff is responsible for booking their annual leave at least six weeks in advance.

2 NHS Tayside Working Time Regulation Guidance Documenthttp://staffnet.tayside.scot.nhs.uk/NHSTaysideDocs/idcplg?IdcService=GET_FILE&dDocName=PROD_277603&Rendition=web&RevisionSelectionMethod=LatestReleased&noSaveAs=1


4.9 The target percentage of staff on annual leave at any one time is 15% of total staff in post (with a tolerance range of +/- 1%). Each department should calculate how many registered and unregistered staff MUST be allocated annual leave in any one week, with a defined limit for each Band (see appendix 2 for the time out algorithm). An agreed number will be set and must be adhered to, however the Senior Charge Nurse/Midwife/Clinical Team Leader can use some discretion in allocating leave across pay bands, as long as skill mix is maintained, however this MUST NOT lead to the need for supplementary staffing to cover periods of annual leave.

4.10 Senior Charge Nurse/Midwife/Community Team Leaders are expected to ensure

that staff use their leave entitlement across the year. All staff MUST be aware of the need to maintain the 15% target of total staff in post on annual leave (with a tolerance range of +/- 1%) constantly throughout the year when requesting annual leave.

Where annual leave is not being requested appropria tely the Senior Charge Nurse/Midwife/Community Team Leaders must meet the member of staff and reach agreement of when leave will be taken ensurin g compliance with 4.9 above.

A maximum of fourteen consecutive calendar days of annual leave can be requested. Any more than this will need special approval from the Head of Nursing/Clinical Nurse Manager.

4.11 Annual leave should be approved before a roster is published as per 4.10. Annual

leave requested after this can only be given if staffing levels permit. Annual leave requests that exceed the documented acceptable level for the department will NOT be approved. If additional leave has to be allocated, due to accumulated leave e.g. sick/maternity leave, this must be discussed with Head of Nursing.

4.12 Peak Holiday Periods - The amount of annual leave taken during peak holiday

periods MUST remain within the 14% - 16% range. Discussions should be encouraged between those requesting time off so that each member of staff has an equal chance of being granted annual leave. Annual leave requests for peak holiday periods will be shared equally amongst those making requests. The use of supplementary staffing to cover annual leave is unacceptable.

4.13 Study leave The Senior Charge Nurse/Midwife/Community Team Leaders will:

• utilise the available number of study leave days in each roster calculated using the time out algorithm

• Prioritise mandatory training requirements for staff which may include induction, updates, etc.

• produce roster ensuring staff have the required mandatory training • record all study leave time on HealthRoster and SSTS

4.14 Sickness Absence

Sickness Absence will be managed in accordance with the NHS Tayside’s Promoting Attendance at Work Policy. In accordance with policy, employees are required to notify their Senior Charge Nurse/Midwife/Community Team Leaders Nurse or nominated deputy, as early as possible by telephone if they are sick (not text or e-mail).

4.15 Changes to Published Rosters


Whilst it is acknowledged that this task may be delegated, it is the responsibility of the Senior Charge Nurse/Midwife/Community Team Leaders to ensure that rosters are amended and kept up to date with additional shifts and timeout e.g. sickness, absence, study leave, etc. Shift changes should be kept to a minimum; staff are responsible for negotiating their own changes once the roster is completed. These changes must be approved by the Senior Charge Nurse/Midwife/Community Team Leaders. All shift changes should be made with staff at an equal grade and with consideration for the overall skill mix of all shifts being changed. Where staff are allocated as a mentor to a student, shift changes should not occur without ensuring the student either changes with the staff member or is allocated to another suitable member of staff and that the student is aware of the change and that this change is recorded on the roster.

4.16 Updating changes to the roster

• All changes to the published duty roster must be updated on the electronic roster at the time the change is agreed due to the link with the Safe Care© system to ensure that safe staffing levels are maintained and that staff are deployed effectively (this includes changes to shifts, times of attendance, late finishes, sickness and annual leave)

• The actual worked roster must be finalised by the Senior Charge Nurse/Midwife/Community Team Leaders within the timescales determined by payroll. It is the Senior Charge Nurse/Midwife/Community Team Leaders responsibility to ensure appropriate staff have access and are trained to make these changes in her/his absence

• Employees taking up new posts within a ward/department will be added to the electronic roster for that area from the start date of their new contract

• Employees leaving their posts from a ward/department can be removed or transferred from that electronic roster from their last working day.

• Any changes of contracted hours must be notified to the HealthRoster Team. Skill Mix

• An agreed and funded staffing Whole Time Equivalent and skill mix baseline is essential to delivering high quality care. Each Ward/Unit/Team should have an agreed total number of staff and skill mix determined by the use of the appropriate National Nursing & Midwifery Workload & Workforce Planning Tools for the specific specialty. The establishment will be approved by the General Manager and Associate Nurse Director.

• The skill mix and establishment must be reviewed at least annually, within the

budget setting and workforce planning process. Skill Mix and establishment reviews may take place more frequently if clinical need / risk is identified. In areas where the workload is known to vary according to the day of the week staff numbers and skill mix should reflect this. Each ward/unit/team should have an agreed level of staff with specific competencies on each shift, to enable appropriate cover, e.g.:-

• administration of medication • IV therapies administration • taking charge of the shift • ability to perform patient assessments and observations

• The roster for senior staff must be compatible with their commitment to any

bleep holders roster. There must be designated person in charge for each shift who has been identified as having the required skills and competencies


for a co-ordinating role. To achieve a balance of skills across all shifts senior staff should work opposite shifts.

Flexible Working

• NHS Tayside is committed to the principles laid down by the NHS Scotland

Staff Governance Standard and Partnership Information Network (PIN) Policies, to promote the principles and approaches to achieving health and wellbeing, which includes: work life balance, flexible working and family friendly working (refer to relevant NHST Human Resources Policies).

• All applications for flexible working will be considered in line with appropriate

NHS Tayside HR Policy, but it may on occasion not be possible to agree to requests of individuals if their proposed working pattern cannot be accommodated within service needs. Service needs will take priority when creating a roster and achieving safe staffing numbers and an appropriate skill mix is essential.

Working Adjustments

• All working adjustments MUST be formally agreed between the Senior Charge

Nurse/Midwife/Community Team Leaders, Head of Nursing or equivalent, HR and the employee, so all parties know what has been agreed. This also allows the ward/unit to review if the working adjustments will overly impact on the ability of the Senior Charge Nurse/Midwife/Community Team Leaders to deliver rosters that are fair and equitable and meet the needs of the patients. For example, if there are a number of staff in a ward/unit who cannot work on a specific day of the week, and an additional employee wants an adjustment to not work on that same day, this may cause challenges to meeting patient care requirements. The staff member’s needs could be met without impacting the service by moving them to ward/unit without a high level of staff with that particular adjustment. When adjustments are agreed there MUST be regular formal review of these adjustments at an agreed timescale in line with policy. If working adjustments are lifted for some employees, it makes it more likely that new requests for adjustments can be accommodated for other employees, whose circumstances may have also changed.

4.19 Requests

Senior Charge Nurse/Midwife/Community Team Leaders are responsible for ensuring a system of documenting requests is available to all staff (where Employee On Line is available this MUST be used). When making a request staff must provide a comment indicating whether the request is high priority or low priority. • All requests will be considered in the light of patient care and service needs

and the Senior Charge Nurse/Midwife/Community Team Leaders will endeavour to meet individual requests. However, it cannot be assumed that the roster will be developed to accommodate all requests, including high priority requests, as service needs will take priority. Requests should be for specific days off, only in exceptional circumstances will requests for specific days/shifts to be worked be considered.

Fairness in the allocation of requests will be monitored by SCN/SCM/CTL and Heads of Nursing (or equivalent).


• It is acknowledged that a Duty Roster can be compliant with policy when published by the SCN and that changes to the roster to cover additional staff sickness absence can impact on compliance with the policy. In addition, staff who then request amendments to their individual roster can also impact on the compliance of the roster. It is important that an audit trail is retained that describes the reasons for such changes. SCN‘s should use professional judgement prior to agreeing to roster changes to ensure safe staffing levels and skill mix are maintained in the clinical area.

Please note : The inclusion of the weekend before annual leave, as days off cannot be guaranteed. This will be dependent upon service needs and staff capacity at the time. The approval of requests cannot be guaranteed

4.20 Flexible Deployment

• During staff shortages it is accepted that staff may be required to work in other clinical areas to provide a safe and efficient service. The Head of Nursing/Clinical Team Manager or delegated Senior Charge Nurse/Midwife/Community Team Leaders or other designated person for each area, is responsible for the redeployment of staff within the Directorate/Health and Social Care Partnership to meet service requirements. Out of hours, this decision will be made by the Bleep Holder/On call Duty Manager. It is recognised that occasionally staffing levels need to be viewed as a whole, i.e. across Directorates or across sites/ Directorate/Health and Social Care Partnership or cross Directorate/ Directorate/Health and Social Care Partnership when staffing redeployment within a particular area is not possible. All staff deployment will adhere to the principles within the guide for the Deployment of Nursing and Midwifery Staff within NHS Tayside. (See appendix VII of Nursing and Midwifery Bank and Agency Policy.)

It is accepted that in the event of a major incident or significant event; staff will be redeployed, taking into consideration their skills and competencies, to maintain the provision of safe, effective, person centred patient care.

4.2 KEY CONTACTS

Charles Sinclair Jenny Alexander Associate Nurse Director Partnership Facilitator Level 9, Ninewells Hospital Kingsway Care Centre Dundee Dundee DD1 9SY DD2 3QB [email protected] [email protected] 01382 660111 01382 632490

mailto:[email protected]

mailto:[email protected]


Audit tool Appendix 1


Policy Compliance Monitoring

Change of Shifts/ Extra Hours / Overtime. WEEK BEGINNING: ___________________________________ All

Staff Name Mon Tues Wed Thu Fri Sat Sun Request made by staff/service

Provide reason

Breaching

policy

Y/N

I understand that this swap

may breach rostering policy

Staff and SCN/C/N signatures


Predicted Absence Allowance Algorithm A ppendix 2 Clinical Area X has 21 wte Registered staff and 7.5 wte HCSW’s *. The percentage of staff on time out at any time is 22.5% Therefore Target Levels are: Total Time Out Registered Staff = 21 x 0. 225 = 4.73 wte HCSW = 7.5 x 0.225 = 1.69 wte Within that total annual leave must account for 15% and therefore Registered staff = 21 x 0.15 = 3.15wte HCSW = 7.5 x 0.15 = 1.13wte You would therefore need to allocate 3.15 wte Registered staff 1.13 wte HCSWA per week on leave to achieve balance over the year. This equates to 15 – 16 days leave per week for Registered Nursing/Midwifery staff and 5 – 6 days leave per week for HCSW. Please note: This number is based on wte in post ; therefore as staff join and/or leave you will need to recalculate the above.


Appendix 3

NHS TAYSIDE – POLICY APPROVAL CHECKLIST

This form must be completed by the Policy Manager a nd this checklist must be completed and forwarded with the policy to the Exec utive Team, Clinical Quality Forum or Area Partnership Forum for approval and to the appropriate Committee

for adoption. POLICY AREA: (See Intranet Framework) Nursing and Midwifery POLICY TITLE: Rostering Policy for Nursing and Midwifery Staff POLICY MANAGER: Nurse Director

Why has this policy been developed? To ensure the compliance with current rostering best practice to ensure safe and effective patient care.

Has the policy been developed in accordance with or related to legislation? – Please give details of applicable legislation.

European Working Time Directive

Has a risk control plan been developed and who is the owner of the risk? If not, why not?

No

Who has been involved/consulted in the development of the policy?

Nursing and Midwifery Directorate, HR Directorate, Staff Side, Senior Charge Nurses, Heads of Nursing

Has the policy been Equality Impact Assessed in relation to:- Has the policy been Equality Impact Assessed not to disadvantage the following groups:-

Age Disability Gender Reassignment Pregnancy/Maternity Race/Ethnicity Religion/Belief Sex (men and women) Sexual Orientation

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Yes Yes

People with Mental Health Problems Homeless People People involved in the Criminal Justice System Staff Socio Economic Deprivation Groups Carers Literacy Rural Language/Social Origins

Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Does the policy contain evidence of the Equality Impact Assessment Process?

Yes

Is there an implementation plan? Yes

Which officers are responsible for implementation? HoN, Lead Nurses, Snr Nurses & Operational Managers When will the policy take effect? Immediately Who must comply with the policy/strategy? All Registered and Non-Registered Nursing & Midwifery

Staff How will they be informed of their responsibilities? Local ward/team meetings Is any training required? All staff responsible for roster creation will receive

training If yes, attach a template See above Are there any cost implications? None If yes, please detail costs and note source of funding Who is responsible for auditing the implementation of the policy? Policy Leads What is the audit interval? Monthly compliance with rostering policy Who will receive the audit reports? HoN, Lead Nurses, Snr Nurses, Operational Managers &

Policy Leads When will the policy be reviewed and provide details of policy review period (up to 5 years)

3 Years, Associate Nurse Director, Partnership Representatives and Human Resources colleagues

POLICY MANAGER: Charlie Sinclair and Jenny Alexander DATE: _June 2019______________ APPROVAL COMMITTEE TO CONFIRM: ____Clinical Quality Forum_______________________ ADOPTION COMMITTEE TO CONFIRM: ____Care Governance Committee_________________


Appendix 4

EQUALITY IMPACT ASSESSMENT Name of Policy, Service Improvement, Redesign or St rategy: Rostering Policy for Nursing & Midwifery Staff Lead Director of Manager: Nursing and Midwifery What are the main aims of the Policy, Service Impro vement, Redesign or Strategy? To ensure nursing and midwifery rosters are developed in line with current best practice. Description of the Policy, Service Improvement, Red esign or Strategy – What is it? What does it do? Who does it? And wh o is it for? This policy is for use by ALL Nursing and Midwifery areas within NHS Tayside and Health & Social Care Partnerships that require staff to be rostered over 24 hours to provide safe, effective services. What are the intended outcomes from the proposed Po licy, Service Improvement, Redesign or strategy? – What will happen as a resul t of it? - Who benefits from it and how? This policy aims to support and assure the provision of safe, effective and person centred care. This policy supports the required planning to ensure there are the right staff available, at the right time, in the right place and with the necessary skills and knowledge required. Name of the group responsible for assessing or cons idering the equality impact assessment? This should be the Policy Working Grou p or the Project team for Service Improvement, Redesign or Strategy. Roster Scrutiny Group


SECTION 1 Part B – Equality and Diversity Impacts Which equality group or Protected Characteristics d o you think will be affected Item Considerations of impact Explain the answer and if

applicable detail the impact Docum ent any Evidence/Research/Data to support the consideration of impact

Further actions required

1.1 Will it impact on the whole population? Yes or No. If yes will it have a differential impact on any of the groups identified in 1.2. If no go to 1.2 to identify which groups

No


Item Considerations of impact Explain the answer and if applicable detail the impact

Document any Evidence/Research/Data to support the consideration of impact


1.2 Which of the protected characteristic(s) or groups will be affected?

• Minority ethnic population (including refugees, asylum seekers & gypsies/travellers)

• Women and men • People in

religious/faith groups • Disabled people • Older people, children

and young people • Lesbian, gay, bisexual

and transgender people

• People with mental health problems

• Homeless people • People involved in

criminal justice system

• Staff • Socio- economically

deprived groups





1.3 Will the development of the policy, strategy or service improvement/redesign lead to

• Discrimination • Unequal opportunities • Poor relations

between equality groups and other groups

• Other

No None


SECTION 2 – Human Rights and Health Impact. Which Human Rights could be affected in relation to article 2, 3, 5, 6, 9 and 11. (ECHR: European Conv ention on Human Rights) Item Considerations of impact Explain the a nswer and if

applicable detail the impact Document any Evidence/Research/Data to support the consideration of impact


2.1

On Life (Article 2, ECHR) • Basic necessities such as

adequate nutrition, and safe drinking water

• Suicide • Risk to life of / from

others • Duties to protect life from

risks by self / others • End of life questions

None

2.2

On Freedom from ill -treatment (Article 3, ECHR) • Fear, humiliation • Intense physical or

mental suffering or anguish

• Prevention of ill-treatment,

• Investigation of reasonably substantiated allegations of serious ill-treatment

• Dignified living conditions

None





2.3 On Liberty (Article 5, ECHR) • Detention under mental

health law • Review of continued

justification of detention • Informing reasons for

detention

None

2.4 On a Fair Hearing (Article 6, ECHR) • Staff disciplinary

proceedings • Malpractice • Right to be heard • Procedural fairness • Effective participation in

proceedings that determine rights such as employment, damages / compensation

None


Item Considerations of impact Explain the answer and i f



2.5 On Private and family life (Article 6, ECHR) • Private and Family life • Physical and moral

integrity (e.g. freedom from non-consensual treatment, harassment or abuse

• Personal data, privacy and confidentiality

• Sexual identity • Autonomy and self-

determination • Relations with family,

community • Participation in decisions

that affect rights • Legal capacity in decision

making supported participation and decision making, accessible information and communication to support decision making

• Clean and healthy environment

None





2.6 On Freedom of thought, conscience and religion (Article 9, ECHR) • To express opinions and

receive and impart information and ideas without interference

None

2.7 On Freedom of assembly and association (Article 11, ECHR) • Choosing whether to

belong to a trade union

None

2.8 On Marriage and founding a family • Capacity • Age

None

2.9 Protocol 1 (Article 1, 2, 3 ECHR) • Peaceful enjoyment of

possessions

None


SECTION 3 – Health Inequalities Impact Which health and lifestyle changes will be affected ? Item Considerations of impact Explain the answer and if



3.1 What impact will the function, policy/strategy or service change have on lifestyles?

For example will the changes affect:

• Diet & nutrition • Exercise & physical

activity • Substance use:

tobacco, alcohol or drugs

• Risk taking behaviours

• Education & learning or skills

• Other

None None

3.2. Does your function, policy or service change consider the impact on the communities?

Things that might be affected include:

• Social status • Employment

(paid/unpaid) • Social/family support • Stress • Income

No None





3.3 Will the function, policy or service change have an impact on the physical environment? For example will there be impacts on:

• Living conditions • Working conditions • Pollution or climate

change • Accidental

injuries/public safety • Transmission of

infectious diseases • Other

No None

3.4 Will the function, policy or service change affect access to and experience of services? For example

• Healthcare • Social services • Education • Transport • Housing

No None





3.5 In relation to the protected characteristics and groups identified:

• What are the potential impacts on health?

• Will the function,

policy or service change impact on access to health care? If yes - in what way?

• Will the function or

policy or service change impact on the experience of health care? If yes – in what way?

None None


SECTION 4 – Financial Decisions Impact How will it affect the financial decision or propos al? Item Cons iderations of impact Explain the answer and if



4.1

• Is the purpose of the financial decision for service improvement/redesign clearly set out

• Has the impact of your financial proposals on equality groups been thoroughly considered before any decisions are arrived at

None

4.2 • Is there sufficient information to show that “due regard” has been paid to the equality duties in the financial decision making

• Have you identified methods for mitigating or avoiding any adverse impacts on equality groups

• Have those likely to be affected by the financial proposal been consulted and involved

None





5. Involvement, Consultation and Engagement (IEC) 1) What existing IEC data do we have?

• Existing IEC sources • Original IEC • Key learning

2) What further IEC, if any, do you need to undertake?

None None


Item Considerations of impact Explain the answer and if



6. Have any potential negative impacts been identified?

• If so, what action has been proposed to counteract the negative impacts? (if yes state how)

For example: • Is there any unlawful

discrimination? • Could any community

get an adverse outcome?

• Could any group be excluded from the benefits of the function/policy?

(consider groups outlined in 1.2)

• Does it reinforce negative stereotypes?

(For example, are any of the groups identified in 1.2 being disadvantaged due to perception rather than factual information?)

None None


Item Considerations of impact Explain the answer and if



7. Data & Research • Is there need to

gather further evidence/data?

• Are there any apparent gaps in knowledge/skills?

No None

8. Monitoring of outcomes • How will the

outcomes be monitored?

• Who will monitor? • What criteria will you

use to measure progress towards the outcomes?

None

9.. Recommendations State the conclusion of the Impact Assessment

No impact None

10. Completed function/policy • Who will sign this off? • When?

Workforce Assurance Group 11 June Clinical Quality Forum tbc Care Governance Committee tbc

11. Publication

None


Conclusion Sheet for Equality Impact Assessment

Positive Impacts (Note the groups affected)

Negative Impacts (Note the groups affected)

What if any additional information and evidence is required

None

From the outcome of the Equality Impact Assessment what are your recommendations? (refer to questions 5 - 10) No action required