Two more hospitals have just started their pilots as part of our FlexAbility in Nursing programme. Here’s a look at what’s gone well with our first pilot hospital, what participants think of the pilot so far, and how we’re applying our learnings.
After spending eight months working with nurses on three wards at Birmingham Women’s and Children’s Hospital (BWCH) to pilot team-based rostering, we’re now able to describe what we’ve learned and, importantly, report on nurses’ satisfaction with the changes. We’re also applying these learnings to two further pilots, at Nottingham University Hospital (NUH) and University Hospital Southampton (UHS).
Here are some key points:
As we have explored previously, flexibility in nursing often means predictability – that is, the ability to work a more regular shift pattern, rather than being subject to the extremes of variability which are common in nursing. In general, such bespoke working arrangements have often been allocated on a request-response basis, usually for parents or people with other caring responsibilities.
One of the aims of our team-based rostering approach is to ensure that everyone, not just the carers in the team, can have a say in their working pattern. However, it’s hard to shift a long-held conviction that going to the gym, singing in a choir or just having a long weekend are less valid reasons for a bespoke working arrangement.
We are therefore incorporating discussion of this shift in mindset very early on in the training for the NUH and UHS pilots, and have already noted that this helps those staff who do not have childcare needs feel like they are as highly valued, and their priorities as important, as their colleagues with children.
Data from our mid-pilot survey at BWCH shows that the proportion of nurses who feel they have an input into the roster is moving gradually upwards, having gone from 60% to 66% in four months, while the proportion who felt they had insufficient input has reduced from 20% to 9%. Furthermore, the proportion who feel that they understand their colleagues’ work-life balance needs has gone from 58% to 70%.
The BWCH pilot has also begun to address the issue of long-standing fixed working arrangements, which can have a negative impact on everyone else. For example, an employee who was given Fridays off for childcare reasons – whether formally or informally – may no longer have the same needs, but may have continued with this arrangement.
Understandably, these employees are loath to lose an arrangement which works well for them, but this can be incompatible with a team-based approach. There needs to be a recognition of the needs of the team as a whole, and a negotiation that is fair to everyone, rather than some nurses acquiring a special ‘accommodation’ by virtue of having asked first, or having a ‘better’ reason. Under our new system, 75% of the BWCH nurses now feel a collective responsibility for producing the roster.
Under the previous system, where nurses could make a small number of shift requests, but otherwise had their rosters imposed on them, there was frequent grumbling when people didn’t get what they had asked for, but also an acceptance that the system was not going to change.
Our new approach involves a ‘lead team’ of nurses (approximately one lead team member for every 6-8 nurses) asking staff about their preferences, then working more collectively to create the roster and fulfil as many of those preferences as possible.
However, some nurses’ expectations were raised to unrealistic levels, and they then tried to override the lead team members’ decisions, thereby undermining both the system and the sense of teamwork. Clearly, there needs to be an acceptance that, in a 24/7 environment, compromise is required, and that preferences are just that, preferences, not guarantees. And the role of the team leader in fostering this acceptance is critical.
The major change we’ve made to tackle this for our two new hospital pilots is to invest more time in identifying lead team members who have the right balance between being assertive and being caring. We’re also spending more time training them in how to deal with dissatisfied colleagues. This includes role-playing tricky conversations, articulating the kinds of problems that may come up, and even providing them with the right language to use – helpful phrases that capture the new approach.
One of the wards at BWCH got to grips with the concept of team-based rostering much more quickly than the other two. Becoming a lead team member means going up a rapid learning curve about how a roster is built, and what the constraints are – and some of them found the roster-building process uncongenial. So the more successful wards changed those lead team members who were not happy in the role at an early stage.
It’s vital that the lead team have the right skills and qualities to produce effective rosters and manage staff demands. So, for NUH and UHS, we have increased the time allocated to training the lead team on how to use the e-roster to manage operational challenges and clinical constraints (such as getting the right skills mix for every shift), so they can hit the ground running. Then, once the lead team is correctly staffed and up to speed, we are monitoring lead team members’ skills and comfort levels in the role, so that we can make changes if needed.
The new process is having a positive impact on nurses’ understanding of how a roster is built: the proportion of nurses at BWCH who say they understand the roster process has gone up from 65% to 85%, while the proportion who felt they did not understand the process has decreased from 35% to 15%.
We have also created an implementation guide, which includes a walk through the rostering process and the lead team members’ role in it, and a series of FAQs gleaned from our experience to date, so the teams have a source of information which they can refer to.
We are now working across seven wards, with a total of over 200 nurses, at our three hospitals. All three will continue to use the new process we’ve developed until the end of the pilot in March 2019. At this point, we will publish our final report and circulate our learnings to the sector as a whole.
In the meantime, while FlexAbility in Nursing has focused on one of the three cornerstones of designing flexible working for a shift based environment (input into scheduling) we are excited to be starting another, similarly ambitious pilot. This time we will be investigating how to tackle the variability of scheduling and its effect on individuals.
The project will explore whether a more predictable schedule will encourage more nurses to stay in the profession – and tackle the operational challenges of making that happen. We’re looking forward to getting started and will keep you informed of our progress.
Published June 2018
