An education programme for junior nurses working in acute medicine

Introduction

Health and social care providers face major challenges recruiting and retaining nursing staff. In 2017, for the first time, more nurses left the Nursing and Midwifery Council register than joined it (NMC, 2017). At one point in 2018, University Hospitals Birmingham NHS Foundation Trust (UHBFT) had a nurse vacancy rate of 20% in acute medicine across three of its four sites, with 115 roles unfilled.

As part of its recruitment and retention strategy, it has developed and piloted a foundation education programme for junior nurses in acute medicine. The Programme for Acute Medicine Nurse Development and Accreditation (PANDA) runs one day a week for eight weeks; it is described here, along with the results of a survey of the first cohort of learners.

Attracting nurses to acute medicine

Acute medicine (Box 1) works closely with emergency departments (EDs) but is a relatively new specialty. Lees and Myers’ (2010) national survey of nurses working in acute medicine units suggested that nurses used to stay in the specialty for up to 20 years, but those with significant experience were becoming dissatisfied by a lack of opportunities to advance. Jones and Lees (2009) found newly registered nurses were attracted to acute medicine because it offered multidisciplinary team working and opportunities to develop diverse skills.

However, retaining nurses in acute medicine and helping them to sustain their enthusiasm to deliver high-quality patient care is increasingly difficult in the current climate of high workloads and continued staff shortages. Nurses who leave acute medicine report worrying about how to cope with the unrelenting pressures of rising admissions to this busy environment – these increased by 5.7% in March 2019 compared with the same month in 2018 (NHS England, 2019).

Recruitment and retention strategies

In England, some acute hospitals have developed strategies to address recruitment and retention challenges, which include marketing campaigns, preceptorship programmes for newly registered nurses, flexible working hours, rewards for staff excellence and registered nurse rotations for a variety of experience in different clinical areas, such as EDs, intensive care and theatres (Association of UK University Hospitals, 2018).

While generic activities can be helpful in addressing recruitment and retention, additional local strategies may be needed in clinical areas with specific staff requirements, such as EDs. Indeed, Evans et al (2017) showed how local strategies dramatically reduced nurse vacancy rates in the ED at Medway NHS Foundation Trust.

Competency frameworks for nurses working in acute medicine have been developed, including by the Society for Acute Medicine in the UK (Myers and Lees, 2013) and the Health Service Executive in Ireland (Casey et al, 2016). However, there is a dearth of literature on how newly registered and junior nurses can be better supported and retained in acute medicine.

Developing the programme

In April 2018 a ‘task and finish’ group, comprising the matron, senior sisters and advanced clinical practitioners at Heartlands Hospital, part of UHBFT, met to discuss the aims and focus of an educational programme. The overall goal was to maintain high-quality patient care and ensure patient safety; the aims for acute medicine were to:

• Improve the recruitment and retention of newly registered and junior nurses;
• Deliver a consistent approach to post-registration education for newly registered and junior nurses;
• Develop the emotional intelligence, resilience and confidence of newly registered and junior nurses;
• Create a supportive learning environment that values the contribution of newly registered and junior nurses.

The competency frameworks by Casey et al (2016) and Myers and Lees (2013) helped us with the choice of topics, namely: cardiac, respiratory, gastroenterology, diabetes, acute kidney injury, infectious diseases, mental health, care of the older person (frailty, dementia and delirium) and patient discharge.

PANDA takes place one day a week for eight weeks. Each day is split into didactic core lectures, self-directed work-based learning activities, and action learning sets. The didactic core lectures are delivered by acute medicine consultants, specialist nurses and therapists, who are encouraged to draw from students’ self-directed work-based learning. The aim of the action learning sets is to discuss challenges in the workplace and build the resilience of nurses.

The last day of PANDA incorporates the one-day Adult Acute Illness Management (AIM) course developed by critical care staff in Greater Manchester. This course enables nurses to assess and manage deteriorating patients using the ABCDE (airway, breathing, circulation, disability, exposure) approach, covering sepsis and other medical emergencies. Although the AIM course is not part of the overall assessment strategy, we were given the chance to pilot new competencies developed for it by the critical care outreach team. The competencies integrate clinical assessment of clinical competence in practice with ongoing support from the critical care outreach team and clinical educator in acute medicine after PANDA.

Evaluating the programme

PANDA was piloted between October and November 2018 with a cohort of 10 junior and newly registered nurses. The evaluation takes a prospective, longitudinal approach using Kirkpatrick and Kirkpatrick’s (2005) model of four levels:

• Reaction;
• Learning;
• Behaviour;
• Results.

It also uses mixed methods – namely, a questionnaire, interviews, and examination of recruitment and retention data.

The first stage of the evaluation (first level of learning: reaction) was carried out in December 2018 using a survey of 10 questions spanning three areas (overall satisfaction, satisfaction with the programme delivery, retention factors). A five-point Likert scale (from ‘strongly agree’ to ‘strongly disagree’) was used. Anonymous data was collected and stored using encrypted, password-protected electronic files. Written consent to publish information from the questionnaire was elicited from the participants. All responses were positive and most respondents ‘strongly agreed’ with the statements (Table 1).

The questionnaires also allowed respondents to elaborate on the programme’s strengths and weaknesses, and suggest improvements. Participants felt well supported but that they could do with less self-directed study time. Their comments (Box 2) show that study days may be too long and off-duty arrangements before and after study days may be needed.

Kirkpatrick and Kirkpatrick’s (2005)evaluation model is being used over 24 months, so the evaluation of PANDA is ongoing. We are currently approaching the third stage (interviews) with the first PANDA cohort, which is due to end in October 2020.

Next steps

PANDA was delivered for a second time between April and June 2019 to a cohort of 20 junior and newly registered nurses from three sites. The nurses who have been through PANDA will continue to be supported in practice through ongoing clinical mentorship, agreed via the critical care outreach team and clinical educator in acute medicine. The programme lead has agreed, in principle, to carry on with the action learning sets on a quarterly basis, which we hope will help our junior nurses continue to build their resilience.

We have worked with a local university to obtain academic accreditation for PANDA as a level 7 post-graduate double module (40 credits). Learners from the second PANDA cohort were given the option of undertaking continued professional development (eight study days) or completing the accredited learning components, through which they will also be assessed via a :

• Case study (3,000 words);
• Viva;
• Work-based learning portfolio, comprising eight practice reflections (as per the NMC revalidation format), critical reviews of patient cases and other self-directed learning elements.

We are working towards enabling nurses to complete a post-graduate certificate (requiring a further 20-credit, level 7 module), providing a platform for them to continue developing their career in acute medicine while working towards a full Master’s degree in acute care over 3-5 years.

Conclusion

Our plans to develop an education programme when vacancy rates were high were ambitious. PANDA was made possible by the collaborative efforts and commitment of a senior nursing team and consultants. It supports newly registered staff transitioning from student to registered nurse, and invests in them at what could be the beginning of a career in acute medicine.

If we are able to retain junior nurses in acute medicine, their individual capacity to care will gradually build up, which will benefit patient safety and improve patient outcomes. Although nursing in acute medicine is often described as generalist, we believe that, with the identification of essential areas of practice, the role of the nurse in acute medicine could compete alongside areas such as ED for equal recognition as a specialty area in which to work