6 PILOT OPERATION - VIEWS ON RECRUITMENT
Introduction
6.1 In this chapter we outline stakeholder perceptions of the identification and recruitment of eligible HCSWs; the views of participating healthcare support workers on getting involved with the pilot and views from support workers who chose not to volunteer.
6.2 The final recruits represented a broad cross section of clinical support workers (Table 5.4) across the three service areas and hospital and community sites (Table 5.5) and across urban and rural bases. However the pilot largely failed to attract non-clinical staff and therefore the model was tested with only a small number of ancillary and laboratory staff (Table 5.4).
The recruitment process in operation
Targeting and identification of eligible HCSWs
6.3 All HCSW participation was voluntary as there was no legislative underpinning the pilot to require mandatory participation. The approach to engaging HCSWs or 'marketing' the pilot was therefore critical to its success. The Local and National Pilot Coordinators collaborated to design an approach and to develop a range of recruitment materials. The basic approach consisted of advance publicity specifying all staff to be included (posters, leaflets, newsletter articles); identification of eligible HCSWs via managers and human resources listings; briefing sessions; an invitation letter plus consent sheet; information pack and Disclosure Scotland application. The approach and materials ( Annexe I) were adapted to some degree by pilot sites to suit local needs and differing cultures as the pilot progressed.
6.4 The three sites varied in their approach to identification and targeting of eligible HCSWs. As the pilot was voluntary, marketing it to HCSWs entailed a fine balance between 'invitation' and stronger 'encouragement' to take part. The voluntary aspect was clearly maintained at all sites but the strength of marketing at each site appears to have led to different results. The overall level of Board support for the pilot appeared more consistent at Ayrshire and Arran and Lanarkshire, which both achieved a greater number of recruits, than at Lothian (Table 5.1).
6.5 The first two pilot sites, Ayrshire and Arran and Lothian, began with an open, broadcast information-giving approach, relying upon HCSWs to come forward, and this was followed at a later stage with more targeted action. These sites recruited using a multi-pronged approach to identify all eligible HCSWs including: comprehensive identification and widespread engagement with senior and middle mangers; attendance at standing meetings; email to middle managers; plus cross checking of lists from HR systems. Lothian issued an individual letter in one batch (August 2007) and Ayrshire and Arran issued invitations in batches by occupational grouping, offering briefings by occupational group or one-to-one sessions.
6.6 Ayrshire and Arran lead officers had, in the first two months of the pilot, conducted a series of five promotional briefings attracting more than sixty HCSWs. The LPC, building upon this activity, found it easier to identify the smaller number of HCSWs involved (500+ excluding bank staff). The much larger NHS Lothian site (1400+ at the outset) faced a much more complicated task due to the diverse range of locations and the local reorganisation legacy of changed structures, multiple job titles following Agenda for Change assimilation, multiple data systems and unaligned data. The ease of identification of HCSWs also varied across services and locations. For example, children's services were relatively contained in one hospital in Lothian but across two large general hospitals in Ayrshire and Arran.
6.7 Lanarkshire, starting later, was able to learn from the slower recruitment at the first two sites. This site took a defined cohort approach from the outset and began by targeting middle managers, getting them to identify and sign up briefing times for their HCSWs, as opposed to waiting for HCSWs to 'volunteer' to attend briefings. This approach resulted in an almost 100% sign up at various Lanarkshire locations. However the Lanarkshire approach, although most successful in terms of recruitment, was thought to be unrealistic for much larger sites with much larger numbers of eligible HCSWs, where it would have taken too long for the LPC to visit each individual manager at the outset.
6.8 All sites included bank staff but this was a later addition for Ayrshire and Arran (September 2007). Lanarkshire hoped to include some 10 new Bankaide starts per month, presenting a further potential challenge as these clinical support staff could be placed anywhere across the Board. Lothian had a potential 330 Nurse Bank staff and planned for the coordinator to undertake the oral assessment element.
6.9 The process of 'follow through' also varied across sites. All stakeholders felt it was essential to try to keep up the recruitment momentum to ensure engagement. Ideally this would be by quickly following up initial invitation letters, identifying a WPS once the HCSW volunteered and if possible by organising the first HCSW/ WPS meeting within two weeks of the WPS being trained.
6.10 However the LPCs had to balance their time between recruitment into the pilot and ensuring completion of the process for the individual. The Ayrshire and Arran LPC continued to be very flexible - working evenings and weekends to capture different shifts and different types of workers. The LPC also paid close attention to developing follow-up tracking systems. The Lothian pilot started very well, with a huge effort going into recruitment, but this lapsed somewhat over the summer of 2008. The first LPC left the post in April 2008 and although temporary cover was put in place, recruitment momentum was lost. In hindsight the site felt more attention could have been put into ensuring the link-up of HCSW with the supervisor once HCSW consent had been received. The Lanarkshire LPC had a very strong focus on recruitment but the site felt there was further work to do at acute sites to ensure facilitation of HCSW engagement.
Engaging HCSWs with the pilot
6.11 Initially the NPC/ LPC team decided that recruitment would run August 2007-January 2008 (once pilot materials were in place) but as recruitment was slow in late summer the period was extended to April/May 2008, which would still allow a three month window for late recruits to complete assessment.
6.12 All sites held multiple HCSW briefing/awareness sessions lasting around one hour ( e.g. Lothian ran some 8 initial HCSW briefing days, a total of 32 sessions, held at multiple sites, followed later by more tailored one-off sessions). The numbers of HCSWs attending varied from none to one, two, twelve and nineteen. The format varied from open to all (Lothian), grouped by occupation (Ayrshire & Arran), specific invitees (Lanarkshire). In Lothian it appeared more first line managers attended, sometimes in place of HCSWs. LPCs were very flexible, holding sessions in ward meeting rooms, at regular team meetings, going direct to wards when it was difficult to get staff released ( e.g. children's hospital, where there were small teams or low staffing levels).
6.13 In Lothian partnership support was underlined as sessions were run by both the LPC and a UNISON steward. As the pilot progressed it appeared that there was some shift away from messages about 'protection' (para 3.26) and more towards an emphasis on messages about improvement of HCSW 'competencies' and moving towards more recognition of their work. The message about opening up career pathways, meeting KSF objectives and the potential for attaining other SQA credits was particularly strong in early Lothian recruitment. The message about 'having your say' and a chance to influence potential regulation was strong at all three sites. LPCs used PowerPoint presentations or adopted a more informal style as required, with plenty of time for questions.
6.14 In the formative stage stakeholders anticipated a range of uptake by HCSWs. It was expected that the pilot would "make sense" for nursing and allied health assistants, working within an area where there was already strong professional ownership by registered professions. The UNISON Scotland survey of nursing assistants (2005) had already found a keenness to be accredited. It was expected many workers would see the standards as a route back into learning and career development opportunities. Some workers would already have awareness of patient and employee vulnerability issues.
6.15 Stakeholders also anticipated a number of potential challenges to recruitment including HCSW personal fears (of intimidation and potential failure, individual 'attitude', Disclosure Scotland checks, they might have to pay for regulation, feeling 'untrusted' if already working some time in post); past experiences (aftermath of Agenda for Change; previous inadequately resourced SVQ programmes); fear of assessment (literacy issues, potential multiple assessment and lack of integration); resource issues (freeing up WPS and HCSW staff) or some HCSWs might be looking for financial incentives.
6.16 It was anticipated that engaging ancillary staff would present the greatest challenge for several reasons. They were seen as a group with little history of a public protection approach and were a relatively un-empowered workgroup who might be less familiar with 'volunteering' for projects. Many were on short hours contracts and some groups of workers had a more transient population.
6.17 In practice the timing and method of identifying and contacting non-clinical support workers varied by site. Lothian and Ayrshire and Arran aimed to recruit the full range of workers from the outset whereas Lanarkshire tackled this group at a much later stage.
6.18 Lothian had more success in establishing earlier contact with the Board Facilities Group (May 2007) and managers who were supportive of the pilot; however few catering or domestic staff attended briefings. By October 2007 Ayrshire & Arran had yet to make firm arrangements with some hospital Hotel Services. It was hard to identify which of the large (600+) generic hospital hotel/catering staff group had direct contact or influence on patients or public within children's services, including those who might provide sickness absence cover to children's wards. It was most difficult for Ayrshire & Arran to engage with hotel services staff (catering, porters, domestics) for a variety of reasons: no regular staff group meetings to easily access; short shifts ( e.g. cleaner 4-7pm on ward); unfamiliarity with volunteering; staff taken away from post already by Agenda for Change and KSF. There was small turnout to briefing sessions but the LPC found some individual sessions successful. However by the end of the pilot Ayrshire & Arran had been the most successful in recruiting non-clinical staff (Table 5.3)
6.19 Lanarkshire had been clear from the initial bid that it would recruit on a phased basis, initially focussing on four distinct cohorts of clinical support workers with a view to recruiting ancillary workers later. In June 2008 recruitment of the first two cohorts was only just complete. Lanarkshire was then disappointed to find its own plans disrupted by the 'centre's' request to reprioritise Lanarkshire's project plan towards recruitment of ancillary staff. SGHD however were clear that including ancillary staff was a requirement of the initial bid. Lanarkshire then began to make arrangements for recruitment of ancillary staff. After delay because of re-arranged meetings with senior non-clinical managers, arrangements were finally made for an additional exercise (late October 2008). During a recruitment/assessment day a total of six HCSWs (4 domestics, 1 catering assistant and 1 porter) worked through and completed the assessment process and signed the Code of Conduct declaration. One WPS (a project manager from property support services) attended and therefore the pilot LPC and the site lead officer acted as additional supervisors.
Views of participating Healthcare Support Workers
6.20 There was a 43% ( 164) response rate from the HCSW-participant survey with similar proportions from the three pilot sites (Table 0.1). Almost half the HCSW survey returns came from Lanarkshire. Returns were weighted towards clinical support workers, older people's services and longer serving staff. (Table 0.2). The returns were mainly from clinical support workers (nursing assistants 70% ( 115); allied health assistants 21% ( 35) with just 8 from non-clinical staff (7 facilities; 1 laboratory assistant) (Table 0.3). The largest group was from older people's services (47% ( 77) mostly from Lanarkshire ( 64). Just 11% ( 18) were from children's services and 38% ( 62) from mental health services (Table 0.5). There was feedback from 21 bank staff (Lanarkshire) but just 12 returns from workers new to the Health Board or in post less than one year.
6.21 Evaluation questionnaires were received from 4 of the 6 late recruited Lanarkshire non-clinical HCSWs, all long-serving and hospital-based. These returns are not included in the evaluation numbers but some quotations have been included in the report.
6.22 All HCSWs were sent an introductory letter but face-to face communication registered most (from their line manager (57%); a briefing (30%) Table 0.16). Local publications registered with very few. Some HCSWs commented it would have been good if HCSWs and WPS could have been briefed together.
6.23 At the outset of the pilot stakeholders expressed concern that the pilot might not appear truly voluntary or that HCSWs might feel pressured to participate lest they be excluded from other development opportunities. The evaluation observed that all LPCs were very careful to make it clear that the pilot was voluntary.
6.24 The majority of participating HCSWs clearly felt that sign-up to the pilot was voluntary (94%) (own decision (76%); shared decision with the line manager (18%)). However 8 felt the decision was made for them by a line or senior manager. Most (68%) felt they received enough information before starting (Table 0.17).
6.25 The main reasons HCSWs got involved in the pilot were altruistic ("help my patients/improve patient safety" (56%, 92); "do my job better" (54%, 88) followed by the attraction of learning and development ("I like learning new things" (45%, 73); "To develop job and career opportunities" (41%, 67); "time to think about what I do in my job" (37%, 61). There was some influence by senior staff "Strong direction from senior staff" (21%, 34) or colleagues "Other staff I knew were doing it" (13%, 22), some wanted to "Have my say" (30%, 50); or for their patients to know they were doing a good job (26%, 42). Table 0.17).
I was only asked to attend the pilot one day prior to the meeting and went into it with an open mind. I feel that this scheme will be of great benefit to all involved.
(Domestic Supervisor)
6.26 A smaller proportion of HCSWs noted concerns before sign-up to the pilot: a third were concerned about having time to do the pilot "Might be too much work" (33%); "Too busy at work" (28%); and a fifth (21%) were concerned it "Might be too difficult for me". Around a third (30%, 50) had no concerns before sign-up.
6.27 The evaluation team attended several HCSW briefings. Some reasons put forward by HCSWs for being supportive of the pilot were:
- we already do this anyway
- everyone should have the chance for a PDP
- carers of children in hospital need to know standards are in place; a HCSW does not want to appear ignorant in front of patients
6.28 Questions raised by HCSWs at sessions included wanting clarification about: the WPS (how many WPS and ratio to HCSW, will it always be the line manager what training will they receive, will they do the DS application); assessment (will it be adapted for older, slower learners, approaching retirement; staff on nights, backlog of non-disclosed staff); time required (is it like SVQs, will we be released if we are short staffed); and how flexible it was (how fit with the Domestic Workbook, can standards be changed).
6.29 Attendees, both some HCSWs and some supervisors, suggested that groups of staff might like to go through the process together and approaches to group learning could be explored. However, a potential staffing shortage was identified by one supervisor of a small team of four, where she already supervised a student and someone already undertaking an SVQ.
Views of Non-participant HCSWs
6.30 The non-participant HCSW survey had a 12% ( 242) return and the majority came from Lothian (86%, 208) of which 104 came from older people's services, the service area added to the pilot to try to increase numbers of recruits (Table 0.2, Table 0.14). Half the participants felt they had not heard about the pilot (56%, 132) and 5% ( 13) were not sure what it was. Only around a third felt they had actually heard of the pilot (39%, 92) or been given information about it (32%, 64). The majority (59%, 119) had not and the remainder ( 18) were not sure. Where information had been received, almost half (47%, 43) said that it was all the information they needed, while almost one in five (18%, 16) did not feel that they got the information they needed. There was also an evident untapped pool of potential volunteers as 8% ( 14) thought they would definitely take part in the next few months and 13% ( 24) thought they might; two in five (39%, 71) were unsure. Forty percent ( 74) of the non-participants were, however, definite that they would not take part.
6.31 Half (54%, 132) of the non-participant respondents gave reasons for not taking part in the pilot. The main reasons put forward were either: personal - "I had other personal commitments" (20%, 48), "I am soon due to retire" 14%, 35) or work-related - "I am too busy at work" (21%, 51) "we are short staffed at work" (19%, 46) and already having an SVQ or above (20%, 48); or about the pilot "it might be too much work" (15%, 36) and "I did not see any value in taking part" (14%, 33). Written comments confirmed and added detail to the above. Most concerned not knowing enough about the pilot ( 39 of the 40 who said this were from Lothian) or being about to retire or change job soon. Some ( 12) were already doing or about to start another training/course or had other personal commitments ( 11). Ten said that they did not have enough time to take part and some found it not relevant to their job.
6.32 A small number of responses were angry: one talked of feeling pressure to participate in something supposed to be voluntary, one wanting a definition of healthcare support worker, two felt resentful about feeling unfairly treated by Agenda for Change, and two felt there had been unclear instructions and support.
Summary
6.33 As the pilot was entirely voluntary the method of marketing the pilot was critical to its success. NHS Lanarkshire's phased cohort approach, targeting line managers was most effective but considered to be potentially unrealistic for larger sites. The successful engagement and tracking of recruits depended upon a greater level of flexibility and input from LPCs than anticipated. Planned group HCSW briefing sessions had to be enhanced with multiple individual sessions in order to attract recruits.
6.34 43% ( 164) of participating HCSWs replied to the survey and most (94%) confirmed they took part voluntarily. They were motivated by improving patient safety and improving their own performance but expressed some concern that the pilot might be too hard or they might not have time to do it. The non-participant HCSW survey attracted a 12% ( 242) response, mostly from NHS Lothian (86%). It appeared there was an untapped pool of volunteers as many had not heard of the pilot and some (21%) indicated that they might wish to take part in future. The main reasons for non-participation included having other personal commitments, being about to leave post or feeling they did not have time at work.