Workforce and patient safety: temporary staff - integration into healthcare providers

1.1.1 This investigation report is part of a wider programme of work being carried out by HSSIB on the theme of workforce and patient safety. The investigation focused on temporary clinical healthcare staff who work in the NHS in England and sought to identify the challenges this cohort of staff experience that may impair their ability to deliver safe patient care. While temporary staff are present throughout the NHS, including in non-clinical roles, the scope of this investigation was limited to clinical staff only (that is, those with a direct role in the care and treatment of patients).

1.1.2 The investigation analysed 30 serious incident reports (investigation reports by local trusts into patient safety incidents) that were conducted between May 2022 and May 2023, where temporary staff had been involved in the incident. More details about how the analysis was carried out can be found in the appendix. This analysis identified that the safety of patients may be put at risk where temporary staff have not been appropriately integrated into healthcare providers and local clinical teams (for example, a ward). This investigation specifically considers the role of induction and orientation for temporary staff.

Jack

2.1.1 Jack had been receiving mental health care and his care had recently been transferred from child to adult mental health services. He had been detained under Section 2 of the Mental Health Act and was working towards discharge. This had led to increased anxiety and some thoughts of self-harm.

2.1.2 One evening Jack telephoned his father and told him that he had ingested batteries, in an act of self-harm. Jack’s father contacted the ward and the ward staff talked to Jack; he was taken to the local emergency department (ED) for assessment and treatment.

2.1.3 Jack was escorted to the ED by a member of agency staff from the mental health ward. Limited handover had been given about what the role of the escorting staff member was, whether they were just escorting the patient, or were expected to maintain continuous observation (the clinical intervention of continuously engaging with and observing a patient to reduce their risk of self-harm).

2.1.4 While ED staff were deciding whether Jack needed to have surgery, the escorting staff member went to use the toilet, leaving Jack alone. While they were absent Jack absconded from the hospital and was later found near a railway track. Jack was returned to the ED by the police and received treatment for the battery ingestion.

2.1.5 The incident was initially not recorded on the mental health trust’s incident reporting system as the agency staff member did not have access to the system. It was recorded by a substantive member of staff who was not present at the time of the incident.

Enzo

2.1.6 Enzo, who was 88 years old, was admitted to the acute hospital via the ED following a fall at home. Enzo had not sustained any injury from the fall but was found to have a urinary tract infection. His past medical history included recurrent falls and dementia.

2.1.7 Enzo remained in hospital, receiving treatment for his urinary tract infection while plans were made with the local authority in relation to a package of care. His discharge was delayed due to him developing pneumonia.

2.1.8 Enzo got up from his bed in the early hours of the morning to use the toilet and fell to the floor. A nearby staff member immediately came to his aid and a doctor was called to attend. Enzo suffered a broken hip which required surgery. During this time the ward was being staffed, in part, by temporary staff.

2.1.9 The local investigation identified that the nightlights on the ward had been turned off, limiting visibility in the area where Enzo had his fall. The local investigation found that the requirement to keep nightlights on was not included in temporary staff induction. Similarly, the local investigation found that following his fall, Enzo’s risk assessment was not updated, again due to temporary staff’s lack of knowledge of this policy because it was not included in their induction.

Mary

2.1.10 Mary, who was 86 years old, suffered a traumatic haemothorax (blood inside the chest cavity) when she lost consciousness and fell at home. She was taken to the ED and had a chest X-ray before being moved to the same day emergency care unit for older people.

2.1.11 The local investigation found that there were delays in a CT scan of her chest being completed, which meant that this was outstanding when her health deteriorated and she died, 2 days after admission. One factor that contributed to the delay was that access restrictions meant the locum doctor in the same day emergency care unit was not able to use the electronic system to request a CT scan.

3.1.1 The investigation explored the process by which temporary staff are deployed within NHS trusts and how patient safety is considered in their deployment. These elements are explored through the consideration of rota gaps and the redeployment of staff.

Rota gaps

3.1.2 Through engagement with trusts, the investigation learned that most trusts used a tiered approach to advertising available shifts, to encourage these to be filled firstly by substantive and then bank staff before being offered to agencies. Several trusts told the investigation that the main reason for this approach was to minimise costs, because it is more expensive to hire staff through an agency.

3.1.3 Agencies told the investigation that when shifts were made available to them, aside from the date and time, commonly the only information provided was the type of staff being sought (for example nurse or health care assistant), and the name of the ward. They explained that they would usually know the type of ward from their experience with the provider, but that additional information about the skills being sought was not provided and this affected their ability to identify appropriate staff.

3.1.4 Similarly, temporary staff managers in trusts told the investigation that they would be informed of a staffing gap which needed to be filled but not the experience that was required. They may be told “I need an RMN [registered mental health nurse], rather than I need an RMN with experience in XYZ”. The investigation was told that this lack of information meant that identifying the correct person, whether bank or agency, to fill a rota gap was challenging.

3.1.5 Nationally it has been recognised that ‘having the right numbers of nursing staff, with the right skills, in the right place, at the right time improves health outcomes, the quality of care delivered, and patient safety’ (Royal College of Nursing, 2021).

3.1.6 Similarly, the Nursing and Midwifery Council has recognised that the delivery of safe care relies on safe staffing, which is about ‘skill mix as well as numbers’ (Nursing and Midwifery Council, 2016). Studies have also shown that the way temporary staff are ‘recruited, employed and used by organisations, may result in a higher risk of harm to patients’ (Ferguson et al, 2021).

3.1.7 Trust staff told the investigation that they had no information about the skill set of a temporary staff member prior to their arrival and this meant that the allocation could only be done on the basis of their role rather than their skills or experience. Agencies told the investigation that CVs of temporary staff were provided when they were put forward to work at a trust but that this information was not commonly available to ward staff. This led to temporary staff “not being used to their full capacity”.

3.1.8 In addition, trusts told the investigation that while a certain skill level could be expected of registered staff, such as nurses, there was a lack of “trust” between providers in relation to the training of clinical skills. There was also no system which enabled temporary staff to demonstrate verifiable competencies over and above core skills across different organisations. This meant that incoming temporary staff would usually not be allowed to carry out interventions, such as siting a cannula (a thin tube inserted into a vein to enable administration of medications and fluids), until their skills had been assessed by a member of the team. The need to assess skills placed an extra burden on the ward staff and, the investigation learned, often led to temporary staff being allocated to a clearly defined task rather than wider duties.

3.1.9 For example, the investigation was told that in a mental health setting temporary staff were commonly allocated to undertake continuous observation, as this was considered to be a clearly defined task which was not complex. However, the investigation heard of many instances where temporary staff carried out this role for many hours at a time. HSSIB has explored the task of continuous observation and noted the importance of supporting staff who undertake this task, including the need for regular rotation and adequate breaks (Health Services Safety Investigations Body, 2024).

3.1.10 Studies have identified that locum doctors too were often allocated what were considered to be ‘low-risk/low skill routine procedures’ (Ferguson et al, 2021). Agencies and national organisations told the investigation that when temporary staff were seen to be doing less than their substantive colleagues it caused frustration and added to the cultural challenges between the groups (see 3.3).

3.1.11 The investigation explored initiatives such as e-rostering and the digital staff passport, which were respectively developed to enable the more efficient use of staff and to ‘enable staff to more easily move from one NHS employer to another’ (NHS England, 2021). While e-rostering systems have the functionality to record skills, this function is not always used for substantive staff, and while some providers did include temporary staff on their system, this was not the norm.

3.1.12 The digital staff passport is currently being developed to hold a staff member’s personal, employment, core skills and occupational health information for substantive staff who are moved temporarily, and postgraduate doctors on rotation. NHS England told the investigation that there were plans to further develop the digital staff passport to include bank workers and that while including agency workers was technically possible, there were no plans to do so. It was explained that there were challenges around including experience or skills over and above core skills (which include fire safety, moving and handling and safeguarding) as these would need to be independently verifiable. The investigation explored the use of credentialing systems used by other industries, as detailed below.

3.2.1 The investigation was told by trusts that due to the short-term nature of their position, agency workers did not follow the usual induction processes that are in place for substantive staff, which could last several days. While bank staff usually received the standard induction, agency workers and short-term locums expected to receive an induction when they arrived for their shift.

3.2.2 Trust senior leadership teams engaged with during the investigation recognised that inductions “should” take place but acknowledged that they did not always happen; few knew how often they occurred. Reflecting this, one trust told the investigation that while an induction was mandated on its wards, it could not say “hand on heart” that it took place.

3.2.3 National documents have outlined the expectation that inductions take place, including the Royal College of Nursing (2021) workforce standards and NHS England’s ‘Supporting locums and doctors in short-term placement’ guidance (NHS England, 2018). The completion of an induction by a trust is also a requirement which forms part of the auditing process by agency framework providers (see 1.2.9), although this does not require any exploration of the content or effectiveness of the induction.

3.2.4 Studies have identified that the lack of an ‘adequate induction’ for locums impacts on their awareness of local contexts and their knowledge of local policies and procedures which are ‘relevant to providing safe and effective care’ (Ferguson and Walshe, 2019). Similarly, the Care Quality Commission (2024) found that ‘a lack of training and support can prevent agency staff from providing the high-quality care they set out to deliver’.

3.2.5 The investigation explored the induction processes in place at nine NHS trusts. These processes varied in their content and delivery, and in the expectations of what pre-deployment induction (induction provided prior to a shift) had been completed by the temporary worker. Some trusts and wards had developed induction checklists to try and ensure consistency of approach and content. However, the checklists varied between providers and individual wards which meant that it was unclear whether inductions were being completed as expected.

3.2.6 Trust ward staff who led inductions told the investigation that that there was often limited time to complete an induction as the arrival of temporary workers would coincide with the shift handover. This meant that inductions added to their workload at a busy time. Staff described inductions as taking anywhere between a few minutes to an hour, depending on the environment and the person leading the induction. Staff who led inductions told the investigation that completing inductions was seen as an additional task and not an acknowledged part of their workload.

3.2.7 The investigation was told by ward staff that there was no protected time for temporary staff inductions and the number of inductions needed would vary from shift to shift, making the task more onerous on some shifts than others. A further complication was that sometimes temporary staff arrived after a shift had already started, because they were late or had been redeployed, leaving no time to complete an induction. Agencies told the investigation about temporary staff receiving an induction while the shift handover was taking place, which meant that although they had received an induction, they had no knowledge of the patients they then had to care for.

3.2.8 The investigation engaged with staff at a membership organisation which also links locum GPs with practices requiring cover. They explained that if a practice wished to advertise their available role(s) using their platform they had to complete an online locum pack. This included information about the practice’s processes and key contacts as well as detailing processes for arranging clinical investigations and referrals. The locum pack was designed as a directory which the locum could search to quickly identify the information they needed. The membership organisation told the investigation that the availability of such information was vital for GP locums as they are licensed to practice independently, without supervision.

Content of the induction

3.2.9 Healthcare providers and national stakeholders that the investigation engaged with recognised that a good induction is important to the successful placement of a temporary worker and to patient safety. However, agencies and temporary workers told the investigation that the induction felt like a “tick box” exercise. National documents produced by the Royal College of Nursing, the Royal College of Obstetricians and Gynaecologists and NHS England have outlined expectations of what a local induction should include (NHS England, 2018; Royal College of Obstetricians and Gynaecologists, 2022; Royal College of Nursing, 2021; Royal College of Nursing, n.d.). However, none of these documents are binding on providers, and apart from these indications there is no standard description of what constitutes a local induction or what it should include.

3.2.10 This lack of a standard reinforced the variability between providers and even wards. The investigation was told by an agency that when workers reported not having received an induction, it had been confirmed that an induction had taken place but may not appeared as such as it only lasted “a couple of minutes”. At one trust visited by the investigation it was explained that the induction for temporary staff simply involved giving them a trust policy to read which related to the task they were to be allocated to; no other information was provided. At another trust an induction in the emergency department consisted of showing temporary staff the fire exits and resuscitation trolley.

3.2.11 The investigation was told by trusts that when complaints had been made about the effectiveness of temporary staff it often transpired that they had not been given any induction. This meant that they did not have the same opportunity to follow the local processes and procedures and that they were seen as ineffective without being given to the tools to practise effectively. An example of this can be seen at 2.1.9.

3.2.12 The investigation was told by trust staff that because the requirements of wards and departments differed, a standard induction would not be possible and they needed to be individually tailored. However, the investigation observed that even the approach to the induction of temporary staff was different from ward to ward. This meant not only that learning across wards was limited, but that temporary staff who worked on different wards would experience different induction formats.

3.2.13 The investigation observed that the ownership of inductions differed between wards and providers and this affected whether or not they took place. Some trusts had introduced the role of professional lead for inductions who was accountable for ensuring they were done. This led to more inductions being completed. The use of accountabilities to manage safety risks is in line with a safety management approach (Health Services Safety Investigations Body, 2023) and may be a way of healthcare providers managing this risk.

3.2.14 The investigation explored potential recommendations in relation to staff inductions. It noted that while a standard of core components for a local induction could be created this would not generate capacity in the system to complete inductions, which was a core problem. The investigation has therefore provided local-level learning for consideration by individual providers, which can be found above.

Access to electronic systems

3.2.15 To provide safe care to patients, healthcare workers require access to electronic systems such as patient records systems, referral systems and results systems, as well as incident reporting systems (Health Services Safety Investigations Body, 2024). However, the investigation was told that it was not uncommon for temporary staff to be unable to access such systems, as demonstrated in 2.1.5.

3.2.16 Providers told the investigation that temporary staff may not have access to many electronic systems used within a department as “everything relies on passwords” and that while “longer-term temporary staff [may] have good access” it was not seen as “worth the trust’s efforts” for shorter-term staff.

3.2.17 The problem of access to electronic systems was well known across providers and national stakeholders, with some commenting that “the safest environments for temporary staff to work in were those where paper-based notes were still used as there were no access issues”. The potential impact of such challenges is highlighted in the vignette about ‘Mary’ (see 2.1.10 to 2.1.11) where a delay in requesting a CT scan, caused by a locum doctor not having requesting rights, contributed to the incident, in which the patient died.

3.2.18 The investigation was told that temporary staff sometimes had to rely on substantive staff to access systems on their behalf and, on occasion, record actions in the notes. This was said to increase the pressure on substantive staff by adding to their workload and ‘risks resentment’ as a result. Some wards visited had ‘generic’ logins for use by temporary staff to enable them to record care provided. The availability of such logins varied not only between healthcare providers but also between individual wards within a provider.

3.2.19 One risk of this approach, highlighted to the investigation during a site visit, was that it relied on the temporary staff member including their name when recording in the notes. If they left out their name, it was impossible to show who had written the entry. The Parliamentary Health Service Ombudsman told the investigation that it had experienced this challenge when undertaking an investigation, as the nurse involved in a specific aspect of care could not be identified because they had used a shared login.

3.2.20 The investigation was also told of “break glass” logins which would allow a temporary staff member to be allocated a login, assigned to them, which lasted 24 hours. These were used as the exception rather than the rule.

3.2.21 Some agencies and trusts had put processes in place to ensure that temporary staff coming into the healthcare provider had access to the required electronic systems. For example, in one case the contract between the agency and trust required temporary staff to complete the relevant training or access requirements before they could be booked for any work. Trusts indicated that this stipulation had not affected their ability to fill rota gaps and had eliminated access problems for temporary staff.

3.2.22 Following the publication of ‘Workforce and patient safety: temporary staff – involvement in patient safety investigations’ (Health Services Safety Investigations Body, 2024), HSSIB was contacted by someone who volunteered at a trust. They explained that the issues around access to systems, including incident reporting and electronic patient record systems, also applied to people who volunteer at trusts. They described being one of over 1,000 volunteers at the trust, of whom a “significant number” had direct patient contact. While volunteers are outside of the scope of this investigation, this highlights that issues around access to electronic systems are not limited to temporary staff and access needs to be considered more widely.

3.2.23 The NHS England Learn from Patient Safety Events service (LFPSE) is a system for recording patient safety events and enabling them to be analysed. It replaces the National Reporting and Learning System and the Strategic Executive Information System. LFPSE was due to be fully rolled out in autumn 2023. Local reporting systems feed into the LFPSE service, and there is also an option to record patient safety events online without the need for access to a local reporting system.

3.2.24 Although the roll-out of LFPSE has been underway for 2 years, it was not mentioned to the investigation by any healthcare provider, or by any organisation that provides temporary staff. While temporary staff are often unable to access local systems for recording patient safety events, there is an online national system which this staff group can access without the need for a login. However, lack of knowledge of this system appears to be a barrier to its effective use.

HSSIB makes the following safety observation

3.2.25 The investigation was told that physical access could also be a problem for temporary staff, with staff not being provided with keys/passes and so being unable to make their way around locked wards. One trust told the investigation that they “found that there are certain bits they [temporary staff] can't do, for example they don't have swipe cards which means they can't get into sluices (closed areas used to manage waste) or into one of the drug rooms”. In one extreme example, the investigation was told by a locum doctor that they were delayed in attending an emergency because it occurred in a ward requiring card access and, as a temporary staff member, they had not been given a card.

3.3.1 The culture of an organisation is known to influence the safety of patients and the wellbeing of staff (Lu et al, 2022). For the purposes of this report, the investigation has defined organisational culture as the values and norms of an organisation which influence beliefs about, and attitudes and behaviours towards, temporary staff.

3.3.2 The investigation engaged with national stakeholders and organisations who all agreed that elements of the NHS are currently unable to function safely without the use of temporary staff. These stakeholders told the investigation that without temporary staff, patients would likely come to harm because of workforce shortages. However, they also described that the knowledge, skills and attitudes of some temporary workers could put patient safety at risk. These concerns were shared by substantive NHS staff, both frontline and within senior management, as well as by national stakeholders.

3.3.3 Temporary staff and organisations providing temporary staff acknowledged that, as with substantive staff, the mixture of knowledge, skills and attitudes among temporary workers varied. They described concerns that substantive staff in NHS organisations made generalisations that all temporary workers provided poorer care to patients. Temporary workers told the investigation that “the NHS do not like agencies” and the “culture is not good”. Similarly, one national organisation described a “long-term insidious bias” towards locum doctors.

3.3.4 During site visits the investigation heard comments suggesting these generalisations were being made across different organisations. Similarly, studies have found that temporary staff are perceived as ‘inferior’ to permanent staff in terms of quality, competency and safety and this perception impacts on their professional identity, team functioning and relationships (Ferguson et al, 2021). However, studies have also shown that there is ‘very limited’ evidence to support these perceptions (Ferguson and Walshe, 2019). Academics working in organisational behaviours told the investigation that temporary staff were also at risk of being targets of sexual harassment and abuse due to being an isolated group.

3.3.5 The investigation explored how this culture had developed and, through discussions with temporary and substantive staff and national organisations, identified factors which had contributed to the culture. Concerns shared with the investigation included were:

• The perceived pay gap – temporary staff being paid more than substantive staff was consistently reported to the investigation as being the main cause for the sometimes difficult relationship between these groups, and
• negative perceptions – the media coverage around agency costs, the national agenda of reducing the reliance on temporary staff and the perception that they “do less for more money” and were “less accountable”.

3.3.6 The investigation observed that this national narrative had led to the acceptance of othering (distancing a group based on characteristics) temporary staff as there were moves to stop their use, despite acceptance that temporary staff are necessary for the health service to function. One stakeholder commented that the terminology of ‘temporary worker’ was unhelpful and in fact this group were more appropriately described as “flexible workers”. They explained that often people decided to work in this way to support their personal circumstances, including other responsibilities they may have such as being a carer or having young children.

3.3.7 The investigation found that the culture in relation to temporary workers had a negative impact on their ability to integrate into clinical teams. This was found to affect their ability to deliver safe and effective care and to raise concerns (see 3.3.12). It is outside of the scope of this investigation to comment on the value for money of temporary staff, but it is important to acknowledge that perceptions around pay may have an impact on the relationship between temporary and substantive staff.

3.3.8 The investigation experienced challenges in engaging with some agencies, who had concerns about how their organisations may be presented in a published report and how this may be “biased” by the way they are presented in the media. The investigation noted that this stance may be a reaction to the attitudes and behaviours towards temporary staff explored above. Other agencies openly engaged with the investigation and were supportive throughout.

Patient safety impact

3.3.9 As a result of the culture described above some temporary staff felt unwelcome, not part of the team and “disposable” while working in the NHS. They described being told "we don’t need you" when having been deployed and substantive staff sticking together, not providing them with support and, on occasion, not passing on important clinical information or answering questions.

3.3.10 In his first report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, Sir Robert Francis identified cultural themes among the workforce which had contributed to patient harm at the Trust. These included bullying, isolation and acceptance of poor behaviours (Francis, 2013). Similarly, there has been recognition that those in temporary roles are part of an ‘outsider group’ and that this can affect the support they receive (General Medical Council, 2019; Nursing and Midwifery Council, 2022). The investigation observed evidence of isolation such as temporary clinical staff being referred to as “agency” instead of their role, such as a nurse.

3.3.11 Temporary workers also described to the investigation the wider impacts of the above cultures, such as limited support after incidents (Health Services Safety Investigations Body, 2024) and a more punitive response compared to substantive staff to any concerns raised about their performance. The rationale given by substantive ward staff for this was that “It’s not the same, they’re bank”. Trusts told the investigation that there were limited remedies available to them when an issue had been raised about a temporary worker. They explained that in such circumstances patient safety was paramount, which meant their chosen route was to block temporary staff from working, even for minor complaints. However, trusts acknowledged that the response to issues with temporary staff was often harsher than for substantive staff.

Speaking up

3.3.12 The investigation was told by agencies that because of the culture that can exist within healthcare providers, temporary staff can feel vulnerable about raising concerns. Temporary staff told the investigation that raising concerns can lead to them being seen as a “troublemaker”, potentially resulting in them being “blacklisted” from working at the provider.

3.3.13 Agencies told the investigation that workers who are concerned about safety on a ward may ask the agency not to place them there again, rather than telling the agency about their concerns. They might only talk about their concerns after further probing by the agency. While it was acknowledged that there is a professional duty to report such concerns, staff are afraid to do so because of fear of reprisal. The ‘Reading the signals’ report (Kirkup, 2022) described similar findings.

3.3.14 The NHS Race and Health Observatory told the investigation that workers from ethnic minority backgrounds are less likely to speak up as they are more likely to experience “harsher consequences” if they do. This was also described by the National Guardian’s Office. Both organisations said that there was a high number of people from ethnic minority backgrounds employed as temporary workers, which is supported by NHS data (NHS Staff Survey, 2024), and these workers then experienced additional challenges around speaking up due to their status as temporary workers.

3.3.15 The investigation was told by some temporary staff that they had experienced discrimination on the grounds of race from both patients and other staff members. The investigation observed that some temporary staff accepted such discriminatory behaviours as the norm, saying “that is just the way it is”.

3.3.16 Trusts, national stakeholders and organisations who supply temporary staff to the NHS told the investigation that they were aware that this group may experience discrimination on the grounds of race when working in the NHS. Reflecting this, studies have identified racism towards locum doctors (Walshe et al, 2023). The 2023 NHS bank only staff survey results identified that bank workers from ethnic minority backgrounds were more likely to experience discrimination both from patients and from colleagues, (NHS Staff Survey, 2024). The NHS Race and Health Observatory told the investigation that temporary staff were seen as “other” due to not being part of the core team. This, coupled with experiencing racist behaviour, may mean they do not feel psychologically safe (feeling able to take risks without fear of negative consequences) to ask questions or raise concerns, which in turn impacts on patient safety may impact their psychological safety to ask questions or raise concerns, impacting on patient safety.

3.3.17 The National Guardian’s Office told the investigation that temporary workers were a group which had been recognised as facing barriers to speaking up. They explained that the National Guardian’s Office purposely used the inclusive term ‘workers’ in their information as they recognised that speaking up was important not only for those directly employed by the NHS but for anyone who worked within the NHS. The National Guardian’s Office said that it had developed a training module for Freedom To Speak Up Guardians in relation to equality, diversity and inclusion which would be relevant to temporary workers, and that work in progress relating to international recruitment may also be relevant to this group. However, there was currently no planned or ongoing work specifically relating to the challenges faced by this group.

3.3.18 As well as having a negative impact on their wellbeing, temporary workers’ experience of discrimination and barriers to speaking up may mean they do not share patient safety concerns, and therefore mitigations to safety risks may not be put in place. The National Guardian’s Office told the investigation it would be able to develop learning for Guardians, and engage with agencies to explain the role of the National Guardian’s Office and how temporary staff can speak up.

HSSIB makes the following safety recommendation