Art & science research

Attendance at NHS mandatory training sessions Brand D (2015) Attendance at NHS mandatory training sessions. Nursing Standard. 29, 24, 42-48. Date of submission: May 20 2014; date of acceptance: September 23 2014.

Abstract Aim To identify factors that affect NHS healthcare professionals’ attendance at mandatory training sessions. Method A quantitative approach was used, with a questionnaire sent to 400 randomly selected participants. A total of 122 responses were received, providing a mix of qualitative and quantitative data. Quantitative data were analysed using statistical methods. Open-ended responses were reviewed using thematic analysis. Findings Clinical staff value mandatory training sessions highly. They are aware of the requirement to keep practice up-to-date and ensure patient safety remains a priority. However, changes to the delivery format of mandatory training sessions are required to enable staff to participate more easily, as staff are often unable to attend. Conclusion The delivery of mandatory training should move from classroom-based sessions into the clinical area to maximise participation. Delivery should be assisted by local ‘experts’ who are able to customise course content to meet local requirements and the requirements of different staff groups. Improved arrangements to provide staff cover, for those attending training, would enable more staff to attend training sessions.

Author Darren Brand Senior lecturer, School of Health Sciences, University of Brighton, Brighton, England. Correspondence to: [email protected]

Keywords Education, mandatory training, patient safety research

Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.

Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines

ALL NHS HEALTHCARE PROFESSIONALS should be familiar with annual mandatory training requirements, including infection control, basic life support, and moving and handling training (East Sussex Healthcare NHS Trust 2013). Attendance at such training ensures that healthcare professionals’ standards remain high and that they are delivering care according to evidence-based best practice (Marshall and Manus 2007). Mandatory training exists in various forms in health care. The word ‘mandatory’ means obligatory or compulsory (Collins 2013) and might have negative connotations for staff related to worries about didactic teaching diminishing individual autonomy (Freire 1972, Rogers 1983). Concerns are often raised about the value of mandatory training, especially with regard to the volume of training required (Morgan et al 2008). Mandatory training encompasses many areas. Medical device training was selected as the focus for this study, since this was the area in which the author was employed. This study replicated a small-scale study undertaken by a clinical trainer employed by a medical device manufacturer. The author selected this study for replication after noticing reduced attendance at mandatory training sessions he facilitated in East Sussex Healthcare NHS Trust while an educator in clinical practice. Governance data within the trust also indicated that staff were falling behind on mandatory training requirements, with an average compliance rate of only 50% of staff in many clinical areas.

Literature review Education and training are linked intrinsically to a competent workforce delivering safe and effective patient care. Without suitable investment in education and training, patient safety is potentially at risk (Timmins and McCabe 2005, Milligan 2007, Nursing and Midwifery Council (NMC) 2008a, Castledine 2009, Dean 2011, Health and Care Professions Council (HCPC) 2012, McHale 2012, Pearson 2013).

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Effective education occurs in an environment in which students are motivated to attend and gain new knowledge (Bandura 1977). However, measuring the effectiveness of mandatory training in health care is difficult (Mythen and Gidman 2011). Maben et al (2012) researched the relationship between the care delivered by staff (as perceived by staff) and the influence of staff wellbeing, motivation and affect. Focusing on the wellbeing of workers, particularly by providing a supportive work environment, ensures the care delivered will be of a higher quality (Kang et al 2012). Staff motivation is associated closely with attendance at mandatory training sessions (Moore 2002). Moore (2002) refers to support staff competing for opportunities to attend education and training events in a theatre environment, and notes the importance of empowering staff as well as the value of lifelong learning. The Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013) and Patients First and Foremost: The Initial Government Response to the Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Department of Health (DH) 2013) both have a strong focus on the importance of a trained and skilled workforce. The trade union Unison has reported that some nurses fail to meet basic Nursing and Midwifery Council (NMC) continuing professional development requirements because of low staffing levels within their practice areas (Dean 2011). At the outset of this study, the author noted a significant number of cancellations of mandatory training sessions, directly related to staffing pressures and the need for staff to remain in wards and clinical areas. There was commitment at board level in the trust to improve mandatory training compliance figures across all areas of the organisation.

Aims This study aimed to gather and review data from healthcare staff to identify factors that influence attendance at NHS mandatory training sessions – both motivational factors and perceived barriers to accessing education and training. It also set out to develop recommendations to promote attendance at mandatory training sessions, ensuring safe patient care could be delivered consistently in all areas of the hospital. More specifically, the study aimed to identify the main factors affecting attendance at medical device training and to use these to review and revise existing mandatory training policies to enable improved attendance levels.

Method The data collected in the study came from a cross-sectional representation of nursing and healthcare support staff. Cross-sectional studies gather data collected at a defined time. They are frequently referred to as a census and are effective in identifying the prevalence of a particular issue (Bowie et al 2013). A questionnaire was produced to obtain a mix of qualitative and quantitative perceptive data from respondents about why they had attended, or failed to attend, a mandatory training session within the past 12 months. Questionnaires are one of the most common forms of research (Dyson and Norrie 2010), since they are flexible and can be adapted to the requirements of the researcher. A flexible approach was necessary to document participants’ views and opinions accurately, since the research question focused on staff perceptions that were to be used to inform the policy review. A well-designed questionnaire assists in eliminating interviewer bias (Davis et al 2010); it also has the potential to influence clinical practice (Coates 2004). Questionnaires are a form of survey design. Surveys enable large amounts of data to be collected concurrently, and allow effective comparison of variables to be made at the analysis stage (Polit and Beck 2011). It was important that the survey tool could record the perceptions of staff on mandatory training attendance, and also their perceptions of what might improve attendance at such sessions, as accurately as possible. Questionnaires are effective in gathering accurate, reflective data in an anonymous fashion. Individuals are more likely to participate in a questionnaire than in face-to-face data collection (Rudestam and Newton 2007). Participants are also more likely to give unbiased opinions in a questionnaire, as opposed to giving expected answers in a face-to-face situation (Denehy 2006). The questionnaire for the study is reproduced in Box 1. A pilot study took place in a single ward area, before issuing the questionnaire to the respondents in the full study. This proved successful and no subsequent changes were required to the data collection method.

Study participants

The inclusion criteria for the study were: Respondents must be a nurse, healthcare assistant, midwife, operating department practitioner or other allied health professional. They must have either attended, or failed to attend, a booked mandatory training session within the previous 12 months.

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Art & science research Staff must be employed to work within the acute care sector of the organisation (because community mandatory training is different). The target population totalled 2,000 clinical staff. It was intended to gain a 10% representational view of this section of the workforce, so the study aim was to achieve a total of 200 completed and returned questionnaires. Based on an aspirational 50% response rate, 400 questionnaires were issued by the learning and development department within the trust using a convenience (opportunity) sample approach. Questionnaire packs were issued to all staff, irrespective of their role, grade or banding. The packs contained a letter of introduction, an information sheet, a consent form, the questionnaire and a return envelope. Questionnaires were completed by hand. They were issued via the internal mail system.

BOX 1 Questionnaire 1. Gender: Male  Female  2. Age: 18-25  26-39  40-55  56-65  65+  3. Professional role: Nurse  Healthcare assistant  Other  4. Highest qualification (for example national vocational qualification, diploma, degree): 5. Time in current professional role since qualification (in years): 6. Area of the trust in which you are employed (clinical division): 7. Full time or part time? Full time  Part time  8. Do you use medical devices in your role, for example vital sign monitors, infusion pumps and thermometers? Yes  No  9. Have you attended mandatory training in the last 12 months? Yes  No  10. If no, please explain why not: 11. What are your feelings about the value of mandatory training? 12. Do you feel that there are any barriers to attending mandatory training sessions? Please list, if any: 13. What factors, if any, do you feel would lead to increased attendance levels at mandatory training sessions? 14. Do you feel supported by your line manager to attend mandatory training? Yes  No 

Follow-up packs were re-issued two weeks later to ensure that as many completed responses were received as possible.

Data collection

Data were collected by use of a questionnaire, issued to staff meeting the inclusion criteria by the learning and development department, using a convenience (opportunity) sample approach. Respondents completed the questionnaire and returned it, together with the consent form, to the learning and development department using an address label supplied in the main pack. On receipt of the completed questionnaire, the department separated the consent form from the responses, to ensure the responses were anonymous.

Data analysis

Completed responses were analysed using a combination of spreadsheets and Minitab, a statistical analysis software package. A statistician was consulted to ensure that a comparison of variables could be made using the quantitative data. Chi-square tests were undertaken to identify significance within categorical variables and to test the significance of appropriately comparable questions (Ford and Bammer 2009). Qualitative data collected through open-ended questions were analysed through a small-scale thematic analysis, with category allocation by subgrouping depending on the response or feedback received.

Ethical issues

This study formed the dissertation element of an MSc in health and education. The study research question was: ‘What factors influence attendance at mandatory training events within an acute hospital?’ Ethical approval was obtained from the NHS trust’s research and development department and from the university research governance and ethics committee (level 2). The author’s own professional bias was reduced in this study by his starting a new post where he no longer had responsibility for the delivery of mandatory training.

15. If no, please comment on this. 16. Does your clinical area prioritise mandatory training events? Yes  No  17. If yes, how does this prioritisation take place? 18. What factors facilitate attendance at mandatory training events? 19. Please use the space below for any comments relating to factors that would lead to increased attendance at mandatory training. 20. What factors are likely to lead to reduced attendance at mandatory training sessions? 21. Please use the space below to provide any other comments you may have on mandatory training.

Findings Of 400 questionnaires issued, 122 were returned, equating to a 30% response rate.

Demographics

The majority of respondents (n = 72, 59%) were registered nurses, with (n = 28, 23%) healthcare assistants and (n = 22, 18%) other staff. Of the respondents, 99 (81%) were female, and 23 (19%) were male, in line with the recognition that the nursing workforce is predominantly female

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The majority (n = 100, 82%) of respondents stated that their role involved use of medical devices, such as infusion pumps, thermometers or vital sign monitors. Only 22 (18%) respondents stated that they did not use such equipment. The majority of respondents (n = 98, 80%) had attended mandatory training on medical devices in the past year, whereas only 24 (20%) of respondents had failed to do so. The respondents who had failed to attend mandatory training were asked to comment on why this had occurred. Ten respondents (8%) made 29 comments in response to question ten (Box 1). The two main themes identified from these comments were (percentages are proportions of all comments): bookings being cancelled by senior staff because of ward pressures (n = 7, 24%), and the view that medical device training was not relevant to their role (n = 7, 24%). Sickness on the day of training sessions was a factor for five respondents. Multiple comments were also made relating to the inflexibility of the timing and day of the sessions (n = 15, 52%). Respondents were asked to comment on the value of attending mandatory training. A thematic review of the comments was undertaken to categorise the responses given. Respondents were not limited to a single response. The percentages given reflect the response as a proportion of the

FIGURE 1 Age distribution of respondents 60 Number of respondents

Mandatory training and medical devices

total number of comments provided (n = 188). The most prominent theme (n = 47, 25%) was that mandatory training is essential to remain up-to-date and ensure current knowledge for safe practice. Twenty four comments (13%) consisted of a matching one word answer: ‘essential’. Twenty one responses (11%) related to improved patient safety. One negative theme (n = 13, 7%) on the value of mandatory training was that staff felt that the sessions were not updated frequently enough. There were 168 comments concerning potential barriers to attendance at mandatory training. Fifteen people (12%) gave no response. A quarter of the comments (n = 43, 26%) indicated low staffing levels on the wards was the greatest issue. Twenty-two comments (13%) indicated that there were no barriers. When questioned about what factors could improve attendance, 40 people (33%) provided no comments. Of 152 comments, 21 (14%) indicated that increased staffing would improve attendance. Comments suggested changing the set day of training (n = 16, 10%), the option of local delivery, such as in ward meetings (n = 14, 9%), and variation in delivery methods, for example

50 40 30 20 10 0

18-25

26-39

40-55

56-65

>65

Age in years

FIGURE 2 Years since qualification Number of respondents

(of nurses on the NMC register, 89% are female and 11% are male (NMC 2008b)). A total of 41% (n = 50) of respondents held a diploma-level qualification, and 34% (n = 41) of respondents held a degree. Only two (1.6%) staff surveyed held a master’s level qualification, with no respondents qualified at doctoral level. Of the respondents, 66% (n = 81) were full-time workers, with 34% (n = 41) working on a part-time basis. Figure 1 indicates the age distribution of respondents. 42% (n = 51) of respondents are aged between 26 and 39 years, with an additional 31% (n = 38) of respondents aged between 40 and 55 years. These staff are likely to be looking at promotion or career progression, and will therefore be keen to maintain their qualification levels and competency. For staff holding management or supervisory roles, their compliance with trust policies is likely to be better than other staff, demonstrating positive role modelling (Curry et al 2011). Figure 2 indicates the length of time respondents have been qualified. In terms of their years of experience, respondents’ experience ranged from less than one year to over 20 years. The largest group among the respondents was staff with the most experience (over 20 years, n = 34, 28%).

40 35 30 25 20 15 10 5 0

20

Time since qualification in years

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Art & science research e-learning, podcasts and written material (n = 17, 11%). Most staff (n = 110, 90%) stated that they felt supported by their line manager in attending mandatory training, with only 11 (9%) responding that they felt unsupported. Seventy five (61%) respondents worked in areas that operated some form of prioritisation for mandatory training, while 47 (39%) respondents reported no such prioritisation. In areas where staff did not feel supported by their manager, numbers were too small (n = 11, 9%) to identify specific themes. Comments included: priority being given to registered nurses over healthcare assistants (n = 2, 1.6%) and a lack of understanding of an individual’s role by a line manager. There were 93 comments received about prioritisation. Where prioritisation occurred, there tended to be a specific individual with responsibility for booking and managing all aspects of education and training (n = 15, 16% of comments). A ‘traffic light system’, whereby red, amber and green ratings assist in the prioritisation process (n = 10, 11%) appeared to be effective and commonplace. Other comments (n = 8, 9%) referred to a paper-based system, and the departmental manager identifying gaps in training (n = 10, 11%). Table 1 shows the main factors that assist attendance at mandatory training sessions as identified by healthcare staff. The factors listed in Table 1, responses to question 18 (Box 1), emphasise the importance of support from the ward or department manager, when staff are attempting to attend training events. The line manager is crucial to whether staff will be released to attend. The main factors identified in Table 1 all relate to staffing overall, the ability to provide ‘backfill’ (Box 2) and to maintain safe staffing levels at the time of the training event. Two chi-square tests were used to establish the statistical significance of specific observed data. The analysis of responses provided to questions 14 and 9 (Box 1) gave a result of p = 0.035, which

TABLE 1 Main factors that enable attendance at mandatory training sessions Factor Matron support

Number of responses 91

Time owing in lieu

51

Increased staffing levels

70

Temporary cover for staff

51

Attend on day off

40

indicates statistical significance. This test sought correlation between staff who felt supported to attend mandatory training by their line managers with staff who had attended mandatory training in the previous year. This helped highlight the importance of support by line managers for mandatory training, but does not allow for pressures in the clinical area that may prevent attendance. The second test compared responses given to questions 9 and 16 (Box 1), correlating the prioritisation of mandatory training events with staff attendance at mandatory training in the previous 12 months. This gave a result of p = 0.001, denoting high statistical significance. When priority is given to enable attendance, mandatory training attendance is increased. By sharing different means of prioritising attendance within the organisation, attendance may be further improved.

Limitations The key limitation in this study was the low response rate (30%), with the majority of respondents having already met their mandatory training requirements and aware of the benefits of attendance. If this study was to be repeated, an improved response rate would increase the validity of the survey. A longer period in which to collect data would allow additional follow-up mailings to occur. A more targeted approach could ensure that staff were aware of the importance of the study. Follow-up interviews with staff who indicate that that they are happy to participate might also improve the outcomes of the study. It may also be beneficial to replicate the study in other NHS trusts, to establish whether non-attendance is a localised, or a wider, problem.

Discussion From the questionnaire responses, it is clear that mandatory training for healthcare staff is held in high regard, with an awareness that training is necessary to maintain patient safety and to ensure that all staff can demonstrate high levels of skill, competency and knowledge consistently. Many areas reported difficulty in releasing staff to attend such sessions – mandatory training attendance is often cancelled by managers when patient acuity levels are high. The Royal College of Nursing (RCN) (2010a) report this as an increasing concern, especially given funding cutbacks and the £20 billion of NHS savings required by 2015 (RCN 2012). Nationally, almost one third of nurses have been unable to access mandatory training in recent years (RCN 2010b).

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In recent times, considerable attention has been focused on safe nurse staffing levels. To help improve compliance with mandatory training attendance, the trust in this study has adopted the Hurst model (Hurst 2003). The trust’s intention is that this approach should alleviate current staff difficulties in attending mandatory training. Although not a common theme among respondents, there were several instances where staff new to the trust, who had recently undertaken mandatory training with their previous NHS employer, were asked to re-attend sessions to comply with local policy (Mythen and Gidman 2011). Holmström (2011) advocates the use of training passports to alleviate this issue and this is currently being explored by the local education and training board.

Questionnaire responses demonstrated that staff are conscious of the value of mandatory training – to ensure that their knowledge and skills remain current, and that they consistently deliver safe practice and high standards of care to all patients. Staff are aware of the need for mandatory training and the principles underlying it but may encounter difficulties in attending because of staffing and clinical pressures they encounter on a daily basis. In many clinical areas prioritisation for training attendance exists, but this is not universal. Patient safety remains a priority within the rapidly changing NHS and can be delivered only through a robust and well-trained workforce. The requirement for regular training is not in doubt; however, the current format in which mandatory training is delivered is problematic NS

Recommendations

BOX 2

From this study various recommendations can be made to improve staff attendance at mandatory training events (Box 2). These recommendations arose from a review of the data, and the author’s reflections on the data analysis. The key priorities are as follows. First, with over 25 events classified as ‘mandatory’, it is advised that a full review of such sessions be undertaken, to determine what is statutory, what is mandatory from a regulatory perspective, and what is important but not vital to patient safety. This would reduce the burden on staff and clinical leads when mapping out education and training priorities for the year ahead. The study also identified the potential for training to move away from an inflexible programme of classroom sessions into the clinical area. This could be achieved through the use of educators and local ‘experts’ who have link roles in areas such as infection control, falls or moving and handling. These individuals could enable local training at times that are convenient to the needs of both the individual and the clinical area. Feedback was also received focused on the generic content of sessions, with an identical infection control lecture delivered to staff based in all areas. Using local experts, the content of individual sessions could be made more specific to clinical areas, which would make the learning experience more positive for everyone involved.

Conclusion The aim of this study was to gain an understanding of perceived barriers to attending mandatory training updates and factors that may hinder staff working in an NHS trust from accessing training.

Recommendations to improve staff attendance levels at mandatory training events  Undertake a full-scale review of the existing mandatory training policy.  Benchmark your trust against other trusts’ policies to seek best practice solutions to manage mandatory training.  Review the classification ‘mandatory’ within the existing mandatory training portfolio, with a view to reducing the frequency of training.  Analyse ward staffing levels, particularly the capacity to provide cover for staff to attend mandatory training sessions.  Implement a ‘backfill’ team facility, with a team employed to ensure staff are available to cover the release of staff from a ward or area to attend mandatory training.  Record mandatory training compliance levels on local risk registers to flag up the inability of some staff to attend sessions.  Consider localised training, specific to the area in which it is being delivered. By introducing a ‘train the trainer’ system, role modelling and contextualised training can be delivered at local level.  Vary the delivery day on which mandatory training sessions are delivered, ensuring that staff who work set days are able to attend.  Review mandatory training delivery strategies, with a view to using online media and summative assessment to confirm learning has occurred.  Investigate the use of e-learning for aspects of mandatory training to improve the accessibility for staff in all areas of the trust.  Consider the introduction of mandatory training passports, in collaboration with local NHS organisations.  Explore a self-verification of competency scheme for clinical staff who undertake a link facilitator role within their local area, through the development of a training passport system.

IMPLICATIONS FOR PRACTICE  Nurses and healthcare workers value mandatory training to ensure that they remain clinically safe and competent.  Managers should consider a review of the delivery of mandatory training to ensure that patient safety is maintained and expectations of staff are achieved.  Consider local delivery of mandatory training by departmental ‘experts’ who have received additional education in the subject area.

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CALL FOR PAPERS Nursing Standard is welcoming submissions from experienced or new authors on a variety of subjects. For further information contact the art & science editor Gwen Clarke at [email protected]

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Attendance at NHS mandatory training sessions.

To identify factors that affect NHS healthcare professionals' attendance at mandatory training sessions...
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