The importance of including temporary staff in NHS patient safety investigations

The NHS often relies on temporary staff (bank only staff, agency staff and locum doctors) to fill gaps in its workforce. However, a recent investigation by the Health Services Safety Investigations Body (HSSIB) has highlighted the challenges of involving temporary clinical staff in Trust-level patient safety investigations.

Such investigations are crucial for identifying areas of improvement in healthcare systems and reducing the potential for harm to patients. The HSSIB has concluded that without the engagement of temporary staff, important learning opportunities may be lost, posing a risk to patient safety.

During its investigation, the HSSIB analysed serious incident reports from acute and mental health NHS Trusts. It also conducted site visits and engaged with NHS trusts, bank and agency staffing providers, substantive NHS staff, bank and agency staff, and a range of national stakeholders.

What did the investigation find?

The investigation found that:

• Patient safety investigations are being concluded without vital information because of observed and perceived barriers to engaging with temporary staff.
• Limited engagement with temporary staff may limit the potential for learning and undermine an investigation's ability to influence future safety improvements.
• Temporary staff are not always able to report patient safety incidents, impacting upon the development of an open reporting culture and the ability to learn from such incidents.
• The extent to which patient safety investigation findings are fed back to temporary staff varies, limiting the ability for all those involved to learn.
• Support is also not always provided for temporary staff following a patient safety incident, which can have an impact on staff members' welfare and patient safety.

What about the new Patient Safety Incident Response Framework (PSIRF)?

In August 2022, NHS England published PSIRF as a replacement for the Serious Incident (SI) framework. PSIRF is now the approach being used by healthcare providers, and it differs quite dramatically from the SI framework. Importantly, there is no longer a requirement for NHS Trusts to investigate every “serious incident” – this term is not used under PSIRF. Rather, PSIRF is a framework that provides organisations with more autonomy and flexibility in their approach to patient safety incidents. A response might involve a Patient Safety Incident Investigation (PSII) or another type of learning response.

One of the key aims of PSIRF is “compassionate engagement and involvement of those affected by patient safety incidents.” However, HSSIB’s investigation found that staffing agencies and providers of bank staff had limited awareness of PSIRF, and that most NHS Trusts had not considered how they might complete interviews with temporary staff as part of an investigation under the new framework. Further, whilst PSIRF guidance emphasises the need to support staff involved in incidents, some Trusts do not routinely offer such support to short term temporary staff. This is for a variety of reasons, including access to support resources being through systems that are not available to temporary staff, such as the Trust’s intranet.

Safety recommendations

The HSSIB made two key safety recommendations to address the issues identified in its investigation:

• One recommendation is for NHS England to include guidance on how to engage temporary staff in learning responses, within their existing PSIRF supporting guidance titled “Engaging and involving patients, families and staff following a patient safety incident”. This should be developed in collaboration with providers of temporary staff to the NHS.
• The other recommendation is for NHS England to update the agency worker framework agreement criteria, to explicitly require framework agreements to adhere to the PSIRF staff support principles.

HSSIB also made a “safety observation” that agencies providing temporary staff to the NHS can improve patient safety by facilitating the involvement of temporary staff in investigation processes, including interviews.

What now?

Healthcare providers can use the findings from this investigation as prompts, to help them consider how they involve temporary staff in patient safety investigations. Healthcare providers should ask themselves:

• How do we ensure that temporary staff are aware of how to record patient safety incidents?
• How do we ensure temporary staff are able to record incidents?
• How will we engage temporary staff in a learning response, under PSIRF?
• What processes do we have in place to ensure we can conduct interviews with temporary staff?
• Can we work with employment agencies to create agreed methods of including temporary staff in learning responses, through contractual arrangements?

Additionally, providers should ensure that learning is fed back to all staff involved, including temporary staff.

By considering and addressing these issues, healthcare providers will help to ensure that patient safety investigations and learning responses are more thorough and robust, in turn improving patient safety and reducing the risk of harm to patients.