The Big Conversation about the Quality of Nursing ... - CLAHRC-NDL

The Big Conversation Tit about the Quality of
Nursing Care across Derby City and Derbyshire
Derby City and Derbyshire
9th December 2011
The Derby Conference Centre
NHS Derby City and NHS Derbyshire County

Forward
Recently, the quality of nursing care in health and social care has attracted much
media attention and has been a shocking reminder to patients, carers and
professionals of the impact of poor professional practice, poor leadership and
unhealthy cultures. As with Castlebeck, sometimes it is just cruel individuals inflicting
harm and using their power on vulnerable patients.
It is disappointing that excellent nursing practice is not systematically applied across
health and social care and that inconsistencies exist. These inconsistencies impact
greatly on patients and families and cause much stress and anxiety.
NHS Derbyshire and Derby City consider improving the patient experience for residents
as a key priority. At first, it is important to understand what are the patients’ stories and
experiences, what are the challenges facing staff, how can we improve care and
where is the patient’s voice in our planning and delivery of services. While we
recognise that there is excellent care, this is not consistently delivered. Patients are our
biggest resource but in the recent past we have not recognised that working closely
with us can bring about real change that is sustainable. It is often small actions that
make a significant difference. Thus, our shift in thinking and approach commenced
with an event to listen to views and opinions from staff and patient groups – The Big
Conversation. This is the first step on a journey to promote improvements in ‘care’
across Derbyshire.
I hope you find the report of interest as it captures the stories and themes from the
day. It is the start of our journey to make sure the patient’s voice is heard through the
health reforms.
I would like to thank my Director colleagues for their leadership and Bridget Roe for her
attention on the day to capture the obvious - and not so obvious - to write the report.
Any feedback or ideas are welcome.
Maggie
Director of Clinical Quality &Nursing
NHS Derbyshire County PCT
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About the author
Bridget Roe is a doctoral researcher at Nottingham University Business School/CLAHRC-NDL.
She has 22 years‟ experience as a nurse, midwife and care home manager and has worked in
the charity sector as a project leader. After gaining a BA in Human Resource Management and
an MA in Management and Organisational Analysis at Warwick Business School, Bridget is
currently researching the learning and socialisation of novice nurses in the context of current
policy and practice.
The Directors of Nursing
Maggie Boyd is Director of Clinical Quality and Nursing for NHS Derbyshire County PCT. She
has 30 years‟ experience as a nurse, midwife and Health Visitor with clinical experience in acute
surgery, accident and emergency, occupational health, midwifery, health visiting and public
health development work. Maggie‟s first leadership role was as King‟s Fund clinical leader of a
health visiting team in a socially deprived area with chronic staff shortages. Senior roles have
included primary care development in a London Health Authority, NHS Executive Director roles
since 2000 within NHS Trust Community Provider, Workforce Confederation, SHA and since
2006 in Derbyshire PCT. Maggie is a Florence Nightingale Scholar 2011/12, a member of the
Nursing Times editorial team and also a clinical fellow from Derby.
Kath Henderson joined Derbyshire Community Health Services as Director of Quality and
Chief Nurse in June 2011. She is a qualified nurse and has worked within the NHS since starting
her nursing career in 1977. She has worked in a variety of roles and organisations including the
acute sector, an integrated NHS Trust (acute, community and mental health services), a
specialist children‟s NHS Trust, NHS Direct and a Primary Care Trust. Prior to moving to DCHS
Kath was the Managing Director and Chief Nurse for Rotherham Community Health Services. In
addition to her nursing qualifications Kath has a MSc in Health Economics and Management.
Kath is a Trustee at Bluebell Wood Children‟s Hospice. She is married and has three daughters.
Paul Lumsdon is Director of Nursing at Derbyshire Healthcare NHS Foundation Trust. He has
worked within the NHS for 26 years and is very proud of the nurse training he received in
Macclesfield. Since qualifying, Paul has gained clinical experience in a broad range of mental
health services including Child and Adolescent Services, Adult of Working Age and Older
Peoples Services working in areas such as Cheshire, Derbyshire, South Wales and Dorset. Paul
has gained management experience in various setting within primary care, community care,
district general as well as mental health services. Prior to joining the Trust, Paul had been
working as Nurse Executive for 14 years
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Brigid Stacey joined the Royal Derby Foundation Trust in August 2010 as Director of Patient
Experience and Chief Nurse. Previously she was the Chief Operating Officer/Nurse Director at
Walsall Hospitals NHS Trust where she became Deputy Chief Executive.
Alfonzo Tramontano is Chief Nurse at Chesterfield Royal Hospital NHS Foundation Trust. As
General Manager of the Surgical Directorate Alfonzo oversaw the early hitting of the 18-week
target, helping introduce the one matron per in-patient ward through his a „hands on‟
approach.
Presenters
Dame Elizabeth Fradd is an independent health service adviser. The focus of her work and
abiding passion is the continuous improvement of health care. She was until April 2004 the
Nurse Director and lead Director for the Review and Inspection programme in the Commission
for Health Improvement (CHI) and prior to this Assistant Chief Nurse in the Department of
Health. Her current portfolio of work includes commissioned independent Inquiries /
investigations, the delivery of innovative professional development programmes and the
mentoring of senior personnel.
Mark Todd was Member of Parliament for South Derbyshire between 1997 and his retirement
from the seat in 2010. He served on the Treasury Select Committee through the banking crisis
scrutinising the work of ministers, finance sector leaders and the Bank of England. Before his
parliamentary career he worked for 20 years in the Pearson Group leaving as UK Operations
Director for Addison Wesley Longman (then one of the largest education publishers in the
world). Since leaving Parliament he has been successively Chair of NHS Derby City and of the
Derbyshire Cluster of PCTs. He is also Chair of Trustees of the Motor Neurone Disease
Association which provides care support to those living with the disease, campaigns on their
behalf and funds research into the disease. He lives just outside Derby.
Stephanie Austin is Head of Clinical Quality at NHS Derby City. Steph set up the local COPD
service in 2003 which she led for 6 years. She also has clinical experience in a variety of settings
including primary care, acute care and in the pharmaceutical industry.
Hayley Veal is the Head of Clinical Quality within NHS Derbyshire County. She works closely
with care homes, the local authority and the Care Quality Commission to quality assure
independent providers within the care home sector in order to drive up the quality of care
received by residents.
Gaynor Ward is a Nurse Consultant in Learning Disabilities and Mental Health at Derbyshire
Healthcare Foundation Trust. She provides expert nursing practice, clinical leadership and
consultancy to the learning disability service, within the sphere of mental health.
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Acknowledgements
The author is grateful to everyone who helped with this report, including all those who
contributed to the „Big Conversation‟ meeting in December 2011.
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Table of Contents
Executive Summary…………………………………………………………………………………………………………………………..4
Background………………………………………………………………………………………………………………………………….4
The Tabletop Discussions…………………………………………………………………………………………………………….5
The Themes………………………………………………………………………………………..………………………………….……7
Feedback……………………………………………………………………………………………………………………………........10
Action Learning Points……………………………………..…………………………………………………………………...10
The Report of the Day’s Proceedings……………………………………..………………………………………………...…….12
Plenary: Dame Elizabeth Fradd………………………………..………………………………………………………..….…..13
Conversation 1: What are we getting right?.................................................................................16
Conversation 2: When and how are we letting out patients down?............................................17
Conversation 3: What is needed and how will we know we are giving good care consistently….17
Plenary……………………………………………………………………………………………………………………………………..…….19
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Executive Summary
Background
This meeting took place as a response to the collective desire of nursing to open up the
conversation about nursing care, to reinforce patient experience as a key strand of reform and
discuss what a shared vision for the future might look like.
The conversation was to take place between a broad range of people including frontline
nurses, patient consultation groups and primary and acute and mental health care providers to
encourage a collaborative approach to maintaining good professional standards and
improving care for patients. Therefore, it was hoped that the event could also inform providers
about what the patient experience might be at best, and what were the hopes and predictions
for the future. The day also had a strong leadership focus supported by the East Midlands
Leadership Academy and CLAHRC-NDL. This report is prepared by Bridget Roe on behalf of the
CLAHRC NDL.
There were 68 attendees from a range of organizations including NHS Trusts, GP Surgeries,
patient groups, care homes, academic institutions and the third sector. Most attended held
senior roles; only a minority of delegates (around 6) were „front-line‟ staff. There were 47
people in either a management or senior role (including directors, matrons, and a chief
executive), 9 in an academic/media role, 9 RGNs below matron/consultant level and 4 patient
representatives. The attendance was therefore heavily weighted to those with senior roles in
services.
The day began with introductions from Mark Todd, Chair of NHS Derby City and NHS
Derbyshire County Cluster and Maggie Boyd, Executive Director of Clinical Quality and
Nursing. This was followed by a keynote address on best practice by Dame Elizabeth Fradd,
board facilitated table top discussions between delegates, and a plenary session that focused
on examples of good practice and the areas of concern. Finally, there was a series of
presentations from the Directors of Nursing and their teams followed by questions.
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The Table Top Discussions
Delegates were allocated tables so that people were distributed and each table was facilitated
by a member of the Board or from East Midlands Leadership Academy. The tables were asked
to engage with:
1. What is good practice, what are we getting right?
2. When and how are we letting our patients down?
3. What is needed and how will we know we are delivering good quality care consistently?
Delegates were firstly asked, “What are we getting right?”. Although the conversations started
with thoughts about good practice, tables soon slipped into conversations about poor practice.
One group noted, “We are not good at blowing our own trumpet and it‟s hard because there is
no point of reference”. The conversations recognised that intentions are usually good which
should be appreciated, however practitioners are reticent about celebrating what they do well.
Good practice should be celebrated and talent should be spotted at whatever level. Nurses are
good at listening and big thoughts need to be retained and shared.
When considering „how we are letting our patients down‟ and „what is needed and how will we
know we are delivering good care‟, a number of issues were discussed. These included
organisational culture, the impact of time, problems of communication between different
services and a lack of staff. Delegates wanted a „no blame‟ culture, however, they also
highlighted the stigma of mentioning a shortage of nurses; it was seen to be regarded as „an
old chestnut‟. An honest discussion was often not had for fear of reprisal amidst a highly
political context. The lack of ownership over patient care was highlighted and it was
considered important to find evidence that there were problems, there is a need to sharpen up
thinking but there are concerns that this may „kill‟ the Darzi principles. It was noted that nurses
can and do expose poor practice, however, communication needs to be improved to make this
more effective. Delegates also talked about the need for good leadership and clinical
supervision to support exposing poor practice.
Groups used stories to help understand each other‟s perspectives and recognise how poor
practice is manifest. It was noted that the understanding of culture often comes from intuition
- a gut feeling. This is not problematic if used against indicators, but intuition still needs acting
on. Nurses need patients to help them to evaluate care, however, patients are not always able
to recall details retrospectively. Members of Derbyshire LINk informed other delegates about
their model of partnership and successful visits to care homes and how this information was
used by NHS Derby County. Delegates representing from LINk had brought patient feedback
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which were complimented by groups swapping real life stories with each other and considering
what it must feel like to be a patient. It was suggested that we are dominated by targets and
numbers and forget people. A return to patient/nurse thinking was called for rather than just
thinking about the process. It was suggested that stories should be used in meetings with
business managers to help them to understand the anomalies in the service and processes.
The problem of understanding different „languages‟ between roles was recognized, however,
so much so, that things often need spelling out. This was recognised to be part of the” game
we play”. It was also suggested that issues could be themed or to think about the internal and
external factors that influence nursing care.
Following the plenary, several key points emerged. These included a welcome of the patient
focus (putting their patients first), to get the basics right and encourage a just, fair and „no
blame culture‟ where nurses care for each other and celebrate success. Communication was
considered to be central to providing excellent care and managing expectations and education
and training should be at all levels, including the Board. There was also a strong recognition
that there needs to be more collaborative working and sharing of good practice and systems,
and we should all ask what we would want for our own VIPs. Story telling dominated the
conversations at the tables.
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The Themes
The following five themes are drawn from both the guided and informal conversations, the
invited speaker‟s suggestions on post-it notes, evaluation forms and this author‟s observations.
1. Sharing Practice
2. Improving Communication
3. Integration of Approach/Transformation to 24 hour seamless high quality care
4. Patients First - getting the basics right
5. Training, Valuing and Motivating the Workforce.
Sharing Practice
An overriding theme of the day was a desire to share best practice, however there was also a
wish to understand each other‟s services better and move towards working more
collaboratively to improve standards of care.
For example, delegates suggested a need for “cross pollination” and “drip-feeding good ideas
and practice”. Nevertheless, as Dame Elizabeth Fradd noted, nurses are not always good at
talking about what they do well and although there are pockets of sharing good practice, it is
often difficult to do. Many delegates tried to think of ways in which this could be achieved, for
example the use of forums and notice boards was suggested. There were also calls for a more
systematic approach and opportunities to share across organisations, both in Derbyshire and
nationally. As one person noted, we need change “across the whole system” and as another
wrote, there is a need to “work with voluntary, private sectors etc to find solution, we could be
a „critical friend‟. This would include not only sharing the good ideas, innovations and big
successes, but also best practice and actions from day-to-day working and incidents. Delegates
called for the chance to observe practice increasing “access to knowledge” and acknowledging
the role of patients in this process. There was however, an understanding that „Best Practice‟
does not necessarily work from context to context. It was recognised that resources, support
and space is required for evaluation and time is needed to see if the change works,
summarised through comments such as “give change a chance”.
Improving Communication
The need to improve communication was a strong theme throughout the day, seen in both the
conversations and the post-it notes. Many delegates expressed that they wanted a more open
(we are not expert in everything) and honest conversation with colleagues and patients, and as
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someone noted, develop an “NHS Speak”. This fits with some comments from the table top
discussions, where people stated that they did not have a common language for
understanding each other‟s practices. There is a desire for good communication to cross the
hierarchies and for patients and staff to be heard. There is a need to listen to front-line staff.
However the problems of communicating difficult messages between nurses and senior
managers were noted and it was suggested that „Front Line Friday‟ should be done by all.
A clearer understanding of each other‟s roles was considered to be paramount for integrated
care, and although listening was seen as important, people also expressed the view that
responsive action should closely follow what was heard, therefore avoiding „lip-service‟. In
particular, it was felt that patients should be listened to, that this is at the heart of a patient
centered approach and could save valuable time and resources. It would also help to guide
patient‟s expectations from the start (remembering outcomes are not just medical), possibly by
have a „contract of expectation‟ but also to avoid information overload as it could cloud the
issues at stake. It was suggested that in particular, communication with vulnerable people
should be considered and supported by appropriate safeguarding frameworks to „give them a
voice‟. The use of nominated individuals for all service users was advocated. The building of
effective relationships, for example, between higher education and service was suggested so
that “nurses of the future reflect the values and beliefs, skills and competencies that were
discussed today”.
Integration of approach / transformation to 24 hour seamless high quality care
Integrated thinking and service provision (linked to the recognition that there is a lack of
understanding of each other‟s practice areas) was another important theme. There was a call
for 24/7 care, a more seamless service and to develop and to improve the culture, 24 hours a
day to give a consistent approach and to think beyond 8am to 6:30pm, Monday to Friday.
Again, there was the recognition that to integrate thinking and services, there needs to be
more opportunity to exchange ideas and share experience and knowledge with other service
and each other.
Patients First - Getting the Basics Right
Dame Elizabeth Fradd reminded delegates that we need to “find the person inside the patient”
and put the patient first. Getting the basics right was a key concern of the delegates. There is a
need to focus services on all users, but increasingly on the elderly, those with learning
disabilities and the vulnerable. Questions were raised as to how to recognise if we are caring
for the most vulnerable. Timeliness was discussed, and ideas such as collecting information
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early to allow rapid pathway implementation and planning for discharge early were suggested.
A “Patient Centric Record” was suggested. The importance of focusing on the ordinary and
getting the „little things‟ right, was seen as vital. Both the speakers and the delegates discussed
the challenges of changing targets and the current financial situation. Not enough is learnt
following incidents and there is a desire for more timely action. Involving patients in key
decision making was urged, and delegates were shown exemplars from other areas such as
Kings College‟s initiative “How are we doing?”
Training, Valuing and Motivating the Workforce
It was suggested that Derbyshire could become the “Beacon of Excellent Patient Care”. Staff
needed space to create, be innovative but also to fail. Leadership and role modeling is needed
from all levels of employees. It was also suggested that there be better healthcare worker
training in areas such as dementia. A comment on a post-it note described how „we are letting
our nurses down and therefore the patients; we should have realistic expectations from staff‟.
Delegates were reminded that the „good‟ is rarely reported in the media and celebrating
success is not easy, as “we are not good at blowing our own trumpet”. The chance to talk
about similar challenges whilst acknowledging the common desire to provide good quality
patient care was valued.
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Feedback
Around 50% of delegates filled in feedback forms and the majority of delegates agreed that
their understanding of the national and local leadership agenda has increased and were clearer
about their personal leadership and development needs. The delegates were also confident
and committed that they could use what they had learnt in their own Trust and valued the
chance for interaction and networking, engaging in genuine conversations from work settings
trying to tackle similar challenges. The lack of attendance from frontline staff was noted. Whilst
the examples of best practice and good clinical leadership provided inspiration for delegates,
some remarked that there were too many speakers just after lunch. It was suggested that
instead, the open conversations should be had during this time. Delegates also expressed a
wish for more time to have the open table conversations across the tables.
This was a new and unique event. Early informal conversations indicated that the majority of
delegates were genuinely enthusiastic and wanted to engage with the aims of the day, to be
able to voice opinions freely and exchange ideas. Delegates had the chance to network and
meet with like-minded others and this was later regarded as one of the key benefits of the day.
In addition to the guided discussions, these informal conversations over coffee and lunch
supported the exchange of ideas and shared experiences.
Action learning Points
The use of storytelling to illustrate points was a strong feature of the conversations, however,
there were indications that some delegates still did not feel that this was a safe forum. At
future events there could be an even stronger emphasis that delegates have permission to be
honest and express their opinions and tell stories without a concern about negative
consequences.
There were different styles of facilitating the table top discussions which demonstrated
different skill sets. The conversations appeared to be more productive when the facilitator was
able to spend most of the time listening and where where people in the groups had the space
to seek clarification from each other (which often corrected misunderstandings about each
other‟s services) and build up rapport and trust with new colleagues. This shows a need for
good listening skills and taking the pace of the event down in order to cultivate the
conversations.
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At future events many delegates would prefer the conversations to take place in the afternoon
with more time allocated to the open discussions. At this event, people were still trying to
capture the issues and had just gained momentum when time was called. Although delegates
were interested in this meetings afternoon talks it was felt there were too many and too much
emphasis on existing best practice which does not always transfer to different contexts. Future
events therefore may needs to be redesigned to allow more conversations between delegates
to take place.
Key areas to consider may include:
Developing leadership
How to share best practice, the use of websites and communities of practice to enable
sharing and learning
Job „swaps‟ to understand each other‟s areas
The importance of critical reflective practice
Good models of supervision, mentorship, preceptorship.
The importance of storytelling
How to hear the key voice of frontline staff
Promoting a culture of innovation and support
The overriding evaluation is that the event was very positive through nurses being heard,
having some honest, genuine and open dialogue and positively engaging with like-minded
people. The event gave delegates the inspiration and confidence to consider how to take
things forward and influence others, and there was a sense of the event being an opportunity
that gave nurses hope for the future. The next steps will be a launch of a Nursing Cabinet to
oversee the ongoing improvements and bring the strategic priorities into a nursing strategy
to facilitate change where the patient voice is heard in a way that is meaningful at every level.
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Report of the Day’s proceedings
There was a wide spread of people from a range of healthcare, institutional and third sector
settings. The majority of attendees had a senior role in the provision of care. There were 47
people in either a management or senior role (including directors, matrons, a chief executive),
9 in an academic/media role, 9 RGN‟s below matron/consultant level and 4 patient
representatives. The attendance was therefore heavily weighted to those with senior roles in
services.
Opening remarks: Maggie Boyd- Director of Nursing and Clinical Quality
Maggie Boyd opened the proceedings, and expressed her hope that the day would be a great
opportunity to help the sector to move forward, that there would be plenty of opportunity for
a decent, relaxed conversation, that delegates would feel able to express themselves and that
the focus would be towards service users.
Mark Todd- Chair of NHS Derby City and NHS Derbyshire County Cluster
Mark Todd discussed care from a board perspective, and drew on:
1. The timeliness of the event amidst the current concerns of quality in NHS and Social
Care. He spoke about the importance of defining what quality means, and described
how it is increasingly defined by the patient and carers experience. Nevertheless, he
argued that there is a need to understand, collect and assimilate patient perceptions
about care.
2. Integration of the organisation of care, including how to organise a seamless service,
and the challenge of working this out.
3. Governance - defining how we know what we are doing is right, and what evidence is
required. The delegates heard how we need a range of information sources, and to
define the tools we need.
4. Transformation. The challenge is the reduction of costs, whilst also ensuring that
patients are protected and quality of care is enhanced. This should be possible through
transformation but it raises issues of understanding the potential impact of having to
confront the crisis.
5. Context. Not only an aging population but also increasing expectations. Stoicism is
now changing to rightly higher expectations of good quality of care.
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Plenary: Dame Elizabeth Fradd - University of Nottingham
Dame Elizabeth Fradd spoke about the issue as one of the need to balance professional and
corporate responsibility to provide best practice, to understand the relevance of these care
issues to your service and role and the part individuals play in safeguarding and experience.
Four areas of concern were highlighted: failure to communicate, pain relief, assistance to the
toilet and adequate nutrition and hydration. Dame Elizabeth Fradd argued that there were no
surprises in the reports from the Mid Staffordshire and CQC inquiries, and how “we don‟t know
what a good service is until we don‟t get it”. The Big Conversation is about putting the jigsaw
and hearts and minds together. Culture is the most significant thing that makes a difference in
failing to recognise concerns; it is never about one person, it is about systems and processes.
Dame Elizabeth Fradd reminded everyone of the NHS survey which shows a clear link between
good HR practice and high staff engagement. There is new research based in looking at
adverse events in 12 countries and they have been linked to a poor working environment.
Everybody has a responsibility; it‟s always bigger than one person.
Dame Elizabeth Fradd summarised the common findings in recent reviews of care:
General Findings
1. There are many very dedicated staff
2. There are always pockets of good practice (but often not shared)
3. The majority of service users get good care but not all
4. There have been too many reconfigurations and restructures; an eye has been taken off
the patient experience
5. Too much emphasis has been placed on targets and the financial position
6. The existence of too many committees clouds the line of decision making
7. The culture of the NHS determines the outcome
8. Insufficient emphasis has been placed on safety and quality. Quality can be hard to
report but improving with the introduction of KPI‟s. The „circle‟ has often not been
reported after an audit, and there aren‟t enough lessons learnt or shared. Dame
Elizabeth Fradd asked people to think about what they can remember from the last
audit.
9. There has been insufficient involvement of patients in key decision making/service
design/policy, are you feeding the audit back to the patient? Dame Fradd informed
delegates of the King‟s College Hospital exemplar
10. There has been inadequate staffing levels and inadequate leadership in some areas of
health
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11. Variable quality of monitoring/audit. There are too many action plans, diluting the
focus.
12. Risk management processes are immature, with little understanding of how this gets
fed into the framework or what the priorities are.
13. Boards often not aware of the frontline reality. Exemplar: Whipps Cross “In your Shoes”
Clinical Findings
1. The Importance of good Clinical leadership.
2. Communication and thresholds for sharing.
3. Team Working- What is it? Who is involved?
4. Issues of training/updating, there is often confusion with supervision.
5. Use of policies, important to use intranet as paper copies can be out of date (St
George‟s problem)but how? The way the intranet is navigated is often changed which
makes it difficult to locate policies and procedures and other resources.
6. The patient is not seen as an individual; we need to find the person inside the patient,
as a family member and a person in the community.
7. “Good service is giving customers a little more than they expect”- it‟s the little things.
The White paper “Equity and Excellence- Liberating the NHS” matches closely to what we know
about the expectations of patients - compassionate, dignified, respectful and individualised
care. Delegates were reminded of the NMC code and accountability and that they must be
able to justify the decisions that you make and consider:
How do you know?
How do you assure yourself? (not ensure or reassure)
How can you be certain that you are not immune to poor care?
It was noted that people often do become immune to what they see going on. Therefore we
must consider responsibility, how certain can nurses be when they delegate and what tools are
they using to determine adequate staffing levels. It‟s about raising concerns, incident reporting,
whistle-blowing and communicating with professional bodies, but this is very hard to do.
Dame Elizabeth Fradd told delegates about the new GMC guidance which will hopefully
provide reassurance. It defines management, getting things done through and with people,
and the need to create an environment in which people can perform appropriately.
Management roles involve teams but all individuals have a duty of care.
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The delegates were told of the 7 Principles of Public Office. This is relevant to all healthcare
managers. It was acknowledged that it is hard for middle managers, who are accountable to
both management and the profession, and there is a conflict between operational and
professional practice and they often become risk averse. It comes down to leadership again.
Passing problems upwards is hard, particularly when it is not good news. The absence of
curiosity is a big issue.
The audience heard how we face challenging times: the economic downturn, challenges of
regulation, uncertainty in new government policy and difficultly in working across agencies.
However, the real concern is identifying who can speak out on behalf of the patient. The power
of the chief nurse is diminishing. What is needed is the management of the expectations of
patients, carers, commissioners and regulators. Care needs to flexible and cost effective (such
as the productive ward, and lean strategies), the organisational reputation must be good and
the potential of the staff and service should be maximised. Leaders need to be empowered
and secure a personal reputation. DameElizabeth Fradd highlighted the exemplar of Honda
and the Power of Dreams http://dreams.honda.com. This shows us that staff in care need space
to be creative and innovative. There are lessons to be learnt from the Improvement Project
from the Department of Improvement and Innovation. It‟s often the small things that matter,
the relevant things need to be selected and success should be celebrated.
To conclude, Dame Elizabeth Fradd talked of the need to recognise failure and that everybody
has a responsibility for patient care. Patient and public feedback is vital, do something about it
and be seen to do something about it. The care environment is complex and any action is not
easy but have a go and don‟t give up.
Questions
1. Delegate: What about the influence of external factors on nursing? A nurse may not
understand all the agenda, you get encouragement but then your ideas get dropped.
Maybe you need to know how to recognise what you are not asking? People can
misinterpret support. When policy moves on, nurses need a safety net.
DEF: This is at the heart of what people experience. Supervision needs to be improved,
people need someone to talk things through with. To understand the core business,
appreciate the ripple effect of death etc, we are still learning. The RCN Political Leadership
Programme is useful guidance for nurses.
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2. Delegate: Are things worse?
DEF: no, not worse. Healthcare has got better and it is now in the public domain. The
doctor used to be God and the nurse was the angel. There has also been a huge amount
of misreporting and nurses are an easy target. Good practice is never reported.
3. Service User: How can you train a nurse to be a bit more emotional? How can you guide
the profession?
DEF: The heart of the issue is in education for nurses. Anyone who does not feel should
not be a nurse, we need careful selection. But nurses can behave unemotionally that
supports people humanely as it helps deliver care. Good role modelling is important. EF
learnt from working as a nanny for Glenda Jackson who had such humility; good leaders
show humility, it is not about formal teaching.
4. Delegate: I work in education and you can‟t teach compassion but you can teach self-
awareness and how to sense.
DEF: Yes, it‟s about being guided, supervision, reflection.
Conversation 1: What are we getting right?
Examples
Intentions are good and need recognising.
Often people feel they can‟t complain about medical care because it‟s seen to be good.
We should bring in real life stories about differing perceptions.
People are good at listening.
Communication is not as good as it could be, misunderstandings happen but how to
capture this?
People described leadership initiatives, a chief nurse spoke about changing times,
listening to frontline staff that have the good ideas.
The importance of clinical supervision, recognising when they are needed.
Having a big thought and being able to hold it.
We are good at exposing poor practice and being vocal. A table considered the
difficulties in talking about the good.
Patients are more important than benchmarks
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When we look at the negatives we have to look at the culture.
We are too shy about celebrating the good.
A member of this group described their work in learning disability as “second to none”
but that they don‟t get enough compliments
A table included patient representatives from the LINKS. They talked about models of
partnership and their visits to care homes which worked very well, was well received, and had a
great outcome. The Information was used by the NHS Derby County. They talked about the
need for witnesses and to be reactive. They hold coffee mornings where people can talk freely.
Delegates were story-telling and talked of the need not to understate the good things, and
that we need a platform for raised expectations. In the mental health field, professionals can
visit groups go to where the patients are and try to understand the real issues.
Conversation 2: When and how are we letting our patients down?
Conversation 3: What is needed and how will we know we are delivering good
quality care consistently?
Examples of conversations summarised together
It was thought to be critical that in care we have an open, no blame culture, maintain open
attitudes however some delegates can we even to this today? Some people thought yes but
others thought no. One person was very concerned and said its different when you have to
answer to everybody, when you do speak you have to be corporate. The problems are similar
in every area and we “need the truth of the matter”. It was thought that not enough nurses was
considered „an old chestnut‟ and that culture „shouldn‟t be mentioned‟.
Time was considered to be a key issue in terms of providing high quality care but again, it was
a big taboo. The new language of lean was perceived to be useful, but it was recognised that
there are not enough bodies, especially with the impact of the aging population, in order to
provide good quality care. Recognition of the need for proper discussion was stated, but this
was deemed impossible because of QIPP, economics and politics and the fear of reprisal.
Moreover, whilst the need to look at the basics was recognised, there was little certainty about
what is needed, what opportunities could be taken, and how could the focus be shifted. The
problem of mental health and accountability issues in acute settings was highlighted. People
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often do not take responsibility and need to acknowledge the limitations and clear up
misunderstandings between different areas.
It was highlighted that we need evidence to show that things are not in place. There is lack of
ownership; we need to explore what prompts good care, and put time-frames on care as it can
go on for too long. We should sharpen up our thinking, and avoid silos but also consider the
impact on the patient at the same time. However, does sharpening up thinking „kill‟ the Darzi
principles?
What can we do from a service user perspective to make their lives less stressful? One
suggestion was to try to avoid admission in the first place, promote best practice in the
community. It was considered that we need people that understand both systems and use to
care pathways that translate into people‟s everyday thinking.
One key area that should be looked at was thought to be admission and discharge, and there
was potential here to change the processes to improve care. Discharge planning needs to start
even before patients go in to hospital, for example, start thinking about pain relief and so on,
however this requires a huge amount of communication, a culture shift and to think
proactively. Think about long term chronic conditions, the transferability of an approach, the
key principles should be the same. Learn from patients who talk about the reality of their
discharge with personal budgets. People should be named in discharge packages so they can
be identified if needed. We let people down by asking repeated questions, there has got to be
a better way than tick boxes; one person said “I blame the managers”.
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Plenary
Delegates were reminded that the event was about engagement and a need to „bottle up‟ their
approach. Even if one ward is „cracked‟ the approach doesn‟t transfer, it‟s about making it
known and understanding how to share best practice and which forums to use for doing so.
Practice doesn‟t necessarily transfer, but talking to each other helps, asking for the reality in
practice, sharing the bad and the good. It‟s similar to the end of a project, reflecting so people
can see the process. Patients also need to understand the process and then it isn‟t so stressful.
A key issue is helping and empowering each other and being aware that change isn‟t for its
own sake. During this session the board answered questions and at times it was only a 2 way
discussion and not enough space for debate across the tables.
Key Points
Work collaboratively
Get the basics right
Manage expectations, some systems don‟t fit with modern life
Give change a chance
Don‟t give up on a bad idea
Everything involves communication
Understanding different systems and therefore expectations
We need continuous improvement, communities of practice
We find it hard to share, if we can crack this then it would be really good.
The board were asked about the future and what „spin‟ would be put onto care. Delegates
were told we must learn from ideas such as AQP and not just implement blanket reform, for
example as in Derbyshire Choices. We may have to change the way some people work, as the
hospital does not „wake-up‟ until 8:30am. Another new idea is the elderly care pathway. The
board were asked how can we feed into this and delegates were told that we must get it right
as we develop.
The stress of the workload was highlighted which was linked to not achieving the
fundamentals and compromising the integrity of the nurse. It was asked, is the nurse going
under? It was stated that we should monitor, measure and report the problem using nurse
sensitive indicators.
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Delegates from learning disability teams informed delegates of the work they had been doing
and it was recommended that they try to get publishes so that their best practice could move
beyond Derbyshire.
Key Points
We need to care for each other
We should celebrate success
Be patient focused
Continuous sharing of good practice
No blame culture
Positive learning environment (focus on organizational to value professional
requirements for
PREP and clinical supervision)
Nurse directors have a responsibility for variability in care but poor care is usually not
deliberate
We need a just and fair culture
We should all ask would I want this for my VIP?
Delegates were asked to save 3 points that were raised so it isn‟t just talking but also doing
something about it.
Examples of 3 learning points
1. The patient experience is a welcome focus as the patient has often been unheard
2. Focus on the ordinary, invest and empower HCA‟s
3. Listen to the voice of the frontline nurse, ward to ward e.g. back to floor
1. Clear focus on priorities
2. Revisiting the basics, better access to care
3. Education and training at board level.
Dame Elizabeth Fradd asked the delegates to listen carefully to one another, as they were
doing fantastic things. She urged them to hold onto what they are doing and what you know is
good. She asked them to put their heads above the parapet where needed and have a
courageous discussion.
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After lunch, during which the issues continued to be discussed informally, delegates were
shown the Panorama film about the abuse at the Castlebeck care home. This altered the mood
of the delegates, although it was a stark reminder to everyone about what can happen when
things go wrong. Following this, there were 5 presentations that showcased best practice and
ideas:
Brigid Stacey, Derbyshire Hospitals Foundation Trust, “Leading for Quality”
Gaynor Wars, Derbyshire Health Foundation Trust, “Access to mental health service
made easier”
Alfonzo Tramantano, Chesterfield Royal Hospital Foundation Trust, “Dignity in Care”
Kath Henderson and colleagues, Derbyshire Community Health Services, Hayley Veal
and Steph Austin, Heads of Clinical Quality (Commissioning) PCT cluster, “Quality
Assurance in care homes across Derbyshire”
The delegates were then asked to consider what next? It was hoped that the momentum
would not be lost and that everyone could be ambassadors of the day. One member of a
patient group noted that his vision would be that professionals volunteered their „know how‟
but that this had many constraints. It was asked how we can harness leadership capability
across sectors. The passion, the energy and positivity in the room was acknowledged and
delegates were reminded that they all have a responsibility for improving and communicating
ideas, which should be a top priority. Patients require integrated, seamless care but we also
need to value staff and motivate the workforce. Professor Guy Daly remarked that it was crucial
for education and practice to collaborate, and work together on good graduate programmes.
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About CLAHRC-NDL
The Collaboration for Leadership in Applied Health Research and Care – Nottinghamshire,
Derbyshire and Lincolnshire (CLAHRC-NDL) is a partnership between the University of
Nottingham and NHS organisations across the region.
It is one of nine CLAHRCs in England, and is funded by the National Institute for Health
Research (NIHR).
CLAHRC-NDL undertakes high quality, applied health and social care research and translates
that research into practice; improving services for patients and service users across the East
Midlands and beyond. Its core objective is to transform healthcare by speeding up the time it
takes to get the findings from research into clinical practice.
www.clahrc_ndl_nihr.ac.uk
Disclaimer
This report presents independent research commissioned by the National Institute for Health
research (NIHR). The views expressed in this publication are those of the author(s) and not
necessarily those of the NHS, the NIHR or the Department of Health
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