Improving Patient Outcomes: a guide for Ward Managers

978-1-905539-03-1

Improving Patient Outcomes

A resource for ward leaders

Alison Wells

MSc PGDAE BA(Hons) DPNS RM RGN

ISBN: 978-1-905539-06-2

First published 2007

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British Library Catalogue in Publication Data

A catalogue record for this book is available from the British Library

Notice:

Clinical practice and medical knowledge constantly evolve. Standard safety precautions must be followed, but, as knowledge is broadened by research, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers must check the most current product information provided by the manufacturer of each drug to be administered and verify the dosages and correct administration, as well as contraindications. It is the responsibility of the practitioner, utilising the experience and knowledge of the patient, to determine dosages and the best treatment for each individual patient. Neither the publisher nor the authors assume any liability for any injury and/or damage to persons or property arising from this publication.

The Publisher

To contact M&K Publishing write to:

M&K Update Ltd · The Old Bakery · St. John’s Street

Keswick · Cumbria CA12 5AS

Tel: 01768 773030 · Fax: 01768 781099

publishing@mkupdate.co.uk

www.mkupdate.co.uk

Designed & typeset in 10pt Usherwood Book by Mary Blood

Printed in England by Ferguson Print (Keswick) Ltd.

Contents

About the author

Introduction

Acknowledgements

1. Improving patient outcomes

2. Diagnosis: how well is your team performing?

3. Selecting team members

4. Creating and sustaining a learning environment

5. Performance management

6. Understanding change and its impact on team performance

7. Implementing systems to support effective team working

8. Involving patients in their care

9. Measuring performance

Appendix 1: Interview scoring/rating template

Appendix 2: Team work survey

Appendix 3: Providing references

Appendix 4: Templates for effective meetings

Appendix 5: Return to work interview template

Appendix 6: Complaints analysis pro forma

Common acronyms

References

Index

About the author

Alison Wells has worked in an acute hospital settings for most of her career. She became a ward leader in 1989 – a role which she found challenging, rewarding and enjoyable for more than four years.

She moved into practice development where she developed her teaching and facilitation skills. Alison also has experience as a Change Leader delivering workshops on managing transitions, team building and redesign techniques all over the UK. Her most recent role in the NHS has been as Professional Head of Nursing (Education and Research) in an acute trust. There she led a number of projects including developing competencies for nurse practitioners and running a ward leader development programme.

Alison set up Smart Work Consulting in 2005 and has established a successful business working with organisations across the country. Her work includes training and development, strategy development, programme evaluation and event organisation.

Alison is committed to the improvement of patient care and developing people. Everything she does is based on these two principles. Her expertise includes working with teams, strategy development, change management, nurse-led discharge, writing for publication, patient and public involvement, customer care, political awareness, coaching, mentoring and much more.

Introduction

The ward leader has long been recognised as a pivotal role in the effective running of the ward team and the maintenance of high standards of care (King’s Fund, 1988; Kitson, 1991; Pembrey 1980). Yet ward leaders are often ill prepared for the role, lack support and time. They report conflicting objectives and priorities (Allen, 2001; Binnie & Titchen, 1998).

This book is aimed at ward leaders and prospective ward leaders. The evidence for effective team working and its impact on patient care is readily available. As a ward leader you do not have to make enormous changes to the way you work to have an effect.

Kotter describes leadership as aligning people, setting the direction, motivating and inspiring people, developing credibility, being visionary, anticipating and coping with change (Kotter, 1990). I hope this book will help you to build on and develop skills in all these areas.

All the chapters link with each other but they also stand alone. You are not expected to work on your own to implement changes but to seek out help from your peers and colleagues within your team and organisation.

Good luck!

Acknowledgements

I would like to thank my husband Tim for his patience and support, here and in France, whilst I wrote this book. I need to thank him for much more, but he knows that.

I would also like to thank my close friends and colleagues who have readily shared their knowledge with me.

Thank you also to Mike who put up with me missing endless deadlines.

Chapter 1

Improving patient outcomes

The nurse’s role in relation to patient outcomes

The nurse’s role

There are numerous misunderstandings and stereotypes of what nurses do. If you put ‘nurse’ into an internet image search engine you will find nurses in scanty uniforms, or domineering Hatty Jacques-type images and the occasional nurse in theatre garb. None of these capture what nursing is really about. Lots of people have attempted to define nursing, starting with Florence Nightingale, who described nursing as:

Nature alone cures … and what nursing has to do is to put the patient in the best condition for nature to act upon him.

(Nightingale, 1859)

Virginia Henderson’s (1966) definition is one of the best known and most well used:

The unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will or knowledge … and to do this in such a way as to help him gain independence as rapidly as possible.

The International Council of Nurses (ICN) claims that:

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings. Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe environment, research, participation in shaping health policy and in patient and health systems management, and education are also key nursing roles. (www.icn.ch/definition.htm)

Finally the Royal College of Nursing (RCN) published a definition following consultation and discussion with representatives of its members in 2003:

Nursing is the use of clinical judgement in the provision of care to enable people to improve, maintain, or recover health, to cope with health problems, and to achieve the best possible quality of life, whatever the disease or disability, until death.

This definition is supported by six characteristics: mode of intervention, domain, focus, value base, commitment to partnership and purpose.

Between them these definitions paint a picture of nursing as being about assisting, being attentive, reliable, enabling and acting as advocate, as well as about influencing policy. All of them describe the nursing role as one which improves patient outcomes – even Florence Nightingale as long ago as the nineteenth century.

The Healthcare Commission (2005) states:

Ward staff spend more time with patients than any other staff group in hospitals. They have a major impact on the experience of patients and the outcomes of their stay in hospital, as well as on the overall efficiency of trusts.

Nurse managers have a responsibility to ensure the delivery of safe care. This has to be achieved not only during the day-to-day running of a ward but also by using research findings to influence the delivery and organisation of care and by influencing policy making.

Acute trusts spend on average 30% of their budget on staffing wards and yet between 10% and 20% of patients are not happy with their care (based on complaint figures (Healthcare Commission, 2005)).

The National Patient Survey which is carried out across acute trusts by the Picker Institute, on behalf of the Healthcare Commission, demonstrates that most patients are satisfied with their care but there are still areas of concern. In the 2006 survey approximately 40% of the 82,000 respondents felt that there were not enough nurses on duty and there are still patients who do not get the help they need with feeding and those who experience slow responses to call bells.

There are a number of drivers to improve patient care not least the need to respond to patient expectations. The financial incentive to improve patient outcomes is great. Poor patient outcomes lead to increased length of stay and therefore increased costs. Chief executives have an obligation to ‘balance the books’ and this is becoming increasingly difficult. In the financial year 2005–6, NHS overspending hit £536 million. This year hospitals and primary care trusts have been told to cut £1 billion (Reuters, 2006). As a result, job cuts have been announced in a number of trusts (Lister, 2006). Nurses, therefore, have a responsibility to ensure that care is delivered economically as well as safely, something which does not always sit well with nurses who strive to give a high standard of care (Bradshaw, 2003; Torjuul, 2006; Forsyth, 2006).

There are many factors that influence the ability of nurses to deliver high quality care. There is also a wealth of evidence to help nurses to improve patient outcomes by ensuring the right factors are in place. Nurses need therefore to be familiar with the research and also how to interpret and implement it, and a number of research texts are available to help nurses develop these skills (Clifford, 2004; Crookes, 2004; Polit, 2004).

Nurses will often complain that there are not enough nurses working a shift. While the nurse to patient ratio is important, research shows that it is not the necessarily the number of nurses working but the skill and experience of those nurses and the ratio of registered nurses to healthcare assistants that matter (RCN, 2002). Other factors include team working and organisational culture.

Nursing numbers

Nursing numbers

Insufficient nurse staffing levels can lead to poor or unsafe care (NHS Executive, 1999). Research undertaken by Aiken (2002) and Rafferty (2006) shows that high patient to nurse ratios can lead to increased risk of patient mortality. For example, post-operative patients are at higher risk of dying (7% for each additional patient per nurse). Clarke (2002) demonstrated that low staffing levels can lead to an increased likelihood of staff sustaining needlestick injuries. Higher nurse staffing levels have also been shown to result in reduced numbers of urinary tract infection, pneumonia and upper gastrointestinal bleeding (ICN, available at www.icn.ch under Factsheets).

Rafferty has also demonstrated that staff in hospitals that have a high patient to staff ratio are likely to be twice as dissatisfied as staff in hospitals with a lower staff to patient ratio. They also report a lower standard of care.

In some parts of the world where this is recognised, nurse to patient ratios are set and are mandatory (parts of America and Australia and all of Belgium). Whilst minimum staffing levels would appear to be a good idea, they can become acceptable levels rather than minimal levels.

It is good practice to review your skill mix and staffing levels regularly, to ensure your team matches the needs of the service. Triggers to undertake a review will include increased staff turnover, increased incident reporting and changes in practice or competence of the team.

There are no national standards for ward staffing in the UK and no formulas to help calculate skill mix and staffing levels. Ward budgets tend to be set using local judgement and cost constraints. There are five broad methods of calculating nurse staffing levels. The most commonly used method is professional judgement, using approaches such as Telford. The Telford approach has three basic stages:

The Telford approaches

1. Ward staff set safe and acceptable levels of staff for each shift for each day of the week. They then support this with written evidence and support for their decisions.

2. The numerical assessments are then transposed into bands of staff and whole time equivalents.

3. Actual numbers and bands of staff are summarised and appropriate allowances for trained and permanent staff are built in by managers.

This simple method needs to be supported by audits to ensure that quality of care is delivered.

Other approaches

The nurses per occupied bed criterion calculates the average number of staff by grade per bed. The acuity-quality method takes into account patient dependency and quality of care, which makes it more complex to calculate but more