ORIGINAL ARTICLE
Evaluating the Productive Ward at an acute NHS trust: experiences and implications of releasing time to care Stella Wright and Wilfred McSherry
Aims and objectives. To demonstrate how a national programme aimed to increase the amount of direct time nurses spend with patients’, impacts on both staff and patient experience. Background. The Productive Ward is an improvement programme developed by the NHS Institute for Innovation and Improvement (2007, http://www.institute. nhs.uk/quality_and_value/productivity_series/productive_ward.html) which aims to enable nurses to work more efficiently by reviewing process and practice, thus releasing more time to spend on direct patient care. However, there is little empirical published research around the programme, particularly concerning impact, sustainability and the patient perspective. Design. This manuscript presents the findings from qualitative interviews involving both staff and patients. Methods. Semi-structured one-to-one interviews were conducted with patients (n = 8) and staff (n = 5) on five case study wards. Seven focus groups were held according to staff grade (n = 29). Results. Despite initial scepticism, most staff embraced the opportunity and demonstrated genuine enthusiasm and energy for the programme. Patients were generally complimentary about their experience as an inpatient, reporting that staff made them feel safe, comfortable and cared for. Conclusion. Findings showed that the aims of the programme were partially met. The implementation of Productive Ward was associated with significant changes to the ward environment and improvements for staff. The programme equipped staff with skills and knowledge which acted as a primer for subsequent interventions. However, there was a lack of evidence to demonstrate that Productive Ward released time for direct patient care in all areas that implemented the programme. Relevance to clinical practice. Developing robust performance indicators including a system to capture reinvestment of direct care time would enable frontline staff to demonstrate impact of the programme. Additionally, staff will need to ensure that reorganisation and instability across the NHS do not affect sustainability and viability of the Productive Ward in the long term.
Authors: Stella Wright, BSc, Research Officer, NISCHR CRC North Wales Research Network, Abergele, Conwy; Wilfred McSherry, PhD, RGN, FRCN, Professor in Dignity of Care for Older People, Faculty of Health Sciences, School of Nursing and Midwifery, Staffordshire University/The Shrewsbury and Telford Hospital NHS Trust and Part-time Professor Haraldsplass Deaconess University College, Bergen, Norway
1866
What does this article contribute to the wider global clinical community?
• Extends understanding of a
•
•
national/international programme of innovation designed to enhance the quality of nursing care by capturing and presenting the opinions of patients. Describes how qualitative techniques can be used with patients and staff to gain valuable insight into benefits that may not have been apparent or captured using standard quantitative performance measures. Affirms the need for stability within organisations and sectors for any programme of reform to be sustainable as organisational instability may counteract the positive influences of the proposed change.
Correspondence: Stella Wright, Research Officer, NISCHR CRC North Wales Research Network, Building 5440, North Wales Business Park, Abergele, Conwy LL22 8LJ, UK. Telephone: +44 1745 448681. E-mail: [email protected]
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876, doi: 10.1111/jocn.12435
Original article
Evaluating the Productive Ward
Key words: care, improvement, lean, nursing, patient experience, Productive Ward, qualitative, quality and safety, releasing time to care, staff development Accepted for publication: 30 May 2013
Introduction In 2007, a programme designed to enable nurses to work more efficiently and effectively was introduced in the UK and has now been adopted internationally. The programme was called ‘Releasing Time to Care: The Productive Ward (PW)’. The practical improvement programme was developed by the NHS Institute for Innovation and Improvement (NHSI 2007) and aimed at frontline nursing staff. The programme consists of eleven modules; three foundation modules are implemented first and are intended to underpin the introduction of the eight process modules. An explanation of all the modules in the PW programme is provided in Box 1. Working on the PW is intended to increase efficiency and reduce waste and wasteful activities such as time spent in motion or collecting items away from the patient, thereby enabling nursing staff to spend more time with the patient providing care. The three aims of the programme are to: 1 increase the proportion of time spent providing direct patient care. 2 improve the patient and staff experience. 3 reorganise the ward environment. The PW places strong emphasis on empowering frontline staff to lead the programme and implement change on their own ward. This manuscript presents the qualitative findings from a mixed methods research study undertaken at one acute NHS hospital trust in the UK. At the time of data collection, the three foundation modules had been implemented across the trust, together with the handover module. A small number of wards were piloting the implementation of the meals and medicines modules.
Background
Box 1 Modules in the Productive Ward programme Foundation Modules Knowing How we are doing: Developing ward-based measures to help the team make informed decisions. Well organised ward: Make the ward areas work for your staff so that staff don’t have to work around the ward areas. Patient status at a glance: Patient information that improves communication, patient experience and patient flow. Process modules Meals: Reduce the time the team spends physically delivering meals and allow more time for assistance with feeding and ensure proactive nutritional assessment for the patients in their care. Medicines: Ensure medicine rounds do not clash with other ward processes. Reduce interruptions on staff and ensure everything is ready. Admission and planned discharge: Remove the rush of admission and discharge by making the process planned. Ensure the team launch social and support functions, to aid discharge, at the correct point in the patient journey. Shift handovers: Reduce the time the team spends on handovers, while making the information handed over more appropriate, easier to remember and understand. Patient hygiene: Ensure the dignity of the patients by delivering safe, clean and responsive care. Patient observation: Increase the standard of patient observations being carried out. Ensure they are accurate and that appropriate action is taken on the results. Nursing procedures: Improve the supporting processes for nursing procedures so they are consistent, a better patient experience and achieve the standards the trust aspires to. Ward round: Ensure clarity of outcome and clear planning from ward rounds while making the ward round quicker and more consistent. With kind permission from NHS Institute for Innovation and Improvement (2008) available from http://www.institute.nhs.uk/ quality_and_value/productivity_series/the_productive_ward_mo dule_structure.html
Literature The PW was launched nationally in 2007, and despite great interest, there is limited published empirical research assessing the impact of the programme. As part of the larger study, the authors undertook a systematic literature review of the current research evidence base surrounding the PW which returned 243 references. After discarding irrelevant or duplicated results, 89 unique articles were screened for eligibility. The methods and results of the literature review are described in detail elsewhere (Wright & McSherry 2013). © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
A quality appraisal classified the results as being anecdotal, experiential, procedural or research. Overall, there were few empirical studies on the PW. In total, just five of the results were classified research: NHS Scotland (2008), National Nursing Research Unit (NNRU 2010) at King’s College London, undertakes empirical study and associated scholarly activities to inform nursing policy and practice, NNRU (2011), Robert et al. (2011) and NHSI (2011). The NHSI was created in 2005 to support the change of
1867
S Wright and W McSherry
the NHS, through innovation, improvement and the use of best practice. With the exception of the research from NHS Scotland (2008), all articles classified as research were published by or had input from the NHSI who originally developed the PW. An economic appraisal undertaken by the NHSI (2011) calculated that implementing PW at scale and pace had the potential to yield a £270,064,613 benefit by March 2014. Research with staff undertaken by NNRU (2010) found that time savings (through working more efficiently) and time investment (an increase in time for direct patient care) were the most tangible outcomes. The overall aim of PW was to release time to care, and an increase in direct care time was widely reported in the literature. Increases ranged from 8% (Shepherd 2009a) to 43% (NHS Scotland 2008), and one trust experienced a rise from 45–87% (Blakemore 2009). An increase in direct care time was linked to improvements in the patient and staff experience such as increased patient satisfaction (Lipley 2009, Wilson 2009) and a reduction in staff sickness from 78–099% (Smith & Rudd 2010). Implementing PW was associated with improvements in patient safety such as a reduction in infections like MRSA and C Difficile (Dean 2009, Foster et al. 2009, Shepherd 2009a, Smith & Rudd 2010), pressure sores (Anderson 2009, Bloodworth 2011) and falls (Shepherd 2009b, Wilson 2009, Bloodworth 2011). The literature highlights that support and commitment from senior management is crucial to the successful implementation of the programme (NHS Scotland 2008, Blakemore 2009, Bloodworth 2009, Wilson 2009, NNRU 2011) along with staff training (NHS Scotland 2008, Blakemore 2009, Bloodworth 2009) and involvement and teamwork (Smith & Rudd 2010). However, a number of papers retrieved from the literature search (Shepherd 2009a, NNRU 2010, Bloodworth 2011) stated that further work was needed to determine the impact of the PW. From evaluating the literature we established this was a common theme, as there was little evidence of research around impact, sustainability or outcomes from the patient perspective.
Research questions and aims This research attempted to address several gaps in the literature, adding to and building on existing knowledge by addressing two broad research questions: 1 What impact has the PW programme had on the patient and staff experience? 2 How can the PW programme be sustained in the long term?
1868
The aims of the research were to: 1 Examine the extent to which the aims of the PW have been met: improved patient and staff experience, increased direct care time. 2 Identify factors which influence successful implementation and sustainability of the programme leading to potential improvements in patient safety, effectiveness and patient experience.
Methods Design The larger study used a mixed methods design incorporating a case study approach to investigate the impact of the PW at one trust (comprising two hospital sites). This manuscript only presents the findings from the qualitative phase of the investigation. This phase used qualitative interviews and focus groups to explore the impact of the programme on patients and staff.
Ethical consideration The research was approved by the university faculty of health independent peer review, NHS research ethics committee and trust R&D committee prior to undertaking data collection. Written informed consent was gained from all participants, and principles of good clinical practice (GCP) were adhered to throughout the investigation. GCP is a course undertaken that covers areas such as the design, conduct and documenting of research that involves people in the NHS.
Data collection Originally six areas across the two sites were selected as case study wards but an organisational restructure resulted in the closure of one of the wards. Staff and patients who met the inclusion criteria (outlined below) from the five case study wards were invited to take part in individual semi-structured interviews. Staff from all wards and departments which had worked on PW were invited to join focus group interviews. All eligible participants were provided with an invitation letter and information sheet to enable them to make an informed decision about their participation in the study. An identical interview schedule was used for staff one-to-one interviews and focus groups to integrate responses. The staff interview schedule addressed the following broad areas: extent of involvement in PWP, perceived impact of PWP on patient care, benefits of imple© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Original article
Evaluating the Productive Ward
mentation for staff and patients. The interview schedule for patients was developed from an established patient satisfaction survey already in use at the trust. The broad topics explored with patients were the extent individuals were involved in their care, communication such as did staff listen to them, receiving adequate and timely assistance, and preservation of privacy and dignity. The two different interview methods provided an in-depth and rich insight into the impact of PW across the organisation and enabled comparisons to be made, thus adding to the rigour and validity of the processes. Participants Data collection was undertaken between January and April 2012. Convenience sampling was used to recruit staff and patient participants. Staff focus groups were held according to pay band to explore how staff role impacted upon their experience of the programme, staff were recruited for focus groups from all wards that had participated in the PW. Participant information is detailed in Tables 1 and 2. In Table 1 area D was initially chosen but had to be withdrawn because it no longer existed after service reconfiguration. In area C, the researchers were unable to recruit any patients into the study because patients were transferred/ discharged before the scheduled interview or too ill for interview. In areas A, D and E no staff were recruited because of the service reconfiguration (area A and D) and staffing pressures (area E) meaning staff could not be released or interviews were cancelled at short notice. Inclusion and exclusion criteria The sample population were current staff or inpatients at the trust aged over 18. Only staff members who had been involved with PW were eligible to participate. Patients without the capacity to make an informed decision about their participation were excluded (Mental Capacity Act 2005) as were those who were too ill to be interviewed. NonEnglish speakers were excluded as there were insufficient resources for interpreters to be made available. We
Table 2 Details of staff focus group participants Focus group – staff grade
Number of participants
2
5
6
7
Two focus groups
Two focus groups
Two focus groups
One focus group
11
7
5
6
acknowledge that this means that the sample does not reflect the rich diversity that exists within society meaning the data are skewed to a particular population. This point urges consideration by all those conducting research to ensure that unheard voices and under-represented groups are heard in all forms of research enquiry.
Data analysis All interviews were audio recorded and transcribed verbatim. Each transcript was reviewed line by line, and thematic analysis (Braun & Clarke 2006) was used to identify themes occurring within the transcripts. Data was manually coded by one researcher (SW) and categorised using QSR NVIVO version 9 (QSR International Pty Ltd, Doncaster, Australia). Categories were collated into initial themes, which were reviewed and refined. A sample of transcripts was analysed independently by a second researcher (WM). Data from staff interviews and focus groups were integrated and analysed collectively to develop themes representative of the overall experience of staff. Themes for patients and staff were developed separately due to a lack of congruence in responses from the two groups.
Results The analysis of one-to-one staff interviews and focus groups identified an overarching theme of change management, together with four subthemes: personal/emotional experi-
Table 1 Details of interview participants from the case study wards
Number of patient participants Staff participants
Area A
Area B
Area C
Area D
Area E
Area F
2 0
2 1 9 band 2 1 9 band 6
0 1 9 band 7 1 9 band 5
0 0
2 0
2 1 9 band 2
Staff grades and roles Band 2/3 – Support staff including housekeepers, ward clerks and healthcare assistants Band 5 – Registered nurse/staff nurse Band 6 – Sister Band 7 – Ward manager
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
1869
S Wright and W McSherry
ence, leadership, organisation and competing priorities. Issues around direct care time and sustainability were also explored. Four themes emerged from one-to-one interviews with patients: care and compassion, time for patient care, personalised care, and communication and involvement. Each theme is outlined below, supported by excerpts from participant transcripts.
Values Involvement Empowerment Awareness
Group ownership
Team cohesion
Staff Process of change and change management The overarching theme encompassed the process of change and the effect of the programme on the individual, team, ward and organisation. Staff acknowledged that working on the programme was challenging at times (for all levels of seniority), describing initial work as ‘disruptive’ and ‘chaotic’, particularly for long-serving staff. These challenges are reflected in the following extract:
Support Ward hierarchy flatter
Figure 1 A model depicting the experience of staff.
All staff were involved in the roll-out and had a role in the implementation of the programme. This was articulated by one ward manager: Everybody had a role and everybody had a voice, and by having a
I think that was perhaps the hardest thing for one or two of them
voice they could say, even the quietest of team member would say
you know, to change, to bring about change because if you’ve been
“can we try so and so” and we tried to see you know, whether
working a system for a long, long time it’s not easy to expect peo-
everybody could work towards it. (Participant 57, Ward Manager)
ple to change overnight. (Participant 37, Healthcare Assistant)
Despite initial scepticism, most staff embraced the opportunity and demonstrated genuine enthusiasm and energy for the programme. The following participant affirms the transition from scepticism to enthusiasm and acceptance of the programme: at first people were like ‘oh God what now,…what else do they want us to do?’. But once the ball was rolling… you started to think ‘Oh God, this is a bit better, this is going to work’, then we all started picking it up and now it’s just… second nature. (Participant 31, Healthcare Assistant)
Personal experience The subtheme of personal experience was found to be significant and was separated further to incorporate involvement, recognising skills, empowerment, teamwork and ownership. Each of the components is included within an integrated model, underpinned by support and awareness of the programme (summarised in Fig. 1). The model starts with awareness at the outset, when the PW team provided assistance, but explained that it was the responsibility of the ward team to take ownership of the programme: They said ‘we are here to support you but we are not going to do it for you, we want you to do it’ and it was down to us. (Participant 36, Healthcare Assistant)
1870
As a result, nonclinical skills were recognised and staff felt valued for their contribution. The sense of value was considered fundamental to the success of the programme: you found skills that you didn’t realise they’d got even from reading their CV, you couldn’t have imagined that they’d got all these skills. (Participant 57, Ward Manager)
Consequently, staff felt empowered, especially junior members of the team who may not have been involved with previous innovations, or had the opportunity to contribute to change. This was said to flatten the ward hierarchy and strengthen team cohesion: The staff feel more able to make suggestions on how the ward can be improved and save time and things whereas before I think it was more of a hierarchy, it had to come from the team leader. (Participant 56, Ward Sister) not one person on their own can change anything and that’s the whole point of the team coming together. (Participant 46, Staff Nurse)
An additional component of the personal experience was the emotional response. Working on the programme affected individuals at a personal level and staff spoke of increased morale, ‘enthusiasm’, ‘a buzz’ and feeling ‘less frustrated’ and ‘more valued’. This leads to staff having a greater sense of self-esteem in that they felt they were making a positive difference as expressed by one staff nurse:
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Original article I felt better about myself being involved in this thinking ‘wow, I am making a difference to our working environment’. (Participant 46, Staff Nurse)
Evaluating the Productive Ward
turnover, involving all members of the team and organisational change: it was quite hard to involve everybody and carry on working on the ward. (Participant 26, Housekeeper)
Leadership The PW house incorporated resource guides for the ward, project and executive leaders to promote engagement with the programme. Support from all levels of management was unanimously cited as providing an essential source of enthusiasm, advice and encouragement. Staff spoke of the importance of a ‘push’ from senior management while retaining ward-level ownership of the programme and free rein to drive change. In particular, they valued ward visits from management and trust board members which motivated staff: we all like a bit of praise and reward, say ‘yes you’ve done a good job, well done’… We don’t want much but for somebody to say well done, it’s worth a lot. (Participant 47, Ward Sister)
The engagement of senior staff also provided practical assistance, for example releasing staff from clinical duties to work on the programme: I think you need to have the management support there to actually carry things out, because you know, everything else doesn’t stop while you’re doing it. (Participant 60, Ward Manager)
if you’re busy you just haven’t got that time to do it. (Participant 24, Ward Manager) does it offer more time to care? Yes I think it does but certainly in the last five years the pace on the ward has changed. (Participant 37 Healthcare Assistant) the trust has been constantly changing and the managers have had other things.. There’s been other issues really. (Participant 59, Ward Manager)
Direct care time Activity follow charts were a resource from the NHSI (nd), used to calculate the proportion of time spent providing direct patient care compared with other ward activities. Trust data revealed that direct care time increased from an average of 42–53% after implementing the foundation modules. When asked whether PW had enabled them to spend more time with patients, staff responses varied widely. Some felt the programme had released time to spend with patients for example: You were able to do some of the little niceties that you don’t get
Organisation The theme of organisation was classified both in terms of improvements to the physical ward environment and in the efficiency of staff. The well-organised ward was repeatedly named as being the most influential module as it introduced lean methodology and improvement tools such as 5S (described in Waring & Bishop 2010, p. 1333). Employing lean resulted in a reduction in waste and changes to the ward environment, which became tidier, more accessible and not overstocked. Staff also described how the ward was generally more efficient and how ‘flow’ improved, which enabled them to attend to patients faster: for us to have everything organised and streamlined, it means that we can get to the patient quicker really. (Participant 25, Staff Nurse)
Competing priorities Staff recognised a number of issues which affect their ability to spend time working on the programme, to provide direct patient care and sustain change long term. These included having protected time specifically for PW away from clinical duties, increase in ward pace and patient © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
time to do. (Participant 18, Ward Manager)
Others felt they were ‘less rushed’; while a proportion reported that the programme had no discernible impact on their ability to spend time with patients: I don’t know it’s necessarily released that much more time for nurses to have one-to-ones with patients. (Participant 32, Ward Clerk)
A number of staff commented that the programme had originally released time for care, but that it has subsequently been ‘eaten back up’ with other activities. This brings the sustainability of the programme into question as staff had not been able to reinvest time effectively. Some of the literature around PW reported significant increases in the proportion of time spent providing direct patient care (such as Smith & Rudd 2010, Bloodworth 2011) without specifying how staff were ‘reinvesting’ this time with patients. Therefore, an aim of this research had been to examine how time released through working efficiently was being spent with patients. One ward manager recounted how staff spent any additional time with patients:
1871
S Wright and W McSherry have their hair done and maybe spend some time doing their nails, and people had more time to talk to them as well. (Participant 18,
Table 3 Enablers and inhibitors affecting the implementation and sustainability of PW
Ward Manager)
Enablers
Inhibitors
But in general staff found it difficult to articulate how they ‘reinvested’ time or identify specific activities they were able to undertake as a result of PW. Using qualitative techniques revealed improvements which may not have been recognised through standard staff surveys or satisfaction measures, but which potentially benefit patients. These included improved staff retention, motivation and morale. A number of staff also acknowledged that the skills and experience gained from working on PW provided ‘a good grounding’ for changes which have subsequently been brought in:
Good communication Awareness and promotion Leadership and support Tailor/personalise the programme for each area Planning and preparation Embedded into everyday practice (culture) Harness staff with energy Ward – roles, ownership, involvement, empowerment Bottom-up change Shared learning
Slow pace of roll-out Novelty – view as novel or discrete event not a continuous improvement programme Change within the organisation Competing demands Fail to review, feedback, PDSA Nontraditional wards, e.g. day surgery, A&E Poor understanding of aims/what constitutes PW Resentment/conflict due to lack of involvement Practical difficulties (including resources) Not enough time to release staff to work on PW Low engagement with the wider hospital: doctors, MDT, nonclinical departments (e.g. estates, facilities, stores, transport, porters)
we have introduced additional services onto our ward…had the Productive Ward not come into play…I don’t think it could have been managed quite so well. (Participant 36, Healthcare Assistant)
Sustainability As with direct care time, opinions on the sustainability of PW occurred on a continuum. Some staff felt the programme had been embedded into everyday working practice: It’s how the ward is run now, it’s second nature to them. Even the new ones that came in, they didn’t know any different. (Participant 26, Housekeeper)
However, a minority were of the opinion that the PW had not been sustained: If nobody mentions it you forget about it, there’s something else to be worried about. (Participant 24, Ward Manager)
and then we would work as a team. (Participant 18, Ward Manager)
Inhibitors included pace of roll-out: some of the wards were just getting their well organised ward, the rest of us were chomping on the bit to get going. (Participant 56, Ward Sister)
Also, viewing the programme as a discrete or novel event rather than a continuous improvement programme: it just got lost didn’t it,…you know, the novelty wore off. (Participant 47, Ward Sister)
Enablers and Inhibitors An aim of this study had been to identify recurring factors which affected the successful implementation and sustainability of the programme, these are summarised in Table 3. The analysis of the qualitative data also confirmed the findings of the literature review (Wright & McSherry 2013) undertaken as part of the larger study. A key enabler was good communication between team members, departments and hospital trusts, whereby shared learning provided a vehicle to promote progress and best practice: a couple of us would go and see what the next project was, get the ideas from there and then come back and feed them to the team
1872
Patients The patient experience was harder to capture as they had no direct involvement or exposure to PW; therefore, we were measuring perceived impact rather than assessing awareness and understanding of the programme. The interviews explored whether increased time for direct patient care was associated with improved quality of care and a better experience. An established patient survey provided the basis for interview questions which allowed us to examine specific aspects of care such as privacy and dignity, staff attitude and communication. A total of eight patients participated (five female and three males). All patients had been in © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Original article
hospital over 48 hours, and several had been inpatients for longer. Patients were recruited from a range of clinical areas with a wide range of medical and surgical needs. Data pertaining specifically to the patient’s condition were not collected for research purposes; however, a number of patients disclosed details during interviews.
Evaluating the Productive Ward
learn more about them as a person alongside their medical condition: It’s the whole package. It’s not just ‘oh you’re a patient, you’re a number in a bed.’ You’re a person, you’re an individual and everybody needs to be treated differently because we are different. The staff on here seem to take it that little bit further, they take that little bit extra interest. (Patient Participant 62)
Care and staff compassion On the whole, patients were complimentary about their experience as an inpatient, reporting that staff made them feel safe, comfortable and cared for:
In instances where staff had a better understanding of the individual, patient confidence increased: They’ve taken the time to get to know me and know my condition so this is the ward for me. That knows me inside and out, and I’ve
The girl that was on last night was so caring, she just had great
peace of mind that if I can come here I know I’m going to get the
compassion and I don’t think the staff get praised enough for that.
best care and I’m going to get better. (Patient Participant 62)
(Patient Participant 83)
Almost all patients commended the hourly comfort round (intentional rounds) where a member of staff visits each patient to check they are comfortable and whether they require support with hydration, pain management and toileting. Although it was not implemented as a component of PW, comfort rounds ensure regular contact with a member of staff and mean frail or elderly patients receive assistance which they may not otherwise have been able to request.
Communication and involvement Good communication was reported at a number of levels, from staff attitude to how they address, listen to and communicate with patients. Patients also felt that staff were efficient in relaying information and ultimately involving patients in decisions about their care while in hospital: If you ask them something they explain, it’s not ‘I’ll be back in a moment’ and then you just sit here and then you don’t see them.
Staff time for patient care Like staff, patients were asked whether they felt staff had enough time to spend providing care. A number of patients reported that the ward was busy, but staff made time for them whenever possible: They’re always rushed, they always seem to have an awful lot of workload but they always make that time… but they always do seem busy, they are always busy. (Patient Participant 62)
Patients were also conscious of the demands on staff which affect their ability to spend time with individual patients: You just started talking to them about something and then somebody else needs attention. It’s inevitable isn’t it, when you’ve got thirty odd people that something else will happen while you’re dealing with one. (Patient Participant 42)
In addition, some patients spoke of not wanting to ‘bother’ staff, although this may reflect the personal perception of the patient rather than willingness of staff.
Personalised care A good relationship with staff greatly enhanced the experience for patients, who appreciated the effort staff took to © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
They come back. If they’re dealing with someone else they’ll explain to you or someone else will. You’re not fobbed off. (Patient Participant 63)
Discussion The present research aimed to address the gaps in the current literature by assessing the impact of the PW on patients and staff. Despite being marketed as an improvement programme aimed at releasing time to care, the responses of staff generally centred on the process of change and outcomes from a personal perspective. The programme produced considerable energy, enthusiasm and motivation that some staff had never previously encountered in the workplace. But there was a lack of consensus as to whether the programme released time for patient care. In support of this, Peter Griffiths (involved with the NNRU 2010, 2011 reports) recently stated that he is ‘sceptical of the claims for the amount of time released by the scheme’. (Griffiths 2012, p. 7). Furthermore, staff reporting an increase in direct care time were not generally able to define how time released through work on PW was ‘reinvested’ or identify tasks which could be undertaken with patients as a result of the programme. Many staff
1873
S Wright and W McSherry
believed that improvements such as better organisation (e.g. efficiency meant patients could be attended to faster) and increased staff morale indirectly benefited patients. As the focus of PW, future implementation must demonstrate how direct care time and staff contact translate into meaningful outcomes for patients. Similarly, responses on sustainability of PW varied. Some staff reported that PW had become embedded into everyday practice, but others stated that the programme had not been sustained. This would suggest that additional work is required to ensure that the PW is sustained in a standardised manner across all wards implementing the programme. Opportunities for shared learning may ensure that best practice becomes trust standard. Staff also identified a number of competing priorities which affect sustainability, and the ability to provide direct care, for example, protected time to work on PW and organisational change. Addressing these challenges will optimise sustainability of PW and future change. These findings build on the current evidence base to provide an in-depth understanding of outcomes from the PW for patients and staff and complement the largest body of research on PW undertaken by NNRU (2010, 2011). Similarities in the findings include leadership as a facilitator, the significant influence of the foundation modules, better team working and a calmer ward environment. As research was conducted at just one trust, some responses tended to be consistent across all wards, for example the type of tools used, whereas NNRU (2010) received a broader range of responses and also considered strategic and organisational factors. In contrast to the current research, NNRU (2011) focused specifically on spread and uptake of PW and developed a threefold explanation of spread based on determinants, processes and measures. More recently, Davis and Adams (2012) undertook semi-structured interviews to explore the perspectives of six staff and grouped the responses into five themes: starting to implement the programme, anxiety and defensiveness, the importance of leadership and communication, challenges, and learning and personal development. Aspects of all five themes can be incorporated into the themes identified in the current study, which may indicate that they are representative of the benefits and challenges staff can expect to experience when initiating large scale change in a complex organisation. Previous research on PW was extended by obtaining patient opinion. Four themes emerged from interviews with patients: time for patient care, caring and staff compassion, personalised care, and communication and involvement. Most, but not all patients were of the
1874
opinion that staff did have enough time to provide patient care. With patients, we were not able to measure how the patient experience has changed since the programme was implemented; therefore, it was necessary to assess perceived patient impact and attribute to the PW where possible. Overall, patient feedback was positive which could be due to an increase in direct care time. For example, working on the programme may have released additional time which enabled staff to become better acquainted with patients to provide personalised care and involve patients in decisions about their care. Additionally, the use of qualitative techniques allowed the researchers to gain insight into some of the benefits which may not have been apparent from standard performance measures, for example PW providing grounding for future initiatives and staff having more time to attend training or study days, both of which indirectly benefit patients.
Limitations The research was undertaken with a small sample at one acute trust; therefore, it lacks generalisability across the NHS. Additionally, the use of convenience sampling does not allow definitive, generalised findings as participants were invited to volunteer from the staff and patient population meaning their views may not be representative. From the patient perspective, this sample also lacked diversity which also impacts on the generalisability of the findings. Data on staff were generated from one-to-one and focus group interviews, whereas patients only took part in oneto-one interviews meaning a much smaller proportion of data was obtained on the patient experience. The fact that patients were interviewed while in hospital may have influenced and resulted in the positive findings. Patients may not want to appear over critical while they are receiving ongoing care in fear of recrimination.
Conclusion The research findings identified improvements for staff (and potentially patients) resulting from the PW. In future, it would be beneficial to evaluate other programmes in the productive series as they become established and identify key benefits. From analysing the data, it was not possible to obtain definitive results as to whether PW was successful in releasing time for patient care. A general difficulty was that the assessment of impact is open to individual perception and motivation. Furthermore, the notion of ‘time for care’ may be subjective, depending upon whether it is © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Original article
Evaluating the Productive Ward
classified as time providing clinical care vs. spending time with patients in a social or nonclinical capacity. Conducting focus groups and interviews provided staff with a unique outlet to discuss their experience. Staff proposed a number of recommendations based on their experience of the programme which would be applicable to all trusts involved with Productive Ward or productive series. These included appointing a Productive Ward champion in each area, and the involvement of clinical and nonclinical staff across the trust. Furthermore, the engagement of senior staff will ensure support is available to incorporate the suggestions in the future roll-out of the Productive Ward.
Relevance to clinical practice The findings from this mixed methods study suggests that PW has the potential to lay the foundations for future change. The legacy of PW may be the priming of staff, providing transferable skills and knowledge, making them more receptive for ongoing development. PW appears to equip staff with a cultural confidence for subsequent innovation. However, care must be taken to avoid innovation fatigue (as a result of constant efforts to innovate) and extremes in pace of roll-out (either too fast or too slow) which may have a detrimental impact on the uptake and sustainability of the programme. Involvement in PW leads to greater staff morale and satisfaction. Participation generates a sense among staff that they are worthy of investment and valued by senior management. PW facilitates engagement of staff at all levels in the design and implementation of the programme. Leadership and managerial support are pivotal to the implementation and long-term sustainability of the programme. PW has the potential to flatten hierarchical structures, but the ‘ward to board’ philosophy must be a reality and fully operational for ongoing success of the programme. Patient involvement and engagement with PW need to be strengthened. Matrices and performance indicators need to be developed to assess the impact of PW on the quality of patient care and the patient experience. There is a need for a more robust system to capture how direct care time is reinvested into patient care. The retrospective findings from this investigation suggest PW is having a positive impact on patient satisfaction.
Organisational reconfiguration across the NHS may impact on the long-term viability and sustainability of the PW programme. One key observation is the notion that for PW to be sustainable then there must be relative stability within the organisations and sectors where it is being implemented as organisational instability may counteract the positive influences of PW.
Acknowledgements We would like to thank all the patients and staff who participated in the research by sharing with us, their thoughts and experiences. Without them this research would not have been possible. We would also like to thank the sponsors of the KTP, the Local Management Committee and all colleagues who supported the project.
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.
Funding This manuscript presents the qualitative findings from a mixed methods research project undertaken as part of a Knowledge Transfer Partnership between Shrewsbury & Telford Hospital NHS Trust and Staffordshire University which was funded by the NHS trust, Technology Strategy Board and Department of Health.
Conflict of interest None. SW was employed by the university and worked at the trust at the time the research was undertaken. WM works three day at the university and two days in the trust where the investigation was undertaken. However, neither had direct involvement in the PW.
References Anderson P (2009) The Productive Ward initiative and its effects on patient safety. Health Care Risk Report 16, 18–19.
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Blakemore S (2009) How Productive Wards can improve patient care. Nursing Management 16, 15–18.
Bloodworth K (2009) Productive Ward 1: implementing the initiative across a large university teaching hospital. Nursing Times 105, 22–25.
1875
S Wright and W McSherry Bloodworth K (2011) The productive ward and productive operating theatre. Journal of Perioperative Practice 21, 97–103. Braun V & Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77–101. Davis J & Adams J (2012) The Releasing Time to Care – the Productive Ward programme: participants perspectives. Journal of Nursing Management 20, 354–360. Dean E (2009) Productive Ward Measures see hospital’s mortality rate plummet. Nursing Standard 24, 8. Foster S, Gordon P & McSherry W (2009) Rolling out Productive Ward foundation modules across a hospital trust. Nursing Times 105, 28–30. Griffiths P (2012) New forum must focus on the future and not look backwards. Nursing Times 108, 7. Lipley N (2009) Productive Wards hailed for transforming care. Nursing Management 16, 4. National Nursing Research Unit & the NHS Institute for Innovation and Improvement (2010) The Productive Ward: Releasing Time to Care. Learning & Impact Review. NHS Institute for Innovation and Improvement, Warwick. National Nursing Research Unit & the NHS Institute for Innovation and Improvement (2011) Improving Healthcare Quality at Scale and Pace Lessons
from The Productive Ward: Releasing Time to Care Programme. NHS Institute for Innovation and Improvement, Warwick. NHS Institute for Innovation and Improvement (2007) Releasing Time to Care: The Productive Ward. Available at: http://www.institute.nhs.uk/quality_ and_value/productivity_series/the_pro ductive_series.html (accessed 22 June 2011). NHS Institute for Innovation and Improvement (2008) The Productive Ward Module Structure. Available at: http:// www.institute.nhs.uk/quality_and_value/ productivity_series/the_productive_ ward_module_structure.html (accessed 5 February 2013). NHS Institute for Innovation and Improvement (2011) Rapid Impact Assessment of the Productive Ward: Releasing Time to Care. Available at: http:// www.institute.nhs.uk/images//documen ts/Quality_and_value/productiveseries/ Rapid%20Impact%20Assessment%20 full%20report%20FINAL.pdf (accessed 22 June 2011). NHS Institute for Innovation and Improvement (nd) Toolkit Resources. Available at: http://www.institute.nhs. uk/index.php?option=com_joomcart& main_page=document_product _info& products_id=687&cPath=73 (accessed 20 September 2012).
NHS Scotland (2008) Releasing Time to Care Evaluation. Available at: http:// www.lanpdc.scot.nhs.uk/Resources/ Lists/Publications/Attachments/34/Releas ing%20Time%20to%20Care%20-%20 Evaluation.pdf (accessed 22 June 2011). Robert G, Morrow E, Maben J, Griffiths P & Callard L (2011) The adoption, local implementation and assimilation into routine nursing practice of a national quality improvement programme: The Productive Ward in England. Journal of Clinical Nursing 20, 1196–1207. Shepherd S (2009a) This is a phenomenon. Nursing Times 105, S4. Shepherd S (2009b) Rolling out the productive ward. Nursing Times 105, S12–S13. Smith J & Rudd C (2010) Implementing The Productive Ward management programme. Nursing Standard 24, 45–48. Waring JJ & Bishop S (2010) Lean healthcare: rhetoric, ritual and resistance. Social Science & Medicine 71, 1332– 1340. Wilson G (2009) Implementation of releasing time to care – the Productive Ward. Journal of Nursing Management 17, 647–654. Wright S & McSherry W (2013) A systematic literature review of Releasing Time to Care: The Productive Ward. Journal of Clinical Nursing 22, 1361–1371.
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
1876
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Evaluating the Productive Ward at an acute NHS trust: experiences and implications of releasing time to care Stella Wright and Wilfred McSherry
Aims and objectives. To demonstrate how a national programme aimed to increase the amount of direct time nurses spend with patients’, impacts on both staff and patient experience. Background. The Productive Ward is an improvement programme developed by the NHS Institute for Innovation and Improvement (2007, http://www.institute. nhs.uk/quality_and_value/productivity_series/productive_ward.html) which aims to enable nurses to work more efficiently by reviewing process and practice, thus releasing more time to spend on direct patient care. However, there is little empirical published research around the programme, particularly concerning impact, sustainability and the patient perspective. Design. This manuscript presents the findings from qualitative interviews involving both staff and patients. Methods. Semi-structured one-to-one interviews were conducted with patients (n = 8) and staff (n = 5) on five case study wards. Seven focus groups were held according to staff grade (n = 29). Results. Despite initial scepticism, most staff embraced the opportunity and demonstrated genuine enthusiasm and energy for the programme. Patients were generally complimentary about their experience as an inpatient, reporting that staff made them feel safe, comfortable and cared for. Conclusion. Findings showed that the aims of the programme were partially met. The implementation of Productive Ward was associated with significant changes to the ward environment and improvements for staff. The programme equipped staff with skills and knowledge which acted as a primer for subsequent interventions. However, there was a lack of evidence to demonstrate that Productive Ward released time for direct patient care in all areas that implemented the programme. Relevance to clinical practice. Developing robust performance indicators including a system to capture reinvestment of direct care time would enable frontline staff to demonstrate impact of the programme. Additionally, staff will need to ensure that reorganisation and instability across the NHS do not affect sustainability and viability of the Productive Ward in the long term.
Authors: Stella Wright, BSc, Research Officer, NISCHR CRC North Wales Research Network, Abergele, Conwy; Wilfred McSherry, PhD, RGN, FRCN, Professor in Dignity of Care for Older People, Faculty of Health Sciences, School of Nursing and Midwifery, Staffordshire University/The Shrewsbury and Telford Hospital NHS Trust and Part-time Professor Haraldsplass Deaconess University College, Bergen, Norway
1866
What does this article contribute to the wider global clinical community?
• Extends understanding of a
•
•
national/international programme of innovation designed to enhance the quality of nursing care by capturing and presenting the opinions of patients. Describes how qualitative techniques can be used with patients and staff to gain valuable insight into benefits that may not have been apparent or captured using standard quantitative performance measures. Affirms the need for stability within organisations and sectors for any programme of reform to be sustainable as organisational instability may counteract the positive influences of the proposed change.
Correspondence: Stella Wright, Research Officer, NISCHR CRC North Wales Research Network, Building 5440, North Wales Business Park, Abergele, Conwy LL22 8LJ, UK. Telephone: +44 1745 448681. E-mail: [email protected]
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876, doi: 10.1111/jocn.12435
Original article
Evaluating the Productive Ward
Key words: care, improvement, lean, nursing, patient experience, Productive Ward, qualitative, quality and safety, releasing time to care, staff development Accepted for publication: 30 May 2013
Introduction In 2007, a programme designed to enable nurses to work more efficiently and effectively was introduced in the UK and has now been adopted internationally. The programme was called ‘Releasing Time to Care: The Productive Ward (PW)’. The practical improvement programme was developed by the NHS Institute for Innovation and Improvement (NHSI 2007) and aimed at frontline nursing staff. The programme consists of eleven modules; three foundation modules are implemented first and are intended to underpin the introduction of the eight process modules. An explanation of all the modules in the PW programme is provided in Box 1. Working on the PW is intended to increase efficiency and reduce waste and wasteful activities such as time spent in motion or collecting items away from the patient, thereby enabling nursing staff to spend more time with the patient providing care. The three aims of the programme are to: 1 increase the proportion of time spent providing direct patient care. 2 improve the patient and staff experience. 3 reorganise the ward environment. The PW places strong emphasis on empowering frontline staff to lead the programme and implement change on their own ward. This manuscript presents the qualitative findings from a mixed methods research study undertaken at one acute NHS hospital trust in the UK. At the time of data collection, the three foundation modules had been implemented across the trust, together with the handover module. A small number of wards were piloting the implementation of the meals and medicines modules.
Background
Box 1 Modules in the Productive Ward programme Foundation Modules Knowing How we are doing: Developing ward-based measures to help the team make informed decisions. Well organised ward: Make the ward areas work for your staff so that staff don’t have to work around the ward areas. Patient status at a glance: Patient information that improves communication, patient experience and patient flow. Process modules Meals: Reduce the time the team spends physically delivering meals and allow more time for assistance with feeding and ensure proactive nutritional assessment for the patients in their care. Medicines: Ensure medicine rounds do not clash with other ward processes. Reduce interruptions on staff and ensure everything is ready. Admission and planned discharge: Remove the rush of admission and discharge by making the process planned. Ensure the team launch social and support functions, to aid discharge, at the correct point in the patient journey. Shift handovers: Reduce the time the team spends on handovers, while making the information handed over more appropriate, easier to remember and understand. Patient hygiene: Ensure the dignity of the patients by delivering safe, clean and responsive care. Patient observation: Increase the standard of patient observations being carried out. Ensure they are accurate and that appropriate action is taken on the results. Nursing procedures: Improve the supporting processes for nursing procedures so they are consistent, a better patient experience and achieve the standards the trust aspires to. Ward round: Ensure clarity of outcome and clear planning from ward rounds while making the ward round quicker and more consistent. With kind permission from NHS Institute for Innovation and Improvement (2008) available from http://www.institute.nhs.uk/ quality_and_value/productivity_series/the_productive_ward_mo dule_structure.html
Literature The PW was launched nationally in 2007, and despite great interest, there is limited published empirical research assessing the impact of the programme. As part of the larger study, the authors undertook a systematic literature review of the current research evidence base surrounding the PW which returned 243 references. After discarding irrelevant or duplicated results, 89 unique articles were screened for eligibility. The methods and results of the literature review are described in detail elsewhere (Wright & McSherry 2013). © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
A quality appraisal classified the results as being anecdotal, experiential, procedural or research. Overall, there were few empirical studies on the PW. In total, just five of the results were classified research: NHS Scotland (2008), National Nursing Research Unit (NNRU 2010) at King’s College London, undertakes empirical study and associated scholarly activities to inform nursing policy and practice, NNRU (2011), Robert et al. (2011) and NHSI (2011). The NHSI was created in 2005 to support the change of
1867
S Wright and W McSherry
the NHS, through innovation, improvement and the use of best practice. With the exception of the research from NHS Scotland (2008), all articles classified as research were published by or had input from the NHSI who originally developed the PW. An economic appraisal undertaken by the NHSI (2011) calculated that implementing PW at scale and pace had the potential to yield a £270,064,613 benefit by March 2014. Research with staff undertaken by NNRU (2010) found that time savings (through working more efficiently) and time investment (an increase in time for direct patient care) were the most tangible outcomes. The overall aim of PW was to release time to care, and an increase in direct care time was widely reported in the literature. Increases ranged from 8% (Shepherd 2009a) to 43% (NHS Scotland 2008), and one trust experienced a rise from 45–87% (Blakemore 2009). An increase in direct care time was linked to improvements in the patient and staff experience such as increased patient satisfaction (Lipley 2009, Wilson 2009) and a reduction in staff sickness from 78–099% (Smith & Rudd 2010). Implementing PW was associated with improvements in patient safety such as a reduction in infections like MRSA and C Difficile (Dean 2009, Foster et al. 2009, Shepherd 2009a, Smith & Rudd 2010), pressure sores (Anderson 2009, Bloodworth 2011) and falls (Shepherd 2009b, Wilson 2009, Bloodworth 2011). The literature highlights that support and commitment from senior management is crucial to the successful implementation of the programme (NHS Scotland 2008, Blakemore 2009, Bloodworth 2009, Wilson 2009, NNRU 2011) along with staff training (NHS Scotland 2008, Blakemore 2009, Bloodworth 2009) and involvement and teamwork (Smith & Rudd 2010). However, a number of papers retrieved from the literature search (Shepherd 2009a, NNRU 2010, Bloodworth 2011) stated that further work was needed to determine the impact of the PW. From evaluating the literature we established this was a common theme, as there was little evidence of research around impact, sustainability or outcomes from the patient perspective.
Research questions and aims This research attempted to address several gaps in the literature, adding to and building on existing knowledge by addressing two broad research questions: 1 What impact has the PW programme had on the patient and staff experience? 2 How can the PW programme be sustained in the long term?
1868
The aims of the research were to: 1 Examine the extent to which the aims of the PW have been met: improved patient and staff experience, increased direct care time. 2 Identify factors which influence successful implementation and sustainability of the programme leading to potential improvements in patient safety, effectiveness and patient experience.
Methods Design The larger study used a mixed methods design incorporating a case study approach to investigate the impact of the PW at one trust (comprising two hospital sites). This manuscript only presents the findings from the qualitative phase of the investigation. This phase used qualitative interviews and focus groups to explore the impact of the programme on patients and staff.
Ethical consideration The research was approved by the university faculty of health independent peer review, NHS research ethics committee and trust R&D committee prior to undertaking data collection. Written informed consent was gained from all participants, and principles of good clinical practice (GCP) were adhered to throughout the investigation. GCP is a course undertaken that covers areas such as the design, conduct and documenting of research that involves people in the NHS.
Data collection Originally six areas across the two sites were selected as case study wards but an organisational restructure resulted in the closure of one of the wards. Staff and patients who met the inclusion criteria (outlined below) from the five case study wards were invited to take part in individual semi-structured interviews. Staff from all wards and departments which had worked on PW were invited to join focus group interviews. All eligible participants were provided with an invitation letter and information sheet to enable them to make an informed decision about their participation in the study. An identical interview schedule was used for staff one-to-one interviews and focus groups to integrate responses. The staff interview schedule addressed the following broad areas: extent of involvement in PWP, perceived impact of PWP on patient care, benefits of imple© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Original article
Evaluating the Productive Ward
mentation for staff and patients. The interview schedule for patients was developed from an established patient satisfaction survey already in use at the trust. The broad topics explored with patients were the extent individuals were involved in their care, communication such as did staff listen to them, receiving adequate and timely assistance, and preservation of privacy and dignity. The two different interview methods provided an in-depth and rich insight into the impact of PW across the organisation and enabled comparisons to be made, thus adding to the rigour and validity of the processes. Participants Data collection was undertaken between January and April 2012. Convenience sampling was used to recruit staff and patient participants. Staff focus groups were held according to pay band to explore how staff role impacted upon their experience of the programme, staff were recruited for focus groups from all wards that had participated in the PW. Participant information is detailed in Tables 1 and 2. In Table 1 area D was initially chosen but had to be withdrawn because it no longer existed after service reconfiguration. In area C, the researchers were unable to recruit any patients into the study because patients were transferred/ discharged before the scheduled interview or too ill for interview. In areas A, D and E no staff were recruited because of the service reconfiguration (area A and D) and staffing pressures (area E) meaning staff could not be released or interviews were cancelled at short notice. Inclusion and exclusion criteria The sample population were current staff or inpatients at the trust aged over 18. Only staff members who had been involved with PW were eligible to participate. Patients without the capacity to make an informed decision about their participation were excluded (Mental Capacity Act 2005) as were those who were too ill to be interviewed. NonEnglish speakers were excluded as there were insufficient resources for interpreters to be made available. We
Table 2 Details of staff focus group participants Focus group – staff grade
Number of participants
2
5
6
7
Two focus groups
Two focus groups
Two focus groups
One focus group
11
7
5
6
acknowledge that this means that the sample does not reflect the rich diversity that exists within society meaning the data are skewed to a particular population. This point urges consideration by all those conducting research to ensure that unheard voices and under-represented groups are heard in all forms of research enquiry.
Data analysis All interviews were audio recorded and transcribed verbatim. Each transcript was reviewed line by line, and thematic analysis (Braun & Clarke 2006) was used to identify themes occurring within the transcripts. Data was manually coded by one researcher (SW) and categorised using QSR NVIVO version 9 (QSR International Pty Ltd, Doncaster, Australia). Categories were collated into initial themes, which were reviewed and refined. A sample of transcripts was analysed independently by a second researcher (WM). Data from staff interviews and focus groups were integrated and analysed collectively to develop themes representative of the overall experience of staff. Themes for patients and staff were developed separately due to a lack of congruence in responses from the two groups.
Results The analysis of one-to-one staff interviews and focus groups identified an overarching theme of change management, together with four subthemes: personal/emotional experi-
Table 1 Details of interview participants from the case study wards
Number of patient participants Staff participants
Area A
Area B
Area C
Area D
Area E
Area F
2 0
2 1 9 band 2 1 9 band 6
0 1 9 band 7 1 9 band 5
0 0
2 0
2 1 9 band 2
Staff grades and roles Band 2/3 – Support staff including housekeepers, ward clerks and healthcare assistants Band 5 – Registered nurse/staff nurse Band 6 – Sister Band 7 – Ward manager
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
1869
S Wright and W McSherry
ence, leadership, organisation and competing priorities. Issues around direct care time and sustainability were also explored. Four themes emerged from one-to-one interviews with patients: care and compassion, time for patient care, personalised care, and communication and involvement. Each theme is outlined below, supported by excerpts from participant transcripts.
Values Involvement Empowerment Awareness
Group ownership
Team cohesion
Staff Process of change and change management The overarching theme encompassed the process of change and the effect of the programme on the individual, team, ward and organisation. Staff acknowledged that working on the programme was challenging at times (for all levels of seniority), describing initial work as ‘disruptive’ and ‘chaotic’, particularly for long-serving staff. These challenges are reflected in the following extract:
Support Ward hierarchy flatter
Figure 1 A model depicting the experience of staff.
All staff were involved in the roll-out and had a role in the implementation of the programme. This was articulated by one ward manager: Everybody had a role and everybody had a voice, and by having a
I think that was perhaps the hardest thing for one or two of them
voice they could say, even the quietest of team member would say
you know, to change, to bring about change because if you’ve been
“can we try so and so” and we tried to see you know, whether
working a system for a long, long time it’s not easy to expect peo-
everybody could work towards it. (Participant 57, Ward Manager)
ple to change overnight. (Participant 37, Healthcare Assistant)
Despite initial scepticism, most staff embraced the opportunity and demonstrated genuine enthusiasm and energy for the programme. The following participant affirms the transition from scepticism to enthusiasm and acceptance of the programme: at first people were like ‘oh God what now,…what else do they want us to do?’. But once the ball was rolling… you started to think ‘Oh God, this is a bit better, this is going to work’, then we all started picking it up and now it’s just… second nature. (Participant 31, Healthcare Assistant)
Personal experience The subtheme of personal experience was found to be significant and was separated further to incorporate involvement, recognising skills, empowerment, teamwork and ownership. Each of the components is included within an integrated model, underpinned by support and awareness of the programme (summarised in Fig. 1). The model starts with awareness at the outset, when the PW team provided assistance, but explained that it was the responsibility of the ward team to take ownership of the programme: They said ‘we are here to support you but we are not going to do it for you, we want you to do it’ and it was down to us. (Participant 36, Healthcare Assistant)
1870
As a result, nonclinical skills were recognised and staff felt valued for their contribution. The sense of value was considered fundamental to the success of the programme: you found skills that you didn’t realise they’d got even from reading their CV, you couldn’t have imagined that they’d got all these skills. (Participant 57, Ward Manager)
Consequently, staff felt empowered, especially junior members of the team who may not have been involved with previous innovations, or had the opportunity to contribute to change. This was said to flatten the ward hierarchy and strengthen team cohesion: The staff feel more able to make suggestions on how the ward can be improved and save time and things whereas before I think it was more of a hierarchy, it had to come from the team leader. (Participant 56, Ward Sister) not one person on their own can change anything and that’s the whole point of the team coming together. (Participant 46, Staff Nurse)
An additional component of the personal experience was the emotional response. Working on the programme affected individuals at a personal level and staff spoke of increased morale, ‘enthusiasm’, ‘a buzz’ and feeling ‘less frustrated’ and ‘more valued’. This leads to staff having a greater sense of self-esteem in that they felt they were making a positive difference as expressed by one staff nurse:
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Original article I felt better about myself being involved in this thinking ‘wow, I am making a difference to our working environment’. (Participant 46, Staff Nurse)
Evaluating the Productive Ward
turnover, involving all members of the team and organisational change: it was quite hard to involve everybody and carry on working on the ward. (Participant 26, Housekeeper)
Leadership The PW house incorporated resource guides for the ward, project and executive leaders to promote engagement with the programme. Support from all levels of management was unanimously cited as providing an essential source of enthusiasm, advice and encouragement. Staff spoke of the importance of a ‘push’ from senior management while retaining ward-level ownership of the programme and free rein to drive change. In particular, they valued ward visits from management and trust board members which motivated staff: we all like a bit of praise and reward, say ‘yes you’ve done a good job, well done’… We don’t want much but for somebody to say well done, it’s worth a lot. (Participant 47, Ward Sister)
The engagement of senior staff also provided practical assistance, for example releasing staff from clinical duties to work on the programme: I think you need to have the management support there to actually carry things out, because you know, everything else doesn’t stop while you’re doing it. (Participant 60, Ward Manager)
if you’re busy you just haven’t got that time to do it. (Participant 24, Ward Manager) does it offer more time to care? Yes I think it does but certainly in the last five years the pace on the ward has changed. (Participant 37 Healthcare Assistant) the trust has been constantly changing and the managers have had other things.. There’s been other issues really. (Participant 59, Ward Manager)
Direct care time Activity follow charts were a resource from the NHSI (nd), used to calculate the proportion of time spent providing direct patient care compared with other ward activities. Trust data revealed that direct care time increased from an average of 42–53% after implementing the foundation modules. When asked whether PW had enabled them to spend more time with patients, staff responses varied widely. Some felt the programme had released time to spend with patients for example: You were able to do some of the little niceties that you don’t get
Organisation The theme of organisation was classified both in terms of improvements to the physical ward environment and in the efficiency of staff. The well-organised ward was repeatedly named as being the most influential module as it introduced lean methodology and improvement tools such as 5S (described in Waring & Bishop 2010, p. 1333). Employing lean resulted in a reduction in waste and changes to the ward environment, which became tidier, more accessible and not overstocked. Staff also described how the ward was generally more efficient and how ‘flow’ improved, which enabled them to attend to patients faster: for us to have everything organised and streamlined, it means that we can get to the patient quicker really. (Participant 25, Staff Nurse)
Competing priorities Staff recognised a number of issues which affect their ability to spend time working on the programme, to provide direct patient care and sustain change long term. These included having protected time specifically for PW away from clinical duties, increase in ward pace and patient © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
time to do. (Participant 18, Ward Manager)
Others felt they were ‘less rushed’; while a proportion reported that the programme had no discernible impact on their ability to spend time with patients: I don’t know it’s necessarily released that much more time for nurses to have one-to-ones with patients. (Participant 32, Ward Clerk)
A number of staff commented that the programme had originally released time for care, but that it has subsequently been ‘eaten back up’ with other activities. This brings the sustainability of the programme into question as staff had not been able to reinvest time effectively. Some of the literature around PW reported significant increases in the proportion of time spent providing direct patient care (such as Smith & Rudd 2010, Bloodworth 2011) without specifying how staff were ‘reinvesting’ this time with patients. Therefore, an aim of this research had been to examine how time released through working efficiently was being spent with patients. One ward manager recounted how staff spent any additional time with patients:
1871
S Wright and W McSherry have their hair done and maybe spend some time doing their nails, and people had more time to talk to them as well. (Participant 18,
Table 3 Enablers and inhibitors affecting the implementation and sustainability of PW
Ward Manager)
Enablers
Inhibitors
But in general staff found it difficult to articulate how they ‘reinvested’ time or identify specific activities they were able to undertake as a result of PW. Using qualitative techniques revealed improvements which may not have been recognised through standard staff surveys or satisfaction measures, but which potentially benefit patients. These included improved staff retention, motivation and morale. A number of staff also acknowledged that the skills and experience gained from working on PW provided ‘a good grounding’ for changes which have subsequently been brought in:
Good communication Awareness and promotion Leadership and support Tailor/personalise the programme for each area Planning and preparation Embedded into everyday practice (culture) Harness staff with energy Ward – roles, ownership, involvement, empowerment Bottom-up change Shared learning
Slow pace of roll-out Novelty – view as novel or discrete event not a continuous improvement programme Change within the organisation Competing demands Fail to review, feedback, PDSA Nontraditional wards, e.g. day surgery, A&E Poor understanding of aims/what constitutes PW Resentment/conflict due to lack of involvement Practical difficulties (including resources) Not enough time to release staff to work on PW Low engagement with the wider hospital: doctors, MDT, nonclinical departments (e.g. estates, facilities, stores, transport, porters)
we have introduced additional services onto our ward…had the Productive Ward not come into play…I don’t think it could have been managed quite so well. (Participant 36, Healthcare Assistant)
Sustainability As with direct care time, opinions on the sustainability of PW occurred on a continuum. Some staff felt the programme had been embedded into everyday working practice: It’s how the ward is run now, it’s second nature to them. Even the new ones that came in, they didn’t know any different. (Participant 26, Housekeeper)
However, a minority were of the opinion that the PW had not been sustained: If nobody mentions it you forget about it, there’s something else to be worried about. (Participant 24, Ward Manager)
and then we would work as a team. (Participant 18, Ward Manager)
Inhibitors included pace of roll-out: some of the wards were just getting their well organised ward, the rest of us were chomping on the bit to get going. (Participant 56, Ward Sister)
Also, viewing the programme as a discrete or novel event rather than a continuous improvement programme: it just got lost didn’t it,…you know, the novelty wore off. (Participant 47, Ward Sister)
Enablers and Inhibitors An aim of this study had been to identify recurring factors which affected the successful implementation and sustainability of the programme, these are summarised in Table 3. The analysis of the qualitative data also confirmed the findings of the literature review (Wright & McSherry 2013) undertaken as part of the larger study. A key enabler was good communication between team members, departments and hospital trusts, whereby shared learning provided a vehicle to promote progress and best practice: a couple of us would go and see what the next project was, get the ideas from there and then come back and feed them to the team
1872
Patients The patient experience was harder to capture as they had no direct involvement or exposure to PW; therefore, we were measuring perceived impact rather than assessing awareness and understanding of the programme. The interviews explored whether increased time for direct patient care was associated with improved quality of care and a better experience. An established patient survey provided the basis for interview questions which allowed us to examine specific aspects of care such as privacy and dignity, staff attitude and communication. A total of eight patients participated (five female and three males). All patients had been in © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Original article
hospital over 48 hours, and several had been inpatients for longer. Patients were recruited from a range of clinical areas with a wide range of medical and surgical needs. Data pertaining specifically to the patient’s condition were not collected for research purposes; however, a number of patients disclosed details during interviews.
Evaluating the Productive Ward
learn more about them as a person alongside their medical condition: It’s the whole package. It’s not just ‘oh you’re a patient, you’re a number in a bed.’ You’re a person, you’re an individual and everybody needs to be treated differently because we are different. The staff on here seem to take it that little bit further, they take that little bit extra interest. (Patient Participant 62)
Care and staff compassion On the whole, patients were complimentary about their experience as an inpatient, reporting that staff made them feel safe, comfortable and cared for:
In instances where staff had a better understanding of the individual, patient confidence increased: They’ve taken the time to get to know me and know my condition so this is the ward for me. That knows me inside and out, and I’ve
The girl that was on last night was so caring, she just had great
peace of mind that if I can come here I know I’m going to get the
compassion and I don’t think the staff get praised enough for that.
best care and I’m going to get better. (Patient Participant 62)
(Patient Participant 83)
Almost all patients commended the hourly comfort round (intentional rounds) where a member of staff visits each patient to check they are comfortable and whether they require support with hydration, pain management and toileting. Although it was not implemented as a component of PW, comfort rounds ensure regular contact with a member of staff and mean frail or elderly patients receive assistance which they may not otherwise have been able to request.
Communication and involvement Good communication was reported at a number of levels, from staff attitude to how they address, listen to and communicate with patients. Patients also felt that staff were efficient in relaying information and ultimately involving patients in decisions about their care while in hospital: If you ask them something they explain, it’s not ‘I’ll be back in a moment’ and then you just sit here and then you don’t see them.
Staff time for patient care Like staff, patients were asked whether they felt staff had enough time to spend providing care. A number of patients reported that the ward was busy, but staff made time for them whenever possible: They’re always rushed, they always seem to have an awful lot of workload but they always make that time… but they always do seem busy, they are always busy. (Patient Participant 62)
Patients were also conscious of the demands on staff which affect their ability to spend time with individual patients: You just started talking to them about something and then somebody else needs attention. It’s inevitable isn’t it, when you’ve got thirty odd people that something else will happen while you’re dealing with one. (Patient Participant 42)
In addition, some patients spoke of not wanting to ‘bother’ staff, although this may reflect the personal perception of the patient rather than willingness of staff.
Personalised care A good relationship with staff greatly enhanced the experience for patients, who appreciated the effort staff took to © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
They come back. If they’re dealing with someone else they’ll explain to you or someone else will. You’re not fobbed off. (Patient Participant 63)
Discussion The present research aimed to address the gaps in the current literature by assessing the impact of the PW on patients and staff. Despite being marketed as an improvement programme aimed at releasing time to care, the responses of staff generally centred on the process of change and outcomes from a personal perspective. The programme produced considerable energy, enthusiasm and motivation that some staff had never previously encountered in the workplace. But there was a lack of consensus as to whether the programme released time for patient care. In support of this, Peter Griffiths (involved with the NNRU 2010, 2011 reports) recently stated that he is ‘sceptical of the claims for the amount of time released by the scheme’. (Griffiths 2012, p. 7). Furthermore, staff reporting an increase in direct care time were not generally able to define how time released through work on PW was ‘reinvested’ or identify tasks which could be undertaken with patients as a result of the programme. Many staff
1873
S Wright and W McSherry
believed that improvements such as better organisation (e.g. efficiency meant patients could be attended to faster) and increased staff morale indirectly benefited patients. As the focus of PW, future implementation must demonstrate how direct care time and staff contact translate into meaningful outcomes for patients. Similarly, responses on sustainability of PW varied. Some staff reported that PW had become embedded into everyday practice, but others stated that the programme had not been sustained. This would suggest that additional work is required to ensure that the PW is sustained in a standardised manner across all wards implementing the programme. Opportunities for shared learning may ensure that best practice becomes trust standard. Staff also identified a number of competing priorities which affect sustainability, and the ability to provide direct care, for example, protected time to work on PW and organisational change. Addressing these challenges will optimise sustainability of PW and future change. These findings build on the current evidence base to provide an in-depth understanding of outcomes from the PW for patients and staff and complement the largest body of research on PW undertaken by NNRU (2010, 2011). Similarities in the findings include leadership as a facilitator, the significant influence of the foundation modules, better team working and a calmer ward environment. As research was conducted at just one trust, some responses tended to be consistent across all wards, for example the type of tools used, whereas NNRU (2010) received a broader range of responses and also considered strategic and organisational factors. In contrast to the current research, NNRU (2011) focused specifically on spread and uptake of PW and developed a threefold explanation of spread based on determinants, processes and measures. More recently, Davis and Adams (2012) undertook semi-structured interviews to explore the perspectives of six staff and grouped the responses into five themes: starting to implement the programme, anxiety and defensiveness, the importance of leadership and communication, challenges, and learning and personal development. Aspects of all five themes can be incorporated into the themes identified in the current study, which may indicate that they are representative of the benefits and challenges staff can expect to experience when initiating large scale change in a complex organisation. Previous research on PW was extended by obtaining patient opinion. Four themes emerged from interviews with patients: time for patient care, caring and staff compassion, personalised care, and communication and involvement. Most, but not all patients were of the
1874
opinion that staff did have enough time to provide patient care. With patients, we were not able to measure how the patient experience has changed since the programme was implemented; therefore, it was necessary to assess perceived patient impact and attribute to the PW where possible. Overall, patient feedback was positive which could be due to an increase in direct care time. For example, working on the programme may have released additional time which enabled staff to become better acquainted with patients to provide personalised care and involve patients in decisions about their care. Additionally, the use of qualitative techniques allowed the researchers to gain insight into some of the benefits which may not have been apparent from standard performance measures, for example PW providing grounding for future initiatives and staff having more time to attend training or study days, both of which indirectly benefit patients.
Limitations The research was undertaken with a small sample at one acute trust; therefore, it lacks generalisability across the NHS. Additionally, the use of convenience sampling does not allow definitive, generalised findings as participants were invited to volunteer from the staff and patient population meaning their views may not be representative. From the patient perspective, this sample also lacked diversity which also impacts on the generalisability of the findings. Data on staff were generated from one-to-one and focus group interviews, whereas patients only took part in oneto-one interviews meaning a much smaller proportion of data was obtained on the patient experience. The fact that patients were interviewed while in hospital may have influenced and resulted in the positive findings. Patients may not want to appear over critical while they are receiving ongoing care in fear of recrimination.
Conclusion The research findings identified improvements for staff (and potentially patients) resulting from the PW. In future, it would be beneficial to evaluate other programmes in the productive series as they become established and identify key benefits. From analysing the data, it was not possible to obtain definitive results as to whether PW was successful in releasing time for patient care. A general difficulty was that the assessment of impact is open to individual perception and motivation. Furthermore, the notion of ‘time for care’ may be subjective, depending upon whether it is © 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Original article
Evaluating the Productive Ward
classified as time providing clinical care vs. spending time with patients in a social or nonclinical capacity. Conducting focus groups and interviews provided staff with a unique outlet to discuss their experience. Staff proposed a number of recommendations based on their experience of the programme which would be applicable to all trusts involved with Productive Ward or productive series. These included appointing a Productive Ward champion in each area, and the involvement of clinical and nonclinical staff across the trust. Furthermore, the engagement of senior staff will ensure support is available to incorporate the suggestions in the future roll-out of the Productive Ward.
Relevance to clinical practice The findings from this mixed methods study suggests that PW has the potential to lay the foundations for future change. The legacy of PW may be the priming of staff, providing transferable skills and knowledge, making them more receptive for ongoing development. PW appears to equip staff with a cultural confidence for subsequent innovation. However, care must be taken to avoid innovation fatigue (as a result of constant efforts to innovate) and extremes in pace of roll-out (either too fast or too slow) which may have a detrimental impact on the uptake and sustainability of the programme. Involvement in PW leads to greater staff morale and satisfaction. Participation generates a sense among staff that they are worthy of investment and valued by senior management. PW facilitates engagement of staff at all levels in the design and implementation of the programme. Leadership and managerial support are pivotal to the implementation and long-term sustainability of the programme. PW has the potential to flatten hierarchical structures, but the ‘ward to board’ philosophy must be a reality and fully operational for ongoing success of the programme. Patient involvement and engagement with PW need to be strengthened. Matrices and performance indicators need to be developed to assess the impact of PW on the quality of patient care and the patient experience. There is a need for a more robust system to capture how direct care time is reinvested into patient care. The retrospective findings from this investigation suggest PW is having a positive impact on patient satisfaction.
Organisational reconfiguration across the NHS may impact on the long-term viability and sustainability of the PW programme. One key observation is the notion that for PW to be sustainable then there must be relative stability within the organisations and sectors where it is being implemented as organisational instability may counteract the positive influences of PW.
Acknowledgements We would like to thank all the patients and staff who participated in the research by sharing with us, their thoughts and experiences. Without them this research would not have been possible. We would also like to thank the sponsors of the KTP, the Local Management Committee and all colleagues who supported the project.
Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.
Funding This manuscript presents the qualitative findings from a mixed methods research project undertaken as part of a Knowledge Transfer Partnership between Shrewsbury & Telford Hospital NHS Trust and Staffordshire University which was funded by the NHS trust, Technology Strategy Board and Department of Health.
Conflict of interest None. SW was employed by the university and worked at the trust at the time the research was undertaken. WM works three day at the university and two days in the trust where the investigation was undertaken. However, neither had direct involvement in the PW.
References Anderson P (2009) The Productive Ward initiative and its effects on patient safety. Health Care Risk Report 16, 18–19.
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
Blakemore S (2009) How Productive Wards can improve patient care. Nursing Management 16, 15–18.
Bloodworth K (2009) Productive Ward 1: implementing the initiative across a large university teaching hospital. Nursing Times 105, 22–25.
1875
S Wright and W McSherry Bloodworth K (2011) The productive ward and productive operating theatre. Journal of Perioperative Practice 21, 97–103. Braun V & Clarke V (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3, 77–101. Davis J & Adams J (2012) The Releasing Time to Care – the Productive Ward programme: participants perspectives. Journal of Nursing Management 20, 354–360. Dean E (2009) Productive Ward Measures see hospital’s mortality rate plummet. Nursing Standard 24, 8. Foster S, Gordon P & McSherry W (2009) Rolling out Productive Ward foundation modules across a hospital trust. Nursing Times 105, 28–30. Griffiths P (2012) New forum must focus on the future and not look backwards. Nursing Times 108, 7. Lipley N (2009) Productive Wards hailed for transforming care. Nursing Management 16, 4. National Nursing Research Unit & the NHS Institute for Innovation and Improvement (2010) The Productive Ward: Releasing Time to Care. Learning & Impact Review. NHS Institute for Innovation and Improvement, Warwick. National Nursing Research Unit & the NHS Institute for Innovation and Improvement (2011) Improving Healthcare Quality at Scale and Pace Lessons
from The Productive Ward: Releasing Time to Care Programme. NHS Institute for Innovation and Improvement, Warwick. NHS Institute for Innovation and Improvement (2007) Releasing Time to Care: The Productive Ward. Available at: http://www.institute.nhs.uk/quality_ and_value/productivity_series/the_pro ductive_series.html (accessed 22 June 2011). NHS Institute for Innovation and Improvement (2008) The Productive Ward Module Structure. Available at: http:// www.institute.nhs.uk/quality_and_value/ productivity_series/the_productive_ ward_module_structure.html (accessed 5 February 2013). NHS Institute for Innovation and Improvement (2011) Rapid Impact Assessment of the Productive Ward: Releasing Time to Care. Available at: http:// www.institute.nhs.uk/images//documen ts/Quality_and_value/productiveseries/ Rapid%20Impact%20Assessment%20 full%20report%20FINAL.pdf (accessed 22 June 2011). NHS Institute for Innovation and Improvement (nd) Toolkit Resources. Available at: http://www.institute.nhs. uk/index.php?option=com_joomcart& main_page=document_product _info& products_id=687&cPath=73 (accessed 20 September 2012).
NHS Scotland (2008) Releasing Time to Care Evaluation. Available at: http:// www.lanpdc.scot.nhs.uk/Resources/ Lists/Publications/Attachments/34/Releas ing%20Time%20to%20Care%20-%20 Evaluation.pdf (accessed 22 June 2011). Robert G, Morrow E, Maben J, Griffiths P & Callard L (2011) The adoption, local implementation and assimilation into routine nursing practice of a national quality improvement programme: The Productive Ward in England. Journal of Clinical Nursing 20, 1196–1207. Shepherd S (2009a) This is a phenomenon. Nursing Times 105, S4. Shepherd S (2009b) Rolling out the productive ward. Nursing Times 105, S12–S13. Smith J & Rudd C (2010) Implementing The Productive Ward management programme. Nursing Standard 24, 45–48. Waring JJ & Bishop S (2010) Lean healthcare: rhetoric, ritual and resistance. Social Science & Medicine 71, 1332– 1340. Wilson G (2009) Implementation of releasing time to care – the Productive Ward. Journal of Nursing Management 17, 647–654. Wright S & McSherry W (2013) A systematic literature review of Releasing Time to Care: The Productive Ward. Journal of Clinical Nursing 22, 1361–1371.
The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of clinically related scholarship which supports the practice and discipline of nursing. For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http:// wileyonlinelibrary.com/journal/jocn
Reasons to submit your paper to JCN: High-impact forum: one of the world’s most cited nursing journals, with an impact factor of 1316 – ranked 21/101 (Nursing (Social Science)) and 25/103 Nursing (Science) in the 2012 Journal Citation Reportsâ (Thomson Reuters, 2012). One of the most read nursing journals in the world: over 19 million full text accesses in 2011 and accessible in over 8000 libraries worldwide (including over 3500 in developing countries with free or low cost access). Early View: fully citable online publication ahead of inclusion in an issue. Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur. Positive publishing experience: rapid double-blind peer review with constructive feedback. Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley Online Library, as well as the option to deposit the article in your preferred archive.
1876
© 2013 John Wiley & Sons Ltd Journal of Clinical Nursing, 23, 1866–1876
