Art & science | evaluation
Inspiring senior nurses to lead the delivery of compassionate care Abigail Masterson and colleagues describe an innovative programme that gave participants the confidence to make changes in practice and return to the core values of nursing Correspondence abigail.masterson@ abigailmasterson.com Abigail Masterson is director, Abi Masterson Consulting, London and a member of the Nursing Older People editorial advisory board Elizabeth Robb is chief executive, Florence Nightingale Foundation, London Pippa Gough is independent consultant Sue Machell is independent consultant Date of submission July 27 2014 Date of acceptance September 1 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/nop-authorguidelines
Abstract The enabling compassionate care in practice programme was an innovative development programme for bands 6 and 7 nurses working with older people in all settings. It was commissioned by the Department of Health from the Florence Nightingale Foundation. A total of 117 nurses participated. They included experienced and newly appointed clinical leaders from medicine, surgery, acute specialties, community services, mental health, emergency departments, hospices and care homes. All participants reported increases in their knowledge, understanding and practical application of the 6Cs; courage and confidence to lead; and ability to change practice. Participants also reported feeling reinvigorated and being brought back in touch with why they entered nursing. At the close of the programme most participants had already made small but significant changes in their areas for the benefit of frail older people. Keywords Compassionate care, leadership, nurse leaders IN RECENT years significant concerns have been raised in the media and by the public about the care of frail older people, and in particular a perceived lack of compassion in that care (Siddique 2012, Coward 2013). Nurses in bands 6 and 7 are essential to the delivery of compassionate care for older people in all services and settings but to ensure their effectiveness, they need to be properly developed. This article reports on the evaluation of a bespoke development
26 October 2014 | Volume 26 | Number 8
programme for nurses in bands 6 and 7 that was commissioned by the Department of Health (DH) from the Florence Nightingale Foundation. The programme was designed to reflect the ambitions outlined in the chief nursing officer for England’s Compassion in Practice strategy (DH and NHS Commissioning Board 2012) and the government’s response to the Francis inquiry into Mid Staffs (DH 2014). Evidence (Hay Group 2006, RCN 2009) suggests that successful development of senior nurses requires structured support to enable them to understand how they can lead in a way that influences team ethos and culture. Drawing on this evidence and the expertise of the facilitators, a programme was designed for nurses in bands 6 and 7 to enable them to foster compassionate care for older people in their teams and organisations. The evaluation findings suggest that the programme has had a significant effect on the nurses and their teams, as well as provoking positive changes in practice. Evaluation data included evaluation forms and written reflections completed by participants and stimulated discussion with participants.
Aims, objectives and design The enabling compassionate care in practice programme was designed and delivered by experienced facilitators with nursing backgrounds. Based on the chief nursing officer for England’s Compassion in Practice strategy (DH and NHS Commissioning Board 2012), it featured the ‘6Cs’, namely care, compassion, courage, competence, communication and commitment. It was designed to NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
be short, intensive and practical and was targeted at senior nurses with responsibility for leading teams in any healthcare setting used by older people. It comprised a two-day residential programme and a one-day follow up six weeks later. Participants were expected to undertake a work-based experiment between the programme and follow up, using the skills they had gained in the first two days. The overarching aims were to provide a space for senior nurses to explore together how they could improve further the quality of care for frail older people in a variety of settings and lead their teams to enable this improvement to occur and embed changes in practice. Specifically, the programme aimed to: ■■ Create an environment that enabled nurses to learn together and draw on the collective wisdom, insights and experiences of the group. ■■ Expose nurses to current thinking on leadership for quality improvement and support them in putting the 6Cs into practice. ■■ Facilitate deep reflection about, and scrutiny of, the effect and outcome of individual actions. ■■ Enhance the skill and effectiveness of senior nurses by providing leadership development interventions that were effective and grounded in best practice. ■■ Promote multidisciplinary and cross-organisational learning about leading change to improve overall quality of patient care. ■■ Demonstrate to each organisation how investing in senior nurses is worthwhile and reaps rewards. The programme was run in each of the four NHS England regions, North, Midlands and East, London and South, between March and May 2014. In each of the four NHS England regions 30 places were available, giving a total of 120 places, however, 117 nurses participated. Applications exceeded available places by a factor of three to one. A selection process was devised to ensure maximum diversity of settings and services in the learning community to maximise the richness of the experience. Participants included experienced and newly appointed clinical leaders. Medicine, surgery, acute specialties, community services, mental health, emergency departments, hospices and care homes were represented. Figure 1 presents the distribution of participants across service types. Concerns have been raised about the disproportionately low number of nurses from black and minority ethnic (BME) groups in senior positions (Kline 2014). Ensuring access to appropriate leadership development opportunities is vital to address this disparity. In 2013, only 4% of recruits to the NHS Leadership Academy’s nurse leadership programme were from a non-white background NURSING OLDER PEOPLE
Figure 1 Distribution of participants across service types (n=117)
20, 17% 12, 10%
61, 52%
25, 21%
Acute Mental health Care homes/ voluntary Community
(Kline 2014). In contrast the enabling compassionate care in practice programme achieved significant representation from BME nurses. Table 1 presents BME representation across all venues and each region.
Evaluation Evaluation forms were completed by 95% (n=111) of participants and these data were augmented by a whole group discussion session on the final afternoon. Participants spoke and wrote enthusiastically about the programme and what they thought it had enabled them to do. Four themes emerged from an analysis of these spoken and written comments: ■■ Increased knowledge, understanding and practical application of the 6Cs. ■■ Gaining the courage and confidence to lead. ■■ Getting back in touch with core nursing values. ■■ Delivering change in practice. Increased knowledge, understanding and practical application of the 6Cs Participants explained how the programme had helped their, and in turn their team’s, understanding and implementation of the 6Cs: ‘This course has now equipped me with the required skills and knowledge to implement the 6Cs in improving quality of care to my ward’ (South, P41). Table 1
Black and minority ethnic representation
Venue
BME representation
All venues (n=117)
31, 26%
London (n=27)
16, 59%
North (n=30)
3, 10%
Midlands and East (n=30)
4, 13%
South (n=30)
8, 27%
October 2014 | Volume 26 | Number 8 27
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | evaluation xxx Participants reported feeling reinvigorated and brought back in touch with their core values and why they had entered nursing In particular the programme had helped participants develop creative ways of making the 6Cs real to their teams: ‘I felt I needed to bring the 6Cs from the abstract into reality in my team. We had a team meeting planned during the following week and with the team I asked them to think of any care they had delivered to patients during the previous two shifts and how this demonstrated the 6Cs. ‘The team were enthusiastic and very engaged. We now have “The 6Cs are live!”, each “C” was highlighted and the team gave examples to each one. Feedback from staff is that they appreciate what each other have done – and what their own values are. On the back of the session in the programme myself (band 7) and band 6 team members have thought about what as leaders we need to provide to support the rest of the team in ensuring the 6Cs are in practice. This is to be our “leadership pledge” to the team’ (South, P33). Discussions enabled participants and their teams to further explore how to improve quality of care. Gaining the courage and confidence to lead Participants reported that they understood better how to lead as a consequence of the programme: ‘I have been able to look at myself as a leader in my organisation and look at ways of moving forward. I have become more assertive in my working environment in regards to empowering staff in embracing the 6Cs. ‘It has been challenging and complex due to the ever-changing staff/bank agency that I work with. It has been difficult to have continuity of care with the volume of staff that are coming through the ward. The only constant people are the locum doctors, ward clerks and a small number of substantive staff. As a small team we have concentrated on nutrition and hydration using hydration bottles for those patients who cannot manage to drink themselves. I have gained a voice and I have used that voice in the best interest of my staff and patients to ensure care is delivered in a timely fashion. I am looking at myself and what my future is in the organisation I work in. I am changing as a person as my thinking is changing on my role’ (Midlands and East, P71). The words ‘courage’ and ‘confidence’ often recurred in participants’ spoken and written 28 October 2014 | Volume 26 | Number 8
accounts. They emphasised how the programme had increased their courage and given them the confidence to challenge practices and individuals – junior and senior, nurses, other members of the multidisciplinary team and managers – that were not reflecting the values of the 6Cs. Participants attributed this gaining/regaining in courage and confidence to lead to the programme enabling them to have a better understanding of themselves and the perspectives of others around them. This increased self-awareness, along with the practical tools they had been introduced to, reportedly increased their effectiveness in implementing change. Getting back in touch with core nursing values Participants reported feeling reinvigorated and brought back in touch with their core values and why they had entered nursing: ‘Discussions with the tutors and the workshops sparked a small flame inside of me, waking me up from the robotic individual I had developed into. I realised I had the skills but they needed to be revised and refreshed in order for me to do my work efficiently but with compassion and empathy. This workshop was a valuable tool helping with my nursing leadership and managing the 6Cs’ (South, P46). The opportunity to mix with nurses from a wide range of settings and services was also thought to be beneficial in enabling them to reconnect with nursing values: ‘The opportunity to meet other nurses/practitioners from across multiple NHS and private hospitals/homes has enabled me to feel privileged being a nurse and that we as a group can change practice by challenging poor practice/ dogma by being able to find solutions and support from a wider skill mix of people’ (South, P46). Delivering change in practice Most participants were able to provide examples of what they had changed as a consequence of the programme. These varied in scale, scope and focus but all were likely to have a positive effect on care for frail older people. Some were still in the planning stages. For example, one participant was intending to implement post-discharge telephone calls to patients to check that they understood their medication, that their care package had started and to answer any queries or concerns they had. Others had already started. One participant from the North region explained how she had been inspired to provide special bags and boxes in which to return jewellery to relatives after a loved one had died in intensive care and that NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
this idea was now being implemented across the trust. Another from the Midlands and East region had involved her team in changing practice to ensure that patients were being weighed. Participants wrote and talked evocatively about feeling empowered and more able to make changes for the benefit of patients: ‘As a result of this programme I introduced the “Good morning smile” (GMS) project to our office. The nurses were feeling demoralised and overworked. This was evident and showed in an increased sickness rate. The GMS was simple – on entering the office you had to smile and say loudly “Good morning everyone.” This prompted responses from other staff and often brought a little cheer to the day and helped to change the mood in the office’ (Midlands and East, P67). ‘I have created a ward where my patients are dressed in their own clothes and washed in their own toiletries and do not wear pant (netty) and pads unless they are assessed and are incontinent. Instead patients are regularly toileted. With my team we have created a patient and relative family information leaflet, asking for relatives to bring day and night clothes, plus toiletries. Dirty clothes are put in a bag that dissolves in the washing machine. We have donations of clothes and toiletries for patients who don’t have relatives. I now intend to carry this change out across the trust. My biggest challenge yet!’ (London, P96). Participants’ feelings of empowerment were being translated into practice improvements and enabling them to take an empowering approach with their own teams with positive results: ‘One success story – small plated meals for patients. Discussed with catering and colleagues; now successful in achieving small meals. Patient food diary has indicated that more food has been eaten than previous. Food more attractive and less portions have enabled patients to eat more. Perseverance is the key word. I will continue to put the 6Cs into practice’ (South, P47). Participants particularly valued being introduced to practical skills such as quality improvement techniques and a co-consulting process that they could use in their own workplaces to support them in changing practice: ‘I went back to my workplace after the two days and used the simple theory of change we looked at and asked my colleagues to use it to plan for a very small change they would like to implement for themselves or for the ward, bearing in mind the 6Cs. Their plans were included in their appraisal. I used the co-consulting process to assist during supervision in order to find out NURSING OLDER PEOPLE
what sort of support was needed. Plans have been amended regularly. I have used the leadership skills I learnt to support colleagues. I am pleased with the increased commitment my team have shown’ (London, P93).
Discussion The challenges encountered arose from the logistics of running a programme that covered vast geographical areas, which meant some participants were travelling long distances. However, having participants from a large number of different trusts added hugely to the learning, as did ensuring representation from a range of services and specialties. It is clear there is a significant unmet need for such programmes given that we were inundated with applications and oversubscribed by a factor of three to one when admissions closed. The residential nature of the programme was important because it enabled participants to bond. This in turn promoted the development of robust networks and maximised opportunities for sharing good practice. Even though this element added to the costs it proved effective. This programme was designed to enable nurses at bands 6 and 7 to lead in a way that was likely to foster compassionate care. Demonstrating the effect of leadership development on practice is difficult. The evaluation is based on participants’ own reports of the changes they experienced and the changes they made in practice, rather than the views of their colleagues or patients. The brief was to develop and test a short, intensive and practical development programme grounded in and designed around the 6Cs and much was achieved in just three days of face-toface contact. Participants suggested, however, that a further follow-up day six months later would have been beneficial because it would have given them the opportunity to embed the practice changes they were leading. Participants’ comments in the classroom, their written reflections and completed evaluation forms indicated that they thought the programme had had a significant effect on them and their leadership practice. The overarching aim of the programme was to provide a space in which senior nurses could explore with others how they could best lead to
Participants valued being introduced to practical skills such as quality improvement techniques and a co-consulting process October 2014 | Volume 26 | Number 8 29
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | evaluation enable high quality care for frail older people. This was achieved through the programme design which, along with formal input on quality improvement and managing change, involved participants working together in many differently constituted small groups and ensured opportunities for informal conversations over lunch and dinner. It enabled the nurses to draw on the collective wisdom, insights and experiences of the group and promoted cross-organisational learning. Identifying the elements that make a programme successful is also difficult, however, the following seem to have been significant: ■■ The facilitators who co-designed the programme were all highly experienced, had been nurses and worked extensively in the health sector enabling the interventions to be grounded in practice. ■■ The programme design reflected a philosophy of adult and experiential learning that assumed a rich mix of experience, knowledge and competence and recognised the existence of individual learning styles and preferences. ■■ A fundamental belief informing the programme that the role of today’s nursing leaders is to enable their teams in partnership with patients and their families to ‘co-produce’ compassionate care. ■■ Careful selection of content to increase participants’ understanding of context, their practical skills and their personal and relational development. ■■ Recruiting a diverse group of participants from a wide range of backgrounds, disciplines, services and sectors.
Conclusion Despite its brevity, this programme appears to have had a significant effect on participants and the care frail older people are likely to receive in their services. The programme was well evaluated by participants who reported increases in their: knowledge, understanding and practical application of the 6Cs; self-awareness and understanding of others; courage and confidence to challenge; and sense of power, enthusiasm and ability to make changes. Participants also particularly valued being introduced to practical skills they could use to enhance their leadership roles and benefited from being exposed to staff from a range of different organisations and services. Perhaps most importantly, given public concern about nursing having lost its way, participants reported feeling more at ease in their leadership roles and being reinvigorated and brought back in touch with why they entered nursing: ‘I have been able to reflect on why I came into nursing in the first place, took myself back to basics and remembered the service user at the heart of my practice at all times. Sometimes other things take over and you forget the basic things that motivate you and your team. I have developed myself personally in terms of learning about myself and how I impact on my team, equally how they impact on me.’
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References Coward R (2013) Why Have so Many Nurses Stopped CARING? An Investigation into the Crisis-hit NHS. www.dailymail.co.uk/health/ article-2275943/NHS-Why-nurses-stoppedCARING.html (Last accessed: August 29 2014.) Department of Health (2014) Hard Truths. The Journey to Putting Patients First. DH, London.
Department of Health and NHS Commissioning Board (2012) Compassion in Practice. Nursing, Midwifery and Care Staff Our Vision and Strategy. www.england.nhs.uk/ wp-content/uploads/2012/12/compassion-inpractice.pdf (Last accessed: August 29 2014.) Hay Group (2006) Nurse Leadership: Being Nice is not Enough. www.haygroup.com/downloads/ uk/Nurse%20leadership%202012.pdf (Last accessed: August 29 2014.)
30 October 2014 | Volume 26 | Number 8
Kline R (2014) The ‘Snowy White Peaks’ of the NHS: a Survey of Discrimination in Governance and Leadership and the Potential Impact on Patient Care in London and England. Middlesex University, London.
Siddique H (2012) Nurses Told to Focus on Compassionate Care. www.theguardian.com/ society/2012/dec/04/nurses-compassionatecare (Last accessed: August 29 2014.)
Royal College of Nursing (2009) Breaking Down Barriers, Driving up Standards. The Role of the Ward Sister and Charge Nurse. RCN, London.
NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Inspiring senior nurses to lead the delivery of compassionate care Abigail Masterson and colleagues describe an innovative programme that gave participants the confidence to make changes in practice and return to the core values of nursing Correspondence abigail.masterson@ abigailmasterson.com Abigail Masterson is director, Abi Masterson Consulting, London and a member of the Nursing Older People editorial advisory board Elizabeth Robb is chief executive, Florence Nightingale Foundation, London Pippa Gough is independent consultant Sue Machell is independent consultant Date of submission July 27 2014 Date of acceptance September 1 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/nop-authorguidelines
Abstract The enabling compassionate care in practice programme was an innovative development programme for bands 6 and 7 nurses working with older people in all settings. It was commissioned by the Department of Health from the Florence Nightingale Foundation. A total of 117 nurses participated. They included experienced and newly appointed clinical leaders from medicine, surgery, acute specialties, community services, mental health, emergency departments, hospices and care homes. All participants reported increases in their knowledge, understanding and practical application of the 6Cs; courage and confidence to lead; and ability to change practice. Participants also reported feeling reinvigorated and being brought back in touch with why they entered nursing. At the close of the programme most participants had already made small but significant changes in their areas for the benefit of frail older people. Keywords Compassionate care, leadership, nurse leaders IN RECENT years significant concerns have been raised in the media and by the public about the care of frail older people, and in particular a perceived lack of compassion in that care (Siddique 2012, Coward 2013). Nurses in bands 6 and 7 are essential to the delivery of compassionate care for older people in all services and settings but to ensure their effectiveness, they need to be properly developed. This article reports on the evaluation of a bespoke development
26 October 2014 | Volume 26 | Number 8
programme for nurses in bands 6 and 7 that was commissioned by the Department of Health (DH) from the Florence Nightingale Foundation. The programme was designed to reflect the ambitions outlined in the chief nursing officer for England’s Compassion in Practice strategy (DH and NHS Commissioning Board 2012) and the government’s response to the Francis inquiry into Mid Staffs (DH 2014). Evidence (Hay Group 2006, RCN 2009) suggests that successful development of senior nurses requires structured support to enable them to understand how they can lead in a way that influences team ethos and culture. Drawing on this evidence and the expertise of the facilitators, a programme was designed for nurses in bands 6 and 7 to enable them to foster compassionate care for older people in their teams and organisations. The evaluation findings suggest that the programme has had a significant effect on the nurses and their teams, as well as provoking positive changes in practice. Evaluation data included evaluation forms and written reflections completed by participants and stimulated discussion with participants.
Aims, objectives and design The enabling compassionate care in practice programme was designed and delivered by experienced facilitators with nursing backgrounds. Based on the chief nursing officer for England’s Compassion in Practice strategy (DH and NHS Commissioning Board 2012), it featured the ‘6Cs’, namely care, compassion, courage, competence, communication and commitment. It was designed to NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
be short, intensive and practical and was targeted at senior nurses with responsibility for leading teams in any healthcare setting used by older people. It comprised a two-day residential programme and a one-day follow up six weeks later. Participants were expected to undertake a work-based experiment between the programme and follow up, using the skills they had gained in the first two days. The overarching aims were to provide a space for senior nurses to explore together how they could improve further the quality of care for frail older people in a variety of settings and lead their teams to enable this improvement to occur and embed changes in practice. Specifically, the programme aimed to: ■■ Create an environment that enabled nurses to learn together and draw on the collective wisdom, insights and experiences of the group. ■■ Expose nurses to current thinking on leadership for quality improvement and support them in putting the 6Cs into practice. ■■ Facilitate deep reflection about, and scrutiny of, the effect and outcome of individual actions. ■■ Enhance the skill and effectiveness of senior nurses by providing leadership development interventions that were effective and grounded in best practice. ■■ Promote multidisciplinary and cross-organisational learning about leading change to improve overall quality of patient care. ■■ Demonstrate to each organisation how investing in senior nurses is worthwhile and reaps rewards. The programme was run in each of the four NHS England regions, North, Midlands and East, London and South, between March and May 2014. In each of the four NHS England regions 30 places were available, giving a total of 120 places, however, 117 nurses participated. Applications exceeded available places by a factor of three to one. A selection process was devised to ensure maximum diversity of settings and services in the learning community to maximise the richness of the experience. Participants included experienced and newly appointed clinical leaders. Medicine, surgery, acute specialties, community services, mental health, emergency departments, hospices and care homes were represented. Figure 1 presents the distribution of participants across service types. Concerns have been raised about the disproportionately low number of nurses from black and minority ethnic (BME) groups in senior positions (Kline 2014). Ensuring access to appropriate leadership development opportunities is vital to address this disparity. In 2013, only 4% of recruits to the NHS Leadership Academy’s nurse leadership programme were from a non-white background NURSING OLDER PEOPLE
Figure 1 Distribution of participants across service types (n=117)
20, 17% 12, 10%
61, 52%
25, 21%
Acute Mental health Care homes/ voluntary Community
(Kline 2014). In contrast the enabling compassionate care in practice programme achieved significant representation from BME nurses. Table 1 presents BME representation across all venues and each region.
Evaluation Evaluation forms were completed by 95% (n=111) of participants and these data were augmented by a whole group discussion session on the final afternoon. Participants spoke and wrote enthusiastically about the programme and what they thought it had enabled them to do. Four themes emerged from an analysis of these spoken and written comments: ■■ Increased knowledge, understanding and practical application of the 6Cs. ■■ Gaining the courage and confidence to lead. ■■ Getting back in touch with core nursing values. ■■ Delivering change in practice. Increased knowledge, understanding and practical application of the 6Cs Participants explained how the programme had helped their, and in turn their team’s, understanding and implementation of the 6Cs: ‘This course has now equipped me with the required skills and knowledge to implement the 6Cs in improving quality of care to my ward’ (South, P41). Table 1
Black and minority ethnic representation
Venue
BME representation
All venues (n=117)
31, 26%
London (n=27)
16, 59%
North (n=30)
3, 10%
Midlands and East (n=30)
4, 13%
South (n=30)
8, 27%
October 2014 | Volume 26 | Number 8 27
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | evaluation xxx Participants reported feeling reinvigorated and brought back in touch with their core values and why they had entered nursing In particular the programme had helped participants develop creative ways of making the 6Cs real to their teams: ‘I felt I needed to bring the 6Cs from the abstract into reality in my team. We had a team meeting planned during the following week and with the team I asked them to think of any care they had delivered to patients during the previous two shifts and how this demonstrated the 6Cs. ‘The team were enthusiastic and very engaged. We now have “The 6Cs are live!”, each “C” was highlighted and the team gave examples to each one. Feedback from staff is that they appreciate what each other have done – and what their own values are. On the back of the session in the programme myself (band 7) and band 6 team members have thought about what as leaders we need to provide to support the rest of the team in ensuring the 6Cs are in practice. This is to be our “leadership pledge” to the team’ (South, P33). Discussions enabled participants and their teams to further explore how to improve quality of care. Gaining the courage and confidence to lead Participants reported that they understood better how to lead as a consequence of the programme: ‘I have been able to look at myself as a leader in my organisation and look at ways of moving forward. I have become more assertive in my working environment in regards to empowering staff in embracing the 6Cs. ‘It has been challenging and complex due to the ever-changing staff/bank agency that I work with. It has been difficult to have continuity of care with the volume of staff that are coming through the ward. The only constant people are the locum doctors, ward clerks and a small number of substantive staff. As a small team we have concentrated on nutrition and hydration using hydration bottles for those patients who cannot manage to drink themselves. I have gained a voice and I have used that voice in the best interest of my staff and patients to ensure care is delivered in a timely fashion. I am looking at myself and what my future is in the organisation I work in. I am changing as a person as my thinking is changing on my role’ (Midlands and East, P71). The words ‘courage’ and ‘confidence’ often recurred in participants’ spoken and written 28 October 2014 | Volume 26 | Number 8
accounts. They emphasised how the programme had increased their courage and given them the confidence to challenge practices and individuals – junior and senior, nurses, other members of the multidisciplinary team and managers – that were not reflecting the values of the 6Cs. Participants attributed this gaining/regaining in courage and confidence to lead to the programme enabling them to have a better understanding of themselves and the perspectives of others around them. This increased self-awareness, along with the practical tools they had been introduced to, reportedly increased their effectiveness in implementing change. Getting back in touch with core nursing values Participants reported feeling reinvigorated and brought back in touch with their core values and why they had entered nursing: ‘Discussions with the tutors and the workshops sparked a small flame inside of me, waking me up from the robotic individual I had developed into. I realised I had the skills but they needed to be revised and refreshed in order for me to do my work efficiently but with compassion and empathy. This workshop was a valuable tool helping with my nursing leadership and managing the 6Cs’ (South, P46). The opportunity to mix with nurses from a wide range of settings and services was also thought to be beneficial in enabling them to reconnect with nursing values: ‘The opportunity to meet other nurses/practitioners from across multiple NHS and private hospitals/homes has enabled me to feel privileged being a nurse and that we as a group can change practice by challenging poor practice/ dogma by being able to find solutions and support from a wider skill mix of people’ (South, P46). Delivering change in practice Most participants were able to provide examples of what they had changed as a consequence of the programme. These varied in scale, scope and focus but all were likely to have a positive effect on care for frail older people. Some were still in the planning stages. For example, one participant was intending to implement post-discharge telephone calls to patients to check that they understood their medication, that their care package had started and to answer any queries or concerns they had. Others had already started. One participant from the North region explained how she had been inspired to provide special bags and boxes in which to return jewellery to relatives after a loved one had died in intensive care and that NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
this idea was now being implemented across the trust. Another from the Midlands and East region had involved her team in changing practice to ensure that patients were being weighed. Participants wrote and talked evocatively about feeling empowered and more able to make changes for the benefit of patients: ‘As a result of this programme I introduced the “Good morning smile” (GMS) project to our office. The nurses were feeling demoralised and overworked. This was evident and showed in an increased sickness rate. The GMS was simple – on entering the office you had to smile and say loudly “Good morning everyone.” This prompted responses from other staff and often brought a little cheer to the day and helped to change the mood in the office’ (Midlands and East, P67). ‘I have created a ward where my patients are dressed in their own clothes and washed in their own toiletries and do not wear pant (netty) and pads unless they are assessed and are incontinent. Instead patients are regularly toileted. With my team we have created a patient and relative family information leaflet, asking for relatives to bring day and night clothes, plus toiletries. Dirty clothes are put in a bag that dissolves in the washing machine. We have donations of clothes and toiletries for patients who don’t have relatives. I now intend to carry this change out across the trust. My biggest challenge yet!’ (London, P96). Participants’ feelings of empowerment were being translated into practice improvements and enabling them to take an empowering approach with their own teams with positive results: ‘One success story – small plated meals for patients. Discussed with catering and colleagues; now successful in achieving small meals. Patient food diary has indicated that more food has been eaten than previous. Food more attractive and less portions have enabled patients to eat more. Perseverance is the key word. I will continue to put the 6Cs into practice’ (South, P47). Participants particularly valued being introduced to practical skills such as quality improvement techniques and a co-consulting process that they could use in their own workplaces to support them in changing practice: ‘I went back to my workplace after the two days and used the simple theory of change we looked at and asked my colleagues to use it to plan for a very small change they would like to implement for themselves or for the ward, bearing in mind the 6Cs. Their plans were included in their appraisal. I used the co-consulting process to assist during supervision in order to find out NURSING OLDER PEOPLE
what sort of support was needed. Plans have been amended regularly. I have used the leadership skills I learnt to support colleagues. I am pleased with the increased commitment my team have shown’ (London, P93).
Discussion The challenges encountered arose from the logistics of running a programme that covered vast geographical areas, which meant some participants were travelling long distances. However, having participants from a large number of different trusts added hugely to the learning, as did ensuring representation from a range of services and specialties. It is clear there is a significant unmet need for such programmes given that we were inundated with applications and oversubscribed by a factor of three to one when admissions closed. The residential nature of the programme was important because it enabled participants to bond. This in turn promoted the development of robust networks and maximised opportunities for sharing good practice. Even though this element added to the costs it proved effective. This programme was designed to enable nurses at bands 6 and 7 to lead in a way that was likely to foster compassionate care. Demonstrating the effect of leadership development on practice is difficult. The evaluation is based on participants’ own reports of the changes they experienced and the changes they made in practice, rather than the views of their colleagues or patients. The brief was to develop and test a short, intensive and practical development programme grounded in and designed around the 6Cs and much was achieved in just three days of face-toface contact. Participants suggested, however, that a further follow-up day six months later would have been beneficial because it would have given them the opportunity to embed the practice changes they were leading. Participants’ comments in the classroom, their written reflections and completed evaluation forms indicated that they thought the programme had had a significant effect on them and their leadership practice. The overarching aim of the programme was to provide a space in which senior nurses could explore with others how they could best lead to
Participants valued being introduced to practical skills such as quality improvement techniques and a co-consulting process October 2014 | Volume 26 | Number 8 29
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | evaluation enable high quality care for frail older people. This was achieved through the programme design which, along with formal input on quality improvement and managing change, involved participants working together in many differently constituted small groups and ensured opportunities for informal conversations over lunch and dinner. It enabled the nurses to draw on the collective wisdom, insights and experiences of the group and promoted cross-organisational learning. Identifying the elements that make a programme successful is also difficult, however, the following seem to have been significant: ■■ The facilitators who co-designed the programme were all highly experienced, had been nurses and worked extensively in the health sector enabling the interventions to be grounded in practice. ■■ The programme design reflected a philosophy of adult and experiential learning that assumed a rich mix of experience, knowledge and competence and recognised the existence of individual learning styles and preferences. ■■ A fundamental belief informing the programme that the role of today’s nursing leaders is to enable their teams in partnership with patients and their families to ‘co-produce’ compassionate care. ■■ Careful selection of content to increase participants’ understanding of context, their practical skills and their personal and relational development. ■■ Recruiting a diverse group of participants from a wide range of backgrounds, disciplines, services and sectors.
Conclusion Despite its brevity, this programme appears to have had a significant effect on participants and the care frail older people are likely to receive in their services. The programme was well evaluated by participants who reported increases in their: knowledge, understanding and practical application of the 6Cs; self-awareness and understanding of others; courage and confidence to challenge; and sense of power, enthusiasm and ability to make changes. Participants also particularly valued being introduced to practical skills they could use to enhance their leadership roles and benefited from being exposed to staff from a range of different organisations and services. Perhaps most importantly, given public concern about nursing having lost its way, participants reported feeling more at ease in their leadership roles and being reinvigorated and brought back in touch with why they entered nursing: ‘I have been able to reflect on why I came into nursing in the first place, took myself back to basics and remembered the service user at the heart of my practice at all times. Sometimes other things take over and you forget the basic things that motivate you and your team. I have developed myself personally in terms of learning about myself and how I impact on my team, equally how they impact on me.’
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References Coward R (2013) Why Have so Many Nurses Stopped CARING? An Investigation into the Crisis-hit NHS. www.dailymail.co.uk/health/ article-2275943/NHS-Why-nurses-stoppedCARING.html (Last accessed: August 29 2014.) Department of Health (2014) Hard Truths. The Journey to Putting Patients First. DH, London.
Department of Health and NHS Commissioning Board (2012) Compassion in Practice. Nursing, Midwifery and Care Staff Our Vision and Strategy. www.england.nhs.uk/ wp-content/uploads/2012/12/compassion-inpractice.pdf (Last accessed: August 29 2014.) Hay Group (2006) Nurse Leadership: Being Nice is not Enough. www.haygroup.com/downloads/ uk/Nurse%20leadership%202012.pdf (Last accessed: August 29 2014.)
30 October 2014 | Volume 26 | Number 8
Kline R (2014) The ‘Snowy White Peaks’ of the NHS: a Survey of Discrimination in Governance and Leadership and the Potential Impact on Patient Care in London and England. Middlesex University, London.
Siddique H (2012) Nurses Told to Focus on Compassionate Care. www.theguardian.com/ society/2012/dec/04/nurses-compassionatecare (Last accessed: August 29 2014.)
Royal College of Nursing (2009) Breaking Down Barriers, Driving up Standards. The Role of the Ward Sister and Charge Nurse. RCN, London.
NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 21, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
