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Confidence in caring
A framework for best practice
DH InformatIon
Document Best Practice Guidance
roCr ref: Gateway ref: 8012
title Confidence in Caring Project Overview
author Department of Health – CNO’s Directorate
Publication date September 2007
target audience Directors of Nursing
Circulation list Directors of Nursing
Description Confidence in Caring’ Project. A project sought to explore ‘caring’ and also to identify how dignity and caring could be improved.
Cross reference N/A
Superseded documents N/A
action required N/A
timing N/A
Contact details Ros Moore Experience and Involvement – Professional Leadership Room 5E58, Quarry House, Quarry Hill, Leeds LS2 7UE 011325 46063 www.dh.gov.uk/cno
for recipient’s use
Policy Estates HR/Workforce Commissioning Management IM & T Planning/ Finance Clinical Social Care/Partnership
working
© Crown copyright 2008
First published January 2008
Produced by COI for the Department of Health
The text of this document may be reproduced without formal permission or charge for personal or in-house use.
www.dh.gov.uk/publications
2
Contents
1. Introduction 3
2. Some fundamental truths about caring 5
3. What creates confidence? 6
3.1 A calm, clean, safe environment 7
3.2 A positive, friendly culture 9
3.3 Good team-working and good relationships 11
3.4 Well-managed care and efficient delivery 13
3.5 Personalised care for and about every patient 15
4. How to increase confidence in the care you provide 18
5. Leading to create confidence 24
6. Simple rules for staff 27
7. Conclusions 29
8. Resources 30
8.1 Confidence creators 30
8.2 Simple rules to create a confidence action plan 31
8.3 Further guidance and information 33
9. Acknowledgements 35
3
1. Introduction
patient needs and preferences at the centre of care design
and delivery.
Confidence in caring is designed to help nurses, carers
and care planners to do this. It offers a framework
of best practice guidelines to help carers focus on
the issues that matter most to patients and provide
a positive experience for them. It can be used in
conjunction with initiatives like The productive ward
and Essence of care.
The guidelines are based wholly on the feedback and input
of patients and nurses working in acute hospital wards and
were developed by a project team from the Department
of Health, two strategic health authorities (SHAs) and
volunteer ward teams. Patients were asked what gave
them confidence in the care they received. At the same
time, nurses were asked what factors they thought
were central to a positive patient experience. The results
enabled the team to identify a set of five ‘confidence
creators’ which patients and nurses felt were central to a
positive patient experience. Section 3 of this best practice
Providing care in hospitals today is more complex than ever
before. Healthcare has changed, with more technology
involved, more specialist care offered and more complex
patient needs being supported. But the most fundamental
aspects of care remain the same as they ever were:
patients and users expect to be safe and to be treated with
courtesy, respect and kindness. Those basic principles are
vital to ensuring that patients have confidence in the care
they receive.
Healthcare staff everywhere know this, and want to
provide patients with care that meets their expectations.
But recent evidence has suggested that, even though
overall care outcomes continue to improve and overall
satisfaction with nursing remains high, patients – and in
particular, older patients – do not always have confidence
in the care they receive. That in turn can affect their
satisfaction with the treatment they receive and their
future choices about treatment. Given that patients’
experience of care is a core component of commissioning,
quality monitoring and regulation, it’s crucial to put
4
In many cases, the behaviours and steps recommended
will be familiar to nurses and carers. The aim of this
toolkit is to bring all these steps together in one simple
framework that can act as a quick reminder and a source
of new ideas. Because of this, the framework will be
a valuable resource for staff at all levels caring for all
groups of patients.
framework explains what these confidence creators are
and provides some recommended steps that can be taken
to increase patient confidence.
Though the steps themselves are often very simple, putting
them in place might not be so easy. Who is responsible for
the new actions or changed processes? Are new resources
needed to enable nurses to make changes? To help with
this, section 4 of this document suggests a systematic
approach that nurses can take to reviewing, redesigning
and implementing improvements in practice to ensure
that patients and carers have confidence in their care.
Section 5 then looks at how leaders in care environments
can support, encourage and empower their teams to
build patient confidence.
5
2. Some fundamental truths about caring
patients and their families. All of these aspects of care
are interdependent; to be effective, change must be
embedded in the whole system – not just one part of it.
n Although staff know what they should be doing, they
don’t always do it. Standards, policies and competencies
only guarantee what people can do, not what they do
in practice.
n Patients and visitors are constant monitors of quality.
Confidence in care is not just determined by their own
experience. It is determined by what surrounds them
and what they see happening to others.
n Confidence in caring is a two-way thing – staff
must feel able to care with confidence to promote
confidence.
These fundamental truths will come as no surprise to most
carers. But reiterating them here helps to confirm what
matters to patients, and provides the foundations for the
way care can be improved to increase patient confidence.
In the project, there were a number of common themes
that kept being mentioned by participants. These themes
emerged as fundamental truths about caring – things
that nurses, other care staff and patients all agree on.
These truths form a shared understanding of what care
is about today, who is responsible for it and how the
care experience is linked to patient confidence.
n Care today is more complex than ever before, and
patients and teams are more culturally diverse than
ever before.
n Patients and relatives see nurses as the ‘owners’ of the
caring system.
n Nursing is an art and a science: nurses must ‘care for’
and ‘care about’ in equal measure. It takes no more
time to deliver care with kindness.
n Caring isn’t just about what each member of staff
does: it also involves the environment, culture and
history of the ward and team, as well as the way
staff behave and interact with each other, and with
6
3. What creates confidence?
The project identified five ‘confidence creators’ – core
issues that patients care about and that effective carers
seek to deliver. These are:
n a calm, clean, safe environment;
n a positive, friendly culture;
n good team-working and good relationships;
n well-managed care with efficient delivery; and
n personalised care for and about every patient.
Each of these confidence creators is of equal importance:
there is no standard priority among them. What’s more,
they are all interrelated, and all depend on the involvement
of people at all levels of the care system.
n At the organisational level, or at the level of the
clinical area or unit, confidence depends on the means
by which care is provided. The physical features of the
clinical area, the resources available and the overall
culture are vital to patient confidence.
n At the team level, confidence depends on the way care
is delivered, co-ordinated and led.
n At the individual level, confidence can be created
when patients see that individuals have the skills to
do the job and the will to provide the level of care the
patient wants.
In looking at how to improve performance in each of the
confidence creators, the framework identifies potential
improvements in each of the three areas of: means; ways;
skills and will. It doesn’t set out to provide an exhaustive
list, but it does show a wide range of simple and practical
things that carers can do to improve patient confidence.
7
Figure 1: Confidence creators
Patients haveconfidence in caring
Staff are caringwith confidence
Organisation/clinical area/unit
Team
Individual
Skills and will
Ways
Means
A calm, clean,safe environment
A positive,friendly culture
Good team-workingand good relationships
Well-managedcare with efficient
delivery
Personalised care forand about every
patient
3.1 A calm, clean, safe environment
Patients see the ward environment as being a direct
indication of how attentive staff are – not only to them
directly, but to the whole process of caring. They equate
ongoing noise, lack of cleanliness or mess with a lack of
care. Patients told the project team:
‘There was a sweet wrapper on the floor for
ages. If they don’t do anything about those sweet
wrappers, what else are they missing?’
‘I was exhausted – I hardly got any peace at night
due to the noise and activity.’
Confidence is created by keeping the patients’ area quiet
and clean. There are a number of steps that patients and
staff suggested to improve the physical environment, but
perhaps the most fundamental is to look at the layout
of the wards or care environment and see if it can be
changed to reflect the needs of patients, rather than the
organisation or even staff.
8
MEANS – actions for the organisation/ unit/clinical area
n Make sure the entrance to the ward or area is attractive and has welcoming signs
n Ensure that the environment as a whole is well lit, bright, tidy and uncluttered. It should be attractive and well decorated
n Ensure that the whole environment is clean (including the hidden areas, nooks and crannies)
n Keep facilities and equipment well maintained and operating at the optimum level
n Eliminate mixed-sex accommodation
WAYS – actions for the team
n Work as a team to improve the environment
n Minimise unwanted noise in every way possible
n Seek to accommodate preferences regarding location
SKILLS AND WILL – actions for individuals
n Take responsibility for the quality of the environment
n Deal with patient concerns there and then, or take action and then follow up
n Try to look at the environment through fresh eyes every day – ‘walk in the shoes of patients and relatives’
n Remove stocks, supplies and equipment from public spaces and empty bins
n Minimise unwanted noise yourself (for example, by wearing the right footwear) and challenge those – whether they are staff or patients – who don’t
n Tidy up after yourself
n Anticipate patients’ needs and leave personal requirements within their reach
9
One valuable way of engaging patients and making them
feel included – as well as helping them build up friendships
– is to involve them in ward life.
‘Some of the staff would let me take the tea
trolley round. I liked that; it made me feel useful
and it kept me moving.’
‘I wanted to be part of the solution not the
problem.’
This is something that was not only suggested by patients,
but also by some of the experienced nurses involved in
the project. The better relationships staff can have with
patients, the more confident patients will be with the care
they receive. It also means a more pleasant environment
for staff.
‘I like a laugh with the staff and you can tell those
who like it and those that don’t.’
3.2 A positive, friendly culture
Getting the culture right makes a huge difference to
patients’ confidence from the minute they arrive on the
ward. It’s important to be positive, friendly and welcoming
not just when patients arrive, but at the beginning of
each shift too. It helps create an air of professionalism and
gives patients the confidence to talk to staff and to other
patients. It’s something that patients are very sensitive to,
as some of the comments received show:
‘I know in the first five minutes what a ward’s
going to be like. There is a feel to every ward – if
they are not expecting you or no one’s been to let
you know what’s happening within five minutes,
you know there’ll be problems.’
‘Within five minutes of the nurses coming on,
I can tell what the rest of the shift will be like –
sometimes it’s chaotic, and other times it’s calm.’
‘When you met staff on the corridor they
avoided contact – they seemed self-absorbed
and inward-looking.’
10
MEANS – actions for the organisation/ unit/clinical area
n Make the environment as a whole open, welcoming, positive and patient orientated
n Have a unit philosophy, information pack, and care standards. Make them visible and communicate them in a way that people understand. This should include information on how staff will work with relatives
n Structure the environment around the needs of patients
WAYS – actions for the team
n Maintain high energy levels and create a calm, positive and friendly climate
n Work with patients and relatives and/or carers as partners in care
n Handle concerns before they become complaints
n Maintain a set routine for meeting and orientating new or transferred patients
n Deliver the service promised in trust literature or patient information – actions should match words
n Encourage patients and visitors to feel confident about approaching nurses’ stations (or other areas) by making sure that they are welcomed by staff
n Give information to patients in a user-friendly way
SKILLS AND WILL – actions for individuals
n Be outward-looking, and engage sociably with patients and relatives. Acknowledge patients and visitors every time
n Welcome and orientate new or transferred patients within five minutes of arrival
n Help patients build rapport with staff and others
n Value patients and relatives as part of the community and encourage their contributions
n Work in partnership with relatives or carers to agreed standards
11
The way to build confidence is to work together, support
colleagues and resolve any differences of opinion
away from patients. Staff questioned in the project
acknowledged this but also mentioned that, because
teams are more diverse than ever before, this can lead
to different expectations and make it harder to resolve
differences. They asked for more diversity training and
team-building to help with this – which is something
organisations might look to offer.
3.3 Good team-working and good relationships
It’s no surprise too that the project showed how much
patient confidence can be affected by gossip, blame and
lack of co-operation among staff. Patients are sensitive
to relationships, aware of problems and think it is the
responsibility of leaders to resolve them.
‘The nurses were talking about the night staff and
saying how rubbish they were.’
‘It’s the ward sister who really sets the tone,
isn’t it?’
Patients see all ward staff as a team, who should work
together for their care. This is exactly the way in which
most staff want to work too. One of the best ways to
act as a team is to take responsibility for what’s going
on, and if there are concerns, try and help resolve them.
It builds confidence in patients that their information is
being passed on and is available to other team members.
Patients don’t want to hear things like:
‘I don’t know, I’ve not been on duty.’
‘You’re not my patient.’
‘It’s not my job.’
12
MEANS – actions for the organisation/ unit/clinical area
n Provide strong leadership and set clear expectations for staff about positive team-working and relationships
n Sisters or charge nurses should support and enable the team to care with confidence
n Put systems in place to monitor quality and performance against key issues such as responsiveness
n Offer diversity training and support for team-building initiatives
n Ensure that diversity is valued across the organisation
WAYS – actions for the team
n Have someone in charge who clearly manages the team and provides clinical co-ordination
n Be well briefed about patients
n Supervise and coach staff as needed
n Demonstrate positive healthy relationships between colleagues
n Organise and deliver care to maximise the performance of the whole team
n See the clinical area as a whole and work ‘as a team’ not just in a team
n Let patients know who’s who and what will happen at the beginning of each shift
SKILLS AND WILL – actions for individuals
n Be well organised
n Know something about all patients and their general progress
n Recognise different perspectives and reconcile professional differences in private
n Handle conflict well. Never criticise or blame colleagues during conversations with patients, relatives or colleagues
n Strive to improve in all areas of competence
n Support colleagues willingly
n Display loyalty to other members of the team and promote a positive image of the clinical area, colleagues and the organisation
13
Care staff involved in the project were very aware of the
problems of both seeming inefficient and being inefficient.
Several felt that they often spent a lot of time and effort
getting round problems in the short term, but rarely had
the time to look at the way they worked overall – which is
when real improvements could be made. They added that
often it was just small improvements or changes that made
all the difference.
One specific example of this was that, in many locations,
patients felt they had less contact with staff later in the
day. They were often left waiting and found it difficult to
get attention.
‘After I moved down the ward I never saw anyone
after 2pm! Someone would come round with
a drink and tell you to go for your tea but that
was it.’
When this came up in discussion with staff, they
acknowledged that they tend to prioritise their attention
to those who are most ill or highly dependent – particularly
when there were fewer staff on duty. What’s more, because
there are few people around at this time, care staff have
additional administrative duties, such as answering the
telephone. The challenge for staff, therefore, is to be more
flexible in the way they allocate resources and particularly
in the way they spend their time in these hours.
3.4 Well-managed care and efficient delivery
Effective care is not just about people: it’s also about
processes. Care needs to be delivered efficiently, with things
happening on time, staff knowing what they’re expected to
do, and a clear sense of priorities and of someone being in
charge. This puts extra emphasis on leadership as managers
need to plan ahead and take charge during their shifts.
Where delivery doesn’t seem to operate efficiently, patients
become concerned that important aspects of their care may
be missed – as some of the comments received show:
‘Everybody was really nice but there was no
organisation: everybody was rushing about doing
their things but no one seemed to be in charge.
They had no idea of what was happening in the
rest of the ward.’
‘Did they think I couldn’t hear those desperate
calls every night begging people to do an extra
shift? It doesn’t give you confidence!’
On the other hand, patients are immediately reassured by
a visible sense of purpose.
‘If the ward looks efficient, then it is efficient.’
14
MEANS – actions for the organisation/ unit/clinical area
n Ensure that the clinical area looks efficient
n Make leadership visible on every shift
n Keep care planning systems rigorous
n Look at administrative support out of hours so that care staff can be with patients
n Ensure that the unit has up-to-date information for new and transferred patients
n Ensure that documents and beds are named accurately
WAYS – actions for the team
n Have someone in charge who clearly manages the ward and team and who provides care co-ordination
n Assess care delivery methods at every shift, in order to balance staff skills with patient needs
n Review the team’s approach to handling telephone calls and administrative duties out of hours
n Use care plans to guide care
n Communicate with patients regularly and clearly about their care
n Supervise and coach staff as needed
n Proactively monitor all patients
SKILLS AND WILL – actions for individuals
n Be well organised
n Manage expectations and talk to patients and relatives about unanticipated events or pressures, to negotiate priorities
n Know something about all patients and their general progress
n Be well briefed about patients
n Give care and information in a timely, proactive manner
n Do what you’ve promised
15
Patients don’t expect each staff member to know every
detail, but they do expect them to be able to find out
important details when needed.
Caring about patients
Caring about patients is as important as caring for
patients, and how staff behave, look and talk to people
is as important as what they say. Patients expect to be
treated with kindness and courtesy at all times, and also
expect staff to retain an upbeat manner most of the time
and to avoid communicating (consciously or unconsciously)
personal concerns and frustrations in their company.
In general, patients take it for granted that nurses have
the clinical knowledge and technical skills needed to
provide effective care, but were less confident about the
quality of fundamental care and the caring attitudes of
staff. Some patients will say they have received good care
themselves, but that they have seen others not being
cared about as much as they would expect. For example,
patients mentioned to the project team instances of lack of
help with feeding, ignoring calls or expression of distress,
breaches of dignity and privacy, and lack of courtesy. All of
this can dent overall confidence in the care staff.
3.5 Personalised care for and about every patient
Patients are enormously reassured by effective case
management, with a single co-ordinator acting on their
behalf and keeping track of progress. This needn’t be a
doctor: in fact, patients are very happy to have nurses
managing their cases and liaising with doctors and others
on their behalf. But it does mean that the patient’s overall
case should be managed continually and information given
to them proactively.
Though different patients will want different relationships
with staff, the simple fact is that patients feel most
comfortable and confident when staff know them
on a personal level: their family circumstances, living
arrangements and, above all, their concerns. Once staff
know these concerns, they can then work proactively to
resolve them – keeping patients (and their relatives or carers)
informed about their case. Often, just having staff around
to answer questions can help maintain patient confidence
in their overall care, as one of the comments received
illustrates:
‘I expected people to know about me – what my
problems were and what help I needed. Having
a label stuck on your bed is not the same as
communicating.’
16
Others feel that nurses are not as familiar as they would
expect them to be with common beliefs and practices
associated with particular cultures. This project shows
that patients see all of these issues as part of providing
professional care that builds confidence.
‘It’s the whole package: standards, how things are
done. Can you learn that?’
Staff involved in the project all agreed that these were vital
aspects of caring with confidence, but felt that there was
little formal development available in these areas – and
that there were often no methods in place to monitor how
well staff dealt with patients on an interpersonal level. For
example, while things like diversity training are now widely
available to help understand different cultures, there are
some areas where staff felt they didn’t have the right
competencies. The staff who participated in the project
would welcome further training on:
n how to provide care in accordance with functional age
(rather than just physical age);
n how to manage medical deterioration better; and
n how to deal with patients whose behaviour is
challenging.
17
MEANS – actions for the organisation/ unit/clinical area
n Ensure that there is a system of clinical co-ordination
n Locate patients to reflect social as well as medical needs
n Give patients milestones and have systems in place for case management and to provide patients and relatives with daily updates on progress
n Treat care as personalised, rather than being driven by medical condition or specialism
n Put in place a system to monitor and improve the skills to care for patients. This includes a systematic approach to improving age and cultural sensitivity, supporting confused patients, providing acute medical care and managing deterioration
n Put in place a system to systematically monitor and develop the skills to care about patients. This might include random observation and review of care
n Develop training plans for staff based on the outcomes of random observations and review of caring episodes
WAYS – actions for the team
n Make patients and relatives partners in care
n Give behavioural feedback to staff on caring competence
n Agree clear milestones for patients and ensure that all relevant people know about them
n Provide patients with an up-to-date progress report against their care plan and milestones
n Extend caring to relatives and carers
n Proactively monitor all patients
SKILLS AND WILL – actions for individuals
n Provide care that is culturally sensitive to age, social class, regional or group affiliation as well as ethnic, religious or national origins
n Stick to the simple rules of caring; praise good care but always challenge the lack of caring
n Ensure that fundamental care is provided: appropriate food and drink should be available for all patients, and help provided for those who need assistance with eating and drinking
n Actively engage with patients in order to prevent problems or anxieties – there’s no need to wait for requests or problems to arise
n Demonstrate high levels of knowledge about medical conditions, diagnosis, treatments and care
n Have a solid grasp of individual patients’ backgrounds, needs and progress, particularly in terms of their treatment and care milestones, and accommodate individual differences
n Show interest in patients and anticipate their needs
n Make a personal connection with patients and relatives and make decisions on personal care jointly with them
n Obtain consent for any intervention or interaction including permission to enter or approach patients’ personal space
n Protect the privacy and dignity of patients at all times: maintain confidentiality when caring, so that no one overhears conversations with, or about, patients
n Perform all tasks or procedures – no matter what they are – with courtesy, respect and kindness
n Anticipate and minimise patients’ feelings of anxiety, worry, anger, embarrassment, pain or discomfort
n Accept negative as well as positive responses and provide emotional support
n Attend to spiritual needs
n Be smart and well presented, and demonstrate professional behaviour at all times
n Be a role model for healthy living
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4. How to increase confidence in the care you provide
Clinical benchmarking has shown that by paying attention
to these issues and making small, targeted changes in
the way care is provided, hospitals can make enormous
improvements for patients. To help with this process, this
section provides a systematic approach to assessing and
then improving care. This approach consists of five linked
stages, as Figure 2 on page 19 shows.
For many nurses, carers and managers, the confidence
creators in section 3 will have come as little surprise. The
actions suggested are exactly the sort of things good staff
already do; in fact, most of the actions come directly from
staff input. But there are still far too many instances where
these simple things outlined above aren’t taking place on a
systematic or habitual basis.
19
Figure 2: Introducing a systematic approach to assessing and improving care
Stage 1Identify what
creates confidence
Stage 4Identify suitable
interventions
Stage 5Implement
interventions
Stage 2Examine the
existing care system
Stage 3Compare yoursystem with
known confidencecreators
20
Stage Suggested steps
1. Identify what creates
confidence
n Use the confidence creators identified in section 3 as indicators of what gives
patients and carers confidence in general
n Audit patients’ views in your organisation
2. Examine the existing care system To help assess how care in your hospital, ward or team measures against the
confidence creators, collect data on the following:
Clinical area/unit level
n Staff demographics (for example, grade and experience of staff)
n Staff competencies (for example, profile the technical and interpersonal
competencies of staff)
n Care system (for example, using the Essence of Care* benchmarks)
n Work activity (for example, how staff use and organise their time, how staff
deliver care, etc)
n Patient satisfaction (for example, by assessing achievement of the confidence
creators using a validated satisfaction tool from the local organisation)
n Patients’ and users’ views (for example, using complaints and compliments)
* Department of Health (2001). Essence of Care: Patient focused benchmarking for healthcare practitioners.
21
Stage Suggested steps
2. Examine the existing care system
(continued)
Team level
n Teams’ perspective of care (for example, using workshops where staff visualise
and analyse the caring system)
n Wider team effectiveness (for example, conducting 360º review, taking in the
perspectives of patients, staff and colleagues)
Individual level
n Staff satisfaction (for example, using a questionnaire validated by the organisation)
n Random observations of staff, with comparison of working practices with
confidence creators and the ‘fundamental truths’ about caring (see section 2)
and the ‘simple rules’ (see section 6).
Much of this data might already be collected elsewhere in the organisation. There’s
no need to duplicate the process, or to be too exhaustive about what data you get –
the aim is to ensure that you have a big enough picture to understand what you and
your staff are doing well, and where you could make improvements.
22
Stage Suggested steps
3. Compare your care system with
known confidence creators
Once you’ve got data about the care system in your organisation or team (stage 2),
you can then compare that data with the known confidence creators and patient
views (stage 1) to identify what aspects of your care system improve confidence and
what aspects diminish confidence.
Some key questions to ask include:
n Does your staff profile reflect the needs of the patients?
n How well do you match care capacity and capability with care demand in a
dynamic way, considering all patients?
n Do the technical, interpersonal and cultural competencies of the staff reflect the
needs of the patients?
n Do the staff have the skills to deliver those activities that affect patients’ and
carers’ confidence in care?
n Does the care environment reflect what patients and carers view as giving
confidence?
In addition, there will be specific questions that reflect your care system and the type
of care you provide.
23
Stage Suggested steps
4. Identify suitable interventions Once you have identified where you can make improvements, the next step is to
work out what interventions might be suitable.
n The best results generally come from discussing potential interventions with the
team, so that they can offer their input on what might work and take ownership
of particular areas for improvement.
n There are lots of sources of information on potential interventions, including:
– the actions suggested in section 3
– the leaders’ ‘dashboard’ in section 5 below
– Essence of Care
– the new Clinical Benchmarks for the Care Environment
– Releasing Time to Care: The Productive Ward
– practical training programmes such as Being with Patients
(See section 8.3 for references.)
5. Implement interventions The most effective interventions are highly targeted to specific issues locally. It’s good
practice to measure the impact of your interventions a few weeks and months down
the line.
24
5. Leading to create confidence
4. Routinely assess the caring system using the
Confidence in Caring framework, monitoring efficacy
and taking action where necessary. This demands
involving patients and carers in their care and in
reviewing and improving the caring system.
5. Use the guidance in Releasing Time to Care:
The Productive Ward to improve efficiency and
effectiveness on your wards.
6. Use Essence of Care clinical benchmarks to monitor
and improve fundamental care.
7. Ensure that each shift has a strong co-ordinator who
is a good role model for staff. The shift leaders can
match care capacity with care demand.
8. Agree realistic objectives for improvement and
communicate these to staff.
Care leaders have a vital role to play in creating and
retaining confidence in caring. Effective leaders not
only set the tone for their staff but also put in place the
processes and systems needed to give patients confidence
in the care they receive and give staff confidence in the
team they’re working with.
Based on the confidence creators identified by staff and
patients, a list has been developed of key ways that leaders
can influence the care environment to build confidence
from patients and staff:
1. Provide strong, visible clinical leadership with effective
management.
2. Agree a clear vision for the caring system with
stakeholders and set standards and targets for
confidence creators.
3. Foster a culture that empowers, values and is
respectful of staff.
25
9. Make sure that Knowledge and Skills Framework
profiles are in place for all staff. The sister or charge
nurse should then be aware of the strengths and
development needs of themselves, their team and
individuals. This should include measuring and
developing caring skills and attitudes to patients,
as well as technical or medical knowledge.
10. Always look out for new ideas around leadership and
best practice in hospital management. For example,
one source of ideas is the Magnet Recognition
Program used in many hospitals in the US
(www.nursecredentialing.org/magnet).
Effective leadership will have an impact at the
organisational level, on teams and on individuals. The table
on page 26 shows the characteristics of care environments
where leadership is effective and can be used as a
‘dashboard’ for leaders to assess their performance.
26
MEANS – how effective leadership impacts on the organisation/unit/clinical area
n Staffing levels are matched to care demand
n The environment is patient centred and promotes confidence for patients and staff
n The right equipment is available to meet patients’ needs
n Administrative and customer care services are in place at key times
n Systems are in place that proactively provide information to patients (as appropriate)
n Systems for co-ordinating care and/or case management are in place
WAYS – how effective leadership impacts on the team
n People follow the ‘simple rules’ (see section 6) and take action to increase confidence in caring
n Care delivery methods respond dynamically to changes in care demand and support timely, effective and personalised care
n Caring is part of the recruitment process and is assessed at selection and beyond
n Capability gaps are identified, monitored and resolved
n Confidence in caring is a routine part of induction for permanent staff
n Staff receive periodic education, training and development to promote confidence in caring (e.g. cultural sensitivity, human rights, care for older people, and assessing and managing life-threatening symptoms)
n Observation and review of care is routine
n Staff are supervised appropriately
SKILLS AND WILL – how effective leadership impacts on individuals
n Skill profiles are matched to care demand
n The sister or charge nurse is a good leader with practical management skills to ‘make real’ the vision
n Ward and shift leaders have frontline leadership and management skills
n Care delivery staff have self-management and leadership skills at the point of care
n Staff have the right knowledge, skills and attitudes to care for patients and relatives in a personalised way
n Skill profiles are matched to care demand
n There is commitment to a shared vision for caring and staff take collective responsibility for achieving this
n All staff understand and respect human rights and they are committed to the caring ethos
n Staff appearance and personal approaches promote confidence
n Staff place patients and users at the centre of decisions and actions
Overall outcomes and performance measures
n Care is moving towards standards and stated best practice (as set out in Essence of Care, for example)
n Nurse-sensitive indicators, local key performance indicators and audits show positive outcomes
n Patient satisfaction scores are improving and show that people are being cared for and being cared about in equal measure
n Complaints are within organisational limits and the number of compliments is rising
n Team questionnaire results show high levels of satisfaction
n Attrition rates are within agreed limits and people are applying for jobs
n Student satisfaction is at appropriate levels
n Observations and care review show the simple rules being followed consistently
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6. Simple rules for staff
Although there are lots of possible actions that can be
taken, these simple rules can be used by all staff as a
quick reminder of everyday actions that create confidence
among patients. The list was put together based on
the feedback and can act as a quick reminder or basic
guidance in any caring environment at the beginning of
every shift.
n Welcome, orientate and introduce new patients.
n Give patients, relatives and the situation your full
attention.
n Get to know people and help them to get to know
each other.
n Improvise together: tell patients and families what is
happening and, where appropriate, let them help.
n Anticipate and act without being asked.
n Do what you say you will do – keep promises.
n Respond quickly.
n Make sure that patients have essentials within reach.
n Stay alert: know what is happening across the
clinical area.
n Notice and correct clutter, dirt, litter and stains.
n Minimise unwanted noise in every way you can.
n Look smart and professional, be a good role model
for health.
n Be seen.
n Keep the mood upbeat, friendly and calm.
n Learn about cultures you are likely to meet.
n The person in charge must act with authority.
n Practise good teamwork.
n Show loyalty and respect for all colleagues and
the organisation.
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n A champion who puts their interests first and protects
them when they are vulnerable.
n A co-ordinator who is constant, accessible and
accountable for communicating the plan and
monitoring the delivery of care. Patients want to know
that there is someone who is proactively managing the
care journey and who orchestrates interventions from
various caregivers, disciplines and agencies.
Finally, always remember what patients want from
healthcare providers:
n A care provider who looks and behaves professionally;
is caring, competent, knowledgeable and
compassionate; and provides personalised, holistic,
timely, seamless care and information.
n A care partner who works with patients and relatives
to plan care, gives constant feedback and reports,
and helps them to navigate the health and social care
system.
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7. Conclusions
The guidance in this best practice framework is intended
to be just that – guidance. It offers suggestions on how
nurses and other healthcare workers can change their
behaviours and put in place new processes to help build
patient confidence.
What happens between nurses and patients is often the
benchmark against which the rest of the organisation,
and indeed the NHS and healthcare system as a whole,
are judged. By following these rules, nurses and carers
will help give their patients confidence in the care they’re
receiving – and so increase confidence in the overall
healthcare system.
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8. Resources
In this section, you can find a set of resources to help you increase confidence in caring in your workplace.
8.1 Confidence creators
Means, ways, skills and will for creating confidence in care, caring and care systems
How confidence can be created through the means by which care is provided
in the organisation, clinical area or unit
How confidence can be created by the team and the
way care is delivered, co-ordinated and led
How confidence can be created through the skills
and will of individuals
A safe and clean environment
The following are in place: The team acts to: The individual acts to:
A welcoming culture The following are in place: The team acts to: The individual acts to:
Good team-working The following are in place: The team acts to: The individual acts to:
Well-managed and efficient care delivery
The following are in place: The team acts to: The individual acts to:
Personalised care for and about every patient
The following are in place: The team acts to: The individual acts to:
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8.2 Simple rules to create a confidence action plan
Simple rules to create a confidence action plan
Key objectives for team Action Who’s responsible Progress report
All new patients are oriented to the ward
‘Meeting and Greeting Week’ Healthcare Assistant Smith Start 24 July
Give the person and the situation your full attention
Get to know people and help them to get to know each other
Improvise together: tell patients and families what is happening and, where appropriate, let them help
Anticipate and act without being asked
Do what you say you will do – keep promises
Respond quickly
Make sure that patients have essentials within reach
32
Simple rules to create a confidence action plan
Key objectives for team Action Who’s responsible Progress report
Stay alert – know what is happening across the clinical area
Notice and correct clutter, dirt, litter and stains
Minimise unwanted noise in every way you can
Look smart and professional, be a role model for healthy living
Be visible
Keep the mood upbeat, friendly and calm
Learn about different cultures
The person in charge must act with authority
Practice good teamwork
Show loyalty and respect for all colleagues and the organisation
33
There are also a number of reports or tools from other
organisations that may be helpful:
n Age Concern (2006). Hungry to be Heard. The Scandal
of Malnourished Older People in Hospital:
www.ageconcern.org.uk/AgeConcern/Documents/
Hungry_to_be_Heard_August_2006.pdf;
n American Nurses Credentialing Center Magnet
Recognition Program: www.nursecredentialing.org/
magnet/;
n Burdett Trust for Nursing (2006). Who Cares, Wins.
Leadership and the Business of Caring;
n Coulter A (2005). Opinion and Experience: Do they
Concur? Picker Institute Europe report via website:
www.pickereurope.org/Filestore/Downloads/
Populus_What_patients_really_want.pdf
(accessed 22 June 2007);
n East Lancashire Hospital NHS Trust Being with Patients
– a unique programme that empowers healthcare
professionals to understand what it really means to be a
patient: www.beingwithpatients.nhs.uk/;
8.3 Further guidance and information
The following Department of Health publications and
website may be of use to care planners and leaders in
taking action to improve confidence:
n A Matron’s Charter: An Action Plan for Cleaner
Hospitals (2004);
n Assessing the Successes and Impact of the Ward
Housekeeper Role Summary Report (2008);
n Clinical Benchmarks for the Care Environment (2007);
n Healthcare Environment: www.dh.gov.uk/en/
managingyourorganisation/leadershipandmanagement/
healthcareenvironment/index.htm;
n Now I feel tall (2005);
n Privacy and Dignity – A report by the Chief Nursing
Officer into Mixed Sex Accommodation in Hospitals
(2007);
n Releasing Time to Care: The Productive Ward (2007/8);
n Standards for Better Health (2004); and
n Summary of Successes and Impact of ‘A Matron’s
Charter: An Action Plan for Cleaner Hospitals’ (2007).
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n Healthcare Commission (2007). Inpatients. The Views
of Hospital Inpatients in England. Key findings from
the 2006 Survey: www.healthcarecommission.org.
uk/_db/_documents/Inpatient_survey_briefing_note.pdf
(accessed 25 June 2007);
n NHS Estates (2001). Housekeeping. A First Guide to
New, Modern and Dependable Ward Housekeeping
Services in the NHS;
n NHS Modernisation Agency (2003). Essence of Care
Benchmarks. Patient-Focused Benchmarks for Clinical
Governance; and
n The London Network for Nurses and Midwives (2007).
Perceptions of Care. Strategies for Improving the Patient
Experience.
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9. Acknowledgements
Thanks are extended to all those who contributed to the project and gave their time and energy. These include the patients
and carers who attended the workshops; ward sisters and staff; service managers, audit and statistical staff; and colleagues
from local higher education partner institutions.
Project team participants
Project team participants
Department of Health Ros Moore, Project Lead
Deborah Sturdy
Professional Officer, Acute Nursing
Nursing Advisor for Older People
Strategic health authorities Gabrielle Atmarow
Debbie Stubberfield
Daljit Athwal
SHA Sponsor
SHA Sponsor
SHA Project Advisor
Centre for the Development of
Healthcare Policy and Practice,
University of Leeds
Gayle Garland
Jane Mallett
Elaine McNichol
Document production, editing and formatting
36
Project Advisory Board
Anne Benson
Daljit Athwal
Debbie Dzik-Juasz
Debbie Stubberfield
Deborah Sturdy
Elizabeth Jones
Fiona Ross
Gabrielle Atmarow
Joe Nichols
John Badman
John Mercy
Liz Fradd
Rosemary Cook
Ruth Harris
Royal College of Nursing
Nursing and AHP Lead, Leicestershire, Northamptonshire and Rutland SHA
Royal College of Nursing
Director of Nursing, South West London SHA
Department of Health
Department of Health
King’s College London
Director of Nursing, South Yorkshire SHA
Nursing and Midwifery Council
Clinical Governance Support Team
Nursing and Midwifery Council
Service User Adviser
Queen’s Nursing Institute
Nursing Research Unit, King’s College London
37
Project sites
Epsom and St Helier University
Hospitals NHS Trust
Steve Lennox
Jenny Muir
Sharon Hamilton
Board Sponsor
Project Lead
Project Advisor
Mid Yorkshire Hospitals NHS Trust Tracey McErlain Burns
Dianne Edwards
Board Sponsor
Project Lead
Sheffield Teaching Hospitals NHS
Foundation Trust
Heather Tierney Moore
Jane Hopkins
Mandy Abbey
Martine Tune
Board Sponsor
Project Lead
Project Advisor
Project Advisor
St George’s Healthcare NHS Trust Geraldine Walters
Jayne Quigley
Clare Addison
Board Sponsor
Project Lead
Project Team
© Crown copyright 2008 285121 Mar 08
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