Managing Performance Concerns

and Nurses in Difficulty

Patricia Reid

Chief Nurse

Our Workforce

“To really embrace the full and challenging

definition of a good quality patient experience

requires a high quality workforce”

NHS Constitution

Our Workforce

• Need an efficient, compassionate workforce

that is adequate, skilled and empowered

• Need the right behaviours!

Encouraging and reiterating the right

individual staff behaviours is vital…..as

feelings and impressions are as important

as the quality of the product

Our Workforce

However, sometimes things go wrong and

a healthcare professional may find their

practice called into question

What can go wrong?

• Poor clinical practice - frequent mistakes,

not following a task, lack of skills, inability to

cope with instructions given

• Unable to handle a reasonable volume of

work to a required standard

• Poor supervision of the work of others when

this is a requirement of the post

• Acting outside limits of competence

What can go wrong?

• Poor punctuality and unexplained absences

• Consistently failing to achieve agreed

objectives

• A health problem

• Unacceptable attitudes/behaviours to

patients/colleagues

What can we do to prevent this?

• Staff and managers should understand the factors that may contribute to performance concerns

• personal factors

• systems and process issues

• the work environment

• harassment

• Inadequate education and training

• Poor leadership from line manager

What can we do to prevent this?

• Good human resources practice will help prevent performance problems

• Effective recruitment, induction

• Clarity about skills and experience

• training and support

• Clear definitions of roles and accountabilities

• Appraisal (supervision/ongoing feedback)

• Training line managers in effective staff management

Getting the culture right

• Established strong association between aspects of staff engagement and satisfaction and indicators of the quality and costs of care

• Individual staff wellbeing is best seen as an antecedent rather that as a consequence of patient care performance

• Staff wellbeing is a function of good leadership

• Board – a duty to concentrate on the humanity of patient care and not just the timeliness of its delivery

• Patients knowing the values of the Trust and seeing those lived out every day…. consistently from Board to Ward

Getting the environment right

• Right number of staff with the right skills at the

right time

• Optimum organisation of care

• Empowered staff to make decisions

• Rich learning environment

• Encouragement to raise concerns

Getting it right first time - students

• Good Planning on arrival with clarity regarding

expectations on performance

• Monitoring progress against plan weekly with full

review at the halfway point

• Appropriate challenge throughout – you can refer

and fail!!

• Ensuring adequate supervision and a good learning

environment is key

Getting the Leadership Right

• Strong, skilled leaders with first hand knowledge of the system

• Leading at the bedside – provide visible leadership at the place where patient care is delivered

• Compassionate care at ward level - visible to patients and visitors

• Leaders have the time and ability to lead and are held accountable to do so

• Enhancing professionalism – develop knowledge, skills and evidence in our relentless pursuit of excellence

What else can we do?

• Proactively seek and root out poor

behaviours and performance!!

• Highlight poor leadership

Case Study :

Root out poor performance

• 2 wards with performance issues (attitude)

• Both wards had reasonable quality indicators

• Both wards had the poorest patient experience

scores

Case Study :

Root out poor performance

• 2 wards with the highest patient experience scores

• 2 wards with the lowest patient experience scores

• Used a Quality of Interaction (QUIS) to enable us to observe, assess and judge the quality of the interaction between staff and patients on our in-patient wards

Case Study:

Root out poor performance

Quality of Interaction

• Staff interaction with patients and relative

• During personal care, lunchtime, early evening when visitors are present

• Observers are able to follow guidance to ensure similarity in rating

Case Study:

Root out poor performance

The Cup of Tea:

• Positive social

• Basic Care

• Neutral

• Negative

Case Study:

Root out poor performance

• The 2 wards with the highest patient

experience scores delivered a high percentage

of ‘positive social care’

• The 2 wards with the lowest patient experience

scores delivered a high percentage of ‘neutral

care’

Leadership is key!

What did we do?

• Reviewed our approach to managing

performance

• Complexity of healthcare means a single

solution is unlikely to be successful

• Moved one poor performing nurse to a

good performing ward – a transformation in

performance!!

Leadership is key!

• The underlying difference between high and low performing ward managers was found to relate to leadership capability

• The management style of the ward sister was found to be central to the effective organisation of the ward and maintenance of the standards of care, patient experience and performance of staff

Leadership is key!

• Developed the role of the lead nurse for clinical leadership

• Works and integrates with a clinical team to develop, support and direct the ward manager to improve the effective organisation of the ward and their leadership skills

Revalidation will help

• The process whereby registered nurses and

midwives are required to demonstrate to the

NMC that they continue to remain fit to practise

• Promotes greater professionalism and

improves the quality of care through reflection

on the revised code of conduct

• Reinforces a culture of demonstrating capability

Revalidation for nurses

• All nurses and midwives will be revalidated every 3 years

at the point of renewal

• Accountable for their revalidation and required to gather

evidence based on the criteria in the code of conduct

• Have met the required CPD hours

• Have sought and received third party feedback which has

informed their reflection (patients/peers)

• Have sought and received third party confirmation that they

are fit to practice (employer)

Internal Revalidation for Band 7s

• Start with the leaders

• Band 7 revalidation model • Internal leadership course

• Achieve key KPIs

• Appraisal

• Peer and patient feedback

You’ve got it right…..but

• …. poor performance will always exist to a

greater or lesser extent …. so …

• ….. make sure you adopt good practice in

managing performance

Principles of Good Practice

• The overriding principle is patient safety

This must be the primary consideration and

action must be taken to ensure that patients

will not be at risk whilst an assessment or

investigation is carried out.

Principles of Good Practice

• Clear policy for local investigation

• Avoid unnecessary or inappropriate exclusion

of practitioners

• Fairness, consistency and objectivity of

investigation process

• Timeliness of investigation

Leadership is key!!

The best leaders don’t come down harder on

people whose performance is lagging; they

come to their aid…….so

Get your leaders right!