Leading change

The Chief Nurse at Guy’s and St Thomas’ NHS Foundation Trust led on the development and implementation of the ‘Nightingale Programme Initiative Committee’. This is a programme of work to increase standardised practice and enhance integration across the ward environments, tackling unwarranted variation identified in practice. This initiative has led to improved experience and use of resources across the organisation.

Where to look

Guy’s and St Thomas’ is a large hospital Trust which advocates and supports ward sisters and charge nurses to feel empowered to lead change. However, at a time of increasing challenges, coupled with increasingly complex clinical environments, the Chief Nurse recognised that their ward model needed modernising. The Chief Nurse identified unwarranted variation in the operating models of the wards, as well as variation in culture and working practices. This was hindering truly integrated working across the wards.

What to change

The Chief Nurse and the senior nursing team identified there was a need to ensure that care provided on the wards was delivered in a consistent and standardised approach. This would facilitate streamlined transition between the hospital wards and would support both staff and patients to feel confident in the environment. It would also enhance multi-disciplinary working across the different wards and specialisms at the hospital. The Chief Nurse and the senior nursing team led a programme of work to support staff to improve efficiency in all aspects of care, as well as ensuring they understood their roles, had the right skills and could work effectively in a ward and hospital team with confidence.

The Chief Nurse recognised this was a complex task and therefore needed a planned, structured approach to meet their three overarching aims:

• To reduce unwarranted variation by standardising practice across the wards;
• To improve patient safety and quality; and,
• To improve patient and staff experience.

How to change

A working group was established, led by the Chief Nurse, to support development and roll out of the programme. This ‘Nightingale Programme Innovation Committee’ included senior nurses from across the organisation, supported by a project manager and the Medical Education team. The programme was launched on International Nurses day and was rolled out to eleven test and learning sites at the Trust. It comprised:

• A standardised set of core tools to support effective nursing handover and communication in the first, middle and last hour of each twelve-hour shift;
• Focus group work with ward staff aided the development as well as the testing and refining of these tools through simulation training;
• An innovative one-day training programme was developed and delivered to 1053 nurses to introduce the tools and strengthen team resilience;
• A drive to foster interdependence, enhance multi-professional working and increase staff satisfaction, thereby enhancing retention of staff alongside sustaining safe patient care; and,
• Team based skills focussed on communication skills, leadership and team membership, decision making and situational awareness that enhances safety and supports quality care.

Adding value

The impact of the programme was measured using a number of key metrics and have led to the following achievements:

Better outcomes A pre- and post-programme evaluation was carried out, to evaluate the impact of the Nightingale Programme on nurses’ enhanced skill set, staff experience and patient reported outcomes. The results showed that the 1053 nurses trained and supported to work differently had significantly improved ‘human-factors’ skills and self-efficacy following training which was maintained after six months. Following training, staff reported they were significantly more likely to “speak up if they noticed something that caused them to be concerned”. There has been an increase in the number of wards reporting partnership working and shared decision making. Patient reported outcomes were compared across matched six-month periods pre- and post-training, highlighting significant improvements in experience of: talking to staff about their worries and fears, staff management of their pain, and doctors and nurses working together.

Better experience – The training on this ward initiative has demonstrated significant improvement in staff learning which translated to staff experience and patient outcomes. Staff responses to the Friends and Family test were compared at matched time points pre- and post-training which showed a significant improvement.

Better use of resources – Although a formal evaluation of the impact of the ward improvement initiative has not yet been undertaken, anecdotally the feedback has been that this has had a positive impact on staff satisfaction and empowered staff to lead system-wide change. From the original cohort of the working group, the Trust now has all 12 Directorates in the organisation represented on the Nightingale Committee, enabling a wider view to practice and a diverse contribution to solutions and actions.

Challenges and lessons learnt for implementation

• Internal communications need to be robust and highly effective to ensure success of the programme. Using social media, web based platforms, board-to-ward level meeting presentations and staff forum have supported shared ownership of the programme;
• Involving a wide and diverse group of staff and patient representatives from across a range of directorates to support a change across the whole system was key;
• Nursing leadership is extremely important: role modelling and coaching was used to support change management;
• Ensure both patients and staff remain central to any change work and that as benefits emerge these are showcased and celebrated;
• Constant review of the programme ensures the programme doesn’t deviate from meeting its targets and goals; and,
• Due to the successes of the programme, the Trust are now embarking on Phase 2 which includes standardising the nurse in charge role and developing a framework for ward away days.

For more information contact

Jo Carter
Director of Nursing – Adults
Guy’s and St Thomas’ NHS Foundation Trust
jo.carter@gstt.nhs.uk

Jeff Whitear
Project Lead
Guy’s and St Thomas’ NHS Foundation Trust
jeff.whitear@gstt.nhs.uk