Developing Practice to Improve Ward Culture: "Back to Basics"

Keywords: Ward culture, leadership, teamwork, managing change, patient centred care

Duration of Project: February 2006 - August 2007 Report submitted for publication: February 2009

Project Leader: Chrystal Fox, Deputy Director of

Project Team: Lib Jones, ; Helen Davies, Ward Manager; Lucy Power, Ward Sister; Moya Bolton, Staff Nurse

Contact Details: [email protected]; [email protected]; [email protected]

Summary of the Project The Matron identified an increasing number of complaints about nursing care and attitudes, also problems with staff recruitment and retention, high sickness levels and low staff morale. Initially the nursing team did not acknowledge that there was a problem, considering these issues were the norm. However, working in partnership with senior management, analysing data, developing self awareness, reflecting on practice and "looking through the patients’ eyes", the team concluded that care was given in an untidy, cluttered environment and not up to the standard they imagined. Through transformational leadership and effective communication the culture of the ward was challenged and by managing change using simple tools and techniques the ward team developed and changed their practice. The ward now provides "patient centred care" taking into account individual needs and preferences and respects the rights of not only the patient but of the families and carers. The culture of the ward has changed from "we’ve always done it this way" to a culture that embraces change as the way forward to consistently improve the patient experience.

Background Concerns about the standards and quality of care on an acute orthopaedic ward had been raised by the Matron and Deputy Director of Nursing, particularly the increasing number of complaints regarding staff attitudes, behaviour and inadequate nursing care.

In 2005 the Deputy Director of Nursing was successful in an application to the Foundation of Nursing Studies Small Projects Programme and secured support for a healthcare improvement project on the ward.

Meetings between the Deputy Director of Nursing, Matron and senior nursing staff identified that central to the problem was the ward culture and it became clear that the healthcare team needed to go "Back to Basics" i.e. making the

1 patient the centre of care and review how the healthcare team needed to change their behaviour to improve the patients’ experience of care.

The NHS Plan (2000) reinforced the importance of getting the basics right and improving the patient experience. The Essence of Care, first introduced by the Department of Health in 2001, suggests that all healthcare workers take a structured approach to patient care, enabling them to identify good practice and develop action plans to remedy poor practice.

Project Focus The focus of the project was to examine the culture of the ward by reviewing and addressing the fundamentals of nursing care by analysing and reflecting on our attitudes, behaviours, and practice, with the aim of creating a culture of respect and patient centred care.

Although the ward team recognised the need to reduce the number of complaints, staff felt that it was often the relatives and carers that were critical of the care given rather than the patient in question, and the complaints could sometimes seem petty and unreasonable. The Deputy Director of Nursing and the Matron therefore felt that a "bottom up" approach would be the most appropriate strategy as this would foster ownership of the project, empowering the nursing team to begin the change process.

Preparing for Change Preparing for change required a high level of commitment from the nursing team as this initiative was initially seen as a "management project" which would undoubtedly involve more work without any advantage to an already busy ward.

Adapting to change can be an overwhelming and threatening experience and changing nursing practice in a culture of "we’ve always done it this way" would prove to be a challenge. Although, Moffatt and Dorman (1996) state that nurses must believe that change is possible and begins with them, it is acknowledged that implementing changes into practice can be a complex and messy process (Rycroft-Malone et al, 2002).

The Process It was the intention of the Deputy Director of Nursing that the ward team should take ownership of the project and for the Ward Manager to facilitate the change process. However, the Ward Manager had only recently been appointed and had limited knowledge and experience of leading and facilitating changes in practice.

Manley (2000, 37) argues that "the role of leadership in achieving cultural change is almost indisputable." Similarly, Rycroft-Malone et al. (2002) identify that strong leadership is key to the successful implementation of evidence into practice.

Recognising the need for support, the Matron arranged for the secondment of a more experienced Ward Manager to work alongside the novice Ward

2 Manager for a six month period to assist with the implementation of change. It was known throughout the Trust that this manager had a well established team, had explicit values and beliefs relating to teamwork, communication and documentation, knowing her patients, and was considered a transformational leader.

Transformational leadership combines the ideals of leaders and followers (Sullivan and Decker, 2001) and its focus is to unite both manager and employee and "encourages others to exercise leadership" (p57). The ward staff were conscious that the experienced manager was to model the way, by setting an example and the team’s reaction to this differed, some felt their practice was in question, whereas for others it clarified the need for change.

Preparing the team for change began at a very fundamental level. The strategy utilised by the Ward Managers was to develop a systematic approach to improving practice by "unfreezing" current ways of working, promoting confidence and commitment, therefore empowering staff to challenge and change their actions.

This process relates to Lewin’s (1958) force field model of change which suggests that the change agent must progress through a three step process of: • Unfreezing • Movement • Refreezing

Unfreezing involves being aware that a problem exists. The force field model sees driving and restraining forces acting in conflicting directions within a group or organisation, and to enable change to take place the driving forces must exceed the restraining forces. To enable the ward team to realise that the current practice was poor, it was essential to determine the forces that were driving for change and the forces that were resisting change.

The perceived driving forces were identified by considering complaints, evidence from the Patient Advice and Liaison Service (PALS), the ward culture workshops and staff discussions. These included: • An increase in complaints • An awareness that the problem exists • Poor communication and documentation skills • A need to promote evidence based practice • The current ward culture • The support of the Deputy Director of Nursing and Matron

The perceived resisting forces were: • Staff attitude • Low staff morale • High sickness rates • Lack of teamwork

3 • Reluctance to change existing practice Movement involves acknowledging that problems exist and looking for solutions. To achieve this by using a "bottom up" approach, a series of meetings were arranged to collect and discuss data relating to current practice to raise awareness of the need for change. All staff who were interested were invited to attend and included nursing and healthcare support workers, domestic staff, ward clerks and a chaplaincy visitor. Attendance at the groups varied from approximately six to twenty participants and the activities involved:

• A review of the ward profile i.e. staffing levels, staff sickness, bed occupancy, length of stay • A literature search to define ward culture • Analysis of complaints • Staff and patient interviews • Patient opinion questionnaires • A review of the environment • A review of Essence of Care • A ward culture workshop

This stage proved more difficult than anticipated due to an initial lack of commitment, low staff levels and resistance to accept the need for change, and it took a period of four months to arrange a "time out" day to analyse the data that had been collected.

The following sections outline the data that was collected and the key findings from the analysis.

Literature Search The process of reviewing the literature according to Burns and Grove (1997) includes: • Using the library • Identifying sources • Locating sources • Reading sources • Critiquing sources

This process was utilised, and library resources and nursing journals were accessed continually throughout the review.

Researching the literature, it became apparent that there are many types of culture within healthcare and even more definitions. There seems to be little agreement on how to define culture or how to change it. The Sainsbury Centre Report (2006) and also the HUG Reports of 2001 and 2003, however seemed particularly relevant to this project as they reflected what was trying to be achieved by highlighting several aspects of good acute inpatient care including ward culture and the environment. The Sainsbury Centre Report (2006, p5) states "What a ward feels like is as important as what it looks like, although both are relevant. The culture of the ward is set by the people who

4 work there and the values to which they aspire, good ward culture is shorthand for positive supportive relationships between staff, service users, relatives and carers".

Analysis of Complaints All the members of the ward team were invited to a meeting arranged by the Deputy Director of Nursing and Matron to discuss the nature of the complaints. At this meeting, they shared approximately twenty recent complaints from patients and relatives, primarily about poor staff attitudes. Staff were invited to read out the complaints and as a result, they began to realise that the attitudes and behaviours that were highlighted in these complaints were true reflections of what was happening in practice.

According to Lowson (2003, 32) "Complaints are a way of life, no organisation can avoid them and it is inadvisable to ignore them or belittle them." Complaints in the health service often stem from stressful events that occur when patients and carers feel vunerable and scared (Gunn, 2001). They at times seem unreasonable, but must always be assessed objectively. However, complaints can be stressful for NHS staff too as they may feel they have done their best in difficult circumstances but the only outcome for them is criticism (Lowson, 2003).

From analysing the complaints, the staff acknowledged the vunerability of patients and carers and how staff were perceived by them. The conclusion was that this was unacceptable nursing practice and a complex issue that would require staff to develop innovative approaches and new ways of working to improve patients’ experiences of care.

Patient Discussions Patient and public opinion is now widely used as a means of informing healthcare managers about the perceived quality of patient care. The Chaplaincy Visitor routinely visits the ward on a weekly basis to speak to patients and relatives, and at the start of the project, the Deputy Director of Nursing asked her to invite patients to talk about the care they were receiving and the attitudes of the staff. Feedback from the patients was then given to staff at the discussion meetings. The feedback suggested that the care was adequate for many patients however; some patients found nurses insensitive to their needs and did not appreciate their vunerability.

Preston et al, (1999) found that patients felt comfortable when nurses and other ward staff seemed caring and responsive to their needs. However, when care was viewed as impersonal or dictated by staff routines, patients described feeling anxious, insignificant and powerless, and felt they had to fit into a system that "appeared to take no account of them as people" (p 18).

Since nurse caring behaviours are important to patients and are noticed by patients, additional emphasis needs to be placed on nurse’s interpersonal competence and on the barriers and facilitators to caring (Latham, 1996).

5 Staff Interviews The Head of Education was invited to come to the ward and to talk to staff about their experiences of working on the ward. Approximately fifteen staff were selected on a random basis, according to who was available when he visited the ward. These semi-structured interviews highlighted concerns regarding the ward being chaotic and disorganised, high sickness and absence levels, low staff morale and lack of job satisfaction, with several of the nurses considering leaving the profession. Ruggiero (2005, 254) states that "job satisfaction is crucial to consider when searching for solutions that might increase the retention of nurses at the bedside." Lack of job satisfaction is also recognised as a factor in variables such as, motivation (Khowaja et al 2005) and quality of service and healthcare (Aiken et al 2001).

Patient Opinion Survey "It is becoming common practice to involve users in service evaluation by obtaining their views to help improve patient care, facilities and the clinical environment", (Prichard and Howard 2006, 37). The Trust’s "Your Opinion Counts" survey form was distributed to thirty eight patients (all the patients on the ward at a given time). They were addressed individually to each patient and family, with an accompanying covering letter asking their opinion of the care provided. The letter made it clear there was no obligation to take part in the survey and in addition the letter assured confidentiality and anonymity. We requested any completed forms to be returned, sealed in the envelope provided.

Twenty nine completed forms were received and analysed with mostly positive comments. There were some negative comments which were more typical of suggestion rather than criticism; however, some comments were concerned with the abrasive attitude of nursing staff and named the nurses in question. These findings reflect those of Jacelon (2002) who found that nurses who were memorable to patients tended to be those who were unpleasant in their actions.

Exploring Ward Culture As part of the data collection, approximately ten of the multidisciplinary ward team took part in a creative art workshop to explore their perceptions of the current ward culture and how they thought it needed to change. The staff were asked to work in small groups of their own choosing and to create a picture, or collage of how they experienced the ward culture. The definition of culture that was offered was "the way things are done around here," Drennan (1992). The groups then provided feedback to the large group and the key themes were collected.

The groups were then asked to revisit their collages and make changes reflecting how they would like their culture to be. These changes were also fed back and collected. The key themes to emerge from this session were recorded on flip- charts and reviewed during the afternoon session of the "time out" day held in the Trust boardroom. These included:

• The ward was chaotic and disorganised

6 • It is a noisy and stressful environment • Broken and obsolete equipment stored in a clinical area • Staff feel overworked and undervalued • Nurses run around like "headless chickens" • No time for adequate patient care/interaction • Lack of continuing education/inservice training • Ineffective communication • Inadequate documentation of clinical care

The reality was the ward was dull, outdated and cluttered. Notice boards were inappropriately placed with out of date information, there was no specific storage areas for dressings and equipment, and a lack of team work and poor communication systems led to what the nursing team described as "organised chaos." Documentation in the notes was scanty, with the majority of patient care planning and information scribbled in a diary next to each patient’s name.

Giudelines for records and record keeping published by the Nursing and Midwifery Council (2005) suggest that good record keeping is a mark of a safe and skilled practitioner. Writing accurate records not only ensures quality practice but also safeguards the nurse by providing evidence of his or her professional ability (Dion, 2001).

The findings were agreed as generally reflecting the culture of the ward, the majority of the team now recognised the need for change, and the need for ideas on how to begin the change process.

As a group of people have a wider range of opinions and greater collective knowledge, the team decided on a brainstorming session, this exercise generated a large number of ideas and possible solutions to how we could approach the issue.

Essence of Care Evidence suggests that the benchmarking process is an effective tool to ascertain standards of care. For example, Bland (2001), over a four year period, examined benchmarking scores and found they confirmed improvements in standards of care, highlighting that the system is effective. To assess the present care standards, the Deputy Director of Nursing asked the staff to review any information that had been collected using the Essence of Care benchmarking process. However, the staff identified that although there was a designated link nurse for each aspect of care, there was lack of clarity regarding the role and responsibilities, and there had been no education of the benchmarking process. Therefore, despite its long history and the increasing focus on quality care, we had yet to implement the Essence of Care initiative.

Implementing Change Implementing the change process began with analysing the variety of data that had been collected. The most enlightening results were from the "time out" days and creative art workshops, which were specifically aimed at enabling the ward team to examine current practice and question their

7 attitudes and beliefs.

Despite the strong evidence supporting the need for change, not everyone was receptive to change. This should be expected as resistance is commonplace and can be attributed to fear or a threat to security and inconvenience (Mullins, 1996). However, the data analysis confirmed that the driving forces for accepting the need for change outweighed the resisting forces; the need to change the culture of the ward became evident to the majority of the team.

Reflecting on the evidence, the team concurred that in the past care giving was reactive in nature, rather than proactive and we needed to go "Back to Basics" to improve the patient experience.

Five areas of action were identified for change, which led to the concept of the "Big 5 Plan." This involved reviewing:

• The ward culture • The environment • Communication and documentation • Education and in service training • Patient centred care

The role of strong leadership cannot be underestimated in enabling change and the experienced Ward Manager devised a plan of action to develop the leadership skills of all the ward team. Such leadership development of staff improves the ways that ward work and patient care are organised (Cunningham and Kitson, 2000).

Team Work Effective teamwork is perhaps one of the most important aspects when attempting to improve the culture of a nursing team. Developing effective teamwork takes time, especially amongst diverse groups of people with different personalities, values, ideals and communication styles (Makely, 2005)."By developing an intimate knowledge of the team, the leader is able to manage the relationship between motivation and work performance, thus optimising the capacity of the team to deliver high-quality patient care," (Clegg 2000, 45).

Kimball and O`Neil (2002) are of the opinion that, a thriving healthcare workforce depends on nurse managers valuing the unique contributions of their staff. The experienced manager spoke to the team individually, and taking into account their skills, preferences and abilities, divided the nursing staff into three teams with each team being allocated a section of the ward and a senior staff nurse to lead them. The staff now felt that each team had structure, which is a crucial factor for teams to be effective (Zaccaro et al 2001).

Good leadership is essential for management effectiveness (Scoble and Russell 2003). The manager’s transformational leadership style led to staff

8 feeling empowered and their opinions valued. Transformational leaders invite, listen and value the opinions of all staff, which decreases interpersonal conflict and non co- operative relationships (Stordeur et al, 2001).

Empowering the staff led to increased job satisfaction, motivation and a reduction in nursing hours lost through sickness. Similarly, improving ward culture and a happier environment helps to improve staff retention and reduce absence (Scott et al, 2003).

Environment Photographs of various areas of the ward had been taken by Matron, which left little doubt that the ward’s physical environment required consideration. Seeing the ward through "different eyes" revealed unused and broken equipment stored in the corridors, cardboard boxes blocking fire doors, clinical room cupboards overfilled and untidy with doors left unlocked, clarified the need for improvement.

The Deputy Director of Nursing advocated a "spring clean" day and to achieve this, members of senior management, along with nursing and clerical staff worked together with our team of ward assistants. Workmen from the Trust’s estates department were enrolled to repair, replace or remove damaged fixtures and dispose of obsolete equipment. Cupboards and storerooms were cleared out, items with old packaging, products no longer used and opened bottles were discarded. As a result, a clean, tidy and hygienic ward environment is now the norm and anything out of place stands out. Standards are maintained by each member of the ward team having their own particular area to care for. Checklists for daily cleaning of sluice areas and commodes are in place and audited on a daily basis. This ensures that shortfalls in levels of care can be identified and as such, this process can be defined as a quality improvement process that seeks to improve patient care and outcomes through systematic review against explicit criteria and the implementation of change (National Institute for Health and Clinical Excellence, 2002).

Communication and Documentation There were clear indications from the data that a significant factor in the increase in complaints was due to lack of communication and documentation. However, the team were now of the opinion that promoting effective communication skills was of the utmost importance and the development of a positive nurse-patient and carers relationship was essential for the delivery of quality nursing care.

This was achieved by actually getting to know our patients. The Deputy Director of Nursing asked staff to interact with patients, on a non clinical basis, initially for five minutes each shift. This skill had been lost due to the "busyness" of the ward and had become to be perceived as skiving. Attree (2001) found that patients spoke appreciatively about staff who showed an interest in them as individual people, and staff who "got to know patients as people" (p 460) encouraged more social contact with both patients and relatives. Improving the quality and effectiveness of staff-patient communication and information sharing may be achieved when healthcare

9 professional’s attitudes and interpersonal aspects of caring are perceived as essential attributes and not optional extras (Attree, 2001).

A "tea round" was another initiative introduced to improve communication between relatives, staff and patients and has been a great success. This informal approach involves the ward manager and qualified staff serving tea to encourage patients and relatives to use this time to discuss a variety of issues which they may not do in a more formal setting. Unfortunately due to time constraints this can only take place at certain times e.g. during visiting hours at weekends or bank holidays.

A further initiative to prioritise written communication between ward staff, patients and relatives was the development of an updated ward information booklet. The Department of Health (2003) confirms that effective communication includes the written word. The opinions of patients and relatives in collaboration with staff were applied in devising the booklet and shared decision making contributed to the contents. The booklet contains general information such as shift changeover times, the significance of different staff uniforms, meal and refreshment times, an example of the daily ward routine and an A to Z of the facilities available.

Communication at patient handover was another concern. Due to lack of time, little information was documented in the patient’s case notes but was written in the ward diary instead. As a consequence, handover was given from this source. Currie (2000) identified that often no sources of patient information, such as medical or nursing notes were used to impart information during handover. Considering the professional responsibility to document thoroughly aspects of patient care delivery (NMC, 2005), individual patient documentation should serve as the basis for handover as it identifies what has been done and what needs to be done for the patient. The approach adopted by courts of law to record keeping tends to be that; if it is not recorded, it has not been done, (NMC, 2002).

It is now recognised by the nursing team that good record keeping is an integral part of nursing and indicates good practice and although time constraints will continue to be an issue, record keeping will remain a fundamental aspect of nursing care. The multidisciplinary team now all record information about patients in the same set of notes. As a consequence, the staff are now able to inform relatives about patients who are not in their team and are in a position to reflect on any complaints or concerns by using the entries in the notes. This maintains quality of care and promotes a fullness of knowledge about patients for all care providers involved (Kerr, 2002).

Education and Training To aid in the facilitation of the change process, the need to apply evidence based practice was clear. Reflecting on the diversity of the nursing team with a variety of knowledge and experience, a strategy for work based learning was developed. McKee and Burton (2003) suggest that effective learning leads to effective practice and good clinical practice is closely linked to education (Kenny, 2002).

10

A ward based workshop approach was used, with nurses giving short teaching sessions in their area of expertise. These sessions also gave the opportunity for the nurses to cascade knowledge gained from the link nurse meetings. According to Flanagan (1998), developing educational strategies that promote the use of evidence based practice is achieved through sharing knowledge.

Our experienced healthcare support workers hold a wealth of knowledge regarding the fundamental aspects of care, and this is utilised by teaching newly qualified nursing staff, student nurses and less experienced support workers how to ensure dignity and respect for the patient during their time in hospital or in the event of their death. The ward has one particular support worker who educates all staff on caring for the patient in the last stages of life and how to perform last offices with dignity and respect as this is a particular area of interest and expertise.

Work based learning gave the team the opportunity to benefit from specialist nurses across the disciplines, including infection control, pain management and tissue viability. Currently the tissue viability teaching sessions are on a monthly basis, with others such as pain management on a more flexible timetable.

Repeat of Ward Culture Workshop In February 2007, the ward culture workshop that had been held at the beginning of the project was repeated to explore how staff felt the culture had changed and to identify any changes that still needed to be made. Approximately eight members of the ward team were involved. These included staff nurses, healthcare support workers, therapists, the ward receptionist and Matron. The Deputy Director of Nursing joined the workshop during the discussions. The participants worked in two groups to create collages of how they experienced the ward culture now. The themes arising from these collages were fed back to the group as a whole and captured on a flip chart (see Box 1).

The groups were then asked to re-visit their collages to identify what changes still needed to be made to improve the ward culture. The groups made changes to their collage to reflect these and these were also fed back to the group (see Box 2).

Both groups created collages that reflected a positive and negative side to the current ward culture. However, in both cases the positive outweighed the negative and this was reflected by the use of more pictures and space on the positive side. The collages reflected that although the ward was still very busy, it was now much calmer and there seemed to be more time for both patients and staff. An improvement in the ward environment was also reflected. Teamwork was a strong theme on both collages and the participants identified that there had been improvements in teamwork both at a nursing level but also at a multidisciplinary level. However, in both cases, it was recognised that teamwork could still be improved, particularly in relation

11 to developing a greater understanding of each others roles and perspectives. There was a sense that improvement was going to be a continuous process and that small changes could ultimately make a big difference.

Box 1. The current ward culture

Group 1

Two sides to the creation:

• one positive (more pictures on this side)

• one negative (aspects that could be developed further)

Key themes: • Calm amongst the busyness • Chilled out/relaxed but still learning o There are quiet times and these could still be used more as opportunities to do more for/with patients • Thanks and celebration • Good food • Strong team (multi-disciplinary) • Willing to share • Making time for staff and patients – doing more for patients – proactive • Individuals – make up a team but sometimes stay in their own bubble, need to know more about each others role/expectations • Wheel – connections - now time to explore roles/connections between members of the MD team • Need to pull together as a team – one weak link could affect the team

Group 2

Two parts to the creation: • Positive aspects of culture • Negative aspects of culture – positioned in a corner not taking up as much space as positives

Key themes: • Teamwork – across the centre – patient and ward sister in the middle – teamwork between staff and patients • Sometimes not enough staff but determined to work together • Good food • Bright future • Need to be out with the patients • Still running – but smiling • Ward closure and length of stay sometimes too long • Teamwork made up of individuals MD team don’t always work effectively together – need to develop understanding/be mindful of other work pressures • Calm • Taking a fresh look • Welcoming • A ‘new’ ward – want to be seen as you are now

• Used to be a ‘madhouse’

• Birds – peace, freedom

12 Box 2. Changes that still need to be made to the ward culture

Group 1

• Developing work relationships – all hands on deck • Life never without incident – be realistic about what can be achieved • Continue to break the cycle of having a weakest link – we can do it • Glasses – see things from different perspectives – patients, staff – need to reflect • Communicate – use any spare time to talk, help others • Maintain strength and positive attitude

Group 2

• Small changes can make a big difference – this has worked before, need to continue • Improving working patterns with doctors e.g. ward rounds • Develop further working relationships with MD team • Continuing education process – shared expectations/understandings • Taking control – having a direction – working together – define roles

Conclusion The importance of involving the whole team in a process such as this cannot be emphasized enough. At the beginning of the project many staff were cynical and felt their opinions would not be taken into account, but over time this changed and the ongoing commitment and input from the team has been outstanding.

There is little doubt that the change in leadership style had the greatest impact on the success of the project, the managers took the time to listen to the staff, and considered every member as an integral part of the team. According to Kerfoot (1997), by listening, the leader can obtain a good perspective about the needs, abilities and variables that are conducive to staff satisfaction.

The project has been progressively successful in achieving increased staff retention, reduced absenteeism, increased staff satisfaction, improved multidisciplinary teamwork and patient centred care, all of which have been sustained to date.

In addition, the project has established that nursing belongs to a culture of change, caring and respect and demonstrated how the attitudes and actions of staff can impact on the patient experience. By becoming self aware and reflecting on our practice, practitioners can provide a system that enables the best possible care.

Morrison and Burnard (1991) maintain that, by reflecting on who we are, we can reflect on what we do, and patient centred care becomes a reality rather than an ideal.

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