Analysis

Compassion in Practice model lacked junior nurse buy-in

As NHS England unveiled the details of Leading Change, Adding Value, the new nursing framework for England, an evaluation of its predecessor Compassion in Practice (CiP) revealed some interesting learning points for implementation and success of the new strategy.

As NHS England unveiled the details of Leading Change, Adding Value, the new nursing framework for England, an evaluation of its predecessor Compassion in Practice (CiP) revealed some interesting learning points for implementation and success of the new strategy.

CiP was launched in December 2012, in the wake of revelations about poor care at Mid Staffordshire NHS Foundation Trust between 2005-09, and abuse at Winterbourne View hospital near Bristol in 2011. It was a vision that focused on six core values, the 6Cs: care, compassion, competence, communication, courage and commitment.

Compassionate care

At the time, England’s chief nursing officer (CNO) Jane Cummings said the actions set out in the strategy would ‘change the way we work, transform the care of our patients, and ensure we deliver a culture of compassionate care.’

Helen Allan, professor of nursing at the Centre for Critical Research in Nursing and Midwifery at Middlesex University, London, was commissioned by NHS England to evaluate the strategy. In July 2015, a survey was sent out to 37 NHS trusts in England, 36 participated and researchers obtained 2,267 responses – the majority from nurses and midwives.

The evaluation also used additional qualitative interviews and assessed data from NHS England’s family and friends test, designed as a feedback tool about whether people would recommend the services they have used, the staff family and friends test, and the NHS staff survey.

Professor Allan, who describes her academic role as being a ‘critical friend’ of NHS England, has plans to have the research fully published and the results will make interesting reading.

Among the evaluation findings:  

  • 58% of respondents said they were aware of the CiP strategy
  • 30% said they had never heard of it
  • 11% said they were unsure whether they had heard of it
  • 71% of those who responded said they had no involvement in any aspect of the CiP strategy

Professor Allan explains: ‘We found there was a noticeable difference between senior and more junior nursing and midwifery staff in their awareness of the CiP strategy, involvement and ability to assess its impact. The higher your band, the more likely you were to be involved in one of the programmes to do with the strategy.’

The reasons given by respondents for not being involved were:

  • 65% were not aware of any CiP programmes at their trust.
  • 18% were unsure.
  • 11% said it was down to lack of time.
  • 6% said they were too busy.

The research also showed a variation in awareness depending on the type of trust staff worked for.

‘If they worked in a community rather than an acute or mental health trust they were more likely to be aware of CiP,’ says Professor Allan. ‘That in itself is quite worrying in light of the Francis report, as institutionally poor care and poor care of older people has been exposed across health care and not just in the community.

‘Trusts with the highest level of awareness were mid-size organisations, then larger trusts. The smaller trusts were less likely to be aware.

Communication

‘Middle management and those at a more junior level felt communication could be improved in trusts about the national strategy, along with communication generally. There is a question about whether information is effectively cascaded down from senior management.

Professor Allan says that while the results suggest a large amount of the respondents saw the potential of CiP, those who cited structural constraints gave examples such as high workload, lack of resources and a high amount of paperwork, which takes them away from being able to respond to a strategy which is about delivering compassionate care.

She adds that in spite of a lot of good practice and staff who value the 6Cs, the findings also revealed cultural constraints of bullying and a lack of support for ward-level staff.

Hurt and anger

‘There were a lot of open-ended responses that expressed hurt and anger such as: “You’re telling me I’m not delivering compassionate care, but I’m doing the best I can with my workload”.’

The general method by which nurses and midwives found out about CiP was via email, according to the evaluation.

Professor Allan says: ‘Senior management have much more interaction with emails so maybe trusts need to think about different engagement strategies?

Coproduction approach

‘We would recommend adopting more of a coproduction-based approach, based on identifying what barriers there might be within trusts to implementing a strategy, and inviting staff to take part in action-based change rather than imposing it from above.

‘When staff identify a problem they are constantly going on about, if you offer the option of changing it they will engage; even if it means more work they will respond. The 6Cs was a defensive reaction, partly because it was known what was to come out in the final Francis report.’

Professor Allan says the findings provide nurse leaders with important learning and action points to help them embed the new strategy and ensure its success.

Morale

She adds: ‘The new vision needs to be responsive to all staff, and NHS England should recognise the hard work nurses and midwives are already doing to boost morale at grass roots level, and acknowledge there needs to be a cultural change to tackle policy fatigue, bullying and a focus on targets which can be overwhelming for staff.’

RCN professional lead for acute, emergency and critical care Anna Crossley, says that in order for any new strategy to be embedded, staff need to be supported to conduct their nursing role to best effect.

‘Nurses need sufficient resources, safe staffing levels, time for clinical supervision, the opportunity to debrief and discuss, and to learn with supervision and support. Unless the policy is meaningful and the outcomes are clearly stated, it is difficult for nurses to feel that there will be any benefit in adopting it.’

She agrees that NHS England needs to be seen to support trusts and their staff in delivering high quality patient care, and says this can be done by allowing employees access to training and education and the time to participate.

Spreading the word

Dean of the Florence Nightingale faculty of nursing and midwifery at King’s College London Anne Marie Rafferty says CiP was a powerful communication device.

‘No one could object or complain about any element of the 6Cs and the attempt to try to boost the profession which had become quite demoralised.

It was not a magic wand, but there have been some beneficial effects to concentrate energy and refocus the profession.

‘However, if I was on the front line and under pressure from the system, I could be a bit hacked off if someone came and said to me you have to be compassionate. When you look at all the complexities of the system, saying thank you and acknowledging how difficult it is to get things done and the lengths that nurses go to, is vital.’

Embedding CiP

Liverpool Heart and Chest Hospital NHS Foundation Trust won a CiP award from NHS Employers and NHS England two years ago, and was named as an organisation that has improved experiences of care by embedding CiP into its ways of working.

The lead nurse for patient and family experience and safeguarding, Joanne Shaw, says the trust developed a model for nursing care based around family and patient-centred care.

Initiatives include a care partner programme which allows carers to stay overnight and open visiting hours for all wards, apart from critical care.

‘Nurses were anxious at first, but now they embrace it,’ says Ms Shaw. ‘They are able to give each family more time because everyone isn’t arriving at once.’

Patient shadowing

The trust has also introduced patient and family shadowing, so staff from all areas can observe care from their point of view; from meeting them in the car park and watching how they navigate signs around the trust, to assessing a patient’s postoperative environment.

Ms Shaw says: ‘As nursing staff, we shouldn’t see family as visitors but partners in care to look after somebody.’

Her advice for any trust implementing the new nursing strategy is for the organisation to align the new framework to what it is already doing.

Positive

‘View it as a positive; every member of staff has a role. CiP has not ended for us; we are still trying to embed it in everything we do,’ she adds.

Professor Cummings says that the new framework, which will be for all nursing, midwifery and care staff, represents a ‘great opportunity for nurses, midwives and others who provide nursing care to maximise what we can offer to patients, ensuring we deliver the best possible care now and in coming decades’.

More information

Compassion in Practice 

Leading Change, Adding Value is available at www.england.nhs.uk/leadingchange

 

 

 

 

 

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