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How can you make your trust the best place to work?

Leaders at two London trusts reveal how they empowered staff to improve practice

Leaders at two London trusts reveal how they empowered staff to improve practice

  • Invite ideas and involve all staff in decisions, not just senior nurses
  • Move away from blame and learn from failure
  • Set up small projects looking at ways to improve staff fulfilment

Left to right: Barts Health NHS Trust chief nursing officer Caroline Alexander at​​ the
Royal London Hospital’s recovery ward with staff nurse and recovery practitioner
Janette Cutin and recovery sister Afinee Tan. Picture: Barney Newman

Four years ago, Barts Health NHS Trust – one of the largest in the country – was placed in special measures after a Care Quality Commission (CQC) inspection found serious failures in the quality of care at some of the trust’s hospitals.

Chief nursing officer Caroline Alexander joined the trust a year later, in 2016. ‘Staff felt very burnt,’ she recalls. ‘They’d had a challenging time and many felt distressed by the situation. Leaders have an emotional responsibility when things don’t go well – we all take it very personally.’

But she also discovered a commitment to turn things around and drive improvements. ‘There were people who knew this organisation could achieve great things,’ says Ms Alexander. ‘When I talk about what they’ve achieved, I get very emotional. I’d say we’re half-way there now.’

‘My gut feeling is that if you do right by your staff it will work out’

Caroline Alexander, chief nursing officer, Barts Health NHS Trust

Key to bringing about change has been a large recruitment campaign, targeting people locally and internationally. ‘We didn’t just have high staff turnover, there were a lot of vacancies too,’ Ms Alexander says. ‘Before we went into special measures there had been a history of severe staff restructuring.’

The trust has improved both induction and preceptorship for newly qualified nursing staff, with more than 93% retention after two years. ‘In London, keeping people even for their first couple of years is notoriously difficult,’ says Ms Alexander.

It has also changed employment processes. ‘They were terrible. People would be hanging around waiting for weeks,’ she says. ‘There’s nothing worse than losing someone who wants to come and work for you, just because you haven’t got your processes right.’


Chief nursing officer Caroline Alexander with nurses at Royal London Hospital's
recovery ward. Picture: Barney Newman

The ‘best place to work’

She attends the trust’s induction programme every month. ‘I always ask how many people have come back,’ says Ms Alexander. ‘And there are always those who have, because they’ve heard things are much better now. I find that very heartening.’

In March she took part in a panel discussion on ‘The best place to work’ at the chief nursing officer for England’s summit, in Birmingham. Among the issues discussed was involving staff in decisions they would traditionally have been excluded from making.

‘In organisations of this size it’s hearing the voice, listening and interpreting,’ says Ms Alexander. ‘I don’t just mean the voice of very senior nurses, but a mix of people from all walks of life, debating and sharing.’

‘When we’re informing policy in the organisation the clinical senate ensures we have the broadest range of ideas, insights and perspective’

Caroline Alexander

Among the ways they have achieved this is through the introduction of a clinical senate two years ago. This brings together nurses, midwives and allied healthcare professionals, ranging from those starting out in their careers to the most senior, to discuss and plan areas such as clinical practice, teaching and learning, workload, documentation and IT.

Ms Alexander describes it as an influencing forum. It meets three or four times a year and is open to anyone. ‘When we’re informing policy in the organisation it ensures we have the broadest range of ideas, insights and perspective,’ she says.

Issues the senate has tackled so far include reviewing the clinical nurse specialist (CNS) role. ‘We’d not dealt with that review very well a few years ago and there was a history of unhappiness,’ says Ms Alexander.

‘I wanted to make sure that we went into this one in the most constructive and positive way, which was about doing right by our CNSs.’


Picture: Alamy

‘Change is best driven locally’

A second example looked at the introduction of e-documentation. ‘Staff were able to influence the design in a way that was much more creative than if they’d just been consulted on it,’ she says.

They also do a lot of smaller-scale improvement work. ‘We know change is best driven locally,’ says Ms Alexander. ‘At the beginning we had some big conversation involving lots of people, but now we have small collaborative projects that might be ward-based or focus on a theme to help get people involved.’

Tips on becoming a good leader

Remember leaders aren’t confined to a role, says East London NHS Foundation Trust (ELFT)  chief executive Navina Evans.

Be yourself, advises Barts Health NHS Trust chief nursing officer Caroline Alexander. ‘Realise you have an impact on other people, just by being a manager,’ she says.

Understand the importance of making staff feel happy at work. ‘We spend such a big proportion of our time here,’ says Dr Evans. At ELFT there are around 40 small projects looking at improving fulfilment at work. ‘Little things, such as a personal thank you, make the difference,’ she says.

Don’t hide behind policies, says Ms Alexander. ‘If you’re not confident in managing a situation, the tendency is to rigidly follow policy, but then you forget the individual.’

Instead, try to understand why people have behaved in particular ways, she advises. ‘Good leadership is inclusive and compassionate.’

See problems as opportunities, says Dr Evans. ‘If you identify a problem, come with possible solutions to try to fix it.’

‘My role is to support and facilitate’

Integral to Ms Alexander’s leadership style is trusting, empowering and enabling others. ‘I’m there in a supportive role, giving them the confidence that they can do it,’ says Ms Alexander. ‘My job is to help you be the best you can be and undo blockages. You and your patients know best what’s getting in the way and often we don’t need complicated change programmes.’

It is an approach that has been influenced by the behaviour of those around her throughout her career. ‘As a leader or a manager it’s understanding the impact you have on other people. I’ve thrived in some environments and not in others,’ she says.

To find out what is happening on the ground, she does regular walkabouts, but never wearing a uniform. ‘Our directors of nursing in each hospital are the figureheads,’ she says. ‘My role is to support and facilitate.’


Chief nursing officer Caroline Alexander at the Royal London Hospital with
healthcare assistant Aniraj Augustine. Picture: Barney Newman

‘We don’t have everything right as yet’

While the trust is now out of special measures, the latest CQC report, which followed an inspection last September, says it still requires improvement. ‘We’re a massive organisation with a history of certain problems and we don’t have everything right as yet,’ says Ms Alexander.

‘For instance, we still have pockets of bullying, among other issues, as most organisations do.’

About a year ago the trust started manager inductions, helping leaders to understand what was expected of them. ‘My gut feeling is that if you do right by your staff it will work out,’ says Ms Alexander. ‘If you know your staff and understand their needs, you’ll be more adaptable and flexible, and you’ll listen and get the best out of your team.’

‘Most of the time when something goes wrong it’s not about the individual but the systems and processes we’ve put in place’

Navina Evans, chief executive at East London NHS Foundation Trust

In contrast, the much smaller East London NHS Foundation Trust (ELFT), with 5,500 staff in total – compared with more than 16,000 staff at Barts, including around 7,000 nurses – has been rated outstanding by the CQC since September 2016.


ELFT chief executive Navina Evans

Yet its chief executive, Navina Evans, told the chief nursing officer’s summit in March that she loved learning from failure. ‘For me, it’s about moving away from blame and who is responsible,’ she says.

‘Most of the time when something goes wrong it’s not about the individual but the systems and processes we’ve put in place.’

‘We don’t want people to be motivated by fear’

As a consequence, she believes it is her responsibility to study what is not working, because she can make the necessary changes, while those closest to the point of care should spend more time focusing on success.

‘It’s reinforcing, because it’s usually the result of someone’s initiative, compassion or kindness,’ she says. ‘We don’t want people to be motivated by fear.’

While Dr Evans welcomes the CQC’s rating she admits it makes her nervous. ‘There will always be patients and staff who say, “Actually, I think you’re pretty rubbish.” So we have work to do.’

‘We’re very focused on improvement and we try hard to be transparent about what’s not working well and needs to change. We give ourselves permission to say this isn’t working, so let’s just stop and do something different.

‘We give ourselves permission to say this isn’t working, so let’s just stop and do something different’

Navina Evans

‘In the past we would just carry on doing the same thing over and over again – but maybe put more effort into it and be even more fed up when it doesn’t work.’

Patients’ contribution is crucial. ‘When we as professionals say "we can’t do that" they just ask why not,’ she says.

Collective ownership and commitment

Dr Evans sees leadership at ELFT as a self-identified role. ‘It’s a given that I’m a leader, but the people who lead change aren’t necessarily people like me, with the title and the power. We’ve tried to develop leadership in the context of collective ownership and commitment.’

Issues she is keen to tackle include bullying and harassment, reported by some staff in the trust’s surveys. ‘It’s really subtle,’ says Dr Evans. ‘But it’s unacceptable.’

To challenge it, all staff are being asked to examine their own behaviour. ‘Are we really being respectful? Are we treating each other with dignity?’

‘People bring their distress to us’

Bringing hope is among her most important responsibilities. ‘Working within health and social care can be hard,’ says Dr Evans. ‘People bring their distress to us. We see people in pain who are frightened and anxious. That’s the job.

‘We can’t have chief executives who talk about how impossible everything is and how there’s no money. We might feel it, but we have to protect our staff, who are doing amazing things with limited resources.

Dr Evans says that when patients give feedback, they don’t say, “Your MRI scan was brilliant,” they say, “That nurse was so kind.”


Lynne Pearce is a health journalist

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