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Using a positive practice environment framework to support recruitment

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Pathway to Excellence is an accredited programme that empowers nursing staff through shared decision-making and aims to increase staff and patient satisfaction as well as the quality of care. This article comes with a handout for a journal club discussion


The nursing shortage means employers need to find strategies to recruit and retain staff, and ensure they provide high-quality care. Pathway to Excellence is an accredited programme focused on shared decision-making to empower staff to influence the care they provide. This article reports on the progression of the first district general hospital in the UK to aim for Pathway to Excellence designation. It discusses the six standards that are core to the Pathway to Excellence programme and the work that has already been done to help the hospital achieve designation in 2018/19. It explores some of the benefits of this journey towards accreditation in relation to vacancy rates, patient experience and nursing indicators.

Citation: Pauley T, Fox C (2018) Using a positive practice environment framework to support recruitment. Nursing Times [online]; 114: 10, 26-28.

Authors: Tara Pauley is associate director – Pathway to Excellence lead; Carolyn Fox is director of nursing, midwifery and patient services; both at Northampton General Hospital, Northampton.


It is well known that the nursing and midwifery professions in the UK face challenges in recruitment and retention, with thousands of unfilled vacancies across the NHS. The problem is multifactorial and long-term: many nurses are approaching retirement age, numbers of students have fallen since the loss of the bursary, and overseas recruitment from Europe has become more challenging since Britain voted to leave the EU. NHS providers need to identify strategies that will help them meet these challenges in recruitment, retention and retirement.

One strategy adopted by some NHS organisations and other healthcare providers is to gain recognition from the American Nurse Credentialing Center (ANCC), which promotes nursing excellence by offering accreditation and certification for individual nurses. It also recognises the need to support healthcare providers in providing a positive journey for both staff and patients, and has developed two programmes for organisations – Magnet and Pathway to Excellence.

Magnet eligibility criteria and application process are stringent; all the organisation’s nurse leaders and nurse managers require a degree. Pathway to Excellence enables organisations to develop and demonstrate a positive working environment with a culture of sustained excellence to increase staff job satisfaction and aid recruitment and retention. The programme has less-exacting eligibility criteria; for example, regarding staff qualifications, only the organisation’s chief nursing officer/director of nursing is required to be educated to degree or higher-degree level.

Northampton General Hospital (NGH), a district general hospital, aspires to be the first in the UK to gain Pathway to Excellence designation. Pathway to Excellence evaluates organisations against six practice standards (Box 1) (Dans et al, 2017); in this article we give examples of our activities in relation to these.

Box 1. Pathway to Excellence practice standards

  • Shared decision making
  • Leadership
  • Safety
  • Quality
  • Wellbeing
  • Professional development

Practice standards and NGH activities

Shared decision-making

The practice standard on shared decision-making requires that staff across all levels – particularly those providing direct patient care – are involved in decision-making. NGH has established 20 shared decision-making ‘councils’ to enable this, with more being set up. One of the councils, Fighting Fit (FFIT), comprises tissue viability, pressure ulcer, falls prevention and infection control specialists; its members have collaborated to develop a ‘safety board’, which combines information across the specialties to communicate the most up-to-date safety-related information to staff.


Support from those who supervise nurses is associated with more personalised patient care, higher professional commitment and lower intention to leave the profession (Jourdain and Chenevert, 2010). Excellent leadership is, therefore, crucial to high-quality care. Nurse leaders need to be able to advocate for frontline staff, and should also be both visible and available for them.

In 2017, NGH started the Royal College of Nursing (RCN) Leadership programme for staff. We have also launched a Director of Nursing Junior Fellows programme. This enables selected nurses who aspire to senior leadership to be released from the clinical area one day a week and receive mentorship from organisational leaders to develop a project that benefits the organisation and fulfils the standards of Pathway to Excellence. The first two fellowship posts started in June 2018; their outcomes will be closely evaluated.


Safety is paramount in the NHS and most organisations have systems in place to reduce the risk of harm to both patients and staff; these are regularly monitored so their efficiency can be assessed. It is important that measures of safety are accurate and that staff understand their purpose and comply with reporting systems. Having representatives of all levels of the workforce involved in decision-making gives staff more opportunities to contribute to safety initiatives.

At NGH, an assessment tool developed on one ward to improve the monitoring and assessment of babies’ skin was recognised by the Care Quality Commission in its inspection report (CQC, 2017).


To continuously improve patient outcomes, healthcare providers need to benchmark against internal and external measures. Indeed, participation in national quality metric benchmarking has been shown to lead to a reduced risk of in-hospital mortality (Hickey et al, 2013). This can help highlight areas where staff’s knowledge and skills need to be improved or which current hospital policies need to be reviewed to ensure they are evidence-based.

The National Institute for Health Research (NIHR) highlighted that hospitals that were actively engaged in research showed more favourable clinical outcomes for patients, which demonstrates the importance of participating in research and adopting evidence-based practice (NIHR, 2015; Ozdemir et al, 2015).

Quality improvement is given priority at NGH, with a commitment to reduce avoidable harm and there is a dedicated strategy in place until 2019. That strategy has collaborative working at its core. For example, our infection prevention and control team monitor rates of hospital-acquired infections, and then, by using collaborative working, the organisation has adopted techniques to keep us within the trajectory targets that have been set.


The ANCC devised the wellbeing standard to help staff balance their work and their personal lives.

NGH has a range of initiatives to promote health and wellbeing; the staff canteen offers a range of healthy food options and there is an on-site pool and gym with subsidised staff membership. The trust also offers:

  • Slimming classes;
  • Priority physiotherapy self-referrals for musculoskeletal problems;
  • Advice on smoking-, eating-, sleeping- and alcohol-related issues;
  • Mental health workshops facilitated by the charity Mind;
  • Access to counselling if required.

Professional development

Offering ongoing professional development and a culture that focuses on establishing and guiding the next generation leads to higher job satisfaction and lower intention to leave (Warshawsky et al, 2016). The ‘professional development’ standard focuses on continuous learning and development.

As part of its nursing and midwifery strategy, NGH promotes lifelong learning for staff through a clinical framework that aims to take them from newly qualified status to a matron development programme. Some staff have already completed the RCN Leadership programme and are implementing their learning in their current roles to enhance their work environment and for their own career progression.

Frontline staff can also be empowered to improve the professional development provided by NGH: one of our shared decision-making councils, the Newly Qualified Forum, wanted to improve the preceptorship programme and created an ‘on-board’ bag containing many items considered essential for new starters.

Nurse recognition

In addition to the six quality standards, an important aspect of Pathway to Excellence is the recognition of the workforce. NGH visibly celebrates the contribution of nurses in a number of ways; for example, departmental managers organise local awards such as the emergency department’s ‘Good Egg’ award and the stroke ward’s ‘Star of the Month’ award, and staff who have gone above and beyond their duties can be referred by their line manager for tea with the director of nursing.

The trust has also implemented an international recognition programme. The DAISY Foundation was established by the family of Patrick Barnes after he died from a disease that attacked his autoimmune system (hence ‘DAISY’). The family appreciated the nursing care Mr Barnes received so much, they set up the DAISY Award programme to recognise ‘extraordinary nurses’. NGH adopted the programme in 2017 and we receive numerous nominations from patients.


We will continue to embed the Pathway to Excellence standards across the organisation, and have made a significant start in the culture change required. As part of the Pathway to Excellence assessment process, conducted in 2018, we collated evidence on our own performance and metrics in several areas. One such area is registered nursing vacancy rates: these were 17% in 2015 but are now much closer to the 9% target (Fig 1).

fig 1. nurse vacancies at northampton general hospital

We have passed the elements of the performance stage of the assessment process (which included 64 pieces of evidence from the organisation); the final part of the process includes asking frontline staff to confirm that their experience at NGH meets the standards, giving them a voice to ensure Pathway to Excellence standards are embedded throughout.

In November 2015, the trust also launched the Pressure Ulcer Collaborative, an inter-professional group of nurses, physiotherapists and infection prevention control staff. The collaborative works with clinical teams to select, test and implement changes in care and practice, redesigning systems from the bottom up and using small tests of change. Since the collaborative was created, the incidence of pressure ulcers has reduced from a mean of 1.2 per 1,000 bed days in October 2015 to 0.5 in May 2018.

The Weekly Surgical Clostridium difficile Collaborative was a nurse-led quality initiative supported by the consultant microbiologist, antimicrobial pharmacy team and other members of the multidisciplinary team. Set up when we realised our organisation was an outlier for C. difficile, the collaborative ran for 90 days between July and October 2017, with the aim of reducing incidence of the infection. The trust was within its trajectory target of 21 cases for 2017/18 as a result of the collaborative’s work.

We have worked hard to improve the patient experience at NGH, for example by feeding back information from the National Inpatient Survey to frontline staff and helping them to understand how they can make changes in their own areas in response to the findings. Between 2012 and 2016, the number of survey responses ranking NGH in the bottom 20% of NHS trusts had progressively risen from 3% to 15%, indicating declining performance and patient satisfaction. After our work to engage and empower nursing staff, this figure had gone down to 6% in 2017. The trust has also seen a notable reduction in the number of complaints relating to nursing care, from 132 between July 2015 and June 2016 to 38 the following year. The critical factors for these successes include:

While it cannot be said that there is a direct correlation between these outcomes and the Pathway to Excellence programme, they do reflect the benefits of the Pathway to Excellence claimed by the ANCC (Box 2).

The six Pathway to Excellence standards form an integral part of our nursing and midwifery strategy and align with our trust values:

  • We put patient safety above all else;
  • We reflect, we learn, we improve;
  • We respect and support each other;
  • We aspire to excellence.

Box 2. Benefits of Pathway of Excellence designation

  • Improving nurse satisfaction
  • Retaining excellent nursing staff and leaders
  • Cultivating interprofessional teamwork
  • Championing high-quality nursing practice
  • Supporting business growth

Source: American Nurses Credentialing Center


Pathway to Excellence offers organisations a framework to help them create a positive work environment. It can help address major recruitment and retention challenges, and empower staff to take actions that improve patient outcomes and staff satisfaction. 

Key points

  • The nursing shortage is a multifactorial problem requiring employers to improve recruitment and retention
  • A positive work environment and empowerment improve staff recruitment, staff retention and quality of care
  • The Pathway to Excellence programme involves frontline staff in decision-making, empowering them to make changes
  • The Pathway to Excellence practice standards are designed to embed a culture of sustained excellence across organisations
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