This article outlines the development of a new role called the ‘patient well-being champion’, with the aim of delivering more personalised, patient-centred care.
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
Tim Couchman, BD, Dip PS, is trust-wide senior and managing chaplain; Marie McDermott, BSc, Cert Ed, ONC, RGN, is senior clinical tutor, both at United Lincolnshire Hospitals NHS Trust; Wilfred McSherry, PhD, MPhil, BSc, PGCE (FE), PGCRM, RGN, NT, ILTM, is senior lecturer and director, Centre for Spirituality Studies, University of Hull.
Couchman, T. et al (2007) Using well-being champions to deliver holistic care. This is an extended version of the article published in Nursing Times; 104: 2, 37-38.
This article outlines the development of a new role called the ‘patient well-being champion’, with the aim of delivering more personalised, patient-centred care.
Health professionals need clear guidance on effective implementation of national initiatives in local healthcare communities (Fig 1) [check]. This article gives an overview of a project designed to equip practitioners with the knowledge and skills to implement these standards in clinical practice in order to help deliver personalised patient care. It outlines the development of an innovative role entitled the ‘patient well-being champion’ (PWBC) in the United Lincolnshire Hospitals NHS Trust (ULHT) and describes the preparation and implementation of the PWBC. The article illustrates the knowledge, skills and attitudes that PWBCs need to implement fundamental aspects of care – that patients feel safe, valued and respected while in hospital.
The unique aspect of this development is that it allows existing clinical roles to be redesigned, which, in turn, brings a fresh focus on the holistic concepts of care (Pearson et al, 2004). It is envisaged that as the project evolves it will provide a conceptual framework for putting patients at the heart of care delivery in partnership with all practitioners.
An essential aspect of this project is that it enables the organisation to deliver quality care within the Department of Health’s Payment by Results system. In the proposed move to foundation status, it will empower all members of the trust to listen and respond to service users. The focus of this innovation will undoubtedly raise the professional standing of the ULHT. This, in turn, will make it more welcoming to the community it serves.
Background to the project
The origins for this initiative came from the hospital chaplaincy, while working in partnership with other health professionals during local implementation of the Liverpool Care Pathway (LCP) for the Dying (Ellershaw and Wilkinson, 2003). This pathway has influenced the national agenda on care of the dying (Ellershaw and Murphy, 2003). It provides a generic and standardised framework for the provision of high-quality end-of-life care in all healthcare settings. These developments are also echoed in the Department of Health’s frameworks for care of the dying (DH, 2007).
An audit of the LCP’s implementation was undertaken within the trust. Analysis of the information obtained by the audit process indicated a disparity between the quality of religious and spiritual care that practitioners felt they were providing and what they actually were providing. Health professionals felt they were providing the type of care required by the LCP when audit data revealed the opposite – that they were not doing so.
This issue was explored through structured teaching sessions, where healthcare workers expressed feelings of inadequacy about their understanding of the issues and ability to meet patients’ spiritual and religious needs. This finding seems to be a national rather than a local phenomenon. McSherry’s (2004) research suggests some health professionals are still uncertain about what constitutes spirituality and spiritual care.
The concerns expressed by healthcare staff validated the evidence collected in the audit and gave cause for concern, given the growing emphasis on the delivery of spiritual and religious care (NMC, 2007; DH, 2003). The need to explore and resolve these questions became the catalyst to address not only the religious and spiritual aspects of care, but also many other holistic concepts that are often overlooked, such as privacy, dignity and breaking bad news. Equally, it highlighted the fact that these issues were not only important to end-of-life care but to all areas of patient well-being.
In addition this project responds to clinical directorate action plans designed to address issues of concern and complaint. These are compiled on a quarterly basis and presented to the board by the risk manager. An annual summary is then compiled to provide benchmark indicators for the annual ‘Standards for Better Health’ reports. Particular emphasis has also been attributed to those concerns directly relating to aspects of holistic care, for example, dignity and communication issues.
With these factors in mind it was imperative that this project should be supported by a key member of the executive team with a commitment to ensuring best practice is interwoven into the ethos of care. The chief nurse was approached and agreed to support – and indeed inspired – the project from its inception through to different phases of implementation.
Vision and aim of the project
All members of the project team signed up to the shared vision to develop and deploy PWBCs. The PWBCs, in collaboration with senior health professionals, would lead, implement and evaluate this personalised and holistic model of care. The political climate presented an ideal opportunity for the launch of this innovative initiative.
In partnership with the senior clinical tutor and the patient and public involvement manager, a strategy was devised and presented to the matrons and senior managers within the trust. Their ownership and support have been integral to the project’s success, and was gained through open consultation and discussion to address their initial disappointment that such a fundamental project was necessary, despite all health professionals’ commitment to holistic care and best practice.
This sentiment is clearly echoed by the chief nursing officer in the publication Modernising Nursing Careers: Setting the Direction (Beasley, 2006).
Champions’ education and training
The recruitment process required line managers to nominate appropriate professionals to be trained as PWBCs. This information was communicated to the matrons via the chief nurse. Nominees had to fulfil certain criteria, one of which was that they were in a position to effect change within their clinical area. Furthermore, this role was inextricably linked to the development of their Agenda for Change KSF outlines (DH, 2004).
The PWBCs came from a diverse range of clinical disciplines/specialties including midwifery, paediatrics, critical care, elderly care, oncology, surgery and occupational therapy. There were 17 participants in the first cohort, each of whom continued to fulfil their clinical role while developing the skills required of PWBCs.
This role was recognised by the organisation as part of champions’ continuing professional development. No financial incentive was offered as the selection process was structured to reflect a level of competence in line with nominees’ current KSF to reflect the post outline.
The PWBCs received structured education and training, which consisted of an introductory pre-course day followed by a five-day training programme. This involved a range of clinical/academic specialists who addressed the key areas of the role.
In accordance with post-registration standards for professional development, the participants were released to undertake the training with full support of their managers. This was vital to the success of the project. Managers and key stakeholders at all levels, including the chief executive, recognised the value and impact on patient experience that the programme would have. The training forms part of PWBCs’ CPD and is resourced through their KSF.
In line with modernising education and training, interprofessional learning and service-user involvement was advocated throughout the programme. The use of action learning sets (Marquardt, 2004) encouraged the development of peer-group networks that addressed key themes within practice. These consisted of:
Spirituality in healthcare;
Multifaith and cultural awareness (including race and ethnicity);
Confidentiality and consent;
Patient and public involvement;
Communication and breaking bad news;
Sudden loss and change.
The training included lectures, small group study and patient experience seminars focusing on multiprofessional learning. The involvement of service users throughout the initiative enabled us to engage in true partnership working and was achieved by:
Active engagement with the local patient and public involvement forum;
Inclusion of a patient representative on the steering group;
Patient participation through the sharing of individual experiences of their journey;
Participation in conducting five-senses surveys, whereby patient representatives and champions conduct a simple, instant evaluation of a clinical/departmental area on first impressions. It is done by using the five senses of smell, touch, taste, hearing and sight and is a very powerful tool (Mid-Trent Cancer Network, 2006).
The sharing of patient experiences served as a catalyst for the PWBCs to document and evaluate their own feelings in reflective journals, which allowed critical analysis of thoughts and feelings. This academic process of critical analysis is essential for the effective development of this role within the organisation. The ability to analyse critically personal and professional behaviour is integral to the role of the PWBC, but can be a daunting and intense learning process. This was acknowledged at the beginning of the programme by the project leaders, so to safeguard the well-being of the champions – and those of the people whose interests they promote – ongoing clinical supervision was included in the programme and will remain in the champion role. This has been further cemented by the publication of the ULHT’s clinical supervision policy (2007a), which acts as a clear and robust framework for the champions.
The champions’ CPD
The uniqueness of the role precipitated the need to devise an individual CPD framework to support the champions. This resulted in customised post outlines being devised to assist professional development and to cement the champion role within clinical practice. The core and specific dimensions, as outlined in the Agenda for Change KSF (DH, 2004), served as benchmarks to show how practitioners successfully effect change in care delivery. This also offers organisations a system to monitor and evidence the continual development of the multiprofessional bodies delivering safe, high-quality and coordinated care.
The role of the PWBCs
The primary role of PWBCs is to ensure that all patients feel safe, secure and valued when receiving direct care. They should also actively encourage and develop partnership working with patients and carers, to involve them in their treatment and rehabilitation. This is achieved by ensuring that all patients in champions’ clinical areas are aware of the PWBC role and what it entails.
Noticeboards were used to identify champions and inform patients about the role on their admission to the clinical area. In addition, a patient information booklet supported by a screensaver to be introduced via Patientline (a service providing patients with individual access to a television and phone system) will be implemented this year.
A number of key initiatives have been implemented to ensure dignity within care. These include nominating a dedicated lift to be used for transporting patients, for example to surgery or for diagnostic tests. Removable signs have been introduced to attach to curtains, reminding all staff to request access before entering.
The project is being evaluated using patient experience trackers from Dr Foster, an organisation which collates information to improve the quality and efficiency of health and social care. These have been piloted in the areas where PWBCs are currently operating, and enable ward teams to elicit prompt patient feedback on the quality of care.
Patients are asked to respond to five questions programmed into a hand-held monitor. The data is then fed into a central system and is then disseminated in the form of weekly reports to the clinical teams via the heads of nursing. This enables professionals to view and respond to the findings.
Within the first month of implementation of this tracker system, patients were expressing satisfaction in relation to the dignity question. The only amendment to the system has been the rewording of one question, which was heavily biased towards the ward setting, as opposed to other departments and units. A poster is displayed in the clinical area enabling patients, relatives and staff to monitor the progress and outcomes of the feedback.
This process complements the patient satisfaction surveys being undertaken by a number of champions throughout the organisation.
A number of patient representatives have commented how this process, in conjunction with the PWBCs’ role, is a positive step forward for patient involvement.
Cost of the project
The initiative has been extremely cost-effective. Project leads have incorporated the delivery of the programmes into their existing schedules. However, because the demand for the programme has exceeded supply and been recognised within the local community for possible commissioning, it has been necessary to employ a part-time PWBC lead. This has been incorporated into the business plan presented to the chief executive and it is envisaged that the patient well-being programme will become a mandatory training component for all staff within the trust.
Organisational benefits of the PWBC
Continued investment at all levels (both financial and pastoral) in this new ethos of care would further encourage a culture of quality, thereby positively enhancing the image of ULHT as a potential centre of excellence.
A centre of excellence must be able to provide evidence on how patients are truly engaged, for example by:
Fulfilling Healthcare Commission standards;
Complying with ‘Better Value’ indicators in the commissioning process;
ensuring Payment by Results/‘Invest to Save’, whereby the money follows the patient if the care and the organisation is safe and effective;
Contributing to foundation trust status;
Influencing the development and delivery of the ULHT service and financial plan for 2007–2010 (ULHT, 2007b);
Proactively responding to the challenges detailed within the local results of the national inpatient survey (Healthcare Commission and Picker Institute, 2007).
All these outcomes have been introduced in a climate of financial and structural change within the NHS. The financial impact of this initiative has been minimal as a result of using current resources and unifying an existing pool of clinical, educational and service-user expertise with a clear patient-focus.
As it is not appropriate to introduce a new role in the current financial climate, the emphasis has been on refocusing and redesigning existing professional competencies.
Interrelationships with other services
This project has reinforced an inter-disciplinary partnership with local universities. This has evolved through the lecturers participating in the delivery of the programmes. One of the defining elements of this initiative is its unique ability to highlight the important issues of patient well-being throughout both pre- and post-registration practice.
In spite of the original purpose of this project (to influence issues relating to holistic care and ensure that the ‘constants of care’ are embedded in the philosophy of care delivery), key elements already have academic value and recognition. For example, the concepts of dignity and spirituality within healthcare are currently being studied at PhD level within these organisations.
As this programme is the first national prototype of its kind, it would be an ideal vehicle to pilot national initiatives, such as clinical skills projects and workforce modernisation and planning. Therefore, the potential benefits for income generation through local and national interest need analysis and exploration. This has been identified through a scoping exercise to ascertain the benefits of this project within a 3- to 5-year plan – and future mapping process. This served a dual purpose as it proved visionary in the initial stages of planning and also permitted project leads to identify the future direction and sustainability of this activity.
In order to interweave this cultural change into the fabric of the organisation, PWBCs must be clearly identified. The reporting framework of ULHT has identified this role as an integrated governance indicator within the clinical directorates – this means a benchmark to achieve and measure best practice throughout the patient experience.
In order to ensure this vital component, the key stakeholders who exercise strong clinical leadership (for example, matrons) must show a commitment to supporting PWBCs in addressing the challenges and issues this dynamic role will encounter. This can only be realised by providing protected time, scheduled into the champions’ work activity. This must be a condition of service for those undertaking and supporting this role, as initially agreed in the interim planning stages of the pilot project.
It quickly became evident that this programme must continue to be rolled out throughout the trust and indeed the wider healthcare community. The demand for this initiative at all levels can be demonstrated by the planning and implementation of the second and third cohorts of PWBCs. The trust now has 37 champions. In June 2007 the health care support workers accessed and completed this training. This is to be followed by further training to include all clinical directorates throughout the trust.
Furthermore, the trust chief executive has requested that all staff members are enabled to access this training within a three-year period. This will consist of a menu of programmes being customised to the levels of knowledge and skill required to meet service delivery.
As a result of this initiative, preliminary findings have generated the following recommendations:
The intellectual copyright of this strategy is retained within the ULHT chaplaincy and clinical training departments;
The findings and recommendations of this initiative are firmly embedded in the organisation’s reporting structure;
this commitment to best practice is locally recognised by the people of Lincolnshire when selecting their care centre;
Recognition for undertaking this important role is linked to levels of competence within the PWBCs’ KSF post outline;
This innovation influences the design and content of future pre- and postgraduate training courses;
A project leader is appointed to initiate and oversee these recommendations.
Finally, this project is directing the organisation towards the process of transformational change from the perspective of personalised patient care.
Implications for practice
Beasley, C. (2006) Modernising Nursing Careers: Setting the Direction. London: DH.
Department of Health (2007) Operating Framework for 2007-08 PCT Baseline Review of Services in End of Life Care. London: DH.
Department of Health (2004) Agenda for Change Knowledge and Skills Framework. London: DH.
Department of Health (2003) NHS Chaplaincy Meeting the Religious and Spiritual Needs of Patients and Staff. London: DH.
Ellershaw, J, E., Murphy, D. (2003) The Liverpool Care Pathway (LCP) influencing the UK national agenda on care of the dying. International Journal of Palliative Nursing; 11: 3, 132–134.
Ellershaw, J., Wilkinson, S. (2003) Care for the Dying: A Pathway to Excellence. Oxford: Oxford University Press.
Healthcare Commission and Picker Institute (2007) Acute Hospital Trusts: National Survey of Adult Inpatients 2007. London: HC/PI. www.nhssurveys.org
McSherry, W. (2004) The Meaning of Spirituality and Spiritual Care: An Investigation of Health Care Professionals’, Patients’ and Public’s Perceptions. Unpublished Doctor of Philosophy Thesis. UK: Leeds Metropolitan University.
Marquardt, M.J.J. (2004) Optimising The Power of Action Learning: Solving Problems and Building Leaders in Real-time. Palo Alto, CA: Davis-Black Publishing.
Mid-Trent Cancer Network (2006) 5-Senses Survey. Unpublished.
Nursing and Midwifery Council (2007) Draft Code of Conduct. London: NMC.
Pearson, A. et al (2004) Nursing Models for Practice (3rd Ed) Oxford: Butterworth Heinemann.
United Lincolnshire Hospitals NHS Trust (2007a) Clinical Supervision Policy. Lincolnshire: ULHT.
United Lincolnshire Hospitals NHS Trust (2007b) Services and Financial Plan 2007–2010. Lincolnshire: ULHT