Looking after nursing staff is the key to reducing turnover, rather than pay, according to a nurse expert on healthcare regulation.
Evidence suggested that good line management was the most important factor in staff retention, said Ellen Armistead, deputy chief inspector of hospitals at the Care Quality Commission.
“You will keep staff if you look after staff, if you listen to staff”
“There’s so much evidence that the reason you have high turnover isn’t that your neighbouring trust is paying a band higher, it’s whether people like being managed and feel safe in that team,” she told trust directors of nursing at a Nursing Times conference in Manchester.
“You will keep staff if you look after staff, if you listen to staff,” she said. “All of your recruitment plan credibility has to be underpinned by what does line management look like, what is the leadership of that area and would I want to go and be part of that team.”
Ms Armistead, herself a nurse and former trust chief nurse, gave an overview of the CQC’s findings including a number of “nursing headlines” she had identified from the regulator’s inspections.
Nurse staffing levels were a key safety issue, which the CQC was often asked about how it based its judgements, she told the second Directors’ Congress.
She acknowledged that nurse to patient ratios were “one part of the picture” in its assessments on whether staffing was safe, but suggested the CQC attached more importance to the “credibility” of plans for recruitment and retention, and the escalation of concerns.
“It’s how people feel empowered to escalate concerns when there are staffing issues – whether people are encouraged to report staffing as incidents,” she said.
“Nurses are so busy with their heads down that it’s difficult to think what excellent in nursing looks like”
She highlighted that the regulator saw a variety of practices, from very good to staff “actually not knowing how they escalate concerns and if they do so how well those concerns are listened to”.
“In terms of best practice, the areas where we have more confidence is where we know you can go up to any staff nurse, any sister and say what is your process if you are concerned about staffing levels on your shift today and they can articulate where they’ve done it, show me the incident forms and talk me through the journey of how they resolved that particular problem.”
Later, she also highlighted the important role of “oversight” by trust boards, with the need for regular safe staffing reviews, as well as involving frontline clinicians who “work at the sharp end” and “know best” in defining appropriate levels.
Meanwhile, she warned of a “mixed picture” in the management of the deteriorating patient, ranging from doing “absolutely brilliantly” to “inconsistencies from service to service or ward to ward”. She also said quality was “patchy” regarding record keeping by nurses.
Ms Armistead acknowledged that it was difficult to measure the effectiveness of nursing care in hospitals, especially on general medical wards.
Looking after nurses cited as key to retention
Source: Andy Paraskos
“How do you actually produce a credible set of outcomes that mean something,” she asked. “A lot of data is gathered at ward level but in actual fact how often do you get a holistic picture of how well a patient was cared for – in some areas that’s really easy to do and in other areas it’s harder.”
Ms Armistead identified two areas where nurses could especially “contribute” as dealing with complaints and patient flow through hospitals.
“Most teams deal with complaints very well and we’re able to see complaints are discussed and used as examples of learning and have an impact on service change and delivery,” she said. “But sometimes that’s not always the case.”
She added: “Nursing has such a massive contribution to access and flow, and again in some areas I think the nursing voice is very strong in dealing with the flow through the hospital but in other areas a little bit patchy.”
Again, she noted “variety” in multi-disciplinary team working, care based around individual patient needs and quality of nurse leadership, which she said was most marked in community settings.
“We do see particularly in geographically dispersed services that there is a massive variation in how people perceive the quality of leadership,” she told delegates.
- Safety: staffing, deteriorating patient, records
- Effective: outcomes, multi-disciplinary teams, individual needs
- Caring: few outstanding examples
- Responsive: complaints, access and flow
- Well-led: variation
Ms Armistead went on to outline what she described as “some of the improvement challenges” for nursing. In particular, she highlighted the importance of ward managers and suggested national standards needed to be drawn up for the role to reduce variations.
“Maybe it’s time to get some national accredited leadership standards for those people who do an incredibly challenging job,” she said. “Where you’ve got a good ward you’ve got a good leader.”
She also noted the “real challenges with workforce planning”, saying the NHS needed to “think more creatively”.
Meanwhile, Ms Amistead raised questions about whether resources could be used by nurses in a more efficient and patient-centred way, highlighting that the former productive ward programme “seems to have disappeared”.
She also asked whether “nursing excellence” had been lost amid the current workforce pressures and called for the profession to “start thinking about” ways of benchmarking it.
“Nurses are so busy with their heads down that it’s difficult to think what excellent in nursing looks like, but if we’re really going to make a difference, I think that’s where we should be focusing some of our attention.”
- Workforce planning
- Use of resources
- Nursing excellence
She noted that the CQC was due to complete its programme of comprehensive inspections of all NHS trusts by the end of June, after which it would focus on the independent sector.
In future, she said the CQC would move “towards targeted and tailored inspections, which are risk based and have a heavier focus on intelligent monitoring” for the NHS..
Ms Armistead highlighted that 168 comprehensive inspections had been carried out so far, with only four trusts rated as “outstanding”, while 50 were rated “good”, 12 as “inadequate” and the “lion’s share” as “requires improvement”.
“I’m hoping to produce, later in the year, a state of nursing report from our CQC reports”
She told delegates that the problem that the commission had “noticed most” was the level of variation within the best and worst trusts, as well as between them.
“The thing that surprised me… was the difference within services within trusts, the difference from ward to ward, sometimes within the same directorate, and even between teams of nurses in the same ward,” she said.
Ms Armistead said that, generally, intensive care and critical care had “come out of our inspections quite positively”, it being unusual for them to be rated “inadequate” or “requires improvement”.
She suggested the reason was that mandated staffing level guidance and long-standing national standards were in place for critical care, and noted it was a “similar picture” for services for children and young people.
However, she said it was a “mixed picture” for end of life care and also maternity and gynaecology services. “Most units had taken on board the findings of [Dr Bill] Kirkup and done something about that, but we do see quite a lot of variety around safety,” she said.
She added that, despite other failings, trusts were nearly always rated as “good” for being caring. But she questioned whether there was room for improvement.
“The thing for me, as a nurse by background, is caring being ‘good’ is maybe not good enough and we should all really be striving for ‘outstanding’,” she said. “I think we need to start ramping it up a bit now.”
“Where we do see ‘outstanding’ on caring it is generally speaking where the whole multidisciplinary team has the same set of values,” she said. “It’s not just seen as the nurses’ job.”
“One of the things I’m looking to do is to look at how we define caring and how we assess caring,” she told delegates, noting that she intended to review how the CQC rated trusts on being caring.
Ms Armistead also said she was hoping to pull together the CQC’s findings on nursing into a report in the same way that it already did annually for different healthcare sectors.
“I’m hoping to produce, later in the year, a state of nursing report from our CQC reports. I thought it would be really helpful to put some of the nursing issues into a report,” she said.