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Hospital inspector reveals ‘headline’ findings on nursing quality


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”

Ellen Armistead

“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”

Ellen Armistead

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.

Directors' Congress 2016

Looking after nurses cited as key to retention

Source: Andy Paraskos

Ellen Armistead

“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.

Nursing headlines

  • 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.”

Improvement challenges

  • Leadership
  • 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”

Ellen Armistead

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.”

Ellen Armistead

Ellen Armistead

Ellen Armistead

“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.



Readers' comments (15)

  • It has taken all this time to find out when staff have known and reported on this for very many decades? How long will this continue just to be talked about without any positive change been made? ...and the rcn even had the audacity to come and deliver a lecture on the subject to a national nursing congress in Europe which I attended and where we enjoyed excellent standards of employment which reflected on the very high and advanced quality of care we were able to offer our patients and to their equally high, often outwardly expressed, level of satisfaction!

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  • If someone were to ask any nurse (I mean the ones who interacts with patients) not the clipboarders (senior management). They would say and have been saying this for many years.

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  • Agree with the other comments; this is not news!

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  • Wow! taken them this long to come up with this. The treatment of nurses by an in built culture of bullying and harassment in lots of areas of health care run by pathological management is abysmal. A lot of managers are not concerned with either the welfare of patients or staff, just themselves and will use all types of methods to attack nurses.

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  • i left a job of 7 years due to incompetent management and being bullied into 12 hour shifts, they blame agencys for vast overspend absolute rubbish, look after your dedicated, overworked, underpaid staff and get rid of incompetent, huge salaried management who do F*** all !!!!

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  • Don't kid yourself that it's not about pay! The pay for nurses is now abysmal, mature nurses have children leaving university and walking into first jobs that pay more than nursing. How much longer do they think they can keep on screwing nurses? We cant live on fresh air. And we can't have compassion when we are stressed about being able to pay bills. Get real!

    Of course, decent management would help too. The NHS HR function is unbelievably awful too, not somewhere you would want to have any contact with if you can help it. The only reason many of us are hanging on in there is because of the pension - so mess with that at your peril!

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  • With all hospitals paying the same, the other reason to leave a job is the management it self. PLEASE CAN SOMEONE stop putting out this message about we don't want better pay. We want more money. Wanting more money has nothing to do with the fact we love our jobs. Stressed nurses more issues happens.

    1) pay us more we deserve it. We work had in a very emotionally, mentally, physically that test that every day of the week. We have to do both the Manual labour of a hca and mental work of a doctor.

    2) stop this constant nurse bashing and demeaning of out jobs. We need a define roll between hca and nurses. If every one can do our jobs why have us.

    3) promote nursing as a field, career and something positive. The NMC wants us to act in emergencies. So why doesn't the rcn and government alike promotes the community and business alike to. Care more about the roll we play in society.

    4) Give us better training. A student nurse these days or a nurse moving hospitals have to go right to the bottom of everything. They have to get training to do things they have been doing for months years etc.

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  • It is not all about pay. Have a look at Maslows hierarchy of needs as a ward nurse working 12.5 hour shifts I do not get to eat properly breaks are if and when you can fit them in, working nights with one rest day then back on day shifts you can't sleep properly. No staff room to rest in. Can't leave the ward on your breaks due to staffing. Working on computers with poor lighting leading to eye strain I could go on and can we achieve self fulfilment when even the most basic of needs are not addressed. When you raise these points you get the well you know where the door is attitude...nurses do this job because they care but we are not robots what about looking after our physical and mental wellbeing? It's not rocket science it is basic the job we do is physically and emotionally draining and it's about time we were shown some compassion and respect.

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  • Financial security is a major factor in stress and anxiety, which is driving burnout, which is driving the recruitment and retention crisis. It's not the *only* thing but you can't just have an "expert" hand-wavingly dismiss a >15% real terms pay cut, downbanding, attacks on pensions, introduction of a nurse graduate tax etc etc as if it doesn't matter.

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  • Well, dare I say it duh!. This has probably taken a lot of money to find out what is not rocket science. We all know we are rather more motivated when our bosses at whatever level treat us like human beings and are minded about our well being, but this was the past and now we are just but a number, and probably many bosses don't even know the number.

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