Winning the “hearts and minds” of nursing staff is among the first priorities in a concerted drive to improve her struggling hospital trust’s performance, a new chief nurse has told Nursing Times.
Since joining Worcestershire Acute NHS Trust just over six months ago, Vicky Morris has introduced a raft of initiatives and maintains “absolute belief” that frontline staff can turn the organisation round. She also admits that she “enjoys a challenge”.
Her new trust is currently rated “inadequate” by the Care Quality Commission and in special measures. In recent years, it has also been the subject of negative headlines about poor nurse staffing levels, bullying and accident and emergency patients being treated in corridors.
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In an interview with Nursing Times on her experiences so far, the chief nurse said her initial feeling was that the trust’s staff “desperately wanted stability” after successive changes in leadership.
“Staff were really thirsty for a stable team,” she said. “I had people I thought wouldn’t even recognise me yet, coming up to me on my first or second day and saying, ‘welcome to the organisation’. It was a really good, positive start.”
She said a key goal from day one was winning the “hearts and minds” of her nursing staff. “For me, getting out and about being very visible was key,” she said. “Being seen across the organisation and seen in the context of my clinical credibility was a top priority.”
“There are loads of really good people in the organisation and I am confident we can turn this around”
Since the start of April, Ms Morris has been on the wards in uniform at least twice a week to listen in on nursing handovers, she said. This gave her real insight into standards of care and confidence within teams, as well as a chance to introduce herself to frontline nurses, she told Nursing Times.
“I treat it as if I was an agency member of staff, and ask myself whether or not I would be confident to work with that team – is it a safe handover, is it effective?” she said. “As you’d expect, there is some variation and there are ones that have given me an indication of concern, which I have been able to follow through.”
She said one of the very first handovers she attended had led to that ward getting extra support to make key improvements.
“It was an intuitive feel that actually this is a ward that doesn’t feel quite strong enough,” said Ms Morris. “There has been a change of leadership and we now have a new ward manager in there and she is fantastic – she knows the challenges she has got but is actually working with the team around those challenges, which is exactly what you want.”
The trust already had a system of snap audits to look at 10 sets of case notes per month. However, since mid-July, a new system of quality audits has been introduced, which involves matrons checking and reporting back on five sets of case notes per ward per day.
“Nurses have enjoyed being able to compare and contrast”
This includes looking at whether falls and pressure ulcer assessments have been completed and care plans put in place, whether NEWS (National Early Warning Scores) have been recorded accurately and details of infection prevention measures, such as hand hygiene.
Ms Morris admitted matrons were concerned about whether they would have time to do the audits, which take at least 40 minutes and often longer if questions need to be asked and care discussed.
However, the process is being supported by senior executives including Ms Morris, divisional directors of nursing and other leaders, who have all committed to taking on a certain number themselves.
Matrons bring their findings to a “quality hub” where they are put on the system, which generates a report within 24 hours. “We recently shared weeks one to five of that process, so they can see where they are on the ‘league table’, if you like, in terms of performance,” she said.
“I think it has really spurred people on,” she said. “Nurses have enjoyed being able to compare and contrast and it has generated conversations, active discussion and a bit of competition – as you would expect in nursing – of not wanting to be at the bottom of the league.”
Nursing staff at troubled trust under ‘consistent heavy pressure’
Additional checks include a recent unannounced inspection, which was carried out by Ms Morris with the help of nursing director colleagues from other organisations.
“We’re really trying to get a very positive energy going, in terms of these are the issues, let’s look at whether we’re making improvements and if we’re not, let’s have a discussion,” said Ms Morris. “It is positive and supportive, at the same time as holding to account in terms of the standards of care we’re providing.”
Another innovation has been the introduction of a safe staffing app, which ward managers or the nurse in charge of a shift use twice a day to record staffing levels and flag up any concerns.
Ms Morris said the system was still being refined but it allowed nurses to record planned and actual staffing levels and – depending on the dependency and acuity of patients and their own professional judgement – report whether they felt staffing was safe on that shift. Results are reviewed by matrons who take action where necessary.
“We have e-rostering in place so this is over and above that. It is not saying staffing next Tuesday will be safe but whether it is safe today, this shift,” she said.
“So, we have this belts and braces attention to detail in staffing, as well as quality and safety,” she said. “We have got a lot more to do, but this is a key part – staff on the wards need to know they are going to get a response where they are concerned about staffing.”
As well as supporting frontline staff, Ms Morris said an important goal was strengthening nursing leadership within the organisation. One of the key messages she received from her senior nurses was the need for a “confident, loud nursing voice” at board level, she said.
“I understand that completely, but it has to be collective nursing voice – we need to be speaking with one voice and have an opportunity to listen to each other, articulate our concerns and address them,” she said.
To this end, she has drawn up a statement of intent designed to boost nursing leaders’ “collective visibility” and “build up a much more clinically present and confident senior nursing team”.
The document – signed by Ms Morris, her deputies, divisional directors of nursing and matrons – contains various commitments to listening in to handovers and observing and monitoring care.
“Nobody would say it is a situation that is desirable but the team are doing everything they can”
Ms Morris has personally paid particular attention to emergency care – a source of ongoing concern that was highlighted in the trust’s latest CQC report, published during August, and which came with an official warning notice. A key problem is that patients continued to be cared for in corridors of the emergency departments at both the Worcestershire Royal and Alexandra hospitals.
“Matrons have taken the brunt of the criticism, when it is actually a whole-system and also a whole-hospital approach in terms of managing patients safely,” said Ms Morris.
New safety assessments of those waiting for beds on a main ward have been introduced and Ms Morris said she regularly visited A&E to talk to patients in the corridor, look at their notes and speak to the nurses caring for them.
“Nobody would say it is a situation that is desirable but the team are doing everything they can to manage privacy and dignity and are very clear about access to call bells,” she said.
She highlighted that the trust had not really seen any downturn in the number of patients coming through the doors of A&E, with “almost as many if not more than over the winter period”. But it had seen a reduction in 12-hour trolley waits and one-hour waits in terms of ambulance handovers.
“There are some indications of improvement but we still have patients who are unfortunately having to be nursed in the corridor,” she noted. She said efforts were under way to improve patient flow, including changes in the way the trust managed acute medical patients and frailty, with the frailty assessment unit moving to its Alexandra site.
Ms Morris said part of this drive was about creating “clear pathways” and deploying advanced practitioners to ensure patients moved from emergency to specialist areas, like stroke, as soon as they were triaged.
Other areas she is keen to focus on include improving the trust’s “hospital at night” process. “We have got some senior nurses who are supporting that type of model, but it’s a very historic model and needs to be much more effective and that will need some training and support,” she said.
When it came to nurse recruitment to fill staffing gaps, Ms Morris said the trust had a “clear, pro-active” plan but admitted its poor CQC inspection rating and being in special measures did make recruitment harder.
She said fluctuations in trust leadership and a review of the future of acute services in Worcestershire had created uncertainty, but the trust was now able to provide reassurance to potential staff.
“Some of our student evaluations are very positive, so it is just making sure they feel they have got stability going into a substantive staff nurse post,” said Ms Morris.
She said the trust had attended recruitment events in Birmingham and Dublin – but was not looking to recruit nurses from abroad at the moment.
“I enjoy a challenge and wanted to be in a post that would use all that experience”
The trust was keen to develop more advanced nurse practitioner roles and also the new nursing associate role, she said. It was also looking at “different disciplines and input across the team”, including allied health professionals on ward teams and generic roles with occupational therapy, physiotherapy and nursing components.
The job at Worcestershire Acute is the fourth nurse director post undertaken by Ms Morris, who was one of the first people to take part in the prestigious NHS Top Leaders programme and has previous experience of developing quality improvement strategies.
“I enjoy a challenge and wanted to be in a post that would use all that experience,” she said, adding that she was confident nursing staff and others at the trust could make the necessary improvements.
“There are loads of really good people in the organisation and I am confident we can turn this around,” she said. “I have absolute belief that nurses on the frontline can do it.
“We have to provide the support, structure and guidance but their attitude and approach in terms of wanting to do the right thing and provide the best care is absolutely there,” she told Nursing Times.
CV: Vicky Morris
Vicky Morris joined Worcestershire Acute Hospitals NHS Trust in March 2017 from Betsi Cadwaladr University Health Board.
She has over 10 years’ experience at executive board level and was nominated onto the NHS Top Leaders programme in 2010.
She has previously held nursing director roles at Shrewsbury and Telford Hospital NHS Trust, Robert Jones and Agnes Hunt Orthopaedic Hospital, and the Royal National Orthopaedic Hospital NHS Trust.