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High impact actions

The high impact actions for nursing and midwifery 2: fit and well to care

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Sickness absence impacts on continuity of care and costs the NHS £1.7bn each year. Ward managers must take action to improve nurses’ health and wellbeing


Liz Ward, RGN, is associate, high impact team, NHS Institute for Innovation and Improvement; Katherine Fenton, MA, RCNT, RM, RGN, is chief nurse and director of clinical standards and workforce, NHS South Central; Lynne Maher, DProf, MBA, RGN, is interim director for innovation, NHS Institute for Innovation and Improvement.



Ward L et al (2010) The high impact actions for nursing and midwifery 2: fit and well to care. Nursing Times; 106; 28, early online publication.

Each year in the NHS in England, 10.3 million working days are lost to sickness absence (CIPD, 2009). This is the equivalent of 4.5% of the current workforce, or 45,000 whole time equivalent nurses.

This article, the third in our series on the high impact actions for nursing and midwifery, looks at how ward managers and team leaders can provide support and information to improve nurses’ health and wellbeing.

Keywords: High impact actions, Staff wellbeing, Sickness absence




Rates of sickness absence within nursing and midwifery average at 4.96% - the third highest in the NHS, behind healthcare assistants and ambulance staff. This impacts on patient care as there is a direct correlation between the quality of care provided and the level of sickness absence in departments and wards. Wards that care for older patients are particularly badly affected (National Audit Office, 2006).

Cost is also a major factor. Annually, the direct cost of sickness absence to the NHS is £1.7bn (Department of Health, 2009a). The indirect cost (that is, the use of agency and other temporary staff to cover staff absence) adds £1.45bn to the bill each year. By reducing sickness absence by one third, the DH (2009b) pointed out we could save 3.4 million working days a year, amounting to a direct cost saving of £555m.

It is vital to have nurses who are fit and well if we are to ensure quality in the NHS. The proportion of working days lost to sickness absence varies widely from trust to trust: in some it is as low as 1.75%, in others as high as 7.42% (NHS Information Centre for Health and Social Care, 2009). The impact on patients and the costs involved are significant. By developing a positive focus on nurses being “fit and well to care”, we can make a positive impact on quality and cost reduction. Reducing our reliance on bank and agency staff will result in more regular and consistent staffing, leading to better team work and care provision. Even more significantly, we can ensure that NHS nurses feel valued and supported in their work.

What can nurses do?

Reducing sickness absence by one third is an achievable ambition. Organisations such as BT and Royal Mail have demonstrated that it is more than possible and that communication is the key to success. Nurses need to feel empowered to lead the change and they must believe they matter. They need to be involved in any changes and participate actively in the decision making process, as feeling included will increase their sense of control. Regularly setting aside time to review how the day went is important. It is a way of drawing out both positive and less positive aspects, particularly after a difficult shift or a training day.

The role of ward managers and team leaders is to provide support to nurses and offer information about health and wellbeing. They need to be able to recognise signs of stress and anxiety, especially when change is taking place.

As with any change, measurement is a vital component. Trusts need to make sure their reporting systems are accurate, transparent and visible. Everyone needs to be aware of the goal for reducing sickness absence and trusts should focus on the benefits of improving health and wellbeing, rather than adopting a punitive approach.

The Essential Collection (NHS Institute for Innovation and Improvement, 2010) includes three case studies from different settings, each of which has succeeded in improving staff health and wellbeing.

The Essential Collection

The Essential Collection, plus literature reviews for each high impact action, can be downloaded from the NHS Institute website. This also contains an opportunity estimator so that you can calculate potential savings, and a range of tools and resources.

Case study 1: using the 2012 London Olympics to embrace physical health

Homerton University Hospital Foundation Trust used the forthcoming London Olympics and its status as an official Olympic hospital to promote the benefits of physical health and encourage staff to exercise. The idea was to leave an Olympic legacy that would touch all 2,000 of the hospital’s staff.

Homerton serves a deprived and diverse area with a transient population and high levels of obesity. The health of nurses in the hospital reflects that of the population and, in 2008, the trust had sickness absence rates of 4.4%. It used funds from Olympic sponsors to employ Olympic athlete and personal trainer Shani Anderson to lead its health and wellbeing project. Ms Anderson coordinates a growing number of regular classes and short workshops to fit around shift patterns and family life.

Homerton has also developed an occupational health service and worked with a local heart charity to measure staff health and fitness levels. Plans are being made to secure funding from charities to continue the champion role once the sponsorship money comes to an end, and the trust hopes to start offering complementary therapies as well.

Impact of the initiative

Almost half the entire workforce attended the launch event, reflecting the general level of interest in the idea. Nurses at all levels are engaged in the programme and they report feeling fitter and more energised and losing weight. Staff sickness absence has dropped from 4.4% to 3.4% in one year. This has created a better working environment, with nurses who are happier and more engaged. Less sickness absence means better continuity of care across shifts, which has improved patient experience. Reducing sickness absence by 1% equates to a saving of £1m. The trust recognises that it cannot attribute the whole reduction in sickness absence to the physical health programme, but conservative estimates consider that 50% of it is due to the programme – hence a saving of £500,000. That means, for every £1 spent, the trust has achieved £10 worth of benefits (in terms of staff being present for work who would otherwise have reported sick).

Case study 2: using staff wellbeing to create change

Leicester City Community Health Service was formed in 2006, following the merger of two primary care trusts covering the city of Leicester. Following the merger, which had meant some redundancies, morale among nurses was low and the 2007 staff survey made uncomfortable reading. The trust board made improving staff wellbeing and morale a corporate objective. It began by commissioning an external researcher to look at what makes a difference to staff sickness and absence and surveyed nurses to find out how they thought health and wellbeing could be improved.

The research found that rewarding nurses and giving them recognition were the most important factors in reducing sickness levels. This meant reviewing management behaviour with a view to maximising the positive. Inter-personal relationships between colleagues were found to be critical for health and the research found that, if nurses turned to family and friends for support, sickness and absence levels increased. Conversely, if they turned to line managers, absence levels noticeably decreased.

The research was part of a comprehensive programme designed to improve health and wellbeing among staff, with a view to reducing sickness absence. Management responsibility – specifically giving clinical leads and managers clear responsibilities to “manage” staff sickness and absence in their area – was another key component. The trust launched a programme to coach managers in sickness management skills. New IT systems were introduced that provide real-time, bespoke reporting on staff sickness by area and the trust updated its sickness and absence policy to reflect a 3% target.

Impact of the initiative

The trust has now achieved a 4.04% sickness and absence rate (January 2010). This has contributed to reduced use of agency and locum staff. Improved staff morale has increased retention of existing staff, reducing the cost of advertising vacancies and releasing management time from the burden of recruiting.

Leicester City Community Health Service found a clear link between staff sickness levels and a range of quality measures. Reducing staff sickness means better continuity of care and patient experience. Lower levels of stress enable nurses to communicate more effectively with patients and partner organisations. There are now better training opportunities for nurses and more support and acknowledgement for their efforts. Key processes, such as appraisals, are now carried out more reliably and staff recognise the need to look after their own health and take time to debrief with colleagues to reduce stress.

The trust has earmarked £50,000 to spend over the next two years on improving health and wellbeing, using the research to target interventions that will have the most impact.

Case study 3: using The Productive Mental Health Ward to measure staff wellbeing

Hertfordshire Partnership Foundation Trust is a large mental health and learning disability trust, with more than 44 separate units and a wide geographical spread. The new Cassio Unit merged two teams, which led to uncertainty and raised stress levels as a result of the temporary redeployment of staff. The trust used tools from The Productive Mental Health Ward (see to measure staff wellbeing. Wards and units were asked to choose at least one measure from the “improving staff wellbeing” area of the measurement jigsaw. The Cassio Unit chose three measures: clinical supervision, staff stress levels and staff sickness, which is measured using bank and agency use as a proxy. Now, at the end of each shift, nurses are asked to rate their stress levels – green (no stress), amber (moderate) or red (high). These visual indicators are displayed prominently so that everyone can see how the unit is performing. Nurses are offered regular clinical supervision – the aim is one session every 4-6 weeks per nurse - and the trust is now aware of the links between stress levels and other indicators, such as high bank or agency use.

Impact of the initiative

The challenging nature of the patient group that the trust works with means that interaction with staff is vital. Continuity of care is important and this is maintained by reducing sickness absence. Since the changes were introduced, the average number of hours lost has fallen from 96 per month (August 2009 to January 2010) to 59 per month (January to May 2010).

Staff report a better working environment. They are given the opportunity to discuss concerns and unload any stress and they have an active training programme through well planned and monitored clinical supervision. The Cassio Unit has been recognised across the trust and nationally for its work on The Productive Mental Health Ward.




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