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Are nurses engaged in quality initiatives?

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A national survey on nurses’ views of quality improvement initiatives found the profession actively engaged in attempts to improve care while reducing costs.

This article…

  • Aims of Energise for Excellence (E4E)
  • Findings of a national survey on nursing awareness and nurses’ contribution to quality improvement
  • How Energising for Excellence can benefit patient care


Michelle Mello is national implementation director, Energise for Excellence; Jane Cummings is chief nurse and deputy chief executive, NHS North West, and senior responsible officer for E4E.

Abstract Mello M, Cummings J (2011) Are nurses engaged in quality initiatives? Nursing Times; 107: 37, early online publication.

Energise for Excellence is a quality and safety framework that brings together existing initiatives, such as Essence of Care, under one umbrella. This article discusses the findings of a national survey looking at nurses’ awareness of national quality improvement initiatives and their contributions to improving care.

Keywords: Energise for Excellence, Quality, Safety

  • This article has been double-blind peer reviewed
  • Figures and tables can be seen in the attached print-friendly PDF file of the complete article

5 key points

  • Energise for Excellence (E4E) is a quality and safety framework that draws together existing initiatives under one umbrella
  • Its main aim is to encourage nurses to engage in quality and cost improvement
  • E4E has a target of signing up 200,000 nurses and midwives to take action
  • E4E seeks to harness nurses’ collective energy to make a difference to both care and how nurses feel about their work and themselves
  • It provides a platform to align national quality improvement programmes in a way that makes sense to nurses

 Energise for Excellence (E4E) is a quality and safety framework that draws together existing initiatives under one umbrella (Fig 1). It is based around five domains:

  • Getting staffing right;
  • Delivering care;
  • Measuring impact;
  • Patient experience;
  • Staff experience.

The main aims of E4E are to encourage, motivate and enable nurses to engage in quality and cost improvement so that patients receive the best possible care. It also aims to demonstrate and celebrate nursing commitment, expertise and contribution to quality improvement, thereby increasing professional pride.

Many of its supporting tools, approaches and measures will be familiar to nurses, such as Essence of Care (Department of Health, 2001), Productive Series and High Impact Actions (NHS Institute for Innovation and Improvement, 2007; 2009). However, E4E is different from other quality and safety programmes in a number of ways:

  • It has been developed by nurses for nurses;
  • It focuses not only on quality improvement but also on cost reduction;
  • It brings existing initiatives together and allows nurses to look at the links between them, such as how staffing affects patient experience;
  • It encourages nurses to lead improvements through a call to action;
  • It is supported by a call to action for senior leaders, giving nurses executive support in its implementation;
  • It highlights the importance of celebrating success and sharing good news stories.

The vision for E4E is to have 200,000 nurses and midwives signed up to take action and tell others about their successes. It is about nurses leading in quality improvement and being recognised for this.

Many nurses already make significant contributions to quality improvement, but how aware of this are the profession and the public? E4E tries to harness nurses’ collective energy to make a difference not only to care but also to understand how nurses feel about their work and themselves. The E4E call to action asks nurses to commit to five tasks:

  • Take a specific action to make a specific change within a specific timescale;
  • Use the most relevant tools;
  • Measure the result of their action;
  • Celebrate success;
  • Tell their story to others.

Each strategic health authority has a nominated E4E lead. Their contact details are on the E4E website ( As part of introducing E4E, we carried out a national survey, supported by the NHS Institute for Innovation and Improvement (NHSI) to find out about nurses’ awareness of and contribution to quality improvement.


The NHSI hosted an online survey in May 2011, which was open to all nursing, midwifery and support staff. It was publicised via SHA chief nurses and via regional nurse director networks, E4E regional leads and quality and safety trust champions.


A total of 1,690 nurses completed the survey – the best response rate ever for an NHSI survey; 87% were nurses, 5% directors or deputy directors of nursing, 3% healthcare support staff, and 5% other. Respondents came from a mixture of organisations – acute (47%), mental health/learning disability (19%) and primary care/community (23%); the remaining 11% came from care trusts, commissioning in PCTs and other healthcare providers.

Involvement in quality improvement

Respondents were extremely positive about the level of priority quality improvement was given in their organisation. The vast majority was aware of or involved in quality improvement initiatives; 83% of nurses had been involved in such an initiative, with only 6% being unaware of any of these being run in their organisation.

Perspectives on quality improvement initiatives

Awareness of national quality improvement initiatives was generally high, with many described as organisational priorities in a large percentage of workplaces.

There were high levels of awareness of Essence of Care (91%) and High Impact Actions (HIAs) (56%) in particular. Over one third (36%) of respondents were aware of E4E.

The Productive Series was thought to have had most impact on organisations among large numbers of nurses and nurse directors; nurses also rated Essence of Care as having had a significant impact.

The general impression is that there is little national coordination between quality improvement initiatives, but that individual organisations try to coordinate on a more local level.

Organisational priorities on quality improvement initiatives

A high percentage of nurse directors said that HIAs (80%) and the Productive Series (69%) were organisational priorities. Fewer mentioned E4E (49%).

Team priorities identified by nurses were slightly different from the organisational priorities identified by nurse directors. Nurse directors identified the HIAs and Productive Series as being key priorities over the coming year, whereas teams focused on Essence of Care as a priority (53%). Nurse directors identified the HIAs and Productive Series as being key priorities over the coming year, while teams focused on Essence of Care as a priority (53%).

Access to training – nurses’ perspective

Nurses felt that they had been encouraged to access training on Essence of Care, HIAs and the Productive Series.

Comparative impact of quality improvement programmes

The largest percentage (37%) of nurse directors believed that, of the quality improvement initiatives in their organisation, the Productive Series had had the most impact. Over one quarter (26%) of nurses agreed that the Productive Series had had an impact in their workplace; the same percentage believed that Essence of Care had had the greatest impact.


Improved patient experience (64%) and quality nursing and midwifery care (50%) were identified as the most useful elements of E4E.

Nurse-sensitive outcome indicators

There was a mixed response as to whether the nurse-sensitive outcome indicators were being used. Only 42% of respondents said their organisations were using them.

High Impact Actions

The most common HIAs used were: staying safe – preventing falls (74%); protection from infection (73%); your skin matters (66%); and keeping nourished – getting better (60%).

The most useful resource was said to be the Essential Collection, which offers advice on achieving HIAs (NHSI, 2010).

Productive Series

Productive Ward was the most adopted scheme in respondents’ organisations (69%). Improved ward environment is the benefit most commonly seen by those who had implemented a Productive Series product (71%). The most commonly mentioned barriers to implementing the Productive Series were lack of resources (47%) and lack of staff engagement (37%).

Board reporting

For nurse directors who had HIAs, Productive Series or E4E as organisational priorities, it was common for progress on quality improvement initiatives to be reported to trust boards – 87% said that one or more of the initiatives were reported to the board.

Of these, 46% said progress was reported quarterly and 26% said it was reported monthly; the remainder said reporting was six-monthly or annual.

Potential for improvement

There was strong agreement that improvements needed to be shared across the NHS. Many respondents said more protected time was needed for improvement, with 34% of agreeing and 61% agreeing strongly.


Most nurses are engaged in and support quality improvement. However, a small proportion (6%) had not noticed any quality improvements in the past year within their organisation, which is a cause for concern.

Nurse directors have a crucial role in leading and championing quality and safety improvement. It is reassuring to see reporting to trust boards in most cases, although the frequency of reporting did vary. Further work needs to be done to ensure greater synergy between individual and organisational priorities so that nurses can feel valued, and recognise and articulate their contribution.

E4E gives nurses a unique opportunity to highlight, share and celebrate good practice as well as demonstrate a lead role in quality improvement. The E4E approach also encourages nurses to connect with professional values and focus on raising standards of nursing.

Awareness of a range of quality and safety improvement initiatives was good. Some nurses are aware of E4E, but the message needs to be spread if 200,000 nurses are to be signed up.

E4E provides a platform to ensure national programmes are aligned in a way that makes sense to nurses; it uses a framework to adapt, adopt and sustain quality improvement. It is also an opportunity to build on existing programmes that nurses agree have already improved quality. For example, Productive Series reinforces the message of the nursing contribution to quality and cost improvement. It also encourages the need to celebrate and share improvements across the NHS. NT

Further information is available at To sign up for E4E or post queries, email

  • The authors would like to acknowledge the NHS Institute for Innovation and Improvement for their support with running and analysing the survey.

Case study. Energising for Excellence in practice

Susan Pettigrew is ward manager on a general medical ward. She says:

A colleague told me that Marjorie Wilson*, one of our regular attendees, had been readmitted, and had acquired a grade 3 pressure ulcer for the first time.

I was thinking about Mrs Wilson when I read an email showing the latest ward nursing quality indicators. The incidence of ward-acquired ulcers was not reducing, attempts to improve this were not working.

I spoke to Mrs Wilson, who was distressed. Her notes showed a picture of the ulcer and details of the care it required. It was shameful, as I knew Mrs Wilson’s suffering could have been prevented.

Returning to my emails, I came to one about the trust’s programme to improve quality and reduce costs. Everything came into focus – poor-quality care, harm to patients such as Mrs Wilson and the need to help the hospital be more cost effective. I wondered if cutting costs would mean lower-quality care.

Mrs Wilson’s stay was already longer than usual. She was experiencing considerable pain from the ulcer and I knew that when she went home she would need ongoing care. The sadness and frustration I felt made me determined to get involved with the hospital’s aim to cut costs by reducing harm to patients such as Mrs Wilson.

I arranged to see the medical matron, Jane Coles, who told me about E4E. We looked at the E4E website and found links to many tools and approaches – we were pleased to see it included the Productive Ward, which we had embarked on three months previously. We agreed that the time released as a result of this could be used to tackle the incidence of pressure ulcers.

I also learnt that my trust was one of over 100 that had signed up to the Safety Express campaign, which has a specific aim to reduce the incidence of pressure ulcers.

Action to reduce pressure ulcers is one of the High Impact Actions for nurses and midwives, so there was a wealth of information about this, so I didn’t need to reinvent the wheel.

Previously, a mass of information on quality issues and reducing costs had come piecemeal from different directions. Now I could see ways forward.

The Productive Ward was showing early benefits and provided a terrific foundation for our new work. Jane agreed that my ward would be included in the initial stages of Safety Express and we would use the Safety Thermometer, which measures the prevalence of several harms, including pressure ulcers. When I learnt about Safety Express, I was keen that the team would take action on other harms including falls and urinary tract infections. I recognised that, together, these actions would greatly help my drive to measure and eliminate pressure ulcers.

The ward team took an approach based on the SKIN bundle from Abertawe Bro Morgannwg Health Board, in the Essential Collection (NHSI, 2010).

The best outcome was the impact on patients. The rate of patients with pressure ulcers on my ward dropped from 6.5 a month to zero. I calculated the saving to the trust on this ward alone to be £8,000 a month.

Jane and I highlighted the potential to prevent pressure ulcers to the trust board by reporting progress in the monthly matron’s report.

This meant our ideas and good practice were spread across the trust. Once every ward was measuring the occurrence of pressure ulcers using the Safety Thermometer, we knew the message was getting across. I worked with other trust nursing leaders and we integrated our work on Safety Express, Productive Ward and High Impact Actions under the banner of Energising for Excellence.

We had a consistent approach and a powerful joined-up story. I linked up with colleagues from other professions – nurses, medics, allied health professionals and managers. We aim to eradicate pressure ulcers in our trust, and have introduced the SKIN bundle to all medical wards.

I told my story and celebrated the success of this initiative at the annual International Nurses’ Day event at the trust, and won an award for the improvements.

I captured the actions of our ward team, talked about our triumphs and what we were most proud of – no more cases like Mrs Wilson’s, taking part in Safety Express and High Impact Actions and our courage to make changes. For me, personally, these were a colleague telling me the effect my story had on him and getting to know Mrs Wilson.

My story was highlighted on the Energising for Excellence website, and I have received many requests to tell my story and help others to do the same thing.

* The name has been changed 

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