Nurses responded to complaints by implementing the iCARE programme to transform ways of working. The trust explains the impact this has had on care
Jo Ryan, RN, is the head of nursing for urgent care, medicine and the elderly at Yeovil District Hospital Foundation Trust; John Park, MA PhD, is a public governor for the Dorset constituency of Yeovil District Hospital Foundation Trust.
Ryan, J.M.B, and Park, M.J.M. (2010) Communication, attitude, respect: implementing an iCARE philosophy.Nursing Times; 106:44, early online publication.
Responding to complaints, nurses at Yeovil District Hospital led a drive to improve the quality of care for the trust’s patients and the engagement of relatives and carers, while at the same time boosting employee morale. Over the last four years this has been achieved by implementing the iCARE philosophy - a new way of working – which operates throughout the trust.
Keywords Communication, Respect, Hospital environment, Leadership
- This article has been double blind peer reviewed
The iCARE philosophy was initiated by nursing staff at Yeovil District Hospital, but was quickly taken up by all other groups.
- It covers the approach of every individual to communication, attitude, respect and the hospital environment.
- iCARE has become a philosophy for the trust that governs the behaviour of all staff towards their colleagues, patients and other stakeholders.
- It guides human resource policy and management style at all levels.
- Patient complaints often provide information that can be the catalyst for positive change.
- When developing an organisational philosophy it is important to ensure it is not just an initiative, but a lasting change to the way of working.
- Involving patients and their carers in developing the philosophy can help to ensure it reflects their perspectives.
- Organisational philosophies can have a positive effect on staff morale as well as the quality of services.
Front Line Care, the report by the Prime Minister’s Commission on the Future of Nursing and Midwifery in England (2010), challenges all nurses and midwives to provide high quality, compassionate care. This article describes how the nurses in one trust have already committed to fulfilling this promise by developing a philosophy that now influences all aspects of its activity, from care provision to staff interaction.
Over a three year period, the iCARE philosophy has come to be at the heart of Yeovil District Hospital. iCARE stands for: Communication, Attitude, Respect and Environment - the four key themes which staff focus on when trying to meet and exceed the expectations of patients and everyone who deals with the trust. The ‘i’ in iCARE, stands for the individual, emphasising that every employee has a fundamental role to play in delivering exceptional care. iCARE equally applies to how staff work together and respect each other to help make the trust one of the top 10 healthcare employers in the country.
iCARE came about following complaints and conciliation meetings that highlighted the poor standards of care being delivered to some patients and their relatives. It was clear that although patients were being seen and treated according to national targets and although external standards were being met, there were serious lapses in care which had more to do with interpersonal skills and behaviour. Some staff seemed not to demonstrate humanity in care and failed to respect the dignity of patients and their families.
The origin of iCARE
In 2006, one of the hospital matrons who was responding to complaints raised by patients and their families about their care identified the need for a change in the way of working at the hospital. Although conciliation meetings had been held to address the issues separately, the director of nursing asked the matron to identify any themes linking these failures.
Focusing on two complex cases the issues could be put under four simple headings:
- Communication: there was a lack of communication with the GP and the patient, while staff were not listening to carers.
- Attitude: there was a lack of leadership, with no one owning the ward. Staff confidence and competence was below standard.
- Respect: insufficient dignity was afforded to end of life care. Nurses were not fulfilling commitments made to patients and carers.
- Environment: soiled items were not being removed immediately from a patient’s bedside. Overall there was a poor physical environment and atmosphere.
There was a feeling that as nursing staff had begun to take on more tasks that had previously been done by doctors and specialists they had lost sight of the fundamentals of nursing and caring. The senior nursing team turned these negative behaviours into positive actions that all staff would be expected to aim for. These were:
- C: Effective communication;
- A: Positive attitude;
- R: Respect for patients, carers and staff;
- E: Environment conducive to care and recovery.
A small “i” was put at the front of CARE to emphasise the individual’s role in delivering exceptional care.
The change process
The director of nursing took this concept to the trust board, who recognised the power of the iCARE philosophy. Although originating from nursing, it was decided that it could and should be adopted as a way of working across the trust. In September 2007, a steering group was established consisting of representatives of all staff groups, patients and academic partners from the University of Western England, and chaired by the chief executive. This group endorsed the concept and decided on the best way to get the message to all employees.
Internally the main thrust was a staff awareness campaign with iCARE training sessions set up for all staff, including directors. The sessions run for 2-3 hours with 16-25 attendees led by two facilitators. Currently 98% of staff have had iCARE training, which has two major themes:
Learning from previous mistakes or complaints: Participants analyse real cases where complaints have been made, identify which iCARE principles were violated and suggest remedial action. These suggestions are then compared with the action already taken.
Learning from successes: Participants share examples where things have gone particularly well in their experience or “magic moments”. This expression is now widely used in day to day work in the hospital, for example when staff get particular recognition or thanks from a patient or colleague.
iCARE training events are attended by a mixture of staff across all disciplines so that each course covers a wide range of perspectives. Participants are encouraged to take the opportunity to explore how the philosophy can influence their own area of work and responsibility. When staff have attended a training session they receive iCARE@ydh badges or lanyards, which serve as visual reminders of the key iCARE messages.
The iCARE change programme was also announced externally, first at the trust’s annual general meeting in September 2007 and then in May 2008 when Dame Christine Beasley, the Chief Nursing Officer for England, was invited to Yeovil where she added her support for iCARE and officially launched it.
To engage as many stakeholders as possible, a variety of material was developed including:
- Leaflets to distribute to all visitors to the hospital;
- iCARE questionnaires to be completed by patients on discharge, with enthusiastic support from the trust’s patient and public involvement group
- iCARE movies on DVD and on the trust intranet with participation from directors and other staff. These provide explain the origins of iCARE and its fundamental principles – with enough detail around the principles and processes that the viewer can understand how and why the philosophy works.
This material has been shared with and used by other local health organisations, including St Margaret’s Hospice in Yeovil and the Bath and North East Somerset PCT.
The iCARE programme is not a one-off initiative but a change in the way of working, so real commitment is needed to ensure its continued application. An overview of the programme structure is given in Box 1.
At board level, iCARE is the foundation of the trust’s quality strategy, equality and diversity strategy and service improvement programme. In the human resources directorate, all new policies are designed on iCARE principles: for example in recruitment all potential new staff are assessed against iCARE behaviours.
All those who join the hospital in any capacity, staff, management, directors, governors, attend the iCARE training as part of their induction. Each event is introduced by the chief executive or another director. New applications are actively sought, such as using an iCARE framework to address team building, and challenge individual and team performance issues.
The iCARE programme has transformed the way the hospital works, and in particular paved the way for the trust to respond to the Department of Health White Paper Equity and excellence: Liberating the NHS (2010). The patient experience is now seen as a key measure of how organisations deliver their services and, with iCARE real-time feedback, the hospital can address this area with confidence.
The programme has received wide external recognition in its own right - in addition to the endorsement from Christine Beasley it gained first place in the South West Health and Social Care Awards.
iCARE has had a huge impact on the way of working in the hospital. Yeovil District Hospital was ranked as one of the top performing NHS acute hospitals in England in the 2008, 2009 and 2010 Healthcare 100 awards. In 2010 it was described as being “in the top 10% of trusts in the annual staff survey, and believes in empowering staff to bring about improvements for patients” (Healthcare 100 awards, 2010). iCARE now forms an important visible element of the trusts’ corporate image, for example as the standard for internal and external presentations, while the lapel pins and lanyards for ID badges are widely used by employees.
NHS Employers recognised Yeovil District Hospital as one of the top trusts leading on equality and diversity and in 2009/10 made the trust one of its equality and diversity partners (Taylor, 2009).
Measuring the effects of behavioural and cultural changes such as iCARE is difficult. With this initiative, the hospital has set itself up as an organisation that actively seeks critical appraisal of its service from the patients and relatives who use it. This, together with raising expectations by publicising the iCARE promise, could lead to an initial increase in complaints registered, however, this is seen as an essential part of the iCARE journey. The trust has begun to analyse complaints received from patients, their carers and relatives according to the four iCARE themes (Fig 1) with clinical care as a separate category. There are some significant changes, and while it is too early to draw detailed conclusions from these data, so far we have received far more compliments than complaints.
Another indication of how iCARE has affected the trust comes from the results from the National Staff Satisfaction Survey. The number of key findings where Yeovil District Hospital is above average among acute trusts has increased since 2006 and it was the top rated acute trust in the South West for 2009, as shown in Fig 2. However, there are still key findings where the trust ranks below average in the survey, which are taken seriously and being addressed.
More proof of iCARE’s success is that a patient’s relative involved in one of the cases that triggered iCARE has played a key role in its development, and is now chair of the patient and public involvement group.
The iCARE implementation phase was particularly effective because all the critical factors for a successful organisational change programme came together. The need to work better was recognised by leaders, namely matrons and the director of nursing, who were committed to improve performance, and the compelling case for change was recognised by employees and leaders alike.
A diagnostic review was made of the instances where things had gone wrong and four specific areas of behaviour were identified for improvement. Implementation was driven by leadership working together “from board to ward”. All employees understood the case for change, how it would affect them and what their role would be in making it work. The programme was simple, had immediate impact and was designed to improve working conditions as well as performance.
The staff most affected by the programme were most closely involved in its design and implementation. Those taking part, especially in designing and delivering the training programme were given the time needed to do it effectively.
The management steering group monitored progress and ensured that lessons were learnt during implementation. Change has been established as part of the trust’s normal day to day working. Success is publicly celebrated, such as through Outstanding Achievers’ awards at the trust’s annual general geetings.
It is important in this context to realise that the iCARE programme is not complete and never will be. It is a continuous process which includes training for new recruits and refresher training to keep the programme alive for all staff.
Over the last year, Yeovil District Hospital has come under increased pressure. Having achieved “double excellent” for two years in a row under the Health Care Commission, in the 2009 Care Quality Commission’s Annual Healthcheck, the trust was awarded “Good” for quality of services and “Excellent” for use of resources. Although these are high ratings, our aim is to recover the “double excellent” status and with iCARE we are ready to face these challenges as a unified organisation.
Spreading the word
One of the critical success factors for iCARE was that it originated in the hospital with those who wanted to change the way things happened around them. It may not be simple to transplant in other organisations, although early indications are that it has been done successfully at Bath and North East Somerset PCT with their iCARE@BANES programme.
Where there is a desire for change there are valuable lessons to be learnt from Yeovil District Hospital, but any organisation wanting to do something similar will need to go through the process of building its own programme that captures its own aims and generates real cultural change. This can be made easier if it is built on a foundation of staff ownership and a corporate willingness to drive improvement in the patient experience.
Yeovil District Hospital has improved the quality of care for its patients and engagement of their relatives and carers, while at the same time boosting employee morale. All this has been achieved through implementing a simple and clear new way of working - the iCARE philosophy. iCARE has become a strong foundation for the trust as it faces challenging times ahead.
Professor Philip Darbyshire - a leader in nursing and healthcare research and practice development, whose international roles include visiting professor at Bournemouth University - spent some time with the nurses at the trust in May 2010. He said of iCARE: “They have managed to blend the elegant simplicity of the best theories with the absolute practicality demanded in the everyday world of a busy clinical environment. Such is iCARE’s power to engage the hearts, minds and practices of staff that this respect fans out throughout the organisation, from CEO to shop volunteer, from surgeon to student nurse.”
The last word goes to a patient cited on the NHS Choices website, (2009). “This hospital has improved beyond belief in recent years. Without exception all the staff I met were kind, polite, helpful, patient, professional and caring.”
For further information on Yeovil District Hospitalclick here.
Box 1. iCARE programme structure
- 2.5 hour training sessions for all current and new staff, led by trust board
- Recruitment and selection process
- Workforce development
- Education framework
- Quality strategy
- Equality and diversity strategy
- Patient/user feedback
Practice Module (under development)
- Change management
- Team building
- Project development
- Service improvement
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Department of Health (2010) Equity and Excellence: Liberating the NHS.
Prime Minister’s Commission on the Future of Nursing and Midwifery in England (2010) Front Line Care:the future of nursing and midwifery in England. March 2010.
NHS Choices, Yeovil District Hospital pages.
Taylor J (2009) How to tackle equality and diversity in the health service.Health Service Journal, 29 June 2009.
Health Service Journal, Nursing Times (2010)The Healthcare 100 2010.