Confidence in caring · Confidence in caring is designed to help nurses, carers and care planners to do this. It offers a framework of best practice guidelines to help carers focus

Confidence in caring

A framework for best practice

DH InformatIon

Document Best Practice Guidance

roCr ref: Gateway ref: 8012

title Confidence in Caring Project Overview

author Department of Health – CNO’s Directorate

Publication date September 2007

target audience Directors of Nursing

Circulation list Directors of Nursing

Description Confidence in Caring’ Project. A project sought to explore ‘caring’ and also to identify how dignity and caring could be improved.

Cross reference N/A

Superseded documents N/A

action required N/A

timing N/A

Contact details Ros Moore Experience and Involvement – Professional Leadership Room 5E58, Quarry House, Quarry Hill, Leeds LS2 7UE 011325 46063 www.dh.gov.uk/cno

for recipient’s use

Policy Estates HR/Workforce Commissioning Management IM & T Planning/ Finance Clinical Social Care/Partnership

working

© Crown copyright 2008

First published January 2008

Produced by COI for the Department of Health

The text of this document may be reproduced without formal permission or charge for personal or in-house use.

www.dh.gov.uk/publications

2

Contents

1. Introduction 3

2. Some fundamental truths about caring 5

3. What creates confidence? 6

3.1 A calm, clean, safe environment 7

3.2 A positive, friendly culture 9

3.3 Good team-working and good relationships 11

3.4 Well-managed care and efficient delivery 13

3.5 Personalised care for and about every patient 15

4. How to increase confidence in the care you provide 18

5. Leading to create confidence 24

6. Simple rules for staff 27

7. Conclusions 29

8. Resources 30

8.1 Confidence creators 30

8.2 Simple rules to create a confidence action plan 31

8.3 Further guidance and information 33

9. Acknowledgements 35

3

1. Introduction

patient needs and preferences at the centre of care design

and delivery.

Confidence in caring is designed to help nurses, carers

and care planners to do this. It offers a framework

of best practice guidelines to help carers focus on

the issues that matter most to patients and provide

a positive experience for them. It can be used in

conjunction with initiatives like The productive ward

and Essence of care.

The guidelines are based wholly on the feedback and input

of patients and nurses working in acute hospital wards and

were developed by a project team from the Department

of Health, two strategic health authorities (SHAs) and

volunteer ward teams. Patients were asked what gave

them confidence in the care they received. At the same

time, nurses were asked what factors they thought

were central to a positive patient experience. The results

enabled the team to identify a set of five ‘confidence

creators’ which patients and nurses felt were central to a

positive patient experience. Section 3 of this best practice

Providing care in hospitals today is more complex than ever

before. Healthcare has changed, with more technology

involved, more specialist care offered and more complex

patient needs being supported. But the most fundamental

aspects of care remain the same as they ever were:

patients and users expect to be safe and to be treated with

courtesy, respect and kindness. Those basic principles are

vital to ensuring that patients have confidence in the care

they receive.

Healthcare staff everywhere know this, and want to

provide patients with care that meets their expectations.

But recent evidence has suggested that, even though

overall care outcomes continue to improve and overall

satisfaction with nursing remains high, patients – and in

particular, older patients – do not always have confidence

in the care they receive. That in turn can affect their

satisfaction with the treatment they receive and their

future choices about treatment. Given that patients’

experience of care is a core component of commissioning,

quality monitoring and regulation, it’s crucial to put

4

In many cases, the behaviours and steps recommended

will be familiar to nurses and carers. The aim of this

toolkit is to bring all these steps together in one simple

framework that can act as a quick reminder and a source

of new ideas. Because of this, the framework will be

a valuable resource for staff at all levels caring for all

groups of patients.

framework explains what these confidence creators are

and provides some recommended steps that can be taken

to increase patient confidence.

Though the steps themselves are often very simple, putting

them in place might not be so easy. Who is responsible for

the new actions or changed processes? Are new resources

needed to enable nurses to make changes? To help with

this, section 4 of this document suggests a systematic

approach that nurses can take to reviewing, redesigning

and implementing improvements in practice to ensure

that patients and carers have confidence in their care.

Section 5 then looks at how leaders in care environments

can support, encourage and empower their teams to

build patient confidence.

5

2. Some fundamental truths about caring

patients and their families. All of these aspects of care

are interdependent; to be effective, change must be

embedded in the whole system – not just one part of it.

n Although staff know what they should be doing, they

don’t always do it. Standards, policies and competencies

only guarantee what people can do, not what they do

in practice.

n Patients and visitors are constant monitors of quality.

Confidence in care is not just determined by their own

experience. It is determined by what surrounds them

and what they see happening to others.

n Confidence in caring is a two-way thing – staff

must feel able to care with confidence to promote

confidence.

These fundamental truths will come as no surprise to most

carers. But reiterating them here helps to confirm what

matters to patients, and provides the foundations for the

way care can be improved to increase patient confidence.

In the project, there were a number of common themes

that kept being mentioned by participants. These themes

emerged as fundamental truths about caring – things

that nurses, other care staff and patients all agree on.

These truths form a shared understanding of what care

is about today, who is responsible for it and how the

care experience is linked to patient confidence.

n Care today is more complex than ever before, and

patients and teams are more culturally diverse than

ever before.

n Patients and relatives see nurses as the ‘owners’ of the

caring system.

n Nursing is an art and a science: nurses must ‘care for’

and ‘care about’ in equal measure. It takes no more

time to deliver care with kindness.

n Caring isn’t just about what each member of staff

does: it also involves the environment, culture and

history of the ward and team, as well as the way

staff behave and interact with each other, and with

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3. What creates confidence?

The project identified five ‘confidence creators’ – core

issues that patients care about and that effective carers

seek to deliver. These are:

n a calm, clean, safe environment;

n a positive, friendly culture;

n good team-working and good relationships;

n well-managed care with efficient delivery; and

n personalised care for and about every patient.

Each of these confidence creators is of equal importance:

there is no standard priority among them. What’s more,

they are all interrelated, and all depend on the involvement

of people at all levels of the care system.

n At the organisational level, or at the level of the

clinical area or unit, confidence depends on the means

by which care is provided. The physical features of the

clinical area, the resources available and the overall

culture are vital to patient confidence.

n At the team level, confidence depends on the way care

is delivered, co-ordinated and led.

n At the individual level, confidence can be created

when patients see that individuals have the skills to

do the job and the will to provide the level of care the

patient wants.

In looking at how to improve performance in each of the

confidence creators, the framework identifies potential

improvements in each of the three areas of: means; ways;

skills and will. It doesn’t set out to provide an exhaustive

list, but it does show a wide range of simple and practical

things that carers can do to improve patient confidence.

7

Figure 1: Confidence creators

Patients haveconfidence in caring

Staff are caringwith confidence

Organisation/clinical area/unit

Team

Individual

Skills and will

Ways

Means

A calm, clean,safe environment

A positive,friendly culture

Good team-workingand good relationships

Well-managedcare with efficient

delivery

Personalised care forand about every

patient

3.1 A calm, clean, safe environment

Patients see the ward environment as being a direct

indication of how attentive staff are – not only to them

directly, but to the whole process of caring. They equate

ongoing noise, lack of cleanliness or mess with a lack of

care. Patients told the project team:

‘There was a sweet wrapper on the floor for

ages. If they don’t do anything about those sweet

wrappers, what else are they missing?’

‘I was exhausted – I hardly got any peace at night

due to the noise and activity.’

Confidence is created by keeping the patients’ area quiet

and clean. There are a number of steps that patients and

staff suggested to improve the physical environment, but

perhaps the most fundamental is to look at the layout

of the wards or care environment and see if it can be

changed to reflect the needs of patients, rather than the

organisation or even staff.

8

MEANS – actions for the organisation/ unit/clinical area

n Make sure the entrance to the ward or area is attractive and has welcoming signs

n Ensure that the environment as a whole is well lit, bright, tidy and uncluttered. It should be attractive and well decorated

n Ensure that the whole environment is clean (including the hidden areas, nooks and crannies)

n Keep facilities and equipment well maintained and operating at the optimum level

n Eliminate mixed-sex accommodation

WAYS – actions for the team

n Work as a team to improve the environment

n Minimise unwanted noise in every way possible

n Seek to accommodate preferences regarding location

SKILLS AND WILL – actions for individuals

n Take responsibility for the quality of the environment

n Deal with patient concerns there and then, or take action and then follow up

n Try to look at the environment through fresh eyes every day – ‘walk in the shoes of patients and relatives’

n Remove stocks, supplies and equipment from public spaces and empty bins

n Minimise unwanted noise yourself (for example, by wearing the right footwear) and challenge those – whether they are staff or patients – who don’t

n Tidy up after yourself

n Anticipate patients’ needs and leave personal requirements within their reach

9

One valuable way of engaging patients and making them

feel included – as well as helping them build up friendships

– is to involve them in ward life.

‘Some of the staff would let me take the tea

trolley round. I liked that; it made me feel useful

and it kept me moving.’

‘I wanted to be part of the solution not the

problem.’

This is something that was not only suggested by patients,

but also by some of the experienced nurses involved in

the project. The better relationships staff can have with

patients, the more confident patients will be with the care

they receive. It also means a more pleasant environment

for staff.

‘I like a laugh with the staff and you can tell those

who like it and those that don’t.’

3.2 A positive, friendly culture

Getting the culture right makes a huge difference to

patients’ confidence from the minute they arrive on the

ward. It’s important to be positive, friendly and welcoming

not just when patients arrive, but at the beginning of

each shift too. It helps create an air of professionalism and

gives patients the confidence to talk to staff and to other

patients. It’s something that patients are very sensitive to,

as some of the comments received show:

‘I know in the first five minutes what a ward’s

going to be like. There is a feel to every ward – if

they are not expecting you or no one’s been to let

you know what’s happening within five minutes,

you know there’ll be problems.’

‘Within five minutes of the nurses coming on,

I can tell what the rest of the shift will be like –

sometimes it’s chaotic, and other times it’s calm.’

‘When you met staff on the corridor they

avoided contact – they seemed self-absorbed

and inward-looking.’

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n Make the environment as a whole open, welcoming, positive and patient orientated

n Have a unit philosophy, information pack, and care standards. Make them visible and communicate them in a way that people understand. This should include information on how staff will work with relatives

n Structure the environment around the needs of patients


n Maintain high energy levels and create a calm, positive and friendly climate

n Work with patients and relatives and/or carers as partners in care

n Handle concerns before they become complaints

n Maintain a set routine for meeting and orientating new or transferred patients

n Deliver the service promised in trust literature or patient information – actions should match words

n Encourage patients and visitors to feel confident about approaching nurses’ stations (or other areas) by making sure that they are welcomed by staff

n Give information to patients in a user-friendly way


n Be outward-looking, and engage sociably with patients and relatives. Acknowledge patients and visitors every time

n Welcome and orientate new or transferred patients within five minutes of arrival

n Help patients build rapport with staff and others

n Value patients and relatives as part of the community and encourage their contributions

n Work in partnership with relatives or carers to agreed standards

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The way to build confidence is to work together, support

colleagues and resolve any differences of opinion

away from patients. Staff questioned in the project

acknowledged this but also mentioned that, because

teams are more diverse than ever before, this can lead

to different expectations and make it harder to resolve

differences. They asked for more diversity training and

team-building to help with this – which is something

organisations might look to offer.

3.3 Good team-working and good relationships

It’s no surprise too that the project showed how much

patient confidence can be affected by gossip, blame and

lack of co-operation among staff. Patients are sensitive

to relationships, aware of problems and think it is the

responsibility of leaders to resolve them.

‘The nurses were talking about the night staff and

saying how rubbish they were.’

‘It’s the ward sister who really sets the tone,

isn’t it?’

Patients see all ward staff as a team, who should work

together for their care. This is exactly the way in which

most staff want to work too. One of the best ways to

act as a team is to take responsibility for what’s going

on, and if there are concerns, try and help resolve them.

It builds confidence in patients that their information is

being passed on and is available to other team members.

Patients don’t want to hear things like:

‘I don’t know, I’ve not been on duty.’

‘You’re not my patient.’

‘It’s not my job.’

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n Provide strong leadership and set clear expectations for staff about positive team-working and relationships

n Sisters or charge nurses should support and enable the team to care with confidence

n Put systems in place to monitor quality and performance against key issues such as responsiveness

n Offer diversity training and support for team-building initiatives

n Ensure that diversity is valued across the organisation


n Have someone in charge who clearly manages the team and provides clinical co-ordination

n Be well briefed about patients

n Supervise and coach staff as needed

n Demonstrate positive healthy relationships between colleagues

n Organise and deliver care to maximise the performance of the whole team

n See the clinical area as a whole and work ‘as a team’ not just in a team

n Let patients know who’s who and what will happen at the beginning of each shift


n Be well organised

n Know something about all patients and their general progress

n Recognise different perspectives and reconcile professional differences in private

n Handle conflict well. Never criticise or blame colleagues during conversations with patients, relatives or colleagues

n Strive to improve in all areas of competence

n Support colleagues willingly

n Display loyalty to other members of the team and promote a positive image of the clinical area, colleagues and the organisation

13

Care staff involved in the project were very aware of the

problems of both seeming inefficient and being inefficient.

Several felt that they often spent a lot of time and effort

getting round problems in the short term, but rarely had

the time to look at the way they worked overall – which is

when real improvements could be made. They added that

often it was just small improvements or changes that made

all the difference.

One specific example of this was that, in many locations,

patients felt they had less contact with staff later in the

day. They were often left waiting and found it difficult to

get attention.

‘After I moved down the ward I never saw anyone

after 2pm! Someone would come round with

a drink and tell you to go for your tea but that

was it.’

When this came up in discussion with staff, they

acknowledged that they tend to prioritise their attention

to those who are most ill or highly dependent – particularly

when there were fewer staff on duty. What’s more, because

there are few people around at this time, care staff have

additional administrative duties, such as answering the

telephone. The challenge for staff, therefore, is to be more

flexible in the way they allocate resources and particularly

in the way they spend their time in these hours.

3.4 Well-managed care and efficient delivery

Effective care is not just about people: it’s also about

processes. Care needs to be delivered efficiently, with things

happening on time, staff knowing what they’re expected to

do, and a clear sense of priorities and of someone being in

charge. This puts extra emphasis on leadership as managers

need to plan ahead and take charge during their shifts.

Where delivery doesn’t seem to operate efficiently, patients

become concerned that important aspects of their care may

be missed – as some of the comments received show:

‘Everybody was really nice but there was no

organisation: everybody was rushing about doing

their things but no one seemed to be in charge.

They had no idea of what was happening in the

rest of the ward.’

‘Did they think I couldn’t hear those desperate

calls every night begging people to do an extra

shift? It doesn’t give you confidence!’

On the other hand, patients are immediately reassured by

a visible sense of purpose.

‘If the ward looks efficient, then it is efficient.’

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n Ensure that the clinical area looks efficient

n Make leadership visible on every shift

n Keep care planning systems rigorous

n Look at administrative support out of hours so that care staff can be with patients

n Ensure that the unit has up-to-date information for new and transferred patients

n Ensure that documents and beds are named accurately


n Have someone in charge who clearly manages the ward and team and who provides care co-ordination

n Assess care delivery methods at every shift, in order to balance staff skills with patient needs

n Review the team’s approach to handling telephone calls and administrative duties out of hours

n Use care plans to guide care

n Communicate with patients regularly and clearly about their care

n Supervise and coach staff as needed

n Proactively monitor all patients


n Be well organised

n Manage expectations and talk to patients and relatives about unanticipated events or pressures, to negotiate priorities

n Know something about all patients and their general progress

n Be well briefed about patients

n Give care and information in a timely, proactive manner

n Do what you’ve promised

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Patients don’t expect each staff member to know every

detail, but they do expect them to be able to find out

important details when needed.

Caring about patients

Caring about patients is as important as caring for

patients, and how staff behave, look and talk to people

is as important as what they say. Patients expect to be

treated with kindness and courtesy at all times, and also

expect staff to retain an upbeat manner most of the time

and to avoid communicating (consciously or unconsciously)

personal concerns and frustrations in their company.

In general, patients take it for granted that nurses have

the clinical knowledge and technical skills needed to

provide effective care, but were less confident about the

quality of fundamental care and the caring attitudes of

staff. Some patients will say they have received good care

themselves, but that they have seen others not being

cared about as much as they would expect. For example,

patients mentioned to the project team instances of lack of

help with feeding, ignoring calls or expression of distress,

breaches of dignity and privacy, and lack of courtesy. All of

this can dent overall confidence in the care staff.

3.5 Personalised care for and about every patient

Patients are enormously reassured by effective case

management, with a single co-ordinator acting on their

behalf and keeping track of progress. This needn’t be a

doctor: in fact, patients are very happy to have nurses

managing their cases and liaising with doctors and others

on their behalf. But it does mean that the patient’s overall

case should be managed continually and information given

to them proactively.

Though different patients will want different relationships

with staff, the simple fact is that patients feel most

comfortable and confident when staff know them

on a personal level: their family circumstances, living

arrangements and, above all, their concerns. Once staff

know these concerns, they can then work proactively to

resolve them – keeping patients (and their relatives or carers)

informed about their case. Often, just having staff around

to answer questions can help maintain patient confidence

in their overall care, as one of the comments received

illustrates:

‘I expected people to know about me – what my

problems were and what help I needed. Having

a label stuck on your bed is not the same as

communicating.’

16

Others feel that nurses are not as familiar as they would

expect them to be with common beliefs and practices

associated with particular cultures. This project shows

that patients see all of these issues as part of providing

professional care that builds confidence.

‘It’s the whole package: standards, how things are

done. Can you learn that?’

Staff involved in the project all agreed that these were vital

aspects of caring with confidence, but felt that there was

little formal development available in these areas – and

that there were often no methods in place to monitor how

well staff dealt with patients on an interpersonal level. For

example, while things like diversity training are now widely

available to help understand different cultures, there are

some areas where staff felt they didn’t have the right

competencies. The staff who participated in the project

would welcome further training on:

n how to provide care in accordance with functional age

(rather than just physical age);

n how to manage medical deterioration better; and

n how to deal with patients whose behaviour is

challenging.

17


n Ensure that there is a system of clinical co-ordination

n Locate patients to reflect social as well as medical needs

n Give patients milestones and have systems in place for case management and to provide patients and relatives with daily updates on progress

n Treat care as personalised, rather than being driven by medical condition or specialism

n Put in place a system to monitor and improve the skills to care for patients. This includes a systematic approach to improving age and cultural sensitivity, supporting confused patients, providing acute medical care and managing deterioration

n Put in place a system to systematically monitor and develop the skills to care about patients. This might include random observation and review of care

n Develop training plans for staff based on the outcomes of random observations and review of caring episodes


n Make patients and relatives partners in care

n Give behavioural feedback to staff on caring competence

n Agree clear milestones for patients and ensure that all relevant people know about them

n Provide patients with an up-to-date progress report against their care plan and milestones

n Extend caring to relatives and carers

n Proactively monitor all patients


n Provide care that is culturally sensitive to age, social class, regional or group affiliation as well as ethnic, religious or national origins

n Stick to the simple rules of caring; praise good care but always challenge the lack of caring

n Ensure that fundamental care is provided: appropriate food and drink should be available for all patients, and help provided for those who need assistance with eating and drinking

n Actively engage with patients in order to prevent problems or anxieties – there’s no need to wait for requests or problems to arise

n Demonstrate high levels of knowledge about medical conditions, diagnosis, treatments and care

n Have a solid grasp of individual patients’ backgrounds, needs and progress, particularly in terms of their treatment and care milestones, and accommodate individual differences

n Show interest in patients and anticipate their needs

n Make a personal connection with patients and relatives and make decisions on personal care jointly with them

n Obtain consent for any intervention or interaction including permission to enter or approach patients’ personal space

n Protect the privacy and dignity of patients at all times: maintain confidentiality when caring, so that no one overhears conversations with, or about, patients

n Perform all tasks or procedures – no matter what they are – with courtesy, respect and kindness

n Anticipate and minimise patients’ feelings of anxiety, worry, anger, embarrassment, pain or discomfort

n Accept negative as well as positive responses and provide emotional support

n Attend to spiritual needs

n Be smart and well presented, and demonstrate professional behaviour at all times

n Be a role model for healthy living

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4. How to increase confidence in the care you provide

Clinical benchmarking has shown that by paying attention

to these issues and making small, targeted changes in

the way care is provided, hospitals can make enormous

improvements for patients. To help with this process, this

section provides a systematic approach to assessing and

then improving care. This approach consists of five linked

stages, as Figure 2 on page 19 shows.

For many nurses, carers and managers, the confidence

creators in section 3 will have come as little surprise. The

actions suggested are exactly the sort of things good staff

already do; in fact, most of the actions come directly from

staff input. But there are still far too many instances where

these simple things outlined above aren’t taking place on a

systematic or habitual basis.

19

Figure 2: Introducing a systematic approach to assessing and improving care

Stage 1Identify what

creates confidence

Stage 4Identify suitable

interventions

Stage 5Implement

interventions

Stage 2Examine the

existing care system

Stage 3Compare yoursystem with

known confidencecreators

20

Stage Suggested steps

1. Identify what creates

confidence

n Use the confidence creators identified in section 3 as indicators of what gives

patients and carers confidence in general

n Audit patients’ views in your organisation

2. Examine the existing care system To help assess how care in your hospital, ward or team measures against the

confidence creators, collect data on the following:

Clinical area/unit level

n Staff demographics (for example, grade and experience of staff)

n Staff competencies (for example, profile the technical and interpersonal

competencies of staff)

n Care system (for example, using the Essence of Care* benchmarks)

n Work activity (for example, how staff use and organise their time, how staff

deliver care, etc)

n Patient satisfaction (for example, by assessing achievement of the confidence

creators using a validated satisfaction tool from the local organisation)

n Patients’ and users’ views (for example, using complaints and compliments)

* Department of Health (2001). Essence of Care: Patient focused benchmarking for healthcare practitioners.

21


2. Examine the existing care system

(continued)

Team level

n Teams’ perspective of care (for example, using workshops where staff visualise

and analyse the caring system)

n Wider team effectiveness (for example, conducting 360º review, taking in the

perspectives of patients, staff and colleagues)

Individual level

n Staff satisfaction (for example, using a questionnaire validated by the organisation)

n Random observations of staff, with comparison of working practices with

confidence creators and the ‘fundamental truths’ about caring (see section 2)

and the ‘simple rules’ (see section 6).

Much of this data might already be collected elsewhere in the organisation. There’s

no need to duplicate the process, or to be too exhaustive about what data you get –

the aim is to ensure that you have a big enough picture to understand what you and

your staff are doing well, and where you could make improvements.

22


3. Compare your care system with

known confidence creators

Once you’ve got data about the care system in your organisation or team (stage 2),

you can then compare that data with the known confidence creators and patient

views (stage 1) to identify what aspects of your care system improve confidence and

what aspects diminish confidence.

Some key questions to ask include:

n Does your staff profile reflect the needs of the patients?

n How well do you match care capacity and capability with care demand in a

dynamic way, considering all patients?

n Do the technical, interpersonal and cultural competencies of the staff reflect the

needs of the patients?

n Do the staff have the skills to deliver those activities that affect patients’ and

carers’ confidence in care?

n Does the care environment reflect what patients and carers view as giving

confidence?

In addition, there will be specific questions that reflect your care system and the type

of care you provide.

23


4. Identify suitable interventions Once you have identified where you can make improvements, the next step is to

work out what interventions might be suitable.

n The best results generally come from discussing potential interventions with the

team, so that they can offer their input on what might work and take ownership

of particular areas for improvement.

n There are lots of sources of information on potential interventions, including:

– the actions suggested in section 3

– the leaders’ ‘dashboard’ in section 5 below

– Essence of Care

– the new Clinical Benchmarks for the Care Environment

– Releasing Time to Care: The Productive Ward

– practical training programmes such as Being with Patients

(See section 8.3 for references.)

5. Implement interventions The most effective interventions are highly targeted to specific issues locally. It’s good

practice to measure the impact of your interventions a few weeks and months down

the line.

24

5. Leading to create confidence

4. Routinely assess the caring system using the

Confidence in Caring framework, monitoring efficacy

and taking action where necessary. This demands

involving patients and carers in their care and in

reviewing and improving the caring system.

5. Use the guidance in Releasing Time to Care:

The Productive Ward to improve efficiency and

effectiveness on your wards.

6. Use Essence of Care clinical benchmarks to monitor

and improve fundamental care.

7. Ensure that each shift has a strong co-ordinator who

is a good role model for staff. The shift leaders can

match care capacity with care demand.

8. Agree realistic objectives for improvement and

communicate these to staff.

Care leaders have a vital role to play in creating and

retaining confidence in caring. Effective leaders not

only set the tone for their staff but also put in place the

processes and systems needed to give patients confidence

in the care they receive and give staff confidence in the

team they’re working with.

Based on the confidence creators identified by staff and

patients, a list has been developed of key ways that leaders

can influence the care environment to build confidence

from patients and staff:

1. Provide strong, visible clinical leadership with effective

management.

2. Agree a clear vision for the caring system with

stakeholders and set standards and targets for

confidence creators.

3. Foster a culture that empowers, values and is

respectful of staff.

25

9. Make sure that Knowledge and Skills Framework

profiles are in place for all staff. The sister or charge

nurse should then be aware of the strengths and

development needs of themselves, their team and

individuals. This should include measuring and

developing caring skills and attitudes to patients,

as well as technical or medical knowledge.

10. Always look out for new ideas around leadership and

best practice in hospital management. For example,

one source of ideas is the Magnet Recognition

Program used in many hospitals in the US

(www.nursecredentialing.org/magnet).

Effective leadership will have an impact at the

organisational level, on teams and on individuals. The table

on page 26 shows the characteristics of care environments

where leadership is effective and can be used as a

‘dashboard’ for leaders to assess their performance.

http://www.nursecredentialing.org/magnet

26

MEANS – how effective leadership impacts on the organisation/unit/clinical area

n Staffing levels are matched to care demand

n The environment is patient centred and promotes confidence for patients and staff

n The right equipment is available to meet patients’ needs

n Administrative and customer care services are in place at key times

n Systems are in place that proactively provide information to patients (as appropriate)

n Systems for co-ordinating care and/or case management are in place

WAYS – how effective leadership impacts on the team

n People follow the ‘simple rules’ (see section 6) and take action to increase confidence in caring

n Care delivery methods respond dynamically to changes in care demand and support timely, effective and personalised care

n Caring is part of the recruitment process and is assessed at selection and beyond

n Capability gaps are identified, monitored and resolved

n Confidence in caring is a routine part of induction for permanent staff

n Staff receive periodic education, training and development to promote confidence in caring (e.g. cultural sensitivity, human rights, care for older people, and assessing and managing life-threatening symptoms)

n Observation and review of care is routine

n Staff are supervised appropriately

SKILLS AND WILL – how effective leadership impacts on individuals

n Skill profiles are matched to care demand

n The sister or charge nurse is a good leader with practical management skills to ‘make real’ the vision

n Ward and shift leaders have frontline leadership and management skills

n Care delivery staff have self-management and leadership skills at the point of care

n Staff have the right knowledge, skills and attitudes to care for patients and relatives in a personalised way

n Skill profiles are matched to care demand

n There is commitment to a shared vision for caring and staff take collective responsibility for achieving this

n All staff understand and respect human rights and they are committed to the caring ethos

n Staff appearance and personal approaches promote confidence

n Staff place patients and users at the centre of decisions and actions

Overall outcomes and performance measures

n Care is moving towards standards and stated best practice (as set out in Essence of Care, for example)

n Nurse-sensitive indicators, local key performance indicators and audits show positive outcomes

n Patient satisfaction scores are improving and show that people are being cared for and being cared about in equal measure

n Complaints are within organisational limits and the number of compliments is rising

n Team questionnaire results show high levels of satisfaction

n Attrition rates are within agreed limits and people are applying for jobs

n Student satisfaction is at appropriate levels

n Observations and care review show the simple rules being followed consistently

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6. Simple rules for staff

Although there are lots of possible actions that can be

taken, these simple rules can be used by all staff as a

quick reminder of everyday actions that create confidence

among patients. The list was put together based on

the feedback and can act as a quick reminder or basic

guidance in any caring environment at the beginning of

every shift.

n Welcome, orientate and introduce new patients.

n Give patients, relatives and the situation your full

attention.

n Get to know people and help them to get to know

each other.

n Improvise together: tell patients and families what is

happening and, where appropriate, let them help.

n Anticipate and act without being asked.

n Do what you say you will do – keep promises.

n Respond quickly.

n Make sure that patients have essentials within reach.

n Stay alert: know what is happening across the

clinical area.

n Notice and correct clutter, dirt, litter and stains.

n Minimise unwanted noise in every way you can.

n Look smart and professional, be a good role model

for health.

n Be seen.

n Keep the mood upbeat, friendly and calm.

n Learn about cultures you are likely to meet.

n The person in charge must act with authority.

n Practise good teamwork.

n Show loyalty and respect for all colleagues and

the organisation.

28

n A champion who puts their interests first and protects

them when they are vulnerable.

n A co-ordinator who is constant, accessible and

accountable for communicating the plan and

monitoring the delivery of care. Patients want to know

that there is someone who is proactively managing the

care journey and who orchestrates interventions from

various caregivers, disciplines and agencies.

Finally, always remember what patients want from

healthcare providers:

n A care provider who looks and behaves professionally;

is caring, competent, knowledgeable and

compassionate; and provides personalised, holistic,

timely, seamless care and information.

n A care partner who works with patients and relatives

to plan care, gives constant feedback and reports,

and helps them to navigate the health and social care

system.

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7. Conclusions

The guidance in this best practice framework is intended

to be just that – guidance. It offers suggestions on how

nurses and other healthcare workers can change their

behaviours and put in place new processes to help build

patient confidence.

What happens between nurses and patients is often the

benchmark against which the rest of the organisation,

and indeed the NHS and healthcare system as a whole,

are judged. By following these rules, nurses and carers

will help give their patients confidence in the care they’re

receiving – and so increase confidence in the overall

healthcare system.

30

8. Resources

In this section, you can find a set of resources to help you increase confidence in caring in your workplace.

8.1 Confidence creators

Means, ways, skills and will for creating confidence in care, caring and care systems

How confidence can be created through the means by which care is provided

in the organisation, clinical area or unit

How confidence can be created by the team and the

way care is delivered, co-ordinated and led

How confidence can be created through the skills

and will of individuals

A safe and clean environment

The following are in place: The team acts to: The individual acts to:

A welcoming culture The following are in place: The team acts to: The individual acts to:

Good team-working The following are in place: The team acts to: The individual acts to:

Well-managed and efficient care delivery


Personalised care for and about every patient


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8.2 Simple rules to create a confidence action plan

Simple rules to create a confidence action plan

Key objectives for team Action Who’s responsible Progress report

All new patients are oriented to the ward

‘Meeting and Greeting Week’ Healthcare Assistant Smith Start 24 July

Give the person and the situation your full attention

Get to know people and help them to get to know each other

Improvise together: tell patients and families what is happening and, where appropriate, let them help

Anticipate and act without being asked

Do what you say you will do – keep promises

Respond quickly

Make sure that patients have essentials within reach

32

Simple rules to create a confidence action plan

Key objectives for team Action Who’s responsible Progress report

Stay alert – know what is happening across the clinical area

Notice and correct clutter, dirt, litter and stains

Minimise unwanted noise in every way you can

Look smart and professional, be a role model for healthy living

Be visible

Keep the mood upbeat, friendly and calm

Learn about different cultures

The person in charge must act with authority

Practice good teamwork

Show loyalty and respect for all colleagues and the organisation

33

There are also a number of reports or tools from other

organisations that may be helpful:

n Age Concern (2006). Hungry to be Heard. The Scandal

of Malnourished Older People in Hospital:

www.ageconcern.org.uk/AgeConcern/Documents/

Hungry_to_be_Heard_August_2006.pdf;

n American Nurses Credentialing Center Magnet

Recognition Program: www.nursecredentialing.org/

magnet/;

n Burdett Trust for Nursing (2006). Who Cares, Wins.

Leadership and the Business of Caring;

n Coulter A (2005). Opinion and Experience: Do they

Concur? Picker Institute Europe report via website:

www.pickereurope.org/Filestore/Downloads/

Populus_What_patients_really_want.pdf

(accessed 22 June 2007);

n East Lancashire Hospital NHS Trust Being with Patients

– a unique programme that empowers healthcare

professionals to understand what it really means to be a

patient: www.beingwithpatients.nhs.uk/;

8.3 Further guidance and information

The following Department of Health publications and

website may be of use to care planners and leaders in

taking action to improve confidence:

n A Matron’s Charter: An Action Plan for Cleaner

Hospitals (2004);

n Assessing the Successes and Impact of the Ward

Housekeeper Role Summary Report (2008);

n Clinical Benchmarks for the Care Environment (2007);

n Healthcare Environment: www.dh.gov.uk/en/

managingyourorganisation/leadershipandmanagement/

healthcareenvironment/index.htm;

n Now I feel tall (2005);

n Privacy and Dignity – A report by the Chief Nursing

Officer into Mixed Sex Accommodation in Hospitals

(2007);

n Releasing Time to Care: The Productive Ward (2007/8);

n Standards for Better Health (2004); and

n Summary of Successes and Impact of ‘A Matron’s

Charter: An Action Plan for Cleaner Hospitals’ (2007).

www.ageconcern.org.uk/AgeConcern/Documents/Hungry_to_be_Heard_August_2006.pdf

http://www.nursecredentialing.org/magnet/

www.pickereurope.org/Filestore/Downloads/Populus_What_patients_really_want.pdf

http://www.beingwithpatients.nhs.uk/

www.dh.gov.uk/en/managingyourorganisation/leadershipandmanagement/healthcareenvironment/index.htm

34

n Healthcare Commission (2007). Inpatients. The Views

of Hospital Inpatients in England. Key findings from

the 2006 Survey: www.healthcarecommission.org.

uk/_db/_documents/Inpatient_survey_briefing_note.pdf

(accessed 25 June 2007);

n NHS Estates (2001). Housekeeping. A First Guide to

New, Modern and Dependable Ward Housekeeping

Services in the NHS;

n NHS Modernisation Agency (2003). Essence of Care

Benchmarks. Patient-Focused Benchmarks for Clinical

Governance; and

n The London Network for Nurses and Midwives (2007).

Perceptions of Care. Strategies for Improving the Patient

Experience.

www.healthcarecommission.org.uk/_db/_documents/Inpatient_survey_briefing_note.pdf

35

9. Acknowledgements

Thanks are extended to all those who contributed to the project and gave their time and energy. These include the patients

and carers who attended the workshops; ward sisters and staff; service managers, audit and statistical staff; and colleagues

from local higher education partner institutions.

Project team participants

Project team participants

Department of Health Ros Moore, Project Lead

Deborah Sturdy

Professional Officer, Acute Nursing

Nursing Advisor for Older People

Strategic health authorities Gabrielle Atmarow

Debbie Stubberfield

Daljit Athwal

SHA Sponsor

SHA Sponsor

SHA Project Advisor

Centre for the Development of

Healthcare Policy and Practice,

University of Leeds

Gayle Garland

Jane Mallett

Elaine McNichol

Document production, editing and formatting

36

Project Advisory Board

Anne Benson

Daljit Athwal

Debbie Dzik-Juasz

Debbie Stubberfield

Deborah Sturdy

Elizabeth Jones

Fiona Ross

Gabrielle Atmarow

Joe Nichols

John Badman

John Mercy

Liz Fradd

Rosemary Cook

Ruth Harris

Royal College of Nursing

Nursing and AHP Lead, Leicestershire, Northamptonshire and Rutland SHA

Royal College of Nursing

Director of Nursing, South West London SHA

Department of Health

Department of Health

King’s College London

Director of Nursing, South Yorkshire SHA

Nursing and Midwifery Council

Clinical Governance Support Team

Nursing and Midwifery Council

Service User Adviser

Queen’s Nursing Institute

Nursing Research Unit, King’s College London

37

Project sites

Epsom and St Helier University

Hospitals NHS Trust

Steve Lennox

Jenny Muir

Sharon Hamilton

Board Sponsor

Project Lead

Project Advisor

Mid Yorkshire Hospitals NHS Trust Tracey McErlain Burns

Dianne Edwards

Board Sponsor

Project Lead

Sheffield Teaching Hospitals NHS

Foundation Trust

Heather Tierney Moore

Jane Hopkins

Mandy Abbey

Martine Tune

Board Sponsor

Project Lead

Project Advisor

Project Advisor

St George’s Healthcare NHS Trust Geraldine Walters

Jayne Quigley

Clare Addison

Board Sponsor

Project Lead

Project Team

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