leading better care · 2 leading better care: ... centred care for every patient, first time and...

1Leading Better Care: lessons from the boards

Leading Better Care: lessons from the boards

32 Leading Better Care: lessons from the boardsLeading Better Care: lessons from the boards

© NHS Education for Scotland 2016. You can copy or reproduce the information in this document for use within NHSScotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.Text by Daniel Allen and Alex Mathieson


Inspirational nursing and midwifery clinical leadership can make a difference – to patients, teams and organisations. It harnesses individual strengths and creates a collaborative, supportive environment in which all team members work together to provide safer, more effective care that improves patients’ experiences and delivers better outcomes. Good clinical leaders are also instrumental in helping organisations to achieve strategic objectives.

Evidence for this includes the 2008 Senior Charge Nurse Review, which emphasised the vital role of clinical leaders in determining the quality of care in the areas where they work. But the review also identified wide variation in the role and function of those leaders – and Leading Better Care (LBC) emerged from that recognition.

LBC supports senior nursing and midwifery clinical leaders – for brevity, often referred to here as senior charge nurses or SCNs – to deliver care in a more consistent, measureable, evidence-based way.

LBC offers facilitation and local and national support and development opportunities to help clinical leaders build teams that can achieve safe and effective person-centred care for every patient, first time and every time.

Of course, LBC does not stand alone. It is one of a raft of measures, including Releasing Time to Care and the Scottish Patient Safety programme, whose purpose is to sharpen the focus on how patients experience health care and how that care can be improved and made safer.

But what does LBC actually do for senior clinical leaders? How, in practical terms, does it channel their skills, knowledge and experience, and encourage them towards innovative responses to the challenges they meet daily? The short answer is – in many different ways.

Personal experiencesIt emerged from an evaluation report conducted by independent consultants Blake Stevenson that among the outcomes of LBC reported by SCNs were enhanced skills and confidence. The purpose of this series of narratives is to explore further the personal experiences of those who have been closely involved in LBC, some since its inception eight years ago. More than that, the narratives provide insights and lessons from all of Scotland’s territorial NHS boards and some of the NHS special health boards, and we would encourage senior nursing and midwifery managers to use them to consider how they can further develop their own clinical leaders.

The pages that follow include reflections from each of the boards on how LBC is being progressed locally and the impact it is making. You will hear principally from the boards’ LBC facilitators but also from those who passed through the various programmes, projects and initiatives that developed under the LBC banner and went on to apply what they had learnt. How did they change? What did LBC enable them to do? And did patient care improve as a result?

Thoughts are also shared about LBC’s links with other NHSScotland quality initiatives and how LBC acts as a key driver for Excellence in Care and the care assurance agenda.

Individually and collectively, the accounts are absorbing and stimulating. They demonstrate that when senior clinical leaders in nursing and midwifery are encouraged, motivated and emboldened, they and their teams can revitalise the care they deliver.

As one of the LBC facilitators quoted in this document says: “The difference that LBC has made is that senior charge nurses are now empowered to be the people who are really in charge of their areas.”

Kathleen Winter, Project Lead, and Dr Stuart Cable, Programme Director, NES Leading Better Care

March 2016

EMPOWERING NURSING AND MIDWIFERY CLINICAL LEADERS

CONTENTSEmpowering nursing and midwifery clinical leaders.................... NHS Ayrshire & Arran...........................................................................NHS Borders...........................................................................................NHS Dumfries & Galloway..................................................................NHS Fife...................................................................................................NHS Forth Valley....................................................................................NHS Grampian.......................................................................................NHS Greater Glasgow & Clyde..........................................................NHS Highland........................................................................................NHS Lanarkshire....................................................................................NHS Lothian...........................................................................................NHS Orkney............................................................................................NHS Shetland.........................................................................................NHS Tayside............................................................................................NHS Western Isles.................................................................................NHS special boards...............................................................................Follow the story......................................................................................

346810121416182022242628303234


assurance are about outcomes,” she explains. “But the one follows the other. So when you have a ward or unit where the SCN is working to the four domains of the role, is skilled and knowledgeable, is resilient, is leading the team and bringing the members with him or her – in short, a quality leader who has it all – then that ward or unit is going to be delivering on Excellence in Care. And you’ll be able to feel it whenever you walk in.”

There is one area in which Chris feels SCNs still need to change – understanding their own worth and value.

“Sometimes our SCNs don’t see what they’re doing as special,” she says. “Very modestly they think, ‘Well, this is my job’. But they’re doing phenomenal things.”Often, the changes the SCNs are

making are very small, but cumulatively, they grow into much larger benefits.

“It’s the simple things, maybe tweaking a process, that actually bring great outcomes for patients and save a lot of time and money,” she says. “But I think our SCNs sometimes undervalue what they’re doing and their successes. And that’s a challenge for all of us involved in practice development, LBC, quality improvement and now Excellence in Care – how can we get SCNs to realise just how vital they are to everything that goes on?”

Small change, big impactKaren McCormick was new to her post as an SCN when she started the board’s leadership development programme, but she could see immediately that it provided her with a great opportunity to introduce change and improvement to her vascular surgery ward.

“There was a high incidence of pressure ulcers and a high number of falls among our patients, many of whom are very vulnerable,” she says. “I knew we needed to do things differently to reduce these adverse events and have a more co-ordinated approach.”

After trialling some different methods and consulting with ward staff, she decided on care and comfort rounding, which ensures that each patient’s needs are always addressed in a regular and co-ordinated way.

Recognising that change can be challenging, she adopted a small-step approach, gradually introducing the scheme and keeping her staff with her all the way.

She also developed a document in which they could record the care provided, which serves both to assure quality and serve as an aide memoire for the team.

Outcome measures have been used to show that improvements in rates of adverse events have been achieved.

“The results not only demonstrate that the quality of care is improving, but also show the team that what they’re doing is making a difference,” Karen says.

Karen believes that participating in the board’s leadership and improvement science programme gave her the confidence to make changes and sustain improvement in the team. “It gave me the tools and knowledge to make small changes that have a big impact.”

MOVING TO IMPROVEMENT NHS AYRSHIRE & ARRAN

Improvement is a big word in NHS Ayrshire & Arran. It is the underpinning principle driving the board’s efforts to make the experience of patients and staff better. And it is the core component of the role of Chris Rodden, the board’s LBC facilitator.

Quality Improvement Lead, Professional and Improvement Education is Chris’s full job title. This aptly reflects the focus of her work in leadership development with SCNs, which builds from LBC towards achieving improvement.

“Improvement – it’s in my job title and in my team’s title, so yes, it’s very strong,” she says.

Chris believes that LBC has developed leaders who can identify the clinical, management and interpersonal challenges in their areas – leaders who “understand the pebbles in their shoes”, as she puts it. And that, she feels, leads logically to the ideas and methods of improvement science.

“So now the focus, and the language, is about improvement,” she says. “We’ve provided practice development to support the SCNs through the four pillars of the role defined by LBC and have now moved towards a quality improvement approach. We’re saying to them, ‘Here are some skills and toolkits that will let you take ownership of what happens in your clinical areas –

they will empower you to lead in the way LBC envisioned’.”

The change in language is significant, Chris believes, because it’s important that everyone in clinical leadership positions is reading from the same script.

“LBC came at the right time, because we wanted to clearly define that the SCNs and community team leaders were the leaders in their areas,” she says. “But LBC is now so firmly embedded that the SCNs tend not to refer to it – LBC is no longer overtly discussed, it’s just the way things are done.

Golden thread“I’d describe LBC as the golden thread that runs through what the SCNs do, but it’s hidden within the overall pattern, which has many other threads,” she continues. “Quality improvement has really taken off across Scotland in the last five years or so. So that is the focus now, and the language the SCNs use is the language of improvement methodology.” Chris feels that SCNs whose skills and awareness have been honed through involvement with LBC are in a great position to make a real contribution to the improvement agenda. They take part in a local improvement science programme that provides the springboard for innovative approaches to clinical leadership. Coaching from an

improvement expert is offered over six months to support them through clinical projects that tackle identified problems.

“It’s about building on what they’ve learned through LBC to give them skills and knowledge to further enhance the way their teams work, using improvement methodology to bring the team along with them,” Chris says.

The results can be seen in presentations the SCNs and other professionals who have been through the programme give to a chief executive’s celebration event, highlighting the progress made and challenges faced.

The focus on clinical leadership and improvement fits very nicely, Chris feels, with the Excellence in Care idea. For her, Excellence in Care represents the outcomes of teams’ endeavours.

“LBC is quite process-oriented – it’s about leading your team and delivering the care – whereas for me, Excellence in Care and care

Senior charge nurses in NHS Ayrshire & Arran are building on Leading Better Care to drive improvement – and are doing “phenomenal things” as a result

It’s the simple things, maybe tweaking a process, that actually bring great outcomes for patients and save a lot of time and money


on improvement. One describes how supervisory status allowed for greater control over the quality of care, while another speaks of “achieving more”.

As well as being beneficial for patients, the project brought increased job satisfaction for SCNs and made them more attentive to the needs of their teams. Another charge nurse said the project offered the opportunity “to do the job I’m employed to do”.

Attention to detailA report on the pilot acknowledges that some improvements resulting from the project were small – but, according to marginal gains theory, it is attention to detail that matters.

No matter how slight, in the long term those minor improvements can make the difference between good and excellent. For example, using a checklist developed as a result of the supervisory pilot, SCNs are now encouraged to provide support and leadership, and improve core care principles in the clinical setting following daily conversations with patients, asking what matters to them.

After completion of the pilot, the supervisory role has been introduced on one ward and work is currently underway to implement it for SCNs across inpatient areas in acute and community settings.Kim Smith, practice development lead for NHS Borders, has long

experience of LBC, having been involved since its inception. She says the national emphasis on the role of senior nursing and midwifery clinical leaders, and in particular on greater role clarity, is helping to ensure change is effected locally.

“Having the SCN role defined is helpful because it had become so multi-faceted,” she says. “We are all here for the patients, and that emphasis on the role strengthens charge nurses’ ability to engage and support their teams to deliver safe, person-centred, quality care.”

But embedding change is often challenging, especially if teams, professions or departments are inclined to operate in relative isolation.

Kim says a series of “improvement clinics” helped address that issue and break down barriers. Chaired by the director of nursing and midwifery, the clinics were attended not only by SCNs and clinical improvement staff but by human resources and finance teams as well. Improvement case studies were then publicised on the local intranet.

Consistent processesKim is hopeful that Excellence in Care will help promote consistent processes for measuring and assuring care across NHSScotland. “But it will be imperative to involve all stakeholders when identifying

High-quality care is dependent on senior nurses who are highly skilled, knowledgeable and motivated, and recognised as leaders. But bind those leaders with red tape, or burden them with management duties with little obvious connection to the direct experience of patients, and the potential of their contribution will not be realised.

Those messages lie at the core of LBC, with plenty of evidence to support them. And that evidence now includes a study undertaken by NHS Borders where a seven-month pilot across 13 wards explored what happens when senior clinical leaders adopt a supervisory role, freeing them to be more visible on the wards and to have greater involvement in patient care. The results were notable.

During the pilot:

• falls causing harm to patients in two mental health wards were reduced by 36 per cent

• sickness absence within four community hospital wards improved by 17 per cent

• on seven wards at Borders General Hospital, there was a reduction of almost 40 per cent in the number of complaints made by patients

• staff motivation, morale and wellbeing all increased.

SCNs involved in the project say it helped generate a strong focus

ACHIEVING MORE NHS BORDERS

Using Leading Better Care to empower senior nursing staff to effect change and drive improvements to care is at the heart of the approach taken by NHS Borders

Light-bulb momentPhilip Grieve is NHS Borders’ operational manager for mental health services.

He first engaged with LBC some years ago but says at the time he felt too caught up in the day-to-day challenges of running an acute ward and managing his team to see its benefits clearly.

“My light-bulb moment came when we started the supervisory pilot (see main story) and I realised I had missed the opportunity of using the LBC framework as a support to articulate successes and challenges. In my five years as an SCN, I learned to balance the role of leader and manager, and found the LBC framework a helpful tool to do just that.”

Philip cites powerful examples of ways in which LBC helps him to make telling contributions to improving care. “I led the team in reviewing the assessment and care-planning process, and by adopting change methodology we implemented a new way of working, which moved us completely to recovery-focused, strengths-based, person-centred care.” He also devised an audit tool to benchmark and monitor the care delivered.

Philip says a particular challenge for him as a leader came when an acute adult inpatient mental health ward had to relocate from Melrose to Hawick while essential upgrades took place. But, supported by his team, he drew on his development through LBC to ensure the move

occurred with few difficulties, thereby demonstrating an effective contribution to organisational objectives as well as patient care.

“The measure of our success was a smooth transition for the multidisciplinary team and, more importantly, minimal disruption to the patient journey.”

Philip says: “LBC is the consistent framework which supports my development in the SCN role and it prepared me for my successful application for the operational manager post in November 2014.”

criteria for a national system,” she says. “To have consistent systems for measuring, assuring and reporting on the quality of nursing and midwifery care is a real opportunity to engage national stakeholders in the process of reducing the current data burden.

“Once that process is complete, SCNs will be the vehicle to promote, test and implement the changes required and celebrate success.”

She adds: “But I agree that measurement and compliance don’t change practice – that’s down to people feeling valued and empowered, and working within conditions where they can thrive.”

Measurement and compliance don’t change practice – that’s down to people feeling valued and empowered


A TEAM GAME NHS DUMFRIES & GALLOWAY

In Dumfries & Galloway, Leading Better Care is one strand in a unified approach to developing staff at all levels – and as a result there is much to celebrate

There’s a lot to celebrate in NHS Dumfries & Galloway. So much in fact that the board now hosts an annual event to mark the achievements of staff. Importantly, the occasion also serves as a networking opportunity and allows people to learn about various programmes that encourage professional development.

Karen Hills, the board’s facilitator for LBC and Releasing Time to Care (RTC), says originally the event was intended to showcase the work of dementia champions and newly qualified staff who had gone through the Flying Start NHS® programme.

“But things developed and we also wanted to celebrate the good work staff were doing in community services and on the wards with RTC projects,” says Karen. “Our deputy director of nursing, rather than having so many small celebrations, turned it into one big event, with an open invitation to all staff to come.”

Now, as well as details of the various projects people are engaged in, attendees can gather information from an assortment of stalls and stands on, for example, LBC and sessions run by the board’s clinical practice education team. “It’s a great opportunity for people to find out more,” Karen says.

This year the event will include staff who have completed Aspire 2 Lead, a locally developed

programme that enhances leadership qualities among band 5 and 6 staff. It features a process of transformational development through appreciative inquiry, using caring conversations, action learning and improvement science.

Well embeddedLBC is well embedded in Dumfries & Galloway and Karen considers herself fortunate to be a full-time LBC and RTC co-ordinator. But LBC counts for little if it is not part of a wider commitment to learning and development – and, as the celebration event demonstrates, Dumfries & Galloway staff at all levels have equal access to training through a range of opportunities that support individual, team and organisational objectives.

One of those organisational objectives is ensuring the next generation of SCNs is equipped to step up when current post-holders retire or change jobs. Succession planning is the basis for a series of education days open to band 6 staff which began last year. The four domains of the SCN role are covered – safe and effective practice; enhancing patients’ experience; managing and developing team performance; and contributing to the delivery of the organisation’s objectives – and participants work on a quality improvement project relevant to their area.

The board also offers a separate programme for band 7 nurses working in community settings

designed to equip them with new skills relevant to their area. “It began as a pilot,” Karen explains. “There had been a lot of change and there were quite a few new SCNs so we set up a dedicated development programme.”

But the change continued, with some staff leaving and others being promoted, which proved disruptive to the course. So, learning from that, the programme has been reviewed – six sessions, one a month, but no new joiners during the course. They will be asked to wait for the next block of sessions to begin.

Karen says: “At first it didn’t work as well as it should have. But having said that, even with the original pilot, the SCNs were still able to take a lot of what they learned and implement it in their workplace, and we had really positive feedback – they were saying things like ‘I would never have done this

before’. But they have done it and they’ve supported their teams to make changes as well. Their confidence has grown and I’ve seen them have really courageous conversations with their staff or line managers.”

Karen also organises RTC events three times a year with the aim of building knowledge and skills in different areas – for example, improving medicine safety, enhancing nutritional care for patients and improving care for older people in hospitals. Between 15 and 18 facilitators bring their specialist knowledge and present short sessions. They are also contactable afterwards to give support where necessary as attendees review their practice and work through a pack on the given topic designed to improve the care they offer (see box).

Analysing outcomes and how all or any of the above feeds

into care assurance is, of course, critical. Gathering hard data is a fundamental part of that, but Karen is also a strong believer in the benefits of learning from patients’ experiences. Emotional touchpoints – people’s stories – are used by various staff throughout the health board to hear how patients feel about the care they receive. The touchpoints are used to review practice, initiate change where necessary and to celebrate things done well. “You can get so much from the stories and we use them wherever we can,” says Karen. One SCN uses the tool with student nurses to explore their placement experiences.

Many approachesLBC is one of many approaches in NHS Dumfries & Galloway that combine to develop staff as skilled, safe and effective practitioners and leaders.

Karen says: “LBC has definitely given SCNs a clear direction of what’s expected of them – especially when they are new to the post because there’s a big difference when you go from band 6 to band 7.”

She gives an example – a new SCN working in mental health. SWOT analysis was used in relation to one of the key SCN roles outlined in the LBC framework to give her an idea of what she did well and where she thought she might improve. An action plan was then developed. “A year later, looking at that dimension, she was able to say she had met all her objectives,” Karen says. “It really gave her clarity about her role – and it also made her think about what she did well.”

Time to thinkA number of events organised by LBC facilitator Karen Hills with the aim of strengthening and supporting the SCN role have resulted in specific improvements to the way care is delivered:

• following a session on improving nutritional care, nurses in one area designed placemats for use at mealtimes to remind staff about the importance of recording fluid balance

• after a medicines management event, day-surgery staff reviewed the way they administered pain relief and organised training in IV analgesia, which enabled patients to receive pain relief more efficiently and effectively

• a team-working module gave staff a stronger voice in relation to how they felt about their work; as a result, they collaborated on ways to improve communication with each other, which in turn enhanced patients’ experiences.

LBC has definitely given SCNs a clear direction of what’s expected of them – especially when they are new to the post


DELIVERING THE BEST NHS FIFE

A combination of positive practice initiatives, including Leading Better Care, is contributing to a dynamic culture of quality improvement spearheaded by senior nursing and midwifery clinical leaders

LBC did not start life on its own. When it was launched in 2008, it was bonded with the Clinical Quality Indicators project, making a direct and unmistakable link between clinical leadership and quality.

And so it has continued. LBC has constantly looked to make links and strengthen ties with other national and local programmes and initiatives – including Releasing Time to Care and the Scottish Patient Safety and national Healthcare Associated Infection programmes.

Many of the innovations being progressed by senior nursing and midwifery clinical leaders in Fife, such as those in one of the wards for older people with dementia and delirium (see box), have certainly been influenced by LBC, albeit not exclusively. The board’s head of practice of professional development, Lynn Campbell, believes this presents a very positive message about LBC’s ability to link with national and local priorities.

“Positive practice initiatives are driven from lots of different places, and they are all connected,” she says. “The patient-safety, person-centred care, and health and social care integration agendas all play their part, with leadership at the centre.

“SCNs who are driving change have benefited from LBC and it is

a very strong contributor to what they do. Alongside LBC, the other initiatives and programmes provide a fantastic framework for our SCNs to support themselves and their teams to deliver much more effectively.”

LBC’s flexibility is now central to a process underway in NHS Fife that will link with a newly refreshed clinical leadership development model. The model will provide a framework reflecting core elements of multidisciplinary leadership initiatives and key priority areas in the board, and also offer a central focus for care assurance.

“We recognised that a number of leadership programmes had been available in Fife, one of which was LBC,” Lynn explains. “Understandably, there was some duplication across the programmes, but each had its own unique features. The model moving forward supports a refreshed approach to LBC, complemented by and linked to other programmes to ensure our senior charge nurses and band 6s are getting the best core development possible.”

Innovative elementsIt is too early to identify the precise features of the new model, but it will certainly reflect a range of themes and current drivers, be tailored to SCNs’ and other clinical leaders’ needs, and feature innovative elements such as specialist-led masterclasses.

“Our director of nursing is quite clear on how she sees LBC as a central component of the new model,” Lynn says. “LBC is focused on nursing, but we can’t see it as completely isolated. It will reflect the reality of multidisciplinary, multisectoral working, with contributions from other professional groups and SCNs contributing more to the learning of others. Looking at the range of opportunities offered to SCNs within wider clinical leadership development activities in the board offers a huge opportunity to refine and integrate the approach. There is a clear sense of building on the foundation of SCNs being the visible, senior clinical leaders who set the standards of care and drive improvement with clinical teams.”

At the moment, monthly LBC sessions are planned for all SCNs.

“It doesn’t matter if they’ve been in the job two days or 20 years, there are benefits in bringing the SCNs together,” Lynn says. “The sessions are framed on LBC and the big national programmes and are responsive to what is happening in the board at the time. They provide an opportunity to share learning from things like significant adverse event reviews and complaints, and also highlight where things are going very well.”

The emerging model will continue to be responsive to live issues in the board to reflect the emphasis on care assurance. It will also be influenced and shaped by SCNs and include a focus on staff resilience, a topic that has already been explored with SCNs and teams through development activity.

“It’s about how we look after ourselves and each other as colleagues,” Lynn explains. “How we behave with and speak to each other very much influences how we are able to look after patients. We are trying to support staff to focus on their own needs, self-confidence and resilience, provide an opportunity for them to stop and take a breath, and challenge some of the behaviours that degrade staff resilience. And that is very close to the spirit of LBC.”

The Excellence in Care agenda will also be a big driver. Work taken forward in NHS Fife in areas such as patient documentation provides a very solid platform from which Excellence in Care can be progressed.

“Again, we can see links with work we have done under the LBC banner and the wider agenda in

NHSScotland around care assurance and quality improvement,” Lynn says. “They are all seeking the same outcomes – a safer and better experience for patients.”

Easy sellThe enthusiasm with which SCNs in NHS Fife have accepted LBC gives Lynn confidence that the new LBC and clinical leadership development model will be an easy sell.

“LBC is a given now,” she says. “It’s embedded in the SCN culture, and there is still strong demand from SCNs for leadership development opportunities.

“But the vision we’re working to does not see SCNs going on a leadership programme, ticking the boxes and emerging as a nice shiny new leader. We want to make the process much more dynamic and ongoing.”

Improvement in dementia careThe newly appointed SCN of a ward specialising in caring for older people with dementia and delirium recognised the need for positive responses to negative feedback on staff attitudes and behaviours and evidence of patients’ dignity being compromised.

The SCN worked with the team to introduce a range of improvements, including:

• a communication/thoughts diary where staff can comment on how their shift went, whether positive or negative

• a suggestion box for staff to come up with ideas for improvements

LBC is a given now. It’s embedded in the culture, and there is still strong demand from SCNs for leadership development opportunities

• support for staff to better manage episodes of challenging behaviour

• the SCN having greater involvement in multidisciplinary team decisions and sharing these with staff.

Patients now receive high-quality individualised care in which their dignity and privacy are protected and communication with staff has improved.

Staff are perceived to be happier and have reported feeling supported on the ward, with their opinions and suggestions being heard. Sickness/absence rates for work-related stress and the number of complaints received have reduced.


FREE THINKERS NHS FORTH VALLEY

When senior charge nurses and charge midwives are freed up from holding a caseload, they have more time to come up with innovative solutions to care issues

Things happen when nursing and midwifery clinical leaders have time to think. Time allows them to be proactive rather than fighting fires. It gives them a chance to reflect on the care being delivered and to consider ways it might be improved.

In NHS Forth Valley, the difference this freedom affords staff is quantifiable. When SCNs became non-caseload-holding as a result of changes introduced through LBC, one was able to research and trial care and comfort rounds and their impact on patients in a surgical rehabilitation unit. The results were impressive (see box).

But to understand the impetus for changes like these, it’s necessary to rewind a few years. If nurses are to work to their full potential they need to have champions in senior positions. And NHS Forth Valley had nurse director Angela Wallace. Professor Wallace has spoken of her ambition for the board’s nursing and midwifery brand to be the best in the world and, according to LBC facilitator May Fallon, she has been instrumental both in inspiring nursing staff and convincing the board that removing caseloads from SCNs would bring tangible benefits to patients.

“SCNs are innovators now,” May says. “But they’ve also got their fingers right on the pulse. Certainly before LBC and before SCNs became non-caseload-holding, when they were doing audits, when people were wanting hard evidence, that sort of thing was often just dumped on them and they never got any feedback from it. But now they’ll do something, they’ll evaluate it, and they’ll see that as part of their role, not as an added extra.”

She adds: “The difference that LBC has made is that SCNs are now empowered to be the people who are really in charge of their areas – making sure they are truly responsible for the quality of care. They’re supervising it, they’re monitoring it, and that’s recognised in their role. It’s not an add-on.”Having their fingers on the pulse means that senior nursing and midwifery clinical leaders are well

placed to take forward Excellence in Care. “Staff are now comfortable with data-gathering, analysis and improvement work,” May says, “and care assurance is the next progression for LBC.” But she warns against gathering numbers for the sake of it. “What we need to be aware of is data overload. We must make sure that what we are gathering is necessary and productive.”

Hurdles facedGetting to a position where SCNs are, as May puts it, “really in charge” and are confident, self-assured leaders and innovators does not happen overnight. Forth Valley has invested heavily in developing staff and equipping them with the necessary insight and skills. And as LBC facilitator, the hurdles May faced were many and varied. “For example, one of my main challenges was that senior charge nurses, midwives and team leaders were not used to prioritising their own development and support. Time and capacity were always issues that came to the fore.”

Slowly, however, May has been able to demonstrate how networking and taking time out can actually make things easier for staff.

An example of how that plays out in practice is the regular meetings held in each unit between SCNs and midwives, team leaders and band 6 nurses. The meetings focus on a particular subject that staff

feel requires wider discussion – managerial issues or clinical matters such as pressure ulcer awareness. Revalidation is a popular theme currently, as is care assurance – a strategic objective for the board. May says: “Those meetings are one of the best things to have come out of LBC. Before, SCNs were quite worried about sharing their challenges but now they’re very comfortable with it and they get great support from people who say, ‘We’ve been there and this is what we did to get round it’.”

As well as providing an opportunity to meet and share intelligence, the meetings feed into monthly educational events where the topics identified can be explored in greater depth.

Incidentally, the capacity of LBC to open up debate about issues of concern should not be underestimated. May recounts how LBC led directly to a change in uniforms. “All the district nurses who lead teams were in staff uniforms. Because of LBC they’re now in dark blue uniforms – and that makes such a difference to them. They feel valued, they are identifiable, they feel people are paying attention to them.”

But securing non-caseload-holding status for SCNs and senior midwives is unquestionably the most significant change introduced under the banner of LBC, May believes. “This has truly allowed SCNs to fulfil their role in terms of leadership, quality control, team development and safe, evidence-based care, with an emphasis on continuous quality improvement.”

A rounded pictureWhen Forth Valley Royal Hospital opened in 2010, there was one aspect of the impressive new facilities that caused a degree of concern for Barbara-Anne Niven, an SCN in surgical rehabilitation: half the beds were in single rooms. She was worried that patients with cognitive impairment or whose medical needs were less complex would not receive the care they required if nurses were prioritising sicker patients.

Barbara-Anne was able to research possible solutions to the problem because LBC had introduced a shift in the focus of the SCN role. She was free to consider not simply the day-to-day needs of individuals but also wider, systemic issues affecting the quality of care.

After gathering baseline data, Barbara-Anne introduced a process of patient comfort rounding, which meant that at least every two hours nurses would attend each patient and check on basic needs such as food, fluids and pressure area care, and other needs as required.

The intention was to pilot the care and comfort model for six weeks. “But it embedded very quickly,” says Barbara-Anne. “So we didn’t stop after six weeks – we kept going.”

And after three months, she had some impressive evidence. Among other improvements, the figures showed:

• more contact between nurses and patients

• patients’ use of buzzers fell by 50 per cent

• falls had reduced in number

• patients who were independent reported more efforts made to discuss their care and wellbeing

• a quieter, calmer environment

• an increase in staff morale.

After many tweaks and several different drafts the model has now been adopted across the hospital and Barbara-Anne’s work has featured in nursing journals and at a national conference.

The difference that LBC has made is that SCNs are now empowered to be the people who are really in charge of their area


A FIRM FOUNDATION NHS GRAMPIAN

A three-day programme with a full agenda provides the basis for the ongoing development of clinical leaders, while follow-up sessions offer an opportunity to reflect on progress

LBC facilitators in NHS Grampian deliver three-day development programmes for SCNs and senior charge midwives (SCMs) based on the LBC education and development framework.

One of those facilitators, Lesley Lawson, explains that for all those who have attended the programme, individual follow-up meetings are arranged where facilitators offer further guidance and support.

“For our SCNs, SCMs and team leaders, the three-day programme is the foundation of their development,” says Lesley. “The agenda covers a range of subjects and it’s reviewed according to feedback received from previous groups.”

She offers a list of topics usually covered by the facilitators: introduction to the LBC framework and the impact tool; introduction to clinical and personal leadership; NHSScotland’s Delivering Quality through Leadership strategy; change management; quality improvement methodology.

“We also include sessions presented by other speakers on subjects such as workforce planning, quality and accountability, and the effective practitioner, as well as e-portfolios and revalidation,” Lesley says.

Board executives present as well, and with executive-level discussions about Excellence in

Care well underway in Grampian, synergies with LBC are likely to feature. Lesley believes that through LBC, senior nursing and midwifery clinical leaders are already demonstrating some of the objectives of Excellence in Care.

Feedback on the programme is positive. “We encourage delegates to complete evaluations at the end of each day, and generally they’re very good,” says Lesley. “People get a lot from the course.” Particularly, she adds, those who are new in post as an SCN, SCM or team leader. “As well as everything else, they receive information about NHS Grampian, NHSScotland and the Scottish Government, and where a lot of our policies, procedures and targets come from.”

Progression planningBand 6 senior staff nurses are now invited to attend as well. This is partly with an eye on progression planning, Lesley says. “But also quite a lot of wards within Grampian, and the community teams, are large, and it’s useful for the band 7 nurse to have a deputy who can be developed to take on certain leadership and management responsibilities – the course helps band 6 staff to do that.”

Group work, open discussion and sharing across sectors encourages learning and development. During the course, participants complete two reflective accounts based on their learning and are encouraged to write two more, based on

clinical practice, for discussion at the subsequent one-to-ones. These also support the revalidation process – Lesley’s colleague, facilitator Julie Stewart, has mapped the LBC framework dimensions and capabilities to the Nursing and Midwifery Council code.

Other learning and development opportunities are highlighted as part of the programme, as well as relevant future events, local and national. And the LBC facilitators encourage senior clinical leaders to build networks – among their peers in their own areas of work and across the organisation.

The follow-up meeting, usually held between six weeks and three months after attending the programme, is an ideal time for participants to discuss how they plan to demonstrate the impact of their role. “One-to-ones are also an opportunity for them to talk things over with their facilitator if they’re struggling with anything,” Lesley says. “It gives them somebody else to turn to and we can try to coach them through a challenging situation, enabling them to decide on the correct course of action, or signpost them to other services or experts. That way, they never feel they’re on their own.”

The majority of NHS Grampian’s SCNs have now attended the programme and June Brown, associate nurse director for modernisation, is keen for the LBC facilitators to develop new ways of supporting them.

The facilitators have begun running sessions for managers of SCNs, SCMs and team leaders. The aim is to explain the LBC impact tool and how they can extract and use data from it. Lesley says: “We also encourage discussion around the benefits of using the four dimensions of LBC during managers’ one-to-one sessions and appraisals with their staff.”

Valuable insightAs a former SCN herself and now an LBC facilitator, Lesley has valuable insight into the development needs of her erstwhile colleagues. “I think my experience gives me quite a good perspective and it helps me when I’m discussing with others the

challenges they face.” She’s also well placed to see how the support offered by LBC encourages less experienced SCNs to develop and grow in confidence. She has, after all, been there herself. “Having been an SCN who attended the LBC programme, I know how much I got from it and how much I was able to do afterwards. I focused more on person-centred care, making improvements, facilitating my staff to develop, and leading my team more effectively. I could relate everything I did on a day-to-day basis, with my team-leader hat on, to what LBC is all about.”

Making an impactKey to demonstrating ongoing commitment to working within the four dimensions of the LBC framework is use of the online impact tool. June Brown, associate nurse director for modernisation, has mandated that all NHS Grampian senior clinical leaders utilise this resource and update it every six months. The tool can be used in conjunction with a template devised by Lesley which SCNs, SCMs and team leaders can use to document outcomes and evidence related to the framework.

The template completed by SCN Catriona Sutherland, which runs over three pages, describes outcomes and lists supporting evidence. So, for example, under dimension three, “Managing and developing the performance of the team and its capabilities”,

Catriona’s outcomes include:

• all staff receive mentorship/coaching as required

• the learning needs for an area are identified and a learning plan or equivalent which schedules education and training for an individual is in place

• monitoring and management of sick leave towards a given target

• financial balance is achieved.

Her supporting evidence includes reflection on the visibility of the SCN, staff education and training records, and sickness absence reports.

Catriona has taken the same approach with the three other LBC dimensions.

Having attended the LBC programme, I know how much I got from it and how much I was able to do afterwards


CLOSING THE LOOP NHS GREATER GLASGOW & CLYDE

Leading Better Care has laid strong and lasting foundations from which Excellence in Care can be delivered in NHS Greater Glasgow & Clyde

The introduction of LBC to Scotland’s biggest NHS board brought great opportunities, but also significant challenges, as Kate Cocozza, LBC facilitator for acute services in NHS Greater Glasgow & Clyde, explains.

“We had a short deadline – something like 14 months – to provide education on LBC and the new role framework for all 200 or so SCNs in the acute sector and ensure they had the knowledge and skills required to make the transition to their new role,” she recalls.

“The early cohorts threw up some challenges, particularly around change, but we learned from them and soon heard SCNs saying ‘we’re really excited about coming on to the LBC programme’. They enjoyed learning new things, especially

about IT systems and measurement for improvement. They also found they were learning alongside people who had similar issues and valued the opportunity for peer support, networking and shared learning.”

Same situationExactly the same situation was found when LBC moved to community and children’s services in the board, according to fellow LBC facilitator Annie Hair.

“Team leaders and health visitors found they were being equipped with a set of tools to use with their teams to secure their engagement from the bottom up,” she says. “They now have the right leadership and coaching skills to inspire and enthuse people.”

Kate and Annie believe that LBC liberates SCNs and enables them to see things in a different way, to think things through and collate an evidence base to help them address any issues with the quality of patient care.

“LBC gives SCNs permission to lead,” Kate says. “It helps them see that they are the guarantors of standards in their units. And perhaps for the first time, it is supporting them to talk about improvement, not as something you might do on a good day, but as something we should all be doing all the time.”

Annie notes that LBC also equips community team leaders with a better understanding of how to present an evidence-based case

for change. “They have developed knowledge that helps to inform and shape their questions, review the evidence base and make changes to improve the quality of care they deliver,” she says.

Both facilitators feel that LBC puts SCNs in a very strong position to take the care assurance element of Excellence in Care forward. “LBC gives SCNs the skills and tools they need to measure care,” Kate says. “They now measure quality in a way they didn’t before, focusing on what matters to patients and their experience of care.”

Some concerns have been expressed that an enhanced focus on care assurance might increase SCNs’ already considerable data burden, but Kate doesn’t believe

that needs to be the case. She says: “LBC shone a light on what SCNs needed to measure and how to do it. Care assurance takes this a step further and provides a system for SCNs to evidence the quality of care they are delivering – closing the loop, so to speak. So Excellence in Care is well timed.

Multiple purposes“We are working towards SCNs being able to collect data once and use it for multiple purposes,” she continues. “That will reduce their existing data burden and make it easier for them to measure their successes and identify where things need to be improved. That was always the aim of LBC – we’re not quite there yet, but we are on the road and are finding our way.”

There’s a clear message of evolution here, with SCNs realising the full range of responsibilities LBC confers on them and recognising that the tools and learning give them opportunities to make positive changes. But Kate believes the journey is far from over.

“We’ve educated and supported SCNs in their new roles, given them the opportunity to practise their new knowledge and skills, provided a new framework that’s been tried and tested. Now we need to ask – so what?

“And the ‘so what’ comes from care assurance,” Kate asserts. “We can now assure the care the SCNs have been asked to deliver, so can truly demonstrate the delivery of excellence in care.”

Self-awarenessSCN Anna Syme is in no doubt about the key benefit LBC has delivered for her.

“The main thing is that it has given me greater self-awareness,” she says. “Everything around me changes all the time, but I can be consistent in my approach.”

Practising with self-awareness requires conscious effort, she believes.

“Sitting at report in the morning, for example – I might be a staff nurse down and there’s a lot going on, but I know to make

sure I don’t display any negative vibes – just lead, be positive and support the team. That’s a massively important step to take when so many eyes are upon you.”

Anna, who has been an SCN for seven years and is in charge of a respiratory ward in Glasgow, is also asking questions of her team.

“Before LBC, my approach to a problem presented by a member of staff would be to try and solve it. Now I ask them ‘What do you think, how do you think we should approach it?’ People feel they are being listened to, and their opinion counts.

“You never know what anyone is going to say,” she continues, “and you have to learn to respond positively to challenge. It’s about being honest with people and adopting a default position of being supportive.”

Being visible on the ward wasn’t a big issue for Anna, as she was out on the floor most of the time anyway, but not taking a caseload was more testing. “I think that’s a challenge for every SCN,” she says. “But I can see the value of it – you can’t influence and oversee every patient’s care if you’re looking after a select group.”

LBC shone a light on what SCNs needed to measure and how to do it


NEXT STEPS NHS HIGHLAND

Strategy changes and feedback from an earlier development programme for nursing and midwifery leaders are feeding into a review of Leading Better Care – but core principles remain

If you want people to make a lasting connection between two different but related work streams, give them something tangible to take away, suggests Stephen Loch, LBC contact for NHS Highland.

At a recent board event on Excellence in Care, he distributed LBC-branded bags and cups he had collected on a visit to the central belt. “It makes complete sense to ensure that LBC and Excellence in Care are linked together,” he says. “In conversations I’ve had at national level, in the LBC facilitators’ group, we’ve been trying to see how we can do that.”

Maximum benefitThe Highland event was a success as a means of introducing practitioners to care assurance. “And it was a good opportunity to link the two things together – LBC and Excellence in Care. They need to link to get maximum benefit,” Stephen says. “We had a very good mix of people – Pat Tyrrell, our deputy director of nursing, led it, we had Vicky Thompson from the Scottish Government, there were education people and key staff from practice.”

NHS Highland is huge – the size of Belgium, Stephen points out, with more sheep than people. But technology is employed to the full to ensure staff do not miss out on development opportunities. There are videoconferencing and WebEx facilities, and these are

used to facilitate online training and connect staff. Stephen says: “We’re using all these systems to try and reach out to as many staff as possible. But we do have key locations where we can deliver sessions face to face. Inverness is one, Fort William another – a number of sites we go to and we then videoconference out to the very remote and rural areas.”

But when it comes to LBC, technology can’t do it all. “A key thing is bringing people together and I think sometimes that the videoconferencing element can alienate people. It’s good in certain scenarios – if you’re delivering a lecture it works quite well. But we’re really conscious that getting people together is very helpful for SCNs – good networking, conversations over coffee, that kind of thing.”

Stephen speaks from experience: “Having been an SCN myself and gone through a development programme, a lot of the benefit was just in getting together, speaking to colleagues outwith the programme, saying ‘What are you doing in this situation?’ and building up relationships and knowledge in that way.”

The retirement of the previous LBC co-ordinator prompted a leadership review. The new approach needs to incorporate changes of strategy within the board, such as a training programme on LEAN methodology

and an NHS Highland leadership and management development programme that will start next year.

A generally successful three-day LBC programme for SCNs, which focused on management, leadership and development, came to the end of its natural life when, in a board with low turnover, most senior staff had completed it – although LBC principles were applied to a similar programme for band 6 nurses in Argyll & Bute.

“Now,” says Stephen, “we’re in the process of reviewing exactly what we’re going to be doing in the future, but LBC is right at the core of it.” A group that includes Stephen, as head of practice development, a NES practice educator, a lead nurse and lead allied health professional is working on a career development framework. This is likely to remain rooted in LBC principles (see box) but will try to address the development needs of a more diverse group. So, as well as SCNs who may have been in post for two months or 10 years, it will be open – and relevant – to less senior nurses and other professions as well.

Improves patient care“We want something that fits with the NHS Highland Quality Approach, that fits with what SCNs and others need, and ultimately that improves patient care,” Stephen says. “It’s exciting, and not just about doing it for the sake of it – we’re doing it so our staff are

better supported and our patients are receiving even better care.”

That said, he’s aware of potential obstacles ahead. “Some of the feedback we were getting on the earlier programme was that we had a ‘one-size-fits-all’ approach. But one size didn’t fit all. So I think for the future we’re going to have to be more flexible and maybe try to be more person-centred. That’s going to be a real challenge because flexibility can be really quite complex.”

Stephen acknowledges that quantifying the impact of LBC on patient care has been challenging. “But I know from having close links with SCNs that they found the LBC programme we ran especially helpful in regards to patient safety. That was one of the key parts of it – how do your ensure patient safety is built into the work you do? And having spoken to one or two informally I know they used those principles to look at safety in their areas.”

Dignity and compassion were also elements that were built into the SCN leadership programme developed under the LBC banner. “We delivered a number of workshops around dignity and compassion just to make sure that is the focus of everything we do.”

And what have senior nursing and midwifery clinical leaders made of the board’s attempts to underpin and strengthen their position as important players in the delivery of quality care? Stephen says: “SCNs, SCMs and team leaders have a pressured and very demanding job. And anything that helps is a good thing because they do have absolutely key roles.”

A point of principle

The enduring quality of the principles of LBC was highlighted in a national evaluation produced last year. The report, by organisational development consultants Blake Stevenson and available on the NES website, found that although there were variations across health boards in the way they had implemented LBC, boards and SCNs were united by a “strong belief” in LBC’s core values. The four role domains were also regarded as appropriate and relevant to delivering high-quality patient care.

It makes complete sense to ensure that LBC and Excellence in Care are linked together


BUILDING THE BRAND NHS LANARKSHIRE

Leading Better Care was the starting point for a collaboration that developed projects aimed at supporting the role of clinical nurse leaders and extending the LBC “brand”

LBC has been adopted as the “brand” under which a wide range of leadership, quality, improvement and research work is being taken forward in NHS Lanarkshire.

The LBC brand, explains Margot Russell, director of nursing, midwifery and allied health professional practice development, has become a symbol for improvement and quality.

“We don’t see LBC as a training programme,” she says. “We decided we would use LBC as the banner under which we would place initiatives like Releasing Time to Care and other developments that support SCNs and team leaders to fulfil their responsibilities within the role framework. It’s a very deliberate approach to help people realise that LBC is about everything that fits around SCNs and the mechanisms that support delivery of better care.”

NHS Lanarkshire developed a collaborative relationship with the University of the West of Scotland (UWS) to support LBC three years ago. The collaboration has responsibility for the design, implementation and evaluation of a wide range of activities and strategies to address the key dimensions of LBC. Programme manager Jacqueline Kerr is in place at the university to support LBC-related activities and provide reports to NHS Lanarkshire’s LBC Programme Board, which Margot chairs jointly with Professor Jean Rankin of UWS.

“LBC gives us licence to try some things and see if they are of benefit,” Margot says. “Everything is done under the LBC banner and features the LBC logo, and our work with the university means we’ve been able to have an evaluation strategy underneath. So we have ideas, but then have a means to evaluate the impact of the ideas.”

The “ideas” Margot refers to are generated or approved by the Programme Board.

“We challenged the Programme Board from the start to think about what could make the biggest difference to SCNs,” Margot explains. “We did a scoping exercise that led to 12 work

packages being developed. People could then bid for or commission pieces of work – we’ve had 41 projects under the LBC banner over a three-year period, covering the parts of what we call the ‘honeycomb’ model” (see figure).

encouraging us to write publications (see box), promote what we’ve been doing through conference presentations and ensure we always have an underpinning evaluation strand for all our programmes.”

The formal collaboration ends in March 2016, but Margot is determined that the model will continue. “LBC and the work that has come from it – its legacy – will not fold when the collaboration

agreement completes,” she says. “And the experience has left us in a much better place as we move towards Excellence in Care.”

Margot and her colleagues see Excellence in Care as a natural progression from LBC.

“LBC and Excellence in Care are asking for slightly different, but linked, things,” she says. “LBC will now become the vehicle to support

The evaluation strand is prominent in all the initiatives, meaning the partnership with the university is very important.

“The collaboration has been key in enabling us to have a more thoughtful and considered approach,” Margot explains. “It has allowed us to spread some of thework programmes over a period of time, supported by quite significant investment. The university has strong research expertise and has been

Excellence in Care, which will be the overarching framework. It doesn’t succeed or replace LBC, because you can’t have Excellence in Care without LBC, but Excellence in Care will be the banner under which new initiatives will be progressed.”

Branching outProjects taken forward under the LBC “brand” in NHS Lanarkshire include the following.

Values-based recruitment and selectionThe quality of leadership is largely irrelevant if staff with the right values, attitudes and behaviours are not in place. The board has carried out an early evaluation of options relating to recruitment and selection, and is working with UWS to set up a longitudinal study to see how successful it has been in getting the right people into post.

Assessing and implementing the SCN supervisory rolePilot and primary assessments of the implementation of the SCN supervisory role have been carried out and the final evaluation of the differences it has made 18 months down the line will soon be complete. Indications at the moment suggest that while challenges remain, SCNs now expect protection of their supervisory

time and are valuing it more. They are recognising that they need to use it to assure the quality of care, which feeds back into the board’s care assurance work.

Developing and refining a general ward nursing dashboard Work has started on the development and refinement of a ward dashboard that reflects key national performance indicators and articulates with national systems, such as NSS Discovery. A collaborative approach involving nursing staff, programme leads and the board’s eHealth team has been adopted to develop the dashboard as a means of ensuring person-centred, safe and effective care.

Documentation design and reviewA full review of existing nursing records has been completed and amendments made. Further work is now required to scope and review electronic solutions that support safe and person-centred care delivery across health and social care arenas.

Community nurse development framework The framework looks at how to develop staff to support team leaders. Evaluation is focusing on identifying how competent and confident practitioners feel in their substantive roles as caseload managers.

PublicationsMargot and her colleagues prepared a series of seven articles on the approach to LBC in NHS Lanarkshire that were published by Nursing Standard between October and December 2014 (volume 29, issues 9–15). Themes included developing a general ward nursing dashboard, implementing supervisory status for SCNs, supporting band 5 practitioners in professional and leadership roles, and developing better documentation to improve patient care. They also had a paper on a qualitative study into facilitators and barriers to the increased supervisory role of SCNs published in the Journal of Nursing Management in 2015: the paper can be accessed at http://bit.ly/1TwLSux “Honeycomb” model: LBC work packages

LBC gives us licence to try some things and see if they are of benefit

HR recruitment and selection

processes

Workforce integration

Line managers’ development

Care documentation

Band 5 development

Support worker development

Leading Better Care communications

Programme management and

administration

Band 6 development

Band 7 development

Clinical dashboard

Research and evaluation


THINKING DIFFERENTLY NHS LOTHIAN

With management support and skilful facilitation, Leading Better Care can precipitate a change in culture and self-belief – and initiate improvements in people’s experiences of care

“When Leading Better Care launched in 2008, we had excellent support from the executive nurse director, associate nurse directors and senior nurse leaders,” says Linda Conway, explaining the success of LBC in NHS Lothian. “That message about how important it is went deep into the clinical management team. LBC is high on the agenda.”

NHS Lothian invested heavily in LBC from the start. An LBC lead and two facilitators were appointed – one was Linda – to help shape its development. In the seven years she held that post, Linda says she saw LBC shift from a concept to “something we do every day”.

A plan was soon developed to enact the LBC recommendations for SCNs’ revised role and truly embed their learning and the sharing of good practice. Linda says a single-system approach allowed SCNs from different clinical areas to learn from each other and to understand clearly the patient’s journey across the healthcare system.

At the heart of this approach were full-day workshops themed around the four role domains of the SCN, supported by action learning (see box). The workshops included an introductory contracting session where ways of working were agreed, and a day of reflection and planning of next steps at the end. A follow-up workshop six months later supported the sustainability of ongoing leadership development and captured impact-evaluation data.

Over the three years following the introduction of LBC in 2008, 450 SCNs, SCMs and team leaders engaged in the programme in 10 cohorts. Community colleagues participated in LBC from the third cohort and, to promote workforce development and succession planning, staff who aspired to be in these roles were later invited to participate.

The programme has been continually reviewed and redesigned to meet the needs of the workforce and respond to participants’ feedback. Eight years on, in excess of 600 nurses and midwives are engaging with LBC.

For Linda, the merits of LBC have been clear from the outset. “I could see the difference this could make around the SCN role and the Clinical Quality Indicators. I needed little convincing.”

Positive feedbackFeedback from participants has been positive, too. “It allows a lot of the SCNs to evidence their role. They never before had a framework that allowed them to do that and it gave them an opportunity.”

Crucially, says Linda, the development workshops also precipitated an enduring shift in attitude that has allowed LBC to become something much more than a one-off series of workshops. “There has definitely been a change in thinking. And that transition is happening through LBC.”

But has patient care changed as a direct result of LBC? “That’s a tricky one,” Linda says. “I think it would be difficult to say the changes are specific to LBC because at the same time we have the Scottish Patient Safety programme, Releasing Time to Care, the Quality Strategy and many other initiatives and programmes. SCNs are involved in so many it would be difficult to say change was down to any one of them. But with LBC I can see a change in attitude, culture and self-belief. LBC is certainly the lynchpin and has provided a platform for many to embrace their leadership role.”

An example of how LBC contributed to quantifiable improvement is through care rounding in the emergency department (ED). SCNs saw that greater uniformity in their approach to patient care, planning and assessment could be beneficial in the context of managing up to 300 patients in every 24-hour period. The SCNs felt a formalised, redesigned approach to care rounding would help join up a series of national and local initiatives

relating to care quality and would improve the patient experience. With management backing, the new process was incorporated within the board’s quality information database system, known as QIDS. This allows staff to record practice, assess activity at any one time, and demonstrate contributions to national and local targets, including the Clinical Quality Indicators. A DVD was produced, explaining the process to staff and its rationale.

Smoother transition Among the outcomes of that work are a smoother transition for patients between ED and inpatient areas, an increase in patient satisfaction and a decrease in complaints. Staff demonstrated greater awareness of the essential elements of care and of care assurance, while organisational benefits included closer collaboration between departments and a shared understanding of the patient’s journey.

Linda suggests that LBC has created firm foundations for Excellence in Care because SCNs are already familiar with improvement methodology. And they value measurements that demonstrate the quality of the care they give. “Like LBC, Excellence in Care will become very much a part of what we do on a day-to-day basis,” she says.

LBC workshops – examples of topics

Ensuring safe and effective clinical practice• Clinical Quality Indicators

(CQIs)• Improvement

methodologies• Scottish Patient Safety

programme• Ten Essential Shared

Capabilities – positive risk-taking

• Group activities to explore ways of improving teamwork and communication; ensuring early interventions for deteriorating patients; prevention of adverse drug events

• Marketplace – working lunch• Action learning

Managing and developing the performance of the team• “Making the links” – enabling

and engaging leadership• CQIs – food, fluid and

nutrition• Releasing Time to Care and

how the team can benefit

Ringside seat

Being an LBC facilitator changed me, says Linda Conway

As LBC facilitators, we were very fortunate and got opportunities we wouldn’t get otherwise. We communicate with other health boards through a variety

• National perspective on LBC• Marketplace• Action learning

Contributing to the delivery of the organisation’s objectives• Political astuteness – policy,

objectives, key drivers and targets; delivering the service – holding to account

• Effective and strategic influencing

• Equality and diversity – interactive case studies

• Collaborative working• Marketplace• Action learning

Enhancing the patient’s experience• Seeking, hearing and acting

on feedback• Compassionate care and

leadership – links to CQIs, Better Together programme, long-term conditions/anticipatory care

• Communication skills• Person-centred care• Marketplace• Action learning

of forums, interact with people we might not have met before, we have spoken at national conferences and organised many local events.

When I look back, I see the difference LBC made for me as a person. It’s shifted my thinking and I embrace challenges I

may otherwise have not. Through LBC I have learned so much, grown and developed both personally and professionally. The knowledge and experience we were privileged to get as facilitators are just phenomenal. Without doubt, it’s been the best opportunity of my nursing career.

There has definitely been a change in thinking. And that transition is happening through LBC


KEEPERS OF GOOD CARE NHS ORKNEY

Senior nursing staff in Orkney have to be flexible and wear many different hats – but no role is more important than that of team leader

“For me and other nurses, LBC has really emphasised the importance of nursing,” says NHS Orkney lead nurse Judy Sinclair. “I think sometimes and in some areas, even here, nursing roles have been dumbed down a little. And LBC gives us focus: we are the keepers of good care and we’ve got a very important role.”

Judy, the board’s LBC facilitator, is Orkney born and bred, and although she moved away to undertake nurse training, the pull of the islands drew her back.

But she recognises that life there is not for everyone – you need a hobby for the long winter nights, she says – and recruiting and retaining staff can be a challenge. Health professionals work on 10 of the 70 islands in the archipelago and the geography demands that nurses must adapt, be flexible.

Different hats“People here wear many different hats, so that’s quite difficult because everybody’s role is very full,” Judy says. “We’ve also had some significant funding challenges over the years and maintaining knowledge and skills in such a small system can be challenging.”

New recruits often come from beyond the islands and the influx of ideas and different ways of working, although healthy in principle, can bring further challenges. A tendency to assume that nursing practice elsewhere must be “better” – safer, more effective – means that new

approaches are sometimes adopted too quickly, without consideration of the remote and rural model of care. The problem then, says Judy, is a tendency to think one size fits all without recognising the local context.

The appointment in 2013 of a new director of nursing, Elaine Peace, has given extra impetus to LBC and a priority was to undertake a training-needs analysis of the entire nursing workforce. SCNs and team leaders play a key role in the clinical-skills development programme that emerged out of that review and they now lead delivery of training for themselves and their teams.

Examples of areas so far covered on the development scheme include:• an ALERT course to help staff

recognise when patients are deteriorating rapidly and act appropriately in treating them

• adults with incapacity• diabetes care• record-keeping and assessment/

care-planning• the development of healthcare

support workers.

In line with the LBC framework, senior charge nurses use the “pink book” to establish their own development needs, which are then reflected in their personal development plans. There are only seven hospital-based SCNs in Orkney so it’s more cost-effective and beneficial if education and development draws in others as

well, including the SCNs working in community, mental health and children’s services. In her joint capacity as LBC facilitator and lead nurse, Judy holds regular meetings with the SCNs and team leaders to discuss issues relating to quality and professionalism; and LBC principles are also used to support a development programme for band 6 nursing staff.

But how does this education and development translate into more effective care for patients? One way is through a review of documentation used in inpatient areas – although “documentation” doesn’t really cover the scope of the exercise, Judy says, because it was always about more than simple paperwork. The review evolved into an initiative called Leading Better Assessment and Care-planning. Its aim was to highlight what works well in the assessment process and then identify any necessary changes or improvements. “It’s taken a long time,” Judy says, “but this is going to improve the care we give.”

SCNs have been heavily involved throughout the assessment and care-planning project and their role is critical to its success.

Judy says: “Such a lot is placed on nursing staff, and the leadership within these teams is crucial to standards of care. The standards need really strong leadership – and well-informed leadership – to work.”

In Orkney there’s an extra reason why strong nursing leaders who can drive a culture of care excellence are so vital, she suggests.

“We’re very visible to our public – we are the public we serve. It’s our grannies, our mums, our dads, sisters, brothers who are in the wards and on our caseloads. We’re a small community so when you go into a ward you can know a lot of the people in the beds. That’s another impetus to be the best you can be.”

Proving instrumentalWith the director of nursing firmly behind it, Judy believes LBC is proving instrumental in supporting SCNs to achieve high-quality, safe and effective care in Orkney. She’s keen to see how Excellence in Care is developed and taken forward, and hopes it proves flexible enough to work to the advantage of patients across Scotland and not only in the larger boards.

She says: “Having the four Excellence in Care principles is a good thing. My initial sense is that we have a real opportunity here, but it’s about how it’s distributed, led and taken forward, and how it’s translated to suit each individual area’s perspective.”

Thanks in part to LBC, nursing in Orkney is well positioned to seize that opportunity. “LBC has definitely given nursing credibility,” Judy says. “I’m a big fan.”

A personal perspectiveFiona Forbes, SCN

LBC has provided developmental direction for me during what has been a challenging time in relation to SCN staffing changes in the organisation.

Focusing on the LBC framework has helped, although there continues to be an ongoing challenge with the recognition that SCNs shouldn’t hold a direct caseload on a daily basis, which reduces opportunities for supervising and supporting teams with their personal development.

But I feel LBC has helped support SCNs to develop leadership skills and ultimately gives all nurses a voice to promote safe and effective person-centred care.

LBC also promotes role modelling and encourages development within the ward environment. By doing this, it supports nurses in bands 5 and 6 to identify areas for their own development and this allows the nursing team to develop collectively.

Teams need strong leadership – and well-informed leadership – to make them work


EMPOWERED TO LEAD NHS SHETLAND

An array of projects undertaken in NHS Shetland indicates that senior clinical nurses are confident in their ability to shape and lead change for the benefit of patients and communities

Confidence is a slippery concept to isolate and measure. But NHS Shetland boasts a list of projects that suggests SCNs are applying their skills with an impressive degree of self-assurance and belief (see box).

Kate Kenmure, the board’s LBC facilitator and its child and family health manager, is wary of drawing a solid black line back to LBC. But, she says, the projects, all of which feature SCN leadership, are indicative of nurses’ burgeoning authority.

“The way these projects link to LBC is that SCNs have been empowered to lead them as opposed to them being medically led or driven by the director of nursing or myself,” Kate says. “SCNs have been given the authority and the leadership skills to say ‘My ward needs this. I’m responsible for the ward, therefore I’m going to develop it’. I think that’s where LBC comes in – maybe the projects would have happened anyway but they would have been done in a different way.”

Change processAs an example, she cites a new rehabilitation unit at Gilbert Bain Hospital in Lerwick. Developing the unit meant supporting teams through the change process, embedding multidisciplinary team-working and establishing a goal-setting approach to rehabilitation. Staff from a range of professions were involved, including doctors, physiotherapists and occupational therapists. But the project was led by an SCN, Sharon Henderson.

Kate says: “Everyone had their role to play but Sharon’s was very much a leadership role. She drove the project because it was her ward area. It was multidisciplinary, because that’s the best thing for patients, but she took responsibility for it. I think that’s the difference LBC has made.”

But LBC no longer features as prominently in NHS Shetland as it once did and Kate has views about why that is. “There hasn’t been a lot of focus on LBC in the last couple of years and we don’t have any dedicated time for it.” But, she says, that might indicate that LBC has become mainstream. “If it’s been accepted and become the norm then perhaps it’s achieved what it was supposed to achieve. LBC has focused the organisation on the

SCN role and it has given them the leadership skills, confidence and capabilities to be experts in their field. It’s normal practice across the board.”

The organic nature of LBC brings opportunities to focus on new national policy priorities. The next step in the evolutionary process, she suggests, is care assurance, with SCNs taking on the mantle of delivering Excellence in Care. “We’ve got these individuals who are highly trained, they’ve got leadership skills and excellent practice, and now they’re applying those skills and leadership qualities to care assurance.”

NHS Shetland is in the process of developing a care assurance

framework and a pilot is underway with a tool adapted from those used in other health boards. The challenge is to create a model that can replace all the audits currently undertaken across NHS Shetland and which will draw together work in a number of different streams, such as the Scottish Patient Safety programme and Older People in Acute Hospitals standards. The aim is to develop a model that incorporates observations of care and interactions, patient stories, staff and patient feedback, and measurement of compliance with record-keeping standards.

But while Excellence in Care comes to the fore, the lasting influence of LBC remains. Regular monthly team meetings between SCNs, team leaders and ward sisters continue, and there are quarterly team meetings attended by community team leaders as well. “Those meetings developed out of LBC,” Kate says. “There has been a lot of emphasis on training but also on the collegiate side of the SCN role – supporting each other. The meetings are very well established now and very well attended. I think SCNs feel issues are discussed that need

SCNs lead the waySCNs in Shetland have been involved in a wide range of projects that demonstrate their skills as authoritative, competent and confident leaders. For example:• development of a new endoscopy pathway and embedding it in

practice• supporting the development of a high-dependency unit• supporting expansion of a day-surgery unit• the planning and relocation of chemotherapy services• undertaking new roles, including taking the lead for tissue viability

and for revalidation support• improving recognition of the deteriorating patient• developing care bundles for falls and delirium• planning the expansion of renal services and supporting team

development.

NHS Shetland SCNs have also been involved in the repatriation of gynaecology services from NHS Grampian. “We had a visiting service here but most services were delivered in Grampian,” says LBC facilitator Kate Kenmure. The board’s decision to deliver more care locally, where it is safe and practical to do so, has significant benefits for patients, not least because they will avoid having to make difficult journeys when the weather is poor. Repatriation will also bring savings for the organisation through a reduction in the cost of travel.

decisions from people at their level of responsibility. And that gives them ownership – they’re accountable for developing things.”

Training eventsArising out of LBC, there’s also an impressive range of regular training events organised for SCNs involving both internal and external speakers. Depending on the subject, these sessions are opened up to other professions. Recent topics have included:

• revalidation• HAI-SCRIBE – the tool designed

to assess risk and manage infection in healthcare facilities

• data protection, presented by the Information Commissioner’s Office

• employment law• conducting an investigation• an overview of human resources

polices.

Other subjects are addressed in new resources on the NES website, including a series of LBC webinars, which are available for LBC facilitators and nursing and midwifery clinical leaders across Scotland to draw upon.

The size of NHS Shetland and its low staff turnover mean formal induction and LBC-style development programmes are required less frequently than in other, bigger boards. “But what we’ve tried to do is make LBC part of our ethos and our normal way of working,” Kate says. “I think that was probably the idea. It wasn’t supposed to be something different, it was supposed to be ‘this is the way things are’.”

We’ve tried to make LBC part of our ethos and our normal way of working


IN THE DRIVING SEAT NHS TAYSIDE

NHS Tayside is using a group approach to support clinical leaders to identify their ongoing development needs, with service delivery improving as a result

LBC is not seen by NHS Tayside as something people “do” on a three-day course. Rather, it’s recognised as a change in culture through strengthened clinical leadership, something that continues to grow and change as SCNs’ needs change. And in terms of their ongoing development, SCNs are very much in the driving seat.

“It’s better if people in leadership roles step up and say ‘this is what would benefit me now’,” explains senior nurse in practice development Audrey Fleming. “Clinical leaders told us that instead of rigid training in selected topics, they favoured shared learning through reflection. And while they value the development they’ve had through LBC, they now see a need for ongoing opportunities in topics like improving team cultures and addressing challenging behaviours – the things that make up the difficult, ‘messy’ parts of the job. So we’ve taken that on board in practice development.”

Active learningAs a first step, two facilitated SCN active learning groups are being tested in acute services. Active learning groups enable people at the same level of seniority who do similar jobs to meet in a small group with a facilitator to discuss and explore issues that are important to them.

“Through skilful and professional challenge from the facilitators and peers, the groups help individuals seek out their own solutions and determine a way forward,” Audrey

says. “It’s a completely different way of learning from traditional classroom approaches.”

Audrey is using the national LBC impact tool with the group she facilitates to help members identify strong and weak areas of their leadership.

“I’ve asked the SCNs to use the impact tool to identify areas where they feel they are proficient or expert and those where they think they are a bit less certain or have a knowledge or skills need,” she continues. “We focus on those latter issues in the active learning, inviting experts from other areas, such as finance, to share their expertise with the group when necessary.

“We’re still in the early stages,” she says, “but we’ll continue to tailor sessions to meet the group’s needs as they articulate them, agreeing each time what the focus of the next meeting will be. I’m there to facilitate, but it’s the group’s agenda we address, not mine.”

Audrey believes the active learning group model offers a safe and effective means of supporting SCNs’ ongoing development and improving service delivery, but feels strong facilitation is crucial.

“The SCNs bring things they find challenging to the group and are looking to find solutions that will make a difference to their patients, and you need facilitation for that,” she says. “It’s not about leading the session, but making sure we stick to time and the right level of challenge is coming in – the members run the session and the facilitator can guide the focus of the discussion.”

The support and understanding that comes from being able to discuss and forward-plan with peers is also highly significant.

“Group members understand where each other is coming from,” Audrey explains. “It creates a very safe space. There’s some bad press about health care, and people can feel there is a lot of negativity around. It’s hard for them to be open and expose their vulnerability in that kind of environment.

“So we create these spaces to enable them to do that, become more self-aware and reach conclusions they may not otherwise have come to. Talking something through with peers can change your thinking away from quick-fix reactivity to embedding sustained change. That’s the kind of philosophy we’re trying to promote through LBC.”

Direct linksAudrey accepts that making direct links between the active learning groups and improved patient care will be important, and plans are underway to evaluate achievements. Group members sign a contract with their line managers confirming that attendance will be a priority over the succeeding six months and identifying specific elements of service delivery the SCNs will seek to improve: it is these elements that Audrey and her colleagues are looking to evaluate over time. Feedback from peers, colleagues and patients will also be sought.

Going forward, the emphasis on evaluation and assuring the quality of practice is directly linked to the aims of Excellence in Care, Audrey believes.

“We have some ideas about how we should collect evidence around standards of care that we feel will

make the evaluation of the active learning groups more effective,” she says. “For instance, an SCN scorecard has been tested – it provides the hard data, but also an opportunity to develop a narrative to explain why the measures say what they say. So it’s not just numbers, it’s also the story behind the numbers. Issues raised through collecting this information can be brought to active learning to consider how improvements might be made.

Daily conversationsSCNs in NHS Tayside have introduced daily conversations with patients as a quality assurance and improvement method. The conversations are a bit more than a casual chat, as surgical urology SCN Gillian Birrell explains.

“The aim is to have really meaningful conversations that result in improvements by focusing on issues that either help or hinder the delivery of quality care,” she says.

Gillian worked with fellow SCN Nicola Gunn from the surgical high-dependency unit to create a three-level framework for the conversations:• understanding what really

matters to patients and reassuring them that their care is being supervised by a SCN who recognises what they want

• building capability in the ward by identifying

omissions, delays and patient preferences in care – by sharing patients’ views with the nursing team, the SCN can help staff to recognise how care can be tailored better to people’s needs

• understanding better the challenges faced by the ward team and planning for future improvement.

The conversations are not only reassuring patients and focusing effort on quality, but are also providing evidence of improvement in the ward. “I’m able to give my head of nursing assurance that the ward is delivering person-centred, safe and effective care,” Gillian says. “I can also show that our focus is always on improvement and I know what the key issues are from patients’ perspectives.”

That definitely fits with what Excellence in Care is all about.”

It’s better if people in leadership roles step up and say ‘this is what would benefit me now’


VALUE ADDED NHS WESTERN ISLES

Geographical challenges in the Western Isles demand a flexible approach to development – but the outcomes demonstrate that challenges can be overcome and confident, innovative leadership nurtured

Some things have an effect just by being there and it might be argued that LBC is one of them.

Louise Sullivan, practice educator and LBC facilitator for NHS Western Isles, says that SCNs have benefited simply because the existence of LBC has reaffirmed their worth. “They matter because of LBC,” she says. “It adds value to their role. They realise how pivotal they are within the organisation. If there’s a national programme there to support your particular role, I think it’s bound to increase your confidence.”

And confidence can liberate. It allows senior nurses to push at doors, speak up, innovate. When they do that, patient care is likely to evolve and improve.

Hard workBut for LBC to be truly transformational requires hard work from people like Louise who, with the support of her line manager and others, has helped breathe new life into the development of SCNs in Stornoway and beyond since she came into post in 2012. Before that, the board’s head of professional practice development led on LBC and when she left in 2010 there was a brief hiatus before LBC was reinvigorated following Louise’s arrival.

To appreciate the success of LBC in NHS Western Isles, it’s worth considering for a moment the challenges posed by the islands’ geography. The health needs of

the 26,500 residents, from Lewis in the north to Barra in the south, are met by about 1,000 staff. There are three hospitals, the largest of which is in Stornoway, 140 miles by road and two ferries away from Barra. Professional isolation is a risk that

must be guarded against. But for all the region’s challenges, when describing the board’s staff magazine, Louise offers an insight into the ties that bind the community together. The magazine is thick – 52 pages – and is packed with photos

and features. It is read by the public as well as board employees and copies are everywhere – in GP practices, dental surgeries, even at the airport. “We joke that it’s like the Hello magazine of the NHS,” says Louise. “But it’s taken very seriously. It’s about pride in the local community and because of where we are, and everybody knowing everybody else, people really enjoy looking at it.”

Just as the board’s staff magazine reaches beyond its employees, the need to develop leaders and enhance management skills stretches further than the Western Isles’ small SCN community, which numbers only 17.

A learning needs analysis is undertaken annually by every team and considered by the board’s Nursing, Midwifery and Allied Health Professions Forum. In the past, almost every team has identified gaps in leadership and management.

But to make learning and development programmes cost- effective – for example, in the southern isles – they are opened up to band 6 and specialist nurses as well as SCNs. In some cases, and where appropriate, allied health professional staff are invited too. “Being a small board we have to bring in other professions,” says Louise.

A three-day programme, devised in consultation with an outside company, has helped address identified deficits in leadership and management. “We looked at some of the requirements around the LBC framework and developed a tailor-made programme,” Louise

explains. “It included things such as performance management of a team, learning and development cycles within a team, and some employment issues. We also included sessions on self-awareness and leadership qualities, and on time management as well – which is something we all need but particularly SCNs with busy wards and teams, and all the things they have to look after.”

Quality hubWorking with the board’s quality improvement co-ordinator and the lead on person-centred care, Louise also maps out a programme of quality hub development days for the year ahead. “For some we get a speaker in to talk about a particular topic, while others are simply people sharing challenges around quality improvement. Or they present a case study and share learning about things that have worked well in their area. We’re in our third year of doing these now and they’re well received and valued.”

A personal viewJoan Frieslick, SCN in medical rehabilitation

It was the introduction of the Clinical Quality Indicators, which we learnt about on the LBC programme, that was excellent for us because we had a way of evidencing that the nutritional care we were providing on the ward was good, and helped us see where we could improve on that good care. Now, all the staff are hugely committed to ensuring patients’ nutritional care needs are fully met and documented appropriately.I also greatly appreciated the developmental opportunities that were provided as a result of LBC. In addition, the LBC workshops and leadership programme have given band 6 staff on my ward a chance to develop as leaders.

In terms of its effect on patient care, Louise says one of the main areas of impact of LBC has been a reduction in hospital-acquired pressure ulcers on acute wards. Although there has been considerable national focus on preventing pressure ulcers, originally it was raising awareness through LBC that led to improvement in NHS Western Isles. “LBC highlighted those areas that were essential to good nursing care,” says Louise.

The value of data-gathering is now clear to Western Isles SCNs, which means they are well placed to contribute to robust systems for measuring and assuring the quality of patient care. Louise says: “We know Excellence in Care is coming and we’ve started to think about the things that we already collect data on.” As well as pressure ulcers, that list includes complaints, falls, patient experience, incident reports, documentation, and catheter-acquired infections. “And there are probably lots more,” Louise adds. “Excellence in Care is definitely on our radar.”

All staff are hugely committed to ensuring patients’ nutritional care needs are fully met and documented


SPECIAL APPROACHES NHS SPECIAL BOARDS

Scotland’s NHS special boards have developed their own unique approaches to implementing Leading Better Care, but the principles remain the same

LBC has changed over the years. As well as evolving to include new categories of staff and professional groups, it has also reached out beyond the 14 territorial NHS boards to Scotland’s NHS special boards.

Three of them – the Golden Jubilee Foundation, NHS National Services Scotland and NHS 24 – are at different stages of LBC implementation.

Involved from the startThe Golden Jubilee Foundation has been involved with LBC from the start. The Golden Jubilee National Hospital, part of the Foundation, is home to regional and national heart and lung services, is a major centre for orthopaedics, and is the flagship hospital for reducing waiting times in key elective specialties. Clinical education and improvement nurse Eleanor Lang has no doubt about the positive impact LBC has had in the hospital.

“It’s been instrumental in bringing things back to the leadership role and the accountability that comes with being a senior charge nurse,” she says. “I think it’s done a lot to improve the clarity and expectations of the SCN role.”

LBC has a very strong personal development focus in the hospital. SCNs access opportunities that help them to understand leadership, but also learn about themselves through psychosocial self-assessment measures.

“We use these assessments to help the SCNs gain insight into their own personalities and how they perceive the world,” says Eleanor. “It helps them to develop more effective relationships with colleagues and people they come into contact with every day.”

As is the case elsewhere in Scotland, SCNs in the hospital face challenges in complying with the many national and local programmes and initiatives that are key to their roles. But Eleanor believes the role clarity and development support LBC offers, and the potential opportunities provided by Excellence in Care, have put SCNs in the right place to be positive change agents.

“We’ve struggled at times to enable the SCNs to fully develop their roles,” she says. “But overall, LBC has helped us re-establish their accountability and identifiability. Most SCNs no longer work a 12-hour shift pattern – they have a four- or five-day week which, together with their unique navy blue uniform, helps to heighten their visibility and presence.”

Actively engagedLike the Golden Jubilee Foundation, all band 7 nurses and most band 6 in the Scottish National Blood Transfusion Service (a division of NHS National Services Scotland) are actively engaged in LBC, as head of nursing for donor services Jacqueline Millar explains.

“Our initial approach focused on band 7s who were leading teams,

but we realised that this placed many transfusion practitioners and tissue nurses who didn’t lead teams at a disadvantage,” she says. “We’ve now addressed that.”

The service is the specialist provider of transfusion services to NHSScotland, supplying high-quality blood, tissue and cell products. Its nurses have highly specialist roles, working in areas such as clinical apheresis, tissue donation, immunology and, of course, blood collection.

The nature of the work demands that it is very heavily monitored and regulated. The standard operating procedures and performance review indicators the service has in place put it in a very strong position to engage positively with the Excellence in Care agenda, particularly in relation to care assurance and record-keeping, but can also have an inhibiting effect on nurses’ ability to introduce new ideas.

“Every task the nurses do has a regulated procedure that must be followed,” Jacqueline says. “It’s not so easy for band 7s to introduce new initiatives – they might think something up, and we want to encourage them to do that, but we need to go through a very rigorous review process so they do not deviate from our standard operating procedures.”

That said, changes are happening. Band 7 nurses working in clinical apheresis, for example, have identified and are now investigating

differences between regional services in citrate toxicity. “The band 7s recognised the problem and are now putting in place a process for solving it, communicating with peers in the blood transfusion service in England and working towards creating a national Scottish standard for intravenous calcium administration in this situation,” Jacqueline says. “LBC has given them core skills to address issues like that, which is a big plus. They recognise it is part of their role.”

Jacqueline is not shy about spreading the word on the benefits LBC can bring to a specialist service. She gave a presentation on LBC at the annual UK blood transfusion conference that had quite an impact on colleagues in England.

“They faced the same challenge of band 7s not really working to the full potential of their role,” she says. “As a result, the service in England now has a leadership programme for all their band 7 nurses working in blood collection.”

New to LBCUnlike the other two special boards, NHS 24, Scotland’s national telehealth and telecare organisation, is new to LBC. In a way, though, LBC has always been present, as associate director of nursing and care Brenda Wilson explains.

“We’re at the start of our LBC journey, but feel we’ve been following the principles of LBC in our leadership development without calling it such,” she says. “The four key elements of the SCN role have been there in our leadership development for some time and are

reflected in the work our team leaders do. So now it’s about formalising it and making sure our team leaders have the same kind of leadership development opportunities as SCNs in territorial boards.”

An LBC steering group is in place and has been active across a range of fronts. It has developed an action plan, benchmarked leadership development activity against other programmes and scoped the team leader role, with interesting results.

“One of the debates is around the current title of team leader and if this effectively reflects the clinical nature of this leadership role,” Brenda explains. “The team leaders are keen to be recognised as nurse leaders – it gives them an identity that’s more in line with their peers in territorial boards – but we need to make sure that any revised title has transferability to the telehealth/telecare setting.”

The LBC steering group is now asking team leaders and their managers what kind of development activity they feel they need. One of the options being considered is shadowing opportunities with colleagues in relevant departments in territorial boards, such as pre-assessment and triage services.

NHS 24’s unique care delivery model has been supported by strong quality-assurance and record-keeping systems that Brenda believes not only position it well to engage with Excellence in Care, but also represent vital components of an effective telehealth/telecare system.

“We can show we’re efficient and effective at meeting our targets, such as answering and returning

calls within appropriate time frames,” Brenda says. “But we also recognise the importance of qualitative, as well as quantitative, measures, and we have a number of quality measures in place to ensure the service delivers safe, effective and person-centred health care.”

Fundamental underpinningNHS special boards need special approaches, and the Golden Jubilee Foundation, NHS National Service Scotland (Scottish National Blood Transfusion Service) and NHS 24 have carved out their own way of introducing and implementing LBC to suit the uniqueness of the services they offer. Some job titles, practices and structures may differ from those seen in territorial boards, but the fundamental underpinning of LBC – that clinical leadership is central to the quality and safety of services – is embedded across all three.

[LBC] has been instrumental in bringing things back to the leadership role and the accountability that comes with being a senior charge nurse


The narratives show clearly how LBC and now Excellence in Care are liberating senior nursing and midwifery clinical leaders, empowering them to develop themselves, their teams and the services they offer.

NES is continuing to support and invigorate LBC in Scotland’s NHS board areas through the network of LBC facilitators, consolidating the good practice that has emerged to provide a springboard for future developments. Recent and ongoing initiatives include:• strengthening the LBC facilitator

network• developing the new LBC website• investing in a bespoke coaching

programme for senior nursing and midwifery clinical leaders – for further information, contact [email protected]

• hosting a webinar series.

If, having read the narratives, you now want to find out more, go to the new NES LBC website at www.leadingbettercare.scot.nhs.uk. There you will find resources, advice and development opportunities related to LBC and Excellence in Care and contact details for LBC facilitators and other key personnel. You can also keep yourself updated through the news service and register for the regular series of LBC webinars. More on Excellence in Care can be found in a report published by the Scottish Government – you can access this at www.gov.scot/Publications/2015/09/8281.

FOLLOW THE STORY

So, it’s easy for you to follow the LBC/Excellence in Care story as it continues to grow and evolve.

Far from overThat story is far from over. LBC and Excellence in Care still have much to achieve, particularly in delivering on wider initiatives in NHSScotland focusing on health and social care integration, patient safety, quality improvement and care assurance. Their links with – and significance to – these wider initiatives are profound. And as one of the LBC facilitators notes: “They are all seeking the same outcomes – a safer and better experience for patients.”

36 Leading Better Care: lessons from the boards

© NHS Education for Scotland 2016. You can copy or reproduce the information in this document for use within NHSScotland and for non-commercial educational purposes. Use of this document for commercial purposes is permitted only with the written permission of NES.

This resource may be made available, in full or summary form, in alternative formats and community languages. Please contact us on 0131 656 3200 or email [email protected] to discuss how we can best meet your requirements.

NHS Education for ScotlandWestport 102West PortEdinburghEH3 9DNwww.nes.scot.nhs.uk

Spring 2016 NESD0509

leading better care · 2 leading better care: ... centred care for every patient, first time and...

Documents