Engaging and developing front-line clinical nurses to drive care excellence: Evaluating the Chief Nurse Excellence in Care Junior Fellowship initiative

Abstract

Background

Global challenges in the development of a highly skilled and motivated nursing workforce jeopardise the delivery of high-quality care. Flexible and innovative workforce solutions are required to overcome these challenges.

Aims

To describe the implementation and present the preliminary evaluation of the ‘Chief Nurse Excellence in Care Junior' bespoke Fellowship initiative designed to develop the foundational clinical and academic skills of front-line junior clinical staff.

Methods

This initiative was developed and piloted at a large, inner-city, acute NHS trust. The initiative involved two main components: a bespoke development programme and an improvement project that was supported by clinical and academic mentors. The initiative was evaluated using structured feedback, case studies and data on dissemination activities.

Results

Six front-line nurses completed the first cohort of the initiative that commenced in spring 2016. Results showed a positive impact on professional development relating to the acquisition of new knowledge and skills. Case studies of projects had a demonstrable impact on patient experiences, outcomes and cost savings. Wider organisational and NHS impact was demonstrated through multiple dissemination activities.

Conclusion

This preliminary evaluation provides evidence that this initiative is a sustainable, clinically driven career development opportunity at a foundational level that has a demonstrable positive impact on care and staff development. Further work is underway to carry out a longitudinal structure, process and outcome evaluation with particular focus on impact.

Introduction

The effective professional development of a highly motivated and skilled nursing workforce is at the forefront of international health care debate (Health Education England, 2015; Nursing and Midwifery Council, 2017; World Health Organization, 2016). Nursing workforce deficits have been directly linked to poorer patient outcomes and staff experience (Aiken et al., 2014). Therefore measures to address these workforce challenges have been identified as a global health priority (Ball et al., 2016; Deloitte Centre for Health Solutions, 2017).

Policy documents and drivers (NHS England, 2014) have acknowledged the increasing complexity of patient care needs and expectations, the aspirations of the current and future nursing and midwifery workforce as health care providers, and the need for flexible and innovative workforce solutions and roles, including those that combine opportunities for clinical and academic development (Association of UK University Hospitals, 2016; Health Education England, 2015).

In responding to the historical barriers for aspiring nursing, midwifery and allied health profession clinical academics as outlined in the Finch Report (UK Clinical Research Collaboration, 2007), Health Education England and the National Institute for Health Research (NIHR) have established national funding streams that aim to provide distinct career pathways for those committed to establishing a clinical academic role. These include post-graduate research training, bridging awards and mentorship in order to develop the next generation of clinical academic leaders (Health Education England, 2015). Westwood et al. (2018) outline a successful partnership model that utilises the strengths of strategic partnerships across health care and educational systems. However, despite national supportive infrastructure and examples of good practice, local evidence confirmed that there were limited opportunities for front-line staff to gain exposure to the realities of combining clinical demands and academic development outside of these schemes. Challenges for trusts also include how best to identify, support and further develop those aspiring to or considering clinical academic roles outside the established pathways (Westwood et al., 2018), and recognising and supporting those who are not yet clear whether this is their preferred career option.

Allowing staff to experience aspects of clinical academic role development as part of a strategic talent-management approach is therefore essential in allowing staff to gain insight, experience and confidence, and to develop networks essential for clinical academic roles and NHS leadership more broadly (Strickland, 2017).

Local research evidence (Haines, 2016) and extensive staff engagement identified that an in-house, locally driven ‘foundational level’ was required to provide staff insight, exposure and skill development. Specifically, this comprised junior (NHS Agenda for Change (AfC) band 5) leadership development of evidence-based practice skills, project management, and the opportunity to experience the challenges and opportunities of innovation in today’s NHS.

In this paper we describe an initiative that aimed to specifically target the development of front-line clinical nurses (AfC band 5), ‘Chief Nurse Excellence in Care Junior Fellowships’, and present the preliminary results of the evaluation.

Aims and objectives

The aim of the initiative was to implement and evaluate a bespoke programme designed to develop skills in innovation, leadership, improvement science and change management for front-line junior clinical staff (nurses and operating department practitioners (ODP)).

The objectives were to:

• pilot the initiative and document the process of its implementation; and

• capture outcomes in relation to the impact on individual Chief Nurse Excellence in Care Junior Fellowships (hereafter referred to as Chief Nurse Fellows), patients and the wider organisation.

Methods

Setting

The Chief Nurse Fellow initiative was developed and piloted at a large, inner-city, acute NHS trust whose organisational characteristics can be seen in Figure 1.

Figure 1.

Organisational characteristics.

The initiative

The design and implementation of the initiative involved two main components (Figure 2). Component one was a bespoke individual development programme. This was designed and underpinned by an ‘inclusive’ talent-management theoretical approach that was chosen as it recognised the full range of talent across the organisation and was commensurate with the trusts nursing and midwifery shared governance ethos (Swailes et al., 2014). Personal development included clinical academic and leadership experience. This was guided by a bespoke framework mapped against the VITAE researcher development framework (https://vitae.ac.uk/vitae-publications/rdf-related/researcher-development-framework-rdf-vitae.pdf/view) (VITAE, 2011) and improvement science methodology (Roe et al., 2015). This process was monitored and evaluated using a skills matrix. Individuals assessed themselves against seven domains (1) understanding you and the way you work, 2) contact and support networks, 3) project aims and objectives, 4) managing the change process, 5) knowledge of the implementation/improvement process, 6) project reporting and impact, 7) professional and career development) as either highly competent, competent, developing, or not yet developed.

Figure 2.

Components of the programme.

Component two comprised an improvement project specifically relevant to the Chief Nurse Fellows' clinical area and supported by bespoke mentorship from nurses in clinical, academic and senior leadership positions internal and external to the organisation. This included quarterly meetings with the chief nurse of the organisation and invited health-system leaders to share their career journeys. During the course of the programme, individuals were required to underpin their projects using practice development frameworks and improvement science methodologies for example, plan, do, study, act (PDSA) cycles and PARiHS framework. (Kitson et al., 2008; Roe et al., 2015).

Following organisational nursing and midwifery board-level approval in the autumn of 2015, the initiative was piloted with its first cohort of six direct care junior clinical nurses and one junior ODP. A partnership approach between the corporate nursing team and divisional lead nurses was employed to recruit graduates from across a large tertiary organisation. All roles were advertised externally, with ‘junior’ referring to AfC band 5 posts. Chief Nurse Fellows were recruited in line with standardised NHS Human Resources (HR) policy and procedures, and the selection process included an interview and presentation.

The Chief Nurse Fellows received a bespoke training programme, dependent upon their current experience and development needs and the requirements of the development activity. Each member of the pilot cohort was assigned 1 day a week in the role for the duration of a year. Each Chief Nurse Fellow was aligned with a clinical and an academic mentor to support the development of a personal training plan and an Excellence in Care project, examples of which can be seen in Figure 3. Academic mentorship involved monthly meetings with PhD-prepared nurses to ensure the scientific rigour of the proposed projects. This included regular reviews of project plans, ensuring projects were supported by appraisals of best available evidence, provision of methodological expertise, and support for dissemination and writing for publication. Chief Nurse Fellows met regularly with their mentors to review, modify and develop their project and personal development plan.

Figure 3.

Examples of Excellence in Care projects.

The initiative was resourced by the reallocation of nursing/ODP vacancy funding within each clinical division. Each Chief Nurse Fellow equated to 0.2 whole-time equivalents (NHS Employers, 2017). Recruitment of the first cohort commenced in spring 2016.

Evaluation and analysis

The initiative was evaluated using qualitative and quantitative methods focusing on the process and outcome to establish impact. The evaluation was divided into three main elements:

1. An evaluation feedback form was completed by all Chief Nurse Fellows at the end of the initiative to capture individual comments in relation to their professional development, project development and recommendations for future iterations of the initiative.

2. Case studies of projects conducted by Chief Nurse Fellows were collated, examining outcomes in relation to benefit to patients and/or staff experience.

3. Assessment of wider organisational and NHS impact relating to dissemination activities and the ongoing legacy of the initiative. Academic outputs and awards from projects and associated activities were also captured through a database of publications, awards and conference presentations.

Results

The following sections present the preliminary results from the evaluation; these are structured against the three main evaluation elements detailed above.

Personal development including clinical academic and leadership experience

Following completion of the programme, Chief Nurse Fellows all reported positive personal and professional development, as captured in the statements below.

These roles allow individuals to explore opportunities, evoke change, work with the wider team and uncover their own unique approach to nursing. (Fellow 1)

I feel that this has been a unique opportunity to develop and identify a niche opportunity to develop as an individual. Improved my ability to listen and to engage with others. It has positively impacted upon my career and has helped shape me for the future. I’m not sure if my project was too big to achieve but I feel like there could have been more drawn from this project. (Fellow 2)

Individual feedback also confirmed that exposure to senior nursing leaders proved inspirational.

The Chief Nurse Fellowship has given me opportunities I would never had to meet Directors/Matrons of Nursing within NUH and receive their mentorship, support and advice. These opportunities have helped me to develop my work network within [trust] and my own leadership skills … and I feel the past 6 months to be the highlight of my career so far. (Fellow 3)

In addition, opportunities to collaborate with wider stakeholder groups and departments (such as finance and procurement) gave insight into and understanding of the complexity of decision-making processes and local and national strategic priorities. Through the mentorship process, individual Chief Nurse Fellows described valuing the opportunity to experience transformational leadership in action and witness its fundamental role in improving patients’ care beyond the bedside.

The Chief Nurse Fellow initiative also provided clinical and academic mentorship. This exposed the Chief Nurse Fellows to clinical academic career role models, which in turn raised the profile of this alternative career route. Clinical academic careers are not as established as more traditional career pathways such as nurse manager, advanced clinical practitioner or practice educator, and the initiative helped a number of Chief Nurse Fellows to explore the suitability of a clinical academic career in relation to their future aspirations:

The opportunity allowed me to explore beyond my ward area. In terms of influencing my career I believe that I am a driven individual and would always seek out opportunities for development. The opportunity has given me an insight into research and leadership. (Fellow 5)

Whilst not the primary objective of this initiative, it is of note that one Chief Nurse Fellow subsequently secured an NIHR-funded Masters in Research Methods fellowship, and two others confirmed their intention to undertake PhD-level study later in their career.

Has made me more confident and certain that I would like a clinical academic career and progress on to my PhD. (Fellow 4)

Project outcomes relating to benefit to patients and/or staff experience

The six Chief Nurse Fellows undertook a diverse range of projects across clinical specialties that focused on pertinent issues for clinical practice within their areas. The focus of these projects was initiated by the Chief Nurse Fellows and project plans were drawn up in collaboration with clinical and operational colleagues, patients and the public (PPI), senior nursing leaders and mentors.

Early on in the project, Chief Nurse Fellows were encouraged to engage with improvement science methodologies to support their understanding of the current literature and the importance of engaging with stakeholders as a key part of delivering the project.

Two specific case studies are briefly presented in the following paragraphs to illustrate the work undertaken and the impact on patient or staff outcomes. Both examples demonstrate the value of supporting front-line staff to innovate and provide solutions that maintain quality while also enhancing value and efficiency.

Case study 1: enhancing post-anaesthesia dementia care in the theatre recovery setting

Background: Caring for patients with dementia in theatre recovery can be challenging. No local or national guidelines are available on best practice.

Aim: To improve the quality of care for patients with dementia emerging from general anaesthetic.

Method: Plan Do Study Act cycles were used.

Results: Audits identified that post-anaesthetic nursing care for those with dementia could be more patient-centred. A suite of interventions were implemented that included (1) a dementia care resource trolley that housed a CD player, disposable headphones and a selection of classical music CDs, a twiddlemuff (a knitted muff with accessories sewn on, which is used as a stimulation activity for the restless hands of patients with dementia) and stress-relieving toys; (2) working with ward staff to highlight the importance of accurate documentation on individuals’ lives, likes and dislikes; and (3) flexible training on dementia using e-podcasts for staff. Following implementation, staff reported an increase in confidence when caring for people with dementia. They also noted what a calming influence using the resources had had on distressed patients within the department (Edis, 2017a).

Conclusion: This project led to improvements in the care of patients with dementia through staff education and awareness-raising of the sustainable solutions offered (in the form of the resource trolley) to enhance the patient experience.

Case study 2: enhancing the care of patients with neutropenic sepsis

Background: Patients with suspected neutropenic sepsis are admitted to hospital and given intravenous antibiotics as a first-line treatment.

Aim: To streamline the care pathway for adult patients with suspected neutropenic sepsis.

Method: Quality improvement methodology was used that included audit and feedback cycles and implementation and evaluation.

Results: Findings from a series of audits focusing on diagnosis, length of stay and treatment suggested that a substantial number of patients could avoid admission and antibiotic treatment. Over a 4-month period, a trial implementing routine analysis of full blood count results using a machine located in an adjacent area reduced the inappropriate use of antibiotics in this patient group by 77%, and unnecessary admissions (i.e. not neutropenic) reduced by 47%.

Conclusion: This project demonstrated significant improvements in the neutropenic patient pathway, enhancing experience and outcomes for patients and a reduction in unnecessary admissions.

The wider organisational and NHS impact

The main focus of the Chief Nurse Excellence in Care Junior Fellow initiative was to effectively develop the Chief Nurse Fellows’ strengths and talents. Since completing their year as a fellow, the entire pilot cohort still works within the organisation, with five of them having moved into junior leadership positions. Although we cannot assume that this would not have been their career trajectory had they not undertaken this fellowship, the skills developed and demonstrated through the initiative are essential for the job specifications of more senior posts:

Undertaking this project gave me the confidence and experience to apply for a band 7 role. (Fellow 6)

Furthermore, through undertaking the initiative, the Chief Nurse Fellows were exposed to the broader context of leadership within the NHS, networking with other departments (e.g. finance, ICT, HR), and clarifying career aspirations through experiential learning and exposure to the career pathways of others. This success in developing talented individuals has resulted in the wider adoption of these posts by other senior divisional leaders across the organisation.

Throughout the programme, the Chief Nurse Fellows were encouraged to enhance their learning in the areas of dissemination, networking and influencing. They did this by sharing their experiences in collaboration with The Nursing Times, via blogs (Edis, 2016; Randall, 2016). The Chief Nurse Fellows also presented their work at internal and external trust development days and meetings, including dissemination to a variety of audiences that included nurse leaders, managers, trust board members and national visitors. Formal evaluations of these presentations unanimously confirmed the positive response to front-line, junior clinical nurse development, and were described as ‘totally inspirational’ and ‘just what we need to hear’.

Since completing the programme, two of the Chief Nurse Fellows have gone on to publish articles about their projects in peer-reviewed academic journals (Edis, 2017a; Wells and Manning, 2017). One Chief Nurse Fellow was the first UK nurse to be recognised by the Daisy Foundation and has received a Daisy Award for Extraordinary Nurses™ (https://www.daisyfoundation.org/daisy-award). Others have also received nominations and were shortlisted for national nursing awards. In addition, two of the projects are featured on The Academy of Fabulous NHS Stuff (https://fabnhsstuff.net/), a National NHS website for healthcare innovation and improvement (Edis, 2017b; Leighton, 2017).

Discussion

The evaluation of the process and outcomes of this innovative initiative appears promising, specifically in relation to the development of skills in innovation, leadership, improvement science, and change management for front-line junior clinical staff. Its strengths lie in providing bespoke mentorship, exposure to the complexities of leadership in the NHS, and opportunities to develop clinical and academic skills through a project that directly informed their clinical practice.

Early evidence confirms the value of this initiative as a sustainable, clinically driven career development opportunity at a foundational level that has gained momentum, as the positive impact on care and staff development has been demonstrated. As a result, the initiative is being adopted more widely across the organisation. A further 12 Chief Fellows have been appointed (consisting of two cohorts of six), with projects being delivered on topics relating to the emergency room, adult critical care, operating theatres, cancer care, digestive diseases, major trauma, as well as children and young people and neonates. These additional Chief Nurse Fellow posts are being funded through underspend from existing nursing vacancies within the organisation. There are future plans to appoint Chief Nurse Fellows in midwifery and within the wider allied health professional community. Additionally, the Chief Nurse Excellence in Care Junior Fellow initiative has been adopted by other NHS organisations across the UK, where similar development and staff-retention challenges are being faced.

Further work is underway to carry out a longitudinal structure, process and outcome evaluation with particular focus on impact. This will include economic and patient-sensitive indicators, and alignment with American Nurses Credentialing Centre Magnet® standards as part of the trust’s journey to Excellence in Care based on international benchmarking standards. Activities will continue to be underpinned by engagement with past and current Chief Nurse Fellows, patients and the public, and the testing of a preliminary framework to collect personal, project and wider organisational impact data, including the potential impact on recruitment and retention.

Conclusion

Our experience has shown that this is a relevant, achievable and sustainable initiative that meets the expectations of our contemporary nursing workforce. Allowing staff to experience aspects of clinical academic roles as part of a strategic talent-management approach has proved successful in developing talented individuals. It has also been an opportunity for those individuals to gain the requisite skills in evidence-based practice, improvement science methodologies and change management. Preliminary evaluations of those who have completed their fellowship show that individuals are moving into junior leadership positions at ward and specialty level, and are applying the principles of transformational leadership to seek to create roles and opportunities for innovation within others.

Going forward, the Chief Nurse Fellow Initiative continues to support front-line staff, with plans to expand into other specialties and disciplines. Its merits in identifying and talent-managing individuals in their first steps on the ladder of a clinical academic career have now been recognised and implemented by other organisations across the UK. Innovating and modelling clinical academic career leadership as part of the Chief Nurse Fellow initiative has been instrumental in allowing senior leaders from nursing and beyond to see how front-line nurses, with bespoke support and mentorship, can innovate to influence and improve the quality of care that patients in their charge receive.

Key points for policy, practice and/or research

• Front-line nurses with bespoke support and mentorship can innovate to improve quality of care.

• Innovative initiatives, such as the Chief Nurse Excellence in Care Junior Fellow Initiative, provide opportunities to structurally empower, upskill and enable front-line nurses to embark on the first steps of a clinical academic career pathway.

• Relevant, achievable and sustainable initiatives that meet the expectations of our contemporary nursing workforce are required to enhance recruitment and retention.

• Innovating and modelling clinical academic career leadership as part of the Chief Nurse Excellence in Care Junior Fellow Initiative have been instrumental in encouraging senior leaders to realise the value and impact of supporting front-line nurses to undertake this career pathway.

Biography

Louise Bramley is a Clinical Lead (Research and Innovation) at Nottingham University Hospitals NHS Trust. She is a senior nurse with a wealth of clinical experience in acute care and older people and received her PhD from the University of Nottingham in 2016. Louise currently combines research and practice in a busy NHS trust and holds honorary appointments at the University of Nottingham and Coventry University. She is passionate about building capacity and capability for front-line nurses and midwives to undertake primary research and recently co-founded the East Midlands Clinical Academic Practitioner Network.

Joseph C Manning is a Clinical-Academic Senior Research Fellow in Children, Young People and Families Nursing. He is a registered children's nurse who has specialised in the care of critically ill and injured infants, children and young people. Joseph is committed to undertaking a clinical-academic career to generate, advance and implement nursing science to achieve excellence in the care, experience and outcomes of infants, children and their families. Joseph completed his PhD in 2015 and is actively involved in the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) and is the elected Vice-Chair of the Nursing Science Section.

Joanne Cooper is an Assistant Director of Nursing (Research, Innovation and Professional Regulation) at Nottingham University Hospitals NHS Trust. She also holds the post of Honorary Professor at the University of Nottingham and visiting Professor at Coventry University. Joanne specialises in gastrointestinal disease and was awarded her PhD in 2009. She has a national reputation for advancing clinical academic career development and successfully leads the development of research and innovation, including career opportunities for nurses and midwives in the Institute of Nursing and Midwifery care Excellence.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Ethics

No ethical approval was required for this quality improvement initiative. However, individual projects as part of this Chief Nurse Excellence in Care Junior Fellow Initiative obtained the appropriate ethical and governance approvals.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.