In 2010 the Secretary of State for Health, Andrew Lansley, announced a public inquiry into the events at Mid Staffordshire NHS Foundation Trust. The inquiry and the subsequent report (Francis, 2013a; 2013b; 2013c; 2013d) found systematic failings, neglect, bullying and poor quality care and leadership within the Trust. In particular, the Secretary of State suggested it was not only a failing of the Trust, but a national failing ‘of the regulatory and supervisory system’ (2013a, section 12: 9) and he questioned why the failings at the Trust had only surfaced due to the determined action of families to expose them. The Francis report summary (2013a) identified 290 recommendations. Recommendation 195 suggested that nurse leadership could be improved if ward and nurse managers worked in a supervisory capacity, were not office bound and were involved in supervising patient care plans while not being rostered (supernumerary) to care (Francis, 2013a: 106) (Box 1). Other recommendations suggested giving nurses recognition for their commitment to patient care and acquiring leadership skills (recommendation 196) and commissioning arrangements to ensure leadership training is available (recommendation 197) from students to directors (Box 1). However, there has been criticism that many Francis report recommendations, such as increasing staffing levels on wards, have been implemented only when they do not have resource implications for trusts (Mahony, 2014) due to a false economy perspective (Regan and Ball, 2017).
| Number | Theme | Recommendation | Chapter |
|---|---|---|---|
| 195 | Nurse leadership | Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as part of the nursing provision on the ward. They should know about the care plans relating to every patient on his or her ward. They should make themselves visible to patients and staff alike, and be available to discuss concerns with all, including relatives. Critically, they should work alongside staff as a role model and mentor, developing clinical competencies and leadership skills within the team. As a corollary, they would monitor performance and deliver training and/or feedback as appropriate, including a robust annual appraisal | 23; page 106 |
| 196 | The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient care and … priority to be accorded to dignity and respect, and their acquisition of leadership skills | 23 | |
| 197 | Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all NHS healthcare provider organisations that should be required under commissioning arrangements by those buying healthcare services to arrange such training for appropriate staff | 23 |
Historical elements of supervisory management
The past can teach contemporary nursing a great deal about improving the standard of care. The notion of a supervisory nurse leader is not new and is attributed to the work of Florence Nightingale and her supporters between 1860 and 1890 (Wildman and Hewison, 2009; McDonald, 2010). The role of the matron required trained nurses, an experienced ward sister and assistant matron, leaving her free to supervise the nursing of the sick and exercise greater control over nursing care (McDonald, 2010). Wildman and Hewison (2009) suggested the matron's prominence as a supervisory force changed in the 1960s when the Salmon report (Ministry of Health, 1966) suggested the NHS change to an industrial model, with ward sisters acting as first-line managers, nursing officers as middle managers co-ordinating a group of wards, and top managers managing hospitals (Wildman and Hewison, 2009). The role of the nursing officer acquired the matron's role and the expansion of management posts recommended in the Griffiths report (1983) meant the nursing officer became a largely administrative and non-supervisory role (Wildman and Hewison, 2009).
The Griffiths report (1983) advocated a system of general management and an end to professions managing themselves (Regan and Ball, 2017). Management science aimed to increase productivity, introduce cost savings and measure nursing activities (Regan and Ball, 2017). This new business and measurement culture, however, led critics to suggest nursing leadership was disempowered and also to unprecedented reports of NHS failings (Holme, 2015), such as the Parliamentary and Health Service Ombudsman's report Care and Compassion? (Abraham, 2011), the Mid Staffordshire inquiry (Francis, 2013a; 2013b2013c2013d), and the Morecambe Bay investigation at Furness General Hospital (Kirkup, 2015). All reports apart from the latter refer to nursing in trusts with non-supervisory nurse leaders. The Morecambe Bay investigation criticised supervisory midwives with conflicting dual management and supervision roles (Professional Standards Authority (PSA), 2018).
Reintroduced in The NHS Plan (Department of Health (DH), 2000), the modern matron's role depended on the employing trust and followed three models: a direct clinical care role, similar to that of the ward sister; a managerial role, similar to that of the previous nursing officers; or a mixed role—supervisory with a strong clinical presence (Wildman and Hewison, 2009). The role of supervisory nurse manager in the form of the modern matron is mentioned only once in the three volumes and one summary of the Francis report. In volume 1 of the Francis report (2013b) in relation to the Trust's accident and emergency department and reports of poor cleanliness, discharge planning, medicines management, staffing levels, communication with patients' relatives and carers, responses to complaints and a disorganised management of the department, it briefly mentioned ‘facilitation of the appointment of clinical tutors to assist with service development until the arrival of the intended Modern Matron’ (2013b: 665). However, none of the three models of modern matron practice (clinical, managerial or mixed) was promoted over another (Wildman and Hewison, 2009).
A key factor to improve the quality of nursing care suggested in the Francis report was the reintroduction of supervisory nursing leaders at ward level (recommendation 195). This recommendation was reinforced in action area 4 of the DH's vision and strategy Compassion in Practice (Cummings and Bennett, 2012). This article aims to identify the progress of recommendation 195 from the published literature.
Review of the literature
A review of peer-reviewed literature from 2012 to 2019 was conducted in order to identify the implementation and success of recommendation 195. The search databases CINAHL Complete, CINAHL Plus with Fulltext, AMED, ERIC, British Nursing Index, Medline, PsycINFO, and PsycARTICLES were used. The inclusion criteria were peer-reviewed papers from England, and papers that were workforce-centred and focused on the role of the supervisory ward manager. The exclusion criteria applied to the retrieved literature were nursing management in general and international papers. The search terms ‘ward manager’ and ‘supervisory’, both in the Francis report, were used.
Five retrieved papers met the inclusion criteria: Duffin (2012), Snow (2012), Fenton and Phillips (2013), Kendall-Raynor (2013), and Regan and Shillitoe (2017), the latter a literature review on recommendation 195's progress in the NHS. This is fewer papers than in a previous literature review by Regan and Shillitoe (2017) due to the unavailability of previously retrieved papers. A review of Royal College of Nursing (RCN) documents found a briefing paper on frontline leadership (RCN, 2016). A review of NHS England's website using the same search terms and dates retrieved no reports or papers on the subject, which was an early indicator of the lack of progress of recommendation 195. A Scottish perspective is provided by Russell and McGuire (2014).
Findings
Three key issues from the literature were identified, two directly from the retrieved literature and the third as a result of a wider reading of the key documents in search of a rationale for the dearth of retrieved literature.
The three key issues were:
Inconsistent allocation of time for nurse leaders
A survey of NHS organisations identified that out of 50 NHS trusts responding to the survey, only 10 had implemented supernumerary ward management fully, and out of the remaining 40 trusts, 37 had partial allocation and 3 had not implemented it at all (Snow, 2012). Duffin (2012) found that ward managers in Central Manchester University Hospitals NHS Foundation Trust spent half their time being supernumerary and the other half giving direct care. Duffin (2012) identified that some trusts had implemented supervisory nursing leadership in England, such as:
The list is short, and the implementation scale of recommendation 195 in English hospitals remains relatively unknown to date.
An RCN (2016) policy briefing reviewing international case studies (in the USA, New Zealand and Australia) is discussed here due to key lessons for the UK in relation to supernumerary and supervisory responsibilities of the ward manager/nursing leader. Many of the international ward-based nurse leader roles continue to have significant day-to-day demands in the ward setting, risking diluting the benefits of supernumerary and supervisory status. In the UK, specifying a ‘supervisory’ role does not protect a ward manager's supernumerary status unless there is an adequate and sustainable workforce, skill mix, and an autonomous working culture that empowers nurse leaders to identify and challenge poor practice with the authority to act (RCN, 2016).
Quality improvements of supervisory status
The second key issue refers to the considerable quality improvements noted after the implementation of supervisory ward managers, or nursing leaders. Snow (2012) discussed the benefits of introducing supervisory ward sister roles at Macclesfield District General Hospital in Cheshire. Their supervisory status helped ward sisters to manage rather than be on the staffing rota and, as a result, the health and wellbeing of staff improved through the ward sisters' conduct of staff appraisals and clinical audits, and their ability to deal with complaints and incidents.
Duffin (2012) referred to the term ‘supernumerary’ status where the ward manager was not counted in the staffing numbers. Duffin (2012) suggested there was a clear correlation between trusts where ward managers were fully supervisory and improved quality of care. In a respiratory ward at Milton Keynes University Hospital NHS Foundation Trust, Buckinghamshire, the ward manager was both supernumerary and supervisory, giving them the time to teach directly on customer care and how to address patients, to organise training and developmental opportunities for staff, to complete clinical audits, and to manage incidents and investigations into clinical matters (Duffin, 2012). The clinical benefits of implementing recommendation 195 were found to be having time to give feedback to patients and relatives, and to attend to human resources issues such as sickness, absence, and return-to-work interviews, which were more effective in improving recruitment and retention of staff due to the improved health and wellbeing of staff (Duffin, 2012). The clinical benefits included improvements in pain management, leading to fewer complaints.
Similarly, Fenton and Phillips (2013) found that ward sisters in one trust spent less than 40% of their time on clinical leadership and it was inappropriate to expect that nursing leaders could effectively combine clinical practice and effective ward management. This was despite an RCN campaign launched in 2009 in the report Breaking Down Barriers, Driving Up Standards, which strongly recommended supervisory and supernumerary status of ward leadership to reduce medication errors, promote staff retention, reduce staff sickness rates and greater patient satisfaction (RCN, 2009).
Russell and McGuire (2014) discussed the implementation of supervisory nurse leadership status for frontline senior ward nurses in NHS Lanarkshire, and the benefits of high-quality leadership, accessibility and visibility for patients, relatives, staff and other members of the multidisciplinary team. There was a general acceptance that new initiatives were needed to explore the supervisory nature of ward managers/senior nurse leaders. Evaluation of 18 wards in total within the Trust identified a need for more staff to support the initiative such as the addition of administrative support, which allowed ward managers the opportunity to offer direct care to patients alongside their teams. Positive benefits included time to ensure standards of hygiene, organising staff breaks, staff feeling a greater support from their nurse leaders, with less sickness absence and stress used as a proxy measure for the supervisory initiatives.
Lack of success of implementation
The dates of the retrieved literature indicate an early motivation for English trusts to implement some of the Francis report recommendations, despite criticism that their implementation has been limited (Mahony, 2014). Jane Cummings (Cummings, 2013), former Chief Nursing Officer for England, stated that Compassion in Practice (Cummings and Bennett, 2012) was a vision and strategy and a response to reports of failings in the NHS such as described in the Francis report and abuse at Winterbourne View (DH, 2012). Compassion in Practice introduced the 6Cs—care, compassion, competence, communication, courage and commitment—which were a restatement of demonstrable caring qualities in everyday clinical practice. This was a key supporting vision and strategy to recommendation 195.
Compassion in Practice identified six action areas (Cummings and Bennett, 2012):
These six actions areas parallel some of the Francis report recommendations (see Box 1), and action area 4 (see Box 2) suggested local trust providers should review options for ‘introducing ward managers and team leaders' supervisory status into their staffing structure’ (Cummings and Bennett, 2012: 21) in order to give them ‘time to lead’ (Cummings and Bennett, 2012: 22). Action area 4 in Compassion in Practice suggests providers should undertake a review of their organisational culture and publish the results (Cummings and Bennett, 2012: 21). This issue was considered to be important and repeated in action area 5: ‘ward or community nurse/midwifery leaders are supervisory to give them time to lead. We hope this will be accepted and built into all future workforce tools' (Cummings and Bennett, 2012: 22). Therefore, the lack of published literature indicates a lack of progress of recommendation 195 and action area 4 (Regan and Shillitoe, 2017). In the next section the authors discuss possible reasons for this.
A changed narrative and perspective
Compassion in Practice cannot be viewed as a standalone vision and strategy because there were three yearly updates planned between 2012 and 2015 (NHS England, 2013; 2014a; 2014b; Serrant, 2016). The parallels between the Francis report recommendations (Box 1) and Compassion in Practice's original action area 4 (Box 2) were short lived. These update reports (NHS England, 2013; 2014a; 2014b; Serrant, 2016) identified a shift in priorities away from the very specific recommendation 195. The Compassion in Practice: Two years on update (NHS England, 2014a) did not mention the original supervisory ward manager action area. Instead, in the section on action area 4, the report identified four key areas for action (NHS England, 2014a: 33):
The update reviewers stated they ‘held leadership think tanks’ to identify the four key action points to support commissioned research and recruitment to compassionate leadership programmes (NHS England, 2014a: 33). The NHS England (2014a) update referred to progress such as leadership programmes and piloting of the ‘culture of care barometer’ developed by King's College London to provide a tool for organisations to measure the culture of care between staff and managers with an emphasis on compassion (Rafferty et al, 2015). Research had been commissioned to assess the impact of nurse/midwifery leaders' supervisory roles on wards to provide safe, effective staffing levels and critical decision making (NHS England, 2014a: 44). However, a search of NHS England (2014a) using the word ‘supervisory’ found reference only to the role for nursing and midwifery leaders in action area 5 (‘ensuring the best level of care by demonstrating the right number of staff, the right skills and the right behaviour to meet the needs of people in their care’ (NHS England, 2014a: 41). Hence, the narrative of action area 4 had changed to the promotion of BAME nurses in leadership positions. Nursing leadership was seen in terms of ethnicity in NHS England's document (2014b)Building and Strengthening Leadership: Leading with compassion and in Compassion in Practice: Evidencing the impact (Serrant, 2016).
Changing Compassion in Practice's agenda area 4 has meant that the Francis report's recommendation 195 is no longer supported and promoted, with little chance of it being implemented nationally. This is demonstrated by the few publications retrieved since 2012.
A search of all three volumes of the Francis report (2013a-d) and Compassion in Practice (Cummings and Bennett, 2012) using the terms ‘BAME’ and ‘ethnicity’ found little or no mention of an ethnicity issue. The first and second Francis report (2013b; 2013c) mentioned ethnicity as a measurable criteria for hospital standard mortality rates and quality metrics, not as a care or leadership issue. It was important to find the rationale for such a change. The reasons given in the update reports were an under-representation of BAME leaders at executive level, suggesting this was important because one in five staff in the NHS are BAME (Serrant, 2016). The update reports also suggested BAME staff had experienced discrimination by a lack of training and recruitment (Priest et al, 2015). As a result, the NHS Leadership Academy specifically focused on BAME leadership in the Next Generation Career Acceleration Workshop in 2015, with a leadership programme supported by coaching, mentorship and career guidance (Serrant, 2016). This initiative also relates to NHS organisations now being assessed on indicators for ethnic diversity (Priest et al, 2015). To be clear, while promoting diversity and BAME leadership is of significance, it is not directed by any of the 290 recommendations from the Francis report, which was one inspiration for Compassion in Practice (Cummings and Bennett, 2102) in the first place. It is a separate issue.
Discussion
The authors suggest that if recommendation 195 of the Francis report had been implemented, it would have led to improved quality of care for patients in English trusts. Wildman and Hewison (2009) suggested that the failure to implement supervisory and supernumerary status for ward managers was due to wider policy changes. One policy change was the development of management science in the NHS after the Griffiths report (1983). The Kirkup report (2015) on care at Furness General Hospital found unsafe care related to performance management (Kirkup, 2015: section 1.54: 28), a need to save £24 million from the Trust's budget (Kirkup, 2015: section 3.56: 59), a need to improve multidisciplinary working and record-keeping to reduce the risk of further deaths (Kirkup, 2015: section 4.111: 92) and increased workload pressures (Kirkup, 2015: section 4.36: 76). These all contributed to clinical incompetence, deficient skills and knowledge, failures of risk assessment and care planning. Management failures were also noted in the Francis report (Francis, 2013a: 4) as determining factors in the reduced standards of care. Notably at Furness General Hospital there was a failure to properly investigate incidents or learn lessons from organisational and clinical mistakes. This systemic failure led to 21 serious untoward incidents, the deaths of 3 mothers and 16 babies, and damning criticism of regulatory and supervisory investigative systems (Kirkup, 2015), again mirroring the findings of the Francis report (2013a, section 12: 9).
Confusion was noted in relation to the conflicting duality of managerial and supervisory roles, and conflicts of interest occurred due to supervisors of midwives having no formal links with governance or risk management and the risk manager was also a supervisor of midwives. This meant that an individual could be undertaking both management and supervisory investigations and therefore be subject to potential conflicts of interest (Kirkup, 2015: section 3.46: 57). Ethnicity of midwifery leadership was not mentioned as an issue.
Failure to learn from mistakes is a problem within the nursing and midwifery profession and its regulatory body. The PSA's (2018)Lessons Learned Review on Furness General Hospital focused on the Nursing and Midwifery Council's (NMC) handling of allegations against midwives there. Concerns related to the quality of pre-2014 NMC investigations at the hospital and the suitability of the fitness-to-practise system. The concerns included:
The PSA (2018) report suggested that the NMC had poor record-keeping, poor analysis of case material, poor understanding of the implications of case material, and poor analysis of third-party information. When criticised or asked to provide information to families, which should have reduced their grieving and anxiety, the NMC adopted a defensive approach (PSA, 2018).
The relevance of the PSA (2018) report to this article relates to the poor implementation of the Francis report recommendations nationally (Mahony, 2014), even by the regulatory body for nursing and midwifery, the NMC (PSA, 2018). For example, the PSA (2018) noted that recommendations 139 to 141 of the Francis report, namely the need for the NMC to establish a relationship with trusts so that concerns about a registrant could be communicated, were only adopted in 2016 (despite the NMC intelligence on failing trusts and sharing of information with other stakeholders and the Care Quality Commission). This was in response to investigative findings of the NMC's handling of complaints against registrants.
Conclusion
This article has discussed the Francis report's recommendation 195 that ward managers should have supervisory status (see Box 1). Implementation relied on this change not being a fiscal resource issue for trusts (Mahony, 2014). There is a dearth of published papers on this subject and the findings from the literature identified three key issues:
The Francis report and Compassion in Practice gave trusts the choice to implement the necessary changes (recommendation 195) to improve quality of care; however these changes would affect costs, and cost-saving exercises had directly led to staffing shortfalls, workload pressure and failings in the NHS in the first place (Regan and Ball, 2017).
Recommendation 195 related to action area 4 of Compassion in Practice, yet subsequent update reports did not comment on why the narrative of the original action area 4 had changed. A further search of the literature identified some possible reasons why—the promotion of BAME nursing leadership due to one in five nurses being BAME (Priest et al, 2015).
As the Secretary of State for Health stated in 2010, one trust's failings reflects badly on all trusts nationally, and any organisations disinclined to implement the Francis report's recommendations suggest that not all lessons have been learned, understood or new priorities agreed. Therefore, as reports of failings in the NHS continue (Regan and Ball, 2017), the authors suggest that a lesson not learned is likely to be repeated.