The concept of Back to the Floor (BTTF) has been in existence for many years and the approach is used by nursing and midwifery teams across a wide range of healthcare organisations in the UK. The aim of the approach is to improve patient experience through strengthened, visible, senior clinical leadership. The concept can support the aims and objectives of an organisational nursing, midwifery and allied health professions strategy, which in the case of The Royal Wolverhampton NHS Trust (RWT) and Walsall Healthcare NHS Trust (WHT), is the Quality Framework. RWT and WHT work closely as part of a collaborative model, whereby colleagues across both organisations work together to standardise approaches to health and care delivery as far as possible and nursing and midwifery is no exception to this.
Evaluations of the BTTF approach at other organisations (Thompson, 2009; Jones and Griffiths, 2011) have found that it has had a positive impact on staff and patients, for example, by improving senior team visibility, empowerment, learning together, professional networking, responding to problems collectively and effectively, strengthened communication and championing and implementing change effectively.
What did we do?
Following the COVID-19 pandemic, it was recognised by the senior nursing and midwifery leadership team that a collective re-set and more focus on the fundamentals of care was required. As a result, a variety of interventions were taken. These included, for example, development of a joint Quality Framework and quality and leadership development days for ward/department leaders. To further enhance our approach, the decision was made in November 2022 to introduce the BTTF concept, to enable nursing and midwifery colleagues who work predominantly in a non-patient-facing role to allocate 1 day a week to working within clinical areas. This was in addition to the already established leadership team presence within clinical areas across both organisations. The concept was championed by the group chief nurse, directors of nursing at both organisations and the wider organisational leadership teams.
To provide clarity on the approach, guidance was developed outlining the rationale for the approach, the expectations, feedback mechanisms to enable the collation of themes and to support collective actions, especially in relation to the matters that have been more difficult to unblock.
How does it work?
Each week, a variety of nursing and midwifery leaders undertake a BTTF shift. Initially, a set day was agreed, with Friday identified as the most suitable. However, as colleagues started to undertake the BTTF days, it became apparent that a set day was difficult for colleagues to sustain due to competing priorities. The decision was therefore made to enable a more flexible approach, with colleagues choosing to undertake their BTTF day to suit their professional and personal commitments.
The approach is also flexible in terms of colleagues choosing at what point in the day they undertake their BTTF shift. This can include morning, afternoon or night. Divisional directors of nursing and the head of nursing/midwifery maintain oversight of the BTTF activity in their areas, including collation of key themes and actions required. In addition, a feedback proforma has been developed for colleagues to use as part of sharing their findings with the leaders in each clinical area and enable collation of key themes centrally. This is then used to produce thematic reports, which are shared at relevant nursing and midwifery forums and via the respective chief nursing officer report to both Trust boards.
How do we know whether the process has been beneficial and is working as intended?
Ongoing reviews take place via the relevant nursing and midwifery forums and an evaluation was conducted in June 2023, to provide colleagues with the opportunity to feed back about their experiences and ascertain how the process is working and whether any adjustments are required. In summary, from 43 colleagues who participated in the evaluation, 67% confirmed that they have been able to undertake their BTTF shifts every week. The remaining colleagues stated that last-minute changes in their commitments, operational pressures or having worked a clinical shift on a different day, were the predominant reasons for not completing the shift. Eleven colleagues (26%) have worked their BTTF shift for the whole day, 16 (37%) for half a day, 14 (32%) adopted another flexible approach and 2 (5%) did not answer the question. Eight respondents (18%) worked predominantly morning shifts, 2 (5%) afternoon shifts and 33 (77%) adopted a blended approach, by working various shift patterns (day and night).
As part of the evaluation, colleagues highlighted improved communication, improved staff and patient engagement, increased visibility of senior leaders, better appreciation of pressures and challenges, support with problem solving and regular patient and staff contact as positive outcomes of the approach.
Areas for ongoing focus included, for example, continuing to foster collaborative working between the two organisations, continuing improvements associated with some of the fundamentals of patient care, ensuring that information in clinical areas is current, improvements in policy compliance, consistent participation in the BTTF by all eligible colleagues and maximising opportunities for staff development, retention and talent spotting.
Has the approach had a positive impact on patient outcomes and patient and staff experience?
Although it is not possible to solely attribute improvements in patient outcomes and experience to the introduction of the BTTF concept, it is thought to have positively contributed to various improvements across both organisations. These include, for example, more patient observations being completed on time (compliance increasing by more than 10%) resulting in more timely escalation of deteriorating patients, sustained and improved rate of patient falls (May 2023 saw the lowest rate of patient falls at RWT in 2 years), improvements in the rate of pressure ulcer incidents and positive feedback from staff as a result of a more regular senior nursing leadership team presence within clinical areas and ability to sustain focus on what matters the most to patients and staff. Staff participating in the BTTF shifts have reported their enjoyment of being able to spend more meaningful time with staff and patients within clinical areas, supporting improvements and learning more about the areas and teams they do not usually have contact with.
Conclusions and next steps
Introduction of the BTTF concept has enabled the non-patient-facing nursing and midwifery colleagues to dedicate 1 day each week to working directly with clinical staff and providing patient care, which has in turn contributed to improved staff engagement and satisfaction and better patient outcomes. It is important that mechanisms remain in place to support colleagues to protect their time to continue with their BTTF shifts and ensure an ongoing dialogue with regard to key themes identified, how improvements can be collectively supported and flexibility in the approach to maintain strong engagement with the process.
Both organisations plan to continue with the established approach and future evaluations will be scheduled to maximise the benefits of the BTTF initiative and enable any necessary iterations. As the approach is easily transferable to other professions, the plan is to explore its feasibility with other multiprofessional team colleagues, such as allied health professionals.