the ‘releasing time to care – the productive ward’ programme: participants’ perspectives
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The �Releasing Time to Care – the Productive Ward� programme:participants� perspectives
JACQUELINE DAVIS R N , M S c , B A ( H o n s )1 and JOHN ADAMS R N , P h D
2
1Productive Ward Project Facilitator and Workforce Development Facilitator, Papworth Hospital NHS Trust,Cambridgeshire and 2(Formerly) Senior Lecturer, Anglia Ruskin University, Peterborough, UK
Background
The �Productive Series� of initiatives has been developed
by the National Health Service Institute for Innovation
and Improvement (NHSI). It takes the form of a series
of toolkits, designed by the NHSI and their learning
partners, to support health-care teams in taking a
systematic and inclusive approach to changing systems,
processes, environment and other aspects to improve
the way they work, thus increasing the amount of time
they have to spend on direct patient care (NHSI 2010a).
The impetus behind the development of the �Productive
Series� was the results of research carried out by the
NHSI that found ward nurses in acute settings spent an
Correspondence
Jacqueline Davis
Head of Nursing for urgery &
Urology
Department of Surgery and
Urology
Kettering General Hospital
Rothwell RoadKettering
Northants NN16 8UZ
UK
E-mail: jaxd@btinternet.com
D A V I S J . & A D A M S J . (2012) Journal of Nursing Management 20, 354–360
The �Releasing Time to Care – the Productive Ward� programme: participants�perspectives
Aim The aim of this study was to explore the perceptions of nursing staff
concerning the implementation of the �Releasing Time to Care – the ProductiveWard� programme in a specialist cardiothoracic hospital.
Background The �Releasing Time to Care – the Productive Ward� programme uses
the �lean� philosophy originally developed in the Japanese motor industry to improve
the efficiency of hospital wards. Its aim is to increase the proportion of time that
nurses are able to spend in direct patient care.
Method This study used a descriptive qualitative method with a sample size of four
nurses and two health-care support workers. Thematic analysis of the interview
transcripts was undertaken using the procedure developed by Burnard.
Results Thematic content analysis identified five major themes: starting to imple-
ment the programme, anxiety and defensiveness, the importance of leadership and
communication, challenges, and learning and personal development.
Conclusion Overall, the programme had a positive impact on both the wards
studied. Challenges that were identified included the need to sustain momentum
once the initial enthusiasm had waned.
Implications for Nursing Management This study highlighted the importance of key
transformational leadership skills at ward manager level, such as the ability to
inspire nurses to approach old problems in new ways, in the implementation of the
�Releasing Time to Care – the Productive Ward� programme.
Keywords: descriptive, lean productive ward, qualitative, transformational leadership
Accepted for publication: 7 April 2011
Journal of Nursing Management, 2012, 20, 354–360
DOI: 10.1111/j.1365-2834.2011.01266.x354 ª 2011 Blackwell Publishing Ltd
average of only 40% of their time on direct patient care.
This finding was supported by other research which
found that nearly three in four ward nurses said they did
not spend enough time on direct patient care, with 90%
of those polled saying that patient care suffered as a
result (Evans 2007).
The Productive Ward programme adopts �lean� prin-
ciples used in the manufacturing industry. Lean meth-
odology is described as a sustainable method to improve
quality, cost-effectiveness and delivery of goods and
services (NHSI 2010a). It was developed after a dele-
gation from the Japanese motor company Toyota
visited the USA in the 1950s (Monden 1998). The
delegation first visited several Ford automotive plants in
Michigan; despite Ford being the industry leader at that
time they found many of the methods in use to be less
than effective (Ohno 1988). The delegation were ap-
palled by the large amounts of inventory on site, by how
the amount of work being performed in various
departments within the factory was uneven on most
days, and the large amount of rework at the end of the
process. However, the delegation also visited a local
supermarket. Inspired by how a local supermarket only
reordered and restocked goods once bought by cus-
tomers, Toyota applied this lesson by reducing the
amount of inventory they would hold to a level that its
employees would need for a small period of time, and
then subsequently reorder. While low inventory levels
are a key outcome of lean methodology, an important
element of the philosophy behind the system is to work
intelligently and eliminate waste so that a large inven-
tory is no longer required. Toyota not only became the
world�s leading car manufacturer but an inspirational
company that others have tried to emulate over the
decades (Moore 2001).
One health-care organization that has made signifi-
cant improvements in financial management and pa-
tient safety by applying the lean philosophy since 2003
is the Flinders Medical Centre (FMC) in Australia
(Flinders Medical Centre 2009). They took the key
principles of the lean philosophy and applied them to
health care by identifying aspects of their organization
that would add quality to the patient experience. Their
initial strategy was to consider the facets of the patient
journey that create or diminish value from the patient�sperspective and to identify areas of �waste� (Flinders
Medical Centre 2009). Waste in the context of the
patient journey is considered to be wasted materials,
or unused medications but also any unnecessary de-
lays. Yearly intervention registers are available on their
website and these detail each element (i.e. the waste
or non-value steps) in the patient journey, the inter-
ventions carried out to improve the process, what
was learned, the outcome and sustainability of
improvement (Flinders Medical Centre 2009). This
sharing allows other hospitals to make improvements
using lessons learned at FMC rather than starting
from scratch, thus espousing the lean philosophies of
sharing experience and cutting out waste. The
NHSI programme, �Releasing Time to Care – the
Productive Ward�, launched in 2007, therefore builds
upon international trends in health-care reconfigura-
tion (Wilson 2009).
Aim
The aim of this study was to explore the perceptions of
nursing staff concerning the implementation of the
�Releasing Time to Care – the Productive Ward� pro-
gramme in a specialist cardiothoracic hospital.
Research design
This study was undertaken in 2009 as part of an MSc
degree. It employed a descriptive qualitative design in
order to describe a phenomenon in everyday language
in a natural setting (Sandelowski 2000, Polit & Beck
2010). A purposive sample was selected, consisting of
two senior nurses (Band 7) who had led the Productive
Ward initiative within their clinical areas, two staff
nurses of one Band 5 and one Band 6 level, who had
been closely involved with the initiative. Nurses work-
ing for the NHS in the UK are paid according to a
consolidated national pay scale shared by all staff.
Newly-appointed staff nurses join on Band 5, while
Band 6 indicates a more specialist senior staff nurse.
Nurses on Band 7 are senior nurses who manage clinical
care in a ward or department. The sample also included
two unregistered health-care support workers, from
areas where the initiative has been ongoing for over
1 year. A semi-structured interview, combining ques-
tions on the various stages of implementation with the
opportunity for informants to add any further material
they wished to, was conducted. Each interview lasted
approximately 45 minutes. The resulting transcripts
were analysed in accordance with the procedure de-
scribed by Burnard (1991).
Ethical issues
This study was conducted in furtherance of a service
development agenda and was approved by the relevant
trust�s research and development department. Informed
consent was obtained from all participants and assur-
Head of Nursing for Surgery and Surgical Specialties
ª 2011 Blackwell Publishing LtdJournal of Nursing Management, 2012, 20, 354–360 355
ance was given that their contributions would remain
confidential throughout.
Findings
Thematic content analysis identified five major themes:
• starting to implement the programme;
• anxiety and defensiveness;
• the importance of leadership and communication;
• challenges;
• learning and personal development;
To protect confidentiality, the Band 7 ward leaders
are identified as A1 and A2, the Band 6 and Band 5 staff
nurses as B1 and B2, and the Band 2 healthcare support
workers as C1 and C2.
Theme 1: starting to implement the programme
The NHSI has designed the productive ward as 11
distinct modules, such as, the �Well-Organized Ward�,�Meals�, �Handovers� and �Patient Hygiene�. However,
although separate, they all lead towards the goal of
releasing more time to care for patients (Wilson 2009).
The structured design of the programme helped settle
the tensions around starting the process and made it feel
more manageable.
�We were able to look at the books in the box and
what the modules were and begin to sort of
understand how it would work�.(Respondent C1)
�We had a breakdown of the modules, then we
could sit and look at them and decide what would
be really interesting to us. I think what was so nice
was that our ward sister said, ‘‘Have a look at the
projects, see what you want to get involved with’’
– which was amazing, so you had a choice of what
you wanted to do and that was really good, rather
than being told you were doing x, y and z�.(Respondent B1)
The �Well-Organized Ward� is one of the core mod-
ules, and is the first module that has a significant impact
on the ward environment and the way in which it is
organized.
�Well-Organized Ward was a sort of tidy up the
mess and organizing things and every member of
staff got involved with that. We even came in on
our days off in our casual clothes and all got in-
volved in organizing the storeroom and just
coming up with ideas of what to do with things
and it really got up the enthusiasm, it was a good
old fashioned blitz�. (Respondent B1)
�I assume that if all the wards use the ABC stan-
dard [to organize stores], that if I went to another
area and someone wanted something, I should be
able to put my hand on it, that�s how I see it
working and I would like to think that�s what
happens in our area now we�ve changed�.(Respondent C2)
It was clear from all the responses that the pro-
gramme was seeking to address issues that the nurses
themselves regarded as important and worth devoting
time and energy to resolving. This sense of �working
with the grain� of the local nursing culture was benefi-
cial in facilitating staff commitment.
Theme 2: anxiety and defensiveness
At the beginning of the process all respondents reported
the negative emotion of anxiety.
�I think the whole prospect of it was really quite
daunting…�.(Respondent B1)
�There was many a night waking up thinking
productive ward, productive ward, and going
through it all in my head because there was an
awful lot to think about. It was quite daunting
really�. (Respondent A2)
There was also an element of defensiveness and
reluctance to change, particularly among the more ju-
nior respondents.
�Some of us thought we were doing what we
should be doing and that all our stores are up to
date and we felt we were quite good at it, so how
is this going to make it better?� (Respondent C2)
�At first I was apprehensive, it seemed like a lot of
work, and I wasn�t sure why we were doing
it�. (Respondent C1)
A key aspect of the productive ward is the measure-
ments taken to show the improvements made. One such
measure, called �Activity Follow Through�, entails a
nurse being followed for their shift. The follower doc-
uments on a specifically designed chart what the nurse is
doing every minute of the shift. The focus is on the task
being undertaken, not the quality of the individual
nurse�s work. This exercise is repeated monthly and
J. Davis and J. Adams
ª 2011 Blackwell Publishing Ltd356 Journal of Nursing Management, 2012, 20, 354–360
records the amount of time Band 5 staff nurses spend
directly caring for their patients, what proportion of
their time is spent on other duties, and how much of
their time is spent on elements of waste, for example, in
unnecessary movement around the ward seeking items
that could be stored in a logical fashion close at hand.
Consequently, most nurses on the wards have been in-
volved in this exercise as a follower or as someone being
followed. Yet despite this, the activity continued to
cause a great deal of anxiety and stress.
�They still create a lot of anxiety for the ones that are
being followed, because people still feel, no matter
how much information you give them or no matter
what you say to people, people still feel it is a time
and motion study and you are being watched as to
what you are doing. Yes, you are being watched as
to what you are doing, that�s the whole idea but not
in that context�. (Respondent A2)
�The follow-throughs were probably the aspect
that the staff were most apprehensive about and
they thought we were following them as individ-
uals as a person as opposed to what they were
doing in their role and it took us a while to get
over that�. (Respondent A1)
�Oh my God! Yes, I was really nervous about
being followed and then again it was explained in
more detail that they were not going to be criti-
cizing what you do as a person, as a role, but they
are just going to be seeing what you do time-wise.
I was much happier about that�.(Respondent C1)
Nurse managers, who are used to working in envi-
ronments characterized by constant change and high
levels of continuous scrutiny, may underestimate the
anxiety generated by some of the activities required by
the programme. This issue clearly needs to be explicitly
addressed during the initial briefings, with on-going
support provided as necessary.
Theme 3: the importance of leadership andcommunication
Leadership at all levels of the teams has helped the
success of the productive ward initiative, but the lead-
ership strategies of the ward leaders also played an
important part.
�It was knowing your staff well and knowing what
motivates them really to get the best out of them
and who are the movers and the shakers, who are
the influencers within the team�.(Respondent A2)
�I appointed a co-leader to develop them and to
help me, I chose the particular person because I
knew she would agree with the principles of the
productive ward and by giving her the same
authority as me to implement things and get things
going was very important�. (Respondent A1)
The ward managers developed strategies for facili-
tating and valuing communication and these seem to
have had a large measure of success.
�At the start we asked for ideas and suggestions on
anonymous post-it notes and I was very conscious
of the fact that if there were some negative, silly or
bizarre comments, that they were treated with the
same respect as somebody else�.(Respondent A2)
�We spent a lot of time going through and
involving the rest of the department and not going
ahead just making changes just through the pro-
ductive �team�, rolling it out to the department and
asking them for suggestions about the way they
feel the department could work. Then we had
votes on the best four ideas, got everyone to vote
for which they thought was the best, and then
kind of who would champion that through. We
also used information folders, and notice boards.
There is quite a positive atmosphere about it
and people were quite open with the communi-
cation between everybody – keeping everybody
informed�. (Respondent C1)
Both of the ward leaders agreed that an open and
empowering leadership style fostered ownership of the
process by the whole team.
�I am very open… I share things with people
whenever possible, so they understand why
something might be happening..... I suppose be-
cause it has been fairly open and encouraging and
I have left them very much to their own devices to
a certain extent, given them the whys and the
wherefores and guidance and then to say, �Right –
how is that?� You make of it what you can, make
it your own, empowering�. (Respondent A2)
�For instance, the medicines module which is
currently ongoing is being done by a Band 6
supported by a Band 5 and they have done
Head of Nursing for Surgery and Surgical Specialties
ª 2011 Blackwell Publishing LtdJournal of Nursing Management, 2012, 20, 354–360 357
everything and they are just going to report back
to me at the beginning of next month and, as long
as the changes recommended are reasonable, we
will go with them�. (Respondent A1)
Although not mentioned explicitly by participants,
the management style they described was closely
aligned to the key tenets of transformational leadership.
Considerable effort was made to align the priorities of
the junior staff with those of the programme (Murphy
2005). It was also apparent that the management vision
was communicated to junior staff in an inspirational
way, so that they were energized to take part (Casida &
Pinto-Zipp 2008).
Theme 4: challenges
Accounts of service development have a tendency to
stress the positive aspects of the change process, so it is
important to note that there was resistance in some
quarters. On one ward, there was a particular issue
arising from the structure of the ward team.
�I�ve got a very established, senior team, you could
say top-heavy with experience… it is sometimes
not easy to motivate these people as they have
been here such a long time�. (Respondent A2)
Some respondents discussed their teams in terms of
those who were not engaging and highlighted their
frustration at this development.
�There were frictions in the team, people that have
been there since the year dot and don�t want any
changes…�. (Respondent B2)
After the first flush of enthusiasm from the early
adapters, interest waned on both wards and one leader
in particular found it increasingly difficult to motivate
and enthuse her staff. The ability of the various grades
to deal with this period was significantly different. The
more experienced ward leaders were able to use their
knowledge and transformational skills to re-enthuse
and re-motivate the team whereas the more junior
trained nurse respondents found this much more chal-
lenging and difficult to deal with.
�We have got a bit complacent really. We�ve
slightly forgotten the importance of the productive
ward and our data has backed up a little
bit�. (Respondent B1)
It is interesting to consider both ward leaders�thoughts about the slow period and their strategies for
getting their teams re-motivated.
�I said ‘‘OK. let�s stop, we won�t start any new
modules, let�s go back and re-focus on what we�ve
done’’. So we started the monthly forums again,
brought it back onto the top of the agenda, cele-
brated all our successes, re-emphasized these
improvements – looking at the data and ensuring
they realize the impact of the improvements they
have made. They see the nice graphs, but they
don�t actually �see� them – if that makes
sense?� (Respondent A2)
The other ward leader did not perceive the dip in
progress as much of an issue at all; neither did she
discuss how she would re-motivate her team, as though
it was not necessary.
�We paused for a little bit then carried on�.(Respondent A1)
The other, perhaps predictable, challenge faced was
that of having enough time to give to the initiative.
�Finding time to give to the staff nurses leading on
the process modules was difficult and partly to
blame for loss of momentum. Although I know
that doing the modules will give us more time, it is
still difficult to release time now… I don�t think I
have solved that problem yet, I just try to ensure it
is in the mind of the staff so that if we do get time
they will work on the productive ward�.(Respondent A2)
�We struggle with time and I think it will be an
ongoing issue, so we do our best when we can�.(Respondent A1)
Challenges ranging from overt resistance to change,
to a gradual loss of enthusiasm and momentum as an
initiative loses its novelty, are recognized aspects of the
change process (Glenn 2010). While those promoting
new managerial programmes naturally tend to stress
only the positive outcomes that they can be expected to
produce, a manager requires foreknowledge of likely
problems in order that these can be addressed in a
proactive manner.
Theme 5: learning and personal development
While the primary purpose of the programme was to
provide direct benefit to patients through increasing
contact time with nurses, all the nurses reported that
they had also benefited from the learning experience
that it delivers. Both ward managers confirmed that
impressive personal development was observable.
J. Davis and J. Adams
ª 2011 Blackwell Publishing Ltd358 Journal of Nursing Management, 2012, 20, 354–360
�My co-leader is a different person. She has really
developed, very confident, uses initiative�.(Respondent A1)
�I have seen a lot of confidence in a lot of different
people in different aspects. People who have led
on a particular project or whatever. They are
learning all the time because they have to engage
with other people and get the other staffs� enthu-
siasm to work through a module�.(Respondent A2)
Both staff nurses also felt that it had brought personal
benefits for them.
�I think it has been a very positive learning expe-
rience. I have seen the benefits with my own eyes, I
feel the benefits as well�. (Respondent B1)
�I feel satisfied and a great sense of achieve-
ment�. (Respondent B2)
Perhaps the most striking comments came from the
Band 2 health-care support workers, whose views are
not often recorded when service developments are
implemented.
�I feel it really has helped me to be able to start
focusing on things – which has enabled me to
think I�d really like to learn more about that, as
opposed to before I was always busy doing noth-
ing really, helping there, helping here – it wasn�torganized really. Whereas now I am much more
focused and I can see what I want to know more
and want to get more involved�.(Respondent C2)
�I feel happier in myself, a bit more recog-
nized�. (Respondent C1)
While these aspects of personal development were not
central aims of the programme, it is probable that they
helped to facilitate its adoption. Individual involvement
in decision-making in ward management gave a new
sense of personal responsibility for care (Westwood
2010).
Discussion
A report commissioned from the UK National Nursing
Research Unit (NNRU) at King�s College, London,
found that from the launch of the programme in May
2008 to March 2009, 40% of acute Trusts in England
had implemented it (NHSI 2010b). Dame Christine
Beasley, England�s Chief Nurse, was recently reported
as predicting that it will continue to be adopted even
after the strategic health authorities have been abol-
ished in 2012 (Kendall-Raynor 2010). The results of
this study support the change methodology espoused
by the NHSI in the productive series (NHSI 2010b).
The respondents all discussed how the modular struc-
ture of the process made it feel more manageable as it
gave them a structured experience. This modular sys-
tem was also a positive element of the leadership
development of the nurses who led a module or were
closely involved in a module, most likely through skill
acquisition (Benner 1982). Several of the respondents
also noted that the process is designed to promote
continuing improvement, and so they do not envisage a
definitive end to the initiative. This demonstrates a
cultural shift, as at the beginning the assumption was
that it would be an 18-month to 2-year programme of
improvement, it is satisfying to realize that from senior
to junior, respondents have all come to appreciate the
value of continuing with the process even after the
completion of the 11 modules advocated by the NHSI
(2010b). Perhaps the most significant finding of this
study that adds to the evidence base of the productive
ward initiative is the resultant learning and leadership
development individuals involved with the process in
the clinical areas have experienced. Challenges have
included the need to overcome the resistance of some
staff and the difficulty of maintaining forward
momentum when the initial enthusiasm began to wane.
These findings support those from an earlier study that
focused on the implementation of the programme on a
trauma and elective orthopaedic ward (Smith & Rudd
2010). That study also found that in addition to
increasing contact time, there was positive impact on
staff attitudes and morale. The NNRU study also
found that the great majority of respondents reported
positive attitudes to the programme on the part of
nursing staff. Most organizations had a clearly identi-
fiable champion who was responsible for facilitating
and supporting its introduction. Strong support and
enthusiasm from other senior staff was also identified
as being important. Barriers to implementation in-
cluded staffing pressures, difficulty in sustaining
enthusiasm, finding the necessary time and resources,
and problematic inter-departmental relationships
(NHSI 2010b). The evidence to date suggests that the
adoption of the Productive Ward programme is facili-
tated and sustained through the adoption of manage-
ment strategies associated with transformative
leadership (Murphy 2005).
Head of Nursing for Surgery and Surgical Specialties
ª 2011 Blackwell Publishing LtdJournal of Nursing Management, 2012, 20, 354–360 359
Limitations
The limitations associated with this study included the
small sample size and its focus on two wards in a spe-
cialized cardiothoracic hospital.
Conclusion
This study suggests that the �Releasing Time to Care –
the Productive Ward� programme was generally posi-
tively received by ward nurses of all grades and can
have beneficial effects on staff attitudes and morale that
go beyond its stated aim of increasing contact time with
patients. The importance of skilled nursing leadership in
the introduction and maintenance of the programme
was emphasized.
Acknowledgement
The MSc degree was funded by the NHS Trust educationalbudget.
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