the ‘releasing time to care – the productive ward’ programme: participants’ perspectives

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: [email protected]

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



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.



�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).



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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the ‘releasing time to care – the productive ward’ programme: participants’ perspectives

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