This chapter reports the findings of the process evaluation that was undertaken as part of the feasibility study. The evaluation aimed to identify and explain the extent to which the planned intervention was implemented into existing nursing practices and to draw conclusions about optimising the sustainability of future CLECC interventions. The process evaluation was guided by the principles of NPT and used a mixed-methods approach.
In total, 47 interviews were conducted, over three rounds, with 25 people. Interviews were conducted with a range of staff members, including ward leaders (n = 4 people), deputy ward leaders (n = 2), staff nurses (n = 8), nursing HCAs (n = 7), senior hospital nurses (n = 2) and CLECC PDNs (n = 2). All four wards and all ward nursing staff roles were represented at each interview round. Senior hospital nurses were interviewed just once in the third round. In total, 13 people were interviewed once, two people were interviewed twice and 10 people were interviewed three times. The ward-based interviewees had worked on their current wards for between 2 weeks and 14 years, with an average value of 4 years. Staff nurses and deputy ward leaders had between 2 and 26 years’ nursing experience, with an average of 12 years’ experience. HCAs had between 2 and 35 years’ experience working as a HCA, with an average 13 of years’ experience. All but one of the interviewees were female. Two ward study days were observed in full, in addition to five ward leader action-learning sets.
Sections of this chapter are reproduced in Bridges et al. 121 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/.
Implementation overview
The CLECC intervention was introduced to four ward teams in two hospitals. Its implementation in each hospital was led during a 4-month implementation period (beginning June 2015) by a PDN who was recruited and employed by the hospital and seconded from another role. Over the course of the implementation period, the role of the PDNs was to work with the ward leaders and the wider team to promote ownership of CLECC, to develop the learning activities into ways of working and learning that were seen to be feasible and helpful to the team and to develop a plan for sustaining what was good about CLECC after the departure of the PDN. The PDNs were mentored in their preparation for the implementation period by Jackie Bridges from the research team, working with a range of learning materials to prepare them for their role. The PDNs from each hospital communicated with each other regularly and also met up with Jackie Bridges for mentoring every 2 weeks at the outset, and then less frequently as time progressed.
Three ward teams ran the implementation period at the same time, and a fourth team started a few weeks later. The implementation period began for each ward team with the study days. Study days were exclusive to each ward team (i.e. they were not shared by participating teams from the same hospital). Each ward team had three study days led by the PDN and one-third of team members (RNs and HCAs, day and night staff) attended each of the days. This arrangement was intended to ensure that all team members had a chance to attend a study day. At both hospitals, a final ‘mop-up’ study day was held to include staff from both wards who had not made it to any of the previous study days. Ward leaders were invited to participate in all three study days and all did, with the exception of one ward leader who arranged for a deputy to attend. Study days included an introduction to CLECC principles. Staff were invited to complete CC and FECC questionnaires on the study day and to give a written response to the phrase ‘I feel valued when . . .’. They also undertook a values clarification exercise on compassionate care, but the main focus of activities on the day was to create opportunities for staff to talk together and listen to each other about what is was like to work on the ward and to develop a shared vision for care.
Ward-based learning activities followed the study days. The PDNs initiated and trained staff in the cluster discussions. PDNs trained staff nominated for peer observations, arranged the observations of care and analysed the results. PDNs also analysed the material that staff had completed on the study days and they encouraged meetings between the ward leaders and matrons. Reflective learning sessions for staff were planned by the PDNs who arranged for a senior nursing manager to visit the ward at the end of the implementation period to hear about how the team had used CLECC and what their plans were for taking their ideas forward. They also arranged and facilitated the action-learning sets for ward leaders. The action-learning sets were held for staff from both hospitals jointly so that the set was larger than two members and the PDNs could share the facilitation.
The process of normalising Creating Learning Environments for Compassionate Care into practice
The findings that follow illustrate the amount of cognitive and behavioural work that staff needed to do, individually and collectively, to normalise CLECC into practice. Although many of the individual elements of CLECC were possible to implement during the 4-month implementation period, sustaining this work beyond this time was difficult for some ward teams to achieve, and the findings that follow explain why this was the case. Findings are presented under the four NPT constructs and draw together data from all data sources.
Coherence: Creating Learning Environments for Compassionate Care as a limited set of concrete practices versus underpinning philosophy
There was clear evidence from the interview and observation data that staff at all levels were able to distinguish the CLECC intervention from current ways of working. People were able to articulate activities associated with the CLECC intervention that were new to them. Staff valued the principles behind CLECC, appreciating the focus on staff well-being and the consequent impact on patient care quality:
I thought they [cluster discussions] were a really good idea, not just to bring up problems but to also say – actually we did this this morning, this went really well – for someone to say – oh, that was good, or thank you, just thank you for your hard work this morning, we were really under pressure this morning and everyone’s worked really well as a team, thank you.
For RNs in particular, the CLECC principles aligned with their aspirations for successful team working and high-quality patient care. However, for HCAs who had not always worked in this type of environment for long, this was a new and generally welcomed way of thinking about their workplace. Beyond the activities staff were directly involved in, they struggled to visualise the purpose and potential of CLECC. Staff tended to associate CLECC with the cluster discussions that took place part way through each shift, thus providing an opportunity to gather as a team and check on each other’s well-being:
So, whereas before they might know that orange bay is heavier than green bay, they might not necessarily have volunteered to go and help. Now they are much more aware that if they are going – well actually we’re struggling – well, we’re not, we’ll come and help you and I think that’s because of the [clusters] and the fact that we’re all sitting down and going – is there anything we can do to help you? And if they are going – well actually I’ve got a really poorly patient, so I’ve been struggling with the others – right – well then – we’ll come and help you. And it’s made them more aware of each other.
All staff attended the study days and, on prompting, were able to link these sessions with CLECC. Staff were used to attending study days for a range of purposes but commonly attended as individuals. Participating in a study day in which only other team members were present was considered unusual and was generally welcomed. Staff saw the study day as a way of ensuring that they were working together and an opportunity to engage with the ward vision, which was not previously explicit. The most important aspect of the study day was the chance to get to know each other, which staff reported they had not had the opportunity to do previously:
We had the study days and they were all very good and I found that I got to know the different people within those study days, or how they felt and I thought – oh, I didn’t know that. So that was useful.
The ward managers and PDNs charged with facilitating CLECC were involved in a wider range of CLECC activities. For ward leaders, additional CLECC activities included regular action-learning sets and meetings with their matron in which they discussed CLECC, and they were better able than other staff to note distinctions from usual practice. Ward leaders and PDNs were able to articulate the underlying philosophy of CLECC and to identify associated practices that were derived from CLECC but which fell outside the prescribed CLECC activities. In addition, senior nurse managers who were not directly involved in the CLECC intervention were able to confidently describe the underpinning principles based on what they had observed during the implementation period. These accounts, although expressed differently from the accounts of staff on the ward, reflected what staff gained from the CLECC intervention, even though ward-based staff struggled to define or explain the intervention themselves. The tools that staff required were acquired through reflecting on their own practice with patients and staff and developing support strategies as individuals and as a team:
To me CLECC is about giving staff tools to ensure that they support themselves to do a hard job. So it’s about providing – a nurse with the knowledge of what they need to deliver . . . compassionate care or high-quality person-centred care, whatever you want to describe it as – every day, at a high-quality standard, is what we have to aim for, but also with you having some insight into how your behaviour affects both your patient and your staff.
Um . . . I don’t know. Well I would say – it’s about . . . reviewing your – your practice about the care that you’re giving to patients and to the staff team that you’re working with. It’s to look at – I don’t know – more supportive strategies and a way of working together. I think identifying stress and anxiety in yourself because the job is – is stressful, you know, we’re not robots.
Another influencing feature on coherence was the extent to which team membership and team leadership were transient on the participating wards. High staff vacancy rates resulted in wards frequently being staffed by nurses who were not trained in CLECC or who did not view CLECC as part of their role. Ward leaders reported in the ward profiles that bank or agency staff were used daily. Indeed, team membership and leadership shifted throughout the 12 months under study. One ward leader was appointed as a CLECC PDN and so her ward needed a new ward leader at the outset. Part-way through the implementation period one ward team was split up and relocated because of ward refurbishment and was brought back together again at the end. The ward leader led a smaller team in a different location during refurbishment and this smaller team continued to work with the CLECC intervention, with efforts being made to integrate other team members back into CLECC working practices once the whole team was reunited. The ward leader of another ward retired just after the 4-month implementation period. Therefore, just one of the four participating wards had the same team leader in the pre-implementation period, throughout the implementation period and still in place after 12 months of CLECC. There was turnover of other team members too. On average, 36% of staff left over the course of the study, which is consistent with turnover on the control wards. One senior manager viewed staff turnover as a result of CLECC as a positive outcome:
[CLECC] exposed some practices, provided a culture where people could talk openly about how other members of staff made them feel; there has been a bit of a churn, so maybe some people that needed to go. People have now felt they’ve got a voice and, again, if people aren’t doing what we need them to do, then they need to go.
But there was no provision for inducting temporary or newly arrived staff into CLECC, limiting their opportunity to make sense of CLECC.
In summary, although ward staff appreciated the potential value of CLECC, their understanding of CLECC was limited to and shaped by the concrete activities that they experienced. Additional knowledge about the underpinning principles of CLECC did not filter down to the team as a whole, with no evidence that coherence improved over time from the original induction into CLECC activities.
Cognitive participation: staff keen to participate but not sure who should drive it forward
Staff were generally keen to participate in the CLECC intervention, but it was not always clear whose responsibility it was to ensure that this happened. The PDNs led the implementation of the CLECC intervention as planned during the 4-month implementation programme period. Each PDN worked simultaneously with two wards in their allocated hospital. University staff prepared the PDNs for their role and provided ongoing mentorship. The PDNs organised specified CLECC activities as per the CLECC implementation period for the ward teams and were a visible presence to the ward staff throughout the implementation period. The PDNs experienced challenges in ensuring that all the staff were exposed to the CLECC activities. This was primarily on wards where some staff worked set shifts and were never on shift during the organised activities.
The approach of the individual PDNs to facilitating the CLECC activities influenced the degree of ownership of the CLECC intervention by the ward staff. One of the PDNs continued to be the stimulus for these activities throughout the 4-month period, whereas the other PDN deliberately undertook to transfer ownership for making things happen within the ward team:
The ward hadn’t bothered doing their clusters . . . all I’d asked them to do was their 2 weeks of cluster meetings. They didn’t do one.
The PDN that encouraged the team to take ownership of the CLECC intervention actively worked with staff to make the initiative flexible and fit with the resource pressures:
It [cluster meeting] doesn’t always stick to that time. It kind of depends how it’s going. So we’ve had like busy days when stuff’s been happening on the ward. At one point they [nursing staff] kind of ask permission to make it [cluster meeting] later, it’s kind of sad. But I’m like . . . ’yeah, do it whatever time it works in the ward. If we can do it, that’s a bonus’. So quite often it’s – quite often it’s the Health Care Assistants asking for it [cluster meeting].
Although the PDN and ward leader/shift leader had initially been actively involved in originating the cluster discussions, as the intervention became embedded other team members took it upon themselves to call the cluster meeting in the absence of more senior leadership. In some cases it was the HCAs who led the discussions and on one ward the housekeeper became actively involved:
They [HCAs] will remind whoever is in charge of the ward, and say ‘Are we having a check in today?’ I’ve seen that quite a few times.
The CLECC intervention gave staff the opportunity to see themselves as innovators. The study days provided a mechanism through which staff could articulate their ideas for improving practice on the ward and stimulate the team to set shared goals. Some ideas had been raised in the past but had not been achieved. The staff felt more empowered to act on the ideas and to set things up so that the change was sustainable. Rather than working only at the ward level, staff raised their ideas with the matron, in addition to the ward leader, who was able, in theory, to provide the resource to make the initiative a reality. Previously the matron would not have been aware of the strong feeling held by the ward team about certain direct patient care-related issues as communication was usually through the ward leader alone:
Quite a few of the staff have got involved in various different things that have come out of the study days, what they wanted to change, and thought they could do better. And they’ve gone off and sort of little groups, or twos and threes, and are bringing that stuff back, passing it through the matron; putting a lot of that into place. It’s things like patient’s families not bringing in toiletries; [patients] don’t have clothes to go home [in] . . . getting [relatives] to bring in a set of clothes and make them leave them in the locker. Some of [the staff] are taking more initiative themselves, rather than waiting to be almost told or suggestions. From that point of view, I think it’s helped that way.
Not all the ideas were implemented in practice, and this appeared to be linked to uncertainty about whose role it was to realise them or to authorise them. This lack of follow-through was demoralising for the staff involved who were keen to put forward ideas and action plans:
So I think they – some of them felt a little bit disappointed that they’d made these suggestions and took their time to – to do them and then no one really followed it through or said – yes, we can use that or no we can’t. It just got left.
Everyone interviewed reflected that they saw CLECC as a way to build the team and improve care, and this underpinned their participation in prescribed activities. All ward team members attended the study days, and all ward leaders (except one who sent the same delegate each time) attended all of the action-learning sets. Cluster discussions were also reported as well attended, suggesting that people saw their engagement and participation as important. However, the participatory role of staff outside the ward team was less clear. Fortnightly meetings were encouraged between ward leaders and their matrons (usually the ward leader’s line manager), but these did not go ahead for two of the ward leaders in one hospital, indicating a lack of clarity about the role of the matron in making CLECC happen:
Unfortunately this has been the only element of the programme to have failed the intervention wards and both ward managers felt that there has been a negative impact from the lack of support from the matron. It was felt that items identified by the nursing teams that were considered areas requiring improvement and determining a solution for implementation were unsupported and even in some instances rejected.
Two of the ward leaders (at the second hospital) already attended regular meetings with their matron and chose to use this already established forum to address the CLECC intervention. These already established meetings appeared to be linked with a more proactive matron role in supporting the CLECC intervention:
So my matron’s been very supportive the whole way through; we’ve kept in regular contact all the way through. She’s been asking for updates, she’s known about the interventions that we’ve done on the ward and has been really supportive.
Although the majority of staff were keen to participate in the CLECC intervention when invited, there was variation by work role at all levels and between hospitals and wards, in the extent to which individuals saw it as their role to make CLECC happen.
Collective action: participation shaped by organisational context
Whether or not the activities went ahead as planned was mediated by the extent to which the proposed activity harmonised with the priorities of the wider organisation and the resources made available to the ward team. A particular influence was the organisational priority afforded to material patient care activities over CLECC activities in the context of high patient care workloads. The flexibility of the CLECC intervention enabled staff to try other ways of implementing CLECC that partly overcame these barriers.
Staff reported that senior hospital managers had endorsed the work that had resulted from the CLECC intervention, suggesting that the benefits were visible and valued outside the immediate ward team:
They seemed to be really positive about it and they said – ‘if this is working for you, continue’. And she said ‘it does seem to be working because you’ve got so many things put in place, like a suggestion box, etcetera’ and she said – ‘if this is working for you, you know – go for it.
In spite of this support, and also reflected in the senior nurse interviews, staff members’ participation in planned learning activities was viewed as being of secondary importance to their role in providing patient care. The study days were designed in the original CLECC programme to be for the whole team, but managers were concerned that alternative staffing options for the ward would compromise patient care. Instead, ward teams were divided into three, with each third attending a separate study day. The option to deviate from the protocol, while still maintaining a degree of fidelity to the principles of CLECC, was essential to the implementation of the intervention from the outset:
It wouldn’t really be that compassionate to our patients if we left no staff whatsoever on the wards in order to train them. So, you know – I think that flexibility about how you do that – so I think whatever comes out needs to be about actually the important bit is that there’s time and training and support.
Cluster discussions proved possible to integrate into the working day and went ahead during the 4-month CLECC implementation period, yet they were less readily convened when patient care demands were very high and staffing resource was low. The consistency with which the cluster discussions took place varied with who was on shift and reflected the perceived priorities by the team of the organisation at that time.
Twice-weekly 1-hour reflective discussions as a group were planned, but, on all wards, the demands of patient care in relation to the staff available meant that it was not possible to release staff to attend them. In fact, staff other than the PDNs and ward leaders seemed unaware that the sessions were part of the CLECC intervention. Absence of the sessions meant that there was no forum in which to share with the team the results of the team climate analysis and values clarification exercise from the study days, or the peer observations of practice. Once it became clear that group sessions were not possible, PDNs experimented with different ways to encourage staff reflection. In one ward, the ward leader met with staff on a one-to-one basis. On other wards, results from peer observations were displayed for staff to see.
Interestingly, the part of the ward team relocated with the ward leader because of the refurbishment project (see Coherence: Creating Learning Environments for Compassionate Care as a limited set of concrete practices versus underpinning philosophy ) found a focus on care and compassion much easier to integrate into their working day on the smaller ward and also found that the CLECC intervention had a significant impact on this as a choice of ethos by the ward leader:
So there’s a different ethos at the moment as well, because we’re focusing on care and compassion.
The ward leader’s philosophy drove this focus, but more generous staffing levels and smaller patient numbers were seen as making it possible:
So . . . because of the staffing levels, lack of, you know, less patients, it’s much easier to be more caring and more compassionate and talk to people because you’re not trying to – you know – wash somebody and finish quickly and move on to the next person. So you have got time for those nice little conversations, you know, talking to people about what they did before and – you’ve got time to spend with patients.
Staff also felt less need for formal CLECC activities, such as cluster discussions, while on this smaller ward, as they created other, less formal, opportunities to catch up with each other throughout the shift. Once back as part of a larger team, cluster discussions were seen as necessary again and were resumed by the team. However, staff struggled to find time as lower staffing ratios resulted in them feeling too busy to stop.
As the most visible representative of hospital managers, the support role of the matron in relation to the CLECC intervention featured frequently in interviews. The extent to which the ward team perceived that they were supported in their endeavours by the matron was viewed as a strong mediator of whether or not CLECC was a success in influencing care. Some staff were accustomed to matron involvement only when there were problems, and these teams did not seem to be supported by their matrons to make changes that had arisen from the CLECC intervention. A lack of support with the CLECC intervention appeared to be linked with staff dissatisfaction with support from the matron in general:
We don’t hardly ever see a matron; the only time we ever see her is when she comes on and moans at us – or has something bad to say. She doesn’t come on and praise – encourage or show that she’s interested in the patients.
As noted earlier (see Coherence: Creating Learning Environments for Compassionate Care as a limited set of concrete practices versus underpinning philosophy ), other matrons were reported to be very supportive, keeping in regular contact about the progress of the intervention. There appeared to be a disparity between senior management’s expectations of the matron’s role in the CLECC study and their actual involvement. At interview, one senior nurse manager reflected that their own role could have been more proactive in encouraging matron support for implementing CLECC:
I assumed that my matron was working, was working with the ward managers on a weekly basis but I doubt it was what I expected it to be. So – I think we probably should have – should – could – have put more nursing leadership resources into it, just to provide that support and recognise it.
Staff generally participated in CLECC activities when the opportunity arose, but this was shaped by the extent to which participation harmonised with the priorities of the wider organisation and that resources were available to enable participation. Planned staff learning activities took second place to direct patient care and transient team membership and leadership meant that including the whole team in the CLECC project was not possible. Matron support mediated the extent to which teams were able to implement CLECC. The CLECC property of plasticity enabled staff to develop and adapt practices that suited local circumstances, but what was possible was constrained by the available resources and priorities of the wider organisation.
Reflexive monitoring: valued by staff but challenging to sustain
The findings indicate that staff appreciated and were able to make use of the opportunities presented by CLECC, resulting in reported benefits to personal well-being and capacity to care. Staff spoke of engaging more consciously and deliberately with patients as people, and prioritising this engagement over the completion of tasks. They recognised that their practice was already compassionate at times but CLECC had given them opportunities to value these practices and to make personal commitments to be more consistently compassionate:
CLECC, for me, is about giving the staff the empowerment to feel like they can sit and do things with patients that are – compassionate rather than task orientated, so rather than just doing the obs [observations] and just doing the washes, having that – even if it’s just 5 minutes, just having a chat with the patient about – their life, their family or sitting and doing an activity with them; those rather than just – well we’ve got to get the washes done, we’ve got to get the observations done – which do still need to be done but it’s about – giving the staff that – yes – that empowerment of being able to say, well actually, let’s do something a bit different.
The CLECC intervention was associated with an improvement in staff morale and staff well-being more generally, which was viewed as having a positive impact on patient care. Cluster discussions were often cited as the means through which staff became aware of each other’s needs and identified ways to give each other support. The cluster discussions provided the space to plan when and where additional support might be required, resulting in staff feeling that they were not on their own:
So, whereas before they might know that orange bay is heavier than green bay, they might not necessarily have volunteered to go and help. They might have done but they might not, whereas now they are much more aware that if they are going – well actually we’re struggling – well, we’re not, we’ll come and help you and I think – I think that’s because of the check-ins [cluster discussions] and the fact that we’re all sitting down and going – is there anything we can do to help you? And if they are going – well actually I’ve got a really poorly patient, so I’ve been struggling with the others – right – well then – we’ll come and help you. And it’s . . . I think it’s made them more aware of each other.
Interestingly, some of the legitimacy for these practices seemed to come from the fact that they were part of the CLECC intervention. One interviewee cited an instance in which a senior manager visiting the ward came across a cluster discussion, which was also used by some teams to make sure that staff had a drink of water:
I don’t know who it was, but someone very high in the hospital [came to the ward] and was like, ‘mmm why are people standing and drinking on the corridor?’. But the manager said, ‘oh we have CLECC’, so . . .
Once the manager was told that the cluster discussion was part of CLECC, she was reported to have then understood the purpose behind an activity considered to be unusual enough to be remarked upon.
The study days provided an opportunity for staff who had been working together for a significant time period to get to know each other, which facilitated better team working. Staff demonstrated that they could work together as a team without having to be directly led by someone more senior. The improved team working has reduced the work burden for some staff and has provided opportunities for staff to undertake activities that previously would have been rare occurrences:
But because of the task orientated work – we’ve managed to go, right, we’ve finished, [they] haven’t and then so we can go, right, we’ll give you guys a hand and then we can all be finished together. And then that means we’ve got more time to do things that we might not be able to normally do, like – wash someone’s hair, give them a nice – you know – do their nails and – yes. So it brings out that we – because of the cluster [discussions] – we can focus on who needs a hand and who doesn’t and then we can all try and just do a bit more than – we might not be able to, like, you know, massage someone’s feet, just the little extras that we might not be able to do normally.
Staff were generally in favour of CLECC, and, although some staff have taken ownership of particular aspects of CLECC, for example cluster meetings or doing things differently, there was reliance on the ward leader to facilitate continuation. Staff expressed concern that a change in leadership would result in the loss of a CLECC culture:
I hope it goes on for a long time because – I don’t know – I don’t want it to end; I like it because – and I think everyone else likes it. I think people would miss it, but I think – I don’t know, I don’t know. Things change once you have different managers and things like that, so hopefully it won’t change when [ward leader] leaves but if we get a new manager and she doesn’t like it, then – I don’t know, I don’t know, to be honest.
The sustainability of CLECC was of concern to staff and the data highlighted what happened after the formal implementation period had come to an end. The principles that underpin CLECC appeared to be well embedded into the teams, but the activities that support these principles had not continued on all the wards 12 months after the start of CLECC. Individual wards varied in whether or not they had developed and followed through with a sustainability plan for CLECC. Ward leaders wanted to repeat the study days, but felt that they would not happen in future without the additional funding that came with CLECC as a research study. The ward leader action-learning sets, although reported to provide valuable learning opportunities, had not continued and were not missed. Ward leaders felt able to find the space and support offered by the action-learning sets elsewhere in already established systems. The formal reflective discussions were so sporadic that they did not feature in any CLECC sustainability plans. Peer observations provided a significant learning opportunity for those who did the observations, but without the space for formal reflective discussions to feed back the results to the team, these had quickly been forgotten as being part of the CLECC intervention.
The continuation or not of cluster discussions appears to be the most significant indicator of the sustainability of CLECC. All of the wards continued with the cluster discussions, but some were more sporadic than others. The ward that included a drink for staff in the cluster meeting had the highest meeting rate; however, all the wards were empowered to ‘check in’ with each other and not rely solely on handover. Attention to supporting each other appeared to increase the relational capacity of individual team members and the team as a whole. Although staff were not able to comment on whether or not patients and carers believed that care on their wards was more compassionate, staff had improved awareness of what allowed them to provide compassionate care and what hindered them. The cluster discussion was a tool that they did not have before that helped them to manage the challenges that they perceived as being out of their control.
Chapter summary
This chapter shared findings aimed at identifying and explaining the extent to which the planned CLECC intervention was implemented into existing work practices, to enable conclusions to be drawn about how interventions of this kind can be optimised to support sustained compassionate care delivery in acute settings. Findings reflect that some but not all CLECC activities were feasible to implement into practice, with a variety of factors influencing their impact and sustainability. Staff were generally keen to participate and valued the positive contribution of CLECC to their own well-being, to more cohesive team working and to supporting good patient care. Many original CLECC practices did not continue beyond the implementation period, but staff reported that the philosophy and associated culture that CLECC had nurtured continued to guide their practice. Sustainability was strongly linked by staff to the extent to which the ward leader understood and valued CLECC.
Findings indicate that CLECC had some coherence for staff in that they appreciated its potential value, but their understanding was often limited to the concrete activities of which they had direct experience. In terms of cognitive participation, staff were keen to participate, but ward teams varied in the extent to which individual members saw it as their role to make sure that CLECC happened, and there was uncertainty about the role of matrons in supporting CLECC. There was strong evidence of collective action to implement CLECC, with team members generally participating when the opportunity arose. However, the ability to act or not was shaped by the extent to which activities harmonised with the priorities of the wider organisation. Although staff valued CLECC, its sustainability was linked to factors outside the direct control of the nursing team. These findings are discussed further in Chapter 11 .