Art & science leading better care series: 1
Developing leadership roles in nursing and midwifery McGuire C, Ray D (2014) Developing leadership roles in nursing and midwifery. Nursing Standard. 29, 9, 43-49. Date of submission: March 31 2014; date of acceptance: June 6 2014.
Abstract This article is the first in a series of seven articles on an initiative undertaken in NHS Lanarkshire where a creative partnership with the University of the West of Scotland established a shared commitment to developing nursing and midwifery leadership. This article describes the national context within Scotland. It provides an overview of the innovative programmes of work and systems devised to support leadership throughout the organisation with a particular focus on quality of care.
Authors Clare McGuire Programme manager, Leading Better Care, University of the West of Scotland, Hamilton, Lanarkshire. Devashish Ray Research assistant, Leading Better Care, University of the West of Scotland, Hamilton, Lanarkshire. Correspondence to: [email protected]
Keywords Clinical leadership, Leading Better Care, midwifery, nursing leadership, quality improvement, role development, senior charge nurse
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
EFFECTIVE CLINICAL LEADERSHIP is central to meeting the ever-changing demand for the delivery of high-quality health care (Douglas 2011, Francis 2013, The King’s Fund 2013). Local and national policies and strategies across the UK have acknowledged the importance of supporting nursing and midwifery leadership roles to respond effectively to changing demands and expectations (The Scottish Government 2008, 2010a, Department of Health (DH) 2013). In Scotland, the initiative to support the development of clinical leadership in nursing and midwifery is called Leading Better Care (LBC) (The Scottish Government 2008). This article describes the collaborative approach to LBC undertaken in one Scottish health board, NHS Lanarkshire. In this article, the term ‘senior charge nurse’ (SCN) is used to refer to senior charge nurses, senior charge midwives and team leaders. The term ‘patient’ is used generically to include clients and service users.
Leading Better Care series This series of articles aims to offer an insight into various areas of development during the implementation of the LBC initiative in NHS Lanarkshire. Recognising the importance of selecting the ‘best’ person for each role within nursing, midwifery and allied health professions resulted in the development of a framework of values and competency-based recruitment and selection, which will be discussed in the second article in the series. This article describes ongoing priorities for staff development, while two future articles will explore in more detail the development of band 6 nurses, midwives and allied health professionals, and healthcare support workers. Ensuring there are effective systems and processes to support SCNs and their teams has led to improvements in clinical documentation and advancements in an information technology (IT) system, which will be explored in the last two articles in the series. Developments in NHS Lanarkshire through the LBC programme resulted in
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Art & science leading better care series: 1 12 key areas or work packages. An overview of the forthcoming articles and the links between the article subjects and aligned work packages is outlined in Table 1. The aim of the series is to demonstrate a progressive and systematic journey from value and competency-based recruitment and selection through to role development. The articles provide accounts of improvements to the systems and processes that support SCNs and their teams to deliver safe, effective and person-centred care. The series demonstrates the uniqueness and creativity of a partnership approach to LBC which is committed to improving the quality of care and experience for patients. The delivery of an agreed programme of work capitalised on the expertise of the partners and a desire to contribute to the evidence base in a range of activities. These elements were designed to help SCNs promote quality improvements in their areas of responsibility.
Leading Better Care: national context In Scotland, nursing and midwifery leadership in health care has been a strategic priority for several years (Scottish Executive 2006, NHS Scotland 2007, The Scottish Government 2008, 2010a). The publication of the Mid Staffordshire NHS Foundation Trust public inquiry report emphasised
the need to maintain such a focus by stating that ‘effective leadership is essential to a flourishing NHS’ (Francis 2013). In 2007, a review of the SCN role was undertaken by the Scottish Government (2008), the aim of which was ‘to create a modern clinical leadership role to enable front-line SCNs to maximise their contribution to delivering safe and effective care by developing their leadership capacity and capability’. The SCN role was reviewed following a pilot project involving five NHS health boards in Scotland that tested and refined a role framework for SCNs. The framework was designed to demonstrate the nursing and midwifery contribution to care. Investment and support for clinical leadership was strengthened following the pilot study and resulted in the launch of LBC as a policy in 2008 through which the four dimensions of the framework were established (The Scottish Government 2008). These are to: Ensure safe and effective clinical practice. Enhance the patient’s experience. Manage and develop the performance of the team. Contribute to the organisation’s objectives. The commitment to LBC has been further reinforced by The Healthcare Quality Strategy for NHS Scotland (The Scottish Government
TABLE 1 Leading Better Care: article subjects and their aligned work packages Article subject
Improving staff selection processes
Enhancing clinical leadership with band 6 staff
Implementing supervisory status for senior charge nurses
Developing healthcare support workers
Improved Developing a documentation nursing care improves patient dashboard care
Work package
Human resources recruitment and selection process
Band 6 development
Band 7 development
Support worker development
Care documentation
General ward nursing dashboard
Overview
Strengthen nursing and midwifery recruitment and selection processes within NHS Lanarkshire through values and competencybased interviewing.
Engage in and create opportunities to support band 6 development to enhance clinical leadership and support succession planning.
Plan, implement and evaluate the senior charge nurse supervisory role in the acute hospital setting.
Identify the training needs of healthcare support workers. Provide effective learning opportunities to enhance care delivery.
Develop, implement, monitor and review new care documentation and ensure existing and future documentation adheres to defined standards.
Design, implement and evaluate a general ward nursing dashboard to make data meaningful for senior charge nurses and support improvements to care delivery.
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2010b), which developed the Better Health, Better Care: Action Plan (NHS Scotland 2007). These strategic documents recognise SCNs as clinical leaders and ‘guardians of safety and quality’ in their areas of work (The Scottish Government 2008). There are also links between LBC and other national programmes and strategies, for example, the Scottish Patient Safety Programme (Healthcare Improvement Scotland 2012), the Person-Centred Health and Care Collaborative and the 2020 Workforce Vision (The Scottish Government 2013). An integral component of LBC is quality improvement in patient health, care and experience. In Scotland, SCNs have access to resources, such as Leading Better Care and Releasing Time to Care (The Scottish Government 2010a), which assist healthcare teams in addressing inefficient work practices, increase direct patient care time, improve patient experience and improve staff morale. Continuous quality improvement is demonstrated through the use of continuous quality indicators (CQIs), which are measures for improvement in nursing and midwifery care delivery (The Scottish Government 2008). SCNs and their teams contribute to improvements in important health outcomes such as healthcare-associated infection, nutrition, tissue viability, falls and patient experience. The Scottish Patient Safety Programme (2014) is encouraging the use of some components of CQIs in the reporting of process and outcome measures.
Leading Better Care: local context Ensuring that those working in leadership roles have the core skills and attributes to lead effectively can be challenging. In NHS Lanarkshire, the emphasis on supporting clinical leadership pre-dated the launch of LBC. Practitioners in the nursing, midwifery and allied health professions practice development centre had supported SCNs and their teams in enhancing clinical leadership and the patient experience, implementing quality improvement methods and ensuring patient safety through access to various leadership programmes and a team of care quality facilitators. The nursing, midwifery and allied health professions practice development centre team has integrated and supported a range of activities with SCNs to enhance understanding of LBC and the role framework. These activities include coaching to explore, plan, implement and evaluate quality improvements in care delivery. The LBC role framework for SCNs was implemented locally in 2008 using performance objectives, which helped
SCNs to demonstrate the effect of their roles in the four dimensions outlined earlier. The LBC role framework was reinforced further in Education and Development Framework for Senior Charge Nurses/Midwives and Team Leaders in All Areas of Practice (NHS Education for Scotland 2012). An online guide, the LBC Impact (2014) resource, has since been launched to replace the local SCN performance objectives.
Partnership working The development of innovative partnership approaches in academia, research and health care is supported in the literature, with increasing emphasis on integrating research, education and service delivery at organisational and system levels (Cooksey 2006, DH 2011, Walshe and Davies 2013). Policies and strategies have also recommended greater co-ordination and collaboration between higher education institutions and the NHS (DH 2006, NHS Scotland 2009). Complex workforce issues driven by economic challenges in healthcare services and academia make it imperative that working partnerships are developed and nurtured. These partnerships are particularly important in producing research evidence to support improvements in healthcare delivery. Collaborative working can help meet the challenges of changing healthcare needs and costs, increasing expectations and the quality standards that define clinical and academic excellence (Donaldson and Fralic 2000, Olsen and Neale 2005, Engelke and Marshburn 2006). In 2012, NHS Lanarkshire began to develop and expand the primary aims and objectives of LBC, in partnership with the University of the West of Scotland. Other influencing factors such as the integration of health and social care in Scotland, under the Public Bodies (Joint Working) (Scotland) Bill 2014, further supports this local direction of LBC by enhancing the professional development of SCNs, thereby preparing them for future changes. The Bill provides structure and governance to continue supporting the quality of care delivery and experience throughout the process of health and social care integration. Although supporting and developing SCNs is a priority in the NHS Lanarkshire and University of the West of Scotland collaboration, there is also a need to focus on those working with SCNs, who also have a vital role in the delivery of consistent high-quality health care. Investment in leadership and role development for SCNs and their teams will have a positive effect on nursing and midwifery students working
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Art & science leading better care series: 1 alongside effective mentors who demonstrate leadership qualities. The development of individuals and teams can support the establishment and maintenance of a positive culture for patients (The King’s Fund 2013). There is an abundance of literature focusing on healthcare leadership and leadership development demonstrating clear evidence of the value of developing individuals in leadership roles (Curtis et al 2011, Martin and Learmonth 2012). Edmonstone (2011) suggested that leadership should not be an independent phenomenon but rather an inclusive, collective and team approach. The delivery of person-centred care requires a working approach that exudes a shared culture and philosophy (Manley et al 2011, The King’s Fund 2012, 2013). The vision for LBC in NHS Lanarkshire has therefore expanded to involve a commitment to engage with all members of nursing and midwifery teams and including, where appropriate, colleagues from allied health professions or other disciplines. The purpose of this approach is to establish and support a shared understanding of quality care delivery and the responsibilities this presents for all involved. NHS Lanarkshire previously had a strong partnership with the University of the West of Scotland, and an inclusive and widespread approach to LBC offered the opportunity to enrich this partnership, making good use of clinical and academic expertise. In order to progress, a formal collaboration agreement was conceived in early 2012, resulting in the recognition of 12 key areas for development or work packages (Box 1). The overarching aim of the NHS Lanarkshire and University of the West of Scotland partnership is a shared commitment to LBC, addressing a range of areas considered essential. Expertise within the health board and university was used to develop the overall
BOX 1 Key areas for development (work packages) Human resources recruitment and selection process. Workforce integration. Line manager development. Care documentation. Research and evaluation. General ward nursing dashboard. Support worker development. Band 5 development. Band 6 development. Band 7 development. Leading Better Care communications. Programme management and administration.
aim and subsequent design, delivery and evaluation of the work packages. Collectively, the goals were to: Ensure the existence of appropriate and valuable staff development opportunities. Ensure there are effective systems and processes to support staff, and opportunities to develop the evidence base to enhance the local and national strategic direction of LBC. LBC is governed locally through a joint programme board (key representatives from both the health board and the university), whose function it is to oversee the implementation, review and evaluation of all developments while adhering to the collaboration agreement. As the LBC work packages show (Box 1), investment in development remains a priority and its importance in relation to effective clinical leadership is recognised both nationally and internationally (Royal College of Nursing 2009, Luxford et al 2011, McSherry et al 2012). Although some studies have documented the effect of leadership on patient care and patient safety, further research and inquiry is required (Cook and Lethard 2004, Wong and Cummings 2007). Empowerment, professional development and clinical leadership of healthcare staff can all affect the quality of care delivered (Curtis and O’Connell 2011). Having systems in place to support professional growth and leadership capacity is a practical approach to recruiting and preparing healthcare staff capable of advancing into leadership roles, thereby reducing disruption and supporting transition (Charan 2008). The aim is for all actions and interventions enacted through the partnership to support sustainable leadership capacity, which is essential to improving patient care and experience.
Developing the partnership The potential complexities of working in such a focused partnership were recognised by members of the health board and university. Establishing clarity, common goals, organisational objectives and structure were recognised as being integral to success. In any partnership, efforts to increase engagement between individuals belonging to partner organisations can be hindered by a difference in priorities, deeply embedded power differentials and a lack of trust and mutual understanding (Currie and Suhomlinova 2006, Mitev and Venters 2009). The NHS Lanarkshire and University of the West of Scotland joint programme board provides the infrastructure to support and govern the partnership and the
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opportunity for engagement of all partners, while working to prevent or off-set potential adverse circumstances, such as conflicting priorities, goals or values that impede progress. Management of complex partnerships between academia and healthcare systems requires effective and innovative leadership and a system-wide approach. One key learning point from a review of partnership working among public agencies was that evaluation can be a complex conceptual, methodological and practical challenge (Williams and Sullivan 2007). The importance of considering evaluation at the earliest opportunity was recognised locally and is subsequently reviewed during each joint programme board meeting. Various ‘best practice’ approaches and models of collaborations have been described to create value within a partnership, manage and support value-creating activities, address barriers and measure performance (Cleary and Walter 2008, Kirschling and Erickson 2010). It can take considerable time for all involved to come to a consensus about the common goals and develop a collective vision - the first step in any partnership. This vital step should assess the incentives and opportunities to be produced through collaboration for all interested parties. It has been suggested that restricting objectives at the outset can help to achieve a sense of greater clarity and a common purpose. However, given the professional autonomy of individuals involved in such partnerships, attempts to impose a common vision from the start may be unproductive (Martin et al 2013). The challenge is to construct a set of goals that retain organisational members’ sense of identity and, at the same time, promote cohesiveness (Bate and Robert 2002). To reach a consensus locally and establish cohesiveness, collaborative discussions took place in advance of the formal collaboration agreement in 2012. These discussions helped partners from the health board and the university to progress to a formal collaboration agreement that reflected the interests and expectations of both parties. It is encouraging that, in spite of challenges recognised in the literature, there is evidence that collaborations can and do work and produce mutually rewarding benefits for everyone, with the help of strong leadership, innovation and a sense of purpose (Gerrish 2010, Martin et al 2011). Recognition of the common goal – the delivery of safe, effective, person-centred care – continues to enhance the local LBC partnership.
Benefits of partnership working At an organisational level, creative partnerships between academic and healthcare professionals can be mutually beneficial in enhancing the profile of the respective organisations at a local and national level (Bleich and Hewlett 2004). Sharing of philosophies, paradigms, knowledge and experiences through carefully planned collaborations can promote clinical and research excellence, and contribute to innovation in quality improvement (Schouten et al 2008) and multidisciplinary approaches to patient care (Wilcock and Headrick 2000, McPherson et al 2001). Activities in a range of disciplines can help forge strong links and provide opportunities for training, mentoring, peer support, practice development, research activities, publications and improved communication between researchers and policymakers (Carey et al 2005). To achieve these goals, partnerships need to be innovative. It is important that such collaborative partnerships have a shared vision and goals, create and share resources, recognise potential opportunities and are able to take calculated risks (Engelke and Marshburn 2006, Johnson and Wilson 2006). In addition, Bleich et al (2004) suggested that ‘expanded’ forms of collaborative working can produce benefits in a variety of ventures, such as projects related to public health, improved ways of working with communities, and incorporating clinical information technology education in advanced nursing education programmes. The reason the NHS Lanarkshire and University of the West of Scotland partnership is unique is its role in the local implementation of national health policy. Innovation is evident throughout the partnership and occurs in many different ways. These include the sharing of resources by both academic and clinical practitioners working within and leading specific work packages, harnessing research expertise, and investing in academic study opportunities for clinical staff to contribute to the research agenda and enhance professional development. Taking calculated risks has at times been necessary to develop the vision for LBC. These risks, or possibilities, are perhaps most visible in the variety of work packages, particularly given that in Scotland the main focus for LBC has been SCNs and their deputies.
The next steps Nationally, LBC continues to evolve and is now supported through NHS Education for Scotland, which has been defined as a ‘Special Health
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Art & science leading better care series: 1 Board’ with a remit for education and training for those working throughout the NHS in Scotland (NHS Education for Scotland 2014). There is also a two-year evaluation underway to evaluate LBC since the policy’s introduction in all Scottish NHS boards. In NHS Lanarkshire, the next steps will be to strengthen integration and synergy with other programmes of work, as well as continuing to develop the work packages and the evidence base. This evidence will focus on evaluating components of work already in progress and engaging in additional research opportunities. The NHS Lanarkshire and University of the West of Scotland partnership will be tasked to
demonstrate and share its effect and this series of articles is part of this process. This will not only help to inform future decisions and direction but it will also ensure staff and patients are informed about the work that has taken place under the auspices of LBC. Research activities are already underway, the outcomes of which will be used to inform future education and practice development.
Conclusion The NHS Lanarkshire and University of the West of Scotland partnership has provided an
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specific programmes for developing nursing and midwifery leadership NS Acknowledgements We would like to extend thanks to our colleagues in both NHS Lanarkshire and the University of the West of Scotland who continue to support LBC with creativity and tremendous enthusiasm. Nursing Standard would like to thank Dr Kathleen Duffy, NHS Education for Scotland nursing and midwifery practice educator, Practice Development Centre, NHS Lanarkshire, for developing and co-ordinating the Leading Better Care series of articles.
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Developing leadership roles in nursing and midwifery McGuire C, Ray D (2014) Developing leadership roles in nursing and midwifery. Nursing Standard. 29, 9, 43-49. Date of submission: March 31 2014; date of acceptance: June 6 2014.
Abstract This article is the first in a series of seven articles on an initiative undertaken in NHS Lanarkshire where a creative partnership with the University of the West of Scotland established a shared commitment to developing nursing and midwifery leadership. This article describes the national context within Scotland. It provides an overview of the innovative programmes of work and systems devised to support leadership throughout the organisation with a particular focus on quality of care.
Authors Clare McGuire Programme manager, Leading Better Care, University of the West of Scotland, Hamilton, Lanarkshire. Devashish Ray Research assistant, Leading Better Care, University of the West of Scotland, Hamilton, Lanarkshire. Correspondence to: [email protected]
Keywords Clinical leadership, Leading Better Care, midwifery, nursing leadership, quality improvement, role development, senior charge nurse
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
EFFECTIVE CLINICAL LEADERSHIP is central to meeting the ever-changing demand for the delivery of high-quality health care (Douglas 2011, Francis 2013, The King’s Fund 2013). Local and national policies and strategies across the UK have acknowledged the importance of supporting nursing and midwifery leadership roles to respond effectively to changing demands and expectations (The Scottish Government 2008, 2010a, Department of Health (DH) 2013). In Scotland, the initiative to support the development of clinical leadership in nursing and midwifery is called Leading Better Care (LBC) (The Scottish Government 2008). This article describes the collaborative approach to LBC undertaken in one Scottish health board, NHS Lanarkshire. In this article, the term ‘senior charge nurse’ (SCN) is used to refer to senior charge nurses, senior charge midwives and team leaders. The term ‘patient’ is used generically to include clients and service users.
Leading Better Care series This series of articles aims to offer an insight into various areas of development during the implementation of the LBC initiative in NHS Lanarkshire. Recognising the importance of selecting the ‘best’ person for each role within nursing, midwifery and allied health professions resulted in the development of a framework of values and competency-based recruitment and selection, which will be discussed in the second article in the series. This article describes ongoing priorities for staff development, while two future articles will explore in more detail the development of band 6 nurses, midwives and allied health professionals, and healthcare support workers. Ensuring there are effective systems and processes to support SCNs and their teams has led to improvements in clinical documentation and advancements in an information technology (IT) system, which will be explored in the last two articles in the series. Developments in NHS Lanarkshire through the LBC programme resulted in
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Art & science leading better care series: 1 12 key areas or work packages. An overview of the forthcoming articles and the links between the article subjects and aligned work packages is outlined in Table 1. The aim of the series is to demonstrate a progressive and systematic journey from value and competency-based recruitment and selection through to role development. The articles provide accounts of improvements to the systems and processes that support SCNs and their teams to deliver safe, effective and person-centred care. The series demonstrates the uniqueness and creativity of a partnership approach to LBC which is committed to improving the quality of care and experience for patients. The delivery of an agreed programme of work capitalised on the expertise of the partners and a desire to contribute to the evidence base in a range of activities. These elements were designed to help SCNs promote quality improvements in their areas of responsibility.
Leading Better Care: national context In Scotland, nursing and midwifery leadership in health care has been a strategic priority for several years (Scottish Executive 2006, NHS Scotland 2007, The Scottish Government 2008, 2010a). The publication of the Mid Staffordshire NHS Foundation Trust public inquiry report emphasised
the need to maintain such a focus by stating that ‘effective leadership is essential to a flourishing NHS’ (Francis 2013). In 2007, a review of the SCN role was undertaken by the Scottish Government (2008), the aim of which was ‘to create a modern clinical leadership role to enable front-line SCNs to maximise their contribution to delivering safe and effective care by developing their leadership capacity and capability’. The SCN role was reviewed following a pilot project involving five NHS health boards in Scotland that tested and refined a role framework for SCNs. The framework was designed to demonstrate the nursing and midwifery contribution to care. Investment and support for clinical leadership was strengthened following the pilot study and resulted in the launch of LBC as a policy in 2008 through which the four dimensions of the framework were established (The Scottish Government 2008). These are to: Ensure safe and effective clinical practice. Enhance the patient’s experience. Manage and develop the performance of the team. Contribute to the organisation’s objectives. The commitment to LBC has been further reinforced by The Healthcare Quality Strategy for NHS Scotland (The Scottish Government
TABLE 1 Leading Better Care: article subjects and their aligned work packages Article subject
Improving staff selection processes
Enhancing clinical leadership with band 6 staff
Implementing supervisory status for senior charge nurses
Developing healthcare support workers
Improved Developing a documentation nursing care improves patient dashboard care
Work package
Human resources recruitment and selection process
Band 6 development
Band 7 development
Support worker development
Care documentation
General ward nursing dashboard
Overview
Strengthen nursing and midwifery recruitment and selection processes within NHS Lanarkshire through values and competencybased interviewing.
Engage in and create opportunities to support band 6 development to enhance clinical leadership and support succession planning.
Plan, implement and evaluate the senior charge nurse supervisory role in the acute hospital setting.
Identify the training needs of healthcare support workers. Provide effective learning opportunities to enhance care delivery.
Develop, implement, monitor and review new care documentation and ensure existing and future documentation adheres to defined standards.
Design, implement and evaluate a general ward nursing dashboard to make data meaningful for senior charge nurses and support improvements to care delivery.
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2010b), which developed the Better Health, Better Care: Action Plan (NHS Scotland 2007). These strategic documents recognise SCNs as clinical leaders and ‘guardians of safety and quality’ in their areas of work (The Scottish Government 2008). There are also links between LBC and other national programmes and strategies, for example, the Scottish Patient Safety Programme (Healthcare Improvement Scotland 2012), the Person-Centred Health and Care Collaborative and the 2020 Workforce Vision (The Scottish Government 2013). An integral component of LBC is quality improvement in patient health, care and experience. In Scotland, SCNs have access to resources, such as Leading Better Care and Releasing Time to Care (The Scottish Government 2010a), which assist healthcare teams in addressing inefficient work practices, increase direct patient care time, improve patient experience and improve staff morale. Continuous quality improvement is demonstrated through the use of continuous quality indicators (CQIs), which are measures for improvement in nursing and midwifery care delivery (The Scottish Government 2008). SCNs and their teams contribute to improvements in important health outcomes such as healthcare-associated infection, nutrition, tissue viability, falls and patient experience. The Scottish Patient Safety Programme (2014) is encouraging the use of some components of CQIs in the reporting of process and outcome measures.
Leading Better Care: local context Ensuring that those working in leadership roles have the core skills and attributes to lead effectively can be challenging. In NHS Lanarkshire, the emphasis on supporting clinical leadership pre-dated the launch of LBC. Practitioners in the nursing, midwifery and allied health professions practice development centre had supported SCNs and their teams in enhancing clinical leadership and the patient experience, implementing quality improvement methods and ensuring patient safety through access to various leadership programmes and a team of care quality facilitators. The nursing, midwifery and allied health professions practice development centre team has integrated and supported a range of activities with SCNs to enhance understanding of LBC and the role framework. These activities include coaching to explore, plan, implement and evaluate quality improvements in care delivery. The LBC role framework for SCNs was implemented locally in 2008 using performance objectives, which helped
SCNs to demonstrate the effect of their roles in the four dimensions outlined earlier. The LBC role framework was reinforced further in Education and Development Framework for Senior Charge Nurses/Midwives and Team Leaders in All Areas of Practice (NHS Education for Scotland 2012). An online guide, the LBC Impact (2014) resource, has since been launched to replace the local SCN performance objectives.
Partnership working The development of innovative partnership approaches in academia, research and health care is supported in the literature, with increasing emphasis on integrating research, education and service delivery at organisational and system levels (Cooksey 2006, DH 2011, Walshe and Davies 2013). Policies and strategies have also recommended greater co-ordination and collaboration between higher education institutions and the NHS (DH 2006, NHS Scotland 2009). Complex workforce issues driven by economic challenges in healthcare services and academia make it imperative that working partnerships are developed and nurtured. These partnerships are particularly important in producing research evidence to support improvements in healthcare delivery. Collaborative working can help meet the challenges of changing healthcare needs and costs, increasing expectations and the quality standards that define clinical and academic excellence (Donaldson and Fralic 2000, Olsen and Neale 2005, Engelke and Marshburn 2006). In 2012, NHS Lanarkshire began to develop and expand the primary aims and objectives of LBC, in partnership with the University of the West of Scotland. Other influencing factors such as the integration of health and social care in Scotland, under the Public Bodies (Joint Working) (Scotland) Bill 2014, further supports this local direction of LBC by enhancing the professional development of SCNs, thereby preparing them for future changes. The Bill provides structure and governance to continue supporting the quality of care delivery and experience throughout the process of health and social care integration. Although supporting and developing SCNs is a priority in the NHS Lanarkshire and University of the West of Scotland collaboration, there is also a need to focus on those working with SCNs, who also have a vital role in the delivery of consistent high-quality health care. Investment in leadership and role development for SCNs and their teams will have a positive effect on nursing and midwifery students working
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Art & science leading better care series: 1 alongside effective mentors who demonstrate leadership qualities. The development of individuals and teams can support the establishment and maintenance of a positive culture for patients (The King’s Fund 2013). There is an abundance of literature focusing on healthcare leadership and leadership development demonstrating clear evidence of the value of developing individuals in leadership roles (Curtis et al 2011, Martin and Learmonth 2012). Edmonstone (2011) suggested that leadership should not be an independent phenomenon but rather an inclusive, collective and team approach. The delivery of person-centred care requires a working approach that exudes a shared culture and philosophy (Manley et al 2011, The King’s Fund 2012, 2013). The vision for LBC in NHS Lanarkshire has therefore expanded to involve a commitment to engage with all members of nursing and midwifery teams and including, where appropriate, colleagues from allied health professions or other disciplines. The purpose of this approach is to establish and support a shared understanding of quality care delivery and the responsibilities this presents for all involved. NHS Lanarkshire previously had a strong partnership with the University of the West of Scotland, and an inclusive and widespread approach to LBC offered the opportunity to enrich this partnership, making good use of clinical and academic expertise. In order to progress, a formal collaboration agreement was conceived in early 2012, resulting in the recognition of 12 key areas for development or work packages (Box 1). The overarching aim of the NHS Lanarkshire and University of the West of Scotland partnership is a shared commitment to LBC, addressing a range of areas considered essential. Expertise within the health board and university was used to develop the overall
BOX 1 Key areas for development (work packages) Human resources recruitment and selection process. Workforce integration. Line manager development. Care documentation. Research and evaluation. General ward nursing dashboard. Support worker development. Band 5 development. Band 6 development. Band 7 development. Leading Better Care communications. Programme management and administration.
aim and subsequent design, delivery and evaluation of the work packages. Collectively, the goals were to: Ensure the existence of appropriate and valuable staff development opportunities. Ensure there are effective systems and processes to support staff, and opportunities to develop the evidence base to enhance the local and national strategic direction of LBC. LBC is governed locally through a joint programme board (key representatives from both the health board and the university), whose function it is to oversee the implementation, review and evaluation of all developments while adhering to the collaboration agreement. As the LBC work packages show (Box 1), investment in development remains a priority and its importance in relation to effective clinical leadership is recognised both nationally and internationally (Royal College of Nursing 2009, Luxford et al 2011, McSherry et al 2012). Although some studies have documented the effect of leadership on patient care and patient safety, further research and inquiry is required (Cook and Lethard 2004, Wong and Cummings 2007). Empowerment, professional development and clinical leadership of healthcare staff can all affect the quality of care delivered (Curtis and O’Connell 2011). Having systems in place to support professional growth and leadership capacity is a practical approach to recruiting and preparing healthcare staff capable of advancing into leadership roles, thereby reducing disruption and supporting transition (Charan 2008). The aim is for all actions and interventions enacted through the partnership to support sustainable leadership capacity, which is essential to improving patient care and experience.
Developing the partnership The potential complexities of working in such a focused partnership were recognised by members of the health board and university. Establishing clarity, common goals, organisational objectives and structure were recognised as being integral to success. In any partnership, efforts to increase engagement between individuals belonging to partner organisations can be hindered by a difference in priorities, deeply embedded power differentials and a lack of trust and mutual understanding (Currie and Suhomlinova 2006, Mitev and Venters 2009). The NHS Lanarkshire and University of the West of Scotland joint programme board provides the infrastructure to support and govern the partnership and the
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opportunity for engagement of all partners, while working to prevent or off-set potential adverse circumstances, such as conflicting priorities, goals or values that impede progress. Management of complex partnerships between academia and healthcare systems requires effective and innovative leadership and a system-wide approach. One key learning point from a review of partnership working among public agencies was that evaluation can be a complex conceptual, methodological and practical challenge (Williams and Sullivan 2007). The importance of considering evaluation at the earliest opportunity was recognised locally and is subsequently reviewed during each joint programme board meeting. Various ‘best practice’ approaches and models of collaborations have been described to create value within a partnership, manage and support value-creating activities, address barriers and measure performance (Cleary and Walter 2008, Kirschling and Erickson 2010). It can take considerable time for all involved to come to a consensus about the common goals and develop a collective vision - the first step in any partnership. This vital step should assess the incentives and opportunities to be produced through collaboration for all interested parties. It has been suggested that restricting objectives at the outset can help to achieve a sense of greater clarity and a common purpose. However, given the professional autonomy of individuals involved in such partnerships, attempts to impose a common vision from the start may be unproductive (Martin et al 2013). The challenge is to construct a set of goals that retain organisational members’ sense of identity and, at the same time, promote cohesiveness (Bate and Robert 2002). To reach a consensus locally and establish cohesiveness, collaborative discussions took place in advance of the formal collaboration agreement in 2012. These discussions helped partners from the health board and the university to progress to a formal collaboration agreement that reflected the interests and expectations of both parties. It is encouraging that, in spite of challenges recognised in the literature, there is evidence that collaborations can and do work and produce mutually rewarding benefits for everyone, with the help of strong leadership, innovation and a sense of purpose (Gerrish 2010, Martin et al 2011). Recognition of the common goal – the delivery of safe, effective, person-centred care – continues to enhance the local LBC partnership.
Benefits of partnership working At an organisational level, creative partnerships between academic and healthcare professionals can be mutually beneficial in enhancing the profile of the respective organisations at a local and national level (Bleich and Hewlett 2004). Sharing of philosophies, paradigms, knowledge and experiences through carefully planned collaborations can promote clinical and research excellence, and contribute to innovation in quality improvement (Schouten et al 2008) and multidisciplinary approaches to patient care (Wilcock and Headrick 2000, McPherson et al 2001). Activities in a range of disciplines can help forge strong links and provide opportunities for training, mentoring, peer support, practice development, research activities, publications and improved communication between researchers and policymakers (Carey et al 2005). To achieve these goals, partnerships need to be innovative. It is important that such collaborative partnerships have a shared vision and goals, create and share resources, recognise potential opportunities and are able to take calculated risks (Engelke and Marshburn 2006, Johnson and Wilson 2006). In addition, Bleich et al (2004) suggested that ‘expanded’ forms of collaborative working can produce benefits in a variety of ventures, such as projects related to public health, improved ways of working with communities, and incorporating clinical information technology education in advanced nursing education programmes. The reason the NHS Lanarkshire and University of the West of Scotland partnership is unique is its role in the local implementation of national health policy. Innovation is evident throughout the partnership and occurs in many different ways. These include the sharing of resources by both academic and clinical practitioners working within and leading specific work packages, harnessing research expertise, and investing in academic study opportunities for clinical staff to contribute to the research agenda and enhance professional development. Taking calculated risks has at times been necessary to develop the vision for LBC. These risks, or possibilities, are perhaps most visible in the variety of work packages, particularly given that in Scotland the main focus for LBC has been SCNs and their deputies.
The next steps Nationally, LBC continues to evolve and is now supported through NHS Education for Scotland, which has been defined as a ‘Special Health
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Art & science leading better care series: 1 Board’ with a remit for education and training for those working throughout the NHS in Scotland (NHS Education for Scotland 2014). There is also a two-year evaluation underway to evaluate LBC since the policy’s introduction in all Scottish NHS boards. In NHS Lanarkshire, the next steps will be to strengthen integration and synergy with other programmes of work, as well as continuing to develop the work packages and the evidence base. This evidence will focus on evaluating components of work already in progress and engaging in additional research opportunities. The NHS Lanarkshire and University of the West of Scotland partnership will be tasked to
demonstrate and share its effect and this series of articles is part of this process. This will not only help to inform future decisions and direction but it will also ensure staff and patients are informed about the work that has taken place under the auspices of LBC. Research activities are already underway, the outcomes of which will be used to inform future education and practice development.
Conclusion The NHS Lanarkshire and University of the West of Scotland partnership has provided an
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