Shared governance: giving staff more power over patient care
Collective leadership is gaining traction in the NHS, says King's Fund expert
Collective leadership is gaining traction in the NHS, says King's Fund expert
- Nursing directors urged to consider shared governance to empower staff and improve care
- Younger nurses feel less stifled by policies and procedures
- Different ways of working are giving staff confidence and helping nurse retention
A handful of chief nurses in the Midlands are driving major changes across their nursing workforces by empowering staff to make decisions about patient care.
Bringing about culture change is no mean feat in any hospital, not least in an inner-city trust with 5,500 nurses, nearly 1 million outpatient appointments a year and 2,000 inpatient beds.
However, this is what staff at Nottingham University Hospitals NHS Trust are doing.
As a result, its nurse retention data are now the best of all teaching hospitals in England, according to its chief nurse. Nurses want to work at the trust and they want to stay there.
The culture change forms part of an ambitious vision to work in a new way, free from the hierarchy and tyranny of the more unyielding, traditional corners of the NHS.
The trust’s chief nurse, Mandie Sunderland, says staff are empowered to make decisions about patient care and staff well-being and then to implement them.
This style of working, which is starting to gain traction in some NHS organisations, is known as shared governance.
Autonomy stifled by the NHS
Professor Sunderland believes change is needed because bright nursing students are being trained to graduate, being put on a professional register and being told they are accountable for their own decision-making but then are placed in a hospital where this is ‘all taken away again’ by drowning them in policies and procedures.
of staff do not agree they can make suggestions to improve the work of their team or department
(NHS Staff Survey 2018)
‘All that autonomous professionalism they were trained for tends to get stifled in the NHS,’ she says. ‘Shared governance is about that process: deciding what you want to change then getting on and doing it.
‘It sounds like chaos but it isn’t. Registered nurses are sensible, highly intelligent people with good common sense.’
Freedom to act
The trust has more than 80 staff councils, each of which may represent a ward or a care theme and is chaired by one person, perhaps a healthcare assistant. These councils meet to discuss and decide solutions to problems and have the autonomy to act and solve them.
‘It is now part of the way we do business,’ Professor Sunderland says. ‘It is about pushing decision-making on those irritating things for staff onto the front line, to be able to solve some of those things for themselves and to give them permission to do so.
‘The whole point of shared governance is about bringing back joy at work’
Mandie Sunderland, chief nurse at Nottingham University Hospitals NHS Trust
‘It’s a very different way of working – real culture change – and senior managers have to be able to step away.’
Talking through barriers
A monthly leadership council, chaired by Professor Sunderland, offers the numerous council chairs an opportunity to meet and talk through barriers they may have encountered in their efforts to support good practice.
‘Some of the things we have been looking at around culture change are about what would make the trust an even better place to work,’ says Professor Sunderland.
‘The whole point of shared governance is about bringing back joy at work. It empowers people, gives them confidence and exposes them to different ways of working.’
Parking problem and solution
Changes devised by staff councils and brought about at the trust include overturning a rule that retiring staff had to give back their parking permits. This had meant that staff who wanted to come back to part-time work had nowhere to park, and it was putting off nurses returning.
‘It sounds simple,' says Professor Sunderland, 'but it was important to people. We are an inner-city hospital and we couldn’t park for love nor money.
‘That idea came from the councils and it means we may have saved up to 30 nurses who wouldn’t have come back to work otherwise. It is about being valued.’
Better use of time
Another change has improved patient care and made better use of nurses’ time.
As a regional cardiac centre, patients come to Nottingham City Hospital for major heart surgery. Previously, these patients needed a nurse escort to take them to the other side of the city, to the Queen’s Medical Centre, to be X-rayed in the dental unit before they could have their operation.
of staff do not agree they are involved in deciding on changes that affect their work area, team or department
(NHS Staff Survey 2018)
This process could take a whole day, depending on ambulance availability.
‘Nurses decided this was a waste of time as it took a nurse off the ward for a day,’ says Professor Sunderland. ‘So they talked to the dental department. Now we have a dental X-ray machine at City Hospital. Patients can be walked down there to have X-rays.’
Take a risk to change things
She acknowledges that senior managers may have reservations about this style of working.
‘It is actually quite threatening. The organisational, historical, management hierarchy can feel threatened by these meetings and councils coming up with ideas.
‘You just have to be aware that if something goes wrong you are going to have to justify why you made that decision, but if you don’t take risks sometimes nothing ever happens.
‘The NHS, with its tick-box rules and regulations, has just stifled that kind of involvement.’
Centre of excellence
Part of the reason for the trust working in this way is that senior staff are hoping that this autumn it will become the first hospital trust in the UK to earn international accreditation as a centre of international excellence for nursing through the Magnet Recognition Program.
The US programme, run by the American Nurses Association, recognises excellence in nursing.
Professor Sunderland says: ‘There are 300 hospitals in the US that are Magnet hospitals and they have the best recruitment and retention rates of registered nurses in the US.
‘You see a difference. You see your staff feeling valued’
Sheran Oke, director of nursing, midwifery and patient services at Northampton General Hospital NHS Trust
‘Part of being a great place to work is having an empowered workforce. Our retention data show we have the best registered nurse retention of all the teaching hospitals in England. We stepped up on the Magnet journey.’
Value, retain and attract employees
Staff at the Northampton General Hospital NHS Trust are on a similar journey to value, retain and attract employees and to improve patient care. It is the first UK trust to be accredited for the Pathway to Excellence programme, another internationally recognised scheme for nursing and midwifery standards, also run by the American Nurses Association.
One of the six standards that the programme requires organisations to meet concerns shared decision-making.
Northampton’s director of nursing, midwifery and patient services Sheran Oke recently visited Florida to receive the Pathway to Excellence accreditation award.
Brave and committed
Ms Oke says: ‘We were the only delegation there from the UK and are proud to be the first NHS trust to receive the award.
of staff think they meet too rarely to discuss their team’s effectiveness
(NHS Staff Survey 2018)
‘You have to be brave and committed to do something like this, but the hard work pays off and you see a difference. You see your staff feeling valued.
‘This is about giving them time to reflect, to help encourage them to remain working in your organisation and to attract people to you.’
Like at Nottingham, there are shared decision-making councils at the Northampton trust, 24 in total, that work collaboratively on topics they choose, and a leadership council that meets quarterly.
Northampton’s associate director of nursing Debbie Shanahan says some of the councils survey patients on what they regard as good or bad about a ward.
‘The paediatric ward recently found that kids didn’t want orange juice; they wanted apple juice, and that change was implemented quickly,’ Ms Shanahan explains.
‘Staff come up with a lot of the ideas and these come from shared decision-making councils.
Board’s support crucial
'They might come and ask for advice or guidance, but they are usually empowered to make decisions for themselves.’
Ms Oke says the support of the trust’s board has been crucial. ‘We have a chief executive who has been so supportive of the journey we have been on, as has the whole of the executive team.’
‘We need mindsets in which people can be empowered in their teams to make decisions, to spot improvements and to crack on with them’
Jo Vigor, King’s Fund leadership and organisational development assistant director
Northampton is aiming to hold an event towards the end of the year so that other interested organisations can find out more about the Pathway to Excellence award and shared decision-making.
More widely, the idea of ‘collective leadership’ is gaining traction in the health service, according to the King’s Fund. The charity’s leadership and organisational development assistant director Jo Vigor says the NHS has long been associated with hierarchical working, but academic research has shown that bringing multidisciplinary professionals together, across pay bands, needs a different type of leadership to ensure better patient safety and reduced errors.
‘People are often frightened to speak up if they see a safety issue because of the hierarchical structure,’ says Ms Vigor.
‘We have been training our leaders to be the person everyone turns to, but in a team setting we can’t rely on that leader to make decisions for us.
‘We need mindsets in which people can be empowered in their teams to make decisions, to spot improvements and to crack on with them.’
‘Reduced errors and harm’
Patient safety is paramount in the health service, says Ms Vigor. ‘There is worry about the collective decision-making process. But the flipside is research showing that, when working in this way, there are reduced errors and harm, so a number of organisations are starting to look at how they can change their culture.’
Ms Vigor says NHS England and NHS Improvement have been working with the King’s Fund to develop tools to help trusts adopt collective leadership, and about 80 trusts in England are starting to ‘use and embrace’ these concepts.
She says care providers across the UK and in the Republic of Ireland are looking at collective leadership as well. ‘There is a move towards this work as five nations,’ she says. ‘We are part of an ongoing conversation to progress some of the thinking in this area.’
The shared governance model in action
George Eliot Hospital NHS Trust has a small district general hospital in Warwickshire that employs about 700 nursing and midwifery staff as well as 100 allied health professionals (AHPs).
Last year the trust set up two shared decision-making councils. There are four more at various stages of implementation, plus a monthly leadership council.
The trust’s executive director of nursing Daljit Athwal was formerly deputy chief nurse at Nottingham University Hospitals and experienced the benefits of the shared governance model there.
Ms Athwal says: ‘I would encourage any director of nursing to consider this as an approach to empowering staff and embedding quality improvement where it matters, at the point of patient care.’
Ms Athwal's tips for the shared governance model are:
- This is not a project – it will take time to evolve, so see it as an organic process
- Let your nurses, midwives and AHPs own it and lead it, as it needs to be driven from the front line
- Send staff to visit other councils and let staff see and feel what devolved decision-making means and its results
- Work with and prepare your ward managers and matrons, as councils are usually led by junior staff such as band 5s and healthcare assistants
- Work with and prepare your board, as this is a culture change
- Sometimes councils will make decisions you may not completely agree with, but as long as it’s safe, let them learn for themselves
- Be prepared to let go, as how you lead will need to change too – you will be coaching, facilitating and supporting
- Once your first few councils are up and running invest in a facilitator post to support developing a framework for the model and to ensure there is consistency in how councils emerge
The trust’s councils have implemented a range of initiatives to improve staff and patient experience.
These include ‘proposed change’ cards, an appreciation box for staff, a comfort space for relatives, and red walking frames for patients with visual impairment or suspected or diagnosed dementia.
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Stephanie Jones-Berry is a health journalist