VOL: 97, ISSUE: 36, PAGE NO: 42
Tracey Williamson, MSc, RGN, FAETC, is a research fellow
Steve Taylor, BSc, RGN, RMN, DN, is a senior practice development nurse; andSarah Petts, MSc, is a research assistant, all at Rochdale Healthcare NHS TrustThe need to develop clinical leaders has been highlighted in many recent UK health care reforms (Department of Health, 1997; 1998; 2000). Leadership experts recommend that organisations rethink top-down, command-and-control approaches (Covey, 1990; Senge, 1994) and redesign themselves using the principles of cooperation, empowerment and leadership (Garratt, 1994).
The need to develop clinical leaders has been highlighted in many recent UK health care reforms (Department of Health, 1997; 1998; 2000). Leadership experts recommend that organisations rethink top-down, command-and-control approaches (Covey, 1990; Senge, 1994) and redesign themselves using the principles of cooperation, empowerment and leadership (Garratt, 1994).
In 1988, Rochdale Healthcare NHS Trust developed an organisational framework that was underpinned by the principles of leadership and empowerment and modelled on the concept of shared governance.
While difficult to define, shared governance is essentially based on a philosophy that moves away from traditional hierarchies and adopts a decentralised approach. Control, influence, power and authority are redistributed to the workers (Porter-O'Grady et al, 1997). This redistribution allows workers to exert an influence over decisions that affect their practice.
The success of this type of framework depends on a workforce that is able to demonstrate effective leadership skills, knowledge and attitudes. To meet this need the trust decided to invest in the Leading an Empowered Organisation (LEO) programme - a three-day leadership project licensed by Creative Healthcare Management.
Three senior nurses were trained at Creative Healthcare Management's headquarters in Minneapolis, USA, to deliver the LEO programme to staff. These nurses were selected after interviews that focused on their ability to present, facilitate, be creative and understand leadership theory, as well as their motivation and enthusiasm to become trainers.
Invitations to attend LEO courses were offered to all clinical professionals across the trust. The course runs for three full days and is conducted off site to minimise interruptions from the workplace. The programme is designed as an interactive, fun yet challenging experience.
The participants focus on exploring and developing their leadership skills with relevance to the NHS. Action plans are developed throughout the course for individuals and their teams. Each course is run with a maximum of 25 delegates from a variety of professional backgrounds.
A creative marketing exercise highlighted the anticipated benefits of LEO for individuals and the organisation as a whole. This approach has been successful and the enthusiasm displayed by participants has encouraged other staff to enrol on subsequent courses. The trust intends to continue delivering the LEO course until all staff who wish to attend have done so.
Over the past three years more than 650 members of staff have taken part in the LEO programme, so the trust felt that it was important to evaluate the course's impact by carrying out a survey of staff across the trust. The findings are particularly pertinent now that the LEO programme is being rolled out nationally as part of the NHS strategy to develop leadership skills.
Assessing the training
The study formed part of a wider evaluation of shared governance in an integrated hospital and community trust funded by an NHS research training fellowship. A postal questionnaire was used to identify staff knowledge of and views on shared governance.
Questionnaires were sent to all nurses, midwives, health visitors, staff-grade and consultant doctors, as well as clinical professional services in the trust. The aim was to reinforce the philosophy of shared governance, namely that everyone's views and contributions are valued. The initial response was poor so steps were taken to follow up non-respondents. The final response rate was 34%.
The respondents were asked to indicate how shared governance had affected them, their departments and the trust at large. Computer analysis using the Statistical Package for Social Sciences (SPSS) compared the responses of staff who had undergone LEO training with those who had not. For the purposes of the survey, staff who had participated in LEO were identified as 'LEO staff,' and those who had yet to participate were 'non-LEO staff'.
A number of positive effects described by LEO staff and non-LEO staff were compared. The following differences between the two groups were found to be highly statistically significant (p<0.01):>0.01):>
- Shared governance was perceived to have had some effect on the trust at large by 54% of LEO staff and 21% of non-LEO staff. The effects described included empowerment, involvement in trust decisions and influencing change;
- A substantial proportion of LEO staff (44%) thought that shared governance had an effect at a departmental level, compared with 12% of non-LEO staff. The outcomes included improvements in practice, better communication and a sense of teamwork;
- The effects of shared governance on respondents as individuals were identified by 40% of LEO staff and 15% of non-LEO staff. Examples of these included changes in individual practice, 'having a say' and personal development;
- Shared governance was believed to have had a positive effect on the retention of personnel within the trust by 15% of LEO staff and 4% of non-LEO staff;
- A minority of all respondents (2-4%) perceived negative effects to have occurred at a trust, departmental or personal level. Examples included pressures on their time, more papers to read and frustration.
About 91% of LEO staff and 73% of non-LEO staff showed some degree of knowledge on shared governance, although the difference was not statistically significant.
When planning the introduction of shared governance, the trust accepted that any positive impact might be minimal for the first three to five years. Yet staff reported a number of positive effects after only 18 months. Strong differences in opinion were found between LEO staff and non-LEO staff, suggesting the LEO course had a positive impact on employees.
In general, the perceived effects of shared governance were more apparent at an organisational, as opposed to an individual, level. This may be an indication that respondents were more able to detect changes in those around them than in themselves. LEO staff may be more sensitive to the developing leadership culture within the trust, but feel less able to make a difference on an individual basis.
The positive effect of the LEO course on staff retention may also indicate the value that staff attach to being employed in an empowering organisation. The negative effects of shared governance were also noted but were minimal.
Strong differences in morale and motivation levels were found between the groups. This may indicate the ability of the LEO programme to innovate and inspire.
A key principle of shared governance is the development of staff's decision-making abilities, which is also a key element in the LEO programme. Compared with non-LEO staff, LEO staff felt particularly engaged in decision-making at all levels.
LEO staff and non-LEO staff also had different views on interprofessional working within the trust and personal responsibility for professional updating.
Staff knowledge of shared governance has been promoted in the trust in a variety of ways, including roadshows, presentations, newsletters, information bulletins, word of mouth and an increased body of literature on shared governance.
Our results suggest that the steps taken to raise awareness of shared governance are working similarly for both LEO staff and non-LEO staff. Efforts to promote an understanding of shared governance will be maintained while the trust seeks new ways to share information, such as through the hospital intranet that is currently being developed.
The results of the survey give a clear indication that the LEO course has had a positive impact on the staff's opinion of shared governance. However, there is a need for further evaluation of the LEO initiative in the long term.
Our findings are encouraging and confirm that the LEO programme underpins shared governance within the trust. As the national roll-out of LEO gathers pace, these findings support the programme as a means of developing clinical leaders across the NHS.