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Facilitating collaboration using a clinical teams programme.

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VOL: 102, ISSUE: 05, PAGE NO: 32

Ellen Goodall, BA, RN, SCMDN, is Macmillan clinical nurse specialist and team leader

Libby Lowry, RN, CNT, HV, is health visitor; Carole Jones, RN, DN, CPT, is district nursing sister; all at Reading Primary Care Trust

In 2003 Reading Primary Care Trust was awarded a zero star rating. While this was a great disappointment for the organisation, it resulted in additional support being made available to improve performance. One of the initiatives on offer was the Clinical Teams Programme (CTP).

In 2003 Reading Primary Care Trust was awarded a zero star rating. While this was a great disappointment for the organisation, it resulted in additional support being made available to improve performance. One of the initiatives on offer was the Clinical Teams Programme (CTP).

Clinical Teams Programme
The CTP is based on the RCN Clinical Leadership Programme (RCN, 2006) and aims to develop clinical leadership. The NHS Modernisation Agency, working in close partnership with strategic health authorities, has used the RCN clinical leadership programme to support organisations in improving their performance at the frontline (Cunningham and Kitson, 2000).

Reading PCT applied to participate in the CTP and nominated five teams at various stages of development to take part.

The priorities of the NHS Modernisation Agency were that organisations should be able to:

- See things through the patients' eyes;

- Find better ways of doing things;

- Look at the whole picture;

- Give frontline staff the time and tools to tackle problems;

- Take small steps as well as big leaps.

The programme contributed to those objectives by enabling health and social care teams to:

- Enhance their practice;

- Improve service delivery;

- Contribute to strategic objectives;

- Contribute to the personal and professional development of staff;

- Improve partnership working.

The PCT believed the programme would help develop clinical leaders who would facilitate collaboration between teams by recognising areas of good practice and those requiring development. It would also improve care for service users by developing effective teams.

Reading PCT is divided into five networks, with each taking a local perspective on how to meet the health needs of its population. This gives nurses the opportunity to engage in local health care. Teams were chosen for different reasons:

- Team 1, the Caversham network, is made up of four individual GP practices supported by health visitors, district nurses, practice nurses and administrative staff. The network was chosen to participate in the programme as it was perceived that each practice was working independently and it would promote improved interpractice working;

- Team 2, the intermediate care service, consisting of two units on different sites, was undergoing change with the units merging on one new site at the newly built Prospect Park Hospital. It was envisaged that the teams would be experiencing a period of flux and anxiety and would benefit from improved teamworking to facilitate adjustment;

- Team 3, school nurses in the west of Berkshire, were chosen as they were in the middle of major changes within their service;

- Team 4, the paediatric occupational therapists, asked for help with clinical leadership as they were a relatively new developing team;

- Team 5, the west of Berkshire community Macmillan clinical nurse specialists, were selected as they were preparing to commence weekend and bank holiday working. This meant changes in their working pattern, and the programme was seen as a proactive approach to developing the transition.

However, even before the programme began, the school nurses and occupational therapists declined to participate as they perceived the commitment to be too great. The intermediate teams also withdrew at the initial phase as they felt it was not appropriate for them at their stage in transition.

The process
The first step in commencing the CTP was to identify a representative from each team who was committed to the programme and would undertake all aspects of it (Fig 1). The role of these representatives was to take ideas, thinking and actions back to their teams as well as extending their own personal networks. The role of the other team members was to engage in a range of activities designed to influence teamworking.

It was felt that the sharing of ideas, knowledge and insights would make a real difference to service provision. However, this was a new approach to developing leadership, which meant the work and commitment involved was much greater than anybody involved in the programme had anticipated, including the team facilitator and the PCT.

While they were participating in the programme there was no reduction in the representatives' caseload, nor was backfill money made available, and consequently they had to evaluate their workload to accommodate this. They also used a great deal of their own time.

The programme lasted for 10 months and was supported by a team facilitator from the RCN. The workshops covered a range of subjects, including looking at how to improve patient care by undertaking observations both in clinical areas and patients' homes, as well as examining role clarification, working with conflict, team meetings and the quality of care.

Challenges
At the onset of the programme the teams were unclear about its purpose or benefits. This made it difficult for the representatives to engage and motivate their colleagues. In addition, the facilitator was unclear about the complexities of the structures within Reading PCT and within participating teams, which led to frustrations on both sides.

The predetermined time frame, which was not negotiable, at times appeared unrealistic and overwhelming, and this occasionally caused the team representatives anxiety because of our other work commitments.

Benefits
Participating in the CTP had a range of benefits for the teams:

- It enabled each team to identify existing problems within its practice and, through working together and sharing ideas, helped them to find solutions to improve their service;

- It gave team members time out to evaluate their practices critically and to develop action plans to improve them;

- By requiring them to work collaboratively the programme helped them to develop an understanding of each other's values, vision and expectations;

- It required team members to stop competing with each other and to focus instead on cooperating to achieve common goals.

Over the 10 months the programme was running, the programme facilitator acted as a supporting and challenging influence who was able to look at the issues it raised objectively. This helped the teams to develop and team members to feel confident enough to question practices.

The sharing of knowledge and experience through action learning was a new area of development for the team representatives. Because we became a smaller group as other teams dropped out, we were able to share and pool resources to complete activities within the given time.

The representatives' access and exposure to senior managers facilitated two-way interaction, giving them permission to develop new ideas, feed them back to the PCT and help them to become a reality.

The programme also allowed us to develop our leadership skills helping us to become confident, challenging professionals. This gave us a clearer understanding of the strategic drivers for the trust and the government-led initiatives.

Outcomes
The CTP has led to a number of practical outcomes:

- Pooling financial resources within the Caversham network enabled it to provide an extra peripatetic nurse for the district nursing team;

- It has identified clinicians with expertise in specific areas, who can be used as a resource to ensure staff work to their full potential;

- Closer working between health visitor teams enables them to maintain appropriate professional cover at all times;

- The transition for the Macmillan team to Saturday, Sunday and bank holiday working was undertaken.

Conclusion
Over the 10 months of the programme, Reading PCT has acquired a two-star rating. Although this was not a direct result of the CTP, our increased knowledge and skills have influenced practice and commitment to improve patient care. The programme enhanced our clinical leadership by making us more confident and able to challenge and negotiate with senior management to find solutions to improve existing practice and patient care.

Through the team events we managed to develop a more effective communication pathway, which led to better multidisciplinary working. Exposure to national and local policies helped us to understand how they govern PCT strategies and therefore to inform and motivate other team members about our responsibilities towards influencing key performance indicators for the PCT.

Receiving positive and negative feedback from patients enabled the teams to review and address change within their practice. The involvement with the CTP has had a positive effect on patient care and therefore enabled the staff to be more proactive in their teamworking.

Patient stories highlighted and confirmed that the standard and continuity of nursing care in the community was excellent. However, while named nurses were patients' preferred choice, as long as they were informed of any changes in the nursing staff they were happy to accommodate liaising with other members of the nursing team. They also identified areas that required development - these included the need for the Macmillan nurses to provide an information leaflet, and the health visitors to change the structure of baby clinics. Some of these issues have already been addressed.

Although it was hard work at the time the team representatives realised how much benefit they had gained both personally and professionally from participating in the CTP. While we feel some aspects of the programme could be adapted to better meet the needs of individual teams, there is no doubt that it has contributed to improved teamworking within Reading PCT. This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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