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Nurses are in pole position to make quality a priority

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Pippa Gough and Abi Masterson on nurses’ unique influence over patients’ experiences of care.

Over the last year the Health Foundation has begun to focus attention on the crucial role played by NHS trust boards in setting the culture and agenda for improving quality and safety in their organisations. This reflects national concern about the way in which NHS boards assure themselves about the quality of clinical care that patients receive – especially given the failings at Maidstone and Mid Staffordshire. Boards are under the microscope as never before – they need to squeeze costs and improve quality and the more support and input to enable them to deal with this the better.

Under tha last government the National Leadership Council had identified this as a main part of its work and was designing a development programme which would “enhance the professionalism and quality of NHS boards and equip them to meet both immediate economic challenges and longer term objectives”.

This is a question of leadership and how the board, as the governing body at the top of the organisation, sets the strategic direction for quality and how it models and embodies an approach to quality that can be replicated throughout the trust.

Given our nursing background, we find ourselves thinking about the specific role of the nursing director and how she can help the board up its game. As all boards are pushed to shift their gaze from the financial bottom line to that of quality accounts, it is possible that nursing directors are suddenly finding themselves at the centre of attention. After all, it is nursing directors who are responsible for the practice of the highest proportion of the workforce in any one trust, and arguably, therefore, for the majority of actions that impact most on the quality and safety of patient care.

Nursing directors have an unrivalled influence over patients’ experiences of care.

Does this mean they are now seen to have a new found prowess at board meetings? Do they command a new place in the hierarchy of the health services?

Historically we know nurses have always had to fight for their executive seat on the board of health organisations, as their contribution was thought to have minimal importance to the higher level concerns of the running of the organisation. And yet it now seems the wider political imperative for quality and productivity has suddenly made them indispensible to decision making at this level.

Last month’s King’s Fund report, Putting Quality First in the Boardroom sets out how nursing directors can build on this position. Top of the list is the need for them to develop a broad corporate focus in order to command authority. If the senior nurse is seen and heard to talk knowledgeably about issues across the whole swathe of trust business, more importance will be attached to what she says about nursing.

This is an objectionable dynamic but, wearyingly, not unfamiliar. To be concerned merely with nursing and a nursing view of the world, so the dominant discourse suggests, is to consign oneself to a ghetto. In this place, nurses can be deemed as having no useful perspective on, or robust comprehension of, the context overall. As frustrating as this is to hear, it is still the realpolitik and we just have to get on with it.

In essence, it is the nursing director, more than any other board member, who is well placed to help boards integrate quality with other aspects of the business. This is a unique perspective and clearly important. It also requires certain skills.

The most successful nursing directors, the report observes, are skilled facilitators – those who can enable conversations about risk and harm and poor patient experience within their organisation, without the panic button being pushed; those who can contain and manage the huge anxiety engendered by this type of conversation through the use of timely information.

A well informed, corporately knowledgeable and emotionally intelligent nursing director can help boards think about how best they can fulfil their quality assurance role when anxiety is running high – what information they need about the clinical quality of patient care, in what format they need this to be presented, and how best they can interpret it. This information may be the “soft” intelligence of patient stories or the “harder” edge of quantitative facts and figures, or a combination of the two. All will have impact if the nursing director has earned her “board cred”.

The King’s Fund report states that clinical quality still occupies a fragile position in many NHS boardrooms. It’s an issue which is more likely to be a priority on the board agenda where its relevance to the business of running the organisation is clearly understood. The quality of clinical care is the business of NHS organisations but it’s a complex dynamic to grasp – being a mixture of financial efficiency, clinical effectiveness, operational excellence and continuous improvement. The nursing director is emerging in pole position to lead the way in making sense of the complexity.

About the authors

Pippa Gough and Abi Masterson are assistant directors, leadership, at the Health Foundation

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