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A lesson for NHS chief executives: How to win back nurses

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In a fictional letter from a chief executive, NT politics blogger, Chris Hart, explores the issues surrounding management within the NHS and identifies areas where managers could improve care by going against the status quo.

Dear Colleague,

I use the term ‘colleague’ deliberately. Although I can’t get around the Trust anywhere near as much as I’d like and know very few of you, I want you to know I’ve come to realise you really are my colleague. By which I mean my equal. Despite the gulf between us both in terms of how much we earn, as well as how little time I get to spend with patients – the reason we’re all here – from now on I want to create a new relationship with you and to be ‘with you’ in the great and challenging task facing us.

I know you’re used to seeing me blog about what I’ve been doing in my garden or on holiday, drawing trite lessons about life from what is, in many respects, a very comfortable existence. But this week’s is going to be different. Very different. So I do hope you read it.

Our Trust mission statement, our core values etc describe high minded ideals, of patients first and staff being valued. And you’ve probably been extremely sceptical because what we’ve done often hasn’t reflected them. In fact, I’ll admit, the more we talk about putting the patient at the ‘centre of everything’, the more peripheral they often seem, as we chase apparently meaningless targets and prioritise our financial situation.

Similarly, I know our promises to you often ring hollow. But everything is changing.

I can’t put this any other way. The NHS is in a mess. Everyone knows - well, almost everyone - it’s underfunded. The commissioning arrangements are chaotic. We’ve been reorganised so many times we’re completely disorganised and The Coalition’s NHS Bill was the policy version of a nuclear strike. Relationships between staff and management are poor, to say the least. There’s going to be no extra money. In fact, we have to do more with less. We could seek to attribute blame but that won’t help.

You might remember an arrogant, stupid and failed prime minister once said, “We’re all in this together.” That’s the one thing he got right. We really are.

We all have to behave differently. And I must lead this as your chief executive. The Trust Board has to change as will the different professions. The good news for you, as nurses, is that much of this is going to be to accommodate a new place for you in the order of things. Because nothing can change for the better without you.

So I’m making sure consultants and their medical colleagues give up their position of relative privilege – and I use that term carefully, because I know junior doctors have had it incredibly tough and I also have to forge a better relationship with them. Managers will have to consult with you and involve you in every decision that affects services and your role in them. We will set up structures for this and nurses will no longer be the scapegoats for any organisational failings.

From now on, I really am determined to manage the Trust on the basis of the evidence for best practice. We’ve hammered this home to clinicians for years while totally ignoring it ourselves. Now, I’m making that leap of faith. That means putting you at the centre of everything because then I know the patient will be the beneficiary.

I wrote earlier that we’re going to have do more with less. But this doesn’t mean I can’t reward you. Instead of wasting millions of pounds on temporary staff and recruiting nurses who only stay a short while with us, every nurse is going to get a substantial, one off pay rise. After that, we’ll review your terms and conditions together. They will improve. And why not? It will still save the Trust millions. Money to be invested in patient care. And I know you’ll know many ways in which we can make further savings. We haven’t listened to you before but we will now.

Just be clear on this: the Board is going to demonstrate its commitment to you in every way we can but we recognise the importance of paying a fair wage has to be the starting point after you’ve lost out financially for almost a decade. I need you to want to stay and work with us. I want to ensure the best nurses want to come here and I won’t exploit any of you.

And here, in the interests of full disclosure, I’ll make an admission. This change wasn’t brought about by a blinding flash of inspiration or altruism. It’s naked self interest. Our Trust is not meeting a range of targets, most notably the financial ones. I have no choice. But, having been forced to stop and reflect, I wonder why I didn’t do this years ago.

Looking back, I see we - I - tolerated for too long a culture that was at best putting too much pressure on staff and, at worst, resulted in bullying. I’d like to say it was an unintended consequence of the anxiety and demands that came from the needs for improved performance. Yet I know it was poor management from the very top down.

Everything was focused on targets, performance, systems and outcomes and I completely overlooked how these things are only ever achieved by people, that our relationships with one another are what makes ‘the system’ both tolerable and effective, that the artificial goals I’ve been set and subsequently imposed upon you can be met by actually doing what we receive our funding for i.e. caring for and treating patients. I know. It sounds nuts, doesn’t it?

Worse still, with some of my chief executive colleagues, I conspired to hold down your pay, reduce the limited professional influence you did have, and coerced your directors of nursing into supporting things they knew were damaging to nursing and patients. As always, it’s a slippery slope. It’s not what we set out to do or even realised we were doing. Until it was too late.

Many people, including some of you, blame nurses and attack them for not standing up for themselves. I need to tell you it’s not your fault. You’re the victims of a long, sophisticated and ruthless exercise in power, to the point that we’ve successfully subordinated your wants and needs in ways that haven’t been seen since the 1930s. Indeed, the fact nurses are blamed and blame themselves is perhaps the ‘finest’ example of the insidious nature of that power. I can only apologise. And try to make things right.

Our organisation has paid a price for that. I can see some of you have ‘switched off’, are going through the motions, do enough to ‘survive’ the shift but little more. Worse still, there is an unspoken battle of wills at play. While few nurses openly dissent, many of you, either consciously or unconsciously, don’t comply with ‘the rules’ or go along with ‘the system’. The problem is that, in all of this, the patient is lost.

I want you all to once more feel able to demonstrate compassion to our patients. I know this requires us, as the people managing the organisation, to manage with compassion, which means not just supporting you but being alongside you as you do the emotionally intensive work that is so often underestimated and undermined. It means helping every nurse develop the wide range of skills required for twenty first century nursing and contemporary models of care that enable that, developed with you.

There’s a famous story of a French psychiatrist, Frederick Pinel, unchaining the “lunatics” of the Paris asylum during the French Revolution. But it’s a myth. It was actually the head attendant, a nurse called Jean-Paul Pussin, who unlocked the chains. To me, that story’s a metaphor about the power of nurses and nursing and the way in which nurses are devalued and written out of the narrative of healthcare.

I want you to unlock your potential. To unlock your creativity and start making demands of me, the Trust board, of colleagues from other professions, of one another. I want you to start setting the agenda because you’re the ones with the patients the most, who see their needs and those of their relatives and carers close up. I want critical thinkers, using analytic skills both in their clinical work but also in how they organise that work. And when you haven’t the means to do your job properly, for whatever reason, shout it out loud. Don’t be afraid to give me solutions. We’ll work to make them happen.

Find your voice and don’t stay quiet. I’m going to give you a lot more responsibility but you’ll also have the authority needed to make change, to lead, to shape your future.

So I will open doors for you but, to be honest, that’s the limit of what I can do. I’m relying on you to have the courage to walk through them and fulfil your real potential. You will have to change to make the change we all want to see.

Other chief executives have said that this letter is a professional suicide note. That I’ll either be sacked, at best, or at worst, chained up in an asylum all of my own. We’ll see. I might be a very late convert but I’m a believer in the power of nurses and nursing. Together, I believe we can create something new, fresh and successful. I believe it’s the only way. Who would dare stop that?

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