Gary Etheridge, PGD, BSc, RGN, is director of nursing, midwifery, quality and risk, West Hertfordshire Hospitals NHS Trust
Jenny Thomas, BSc, CertManagement, RGN, is a management consultant
VOL: 100, ISSUE: 34, PAGE NO: 36
Jenny Thomas, BSc, CertManagement, RGN, is a management consultant
The NHS Plan (Department of Health, 2000) reintroduced the role of matron into the NHS but left it up to individual trusts to decide how to prepare and support practitioners taking up this new role.
A year later, the DoH (2001) issued guidance to help trusts with their reintroduction. It emphasised the importance of preparation and adequate support, which included leadership and management training.
The chief nursing officer’s progress report (DoH, 2002) highlighted that some matrons have used the leadership programmes provided by the Modernisation Agency’s Leadership Centre for ward sisters and charge nurses, while some trusts have devised their own programmes.
West Hertfordshire Hospitals NHS Trust used an action-learning approach to provide role-specific development and support for its matrons.
What is action learning?
The action-learning method of professional development grew out of the work of Revans (1983; 1982; 1980), and differs from conventional training and development in that learning is attributed to the process of finding solutions to real workplace issues. It has been defined as ‘a continuous process of learning and reflection, supported by colleagues, with the intention of getting things done’ (McGill and Beaty, 1995).
Action learning involves groups of people (learning sets) solving problems at work, from experience through reflection and action.
Although they may not have it at the beginning of a process, individuals hold the key to a solution if allowed to openly discuss, reflect and challenge ways of thinking within the learning set.
This is not simply ‘learning by doing’ - action learning involves something other than what the person is currently doing. It challenges our current ways of working and the systems within the organisation (Pedlar and Boutall, 1992).
Action learning helps people to develop themselves using four key steps (Box 1) within a structured group setting. While all of the steps are necessary for the action-learning process, reflection is the key element.
Action learning is based on the relationship between reflection and action. Learning from experience can be enhanced through deliberate attention to this relationship (McGill and Beaty, 1995).
Action learning has become a popular approach to leadership development and is used widely within the NHS, for example in chief executive leadership development (NHS Leadership Centre, 2004) and ward sister leadership development (RCN, 1997).
What does action learning involve?
Working in groups
Action learning works best with learning sets of 4-6 people, who meet regularly, for half a day or a whole day, every 4-6 weeks. It is important to establish ground rules to cover issues such as attendance, confidentiality and acceptable behaviour. Set meetings are made up of a collection of individual time slots of up to an hour each.
The role of facilitator
At the beginning of the process it is important to have an experienced group facilitator, whose role is to help the set to support and challenge processes and reflect on their learning. At the beginning, the facilitator will help members of the learning set build the appropriate questioning and interpersonal skills, and later they can take over the facilitator role (Dilworth, 1998).
Involvement must be voluntary and set members must be unafraid to pose difficult questions and arrive at original and potentially controversial answers (Pedlar and Boutall, 1992). Each member has a time slot in which to present her or his issue to the rest of the set who take time to listen, offer support and pose questions. The aim is to ask open-ended questions that lead to new insights. Each set member acts as consultant, adviser and devil’s advocate for every other member (Inglis, 1994).
Taking action and learning from it
Following the discussion and reflection, each person ends up with an action plan and agrees to take action and feed back the results to the group, enabling them to learn from the result. Whether the action has a positive or negative result, the group still learns from the process.
Background to the programme
West Hertfordshire Hospitals NHS Trust is a large acute trust based on four sites, employing about 4,000 staff. A total of 12 matrons were employed in 2002-2003 in five clinical divisions that vary widely in terms of staffing issues, workload and type of nursing. The remit of each matron’s post varies according to the division’s priorities, although job descriptions are essentially the same.
Initially, staff were unsure what the role would entail. Some saw it as another layer of management, others saw it as an opportunity to offload unpopular tasks. At the time, matrons worked separately in their own divisions, but they regularly met as a group with the trust’s director of nursing, midwifery, quality and risk. The rationale for adopting an action-learning approach included:
- It works on real-life solutions to real-life work problems;
- The process supports the concept of challenging current systems and processes in order to things get done;
- It provides a means of support.
The overall programme consisted of 12 days in six months. Between these days, matrons worked on their individual action plans formed within action learning. They undertook some work as a whole group initially - looking at the role of the matron and the task of establishing credibility and change, both as individuals and as a group.
After an initial workshop introducing them to the action-learning process, the group separated into two action-learning sets. Each set of six matrons met monthly and the whole group also met once a month to:
- Review progress and plan further work on the 10 key responsibilities for matrons (Box 2);
- Take part in workshops based on any needs for further knowledge raised as part of the action-learning process.
The programme was evaluated informally on an ongoing basis, with a formal evaluation at the end. It showed improvements had been achieved in five main areas: understanding of the role, confidence and assertiveness, teamwork, management issues and profile.
Better understanding of the role
The matrons now feel they have a better understanding of their role within the trust structure, developed through action learning and concentrating on the 10 key responsibilities. They have also teased out what is not their role. Without the action learning project, it would have been easy to fall into the trap of undertaking work ‘just because there is no one else to do it’.
The matrons also feel much more focused on their primary purpose of improving the patients’ experience. They all ensure that at least 50 per cent of their role involves direct contact with patients. Day-to-day problems involving patient care and staff issues are now formally recorded, which includes not only what the matrons do to resolve the situation and how long it takes, but also what systems/processes they instigate to ensure the situation does not recur.
The group now meets regularly to discuss their work, identify any trends and collaborate to ensure organisation-wide changes where necessary to prevent the same themes recurring. The process by which they maintain high visibility remains individual to each matron and the matron’s division. Most undertake daily walk-rounds, sorting out issues as they go round the wards and departments. After training in time management, this major part of their role is now planned into their diaries and seen as an important aspect of their day.
Increased confidence and assertiveness
Part of the matron’s role is to challenge rigid systems and processes that prevent patients receiving the care they deserve. This requires confidence and assertiveness. Most of the matrons feel that by sharing their problems and supporting each other to challenge processes, they have greater confidence to take issues forward. For example a midwifery matron commented: ‘I feel I am now able to deal more effectively with conflict.’
Working as a cohesive team
At the start of the programme most matrons were new to the role and had not worked together at all. All agreed that the programme has given them necessary support to settle into the role and find their boundaries - one matron described it as being ‘a bit like preceptorship’.
Matrons feel they have generally increased their internal networks, which in turn has improved things for patients by breaking down barriers. The matrons now liaise much more between departments, sharing good practice and identifying areas for improvement. They recognise that by working together they can achieve much more.
A surgery matron commented: ‘We work far more cohesively now and have built up a good rapport. I feel we are now a stronger and a highly identified group within the organisation.’
The matrons now delegate initiatives between themselves, ensuring that one or two take the lead on corporate objectives on behalf of them all. This enables them to share the workload and be more effective.
Although the programme has finished, they continue to meet fortnightly to check on progress, ensure their work is not overlapping, and that they are continuing their work on the 10 key responsibilities.
Better knowledge of management issues
The workshops were based on needs that arose through action learning and worked on the 10 key responsibilities. Most focused on the development of management skills - managing time, complaints, finances and performance.
The workshop on time management had the most impact. Most agreed it changed their approach to work or at least made them more aware of how to be proactive rather than reactive. Many now spend time planning their diary and prioritising their workload, which ensures that they are able to spend more time working clinically, being visible and supporting ward managers.
Many have cascaded information from the workshops to ward managers, empowering them to make more informed decisions. Some are concentrating on increasing ward managers’ awareness of and involvement in issues such as budget management, helping them to identify cost pressures for the business planning process and working together on skill-mix and establishment reviews.
Raising matrons’ profile
Matrons have raised their profile within their divisions by being more visible on walk-rounds, available to deal with staff or patient concerns and advertising their role and contact details via posters/patient information leaflets, as recommended in national guidance (DoH, 2001).
They have also raised their profile across the trust and have become more involved in decision-making on behalf of patients and clinical colleagues. This is something many felt they could only do after gaining confidence through action learning. They now make sure they are involved in all relevant trust-wide initiatives, being able to influence areas such as contracts for curtains.
Instead of dealing individually with the same problems day after day, the matrons jointly take a more positive approach. For example, they will arrange to meet with the appropriate head of services to decide upon joint action to tackle an issue on an organisation-wide basis rather than tackling it individually on a divisional basis.
The trust currently has day-to-day problems with bed management and staff shortages. With this in mind, the matrons devote time to these issues, recognising that this is necessary to ensure ward managers are adequately supported at this difficult time.
Generally, the matrons said that the programme has helped by enabling them to gain insight and greater understanding of issues at trust/organisation-wide level. They also have the confidence to challenge systems and processes that are detrimental to patients. They feel that action learning helps them to work with other managers to develop solutions to problems.
Using venues within the trust premises for action-learning meetings was challenging. Although matrons ensured that work was delegated, it was still difficult to ensure they were uninterrupted when colleagues knew they were on site. Being further away from their work area would have allayed unnecessary stress for some. Ideally, meetings should take place in private, quiet and relatively comfortable surroundings (McGill and Beaty, 1995).
The main challenge was to ensure the matrons continued the learning process once the formal programme ends. They were therefore enabled to develop the skills to facilitate the action-learning sets themselves once formal facilitation was withdrawn. This has been successful, and both action-learning sets continue to provide a forum for matrons to support and challenge each other to tackle awkward workplace issues.
The main role of the matron is to be an authoritative figure, cutting through ‘red tape’ to get things done and empowering ward sisters and charge nurses to get the basics of care right. To do this they need appropriate support and development. Action learning has proved an effective system for the matrons of West Hertfordshire, and has empowered them by encouraging them to take charge of their own problems. It is more difficult to assess whether action learning has had an impact on the organisation, as course evaluations are based on participants’ personal growth. It has been suggested that organisational impact occurs over years (Wallace, 1990).
But it is clear that resources are not wasted on inappropriate learning. Participants develop a learning approach to problem-solving, and more innovative solutions to problems emerge. Action learning is highly recommended for supporting and developing matrons because it helps them fulfil the basic requirements of their role - to take action and progress on issues to improve patients’ experience.
This article has been double-blind peer-reviewed.