VOL: 97, ISSUE: 50, PAGE NO: 34
Susan Alyson Charnock, BSc, RMN, is nurse practice facilitator, Glanrhyd Hospital, Bridgend, Wales
Since the concept of clinical governance was introduced by the Department of Health in 1997, much has been written about its implications for health care professionals. However, a limited amount of attention has been paid to the issues specific to nursing.
This article aims to demystify clinical governance by looking at issues raised by the relevant white papers. It explores four components of clinical governance that apply to everyday nursing practice, namely clinical effectiveness, continuing professional development (CPD), clinical risk assessment and professional self-regulation.
Following its election in May 1997, the New Labour government announced its aim to rebuild the health service and later outlined its plans in The New NHS: Modern, Dependable (Department of Health, 1997). This white paper first introduced the term ‘clinical governance’ and very briefly defined it as an initiative both to assure and to improve clinical standards of care at local level in the health service.
The following year, A First Class Service (DoH, 1998) gave more details of how quality health care for all should be achieved, and introduced the clinical governance framework as the process by which the NHS would assure the quality of its clinical decisions.
What is clinical governance?
The DoH (1998) defines clinical governance as a framework through which NHS organisations are made accountable for the quality of service they provide. The aim is that services will be continuously improved through the creation of an environment in which excellence in clinical care will flourish. More simply, Lilley (1999) describes it as the total of all factors that make the NHS, and the place in which you work, safe.
So what does clinical governance mean in practice? A range of key components have the greatest impact on practice (Wilson, 1998; Butterworth and Woods, 1999; Crinson, 1999; Gilmore, 2000). These include:
- Clinical audit and standard-setting;
- Clinical effectiveness, incorporating evidence-based practice;
- Clinical risk-management and, as a logical follow-on, lessons learned from complaints;
- Continuing professional development (lifelong learning);
- Professional self-regulation;
- Service accreditation;
- Research and development.
Who is responsible for clinical governance?
In order to comply with the requirements for clinical governance each trust must ensure that the clinical governance framework is in place and working effectively. Ultimately, the chief executive is accountable for the delivery of a high standard of care and needs to appoint a clinical lead person to oversee the process. Lugon and Secker-Walker (1999) suggest that this role might be best undertaken by a nurse, although the medical director would more likely be given the overall lead.
Whoever is identified as the lead person, he or she should work closely with the director of nursing to ensure that explicit standards are set for all clinicians. However, the principles of clinical governance apply to all those who provide or manage patient care within the NHS, so ultimately it is the responsibility of each individual to ensure that they understand and fulfil their own role in clinical governance.
The question that many nurses ask is: ‘What will clinical governance mean to me?’ Although many of them say they do not understand the term, they are already familiar with most of its constituents - clinical governance is no more than an umbrella term for the more familiar issues listed above. The key to its success lies in drawing these elements together and integrating their processes (Jackson, 1999).
What nurses need to know
It is still too early to know what will be the full impact of clinical governance on nursing practice. However, some idea was gained from a literature review looking at the four aspects considered to be of greatest significance to nursing practice:
- Clinical effectiveness, incorporating evidence-based practice;
- Continuing professional development (CPD), incorporating clinical supervision;
- Clinical risk-assessment;
- Professional self-regulation.
The NHS Executive (1996) defines clinical effectiveness as the extent to which specific clinical interventions maintain and improve health and secure the greatest possible health gain from the available resources. A simpler definition comes from the RCN (1996), which describes it as doing the right thing, in the right way, at the right time, for the right patient. Clinical effectiveness as it relates to clinical governance is discussed in greater detail in the following article.
Continuing professional development
Since PREP came into force in 1995, nurses have been required to undertake 35 hours of study over each three-year registration period if they wish to remain on the register. This study can be either structured (such as organised study days) or unstructured (self-directed learning).
The clinical governance initiative itself presents nurses with new challenges for education, and both individuals and trusts must respect this. Garbett (1998) suggests that although it offers increased opportunities for nurses, the knowledge and skills necessary to benefit from these opportunities may be thin on the ground. Trusts must therefore provide adequate and appropriate training to allow nurses to gain these skills.
But where does clinical supervision fit into this agenda? Faugier and Butterworth (1994) define clinical supervision as an interaction between practising professionals that enables them to develop professional skills and gives them an opportunity to maintain and develop individual professional practice. Butterworth and Woods (1999) make an explicit link between clinical supervision and clinical governance and explain that active participation in clinical supervision is a clear demonstration of practitioners exercising their own responsibility under clinical governance.
The general public expects the NHS to prevent the kinds of incidents and crises that have occurred as a result of serious failures in the planning and delivery of care. This is one motive behind the development of clinical governance which, if properly organised, should help trusts to avert potential crises. Nurses have an important role in reducing the occurrence of harmful or adverse events, as they are expected to anticipate and prevent problems in their normal, everyday practice. This means there is a clear need to ensure that all staff have the skills required to assess all possible variables and implications of potential problems. Cook (1999) supports this, highlighting the need for multidisciplinary training in health and safety assessment, clinical risk assessment and risk protocol development.
Aydelotte (1981) defines professional regulation as the arrangement by which practitioners exercise authority and maintain control over their practice, self-discipline, working conditions and professional affairs, as they contribute to the mission of their organisation. This form of professional regulation appears to work on two levels - regulation by the statutory bodies, such as the UKCC, and more informally as self-regulation by individuals in the course of their everyday work (Hamer, 1998).
Clinical governance is essentially about control, responsibility and regulation. The DoH (1997) stresses that in order to achieve the aims of clinical governance it expects individual health professionals to be responsible for their own clinical practice and stresses that professional self-regulation must remain an essential element in the delivery of quality patient services.
Under the clinical governance framework nurses will be expected to undertake self- and peer review, reporting when they feel that either they, or their colleagues, are professionally compromised or unfit for duty. The success of clinical governance relies on establishing a strong organisational structure which both monitors and supports practitioners (Wilson, 1998) and nurses will need to be supported in reporting concerns about their own, or their colleagues’ performance.
Expecting nurses to look critically at each other’s practice could affect them more than other professionals because of the close networks they tend to develop. As they care for patients 24 hours a day, nurses also have more opportunity to observe the differences in practice and clinical outcomes among other clinicians (Scott, 1998).
Clinical governance is here to stay, at least for the immediate future. Although it may at first seem a difficult concept, nurses have been grappling with the key issues discussed in this article for some time. Clinical governance has simply encompassed these issues and placed them in a formal framework.
Nurses should not see clinical governance as a negative force - it is the opposite because it gives them a positive framework in which to promote and develop their profession.