VOL: 96, ISSUE: 47, PAGE NO: 38
Helen Austin, MSc, RGN, is health visitor, Dorset Community NHS Trust
Kathryn Backwell, BA, RN, is staff nurse, A&E, West Dorset General Hospitals NHS TrustShared governance has been defined as an approach to nurse management that 'seeks to grant nursing staff control over their professional practice and development, and make a genuine contribution to the wider corporate agenda' (Gavin et al, 1999).
Shared governance has been defined as an approach to nurse management that 'seeks to grant nursing staff control over their professional practice and development, and make a genuine contribution to the wider corporate agenda' (Gavin et al, 1999).
According to Brooks et al (1998), this approach has been expanding rapidly in the UK in recent years, resulting in better patient care through greater staff empowerment and autonomy, and more effective nurse-led innovations. However, there is little evidence to support these claims and British nursing literature recognises the need for a systematic evaluation of shared governance (Geoghegan and Farrington, 1995; Brooks et al, 1998; Gavin et al, 1999; O'May and Buchan, 1999).
An elected council
The elected council for nurses, midwives and health visitors in Dorchester started life in December 1999 and was initiated by Elaine Maxwell, the new director of nursing for the West Dorset General Hospitals NHS Trust. The main purpose of the council is to improve patient care and nursing practice through the empowerment of the nursing staff, and to provide a forum for discussion within a culture of shared governance (Fig 1). It also aims to influence and advise on the agenda for nursing development within the trust.
This is a move away from the hierarchical style of management and is based on core principles:
- The responsibility for managing nursing services must reside with nursing staff;
- Authority for nurses to act must be recognised by the organisation;
- Nurses must be accountable for their own delivery of patient care and professional conduct.
To put this into perspective, O'May and Buchan (1999) stated that shared governance is an ongoing process which requires continual assessment in order to be flexible and to adapt to the environment. In 1995, Leicester General Hospital NHS Trust developed a system of shared governance involving the creation of four councils (dealing with clinical practice, professional development, research and quality), coordinated by a nursing and midwifery council. However, members were self-nominated rather than democratically elected by the nursing body.
Development of the West Dorset elected council
Before March 1999, the trust had a nursing strategy group comprised of H-grade clinical nurse specialists. Following input from Iain Graham, professor of nursing at Bournemouth University, a discussion event, 'Shaping the Future', was held at a local conference centre in April 1999.
It was here that a junior nurse commented: 'This is the first time I have been asked what I personally think, rather than receiving second-hand information from the nursing strategy group.' The day concluded with the decision that nurses should have an elected council. In this way, nurses would have the opportunity to express their opinions and make recommendations to the trust board.
It was agreed that the council's role would be:
- To influence decision-making;
- To empower nurses and make changes within nursing practice and related areas;
- To lobby within hospital committees and enable the director of nursing to speak with the strength of a mandate from a representative body of nurses.
The director of nursing then enlisted a project nurse to instigate elections for the council. Posters were put up and nomination forms were sent to all registered nurses, midwives and health visitors in the trust, including the nursing specialties and grades listed in Box 1.
Although only 29% of the voting papers were completed and returned, the voting system ensured that the 17 nursing council representatives were elected in a democratic manner by their peers.
The inaugural meeting of the council was led by Elaine Maxwell, who explained that Iain Graham would have a supportive and facilitative role regarding the training needs identified by nurses. These needs included negotiation and presentation skills, and updates on current nursing issues, including national nursing policies.
In the next two meetings the council's philosophy was developed. It states: 'We are a democratically elected council representing the nurses, midwives, health visitors and school nurses. We aim to address professional issues which impact upon the quality of care delivered to patients. We will be the voice of our electorate and intend to develop a nursing service that meets the demands of the contemporary NHS. We aim to develop a shared governance culture to facilitate multiprofessional working to enhance service delivery. We aim to work effectively with all health care professionals to develop innovative ways of using the human and financial resources available. We will be advising the director of nursing on the current issues facing the profession and recommending appropriate solutions.'
The council has four subcommittee groups (Box 2):
- Documentation group;
- Education and training group;
- Professional practice group;
- Research into practice group.
Each group is chaired by a council member. Non-council membership is encouraged within the subcommittee groups in order to incorporate wider experience and knowledge and to expand the concept of shared governance. Issues are discussed and recommendations are reported back to the monthly council meetings.
The chief executive of the trust has an open invitation to attend council meetings. Members of the council have requested positions on hospital committees and the council chair regularly meets the medical staffing committee. The director of nursing is not an elected member of the council but it was unanimously felt to be important for her to attend all meetings because of her knowledge of trust dynamics. Also present at council meetings is the clinical practice development nurse, who has an advisory role, and the clinical development secretary, who takes the minutes.
The council has an advisory role and is not a decision-making body, but it is hoped that it will influence policy as a result of collective debate. Minutes of each council meeting are distributed to all nurses and communication also takes place via e-mail, a website, council member surgeries, notice boards and staff meetings.
The council has so far produced guidelines for risk-assessment and workload and has highlighted issues relating to time management within the trust. It has established links with the operational management board and the medical staffing committee and plans to present recommendations to the board on how nurses feel the quality of care can be improved for patients.
The council has representatives on the best practice committee, the education committee, the medical records committee and student groups at Bournemouth University. It is seeking representation on the ethics committee and the drugs and therapeutics committee. The council also intends to try to influence the trust on specific issues determined by the subgroups.
The council has been in existence for six months and it has established its own corporate voice through its elected nurse representatives. There is a good working relationship between council members, the subgroups and the established links with the committees. However, council members have recognised the need to remain proactive in order to be seen as credible and effective by their peers and maintain the council philosophy.