In focussing upon current research and experience of nursing service development, a number of factors are involved in ensuring quality HealthCare delivery is provided. One such factor is the organisational commitment to provide time and opportunity for the development of reflective practice. This commitment is of course multi-dimensional and there needs to be ‘buy in’ from clinical staff and a mutual understanding of how this time is used effectively.
In addition, it is crucial to develop a culture that supports decentralisation and participative management structures. Staff cannot be guaranteed to make good decisions without sufficient information and training and they are unlikely to make suggestions if they feel that this may compromise the stability of their current roles. We need to ensure that the qualities of the current structure are encapsulated and given the opportunity to develop. As an example, there are often multiple projects and initiatives occurring within any health care environment. The common perception is that these are being conducted in a somewhat isolative and non-coherent manner and I feel, this being the case, these projects are not being given the opportunity to realise their full potential in terms of corporate ownership, relevancy, implementation, usefulness to others and, ultimately in Kudos.
No one would question the view that hospital organisation and management matter greatly, in delivering quality HealthCare. Knowledge about the relationship between structures, processes and outcomes within nursing and within healthcare generally, is complex and incomplete and hence it is difficult to recommend ways of organising that actually improve patient care. In defining a quality initiative we need to be mindful of how the organisation and management of care affects outcomes. Naturally, both medical and nursing education tends, quite rightly to concentrate on individual patient care. An awareness of how each clinical encounter is compromised or improved by the system takes many years of clinical experience.
In reflecting on this, it is possible to make judgements on the essential organisational features required for clinical development to occur; these are as an example only, identified within the ‘MAGNET’ programme:
A relatively flat nursing hierarchy with few supervisors
The chief nurse has a strong position in the management structure of the hospital
Nurses have autonomy to make clinical decisions in their own areas of competence and have control over their own practice.
Decision making is decentralised at the level of the unit
Staffing is adequate and limits are placed on the number of new nursing graduates
Methods to facilitate communication between nurses and physicians are established
The organisation of nurses’ work promotes accountability and continuity of care.
The institution demonstrates the value it attaches to nurses-for example, by investing in their education.
It is necessary to look further into the specifics of how these features can be allowed to flourish and an important initiative to consider here therefore is that of Clinical Governance. This is a framework within which we can work towards the improvement of the quality of clinical services. It requires openness, participation, staff empowerment, partnership and collaboration. There is, of course a risk of only tacit understanding amongst staff of the need to embed the philosophy and tools of organisational and strategic development within the clinical workforce. This of course creates additional hurdles to ensuring that our delivery of services is truly client centered and based upon best practice principles.
Much can be gained by the creation of a clinical devlopment coordinator within a nursing directorate. I believe that the focus of the position needs to be carefully set to ensure the following is achieved:
The robust development and implementation of a systematic Clinical Governance framework.
The creation of a culture where reflection, organisational and strategic development and participation is encouraged at all levels of the workforce.
We really must be clear in our stance that the quality of patient care is related in an important way to the quality of life experienced by staff at work. This will be improved by helping individuals to develop their potential, to increase their autonomy, and to achieve their goals.
