for nursing leaders everywhere

February 2008 Volume 14 Number 9 www.nursingmanagement.co.uk

Recruiting with care:choosing the right candidate

Critical thinking among nurses

Service line management

The value of drama based training

Making good decisions

management

February 2008 Volume 14 Number 9 www.nursingmanagement.co.uk

Recruiting with care:choosing the right candidate

Critical thinking among nurses

Service line management

The value of drama based training

Making good decisions

mmaanagnageemmeememmem nnttntnntnnursing

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NURSING MANAGEMENT AT YOUR FINGERTIPS

nursing management HAS GONE DIGITAL

3464_NM_Digital Advert_1 17/1/08 10:39 am Page 1

contents

nursing management Vol 14 No 9 February 2008 1

3 editorial

news

4 new funding for hospital trusts to recruit specialist staff in fight against infection

opinion

6 get connected by Barbara Stuttle on the move

7 your letters under cover by Matthew Rice

8 a new strategy for Scotland health and wellbeing secretary Nicola Sturgeon

sets out the new government health strategy

the ‘year of the HCA’ Paul Vaughan explains why developing

healthcare assistants should be a priority

10 recruiting with care David Foster on the importance of choosing the

right candidates for jobs in the nursing profession

features

12 playing the ideal role Becky Simpson assesses the value of drama

based training to healthcare professionals

16 hearing the alarm in the wake of the Healthcare Commission

report into infection outbreaks at Maidstone

and Tunbridge Wells NHS Trust, Lindsey Scott reflects on the similarities between events in Kent and those at the Bristol Royal Infirmary

20 laying it on the line William Moyes from the independent regulator

of NHS foundation trusts, Monitor, describes why senior nurses should understand service line management theory

22 a tonic for the troops Gail Lusardi, Allyson Lipp and Huw Williams

report on the benefits to non-military healthcare staff of taking part in weekend exercises organised by the Territorial Army

applied leadership

27 ten steps to setting goals Chris Pearce offers a guide to help nursing

leaders set goals

28 critical thinking among nurses concept mapping can help newly registered

staff and nursing students develop the critical thinking skills they lack, says Swaleh Toofany

32 making good decisions: part 1 the first of two articles from The Open University on how professionals make decisions

scan

36 conferences

37 webscan

have your say

nursing managementfor nursing leaders everywhere

2216

12

NM1409 01 con.indd 1 23/1/08 2:32:41 pm

READEROFFER

For nursing leaders everywhere

nursing managementfor nursing leaders everywhere

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To enter the draw, complete the coupon below and send it to:Nursing Leadership offer, Jenifer Payne, Wiley-Blackwell, 9600 GarsingtonRoad, Oxford OX4 2DQ, by February 29 2008.

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The draw will take place on February 29 2008. Winners will be notified by email, telephone or post. Terms and conditions: only one entry perreader. The prize is as stated and no cash alternative will be offered. The judge’s decision is final and no correspondence will be entered into.

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Nursing Leadership explores the importance ofbalancing leadership theory and knowledge with the development of leadership skills based on action learning. The book addresses principles ofeffective leadership that promote successful andsustainable outcomes across different settingsand is brought to life with examples from theInternational Council of Nurses’ experience withits Leadership for Change programme.

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editorial

Managing director and publisher: Linda Thomas OBE

Sales and marketing director: Phil Whomes

Editor: Nick Lipley

Consultant editor: Donna Kinnair

Production editor: Duncan Tyler

Art director: Paul Swainson

Picture editor: Philip Brecht

Assistant picture editor: Helen Jones

Classified advertisement sales manager: Andy McCallum Tel: 020 8423 1333Fax: 020 8872 3197Email: andy.mccallum@rcnpublishing.co.uk

Classified advertisement executive: Mandy Croggon Tel: 020 8423 1333Fax: 020 8872 3197Email: mandy.croggon@rcnpublishing.co.uk

Classified sales DX address: RCN Publishing Co Ltd, DX 4228, Harrow.

Special projects manager:Laura Downes Tel: 020 872 3156,Email: laura.downes@rcnpublishing.co.uk

Advertisement and sponsorship executives: Neil Hobson Tel: 020 8872 3123Julia Gomersall Tel: 020 8872 3122Syretta Allen Tel: 0208 872 3182Kelly Smith Tel: 0208 872 3123Fax: 020 8423 9196

Editorial administrator: Helen Hyland

Editorial admin assistant: Sandra Lynch

Subscription rates and enquiries:RCN members: £4.80 a month by direct debit.For annual direct debit, cheque or credit card rates, institution rates and answers to other subscription enquires, access www.nursingmanagement.co.uk or call 0845 7726 100.Nursing Management, incorporating Senior Nurse, is published ten times a year by RCN Publishing Company Limited, The Heights, 59-65 Lowlands Road, Harrow-on-the-Hill, Middlesex HA1 3AE. Tel: 020 8423 1066.Copyright 2008 RCN Publishing Company Limited. All rights reserved. No part of Nursing Management may be reproduced, stored in a retrieval system or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the publisher. ISSN 1354-5760.

Printed by: Friary Press, Dorset

Cover image: PhotoAlto

David Bentonconsultant in nursing and health policyInternational Council of Nurses, Geneva

Juliet Chambersdeputy director of nursing Calderdale and Huddersfield NHS Trust

Deborah Clatworthyassistant director of nursing (risk management)The Whittington Hospital NHS Trust, London

Geraldine Cunninghamacting director RCN Institute

Jenny Kaydirector of nursingDartford and Gravesham NHS Trust, Kent

Caroline Shuldhamdirector of nursing and governanceRoyal Brompton and Harefield NHS Trust, London

editorial advisory board

nursingmanagementVol 14 No 9 February 2008 �

AS THE NHS enters its 60th year, the government has made clear that, even when flexible and responsive services have been achieved, healthcare reform will continue until clients have the information they need to take responsibility for their own health.

As nurses, we have played a major role in the recent achievements of the NHS such as the reduction of waiting times and improvements in the treatment of patients with cancer. We have set up new roles, learnt new skills, shared our knowledge and improved our abilities to manage and lead.

But, if we are to improve the lives of those we serve, there is still more for us to do.Current changes in healthcare provision require us to develop our skills as both pro-

viders and commissioners of services, and to focus on lifestyle advice. To help one another respond appropriately to these changes, we must continue to

share our experiences and knowledge in both the nature and prevalence of disease, and in the demography and lifestyles of the public.

We must also share our views on how the new policy agenda should be delivered and whether those who devise these policies have thought through the consequences of implementing them.

I believe that clinicians must lead and steer the reforms that are needed for the systematic delivery of a world class health service and so I hope that all nurse managers and leaders will use the pages of Nursing Management to contribute to the debate on improving good health outcomes.

If you read Nursing Management regularly, you will know that we try to ensure that it contains a variety of articles from different settings in the UK healthcare service. To ensure this variety is maintained, we require many different contributors.

If you are a regular contributor therefore, I hope you will keep your articles coming in; and if you have never written for a journal before, I urge you to consider doing so, perhaps as a resolution for 2008, to share your experiences and opinions with our community.

Many of you, like me, may not consider yourselves natural writers but, neverthe-less, want to contribute to the debate on how our profession should deliver excellence across all healthcare settings. Nursing Management can provide you with the forum to do so.

I would also like to invite applications to join the Nursing Management editorial advisory board, which provides excellent stewardship in guiding the journal’s strategic development, and advises on the quality and relevance of articles.

We need to hear from clinicians, academic leaders and managers from across the UK who are committed to helping senior nurses share their experiences and opinions about how to lead the drive for better patient care and outcomes, and for a better health service.

If you would like to apply, send your curriculum vitae and an outline of no more than 150 words of how you would improve Nursing Management to the editor, Nick Lipley, by March 15. We look forward to hearing from you nm4 To make an application to join the Nursing Management editorial board or to find out more about other ways of contributing to the journal, email Nick Lipley at nick.lipley@rcnpublishing.co.uk or write to him at RCN Publishing Company, The Heights, 59-65 Lowlands Road, Harrow-on-the-Hill, Middlesex HA1 3AW. See also How to contribute on page 35

Donna Kinnair, consultant editor

Director of clinical leadership, quality and nursing, and head of children’s integrated commissioning, at Southwark Primary Care Trust, London

NM1409 03 eDK.indd 3 22/1/08 10:20:55

news

� nursing management Vol1�No9February2008

Funds for hospital trusts to recruit specialist staff in fight against infectionby Laura Doherty and Nick LipleyEvery hospital trust in England will be able to recruit extra staff as part of a government initiative to improve infection control.

The Department of Health has earmarked £45 million for trusts to spend on additional special-ist staff, including two infection control nurses and two isolation nurses each.

Health secretary Alan Johnson announced the move last month as part of a funding package of £270 million a year by 2010/11 to support infection control and cleanliness in the NHS.

As part of the government infection control strategy, ‘strin-gent’ requirements will also be introduced to ensure that NHS foundation status applications are supported only if the trusts concerned have hit local targets

on both MRSA and Clostridium difficile consistently.

Citing Health Protection Agency (HPA) data published in November, Mr Johnson said: ‘We have gone from what has been described by the HPA as “a seemingly unstoppable rise in MRSA bloodstream infections

throughout the 1990s” to a 10 per cent fall in cases of MRSA, thanks to the hard work and dedication of NHS staff. But we know that there is still more to be done.’

In referring to the proposals, England’s chief nursing officer Chris Beasley told nurses: ‘We are not saying that you have to recruit these nurses. The money is there for you to use in the way you think best suited to tackle infection control in your area. It is not for us to micromanage what people are doing.’

Meanwhile, RCN general sec-retary Peter Carter said: ‘This announcement is good news for patients and is a recognition of the important role nurses play in tack-ling healthcare acquired infection.

‘However, we need to ensure that money allocated to infec-

tion control reaches the ward and is not diverted elsewhere in the system.

Addressing problems like MRSA is a continual process where only by constantly invest-ing in staff, cleaning and train-ing will we be able to provide environments safe for patients.’

The DH’s infection control strategy, Clean, Safe Care: Reducing infections and saving lives, includes details of a range of programmes to accelerate the development and uptake of new technologies, as well as guidance on human resources procedures that incorporate induction and training on infection prevention and control.

In addition to this strategy, the DH plans to launch a nationwide campaign this month to remind the public, GPs and other doctors

The right medicine: hospital staff have been issued guidance on ensuring that the medication patients take before their admission is documented properly. According to the National Patient Safety Agency, which has produced the guidance with the National Institute for Health and Clinical Excellence, more than 7,000 medication errors between November 2003 and March 2007 involved patient admission or discharge. These included two that were fatal and 30 that caused severe harm. The guidance can be found at www.nice.org.uk/guidance/index.jsp?action=byID&o=11897

The National Institute for Health and Clinical Excellence (NICE) has published six new guides to help NHS staff commission evidence based care for patients.

The guides cover services for: 4 Memory assessment 4 Hysterectomy4 Endometrial ablation4 Female urinary incontinence 4 Intrauterine contraception

and heavy menstrual bleeding4 Bariatric surgery.Each commissioning guide pro-vides the information on key clinical and service related issues that should be considered during the commissioning process. 4 The guides can be accessed at www.nice.org.uk/Commissioning Guides and ideas for future guides can be emailed to com-missioningguides@nice.org.uk

Comissioning care

Ala

my

Revised code of practice

The DH has published a revised code of practice to help NHS trusts plan and implement the control of healthcare associated infections. The code recommends quarterly infection prevention and control reports by matrons and clinical directors. For copies of The Code of Practice for the Prevention and Control of Healthcare Associated Infections, go to www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy AndGuidance/DH_081927

NM1409 04-05 news.indd 4 23/1/08 5:49:20 pm

news

nursing management Vol1�No9February2008 5

Funds for hospital trusts to recruit specialist staff in fight against infectionFunds for hospital trusts to recruit specialist staff in fight against infectionthat antibiotics are ineffective against many common ailments.

Ministers will introduce screen-ing for all elective patients by March 2009 and for all emerg-ency patients as soon as poss ible over the next three years.

They also expect every hospital in England to have undergone a ‘deep clean’ by next month4 For copies of the Clean, Safe Care strategy, go to www.clean-safe-care.nhs.uk/Article-Files/Files/CleanSafeCare_ReducingInfectionsAndSavingLives_Strategy.pdf

Scottish government warned over healthcare strategyThe RCN has warned The Scottish Government against trying to do too much too quickly when implementing its new health strategy.

Better Health, Better Care lays out a vision for a health service that is centred on public, patient and staff involvement.

It emphasises mental and child-ren’s health while proposing that nurse led clinics are based in pharm acies and that primary care access should be more flexible.

RCN Scot land director Theresa Fyffe welcomed the thrust of the plan, but said: ‘We are concerned that the

action plan may be trying to achieve too much too quickly, parti cularly given all the pract-ical and cultural changes pro-posed over the next year.’

See A new strategy for Scotland, by cabinet secretary for health and wellbeing Nicola Sturgeon, on pages 8-9

The Nursing and Midwifery Council and Healthcare Commis-sion have signed a memo randum of understanding to strengthen public protect ion.

The agreement sets out the levels of co-operation and terms by which the two organisations will work together when carry-ing out their regulatory duties in England and Wales.

While the primary focus of the agreement is information sharing, other areas in which the two organisations can collabor-ate include investigat ions and reviews, the provision of train-ing and guidance, complaints and cross reference of issues of concern, and the offering of advice to ministers and joint inspection teams.

New deal to boost public protection

R C N g e n e r a l s e c r e t a r y Peter Carter is meeting with nurs-ing directors and senior nurses to work out how the college can meet their needs better.

As part of the college’s Fresh Start project, meetings are tak-ing place at each of the nine RCN regions, to which the college’s regional direct ors have invited directors of nurs-

ing and other senior nurses in their areas.

Acting head of the RCN pro-fessional nursing department Steve Jamieson said that nurses’ views will feed into a work plan, expected to be written next month, on improving member-ship services for senior nurses.

Chair of the RCN nurses in operational management forum

Deborah Critchley welcomed the move, saying that it would give senior nurses opportunities to alert the college to areas of concern and so would enable the college to support senior nurses better.

But she added: ‘My concern is that, if expectations get raised and nothing happens, it will lie badly with people.’

RCN consults senior nurses on future plans

Staff at NHS, community and independent sector organisations are being urged to tell patients and clients about the Nursing Standard patient’s choice award, launched last month.

The award, supported by The Patients Association, is the latest category in Nursing Standard’s annual Nurse of the Year awards and is for nurses, midwives, health visitors and healthcare assistants who have ‘made a real difference’ to patients, clients or loved ones.

The closing date for nominations is February 15. To nomin ate someone, members of the public can visit www.patients-choice.co.uk or call 020 8872 3140.

Patients to nominate nurses for 2008 awards

Nursing Man-agement edit-orial advisory board member

David Benton, left, has been

a p p o i n t e d chief exec-

utive of the Internat ional Council of Nurses. He takes up the five-year appointment on October 1, after Judith Oulton leaves the post.

Mr Benton has been a con-sultant in nursing and health policy at the council, where he has focused on regulation, licensure and education issues, since 2005. Previously he had been director of nursing at NHS Grampian.

See also On the move, page 6

UK nursing directorappointed ICN chief

Wiping out infection: ministers expect every hospital in England to have undergone a ‘deep clean’ by next month

Pho

todi

sc

NM1409 04-05 news.indd 5 23/1/08 5:49:45 pm

opinion

on the move

get connected

Send details of senior nurses and other healthcare professionals who are on the move to nick.lipley@rcnpublishing.co.uk

6 nursing management Vol 14 No 9 February 2008

Barbara Stuttle CBE, RGN, DN, MHM is an executive nurse at South West Essex Primary Care Trust and a national clinical lead for nursing and midwifery at NHS Connecting for Health

THE NEED FOR community clinicians to acquire up-to-the-minute information is such that the introduction of mobile information technology (IT) in primary care settings is becoming more important than ever.

Meanwhile, the increasing number of nurses asking for this technology to help them provide care in the community has led NHS Connecting for Health (CFH) to establish its Community Mobile Working Project.

The purpose of the project is to study how community clinical staff can use mobile technology to make rapid access to multi-disciplinary records rather than enter data into multiple paper records.

The current ageing population and increasing incidence of long term conditions present the NHS with a huge challenge, and those older people who live with more than one long term conditio often have both clin-ical and social problems to overcome.

Meanwhile, caring for people with long term conditions consumes a large proportion of health and social care resources.

The Department of Health white paper, Our Health, Our Care, Our Say, published two years ago, emphasises the need for healthcare staff to focus on maintaining the independence of older patients while manag-ing their long term conditions, adding that this care will often be delivered outside trad-itional healthcare environ ments. This need explains why community clinical staff require rapid access to multi-disciplinary records.

As part of the National Programme for Information Technology, the NHS Care Records Service can help staff in clinics and acute environments access these records. But clinicians and therapists who work primarily in the community are prevented from taking full advantage of these benefits.

Because these professionals have no forms of mobile connectivity when at the point of care, they cannot access essential patient data and have to enter data into multiple paper records. Ensuring that we make better use of IT therefore will help to improve the effect-iveness and safety of care.

At NHS CFH, we are working with colleagues from various nursing commun-ities, as well as those from the information management and technology departments of primary care trust and strategic health authorities to develop a ‘toolkit’ for organis-ations that want to implem ent techniques of mobile working.

To reduce duplication of effort and risk, the toolkit will build on the experiences of several different health communities that have piloted mobile working already and have made the results available for other organisations.

The toolkit will be made available electron-ically by the end of April and will remain a ‘live’ document thereafter so that the infor-mation it contains can be updated regularly. These updates will ensure that its accuracy and timeliness are maintained nm For further information about the Commun-ity Mobile Working Project, contact senior project manager Helen Hood, at helen.hood@nhs.net

Joyce Cattericktakes up post this month as chair of South West Yorkshire Mental Health NHS Trust, based in Wakefield. Ms Catterick, who has worked in general nursing, paediatric nursing and midwifery and has served on the former Calderdale and Kirklees Health Authority, has been chair of Calderdale Primary Care Trust for almost six years. Her new term of office is for four years. South West Yorkshire Mental Health NHS Trust is applying for foundation status.

Paul Wilsonhas been elected to the Nursing and Midwifery Council’s governing body as the new alternate council member for nurses in Scotland. Mr Wilson is director of nursing in Lanarkshire, Scotland’s fourth largest health board. He has extensive leadership experience within the Scottish health service and as the director for NHS trusts in Scotland’s civil service.

Mansour Jumaahas become the first nurse in the UK to be elected to the influential leadership succession committee of the Honor Society of Nursing, Sigma Theta Tau International. Dr Jumaa is a member of the steering committee of the RCN nurses in executive and strategic roles forum and a chief external examiner on leadership development at the University of Cumbria.

Roger Watsonhas become the first person in the UK to become a fellow of the American Academy of Nursing. Professor Watson, director of research at the University of Sheffield’s school of nursing and midwifery, is one of the first three nurse leaders from outside of the United States to be inducted into the academy.

Jennifer Dixonhas been appointed director of The Nuffield Trust for Research and Policy Studies in Health Services. Dr Dixon takes up post this spring, with the departure of Neil Goodwin, who has served as interim director since August last year. She is currently director of health policy at the King’s Fund, and a board member of both the Audit Commission and the Healthcare Commission.

NM1409 06-07 gcuc054071.indd 6 23/1/08 5:48:25 pm

opinion

nursing management Vol 14 No 9 February 2008 7

SINGLE ROOM ACCOMMODATIONLAST YEAR, the Scottish Executive,

now The Scottish Government, and

NHS Estates issued planning guidance

on the provision of single room

accommodation in hospitals.

The authors of this guidance, which

follows the peer review of Hospital

Wards Confi guration: Determinants

infl uencing single room provisions,

a report prepared for NHS Estates by

the European Health Property Network

(EHPN), suggest that hospitals should

consider providing all their patients

with single rooms.

It is recognised widely that single

room accommodation can:

Reduce the spread of healthcare

acquired infection (HAI)

Protect patients who are

immunosuppressed

Offer patients greater privacy

Make the use of facilities more

fl exible

Increase patient choice.

Few nurses would question the need

for more single rooms in the NHS but

is it necessary to provide single rooms

for all patients?

The EHPN report, which was

published in 2004, highlights the need

for better communication between

staff and patients in single room

accommodation, and suggests that

rooms are designed better to enable

improved observation of patients.

It also notes that ‘the role of single

rooms in preventing HAI is not

proven by randomised controlled

trials’ but also acknowledges that the

role could play a part, along with good

hand hygiene, good ventilation and

adequate space around beds situated

in multi-occupancy areas, in this.

Although there is a lack of literature

to support the continuing provision of

multi-occupancy areas, there seems to

be anecdotal evidence of a need to offer

patients a choice between the two.

This choice may be necessary

because multi-occupancy areas may be

important to patients who:

Are afraid that, if they are placed

in single rooms, they will die in

isolation

Have had traumatic injuries or

episodes while they have been alone

and are afraid of recurrence

Have problems coping with aspects

of their condition such as stomas

and who are greatly reassured by

being able to converse with fellow

patients who have been through,

and dealt with, similar experiences

Rarely have visitors but enjoy casual

social intercourse with people who

visit other patients.

The provision of single room

accommodation for all patients

may also have implications for

staffi ng levels.

A Canadian study by Chaudhury et al

(2006), for example, concludes that

further studies should compare the

incidence of drug error, as well as

opportunities for surveillance and

patient outcome, in single rooms and

multi-bed bays.

It appears therefore that further,

large scale studies are required to

provide evidence supporting each

choice and to identify what patients

really want.

But in the meantime, if we intend to

reduce the impact of hospitalisation,

we should agree that patients must

be given the choice of single-room or

multi-bed accommodation nmLiz Norris MSc, RSCN is a physical planning nurse adviser at NHS Grampian

Reference

Chaudhury H, Mahmood A, Valente M (2006) Nurses’ perception of single-occupancy versus multioccupancy rooms in acute care environments: an exploratory comparative assessment. Applied Nursing Research. 19, 3, 118-125.

your letters under cover

DURING A recent conversation with a professional

violinist on the nature of leadership and teamwork,

I was struck by the similarities between the world

of the orchestra and that of health and social care

teams: the common struggle for leadership within

hier archy; the relationships of conductors or chief

executives and their respective teams; the need for role

clarity; and the shared drive for creativity, innovat ion

and improvement.

I was therefore intrigued, not long

after this conversation, to rediscover

an account, by executive director

of the Orpheus Chamber Orchestra

Harvey Seifter and Peter Economy,

of the culture of ‘collab orative lead-

ership’ developed by this New York

based orchestra.

This account, Leadership Ensemble, describes how

the Orpheus Chamber Orchestra, which rehearses,

performs and records without a conductor, bases its

approach on eight core principles: putting power in the

hands of the people who work hardest; encouraging

individual responsibility for quality; creating clarity of

roles; sharing leadership; fostering ‘horizontal’ team-

work; learning to listen and to talk; seeking consensus;

and being dedicated to a mission.

The development of each of these themes is

accomp an ied by case studies from companies that have

adopted the ‘Orpheus Process’ with great success.

The book is entertaining and contains plenty of

practical steps to integrate its principles into any

workplace.

Although the language used may seem alien to

some, many of the principles it describes are relevant

to all effect ive leadership, teamwork and organisa-

tional cultures, including those of modern healthcare

services nmSeifter H, Economy P (2001) Leadership Ensemble: Lessons in collaborative management from the world’s only conductorless orchestra. Times Books, London.

Matthew Rice is a learning and development facilitator at the RCN

Which book do you think all nurse leaders should read? Email your choice to nick.lipley@rcnpublishing.co.uk

I was therefore intrigued, not long

after this conversation, to rediscover

an account, by executive director

of the Orpheus Chamber Orchestra

Harvey Seifter and Peter Economy,

Leadership Ensemble: Lessons in collaborative management from the world’s only conductorless orchestra by Harvey Seifter and Peter Economy

NM1409 06-07 gcuc054071.indd 7 23/1/08 5:48:32 pm

opinion

The ScoTTiSh Government’s new health strategy, Bet­ter Health, Better Care, sets out a new vision for the NHS in Scotland.

Thi s out l ines ambitious proposals to increase patient

participation, improve access to health care, and focus on the dual challenges of improv-ing Scotland’s public health and tackling health inequalities. The strategy also contains a package of measures to deliver improve-ments to the primary care system over the next three years.

As health and wellbeing secretary for Scotland, I want to see more flexible access

to GP surgeries, more anticipatory care, and easy, walk-in access to a range of primary care services.

These innovations will start to deliver the local and more preventive health service that we will need in the future.

Central to the new plan is patient part-icipation. Not only do I want patients to become partners in their own care, but I also want them to become involved in the design and delivery of health services.

Too often in the past patients have had too little involvement in changes to the provision of the health care that has a direct impact on them. This is something that I want to make sure does not happen in the future.

But I also want to make sure that staff are involved fully in decisions about the design and delivery of the NHS. It is vital that we

listen to those people who form the back-bone of our health service.

It is in this context that chief nursing officer Paul Martin has asked for a review of the senior charge nurse and midwife role in NHS Scotland.

The purpose of this review, which is due to report formally this month, is to enhance the contribution of the nursing and mid-wifery workforce in implementing the policy vision of The Scottish Government, while acknowledging that the senior charge nurse role should be embedded in a strong clini-cal leadership model. This will ensure that senior charge nurses are empowered, not only to improve the delivery of safe, effective and timely care, but also to enhance patients’ experiences at ward level and to contribute to the design and delivery of services.

Around ThiS time last year, there were said to be about 40,000 managers in the NHS, and questions were asked in the media about what they all did. More recently, man-agers at several NHS trusts have been blamed for losing patient records.

It seems that, if this staff group is not being judged superfluous, it is being blamed for something. Surely it is about time we stopped knocking them.

After all, managers and leaders are essent-ial to the success of any business, and manag-

ers are an integral part of NHS teams. When NHS managers are supported, educated and trained, they can improve the care provided to patients significantly.

I know that, when I was an NHS manager, I sometimes didn’t get things right but, with support, education and training, I was able to develop my skills and improve my practice.

However, just as critical opinions of NHS managers are expressed in the media, so man-agers themselves often express similar opin-ions about healthcare assistants (HCAs).

Working in partnershipFor the past three years, I have been lead-ing a national initiative to develop the role of HCAs in general practice, one of the 13 Working in Partnership Programme (WiPP) schemes aimed at increasing capacity in this area. During this time, I have noticed a com-mon view among managers that, unless HCAs are delivering care to patients, they are not working.

I make this observation, not to criticise managers, but to offer them an opportunity to

health and wellbeing secretary nicola Sturgeon sets out what the new government

health strategy means for nursing leaders

Paul Vaughan explains why the development of healthcare assistants should be a priority

for senior nurses in 2008

The ‘year of the hcA’

A new strategy for Scotland

� nursingmanagementVol14No9February200�

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opinion

As part of Better Health, Better Care, we will take several steps over the next three years towards creating a more mutual NHS in which patients, the public and staff are treated as partners in health and co-owners of the NHS.

By May, we will launch a public consulta-tion on proposals for inclusion in a Patients’ Rights Bill to cover waiting time guarantees and the right of patients to be treated as part-ners in their care. Following this consultation, we will introduce by the summer a Local Healthcare Bill, which will include proposals for direct elections to NHS boards.

We will also produce and distribute an annual ‘ownership report’ to every house-hold in Scotland that sets out the rights and responsibilities of patients, and their carers, alongside information on how to access local services and raise issues or complaints.

And, for the first time, a service delivery plan for the future of the NHS will be aligned with the workforce planning strategy to ensure our workforce planning conforms to the principles of Better Health, Better Care.

To help us tackle high rates of student attrit-ion, we will invest £5 million a year to improve

support for nursing and midwifery students throughout their training experience.

We expect this measure will increase both the number of students who complete their courses and, eventually, the number of reg-istered nurses.

This year’s training numbers have been agreed with unions, NHS colleagues and universities, and will ensure that there are enough newly registered nurses and midwives to meet our future health service needs.

The £5 million investment will be in initiatives that enhance the nursing and midwifery student learning experience and support retention on pre-registration pro-grammes.

It will be linked directly to the recom-mendations in the report from The Scottish Government’s student nurse and midwife recruitment and retention sub-group pub-lished in December last year.

A delivery group, with an NHS board nurse director and an academic lead from Scotland’s higher education sector, will be established to oversee the investment process and to assess the impact of the initiative on student recruitment and retention.

Building on the progress made by The Scottish Government in gathering robust workforce data, we will work closely with the national workforce unit to ensure that all stakeholders across the NHS, as well as the emerging independent and voluntary sectors, are engaged fully with the national nursing and midwifery workforce planning process.

By doing so, we shall be able to continue to anticipate demand for nursing resources and have an appropriate skill mix in all areas of provision to support patient client need.

I am confident that the new action plan for health care and the workforce strategy will deliver real improvements for patients and staff across the NHS in Scotland.

I want to make clear though that senior nurses will play a key role in delivering our vision for the NHS. Their skills, experience and expertise are crucial to developing a health service that is fit for the 21st century nm 4 For copies of Better Health, Better Care, access www.scotland.gov.uk/Publica-tions/2007/12/11103453/0

Nicola Sturgeon is cabinet secretary for health and wellbeing

reflect on their attitudes to education and train-ing and, if appropriate, develop a new approach to supporting the development of HCAs.

Of course, many NHS managers have excellent track records in the development of HCAs, but I have heard time and again how HCAs have struggled to obtain sufficient study time to undertake mandatory training even though this is essential for them to carry out their roles safely.

As the NHS tries to balance its books, the first budgets to be cut are often those that relate to training. For example, lead practice nurses who offer education and training opportunities to nurses and HCAs in general practice have lost their posts at several primary care trusts. Yet we hear that the NHS will report a surplus at the end of this financial year.

I have heard from recruitment and retent-ion officers in the acute sector that, in some areas, HCAs receive so little support when

they join ward teams that they remain in them for no more than three months.

Meanwhile, clinical supervision and mentor-ship appear to be a luxury where HCAs are concerned, and there also seems to be a lack of support for HCAs to attend networks or forums to connect with other HCAs.

And I am not questioning attitudes only in the NHS. I regularly hear of occasions when HCAs in the independent sector have to pay for their own training and use their annual leave to attend courses.

delivering care effectivelyIn Securing Good Health for the Whole Popul­ation, which was published in February 2004, Sir Derek Wanless states that, by 2020, the health service will require a further 144,000 HCAs to deliver care to patients effectively.

But, if we do not optimise their skills and talents of those HCAs who are already in the

system, what hope do we have of attracting and retaining a further 144,000 of them?

So wherever you work, help HCAs attend conferences, ensure that they have access to supervision and mentorship, and work with your training departments and local education providers to develop courses from which they can gain transferrable qualifications.

For example, if your HCAs are RCN mem-bers, they can have a 10 per cent discount off any Open University course such as the K100 Understanding Health and Social Care.

Let’s make 2008 the year of the HCA! nm 4 Nurse managers can access further information about HCA development at www.wipp.nhs.uk/hca-gpn

Paul Vaughan is a learning and development facilitator at the RCN Institute and HCA initiative national project manager at WiPP

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RECEIVING LETTERS of resignation can generate mixed emotions. While filling a vacant post offers opportun ities for managerial change or the promotion of valued colleagues, few of us relish the administrative burden of recruitment.

Yet good recruitment practices and sound appraisal techniques can, if underpinned by policy and training, help to identify and prevent potential failures in performance. Confidence, experience and intuition also have roles to play in such situations. 

Organisations must not only be assured that recruitment processes are robust, but also that systems are in place to protect the public from poor performance and, as far as possible, maverick practitioners. This 

assurance requires diligence from managers during the recruitment process.

Identifying and preventing performance problems are not exact sciences and there are roles in them for intuit ion as well as analysis. They also require sufficient confidence to challenge individuals and processes. 

Nevertheless, the importance of policies and procedures in identifying and preventing performance problems should not be underestimated. 

When organisations operate smoothly and successfully, recruitment, appraisal and performance management processes often appear ritualistic and time consuming. They are valuable however in managing situations that deviate from the norm. 

Such situations can often be ident ified only in retrospect so it is import ant at all times to resist the temptation to cut corners and assume all will be well.  

The ‘worst case scenario’In discussing this topic, it often helps to consider the worst case scenario, which, for me, is the ‘Beverly Allitt case’. Her name has become notorious in the nursing world, and it is worth recalling, not only the horror of her crimes, but also the nature of her employment history. 

Ms Allitt worked on Ward 4, a child  ren’s ward at Grantham and Kesteven General Hospital, Lincolnshire, for a total of 58 days as part of a six-month contract, in 1991.  

During her training, she had had a history of excessive sick leave and examination failure but had exhibited a determination to demonstrate her competence. The ward she joined was understaffed and she volunteered for extra duties. She was later described as ‘unemotional’. 

Unexpected patient deaths started to occur on Ward 4, but these were not at first investigated and no suspic ions were raised by staff. There was later said to have been a culture of poor supervision on the ward. 

Eventually, there was an internal inquiry into the high number of card iac arrests that were occurring on Ward 4 but another 18 days passed before police were contacted. 

It was found that, during the 58 days that Ms Allitt was on the ward, 25 separate suspicious episodes had occurred, affecting 13 victims, four of whom died. 

A clear pattern to these events emerged: Ms Allitt was present on each occasion. She was finally convicted and given 13 life sentences for murder and attempted murder. 

Virginia Bottomley, the then health secretary, commissioned judge Sir Cecil Clothier to chair an independent inquiry into the circumstances of these murders. 

Among other things, his report critic-ised the sloppy appointment proced ures at Grantham and Kesteven and dismissed the hospital’s ward staffing shortages as a tangent ial issue. 

David Foster on the importance of choosing the right

candidates for jobs in the nursing profession

Recruiting with care

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The hospital, now called Grantham and District Hospital, is under new management

Of course, nursing is not populated by clones of Ms Allitt, but the risk of one appearing is constant. 

In this context I remember some sage advice given to me when I was a newly appointed manager: ‘Whatever you do, say or record during recruitment, appraisal and performance management, always consider how your documentation will read in two years’ time, and how you will justify your actions and decisions to an employment tribunal or judge.’ 

Protecting the publicThe Nursing and Midwifery Council (NMC) is responsible for regulating the profession nationally and,  by doing so, protecting the public. 

Employing organisations have their own recruitment policies, such as the validation of personal identification numbers, and they often use the NMC employers’ confirmation service. 

In developing local policies however, it is important to ensure that such precautions are not undertaken only once, at the recruitment stage, but that they are part of robust mechanisms for checking expiry dates, recording renewals and cross checking the NMC fitness to practise circulars for suspensions, cautions and removals from the register. 

Electronic systems are excellent at prompting such actions but some scrutiny by ‘human software’ is also necessary. Use of the Criminal Records Bureau (CRB) to make checks on applicants’ criminal records, for example, is now embedded in best practice. 

But Ms Allitt had no criminal record, so even if the CRB had existed at the time, such a check would have failed to indicate that she could commit her crimes. 

Senior nurses may therefore have to decide for themselves, as I have done, whether someone who, 30 years ago, was convicted of misappropriating a Christmas tree or someone else who was convicted recently of stabbing a colleague with scissors are suitable for jobs in health care. 

Most organisations insist that managers who conduct recruitment interviews are trained, not only to elicit useful information at interviews, but also to complete paperwork and demonstrate that decisions are made fairly. These managers also need self confidence and experience to challenge claims made in curricula vitae or to spot gaps in career histories. 

After all, people do not necessarily declare in interviews that they have spent time at Her Majesty’s pleasure. 

If applicants have prolonged training records, these must be explored, as well as the amount and frequency of sick leave they have taken. However, if these issues cannot be discussed with applicants, it is up to referees to discern patterns of absence and reveal whether these are covered by 

certificates.Each candidate’s choice of referees 

is important therefore. The most recent employer should be included along with someone who has sufficient experience, expertise and seniority to offer trustworthy opinions on the candidate’s suitability for the role. 

When reading referees’ comments however, it is important to remember that what they omit can be almost as important as what they include. Although they are obliged to provide honest, factual and balanced testimonies, they are not obliged to recommend candidates for specific posts. 

As well as being expected to read referees’ comments, many managers are asked to provide them. 

I expect candidates to ask me to act as their referee before their potential employers contact me and, if I am asked to provide references for people who have been appointed already, I rarely do so, on the grounds that the employers in such cases cannot be genuinely interested in my opinion. 

Equally, I do not appoint  candidates ‘subject to references’, or before I have had their references checked.

ResponsibilitiesHuman resource departments have differing responsibilities. Some are responsible for recruitment services, others simply advise managers on recruitment processes. 

Whatever recruitment model is used, managers should always develop meaningful links with their human resources departments, as well as their local union learning representatives, so that they can benefit from the expertise of others and ensure that recruitment is a collaborative effort. 

Managers should be in no doubt however that responsibility for decision making rests with them. Throughout the recruitment process, the diligence of managers is crucial, especially as the number of online applications rises. 

The organisational failures that allowed Ms Allitt to be recruited into the nursing profession raise a number of questions that all healthcare managers should ask themselves: How would they have written Ms Allitt’s reference? Would they recruit someone, even on a short term contract, with an excessive sickness record or a history of failing exams? And would they have spotted Ms Allitt as a potential problem if she had applied for a post at their organisations, or would she have slipped through their recruitment nets too? nm

David Foster PhD, MSc, RN, RM, MCIPD is the director of non‑medical postgraduate development at Imperial College Healthcare NHS Trust, London, and chair of the Association of UK University Hospitals Directors of Nursing Group

Managers need self confidence and experience to challenge claims made in curricula vitae or spot gaps in career histories

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Playing the ideal role

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Becky Simpson assesses the value of drama based training

to healthcare professionals

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Many of the people who act as clinicians or patients in television programmes have been involved in some sort of drama based training.

There are many similarities between the acting and clinical professions, and such training can be an exciting and innovative way for healthcare professionals to develop their communication skills.

For drama based training to be effective however, the use of theatre skills such as performing scenes and role playing should involve professional role playing actors and should be managed sensitively by trained facilitators.

Meeting aimsTheatre performances by professional actors can energise and introduce fun into training or conference pro-grammes while helping them to meet their aims.

Sketches can be written and performed so that they are thought-provoking and entertaining, and can highlight issues concerning for example diversity and conflict management.

They can also be used to demonstrate good and bad outcomes, analyse appropriate strategies for improvement, and offer delegates opportunities to reflect on different styles of communication. Such group work can also offer staff opportun-ities to work together in teams.

Most delegates prefer to observe rather than take part in theatre perfor-mances, although such observation can help to persuade them to take part.

Another ‘ice breaker’ is forum theatre, a theatrical device derived from Brazilian theatre practitioner Augusto Boal that involves delegates re-directing and re-enacting the theatre performances they have already seen.

The purpose of this work is usually to identify points of conflict between characters in the performance and, with the help of facilitators, create strategies to resolve these.

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Role playPerhaps the most valuable way to challenge how people usually communicate and to help them develop their self knowledge is role play.

This offers delegates opportunities to practise their communication skills by talking to actors playing patients or colleagues in near real life situations.

Delegates are often surprised by how much they enjoy and are stimulated by role play, and often learn to experiment with different approaches.

Role play must be handled sensitively however, by experienced trainers and actors. Participation must be optional and never humiliating, and delegates should leave role play sessions, not only confident in their existing skills, but with new ideas about developing their expertise further.

If role play is to work well, facilitators and clients must be aware of the criticism it has occasionally received. For example, some delegates will have already had unpleasant experiences performing role play sessions that were managed badly, while others may feel anxious about performing in front of their colleagues.

It should always be part of good role play practice therefore to reassure nervous delegates and to manage their anxiety, and it is the job of profess-ional drama trainers to judge sens-itively when to persuade delegates to express themselves and when to ‘back off’, when to reassure them that their performance is good and when to challenge them to do better.

Role play is not necessarily about ‘getting it right’ but it can provide great opportunities to experiment in a safe environment with different approaches.

When colleagues perform role play without professional actors to help them, it often fails. This may be because their perceived differences in status prevent them from expressing themselves fully or because they fear retribution if they do, or simply because one or more of them suddenly has a fit of the giggles.

Professional actors are experienced however and well briefed in the parts they play. Because they are experts at adjusting their behaviours to different situations while staying in role moreover, they can become ‘foils’ for the non-professional delegates.

Effective role playing is less about acting and more about reacting, and good role play actors are trained to respond appropriately and to adjust their behaviour to the individuals with whom they work.

Actors who regularly work alongside particular professions, for example with clinical professionals, can learn about the arenas in which they work, and can use what they have learned in their role play and feedback.

Feedback is an important aspect of role play and most actors are trained to give constructive comments to delegates.

There are various models for facilitating such feedback, the most commonly used being adapted versions of Pendleton’s rules or the Calgary Cambridge guide (Box 1).

Box 1. Guides for facilitating feedback

Pendleton’s rules adapted for actors and delegates

the delegates describe what was done well

the actors describe what was done well

the facilitator sums up

the delegates say what could be done differently

the actors say what could be done differently

the facilitator sums up and reiterates what was done well

adapted from faculty Development (2007)

The Calgary Cambridge guide adapted for facilitators,

actors and delegates

the delegates describe their aims to the facilitator

the facilitator asks the delegates to describe what help they need to achieve their aims

the facilitator asks the delegates what problems they have experienced in achieving their aims and encourages them to overcome these problems themselves

the facilitator directs feedback sessions among delegates and actors to ensure that it is balanced and objective, and is descriptive rather than judgmental

adapted from Chowdhury and Kalu (2004)

Author Becky Simpson and colleague David Schaal demonstrate role play for delegates

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actors and facilitatorsActors can introduce creativity, energy, enthus iasm, realism and object ivity to drama based training. They are used to managing anxiety and, because they are not caught up in the ‘office politics’ of client organisations, they are not constrained by them.

Like some non-actors however, actors can be unprofessional when performing role play. If they expect a script, make up, lights and special treatment, limousines or pampering, they will be disappointed.

They must be able to improvise and they must understand that the training sessions are about the delegates, not them.

To ensure a professional approach is taken during acting sessions, facilitators are sometimes needed.

Their key qualities are objectivity, sensitivity, flexibility, energy and imagination. They must be confid ent because, if they are not, their anxiety can spread to the groups with whom they work.

But they must not lecture delegates or, worse still, demonstrate how they should have performed interactions. Instead, they must reassure and direct them, and sum up how the inter actions went when they have ended.

The services described in this article were launched 20 years

ago by the commun ications and presentations training company, Playout (Box 2).

It should come as no surprise therefore that actors at Playout have worked alongside clinic ians for several years.

After all, many good healthcare professionals demonstrate acting skills, not least by adjusting their style to communicate effectively with different patients or clients.

Breaking bad news to someone for example requires a different tone of voice from telling someone that an operation has been a success.

Most healthcare professionals know that the ability to commun-icate well is an important part of their jobs, although some argue that they do not have enough time and resources to develop good communicat ion skills.

It takes skill for healthcare profess-ionals to tell patients or their relatives that they do not know what’s wrong with them, or that they know what is wrong but there is nothing they can do about it.

By inviting professional actors to act as patients in role play sessions therefore, nurses and other clinic ians can gain new insights into the exper-iences of their patients nm

Becky Simpson is managing director of Playout

Referencesfaculty Development (2007) Models of Giving Feedback: Pendleton’s rules. www.faculty.londondeanery.ac.uk/e-learning/feedback/models-of-giving-feedback (Last accessed January 16 2008).

Chowdhury RR, Kalu G (2004) Learning to give feedback in medical education. The Obstetrician and Gynaecologist 6, 4, 243-247.

Box 2. Playout

Playout is a commun ications and presentations training company that started to help pioneer drama training 20 years ago.

It uses theatre performances, role play and forum theatre. It also produces DVDs featuring training programmes written by professional scriptwriters and performed by professional actors. these can be used as training tools or as a means to follow up training. Playout also runs training courses for leaders and facilitators, and its members have worked with facilitators from both clinical and non-clinical backgrounds.

Playout has trained health service staff and healthcare students, and regularly provides courses for clients including the Royal Marsden nhS foundation trust, in London, Brighton and hove City teaching Primary Care trust, Brighton and Sussex Medical School and hertfordshire Partnership nhS foundation trust.

further information is available from the author by emailing her at becky@playout.co.uk or from the Playout website, at www.playout.co.uk

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Hearing the alarmIn the wake of the Healthcare Commission report into infection outbreaks at

Maidstone and Tunbridge Wells NHS Trust, Lindsey Scott reflects on the similarities

between events in Kent and those at the Bristol Royal Infirmary

MANY DIRECTORS of nursing will, like me, have read with interest the Healthcare Commission (2007) report into the outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust, Kent, and, being responsible to their trust boards for infection control, will have reassessed their trusts’ policies in light of its recommendations.

I doubt however that many who read the report experienced my sense of unease because I have a personal involvement with a trust that has experienced a similar failure.

Centre of excellenceI was recruited as director of nursing at the United Bristol Healthcare NHS Trust in 1997 both to establish nurse leadership and to lead the implementation of clinical governance. These tasks were particularly important in Bristol at the time because they followed the

recent announcement of a public inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984/95 (Kennedy 2001).

Being at Bristol when the full inquiry report was published, I read it and got to know it line by line. I considered that the trust owed it to the parents of the children who had died during the inquiry period to learn the appropriate lessons so that Bristol would become a centre of excellence with patient safety as its number one priority.

Clinical governance and systems of infection control that are now expected routinely in the NHS were born in part out of the events at Bristol.

The unease and even dismay I felt in reading the Maidstone and Tunbridge Wells report was due to the start ling similarities between the events it describes and those that had occurred at Bristol. For example, both inquiries concern preventable deaths that were the result of cultural

and organisational, rather than individual, failings.

I wondered why the NHS had not, after all, learned the necessary lessons of the Bristol report such as the need to listen to the concerns of patients and staff, and to be aware of events across the NHS. And I wondered how we, as nurse leaders, can ensure that such reports never appear again.

The two inquiriesOf course, there are differences between the two inquiries, most obviously of scale. Sir Ian Kennedy’s inquiry into events at Bristol took three years, evidence was received from more than 570 witnesses, and 900,000 pages of doc uments were reviewed, all at a great financial cost.

The Maidstone and Tunbridge Wells investigation, on the other hand, took only seven months, during which 200 people were interviewed and 1,000 documents examined.

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The clinical contexts of the events they describe are different too. In Maidstone and Tunbridge Wells, it was estimated that 90 deaths were probably or defin itely caused mainly by infection, whereas in Bristol, between 30 and 35 more children under the age of one year died after surgery than was expected for a typical unit in England at the time.

There are also differences in scale between the responses of the general public and the media to the findings of the two reports.

But there are also similarities between the reports. One of the most striking of these is that, in both cases, deaths could have been prevented if the trusts concerned had devised appropriate systems to protect patients.

Kennedy says that his report into events at Bristol ‘was not an account of bad people… or of people who did not care… or of people who wilfully harmed people’. I think that this can be said also of staff at Maidstone and Tunbridge Wells.

Both reports tell stories of trusts struggling with competing object ives during periods of organisational change. Maidstone and Tunbridge Wells, for example, had previously undergone merger, and was focusing on access and financial targets.

High bed occupancy levels directly influenced the spread of infection

at the trust, there was reportedly a lack of organisational stability and board members had a tendency to discourage ‘bad news’.

Cost controlHow similar these events sound to those described in the Bristol inquiry report! This organis ation had also been recently restructured, by becoming a NHS trust, at a time when the NHS culture encouraged cost control and efficiency. Although the new trust appeared to be structurally stable, it was not.

In retrospect, its clinical directorates had too much autonomy and its teams were dysfunctional, while its board members tended to want to hear only solutions, not problems.

Striking similarities can be found in the reports between the role descriptions of external organisations such as the Department of Health, the Health Protection Agency and health service commissioners, namely the primary care trusts and either the strategic health authorities or their predecessor bodies.

At both trusts, confusion of role and function among these external organisations is cited as contributing to internal confusion and an inability to identify problems.

The key factors identified in both reports, of competing objectives and

targets, and of organisational change, are not new to the NHS; in fact, they should probably be seen as the norm.

ComplexityThe management of health services is recognised internationally as one of the most complex management tasks in the world and, while those of us who are in leadership roles must acknowledge this complexity, we must not use it as an excuse when our services fail the public and our patients.

Trust boards are accountable for managing these complex working environments and, if they are to make informed decisions about investment priorities and interventions when things go wrong, they must consider information on performance across the entire service.

After stating that infect ion control is a priority, boards should not pay ‘lip service’ to the issue by reviewing either limited information on infect ion rates, as was the case at Maidstone and Tunbridge Wells, or inaccurate or incomplete information, as was the case at Bristol. The latter trust regarded comprom ises in the quality of care as obstacles to be overcome rather than safety alerts that warranted cessation of services.

Both boards ignored the wide range of information that was available to them, even though this S

tock

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18 nursingmanagementVol14No9February2008

could have warned them of potential problems and helped them to take remedial action.

What strikes me most about the report of events at Maidstone and Tunbridge Wells is that some of the most fundamental recommendations of the Bristol report had not been implemented.

Clinical governance requires NHS organisations to put in place systems to identify problems of quality and to act on them.

Kennedy’s Recommendat­ion 6 for example states that available information should be based on current evidence, while Recommendation 39 describes the NHS regulatory framework and Recommendations 130­134 outline the standards of care required to prevent ‘another Bristol’.

Yet, the Maidstone and Tunbridge Wells investigation, whose remit was to consider whether the trust’s systems for identifying, preventing and controlling infection were adequate, found that they were either non­existent, out of date or inaccessible to staff.

Two fundamental clinical governance system failures had been specifically identified in the Bristol report, namely a failure to listen to staff and patients when they said that things had gone wrong, and a failure to learn from mistakes that had occurred in the wider NHS.

Indeed, the need for trust board members to listen to and involve service users was the subject of 37 of Kennedy’s recommendations.

Yet, at Maidstone and Tunbridge Wells, complaints about quality of care and the concerns of staff members, particularly about infection control, gathered during a national staff survey carried out by the trust in 2005 were ignored by the board.

Most significantly, the directly relevant lessons from C. difficile outbreaks at Stoke Mandeville

Hospital, Buckinghamshire, (Healthcare Commission 2006) were not acted on.

ChallengesWhen I was interviewed for the job in Bristol, I was left in no doubt of the challenges I faced. Not only did I have to introduce effective nurse leadership,

but I also had to change the culture of the organisation, from

one in which the nursing contribution was underrecognised to one in which it was valued and supported.

Directors of nursing and other nursing leaders

must always remember that nurses have a unique role in

health care because, of all healthcare professionals, nurses spend the most time with patients, and therefore have the greatest influence over the patient experience and patient outcomes.

In Kennedy’s report, the then director of nursing at Bristol was criticised for failing to lead the nursing profession adequately. She was said to be ‘feared’ and ‘inaccessible’, and tended to overemphasise her wider operational role.

At Maidstone and Tunbridge Wells, the director of nursing was also the director of infection prevent­ion and control, yet was found to have an inadequate understanding of the role and to have failed to obtain the information he needed either to fulfil the role or to brief the board.

In both trusts, strategic direct­ion was lacking and management arrangements for the teams concerned confusing.

More significantly perhaps, nursing was seen in both trusts as a cost rather than an asset: because of cost controls at Bristol, because of the need to meet financial targets at Maidstone and Tunbridge Wells. There were also staffing shortages at both.

Nurse leaders can do several things to ensure that such reports are not published again. First, we can make sure that the complexity of the NHS does not excuse dysfunctional cultures or failing services again.

Second, we can work with medical directors to ensure that clinical governance systems are effective, and that our boards receive and consider robust information across all services, including information on finances, access targets, clinical quality, safety and patient experience.

Finally, we can improve our personal communication skills to convince our boards that, while we shall always strive for savings, the nursing resource is an asset, not a cost. After all, we have already succeeded in becoming more efficient than other NHS professions.

But, while we strive in our organisations to deliver on this responsibility, we must also challenge the DH and all external stakeholders to learn from the failures of Bristol, and of Maidstone and Tunbridge Wells, and to ensure that the working culture that made them possible never reappears nm

Lindsey Scott SRN, SCM, DipManagement Studies, MBA is chief nurse and director of governance at the United Bristol Healthcare NHS Trust

References

Kennedy I (2001) The Report of the Public Inquiry into Children’s Heart Surgery at the Bristol Royal Infirmary 1984-1995. The Stationery Office, London.

Healthcare Commission (2006) HSE Investigation into Outbreaks of Clostridium Difficile at Stoke Mandeville Hospital, Buckinghamshire Hospitals NHS Trust. Healthcare Commission, London.

Healthcare Commission (2007) Investigation into Outbreaks of Clostridium Difficile at Maidstone and Tunbridge Wells NHS Trust. Healthcare Commission, London.

Under the microscope: C. difficile 

Sci

ence

Pho

to L

ibra

ry

NM1409 16-18 fLS064.indd 18 23/1/08 5:33:30 pm

feature

20 nursingmanagementVol14No9February2008

The firsT NHS found­ation trusts were authorised­ in April 2004 and­ have grown in number ever since. Ind­eed­, by the end­ of this year, most acute and­ mental health care in England­ will be provid­ed­ by NHS found­ation trusts.

This growth in the number of found­­ation trusts in the acute and­ mental health care sector coincid­es with an improvement in their performance, as highlighted­ by the Healthcare Commission in its annual health check, published­ in October 2007.

Accord­ing to this health check, of the 19 NHS organisations rated­ ‘excellent’ for their use of resources and­ the quality of their services, all are found­ation trusts.

These successes are encouraging, but, to create truly patient focused­ health care, continuous improvement is need­ed­ and­ found­ation trusts must tap into the knowled­ge and­ exper­ience of their clinical staff to realise fully the benefits of their new status.

Found­ation trusts d­o not achieve high stand­ard­s simply because the correct d­ecisions have been taken at board­ level; strategies and­ plans to improve quality will have the d­esired­ effect only if front line staff are engaged­ fully in them.

Understanding clinical quality In assessing the performance of trust board­s, staff at Monitor often find­

to their success, and­ this is precisely why Monitor introd­uced­ service line management (SLM) to the NHS.

service line managementFew NHS staff are likely to be familiar with the concept of SLM. If its name has a corporate ring to it, it is because its roots are in the business world­, where it has been used­ wid­ely for many years.

Monitor believes however that SLM represents a logical step forward­ for the UK’s increasingly d­evolved­ healthcare system.

In simple terms, SLM involves id­entifying organisations’ d­ifferent business units, or service lines, such as orthopaed­ics, and­ the contributions they make to overall performance.

In this context, performance is measured­ against a balanced­ range of criteria includ­ing clinical quality, levels of patient experience and­ staff satisfaction, and­ financial performance.

Id­eally, a single ind­ivid­ual, usually a clinician, is held­ accountable for this performance and­ can d­ecid­e how it can be improved­.

Although one way of improving the performance of trusts is to increase their profitability, SLM should­ not be d­ismissed­ as a cost cutting exercise because it can also provid­e clinical staff with opportunities to red­esign services to provid­e better care.

Nevertheless, all NHS found­ation trusts have a responsibility to balance their books.

William Moyes from the independent regulator of Nhs foundation trusts, Monitor,

describes why senior nurses should understand the theory of service line management

Laying it on the lineboard­ members experience greatest d­ifficulty when respond­ing to questions about their und­erstand­ing of quality.

The importance for trusts of establishing robust systems for feed­back on clinical quality is mad­e clear by the Healthcare Commission’s report on Maid­stone and­ Tunbrid­ge Wells NHS Trust, Kent, published­ in October.

This report conclud­es that the process by which issues of potential clinical risk were raised­ at the trust had­ failed­. It states: ‘Overall the system that was intend­ed­ to bring clinical risk to the attention of the board­ d­id­ not function effectively, and­ the board­ seemed­ to be insulated­ from the realities and­ problems on the general ward­s.’

For those who think that the establishment of a found­ation trust is solely a financial matter, Monitor’s focus on quality may be surprising, but, because safe patient care d­epend­s on strong finances and­ good­ governance, we require robust business plans from all applicants for found­ation trust status.

After all, the organisations that perform best in the NHS combine good­ financial management with high quality care. Staff at Monitor are not naïve about the problems encountered­ by NHS and­ found­ation trusts in achieving high performance, however.

Being complex organisations, these must d­evolve the authority to make operational d­ecisions to the appropriate levels.

Obtaining access to appropriate, correct information is therefore key

Service line management should not be dismissed as a cost cutting exercise

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nursingmanagementVol14No9February2008 21

To be viable, they must ensure that their costs d­o not exceed­ their revenues and­, if they can d­eliver improvements in efficiency, they can invest in improvements to quality.

Ind­eed­, this is the basis of the found­ation trust financial mod­el; the ability to reinvest in patient services provid­es the incentive to make surplus income.

Service line management applies this approach to ind­ivid­ual special­ities, or service lines.

Of course, for SLM to be und­erstood­ and­ improvements to be id­entified­, clinical involvement and­ lead­ership are need­ed­.

If clinicians know how much their respective service lines cost, they can take the lead­ on id­entifying and­ implementing change, and­ the more ad­vanced­ their und­erstand­ing, the more they can improve the patient experience.

For example, Fig. 1, which is ad­apted­ from an example used­ by Monitor, shows how the clinical lead­s at a trust have id­entified­ how, by taking a more efficient approach to breast cancer care, savings can be used­ to improve quality elsewhere in patient pathway.

In this example, triple assessment comprises: clinical examination, rad­iological assessment using mammography or ultrasound­, and­ pathological assessment using cyto­logy or biopsy.

Multid­isciplinary meetings were held­ regularly to make d­ecisions on treatment and­ involved­ surgeons, oncologists, rad­iologists, and­ specialist and­ palliative care nurses.

By increasing the proportion of surgeries that are performed­ as d­ay cases, the trust has red­uced­ its costs.

As a result, these savings have been allocated­ for reinvestment to improve care elsewhere in the pathway of patients with breast cancer, for example by increasing the

amount of time nurses can spend­ with patients who are given breast cancer d­iagnoses, and­ by ensuring that all patients receive biopsy, ultrasound­ and­ mammography on the same d­ay that they see their breast surgeons.

Nurse leadership During a presentation at the 2007 annual conference of the chief nursing officer for England­, the author highlighted­ the invaluable contribution of nurse lead­ers to implementing the concept of SLM by ensuring that their staff d­evelop a genuine sense of owner­ship of clinical quality.

Because nurses are closer to the ward­s than any other group of clinic­ians, the role of senior nurses in implementing SLM can be crucial.

Of course, implementing organis­ational policy on the ward­s is a fund­amental part of improving trust performance, but SLM should­ also empower the nurses themselves.

This empowerment requires that nurse lead­ers und­erstand­ service lines across all aspects of performance.

Nurse lead­ers sometimes d­isagree with d­ecisions that affect service performance. They might think for example that the pace of change being proposed­ is unrealistic or that obvious improvement opportunities are being ignored­. Und­er SLM however, they can challenge such d­ecisions.

Monitor believes SLM is fund­­ amental to success in found­ation trusts and­, in those trusts where it has been piloted­, SLM has alread­y d­emonstrated­ benefits. Service Line Management was introd­uced­ into the NHS to help trusts realise their potential but, like any organisation, found­ation trusts are only as good­ as their staff.

Although the quality of services provid­ed­ by d­evolved­ organisations in the NHS varies, d­evolution offers nurses and­ other clinical staff opportunities to use their knowled­ge to improve services for all patients nm

William Moyes is chair of Monitor, the independent regulator of NHS foundation trusts

See also Webscan, on page 37

Fig. 1. Using service line management to improve the breast cancer patient pathway

screening

Triple assessment

Multi-disciplinary meetings and surgery

Chemotherapy and radiotherapy

follow up

Saving identified

4 increase proportion of breast surgeries, including mastectomies without reconstruction and breast conserving surgery, performed as day cases from 5 to 75 per cent

Net saving: £190,000 per year

Investments identified

4 eliminate waiting list

4 ensure that all patients receive a biopsies, ultrasound scans and mammograms on the same day they see their breast surgeons

4 ensure that patients are seen only by consultants, not junior doctors

4 increase time spent with each patient given a diagnosis of breast cancer from 15 to 60 minutes

Net cost: £190,000 per year

NM1409 20-21 fWM061.indd 21 23/1/08 5:28:23 pm

22 nursing management Vol14No9February2008

A tonic for the troopsfeature

Gail Lusardi, Allyson Lipp and Huw Williams report on how non-military healthcare staff

can learn valuable lessons in leadership by taking part in weekend exercises organised

by the Territorial Army, whose 100th anniversary

is celebrated this year

In deep water: participants in Exercise Medical Stretch work their way through an assault course

NM1409 22-25 fHW031.indd 22 23/1/08 5:24:11 pm

ExErcisE MEdical strEtch (EMS) is an annual, weekend event conducted by 203 (Welsh) Field Hospital (Volunteers), which is part of the Territorial Army (TA) medical services and the major TA medical unit in Wales.

The EMS event is held at Sennybridge Training Area, near Brecon, and comprises a series of ten command, leadership and team oriented tasks along a route of about ten kilometres across rugged terrain.

The exercise, which is open to members of all NHS trusts and local health boards in Wales, is designed to challenge participants both physically and intellectually, and to help identify individuals’ strengths and weaknesses.

Its intended outcome, namely the forging of strong bonds of friendship between the field hospital staff and their civilian counterparts, is part­icularly important at a time, as now, when military and NHS staff must work in harmony.

Not only does it act as a recruitment drive for the TA, but it also helps to ensure that, when NHS staff who are TA members are drafted to war zones, non­TA staff will replace them more willingly.

Meanwhile, even a brief experience of military life can help NHS staff understand the healthcare needs of soldiers returning from military service.

the exerciseLast year’s event, in June 2007, had a record number of participants, 117, who came from local health services, the University of Glamorgan and the Welsh Blood Service.

We spent the first night, a Friday, in dormitories, sleeping in bunk beds, which meant we came to know each other pretty quickly.

The following morning began with a 5.30am alarm call, followed swiftly by breakfast, and then we climbed

nursing management Vol14No9 23

A tonic for the troops feature

into vehicles to be taken to the north end of the training area.

We were then separated into teams and taken to various starting points along the route to begin the exercise.

At this point, it started to rain heavily and the sky looked dark for miles around, although this did not appear to dampen the spirit or resolve of any of the team members.

In fact, it became evident as the day progressed that, despite the horrendous weather conditions, every participant was determined to see it through to the end. And so, dressed in our army issue, one­size­fits­all waterproofs, and carrying 18kg backpacks, we marched on.

Every team conducted each of their tasks successfully, and the first day ended at around 8pm with pretty well everyone exhausted by the day’s activities. But the field hospital chefs soon had everyone feeling better by providing a fantastic indoor barbeque. It also helped that there was a bar.

On Sunday morning, we had another early start for the next phase of EMS, a timed march and obstacle course. The four­mile march and run promoted a genuine camaraderie among team members especially because, by then, sleep deprivation and cumulative fatigue were beginning to get the better of us.

To overcome and distract us from this, we encouraged each other, exchanged anecdotes and, typical of healthcare staff, used humour to keep ourselves going.

As we completed the march, we were energised sufficiently to tackle the assault course.

The opportunity to lead the team brought out leadership qualities such as motivating others, thinking creatively, communication skills and using personal resources

NM1409 22-25 fHW031.indd 23 23/1/08 5:24:28 pm

feature

such as motivating others, thinking creatively, and using communication skills and personal resources (Cox and le May 2007). It involved taking charge of disparate groups of people and managing tasks in the best possible way, so using the talents of all team members was essential.

Everyone wanted to contribute to the tasks in the time allocated and so defusing potential disputes was also part of the process.

teamworkAt the beginning of the exercise, we all knew at least one other person in our teams but realised that, if we were to perform effectively, we had to get to know everyone quickly.

Our team comprised members from several NHS trusts, and so was an ideal example of inter­professional teamwork (Hogston and Simpson 2002). It also comprised a mix of young and experienced members so that enthusiasm was tempered with expertise.

Some members held senior positions in health care but, because the command tasks acted as good social levellers, there was no hierarchy in the team other than that which was required by the exercise.

Although we all knew we were fairly physically fit, we weren’t sure we were fit enough to avoid letting the team down and survive on the rations provided. This uncertainty offered all of us opportunities to assist each other in some way, from physically helping those who were flagging to passing round a seemingly limitless supply of sweets carried by some kind participants.

In addition, to ensure that whole teams completed the course successfully, and at the same time, physically fitter members were designated to assist those who were less fit. Thus, the presence of less fit team members acted as a catalyst

for fitter members to create support structures, for example by planning strategies for the assault course that took account of all team members’ abilities.

Managing psychological differences between members was undertaken in much the same way. Some people could work out the problems posed with ease, but did not have the physical strength to perform the tasks without the help of others.

New skillsWe were not told in advance or in detail about what was expected of us, which induced a level of anxiety about how much we would be able to contribute to the command tasks and whether we would let our team members down in completing them.

This lack of knowledge of our abilities to rise to new challenges is in some ways similar to that of patients at the beginning of their care journeys.

We often expect patients at such times to submit themselves to our care without question, but EMS made us realise that, for patients to maintain a sense of control, information is vital and can improve their chances of success (Miller 2002).

In undertaking our tasks, we learned new skills, from tying reef knots to using our ground sheets to make temporary forms of sleeping accommodation called ‘bashers’.

These tasks challenged us physic­ally, emotionally and psychologically; they made us aware of our personal weaknesses and how they can be overcome with team effort.

The only major casualties in our team were our feet. Although we all wore waterproof walking boots, we suffered from wet feet and blisters. This simply served to strengthen our resolve to continue however.

This effort was the epitome of teamwork, with participants helping one another to overcome fears of heights, the dark, confined spaces and fast flowing water.

We returned to the training camp for well deserved showers, followed by a curry lunch and the presentation of certificates.

We felt a real sense of achievement when we received these from commanding officer Colonel Phil Hubbard and representative colonel commandant of the Royal Army Medical Corps Colonel John Tinsley.

leadershipLeadership was a key feature of EMS and each team was allocated two marching drill sergeants.

Our team’s drill sergeants were excellent and employed precisely the right amount of badgering and encouragement to obtain the best out of us. In addition, each team member was given an opportunity to lead their team while it undertook at least one of the tasks.

Our team’s designated leader started by sharing tasks with other team members and seeking their opinions before making decisions but, as the time limit for completing tasks approached, a more autocratic style of leadership was expressed to ensure that they were finished in time. Thus, our team’s dominant leadership style was democratic, combined with either ‘laissez faire’ or autocratic as circumstances required (Girvin 1998).

The opportunity to lead teams brought out leadership qualities

24 nursing management Vol14No9February2008

Exercise Medical Stretch made us realise that, for patients to maintain a sense of control, information is vital and can improve their chances of success

NM1409 22-25 fHW031.indd 24 23/1/08 5:25:32 pm

feature

conclusionExercise Medical Stretch could be described as a recruitment exercise for the TA.

Indeed many of the participants have made further enquiries and at least one is keen to join the regular army. But for most participants, EMS offers a valuable insight into a world that is both different from and, with its emphasis on organisation, stamina, commitment and teamwork, similar to the NHS.

The tasks we undertook contributed to our management and leadership expertise in many ways and at various levels.

In nursing management, playing to everyone’s strengths in this way is an essential skill. It can mean compensating for the weaknesses of some members but this is a small price to pay in ensuring that everyone is

valued for their contribution (Marquis and Huston 2003).

For example, role expansion and changes in service provision, such as reducing junior doctors’ hours, mean that people who might never have considered themselves members of the same team must now work together (Department of Health 2002).

Exercise Medical Stretch proved to all of us that this is possible nm

Allyson Lipp is principal lecturer in health, sport and science at the faculty of health, sport and science, University of Glamorgan

Gail Lusardi is senior lecturer in health, sport and science at the faculty of health, sport and science, University of Glamorgan

Huw Williams is a regimental operations support officer at 203 Field Hospital, Cardiff

References

cox Y, le May a (2007) Leadership for Practice: Principles of professional studies in nursing. Palgrave Macmillan, Basingstoke.

department of health (2002) Developing the Roles of Health Professionals. the stationery Office, london.

Girvin J (1998) Leadership and Nursing. Macmillan Press ltd, Basingstoke.

hogston r, simpson P (2002) Foundations of Nursing Practice: Making a difference. Palgrave Macmillan, Basingstoke.

Marquis B, huston c (2003) Leadership Roles and Management Functions. lippincott Williams and Wilkins, london.

Miller Ja (2002) clinical governance. Nursing Times. Monographs, 56.

Standing easy: the authors’ Exercise Military Stretch team at Sennybridge Training Area

NM1409 22-25 fHW031.indd 25 23/1/08 5:26:09 pm

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leadership resource

nursing management Vol 14 No 9 February 2008 27

SETTING GOALS can help you to define your priorities and so become organised, and almost all motivational experts include goal setting as an important part of their programmes.

PLAN AHEADTake two sheets of paper. On one, state your goals for the next 12 months; on the other, state what you want

to achieve between now and the end of your career. In comparing the two, make sure that achieving the goals on your first list will help you to achieve those on your second.

LINK PERSONAL AND EMPLOYMENT GOALSOn a third sheet of paper, state what you want to achieve before the end of your life. Compare this with what you

want to achieve before the end of your career, and try to link the two sets of goals. You are more likely to attain both personal and employment goals if they are similar.

MAKE CLEAR GOAL STATEMENTSThe ‘goal statements’ you have made should be clear and accurate. To do this, use the SMART formula to

ensure that your goal statements are specific, measurable, action oriented, realistic and time constrained.

FOLLOW THE ‘SMART’ RULESYour goals should be: specific, in that you should be able to define them; measurable, in that you should be

able to tell when you have attained them; action oriented, in that you should undertake specific activities to attain them; realistic, in that they are practical and achievable; and time constrained, in that there are defined deadlines for their completion. A goal statement such as ‘To reduce the waiting time in outpatients by 25 per cent by the end of the year without additional resources’, is an example that follows these rules.

BE COMMITTEDTo attain your goals, you require commitment. Do not state your goals unless you are certain that you have

sufficient commitment to attain them.

BE MOTIVATEDTo complete all of the steps in the goal setting process, you also require motivation. To be motivated, you must

be optimistic, or ‘positive’, about your ability to attain your goals. Pessimism, or ‘negativity’, can kill your sense of motivation.

REDUCE GOALS TO MANAGEABLE STEPS Attaining goals can be difficult unless they are broken down into small, detailed steps. To help you track your

progress towards your overall goals, these ‘goal steps’ should be listed in the form of ‘action plans’. Goal steps should be positive, not negative; that is, they should describe achievements to be made rather than obstacles to be overcome.

SHARE YOUR GOALSSharing your goals with others who can help or support you can increase your chances of success. If possible,

you should also share the work you do in attaining your goals.

RE-ASSESS YOUR GOALS FREQUENTLY Goal setting is a process. When you first start to define your goals, this process can seem difficult and daunt-

ing but, as you gather experience, it becomes easier. You therefore require patience to set and attain goals successfully. All of the goals that you want to attain in the year ahead should be reviewed daily, if possible, or at least once a week. To carry out these reviews, con-struct simple time lines or use matrix charts with planned achieve-ment dates set against your goals.

RECOGNISE YOUR SUCCESSESIn the goal setting process, success can be defined as ‘the progressive realisation of a worthwhile goal’. If you

are carrying out activities that help you to attain a specific goal, you can judge yourself ‘successful’ even if you have not actually attained this goal. Such judgements are important because frequent recogni-tion of success can increase your motivation.

FINAL POINTDo not attempt to attain goals that someone else has set for you, so ensure that both your goals and the activities you carry out to attain them are your own. Make sure too that you genuinely want to attain these goals, that you are excited by them, and that you are committed and motivated sufficiently to attain them. When your career has ended, you should be able to look back and say: ‘Each day, I took a step closer to my goals.’ nm

Chris Pearce MSc, BA, RN, DipN, RNT, CertHSM is a life coach and freelance trainer with Life Goal Specialists

Earlier editions of this leadership resource are available at www.nursingmanagement.co.uk

Ten steps to setting goalsChris Pearce offers a guide to help nursing leaders set goals

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applied leadership

28 nursing management Vol14No9February2008

This article has been subjected to peer review

In today’s complex and ever changing healthcare environment, nurses must be prepared to analyse large amounts of information critically so that they can weigh up the evidence supporting, and arguments for and against, particular issues or procedures.

However, as the amount of knowledge in health care expands, nursing students find such analysis increas­ingly difficult (Beitz 1998), while research suggests that many newly registered nurses lack the abilities or skills to think critically (Shell 2001)

This lack of critical analysis in health care among nursing students and newly registered nurses is becom­ing a major issue for the nurse managers who have to support them, particularly in light of the current emphasis on continual quality improvement.

One way for nurse managers to help nurses develop their analytical, or ‘critical thinking’, skills however is by introducing them to concept mapping.

This article defines critical thinking and explains how concept mapping can be used in educative and clinical settings to develop analytical skills in nurses.

defining critical thinkingCritical thinking is defined by Wilkinson (1996) as both an attitude and a reasoning process that involves several intellectual skills.

Ignatavicius (2001) meanwhile describes critical thinking as a form of purposeful, outcome directed thinking based on a body of scientific knowledge derived from research and other sources of evidence.

Critical thinking is also described as the rational examination of ideas, inferences, principles, argu­ments, conclusions, issues, statements, beliefs and actions (Taylor 2006), and has been referred to as clinical reasoning, clinical decision making and clinical judgement.

Concept mappingConcept mapping is a technique for representing knowledge through a linked network of concepts.

Concept mapping, which is based on Ausubel’s (1968) Assimilation Learning Theory, in which prior knowledge is described as an important factor in the ability to learn about new concepts, was later devel­oped by Novak.

Concept mapping is also known as knowledge, cognitive or mind mapping, as well as web teaching, semantic networking or structured conceptualisation (Irvine 1995, Kathol et al 1998).

Indeed, Trochim and Kane (2005) state that concept mapping can be any methodology used to produce pic­tures, maps or ‘concept trees’ of any individual’s or group’s concepts.

These authors also state that the concept mapping process takes place in six stages:n Preparation n Generation of ideasn Organisation n Representationn Interpretation n Utilisation.

Concept mapsConcept maps are representations of ideas in diagram­matic form (Irvine 1995), usually consisting of nodes or cells that contain linked concepts, items or quest­ions. The links are in turn labeled and made to denote direction to indicate the relationships between the nodes (Schuster 2000)

Because concept maps represent many different concepts, they can take many different forms, includ­ing hierarchy, pictorial landscape, spider and system formats, multi­dimensional or mandal maps, and flow charts. They can be used in lectures, group work, classroom discussion, skills laboratories and in clinical practice (All et al 2003)

Concept maps are context dependent because map makers’ prior knowledge influences the maps they produce. They are also dynamic, rather than static, learning tools because they can change during clinical experiences (Hill 2006).

Critical thinking among nursesConcept mapping can help both newly registered staff and nursing students develop

the critical thinking skills they lack, says swaleh toofany

Keywordsn Critical thinkingn Decision making processn Education methods

Swaleh Toofany MA, RGN, NDN, CPT, DPSN, CertEd is a senior lecturer in the faculty of health and human sciences at Thames Valley University, Slough

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applied leadership

nursing management Vol14No9February2008 29

Critical thinking in nurse educationAccording to Luckowski (2003), critical thinking is a skill that all newly registered nurses must have if they are to succeed in nursing.

In the UK, pre­registration nurse education is embed­ded firmly in mainstream university curricula and, in recent years, the criteria for entry to such courses have been altered to encourage a more academically diverse student population.

To cater for these students, many schools or depart­ments have reviewed their teaching methods. As well as adopting concept mapping, some have adopted systems of problem based learning that help students develop critical thinking skills to understand and resolve specific problems.

Unfortunately, evaluative work in the nursing liter­ature on the effects of enquiry learning on the ability of nursing students to think critically (Biley and Smith 1998) is scarce, while that in the supporting literature focuses on the field of medicine. Caution must be exer­cised therefore when evaluating this method.

Concept mapping as a teaching strategyConcept mapping can increase students’ learning efficiency by encouraging them to make sense of abstract phenomena in terms with which they are familiar (Beitz 1998), and can help them to engage in cognitive processes such as organising, categorising, analysing, evaluating and critical reasoning (Rafferty and Fleschner 1993).

Clayton (2006) advocates concept mapping as an active teaching strategy that can help nurse educators prepare graduates to think critically, and Daley (1996) notes that it can be used to assess students at different times during their education.

The purpose of nursing programmes that include concept mapping strategies is to create practitioners with the characteristics listed in Box 1.

As Walsh and Seldomridge (2006) report however, it is difficult to ascertain whether these programmes have succeeded in this, and whether they have pro­duced nurses with critical thinking skills.

Methods of assessing critical thinking skills in nurses are therefore needed.

assessing critical thinking skillsCritical thinking skills can be assessed or measured by tools such as the Watson­Glazer Critical Thinking Appraisal (WGCTA) or the California Critical Think­ing Skills Test (CCTST). Both of these tools measure abilities to: recognise assumptions; infer, deduce and

Box 1. Characteristics of critical thinkers

n analytical, knowledgeable and observant

n assertive, outcome directed, persistent, resourceful and willing to take risks

n Caring, communicative, flexible and open minded

n Creative, imaginative, innovative and intuitive

interpret; and demonstrate evaluative, analytical, inductive and deductive forms of reasoning.

A UK based study by Girot (2000) concludes that WGCTA can measure differences in student perform­ance before, during and on completing academic pro­grammes although the accuracy of these results may depend on the context in which they are gathered, with variables including students’ ability to learn and the nature of their studies.

Turner (2006), on the other hand, argues that, because there are so many definitions of critical think­ing, there can be no clear way of measuring its effects, which in turn inhibits putting research into practice.

Clearly therefore, assessing critical thinking skills is complex and the choice of tool used to do so depends on context. Seldomridge and Walsh (2001) suggest there­fore that a discipline specific instrument to measure thought and reflection should be developed.

Critical thinking in practiceThe ability to think critically and solve problems in differ­ent clinical practice settings is required of all nurses, including those who are newly registered and students.

Clinical experience is necessary for the develop­ment of critical reasoning and decision making skills (Ferrario 2004a) so, in making the transition from education to clinical practice, nursing students cannot rely on theory alone (Black et al 2000)

One reason why many nursing students appear to be unable to think critically however may be that their teaching programmes emphasise content rather than the use and application of knowledge (Del Bueno 2006).

Critical thinking requires skills in decision making and problem solving. These are complex cognitive phenom­ena, which nurses must often have to carry out quickly.

Ferrario (2004a) proposes therefore that, to reduce the demand on their ‘cognitive reserves’ when making decisions, nurses can take ‘cognitive shortcuts’, which are usually derived from their experiences of similar decisions they have made before.

She also points out that nurses use structured care approaches, such as standardised clinical practice guidelines, care pathways, protocols and algorithms, to assist them with the decision making process,

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30 nursing management Vol14No9February2008

and that concept mapping could also be used to develop their reflective skills, thereby enhancing their decision making skills (Ferrario 2004b)

Concept mapping can therefore promote the higher level thinking and decision making skills that tend to be lacking in newly registered nurses because of their linear pattern of thinking.

Concept mapped care plansAlthough traditional care plans are effective tools for helping students learn, they have been criticised for resulting in linear thinking (Mueller et al 2001)

Consequently, several authors recommend replac­ing traditional care plans with concept mapped care plans to help students learn how patients’ various problems are connected to one another (Koehler 2001, Mueller et al 2001, Schuster 2000). Or, if enquiry learn­ing techniques are used, nursing students and newly registered nurses can be asked to present their resolut­ions or action plans in the form of concept maps. An example of this, with case study, is given in Fig. 1.

King and Shell (2002) explain how encouraging students to create concept maps in this way requires them to act on previously learned knowledge and con­nect it with new knowledge.

These authors further propose that, in clinical situat­ions, concept maps should replace traditional care plans, primarily to synthesise data such as diagnoses, signs and symptoms, health needs, nursing intervent­ions and assessments.

Daley et al (1999) find that the use of concept maps can lead to significant improvements in the ability of students to conceptualise and think critically, while Schuster (2000) describes how nursing students’ criti­

all aC, Huycke LI, Fisher MJ (2003) Instructional tools for nursing education: concept maps. Nursing Education Perspectives. 24, 6, 311‑317.

ausubel dP (1968) Education Psychology: A cognitive view. Holt Reinhart Winston, new york ny.

Beitz JMP (1998) Concept mapping: navigating the learning process. Nurse Educator. 23, 5, 35‑41.

Biley FC, smith KL (1998) Exploring the potential of problem based learning in nurse education. Nurse Education Today. 18, 353‑361.

Black P, Green n, Chapin Ba, owens C (2000) Concept mapping: an alternative teaching strategy. Pelical News. 56, 4.

Clayton LM (2006) Concept mapping: an effective, active teaching‑learning method. Nursing Education Perspectives. 27, 4, 197‑203.

daley BJ (1996) Concept maps: linking nursing theory to achieve practice. Journal of Continuing Nursing Education. 27, 1, 17‑27.

daley BJ, shaw CR, Balistrieri t, Glasenapp K (1999) Concept maps: a strategy to teach and evaluate critical thinking. Journal of Nursing Education. 38, 1, 42‑47.

del Bueno dJ (2006) a crisis in critical thinking. Nursing Education Perspectives. 26, 5, 278‑282.

Ferrario CG (2004a) developing clinical reasoning strategies: cognitive shortcuts. Journal for Nurses in Staff Development. 20, 5, 229‑235.

Ferrario CGd (2004b) developing nurses’ critical thinking skills with concept mapping. Journal for Nurses in Staff Development. 20, 6, 261‑267.

Girot Ea (2000) Graduate nurses: critical thinkers or better decisions makers. Journal of American Nursing. 31, 2, 188‑297.

Hill CM (2006) Integrating clinical experiences into the concept mapping process. Nurse Educator. 31, 1, 36‑39.

Ignatavicius dd (2001) six critical thinking skills for at‑the‑bed‑side success. Dimensions of Critical Care Nursing. 20, 2, 30‑33.

Irvine LMC (1995) Can concept mapping be used to promote meaningful learning in nurse education? Journal of Advanced Nursing. 21, 6, 1175‑1179.

Kathol dMl, Geiger ML, Hartig JL (1998) Clinical correlation map: a tool for linking theory and practice. Nurse Educator. 23, 4, 31‑34.

References

cal thinking skills can be enhanced by replacing trad­itional care plans with concept maps to help them comprehend the relationships between clinical data, and to obtain total patient pictures.

However, Wheeler and Collins (2003), in compar­ing the use of concept maps with traditional nursing care plans to develop critical thinking, found that there was no difference in overall CCTST scores.

Concept mapping is an effective method however of helping students develop critical thinking skills in clinical settings (Wheeler and Collins 2003) and men­tors supporting students are in ideal positions to help them begin the critical thinking process.

ConclusionBecause concept mapping may be incongruent with individuals’ personal beliefs and values, it can be incompatible with linear thinking.

Nevertheless, effective decision making requires a complex series of cognitive processes and it is imper­ative that nurses have these skills. Three steps can be taken to ensure that they do.

First, to encourage critical thinking in education, the amount of classroom time spent, on the one hand, on fact finding and, on the other, on analysing clinical situations critically, can be reassessed.

Second, to encourage critical thinking and enhance clinical judgement skills in practice meanwhile, preceptors can ask students questions rather than sim­ply give them answers, or do the usual ‘show and tell’ (Del Bueno 2006)

Third, nurse managers can ensure that mentors and assessors in their departments are prepared to engage in the concept mapping process nm

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nursing management Vol14No9February2008 31

King M, shell R (2002) teaching and evaluating critical thinking with concept maps. Nurse Educator. 27, 5, 214‑216.

Koehler CJ (2001) nursing process mapping replaces nursing care plans. In Lowenstein aJ, Bradshaw MJ (eds) Fuszard’s Innovative Teaching Strategies in Nursing. Gaithersburg, aspen Md.

Luckowski a (2003) Concept mapping as a critical thinking tool for nurse educators. Journal for Nurses in Staff Development. 19, 5, 225‑230.

Mueller a, Johnston M, Bligh d (2001) Mind mapped care plans: a remarkable alternative to traditional nursing care plans. Nurse Educator. 26, 2, 75‑80.

Rafferty Cd, Fleschner LK (1993) Concept mapping: a viable alternative to objective and essay exams. Reading and Research Instruction. 32, 3, 25‑34.

schuster MP (2000) Concept mapping: reducing clinical care plan paperwork and increasing learning. Nurse Educator. 25, 2, 76‑81.

seldomridge La, Walsh CM (2006) Measuring critical thinking in graduate education. Nurse Educator. 31, 3, 132‑137.

shell R (2001) Perceived barriers to teaching for critical thinking skill by Bsn nursing Faculty. Nursing and Health Care Perspectives. 22, 6, 286‑289.

taylor BJ (2006) Reflective Practice: A guide for nurses and midwives. open University Press, Maidenhead.

trochim W, Kane M (2005) Concept mapping: an introduction to structured conceptualization in health care. International Journal for Quality in Health Care. 17, 3, 187‑191.

turner P (2006) Critical thinking in nursing education and practice as defined in the literature. Nursing Education Perspectives. 26, 5, 272‑277.

Walsh CM, seldomridge La (2006) Measuring critical thinking: one step forward, one step back. Nurse Educator. 31, 4, 159‑162.

Wheeler La, Collins sK (2003) the influence of concept mapping on critical thinking in baccalaureate nursing students. Journal of Professional Nursing. 19, 6, 339‑346.

Wilkinson JM (1996) Nursing Process: A critical thinking approach. addison‑Wesley, Menlo Park Ca.

References

Fig. 1. Case study and concept map

Case studya group of pre‑registration, second‑year nursing students studying at Level 5, or diploma level, were asked to present feedback on, and action plans for, a patient journey as a concept map.

the patient was a 35‑year‑old woman, recently diagnosed with type 2 diabetes. she was worried and anxious about her health and future treatment.

traditionally, the students would have been asked to produce a nursing care plan for the patient, but such plans often lead to linear thinking. Instead, they were asked to produce individual concept maps for their feedback, which they would then share with the group. the concept maps produced would determine the students’ ability to think critically. an example of a concept map for this patient can be seen below.

during the feedback, students had to explain the relationship between each of the concepts identified in the boxes. By recalling and applying their knowledge of physiology, for example, they demonstrated how to maintain the normal blood glucose level.

Concept map

Patient’s concerns: anxiety and worry about her health and future treatment

Observe. reflect. analyse and synthesise

Knowledge derived from: education, clinical research and experience, life experience, and structured care approaches

Interventions: blood sugar monitoring and insulin administration, as well as patient exercise, education, dietary advice and reassurance

Nursing outcomes: being able to monitor blood sugar levels and administer insulin safely, and fulfilling expectations of role

Clinical diagnosis: type 2 diabetes

Nursing diagnosis: obesity due to raised body mass index, raised blood glucose level, anxiety

Patient outcomes: coming to terms with illness, being aware of risk factors and modifying lifestyle while maintaining quality of life

adapted from Ferrario (2004a)

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32 nursing management Vol14No9February2008

continuing professional development

It Is inevitable that managers in the health

and social care sectors have to make decis­

ions; doing so is, after all, part of their jobs.

But they may not always consider what

factors influence their decisions.

Understanding the psychology of deci­

sion making and the social context in which

it is undertaken can help managers make

more informed choices, and can improve

the decision making process in health and

social care organisations.

the decisions people make are usually

based on judgements of the information

with which they are presented. the activity

described in Box 1, for example, can demon­

strate how judgement is exercised.

Unconscious decision makingIn answering the first question in Box 1,

most people would probably assume that

motor vehicle accidents cause more deaths

than stomach cancer, yet the reverse is

actually true and by a ratio of more than

two to one.

some people may make this assumption

because they are influenced by the media,

which are more likely to publicise vivid

accounts of motor accidents, which in turn

tends to exaggerate their incidence.

similarly, in organisational life some peo­

ple tend to give undue weight to informa­

tion that is easily available, more visible or

more emotive.

In the second question in Box 1, Versions 1

and 2 both say the same thing but in dif­

ferent ways. that is, Version 1 is framed in

terms of lives saved and Version 2 in terms

of lives lost.

this is a good illustration of how the way

problems are framed affects decision mak­

ing, even for clinical experts.

People tend to prefer risk aversion for

problems framed in terms of gains, but

take risks to avoid loss where problems are

framed in terms of costs.

Consequently, most people answering

Box 1 choose Programme A of Version 1,

but opt for Programme B of Version 2.

How we are influencedto make better decisions, it is important to

understand all the factors that influence

how we make them. tetlock (1991) ident­

ifies three competing metaphors for under­

standing human decision making:

n the rational perspective, in which people

are judged to be naïve economists

Making good decisions: part 1In the first of two articles on decision making, The Open University examines how the choices made

by healthcare professionals can be influenced by factors of which they are unaware

This article uses course material from The Open University, Milton Keynes

Box 1. Exercising judgement activity

1. Which of the following causes more deaths in Western Europe each year?

n stomach cancer

n Motor vehicle accidents

2. A rare disease has swept through a town, affecting 600 inhabitants. Experts have suggested two possible programmes for tackling the disease, two versions of which are described below. In each version, which programme do you think a clinician presented with this information would choose?

Version 1

n Programme A will save 200 lives out of 600

n Programme B has a one third probability of saving 600 lives and a two thirds probability of saving no one.

Version 2

n Programme A will result in 400 deaths

n Programme B has a one third probability of no one dying and a two thirds probability of 600 deaths.

Adapted from Bazerman (1998)

Keywords❥ �Decision making❥ �Decision making processes ❥ �Management

NM1409 32-34 ouRS058.indd 32 22/1/08 11:26:20

nursing management Vol14No9February2008 33

continuing professional development

The material in this article is drawn from The Open University’s Business School course, B830, Making Decisions.

Management courses offered by The Open University’s Faculty of Health and Social Care include: F52, MSc in Advancing Healthcare Practice; K303, Managing Care; and K307, Managing Health and Social Care.

To discuss development opport-unities for you and your staff, contact The Open University: email do-business@open.ac.uk or telephone 01908 655767.

For more information on other Open University courses, access www.open.ac.uk/courses or call 01908 653231.

n the psychological perspective, in which

people are judged to be naïve psycho­

logists

n the social perspective, in which people

are judged to be naïve politicians.

In the first metaphor, people are assumed

to make rational judgements in pursuit

of the best results. Decision makers are

understood to have ordered preferences

and engage in a rational decision making

process on the basis of these.

For example, someone who prefers A to B

and B to C can be assumed to prefer A to C.

In the second metaphor, people are

assumed to take a ‘heuristic’ approach

by making decisions depending on their

environments.

Decision makers reduce the complexity of

decision making by taking ‘mental short­

cuts’ to help them make quick decisions

when pausing to analyse problems fully

seems unwise (Gigerenzer et al 1999).

For example, someone may associate

product quality with particular brands instead

of weighing up the options available.

In both of these metaphors however, the

focus is on individual behaviour rather than

social processes, which are the starting

points for the third approach.

In the third metaphor, people are assumed

to want to manage the social world they

inhabit.

Decision makers are understood to make

decisions according to their characters.

their goal is to satisfy those people or

groups of people to whom they think they

are accountable, and the decisions they

make are influenced by the social pressures

they are under.

Social pressuresBroadly speaking, there are three kinds of

social pressure that affect how people make

decisions:

n Coercive

n Mimetic

n Normative.

Coercive pressure is applied to those who

fail to act in socially acceptable ways. Law

enforcement agencies are the most obvi­

ous sources of this, but others include the

expectations of other people. For example,

those seeking promotion experience coer­

cive pressure when they think they must

act in ways that are deemed ‘acceptable’

to their industries or professions.

Mimetic pressure drives people to imitate

what is done by others. One way to find

solutions to difficult problems is to copy

others, for example when managers fol­

low fashionable theories of manage­

ment. such imitation can be successful,

but it often occurs with little regard for

the different challenges faced by different

organisations.

Normative pressure concerns what people

think they should do, and relate to the per­

sonal values and broader social values to

which they subscribe.

Organisations, particularly those involved

in health care, accounting and law, can

be susceptible to different and conflicting

social pressures.

In hospitals, for example, there may be

conflict between the normative pressure

exerted by provisional clinical groups such

as nurses and doctors, and the coercive

pressure exerted by government bodies

(Lozeau et al 2002).

Organisations often ‘decouple’ their

responses to these conflicting social pres­

sures. For example, hospitals under norma­

tive pressure from important constituencies,

such as staff unions, may respond with an

appearance of concern but not with genu­

ine engagement.

Because shared social meanings both

influence and constrain how we reason

and decide, social pressures can affect

how decisions are made. For example, the

importance people place on socially shared

concepts such as fidelity, child care, house­

work, separation and divorce can influence

how they think about marriage.

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34 nursing management Vol14No9February2008

Framing problemsthe ways people overcome problems are

often influenced by how they are framed.

Clinical decisions, for example, can be

affected by whether their possible out­

comes are framed as likelihoods of death or

of saving patients.

In a study by Loftus and Palmer (1974),

groups of students were shown the same

film clip of a car accident and then asked:

‘How fast were the cars going when they …

each other?’ with the … being replaced by

a different phrase for each group: ‘smashed

into ’, ‘collided into’, ‘bumped into’, ‘hit’

and ‘contacted’. the results of this research

are summarised in table 1.

Interestingly, those who were asked

‘How fast were the cars going when they

smashed into each other?’ were more likely

to think that they had seen broken glass in

the film clip than those who were asked

‘How fast were the cars going when they

hit each other?’. Yet there was no broken

glass shown in the clip.

How we judge informationthe way people make decisions depends on

the information they have and how import­

ant they think it is.

From birth, people start to filter and prioritise

information and, in their working lives, they

must filter information and discard options to

avoid ‘analysis paralysis’, which is an inability

to make any decision in the face of the com­

plexity and ambiguity of the real world.

But people are bombarded constantly with

information. simply walking across a hospi­

tal ward floor floods them with more sensory

information than they can possibly process.

Filtering information bears a cost, how­

ever. People can become overconfident

about the choices they make and filter out

sources of uncertainty, and can be swayed

by how problems are framed.

People also tend to pay most attention

to information that is easily available or to

memories that are easily retrievable, usually

because they are emotionally vivid or have

personal relevance.

People also tend to pay selective attention

to information, often in self serving ways

by giving greater weight to details that

show them in a favourable light or support

already established points of view.

In health and social care settings, man­

agers are likely to share core ideas about

health care, cause­and­effect relationships

and what constitutes reasonable conduct.

Moreover, because healthcare institutions

are frequently under a media spotlight, it is

common for decision makers in related

organisations to be concerned, not only

with economic outcomes, but also with

legitimacy. they ask themselves the follow­

ing questions: How will decisions be seen

by the public? Do they fit with how things

are done around here? What happens if the

media obtain this information?

some of these concerns can be uncon­

scious. they can also operate at different

levels and refer for example to a nation, an

industry, a firm, a team or an individual.

It is important therefore that people,

particularly decision makers in large

organisations such as the NHs, understand

the factors that influence their decisions.

By paying attention to these factors, they

not only enrich their understanding of how

decisions are taken, but can also be alerted

to how their judgements may be influenced

in the future nm/ou

REfEREncEs

Bazerman M (1998) Judgement in Managerial Decision Making. John Wiley, New York NY.

Gigerenzer G, todd PM, ABC Research Group (1999) Simple Heuristics that Make Us Smart. Oxford University Press, Oxford.

Loftus EF, Palmer JC (1974) Reconstruction of automobile destruction: an example of the interaction between language and memory. Journal of Learning and Verbal Behaviour. 13, 585­589.

Lozeau D, Langley A, Denis JL (2002) the corruption of managerial techniques by organisations. Human Relations. 5, 5, 537­564.

tetlock PE (1991) An alternative metaphor in the study of judgement and choice: people as politicians. Theory of Psychology. 1, 4, 451­475.

Table 1. How fast the cars were judged to be going

Phrase added Mean estimate of speed (mph)

‘smashed into’ 40.8

‘Collided into’ 39.3

‘Bumped into’ 38.1

‘Hit’ 34.0

‘Contacted’ 31.8

NM1409 32-34 ouRS058.indd 34 22/1/08 11:26:24

how to contribute

The aim of Nursing Management

is to inform and encourage

critical reflection among

nursing leaders by publishing

articles with clear implications

for practice and management.

Submitted articles can be in

the form of feat ures, applied

management articles or opinion

pieces. Applied management

sub missions and, where

appropriate, opinion pieces must

be referenced.

One of the best ways of

understanding how to write

articles is to read a selection

of those already published in

Nursing Management. They can

be literature reviews, original

pieces, descriptions of practice or

case studies. If in doubt, contact

nick.lipley@rcnpublishing.co.uk

Please note that your manuscript

must be sent to Nursing

Management only. Editors will not

consider articles that have been

submitted or published elsewhere.

Articles for the features and

opinion sect ions should be

up to 1,500 words long, and

applied management articles

should be between 2,000 and

4,000 words long.

Charts, diagrams, tables,

photographs and illustrations are

always welcome. Please ensure

that any illustrative material is

carefully numbered or labelled,

and captioned. Photographs will

be returned to you on request.

Contributions should be sent

to either by post to The Editor,

Nursing Management, The Heights,

59-65 Lowlands Road, Harrow-

on-the-Hill, Middlesex HA1 3AE,

or by email to helen.hyland@

rcnpublishing.co.uk

Please check that you include

the following information

concerning all authors:

Full name

Qualifications

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Preparing your textSend your article either by post or

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The best way of sending text by

post is on a 3.5-inch disk plus two

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Please indicate which word

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For example:

Use only one space after full

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If you want more than one

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What happens now?All manuscripts are

acknowledged on receipt. Most

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Reviewers often recommend

acceptance subject to amend-

ments that the authors are asked

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Articles will not be published

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Manuscripts are then prepared

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Shortly before publication, the lead

author receives a copy of the article

as it is intended to appear in the

journal. Only minor amendments

are accepted at this stage.

In the textPlease ensure you use the Harvard (name and year) system for references in the text. For example, ‘It has been argued that nurses should examine their own relationship with patients’ (Brown 2004). For three or more authors, print the first author’s name followed by et al, for example, ‘As White et al (2004) argue…’ When several references are cited simultaneously the order should be alphabetical. If there are two or more references to the same author, the order should be chronological.

In the reference list

Journal references should include: Surname(s) and initial(s) of all

authors for references with six or less authors. For seven or more authors, include the first three and add et al

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and in italic Volume, issue number and

first and last page numbers.

ExampleHill D, Hadfield J (2005) The role of modern matrons: infection control. Nursing Standard. 19, 23, 42-44.

Book references should include: Author’s surname and initial(s).

Please indicate if those cited are authors or editors

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chapter title in sentence case Title of book in title case and

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initials of US state if appropriate.

ExampleDougherty L, Lister S (eds) (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Sixth edition. Blackwell Publishing, Oxford.

referencing

nursing management Vol 14 No 9 February 2008 35

NM1409 35 h2c.indd 35 22/1/08 10:41:17

scan

Conferences

36 nursing management Vol 14 No 9 February 2008

Fostering a Culture of Effectiveness through Practice Development March 3-7Comfort Hotel, Antrim

Further details: conference manager Hilary Withers or conference administrator Anna-Marie Boyd.Tel: 02890 384600. Email: hilary.withers@rcn.org.uk or anna-marie.boyd@rcn.org.uk

A Practical Guide to Developing your skills as an Effective Ward Manager March 6London

Further details: Healthcare Events.Tel: 020 8541 1399. Email: jayne@healthcare-events.co.uk Website: www.healthcare-events.co.uk

Integrated Care and the Management of Chronic IllnessMarch 6-7Goteburg, Sweden

Further details: Jennifer Smith.Email: inic@igitur.uu.nl Website: www.integratedcarenetwork. org/Sweden2008/conf2008.php?opt=0

Improving Practice…Improving CareMarch 8RCN Headquarters, London

Further details: conference and events organiser Guillia Ward.Tel: 020 7647 3591. Email: independent@rcn.org.uk Website: www.rcn.org.uk/events

Healthcare Associated Infection 2008March 11London

Further details: Healthcare Events.Tel: 020 8541 1399.Email nickiT@healthcare-events.co.uk Website: www.healthcare-events.co.uk

Transfer of Care: Supported, affordable, flexible, effectiveMarch12RCN Headquarters, London

Further details: RCN conference and events organiser Holly Peppiatt.Tel: 020 7647 3580. Email: liaison@rcn.org.uk Website: www.rcn.org.uk/newsevents/events

A Practical Guide to Developing and Running Effective Nurse Led Pre-Assessment March 12Manchester Conference Centre.

Further details: Healthcare Events.Tel: 020 8541 1399. Email: hannah@healthcare-events.co.uk Website: www.healthcare-events.co.uk

Action Learning: Practices, problems and prospectsMarch 17-19Henley-on-Thames, Oxfordshire

Further details: Helen James.Tel: 01491 571454 x2113.Email: helen.james@henleymc.ac.uk

Towards Professional Wisdom: An international conference on practical deliberation in the people professionsMarch 26-28Edinburgh

Further details: The University of Edinburgh.Email: professionalwisdom@ed.ac.uk Website: www.lifelong.ed.ac.uk/towardsprofessionalwisdom

Care Culture and Climate: Cracking the codeMarch 26-28Sydney

A biennial conference of the Society for the Study of Organising for Healthcare (SHOC).Further details: SHOC.Tel: 0061 409 418530. Email: j.edgecumbe@bigpond.com Website: www.obhc2008.org

The Future Now: Challenges and opportunities in healthMarch 26-29Perth, Australia

Further details: World Health Congress Secretariat.Email: admin@worldhealthcongress.orgWebsite: www.worldhealthcongress.org

Quality of Primary Health Care: The perspective of patientsMarch 28-29Ljubljana

Email: barbara.toplek@mf.uni-lj.si Website: www.ljubljanapatient2008.si/welcome.html

Unity through the Commonwealth: Present challenges in nursingMarch 28-29Malta

Further details: RCN.Tel: 020 7647 3593. Email: cnf@rcn.org.uk Website: mysite.wanadoo-members.co.uk/cnf/EuroConference.htm

The Care ShowApril 1-2Bournemouth International Centre

Further details: Sally Veness.Tel: 020 7955 3732. Email: sveness@cmpi.biz Website: www.careshow.co.uk

Celebrating Success in Tissue Viability : 50 years of multi-professional progressApril 2-3Peterborough

Further details: Michael Clark at The Tissue Viability Society.Email: tissue.viability@btinternet.com

Thirtieth Annual International Association for Human Caring Conference April 6-9North Carolina

Further details: The International Association for Human Caring.Email: iahc2008@unc.edu Website: www.humancaring.org

RCN Annual International Nursing Research ConferenceApril 8-11Liverpool

Further details: assistant conference and events manager Kathryn Clark. Tel: 020 7647 3585. Email: research@rcn.org.uk Website: www.rcn.org.uk/research2008/

Essence of Care Seminars for Health Care Assistants April 8 and 23RCN Northern Ireland, Belfast

Further details: Anna-Marie Boyd.Tel: 02890 384600. Email: anna-marie.boyd@rcn.org.uk

A Practical Guide to Reducing Avoidable Deaths in Hospital April 9London

Further details: Healthcare Events.Tel: 020 8541 1399. Email: hannah@healthcare-events.co.uk Website: www.healthcare-events.co.uk

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scan

Have your sayRuth Williams looks at the latest healthcare proposals

out for consultation

Webscan

nursing management Vol 14 No 9 February 2008 37

Mental healthThe Care Services Improvement Partnership (CSIP) has published Finding a Shared Vision of How People’s Mental Health Problems Should Be Understood, its draft guidance on mental health care.

The aim of the guidance is to enable everyone concerned with developing and delivering services, including users, to understand mental health from a shared viewpoint based on those of different stakeholders.

The consultation itself is also expected to raise awareness of the wide variety of ways to assess mental health, and to build mutual understanding among those who use these different approaches.

Ultimately, the guidance should enable the development of multi-disciplinary and multi-agency teamwork, and the greater engagement of service users and carers.

Consultation closes on March 5, and CSIP is asking

for responses to specific questions as well as general comments. The consultation document and response form can be accessed at www.dh.gov.uk/en/Consultations/Liveconsultations/DH_080913

Learning disabilities

Valuing People Now is the Department of Health’s proposed three-year plan of priorities for the learning disability agenda, based on the Valuing People white paper, published in 2001.

Priorities include moving away from the provision of day centre services, helping people into paid work, introducing a new service framework to support primary

care trusts in commissioning comprehensive health checks and improving access to care, and enabling people with learning disabilities to own their own homes.

The document sets out a number of specific actions to help ensure that policy is delivered, and these include transferring funding for learning disability social care services from the NHS to local government, and introducing new performance indicators on employment and health.

Valuing People Now can be accessed at www.dh.gov.uk/en/Consultations/Liveconsultations/DH_081014 and responses to it must be made before the consultation closing date, March 28.

Service line management

A new guide, offering practical advice on service line management (SLM), has been published by Monitor, the independent regulator of NHS foundation trusts, writes Ruth Williams.

Service lines are the NHS equivalent of a commercial company’s business units. In other words, they are the ‘key’ units, with their own financial and staffing resources, that deliver trust services to patients.

The guide, aimed at managers and clinicians who are starting to introduce SLM to their organisations, gives practical examples of how the concept has been implemented in the NHS

already and adapted to suit different trusts.

Four key areas for development are examined: organisation, the role of service leaders in service lines, what skills they need, and how service lines are organised and governed; strategic and annual planning processes, understanding the market and an organisation’s competitive position; performance management, the rewards and consequences for performance; and information support, access to relevant information and moving towards patient level costing.

The Guide to Implementing Service-Line Management is available at www.monitor-nhsft.gov.uk/publications.php?id=1054

Readmission risk

An advanced computer programme that enables primary care trusts to identify patients most at risk of readmission is available to download from the King’s Fund website.

Known as PARR++, which stands for Patients At Risk of Readmission, the tool is an updated version of a programme that has been in use since 2006.

When patients are admitted to hospital, the tool uses their recent admissions data to calculate the likelihood of readmission over the next 12 months, taking into account diagnoses, sociodemographic information and other factors.

The tool and an information booklet on how to use it can be downloaded free of charge, and demonstrations can be watched and a copy of PARR++ on CD ordered, from www.kingsfund.org.uk/current_projects/predictive_risk/patients_at_risk.html

Long term conditions

A web based resource for professionals with an interest in self care and the management of long term conditions has been launched by the NHS Working in Partnership Programme (WiPP).

The site, at www.selfcareconnect.nhs.uk, claims to be the world’s first interactive, online, self care resource and networking organisation.

It provides news and information on key developments and policy drivers, as well as resources such as skills training and assistive technology tools. It is also an area where views and experiences can be exchanged.

Designing premises

Because managers have become increasingly involved in the process of planning and designing new healthcare premises, two new guides have been made available to help NHS and local planning authority staff work together.

One of the guides, which is written for NHS staff, explains town planning in England, while the other, which is aimed at local planning authorities, explains the NHS.

A Guide to Town Planning for NHS Staff can be downloaded from 195.92.246.148/knowledge_network/documents/NHS_staff_guide_20071004113744.pdf, and A Guide to the NHS for Local Planning Authorities from 195.92.246.148/knowledge_network/documents/LPA_guide_20071004115658.pdf

NM1409 36-37 scan.indd 37 22/1/08 10:41:46

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Nursing Standard Nurse Awards ceremony

To request your Nursing Standard Patient’sChoice Award pack, call 020 8872 3140or visit www.patients-choice.co.uk

Closing date: February 15

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