96 Accountability and Clinical Governance in Nursing: a Manager’s Perspective The feedback from the surveys confirmed too, that a research culture is beginning to pervade nursing. A variety of initiatives are in place throughout trusts which support research endeavour (research fellowships, pilot funding, one month sabbaticals, in-house training for research, protected time for research-trained staff to ‘do’ research and the creation of nurse consultant posts). Some trusts had dedicated support for nurses to write research pro-posals and 25 of the 29 trusts said that they wanted help for their nurses to develop such proposals.
An environment of collaboration between the NHS and higher education institutions (HEIs) is also crucial as regards development of research and an evidence base (for nursing). The questionnaires confirmed that 11 of the 12 HEIs in Scotland had direct collaboration with NHS trusts on specific studies, or NHS personnel as co-grantholders. The NHS were permitting access to academic nurses for research studies and the latter in turn were helping novice researchers develop their ideas and seek funding. Historically, there has been an ‘uneasy alliance’ between academia and the health service, with the former having an ‘ivory tower’ image and being viewed by practitioners as remote and out of touch. That this is clearly not the situation today is due in no small measure to the policy imperatives enshrined in clinical gov-ernance. The latter is making the research process a legitimate activity for both academics and practitioners. Not all nurses want to or indeed are able to do research, but more and more nurses and all senior nurses are seeking research evidence to support their daily practice and wanting to follow pro-tocols that are similarly rooted in an evidence base.
Nurses themselves know that they are accountable for their own practice.
Such accountability has been evident historically in the professional guid-ance material sent, over the years, from the UKCC. It is even more evident in the latest Code of Professional Conduct (2002b), sent by the Nursing and Midwifery Council (the successor regulating body for nursing). I have no doubt that clinical governance activity is helping nurses, in a variety of ways, to be actually accountable for their practice, answerable for their actions and omissions, and to carry out a ‘duty of care’ to their patients and clients.
Clinical governance and cultural change 97 time, the numbers of those seeking to improve quality of care increases, but a significant difference occurs when all efforts to make improvements are fully concerted. Finally, through one means or another the efforts by all to improve healthcare quality become fully and predictably sustainable. We have gradually moved, over the past five years, through these stages towards becom-ing a ‘high quality healthcare’ organisation. I believe that we have moved from having few ‘champions’ of higher quality healthcare, to the present situ-ation in which all our trust nurses are trying to make improvements, and some departments and teams may have reached the stage where collective efforts can be predictably sustained. I also firmly believe that clinical gov-ernance has helped our endeavours, and helped give our nurses direction and a sense of common purpose.
Confirmation that we are moving towards sustainable work towards improving the quality of healthcare is readily available in our trust. Clinical governance activity is no longer purely top-down driven. It is bottom-up driven and top-down supported. We have a clinical governance support team that helps services undertake audits. Field staff themselves are striving to take a more systematic approach to their daily work. Validated screening tools are being used and assessed for efficacy; outcome measures are being developed for application, and services/practice/procedures are being evaluated. We have moved from striving for accreditation awards (e.g. Chartermark) as a ‘must do’, to departments and GP practices taking an active role in developing national accreditation systems and volunteering to take part in internal peer review systems to support continuous quality improvements. Nursing is cru-cially involved in all of this work – testimony, I believe, that nurses want to be accountable for their practice and really find out if they are doing the best they possibly can for patients.
Sharing good practice
We try very hard within our trust to encourage staff to share and generalise good practice. Obviously this saves time and avoids duplication of effort.
From the management perspective we do not want staff wasting time repeating work that has already been undertaken elsewhere in the trust. We hold various events to try and share good practice, via conferences and qual-ity days with a series of oral presentations and poster displays. Some of these have multidisciplinary attendance with a wide range of professions and services represented, other occasions are uni-disciplinary in terms of focus, e.g. the Annual Nursing Conference, with a varied audience. We have a clinical governance newsletter that enables sharing of ideas and good prac-tice across the trust and it also provides a stimulus for staff to undertake further pieces of work to enhance patient care.
Sharing of good practice, however, is hard work as we continually come across the necessary ingredient of change – ownership. Many areas do not want to just adopt someone else’s work, they want to tinker with it and ‘make
98 Accountability and Clinical Governance in Nursing: a Manager’s Perspective it their own’. We also find that many areas are reluctant to share their good work, because they are not used to ‘blowing their own trumpet’. We have not found the answer to this problem but we are sure that we must keep on with our attempts at sharing and dissemination. With time this may get eas-ier – not just for nursing but for all staff groups.
Evidence-based practice – the reality
There are very real problems, from the management perspective, about putting evidence-based practice into place. Circulation of evidence-based guidelines alone is insufficient to ensure that the guidelines are being followed.
Time needs to be spent consulting /debating /discussing them with the vari-ous stakeholders, and up-to-date guidance needs to be part of the training for staff. Key staff also need to be convinced of the merits of evidence-based practice. Old habits die hard! Our experience has been that individual teams and groups of nurses (and other staff) want to customise tools that have been validated and proven to be reliable (by traditional research methods), thus negating the previous research work. We have also found that implementa-tion of evidence-based guidelines is costly, not only in terms of time invested by senior staff, but also in relation to real financial costs (of purchasing and using copyrighted assessment tools, for instance). Undoubtedly, though, it is worth persevering, as the benefits of changing practice and promoting high quality care outweigh the disadvantages of complaints, poor care and, at worst, defending a litigation case.
In summary, developing clinical governance systems cannot be done overnight. Management and ‘quality’ gurus say it takes between eight and twelve years to change a culture. I am sure it will take us at least that to change the culture within nursing from being reactive to proactive.
Traditionally the Health Service has not invested adequately in its nurses in terms of staff development, and it certainly has not invested sufficiently in promoting a research culture or in systems to prevent accidents, errors and mistakes. But this situation is changing and the climate of clinical governance has been a major driver of attitude change.
Clinical governance is a major influencing factor, too, in terms of helping managers develop credible systems for which they can be called to account.
These managers (and I hope I am one of them) are increasingly seen by staff to be directly supporting them in their roles – for which they in turn, are accountable. Walshe (1998a, b) suggests that to implement clinical govern-ance three elements will be required: accountability for clinical performgovern-ance;
internal trust mechanisms for improving performance; and external mechan-isms for improving clinical performance. If not in place, clinical governance will be nothing more than words. I can conclude by saying I believe that in Scotland, and most definitely here in my Trust, for nursing the rhetoric is being turned into reality.