92 Accountability and Clinical Governance in Nursing: a Manager’s Perspective
‘learning organisation’ with a concerted effort being made not to allocate blame but to learn lessons from failures and mistakes.
A good example of this in nursing, within the trust, is how we deal with
‘medication errors’. In 1998 we introduced a ‘medication error reporting’
scheme. Details of this scheme were announced through our ‘Safe Admin-istration of Medicines’ policy document, and the chief pharmacist and I publicised this at ‘road shows’ throughout the different sites within our trust.
We encourage the reporting of medication errors and the scheme has been promoted as an equitable non-blame method of identifying clinical risk in relation to drug mistakes. Each individual report is confidentially and systematically collated, then analysed by a review team (consisting of the medical and nursing directors, the chief pharmacist and head of personnel).
The specific professional groups get feedback on methods to minimise the risk of the error recurring.
To date, the reporting scheme has been successful in generating data for trend analysis, and there has been comparison, year on year of these data.
We have been able to highlight where the incidence of errors has increased (e.g. wrong time of administration, drug omissions, controlled drugs, pre-scribing) and identified areas where the incidence of errors was reducing (e.g.
vaccination, diabetic, self-medication). Through the reporting scheme we iden-tify targets for improvement and direct the various professional groups to appropriate policies, procedures and guidelines. We have also developed and improved particular policies and developed competency-checking proce-dures. Although we strongly suspect that there is under-reporting of errors, as the number of errors has not increased in line with the expanded trust structures, we will continue to encourage use of the scheme as we believe that this systematic mechanism drives forward improvements in patient care. The system is not just for use by nurses but also identifies medication errors by pharmacists and doctors. This sort of system is supported in recent publications (British Medical Journal, 2000; Alberti, 2001).
The medical and nursing directors and the chief executive are called to ac-count (at the clinical governance committee and its various sub-committees) for various trends in activity or patterns in practice. Although one is tempted to be defensive and recoil from such scrutiny, we are all beginning truly to engage in the work to measure our performance and work towards achiev-ing ‘best value’, ‘efficiency’ and ‘effectiveness’.
Clinical governance structures as a vehicle for change
We have established a clinical effectiveness group, chaired by an associate medical director, to give strategic leadership and a focus for clinical effect-iveness activity in the trust. A sub-group has been established to take forward issues relating to the development and implementation of clinical guidelines. We also have a group looking at strategy, priorities and man-agement issues surrounding audit. We have created audit structures relating
Has clinical governance made a difference? 93 to the independent contractors (GPs, dental practitioners, community phar-macist and practice nurses) and over time the work of these groups has become integrated and areas of activity extend across the quality spectrum.
Issue of clinical guidelines is essential to support clinical practice, and initially we set up a group to create an effective system for dissemination of guidelines, called Scottish Intercollegiate Guidelines Network (SIGN).
Recently, we have launched the Lothian guidelines for ‘hypertension’ and
‘management of patients with type 2 diabetes’, developed two new guide-lines, for ‘lithium’ and ‘radiology’, and updated the ‘management of blood lipid disorders’. Our ‘Lothian Joint Formulary’ was also launched. This pro-vides consistent advice on prescribing across all sectors and links to advice provided by the drug evaluation panel, a sub-committee of the area drug and therapeutic committee. Clearly there are costs associated with the dissemina-tion and producdissemina-tion of guidelines. Guidelines support evidence-based practice and clearly use of these lessens the chances of our staff giving poor patient care.
A good example of how guidelines can help promote good nursing prac-tice is the implementation of the RCN and Department of Health-produced guidelines on depot neuroleptic injections (RCN/Department of Health, 1994). Standards within this document state that nurses should give infor-mation to patients, obtain user consent and assess the side effects of the medication. Additionally, good practice should entail nurses carrying out
‘psychosocial interventions’ with patients. These guidelines were issued to Community Psychiatric Nurses (CPNs) through their local nurse managers but in order to assess compliance with the standards, audits had to be done.
The first was undertaken as part of a national audit (Pollock & Turner, 1998), and the second audit process was undertaken as part of the Clinical Standards Board Scotland (CSBS) visit, to assess compliance with the CSBS standards on schizophrenia (CSBS, 2001).
Both audits demonstrated good practice within our trust nursing staff, but the audit findings also demonstrated where nursing practice had to be improved. Following the former audit, the CPNs had to be trained to use systematic side-effect assessment tools, and following the CSBS visit there has been a concerted effort to train our mental health nurses in cognitive behaviour therapy. The latter was happening in fact, but the results of the audit, which were the substance of a written report, gave impetus to the speeding up of this training.
This example from mental health, then, provides an illustration that audit and implementation of guidelines is important. Again we see too, that it takes time for good guidelines to be used and truly put in practice.
Clinical governance and people governance
In our trust, we invest in the training and development of our staff. We are trying to create a culture of lifelong learning for our staff and support ongoing updating. We have an organisational learning, development and
94 Accountability and Clinical Governance in Nursing: a Manager’s Perspective training function with three main components: organisational development and training department, the professional development unit and a general practice staff training team. Combined, these provide an increasingly inte-grated service in support of organisational, team and individual effectiveness.
A training directory provides a list of in-house training programmes available to all staff. Training is provided in relation to all strands of clinical govern-ance, e.g. research and development, clinical effectiveness, risk management, complaints and public involvement.
Specifically in relation to nursing, the clinical governance agenda has made it possible for me to lead in the development of a trust ‘Nursing Policy and Protocols Manual’ for all our trust nursing staff. This, in fact, was a major task. Initially a definition of ‘policy’ and ‘protocol’ had to be agreed and a framework and checklist devised for the development of these.
Prior to gaining such consensus, local teams were developing local policies and protocols, and, partly because several organisations merged, some staff were using inherited but out-of-date policies/protocols. This was unsatisfactory. There was duplication of effort in the trust, and lots of
‘re-invention’ of wheels. Importantly too, this meant that different nurses in different parts of the trust were following ‘local’ policies and protocols. Thus, there was a variety of standards of nursing practice in place within the trust and time was being wasted, with the best of intentions, with groups of nurses trying to be accountable for their local practice.
There was a need to identify what policies needed to be standardised for trust-wide use, and an imperative to ensure that such policies/protocols were influenced by current research, evidence-based practice, clinical guide-lines, UKCC/NMC directives and Government and national policies. Initial prioritisation resulted in the first issue of the manual containing clinical devel-opment policies (relating to the extended role of the nurse), tissue viability, palliative care and care of the dying and bereaved. Further work on child protection, continence management and infection control has taken place more recently, and an additional section of professional matters is to be added to the manual. Each policy/protocol has a review date and plans are in place to audit implementation of them. Crucially important, and a very good reason for developing the nursing manual, is that we could not develop clinical training programmes until the policies/protocols were completed. How could the clinical trainers decide what was to be included in the professional training for clinical competencies unless standards were clear?
Other key developments in people governance to support clinical gov-ernance include:
• the production of comprehensive guidelines for personal development plan-ning and review, to support trust-wide appraisal
• the production of a trust policy for continuing personal development (CPD)
• the development and implementation of a targeted induction programme for nursing staff, mandatory training options
Has clinical governance made a difference? 95
• the development of a competency framework for G-grade nursing staff and a G-grade development programme
These are developed in collaboration with staff representatives and supported by managers who release their staff on appropriate courses/training pro-grammes. All these courses help ensure that staff have the skills to be com-petent in their jobs.
Clinical governance and its impact on nursing
The Royal College of Nursing (2000) illustrated how and why nurses should get involved in action to promote clinical governance. The develop-ment of clinical governance systems directly affects nurses as a major pro-fessional grouping within trusts. It is easy to quote anecdotal evidence that clinical governance is impacting positively on nurses. Examples that come to mind are that nurses in my trust are asking for training/appraisals/
clinical supervision, asking for evidence-based policies to be developed in certain areas of practice, and demanding protected time to undertake audit (and research). None of this would have happened ten or even five years ago.
In the past, nurses worked for years without appraisals, and were ‘sent’ on training. Policy manuals gathered dust on shelves and audit and research were anticipated with dread. I am not saying everything in the garden is rosy but we are seeing improvements in the desired direction.
But what evidence is there to demonstrate that the clinical governance environment is really impacting on nurses? As part of work to develop a ‘Research and Development Strategy for Nursing in Scotland’ a scoping exercise was done. Via questionnaires to nursing directors and heads of nurs-ing departments, the intention was to ascertain progress made within trusts and HEIs to develop nurses to undertake research, or to develop nurses to become more research-orientated in their practice. The findings are fascinating (Hanley, 2002), and show that research and development is beginning to become a reality for nurses/nursing. Four of the 29 trusts who responded to the questionnaires stated that nurses had ‘easy or very easy’ access to libraries, and electronic libraries were recognised as a great improvement.
IT support is still difficult and patchily developed in different trusts; some trusts did not have access to a librarian and some complained that their libraries had limited nursing resources.
Dissemination of research information is also being encouraged. Only two trusts had no method of distribution; and circulation was undertaken via newsletter, research interest groups, research days and web sites. One of the respondents said ‘clinical governance activity, like audit and implementation of clinical guidelines, is raising nursing awareness of the application of research to care and helping to make nurses want to generate research’. This is surely proof – if proof is needed – that the clinical governance agenda is supporting nurses to be evidence-based practitioners.
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.