Shared governance was implemented in this large, acute care teaching trust in the United Kingdom (UK) to empower clinical nurses. The implementation process is described in detail and is followed by a discussion of the current structure, an overview of the evaluation of the structure, and the objectives of each of the four nursing teams (councils): the Quality, Management, Education, and Clinical Practice Teams. Also included are examples of the achievements of each of the teams and an account of the personal experience of one nurse who joined the Trust once shared governance had been implemented.

Background

The implementation of a trust-wide nursing shared governance structure started in 1997 with the arrival of Jonathan Asbridge as Chief Nurse at Barts and The London National Health Service (NHS) Trust, then known as The Royal Hospitals NHS Trust (Asbridge, 1999). A trust is a semi-autonomous, self-governing unit within the NHS, the UK’s public health system. As in the case of many other trusts, Barts and The London is comprised of a group of hospitals that are managed and operated as a single entity.

The Barts and The London Trust, called the Trust – one of the largest acute care teaching trusts in the UK - was formed in 1994 with the merger of four hospitals, all with their own distinctive history and traditions: St. Bartholomew’s Hospital, The Royal London Hospital, The London Chest Hospital, and Queen Elizabeth Hospital for Children (www.bartsandthelondon.org.uk/). This merger brought together over 5,000 staff (now over 6,500), caring for over half a million patients a year.

Nursing took a lead in promoting collaboration under the Trust’s first Chief Nurse, Pam Hibbs. When Jonathan Asbridge took up his post in April 1997, there were 16 directorates, each with a lead nurse who was managerially and professionally responsible for the nursing service within his/her area. These lead nurses headed directorates of varying sizes, with establishments from 20 to over 500. An establishment is the number of nurses funded to work on a ward or department.

Planning: One Dream, One Vision

As Chief Nurse, Jonathan brought a vision of how to provide the highest quality patient-centred care to further develop the many existing examples of excellence in clinical nursing practice at the Trust. The vision had three strands – shared governance, clinical leadership, and practice development (Edmonstone, 2000). This article tells the story of the development of empowerment in the nursing service through a shared governance structure. The definition of empowerment that we worked towards was, "90% of clinical decisions would be made by clinical practitioners" (Porter-O’Grady, Hawkins, & Parker, 1997). At the same time as the Trust was developing shared governance, nurses in the Trust were able to access the in-house course, Leading Empowered Organisations (LEO) course (Geoghegan & Farrington, 1995). This occurred well before leadership programmes were part of the national strategy.

The Journey

Soon after his arrival in April 1997, Jonathan held an externally facilitated day with the lead nurses and corporate nursing team (Asbridge, 1999), as well as the lead nurse of each of the 16 directorates, and the senior clinical nurse specialists. In all, about 30 senior nurses from across the Trust participated in the day.

The structure of the day will be familiar to many. The morning was spent getting to know one another since working in such a large, complex and multi-site organisation, many of the participants were strangers to each other. We also took the time to look back and celebrate the achievements of the past year. In the afternoon, we moved on to capture our aspirations for the future. These included reorganising the nursing management structure (Porter-O’Grady, 1989), addressing the challenge of the recruitment and retention problems, and identifying clinical protocols needed, such as guidance on the presence of relatives at resuscitation attempts.

The Proposal

Within a month of the event, all the flip chart notes and ideas generated on the externally facilitated day were circulated to all the participants. The paper also offered an action plan, mapping out how these many aspirations could be achieved. The words "shared governance" were not actually mentioned, but the paper was based on the principles and concepts of empowerment. Comments were invited on the contents of the notes, and the paper was discussed at the monthly lead nurse meeting. There was support that the suggestions should be developed; and a series of three additional days were held during the autumn with the Chief Nurse, the lead nurses, and Jim O’Malley, an external nurse consultant who is very experienced in implementing shared governance. At these sessions, the proposals were developed and questions raised, such as: how many councils should there be, how many members, and how should the implementation be organised?

The Details

It was agreed to have four teams, (DeSantis & DiTolvo, 1999; Edmonstone, 1998; O'May & Buchan, 1999) one less than in the textbook structure. The Barts and The London structure merged research and quality councils into the Quality and Clinical Effectiveness Nursing Team (the name was later changed to the Quality Team).

...all the lead nurses who had attended the four planning days were now passionate about the structure and very keen to be involved.

There was considerable discussion about having an additional team for Clinical Nurse Specialists. However, it was decided that the teams were established around work streams not roles, and that the input of the clinical nurse specialists would be valuable on the teams. Indeed one of the first chairs was a clinical nurse specialist. We decided that "nursing team" was a title that fitted with the culture of our Trust better than that of "council". (Senge, 1990)

At this stage, it was agreed that the ideal size of a team was 12. Not surprisingly, all the lead nurses who had attended the four days were now passionate about the structure and very keen to be involved. It was agreed that this energy and enthusiasm should be harnessed and the lead nurses provided more than half the members for the teams. In addition, each of the 16 directorates was asked to nominate a clinical nurse to join a team.

All the potential team members were asked to rank the teams in order of preference so as to choose the inaugural membership. The Chief Nurse was asked to nominate the four chairs because it was thought that this would kick start the activity of the teams. He was very resistant to this approach because it was not in the spirit of empowerment, but eventually agreed.

The group of nurses who had reached agreement about the composition of the teams were aware that they needed to have these decisions developed into descriptive terms of reference both for the Nursing Policy Board (the co-ordinating council) and the four nursing teams. This was a task for a small number of people, and so volunteers were sought for a working group to undertake the task. These volunteers formed the Design Team, whose task was formalising the transitional structure of shared governance for Barts and The London ( Figure 1: Nursing Shared Governance Structure [pdf]). This paper, known as the Bylaws, was subsequently approved by the Nursing Policy Board. Later the Design Team developed the bylaws for the permanent structure. These bylaws are reviewed at least every three years (Thompson, 2000a).

During the discussions about the specifics of membership of the teams, it was agreed that representation from the local education provider should be requested. The Dean of the School of Nursing and Midwifery was invited to join the Nursing Policy Board and one place on each team was offered to a staff member from the school (Peterson & Allen, 1986).

A very important part of the implementation of shared governance...has been to increase the visibility and to expand the influence of nursing.

At the same time as these details were being finalised by the lead nurses, the Chief Nurse was building support and approval from his executive team colleagues. The Trust Board approved the establishment of a nursing shared governance structure in February 1998, nine months after the first facilitated day.

As the coordinating council of the structure, the Nursing Policy Board became a standing committee of the Trust Board (Figure 2: Committee Structure [pdf]). A very important part of the implementation of shared governance at Barts and The London has been to increase the visibility and to expand the influence of nursing. The establishment of the Nursing Policy Board was an important part of this strategy. There is no doubt that this aspiration has been realised. The Nursing Policy Board is accepted as the 'voice of nursing' and consulted on a wide range of organisational issues and policies.

Launching The Current Nursing Shared Governance Structure

Next, this article will present the development of strategies to strengthen the shared governance structure. This discussion also describes how the shared governance teams supported team members and maintained momentum.

Development

Jonathan Asbridge had already implemented shared governance in a previous trust, The Oxford Radcliffe Hospitals. Building on his experiences there, training sessions were held for all the members of the new nursing teams at Barts and The London. Three days of training, conducted by our external consultant, provided both the principles and concepts of shared governance, and the practical tools to run effective meetings.

All team members had equal rights and airtime.

The teams also spent time determining norms for attendance and behaviour at meetings and agreeing how meetings would be conducted. A commitment to attend was expected, along with respect and support for the views of all team members regardless of rank or status. All team members had equal rights and airtime.

The teams developed statements about their overall purpose, objectives, and the specific outcomes they aimed to achieve in the first year of work. The initial outcomes for that first year were consistent with the ideas generated at the very first away day. This was encouraging, as it identified consistency and a commitment to the work stream identified early on.

The Launch

In April 1998, the first meeting of the Nursing Policy Board was held. The membership of the Nursing Policy Board was, and is, considerably larger than a normal coordinating council. In addition to the Chief Nurse and chairs of the nursing teams, the lead nurses also became members. There have been many debates and challenges regarding lead nurse membership on these teams. However, the nurses at Barts and The London felt, and continue to believe, that it is important that the nurse managers charged with implementing the decisions of the Nursing Policy Board, developed by the shared governance teams, should be present to be fully informed about the work they are expected to lead. It also ensures that there is clear communication about projects and ongoing work.

The consultant attended team meetings as a process facilitator to help the teams establish norms and ways of working.

Also in April 1998, all the nursing teams held their first meetings. As part of the education and support for these new teams, their chairs and vice chairs and the external consultant who was working with us attended the first three meetings of each of the teams. The consultant attended team meetings as a process facilitator to help the teams establish norms and ways of working. He was also called upon to give some specific advice, most commonly when teams were not sure how to address issues about topics that linked with the work of other teams. Four members of the corporate nursing directorate had been placed in teams to provide support in relation to the Trust and to facilitate negotiation and links with other disciplines and managers. It was agreed these senior members of staff were not eligible to be the chair or vice chair of a team.

The Role of the Nursing Team Members

After the first teams were established in April 1998, it was agreed that self-nomination, with line manager support, should be the way to join one of the trust-wide teams (Geoghegan & Farrington, 1995). Staff members involved in shared governance are supported with one day a month for team work. This is in paid work time and is additional to any study leave. Nurses join a team for a term of 18 months and are able to serve two consecutive terms on any one team.

Members of the nursing teams attend the monthly meetings of their nursing team, which last on average two hours. In addition, most teams also hold subgroup meetings on the same day as the main team meetings (Senge,1990). This evolved as the easiest way for more clinically-based nurses to contribute to the work of the teams. At Barts and The London 12- hour shifts are commonly worked and this means that time away from the clinical area is best arranged as a whole day.

Most of the work of the teams is carried out in the subgroups (Porter-O’Grady, 1989; Westrope, Vaughn, Bott, & Taunton, 1995), including the development and review of policies, procedures and other initiatives. Although the way in which the work is organised varies from team to team, it is quite common for the subgroups to be responsible for specific or ongoing projects. Some of the projects undertaken by the subgroups are chosen by the groups themselves to address issues that they consider important and appropriate. Other projects are undertaken at the request of the Chief Nurse, Nursing Policy Board, or other similar groups or individuals.

Nursing team members may co-opt other nurses not on the team or other Trust staff onto the subgroups and teams.(Senge,1990) Of the four teams, two have permanently co-opted non-nurse members whom the teams believe greatly enrich the team and support the work. These include staff from Human Resources, Communications, Clinical Risk, Clinical Effectiveness, and Pharmacy. Although most subgroups meet only once a month, meetings for more urgent projects can be more frequent, e.g., fortnightly or even weekly. Members of the subgroups may be expected to do additional work in between the meetings to progress projects. Two members of each nursing team are also members of the Design Team and attend its meetings, which take place approximately 10 times a year(Senge,1990).

Chairs and Vice-Chairs of Nursing Teams

Each nursing team has a chair and vice-chair. These posts are filled from within the teams. When a chair/vice chair term of office (one year) is over, the other team members can self-nominate themselves for the vacant post. All team members (except those who have been co-opted) then elect the new postholder from among the names put forward (Buckles Prince, 1997). The role of the chair is that of a facilitator, it is not a position of power; and the agenda is negotiated with all members of the team.

The chairs and vice-chairs of the nursing teams are also members of the Nursing Policy Board and attend its monthly meetings, at which time they give a brief verbal update on the team’s current projects. Although the vice-Chairs were not originally Nursing Policy Board members they were included to provide them with the experience of The Board and also to increase clinical membership on the Board.

Orientation and Team Buddies

Once staff have been accepted on a nursing team, they are invited to join an orientation session which gives them an understanding of how the nursing teams function and how they can get the most out of being a team member. This takes place within two months of their joining the team.

The chair of the nursing team identifies an existing team member to be a "buddy" for each new member of the team. This person contacts the new member before his/her first team meeting and is happy to answer any questions he/she might have. He/she also accompanies the new team member for his/her first team meeting.

Maintaining Momentum

As we moved past the first six months...it was acknowledged that we needed to inform many more staff in the organisation about what we were doing, and why.

As we moved past the first six months of the shared governance structure, it was acknowledged that we needed to inform many more staff in the organisation about what we were doing, and why. We wanted to engage nurses and inform the Trust Board members and senior managers of what had been achieved. In order to do this, a nursing shared governance symposium was planned. It took place in February 1999 and was a tremendous success. Several outside speakers were invited, including the Chief Nursing Officer for England, the Regional Nursing Officer, the General Secretary of the Royal College of Nursing, and the Chief Executive of the United Kingdom Central Council.

This symposium included contributions from these national figures of the nursing world and presentations by the nursing teams describing their achievements to date. The invitations to Trust nursing staff had targeted senior sisters and charge nurses, and very satisfyingly in the month after the symposium several of the participants put themselves forward to join the teams. The permanent structure for shared governance had been agreed by this time and the size of the teams had been increased to 15, so this was possible. Since the symposium, all the members of the Nursing Policy Board and nursing teams have spent a day together each year. This day is spent evaluating the year’s achievements and reviewing the processes in place. This valuable time has ensured that there is an ongoing challenge to the way things are done, and has led to change and a strengthening of the structure.

Symposiums have been held every 18 months with participation by nurses from across the organisation. Their main aim has been to inform and engage staff nurses in the move towards empowerment. They have been great fun and, like the first symposium, have led to an increased number of self-nominations to the teams. They also have communicated the strength of the shared governance initiative and its ongoing success.

Evaluation

The Design Team continues to undertake evaluation of the shared governance structure and an understanding of the principles of shared governance along with as assessment of the extent to which shared governance is permeating the Trust. Surveys in the form of postal questionnaires were circulated to the nursing staff. Communication about the work of shared governance was always acknowledged to be central to the success of the strategy and this section provides details of this communication. It also describes the challenges of implementing an empowerment model.

It is difficult to evaluate the proportion of decisions made by nurses at the bedside; however, there is certainly evidence that clinical nurses lead or are involved in the development of clinical policies and procedures. The Clinical Practice Nursing Team evaluated the patient experience. The team, with the Clinical Effectiveness Unit, surveyed over 600 discharged patients asking them whether they felt that nurses had cared for them in line with the nursing philosophy. Much rich data was obtained from the survey that was mainly of a positive nature.

Survey

Surveys to assess awareness of shared governance and its impact among Trust nurses were undertaken in 2000 and in 2001. A data collection tool was developed in collaboration with the Clinical Effectiveness Unit (CEU). Anonymous survey forms were distributed to all registered nurses in the Trust and returned and analysed by the CEU. A third survey is underway (Thompson, 2000b).

The results of the surveys (Figure 3) showed that the understanding of the principals of shared governance rose from 65% in 2000 to 79% in 2001. Surveyed nurses’ awareness of the implementation of the structure was at 77% and rose to 86% in the second survey. Although a smaller percentage felt that there was an impact on their working lives, 8% in 2000, there was an 18% increase to 46% in 2001. Regarding the impact of empowerment (Figure 4), 40% felt empowered in the first survey and 55% in the second. An additional question was added in 2001; and it demonstrated that 71% of staff were committed to shared governance

 

The number of responses to the two surveys was disappointing and alternative strategies are being implemented to improve the return to the survey currently underway. The increased awareness and understanding of shared governance found in the second survey was, however, very encouraging.

Communication

...a communication strategy is key in involving nurses in the shared governance work.

The members of the Nursing Policy Board and nursing teams have been aware that a communication strategy is key in involving nurses in the shared governance work. This is a challenge in a Trust the size of Barts and The London spread over three sites (Westrope et al., 1995). With the help and support of the Communications Department, there have been many articles in the Trust in-house newspaper, "The Link," and the in-house nursing journal, "Progress in Practice." We have become much more aware of the need to be specific when launching items such as policies, guidelines, and reports, in explaining that these are the result of work by the teams and describing the diversity of membership of the teams.

Challenges

Shared governance was a new way of working, one, that has needed commitment and education in order for development to continue. The Chief Nurse has helped by consistent vigilance in ensuring that we don’t slip back into former ways of working. For example, when opinion is needed on a nursing issue, the first question asked is, "Which team covers this topic?"

Jim O’Malley has continued to work in the Trust, not only supporting the chairs and vice-chairs, but also working with our heads of nursing (new posts taking over from lead nurses, following an organisational re-structuring of the Trust in 1999). One challenge has been how to engage and then supporting more junior nurses in joining teams. In this acute care London teaching trust, many nurses are promoted to senior staff nurses after one year. Ongoing education and support is needed. The various levels of team members are presented on Table 1.

Table 1: - Nursing Team Membership by Grade

Grade of Nurse	1998	1999	2000	2001	2002	2003
Head of Nursing - manages a directorate of up to 500 nurses	-	-	7	7	5	2
Senior Nurse I - manages group of wards or senior clinical nurse specialist	15	13	6	8	6	8
Senior Nurse H - manages smaller group of wards or clinical nurse specialist	11	9	11	9	11	9
Senior Sister/Charge Nurse G Grade - ward manager	13	15	13	19	13	14
Junior Sister/Charge Nurse F Grade -team leader	5	4	8	10	12	15
Senior Staff Nurse E Grade - qualified one year plus, may have specialist post-registration course	0	1	3	1	1	5
Junior Staff Nurse D Grade - newly qualified nurse	0	0	0	2	2	2
TOTAL	44	42	48	56	50	55

One Personal Experience

As the newly appointed Clinical Nurse Specialist for Continence, I , Alison Cain, arrived at the Trust in July 2001 with a certain amount of trepidation associated with the size of the organisation and the task in hand. The task was to develop a seamless Trust-wide continence service incorporating all adult areas while at the same time integrating with the already well-established community continence services. I wondered, "How would shared governance help me?"

In theory, shared governance is one of those structures identified by many as an ultimate aim or gold standard to be achieved. In practice, for many trusts this may come down to a couple of unconnected initiatives which allow a box to be ticked but which have little impact on direct patient care.

When I arrived at Barts and The London, the culture and structure of shared governance was already established and robust. The process for developing policies and guidelines, review, validation, and implementation was and still is, approached in such a way that it fosters ownership across the diversity of the Trust. This made the process of developing the continence service and the necessary elements a joint effort. The nursing teams were available either to take the lead, advise, or help facilitate on issues that are highlighted by any member of staff.

Shared governance is a continually evolving journey that develops and improves as the benefits are discovered and experienced first hand by established and new staff alike.

There is tangible support for individuals who wish to be involved in an initiative, for example a nursing team or resource group working on the Essence of Care programme. Junior members of staff are actively encouraged to participate. The established use of terms of reference, ground rules, and meeting formats aim to ensure a level of equality for all members.

Most recently, as Chair of the Clinical Nurse Specialist Forum, I attended the Nursing Policy Board as a member, which has given me a further level of experience of the process. Shared governance is not just an infrequent episode of activity. Shared governance is a continually evolving journey that develops and improves as the benefits are discovered and experienced first hand by established and new staff alike. In the true spirit of shared governance, as I prepare to leave the Trust, I take with me the working knowledge and experience of a structure that has the power to literally turn the nursing profession upside down in the best possible way.

The Nursing Teams and Their Achievements

Clinical Practice Nursing Team

The purpose of this team is to determine Nursing Practice Standards and lead the development and advancement of Clinical Nursing Practice. The team objectives are:

• To communicate with and make recommendations to other Nursing Teams and forums within the Trust.
• To make recommendations to the Nursing Policy Board regarding nursing practice issues.

Since the development of the clinical practice nursing team, the team has looked at several areas of practice and led a Trust-wide change in practice. One important project was a review of the Trust’s Nil (Nothing) by Mouth Policy. To review this policy the Clinical Practice Nursing Team set up a multi-disciplinary group that included a consultant anaesthetist, a pharmacist,

...the Clinical Practice team set up a multi-disciplinary group that included a consultant anaesthetist, a pharmacist, and a dietician to look at pre-operative fasting practice.

and a dietician to look at pre-operative fasting practice. Traditionally, patients going to theatre would either have nothing by mouth from midnight for the morning list or after a light early breakfast if going to the operating theatre in the afternoon. This meant some patients fasted for long periods of time. The group undertook a literature review, (Jester, 1999; Rowe, 2000; Strunin, 1993) and developed an evidence-based policy. The new guidelines state that patients can have water only six hours pre-operatively and must be strictly nil by mouth for two hours prior to surgery. The policy was approved by the Nursing Policy Board and the Standing Medical Advisory Committee in January 2003, and the group set about launching the policy across the Trust. Implementing the new policy was initially very challenging as people’s beliefs and ideas needed to be questioned and mind sets changed.

Other Clinical Practice Nursing Team achievements include:

• Development of a Continuous Positive Airways Pressure (CPAP) Policy
• Review of all generic and specialist care plans with a sound evidence base
• Update of all nursing documentation
• Standardisation of an observation chart with a patient at risk alert score
• Development of guidelines for the administration of medication via enteral tubes
• Development of a mobility assessment tool for patients at risk of slips, trips, and falls
• Development of a guideline for nurse administration of intravenous fluids to maintain established regimens without a prescription.

Education Nursing Team

The purpose of the Education Nursing Team is to define and evaluate the educational needs of nursing staff, develop strategies, and support educational initiatives in order to provide effective care for patients of Barts and The London NHS Trust. Team objectives are:

• To define educational needs of staff involved in the delivery of care
• To review and evaluate existing educational programmes and their providers to include: content, quality, cost, availability, and accessibility
• To develop priorities for training, linked to professional development and in line with service needs
• To make recommendations for the purchasing of education and training
• To develop a tool to evaluate the effectiveness of education and training programmes on the individual practitioner with the impact on practice
• To communicate with and make recommendations to other Nursing Teams and forums within the Trust
• To inform and make recommendations to the Nursing Policy Board regarding education issues.

One of the first projects the Education Nursing Team undertook was the development of Post Registration Education and Practice (PREP) Guidelines. The United Kingdom Central Council brought in PREP guidelines in order for nurses to re-register every three years.

Anecdotal feedback from staff was positive, and indicated that they found the continuing professional development form useful when completing their portfolios of evidence.

Each individual nurse is expected to demonstrate continuing professional development (CPD). The purpose of the PREP Guidelines developed by the Education Nursing Team was to provide a guide that was clear and concise, explaining what nurses had to do, what they did, and how they could demonstrate continuing professional development. Various examples of reflective practice were included to guide the nurse. A continuing professional development form to use as a template was also included.

There was a Trust-wide launch in 2000. Hard copies were made available to all nurses. Anecdotal feedback from staff was positive, and indicated that they found the continuing professional development form useful when compiling their portfolios of evidence. With the changes to the United Kingdom Council for Nursing and Midwifery in 2002, and formation of the Nursing and Midwifery Council (NMC), the team reviewed and updated the document to include current issues within nursing practice in the UK. Issues will be reviewed on a three-yearly basis in line with Trust policy. The revised document was re-launched in October 2003, and made available both as a hard copy and on-line on the Trust’s Intranet website.

Other Education Nursing Team achievements include:

• Development of a D grade competency framework
• Review of the advanced nurse practitioner, clinical nurse specialist, and nurse consultant roles
• Update of the Preceptorship Pack
• Revision of the Clinical Supervision Resource Pack
• Review of the University’s Preparation for Mentorship Course
• Evaluation of the Link Lecturer role.

Management Nursing Team

The purpose of the Management Nursing Team is to formulate and develop operational systems that support the function and perception of nursing and patient care within the Trust. Team objectives are:

• To develop management tools and systems which support patient care
• To develop strategies for effective resource management
• To recognise the expertise of others and utilise their knowledge and skill as appropriate
• To communicate with and make recommendations to other Nursing Teams and forums within the Trust
• To inform and make recommendations to the Nursing Policy Board regarding management issues

The Management Nursing Team developed the Trust-wide Procedure for Care Policy for handling violent and aggressive patients and visitors in 2000.

The proposal to focus on tackling the problem of abusive behaviour against hospital staff first came from a D grade staff nurse on the team...

The proposal to focus on tackling the problem of abusive behaviour against hospital staff first came from a D grade staff nurse on the team, who highlighted it as a matter of concern affecting many frontline staff in the Trust, and across the NHS nationally.

The Chief Nurse championed the policy and, with his encouragement, the subgroup worked intensively over three months, meeting weekly. The members of the subgroup came from many different areas in the Trust, and pooled their range of experiences in order to come up with a policy that would apply in many different circumstances. There was also a member of the Communications Department to ensure that everybody was aware of the new policy when it was launched.

The policy emphasizes the importance of clinically-led decision making for the implementation of the policy, but the group worked closely with colleagues in Security and other departments to gain their support for some of the practical aspects. The policy – one of the first of its kind in the country – attracted considerable attention and praise. It won a Health and Social Care award in 2001 and was held up as a model for other NHS organisations to follow.

Other Management Nursing Team achievements include:

• Development of the Modern Matron/Senior Nurse post
• Development of an annual re-certification of mandatory training for nurses and midwives
• Development of a trust-wide D grade rotational programme
• Revision of exit questionnaires and interviews
• Development of post-appointment questionnaires
• Review of the sisters/charge nurses handbook
• Review of inter-hospital transport
• Development of an expanded nursing section on the Trust Internet website

Quality Nursing Team

The purpose of the Quality Nursing team is to establish priorities and determine strategies for quality and clinical effectiveness to ensure best practice. The team objectives are:

• To determine the priorities related to quality and clinical effectiveness
• To select and/or develop monitoring tools related to quality and clinical effectiveness
• To review data in order to formulate action plans that will meet identified outcomes
• To inform and make recommendations to other Nursing Teams and forums within the Trust, which support quality, clinical effectiveness, and evidence based practice issues.
• To inform and make recommendations to the Nursing Policy Board regarding quality, clinical effectiveness, and evidence based practice

A recent achievement of the Quality Nursing Team is the development of an information leaflet entitled, "Developing Your Potential in Research and Audit." This leaflet highlights possible options for nurses and midwives to develop their potential in research and audit.

A recent achievement of the Quality Nursing Team is the development of an information leaflet entitled, "Developing Your Potential in Research and Audit."

The leaflet includes information to help nurses access resources both locally and nationally, and includes useful website addresses. It also gives directions to helpful resources within the Trust. The Quality Nursing Team Research Subgroup decided not to provide a comprehensive information guide, but to create something that would complement supplementary information provided by Trust departments, such as Research and Development, Practice Development, Clinical Governance, and Clinical Effectiveness Units. It is hoped that the leaflet will act as a catalyst, to encourage nurses and midwives to develop their research and audit skills. This project aims to raise awareness of research and to promote a culture that is evidence-based and values both research and audit, thus, thus promoting the development of research in nursing and midwifery. This information resource will be available as leaflet and in the Quality Nursing Team section of the Trust’s Intranet, identifying links to other departmental websites and providing additional information on research and audit project development.

Other Quality Nursing Team achievements include:

• Development of a protocol for integrated patient notes
• Conducting an annual audit of patient identification bands
• Conducting an annual Clinical Nursing Audit Programme
• Review of the policy for the nursing management of medication incidents
• Regular review of medication incidents
• Development of an action plan for the nursing elements of a national inpatient survey summary

...other professional groups want to develop shared governance "like the nurses."

The implementation of shared governance has been a positive experience. As a Trust we were very fortunate to be led by a chief nurse who had previously undertaken such work elsewhere. We attribute much of our success in implementing shared governance to the considerable time we spent communicating and involving staff, specifically the middle managers. Of course there were those who did not engage in the shared governance initiative; but they were few in number and did not impact on the changes underway. Feedback has been received over the last two years that other professional groups want to develop shared governance "like the nurses."

There is now a much larger pool of nurses...bringing a more clinical voice to decisions on a wide variety of topics.

In conclusion, the implementation of shared governance has been - and still is - a great challenge, but one that has strengthened nursing in the Trust. A fantastic amount of work has been accomplished by the teams, and more nurses feel empowered. Individuals who have been and are involved in the Trust-wide structure have developed personally and professionally and have gained confidence. There is now a much larger pool of nurses involved in Trust Committees bringing a more clinical voice to decisions on a wide variety of topics. Other staff groups are involved in the work and are developing their own empowerment models following the nursing lead.

We remain committed to the journey.

There is a constant challenge to ensure that more of the junior staff receive are supported and are to be able to attend meetings. New Chairs and Vice-Chairs of the teams particularly need to be offered support through their first meetings. The annual review of the processes of the structure is an invaluable event, enabling us to celebrate what has been achieved, but also to note and act upon any issues before they become too large. We remain committed to the journey.

Authors

Barbara Thompson, RN, Dip Medical Nursing
E-mail: Barbara.Thompson@bartsandthelondon.nhs.uk

Barbara Thompson works in the corporate nursing team at Barts and The London NHS. She facilitated the implementation of shared governance in the Trust and works to support practitioners in policy development. Barbara was originally Corporate Nurse Facilitator to the Clinical Practice Nursing Team and now supports the Quality Nursing Team.

Paul Hateley, MSc, BSc, RN
E-mail: Paul.Hateley@bartsandthelondon.nhs.uk

Paul Hateley is employed as Head of Nursing for Corporate Nursing and Pathology Directorates in Barts and the London NHS Trust. He qualified as a registered nurse in both general and mental health and then worked in a variety of "infection" specialties, including infectious diseases and sexually transmitted infections; he spent over a decade in infection control nursing. He has widely published in many aspects and areas of nursing and infection control. He has worked as an advisor to both national and international organisations relating to the prevention and control of infection. Paul Hateley has been in post since the inception of shared governance at Barts and The London NHS Trust. He was the first chair of the Clinical Practice Nursing Team and now supports the Management Nursing Team as Corporate Nurse Facilitator.

Rebecca Molloy, BSc, RGN
E-mail: Rebecca.Molloy@bartsandthelondon.nhs.uk

Rebecca Molloy is currently employed as Senior Nurse for Competency Development for Barts and The London NHS Trust. This involves the development of generic competencies for nurses across the Trust. Prior to this she has an extensive background in renal nursing. Rebecca has been a member of the Shared Governance Education Nursing Team for the last three years and currently holds the position of chair.

Shirley Fernandez, RN
E-mail: Shirley.Fernandez@bartsanddthelondon.nhs.uk

Shirley Fernandez is an experienced renal nurse who currently holds the post of Practice Development Nurse for the renal inpatient wards. She is the chair of the Quality Nursing Team.

Alison Low Madigan, MA, PhD
E-mail: Alison.Lowmadigan@bartsandthelondon.nhs.uk

Alison Low Madigan is the Internal Communications Manager for Barts and The London NHS Trust and contributes to increasing awareness of shared governance in the Trust among nursing and non-nursing staff. She is a member of the Management Nursing Team, the Design Team, and the Nursing Policy Board.

Carol Thrower, RN, Diploma in Nursing
E-mail: Carol.Thrower@bartsandthelondon.nhs.uk

Carol Thrower is currently a Senior Site Manger. This involves taking responsibility for coordination of the hospital. Carol has a background in intensive care nursing. She was chair of the Clinical Practice Nursing Team and currently holds the post of vice chair.

Alison Cain, RGN, BA (Hons)

Alison Cain is currently Lead Nurse Coordinator for the Long Term Funding and Continuing Care Team in Eastern Leicester Primary Care Trust. Alison has worked in continence nursing for 11 years across both community and acute care settings, most recently as Clinical Nurse Specialist for Continence at Barts and The London NHS Trust, where her primary role was developing a continence service for the acute trust.

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