Clinical leadership and organisational governance in primary care

Author

Natasha Duke, Advanced nurse practitioner, Doctorate of Clinical Practice, University of Southampton.

Short description

Read this learning module and learn more about clinical leadership in primary care from the perspective of nurses working at an advanced level.

Detailed description

This article examines nurse clinical leadership in primary care from the perspective of nurses working at an advanced level, such as advanced nurse practitioners or senior practice nurses. The lead nurse is pivotal to clinical effectiveness and quality of care. Aspects of leadership and its impact on how the nursing team functions are discussed. The article also identifies ways to improve morale, the facets of governance in primary care, ideas on sourcing funds for training and development, and encouraging innovation in the nursing team.

Module overview

This module examines clinical leadership in primary care from the perspective of nurses working at an advanced level, such as advanced nurse practitioners or senior practice nurses. The lead nurse is pivotal to clinical effectiveness and quality of care. Aspects of leadership and its impact on how the nursing team functions are discussed. The module also identifies ways to improve morale, the facets of governance in primary care, ideas on sourcing funds for training and development, and encouraging innovation in the nursing team.

Keywords

advance nurse practitioners, clinical leadership, community, community nurses, community nursing, leadership, management, nurse practitioners, nursing roles, practice nurses, practice nursing, senior nurses.

Aims

The aim of this module is to help you to examine critically what lead nurses (LNs) must do to ensure the development of excellent care environments in the community, working reliably, realistically and responsibly with the requirements of clinical governance frameworks. If you do not have a designated leadership role in a Clinical Commissioning Group (CCG) you may still wish to influence such leaders in your area of expertise.

Intended learning outcomes

After reading this module and completing the time out activities, you should be able to:

• State in which ways a LN offers the authority and authenticity to deliver change in primary care services.
• Summarise the requirements of healthcare governance and why LNs need to work with this locally.
• Describe the importance of staff morale to improvements in primary healthcare and why the LN must remain attentive to this.
• Make a case for why clinical effectiveness, evidence-based practice and audit are interlinked and central to the work of the LN.
• Explore the leadership opportunities of your local practice environment, using clinical governance as a framework for the review.

• Introduction

  Clinical leadership and organisational governance are essential for the implementation of clinical standards and effectiveness (Monitor 2013). This module discusses nursing leadership and governance from the perspective of an advanced nurse practitioner (ANP) in primary care, but it is relevant to all nurses in a LN role. The aspects of governance covered include clinical effectiveness and audit, risk management, integration across organisations, involvement with people, education and training, and research and development.

• Definition

  An advanced nurse practitioner (ANP) is a senior nurse trained to graduate or postgraduate level, who makes autonomous decisions for which they are accountable.
• Using advanced skills they diagnose, plan and deliver care, and independently manage their own caseload (Royal College of Nursing (RCN) 2012). ANPs can order investigations, interpret results, admit, discharge and refer in the same way as doctors. An ANP is different from a ‘clinical specialist nurse’, although both may be working at a senior level (Duke 2012).
• Lead nurse

• The LN in primary care may be a senior practice nurse or an ANP. The Department of Health (DH) identified advanced practice as that which involves research, education and management, but is embedded in direct patient care (DH 2010). LNs at advanced level may include ANPs, clinical nurse specialists or senior nurses.
• Practice nurses may have completed hospital-based training many years ago and not hold a university degree, yet be highly experienced nurses equally suited to the role in primary care. LNs will be responsible and accountable for delivering the strategy of clinical nursing care, and setting clinical standards against national directives (DH 2012).

• Transformational LN

  A transformational LN will lead by enthusiasm (Alimo-Metcalf et al 2007), ensuring integration of clinical and organisational governance in line with the Nolan principles of (Monitor 2013):
  • Integrity.
  • Selflessness.
  • Accountability.
  • Objectivity.
  • Honesty.
  The LN should inspire innovation, service design and care, and foster development of staff potential pathways (NHS Leadership Academy 2014).
1. Clinical leadership and organisational governance including clinical effectiveness and audit, risk management, integration across organisations, involvement with people, education and training, and research and development, are essential for the implementation of clinical standards and effectiveness.
2. An ANP is a senior nurse trained to graduate or postgraduate level, who makes autonomous decisions for which they are accountable. Using advanced skills they will diagnose, plan and deliver care, and independently manage their own caseload.
3. The DH identified advanced practice as that which involves research, education and management, and is also embedded in direct patient care.
4. LNs in primary care may be a senior practice nurse or an ANP responsible and accountable for delivering the strategy of clinical nursing care, and setting clinical standards against national directives.

• Good nursing leadership

  The NHS faces constant change, which in itself can cause anxiety and stress to staff (Carter and Walker 2008). Fear of failure and pressure from management can have profound effects on nurses (Traynor et al 2014). Dynamic nurse leadership that inspires, encourages and leads by example raises morale and can improve quality (NHS Leadership Academy 2014).
  Figure 1

  

  • LNs need to demonstrate the 6Cs of care, compassion, commitment, courage, competence and communication (NHS England 2014a) to staff as well as patients. By doing this, leaders can inspire staff, who are more likely to follow by example.
  • LNs need to ensure that clinical risk is managed appropriately and robustly, ensuring the safety of patients and the cost effectiveness of a service (Bullivant et al 2012).
  • By making mechanisms for quality assurance and improvement evident in every facet of the nursing team, the LN can ensure that the ‘quality curve’ can be shifted from the mean (or average), to the right (or exemplary) (Figure 1), and can strive towards excellence (Hogan et al 2007).
  • 
  • It is essential that LNs share their vision of how the nursing team should function, and they should appreciate the individual strengths of the team so that these are incorporated.
  • By displaying self-confidence, self-awareness, compassion for team members and determination for the team to pursue excellence, the LN can significantly influence whether the team functions well or poorly.
  The NHS is facing tough times, with nurses expected to produce better outcomes with fewer resources (NHS England 2014d). If LNscan acknowledge this pressure with staff, yet inspire them by valuing each individual’s contribution, nurses might feel the struggle is worthwhile.

  Clinical governance

  A governance framework ensures the vision, strategy, leadership, probity and stewardship of an organisation are planned. Accountability ensures that the organisation – whether delivering primary, secondary or tertiary healthcare – is adhering to the plan lawfully, and delivering safe and equitable as well as quality services while managing risk (Bullivant et al 2012). These principles, known as the Nolan principles, should underlie the governance framework and direct behaviour.
  Governance identifies the organisation’s planned outcomes, enabling clearly defined functions, roles and responsibilities (NHS Leadership Academy 2013). It is likely LNs will have input into the governance of information, research, staff training and development and integration across external organisations.
  There are various models to support clinical governance (Huntington 2000, Research and Professional Development 2014). Their over-arching aim should be to improve quality and reduce risk cost effectively, with structure cascading responsibility for delivering quality performance to identified personnel (Westwood and Silvester 2008).
  

  Changes and challenges

  In 2013, the Health and Social Care Act (DH 2012) changed the landscape of the NHS. Primary care trusts and strategic health authorities were replaced with clinical commissioning groups (CCGs), with Monitor, the regulator, responsible for ensuring that quality and cost are managed. The CCG boards are diverse, but must include one hospital doctor, a nurse and a member of the public. They commission most services and are responsible for about 60% of the NHS budget (Naylor et al 2013). The NHS structure is summarised in a King’s Fund video, which is available to view at: www.kingsfund.org.uk/projects/nhs-65/alternative-guide-new-nhs-england.
  The LN is the lead for nursing care, but may also have input into areas such as research, risk, staff and integration across organisations, such as district nursing. The use of frameworks and models can ensure main areas are addressed. Political, environmental, social, technological, legal and environmental factors will also influence short and long-term goals (Weberience 2015).
  Challenges to organisational governance are unique to each organisation; in primary care there are pressures to provide a better service with less financial support, and to boost the morale of the workforce. Challenges are the part-time work patterns of many staff, which can make communication more difficult, and working across geographical boundaries with partner organisations.
  Learning Points
  1. LNs need to demonstrate the 6Cs to staff as well as patients, helping leaders to inspire staff, who are more likely to follow by example.
  2. It is vital that LNs share their vision of how the nursing team should function, and they should appreciate the individual strengths of the team so that these are incorporated.
  3. A governance framework ensures the vision, strategy, leadership, probity and stewardship of an organisation are planned based on the Nolan principles.
  4. Clinical governance’s over-arching aim should be to improve quality and reduce risk cost effectively, with structure cascading responsibility for delivering quality performance to identified personnel.
  5. The CCGs with Monitor and the regulator are responsible for ensuring that quality and cost are managed; they are responsible for about 60% of the NHS budget. The CCG boards are diverse, but must include one hospital doctor, a nurse and a member of the public.
  6. Challenges to organisational governance are unique to each organisation, such as the pressure in the primary care to provide a better service with less financial support and to boost workforce morale.

  • Morale

    The speed of change planned by the Five Year Forward View (NHS England 2014b) and the challenges of staff recruitment and retention in primary care highlight the difficulties associated with translating policies into clinical practice. Clinicians may feel that what matters is what is measured (Bevan and Hood 2006) and morale is usually not measured. Low staff morale can affect the quality of patient care. Sawbridge and Hewison (2011) described nursing leadership, staff education and addressing the ‘emotional cost of labour’ as essential in preventing burnout and poor care.
    In the NHS, the fear of failure, underperforming and hitting targets can drive behaviour (Cornwell and Edwards 2013), which may lead to resistance of new strategies and policies. In addition, in primary care, GPs directly employ staff and salaries are not protected by the hospital pay structures of Agenda for Change. A nurse’s salary can remain static for years if GP partners say they cannot afford to give a pay rise (Davies 2013).
    It is recognised that GPs and practice nurses are at risk of burnout (McMillan and Perron 2013, Pulse 2014). The UK has one of the highest rates of burnout among nurses in Europe (Health Education England 2014) and 73% of GPs say workloads are unmanageable (British Medical Association 2014). Because of stress, nurses may leave primary care when they are needed to implement new plans for community-based care.

  • Importance of LN

    Supportive environments enable staff to deliver quality care (DH 2008). The NHS Health and Well-Being: The Final Report (DH 2009) found that organisations that prioritised wellbeing and health of staff performed better, had stronger quality scores, better patient satisfaction, better outcomes and lower staff sickness, and higher staff retention.
  • LNs who care about their staff can ensure the personal circumstances of staff are incorporated into care and shift planning.
  • To bring out the best in their teams, LNs need to exercise kindness and compassion for their team members.
  • They need to develop their emotional intelligence to understand individual requirements. For example, when a LN becomes aware of personal circumstances that are causing severe stress to a member of the nursing team, the LN could temporarily reduce or rearrange shift hours, and ask colleagues to cover the extra hours for a set period.
  • LNs could also consider the use of stress frameworks to ensure compassion fatigue and burnout are avoided (Thompson 2011), and to help staff remain emotionally available for their patients (Sawbridge and Hewison 2011).
  • In addition, by encouraging regular socialising outside working hours (and not just the yearly Christmas function), LNs can hope that friendships between staff members will deepen and strengthen the team.

Learning Points

• 1. Nursing leadership, staff education and addressing the ‘emotional cost of labour’ are essential in preventing burnout and poor care. Low staff morale can affect the quality of patient care.
  2. The fear of failure, underperforming and hitting targets may lead to resistance of new strategies and policies in the NHS.
  3. Organisations that prioritised wellbeing and health of staff performed better, had stronger quality scores, better patient satisfaction, better outcomes and lower staff sickness, and higher staff retention.
  4. LNs could also consider the use of stress frameworks to ensure compassion fatigue and burnout are avoided and to help staff remain emotionally available for patients.

  Clinical effectiveness

  The new code of practice states that nurses should ‘prioritise people; practice effectively; preserve safety; and promote professionalism and trust’ (Nursing and Midwifery Council (NMC) 2015). All nursing care begins with human contact in a compassionate relationship (RCN 2011), and one that incorporates physical, social, emotional and spiritual aspects.

  In primary care the role of the family is significant, and nurses should be aware of the needs of carers too. The LN should ensure that nursing care and procedures are evidence-based. Quality, efficiency, safety and risk must be addressed. Policies that encourage staff to improve quality, with clinical and technical structures enabling delivery, can raise standards (Hogan et al 2007).

  

  To improve quality the LN could review systems for clinical supervision and practice evaluation, evaluate decision making and give regular feedback to clinical staff (MacKenzie and Manley 2011). Each individual’s responsibility should be clear (NHS Institute for Innovation and Improvement 2013).

  Regular team meetings with nurses and other clinical staff can ensure that quality improvements can be identified and implemented (Westwood and Silvester 2008). Meetings can address any concerns raised by staff and review near misses or safety incidents with root cause analysis. Action plans can identify changes and improvements to be made, and the LN should be presenting any new evidence that necessitates the updating of practice (NICE 2014).

  Yearly reviews should reassess action plans, and ensure organisational memory (Donaldson 2002). It is important that an organisation retains the lessons learned from previous errors, and that these are incorporated into new policies.

Audit for clinical effectiveness

The LN should be involved in conducting regular clinical audit cycles (Figure 2). Clinical audit should ‘improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change’ (National Institute of Health and Care Excellence (NICE) 2002). These audits will confirm transparency (NHS England 2014c), and promote the confidence of all involved.

Audits should be taken of areas with high risk, such as infection control, clinical equipment and medicines management. Risks can be reduced by standardisation of safe practice, such as safe storage of medicines. Human error can be reduced if vulnerabilities in the system are addressed; this especially applies to high-risk areas such as medication error (NHS Leadership Academy 2002).

Learning Points

1. The new code of practice states that nurses should ‘prioritise people; practice effectively; preserve safety; and promote professionalism and trust’.
2. The LN should ensure nursing care and procedures are evidence-based.
3. Regular team meetings with nurses and other clinical staff can ensure that quality improvements can be identified and implemented. Yearly reviews should reassess action plans, and ensure organisational memory to make sure that the lessons learned from previous errors are incorporated into new policies.
4. Clinical audit should be used to ‘improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change’.
5. Areas of high risk, such as infection control, clinical equipment and medicines management, should be audited on a regular basis.

Risk management

Identifying risks to safety is essential. Berwick’s review, A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England (DH 2013), states that quality and safety are paramount, there must be empowerment of the public voice, staff should be supported, and transparency should be evident. The Care Quality Commission (CQC) (2012) provides advice for NHS providers on how to complete quality risk profiles (2012), and standards to be assessed, which are information and involvement, quality care, safety, staffing and management. This is linked to a systems-focused, no-blame safety culture. The Quality Outcomes Framework (QOF) also measures clinical performance (Health and Social Care Information Centre 2013).

To reduce risk LNs could ensure health care assistants complete apprenticeships, and plan working patterns effectively (West et al2004, Skills for Health 2014). LNs should act on any immediate concerns, and ensure that a ‘significant event’ involving the nursing team is recorded, analysed and acted on. This would include ‘near misses’ where an error has been narrowly avoided, for example when a wrong drug was almost given by a nurse but identified just in time, and the correct one administered. A review will ensure theLN plans policies to prevent reoccurrence of the event. Regular nursing team meetings can address root-cause analysis of safety concerns and near misses, provide updates of new practice (NICE 2014) and aid cohesiveness and communication of the team.

Learning Points

1. Identifying risks to safety is essential, the public voice should be empowered, staff should be supported, and transparency should be evident.
2. The CQC provides advice for NHS providers on how to complete quality risk profiles linked to a systems-focused, no-blame safety culture.
3. LNs should act on any immediate concerns, and ensure that a ‘significant event’ involving the nursing team is recorded, analysed and acted on.
4. Regular nursing team meetings can address root-cause analysis of safety concerns and near misses, provide updates of new practice and aid cohesiveness and communication of the team.

Integration across organisations

Integration occurs by developing partnerships with partner organisations such as unscheduled care, community services and hospitals to give a seamless service. Data sharing, in line with Caldicott principles, should lead to safer practice (DH 2012).

Appointing named personnel to liaise with for each partner organisation will help to ensure effective communication. Primary care stakeholders are:

• Staff.
• Patients.
• Linked organisations.

These include the CCG, local authorities, maternity and secondary care, mental health and health visitors, and pharmacists. Links are maintained through computer links and notes, meetings and on-site clinics.

Stakeholders’ opinions can be sought by Patient Participation Groups (PPG), and a ‘comments box’. Surgeries should communicate their vision to all stakeholders. Improving stakeholders’ involvement can be through PPG meetings and newsletters, seeking feedback from partner organisations and encouraging staff and patient innovation and feedback.

Staff should be aware that patients can search any surgery’s QOF results by going to the website: qof.hscic.gov.uk, clicking on ‘search for practice results’ and typing in the name of the surgery in the search box.

Education and training

Staff education and training are important and LNs should ensure their teams have appropriate training that is up to date (CQC 2014). Attending seminars, lectures and training contribute to maintaining competency, but LNs can inspire their team further. One opportunity could be regularly asking staff to present recent journal articles in their subject specialism.

The diabetes LN could, for example, report on latest evidence from a diabetic journal. Significant events or conferences could present opportunities for a nurse to do a literature review in a given area, and present this. Group discussion afterwards could generate ideas from the literature review about improving services.

Learning Points

1. Integration across organisations occurs by developing partnerships with partner organisations such as unscheduled care, community services and hospitals to give a seamless service.
2. Data sharing should be done, in line with the Caldicott principles.
3. Primary care stakeholders are staff, patients and linked organisations including the CCG, local authorities, maternity and secondary care, mental health and health visitors, and pharmacists.
4. Surgeries should communicate their vision to all stakeholders and stakeholder involvement can be achieved through PPG meetings and newsletters, seeking feedback from partner organisations and encouraging staff and patient innovation and feedback.
5. LNs must ensure their teams have appropriate up-to-date training, for example, by attending seminars, lectures and training, which contribute to maintaining competency.

• Integration across organisations

• 
  
  Integration occurs by developing partnerships with partner organisations such as unscheduled care, community services and hospitals to give a seamless service. Data sharing, in line with Caldicott principles, should lead to safer practice (DH 2012).
  Appointing named personnel to liaise with for each partner organisation will help to ensure effective communication. Primary care stakeholders are:
  • Staff.
  • Patients.
  • Linked organisations.
  These include the CCG, local authorities, maternity and secondary care, mental health and health visitors, and pharmacists. Links are maintained through computer links and notes, meetings and on-site clinics.
  Stakeholders’ opinions can be sought by Patient Participation Groups (PPG), and a ‘comments box’. Surgeries should communicate their vision to all stakeholders. Improving stakeholders’ involvement can be through PPG meetings and newsletters, seeking feedback from partner organisations and encouraging staff and patient innovation and feedback.
  Staff should be aware that patients can search any surgery’s QOF results by going to the website: qof.hscic.gov.uk, clicking on ‘search for practice results’ and typing in the name of the surgery in the search box.
• 
  

• Education and training

• 
  
  Staff education and training are important and LNs should ensure their teams have appropriate training that is up to date (CQC 2014). Attending seminars, lectures and training contribute to maintaining competency, but LNs can inspire their team further. One opportunity could be regularly asking staff to present recent journal articles in their subject specialism.
  The diabetes LN could, for example, report on latest evidence from a diabetic journal. Significant events or conferences could present opportunities for a nurse to do a literature review in a given area, and present this. Group discussion afterwards could generate ideas from the literature review about improving services.
• Learning Points

1. Integration across organisations occurs by developing partnerships with partner organisations such as unscheduled care, community services and hospitals to give a seamless service.
2. Data sharing should be done, in line with the Caldicott principles.
3. Primary care stakeholders are staff, patients and linked organisations including the CCG, local authorities, maternity and secondary care, mental health and health visitors, and pharmacists.
4. Surgeries should communicate their vision to all stakeholders and stakeholder involvement can be achieved through PPG meetings and newsletters, seeking feedback from partner organisations and encouraging staff and patient innovation and feedback.
5. LNs must ensure their teams have appropriate up-to-date training, for example, by attending seminars, lectures and training, which contribute to maintaining competency.

Staff development

LNs can encourage staff development and innovation. Financial support for training in primary care is tight, but often LNs are not aware of other sources of funding. Organisations such as the RCN Foundation, the Burdett Trust for Nursing, the Florence Nightingale Foundation and the Foundation of Nursing Studies Centre for Nursing Innovation want to develop nurses’ potential and improve patient care. They offer training, support and funding for all members of the nursing team.

The document Forward View Into Action: Planning for 2015/16 (NHS England 2014d) details plans to prioritise health promotion, patient empowerment and engaging communities and will cover:

• Action on health promotion and illness prevention through partnerships with communities/patients.
• Co-creation of new models of care.
• Seamless integration across healthcare providers.
• Improved safety, quality and outcomes.
• Harnessing of information technology and innovation.
• Increased efficiency.

These goals are all nursing related, and LNs can inspire teams to think creatively about how to improve care for patients. One example of this could be a nurse who likes gardening liaising with the council to enable the GP surgery to have garden allotments. A Gardening Club could be created for patients with chronic long-term conditions so that patients will be getting exercise by gardening in addition to socialising, and perhaps offering nurses an opportunity to learn more about a patient’s condition.

Learning Points

1. Organisations such as the RCN Foundation, the Burdett Trust for Nursing, the Florence Nightingale Foundation and the Foundation of Nursing Studies Centre for Nursing Innovation want to develop nurses’ potential and improve patient care by offering training, support and funding for all members of the nursing team.
2. The document Forward View Into Action: Planning for 2015/16 details plans to prioritise health promotion, patient empowerment and engaging communities. These goals are all nursing related, and LNs can inspire teams to think creatively about how to improve care for patients.

Conclusion and recommendations

• It is important for LNs to explain how and why robust governance is relevant to their teams, as many nurses in primary care may not be aware of the relevance of governance to them.
• Primary care nursing is facing significant challenges.
• LNs experience pressure from management above, and fatigued nursing teams below.
• By staying true to the principles of nursing and by acting as a role model for the team, LNs can influence whether the changes to the NHS succeed.
• Change can be stressful but it can also be a great catalyst for innovation and an opportunity to do things differently.
• Nolan and Smojkis (2003) found that the reasons nurses leave the profession include dissatisfaction with management, poor support, desire for increased autonomy and greater involvement in decision making.
• Conversely, personal experience has shown that nurses stay in practice where they feel valued.
• Changes in the NHS offer ways to rethink care provision.
• If LNs can engage their teams to think in new and creative ways to improve health outcomes for patients, they may be rewarded with innovative ideas.
• Involving the team in encouraging innovation may initially meet with disinterest, but by making this a regular feature of meetings, and by rewarding new ideas, LNs can encourage teams to be creative and to strive for excellence.

Acronyms

6Cs: care, compassion, commitment, courage, competence and communication

ANP: advanced nurse practitioner

CCG: Clinical Commissioning Group

CQC: Care Quality Commission

DH: Department of Health

GP: general practitioner

LNs: lead nurses

NHS: National Health Service

NICE: National Institute of Health and Care Excellence

NMC: Nursing and Midwifery Council

PPG: Patient Participation Groups

QOF: Quality Outcomes Framework

RCN: Royal College of Nursing

Glossary

Accountability: accountability or responsibility for the moral and legal requirements of patient care.

Caldicott principles: recommendations of the Caldicott review which set out expectations of how personal-identifiable information should be used and shared.

Clinical commissioning groups (CCGs): statutory bodies led by clinicians – primarily GPs – tasked with administering approximately 80% of NHS funds to plan and procure local health services.

Community-based care: health care for all ages of people who require health assistance at home.

Nolan principles: the Committee on Standards in Public Life established the Seven Principles of Public Life, also known as the Nolan principles. They are selflessness, integrity, objectivity, accountability, openness, honesty and leadership.

Systematic review: a review of a clearly formulated question that uses systematic and explicit methods to critically appraise research.

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