“The more you circulate on your own travels the better citizen you become – Not only for your own country, but the world as a whole”
F. D. Roosevelt
Before I begin my report I would like to give thanks to EVERYONE who has supported me throughout this life changing experience…
To all the Hospitals and kind staff who responded to my “host a poor British Nurse” email.
To Bob Hess for his contacts, his help, his (and wife, Evi’s) hospitality and for taking a leap of faith on a suspected internet scam (no Staff Nurse could be given such an amazing opportunity, surely it was all a hoax?!)
To the Queen’s Medical Centre’s League of Friends (LoF) who sponsored my Scholarship place. I hope to continue to fund raise and promote the work of this great charity throughout the rest of my career at NUH.
To my parents, sister, friends and family, for skyping, facebooking, tweeting and blogging so much that I never had a chance to be home sick.
To my Roosevelt and LoF mentor, Gordon Waine, for all his advice whilst wearing his many different hats.
To Ellen Burns (Roosevelt secretary) for answering my many email queries over the past year and for her patience with my report writing.
:To my NUH mentors Liz Williamson and Marie Hutchings (2011 Scholar) for all their experience, reassurance and guidance during the stressful planning stage.
To Jenny Leggott (Director of Nursing at NUH) for her continued coaching and for understanding the importance of all aspects of the scholarship.
To Becky Williamson, my “Scholarship Friend”, for really understanding what it’s like and for helping me to normalise the surreal.
This report only talks about my project findings and doesn’t even begin to touch on all the other learning I gained from personal experiences. I want to thank all those who helped me grow over my 3 months travelling across America. I’ll forever remember your kindness.
About Me: I first came to Nottingham as a 6th Form Student from a small town in Bedfordshire. I attended a week-long course for people who wanted to go on to study healthcare. This gave me a taste for this fantastic city and made me blinkered to any other University options. I wanted to go to Nottingham. So you can imagine my joy in 2005, when I was offered an unconditional place at the University of Nottingham to study Nursing. Being a student, I’d lived in various parts of Nottingham and loved the area so much that I decided to stay.
In early 2012, I saw an advert for the Roosevelt Scholarship. The poster said “Would you like to travel around the USA for up to 3 months and investigate a work project?” I thought, “Yes! Yes, I would!” At this point in my career, I’d been a qualified Oncology Nurse for almost 2 years. I loved my job, but needed a new challenge. I’d always dreamt about travelling, but I didn’t want my career to suffer by taking time off work. The only way I felt that I could be challenged and increase my nursing skills, was to move departments. I even contemplated moving hospitals and moving to surrounding counties, if the right opportunity arose. Luckily, I saw the Scholarship and applied in February 2012.
Choosing a Project:
I decided that if I were to investigate a project, I wanted the topic to be broad, so as to have a large impact at Nottingham University Hospitals (NUH) NHS Trust. I wanted my project to improve care, so I looked to the press for inspiration into what the public perceived the NHS to do badly. As you can imagine, this was a rich resource of areas for improvement (especially as stories from the Mid Staffordshire NHS scandal, were coming to light). I finally settled on the topic of nutrition and went to consult the Practice Development Matron (PDM) at NUH, Tracey Warren. I asked her if she could give me some aspects of nutrition, which she felt we needed to improve upon. She told me how we know what needs to be done on the ward areas to improve care, but the Nutrition Link Nurses don’t have enough protected time, the right leadership skills, and aren’t empowered enough to implement change in their local area. It struck me that we needed to look at having a robust structure in place for helping frontline staff to make changes to their practice.
Whilst consulting with a variety of staff, I heard about the Magnet Recognition Program®. Having Magnet® status for a hospital is a little like having a Michelin star for a restaurant. It shows everyone that your organisation’s nursing care is that of an excellent standard. Magnet® recognition is awarded to hospitals worldwide, by the American Nurses Credentialing Center (ANCC).
I researched the outcomes that a hospital needs to meet in order to obtain Magnet® status, and found that an organisation had to have a good working system of nursing Shared Governance. These outcomes are rigorously assessed to insure that Magnet® status is deserved. The fact that Shared Governance features within the list of requirements, illustrates how effective it is as a management structure and how essential frontline staff are, in ensuring high quality care is consistently delivered.
Shared Governance is a “bottom up” style of management. It gives a voice to frontline staff, empowering them to be able to make improvements to the way in which they deliver patient care. This seemed like the answer to the Nutrition Link Nurse issue. If we had a good structure of Shared Governance, we could improve nursing care from the grass roots. Most importantly, this could improve all aspects of nursing, not just nutrition.
Planning My Project:
The beauty of the Roosevelt Scholarship is that it is utterly non-prescriptive. Scholars can use their grant of money however they choose. This sounds like a dream, but in the early planning stages of my itinerary, this was a huge challenge. Where should I start? How do I know which hospitals would be good to visit? And how do I even begin to get in contact with people and organisations that I’ve never visited? In hindsight, juggling shift work and trip planning, taught me invaluable project management skills, which I’d never used before, but now use in my day-to-day working life.
I knew I wanted to use the opportunity to the full and go for three months. Following the advice of my NUH mentors, I also knew I wanted to attend the Magnet Conference® in California (October) and the Institute for Healthcare Improvement (IHI) conference in Florida (December). This gave me two “pins in my map” and a rough time scale to plan my trip around.
Next I “googled” Shared Governance and found the “Forum for Shared Governance” (http://www.sharedgovernance.org/). I contacted the founder of the forum, Dr. Robert Hess and asked him to recommend organisations in the US that use Shared Governance. Dr. Hess has a Shared Governance tool that organisations use to determine where the majority of their decision making takes place and by whom. A number of hospitals across the US have used this tool to assess the efficacy of their Shared Governance structures, which meant that Dr. Hess had many contacts for me to draw upon.
I had previously tried to contact some US hospitals by myself, but these attempts proved unsuccessful, possibly because I didn’t have the direct contact details for “Shared Governance Lead” and so my emails fell on deaf ears, or maybe because my emails didn’t have the authority that I needed to secure good links. I found that by using Dr. Hess’ direct contacts and good reputation within the field, suddenly I had many hospitals opening their doors to me. Once we received confirmation from the contacts that I could visit, Dr. Hess helped me to co-ordinate the visits logistically. I then sent out an email to all the contacts explaining that I was a junior Nurse on a tight budget and that, as part of the Scholarship, I needed to stay with American families to get the “All American Experience”! I had a great response to this and the majority of hospitals went above and beyond, to find me people to stay with. This really did enable me to get the most out of my trip and get much more than just a tourist’s view of the country.
Although I secured most of my visits before I left the UK, I did leave some time in my itinerary for any visits that I may get from meeting Nurses at conferences. This was definitely a worthwhile experience and taught me the skills and etiquette involved in networking. These extra visits also meant that my project didn’t suffer when I unexpectedly had to cancel my New York visits due to Hurricane Sandy in October/November.
Below is a list of places and organisations I visited between September and December 201.
- San Francisco – Malibu, California 27th September – 6th October – Stayed with hosts. Sight seeing road trip down the Californian coast
- Los Angeles, California 7th – 14th October – Magnet Conference® Hollywood, LA, CA
- New Jersey 15th – 27th October – Riverview Medical Center, Red Bank, NJ – Jersey Shore Medical Center, Neptune, NJ – Ocean Medical Center, Brick, NJ – Hunterdon Medical Centre, Flemington, NJ – Morristown Memorial Hospital, Morristown, NJ
- New York City 27th October – 2nd November – Unable to visit planned organisations due to Hurricane Sandy
- Pennsylvania 3rd – 6th November – Pennsylvania Hospital, Philadelphia, PA – The Hospital of the University of Pennsylvania, PA – York Hospital, York, PA
- Baltimore, Maryland 7th November – Mercy Medical Center, Baltimore, MD
- Boston, Massachusetts 8th – 11th November – Brigham and Women’s Faulkner Hospital, Boston, MA
- Dartmouth, Massachusetts 12th – 14th November – Stayed with the Roosevelts
- Wilmington, Delaware 14th – 15th November – Alfred I. DuPont Children’s Hospital, Wilmington, DE
- Philadelphia, Pennsylvania 16th – 18th November – Cultural tour of Philadelphia
- Cincinnati, Ohio 19th – 24th November – Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Alexandria, Virginia 25th – 27th November – INOVA Alexandria Hospital, Alexandria, VA
- Washington D.C. 28th November – 1st December – Sightseeing in the city
- Florida 2nd – 20th December -Sarasota Memorial Hospital, Sarasota, FL – Anna Maria Island, FL – Host family stay, Lithia, nr Tampa, FL – Institute for Healthcare Improvement (IHI) International Conference, Orlando, FL – Sight seeing in Miami, FL – Mariners Hospital, Tavernier, Florida Keys, FL3. FINDINGSDuring my three months I saw many different models of this Shared Governance, with varying levels of success and sustainability. Most hospitals in the US are small in comparison to UK organisations, especially NUH which is one of the largest trusts in Europe. Most hospitals that I visited had around 250 beds. This was something I had to keep in mind when taking note of successful structures, as some aspects couldn’t simply be picked up and placed into our 1700+ bedded trust. For example, some hospitals I visited had a regular meeting for all the unit based Chairs. If we were to do this at NUH, this would involve hundreds of Staff Nurses. Something which is neither logistically viable nor effective for decision making outcomes.I spent my trip learning from the bad, as well as good examples and now feel I have a wealth of knowledge to draw upon when constructing NUH’s own unique model of Shared Governance. For the purpose of this report, I will not go into much detail about the different “models” of Shared Governance (this would be a chapter in itself).Whilst visiting so many organisations, it’s impossible to just look at Shared Governance. I’ve only ever worked at NUH and so, when walking around the American floors (wards) I found myself absorbing all the different ways in which our practice differs. This was really refreshing and gave me a new sense of appreciation for the work we do in the NHS. Since returning home, it has definitely given me a fresh pair of eyes for looking at the way we do things in the UK. Due to the nature of my project, I found myself in a lot of hospital meetings, as well as on the floor. This meant I inadvertently gained an even deeper knowledge of the US Healthcare system. This allowed me to share useful “British” suggestions to healthcare challenges, whilst I was there and “American” suggestions now that I’m home.As I’ve mentioned, I learnt so much during my Scholarship. I could easily write reams on the similarities and differences between the UK and US. Instead, I will try to summarise my findings into three main categories. I see these categories as the three main cogs that drive professional practice forward in the US.
- Empowers frontline staff to make decisions about their own practice
- 90% of the decisions made about patient care, should be made by those who deliver that care, at the point of care. 10% of decisions should be made organisationally
- Creates more staff buy-in for new projects as the ownership is theirs
- Improves professionalism and work environment
- Nurtures “bright stars”, aids talent management, and teaches leadership skills
- Increases job satisfaction and patient outcome
- Gives protected time to use evidence-based practice to conduct literature reviews and to trial changes at a unit level
- Provides a formal structure to report concerns, ideas and issues “up and down” the hospital wide Shared Governance structure
- Allows hospital wide initiatives to be individualised to each specific unit
- Gives non-clinical time to frontline staff, allowing them to work on projects and make improvementsEvidence-Based Practice (EBP):
- Increases professionalism of frontline staff
- Utilises and maintains the academic skills of staff (BSc, MSc and PhD prepared Nurses)
- Keeps practice up to date with current research
- Provides new solutions for current Nursing challenges
- Improves patient care (especially within clinical specialities where nursing practice doesn’t get regularly updated by general/hospital wide initiatives)
- Maintains and strengthens links with the University, the Library and other available resources
- Formalises and promotes the Hospital’s innovative workFormal Career Ladder:
- Retains Nursing expertise at the bedside
- Certification within a chosen speciality (this is a nationally recognised qualification which proves the Nurse has the assessed knowledge to practice in his or her area) drives EBP forward and improves patient care in specialised areas
- Promotes continuing professional development by requiring all staff to prove they’ve had 30 plus hours of education and training per year
- Requires nurses to prove use of EBP (this in turn increases the number of local practice improvement projects as nurse are engaging in research, to progress to the next level on the career ladder)
- Hands responsibility for continuing professional development (CPD) over to the individual Nurse
- Asks for senior Nurses to have increasing responsibilities within the Shared Governance structure – this shows they have an understanding of how the Hospital works and of its aim. It also gives increasing leadership skills
- Rewards and recognises good Nurses (financial reward for development, not just an automatic seasonal pay rise)
- Increases the professionalism of Nursing
- Formal process to apply for the next rung of the career ladder. Submission of CPD portfolio to a board of Staff Nurse peers who have to agree to promote the Nurse
- Promotes the Hospital’s expectations of what is required of each level of Registered Nurse (RN)
- Aids and utilises peer review skills
- Creates a culture of personal and professional development in Nursing, which in turn impacts on the good use of EBP and improves patient care4. CONCLUSIONKey Learning from Shared Governance:I learnt as much (if not more) from problematic examples of Shared Governance as I did from good examples.The key learning from this was;
- Succession planning – key for every role within the Shared Governance structure; from Unit Practice Council members to the Chief Nursing Officer. Poor succession planning and employing a candidate who didn’t fully support Shared Governance lead to embedding and sustainability issues.
- Organisation support – funding to cover frontline staff whilst they attend meetings was often the easiest and first budget to be cut. This was false economy and meant that improvements in patient care were stilted or worse still, stopped. This had great implications across the organisation. Giving staff a voice, then taking it away lead to a decline in job satisfaction, staff retention and patient outcome. Ward Managers – these staff required a lot of training and education. Their role (in a Shared Governance structure) is more facilitative than controlling (which is a cultural change from most typical hierarchical management styles). Organisations that didn’t invest time and resources in supporting their managers with this change, faced major problems with implementation, embedding, and sustainability.What now?Since returning to work, I’ve been fortunate enough to be seconded to Nursing Development as NUH’s Shared Governance Project Lead. I am using my first-hand knowledge of Shared Governance to develop a model that will work for the UK and especially for NUH.There is only so much to gain from reading literature about a topic. Having the opportunity to go to see the nitty gritty of how this works in practice, to see the challenges first hand and to ask probing questions to those who use it, has been absolutely invaluable.Later on this year, I will start my Masters in Advanced Nursing. This is something I never thought I’d do, but my scholarship experience has given me a thirst to carry on learning and develop my skills so that I can improve the care of patients.Strangely enough, if I had known from the beginning, all that could be achieved by applying for the Roosevelt Scholarship, I’d have never put my name forward. This may seem odd, but this is because I never thought I’d be capable of achieving all that I have, in the short space of time and still being so junior. This scholarship has been the making of my career. It has really pushed me and (although clichéd) it has shown me that anything is possible, and for that I will be forever grateful.
“The only limit to our realisation of tomorrow will be our doubts of today” – Franklin D. Roosevelt