February 2008 Volume 14 Number 9 www.nursingmanagement.co.

uk

nursing m
management
anag
nage
em
me
en
ntt
for nursing leaders everywhere

Critical thinking
among nurses
Service line
management
The value of drama
based training
Making good
decisions

Recruiting with care:

choosing the right candidate
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 contents

12

22
16
nursing management
for nursing leaders everywhere

3 editorial and Tunbridge Wells NHS Trust, Lindsey Scott

reflects on the similarities between events
news in Kent and those at the Bristol Royal Infirmary

4 new funding for hospital trusts to recruit 20 laying it on the line

specialist staff in fight against infection William Moyes from the independent regulator
of NHS foundation trusts, Monitor, describes
opinion why senior nurses should understand service
6 get connected line management theory
by Barbara Stuttle 22 a tonic for the troops
on the move Gail Lusardi, Allyson Lipp and Huw Williams
7 your letters report on the benefits to non-military
healthcare staff of taking part in weekend
under cover
exercises organised by the Territorial Army
by Matthew Rice
8 a new strategy for Scotland applied leadership
health and wellbeing secretary Nicola Sturgeon 27 ten steps to setting goals
sets out the new government health strategy Chris Pearce offers a guide to help nursing
the ‘year of the HCA’ leaders set goals
Paul Vaughan explains why developing
healthcare assistants should be a priority
28 critical thinking among nurses
concept mapping can help newly registered
10 recruiting with care staff and nursing students develop the critical
David Foster on the importance of choosing the thinking skills they lack, says Swaleh Toofany
right candidates for jobs in the nursing profession
32 making good decisions: part 1
the first of two articles from
features
The Open University on how
12 playing the ideal role professionals make decisions
Becky Simpson assesses the value of drama scan
based training to healthcare professionals
16 hearing the alarm 36 conferences
in the wake of the Healthcare Commission 37 webscan
report into infection outbreaks at Maidstone have your say

nursing management Vol 14 No 9 February 2008 1

3437_NM_RO_Council Nurses 17/1/08 11:12 am Page 1 3194_JOBS_HP_vert_SJ 17/1/08 11:17 am Page 1

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READEROFFER always working for you
 editorial

Managing director and publisher: Linda Thomas OBE

Sales and marketing director: Phil Whomes
Editor: Nick Lipley
Consultant editor: Donna Kinnair
Production editor: Duncan Tyler As the NHS enters its 60th year, the government has made clear
Art director: Paul Swainson that, even when flexible and responsive services have been achieved,
Picture editor: Philip Brecht healthcare reform will continue until clients have the information
Assistant picture editor: Helen Jones
they need to take responsibility for their own health.
Classified advertisement sales manager:
Andy McCallum   Tel: 020 8423 1333 As nurses, we have played a major role in the recent achievements of the NHS such as
Fax: 020 8872 3197 the reduction of waiting times and improvements in the treatment of patients with
Email: andy.mccallum@rcnpublishing.co.uk
cancer. We have set up new roles, learnt new skills, shared our knowledge and improved
Classified advertisement executive:
Mandy Croggon   Tel: 020 8423 1333 our abilities to manage and lead.
Fax: 020 8872 3197 But, if we are to improve the lives of those we serve, there is still more for us to do.
Email: mandy.croggon@rcnpublishing.co.uk
Current changes in healthcare provision require us to develop our skills as both pro-
Classified sales DX address:
RCN Publishing Co Ltd, DX 4228, Harrow. viders and commissioners of services, and to focus on lifestyle advice.
Special projects manager: To help one another respond appropriately to these changes, we must continue to
Laura Downes   Tel: 020 872 3156,
share our experiences and knowledge in both the nature and prevalence of disease, and
Email: laura.downes@rcnpublishing.co.uk
Advertisement and sponsorship executives:
in the demography and lifestyles of the public.
Neil Hobson   Tel: 020 8872 3123 We must also share our views on how the new policy agenda should be delivered
Julia Gomersall  Tel: 020 8872 3122
and whether those who devise these policies have thought through the consequences of
Syretta Allen   Tel: 0208 872 3182
Kelly Smith   Tel: 0208 872 3123 implementing them.
Fax: 020 8423 9196 I believe that clinicians must lead and steer the reforms that are needed for the
Editorial administrator: Helen Hyland systematic delivery of a world class health service and so I hope that all nurse managers
Editorial admin assistant: Sandra Lynch
and leaders will use the pages of Nursing Management to contribute to the debate on
Subscription rates and enquiries:
RCN members: £4.80 a month by direct debit. improving good health outcomes.
For annual direct debit, cheque or credit card rates, If you read Nursing Management regularly, you will know that we try to ensure
institution rates and answers to other subscription
enquires, access www.nursingmanagement.co.uk that it contains a variety of articles from different settings in the UK healthcare service.
or call 0845 7726 100.
Nursing Management, incorporating Senior Nurse,
To ensure this variety is maintained, we require many different contributors.
is published ten times a year by RCN Publishing If you are a regular contributor therefore, I hope you will keep your articles coming in;
Company Limited,The Heights, 59-65 Lowlands Road,
Harrow‑on‑the‑Hill, Middlesex HA1 3AE.Tel: 020 8423 1066. and if you have never written for a journal before, I urge you to consider doing so,
Copyright 2008 RCN Publishing Company Limited. perhaps as a resolution for 2008, to share your experiences and opinions with our
All rights reserved.
No part of Nursing Management may be reproduced, community.
stored in a retrieval system or transmitted in any Many of you, like me, may not consider yourselves natural writers but, neverthe-
form or by any means electronic, mechanical,
photocopying, recording or otherwise, without prior less, want to contribute to the debate on how our profession should deliver excellence
permission of the publisher. ISSN 1354-5760.
across all healthcare settings. Nursing Management can provide you with the forum
Printed by: Friary Press, Dorset
to do so.
Cover image: PhotoAlto
I would also like to invite applications to join the Nursing Management editorial
advisory board, which provides excellent stewardship in guiding the journal’s strategic
development, and advises on the quality and relevance of articles.
editorial advisory board We need to hear from clinicians, academic leaders and managers from across the
UK who are committed to helping senior nurses share their experiences and opinions
David Benton
consultant in nursing and health policy about how to lead the drive for better patient care and outcomes, and for a better
International Council of Nurses, Geneva health service.
Juliet Chambers
If you would like to apply, send your curriculum vitae and an outline of no more than
deputy director of nursing
Calderdale and Huddersfield NHS Trust 150 words of how you would improve Nursing Management to the editor, Nick Lipley,
Deborah Clatworthy by March 15. We look forward to hearing from you nm
assistant director of nursing (risk management)
4 To make an application to join the Nursing Management editorial board or
The Whittington Hospital NHS Trust, London
Geraldine Cunningham
to find out more about other ways of contributing to the journal, email Nick Lipley at
acting director nick.lipley@rcnpublishing.co.uk or write to him at RCN Publishing Company,
RCN Institute
The Heights, 59-65 Lowlands Road, Harrow-on-the-Hill, Middlesex HA1 3AW.
Jenny Kay
director of nursing
See also How to contribute on page 35
Dartford and Gravesham NHS Trust, Kent
Caroline Shuldham Donna Kinnair, consultant editor
director of nursing and governance
Director of clinical leadership, quality and nursing, and head of children’s integrated
Royal Brompton and Harefield NHS Trust, London
commissioning, at Southwark Primary Care Trust, London

nursing management Vol 14 No 9 February 2008 

 news

Funds for hospital trusts to recruit specialist staff

by Laura Doherty and Nick Lipley
Every hospital trust in England
will be able to recruit extra staff
as part of a government initiative
to improve infection control.
The Department of Health has
earmarked £45 million for trusts
to spend on additional special-
ist staff, including two infection
control nurses and two isolation
nurses each.
Health secretary Alan Johnson
announced the move last month
as part of a funding package of
£270 million a year by 2010/11
to support infection control and
cleanliness in the NHS.
As part of the government
infection control strategy, ‘strin-
gent’ requirements will also be
introduced to ensure that NHS
foundation status applications
are supported only if the trusts
concerned have hit local targets
on both MRSA and Clostridium
difficile consistently.
Citing Health Protection
Agency (HPA) data published
in November, Mr Johnson said:
‘We have gone from what has
been described by the HPA as
“a seemingly unstoppable rise in
MRSA bloodstream infections
Revised code of practice
The DH has published a revised
code of practice to help NHS
trusts plan and implement the
control of healthcare associated
infections.
The code recommends quarterly
infection prevention and control
reports by matrons and clinical
directors.
For copies of The Code of
Practice for the Prevention and
Control of Healthcare Associated
Infections, go to www.dh.gov.
uk/en/Publicationsandstatistics/
Publications/PublicationsPolicy
AndGuidance/DH_081927
throughout the 1990s” to
a 10 per cent fall in cases of
MRSA, thanks to the hard work
and dedicat­ion of NHS staff. But
we know that there is still more
to be done.’
In referring to the proposals,
England’s chief nursing officer
Chris Beasley told nurses: ‘We are
not saying that you have to
recruit these nurses. The money
is there for you to use in the way
you think best suited to tackle
infect­ion control in your area.
It is not for us to micromanage
what people are doing.’
Meanwhile, RCN general sec-
retary Peter Carter said: ‘This
announcement is good news for
patients and is a recognition of the
important role nurses play in tack-
ling healthcare acquired infection.
‘However, we need to ensure
that money allocated to infec-
tion control reaches the ward
and is not diverted elsewhere in
the system.
Addressing problems like
MRSA is a continual process
where only by constantly invest-
ing in staff, cleaning and train-
ing will we be able to provide
environ­ments safe for patients.’
The DH’s infect­ion control
strategy, Clean, Safe Care:
Reducing infections and saving
lives, includes details of a range
of programmes to accelerate the
development and uptake of new
technologies, as well as guidance
on human resources procedures
that incorporate induction and
training on infection prevention
and control.
In addition to this strategy, the
DH plans to launch a nationwide
campaign this month to remind
the public, GPs and other doctors

Comissioning care
The National Institute for Health
and Clinical Excellence (NICE)
has published six new guides
to help NHS staff commission
evidence based care for patients.
The guides cover services for:
4 Memory assessment
4 Hysterectomy
4 Endometrial ablation
4 Female urinary incontinence
4 I ntrauterine contraception
and heavy menstrual bleeding
4 Bariatric surgery.
Each commissioning guide pro-
vides the information on key
clinical and service related issues
that should be considered during
Alamy

the commissioning process.

The right medicine: hospital staff have been issued guidance on ensuring that the medication 4 The guides can be accessed at
patients take before their admission is documented properly. According to the National Patient
www.nice.org.uk/Commissioning
Safety Agency, which has produced the guidance with the National Institute for Health and Clinical
Excellence, more than 7,000 medication errors between November 2003 and March 2007 involved Guides and ideas for future
patient admission or discharge.These included two that were fatal and 30 that caused severe harm. guides can be emailed to com-
The guidance can be found at www.nice.org.uk/guidance/index.jsp?action=byID&o=11897 missioningguides@nice.org.uk

 nursing management Vol 14 No 9 February 2008

 news

in fight against infection Patients to nominate nurses for 2008 awards

that antibiotics are ineffective Staff at NHS, community and independent sector organisations are
against many common ailments. being urged to tell patients and clients about the Nursing Standard
Ministers will introduce screen- patient’s choice award, launched last month.
ing for all elective patients by The award, supported by The Patients Association, is the latest
category in Nursing Standard’s annual Nurse of the Year awards and
March 2009 and for all emerg-
is for nurses, midwives, health visitors and healthcare assistants who
ency patients as soon as possible
have ‘made a real difference’ to patients, clients or loved ones.
over the next three years.
The closing date for nominations is February 15. To nominate
They also expect every hospital
someone, members of the public can visit www.patients-choice.
in England to have undergone a
co.uk or call 020 8872 3140.
‘deep clean’ by next month
4 For copies of the Clean,
Safe Care strategy, go to www.
clean-safe-care.nhs.uk/Article- New deal to boost public protection
Files/Files/CleanSafeCare_ The Nursing and Midwifery While the primary focus of
ReducingInfectionsAndSaving Council and Healthcare Commis- the agreement is information
Lives_Strategy.pdf sion have signed a memorandum sharing, other areas in which the
of understanding to strengthen two organisations can collabor-
c

public protection. ate include investigations and

is

Wiping out infection:

Photod

ministers expect every The agreement sets out the
hospital in England to have levels of co-operation and terms
undergone a ‘deep clean’ by which the two organisations
by next month
will work together when carry-
ing out their regulatory duties in
England and Wales.
reviews, the provision of train-
ing and guidance, complaints
and cross reference of issues
of concern, and the offering of
advice to ministers and joint
inspection teams.

RCN consults senior nurses on future plans UK nursing director

RCN general secretary
Peter Carter is meeting with nurs-
ing directors and senior nurses
to work out how the college can
meet their needs better.
As part of the college’s Fresh
Start project, meetings are tak-
ing place at each of the nine
RCN regions, to which the
college’s regional direct ors
have invited directors of nurs-
Scottish government warned over healthcare strategy
The RCN has warned The
Scottish Government against
trying to do too much too
quickly when implementing its
new health strategy.
Better Health, Better Care lays
out a vision for a health service
that is centred on public, patient
and staff involvement.
ing and other senior nurses in
their areas.
Acting head of the RCN pro-
fessional nursing department
Steve Jamieson said that nurses’
views will feed into a work plan,
expected to be written next
month, on improving member-
ship services for senior nurses.
Chair of the RCN nurses in
operational management forum
It emphasises mental and child-
ren’s health while proposing that
nurse led clinics are based in
pharmacies and that primary care
access should be more flexible.
RCN Scotland director
Theresa Fyffe welcomed the
thrust of the plan, but said:
‘We are concerned that the
Deborah Critchley welcomed
the move, saying that it would
give senior nurses opportunities
to alert the college to areas of
concern and so would enable the
college to support senior nurses
better.
But she added: ‘My concern is
that, if expectations get raised
and nothing happens, it will lie
badly with people.’
action plan may be trying to
achieve too much too quickly,
particularly given all the pract-
ical and cultural changes pro-
posed over the next year.’
See A new strategy for Scotland,
by cabinet secretary for health
and wellbeing Nicola Sturgeon,
on pages 8-9
appointed ICN chief
Nursing Man-
agement edit-
orial advisory
board member
David Benton,
left, has been
appointed
chief exec-
utive of the International Council
of Nurses. He takes up the five-
year appointment on October 1,
after Judith Oulton leaves
the post.
Mr Benton has been a con-
sultant in nursing and health
policy at the council, where
he has focused on regulation,
licensure and education issues,
since 2005. Previously he had
been director of nursing at NHS
Grampian.
See also On the move, page 6

nursing management Vol 1 No 9 February 2008 5

opinion

get connected
THE NEED FOR community clinicians to
acquire up-to-the-minute information is such
that the introduction of mobile information
technology (IT) in primary care settings is
becoming more important than ever.
Meanwhile, the increasing number of
nurses asking for this technology to help them
provide care in the community has led NHS
Connecting for Health (CFH) to establish its
Community Mobile Working Project.
The purpose of the project is to study
how community clinical staff can use mobile
technology to make rapid access to multi-
disciplinary records rather than enter data
into multiple paper records.
The current ageing population and
increasing incidence of long term conditions
present the NHS with a huge challenge, and
those older people who live with more than
one long term conditio often have both clin-
ical and social problems to overcome.
Meanwhile, caring for people with long
term conditions consumes a large proportion
of health and social care resources.
The Department of Health white paper,
Our Health, Our Care, Our Say, published
two years ago, emphasises the need for
healthcare staff to focus on maintaining the
independence of older patients while manag-
ing their long term conditions, adding that
this care will often be delivered outside trad-
itional healthcare environments. This need
explains why community clinical staff require
rapid access to multi-disciplinary records.
As part of the National Programme for
Information Technology, the NHS Care
Records Service can help staff in clinics and
acute environments access these records. But
clinicians and therapists who work primarily
in the community are prevented from taking
full advantage of these benefits.
Because these professionals have no forms
of mobile connectivity when at the point of
care, they cannot access essential patient data
and have to enter data into multiple paper
records. Ensuring that we make better use of
IT therefore will help to improve the effect-
iveness and safety of care.
At NHS CFH, we are working with
colleagues from various nursing commun-
ities, as well as those from the information
management and technology departments
of primary care trust and strategic health
authorities to develop a ‘toolkit’ for organis-
ations that want to implement techniques of
mobile working.
To reduce duplication of effort and risk,
the toolkit will build on the experiences of
several different health communities that
have piloted mobile working already and
have made the results available for other
organisations.
The toolkit will be made available electron-
ically by the end of April and will remain a
‘live’ document thereafter so that the infor-
mation it contains can be updated regularly.
These updates will ensure that its accuracy
and timeliness are maintained nm
 For further information about the Commun-
ity Mobile Working Project, contact senior
project manager Helen Hood, at helen.hood@
nhs.net

Barbara Stuttle CBE, RGN, DN, MHM is an executive nurse at South West Essex Primary Care Trust and a national clinical lead for nursing
and midwifery at NHS Connecting for Health

on the move
Joyce Catterick
takes up post this month as chair of South West
Yorkshire Mental Health NHS Trust, based in Wakefield.
Ms Catterick, who has worked in general nursing,
paediatric nursing and midwifery and has served on
the former Calderdale and Kirklees Health Authority,
has been chair of Calderdale Primary Care Trust for
almost six years. Her new term of office is for four years.
South West Yorkshire Mental Health NHS Trust is
applying for foundation status.
Mansour Jumaa
has become the first nurse in the UK to be elected to
the influential leadership succession committee of the
Honor Society of Nursing, Sigma Theta Tau International.
Dr Jumaa is a member of the steering committee of the
RCN nurses in executive and strategic roles forum and
a chief external examiner on leadership development
at the University of Cumbria.
Roger Watson
has become the first person in the UK to become a fellow
of the American Academy of Nursing. Professor Watson,
director of research at the University of Sheffield’s school
of nursing and midwifery, is one of the first three nurse
leaders from outside of the United States to be inducted into
the academy.

Paul Wilson Jennifer Dixon

has been elected to the Nursing and Midwifery Council’s
governing body as the new alternate council member for
nurses in Scotland. Mr Wilson is director of nursing in
Lanarkshire, Scotland’s fourth largest health board. He has
extensive leadership experience within the Scottish health
service and as the director for NHS trusts in Scotland’s
civil service.
has been appointed director of The Nuffield Trust
for Research and Policy Studies in Health Services.
Dr Dixon takes up post this spring, with the departure
of Neil Goodwin, who has served as interim director since
August last year. She is currently director of health policy
at the King’s Fund, and a board member of both the Audit
Commission and the Healthcare Commission.

Send details of senior nurses and other healthcare professionals who are on the move to nick.lipley@rcnpublishing.co.uk

6 nursing management Vol 14 No 9 February 2008


your letters
SINGLE ROOM ACCOMMODATION
LAST YEAR, the Scottish Executive,
now The Scottish Government, and
NHS Estates issued planning guidance
on the provision of single room
accommodation in hospitals.
The authors of this guidance, which
follows the peer review of Hospital
Wards Configuration: Determinants
influencing single room provisions,
a report prepared for NHS Estates by
the European Health Property Network
(EHPN), suggest that hospitals should
consider providing all their patients
with single rooms.
It is recognised widely that single
room accommodation can:
 Reduce the spread of healthcare
acquired infection (HAI)
 Protect patients who are
immunosuppressed
 Offer patients greater privacy
 Make the use of facilities more
flexible
 Increase patient choice.
Few nurses would question the need
for more single rooms in the NHS but
is it necessary to provide single rooms
for all patients?
The EHPN report, which was
published in 2004, highlights the need
for better communication between
staff and patients in single room
accommodation, and suggests that
rooms are designed better to enable
improved observation of patients.
It also notes that ‘the role of single
rooms in preventing HAI is not
proven by randomised controlled
trials’ but also acknowledges that the
role could play a part, along with good
hand hygiene, good ventilation and
adequate space around beds situated
in multi-occupancy areas, in this.
Although there is a lack of literature
to support the continuing provision of
multi-occupancy areas, there seems to
be anecdotal evidence of a need to offer
patients a choice between the two.
nursing management Vol 14 No 9 February 2008
This choice may be necessary
because multi-occupancy areas may be
important to patients who:
 Are afraid that, if they are placed
in single rooms, they will die in
isolation
 Have had traumatic injuries or
episodes while they have been alone
and are afraid of recurrence
 Have problems coping with aspects
of their condition such as stomas
and who are greatly reassured by
being able to converse with fellow
patients who have been through,
and dealt with, similar experiences
 Rarely have visitors but enjoy casual
social intercourse with people who
visit other patients.
The provision of single room
accommodation for all patients
may also have implications for
staffing levels.
A Canadian study by Chaudhury et al
(2006), for example, concludes that
further studies should compare the
incidence of drug error, as well as
opportunities for surveillance and
patient outcome, in single rooms and
multi-bed bays.
It appears therefore that further,
large scale studies are required to
provide evidence supporting each
choice and to identify what patients
really want.
But in the meantime, if we intend to
reduce the impact of hospitalisation,
we should agree that patients must
be given the choice of single-room or
multi-bed accommodation nm
Liz Norris MSc, RSCN is a
physical planning nurse adviser
at NHS Grampian
Reference
Chaudhury H, Mahmood A, Valente M
(2006) Nurses’ perception of single-
occupancy versus multioccupancy rooms
in acute care environments: an exploratory
comparative assessment. Applied Nursing
Research. 19, 3, 118-125.
opinion
under cover
Leadership Ensemble: Lessons in collaborative
management from the world’s only conductorless
orchestra by Harvey Seifter and Peter Economy
DURING A recent conversation with a professional
violinist on the nature of leadership and teamwork,
I was struck by the similarities between the world
of the orchestra and that of health and social care
teams: the common struggle for leadership within
hierarchy; the relationships of conductors or chief
executives and their respective teams; the need for role
clarity; and the shared drive for creativity, innovat ion
and improvement.
I was therefore intrigued, not long
after this conversation, to rediscover
an account, by executive director
of the Orpheus Chamber Orchestra
Harvey Seifter and Peter Economy,
of the culture of ‘collaborative lead-
ership’ developed by this New York
based orchestra.
This account, Leadership Ensemble, describes how
the Orpheus Chamber Orchestra, which rehearses,
performs and records without a conductor, bases its
approach on eight core principles: putting power in the
hands of the people who work hardest; encouraging
individual responsibility for quality; creating clarity of
roles; sharing leadership; fostering ‘horizontal’ team-
work; learning to listen and to talk; seeking consensus;
and being dedicated to a mission.
The development of each of these themes is
accompanied by case studies from companies that have
adopted the ‘Orpheus Process’ with great success.
The book is entertaining and contains plenty of
practical steps to integrate its principles into any
workplace.
Although the language used may seem alien to
some, many of the principles it describes are relevant
to all effect ive leadership, teamwork and organisa-
tional cultures, including those of modern healthcare
services nm
Seifter H, Economy P (2001) Leadership Ensemble:
Lessons in collaborative management from the world’s
only conductorless orchestra. Times Books, London.
Matthew Rice is a learning and development
facilitator at the RCN
Which book do you think all nurse
leaders should read? Email your choice
to nick.lipley@rcnpublishing.co.uk
7
 opinion
A new strategy for Scotland
Health and wellbeing secretary Nicola Sturgeon sets out what the new government
health strategy means for nursing leaders
The Scottish
Government’s new
health strategy, Bet­
ter Health, Better
Care, sets out a new
vision for the NHS
Press Association
in Scotland.
This outlines
ambitious proposals
to increase patient
participation, improve access to health care,
and focus on the dual challenges of improv-
ing Scotland’s public health and tackling
health inequalities. The strategy also contains
a package of measures to deliver improve-
ments to the primary care system over the
next three years.
As health and wellbeing secretary for
Scotland, I want to see more flexible access
The ‘year of the HCA’
Paul Vaughan explains why the development of healthcare assistants should be a priority
for senior nurses in 2008
Around this time last year, there were
said to be about 40,000 managers in the
NHS, and questions were asked in the media
about what they all did. More recently, man-
agers at several NHS trusts have been blamed
for losing patient records.
It seems that, if this staff group is not
being judged superfluous, it is being blamed
for something. Surely it is about time we
stopped knocking them.
After all, managers and leaders are essent­
ial to the success of any business, and manag-
 nursing management Vol 14 No 9 February 2008
to GP surgeries, more anticipatory care, and
easy, walk-in access to a range of primary
care services.
These innovations will start to deliver the
local and more preventive health service that
we will need in the future.
Central to the new plan is patient part­
ic­ipation. Not only do I want patients to
become partners in their own care, but I also
want them to become involved in the design
and delivery of health services.
Too often in the past patients have had too
little involvement in changes to the provision
of the health care that has a direct impact on
them. This is something that I want to make
sure does not happen in the future.
But I also want to make sure that staff are
involved fully in decisions about the design
and delivery of the NHS. It is vital that we
ers are an integral part of NHS teams. When
NHS managers are supported, educated and
trained, they can improve the care provided
to patients significantly.
I know that, when I was an NHS manager,
I sometimes didn’t get things right but, with
support, education and training, I was able to
develop my skills and improve my practice.
However, just as critical opinions of NHS
managers are expressed in the media, so man-
agers themselves often express similar opin-
ions about healthcare assistants (HCAs).
listen to those people who form the back-
bone of our health service.
It is in this context that chief nursing
officer Paul Martin has asked for a review of
the senior charge nurse and midwife role in
NHS Scotland.
The purpose of this review, which is due
to report formally this month, is to enhance
the contribution of the nursing and mid-
wifery workforce in implementing the policy
vision of The Scottish Government, while
acknowledging that the senior charge nurse
role should be embedded in a strong clini-
cal leadership model. This will ensure that
senior charge nurses are empowered, not
only to improve the delivery of safe, effective
and timely care, but also to enhance patients’
experiences at ward level and to contribute to
the design and delivery of services.
Working in partnership
For the past three years, I have been lead-
ing a national initiative to develop the role
of HCAs in general practice, one of the 13
Working in Partnership Programme (WiPP)
schemes aimed at increasing capacity in this
area. During this time, I have noticed a com-
mon view among managers that, unless
HCAs are delivering care to patients, they
are not working.
I make this observation, not to criticise
managers, but to offer them an opportunity to

As part of Better Health, Better Care, we
will take several steps over the next three
years towards creating a more mutual NHS
in which patients, the public and staff are
treated as partners in health and co-owners
of the NHS.
By May, we will launch a public consulta-
tion on proposals for inclusion in a Patients’
Rights Bill to cover waiting time guarantees
and the right of patients to be treated as part-
ners in their care. Following this consult­ation,
we will introduce by the summer a Local
Healthcare Bill, which will include proposals
for direct elections to NHS boards.
We will also produce and distribute an
annual ‘ownership report’ to every house-
hold in Scotland that sets out the rights and
responsibilities of patients, and their carers,
alongside information on how to access local
services and raise issues or complaints.
And, for the first time, a service delivery
plan for the future of the NHS will be aligned
with the workforce planning strategy to
ensure our workforce planning conforms to
the principles of Better Health, Better Care.
To help us tackle high rates of student attrit­
ion, we will invest £5 million a year to improve
reflect on their attitudes to education and train-
ing and, if appropriate, develop a new approach
to supporting the development of HCAs.
Of course, many NHS managers have
excellent track records in the development of
HCAs, but I have heard time and again how
HCAs have struggled to obtain sufficient
study time to undertake mandatory training
even though this is essential for them to carry
out their roles safely.
As the NHS tries to balance its books, the
first budgets to be cut are often those that relate
to training. For example, lead practice nurses
who offer education and training opportunities
to nurses and HCAs in general practice have
lost their posts at several primary care trusts.
Yet we hear that the NHS will report a surplus
at the end of this financial year.
I have heard from recruitment and retent­
ion officers in the acute sector that, in some
areas, HCAs receive so little support when
nursing management Vol 14 No 9 February 2008 
support for nursing and midwifery students
throughout their training exper­ience.
We expect this measure will increase both
the number of students who complete their
courses and, eventually, the number of reg-
istered nurses.
This year’s training numbers have been
agreed with unions, NHS colleagues and
universities, and will ensure that there are
enough newly registered nurses and midwives
to meet our future health service needs.
The £5 million investment will be in
initiatives that enhance the nursing and
midwifery student learning experience and
support retention on pre-registration pro-
grammes.
It will be linked directly to the recom-
mendations in the report from The Scottish
Government’s student nurse and midwife
recruitment and retention sub-group pub-
lished in December last year.
A delivery group, with an NHS board
nurse director and an academic lead from
Scotland’s higher education sector, will be
established to oversee the investment pro­cess
and to assess the impact of the initiative on
student recruitment and retention.
they join ward teams that they remain in
them for no more than three months.
Meanwhile, clinical supervision and mentor­
ship appear to be a luxury where HCAs are
concerned, and there also seems to be a lack
of support for HCAs to attend networks or
forums to connect with other HCAs.
And I am not questioning attitudes only in
the NHS. I regularly hear of occasions when
HCAs in the independent sector have to pay
for their own training and use their annual
leave to attend courses.
Delivering care effectively
In Securing Good Health for the Whole Popul­
ation, which was published in February 2004,
Sir Derek Wanless states that, by 2020, the
health service will require a further 144,000
HCAs to deliver care to patients effectively.
But, if we do not optimise their skills and
talents of those HCAs who are already in the
opinion
Building on the progress made by
The Scottish Government in gathering robust
workforce data, we will work closely with
the national workforce unit to ensure that all
stakeholders across the NHS, as well as the
emerging independent and voluntary sectors,
are engaged fully with the national nursing
and midwifery workforce planning process.
By doing so, we shall be able to continue
to anticipate demand for nursing resources
and have an appropriate skill mix in all areas
of provision to support patient client need.
I am confident that the new action plan
for health care and the workforce strategy
will deliver real improvements for patients
and staff across the NHS in Scotland.
I want to make clear though that senior
nurses will play a key role in delivering our
vision for the NHS. Their skills, experience
and expertise are crucial to developing a health
service that is fit for the 21st century nm
4 For copies of Better Health, Better Care,
access www.scotland.gov.uk/Publica-
tions/2007/12/11103453/0
Nicola Sturgeon is cabinet secretary
for health and wellbeing
system, what hope do we have of attracting
and retaining a further 144,000 of them?
So wherever you work, help HCAs attend
conferences, ensure that they have access to
supervision and mentorship, and work with
your training departments and local education
providers to develop courses from which they
can gain transferrable qualifications.
For example, if your HCAs are RCN mem-
bers, they can have a 10 per cent discount off
any Open University course such as the K100
Understanding Health and Social Care.
Let’s make 2008 the year of the HCA! nm
4 Nurse managers can access further
inform­ation about HCA development at
www.wipp.nhs.uk/hca-gpn
Paul Vaughan is a learning and
development facilitator at the
RCN Institute and HCA initiative
national project manager at WiPP
 Such situations can often be ident ified 
only in retrospect so it is import ant at all 
times to resist the temptation to cut corners 
and assume all will be well.  

The ‘worst case scenario’

In discussing this topic, it often helps to 
consider the worst case scenario, which, for 
me, is the ‘Beverly Allitt case’. Her name 
has become notorious in the nursing world, 
and it is worth recalling, not only the horror 
of her crimes, but also the nature of her 
employment history. 
Ms Allitt worked on Ward 4, a child  ren’s 
ward at Grantham and Kesteven General 
Hospital, Lincolnshire, for a total of 58 days 
as part of a six-month contract, in 1991.  
During her training, she had had 
a history of excessive sick leave and 
examination failure but had exhibited 
a determination to demonstrate her 
competence. The ward she joined was 
understaffed and she volunteered for 

Recruiting with care

extra duties. She was later described 
as ‘unemotional’. 
Unexpected patient deaths started to 
occur on Ward 4, but these were not at first 
investigated and no suspic ions were raised 
by staff. There was later said to have been a 
David Foster on the importance of choosing the right culture of poor supervision on the ward. 
PhotoAlto

candidates for jobs in the nursing profession Eventually, there was an internal inquiry 

into the high number of card iac arrests that 
were occurring on Ward 4 but another 18 
RECEIVING LETTERS of resignation can  assurance requires diligence from managers  days passed before police were contacted. 
generate mixed emotions. While filling  during the recruitment process. It was found that, during the 58 days 
a vacant post offers opportun ities for  Identifying and preventing performance  that Ms Allitt was on the ward, 25 separate 
managerial change or the promotion of  problems are not exact sciences and there  suspicious episodes had occurred, affecting 
valued colleagues, few of us relish the  are roles in them for intuit ion as well  13 victims, four of whom died. 
administrative burden of recruitment. as analysis. They also require sufficient  A clear pattern to these events emerged: 
Yet good recruitment practices and  confidence to challenge individuals and  Ms Allitt was present on each occasion. 
sound appraisal techniques can, if  processes.  She was finally convicted and given 13 life 
underpinned by policy and training, help  Nevertheless, the importance of  sentences for murder and attempted murder. 
to identify and prevent potential failures in  policies and procedures in identifying and  Virginia Bottomley, the then health 
performance. Confidence, experience and  preventing performance problems should  secretary, commissioned judge Sir Cecil 
intuition also have roles to play in such  not be underestimated.  Clothier to chair an independent inquiry 
situations.  When organisations operate smoothly  into the circumstances of these murders. 
Organisations must not only be assured  and successfully, recruitment, appraisal and  Among other things, his report critic-
that recruitment processes are robust, but  performance management processes often  ised the sloppy appointment proced ures 
also that systems are in place to protect the  appear ritualistic and time consuming.  at Grantham and Kesteven and dismissed 
public from poor performance and, as far  They are valuable however in managing  the hospital’s ward staffing shortages as a 
as possible, maverick practitioners. This  situations that deviate from the norm.  tangent ial issue. 

10 nursing management Vol 14 No 9 February 2008


The hospital, now called Grantham and
District Hospital, is under new management
Of course, nursing is not pop­ulated
by clones of Ms Allitt, but the risk of one
appearing is constant.
In this context I remember some sage
advice given to me when I was a newly
appointed manager: ‘Whatever you do, say
or record during recruitment, appraisal and
performance management, always consider
how your documentation will read in two
years’ time, and how you will just­ify your
actions and decisions to an employment
tribunal or judge.’
Protecting the public
The Nursing and Midwifery Council
(NMC) is responsible for regulating the
profession nationally and,   If applicants have prolonged training
by doing so, protecting the public.
Employing organisations have their own
recruitment policies, such as the validation
of personal identification numbers, and they
often use the NMC employers’ confirmation
service.
In developing local policies however,
it is important to ensure that such
precautions are not undertaken only once,
at the recruitment stage, but that they are
part of robust mechanisms for checking
expiry dates, recording renewals and cross
checking the NMC fitness to practise
circ­ulars for suspensions, cautions and
removals from the register.
Electronic systems are excellent at
prompting such actions but some scrutiny
by ‘human software’ is also necessary. Use of
the Criminal Records Bureau (CRB) to make
checks on applic­ants’ criminal records, for
example, is now embedded in best practice.
But Ms Allitt had no criminal record,
so even if the CRB had existed at the time,
such a check would have failed to indicate
that she could commit her crimes.
Senior nurses may therefore have to
decide for themselves, as I have done,
whether someone who, 30 years ago, was
convicted of misappropriating a Christmas
tree or someone else who was convicted
recently of stabbing a colleague with
scissors are suitable for jobs in health care.
nursing management Vol 14 No 9 February 2008 11
Most organisations insist that managers
who conduct recruitment interviews are
trained, not only to elicit useful information
at interviews, but also to complete
paperwork and demonstrate that decisions
are made fairly. These managers also need
self confidence and experience to challenge
claims made in curricula vitae or to spot
gaps in career histories.
Managers need self confidence and experience
to challenge claims made in curricula vitae
or spot gaps in career histories
After all, people do not necessarily
declare in interviews that they have spent
time at Her Majesty’s pleasure.
records, these must be explored, as well
as the amount and frequency of sick leave
they have taken. However, if these issues
cannot be discussed with applicants, it is
up to referees to discern patterns of absence
and reveal whether these are covered by
certificates.
Each candidate’s choice of referees
is important therefore. The most recent
employer should be included along with
someone who has suffic­ient experience,
expertise and seniority to offer trustworthy
opinions on the candidate’s suitability for
the role.
When reading referees’ comments
however, it is important to remember that
what they omit can be almost as important
as what they include. Although they are
obliged to provide honest, factual and
balanced test­imonies, they are not obliged
to recommend candidates for specific posts.
As well as being expected to read
referees’ comments, many managers are
asked to provide them.
I expect candid­ates to ask me to act
as their referee before their potent­ial
employers contact me and, if I am asked
to provide references for people who have
been appointed already, I rarely do so, on
the grounds that the employers in such
cases cannot be genuinely interested in my
opinion.
opinion
Equally, I do not appoint candid­ates
‘subject to references’, or before I have had
their references checked.
Responsibilities
Human resource departments have differing
responsibilities. Some are responsible for
recruitment services, others simply advise
managers on recruitment processes.
Whatever recruitment model is
used, managers should always develop
meaningful links with their human
resources departments, as well as their
local union learning represent­atives, so
that they can benefit from the expertise
of others and ensure that recruitment is
a collaborative effort.
Managers should be in no doubt
however that responsibility for decision
making rests with them. Throughout
the recruitment process, the diligence
of managers is crucial, especially as the
number of online applications rises.
The organisational failures that
allowed Ms Allitt to be recruited into
the nursing profession raise a number
of questions that all healthcare managers
should ask themselves: How would they
have written Ms Allitt’s reference? Would
they recruit someone, even on a short
term contract, with an excessive sickness
record or a history of failing exams? And
would they have spotted Ms Allitt as a
potential problem if she had applied for
a post at their organisations, or would she
have slipped through their recruitment
nets too? nm
David Foster PhD, MSc, RN, RM,
MCIPD is the director of non‑medical
postgraduate development at Imperial
College Healthcare NHS Trust,
London, and chair of the Association
of UK University Hospitals Directors
of Nursing Group
Playing the ideal role
Becky Simpson assesses the value of drama based training
to healthcare professionals

12 nursing management Vol 14 No 9 February 2008

 feature

Many of the people who act as

clinicians or patients in television
programmes have been involved in
some sort of drama based training.
There are many similarities
between the acting and clinical
professions, and such training can be
an exciting and innovative way for
healthcare professionals to develop
their communication skills.
For drama based training to be
effect­ive however, the use of theatre
skills such as performing scenes and role
playing should involve professional role
playing actors and should be managed
sensitively by trained facilitators.

Meeting aims
Theatre performances by profess­ional
actors can energise and introduce
fun into training or conference pro-
grammes while helping them to meet
their aims.
Sketches can be written and
performed so that they are thought-
provoking and entertaining, and can
highlight issues concerning for example
diversity and conflict management.
They can also be used to
demonstrate good and bad outcomes,
analyse appropriate strategies for
improvement, and offer delegates
opportun­ities to reflect on different
styles of communication. Such group
work can also offer staff opportun­
ities to work together in teams.
Most delegates prefer to observe
rather than take part in theatre perfor-
mances, although such observation can
help to persuade them to take part.
Another ‘ice breaker’ is forum
theatre, a theatrical device derived
from Brazilian theatre practitioner
Augusto Boal that involves delegates
re-directing and re-enacting the theatre
performances they have already seen.
The purpose of this work is usually
to identify points of conflict between
characters in the performance and,
David Gee

with the help of facilitators, create

strategies to resolve these.

nursing management Vol 14 No 9 February 2008 13

feature
Author Becky Simpson and colleague David Schaal demonstrate role play for delegates
Role play
Perhaps the most valuable way
to challenge how people usually
communicate and to help them develop
their self knowledge is role play.
This offers delegates opportunities
to practise their communication skills
by talking to actors playing patients or
colleagues in near real life situations.
Box 1. Guides for facilitating feedback
Pendleton’s rules adapted for actors and delegates
the delegates describe what was done well
the actors describe what was done well
the facilitator sums up
the delegates say what could be done differently
the actors say what could be done differently
the facilitator sums up and reiterates what was done well
adapted from faculty Development (2007)
The Calgary Cambridge guide adapted for facilitators,
actors and delegates
the delegates describe their aims to the facilitator
the facilitator asks the delegates to describe what help
they need to achieve their aims
the facilitator asks the delegates what problems they have
experienced in achieving their aims and encourages them
to overcome these problems themselves
the facilitator directs feedback sessions among delegates
and actors to ensure that it is balanced and objective, and
is descriptive rather than judgmental
adapted from Chowdhury and Kalu (2004)
14 nursing management Vol 14 No 9 February 2008
Delegates are often surprised by how
much they enjoy and are stimulated by
role play, and often learn to experiment
with different approaches.
Role play must be handled
sensitively however, by experienced
trainers and actors. Participation
must be optional and never
humiliating, and delegates should
leave role play sessions, not only
confident in their existing skills, but
with new ideas about developing
their expertise further.
If role play is to work well,
facilitators and clients must be aware
of the criticism it has occasionally
received. For example, some delegates
will have already had unpleasant
experiences performing role play
sessions that were managed badly,
while others may feel anxious about
performing in front of their colleagues.
It should always be part of good
role play practice therefore to reassure
nervous delegates and to manage their
anxiety, and it is the job of profess-
ional drama trainers to judge sens-
itively when to persuade delegates to
express themselves and when to ‘back
off’, when to reassure them that their
performance is good and when to
challenge them to do better.
Role play is not necessarily about
‘getting it right’ but it can provide
great opportunities to experiment
in a safe environment with different
approaches.
When colleagues perform role
play without professional actors to
help them, it often fails. This may be
because their perceived differences in
status prevent them from expressing
themselves fully or because they
fear retribution if they do, or simply
because one or more of them
suddenly has a fit of the giggles.
Professional actors are experienced
however and well briefed in the parts
they play. Because they are experts at
adjusting their behaviours to different
situations while staying in role
moreover, they can become ‘foils’ for
the non-professional delegates.
Effective role playing is less about
acting and more about reacting, and
good role play actors are trained to
respond appropriately and to adjust
their behaviour to the individuals
with whom they work.
Actors who regularly work
alongside particular professions, for
example with clinical professionals,
can learn about the arenas in which
they work, and can use what they have
learned in their role play and feedback.
Feedback is an important
aspect of role play and most actors
are trained to give constructive
comments to delegates.
There are various models for
facilitating such feedback, the most
commonly used being adapted
versions of Pendleton’s rules or the
Calgary Cambridge guide (Box 1).

actors and facilitators
Actors can introduce creativity,
energy, enthusiasm, realism and
objectivity to drama based training.
They are used to managing
anxiety and, because they are not
caught up in the ‘office politics’ of
client organisations, they are not
constrained by them.
Like some non-actors however,
actors can be unprofessional when
performing role play. If they expect
a script, make up, lights and special
treatment, limousines or pampering,
they will be disappointed.
They must be able to improvise
and they must understand that
the training sessions are about the
delegates, not them.
To ensure a professional approach
is taken during acting sessions,
facilitators are sometimes needed.
Their key qualities are objectivity,
sensitivity, flexibility, energy and
imagination. They must be confident
because, if they are not, their anxiety
can spread to the groups with whom
they work.
But they must not lecture
delegates or, worse still, demonstrate
how they should have performed
interactions. Instead, they must
reassure and direct them, and sum up
how the interactions went when they
have ended.
The services described in this
article were launched 20 years
nursing management Vol 14 No 9 February 2008 15
feature
David Gee
ago by the communications and It takes skill for healthcare profess-
presentations training company, ionals to tell patients or their relatives
Playout (Box 2). that they do not know what’s wrong
It should come as no surprise with them, or that they know what
therefore that actors at Playout have is wrong but there is nothing they
worked alongside clinicians for can do about it.
several years. By inviting professional actors to
After all, many good healthcare act as patients in role play sessions
professionals demonstrate acting therefore, nurses and other clinicians
skills, not least by adjusting their can gain new insights into the exper-
style to communicate effectively with iences of their patients nm
different patients or clients.
Breaking bad news to someone Becky Simpson is managing
for example requires a different tone director of Playout
of voice from telling someone that an References
operation has been a success. faculty Development (2007) Models
Most healthcare professionals of Giving Feedback: Pendleton’s rules.
know that the ability to commun- www.faculty.londondeanery.ac.uk/e-
learning/feedback/models-of-giving-
icate well is an important part of
feedback (Last accessed January 16 2008).
their jobs, although some argue
Chowdhury RR, Kalu G (2004) Learning
that they do not have enough time
to give feedback in medical education.
and resources to develop good The Obstetrician and Gynaecologist
communication skills. 6, 4, 243-247.
Box 2. Playout
Playout is a communications and presentations training company that started to help pioneer drama
training 20 years ago.
It uses theatre performances, role play and forum theatre. It also produces DVDs featuring training
programmes written by professional scriptwriters and performed by professional actors. these can be
used as training tools or as a means to follow up training. Playout also runs training courses for leaders and
facilitators, and its members have worked with facilitators from both clinical and non-clinical backgrounds.
Playout has trained health service staff and healthcare students, and regularly provides courses for clients
including the Royal Marsden nhS foundation trust, in London, Brighton and hove City teaching Primary
Care trust, Brighton and Sussex Medical School and hertfordshire Partnership nhS foundation trust.
further information is available from the author by emailing her at becky@playout.co.uk or from the
Playout website, at www.playout.co.uk
feature

Hearing the alarm

In the wake of the Healthcare Commission report into infection outbreaks at
Maidstone and Tunbridge Wells NHS Trust, Lindsey Scott reflects on the similarities
between events in Kent and those at the Bristol Royal Infirmary
MANY DIRECTORS of nursing will, recent announcement of a public and organisational, rather than
like me, have read with interest the inquiry into children’s heart surgery individual, failings.
Healthcare Commission (2007) report at the Bristol Royal Infirmary I wondered why the NHS had not,
into the outbreaks of Clostridium  1984/95 (Kennedy 2001). after all, learned the necessary lessons
difficile at Maidstone and Tunbridge Being at Bristol when the full inquiry of the Bristol report such as the need
Wells NHS Trust, Kent, and, being report was published, I read it and got to listen to the concerns of patients
responsible to their trust boards for to know it line by line. I considered and staff, and to be aware of events
infection control, will have reassessed that the trust owed it to the parents of across the NHS. And I wondered how
their trusts’ policies in light of its the children who had died during the we, as nurse leaders, can ensure that
recommendations. inquiry period to learn the appropriate such reports never appear again.
I doubt however that many who lessons so that Bristol would become a
read the report experienced my sense centre of excellence with patient safety The two inquiries
of unease because I have a personal as its number one priority. Of course, there are differences
involvement with a trust that has Clinical governance and systems of between the two inquiries, most
experienced a similar failure. infection control that are now expected obviously of scale. Sir Ian Kennedy’s
routinely in the NHS were born in part inquiry into events at Bristol took
Centre of excellence out of the events at Bristol. three years, evidence was received
I was recruited as director of nursing The unease and even dismay I from more than 570 witnesses, and
at the United Bristol Healthcare felt in reading the Maidstone and 900,000 pages of documents were
NHS Trust in 1997 both to Tunbridge Wells report was due to reviewed, all at a great financial cost.
establish nurse leadership and to the startling similarities between the The Maidstone and Tunbridge
lead the implementation of clinical events it describes and those that had Wells investigation, on the other hand,
governance. These tasks were occurred at Bristol. For example, took only seven months, during which
particularly important in Bristol at both inquiries concern preventable 200 people were interviewed and
the time because they followed the deaths that were the result of cultural 1,000 documents examined.

16 nursing management Vol 14 No 9 February 2008


The clinical contexts of the events
they describe are different too.
In Maidstone and Tunbridge Wells,
it was estimated that 90 deaths were
probably or definitely caused mainly
by infection, whereas in Bristol,
between 30 and 35 more children
under the age of one year died after
surgery than was expected for a
typical unit in England at the time.
There are also differences in scale
between the responses of the general
public and the media to the findings
of the two reports.
But there are also similarities
between the reports. One of the most
striking of these is that, in both cases,
deaths could have been prevented
if the trusts concerned had devised
appropriate systems to protect patients.
Kennedy says that his report into
events at Bristol ‘was not an account
of bad people… or of people who did
not care… or of people who wilfully
harmed people’. I think that this can
be said also of staff at Maidstone and
Tunbridge Wells.
Both reports tell stories of trusts
struggling with competing objectives
during periods of organisational
change. Maidstone and Tunbridge
Wells, for example, had previously
undergone merger, and was focusing
on access and financial targets.
High bed occupancy levels directly
influenced the spread of infection
nursing management Vol 14 No 9 February 2008 17
at the trust, there was reportedly a
lack of organisational stability and
board members had a tendency to
discourage ‘bad news’.
Cost control
How similar these events sound
to those described in the Bristol
inquiry report! This organisation
had also been recently restructured,
by becoming a NHS trust, at a time
when the NHS culture encouraged
cost control and efficiency. Although
the new trust appeared to be
structurally stable, it was not.
In retrospect, its clinical directorates
had too much autonomy and its teams
were dysfunctional, while its board
members tended to want to hear only
solutions, not problems.
Striking similarities can be found
in the reports between the role
descriptions of external organisations
such as the Department of Health,
the Health Protection Agency and
health service commissioners, namely
the primary care trusts and either the
strategic health authorities or their
predecessor bodies.
At both trusts, confusion of role
and function among these external
organisations is cited as contributing
to internal confusion and an inability
to identify problems.
The key factors identified in both
reports, of competing objectives and
feature
targets, and of organisational change,
are not new to the NHS; in fact, they
should probably be seen as the norm.
Complexity
The management of health services
is recognised internationally as one
of the most complex management
tasks in the world and, while those of
us who are in leadership roles must
acknowledge this complexity, we
must not use it as an excuse when our
services fail the public and our patients.
Trust boards are accountable
for managing these complex
working environments and, if they
are to make informed decisions
about investment priorities and
interventions when things go wrong,
they must consider information on
performance across the entire service.
After stating that infection control
is a priority, boards should not pay
‘lip service’ to the issue by reviewing
either limited information on infection
rates, as was the case at Maidstone
and Tunbridge Wells, or inaccurate
or incomplete information, as was
the case at Bristol. The latter trust
regarded compromises in the quality
of care as obstacles to be overcome
Stock Illustration Source
rather than safety alerts that
warranted cessation of services.
Both boards ignored the wide
range of information that was
available to them, even though this
 feature
could have warned them of potential
problems and helped them to take
remedial action.
What strikes me most about the
report of events at Maidstone and
Tunbridge Wells is that some of the
most fundamental recommendations
of the Bristol report had not been
implemented.
Clinical governance requires NHS
organisations to put in place systems
to identify problems of quality and to
act on them.
Kennedy’s Recommendat­
ion 6 for example states that
available inform­ation should be
based on current evidence, while
Recommend­at­ion 39 describes the
NHS regulat­ory framework and
Recommendations 130-134 outline
the standards of care required to
prevent ‘another Bristol’.
Yet, the Maidstone and Tunbridge
Wells investigation, whose remit was to
consider whether the trust’s systems for
identifying, preventing and controlling
infection were adequate, found that
they were either non-existent, out of
date or inaccess­ible to staff.
Two fundamental clinical
governance system failures had been
specifically identified in the Bristol
report, namely a failure to listen to
staff and patients when they said that
things had gone wrong, and a failure
to learn from mistakes that had
occurred in the wider NHS.
Indeed, the need for trust board
members to listen to and involve
service users was the subject of 37 of
Kennedy’s recommendations.
Yet, at Maidstone and Tunbridge
Wells, complaints about quality
of care and the concerns of staff
members, particularly about infection
control, gathered during a national
staff survey carried out by the trust in
Science Photo Library
2005 were ignored by the board.
Most significantly, the directly
relevant lessons from C. difficile
outbreaks at Stoke Mandeville
18 nursing management Vol 14 No 9 February 2008
Hospital, Buckinghamshire,
(Healthcare Commission 2006) were
not acted on.
Challenges
When I was interviewed for the job in
Bristol, I was left in no doubt of the
challenges I faced. Not only did I have
Under the to introduce effective nurse leadership,
microscope:
C. difficile but I also had to change the culture
of the organisation, from
one in which the nursing
contribution was
underrecognised to one
in which it was valued
and supported.
Directors of nursing
and other nursing leaders
must always remember that
nurses have a unique role in
health care because, of all healthcare
professionals, nurses spend the most
time with patients, and therefore have
the greatest influence over the patient
experience and patient outcomes.
In Kennedy’s report, the then
director of nursing at Bristol was
criticised for failing to lead the nursing
profession adequately. She was said
to be ‘feared’ and ‘inaccessible’, and
tended to overemphasise her wider
oper­ational role.
At Maidstone and Tunbridge
Wells, the director of nursing was
also the director of infection prevent­
ion and control, yet was found to
have an inadequate understanding of
the role and to have failed to obtain
the inform­ation he needed either to
fulfil the role or to brief the board.
In both trusts, strategic direct­
ion was lacking and management
arrangements for the teams
concerned confusing.
More significantly perhaps, nursing
was seen in both trusts as a cost rather
than an asset: because of cost controls
at Bristol, because of the need to meet
financial targets at Maidstone and
Tunbridge Wells. There were also
staffing shortages at both.
Nurse leaders can do several
things to ensure that such reports are
not published again. First, we can
make sure that the complexity of the
NHS does not excuse dysfunctional
cultures or failing services again.
Second, we can work with medical
directors to ensure that clinical
governance systems are effective, and
that our boards receive and consider
robust information across all services,
including information on finances,
access targets, clinical quality, safety
and patient exper­ience.
Finally, we can improve our
personal communication skills to
convince our boards that, while we
shall always strive for savings, the
nursing resource is an asset, not
a cost. After all, we have already
succeeded in becoming more efficient
than other NHS profess­ions.
But, while we strive in our
organisations to deliver on this
respons­ibility, we must also challenge
the DH and all external stakeholders
to learn from the failures of Bristol,
and of Maidstone and Tunbridge
Wells, and to ensure that the working
culture that made them possible
never reappears nm
Lindsey Scott SRN, SCM,
DipManagement Studies, MBA
is chief nurse and director of
governance at the United Bristol
Healthcare NHS Trust
References
Kennedy I (2001) The Report of the Public
Inquiry into Children’s Heart Surgery
at the Bristol Royal Infirmary 1984-1995.
The Stationery Office, London.
Healthcare Commission (2006)
HSE Investigation into Outbreaks of
Clostridium Difficile at Stoke Mandeville
Hospital, Buckinghamshire Hospitals NHS
Trust. Healthcare Commission, London.
Healthcare Commission (2007)
Investigation into Outbreaks of
Clostridium Difficile at Maidstone and
Tunbridge Wells NHS Trust. Healthcare
Commission, London.
feature
Laying it on the line
William Moyes from the independent regulator of NHS foundation trusts, Monitor,
describes why senior nurses should understand the theory of service line management
The first NHS found­ation trusts
were authorised in April 2004 and
have grown in number ever since.
Indeed, by the end of this year, most
acute and mental health care in
England will be provided by NHS
found­ation trusts.
Service line management
should not be dismissed as a cost
cutting exercise
This growth in the number of found­
ation trusts in the acute and mental
health care sector coincides with an
improvement in their performance,
as highlighted by the Healthcare
Commission in its annual health check,
published in October 2007.
According to this health check,
of the 19 NHS organisations rated
‘excellent’ for their use of resources
and the quality of their services, all
are foundation trusts.
These successes are encouraging,
but, to create truly patient focused
health care, continuous improvement
is needed and foundation trusts must
tap into the knowledge and exper­
ience of their clinical staff to realise
fully the benefits of their new status.
Foundation trusts do not achieve
high standards simply because the
correct decisions have been taken at
board level; strategies and plans to
improve quality will have the desired
effect only if front line staff are
engaged fully in them.
Understanding clinical quality
In assessing the performance of trust
boards, staff at Monitor often find
20 nursing management Vol 14 No 9 February 2008
board members experience greatest
difficulty when responding to questions
about their understanding of quality.
The importance for trusts of
establishing robust systems for
feedback on clinical quality is made
clear by the Healthcare Commission’s
report on Maidstone and Tunbridge
Wells NHS Trust, Kent, published in
October.
This report concludes that the
process by which issues of potential
clinical risk were raised at the trust
had failed. It states: ‘Overall the
system that was intended to bring
clinical risk to the attention of the
board did not funct­ion effectively,
and the board seemed to be insulated
from the realities and problems on
the general wards.’
For those who think that the
establishment of a foundation
trust is solely a financial matter,
Monitor’s focus on quality may be
surprising, but, because safe patient
care depends on strong finances and
good governance, we require robust
business plans from all applicants for
foundation trust status.
After all, the organisations that
perform best in the NHS combine
good financial management with high
quality care. Staff at Monitor are not
naïve about the problems encountered
by NHS and found­ation trusts in
achieving high performance, however.
Being complex organisations,
these must devolve the authority to
make operational decisions to the
appropr­iate levels.
Obtaining access to appropriate,
correct information is therefore key
to their success, and this is precisely
why Monitor introduced service line
management (SLM) to the NHS.
Service line management
Few NHS staff are likely to be
familiar with the concept of SLM. If
its name has a corporate ring to it, it
is because its roots are in the business
world, where it has been used widely
for many years.
Monitor believes however that
SLM represents a logical step
forward for the UK’s increasingly
devolved healthcare system.
In simple terms, SLM involves
identifying organisations’ different
business units, or service lines,
such as orthopaedics, and the
contributions they make to overall
performance.
In this context, performance
is measured against a balanced
range of criteria including clinical
quality, levels of patient experience
and staff satisfact­ion, and financial
performance.
Ideally, a single individual, usually
a clinician, is held accountable for
this performance and can decide how
it can be improved.
Although one way of improving
the performance of trusts is to
increase their profitability, SLM
should not be dismissed as a cost
cutting exercise because it can
also provide clinical staff with
opportunities to redesign services to
provide better care.
Nevertheless, all NHS foundation
trusts have a responsibility to balance
their books.

To be viable, they must ensure
that their costs do not exceed their
revenues and, if they can deliver
improvements in efficiency, they can
invest in improvements to quality.
Indeed, this is the basis of the
foundation trust financial model;
the ability to reinvest in patient
services provides the incentive to
make surplus income.
Service line management applies
this approach to individual special­
ities, or service lines.
Of course, for SLM to be
understood and improvements to be
identified, clinical involvement and
leadership are needed.
If clinicians know how much their
respective service lines cost, they
can take the lead on identifying and
implementing change, and the more
advanced their understanding, the
more they can improve the patient
experience.
For example, Fig. 1, which is
adapted from an example used by
Monitor, shows how the clinical
leads at a trust have identified how,
by taking a more efficient approach
to breast cancer care, savings can be
used to improve quality elsewhere in
patient pathway.
In this example, triple assessment
comprises: clinical examin­ation,
radio­logical assessment using
mammography or ultrasound, and
pathological assessment using cyto­
logy or biopsy.
Multidisciplinary meetings were
held regularly to make decisions on
treatment and involved surgeons,
oncologists, radiologists, and specialist
and palliative care nurses.
By increasing the proportion of
surg­eries that are performed as day
cases, the trust has reduced its costs.
As a result, these savings have
been allocated for reinvestment
to improve care elsewhere in the
pathway of patients with breast
cancer, for example by increasing the
nursing management Vol 14 No 9 February 2008 21
amount of time nurses can spend with
patients who are given breast cancer
diagnoses, and by ensuring that all
patients receive biopsy, ultrasound
and mammo­graphy on the same day
that they see their breast surgeons.
Nurse leadership
During a presentation at the 2007
annual conference of the chief nursing
officer for England, the author
highlighted the invaluable contribution
of nurse leaders to implementing the
concept of SLM by ensuring that their
staff develop a genuine sense of owner­
ship of clinical quality.
Because nurses are closer to the
wards than any other group of clinic­
ians, the role of senior nurses in
implementing SLM can be crucial.
Of course, implementing organis­
ational policy on the wards is a
fund­amental part of improving trust
performance, but SLM should also
empower the nurses themselves.
This empowerment requires that
nurse leaders understand service lines
across all aspects of performance.
Fig. 1. Using service line management to improve the breast cancer patient pathway
Saving identified
4 Increase proportion of
breast surgeries, including
mastectomies without
meetings and surgery
reconstruction and breast
conserving surgery,
performed as day cases
from 5 to 75 per cent
Net saving: £190,000 per year
feature
Nurse leaders sometimes disagree
with decisions that affect service
performance. They might think for
example that the pace of change being
proposed is unrealistic or that obvious
improvement opportunities are being
ignored. Under SLM however, they
can challenge such decisions.
Monitor believes SLM is fund-
amental to success in foundation trusts
and, in those trusts where it has been
piloted, SLM has already demon­strated
benef­its. Service Line Management
was introduced into the NHS to help
trusts realise their potential but, like
any organisation, foundation trusts are
only as good as their staff.
Although the quality of services
provided by devolved organisations
in the NHS varies, devolution
offers nurses and other clinical staff
opportunities to use their knowledge to
improve services for all patients nm
William Moyes is chair of Monitor,
the independent regulator of NHS
foundation trusts
See also Webscan, on page 37
Screening
Investments identified
Eliminate waiting list
4 
4 E
 nsure that all patients receive
Triple assessment
a biopsies, ultrasound scans and
mammograms on the same day
they see their breast surgeons
Multi-disciplinary
4 E
 nsure that patients are seen only
by consultants, not junior doctors
Increase time spent with each
4 
patient given a diagnosis of breast
Chemotherapy
and radiotherapy cancer from 15 to 60 minutes
Net cost: £190,000 per year
Follow up
feature

A tonic for the troops

Gail Lusardi, Allyson Lipp and Huw Williams report on how non-military healthcare staff
can learn valuable lessons in leadership by taking part in weekend exercises organised
by the Territorial Army, whose 100th anniversary
is celebrated this year

In deep water: participants

in Exercise Medical Stretch
work their way through
an assault course

22 nursing management Vol 14 No 9 February 2008


Exercise Medical Stretch
(EMS) is an annual, weekend event
conducted by 203 (Welsh) Field
Hospital (Volunteers), which is part
of the Territorial Army (TA) medical
serv­ices and the major TA medical
unit in Wales.
The EMS event is held at
Sennybridge Training Area, near
Brecon, and comprises a series of
ten command, leadership and team
oriented tasks along a route of about
ten kilometres across rugged terrain.
The exercise, which is open to
members of all NHS trusts and local
health boards in Wales, is designed to
challenge participants both physic­ally
and intellectually, and to help identify
individuals’ strengths and weaknesses.
Its intended outcome, namely the
forging of strong bonds of friendship
between the field hospital staff and
their civilian counterparts, is part­
icularly important at a time, as now,
when military and NHS staff must
work in harmony.
Not only does it act as a
recruitment drive for the TA, but it
also helps to ensure that, when NHS
staff who are TA members are drafted
to war zones, non-TA staff will
replace them more willingly.
Meanwhile, even a brief experience
of military life can help NHS staff
understand the healthcare needs
of soldiers returning from military
service.
The exercise
Last year’s event, in June 2007, had a
record number of participants, 117,
who came from local health services,
the University of Glamorgan and the
Welsh Blood Service.
We spent the first night, a Friday,
in dorm­itories, sleeping in bunk beds,
which meant we came to know each
other pretty quickly.
The following morning began with
a 5.30am alarm call, followed swiftly
by breakfast, and then we climbed
nursing management Vol 14 No 9 23
feature
into vehicles to be taken to the north
end of the training area.
We were then separated into teams
and taken to various starting points
along the route to begin the exercise.
At this point, it started to rain
heavily and the sky looked dark for
miles around, although this did not
appear to dampen the spirit or resolve
of any of the team members.
In fact, it became evident as the
day progressed that, despite the
horrendous weather conditions, every
participant was determined to see it
through to the end. And so, dressed
in our army issue, one-size-fits-all
waterproofs, and carrying 18kg
backpacks, we marched on.
The opportunity to lead the team
brought out leadership qualities
such as motivating others, thinking
creatively, communication skills
and using personal resources
Every team conducted each of
their tasks successfully, and the first
day ended at around 8pm with pretty
well everyone exhausted by the day’s
activities. But the field hospital chefs
soon had everyone feeling better by
providing a fantastic indoor barbeque.
It also helped that there was a bar.
On Sunday morning, we had
another early start for the next phase
of EMS, a timed march and obstacle
course. The four-mile march and run
promoted a genuine camarad­erie
among team members especially
because, by then, sleep deprivation
and cumulative fatigue were
beginning to get the better of us.
To overcome and distract us
from this, we encouraged each other,
exchanged anecdotes and, typical of
healthcare staff, used humour to keep
ourselves going.
As we completed the march, we
were energised sufficiently to tackle
the assault course.
feature
This effort was the epitome of
teamwork, with participants helping
one another to overcome fears of
heights, the dark, confined spaces
and fast flowing water.
We returned to the training camp
for well deserved showers, followed
by a curry lunch and the presentation
of certificates.
Exercise Medical Stretch made us
realise that, for patients to maintain
a sense of control, information is
vital and can improve their chances
of success
We felt a real sense of achievement
when we received these from
commanding officer Colonel
Phil Hubbard and representative
colonel commandant of the Royal
Army Medical Corps Colonel John
Tinsley.
Leadership
Leadership was a key feature of EMS
and each team was allocated two
marching drill sergeants.
Our team’s drill sergeants were
excellent and employed precisely
the right amount of badgering and
encouragement to obtain the best out
of us. In addition, each team member
was given an opportunity to lead
their team while it undertook at least
one of the tasks.
Our team’s designated leader
started by sharing tasks with other
team members and seeking their
opinions before making decisions
but, as the time limit for completing
tasks approached, a more autocratic
style of leadership was expressed to
ensure that they were finished in time.
Thus, our team’s dominant leadership
style was democratic, combined with
either ‘laissez faire’ or autocratic as
circumstances required (Girvin 1998).
The opportunity to lead teams
brought out leadership qualities
24 nursing management Vol 14 No 9 February 2008
such as motivating others, thinking
creatively, and using communication
skills and personal resources (Cox
and le May 2007). It involved taking
charge of disparate groups of people
and managing tasks in the best
possible way, so using the talents of
all team members was essential.
Everyone wanted to contribute to
the tasks in the time allocated and so
defusing potential disputes was also
part of the process.
Teamwork
At the beginning of the exercise, we
all knew at least one other person
in our teams but realised that, if we
were to perform effectively, we had
to get to know everyone quickly.
Our team comprised members
from several NHS trusts, and so was
an ideal example of inter-professional
teamwork (Hogston and Simpson
2002). It also comprised a mix of
young and experienced members so
that enthusiasm was tempered with
expertise.
Some members held senior
positions in health care but, because
the command tasks acted as good
social levellers, there was no
hierarchy in the team other than that
which was required by the exercise.
Although we all knew we were
fairly physically fit, we weren’t sure
we were fit enough to avoid letting
the team down and survive on the
rations provided. This uncertainty
offered all of us opportunities to
assist each other in some way, from
physically helping those who were
flagging to passing round a seemingly
limitless supply of sweets carried by
some kind participants.
In addition, to ensure that
whole teams completed the course
successfully, and at the same time,
physic­ally fitter members were
designated to assist those who were
less fit. Thus, the presence of less fit
team members acted as a catalyst
for fitter members to create support
structures,
for example by planning strategies
for the assault course that took
account of all team members’
abilities.
Managing psychological
differences between members was
undertaken in much the same way.
Some people could work out the
problems posed with ease, but did
not have the physical strength to
perform the tasks without the help
of others.
New skills
We were not told in advance or in
detail about what was expected of
us, which induced a level of anxiety
about how much we would be able
to contribute to the command tasks
and whether we would let our team
members down in completing them.
This lack of knowledge of our
abilities to rise to new challenges
is in some ways similar to that of
patients at the beginning of their care
journeys.
We often expect patients at such
times to submit themselves to our care
without question, but EMS made us
realise that, for patients to maintain a
sense of control, information is vital
and can improve their chances of
success (Miller 2002).
In undertaking our tasks, we
learned new skills, from tying reef
knots to using our ground sheets to
make temporary forms of sleeping
accommodation called ‘bashers’.
These tasks challenged us physic­
ally, emotionally and psychologically;
they made us aware of our personal
weaknesses and how they can be
overcome with team effort.
The only major casualties in our
team were our feet. Although we all
wore waterproof walking boots, we
suffered from wet feet and blisters.
This simply served to strengthen our
resolve to continue however.

Conclusion
Exercise Medical Stretch could be
described as a recruitment exercise for
the TA.
Indeed many of the participants
have made further enquiries and at
least one is keen to join the regular
army. But for most participants, EMS
offers a valuable insight into a world
that is both different from and, with
its emphasis on organisation, stamina,
commitment and teamwork, similar
to the NHS.
The tasks we undertook
contributed to our management and
leadership expertise in many ways and
at various levels.
In nursing management, playing
to everyone’s strengths in this way
is an essential skill. It can mean
compensating for the weaknesses of
some members but this is a small price
to pay in ensuring that everyone is
valued for their contribution (Marquis
and Huston 2003).
For example, role expansion and
changes in service provision, such as
reducing junior doctors’ hours, mean
that people who might never have
considered themselves members of the
same team must now work together
(Department of Health 2002).
Exercise Medical Stretch proved to
all of us that this is possible nm
Allyson Lipp is principal lecturer
in health, sport and science at the
faculty of health, sport and science,
University of Glamorgan
Gail Lusardi is senior lecturer in
health, sport and science at the
faculty of health, sport and science,
University of Glamorgan
Huw Williams is a regimental
operations support officer at
203 Field Hospital, Cardiff
feature
References
Cox Y, le May A (2007) Leadership for
Practice: Principles of professional
studies in nursing. Palgrave Macmillan,
Basingstoke.
Department of Health (2002) Developing
the Roles of Health Professionals.
The Stationery Office, London.
Girvin J (1998) Leadership and Nursing.
Macmillan Press Ltd, Basingstoke.
Hogston R, Simpson P (2002)
Foundations of Nursing Practice:
Making a difference. Palgrave Macmillan,
Basingstoke.
Marquis B, Huston C (2003) Leadership
Roles and Management Functions.
Lippincott Williams and Wilkins, London.
Miller JA (2002) Clinical governance.
Nursing Times. Monographs, 56.
Standing easy: the authors’
Exercise Military Stretch team
at Sennybridge Training Area
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Ten steps to setting goals
Chris Pearce offers a guide to help nursing leaders set goals
SETTING GOALS can help you to define your priorities and so
become organised, and almost all motivational experts include goal
setting as an important part of their programmes.
1 PLAN AHEAD
Take two sheets of paper. On one, state your goals for
the next 12 months; on the other, state what you want
to achieve between now and the end of your career. In comparing
the two, make sure that achieving the goals on your first list will help
you to achieve those on your second.
2
LINK PERSONAL AND EMPLOYMENT GOALS
On a third sheet of paper, state what you want to achieve
before the end of your life. Compare this with what you
want to achieve before the end of your career, and try to link the
two sets of goals. You are more likely to attain both personal and
employment goals if they are similar.
3
MAKE CLEAR GOAL STATEMENTS
The ‘goal statements’ you have made should be clear
and accurate. To do this, use the SMART formula to
ensure that your goal statements are specific, measurable, action
oriented, realistic and time constrained.
4 FOLLOW THE ‘SMART’ RULES
Your goals should be: specific, in that you should be
able to define them; measurable, in that you should be
able to tell when you have attained them; action oriented, in that
you should undertake specific activities to attain them; realistic, in
that they are practical and achievable; and time constrained, in that
there are defined deadlines for their completion. A goal statement
such as ‘To reduce the waiting time in outpatients by 25 per cent by
the end of the year without additional resources’, is an example that
follows these rules.
5 BE COMMITTED
To attain your goals, you require commitment. Do not
state your goals unless you are certain that you have
sufficient commitment to attain them.
6
BE MOTIVATED
To complete all of the steps in the goal setting process,
you also require motivation. To be motivated, you must
be optimistic, or ‘positive’, about your ability to attain your goals.
Pessimism, or ‘negativity’, can kill your sense of motivation.
nursing management Vol 14 No 9 February 2008
leadership resource
7 REDUCE GOALS TO MANAGEABLE STEPS
Attaining goals can be difficult unless they are broken
down into small, detailed steps. To help you track your
progress towards your overall goals, these ‘goal steps’ should be
listed in the form of ‘action plans’. Goal steps should be positive,
not negative; that is, they should describe achievements to be made
rather than obstacles to be overcome.
8 SHARE YOUR GOALS
Sharing your goals with others who can help or support
you can increase your chances of success. If possible,
you should also share the work you do in attaining your goals.
9
RE-ASSESS YOUR GOALS FREQUENTLY
Goal setting is a process. When you first start to define
your goals, this process can seem difficult and daunt-
ing but, as you gather experience, it becomes easier. You therefore
require patience to set and attain goals successfully. All of the goals
that you want to attain in the year ahead should be reviewed daily,
if possible, or at least once a week. To carry out these reviews, con-
struct simple time lines or use matrix charts with planned achieve-
ment dates set against your goals.
10
RECOGNISE YOUR SUCCESSES
In the goal setting process, success can be defined as
‘the progressive realisation of a worthwhile goal’. If you
are carrying out activities that help you to attain a specific goal, you
can judge yourself ‘successful’ even if you have not actually attained
this goal. Such judgements are important because frequent recogni-
tion of success can increase your motivation.
FINAL POINT
Do not attempt to attain goals that someone else has set for you,
so ensure that both your goals and the activities you carry out to
attain them are your own. Make sure too that you genuinely want
to attain these goals, that you are excited by them, and that you
are committed and motivated sufficiently to attain them. When
your career has ended, you should be able to look back and say:
‘Each day, I took a step closer to my goals.’ nm
Chris Pearce MSc, BA, RN, DipN, RNT, CertHSM is
a life coach and freelance trainer with Life Goal Specialists
Earlier editions of this leadership resource are available at
www.nursingmanagement.co.uk
27
applied leadership
Critical thinking among nurses
Concept mapping can help both newly registered staff and nursing students develop
the critical thinking skills they lack, says Swaleh Toofany
Swaleh Toofany MA, In today’s complex and ever changing healthcare
RGN, NDN, CPT, environment, nurses must be prepared to analyse large
DPSN, CertEd is amounts of information critic­ally so that they can
a senior lecturer in weigh up the evidence supporting, and arguments for
the faculty of health and against, particular issues or procedures.
and human sciences However, as the amount of knowledge in health care
at Thames Valley expands, nursing students find such analysis increas­
University, Slough ingly difficult (Beitz 1998), while research suggests that
many newly registered nurses lack the abilities or skills
to think critically (Shell 2001)
This lack of critical analysis in health care among
nursing students and newly registered nurses is becom­
ing a major issue for the nurse managers who have
to support them, particularly in light of the current
emphasis on continual quality improvement.
One way for nurse managers to help nurses develop
their analytical, or ‘critical thinking’, skills however is
by introducing them to concept mapping.
This article defines critical thinking and explains
how concept mapping can be used in educative
and clinical settings to develop analytical skills in
nurses.
Defining critical thinking
Critical thinking is defined by Wilkinson (1996)
as both an attitude and a reasoning process that
involves several intellectual skills.
Ignatavicius (2001) meanwhile describes critical
thinking as a form of purposeful, outcome directed
thinking based on a body of scientific knowledge
derived from research and other sources of evidence.
Critical thinking is also described as the rational
examination of ideas, inferences, principles, argu­
ments, conclusions, issues, statements, beliefs and
Keywords actions (Taylor 2006), and has been referred to
n Critical thinking as clinical reasoning, clinical decision making and
n Decision making process
clinical judgement.
n Education methods
Concept mapping
This article has been Concept mapping is a technique for representing
subjected to peer review knowledge through a linked network of concepts.
28 nursing management Vol 14 No 9 February 2008
Concept mapping, which is based on Ausubel’s
(1968) Assimilation Learning Theory, in which prior
knowledge is described as an important factor in the
ability to learn about new concepts, was later devel­
oped by Novak.
Concept mapping is also known as knowledge,
cognitive or mind mapping, as well as web teaching,
semantic networking or structured conceptualis­ation
(Irvine 1995, Kathol et al 1998).
Indeed, Trochim and Kane (2005) state that concept
mapping can be any methodology used to produce pic­
tures, maps or ‘concept trees’ of any individual’s or
group’s concepts.
These authors also state that the concept mapping
process takes place in six stages:
n Preparation
n Generation of ideas
n Organisation
n Representation
n Interpretation
n Utilisation.
Concept maps
Concept maps are representations of ideas in diagram­
matic form (Irvine 1995), usually consisting of nodes
or cells that contain linked concepts, items or quest­
ions. The links are in turn labeled and made to denote
direction to indicate the relationships between the
nodes (Schuster 2000)
Because concept maps represent many different
concepts, they can take many different forms, includ­
ing hierarchy, pictorial landscape, spider and system
formats, multi‑dimensional or mandal maps, and flow
charts. They can be used in lectures, group work,
classroom discussion, skills laboratories and in clinical
practice (All et al 2003)
Concept maps are context dependent because map
makers’ prior knowledge influences the maps they
produce. They are also dynamic, rather than static,
learning tools because they can change during clinical
experiences (Hill 2006).

Critical thinking in nurse education
According to Luckowski (2003), critical thinking is
a skill that all newly registered nurses must have if they
are to succeed in nursing.
In the UK, pre‑registration nurse education is embed­
ded firmly in mainstream university curricula and, in
recent years, the criteria for entry to such courses have
been altered to encourage a more academic­ally diverse
student population.
To cater for these students, many schools or depart­
ments have reviewed their teaching methods. As well
as adopting concept mapping, some have adopted
systems of problem based learning that help students
develop critical thinking skills to understand and
resolve specific problems.
Unfortunately, evaluative work in the nursing liter­
ature on the effects of enquiry learning on the ability
of nursing students to think critically (Biley and Smith
1998) is scarce, while that in the supporting literat­ure
focuses on the field of medicine. Caution must be exer­
cised therefore when evaluating this method.
Concept mapping as a teaching strategy
Concept mapping can increase students’ learning
efficiency by encouraging them to make sense of
abstract phenomena in terms with which they are
familiar (Beitz 1998), and can help them to engage in
cognit­ive processes such as organising, categorising,
analysing, evaluating and critical reasoning (Rafferty
and Fleschner 1993).
Clayton (2006) advocates concept mapping as an
active teaching strategy that can help nurse educators
prepare graduates to think critically, and Daley (1996)
notes that it can be used to assess students at different
times during their education.
The purpose of nursing programmes that include
concept mapping strategies is to create practitioners
with the characteristics listed in Box 1.
As Walsh and Seldomridge (2006) report however,
it is difficult to ascertain whether these programmes
have succeeded in this, and whether they have pro­
duced nurses with critical thinking skills.
Methods of assessing critical thinking skills in
nurses are therefore needed.
Assessing critical thinking skills
Critical thinking skills can be assessed or measured
by tools such as the Watson‑Glazer Critical Thinking
Appraisal (WGCTA) or the California Critical Think­
ing Skills Test (CCTST). Both of these tools measure
abilities to: recognise assumptions; infer, deduce and
nursing management Vol 14 No 9 February 2008 29
applied leadership
interpret­; and demonstrate evaluative, analytical,
inductive and deductive forms of reasoning.
A UK based study by Girot (2000) concludes that
WGCTA can measure differences in student perform­
ance before, during and on completing academic pro­
grammes although the accuracy of these results may
depend on the context in which they are gathered, with
variables including students’ ability to learn and the
nature of their studies.
Turner (2006), on the other hand, argues that,
because there are so many definitions of critical think­
ing, there can be no clear way of measuring its effects,
which in turn inhibits putting research into practice.
Clearly therefore, assessing critical thinking skills is
complex and the choice of tool used to do so depends on
context. Seldomridge and Walsh (2001) suggest there­
fore that a discipline specific instrument to measure
thought and reflection should be developed.
Critical thinking in practice
The ability to think critically and solve problems in differ­
ent clinical practice settings is required of all nurses,
including those who are newly registered and students.
Clinical experience is necessary for the develop­
ment of critical reasoning and decision making skills
(Ferrario 2004a) so, in making the transition from
educat­ion to clinical practice, nursing students cannot
rely on theory alone (Black et al 2000)
One reason why many nursing students appear to
be unable to think critically however may be that their
teaching programmes emphasise content rather than the
use and application of knowledge (Del Bueno 2006).
Critical thinking requires skills in decision making and
problem solving. These are complex cognitive phenom­
ena, which nurses must often have to carry out quickly.
Box 1. Characteristics of critical thinkers
n Analytical, knowledgeable and observant
n Assertive, outcome directed, persistent, resourceful and willing to take risks
n Caring, communicative, flexible and open minded
n Creative, imaginative, innovative and intuitive
Ferrario (2004a) proposes therefore that, to reduce
the demand on their ‘cognitive reserves’ when making
decisions, nurses can take ‘cognitive shortcuts’, which
are usually derived from their experiences of similar
decisions they have made before.
She also points out that nurses use structured care
approaches, such as standardised clinical practice
guidelines, care pathways, protocols and algorithms,
to assist them with the decision making process,
applied leadership

and that concept mapping could also be used to
develop their reflective skills, thereby enhancing their
decision making skills (Ferrario 2004b)
Concept mapping can therefore promote the higher
level thinking and decision making skills that tend to
be lacking in newly registered nurses because of their
linear pattern of thinking.
Concept mapped care plans
Although traditional care plans are effective tools for
helping students learn, they have been criticised for
resulting in linear thinking (Mueller et al 2001)
Consequently, several authors recommend replac­
ing traditional care plans with concept mapped care
plans to help students learn how patients’ various
problems are connected to one another (Koehler 2001,
Mueller et al 2001, Schuster 2000). Or, if enquiry learn­
ing techniques are used, nursing students and newly
registered nurses can be asked to present their resolut­
ions or action plans in the form of concept maps. An
example of this, with case study, is given in Fig. 1.
King and Shell (2002) explain how encouraging
students to create concept maps in this way requires
them to act on previously learned knowledge and con­
nect it with new knowledge.
These authors further propose that, in clinical situat­
ions, concept maps should replace traditional care
plans, primarily to synthesise data such as diagnoses,
signs and symptoms, health needs, nursing intervent­
ions and assessments.
Daley et al (1999) find that the use of concept maps
can lead to significant improvements in the ability of
students to concept­ualise and think critically, while
Schuster (2000) describes how nursing students’ criti­
cal thinking skills can be enhanced by replacing trad­
itional care plans with concept maps to help them
comprehend the relationships between clinical data,
and to obtain total patient pictures.
However, Wheeler and Collins (2003), in compar­
ing the use of concept maps with traditional nursing
care plans to develop critical thinking, found that there
was no difference in overall CCTST scores.
Concept mapping is an effective method however
of helping students develop critical thinking skills in
clinical settings (Wheeler and Collins 2003) and men­
tors supporting students are in ideal positions to help
them begin the critical thinking process.
Conclusion
Because concept mapping may be incongruent with
individuals’ personal beliefs and values, it can be
incompatible with linear thinking.
Nevertheless, effective decision making requires
a complex series of cognitive processes and it is imper­
ative that nurses have these skills. Three steps can be
taken to ensure that they do.
First, to encourage critical thinking in education,
the amount of classroom time spent, on the one hand,
on fact finding and, on the other, on analysing clinical
situations critically, can be reassessed.
Second, to encourage critical thinking and enhance
clinical judgement skills in practice meanwhile,
preceptors can ask students questions rather than sim­
ply give them answers, or do the usual ‘show and tell’
(Del Bueno 2006)
Third, nurse managers can ensure that mentors and
assessors in their departments are prepared to engage
in the concept mapping process nm

References
All AC, Huycke LI, Fisher MJ (2003) Instructional
tools for nursing education: concept maps.
Nursing Education Perspectives. 24, 6, 311‑317.
Ausubel DP (1968) Education Psychology: A cognitive
view. Holt Reinhart Winston, New York NY.
Beitz JMP (1998) Concept mapping: navigating
the learning process. Nurse Educator. 23, 5, 35‑41.
Biley FC, Smith KL (1998) Exploring the potential
of problem based learning in nurse education.
Nurse Education Today. 18, 353‑361.
Black P, Green N, Chapin BA, Owens C (2000)
Concept mapping: an alternative teaching
strategy. Pelical News. 56, 4.
Clayton LM (2006) Concept mapping:
an effective, active teaching‑learning method.
Nursing Education Perspectives. 27, 4, 197‑203.
Daley BJ (1996) Concept maps: linking
nursing theory to achieve practice. Journal
of  Continuing Nursing Education. 27, 1, 17‑27.
Daley BJ, Shaw CR, Balistrieri T, Glasenapp K
(1999) Concept maps: a strategy to teach and
evaluate critical thinking. Journal of Nursing
Education. 38, 1, 42‑47.
Del Bueno DJ (2006) A crisis in critical thinking.
Nursing Education Perspectives. 26, 5, 278‑282.
Ferrario CG (2004a) Developing clinical
reasoning strategies: cognitive shortcuts.
Journal for Nurses in Staff Development.
20, 5, 229‑235.
Ferrario CGD (2004b) Developing nurses’ critical
thinking skills with concept mapping. Journal for
Nurses in Staff Development. 20, 6, 261‑267.
Girot EA (2000) Graduate nurses: critical
thinkers or better decisions makers. Journal of
American Nursing. 31, 2, 188‑297.
Hill CM (2006) Integrating clinical experiences
into the concept mapping process. Nurse
Educator. 31, 1, 36‑39.
Ignatavicius DD (2001) Six critical thinking
skills for at-the-bed-side success. Dimensions
of Critical Care Nursing. 20, 2, 30‑33.
Irvine LMC (1995) Can concept mapping be
used to promote meaningful learning in nurse
education? Journal of Advanced Nursing.
21, 6, 1175‑1179.
Kathol DMl, Geiger ML, Hartig JL (1998) Clinical
correlation map: a tool for linking theory and
practice. Nurse Educator. 23, 4, 31‑34.

30 nursing management Vol 14 No 9 February 2008

 applied leadership

Fig. 1. Case study and concept map

Case study
A group of pre‑registration, second‑year nursing students studying at Level 5, or diploma level, were asked to present feedback on, and action plans
for, a patient journey as a concept map.
The patient was a 35-year-old woman, recently diagnosed with type 2 diabetes. She was worried and anxious about her health and future treatment.
Traditionally, the students would have been asked to produce a nursing care plan for the patient, but such plans often lead to linear thinking. Instead,
they were asked to produce individual concept maps for their feedback, which they would then share with the group. The concept maps produced
would determine the students’ ability to think critically. An example of a concept map for this patient can be seen below.
During the feedback, students had to explain the relationship between each of the concepts identified in the boxes. By recalling and applying their
knowledge of physiology, for example, they demonstrated how to maintain the normal blood glucose level.

Concept map

Patient’s concerns: anxiety and worry about her health and future treatment

Nursing diagnosis: obesity due to raised body mass index, raised blood glucose level, anxiety

Clinical diagnosis: Type 2 diabetes

Observe. reflect. analyse and synthesise

Knowledge derived from: education, clinical research and experience, Interventions: blood sugar monitoring and insulin administration,
life experience, and structured care approaches as well as patient exercise, education, dietary advice and reassurance

Patient outcomes: coming to terms with illness, being aware of risk factors and modifying lifestyle while maintaining quality of life

Nursing outcomes: being able to monitor blood sugar levels and administer insulin safely, and fulfilling expectations of role

Adapted from Ferrario (2004a)

King M, Shell R (2002) Teaching and evaluating
critical thinking with concept maps. Nurse
Educator. 27, 5, 214‑216.
Koehler CJ (2001) Nursing process mapping
replaces nursing care plans. In Lowenstein AJ,
Bradshaw MJ (eds) Fuszard’s Innovative
Teaching Strategies in Nursing. Gaithersburg,
Aspen MD.
Luckowski A (2003) Concept mapping as a
critical thinking tool for nurse educators.
Journal for Nurses in Staff Development.
19, 5, 225‑230.
Mueller A, Johnston M, Bligh D (2001) Mind
mapped care plans: a remarkable alternative to
traditional nursing care plans. Nurse Educator.
26, 2, 75‑80.
Rafferty CD, Fleschner LK (1993) Concept
mapping: a viable alternative to objective and
essay exams. Reading and Research Instruction.
32, 3, 25-34.
Schuster MP (2000) Concept mapping: reducing
clinical care plan paperwork and increasing
learning. Nurse Educator. 25, 2, 76‑81.
Seldomridge LA, Walsh CM (2006) Measuring
critical thinking in graduate education.
Nurse Educator. 31, 3, 132‑137.
Shell R (2001) Perceived barriers to teaching for
critical thinking skill by BSN Nursing Faculty.
Nursing and Health Care Perspectives. 22, 6, 286‑289.
Taylor BJ (2006) Reflective Practice: A guide for
nurses and midwives. Open University Press,
Maidenhead.
Trochim W, Kane M (2005) Concept mapping:
an introduction to structured conceptualization
in health care. International Journal for Quality
in Health Care. 17, 3, 187‑191.
Turner P (2006) Critical thinking in nursing
education and practice as defined in the literature.
Nursing Education Perspectives. 26, 5, 272‑277.
Walsh CM, Seldomridge LA (2006) Measuring
critical thinking: one step forward, one step
back. Nurse Educator. 31, 4, 159‑162.
Wheeler LA, Collins SK (2003) The influence
of concept mapping on critical thinking in
baccalaureate nursing students. Journal of
Professional Nursing. 19, 6, 339‑346.
Wilkinson JM (1996) Nursing Process: A critical
thinking approach. Addison‑Wesley, Menlo Park CA.

nursing management Vol 14 No 9 February 2008 31


Making good decisions: part 1
In the first of two articles on decision making, The Open University examines how the choices made
by healthcare professionals can be influenced by factors of which they are unaware
This article uses course material from
The Open University, Milton Keynes
Keywords
❥ Decision making
❥ Decision making processes
❥ Management
32 nursing management Vol 14 No 9 February 2008
c o n t i n u i n g p r o f e s s i o nal d e v e l o p m e n t
It is inevitable that managers in the health
and social care sectors have to make decis­
ions; doing so is, after all, part of their jobs.
But they may not always consider what
factors influence their decisions.
Understanding the psychology of deci­
sion making and the social context in which
it is undertaken can help managers make
more informed choices, and can improve
the decision making process in health and
social care organisations.
The decisions people make are usually
based on judgements of the informat­ion
with which they are presented. The activity
described in Box 1, for example, can demon­
strate how judgement is exercised.
Box 1. Exercising judgement activity
1. Which of the following causes more
deaths in Western Europe each year?
n Stomach cancer
n Motor vehicle accidents
2. A rare disease has swept through a
town, affecting 600 inhabitants. Experts
have suggested two possible programmes
for tackling the disease, two versions
of which are described below. In each
version, which programme do you think
a clinician presented with this information
would choose?
Version 1
n Programme A will save 200 lives out of
600
n Programme B has a one third probability
of saving 600 lives and a two thirds
probability of saving no one.
Version 2
n Programme A will result in 400 deaths
n Programme B has a one third probability
of no one dying and a two thirds
probability of 600 deaths.
Adapted from Bazerman (1998)
Unconscious decision making
In answering the first question in Box 1,
most people would probably assume that
motor vehicle accidents cause more deaths
than stomach cancer, yet the reverse is
actually true and by a ratio of more than
two to one.
Some people may make this assumption
because they are influenced by the media,
which are more likely to publicise vivid
accounts of motor accidents, which in turn
tends to exaggerate their incidence.
Similarly, in organisational life some peo­
ple tend to give undue weight to informa­
tion that is easily available, more visible or
more emotive.
In the second question in Box 1, Vers­ions 1
and 2 both say the same thing but in dif­
ferent ways. That is, Version 1 is framed in
terms of lives saved and Version 2 in terms
of lives lost.
This is a good illustration of how the way
problems are framed affects decision mak­
ing, even for clinical experts.
People tend to prefer risk aversion for
problems framed in terms of gains, but
take risks to avoid loss where problems are
framed in terms of costs.
Consequently, most people answering
Box 1 choose Programme A of Version 1,
but opt for Programme B of Version 2.
How we are influenced
To make better decisions, it is important to
understand all the factors that influence
how we make them. Tetlock (1991) ident­
ifies three competing metaphors for under­
standing human decision making:
n The rational perspective, in which people
are judged to be naïve economists
n The psychological perspective, in which
people are judged to be naïve psych­o­
logists
n The social perspective, in which people
are judged to be naïve politicians.
In the first metaphor, people are assumed
to make rational judgements in pursuit
of the best results. Decision makers are
understood to have ordered preferences
and engage in a rational decision making
process on the basis of these.
For example, someone who prefers A to B
and B to C can be assumed to prefer A to C.
In the second metaphor, people are
assumed to take a ‘heuristic’ approach
by making decisions depending on their
environ­ments.
Decision makers reduce the complexity of
decision making by taking ‘mental short­
cuts’ to help them make quick decisions
when pausing to analyse problems fully
seems unwise (Gigerenzer et al 1999).
For example, someone may associate
product quality with particular brands instead
of weighing up the options available.
In both of these metaphors however, the
focus is on individual behaviour rather than
social processes, which are the starting
points for the third approach.
In the third metaphor, people are assumed
to want to manage the social world they
inhabit.
Decision makers are understood to make
decisions according to their characters.
Their goal is to satisfy those people or
groups of people to whom they think they
are accountable, and the decisions they
make are influenced by the social pressures
they are under.
Social pressures
Broadly speaking, there are three kinds of
social pressure that affect how people make
decisions:
n Coercive
n Mimetic
n Normative.
nursing management Vol 14 No 9 February 2008 33
Coercive pressure is applied to those who
continuing
fail to act in socially acceptable ways. Law
enforcement agencies are the most obvi­ p r o f e s s i o nal
ous sources of this, but others include the development
expectations of other people. For example,
those seeking promotion experience coer­
cive pressure when they think they must
act in ways that are deemed ‘acceptable’
to their industries or professions.
Mimetic pressure drives people to imitate
what is done by others. One way to find
solutions to difficult problems is to copy
others, for example when managers fol­
low fashionable theories of manage­
ment. Such imitation can be successful,
but it often occurs with little regard for
the different challenges faced by different
organisations.
Normative pressure concerns what people
think they should do, and relate to the per­
sonal values and broader social values to
which they subscribe.
Organisations, particularly those involved
in health care, accounting and law, can
be susceptible to different and conflicting
social pressures. The material in this article is
In hospitals, for example, there may be drawn from The Open University’s
conflict between the normative pressure Business School course, B830,
exerted by provisional clinical groups such Making Decisions.
as nurses and doctors, and the coercive
Management courses offered by
pressure exerted by government bodies
The Open University’s Faculty of
(Lozeau et al 2002).
Health and Social Care include:
Organisations often ‘decouple’ their
F52, MSc in Advancing Healthcare
responses to these conflicting social pres­
Practice; K303, Managing Care;
sures. For example, hospitals under norma­
and K307, Managing Health and
tive pressure from important constituencies,
Social Care.
such as staff unions, may respond with an
appearance of concern but not with genu­ To discuss development opport-
ine engagement. unities for you and your staff,
Because shared social meanings both contact The Open University:
influence and constrain how we reason email do-business@open.ac.uk or
and decide, social pressures can affect telephone 01908 655767.
how decisions are made. For example, the
For more information on other
importance people place on socially shared
Open University courses, access
concepts such as fidelity, child care, house­
www.open.ac.uk/courses or call
work, separation and divorce can influence
01908 653231.
how they think about marriage.

Table 1. How fast the cars were judged
to be going
Phrase added Mean estimate
of speed (mph)
‘Smashed into’ 40.8
‘Collided into’ 39.3
‘Bumped into’ 38.1
‘Hit’ 34.0
‘Contacted’ 31.8
34 nursing management Vol 14 No 9 February 2008
Framing problems
The ways people overcome problems are
often influenced by how they are framed.
Clinical decisions, for example, can be
affected by whether their possible out­
comes are framed as likelihoods of death or
of saving patients.
In a study by Loftus and Palmer (1974),
groups of students were shown the same
film clip of a car accident and then asked:
‘How fast were the cars going when they …
each other?’ with the … being replaced by
a different phrase for each group: ‘smashed
into ’, ‘collided into’, ‘bumped into’, ‘hit’
and ‘contacted’. The results of this research
are summarised in Table 1.
Interestingly, those who were asked
‘How fast were the cars going when they
smashed into each other?’ were more likely
to think that they had seen broken glass in
the film clip than those who were asked
‘How fast were the cars going when they
hit each other?’. Yet there was no broken
glass shown in the clip.
How we judge information
The way people make decisions depends on
the information they have and how import­
ant they think it is.
From birth, people start to filter and prior­itise
information and, in their working lives, they
must filter information and discard options to
avoid ‘analysis paralysis’, which is an inability
to make any decision in the face of the com­
plexity and ambiguity of the real world.
But people are bombarded constantly with
information. Simply walking across a hospi­
tal ward floor floods them with more sensory
information than they can possibly process.
Filtering information bears a cost, how­
ever. People can become overconfident
about the choices they make and filter out
sources of uncertainty, and can be swayed
by how problems are framed.
People also tend to pay most attention
to information that is easily available or to
memories that are easily retrievable, usually
because they are emotionally vivid or have
personal relevance.
People also tend to pay selective attention
to information, often in self serving ways
by giving greater weight to details that
show them in a favourable light or support
already established points of view.
In health and social care settings, man­
agers are likely to share core ideas about
health care, cause-and-effect relat­ionships
and what constitutes reasonable conduct.
Moreover, because healthcare institutions
are frequently under a media spotlight, it is
common for decision makers in related
organisations to be concerned, not only
with economic outcomes, but also with
legitimacy. They ask themselves the follow­
ing questions: How will decisions be seen
by the public? Do they fit with how things
are done around here? What happens if the
media obtain this information?
Some of these concerns can be uncon­
scious. They can also operate at different
levels and refer for example to a nation, an
industry, a firm, a team or an individual.
It is important therefore that people,
part­icularly decision makers in large
organisat­ions such as the NHS, understand
the factors that influence their decisions.
By paying attention to these factors, they
not only enrich their understanding of how
decisions are taken, but can also be alerted
to how their judgements may be influenced
in the future nm/ou
References
Bazerman M (1998) Judgement in Managerial Decision
Making. John Wiley, New York NY.
Gigerenzer G, Todd PM, ABC Research Group
(1999) Simple Heuristics that Make Us Smart.
Oxford University Press, Oxford.
Loftus EF, Palmer JC (1974) Reconstruction of automobile
destruction: an example of the interaction between
language and memory. Journal of Learning and
Verbal Behaviour. 13, 585-589.
Lozeau D, Langley A, Denis JL (2002) The corruption
of managerial techniques by organisations.
Human Relations. 5, 5, 537-564.
Tetlock PE (1991) An alternative metaphor in the study
of judgement and choice: people as politicians.
Theory of Psychology. 1, 4, 451-475.

The aim of Nursing Management
is to inform and encourage
critical reflection among
nursing leaders by publishing
articles with clear implications
for practice and management.
Submitted articles can be in
the form of features, applied
management articles or opinion
pieces. Applied management
submissions and, where
appropriate, opinion pieces must
be referenced.
One of the best ways of
understanding how to write
articles is to read a selection
of those already published in
Nursing Management. They can
be literature reviews, original
pieces, descriptions of practice or
case studies. If in doubt, contact
nick.lipley@rcnpublishing.co.uk
Please note that your manuscript
must be sent to Nursing
Management only. Editors will not
consider articles that have been
submitted or published elsewhere.
Articles for the features and
opinion sections should be
up to 1,500 words long, and
applied management articles
should be between 2,000 and
4,000 words long.
Charts, diagrams, tables,
photographs and illustrations are
always welcome. Please ensure
that any illustrative material is
carefully numbered or labelled,
and captioned. Photographs will
be returned to you on request.
nursing management Vol 14 No 9 February 2008
Contributions should be sent
to either by post to The Editor,
Nursing Management, The Heights,
59-65 Lowlands Road, Harrow-
on-the-Hill, Middlesex HA1 3AE,
or by email to helen.hyland@
rcnpublishing.co.uk
Please check that you include
the following information
concerning all authors:
 Full name
 Qualifications
 Job title
 Place of work and full address
 Work telephone number
 Work fax number
 Email address
 Home address and telephone
number
 Word count.
Preparing your text
Send your article either by post or
as an email attachment, not both.
The best way of sending text by
post is on a 3.5-inch disk plus two
printed copies of the manuscript
so we can check the accuracy of
the computer translation.
Please indicate which word
processing package you have
used. There can be problems
with translating some computer
commands, so please try to
keep these to a minimum.
For example:
 Use only one space after full
stops
 If you want more than one
space, use the tab key
how to contribute
 Use only one return to denote
the end of a paragraph
 Do not use bold or underline
 Do not start a new page for
each section
 Always use lower case if
you can.
Articles should be printed on
A4 paper, with clear, plain, dark,
serif print such as Times New
Roman, and with double line
spacing. Leave 1.5-inch margins
for reviewer comments and
ensure the pages are numbered.
Two copies should be sent to
Nursing Management and one
kept for your records. If you
have any queries about the disk
format, contact Helen Hyland
on 020 8872 3138.
What happens now?
All manuscripts are
acknowledged on receipt. Most
are subject to review by subject
experts, and reviewer comments
are usually summarised and sent
to the lead author.
Reviewers often recommend
acceptance subject to amend-
ments that the authors are asked
to make.
Authors of accepted
manuscripts are asked to
complete a standard author’s
form and sign a publisher’s
agreement for the purposes
of copyright.
Articles will not be published
without a signed publisher’s
agreement from each author.
Rejected manuscripts are
returned.
Manuscripts are then prepared
for publication, which can involve
editing and shortening them.
Shortly before publication, the lead
author receives a copy of the article
as it is intended to appear in the
journal. Only minor amendments
are accepted at this stage.
referencing
In the text
Please ensure you use the
Harvard (name and year) system
for references in the text. For
example, ‘It has been argued
that nurses should examine their
own relationship with patients’
(Brown 2004).
For three or more authors, print
the first author’s name followed
by et al, for example, ‘As White et
al (2004) argue…’ When several
references are cited simultaneously
the order should be alphabetical. If
there are two or more references to
the same author, the order should
be chronological.
In the reference list
Journal references should
include:
 Surname(s) and initial(s) of all
authors for references with six
or less authors. For seven or
more authors, include the first
three and add et al
 Year of publication in brackets
 Title of article
 Name of journal in title case
and in italic
 Volume, issue number and
first and last page numbers.
Example
Hill D, Hadfield J (2005) The role
of modern matrons: infection
control. Nursing Standard. 19, 23,
42-44.
Book references should include:
 Author’s surname and initial(s).
Please indicate if those cited are
authors or editors
 Year of publication in brackets
 If book is collection of essays,
chapter title in sentence case
 Title of book in title case and
in italic
 Edition if appropriate
 Website address if appropriate
 Name of publisher
 City of publication, and
initials of US state if
appropriate.
Example
Dougherty L, Lister S (eds)
(2004) The Royal Marsden
Hospital Manual of Clinical
Nursing Procedures. Sixth edition.
Blackwell Publishing, Oxford.
35
scan
Conferences
Fostering a Culture
of Effectiveness through
Practice Development
March 3-7
Comfort Hotel, Antrim
Further details: conference manager
Hilary Withers or conference
administrator Anna-Marie Boyd.
Tel: 02890 384600.
Email: hilary.withers@rcn.org.uk or
anna-marie.boyd@rcn.org.uk
A Practical Guide to
Developing your skills as
an EffectiveWard Manager
March 6
London
Further details: Healthcare Events.
Tel: 020 8541 1399.
Email: jayne@healthcare-events.co.uk
Website: www.healthcare-events.co.uk
Integrated Care and the
Management of Chronic Illness
March 6-7
Goteburg, Sweden
Further details: Jennifer Smith.
Email: inic@igitur.uu.nl
Website: www.integratedcarenetwork.
org/Sweden2008/conf2008.php?opt=0
Improving Practice…
Improving Care
March 8
RCN Headquarters, London
Further details: conference and
events organiser Guillia Ward.
Tel: 020 7647 3591.
Email: independent@rcn.org.uk
Website: www.rcn.org.uk/events
36
Healthcare Associated
Infection 2008
March 11
London
Further details: Healthcare Events.
Tel: 020 8541 1399.
Email nickiT@healthcare-events.co.uk
Website: www.healthcare-events.co.uk
Transfer of Care: Supported,
affordable, flexible, effective
March12
RCN Headquarters, London
Further details: RCN conference
and events organiser Holly Peppiatt.
Tel: 020 7647 3580.
Email: liaison@rcn.org.uk
Website: www.rcn.org.uk/
newsevents/events
A Practical Guide to
Developing and Running
Effective Nurse Led
Pre-Assessment
March 12
Manchester Conference Centre.
Further details: Healthcare Events.
Tel: 020 8541 1399.
Email: hannah@healthcare-events.
co.uk
Website: www.healthcare-events.
co.uk
Action Learning: Practices,
problems and prospects
March 17-19
Henley-on-Thames, Oxfordshire
Further details: Helen James.
Tel: 01491 571454 x2113.
Email: helen.james@henleymc.ac.uk
Towards ProfessionalWisdom:
An international conference
on practical deliberation in
the people professions
March 26-28
Edinburgh
Further details: The University
of Edinburgh.
Email: professionalwisdom@ed.
ac.uk
Website: www.lifelong.ed.ac.uk/
towardsprofessionalwisdom
Care Culture and Climate:
Cracking the code
March 26-28
Sydney
A biennial conference of the
Society for the Study of Organising
for Healthcare (SHOC).
Further details: SHOC.
Tel: 0061 409 418530.
Email: j.edgecumbe@bigpond.com
Website: www.obhc2008.org
The Future Now: Challenges
and opportunities in health
March 26-29
Perth, Australia
Further details: World Health
Congress Secretariat.
Email: admin@
worldhealthcongress.org
Website: www.
worldhealthcongress.org
Quality of Primary Health
Care: The perspective
of patients
March 28-29
Ljubljana
Email: barbara.toplek@mf.uni-lj.si
Website: www.ljubljanapatient2008.
si/welcome.html
Unity through the
Commonwealth: Present
challenges in nursing
March 28-29
Malta
Further details: RCN.
Tel: 020 7647 3593.
Email: cnf@rcn.org.uk
Website: mysite.wanadoo-members.
co.uk/cnf/EuroConference.htm
nursing management Vol 14 No 9 February 2008
The Care Show
April 1-2
Bournemouth International Centre
Further details: Sally Veness.
Tel: 020 7955 3732.
Email: sveness@cmpi.biz
Website: www.careshow.co.uk
Celebrating Success in
TissueViability : 50 years of
multi-professional progress
April 2-3
Peterborough
Further details: Michael Clark
at The Tissue Viability Society.
Email: tissue.viability@btinternet.com
Thirtieth Annual International
Association for Human
Caring Conference
April 6-9
North Carolina
Further details: The International
Association for Human Caring.
Email: iahc2008@unc.edu
Website: www.humancaring.org
RCN Annual International
Nursing Research Conference
April 8-11
Liverpool
Further details: assistant
conference and events manager
Kathryn Clark.
Tel: 020 7647 3585.
Email: research@rcn.org.uk
Website: www.rcn.org.uk/research2008/
Essence of Care Seminars
for Health Care Assistants
April 8 and 23
RCN Northern Ireland, Belfast
Further details: Anna-Marie Boyd.
Tel: 02890 384600.
Email: anna-marie.boyd@rcn.org.uk
A Practical Guide to Reducing
Avoidable Deaths in Hospital
April 9
London
Further details: Healthcare Events.
Tel: 020 8541 1399.
Email: hannah@healthcare-events.co.uk
Website: www.healthcare-events.co.uk

Webscan
Service line management
A new guide, offering practical
advice on service line management
(SLM), has been published by
Monitor, the independent regulator
of NHS foundation trusts,
writes Ruth Williams.
Service lines are the NHS
equivalent of a commercial
company’s business units. In other
words, they are the ‘key’ units, with
their own financial and staffing
resources, that deliver trust
services to patients.
The guide, aimed at managers
and clinicians who are starting
to introduce SLM to their
organisations, gives practical
examples of how the concept has
been implemented in the NHS
Have your say
Ruth Williams looks at the latest healthcare proposals
out for consultation
Mental health
The Care Services Improvement
Partnership (CSIP) has published
Finding a Shared Vision of How
People’s Mental Health Problems
Should Be Understood, its draft
guidance on mental health care.
The aim of the guidance is
to enable everyone concerned
with developing and delivering
services, including users,
to understand mental health from
a shared viewpoint based on those
of different stakeholders.
nursing management Vol 14 No 9 February 2008
already and adapted to suit
different trusts.
Four key areas for development
are examined: organisation,
the role of service leaders in
service lines, what skills they
need, and how service lines
are organised and governed;
strategic and annual planning
processes, understanding the
market and an organisation’s
competitive position; performance
management, the rewards and
consequences for performance;
and information support, access
to relevant information and moving
towards patient level costing.
The Guide to Implementing
Service-Line Management is
available at www.monitor-nhsft.
gov.uk/publications.php?id=1054
The consultation itself is also
expected to raise awareness of
the wide variety of ways to assess
mental health, and to build mutual
understanding among those who
use these different approaches.
Ultimately, the guidance
should enable the development
of multi-disciplinary and
multi-agency teamwork, and the
greater engagement of service
users and carers.
Consultation closes on
March 5, and CSIP is asking
Readmission risk
An advanced computer
programme that enables primary
care trusts to identify patients
most at risk of readmission is
available to download from the
King’s Fund website.
Known as PARR++, which
stands for Patients At Risk of
Readmission, the tool is an
updated version of a programme
that has been in use since 2006.
When patients are admitted to
hospital, the tool uses their recent
admissions data to calculate the
likelihood of readmission over the
next 12 months, taking into account
diagnoses, sociodemographic
information and other factors.
The tool and an information
booklet on how to use it can be
downloaded free of charge, and
demonstrations can be watched
and a copy of PARR++ on CD
ordered, from www.kingsfund.org.
uk/current_projects/predictive_
risk/patients_at_risk.html
Long term conditions
A web based resource for
professionals with an interest in
self care and the management
of long term conditions has been
launched by the NHS Working in
Partnership Programme (WiPP).
for responses to specific
questions as well as general
comments. The consultation
document and response form
can be accessed at www.
dh.gov.uk/en/Consultations/
Liveconsultations/DH_080913
Learning disabilities
Valuing People Now is the
Department of Health’s proposed
three-year plan of priorities for the
learning disability agenda, based
on the Valuing People white paper,
published in 2001.
Priorities include moving away
from the provision of day centre
services, helping people into paid
work, introducing a new service
framework to support primary
scan
The site, at www.
selfcareconnect.nhs.uk, claims
to be the world’s first interactive,
online, self care resource and
networking organisation.
It provides news and information
on key developments and policy
drivers, as well as resources such
as skills training and assistive
technology tools. It is also an area
where views and experiences can
be exchanged.
Designing premises
Because managers have become
increasingly involved in the process
of planning and designing new
healthcare premises, two new
guides have been made available
to help NHS and local planning
authority staff work together.
One of the guides, which is
written for NHS staff, explains
town planning in England, while
the other, which is aimed at local
planning authorities, explains
the NHS.
A Guide to Town Planning for NHS
Staff can be downloaded from
195.92.246.148/knowledge_network/
documents/NHS_staff_guide_
20071004113744.pdf, and A Guide
to the NHS for Local Planning
Authorities from 195.92.246.148/
knowledge_network/documents/
LPA_guide_20071004115658.pdf
care trusts in commissioning
comprehensive health checks
and improving access to care,
and enabling people with learning
disabilities to own their own homes.
The document sets out a number
of specific actions to help ensure
that policy is delivered, and these
include transferring funding for
learning disability social care
services from the NHS to local
government, and introducing
new performance indicators on
employment and health.
Valuing People Now can be
accessed at www.dh.gov.
uk/en/Consultations/
Liveconsultations/DH_081014
and responses to it must be made
before the consultation closing
date, March 28.
37
 NEW
Nursing Standard FOR
2008

Introducing a
new Award for 2008
Nursing Standard is inviting the general public to
nominate a nurse* who they feel has gone above
and beyond the call of duty in caring for either
themselves or someone they know.

To help us create awareness about this unique

Award, why not display posters and entry forms
at your place of work?

The winner of this Award will receive:

● £1,000 prize money
● Recognition at the prestigious
Nursing Standard Nurse Awards ceremony

To request your Nursing Standard Patient’s

Choice Award pack, call 020 8872 3140
or visit www.patients-choice.co.uk
* Includes health visitors and midwives registered to practise in the UK as well as healthcare assistants

Closing date: February 15

Nursing Standard
Patient’s Choice Award
Supported by
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