For the purpose of this assignment, the project I will be exploring is the implementation of the organisations five year nursing strategy - a collaboration between children's and adult's community nursing services.
The people challenge question addressed in this assignment is:
How can I as (co) lead on the nursing strategy project team; develop a work plan to implement the nursing strategy, by establishing work groups led by senior nurses to deliver the agreed actions with front line staff, leading on each of the identified key theme?
The assignment will also outline the background of the nursing strategy and the launch event, which took place. This led to is to the development of the work plan.
During the assignment I will explore the organisational cultures and the effect this has on my people challenge - which is to implement the strategy and the work plan. I will also consider the methodology for empowering and influencing the project's key stakeholders, and illustrate how working with my people challenge assignment has enabled me to meet my own continuing development needs including completing a 360-degree evaluation (NHS Institute of Innovation and Improvement 2009) (Appendix ****) and Inspirational Leadership: Insight to Action (DTI 2005) tools (Appendix ****).
As Project Manager for Anywhere Community Health Service (ACHS) - my core responsibilities are to lead on a variety of projects within the organisation. ACHS welcomes fresh thinking working with and managing talent from outside the National Health Service (NHS). This can be evidenced by my appointment as I have a non-NHS, non-clinical background, but can bring my project management skills to the organisation.
Anywhere Community Health Services was formed in January 2008 as an Arms Length Body. Arms Length Bodies (ALBs) are stand alone organisations sponsored by the Department of Health that work closely with the local NHS, Social Care Services and other ALBs to regulate the system, improve standards, protect public welfare & support local services (Department of Health 2009). ACHS is a service provider of NHS Anywhere City and Primary Care Trust. The organisation is a major provider of health services for children and young people, working age adults and older people. The services include community nursing, intermediate care, health visiting and school nursing - delivering services from more than 30 localities in the City. ACHS employ approximately 1600 staff in a wide range of roles. The organisation also provides a range of specialist children's healthcare services to people who live in the county. It also manages five GP Practices in the city, and an Urgent Care Centre walk in services adjacent to the City's emergency departments.
Background to the development and launch of the nursing strategy
The history of the work plan, and why it was developed
There are five national drivers behind the development and implementation of the nursing strategy and its plan:
Transforming Community Services: Enabling new patterns of provision (Department of Health 2009) sets the blueprint for shaping community services together with High Quality for All (Department of Health 2008) and the NHS Constitution (Department of Health 2009) there are real pledges to patient involvement and quality experiences. In addition for Children's Services - The Children's Plan (Department of Health 2008) which aims to make this the best place in the world for children to grow up. The bringing together of regulation of health and social care, through the creation of the Care Quality Commission (CQC), gives a clear message in terms of a move towards integrated partnerships between social and health care.
Locally, our services must be responsive to local population needs, as outlined in the Joint Strategic Needs Assessments (JSNAs) and the Local Area Agreements (LAAs). In the new world of commissioner and provider split, we also need to respond to commissioner intentions to be the provider of choice. Therefore, developing a nursing strategy expresses our response to the above drivers for service change to create a workforce fit for the future challenges. The organising principle is that every person matters - every nurse, every patient, every carer, and every family.
It is almost five years since the last strategy was developed following the launch of Liberating the Public Talents of Community Practitioners and Health Visitors (Department of Health 2003). Since then two workforces from different sides of the city have come together to work as one team. The changing relationship between the commissioning and provider function creates potentially not only independence but also many opportunities (and more change).
In developing nursing strategy there has been a focus on the principle of every single nurse - from band 2 care assistants up to registered nurses - all views and opinions mattered. Together with the focus on every single person counts the strategy contains four key enablers for its future success: the best leadership, quality, productivity and communication. From the four enablers seven themes were then identified which feature as the leading areas for further action and development. They included patient involvement, patient safety, clinical pathways, staff wellbeing, innovation, managing the talent and the environment.
The next five years will see an unprecedented change in healthcare delivery, moving from professional groupings to partnerships, reactive treatment to a prevention model. The future is about local ownership and leadership, of improvement in services with quality and positive patient experience as the organising principles.
The launch of the strategy
Myself and the rest of the nursing strategy project team acknowledged early on and made a commitment that writing the document was just the beginning, and on 29th June 2009 officially launched the strategy across the nursing teams. A major part of the launch event was the World Café process (New Paradigm 2009), which provided the opportunity for all attendees to discuss, debate and contribute ideas and suggestions relating to each of the seven themes.
The nursing strategy project team decided early on that the strategy needed to be a celebration for community nursing in the city, to put the organisation on the map and to let all our stakeholders know out commitment to providing the very best services and to being the very best service provider.
To maximise the opportunity for all staff the day was split into two sessions. The sessions included a high profile motivation speakers and pampering sessions provided by a national store. A dedicated website and email address was also launched for the nurses to capture and share their views, thoughts and what matters to nurses now and over the next five years.
Leadership - The People's Challenge
The next stage of the process as stated previously in my "people challenge":
How can I as (co) lead develop a work plan, by establishing work groups led by senior nurses to deliver the agreed actions with front line staff, leading on each of the identified key theme;
Started by looking a the development of the work plan, where we recognised that the work streams over lapped with some current projects across the organisation, and therefore keen not to duplicate work. It is anticipated that senior organisational leads will integrate the work from the strategy into current action/work plans.
My challenge as a leader was how to work with the people identified to establish work groups led by senior nurses to deliver the agreed actions with front line staff.
The people involved in my challenge are 14 front line staff includes:
Training & Education Lead
Lead Practitioners etc
The project leads are myself (Project Manager), two Associate Directors and Communications Manager.
As Project Manager for the nursing strategy my key responsibilities have been co-author of the Nursing Strategy, Event Manager for the launch of the nursing strategy and co-lead in the development and implementation of the five-year work plan.
As a non-NHS professional, understanding organisational culture reflects on how the work plan is shaped.
Edgar H Schein's (2004) defines organisational culture as:
"The pattern of shared basic assumptions - invented, discovered, or developed by a given group as it learns to cope with its problems of external adaptation and internal integration - that has worked well enough to be considered valid and, therefore, to be taught to new member as the correct way to perceive, think and feel in relation to those problems"
Organisational Culture and Leadership - Page 17
Having critically analysed the above statement I believe, that the organisational culture should encourage change implementation and at the same time establish work quality as a value and vision.
In an article written by Brigit Skela Savic (2007), she describes different health care subcultures, (i.e., physicians/managers, physicians/nurses, employees/leaders, unit cultures, team cultures, and professional cultures), and the affect sub cultures have on an organisation, she writes:
"Subcultures are one of the major obstacles in achieving the common goals of an organization, because the broad differentiation of work leads to a differentiation of tasks and, consequently, to a differentiation of goals within the various departments"
Lynne Perry Wooten et al (2003) presents an interesting observation on professional culture in particular nurses. They suggest that for a health care organisation to implement a constructive change, leadership should recognise the role of the nurse who represents the focal point between quality patient service and organisational process improvements. So if we were to understand that nurses are the nucleus of a health care organization, it is important for leadership to develop systems that clearly convey to the nursing staff the group's culture values and how it operates. Once health care organizations understand and facilitate this process, nurses will feel empowered and seize the opportunity to transform the organization's resources into value and quality for all stakeholders. Therefore I believe that by increasing my understanding of a professional culture (i.e., nurses) in an organisational context is fundamental to the development of the work plan.
Having critically analysed the literature around organisational culture, including Edgar H Schein (2004), Brigita Skela Savic (2007), and Lynne Perry Wooten et all (2003) it appears that organizational culture is a fundamental factor when leading successful implementation of changes in health care organizations. For that reason I believe to make both the strategy and work plan a reality we will require work on the four essential organisational enablers:
Quality: Needs to be central to everything. Striving for the highest quality patient experiences and outcomes with services designed to be sage and reliable protecting the most vulnerable, particularly through Safeguarding.
Productivity: Demonstrating best value for money to commissioners and the public was also seen as vital. Quality and productivity are integrally linked, to focus on designing and streamlining out work processes, to deliver both simultaneously is essential.
Communication: Designing improved communication flows with truly top-down, and bottom-up commitments. To ensure staff at all levels are aware of strategic goals and objectives and their individual role in achieving these. Communicating better with our external partners based on honesty, openness and tailored to need was also identified as paramount.
Leadership: Recognise the principle that 'leadership is not a position it is a choice' (Steven Covey 2007) and the development of leadership skills within everyone.
These will determine the culture that will deliver a world-class service. The development of an appropriate culture will also support and encourage:
Innovation and a
Win-win approach to conflicts, failures and mistakes.
To support the development of an appropriate organisational culture, and help me to work with the people in my people challenge, I have also been part of developing a communications strategy to ensure open communication and the creation of communication channels: this included:
Using Open Space Methodology (Harrison Owen 2008) every nurse from the children and adults community teams was invited to have his or her say. The approach was to gain the views of all nurses, from band 2 and above, across Children and Adult Community Services.
Staff was encouraged to have strategy discussions as part of their daily activities, in operational meetings, team areas and collected views and thoughts; these were fed into the emerging themes and organizational frame of key enablers for success.
A range of communication approaches were used, including developing a succinct staff briefing paper, outlining the context to support face to face discussions; an area on the PCT intranet dedicated specifically to the strategy development; with an email address created for receiving ideas, comments and suggestions
I believe organisational culture is a powerful force inside healthcare organisations and fundamental in change. It is something deliberately cultivated and passed on to incoming employees. It is a pattern of beliefs, attitudes and behaviours, which influence how people work together. This applies to ACHS where a great deal of the selection process in its recruitment and is intended to ensure candidates applying for an appointment, fit in with and maintain the existing culture. There fore I believe a clear well thought out nursing strategy work plan and vision, provides guidance, inspires nurses and brings a sense of purpose to their work. The ongoing principle of the strategy is Every Nurse Matters. Anywhere Community Health Services strives to communicate to its workforce implicitly and openly recognises that its greatest asset it its workforce.
David Nicholson (2007) writes:
'We must recognise that change is difficult, and as we have seen over recent months, can provoke powerful reactions from stakeholders. One of the clear findings from Sir Ian's Carruthers (2006) work was that the NHS needs to be much better at engaging with stakeholders, including; the public and their representatives, patients and carers, clinicians and staff, MPs and a whole range of other stakeholders. The NHS needs to do more to ensure that stakeholders are actively engaged in developing proposals for change and also explaining the reasons behind any decisions that are made'.
NHS for Institute for Innovation and Improvement (2009) advices that Stakeholder Analysis is one of the first steps in any change project.Â
There fore as part of my leadership intervention I felt it was essential that a stakeholder map be undertaken for the implementation of the nursing strategy work plan. The benefits of using a stakeholder map are:
You can use the opinions of the most powerful stakeholders to shape projects at an early stage. Not only does this make it more likely that they will support you, their input can also improve the quality of your project.
Gaining support from powerful stakeholders can help win more resources - this makes it more likely that your projects will be successful.
By communicating with stakeholders early and often, you can ensure that they know what you are doing and fully understand the benefits of your project - this means they can support you actively when necessary.
You can anticipate what people's reaction to your project may be, and build into your plan the actions that will win people's support.
For the purpose of this assignment a stakeholder analysis (Appendix**) was undertaken to highlight the key individuals and groups that will need to be involved in the successful implementation of the nursing strategy work plan. The findings present the community nursing teams as having the loudest voices; this was no surprise to me, as they are after all pivotal to the implementation of the work plan. As a direct result from the key stakeholder map, key messages were identified and a stakeholder communications map produced (Appendix ***). The key messages identified from the stakeholder communications map are:
Communication: Co-ordinate the communication activity across projects to monitor the accuracy of the key messages, improve efficiency and avoid mixed messages being given to different stakeholders
Time: Plan enough time for effective stakeholder engagement - one size doesn't fit all. Employ a variety of techniques to understand the range of stakeholder views
Identifying issues: Allow nurses to given their own views and identify what the potential issues are for them. Collect and analyse the full range of views and group them into themes to get the big picture.
Listen: Be prepared to listen. Not to assume you know what people want and what their aspirations are, as they can be very different to what you perceive them to be.
As a project leader it is easy to get wrapped up in delivering a project in a timely way and forgot about the some of the stakeholders. In the forefront of my mind, I think about how important it is to deliver this work plan. But I must also consider my own stakeholders in this people's challenges. For the work plan to be a successful, I have learnt to be more empathetic to the nurse's needs, and listen to what is being asked and suggested.
Reflective log: On some occasions I found it challenging to understand some of the views and opinions of the nursing teams. This could be, I believe down to my lack of understanding how the NHS world works and thinks. However as I progress with both the assignment and nursing strategy work plan, I am starting to understand the mechanics of the NHS
I completely agree with Judith Dwyer et al (200*) when they say that the main difficulties in leading projects in the health service sector are managing the key stakeholders, influential people and groups who often have different and competing agendas. Often the person with the loudest voice or strongest personality can take a project in an entirely different direction.
We can also forget whom the NHS is for. Brown et al (1994) asks an obvious question - "Who is the NHS for" - and answers it with the most obvious answer - "The patients who use it." This simple answer maybe a fundamental purpose of the NHS, yet it appears that differing views of how this is to be achieved contributes to a misreading between stakeholders and their remit. Not only will the work plan need to take into consideration the national and local NHS changes. It will also need to navigate its way through historical attitudes and cultures. At the same time, it will have to ensure that financial, staff and clinical governance standards are met and, ultimately, raised. For these reasons it is a complex plan, which as part of the nursing strategy project team I will be required to lead in a manner that effectively engages with all key stakeholders, allows creativity, and radical proposals to emerge and be considered throughout its 5-year life span.
Motivation and Empowerment
The concept of the nursing strategy began in March 2009, when it was decided by the project team that all nursing teams (unregistered and registered) involvement was paramount to the development, implementation and delivery of the strategy. The project team felt that this would motivate the nursing teams to embrace the strategy. Every nurse involved in both the production of the strategy and the launch event would be acknowledged on the back of the nursing strategy publication. We endeavoured to have names of 500 (out of approximately 800 staff) of our community nursing teams listed on the publication. So for every workshop attended, comment or email received regarding the nursing strategy, the nurses would be acknowledged.
Motivational theories provide an insight into what determines and influences people. Having an understanding of current factors which effect motivation is another fundamental factor when empowering nurses to deliver the nursing strategy. With so many theories available to consider i.e., Maslows Hieracy of Needs (date), Herberg's Two Factor Theory (date) and David McCllelands - The Theorys of Needs (date), the most appropriate motivational theory for the nursing strategy would be Douglas McGregor (1960). Therefore, for the purpose of the nursing strategy Theory Y methodology was used. Using this methodology, the project team created open communication, and a comfortable environment in which the nurses can develop and use their abilities. This would include sharing decision-making and having a say in decisions that influence them. McGregor felt that organisations followed either one of the other approaches; Theory X or Theory Y. They describe two very different attitudes towards workforce motivation, however both are based on management assumptions:
Theory X attitude
Management assumes employees are lazy and will avoid work if they can and that they inherently dislike work. Therefore, management believes that workers need to be closely supervised and systems of controls developed and a hierarchical structure needed at each level.
Theory Y attitude
Management assumes employees may be ambitious, self-motivated and exercise self-control. They have the ability for creative problem solving, but their talents are under used in an organisation. Given the proper conditions, managers believe that employees will learn to seek out and accept responsibility and to exercise self-control and self-direction in accomplishing objectives to which they are committed. A Theory Y manager believes that, given the right conditions, most people will want to do well at work.
Having considered Douglas McGregor's Theory Y, it is important for the nursing strategy project team to understand where the power and motivation lies when delivering the nursing strategy. Creating open communication channels, and where necessary and appropriate, taking a step back. A shift in the balance of power had to occur to make the necessary changes, and the cultural shift is crucial to the success of the project. The nursing teams need to be involved in decisions that effect service delivery. Empowerment comes when staff owns the policies and are able to bring about real change and service improvement.
Understanding the basic principles of leadership is paramount to the delivery of a successful project. I found that one of the difficulties of looking at leadership for healthcare professionals is that most of the theories were developed in a business context and were then applied to healthcare organisations. Because of the focus on organisational leadership, it is sufficient here to distinguish two important aspects of leadership. The first is that of providing direction, organisational vision and making related decisions about resource allocation and distribution. The second aspect of leadership is the issue of control and exerting influence. Both aspects of leadership involve power and the ability to obtain, retain and move resources. Particular groups or individuals can use power to enforce decisions and ends that may be desired or undesired. Power can also be shared with the group so that the members can have equal participation in decision-making. Variations in power distribution in decision-making are foundational in the development of numerous concepts in leadership (Bass & Aviolio, 1994; Goldring & Pasternak 1994 and Halllinger & Heck 1996). However one of the most influential writers on leading is change is Kotter (1998, 1996). It is claimed that his book Leading Change is one of the top ten leadership publications of all times (Washington Post 2009). Kotter writes that large numbers of people are needed to make change happen rather than any one person, and their needs to be a culture of leadership within the organisation. I agree with Kotter's observation - as a project lead I couldn't successfully implement the strategy to nurses alone, no matter how passionate I was to the cause. The nursing strategy and work plan is about leading change by the nurses for the nurses. So, for the nursing strategy work plan, we focused on two leadership theories, Kotter's eight step formula and adapted this process for the development of the nursing strategy and work plan (Appendix *****). The process of the eight stages is associated with one of the eight fundamental errors that undermine transformation efforts:
Error 1: Allowing too much compliancy
Error 2: Failing to create a sufficiently powerful guiding coalition
Error 3: Underestimating the power of vision
Error 4: Under communicating the vision
Error 5: Permitting obstacles to block the new vision
Error 6: Failing to create short-term wins
Error 7: Declaring victory to soon
Error 8: Neglecting to anchor change firmly in the culture
The 'plan' (Appendix **) demonstrates how the nursing strategy plan was created counteracting the eight errors.