15. Who best to be boss? (resolution)

London Region Board

That this meeting of RCN Congress believes that directors of nursing rather than general managers should be responsible for line managing nurses.

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Progress report

Council Committee: NPPC
Committee decision: Integrate project into current workstream
Council member/other member/stakeholder involvement: Anne Wells
Staff contact: denise.kelly@rcn.org.uk

The RCN Nurses in Management and Leadership Forum will embrace the work of the Congress item. They will be working to establish the risks and benefits of being accountable for workforce management and resources and how this could compromise the impartiality of the nurse director when assessing quality and patient safety issues.

Nurse directors accept managerial and professional accountability for the quality of nursing care, championing care from the point of care to the board room. Nurse directors also have lead responsibility for many, if not all, aspects of the clinical governance agenda and as such nurse directors have the ability to bring to the board an unparalleled understanding of the standards of clinical care that are being delivered, leading the development of clinical assurance systems and processes. Nurse directors have the potential to examine all board decisions and describe to the board the impact of those decisions on patient experience, patient safety and clinical quality. They also have the insight to embed clinical quality at all levels of the organisation.

In high functioning boards, nurse directors are able to champion the patient/user experience and to help the board to integrate financial and commercial acumen with the human experience that patients and users experience on a day to day basis. The RCN Inspire program has led a series of events throughout the UK during 2010 to explore the expanding remit of directors of nursing and how the RCN can support them in maximising their effectiveness at board level and increasing their visibility with staff.

Debate report

Ian Norris, London Region Board, opened the resolution stating that nurses are best placed to be managers of nurses. He called for a way to ensure that nursing staff are integral to decision making processes as they are best placed to make decisions regarding service reconfiguration and clinical staff management.

Ian went on to add that, although acute trusts have nurses at board level this is not the case in other areas. They don’t hold the authority everywhere and there needs to be clear lines of accountability. All speakers strongly supported the resolution

Wendy Fairhurst-Winsternley, Advanced Practitioner Forum, felt that in her PCT nurses had been actively excluded from decision making processes and that the RCN should be lobbying for mandatory nursing presence on regional boards.

Jane Bovey, South West Region, stated that if she was a Director of Nursing she would like nurse directors to be visible on wards, easily identifiable and be seen with both patients and staff. Staff need to know that they are working alongside them.

Bethann Siviter, South Birmingham Branch, wanted to differentiate between line management and professional management. Adding that nursing directors are not necessarily best placed to line manage and that there are other members of the nursing team who are better placed to do this. Ian responded in agreement that directors of nursing are not there for everyday management but to do a strategic support role.

Congress agreed overwhelmingly with this resolution with 97.58% of the vote.

FOR 444 – 97.58%
AGAINST 11 – 2.42%
ABSTAIN 8

Background

Historically directors of nursing were viewed as both leaders and managers, with responsibility for nursing staff management and the delivery of nursing care. The introduction of general management in the NHS in the 1980s, however, resulted in directors of nursing becoming primarily responsible for professional development, education and clinical governance.

While this move could be seen as liberating for directors of nursing – enabling them to focus on professional issues – many felt that directors of nursing were being disempowered. Indeed, front line nurses believed that directors of nursing, with their clinical knowledge and expertise, were better placed to make decisions regarding service reconfiguration and clinical staff management.

Today there is a statutory requirement for a director of nursing to be on the board of a foundation trust, and it now accepted best practice for NHS trusts to have an executive nurse as a board member. In Wales the RCN successfully argued for the inclusion of a Nurse Director on the Board of the NHS Local Health Boards (which replaced NHS trusts in 2009). Where nurse executives are members of the board they can influence decision making in relation to staffing levels and service change; where no executive nurse is present, it can lead to inappropriate decision making regarding nursing resources.

The King’s Fund report Ward to board (2009) identified the impact nurse executive roles can have on the quality of patient care and the distribution of nursing resources, and recommends that nurse executives need to become more financially and commercially astute in order to thrive in today’s increasingly business-oriented boardroom. Such skills should enable nurse executives to contribute to the whole business of the board and increase their overall impact in the boardroom.

While it is important for nurse executives to develop their business-oriented skills, some say they also need to retain their focus on the caring and the patient experience and therefore the effectiveness and credibility of the nurse executive is heavily dependent on their ability to demonstrate a range of capabilities, and in particular their clinical expertise.

Although nurse executives may not have the line management of nursing staff, returning to uniform and working with patients and front line nurses staff on a weekly basis could provide an opportunity to identify problems quickly and bring serious concerns to the attention of the board.

The RCN supports the need for nurse executives, as part of their continuing professional development, to undertake regular clinical duties and responsibilities and has proactively engaged with chief executives and strategic health authority chief nurses in relation to support and development for the role. In Northern Ireland the RCN is working to clarify the role of the director of nursing and to provide appropriate support and development for the role.

References and further reading
King’s Fund (2009) From ward to board: identifying good practice in the business of caring, London: King’s Fund.  www.kingsfund.org.uk/research/publications/from_ward_to_board.html