Guest Editorials

Clinical Governance viewed in the round

It is a great pleasure to be invited by Dr Melanie Jasper

to act as the Guest Editor of this edition of the Journal.

In keeping with the innovative spirit of its Editorial

Policy the current offering has a specific focus on

aspects of Clinical Governance and also includes some

additional challenging items.

Clinical Governance is about improved standards.

But it is also about controlling quality within complex

health service organizations. Our first Guest Editorial

captures the British experience and comes authoritat-

ively from the Modernisation Agency. Hugh Griffiths

from the Clinical Governance Support Team provides a

cogent overview of the strategic effort than is being

expended to set the concept on a sure footing.

A second Guest Editorial adds fuel to the debate

about Modern Matrons in the British NHS. Readers

will recall the scathing criticism of this idea that was

included in the March 2003 edition of the Journal in a

position paper by Roger Watson and David Thompson.

A rejoinder that is somewhat more sanguine about the

notion by David Barrett is carried.

Returning to our main theme, a paper is included

from Celia Burnhope and John Edmonstone that

provides an overview of the literature on Shared

Governance along with an evaluation of a working

example of it. Jaquelina Hewitt-Taylor then provides a

thought provoking piece on Clinical Guidelines and

raises key arguments concerning the interface between

personal clinical discretion and the rigid standardiza-

tion of procedures that are in potential conflict. Next

comes a contribution from Angela Hope who argues

that staff education is fundamental to the success of

any system of Clinical Governance in which she

envisages a crucial role for Lecturer/Practitioners to act

as facilitators.

The initial Euro-centric tone of this edition is much

enhanced through a report of a systematic study of

nursing related adverse events in a Tokyo Hospital that

comes from Manaho Yamagishi, Katsuya Kanda and

Yukie Takemura in Japan. This is complemented by an

evaluation of Clinical Supervision and an exploration of

its effects on the quality of care that has been investi-

gated by Krystiina Hykras and Kristiina Lehti in

Finland. The overarching theme of quality maintenance

in health care is concluded through an account of a

rigorous descriptive study concerning pain and health-

related quality of life among cancer patients that has

been researched by Barbro Bostrom, Hansi Hinic, Dag

Lundberg and Bengt Fridlund in Sweden.

Given the heightened level of anxiety internationally

concerning terrorist acts amongst civilian populations, a

timely and politically significant paper is included by

Michael Hayward. This addresses the management

issues surrounding the United Kingdom health services�ability to deal effectively with major incidents involving

bioterrorism.

The edition concludes with a paper that will fascinate

all nursing managers. In this work, Cornelia Ruland

and Ingrid Ravn in Norway present an analysis of the

usefulness and of the effects of a nursing resource

management information system to complete what I

trust will comprise an intellectually energising range of

topics.

Professor PETER L. BRADSHAW

Guest Editor

Professor in Health Care Studies

University of Huddersfield

Huddersfield, UK

Clinical Governance

It is becoming clearer to all of us who work in health-

care, that at a time of unprecedented growth and

development, there is a greater need than ever to ensure

that we do things effectively, to a high standard of

quality and safety. The task should not be underesti-

mated; 1.25 million people work in the NHS (a further

million work in social care), and yet there is widespread

recognition that we do not have enough staff. Indeed,

the NHS plan calls for 20% more doctors and 10%

more nurses by 2004 with further increases over the

next 20 years. Such developments do beg several ques-

tions; how will professional roles develop? How will the

need for better access and greater numbers of patients

be reconciled with quality improvement? What new

Journal of Nursing Management, 2003, 11, 143–146

ª 2003 Blackwell Publishing Ltd 143

training needs will emerge? In short, what will all the

extra healthcare professionals be doing?

According to the Wanless Report, �Success in deliv-

ering a high quality service is dependent not just on

there being adequate resources but on those resources

being used to maximum effect�. It goes further to say

�…the number of people is not in itself a guide to the

quality and efficiency of the country’s health service�.Clearly, careful thought needs to be given to the way we

deploy resources in future and how we expect different

professions to work together. In addition, interface

issues are likely to assume increasing strategic import-

ance over the next few years and the boundaries

between primary and secondary care, health and social

care and treatment and prevention will demand closest

attention. The inevitable complexities of these issues

combined with evolving professional roles and changing

organisational structures, highlight the need to con-

centrate on quality as an overriding concern, cutting

through the uncertainties of such a changing world.

Doing this properly will entail a firm focus on patients�experiences of healthcare and clearly we will need to

involve them much more closely in developing and

defining outcome measures, to ensure convergence of

view in the development and improvement of health

services. This will mean that we have to be much better

at measuring what matters and ensuring that a shift in

culture occurs, which sees measurement as a central

duty for all professionals.

A great deal is already known about the kinds of

things which are effective in improving quality and

also the organisational and contextual factors which

facilitate them. Crucially, clinical quality should

become the highest priority for all healthcare organ-

isations and existing mechanisms must be adapted to

ensure that staff have both the time and training to

understand quality and its improvement. Integrated

working allied with teamwork attributes and skills are

central to this we will need a future workforce,

flexible enough to lead and adapt to new ways of

working and, above all, challenge established

assumptions.

So far, more than 6000 frontline staff representing 52

specialties have participated in development pro-

grammes run by the NHS Clinical Governance Support

Team. Over 430 multi-disciplinary teams have attended

or are currently on the 5 day, 9-month Clinical Gov-

ernance Development Programme, to establish and

sustain improvement projects in their local services.

Nevertheless, it has become clear that support and

development is required at different levels throughout

the system of healthcare and in particular, it is clear that

top-level commitment is crucial for successful change. A

leadership style, emphasising people and processes

which effectively and appropriately empowers clinical

teams, can make a significant difference; so a Board

Development Programme has been working with 205

NHS boards to ensure the improved delivery of safe and

high quality care.

Poor teamwork can and does lead to poor care but

many organisations have troubled teams, with no

obvious dedicated support to help them improve.

Approximately, 200 teams are going through a cus-

tomised programme with the Clinical Governance

Support Team where, learning from aviation and other

industries is used to facilitate effective change in team

working. Furthermore, a Clinical Governance Rapid

Response Unit provides whole system support and

customised intervention to �nil star�.Much progress has been made, but there is still much

to do. Future challenges will arise which will require an

increasingly flexible and adaptable professional work-

force with a culture of continuous questioning and

learning. It is still early days for Clinical Governance

but the vision of a truly open, reflective practice with

systematic measurement and demonstrable improve-

ment is achievable, as long as we have persistent intent.

The focus of this issue of Journal of Nursing Manage-

ment on Clinical Governance is therefore to be wel-

comed and applauded.

HUGH GRIFFITHS

NHS Clinical Governance Support Team

Leicester, UK

www.cgsupport.org

Will Modern Matrons carry on regardless?A response

In the March edition of The Journal of Nursing Man-

agement, Professors Roger Watson and David Thomp-

son published a guest editorial setting out their views on

the introduction of Modern Matrons into the UK

National Health Service (NHS).

The editorial rightly poured scorn on the term

�Modern Matron�, highlighting how the introduction of

the new title was a futile attempt by the Department of

Health to pander to the public’s mistaken perception

of the matron being responsible for a �golden age� of

cleanliness and high clinical standards on hospital

wards (Watson & Thompson 2003).

Guest editorials

144 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 143–146

Where the editorial was too negative in its tone was in

relation to the underlying principles of the introduction

of Modern Matrons. The policy documents related to

the introduction of Modern Matrons actually provide

an ideal opportunity for nurse managers to re-evaluate

their role and strengthen their position within NHS

organizations.

The proposal to introduce Modern Matrons to the

health service was first put forward in the NHS plan

(Department of Health 2000). The details of the intro-

duction of the new role were announced in a subsequent

health service circular (Department of Health 2001),

and a progress report from the Chief Nursing Officer

was circulated after some initial appointments had been

made (Department of Health 2002). The three main

strands to the matron role set out in these policy

documents are securing and assuring the highest

standards of clinical care, providing an authoritative

presence for patients and families to seek advice from,

and ensuring that support services are designed and

delivered properly (Department of Health 2001).

Of these three strands, the first two are functions that

are already carried out by nurse managers throughout

the NHS – leading the drive to raise clinical standards

and dealing with concerns or complaints should be key

parts of any nurse manager’s job description. It is the

third area, related to the provision of support services

that provides the most interest, and the greatest

opportunity for improvements in care.

The message running through the Modern Matron

initiative is very clearly that nurse managers must be

given the authority to influence all areas of the clinical

setting, from the standard of care given, through to the

cleanliness of the environment and quality of food

provided to patients. As a profession, we should

applaud this aspect of the Department of Health’s

policy. Contracting-out of services and a gradual

reduction in the influence of nurse managers within

NHS organizations has resulted in the loss of nursing

control over the standard of cleanliness, maintenance,

and catering. This can lead to both a reduction in

environmental standards (which can, in turn, adversely

influence clinical standards), and frustration amongst

those nurse managers unable to exert the authority they

desire over their own clinical areas.

Nurse managers should therefore embrace the Modern

Matron initiative and regain authority over environ-

mental issues. However, assurances must be given that

the necessary infrastructure will be in place. Crucially,

NHS Trusts must give modern matrons the organiza-

tional authority to make changes where required. When

catering, cleanliness, or maintenance functions are not

performed to the appropriate standard, the matron must

have a clear line of redress. Complaints about these

functions should not fall into a �black hole� as is often the

case at present. Instead, they should be promptly

addressed, and lead to improvements in service. The

suppliers of these support functions should clearly

understand that they are providers of a service to an area

ultimately managed by the Modern Matron. A complaint

or comment from a Modern Matron should start to carry

the same weight as that from a member of the executive

management team, and yield instant results.

Organizational authority alone will not make the

introduction of Modern Matrons a success. National

Health Service organizations will need to re-evaluate

the job descriptions and support structures for existing

nurse managers. Watson & Thompson (2003) are

entirely correct when they assert that simply adding

responsibility for environmental standards to an already

huge workload for nurse managers is not the way for-

ward. Adequate administrative and secretarial support

must be provided to help ease the burden of added

responsibility. Greater support must also be given

to Modern Matrons in regards to Clinical Governance,

financial, and human resources functions.

In addition to greater support for Modern Matrons,

there must also be a shift in culture within NHS

organizations. Modern Matrons must be empowered to

use their skills and knowledge to drive the development

of organizational policies, rather than simply reacting to

them. Directors of nursing should therefore encourage

the input of their Modern Matrons into policy devel-

opment and ensure that the views of those closest

to the clinical setting are taken on board by senior

management.

Despite the opportunities provided for nurse manag-

ers, there are a number of concerns surrounding the

Modern Matron initiative that go deeper than the

obsolete job title. First, Modern Matrons must ensure

that they are not simply used to provide a new scape-

goat for the ills of the health service. There is always the

risk that the blame for failings in environment and care,

from dirty wards to delayed discharges, will be laid

squarely at the door of the Modern Matron. To avoid

this, it is crucial that Modern Matrons are vocal about

the resources that they need to do the job that the

Department of Health has requested. If resources are

inadequate, Modern Matrons must ensure that protests

are made, letters are written and most importantly,

records are kept. If, as a Modern Matron, you are let

down by the system, make sure that your organization

cannot turn around and blame you for the subsequent

failings in care.

Guest editorials

ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 143–146 145

Concerns must also be raised regarding the lack of

strategic or academic emphasis within the role as laid

out by the Department of Health. The Modern Matron,

as defined in policy documents, appears to be very much

a day-to-day manager, with no mandate for improving

educational standards amongst staff, carrying out

research, or leading evidence-based change. It is

important therefore, that those nurses in Modern

Matron roles take it upon themselves to achieve a

balance between daily management responsibilities and

long-term strategic development of educational and

clinical standards.

Despite these concerns, the profession should wel-

come the fact that the drive to introduce Modern

Matrons has placed the role of the existing nurse

manager under the spotlight. Senior nurses should use

this opportunity to re-evaluate their roles, and to

demand that they are given the authority within their

organization to ensure that the clinical environment

meets the standards that they, and their patients,

demand. The introduction of the title �Modern Matron�is nothing more than a government attempt to demon-

strate responsiveness to public opinion and gain a quick

win with those that still reminisce about the �good old

days� of the NHS. As a profession, we should look

beyond the new job title, and wholeheartedly embrace

the philosophy of an authoritative nurse manager,

thereby reclaiming responsibility for providing a suit-

able environment in which to care for patients.

References

Department of Health (2000) The NHS Plan. The Stationery

Office, London.

Department of Health (2001) Implementing the NHS Plan –

Modern Matrons. Health Service Circular 2001/2010. Depart-

ment of Health, London.

Department of Health (2002) Modern Matrons in the NHS:

A Progress Report. Department of Health, London.

Watson R. & Thompson D.R. (2003) Will Modern Matrons carry

on regardless? Journal of Nursing Management 11, 67–68.

DAVID BARRETT

Lecturer in Clinical Nursing

University of Hull

UK

Guest editorials

146 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 143–146