From strategy to implementation - clinical and academic perspectives

This edition of the Journal of Nursing Management has a two pronged approach. Firstly, there is focus on strategy development from the perspectives of the importance of nurses being involved in the development of strategy in their organization and on the policies that are strategic in nature that nurses are already engaged in. The second focus is on exploring human resource management policy areas that are grounded in strategic management, yet are not generally seen as such. Carney sets the scene for the strategic management approach and outlines the strategic management process and the need for nurses to become more engaged in strategy development. In her documentary analyses study, undertaken in Ireland, titled, Enhancing the nurses’ role in health care delivery through strategic management – recognizing its importance or not?, she attempts to determine the importance of strategy in nursing management and to establish if strategic management has entered the lexicon of nurses’ vocabulary. She contends that developing and managing strategy is a critical success factor for healthcare managers, yet it is by no means clear that nurse managers view strategy development as part of their management role. Her findings indicate that <10% of nursing journal titles contained the word strategy, that the nursing profession does not appear to have adopted the terms strategy or strategic management to any great extent and that strategic policy making by nurses within health care systems remains ill defined. Arman et al. in their paper on what healthcare managers do describe how first and second line managers use their time. The authors applied Mintzberg’s structured observation method in the study. They found considerable variations existing in work time patterns and they suggest the possibility of interventions to support changes in time use patterns in order to enhance work effectiveness. They explored the everyday work of health care managers and found that nearly half of the managers’ time was spent in meetings and that only a small fraction of this time was spent on explicit strategic work, supporting Carney’s study presented above. Strategic policy is discussed by Fyffe in her study, titled ‘Nursing shaping and influencing health and social care policy’; undertaken in Scotland. She explores how nurses’ shape and influence health and social care policy and uses lessons learnt from a policy study tour undertaken in the United States of America and from extensive experience as a senior nurse within the government, the health service and more recently within a professional organization. The results of her study support the need for creative solutions that promote and increase the participation of nurses in the political process and in health policy. She says that even though much has been achieved in positioning nurses and nursing as an influencer in the arena of policy and political decision-making, there is a need for greater co-ordination of action to ensure that nursing is actively supported in influencing and shaping health and health care policy. Similar to Carney, in her findings on strategy presented in this journal, Fyffe finds that gaps in education for nurses on policy and policy development and involvement needs to be addressed and the nurses role in policy development promoted. She says that the nursing profession faces major changes in health and health care and nurses need to be visible in the public debate about future models of health and health care. The next paper takes an educational policy perspective relating to nursing regulation and entry to the nursing Register. Fealy et al. present an educational perspective to policy development titled ‘Models of initial training and pathways to registration; a selective review of policy in professional registration’. The authors explore the pathways leading to registration as a nurse in studies of five Western countries. The main focus of this paper is on the specific pathways to entry to the Register of Nurses that is held by the professional regulatory body in Ireland. The literature review indicates no single uniform system of routes of entry into initial nurse training and no overall consensus regarding the optimal model of initial training. This poses challenges for nurse managers in the recruitment and deployment of nurses trained in different jurisdictions. This paper explores the policies determining entry to the Register and is a timely review of how nursing is regulated from a national perspective and how nursing regulatory policies are developed, implemented and evaluated. The next group of papers focus on policy making with a clinical perspective as well as an underlying education or training dimension. Rowse in her study, titled ‘Support needs of children’s nurses involved in child protection cases’, undertaken in a NHS Trust in Britain, explores the perceptions of the experience of nurses and midwives working in paediatrics in the specific area of child protection. This paper is policy focused and the study was inspired by an awareness of increasing anxiety amongst nurses involved in child protection cases. Her findings highlight the fact that involvement in child protection has a lasting impact on nurses as the emotions generated can lead to inter-agency and inter-professional communication difficulties that can affect the future management of child protection by individuals. Rowse stresses the need for procedural information from a knowledgeable supporter and individualized support for the nurse or midwife during a case. Additionally, the personal qualities of the Named Nurse for Safeguarding Children were crucial. This study has implications for the training of children’s nurses in child protection procedures as the long-term effects of involvement are previously unreported by nurses. The importance of training and education of nurses for their roles is explored further by Rondeau et al. In their study titled ‘Developing human capital: what is the impact on nurse turnover?’, undertaken in Canada, these authors explore the impact that increasing human capital through staff training makes on the voluntary turnover of registered nurses. The authors discuss the turbulent nursing labour markets prevailing in several countries that are characterized by extreme staff shortages and high turnover levels. The result of their study demonstrates that healthcare organizations that have made greater investments in their nursing human capital through education and training are more likely to demonstrate lower levels of turnover of their registered nursing personnel. Flynn and McKeown take a different approach to staffing. The authors re-visit nurse staffing levels and skills mix. In a systematic review of published evidence, spanning a ten year period, they explore the quest by nurse managers to determine optimum nursing numbers and question if it is now time to reconsider how nursing outcomes are defined and measured. Parker et al., in their study exploring the challenges confronting clinicians in acute care in Australia, state that current practice environments are characterized by increasing differentiation, increasing patient acuity, an ageing population of patients and staff, staff shortages and larger numbers of non-graduate nurses, all similar to those reported internationally. They explore how acute care clinicians may prioritise professional issues of concern, through project management, so that they meet and respond to challenges and to ensure safety, efficiency and positive patient and staff outcomes. Therefore clinicians need to be included in decision making and change within their organizations. The need for nurse managers to be supported in rostering, staffing, and resource procurement and allocation is identified. The study highlights a need to refocus management styles on staff empowerment, staff education and training, participation and team building as well as systems improvement issues. Those themes are carried through in the next two papers by Alhusban and AbuAlrub and Brady et al. although from two different perspectives; patient satisfaction and medication errors. Alhusban and AbuAlrub explore the level of patients’ experiences of nursing care in Jordan and identify important aspects that may enhance such experiences. They utilized The Newcastle Satisfaction with Nursing Scale. The findings of the study indicated that the level of satisfaction of Jordanian patients with nursing care was moderate and their experiences of nursing care were positive with female patients demonstrating more satisfaction with nursing care than male patients and patients in semi-private hospitals more satisfied than those in public hospitals. Brady et al. in their literature review of the individual and systems factors that contribute to medication errors in nursing practice, found that contributory factors to nursing medication errors are manifold, and include both individual and systems issues. These include factors such as medication reconciliation, types of drug distribution system, quality of prescriptions, deviation from procedures and nurses’ knowledge of medications. The authors stress the importance of nurse managers implementing strategies to reduce medication errors such as promoting consistency between health care professionals as to what constitutes medication error in order to increase accuracy and compliance in reporting of medication errors, thus reducing the occurrence of medication errors. The authors highlight the importance of acquisition and maintenance of mathematical competency for nurses in practice in the prevention of medication error. Nurse managers’ are ideally placed to implement strategies developed in their organization’s but need to be involved in the development of such strategies. Many nurses are involved in strategy development yet do not perceive this involvement as strategy (Carney 2002). Currie (2006) counters the view that middle nurse managers have little to contribute to strategic change and argues that this group should be involved in strategic change beyond just implementation of decisions made at a more senior level. Crossan (2003) argues that the role of the nurse manager is focused on day-to-day operational problems and issues and that this focus militates against their involvement in strategic planning and policy development. There is an urgent need for all nurses to undertake education and training in the language of strategy and to understand what strategic management means and also how they may seek to become involved in the development of strategy in their organizations (Sambrook 2005, Carney 2006). Carney (2006) says that education in management, leadership and strategy will determine the skills and ability of professionals nurse managers and Cortese (2007) recommends investment in management training and education in providing details of recruitment and retention strategies, as mentioned in this edition. Nurse Managers require knowledge of the strategic management process and the strategic options open to them and need to be prepared to contribute to debate concerning the future strategic planning and direction of their organization and to strategic issues concerning health care at national level. In order to contribute to this debate the requirement for nurse managers to accept their strategic role in health care delivery is necessary. This edition presented papers relating to strategy development, clinical and academic strategy and policy development. However, strategy needs to be converted into action otherwise it becomes a meaningless paper exercise. So, how may nurse managers and nurse educators optimize strategies for academic, research and clinical practice initiatives? It is possible to present only some examples of the areas where strategy development by nurses could benefit nursing practice and academic education. For example, academic core strategies could focus on building the School or Faculty’s international reputation as a centre for high quality research, as measured by research funding and publications. Further strategies for research could focus on creating a research environment and infrastructure that attracts a diverse group of researchers who value interdisciplinary work in education and clinical practice, thereby increasing numbers of post graduate research students in the Faculty and providing capacity for post doctoral research building. A further academic strategy could focus on academic staff in nursing schools striving to be at the leading edge of research projects nationally and internationally as they relate to clinical nursing, midwifery and health areas of relevance, and having an awareness that strategic research in the future will shift increasingly towards translational, clinical and health services’ disciplines. This means translational care – i.e. ‘bench to bedside’ integration of research and patient care programmes to improve patient care. Strategies for collaborative networking could focus on working collaboratively and flexibly with other practitioners, clinical colleagues and with national and international subject matter experts. Other areas for future collaboration include links between leadership, work attitudes and performance within the nursing profession; health administration; women’s health; historical perspectives on nursing; evidence based clinical practice and innovative learning environments Innovative strategies for the future that will benefit patient care include initiatives to develop the application of information technology to healthcare, including the generation and usage of healthcare data that values and focuses on interdisciplinary collaborative research. From a specific clinical perspective the development of the advanced nurse practitioner is a key area for strategic focus. Examples of areas that nurse manager’s need to focus on include strategies in relation to critically analysing research, relevant knowledge and evidence-based practice at advanced practice level and the development of nursing and nursing leadership and its distinctive knowledge base, including the professional concepts that influence such development (TENN 2005). Strategies aimed at evaluating the principle dimensions of legal and ethical frameworks for managing clinical leadership in advanced nursing practice and the ability to evaluate the application of clinical judgement to professional leadership practice by utilising evidence-based practice are core strategies for the future of advanced nurse practice (RCSI 2009). Jasper and Jumaa (2005) say that clinical leadership is an essential skill for nurse managers and explore the concept through the examination of relevant practice and policy and recent research. The nurse manager will require strategies for debating, in a critical manner, the regulatory framework associated with prescribing, including the legislation and professional guidelines supporting safe prescribing and evaluating policy and strategic approaches to health care in various settings. A critical strategy relates to utilising knowledge for forming the basis of clinical assessment, decision making and case management when identifying symptoms that indicate dysfunction, thus contributing to the role of the advanced nurse practitioner (RCSI 2009). Therefore there is a need for nurses and midwives that are well positioned to deliver on their strategic objectives across clinical, education, leadership, research and community areas. In order to do this they must firstly understand the language of strategy and their role in strategic planning and implementation. They need to grasp the importance of balancing the needs of the patient and health service stakeholders, such as hospitals. To do this nursing and midwifery need to look to ‘international best practice’ in developing its clinical, research and academic strategy and to critically discuss partnership approaches to leading health care. The nursing profession does not appear to have adopted the terms strategy or strategic management to any great extent. Nurse managers’ could play a greater role in enhancing healthcare delivery if an understanding of, and acceptance of the importance of strategy in health care delivery was promoted.

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