clinical governance

clinical governance

The definition of clinical governance was proposed by the department of health states that it is a ‘framework’ in which organisations are responsible for continued improvement of services quality and ensuring high standards of care at every level of healthcare, both in primary and secondary care by creating an environment where clinical care flourishes (Gottwald and Lansdown, 2014).

Clinical governance imposes a duty on all practitioners, clinicians, and managers to make sure that the quality of healthcare delivered to patients is satisfactory, consistent and responsive. It can be described as an umbrella under which covers activities that support and enhance a high standard of care for patients.  In this sense, clinical governance has transformed the national health service (NHS) expectation from a need-driven provision of healthcare to a consistently improve and maintain a high standard of care and treatment.

In the early 1990s, clinical governance was a new concept, it was launched as a way of achieving a devolution of responsibility combined with accountability for performance. The main purpose of it is to continuously improve the quality of patient care, it also asserts the central position of the service users, strengthens their right to choose and control their health care packages (Davis et al, 2011) (MISSING REFERENCE ON THE REFRENCE LIST). The ‘pillars’ that support the framework of clinical governance include clinical audit, education, and training, clinical effectiveness, risk management, research and development, Royal College of Nursing (2019). The understanding of Communication, accountability, teamwork, and leadership underpin these elements.

The implementation of clinical governance was due to a number of significant events and high-profile damaging incidents that occurred in the United Kingdom. Some of the clinical issues which led to the birth of clinical governance include:

• Throughout 2005 and 2009, Mid Staffordshire Nhs failed to provide high standards of care, which put patients at risk. High mortality rates were reported
• Between February to April 1991; Nurse Beverley Allitt injured 8 children; assassinated 4 and found another 4 guilty of attempted murder of children while in her care
• The Bristol royal infirmary identified that the treatment of children needing complex cardiac surgery was compromised over a 10-year period from 1984 to 1995 and the mortality rate was nearly double the national average.
• At least 90 patients died of clostridium difficile between 2004 and 2006 because of the lack of infection prevention and control procedure in Maidstone and Tunbridge Wells Nhs trust (Gottwald and Lansdown, 2014)
• There are an estimated 237 million medications error each year in the NHS, with 66 million of these potentially clinically significant (NHS,2019)

Francis (2013) reports says that “every single person” serving patients’ needs to work in a compassionate, committed, safer and caring ways to ensure that clinical governance recommendations are implemented effectively. His description of the breakdown of key clinical governance practice states there was little analysis of complaints or incidents, there has been no up-to date-risk register and the importance of clinical governance was not gripped by the staff.

Quality control is the key to clinical governance.  Unfortunately, as the recent report by Francis has shown, something that should be the responsibility of everyone does not become the responsibility of anyone, thereby creating an inefficient and unsuccessful system.

McSherry and Pearce (2011) explains that clinical governance is more regarding the risk management than anything else.  They also report that most health care organisation fail to enforce clinical governance because health professionals view the risk management in relation to their own professions and positions, therefore, the holistic risk management neglected rather than improved.

On that note, risk management is a process that identifies factors that may stop an individual from delivering excellent, safe and effective care (Aven, 2018). Risk management thus aims at ensuring early identification of these hazards, assessing the best way to handle or control them, and reducing their impact. It is also part of the clinical governance, by which deals with procedures, policies, and systems that health professionals should uphold

A four- year-old Amelia was brought to the children’s ward with a history of respiratory distress accompanied by her mother. Earlier that day, the mother pressed the emergency buzzer as Amelia was lying in bed unconscious, not responding or breathing. All the staffs rushed to the cubicle room, as we arrived on the scene, the nurse exposed Amelia’s chest to observed chest wall movement, breathing was absent so she and other health professional proceeded with resuscitation guidelines. the student nurse was told to bring the resus trolley to the room while other health professionals were examining her and started the CPR. However, some of the resuscitation equipment was out of date and missing during the incident such as Intravenous infusion set, Stethoscope, saturation probe and ECG equipment.

At the beginning of the shift, two first-year students nurse were asked by their mentor to check the resus trolley so they can familiarise themselves with the resus equipment and because the ward short of staffed and the mentor was meant to countersigned it and double check everything at the end. Both did as they had been told, although the students’ nurse knew were not allowed to do so alone. However, they forgot to restock some equipment, during the resuscitation, the mentor realised some of the equipment was missing.

The purpose of returning to this situation is to consider the risks involved. This is because what the mentor has asked the students nurse to do was not in their position to check the resus trolley without the mentor’s supervision.

Within this scenario, the error that occurred was that the staff nurse did not check and countersign the resus trolley with the students’ nurse. This error could have a delay in Amelia treatment which could have potentially led to poor health care. The national patient safety agency (2011) stated that poor functioning or missing equipment on resus trolley is a contributing factor to deaths relating to resuscitation attempts. This issue may, therefore, have an impact on best practice, as resuscitation is a time-critical emergency, so it is important for registered nurses to check and restore the resuscitation trolley daily to avoid this error.

This piece of literature underlines the impact of missing resus equipment on best practice, which therefore indicate that the error identified in this case study could have had a negative impact on the delivery of safe care, because not having enough equipment during resuscitation could have affected Amelia treatment or even contributed to a patient’s death, as some staff nurses had to go back to the storeroom to look for equipment when it was supposed to be in the emergency trolley. However, Amelia overall health care was not diminished by the behaviour of the health professionals involved.

Ineffective teamwork is the first element to be discussed in this case study. Teamwork is the concept of people working together cooperatively as a team in order to accomplish the same objective/ goal (Shirley et al, 2015). The goal in this scenario was to ensure that the resus trolley had all the equipment needed to provide the best care to the patient during resuscitation.

However, in the context of the scenario, each individual held accountability for the prevention of effective care management for Amelia. For the part of the student nurses, they should have ensured that the mentor signed and recheck the resus checklist as soon as they finished checking it or not undertake the task without the mentor supervision and that the mentor held countable for not signing it.

The NMC (2018) domain 4 ‘leadership, management and team working ‘states that as nurses you must work effectively as part of a team. This literature means that nurses must constantly be working as a team to allow them to places patients at the center of their thinking and providing them the best care possible. Clinical governance is about changing the way people work, demonstrating that teamwork is as important to high-quality care as clinical effectiveness.  Therefore, without teamwork, the potential of clinical governance is not achievable.

The previous NHS plan (2000) suggested that poor teamworking is one the reasons why the NHS has failed to deliver high quality of care in the past. However, it is important to note that this is old research. Overall, teamwork has a significant effect on outcomes for patient care, performance as it helps reduce stress, increase staff stratification and clinical governance (Dickinson, 2010)

Therefore, In the above case, the mentor clearly needed to consider the risks involved behind the task she asked the students to do. The above scenario, therefore, reveals poor teamwork in practice as the mentor’s role is to provide support and guidance to students in the practice area.  The NMC (2018) code of professional register states that nurses who are mentors should be a role model of integrity and leadership to which others thrive and are required to by supporting the students to help improve their professional competence and boost their confidence. Nonetheless, the mentor was responsible for monitoring the practice of the student nurse at all time.

Someone can argue that the mentor has failed to comply with the NMC code of Professional because she has not supported or supervised the students when checking the resus trolley. The mentor negligence in working with the student to check the resus trolley could have decreased quality of care receive by Amelia or cause death, as the student has not yet achieved the required standards of proficiency for safe and effective practice to undergo that task alone. However, the care was still effective regardless of the missing equipment. This is because the team during resuscitation worked as a team and the overall outcome was achieved by the team, as the team adjusted to each other and provided high quality of care to Amelia.

According to Curtis (2014), safe care for patients in emergency care services relies on an effective team and, when health professionals work together, there is a higher level of patient satisfaction. Conversely, lapses in teamwork can have a negative impact on the patient and even lead to the death of patients.  Therefore, in order to deliver comprehensive care that is safe and continuous, effective teamwork is critical

Looking at it from a mentor’s perspective, she could have been busy due to a high workload due to lack of staff in shifts, and she forgot to check the resus trolley. Such external pressure could have been the reason why the mentor did not support the student, as she should have done. Therefore, her action could be justified as she could have prioritised the care of the patients she was looking after over checking the resus trolley.  Also, during that time, there was not a clear guideline for mentor to follow when working with students as she was unsure on what the student can and cannot do

The article by Rafferty (2018) points out that the shortage of nurses in the United Kingdom is affecting patient care and threatening lives.  He also believes that the shortage of nurses affects not only the provision of care but also mentor and student, as the quality of support that students receive in practice area can either make or break their decision to become a nurse.

Although, the nurse was wrong for not checking the resus, the nurse acted in line with the NMC (2015) code of professional standards of practice and behaviour for nurse, as she prioritises the needs of her patients that she was looking after and acted in their best interests by balancing the needs of her patients and ensuring they all received an adequate care.

For future recommendation, the ward manager needs to do more mentorship training so staff nurses are up to date to what student are allowed to do and not do. Also, mentorship training will encourage ongoing learning and development and the identification of learning opportunities in the health care setting. Team work cannot be successful without effective communication. Therefore, the mentor and the students need to work on effective communication in order to be able to share their duties fairly in the future and ensure that the role of each individual within the team is understood. Effective communication can be improved by listen to each other and build a better team

The second clinical governance component that is related to the case study is leadership which is the process of influencing others toward the achievement of goals by providing direction and energising others (Shirley, et al 2015). There are many theories of leadership but the main focus of this essay will be on a transformational leadership. Transformational leader has the characteristics of effective communication skills, good time management, provide support, active engagement with patients and health professionals and has high expectations (Porter and Malloch, 2013)

Transformational leadership seem to be widely viewed as the most effective style of leadership in many public sector settings which is the type of leadership that the mentor should have demonstrated in order to delivery an effective care, however not all nurses have the same leadership styles so it is important to acknowledge individual difference (McKimm and Phillips, 2010).

Nevertheless, most of these traits were not shown by the mentor in this case study, for example, she had poor time management which could have been due to shortage of staff or to work under pressure, which caused her not countersign the resus checklist with the students at the right time.  The report by Habid et al (2018) ( MISSING ON REFERENCE LIST) shows that time management is very important for nurses and helps them to plan for their available time and use it to manage their tasks.  As a result of poor time management, the quality of care Amelia could have received could have been limited. This is because the equipment required to care for Amelia was not there ( what equipment), which limited the healthcare and prevented effective care from taking place.

The leadership style demonstrated by the mentor was autocratic, also known as authoritarian. Autocratic leader makes decision based on their own idea and judgements and rarely accept advice from the group. The characteristic of autocratic leader includes authoritarian control over a group and punishment for subordinates in conforming to their decisions (McKenzie and Manley, 2011)

A review of the available literature provides a wealth of supporting evidence that advocating leadership as essential in nursing. For instance, Qarani (2017) argues that leadership in nursing is an essential quality and transformational leadership is the best style to lead, not only because it directs, but also provides opportunity for development and learning: hence, encourages nurses to feel responsible and accountable for their actions. This is reinforced by the recent requirements of the NHS Plan (2019) ( MISSING ON THE REFERENCE LIST), which highlighted the importance of introducing the transformational model of leadership.

This is confirmed by Fischer (2017) who argues that transformational leadership increases feelings of self-worth and capability in their team members because transformational leadership competencies provide nurses with the skills they need to contribute to improving the quality and safety of patient care while enhancing their career satisfaction.

The literature mentioned above highlights’ the importance of an effective leadership in improving the quality of patient care and their experience. Sullivan (2013) reports that transformational leadership has had a positive impact on the practice environment in the health care organisation.

However, some of these characteristics of a good leader can indeed be based on individual personality factors, because some people seem to be natural leader, and others are struggling to attain leadership skills. There is some evidence that this is the case. Fischer (2017), for instance, suggests that transformational leadership is born in such a way this is natural and cannot be made. Therefore, it seems that the NHS plan (2019) for providing more training and teaching around transformational leaderships is not as straightforward and realistic as they were first proposed, as the literature by Fischer indicates that these leaders are born rather than learned.

The NHS leadership framework domain 2 also emphasise the importance of working with others to deliver and improve services. to do so, they must have a clear understanding of their role and responsibility within the team. The mentor did not, however, demonstrate effectiveness in this domain.

Clinical governance seeks to provide a high quality of care to patients at all times. As such, it advocates effectiveness, acceptable, efficient and accessible care. It is important that all aspects of clinical governance are adhered to, in order to improve healthcare.

Therefore, if clinical governance were used effectively in this case by the mentor and students nurse, this error would not occur because the mentor would have known about the importance of risk management as an integral of clinical governance to help reduce the risks to Amelia. Risk management could be following the hospital protocol about the importance of countersigning the resus checklist with the student. The reason for this is that risk management involves the identification and assessment of accidents prevention, so the error identified in this case study could have been handle differently if there were a clear hospital protocol for mentors to follow before asking the student to perform the task.

by doing so, the mentor would have based her practice on following the care quality commission, which works towards promoting good quality of care by monitoring, inspecting and rating services. Therefore, she would have minimised the risk of missing resus equipment

Although, effective leadership is often difficult to achieve within the health and social care setting. More training needs to be put in place to provide health professionals with the opportunity to equip themselves with the relevant leadership skills required to deliver quality services to patients and their relatives and to encourage staffs to have good clinical governance. This is because leadership is considered to be an important component to nursing, therefore, an adequate training is needed to prepared nurses to act as leaders when providing care.

After this incident, the hospital has made a booklet for students which clearly state what students are allowed to do whilst on placement. The ward management also implemented a rule which banned students’ nurses from checking the resus trolley.