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Leadership development: A collaborative approach to curriculum development and delivery
Nurse Education Today (2007) 27, 436–444
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Leadership development: A collaborative approach to curriculum development and delivery Kathleen M. Munro
a,*
, Margot C. Russell
b,1
a
School of Health Sciences, Nursing, Queen Margaret University College, Edinburgh, EH12 8TS, United Kingdom b NHS Lanarkshire Practice Development Centre, Wishaw General Hospital, Lanarkshire, ML2 0DP, United Kingdom Accepted 24 August 2006
KEYWORDS
Summary The Leadership Programme in the National Health Service, Lanarkshire, Scotland began in 2002. The programme has been endorsed by the employer, accredited by a higher education institution and approved by the National Health Service Education Board in Scotland as a recognised continuing professional development programme. The success of the programme is due to the combined efforts of the teaching team from the Practice Development Centre, the different stakeholders within the health service in Lanarkshire and Queen Margaret University College, Edinburgh. The focus of this article is the nature of the collaboration between the partners from the initial ideas to the initiation, validation and ongoing delivery of the programme. The article will provide an account of the criteria for partners and key features of the collaboration as well as quality assurance aspects. It will also draw upon the outcomes of the programme in terms of student views and achievement as well as the benefits to the partners. c 2006 Elsevier Ltd. All rights reserved.
Leadership development; Leadership programme; Collaboration; Accreditation; Curriculum development
Introduction and background The National Health Service (NHS) in Lanarkshire recognised that there was a need to develop a leadership programme that would take forward the * Corresponding author. Tel.: +44 131 317 3564; fax: +44 131 317 3573. E-mail addresses: [email protected] (K.M. Munro), [email protected] (M.C. Russell). 1 Tel.: +44 169 836 6584; fax: +44 169 836 6777.
health care service in line with current government policy (NHS, 1999, 2000; NHS Scotland, 2000, 2001). However, traditional in-house employer led programmes for experienced staff has not in the past been recognised as having merit by some staff in terms of either professional development or the academic worth of the course. In addition it can be argued that some staff may not value such courses because they are identified as employer driven, although employers undoubtedly prefer their organisations internal training programmes
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.08.004
Leadership development: A collaborative approach to curriculum development and delivery to formal higher education courses (Keeling et al., 1998; Poell et al., 1998; Munro and Peacock, 2005). Therefore, to facilitate the development of key staff within the acute and primary care trusts of NHS Lanarkshire, an accredited enquiry based learning leadership programme was developed. The construction of the curriculum went through a number of stages. Representatives from the acute and primary care trusts undertook the initial development, acting together as an employer led group. The group then sought an external education partner by inviting a number of institutions to tender for the accreditation of the programme. This led to the successful collaboration between Queen Margaret University College, Edinburgh and the Practice Development Centre of NHS Lanarkshire. The outcome is an accredited Scottish degree level continuing professional development programme equivalent to 600 hours academic and professional study. In response to the need to invest in Clinical Leadership development, both the acute hospitals and primary care trust entered into a collaborative partnership in order to meet the needs within NHS Lanarkshire as a whole. There had been considerable change within Lanarkshire. Within recent times three acute hospital trusts had amalgamated and the primary care trust evolved. This has since been superseded in 2004 with the dissolution of NHS Trusts within Scotland (NHS Scotland, 2003), and the formation of NHS Lanarkshire as a single body. Furthermore two of the acute hospitals moved into new accommodation in 2001. This also necessitated a change in the way staff work due to their new environments. Also with the ever-changing picture unfolding, communication and networking across the region had been both complicated and poor. Consequently any leadership programme developed or purchased would have, as one of its central outcomes an improvement in such areas. To meet these needs the Practice Development Centre, in partnership with Organisation Development from both divisions undertook a series of focus group events with charge nurses. The purpose of these was to identify their requirements in relation to assisting them in their ‘‘clinical leadership’’ role. Although some indication of development into financial management and personnel issues were identified in the focus groups the main emphasis pertained to improving leadership skills and enhancing attributes. Such findings are not unique to NHS Lanarkshire as other studies indicate strong similarities (Sullivan et al., 2003; Allen, 2001; Fyffe et al., in press). The findings from the focus groups were discussed with the senior management team in primary care, acute care and the organisational
437
development team. It was agreed that clinical leadership development would be most beneficial to the organisation. Cook (1999, p306) supports this notion in defining a clinical leader as ‘‘an expert clinician involved in direct clinical care, who influences others to improve the care they provide continuously’’ In terms of service development this definition fitted into the organisational needs and supported the professional and practice development of those in traditional leadership positions.
External and internal influences on development of leadership programme There are always a number of different ‘drivers’ that influence both positively and negatively the development of any educational programme. These both help and hinder the development team in terms of the focus of the development and the design and construction of the curriculum. The main internal drivers in this development came from the employer, the teaching staff in the Practice Development Centre, the managers and the clinically based staff. In addition there were other external drivers that included the university college academic quality assurance criteria and the Scottish Executive nursing division, which was at that time financially supporting one selected programme from another organisation for leadership courses. Generally these drivers can be described as; economic related to the employer’s costs of meeting staff training needs and staff demand, political in terms of ensuring that staff have the education and training to provide quality health care and to meet government targets, professional in terms of continuing professional development requirements of health care staff as well as educational and personal related to career pathways and lifelong learning. Ultimately the purpose of the programme is to improve services for patients and their carers (Woltring et al., 2003). As a means of ensuring that the programme in NHS Lanarkshire responded to each of these drivers the programme planning team were careful to review the available research evidence, thus constructing a programme which appropriately supported participants in their leadership positions. Antrobus and Kitson (1999) highlight the need for nurse leaders to have political awareness and influencing skills in order to be effective in their roles and positively impact on patient care. The European Foundation for Quality Management (1999) also indicates that the key concepts of
438 person centeredness, continuous learning, and partnership internally and externally and role clarity are central to effective leadership. Through using an enquiry based learning approach to programme delivery participants are required to examine their knowledge and challenge their assumptions surrounding such concepts. Additionally, the use of the leadership practices inventory (Kouse and Posner, 2002) is used to enable participants to identify their leadership attributes and identify action plans for development. Such an approach has been advocated and identified as being of benefit (Tourangeau and McGillon, 2004; Cunningham and Kitson, 2000; Kouse and Posner, 2002). One of the main drivers however was the need for acknowledgement as a high quality course that would be confirmed in terms of accreditation of academic level and worth and recognised within the Scottish Credit Qualifications Framework (QAA, 2001) and by the professional bodies in terms of continuing professional development (NMC, 2005). It was this driver more than any other that brought the collaborative partnership together to achieve academic and professional accreditation for the programme. Apart from the criteria for partnership, which will be explained later, there were key elements for the initial success of the partnership. These were that the higher education institution’s quality assurance frameworks had to be adhered to (QAA, 2000) and as such that they would be accessible to the Lanarkshire Practice Development team. Cost of accreditation and ongoing quality assurance of the programme had to be affordable to NHS Lanarkshire and the higher education instiute. Curriculum development and validation process had to be acceptable to both. Work had to be completed within a specified time limit.
Curriculum development In order to develop the curriculum stakeholder representatives were invited to contribute to the process. These included management, clinical staff and staff from practice development and organisational development to ensure the programme was fit for purpose. Early in discussion a literature review was undertaken in order to assist in ensuring that the programme being planned was based on the evidence provided in the literature. This further assisted in the categorising of content mate-
K.M. Munro, M.C. Russell rial. This was categorised into two main themes – ‘‘Developing Self’’ and ‘‘Leading Others’’, which later became the titles of the two modules delivered. The overall aim of the programme was agreed as, ‘To enhance and develop leadership potential for nurses, midwives, health visitors and allied health professionals in both primary and acute care settings’ In utilising a collaborative approach to curriculum planning the stakeholders were keen to meet the needs not only of the practitioners but also of the organisation and ultimately to have an impact on patient care. Enquiry Based Learning was identified as the learning and teaching strategy for the programme delivery because it was deemed most appropriate for adult learners who require to develop leadership skills within the clinical arena. Previous research surrounding this approach identifies that improved communication; team working and networking are some of the transferable skills developed as a consequence of the approach used (Barrows and Myers, 1998; Frost, 1996; MoralesMann and Kaitell, 2001). Furthermore there has been evidence to suggest that an enquiry based learning approach assists in developing transformational learning in an organisation and promotes not only retention of knowledge but integration of theory into practice (McParland et al., 2004; Wakefield et al., 2003; Williams, 2001; Morales-Mann and Kaitell, 2001). The programme was developed to incorporate tutorial groups and fixed resource session, the latter taking the form of an expert speaker, learning event or group work. The tutorial groups comprise of a maximum of 10 people plus a facilitator to encourage group discussion and learning. From the onset of the development the need to develop an interprofessional approach was clearly identified. Increasingly the benefits of interprofessional education have been recognised with improved team working and increased collaboration being identified as outcomes of this approach to education (UKCC, 1999; Reeves et al., 2002; Rusell and Hymans, 1999). Consequently this approach assisted the programme team in achieving the aim and purpose of the programme. Scenarios used to encourage enquiry are clinical in focus, but abstract in nature thus allowing all tutorial groups to identify with the material. This assists participants to relate the concepts to their clinical practice, thus promoting learning through work. Through facilitated discussion, participants are encouraged to examine and explore pre-existing notions in relation to the concepts discussed. This often means discussions around issues raised from their clinical area.
Leadership development: A collaborative approach to curriculum development and delivery A strong emphasis of the academically accredited programme is placed on personal and professional growth and development. Participants are required to reflect on their practice as part of the learning outcomes of the programme and also as part of the tutorial process. In this sense the role of the facilitator is not just that of facilitative educator but of clinical supervisor. As such the programme attempts to meet the needs both of the individual and of the organisation.
Collaboration There are a number of clearly defined stages of development within any partnership before it can be said that the partners are working together in collaboration. Working together essentially starts tentatively, meeting together and verbally exploring the ideas in the proposal, individual’s thoughts and the realities of what is possible within each partner organisation almost in an informal manner before embarking on the formal agenda for accreditation. The first stage occurred when NHS Lanarkshire formally invited institutions to submit tenders for the accreditation of their proposed programme. The criteria for tender were broadly; academic accreditation, recognition from the NHS Education Board for Scotland (NES), life long learning opportunities for participants, quality assurance mechanisms, affordable costs and additional information about the institution. The Queen Margaret University College response and submission constituted the second stage. Prior to the submission of a tender the university college had established the type and nature of the possible collaboration. This type of partnership was described as a ‘validated collaboration’ with an external non academic partner (as in another institution). The collaboration is one where a programme is developed and delivered by the staff of the partner institution and judged by the university college to be of an appropriate quality and standard to lead to its award of academic credit. In this scenario the home education institution, retains responsibility for the quality and standard of the award of credit and decides on the extent to which it exercises control over the quality assurance aspects of the programme’s management. This is in line with the Quality Assurance Agency code of practice (QAA, 2000) for programme approval, monitoring and review, whether it is for a whole programme leading to academic awards or short courses like the leadership programme.
439
Therefore, each partner knew what to expect of the other in advance of formal working partnership and this knowledge was added to through informal meetings of key staff to discuss how best to take forward the collaborative work. Following the success of the tender process the university college also sought additional information to assist in the development and writing of the partners’ memorandum of co-operation and financial agreement. This was the third stage of the process which evidence was sought regarding the following criteria: Organisational, management and quality assurance arrangements. Regulations and procedures governing the relationships of students, including academic support and guidance and provision for meeting students wider educational needs. Provision of learning support and an infrastructure at a level and quality to meet the requirements for programmes leading to the award of credit from Queen Margaret University College. Ethical research standards. Appropriate provision for staff appointment, induction and development. Financial security and probity. The final stage in the development of the partnership included the establishment of Joint Board of Studies and Joint Board of Examiners. The Joint Board has the same function as any programme committee, and membership includes the teaching team as well as representatives from the employer, the academic institution and current student cohorts. Similarly the Examination Board includes the external examiner but excludes students. To facilitate collaboration communication pathways were also established early in the collaboration to ensure that each partner knew who, when and how to contact colleagues in the other organisation. This was achieved firstly through the identification of the key link personnel who communicate informally, for example seeking advice between librarians, or registry and the NHS course leader or between the course leader and the senior lecturer from the university college.
Accreditation and quality assurance Prior to the establishment of the formal structures to support the quality of the programme it was necessary to gain validation. Therefore the outline curriculum identified by the Lanarkshire group
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K.M. Munro, M.C. Russell Mechanism
ACTION
OUTCOME
Statement of intent to plan
Submitted to QMUC Faculty
QMUC approval to plan.
a programme/CPD course
Academic Board (FAB) and
Follow up by NES for CPD
NHS Education Scotland (NES)
purposes
Peer review as per QAA code of
Validation by QMUC
practice at QMUC
NES approval following
Validation procedure
critical reader comments and responses Regulatory framework and Set out in a definitive document agreed procedures for
for the programme and student
admission of students,
handbooks
Standards explicit to all stakeholders
delivery of programme, examination/assessment and award of credit Establishment of JBS
Responsible for overview and
Monitoring and
monitoring re quality assurance
Maintenance of standards
Issues brought to attention of FAB. FAB and Registry inform JBS of changes within regulations for quality assurance Modifications proposed to FAB JBS includes annual
Submitted to FAB and NES
monitoring report
Follow up in action plan for next year. Maintenance of academic credit awards
Establishment of JBE
Recommends to Academic
Award of credit to students
including appointment of
Council the award of credit
within SCQF. CPD
External Examiner Review of programme
Figure 1
requirements met for NMC Review procedure established by
Re-validation of
Registry following QAA code of
programme for further
practice and QMUC regulations
period
Quality Assurance Framework for Collaborative Programme Development.
needed to be developed further in line with their organisational needs and the academic partner’s requirements. The proposed programme was presented to the university college in line with the quality assurance regulatory framework. This included firstly the submission to faculty of the overall aim, philosophy and outline curriculum prior to full planning and finalisation, to ensure that the necessary resources were available to each partner to develop the programme. Secondly the module planning teams’ expertise and qualifications were considered in terms of appropriateness and ability to deliver the programme. Thirdly the learning units were re-designed as modules and written into the institutional format to incorporate the standards for graduate studies and reflect the Scottish
Credit Qualifications Framework. Then finally the programme was presented for approval through the normal validation and approval mechanisms. Following this Academic Council of the university college appointed an external examiner. The quality assurance mechanisms and framework for the cycle of programme development are summarised in Fig. 1.
Programme outputs There are major outcomes from the programme for each partner and stakeholders. Obviously for the students at the end of the programme they will be individually awarded with 60 Scottish academic
Leadership development: A collaborative approach to curriculum development and delivery credit points at degree level or postgraduate masters’ level, depending on their level at admission. These points are transferable and can be accumulated towards a degree outcome if sought by the individual through the Scottish credit accumulation and transfer scheme offered by higher education. The university college has fulfilled its function and awarded credit to the matriculated students. Similarly the teaching team has also fulfilled its function and ensured the employers needs have been met. More importantly is the impact that the education provision has made on the ability of the participants to do their job better throughout their working lives and the quality of care provided to patients as a result of the learning that has taken place. This outcome is supported by other studies which aim to identify the impact of leadership development on clinical practice (Woltring et al., 2003; Cunningham and Kitson, 2000; Morales-Mann and Kaitell, 2001; Frost, 1996). To date the ongoing monitoring and evaluation of the programme has provided a rich source of information. However further research is in progress to truly measure the impact of the programme on patients. There have been170 participants who have commenced the programme between April 2002 and August 2005. Of this 7 participants have withdrawn from the programme due to a variety of factors and 7 have failed to achieve to the academic standard required for programme assessment. There is an opportunity for participants to defer undertaking module 2, Leading Others should the need arise. Consequently 7 participants are currently in progression on the programme. Prior to the commencement of the 2005 intake programme a questionnaire was sent to the past participants of the programme. A further questionnaire was sent to their line managers and to the se-
nior management team. A 66% response rate was achieved (n = 78). This has provided initial data about participants in relation to positive career progression, academic progression and achievement, peer network development and involvement in projects. The returns were representative of the groups of staff who have participated on the programme (Fig. 2). The average length of employment within healthcare settings was identified at 22.5 years with the maximum being 40 years and the minimum being 6 years. The average age was 43 years – the eldest being 58years of age and the youngest being 34 years. Out of the 78 participants 50 had undertaken some element of post registration education, 29 had completed their bachelors’ degree and one completed a masters degree prior to the commencement of the programme. In addition, follow up evaluation has revealed the individual development of participants following the programme (Fig. 3). In order to allow participants to continue in their development, opportunities to facilitate development of the groups are offered. Each year the completing cohorts are asked if anyone would like to come back and facilitate on the following cohort. This entails shadowing an experienced facilitator for module 1 and developing confidence in a safe environment to facilitating their tutorial group for Module 2. To date seven individuals have taken up this opportunity. Whilst this number may seem low there is a limited capacity to coach these participants. Additionally practice areas find it difficult to support participant undertaking the programme and few can release an additional member of the team for facilitation development. As indicated previously the programme and its impact both on the participants and on patient
General nurses n=38
Occupational therapists n=5
Children’s nurses n=4
Radiographer n=2
Midwife n=13
Physiotherapist n=4
Learning disabilities n=1
Heath visitor n=3
Speech therapist n=2
Podiatrist n=1
Mental health n=4
Figure 2
Career progression
District Nurses n=1
Groups of staff who have participated on the programme.
40%
Academic progression
37%
441
Involvement in projects
57%
Developed 53% peer network
442 care is being explored as part of a research project. Anecdotal evidence suggests that participants undertaking the programme do benefit from it (Fig. 2). In general participants feel that the programme has assisted them in building their confidence in leadership positions, a view echoed by their managers and the senior management team. ‘‘The course gave me the confidence to lead, made me recognise strengths and weaknesses in myself and others and to use the strengths to improve the department. It makes me think more often about what could be improved and then I put the wheels in motion to attain these improvements’’ AHP ‘‘It has helped me to feel a little more confident when dealing with those higher in the organisation. I delegate better and am more flexible. I believe these 2 factors have helped me make a difference to patient care’’ Theatre sister ‘‘I thoroughly enjoyed the programme despite the heavy workload and feel it significantly contributed to my 2 promoted posts successfully gained while attending the programme’’. AHP ‘‘There was a notable difference in the staff who attended in particular there was a difference in their self worth and confidence. It encourages them to think critically and have the confidence to challenge traditional and often bureaucratic processes’’ Associate Director of Nursing ‘‘I have been please by the enhanced skill and confidence demonstrated, and the heightened general awareness’’, General Manager Although further information about the benefits of this programme in relation to person and professional gain for the participants and the impact on patient care, are part of the ongoing study, a general theme is being expressed, that of feeling empowered to lead. This is evidenced by participants appearing to get more involved in shaping the service, thinking more abstractly and having the confidence to function in their role as a leader. They develop and sustain social support networks during and after the programme and they are viewed as seeking solutions to situations rather than perpetuating ritual by their managers and peers. In other words they are providing evidence of having achieved the overall aim of the programme. Such attributes have been identified as essential leadership qualities from the literature (Cook, 2001; Kouse and Posner, 2003; Gaughan, 2001; AlimoMetcalfe, 1998).
K.M. Munro, M.C. Russell This evidence is also provided through the assessed work, which is a reflective portfolio and reflective critical account for each module that assists the participants to relate theory to practice, thus supporting learning through work. In terms of achieving academic credit many of the participants go on to use these points for degree completion.
Benefits There are other collective (as opposed to individual) benefits that should also be highlighted as these are rewarding and sometimes difficult to quantify when first considering collaboration. Some appear obvious to nurses and health care professionals but not necessarily to academics out with the professional. Benefits for academic staff include increased positive communications and links with practice development of clinical staff, familiarity with the staffing arrangements and structures of the NHS organisation and awareness of the impact that changes of policy has on practice. This then informs and potentially influences the development of all other programmes within the education institution. Academic staff can be proactive in seeking solutions to other concerns raised by colleagues working within the health care arena and have a raised profile within the profession. It is also recognized that there is the potential for greater student recruitment to other programmes. Similarly the NHS teaching team, based within a professional development centre, can promote the mission and culture of the organisation, increase the value of their accredited work-based education programmes and potentially contribute towards change within the organisation by virtue of transformational learning (Paton and McCalmon, 2000). Additionally the professional development of the teaching team and access to continuing professional development opportunities are enhanced through close working relationships with education colleagues.
Conclusion Due to increasing requests from allied health professionals and some nursing staff the programme has been developed to post graduate level. This allows graduates to continue on their academic pathway whilst developing their leadership skills and
Leadership development: A collaborative approach to curriculum development and delivery attributes. 2005 was the first year this level has been offered and there are 10 participants studying at this level, with 30 at degree level. The programme has been well evaluated by managers and participants alike and the module planning team are now exploring other means to support leadership development in NHS Lanarkshire. Indeed discussion is ongoing regarding how to provide a formal, structured support network and coaching those during and following the programme. Both partners have benefited enormously from the opportunity to work proactively together in collaboration in the delivery of the leadership programme. The partnership between practice development and higher education is seen by all stakeholders as a positive example of education and practice working together to improve the continuing professional development provision for the NHS. Throughout this collaboration the university college has increased its profile within the NHS by acting as first choice partner and NHS Lanarkshire has gone some way towards developing their own model for organisational learning, one that accepts and addresses the political and economic nature of the NHS (Nutley and Davies, 2001). Therefore NHS Lanarkshire will be in a better position to meet future health care challenges and provide strategies to address them.
Acknowledgements The authors acknowledge the support of Alna Robb and the staff of NHS Lanarkshire Practice Development Centre and the staff of Nursing, School of Health Sciences at Queen Margaret University College, Edinburgh.
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Cunningham, G., Kitson, A., 2000. An evaluation of the RCN Clinical leadership development programme: part 1. Nursing Standard 15 (12), 34–37. European Foundation for Quality Management, 1999. The fundamental concepts of excellence. Available at: http:// excellenceone.efqm.org/uploads/fundamental%20concepts %20English.pdf. Frost, M., 1996. An analysis of the scope and the value of problem based learning in the education of health care professionals. Journal of Advanced Nursing 24 (5), 1047–1053. Fyffe, T., Robb, A., Rodden, C., in press. Focus group interviews career progression and role definition of ward sisters and charge nurses in Scotland. Report to inform ‘‘Agenda for Change’’ Nursing and Midwifery Practice Development Unit for Scotland. Gaughan, A., 2001. Effective leadership behaviour: leading ‘‘the third way’’ from primary care group perspective. A study of leadership constructs elicited from members of primary care group management boards. Journal of Management in Medicine 15 (1), 67–94. Keeling, D., Jones, E., Botterill, D., 1998. Work-based learning, motivation and employer–employee interaction: implications for lifelong learning. Innovations in Education and training International 35 (4), 282–291. Kouse, J., Posner, B., 2002. Leadership Practice Inventory: Psychometric Properties. Wiley, San Francisco. Kouse, J., Posner, B., 2003. The Leadership Challenge, third ed. Wiley, San Francisco. McParland, M., Noble, L.M., Livingston, G., 2004. The effectiveness of problem-based learning compared to traditional teaching in undergraduate psychiatry. Medical Education 38 (8), 859–867. Morales-Mann, E.T., Kaitell, C.A., 2001. Problem-based learning in a new Canadian curriculum. Journal of Advanced Nursing 33 (1), 13–19. Munro, K.M., Peacock, S., 2005. Improving access to learning in the workplace using technology in an accredited course. Nurse Education in Practice 8 (2), 117–126. NHS, 1999. Making a Difference. Strengthening the Nursing, Midwifery and Health Visiting Contribution to Health and Healthcare. DOH Stationery Office, London. NHS, 2000. The NHS Plan. DOH Stationery Office, London. NHS Scotland, 2000. Our National Health. A plan for Action, a Plan for Change. Scottish Executive Health Department Stationery Office, Edinburgh. NHS Scotland, 2001. Caring for Scotland. The Strategy for Nursing and Midwifery in Scotland. Scottish Executive Health Department Stationery Office, Edinburgh. NHS Scotland, 2003. Partnership for Care. Scottish Executive Health Department Stationery Office, Edinburgh. Nursing and Midwifery Council, 2005. The PREPP Handbook located at NMC, London. Accessed July 2006. Nutley, S.M., Davies, H.T.O., 2001. Developing organisational learning in the NHS. Medical Education 35, 35–42. Paton, R.A., McCalmon, J., 2000. Change management: a guide to effective implementation. Sage Publications, London. Poell, R.F., Van der Krogt, F., Wildemeersch, D., 1998. Solving work-related problems through learning projects. International Journal of Lifelong Education 17 (5), 341–351. Quality Assurance Agency for Higher Education, 2000. Code of practice for the assurance of academic quality and standards in higher education. QAA, Gloucester. Quality Assurance Agency for Higher Education, 2001. The framework for qualifications of higher education institutions in Scotland. QAA, Gloucester.
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K.M. Munro, M.C. Russell UKCC, 1999. Fitness to Practice Report of the Commission for Education. UKCC, London. Wakefield, A., Furber, C., Boggis, C., Sutton, A., Cooke, S., 2003. Promoting interdisciplinarity through educational initiative: a qualitative education. Nurse Education in Practice 3 (4), 195–203. Williams, B., 2001. Developing critical reflection for professional practice through problem-based learning. Journal of Advanced Nursing 34 (1), 27–34. Woltring, C., Constantine, W., Schwarte, L., 2003. Does leadership training make a difference? The CDC/UC public health leadership institute: 1991–1999. Journal of Public Health management practice 9 (2), 1003– 1122.
Nurse Education Today intl.elsevierhealth.com/journals/nedt
Leadership development: A collaborative approach to curriculum development and delivery Kathleen M. Munro
a,*
, Margot C. Russell
b,1
a
School of Health Sciences, Nursing, Queen Margaret University College, Edinburgh, EH12 8TS, United Kingdom b NHS Lanarkshire Practice Development Centre, Wishaw General Hospital, Lanarkshire, ML2 0DP, United Kingdom Accepted 24 August 2006
KEYWORDS
Summary The Leadership Programme in the National Health Service, Lanarkshire, Scotland began in 2002. The programme has been endorsed by the employer, accredited by a higher education institution and approved by the National Health Service Education Board in Scotland as a recognised continuing professional development programme. The success of the programme is due to the combined efforts of the teaching team from the Practice Development Centre, the different stakeholders within the health service in Lanarkshire and Queen Margaret University College, Edinburgh. The focus of this article is the nature of the collaboration between the partners from the initial ideas to the initiation, validation and ongoing delivery of the programme. The article will provide an account of the criteria for partners and key features of the collaboration as well as quality assurance aspects. It will also draw upon the outcomes of the programme in terms of student views and achievement as well as the benefits to the partners. c 2006 Elsevier Ltd. All rights reserved.
Leadership development; Leadership programme; Collaboration; Accreditation; Curriculum development
Introduction and background The National Health Service (NHS) in Lanarkshire recognised that there was a need to develop a leadership programme that would take forward the * Corresponding author. Tel.: +44 131 317 3564; fax: +44 131 317 3573. E-mail addresses: [email protected] (K.M. Munro), [email protected] (M.C. Russell). 1 Tel.: +44 169 836 6584; fax: +44 169 836 6777.
health care service in line with current government policy (NHS, 1999, 2000; NHS Scotland, 2000, 2001). However, traditional in-house employer led programmes for experienced staff has not in the past been recognised as having merit by some staff in terms of either professional development or the academic worth of the course. In addition it can be argued that some staff may not value such courses because they are identified as employer driven, although employers undoubtedly prefer their organisations internal training programmes
0260-6917/$ - see front matter c 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.nedt.2006.08.004
Leadership development: A collaborative approach to curriculum development and delivery to formal higher education courses (Keeling et al., 1998; Poell et al., 1998; Munro and Peacock, 2005). Therefore, to facilitate the development of key staff within the acute and primary care trusts of NHS Lanarkshire, an accredited enquiry based learning leadership programme was developed. The construction of the curriculum went through a number of stages. Representatives from the acute and primary care trusts undertook the initial development, acting together as an employer led group. The group then sought an external education partner by inviting a number of institutions to tender for the accreditation of the programme. This led to the successful collaboration between Queen Margaret University College, Edinburgh and the Practice Development Centre of NHS Lanarkshire. The outcome is an accredited Scottish degree level continuing professional development programme equivalent to 600 hours academic and professional study. In response to the need to invest in Clinical Leadership development, both the acute hospitals and primary care trust entered into a collaborative partnership in order to meet the needs within NHS Lanarkshire as a whole. There had been considerable change within Lanarkshire. Within recent times three acute hospital trusts had amalgamated and the primary care trust evolved. This has since been superseded in 2004 with the dissolution of NHS Trusts within Scotland (NHS Scotland, 2003), and the formation of NHS Lanarkshire as a single body. Furthermore two of the acute hospitals moved into new accommodation in 2001. This also necessitated a change in the way staff work due to their new environments. Also with the ever-changing picture unfolding, communication and networking across the region had been both complicated and poor. Consequently any leadership programme developed or purchased would have, as one of its central outcomes an improvement in such areas. To meet these needs the Practice Development Centre, in partnership with Organisation Development from both divisions undertook a series of focus group events with charge nurses. The purpose of these was to identify their requirements in relation to assisting them in their ‘‘clinical leadership’’ role. Although some indication of development into financial management and personnel issues were identified in the focus groups the main emphasis pertained to improving leadership skills and enhancing attributes. Such findings are not unique to NHS Lanarkshire as other studies indicate strong similarities (Sullivan et al., 2003; Allen, 2001; Fyffe et al., in press). The findings from the focus groups were discussed with the senior management team in primary care, acute care and the organisational
437
development team. It was agreed that clinical leadership development would be most beneficial to the organisation. Cook (1999, p306) supports this notion in defining a clinical leader as ‘‘an expert clinician involved in direct clinical care, who influences others to improve the care they provide continuously’’ In terms of service development this definition fitted into the organisational needs and supported the professional and practice development of those in traditional leadership positions.
External and internal influences on development of leadership programme There are always a number of different ‘drivers’ that influence both positively and negatively the development of any educational programme. These both help and hinder the development team in terms of the focus of the development and the design and construction of the curriculum. The main internal drivers in this development came from the employer, the teaching staff in the Practice Development Centre, the managers and the clinically based staff. In addition there were other external drivers that included the university college academic quality assurance criteria and the Scottish Executive nursing division, which was at that time financially supporting one selected programme from another organisation for leadership courses. Generally these drivers can be described as; economic related to the employer’s costs of meeting staff training needs and staff demand, political in terms of ensuring that staff have the education and training to provide quality health care and to meet government targets, professional in terms of continuing professional development requirements of health care staff as well as educational and personal related to career pathways and lifelong learning. Ultimately the purpose of the programme is to improve services for patients and their carers (Woltring et al., 2003). As a means of ensuring that the programme in NHS Lanarkshire responded to each of these drivers the programme planning team were careful to review the available research evidence, thus constructing a programme which appropriately supported participants in their leadership positions. Antrobus and Kitson (1999) highlight the need for nurse leaders to have political awareness and influencing skills in order to be effective in their roles and positively impact on patient care. The European Foundation for Quality Management (1999) also indicates that the key concepts of
438 person centeredness, continuous learning, and partnership internally and externally and role clarity are central to effective leadership. Through using an enquiry based learning approach to programme delivery participants are required to examine their knowledge and challenge their assumptions surrounding such concepts. Additionally, the use of the leadership practices inventory (Kouse and Posner, 2002) is used to enable participants to identify their leadership attributes and identify action plans for development. Such an approach has been advocated and identified as being of benefit (Tourangeau and McGillon, 2004; Cunningham and Kitson, 2000; Kouse and Posner, 2002). One of the main drivers however was the need for acknowledgement as a high quality course that would be confirmed in terms of accreditation of academic level and worth and recognised within the Scottish Credit Qualifications Framework (QAA, 2001) and by the professional bodies in terms of continuing professional development (NMC, 2005). It was this driver more than any other that brought the collaborative partnership together to achieve academic and professional accreditation for the programme. Apart from the criteria for partnership, which will be explained later, there were key elements for the initial success of the partnership. These were that the higher education institution’s quality assurance frameworks had to be adhered to (QAA, 2000) and as such that they would be accessible to the Lanarkshire Practice Development team. Cost of accreditation and ongoing quality assurance of the programme had to be affordable to NHS Lanarkshire and the higher education instiute. Curriculum development and validation process had to be acceptable to both. Work had to be completed within a specified time limit.
Curriculum development In order to develop the curriculum stakeholder representatives were invited to contribute to the process. These included management, clinical staff and staff from practice development and organisational development to ensure the programme was fit for purpose. Early in discussion a literature review was undertaken in order to assist in ensuring that the programme being planned was based on the evidence provided in the literature. This further assisted in the categorising of content mate-
K.M. Munro, M.C. Russell rial. This was categorised into two main themes – ‘‘Developing Self’’ and ‘‘Leading Others’’, which later became the titles of the two modules delivered. The overall aim of the programme was agreed as, ‘To enhance and develop leadership potential for nurses, midwives, health visitors and allied health professionals in both primary and acute care settings’ In utilising a collaborative approach to curriculum planning the stakeholders were keen to meet the needs not only of the practitioners but also of the organisation and ultimately to have an impact on patient care. Enquiry Based Learning was identified as the learning and teaching strategy for the programme delivery because it was deemed most appropriate for adult learners who require to develop leadership skills within the clinical arena. Previous research surrounding this approach identifies that improved communication; team working and networking are some of the transferable skills developed as a consequence of the approach used (Barrows and Myers, 1998; Frost, 1996; MoralesMann and Kaitell, 2001). Furthermore there has been evidence to suggest that an enquiry based learning approach assists in developing transformational learning in an organisation and promotes not only retention of knowledge but integration of theory into practice (McParland et al., 2004; Wakefield et al., 2003; Williams, 2001; Morales-Mann and Kaitell, 2001). The programme was developed to incorporate tutorial groups and fixed resource session, the latter taking the form of an expert speaker, learning event or group work. The tutorial groups comprise of a maximum of 10 people plus a facilitator to encourage group discussion and learning. From the onset of the development the need to develop an interprofessional approach was clearly identified. Increasingly the benefits of interprofessional education have been recognised with improved team working and increased collaboration being identified as outcomes of this approach to education (UKCC, 1999; Reeves et al., 2002; Rusell and Hymans, 1999). Consequently this approach assisted the programme team in achieving the aim and purpose of the programme. Scenarios used to encourage enquiry are clinical in focus, but abstract in nature thus allowing all tutorial groups to identify with the material. This assists participants to relate the concepts to their clinical practice, thus promoting learning through work. Through facilitated discussion, participants are encouraged to examine and explore pre-existing notions in relation to the concepts discussed. This often means discussions around issues raised from their clinical area.
Leadership development: A collaborative approach to curriculum development and delivery A strong emphasis of the academically accredited programme is placed on personal and professional growth and development. Participants are required to reflect on their practice as part of the learning outcomes of the programme and also as part of the tutorial process. In this sense the role of the facilitator is not just that of facilitative educator but of clinical supervisor. As such the programme attempts to meet the needs both of the individual and of the organisation.
Collaboration There are a number of clearly defined stages of development within any partnership before it can be said that the partners are working together in collaboration. Working together essentially starts tentatively, meeting together and verbally exploring the ideas in the proposal, individual’s thoughts and the realities of what is possible within each partner organisation almost in an informal manner before embarking on the formal agenda for accreditation. The first stage occurred when NHS Lanarkshire formally invited institutions to submit tenders for the accreditation of their proposed programme. The criteria for tender were broadly; academic accreditation, recognition from the NHS Education Board for Scotland (NES), life long learning opportunities for participants, quality assurance mechanisms, affordable costs and additional information about the institution. The Queen Margaret University College response and submission constituted the second stage. Prior to the submission of a tender the university college had established the type and nature of the possible collaboration. This type of partnership was described as a ‘validated collaboration’ with an external non academic partner (as in another institution). The collaboration is one where a programme is developed and delivered by the staff of the partner institution and judged by the university college to be of an appropriate quality and standard to lead to its award of academic credit. In this scenario the home education institution, retains responsibility for the quality and standard of the award of credit and decides on the extent to which it exercises control over the quality assurance aspects of the programme’s management. This is in line with the Quality Assurance Agency code of practice (QAA, 2000) for programme approval, monitoring and review, whether it is for a whole programme leading to academic awards or short courses like the leadership programme.
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Therefore, each partner knew what to expect of the other in advance of formal working partnership and this knowledge was added to through informal meetings of key staff to discuss how best to take forward the collaborative work. Following the success of the tender process the university college also sought additional information to assist in the development and writing of the partners’ memorandum of co-operation and financial agreement. This was the third stage of the process which evidence was sought regarding the following criteria: Organisational, management and quality assurance arrangements. Regulations and procedures governing the relationships of students, including academic support and guidance and provision for meeting students wider educational needs. Provision of learning support and an infrastructure at a level and quality to meet the requirements for programmes leading to the award of credit from Queen Margaret University College. Ethical research standards. Appropriate provision for staff appointment, induction and development. Financial security and probity. The final stage in the development of the partnership included the establishment of Joint Board of Studies and Joint Board of Examiners. The Joint Board has the same function as any programme committee, and membership includes the teaching team as well as representatives from the employer, the academic institution and current student cohorts. Similarly the Examination Board includes the external examiner but excludes students. To facilitate collaboration communication pathways were also established early in the collaboration to ensure that each partner knew who, when and how to contact colleagues in the other organisation. This was achieved firstly through the identification of the key link personnel who communicate informally, for example seeking advice between librarians, or registry and the NHS course leader or between the course leader and the senior lecturer from the university college.
Accreditation and quality assurance Prior to the establishment of the formal structures to support the quality of the programme it was necessary to gain validation. Therefore the outline curriculum identified by the Lanarkshire group
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K.M. Munro, M.C. Russell Mechanism
ACTION
OUTCOME
Statement of intent to plan
Submitted to QMUC Faculty
QMUC approval to plan.
a programme/CPD course
Academic Board (FAB) and
Follow up by NES for CPD
NHS Education Scotland (NES)
purposes
Peer review as per QAA code of
Validation by QMUC
practice at QMUC
NES approval following
Validation procedure
critical reader comments and responses Regulatory framework and Set out in a definitive document agreed procedures for
for the programme and student
admission of students,
handbooks
Standards explicit to all stakeholders
delivery of programme, examination/assessment and award of credit Establishment of JBS
Responsible for overview and
Monitoring and
monitoring re quality assurance
Maintenance of standards
Issues brought to attention of FAB. FAB and Registry inform JBS of changes within regulations for quality assurance Modifications proposed to FAB JBS includes annual
Submitted to FAB and NES
monitoring report
Follow up in action plan for next year. Maintenance of academic credit awards
Establishment of JBE
Recommends to Academic
Award of credit to students
including appointment of
Council the award of credit
within SCQF. CPD
External Examiner Review of programme
Figure 1
requirements met for NMC Review procedure established by
Re-validation of
Registry following QAA code of
programme for further
practice and QMUC regulations
period
Quality Assurance Framework for Collaborative Programme Development.
needed to be developed further in line with their organisational needs and the academic partner’s requirements. The proposed programme was presented to the university college in line with the quality assurance regulatory framework. This included firstly the submission to faculty of the overall aim, philosophy and outline curriculum prior to full planning and finalisation, to ensure that the necessary resources were available to each partner to develop the programme. Secondly the module planning teams’ expertise and qualifications were considered in terms of appropriateness and ability to deliver the programme. Thirdly the learning units were re-designed as modules and written into the institutional format to incorporate the standards for graduate studies and reflect the Scottish
Credit Qualifications Framework. Then finally the programme was presented for approval through the normal validation and approval mechanisms. Following this Academic Council of the university college appointed an external examiner. The quality assurance mechanisms and framework for the cycle of programme development are summarised in Fig. 1.
Programme outputs There are major outcomes from the programme for each partner and stakeholders. Obviously for the students at the end of the programme they will be individually awarded with 60 Scottish academic
Leadership development: A collaborative approach to curriculum development and delivery credit points at degree level or postgraduate masters’ level, depending on their level at admission. These points are transferable and can be accumulated towards a degree outcome if sought by the individual through the Scottish credit accumulation and transfer scheme offered by higher education. The university college has fulfilled its function and awarded credit to the matriculated students. Similarly the teaching team has also fulfilled its function and ensured the employers needs have been met. More importantly is the impact that the education provision has made on the ability of the participants to do their job better throughout their working lives and the quality of care provided to patients as a result of the learning that has taken place. This outcome is supported by other studies which aim to identify the impact of leadership development on clinical practice (Woltring et al., 2003; Cunningham and Kitson, 2000; Morales-Mann and Kaitell, 2001; Frost, 1996). To date the ongoing monitoring and evaluation of the programme has provided a rich source of information. However further research is in progress to truly measure the impact of the programme on patients. There have been170 participants who have commenced the programme between April 2002 and August 2005. Of this 7 participants have withdrawn from the programme due to a variety of factors and 7 have failed to achieve to the academic standard required for programme assessment. There is an opportunity for participants to defer undertaking module 2, Leading Others should the need arise. Consequently 7 participants are currently in progression on the programme. Prior to the commencement of the 2005 intake programme a questionnaire was sent to the past participants of the programme. A further questionnaire was sent to their line managers and to the se-
nior management team. A 66% response rate was achieved (n = 78). This has provided initial data about participants in relation to positive career progression, academic progression and achievement, peer network development and involvement in projects. The returns were representative of the groups of staff who have participated on the programme (Fig. 2). The average length of employment within healthcare settings was identified at 22.5 years with the maximum being 40 years and the minimum being 6 years. The average age was 43 years – the eldest being 58years of age and the youngest being 34 years. Out of the 78 participants 50 had undertaken some element of post registration education, 29 had completed their bachelors’ degree and one completed a masters degree prior to the commencement of the programme. In addition, follow up evaluation has revealed the individual development of participants following the programme (Fig. 3). In order to allow participants to continue in their development, opportunities to facilitate development of the groups are offered. Each year the completing cohorts are asked if anyone would like to come back and facilitate on the following cohort. This entails shadowing an experienced facilitator for module 1 and developing confidence in a safe environment to facilitating their tutorial group for Module 2. To date seven individuals have taken up this opportunity. Whilst this number may seem low there is a limited capacity to coach these participants. Additionally practice areas find it difficult to support participant undertaking the programme and few can release an additional member of the team for facilitation development. As indicated previously the programme and its impact both on the participants and on patient
General nurses n=38
Occupational therapists n=5
Children’s nurses n=4
Radiographer n=2
Midwife n=13
Physiotherapist n=4
Learning disabilities n=1
Heath visitor n=3
Speech therapist n=2
Podiatrist n=1
Mental health n=4
Figure 2
Career progression
District Nurses n=1
Groups of staff who have participated on the programme.
40%
Academic progression
37%
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Involvement in projects
57%
Developed 53% peer network
442 care is being explored as part of a research project. Anecdotal evidence suggests that participants undertaking the programme do benefit from it (Fig. 2). In general participants feel that the programme has assisted them in building their confidence in leadership positions, a view echoed by their managers and the senior management team. ‘‘The course gave me the confidence to lead, made me recognise strengths and weaknesses in myself and others and to use the strengths to improve the department. It makes me think more often about what could be improved and then I put the wheels in motion to attain these improvements’’ AHP ‘‘It has helped me to feel a little more confident when dealing with those higher in the organisation. I delegate better and am more flexible. I believe these 2 factors have helped me make a difference to patient care’’ Theatre sister ‘‘I thoroughly enjoyed the programme despite the heavy workload and feel it significantly contributed to my 2 promoted posts successfully gained while attending the programme’’. AHP ‘‘There was a notable difference in the staff who attended in particular there was a difference in their self worth and confidence. It encourages them to think critically and have the confidence to challenge traditional and often bureaucratic processes’’ Associate Director of Nursing ‘‘I have been please by the enhanced skill and confidence demonstrated, and the heightened general awareness’’, General Manager Although further information about the benefits of this programme in relation to person and professional gain for the participants and the impact on patient care, are part of the ongoing study, a general theme is being expressed, that of feeling empowered to lead. This is evidenced by participants appearing to get more involved in shaping the service, thinking more abstractly and having the confidence to function in their role as a leader. They develop and sustain social support networks during and after the programme and they are viewed as seeking solutions to situations rather than perpetuating ritual by their managers and peers. In other words they are providing evidence of having achieved the overall aim of the programme. Such attributes have been identified as essential leadership qualities from the literature (Cook, 2001; Kouse and Posner, 2003; Gaughan, 2001; AlimoMetcalfe, 1998).
K.M. Munro, M.C. Russell This evidence is also provided through the assessed work, which is a reflective portfolio and reflective critical account for each module that assists the participants to relate theory to practice, thus supporting learning through work. In terms of achieving academic credit many of the participants go on to use these points for degree completion.
Benefits There are other collective (as opposed to individual) benefits that should also be highlighted as these are rewarding and sometimes difficult to quantify when first considering collaboration. Some appear obvious to nurses and health care professionals but not necessarily to academics out with the professional. Benefits for academic staff include increased positive communications and links with practice development of clinical staff, familiarity with the staffing arrangements and structures of the NHS organisation and awareness of the impact that changes of policy has on practice. This then informs and potentially influences the development of all other programmes within the education institution. Academic staff can be proactive in seeking solutions to other concerns raised by colleagues working within the health care arena and have a raised profile within the profession. It is also recognized that there is the potential for greater student recruitment to other programmes. Similarly the NHS teaching team, based within a professional development centre, can promote the mission and culture of the organisation, increase the value of their accredited work-based education programmes and potentially contribute towards change within the organisation by virtue of transformational learning (Paton and McCalmon, 2000). Additionally the professional development of the teaching team and access to continuing professional development opportunities are enhanced through close working relationships with education colleagues.
Conclusion Due to increasing requests from allied health professionals and some nursing staff the programme has been developed to post graduate level. This allows graduates to continue on their academic pathway whilst developing their leadership skills and
Leadership development: A collaborative approach to curriculum development and delivery attributes. 2005 was the first year this level has been offered and there are 10 participants studying at this level, with 30 at degree level. The programme has been well evaluated by managers and participants alike and the module planning team are now exploring other means to support leadership development in NHS Lanarkshire. Indeed discussion is ongoing regarding how to provide a formal, structured support network and coaching those during and following the programme. Both partners have benefited enormously from the opportunity to work proactively together in collaboration in the delivery of the leadership programme. The partnership between practice development and higher education is seen by all stakeholders as a positive example of education and practice working together to improve the continuing professional development provision for the NHS. Throughout this collaboration the university college has increased its profile within the NHS by acting as first choice partner and NHS Lanarkshire has gone some way towards developing their own model for organisational learning, one that accepts and addresses the political and economic nature of the NHS (Nutley and Davies, 2001). Therefore NHS Lanarkshire will be in a better position to meet future health care challenges and provide strategies to address them.
Acknowledgements The authors acknowledge the support of Alna Robb and the staff of NHS Lanarkshire Practice Development Centre and the staff of Nursing, School of Health Sciences at Queen Margaret University College, Edinburgh.
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