Date sent:        Sun, 12 May 1996 07:43:22 +0100


Introduction
Change which has been well planned can in effect be the most
important contributory factor to any projects eventual success.
Upton and Brooks [1995] say:
' dissatisfaction alone is not sufficient to bring about change:
people have to believe that the proposed change would lead to an
improvement '
All staff within the NHS in recent years have experienced change
[ref],  particularly change that has been politically led and
therefore experienced a process which has in effect changed the
concept and culture of the NHS with the purchaser / provider
split. Philip Hunt  [1995] says that while the NHS is no stranger
to change because of the rapidly changing social picture since
1948, it is acknowledged that in the four years since the
introduction of the NHS reforms, staff in the NHS:
' have had to see through one of the biggest revolutions
witnessed in any part of the public sector ' 
Change is therefore often viewed suspiciously among health care
staff and effort is required to ensure that change is planned,,
discussed and its purpose is understood.
Planning Revisited
key stages
Key Players
The initial four weeks were spent collecting information and
specking to those involved, the planning of the study days was
the first to be compromised when my planned dates were deferred
because of:
finding a suitable hotel within my budget
availability of speakers

Staff development
In researching the planning for change in practice there was a
need to identify the importance of staff development to an
organisation, Hardy describe a development
as..................... Within my own organisation I explored the
present situation that existed and what the strategic objectives
for the Trust were. There was also the added dimension of PREP
and the expectation of staff that this should be provided by the
employer, regardless of the fact that a practitioners , nurses
and midwives are responsible ultimately for their own
professional update. [find a ref]
However the Trust were happy to facilitate and promote
professional development but there was and is only the limited
resources available.  Review showed that co-ordination  and
planning was what was required. The ultimate strategy to create a
culture of learning and the promotion of personal development,
this would give the basis for improved patient care [ref]
Traditionally access to formal education is mainly provided by
Colleges of Higher Education [find ref] but as PREP makes an
impact upon the formal learning needs of nurses, continuing
education is provided in many formats. The American Nurses'
Association has defined continuing education as:
Planned, organised learning experiences designed to augment the
knowledge, skills, and attitudes of registered nurses for the
enhancement of nursing practice, education, administration, and
research, to the end of improving health care to the public'
This  equates closely to the objectives of my change module,
continuing education is not necessarily confined to educational
establishments but should also encompass the practical
application of  nursing skill and technology, as well as
alternative means to gain new knowledge. Dolphin and Holtzclaw
[1983] support this view saying that 'non-academic' training /
update activities have significant impact upon professional
development. 
To this end managers must realise that technical skills and
experience alone will not achieve competence, importance
considerations such as developing analytical skills and an
understanding of the practice environment need to be facilitated.
Deane and Campbell [1985] consider this as paramount to
developing professional effectiveness.
Promoting Professionalism
There has been a drive by nurses towards greater autonomy and
professionalism, nurses are now educated for registration rather
than trained, and at a higher academic level. This began with the
recognition by government of accepting the principles of Briggs
[1972] and the creation of the Nurses, Midwives and Health
Visitors Act 1979, this created the United Kingdom Central
Council, which in its turn developed Project 2000 , and is
resulting  in the gradual but continuous shift towards degree
level at point of registration. Harrison 1994 discusses this as a
concept of 'new nursing' and as 
'a manifestation of .......... professionalising drive'
but will degree entry to the profession secure improved patient
care? or as is my belief improved continuing education and 
dynamic staff development be the key? What is known that a
learning culture is required within an organisation [ref] and the
change project is the first step to developing that with the
Trust.
roles and responsibilities
managing the transition
In Handy's concept of 'Cultures and temperaments' - Frank Sinatra
as
Apollonian: 'I did it their way'
Zeusian: 'I did it his way'
Athenian: 'I did it our way'
Dionysian; 'I did it my way'
Implementation
Ward Managers Study Day
There are .... ward managers within the Countess and an important
part of the change process was ensuring that all nurse managers
where aware and prepared for the organisation and commitment to
training and continuing education of their nursing staff. As
there was rather a lot of information that I wished managers to
have, I decided to hold a study day for them to impart
information and provide them with learning material that would
become a resource to them and the ward. I held the day away from
the hospital for a number of reasons:
to ensure attendance [past experience has shown me that this is
seen by the managers as a treat as the executive have such days,
previous attendance therefore has always been high]
to ensure it was seen as a study day and therefore important to
their own professional development as nurses
to gain their undivided attention - there was no chance to be
interrupted 
I wished to provide the following:
update / information on the requirements of PREP and its
implications to the Trust and their staff
the importance of a learning culture which incorporates trained
staff as well as students
information upon learning opportunities within the Trust and the
School of Nursing that would require no financial use of
resources
understanding of professional development and the role of
Accreditation of learning and experience
an introduction to clinical supervision and the concept of
supporting professional development 
show them the executive nurses and clinical managers commitment
and support to professional development
A hidden agenda was one of my main objectives of my project and
that was capturing the training  /professional update activity, I
used the study day to introduce the new method of collection
previously agreed with  the data control manager for the Trust. 
I considered  that this study day was of paramount importance as
I was targeting an influential group of staff with the belief
that this will encourage an evidence based practice by sowing the
seeds of a learning organisation.  
Key contacts
Although I organised the study day, I involved the department of
professional development and research, again there were reasons
the first that if an expert is available use them and second it
would either put faces to names or introduce ward managers to key
tutors within the department. This would enable further
networking and  improve communication between the two services. A
further reason was that the department would give certificates of
attendance for the managers to put in their portfolio.
Assessment
The study days were well received by the ward managers, as it was
held on two days to allow for maximum attendance. Those that
attended on the first session gave colleagues on the second day
questions to ask presenters that they wished clarifying or
exploring further. There is also within the Trust a couple of
ward managers who do not tend to turn up to these days but rely
on colleagues to fill them in, they did attend one confirming her
place twice.
The evaluations showed that they felt the day gave them an
improved understanding of PREP and  how to help facilitate staff
to comply. The clinical supervision session made them aware that
as a Trust we have not addressed this, indeed following these
days the ward managers are favourably inclined to the
introduction so mush so that a paper by the Clinical Mnager of
Medicine has been well received with positive support for the
development. Most of the 'when will we have time' comments were
actively discussed on the day, and I was fortunate that the
speaker spoke from a facilitator and practitioners perspective
sharing reflectively his experiences.
Training Directory
There had been a recent attempt within the Trust to capture as
much of the training activity as possible during a Training Needs
Analysis, however there was a reliance that providers of the
training would regularly update the personnel department. There
was also an assumption that the staff development paper including
this information would be generally available to all staff, there
was also disappointingly little information on nursing activity.
The department of professional development and research send to
each ward area details of the next years provision, however this
information is not always readily available to ward staff. 
With this in mind another important aspect of my change project
was to produce a newsletter, however it soon became apparent that
there was also a need for a comprehensive training directory for
the Trust. As I was collating the information for the newsletter
anyhow it was logical to produce this however as it was to be for
the Trust and with the objective of creating a learning
environment throughout it would therefore reflect all training. 
To achieve this I wrote to all those who I knew provided training
sessions, updates or courses and asked them to provide me with
their next 12 months intentions, I also asked each head of
department. I informed them of my intention to provide a yearly
directory supported by a quarterly newsletter, all where
supportive of the idea which often seems to be the case if they
are not being asked to commit more to such a project. Time
restrictions within the project however required me to
concentrate on the information I received promptly so with
respect to the medical training opportunities I only included the
rolling half days.

The compilation of the directory took over a month to produce
mainly because of other commitments within my schedule, the
newsletter took about a week to produce, collated from the
information for the directory.
Cascade of Information
To ensure that all staff are aware of the directory and
newsletter, the concept was introduced to the managers at the
study day and at senior nursing meetings. The Director of
Personnel was involved as proof reader and resource of training
activity in the professions allied to medicine. The launch of the
directory and newsletter was at the 'Team Briefing' in May by the
Chief Executive, this information is cascaded down to all staff
within the Trust over a period of 3 days, those staff who are not
'brief' have access to the team briefing folder. The
effectiveness of this method of communication is audited by
personnel quarterly.
Assessment
The impact of this document will take a period of time to assess
but within the limitations of this project the following has been
identified which could be because of the information provided to
each area:
Capturing Training Activity
One of the first things that I had to try and address was the
capturing of information regarding training. Prior to this the
information was either kept by trainers [including the school] or
wards, to try and collate this information proved impossible
within the last 4 months prior to the project when the Trust
could not identify all the activity within the nursing profession
of achieving PREP requirements or those nurses with varying
oncology qualifications. To this end, with negotiation with  the
data control manager it was agreed that the present system
[Powertec] could be enhanced to capture the activity within the
Trust. The department was already looking for ways to streamline
the documentation that ward managers were having to complete and
by revising the collection of sickness and collecting training
activity separately,  the present data collection system which
the ward managers need to use would become a monthly task rather
than weekly.
Each month a sheet with the names of each member of staff will be
sent to managers and using a simple code identify all training
/update activity, there will also be a 'census' of all
professionally trained staff to capture all their qualifications.
This is because in the past the data inputted into the Powertec
has only included the qualification required to practice such as
RGN or RM, all other qualifications have not been included.
This information while kept centrally will be available to all
ward managers should they wish to identify and cost the raining
activity within their ward. Centrally reports to the NHS
executive will be far easier and last minute demands for
information on training easily accessible.
Improving communication with the college
Work began upon this collaboration well before the start of the
final module. This  was because I had discussed it at the Trust's
nursing issues group [of which I am a member]  as it was the best
forum,  and the meetings were set up promptly by the groups
chairman. These meetings encompass the following:

trust     college 
Executive Nurse     dean 
clinical managers   head of professional development 
research and development officer   head of midwifery Education 

While initial discussions have focused on the provision of
services  [particularly midwifery] useful dialogue has taken
place. Issues such as pertinence of courses and numbers of places
for Trust staff were raised. Uptake of  modules by Trust staff
needed to be monitored as well as how many staff are indexing for
the Higher Award and degree, so we can plan the facilitation of
their courses. 
The tutors also brought to our attention in-service training days
for expanded skills that staff had attended but had not completed
supervised practice. Managers had been unaware of this was
effectively acted upon in the following weeks.
The meetings are to continue on a quarterly basis to continue to
develop a liaison pertinent to both parties and ultimately our
nursing staff.
After the change / analysis
'Co-ordination' so often used and does not sound like a
particularly dramatic activity, but as Pollitt [1994] says when
controlled  it contains two important aspects of management:
information
organisation
without managing these effectively co-ordination is impossible.
Responses to change
Was it controlled change
WAS support given to cope with the change
Effects on the organisation
I was fortunate in many ways with this change project, I
identified something that was needed for nurses and the
organisation, I had co-operation from each service within the
Trust to enable its inception and successful conclusion and the
support of the senior nurse management team in their belief that
I would be successful.
In identifying the need to provide a cohesive strategy to
co-ordinate the training  with the Trust, I had the luxury of
working and facilitating my 'ideal' in an effort to provide
nurses with knowledge of the opportunities available to them. 
staff development  has had  a high priority with the executive
for some time, I also believe that from this project it now has a
 high profile with nurses, if they are supported by their ward
managers and encouraged by the senior nurse managers the
potential to improved patient care is certain [ref] by
facilitating informed, research based practice. Most of all our
nursing staff need to know they are valued, and that the
commitment to their personal development will continue,
ultimately:
'The organisation that learns to learn will survive. To do this
its people must also learn to learn.'
Sir John Harvey-Jones [1989]
