Journal of Nursing Management, 2008

Commentary
Patient centred leadership in practice
MICHELE HISCOCK
1
BSc, RGN
1
and CAROLINE SHULDHAM
PhD, MSc, RGN, RNT, PGCEA
2,3
Head of Nursing Development & Quality, 2Director of Nursing and Governance, Roya
l Brompton & Hare eld Trust, Sydney Street, London SW3 6NP, UK and 3Honorary Clini
cal Senior Lecturer, Imperial College
Correspondence Michele Hiscock Head of Nursing Development & Quality Royal Bromp
ton & Hare eld Trust Sydney Street London SW3 6NP UK E-mail: m.hiscock@rbht.nhs.uk
H I S C O C K M . & S H U L D H A M C . (2008) Journal of Nursing Management 16,
900–904 Patient centred leadership in practice
Aim To explore patient centred leadership at every level in an organisation and
provide practical examples of how this was demonstrated in an acute tertiary NHS
Trust. Background There is a direct relationship between leadership and quality
of care. With increasing expansion of their role nurses are in a key position t
o in uence and lead colleagues to improve patient care. Evaluation The Leadership
Qualities Framework (NHS Institute of Innovation and Improvement 2006) is used t
o illustrate the various qualities used by clinical leaders in examples of leade
rship in practice. Key issue Leadership development with the emphasis on the pat
ient drives improvements in service delivery and patient safety. Conclusion Pati
ent centred leadership is demonstrated when there is support at the top of the o
rganisation. Politically aware nurses make effective patient centred leaders. Le
adership development programmes provide staff with opportunities to acquire esse
ntial skills and qualities in order to contribute to the vision of the organisat
ion. Implications for nursing management Managers should support staff and take
risks in order to empower nurses to implement initiatives which improve patient
care. A process of communication using a variety of tools can have a impact on a
range of staff. Patient centred leaders are role models for tomorrowÕs leaders, t
heir impact has lasting effect and wider implications within an organisation and
beyond. Keywords: leadership, leadership qualities, nurse leaders, patient cent
red leadership
Accepted for publication: 16 October 2008
Background
There is a direct relationship between leadership and the quality of care. This
has been highlighted by the Healthcare Commission (2008: 39) in their report ÔLear
ning from InvestigationsÕ where leadership was one of the Ômost critical factors in
providing good, safe and digni ed careÕ. They conclude that good leadership is impor
tant in setting the direction of the organisation, developing its culture, as we
ll as ensuring delivery of services and maintaining effective governance. This i
s
900
relevant to nursing with its aim to provide excellent, safe, compassionate care.
 In nursing, the senior leadership position in an acute Trust will be the Nurse
Director who sets the direction, looking forward to the future, and determines t
he approach to care which should permeate throughout the organisation. Nurse lea
ders need to bring the Ôbedside to the boardroomÕ and caring to the centre of health
care reforms so that patient satisfaction and care have equal ranking with nance
, targets and other matters on the BoardÕs agenda. (Burdett Trust for Nursing 2006
).
DOI: 10.1111/j.1365-2834.2008.00961.x ª 2008 The Authors. Journal compilation ª 2008
Blackwell Publishing Ltd
Patient centred leadership
Nurse leaders who have brought care to the fore have skills, con dence and tenacit
y that have enabled them to achieve this against competing interests. They have Ôa
sophisticated grasp of their organisational and political context and the abili
ty to tailor their leadership style accordinglyÕ (Burdett Trust for Nursing 2006:
24). Not only do they have to engage the Board but they must be open and visible
in the clinical setting engaging with staff at all levels. Nurse directors ofte
n combine their nurse leadership responsibilities with other managerial function
s and as a Board director have to lead and be in uential in the wider organisation
. Fagin (1996) asks whether nurse executives then see themselves increasing thei
r scope and prestige by minimizing their nursing responsibility. In contrast we
suggest that if nurse leaders bring their nursing skills to bear in focusing on
patients and their experience, the wider nursing leadership role is strengthened
. Some of this is seen in the role of matrons with their focus on patient wellbe
ing privacy and dignity and protection from infection and where the key is to le
ad by example (Department of Health 2001). Ward sisters and charge nurses who ha
ve a more immediate impact on patientsÕ care are the lynch-pin for effective worki
ng in wards/units, in uence staff from many disciplines and the provision of quali
ty patient care (Kitson 1991). All this requires well-developed leadership skill
s, and understanding the various approaches to leadership is useful. Some are fa
miliar with the notion of transformational leadership (Burns 2003). These leader
s have a range of characteristics including vision, the ability to inspire other
s, implementing change and enabling others to grow. That said there are times wh
en transformational leaders use a transactional approach, i.e. concern with gett
ing the task done, is appropriate. Dealing with an emergency is the most obvious
example. This idea of adapting oneÕs leadership style to suit different circumsta
nces has been recognised. Hersey and Blanchard (1988) suggested there is no one
best style and described a range of directing, coaching, supporting and delegati
ng behaviors that might be employed. The role a nurse occupies in an organisatio
n will in uence the way the leadership role is enacted and the skills needed. Whil
st the director engages the Trust Board with a focus on the patient and sets the
culture for this throughout the staff, the ward sister for example has a direct
relationship with patients and on meeting their needs. Both have to enact a lea
dership role, employ recognised leadership skills and learn from experience. The
y might be transformational in style and have power in the organisation derived
from position and personal
characteristics. They need to in uence and engage others, and be effective. The re
lative position of each person determines their role, but each has to be a leade
r as well as an effective manager together they are a team which can ensure clin
ical quality, reduce risk to patients and improve outcomes. Leadeship developmen
t is important, and in the NHS, the Leadership Qualities Framework (LQF) (NHS In
stitute for Innovation & Improvement 2006) provides a tool for use at all levels
to explore our leadership qualities. The framework is arranged in three cluster
s: setting direction, delivering the service and personal qualities. There are q
ualities such as self-belief, personal integrity and drive for improvement. In t
his we see it is important that nurse leaders be self-aware and focus not only o
n themselves but on patients and the quality of the service delivered. To be pat
ient centred leaders, nurses have to focus on improvements that have a positive
impact on patients. They also have to enable patients to bring their experience
to bear when services are designed or changes made (Bate & Robert 2007). This is
the central theme of this paper as we describe projects in an acute setting whe
re leadership has been used to bring about changes which improve care for patien
ts (Figure 1).
Improving dignity and reducing interruptions
Our rst project was initiated when clinical leaders participating in the Royal Co
llege of Nursing Clinical
Figure 1 Institute for Innovation and Improvement (2006).
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of
Nursing Management
901
M. Hiscock and C. Shuldham
Leadership Programme (Cunningham & Kitson 2000a,b, Large et al. 2005), took acti
on to improve the safety of drug administration and the management patientÕs priva
cy and dignity. The clinical leaders conducted observation of care which is one
of the core interventions of the clinical leadership programme. They found that
when nurses administered drugs to patients they were frequently interrupted. Fur
ther exploration revealed that frequent interruptions were the likely cause of d
rug administration errors. Interruptions also interfered with the opportunity fo
r nurses to discuss drug information with patients. The clinical leaders reviewe
d past incident rates and found a high number. At Royal Brompton and Hare eld NHS
Trust patient safety is a priority in everything we say, do and endorse so the c
linical leadersÕ aim was to identify how they could make improvements in medicine
safety. Linking back to the Leadership Qualities Framework (NHS Institute for In
novation & Improvement 2006) which formed the basis of the clinical leadersÕ 360 f
eedback and implementing this improvement in medication safety, the leadership q
ualities broad scanning and seizing the future were demonstrated by the clinical
leaders. They looked into good practice in other organizations and decided to b
uild on a similar project introduced at The Hillingdon Hospital NHS Trust in pro
tecting patientsÕ privacy and dignity by introducing signs and red pegs clipped to
curtains in clinical areas. When displayed they gave the message ÔStop, Wait, Ask
before interruptingÕ. Our clinical leaders also saw the potential to use the sign
s and a red peg to increase awareness amongst all staff not to interrupt when nu
rses are administering drugs to patients, thereby preventing errors and increasi
ng the opportunity for nurses to discuss drugs with patients. The team relished
this challenge and being prepared to stand up for what they believed in, the sel
f-belief quality was highlighted by the clinical leaders as they planned how the
y would implement red pegs. The facilitator who leads the clinical leadership pr
ogramme had a key role in the implementation, by demonstrating empowering others
and leading change through people. She inspired the clinical leaders demonstrat
ing qualities found in transformational leaders. Also she displayed support for
the clinical leaders so they were con dent and supported in driving this service i
mprovement. A date to launch red peg was nalised and the campaign preparations to
ok place throughout the preceding 2 weeks. The clinical leaders and the facilita
tor demonstrated their effective and strategic in uencing by discussing the campai
gn with matrons, allied health 902
professionals and medical consultants, chief executive, directors, catering staf
f, estates team and many more. Everybody acknowledged the importance of improvin
g the patientsÕ experience and when asked to wear a badge with the message Ôask me a
bout the red pegÕ were willing to do so. A red peg symbol was on the home page of
our intranet site, which linked users to further information about the campaign.
Wearing a badge became very fashionable and the clinical leaders were surprised
when their medical colleagues started asking if they too could have a badge: sh
owing how the nursesÕ leadership quality of drive for results was working. The cli
nical leaders were motivated to transform and improve patient care, the extent o
f the strength and power that they had as patient centred leaders meant that the
y were also developing leadership qualities in others. Communication around the
hospitals about the meaning of the red peg during the preceding weeks of the lau
nch was key. Signs were displayed throughout the hospitals to inform everyone. N
otices for doors, drug trolleys, drug cupboards and red pegs were distributed to
patient areas in preparation for their introduction. The clinical leaders celeb
rated their positive impact on patient care when the drug errors for the year fo
llowing the introduction of the red pegs was lower than it had been for the prev
ious 2. However it was important to reinforce the fact that protecting patientsÕ p
rivacy and ensuring their safety when receiving drugs was now part of everyday p
ractice. The campaign had to become part of core activity so the door signs and
pegs needed to be provided from a central budget. The facilitator demonstrating
effective and strategic in uencing secured agreement on future funding and a centr
al collection point. The strongest leadership quality highlighted in this exampl
e is political astuteness – outstanding leaders demonstrate a political astuteness
about what can and cannot be done in how they set targets and identify service
improvements (NHS Institute for Innovation and Improvement 2006 7). Understandin
g who the key stakeholders were in the hospitals and the best strategies to in uen
ce them, the clinical leaders were then in a better position to implement this s
ervice improvement. The aim of the red peg was publicised to patients in their n
ewsletter and in public areas of the Trust. The clinical leaders involved staff
at all levels of the organisation explaining why protecting patientsÕ privacy and
safety is important. The clinical leaders demonstrated that they were attuned to
priorities at national and local level by being aware of improving medication s
afety as a national imperative (Department of Health 2004).
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of
Nursing Management
Patient centred leadership
Providing emergency care
Patient centered leadership was demonstrated by a team of various disciplines wh
en we introduced a primary percutanous coronary intervention service at Hare eld H
ospital for the treatment of ST-segment elevation myocardial infarction (STEMI)
(Nicholas 2006). This example illustrates how the Leadership Qualities Framework
can be used to articulate the contribution the team made to implement a new ser
vice. Initially meetings were set up which involved the nurse manager, cardiolog
ists, key staff from the local general hospital, the ambulance service and cardi
ology staff to plan how they would work together. In order to implement a primar
y percutanous coronary intervention for patients, the team had to in uence commiss
ioners and other policy makers. The team were aware of the national service fram
ework for coronary heart disease (Department of Health 2004) and the review of e
arly thrombolysis (Department of Health 2003) and had a desire to share their wo
rk nationally which could improve patient care. The team knew it was going to be
long-term project with challenges and they adapted their leadership style to me
et the requirements of each issue as it arose. The team worked crossed organisat
ional boundaries and they had the drive improvement, another leadership quality.
The team worked with the local general hospital and ambulance service, somethin
g of which they had little experience as they worked in a tertiary referral cent
re that does not have an accident and emergency department neither does it admit
emergency patients. As a follow up to the rst meeting the nurse manager led a me
eting for the cardiology staff and set clear objectives for implementing the new
service, which would change the whole mindset of admitting patients requiring e
mergency care. She was very clear about what was expected and managed implementa
tion of the agreed actions, demonstrating the leadership quality holding to acco
unt, and using a transformational style. Demonstrating empowering others the car
diology staff discussed how they could work with the ambulance service, gain an
insight into their role and in return how they could provide them with the knowl
edge of the procedure, so they were able to prepare the patient for their emerge
ncy admission during their journey to the hospital. As mentioned earlier, the ho
spital would not normally admit patients with STEMI. With patients arriving via
the main entrance, the team agreed that once the ambulance service gave an estim
ated time of arrival a nurse and cardiology registrar would meet the patient to
escort him/her to the cardiac catheterisation laboratory.
Resuscitation equipment was placed in reception and screens made available in th
e event of a patient having a cardiac arrest in an exposed area. The leaders of
this service development were leading change through people. They shared leaders
hip so everyone who was involved had a sense of promoting, communicating and bei
ng excited about how they were going to contribute to saving patientsÕ lives. Once
the service was implemented, the team re ected on how they could improve the pati
entsÕ experience. In particular clinical staff found that the psychological impact
on patients was even greater than had been anticipated. Demonstrating their bro
ad scanning leadership quality, the team discovered that patients were either in
denial that they had suffered a heart attack or as they had bypassed their loca
l hospital and come to a specialist centre they thought they must be very ill. T
he cardiac rehabilitation nurses recognised that the psychological support and h
ealth education patients needed had to be improved. They demonstrated their driv
e for results when they developed a protocol for telephone follow up 1 and 4 wee
ks after the patient was discharged. The strongest leadership quality demonstrat
ed in this example is effective and strategic in uencing – an unusually high and com
plex level of in uencing, the most effective leaders make things happen by using p
articularly high levels of in uencing (NHS Institute for Innovation and Improvemen
t 2006: 9). This team had to work in partnership with agencies and were successf
ul in improving the patientsÕ clinical outcome. The service has now expanded to ot
her areas within Greater London and Hare eld Hospital has the fastest door to ball
oon time in the UK (Dalby 2007). The team in uenced key staff internally and exter
nally by taking a risk and believing in their professionalism and ability to mak
es changes which focused on patients. The team combined strategic in uencing effec
tively with empowering others because they emphasised that every part of the pat
ientÕs journey from diagnosis to discharge from outpatients contributes to the pat
ientÕs clinical outcome. The team empowered staff to make decisions, emphasising t
hat more than just one or two disciplines were important in this new service. Mu
tual respect and acknowledgement had in turn developed more patient centred lead
ers.
Conclusion
Nurses at all levels can demonstrate their patient centred leadership skills and
the best examples are probably seen when there is support at the top of the org
anisation to enable everyone to participate. When the Trust board demonstrates i
ts commitment to 903
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of
Nursing Management
M. Hiscock and C. Shuldham
patients by expecting to have feedback of their experience and support actions t
o make improvements, it sets a clear example to all staff that patientsÕ experienc
e drives the organisation. It is essential so they understand the impact of thei
r role on patients and outcomes and use their leadership expertise to effect imp
rovement. The leader should demonstrate expertise in making improvements in pati
entsÕ care and safety that is sustainable; quick xes fail and are a poor example to
junior nurses who are the potential leaders of the future. Patient centred lead
ership is about ensuring a focus on patients, their well-being and experience is
the centre of everything we do and where there are obstacles using various lead
ership qualities to overcome them. The attitudes and attributes of individuals m
ake a difference to a patientÕs experience and good patient centred leaders can be
role models and in uence and develop others to do the same. Developing patient ce
ntred leaders, acknowledging examples of it in practice from the board room to t
he oor encourages and supports nurses at every level to deliver care that is safe
and focused on continuous improvements for patients.
Acknowledgement
The authors would like to thank Geraldine Cunningham, Head of Learning & Develop
ment, Royal College of Nursing for her support.
References
Bate P. & Robert G. (2007) Bringing User Experience to Healthcare Improvement; t
he Concepts, Methids and Pratices of Experienced-Based Design. Radcliffe Publish
ing, Oxford/ New York.
Burdett Trust for Nursing (2006) Who Cares, Wins: Leadership and the Business of
Caring. The Burdett Trust for Nursing (and OPM), London. Burns J.M. (2003) Tran
sforming Leadership. Grove/Atlantic Inc, New York, USA. Cunningham G. & Kitson A
. (2000a) An evaluation of the RCN Clinical Leadership Development Programme Par
t 1. Nursing Standard 15 (12), 34–37. Cunningham G. & Kitson A. (2000b) An evaluat
ion of the RCN Clinical Leadership Development Programme Part 2. Nursing Standar
d 15 (13–15), 34–40. Dalby M. (2007) Specialist care cuts heart deaths. Interview wi
th BBC. Available at: http://news.bbc.co.uk/go/pr/fr/-/1/hi/health/ 6719075.stm,
accessed 17 August 2007. Department of Health (2001) Health Service Circular (H
SC) 2001/010. Implementing the NHS Plan-Modern Matrons: Strengthening the Role o
f Ward Sisters and Introducing Senior Sisters. Department of Health, London. Dep
artment of Health (2003) Review of Early Thrombolysis. Faster and Better Treatme
nt for Heart Attack Patients. Department of Health, London. Department of Health
(2004) The National Service Framework for Coronary Heart Disease. Winning the W
ar on Heart Disease. Progress Report. Department of Health, London. Fagin C. (19
96) Executive Leadership: improving nursing practice, education and research. Jo
urnal of Nursing Administration, 26 (3), 30–37. Healthcare Commission (2008) Learn
ing From Investigations. Commission for Healthcare Audit and Inspection, London.
Hersey P. & Blanchard K.H. (1988) Management of Organizational Behavior. Prenti
ce Hall, Englewood Cliffs NJ. Kitson A.L. (1991) Therapeutic Nursing and the Hos
pitalised Elderly. Scutari Press, London. Large S., Macleod A., Cunningham G. &
Kitson A. (2005) A Multiple Case Study Evaluation of the RCN Clinical Leadership
Programme in England. RCN Institute, London. NHS Institute for Innovation and I
mprovement (2006). NHS Leadership Qualities Framework. http://www.NHSLeadershipQ
ualities.nhs.uk (accessed June 2008). Nicholas M. (2006) Setting up a Primary pe
rcutaneous Coronary Intervention Service. British Journal of Cardiac Nursing 1 (
4), 1–6.
904
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd, Journal of
Nursing Management