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The Practicalities of Shared Decision Making: Where to begin

Updated: Sep 1, 2022

This whole section is going to be based on the premise that you’ve decided to implement the councillor model of Shared Governance. This is not the only way to create a culture of Shared Decision Making (SDM), though it is a brilliant way to do so and works well within the structure of the NHS. So, you have decided as an organisation that you want to begin setting up councils and empowering your staff. You’ve seen other organisations benefit from this and now you want to replicate it for your staff and patients. Where do you begin?

"Keep it simple, stupid"

Firstly, I want to emphasise the importance of keeping your model simple. Many organisations coming on board with SDM/SG look to Nottingham University Hospitals (NUH) who have a well-established Shared Governance model which has been incredibly successful. They were the source of a lot of my knowledge on SDM/SG and have helped me enormously. However, the trap here is NUH have been on their journey for around a decade now. Their model has transformed and evolved over time to be what it is today. Jumping in at that level and complexity right off the bat will only cause headaches for new organisations. As well, I'd advise not to try to be too unique and differentiative yourself too much immediately as it will only further complicate things. So I stress the above, ‘keep it simple, stupid’. Additionally, look at it this way. If you pick up your phone and decide to download and use a specific app, yet find it to be complex and unintuitive, you will most likely uninstall the app and not use it. The same goes for frontline staff and engaging with this process. They are immensely busy in their day jobs as it is, so we cannot expect them to engage with a complicated model. Keeping it as simple and easy to access is key to the success and sustainability of your model in the long term.

Step No.1: What is your model?

Before you even consider speaking with staff to form your first councils, it is vital as a senior nursing and midwifery team that you sit down and discuss what your model is going to look like. This might evolve over time, but for now it will provide the structure on which to launch your model from. It will also help to have a core structure in case of personnel change within your senior leadership team, to ensure sustainability of the model. I have detailed how ours looks in my previous post to give you an example, so do check that out if you have not already.

Here is a list of key questions you need to answer, most of which are covered in my previous blog post. In no particular order:

  • What types of councils will you have?

  • How long will you give your councils to meet?*

  • How often can they meet?

  • How many people can sit on a council?

  • Will you have a Leadership Council? If so, when and how will this run? Where will it be?

  • What training will your councils receive? Is there someone to deliver this?

  • Resources, what is required for your councils to be successful?

  • Who is going to lead on this? Will you appoint a facilitator?

  • What do you expect from your councils?

  • What do you think your councils will expect from you?

* Time allocation is integral to the sustainability of Shared Decision Making and enabling this to function in the first place. This allocation of resources should come from the top, your Chief Nurse, and be made clear from the start. Council members will need dedicated time on a monthly basis to be involved in their council meetings and this should not be carried out in their own time.

Infrastructure - Recruiting a Facilitator

With your model agreed upon, your next step is to look at how you intend to implement the model, or rather, who will. Early on at Northampton General Hospital it became apparent the senior team would not be able to grow this successfully without dedicated, hands on support. They created a split position between NUH/NGH with a facilitator working two days a week at NGH, and 3 days clinically at NUH. This position enabled the creation of training sessions, resources and support for councils on a long-term basis.

Some of the roles of the Facilitator are:

  • Promotion of SDM across the organisation

  • Set up of councils

  • Organising & delivering of training

  • Ongoing support thereafter to councils

  • Development of resources, both physical & digital

  • Organising & facilitating the Leadership Council

For a district general hospital, 15-22.5hrs/pw is plenty of time to begin. For a larger, multi-site teaching hospital, initially 15-22.5hrs/pw will be fine but will quickly need increasing soon into your journey. I am now the sole facilitator at University Hospitals of Leicester working full-time, though this is becoming challenging as the model is growing.

Develop a training package

With your model planned and a facilitator in post, your next step is to forward plan a training package for your councils. Our frontline teams often have very little to no experience with quality improvement, and have likely never been involved in this style of group before. Therefore it's important to give them a solid foundation in order for them to be successful. I always ensure a council is trained first prior to meeting for the first time. In my experience, those councils who received training prior to meeting, were much more successful and sustainable, compared to those who began meeting and then received training at a later date. Below are some questions you should consider when planning your training:

  • How long will this be?

  • How often will this run? Adhoc/monthly

  • Who do you want to be involved?

  • Where will you hold this training?

  • What will your councils need to be successful in the long run?

Historically I provided my councils with a one day session on an adhoc (as needed) basis. However, as staffing has become more stretched on the units, I have begun experimenting with the delivery of training spread over their first three council meetings. I request each council's first meetings last between 2-3 hours, and I spend the first half of that delivering training, with the second half over to the council to begin their meetings. Below is a list of topics I cover on a typical training day:

  • Pathway to Excellence

  • Shared Decision Making in two parts (What it is, how it works / projects)

  • Hospital Charity (Who they are, how to access them, how to fundraise)

  • Health & Wellbeing (Who they are, what initiatives are available to staff and how they can support health and wellbeing projects)

  • Patient Experience (How teams can access their friends & family feedback)

  • Q&A with a current council

Although Shared Decision Making is essentially quality improvement, many of the improvements teams will choose to focus on do not require large QI projects or the governance that follows. Therefore I am careful not to overload the councils with quality improvement training, at least at the start (if they want it, it's available). QI can be rather dense and heavy going. Providing that training to councils at the get-go can be overwhelming and has the potential to deter staff rather than motivate. Instead I teach very basic QI condensed into an hour, looking at implementing changes, measuring a change, gathering evidence, etc. I then provide the councils with very simple project templates to get them started.

Spread the word

You've got the fundamentals of Shared Decision Making planned out and you're now ready to go. Pull together a presentation that summarises the below, and then get out there and begin speaking to teams. Go to every meeting you can, such as the Nursing & Midwifery Board, divisional level meetings, band meetings up to matron level, professional nursing forums, ward meetings and all MDT meetings. When selling this, think strategically!

  • Speak for 10-20 minutes

  • What Shared Decision Making is

  • How it works in practice

  • The benefits for staff / patients / the ward or team

  • The benefits for the organisation

Alongside this, begin creating resources such as leaflets, posters, videos and intranet pages. Although you may not be directly speaking to staff, the exposure they all can bring is hugely beneficial and worthwhile. If you have been to one area to 'plant a seed', remember to keep 'watering that plant'.

Although this model should grow naturally, it requires us to continue communicating what the model is and how staff can get involved. Not all areas will be in the right place to begin a SDM council, and some simply may not require it. I make it clear to teams that I am not there to request they set up a council, I am simply offering it. If they wish to get in touch tomorrow, or in 12 months time, that's ok!

Begin to grow your first councils

As a result of your information spree, I can guarantee you will have your first few councils emerge in the form of your most motivated and enthusiastic teams. (It's important to note, this is a strictly natural, organic process. We do not force councils on wards or teams, they must come forward and want to be engaged in this process for this to work.) With those interested having come forward, now is the time to focus on creating well-trained pilot councils. I would recommend beginning with no more than four, unless you are experienced with SDM/SG.

As those councils begin to grow, share their journeys with your organisation and particularly highlight their successes. Go back to those meetings that you were at previously and now share the councils' work. The importance of staff recognition and being valued cannot be understated here. With people being attracted to that success, they will naturally want to be involved and to empower their teams in similar ways. Those initially hesitant teams will now begin to reach out and come on board.

When setting up your first councils, really focus on the frontline. There is no point at this early stage in setting up 'Coordinating Councils' at management level until you have a healthy council base who can feed into them. Going further, I would encourage ward/unit based councils to be set up initially, as these are much more straight forward and will help to grow your experience as an organisation (and particularly grow your facilitator's experience). You can then look to Specialty or Themed councils which are often slightly trickier to get up and running.

This entire process can take time and it's important this is recognised. This is not something you can embed and see massive success with in the space of one year. For me, as an experienced facilitator, it took me a year to get my first 10 councils. I focused heavily on quality over quantity and now we're seeing the pay-off with over triple that number of councils coming on board.

Schedule your first Leadership Council

With your first few pilot councils setup, you can now organise your Leadership Council meetings, which will soon become the best meeting in the calendar. This is a unique meeting which runs approximately every six weeks for roughly 1-2 hours. It is an opportunity for council chairs to meet with the Chief Nurse and their senior nursing team. It enables them to share lessons and progress with one another, and to draw on support from the Chief Nurse to unblock any barriers to their projects. It is an opportunity to network with other councils across the organisation, and can be significant in helping to boost a council's (or chair's) confidence, progress and development. The meetings are deliberately informal and staff are encouraged to ask questions and engage. We ask the three questions:

  1. What are you working on?

  2. What's going well?

  3. What could be better/do you need support on?

I've been asked numerous times for a terms of reference for this meeting, and it pains me each time. You simply do not need a terms of reference for everything, and over-governing will squeeze the magic out of this particular meeting. All you need to do is throw a meeting in the diary, invite you chairs and make sure your chief nurse and members of the senior leadership team are there.

Lastly, never underestimate the power this meeting can have in motivating and enthusing your councils, giving your staff a 'seat at the table' is hugely significant and it will be appreciated and recognised by all involved. As a council chair, I have such fond memories attending my first leadership councils. They were fun, relaxed, I was able to meet colleagues from across the hospital and build a network with them. Above all, it gave us an opportunity to hear directly from our Chief Nurse and that was powerful. With that said, never cancel this meeting! It speaks volumes for staff recognition and support to keep this running throughout the most challenging of times.

With all of those points met, you should be well on your way to finishing chapter 1 of embedding Shared Decision Making at your organisation. Will it mean you have succeeded in transforming the culture? No, that will take many years, however it is potentially the hardest part out of the way.

I will write more in future blog posts about the next steps, the council set up process, training delivery, and more.

If you need any further support or would like any of the points clarifying, please Direct Message me on Twitter @MattKendall17 - Good luck!

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