Giving voice to quality and safety matters at board level: A qualitative study of the experiences of executive nurses working in England and Wales.

BACKGROUND Recent reports into egregious failing in the quality and safety of healthcare in the UK have focussed on the ability of executive boards to discharge their duties effectively. Inevitably the role of executive nurses, whose remit frequently includes responsibility for quality and safety, has become the object of increased scrutiny. However, limited evidence exists about the experiences of the UK's most senior nurses of working at board level. OBJECTIVE We aimed to generate empirical evidence on the experiences of executive nurses working at board level in England and Wales. We posed two research questions: What are the experiences of nurse executives working at board level? What strategies and/or processes do nurse executives deploy to ensure their views and concerns about quality and safety are taken into account at board level? DESIGN Qualitative interviews using semi-structured interviews. SETTING NHS England and Wales. PARTICIPANTS Purposive sample of 40 executive board nurses. METHODS Semi-structured interviews followed by a process of thematic data analysis using NVivo10 and feedback on early findings from participants. RESULTS Our findings are presented under three headings: the experiences of executive nurses working with supportive, engaged boards; their experiences of being involved with unsupportive, avoidant boards with a poor understanding of safety, quality and the executive nursing role and the strategies deployed by executive nurses to ensure that the nursing voice was heard at board. Two prominent and interrelated discursive strategies were used by executive nurses - briefing and building relationships and preparing and delivering a credible case. Considerable time and effort were invested in these strategies which were described as having significant impact on individual board members and collective board decision making. These strategies, when viewed through the lens of the concept of "groupthink", can be seen to protect executive nurses from accusations by board colleagues of disloyalty whislt also actively restricting the development of "groupthink" within the board. Another finding of note was that executive boards may not be permanently fixed as either unsupportive or supportive as participants described how certain boards that were initially unsupportive adopted a more supportive attitude towards matters of safety and quality. CONCLUSIONS These highly positioned nurses can provide invaluable advice and support to boards around matters of quality and safety. However, the work of nurse executives remains an under-research area and more work is needed to better understand the ebb and flow of power and influence at play within hospital boards.