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The development, implementation and evaluation of a leadership programme for midwives

29 September, 2016

The development, implementation and evaluation of a leadership programme for midwives

An innovative midwifery leadership development programme was devised, implemented and evaluated from 2012 to 2016

Mary Ross-Davie1 PhD, MA, RM, BA. Ruth Stevenson2 MA, BA. Kirsty Maynor3 MSc, BA. 

1. Educational project manager, NHS Education for Scotland, Westport 102, Edinburgh EH3 9DN Scotland.
Email: mary.ross-davie@nes.scot.nhs.uk
2. Chief executive officer, Ruthless Research, 68 Silverknowes Eastway, Edinburgh EH4 5NE Scotland.
Email: ruth@ruthlessresearch.co.uk
3. Chief executive officer, Firefly Group, Hesperus Crossway, Edinburgh EH5 1FW Scotland.
Email: hello@thefireflygroup.co.uk

The Delivering Quality through Midwifery Leadership and Best Start Leadership Programme were funded by the Chief Nursing Officer Directorate at the Scottish Government.  Scottish Government support for the programme was led by Ann Holmes, chief midwifery advisor at Scottish Government. Additional tables for this paper can be accessed here 

Abstract 

Background. High-quality leadership is an essential requirement for the delivery of high-quality maternity care. An innovative midwifery leadership development programme was devised, implemented and evaluated from 2012 to 2016. 

Method. The programme combined education, one-to-one coaching and experience of undertaking a local quality improvement project. Each year an external evaluation was undertaken to evaluate the success of the programme in meeting its aims, using the Kirkpatrick Model. 

Recruitment. Each year, the following steps were undertaken/or completed: midwives from junior to senior level were nominated by their HoMs to participate in the programme; online questionnaires were completed by between 70% and 80% of the participants; HoMs and participants were invited to participate in the evaluation; in-depth follow-on telephone interviews were undertaken with 12 volunteers.

Data analysis. Quantitative data from the online questionnaire and qualitative data from the interviews were gathered and analysed by the externally commissioned social research organisation.

Findings. A total of 166 midwives participated over the four years of the programme; 128 participants responded to the online questionnaires; 23 engaged in in-depth interviews. Online questionnaires were completed by 38 HoMs over the four years and nine were interviewed about the programme. The evaluation found that the programme was successful in meeting its key objectives. The programme was enjoyed by participants, led to increased knowledge and skills and also contributed to improvements in service.

Implications. The ‘Best Start Leadership Programme’ was successful in achieving its aim of developing leadership confidence and skills in a cohort of midwives. The programme design, combining education, coaching and quality improvement practice, may provide a useful template for other health professionals and midwives in other areas.

Key words: Leadership, midwifery, coaching, evaluation, quality improvement, authentic leadership, evidence-based midwifery

Background

How we can ensure that midwifery is well led now and in the future is a key issue for all of those concerned with improving maternity services. The importance of leadership in the provision of high-quality health care – and maternity care in particular – is widely recognised (Warwick, 2015; The King’s Fund, 2014; Francis, 2013; WHO, 2007).

Leadership is essential for the successful implementation of health policy and evidence-based guidelines. In 2011, Scotland’s latest maternity policy, A refreshed framework for maternity care in Scotland, was published (Scottish Government, 2011). This framework, along with The healthcare quality strategy for NHS Scotland (Scottish Government, 2010), emphasised a model of maternity care and health care that focuses on reducing health inequalities, providing safe, effective and person-centred care, and develops individual and community assets to help promote health and prevent illness and complications (Scottish Government, 2011; 2010). The framework set out quality indicators that would require leadership to be achieved. 

The development of new leaders is essential to ensure the sustainability of high-quality maternity services. In 2011, the RCM published its first report into the state of maternity services in the UK (RCM, 2011). This identified that the midwifery workforce in Scotland was ageing, with the majority of midwives over 45 years of age (RCM, 2011).  The Scottish Government and NHS midwifery leaders in Scotland recognised that in order to successfully support the implementation of key policies and reduce the impact of a ‘retirement bubble’ among midwives, a national approach to succession planning and proactive leadership development was required. 

NHS Education for Scotland (NES) is a special national health board in Scotland, with a key role in providing continuing professional development to health professionals. The maternal and child health team at NES developed a proposal for a new leadership programme for midwives and funding was agreed in mid-2012 by the Chief Nursing Officer Directorate at the Scottish Government.

The leadership programme, initially called the ‘Delivering Quality through Midwifery Leadership’ (2012-14) and subsequently the ‘Best Start Leadership Programme’ (2014-16), ran each year from 2012 until 2016, providing a structured seven-month programme of education and leadership development for 166 midwives from all over Scotland. From 2014, the programme was also offered to a small number (12) of looked-after children’s nurses (looked-after children’s or LAC nurses are a small group of community-based nurses across Scotland, with a responsibility for the healthcare needs of infants and children living in the care of the local authority or family where there is a child protection order in place).

Aim

The aim was to develop and evaluate a programme to build leadership capacity among the midwifery workforce of NHS Scotland.

Objectives

The Best Start Leadership Programme objectives were to:
•  Engage midwives from all NHS boards across Scotland, working in a range of roles from current leadership to more junior roles in both community and hospital settings.
•  Support the implementation and evaluation of service change and improvement to implement the goals of the Quality Strategy and Refreshed Framework. 
•  Facilitate the development of confidence and leadership skills in real working situations and the creation of leadership teams and networks.
•  Test the impact of the programme on individual participants and on the maternity service.

Theoretical fit and literature
Within the maternity services context, Scottish and UK-wide work has identified a need to support leadership capacity in the midwifery workforce (NES, 2011; Chief Nursing Officers of England, Northern Ireland, Scotland and Wales, 2010). Several key reports have highlighted where poor leadership has contributed to failures in maternity services (Francis, 2013; Lewis, 2011; The King’s Fund, 2008). Both the Department of Health and NHS Scotland have produced frameworks for NHS practitioners to set out the qualities, capabilities and context of high-quality leadership (NES, 2014; NHS Leadership Academy, 2011; NHS Scotland, 2009). These frameworks are based on theories of distributed or engaging leadership in which the focus is on building capacity and capability across organisations. In 2012, the RCM’s Midwifery leadership: competency framework employed this concept of shared leadership, described in six key domains: demonstrating personal qualities, working with others, managing services, improving services, setting direction and delivering services (RCM, 2012).

The Best Start Leadership Programme design drew on these leadership frameworks. Leadership can be defined most simply as ‘a relationship through which one person influences the behaviours or actions of other people in the accomplishment of a common task’ (Byrom and Kay, 2011: 7). The theoretical approach to leadership employed in the programme emphasised the development of individual leadership qualities and behaviours. This reflects modern ideas around leadership in health care, which have moved away from ideas of ‘heroic’ leadership based on innate qualities, to a set of skills and behaviours that can be developed. These qualities and behaviours are described as ‘authentic leadership’, where the individual seeks to be reflective and develop a high level of self-knowledge to understand others with whom they work and to operate and engage in an honest and transparent manner, providing reassurance and direction particularly in times of difficulty (Avolio and Gardner, 2005). ‘Leadership goes further than the common misperception of a leader as the lofty head of a group, institution or country. Rather, it is the everyday work that demonstrates strength, knowledge and ethical behaviour to others’ (Powell Kennedy, 2011: xiv). 

Design and method

The Best Start Leadership Programme was designed to increase the confidence of participants as leaders and to embed and develop leadership skills through practical experiences. The development team included the project lead (a senior midwife with experience of undertaking leadership development), the chief midwifery advisor at the Scottish Government (with experience of leadership development and coaching) and the NES national leadership unit (with experience of developing leadership programmes for senior staff across NHS Scotland). The design was based on the premise that leadership development should take place within the strategic context and should be linked to local processes, developing both ways of being and ways of doing (NES, 2014). ‘Developing leadership capabilities out of context is seen as insufficient on its own. It is crucial to develop the leader in the role and in full recognition of the complexities of their context’ (NES, 2014: 5).

The programme provided participants with a structured programme of leadership education, support and development through three key approaches:
•  Education
•  Coaching
•  Local improvement project implementation.

Education
Prior to beginning the programme, participants were provided with online worksheets in which they were directed to resources on leadership theories, quality improvement approaches and the policy context. They attended a two-day education and networking event where they were provided with further leadership education and introduced to the programme approach. Participants were provided with a ‘community of practice’ website where they could share resources and build supportive networks with each other and previous participants. A final celebration event was held at the end of the programme to enable participants to showcase their learning and projects to peers and invited managers and leaders.

Coaching
An external leadership consultancy, the Firefly Group, was commissioned by NES to provide workshop facilitation and one-to-one telephone leadership coaching to all participants. In the first two years of the programme, participants received three hours, which was increased to five hours in the final two years of the programme. The coaching sessions aimed to enable participants to identify their leadership strengths and to develop and translate these strengths in their professional roles. The coaching approach used a combination of support and challenge to participants to lead positively and effectively.

Local quality improvement project implementation
Each participant was asked to devise, implement and evaluate a local service quality improvement project as part of the programme, either as an individual or as a health board team. Participants chose their project topic in consultation with their service lead and were then provided with guidance and project management support by the NES team. 

At the first event, participants were supported to develop a clear, concise aim for their project, which would be achievable within the seven months of the programme. Participants were then supported by the project lead to develop ‘driver diagrams’ or project plans that set out the clear primary and secondary drivers, which would enable them to achieve their stated aim. The use of driver diagrams mirrored the widespread introduction of quality improvement methodology across NHS Scotland at the time of the programme. This ensured that the participants were gaining experience in using methods that were reflected and supported in their wider organisations. Over the lifetime of the programme, participants were asked to submit their completed driver diagrams and progress reports to the project lead and were offered individual project management support meetings where requested. 

Participants were encouraged to evaluate the impact of their projects and submit a final report identifying their progress and the next steps for their project. It was anticipated that by designing, leading and evaluating a quality improvement project, the midwives would become familiar with the challenges of service improvement and would develop key project management skills, including collaborative working, time management, audit and measurement.

This overall design remained throughout the four years of the programme, though the delivery method of these three key elements was modified in response to the results of annual external evaluation and feedback provided by participants after events. In particular, the increase in the telephone coaching was increased from three hours, to five hours. The initial event was significantly developed from two separate one-day events to a single two-day event, with a focus on practical skill development.

Evaluation design

For each year of the programme, an external evaluation was commissioned and undertaken by a social research organisation, ‘Ruthless Research’. The method of the evaluation was discussed and agreed with the project team to ensure that it was rigorous and measured the extent to which the programme was achieving its intended objectives. The overarching approach to the evaluation was the Kirkpatrick Model – a widely used method of evaluating the effectiveness of training programmes (Kirkpatrick and Kirkpatrick, 2007; 1994). The model examines four key levels: reaction – how the trainees feel about a programme; learning – what increase in knowledge can be evidenced; behaviour – how the participants have applied their learning and results – and what the measurable outcomes are.

Each year, the evaluation examined these four areas through undertaking an online questionnaire with participants, strategic leads and previous participants; documentary analysis of project posters and reports, and undertaking in-depth interviews with a smaller sample of participants and strategic leads.

Findings

The results for the programme will be described by examining the extent to which the four key objectives were met, referring to the external evaluation findings. Each year, participants were invited to complete a short pre-programme questionnaire to identify their level of confidence in leadership and to allow them to identify their personal goals and learning needs from the programme. At the end of the programme, an online questionnaire, developed by the project team to evaluate all aspects of the programme and its outcomes, was conducted with participants, their managers and strategic leads. Past participants were included in the survey in 2015 and 2016. The response rates for the online questionnaire were consistently high – between 68% and 77% of participants.

Following the questionnaire, in-depth interviews were conducted with 12 key stakeholders including participants, past participants and project implementation staff.

To what extent did the programme succeed in engaging with midwives from all NHS boards across Scotland, working in a range of roles from current leadership to more junior roles in both community and hospital settings?

All 14 territorial health boards in Scotland had midwives participating in the programme during the four years. The three smallest island boards of Orkney, Shetland and the Western Isles participated in three years out of the four. Each year, health boards were offered a set number of places, between one and four, based on their size. Uptake of the places reached the allocated target each year.

The number of places on the programme varied from year to year as a result of amendments by the project team. Over the four years, 166 midwives completed the programme. In 2012-13, 52 midwives from Scotland took part, 27 currently working at Band 5 or 6; 17 at Band 7 and 8 at Band 8. In 2013-14, 62 midwives took part in total, with 14 continuing on the programme for a second year, 33 new participants and 15 senior midwives working at Band 8, who received coaching but did not undertake a project. In 2014-15 and 2015-16, six LAC nurses joined 33 midwives on the programme. 

The majority of participants (around 62%) volunteered to attend the programme, with the remainder asked to attend by their HoM. Each year participants worked at a number of levels in the NHS and higher education institutions, from Band 6 to Band 8 and were working in community, hospital and teaching roles.

To what extent did the programme support the implementation and evaluation of service change and improvement to implement national strategic policy goals?

The programme aimed to support the implementation and evaluation of service change and improvement to implement national strategic policy goals primarily through the local quality improvement project element of the programme. All three elements of the programme – education, project management and coaching – aimed to work together to maximise the success of participants in implementing a quality improvement project.

Each year, between 20 and 25 local projects were undertaken by participants, either by individuals or in teams. Project topics were identified by participants following discussion with their HoM on strategic priorities. The projects undertaken focused on all areas of maternity care across the childbirth continuum. These included patient safety initiatives such as: improving hospital handovers using the Situation, Background, Assessment, Recommendation (SBAR) tool; reducing the risk of postpartum haemorrhage; increasing continuity of carer in the antenatal period; introducing supportive multidisciplinary debriefing sessions following significant incidents; developing approaches to understanding service user experience. Project teams developed new DVDs and websites to improve information for women, new care pathways for vulnerable women and women with mental health problems, and improved care for women in the latent phase of labour.

The external evaluation asked participants to identify their reaction to, and learning from, the projects and the impact on their behaviour and service delivery (Kirkpatrick and Kirkpatrick, 2004; 1997). Each year, the participants rated undertaking the quality improvement projects very highly for all of these parameters. 

Over the four years, 128 participants completed the online questionnaire. The local quality improvement projects were the most highly evaluated: 97% (n=124) said they enjoyed undertaking their projects, 90% (n=115) said that the project enhanced their confidence as a leader, 93% (n=119) stated that their project made a positive change in their workplace and behaviours, and 94% (n=120) identified that they learnt something new through undertaking the project. 
Participants described in interviews how the projects supported their leadership development:

“I just loved doing my project, it was a joy to do. I felt a pride in myself, I felt really glad that I got to do it” (midwife depth interview, 2014). 

“The projects… have been empowering, showing that they could put their heads above the parapet. It gives them an opportunity and permission to shine and get a bit of recognition” (strategic staff depth interview, 2014).

All participants were supported to summarise and celebrate their projects with a conference poster and many have gone on to present their projects at local and national conferences. Each year, at the final celebration event in March, around seven participants gave a presentation about their projects to their peers, managers and other midwifery leaders. This was the first experience of public speaking and preparation of a presentation for many and was in itself an important part of their development as leaders.

Strategic leads, generally HoMs, were asked in their online questionnaire to identify the impact of the local quality improvement projects. A total of 38 strategic leads responded to the questionnaire over the four years: 86% (n=32) agreed that the projects helped them to deliver on strategic aims. This figure rose from 72% in the first year of the programme to 100% in the final year. In 2016, 100% of the strategic leads agreed that the programme helped them to feel more confident about succession planning, rising from 79% in 2013 (Ruthless Research, 2016).

Did the Best Start Leadership Programme facilitate the development of confidence and leadership skills in real working situations and the creation of leadership teams and networks?

The success of the programme in meeting this objective was measured through completion of a pre-programme questionnaire and the post-programme external evaluation. 

Following participation in the programme, participants identified a range of benefits from the programme:
•  Enjoyment 
•  Re-igniting an enthusiasm for the job 
•  Appreciation of own leadership potential 
•  Acquiring new skills and knowledge 
•  A changed approach 
•  Progress towards personal goals 
•  Increases in confidence 
•  Access to ongoing opportunities 
•  Enhanced networks.
(Ruthless Research, 2015).
At the programme’s close in 2016, 96% of participants agreed that they had more confidence as a leader. Across all four years of the programme, on average, 60% of the participants ‘strongly agreed’ that they had more confidence as a leader.

The participants were asked a set of questions focusing on their feelings about their leadership abilities at the start and end of the Best Start Leadership Programme in an online pre- and post-programme questionnaire. Each year, the participants demonstrated an increased appreciation of their own leadership potential across the course of the programme. This included 89% of participants feeling that they had the leadership knowledge and skills to do their current role at the end of the programme compared to just 47% before the programme. 

Participants were given the opportunity to acquire new skills and knowledge relating to leadership through their participation in the Best Start Leadership Programme.  Respondents (n=26) were asked to rate what skills and knowledge they had gained. 

More than 85% (n=22) of participants in 2016 identified that they had learnt how to encourage and support others, with 77% (n=20) learning to overcome barriers to change and manage a quality improvement project. The extent to which participants identified that they had developed new skills is detailed in Figure 1, overleaf, reproduced with kind permission of Ruthless Research, 2016.

In order to seek to measure outcomes from the 

programme, participants were asked in 2016 whether they had demonstrated enhanced leadership skills as a result of taking part in the Best Start Leadership Programme. This identified that over 77% (n=20) of participants identified that they had demonstrated authenticity and openness at work, 69% (18) had set goals and priorities and coped with uncertainty, and 65% (17) had supported colleagues and put forward ideas for change. The identified behaviours are detailed in Figure 2 below.

The positive impact of the programme on skills, confidence and behaviours appeared to be sustained in the medium to long term. In 2015, 13 past participants of the programme completed the online questionnaire. They said they had continued to use their leadership skills after the programme and they recognised the impact that the programme had in enabling this. 

A total of 92% (n=12) said that they had acquired new skills and knowledge through their participation in the programme: most often producing a project poster, being a more effective leader and overcoming barriers to change. 

The same number agreed that they had demonstrated enhanced leadership skills as a result of taking part in the programme: most often setting goals and priorities, providing positive feedback to colleagues, supporting colleagues, and making decisions. 

A total of 77% (n=10) agreed that they had initiated further quality improvement projects or tasks after the programme had finished; had made further positive changes in their workplace after the programme; and had experienced career changes since the programme. The latter were most often increased responsibility and a new job or role (Ruthless Research, 2015). 

Did the Best Start Leadership Programme test impact on individual participants and the maternity service? 
As detailed above, the Best Start Leadership Programme included an in-depth evaluation each year commissioned by NES and undertaken by an independent social research organisation. The external evaluation examined each element of the programme:  the educational component, the one-to-one leadership coaching and the engagement in a local quality improvement project. Each element was evaluated by asking participants about their reaction to, and learning from, behaviour following, and outcomes of, each component. 

Initial two-day workshop
The initial learning event was one day in the first two years of the  programme, with a second one-day event half way through the programme. Following review of the evaluation 

results, the first event was changed to a two-day practical skills-based workshop. The changes made to the first event resulted in significant improvements in the evaluation of the event by participants.

In the first year of the programme, 82% (n=32) of respondents stated that they enjoyed the day, 74% learned something new (n=29), but only 46% (n=18) felt that they made positive changes in their workplace as a result of the day (Ruthless Research, 2013). 

Following changes to the first event, this rose to 95% (n=40) enjoying the day in the second year, 97% (n=29) in the third year and 96% (n= 27) in the final year (Ruthless Research, 2016; 2015; 2014). A very high proportion of participants felt that they learned something new from the first event from 76% (n=32) in 2014 to 97% (n=29) in 2015 and 89% (n=25) in 2016 (Ruthless Research, 2016; 2015; 2014) and that they made positive changes to their workplace as a result of attending: 70% (n=29) in 2014, 90% (n=27) in 2015 and 81% (n=23) in 2016 (Ruthless Research, 2016; 2015; 2014). 

Comments in the interviews demonstrated how beneficial many participants found the first educational event:

“It was stimulating and inspiring. They got the motivation bit just right” (LAC nurse 1, 2015). 
“You left feeling buzzing” (past participant 1, 2015). 

“I absolutely loved it. The coaches made you start thinking. The presentations brought you back to the basics of why we do this job. It was varied and I really enjoyed it” (midwife 3, 2015).

One-to-one leadership coaching  
A key component of the Best Start Leadership Programme was one-to-one leadership support, provided by an independent leadership consultancy. Each participant was matched to an individual co-active leadership coach having completed a pre-programme questionnaire and a ‘Realise 2’ profile, which aimed to identify their key strengths. 

At the first event, participants were introduced to their coach and the approach. At the start of the coaching, the coach and participant agreed a contract of engagement and identified the key goals that the participants hoped to achieve through the coaching. 

Leadership coaching is a person-centred development approach that aims to provide participants with support and challenges to identify their strengths and explore new ways of approaching problems.  The focus is on the individual leader and their impact.

The participants described their positive experience of the coaching in the online questionnaire, in-depth interviews and in written evaluations undertaken by the Firefly Group:

“The coaching was invaluable” (midwife interview, 2014). 
“When I first started in midwifery, I had great dreams and what happens is your dreams slowly become eroded in the great big cumbersome machine that is the NHS… I thought ‘what’s the point?’ What’s happened with the coaching is it has allowed me to free up those early dreams I had” (midwife interview, 2014).
“My coaching experience exceeded my expectations” (final event speaker, 2014). 

When reflecting on the time with their coaches, many of the participants described how the coaching had been transformational in both their work and personal lives:

“The coaching sessions have had a huge impact. This allows me to be more fulfilled in my work life, which has had a massive impact on family life” (participant, Firefly evaluation, 2015).

“It has had a bigger impact on me than I could have initially imagined… helping my work and home life” (participant, Firefly evaluation, 2015).

“You have changed my life, both professional and personal. Thank you” (participant, Firefly evaluation 2015). 

Several participants spontaneously commented that a key benefit of the coaching had been the opportunity to have a supportive relationship with someone outside the NHS: 

“The coaching was really good, somebody to talk to that was independent of my workplace” (past participant, 2016). 

“There was always something going on in the workplace, it was good to go through that with someone that wasn’t judging you” (LAC nurse, 2016). 

Across the four years of the programme, 135 respondents provided their responses to the coaching. On average, 91% (n=123) said that they enjoyed the coaching and 87% (n=117) said that the coaching enhanced their confidence as a leader and that they had made positive changes to their working practices following the coaching. 

Challenges and limitations
The biggest challenge of the programme for participants was finding time to participate fully and to undertake project activities. This challenge remained throughout the life of the programme, though many managers and HoMs provided significant support to the programme by providing participants with time away from their clinical duties to participate. A further challenge is long-term funding of leadership development. 

The programme was delivered at a cost of between £1000 and £1250 per participant each year, which included the provision of two fully-funded educational events with accommodation and travel, five hours of one-to-one telephone coaching and project management support. In recognition of the national midwifery workforce demographics, this programme was centrally funded over four years to support local organisational approaches to succession planning.

Conclusions

The Best Start Leadership Programme provides an example of an innovative and impactful leadership development programme for midwives and other health professionals. 

The programme, which ran for four years, provided a structured seven-month leadership development programme for 166 midwives from all over Scotland working at all levels of their organisations. The programme was successful in achieving its stated overall aim to develop and evaluate a programme to build leadership capacity among the midwifery workforce of NHS Scotland. The programme was also successful in its key objectives of engaging midwives from all over Scotland from all parts of the maternity services, supporting service improvement, enhancing leadership confidence and skills and testing the impact of the programme. 

The annual external evaluation of the programme found that it was highly successful in meeting the four key criteria assessed in the Kirkpatrick Model of reaction, learning, behaviour and outcomes. 

In the annual evaluation, participants and strategic leads identified a range of positive outcomes of the programme on individual confidence and skills and on service delivery and quality improvement.

We believe the success of the programme lies in the combination of the three mutually supportive elements 
of education, coaching and quality improvement projects; this enables participants to learn and then embed key leadership behaviours and skills. 

The Best Start Leadership Programme has made a significant contribution to the development of strong midwifery leaders and the improvement of maternity services across NHS Scotland. The programme has tested an innovative, value-for-money design for developing key leadership skills for health professionals. This can provide a helpful template for other programmes and 
other professionals.

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