Shared governance - a US term describing a process of involving staff at all levels in decision-making - could be one way of breaking the stand-off between nurses and managers.

Jacqueline Geoghegan, nursing director at Medway trust, has introduced the system at several trusts with dramatic results. Nurses usually show greater motivation, and the decisions reached tend to be more achievable because of the involvement of those who have to implement them.

The experience can also be invaluable for the nurses.' By being involved it does make them more accountable for what they are doing and they take more responsibility, 'she says.