Facing the Care Challenge Leadership The Ward Sisters Role Pat Bottrill MBE FRCN Glenn Turp, RCN Regional Director Je

1. Facing the Care Challenge Leadership � The Ward Sisters RolePat Bottrill MBE FRCNGlenn Turp, RCN Regional DirectorJenny Kay, Director of Nursing, Dartford & Gravesham NHS Trust

2. � Having been an employee at the hospital I feel very embarrassed and ashamed to have worked there� there was not a day went by that I didn�t go home in tears.� The patient, whose daughter in law was an employee at Stafford Hospital, was admitted to hospital following bowel surgery for unexplained bleeding. His condition began to deteriorate and he was admitted for minor surgery. Hours later his family were asked to identify him as he had been operated on without any wrist identification or notes. The nurse told the family, who were extremely upset, �don�t worry, he is not dead�. On the ward the patient was not cleaned or dressed. Often he was left exposed in view of other patients and nursing staff talked of his low chance of survival in front of him. Five days after being admitted to hospital the patient died. Source: Direct contact When the patient stayed at the Emergency Assessment Unit at Stafford Hospital for three days he received excellent nursing and medical care. Despite the negative reports he continues to have the �highest regard� for the hospital. Source: Direct contact

3. The RCN�s Definition of Supervisory Breakings Down Barriers, Driving up standards (RCN, 2009) recommends that all ward sisters and Team leaders become supervisory for the purpose of maintaining and improving the quality and consistency of health care experienced by patients and service users. The RCN has subsequently defined supervisory[1] in the context of the ward sister/team leader role in all settings as the presence of the following attributes; [1] Supervisory is used in preference to �supernumerary� as �supernumerary� implies being �extra� to the establishment numbers within a clinical team. Whereas �supervisory� encompasses the purpose for which this time would be used; acknowledgement that time is required to undertake supervision over and above the provision of direct care; and a range of strategies for achieving supervision that may involve the provision of direct care with other team members.

4. The RCN�s Definition of Supervisory Being visible and accessible in the clinical area to the clinical team, patients and service users e.g. being approachable to visitors; enabling team members to ask questions Working alongside the team in different ways e.g. supporting junior colleagues in the provision of direct care; facilitating learning in and from practice at the same time as working alongside; undertaking a care plan review Monitoring and evaluating standards of care provided by the clinical team e.g. enabling reflective review at staff handover; bringing staff together to review clinical and workforce data for example balanced score cards Providing regular feedback to the clinical team on standards of nursing care provided to, and experienced by, patients and service users e.g. providing feedback at the end of each interaction with staff members, at the end of the shift or in staff handover Creating a culture for learning and development that will sustain person-centred, safe and effective care e.g. through ensuring there are systems in place to ensure evaluation of practice, clinical supervision and shared governance/decision-making, as well as a focus on patterns of behaviour and the provision of high challenge and high support

5. Breaking down barriers � Driving up standards: Supervisory ward sisters The Dartford and Gravesham NHS Trust experience

6. Context New PFI 460 bed DGH �Good� CQC ratings for quality, �excellent� for finance Very �flat� nursing hierarchy Top ten Nursing Times rating for nursing satisfaction But�. below average staffing levels (Audit Commission benchmarking / Dr Foster).

7. RCN � Breaking Down Barriers� Resonated for us�. Ward sisters felt disempowered Part of �rostered� numbers Crisis management � not proactive leadership PDR rate low� Role confusion and conflict Matrons �acted down� to Band 7 role Difficult to recruit Band 7s. Complaints showed lack of ward leadership Quality wasn�t being monitored

8. Business case Phase 1 � (09/10) release ward sisters 2 days a week Some investment in ward numbers (small) Phase 2 � (10/11) release ward sisters full time Phase 3 � increase ward staffing levels to average for �peer� group (?2011) Total investment c �1.5 million

9. Why was business case accepted? Clinicians as decision makers � business case sub-group of the Clinical Directors� Board � chaired by a CD. Supportive Exec and Board teams The �case� made itself: Maidstone and Tunbridge Wells is next door Mid Staffs Foundation Trust application � Monitor focus on quality Realisation that ward nursing care wasn�t all it should be Realisation that ward sisters had a complex management and leadership task� Recognition of below average staffing levels Context of financial and activity growth

10. Nursing strategy Focus on wards � not other areas Focus on accountability of ward sister Clinical Fridays � metrics Agreed Trust wide job description Formal delegation of ward budgets E-rostering Delegation of people management Need for personal development

11. Role of ward sister: �The Ward Sister/Charge Nurse remains the key nurse in negotiating the care of the patient because she/he is the only person in the nursing structure who actually and symbolically represents continuity of care to the patient. She/he is also the only nurse who has managerial responsibilities for both patients and nurses. It is this combination of continuity in a patient area together with direct authority in relation to patients and nurses which makes the role so unique and so important in nursing� (Susan Pembrey, 1980)

12. What has improved? Fewer nursing complaints Better �collegiate� team of ward sisters Fewer in hospital fractured femurs and pressure ulcers Better MRSA and C Diff rates Fewer Band 7 vacancies ?? Summer effect??

13. Learning points Matrons roles have to change Awaydays for both matrons and ward sisters Formal �performance management� of ward sisters Not all ward sisters will �get it� � some will grasp the new opportunities, some won�t.. Must stay in uniform and be visible Challenges of staffing problems, vacancies and agency ban � �supervisory role� can get lost�

14. Finally �Get off the dance-floor � onto the balcony� Thank you to the RCN

15. Group work