Improved patient awareness of named nursing through audit
Shebini, N. et al (2008) Improved patient awareness of named nursing through audit. This is an extended version of the article published in Nursing Times; 104: 21, 30-31.
The named nurse is an essential role in the delivery of patient care. This article explains the concept, its development and current implementation. It also reports on an audit of patient awareness of their named nurse, conducted in a mental health setting. The findings are discussed with suggestions for improvements to future practice.
Neva Shebini, MBBS, BSc, is senior house officer, psychiatry, Priory Hospital, Roehampton; Rishi Aggarwal, MBBS, is GP registrar, the Parks Medical Practice, Cliffe Woods, Kent; Ajay Gandhi is medical student, Imperial College London.
All patients have the right to receive the care of a named nurse (Department of Health, 1991). This role is crucial in the management of all inpatients, especially in mental health. With over 87,000 nurses on the register working in this particular field, this audit is particularly relevant (Longley et al, 2007).
Marie Manthey developed what we consider to be true 'primary nursing', at the University of Minnesota Hospital in the 1960s. It encapsulated four essential elements:
Patient allocation and acceptance of individual responsibility for decision-making by a single nurse;
Individual assignment of daily care to a single nurse;
Direct communication channels;
One identifiable nurse to be responsible for the quality of care administered to individual patients on a 24-hour basis, seven days a week (Manthey, 1980).
Primary nursing separates qualified nurses into primary and associate nurses: the associate nurse undertakes patients' nursing care in the primary nurse's absence, ideally only altering the care plan in exceptional circumstances (Redfern and Ross, 1999).
The distinction between primary nursing and named nursing lies in the transatlantic transition of the former and its subsequent incorporation by the Audit Commission (1991) into The Patient's Charter (DH, 1991). This took the essence of primary nursing and supported a version termed 'named nursing'. Since Marie Manthey was elected to the UK RCN in 1994, we feel it is likely the terms are synonymous.
The named nurses initiative was launched with the intention of revolutionising nursing standards for patients and nurses alike, simultaneously increasing practitioner autonomy and overall job satisfaction.
The Patient's Charter became a working document in 1992 with a five-year implementation (Kennedy, 1999). It was initially met with cynicism, and the true spirit behind it was often ignored. However, it was an important policy that put patients at the centre of care and gave nurses the freedom to use valuable skills. The vision of the former chief nursing officer for England, Dame Anne Poole, was that the nursing policy for community patients should also be applied to hospitals, arguing that both patients and relatives would want a single port of call for information and responsibility (Wright, 1992).
In 1992, the Scottish Office defined a named nurse as: 'A registered nurse, midwife or health visitor who is responsible for assessing, planning, implementing, evaluating and coordinating patient care on an individual basis with a patient or a caseload of patients from admission/transfer to transfer/discharge.'
Benefits of a named nurse
Named nursing methods essentially increase patient-centred care, individualised treatment, nurse job satisfaction and identification of training needs, while making patient management less fragmented. Ultimately it aims to fulfil service users' wishes to experience skilled practice delivered with warmth, empathy and understanding in a relationship with some degree of continuity (Rose, 2001).
In a clinical setting, there are many options for care and named nurses are free to choose and encouraged to justify their decisions. In Memarian's (2007) evaluation of professional ethics in nursing, one nurse stated: 'I always have respect for myself- but some nurses don't have enough respect for themselves and, when required to make decisions, they refrain from doing so.'
The named nurse role promotes autonomy, which simultaneously brings with it self-respect for nurses as a core part of the clinical team. Being a named nurse offers more opportunity for personalised care delivery, which leads to greater empowerment for nurses. Nurses can take pride in work they have individually planned, conducted and evaluated and this can remove monotony from daily work.
Practitioners who are not yet qualified to become a named nurse can turn to a G-grade nurse for assistance. This is where it becomes important to have the correct grade mix of nurses, encouraging professional development and identifying problem areas.
As outlined in Nursing: Towards 2015 (Longley, 2007), the DH aims to move nurses through their careers from general to specialist nurse status. Interest in a subject will encourage practitioners to improve their skills, which results in satisfaction when their own care targets are met and self-evaluation when they are not (Memarian, 2007).
Organisation of care
Currently, the organisational structures of nursing staff are loosely based on the models in Table 1.
Table 1. Organisation of nursing care (adapted from Jack, 1995)
|Task allocation||Team nursing||Named nursing|
In 1992, the Audit Commission recorded that, while 49% of wards stated they used team nursing, in-depth examination revealed they were actually employing task and patient allocation. Many more recent audits have relied on a trust statement to ascertain whether or not they use the named nurse system. Often these are unreliable and based on assumptions, or a policy may be in place but not adhered to in practice. A true reflection can be obtained by asking patients directly if they are aware of their named nurse.
No reliable nationwide audits have been carried out to discover trusts' real compliance in the last 10 years (DH, 1994; Audit Commission, 1992). This audit aimed to identify the proportion of patients on psychiatric wards who know whom their designated named nurse is. We then make some recommendations on how improvements can be made.
During one week in October 2006, 63 patients on four adult psychiatric wards in an NHS mental health hospital were asked: 'Do you know who is your named nurse?' All available patients on wards A, B, C and D were interviewed. Those who did not know whom their named nurse was or that they had one were informed at the time of interview. Patients who had been on the ward for seven days or fewer were not interviewed, as new patients may have been acutely unwell and unfamiliar with their surroundings. The results were collected, tabulated and percentages of patients were calculated.
Table 2 summarises the results, and Fig 1 illustrates the proportion of patients who knew who their named nurse was.
Table 2. Summary of results
|Ward||No. who knew their named nurse||No. who did not know||No. who did not answer||% who knew|
The best results were on ward A (44%). This is likely to be because each dormitory had the patient's named nurse written on the bed space door. Ward D had similar results (42%). Both these wards had a board at the nurses' station displaying patients' names with their named nurse, which was visible to patients.
The results on wards B and C were the poorest (21% and 0% respectively). Nurses on these wards had a whiteboard inside the nursing office detailing named nurse allocation but this was not visible to patients. Whiteboards were displayed with each patient's name and allocated nurse for each nursing shift, but the allocated nurse was the named nurse only if that nurse was working that particular shift. The lack of visual display of named nurses on wards B and C may be reflected by their relatively poorer results.
Overall, 18 out of 63 patients (29%) could identify their named nurse.
A number of studies have been conducted to establish patient awareness of their care coordinators in different mental health settings. Jeggo (2007) studied inpatients detained under the Mental Health Act 1983 and found 62% were able to identify their named nurse. In the same year, the Healthcare Commission surveyed patients in the community and found 89% could name their care coordinator. Webb et al's (2000) study involved both inpatients and community service users: 80% knew the name of their care coordinator.
Staff should aim to ensure that individual patients are clearly made aware of their named nurse. However, uness patients can remember this information the effectiveness of the named nurse system may be impeded. In mental health settings psychotic disorders, mood disorders and other psychiatric conditions are associated with varying degrees of cognitive impairment leading to disorientation and poor concentration, attention and memory. In addition, some features of psychotic illness include persecutory and paranoid beliefs, which may prevent patients from developing a rapport with others, including their named nurse.
Methods to increase patient awareness
The patient's named nurse should always be visible, through the use of name badges, whiteboards and names listed in bed spaces. Named nurses can also introduce themselves to patients - whether on mental health or general wards, and any other members of staff should do the same.
The whole team should also be made aware of a patient's care plan and briefed in a concise manner during handovers. The different aspects of a care plan may apply to different nurses because of their different skill sets. Therefore delegation may be more appropriately carried out by the nurse in charge and, though there is one named nurse, each member of the unit must practise with utmost accountability and autonomy (Kennedy, 1999).
So far, nationwide implementation of the named nurse policy has brought about mainly structural changes, but an attitudinal change is also necessary. The main argument leading to resistance is primarily concerned with resources. However, the concept of named nursing is driven 30% by resources and 70% by attitude. To be implemented fully, it needs total backing in spirit rather than just mere acceptance.
Essentially, named nursing can help a patient through an anxious and disorientating time simply through improved rapport and a patient-centred care approach. Fig 2 offers some tips on how to introduce named nursing in practice.
Implications for practice
The following recommendations should be implemented to promote patient awareness of named nurses.
Nurses (and other healthcare staff) should wear name badges at all times.
Patients can be given cards (similar to a business card) on admission with the name of their designated nurse.
Each bed space door should display the patient's named nurse.
The named nurse of each patient should be displayed above each bed.
Named nurses must introduce themselves to their respective patient within 24 hours of admission and this should be documented on the admission checklist.
If the named nurse is on night shift or on leave, the associate nurse should introduce her or himself to the patient.
This audit should be repeated out after these recommendations have been implemented.
This audit demontrated that only a small number of patients in the hospital studied knew who their named nurse was - it is likely that the situation is similar in other trusts, despite the system having been introduced over a decade ago. Attention must therefore be given to improving practice in this area.
Being an inpatient in mental health services can be a daunting, frightening and confusing experience. Named nurses can play an important role in guiding patients through this difficult journey. Patients can put their trust in their named nurse, promoting a therapeutic alliance that assists the nurse to make regular assessments of the patient's mental state, risk and inpatient progress. Named nurses are then suitably placed to give feedback to the multidisciplinary team, playing a vital part of the team's decision-making process.
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