Ward sisters must be given the freedom to lead and care

No one who has read any of the nursing journals in the last few months can be in any doubt that there has been a resurgence of interest in developing and supporting the role of the ward sister/charge nurse.

Each of the four UK countries has produced statements on ensuring that in every aspect of the care environment - from staffing levels to single sex accommodation - patients receive the highest quality care and that students and healthcare support workers are tutored to participate fully in providing a first class patient experience.

‘We may have shaken off the trappings of task orientation, but have replaced it with indistinct lines of authority. No wonder there is the drive to regain the ward sister role’

Wales was the first to launch a series of initiatives directed at empowering the ward sister/charge nurse under the title of Free to Lead: Free to Care. At first sight, this may be viewed as just a snappy title - certainly one that has been mirrored elsewhere - but I want to take this opportunity to stop and consider each part of the title and explore what it might mean for colleagues who hold the post of ward sister/charge nurse.

For some time now, a huge amount of effort has been going into leadership development. Accredited programmes that are developed commercially drive home the message that “leadership should be visible at all levels”. That is a noble aspiration and one which, with some caveats, is true.

We have shining examples of leadership shown by healthcare support workers who are working alongside patients and their families to help them to adapt to life changing conditions.

Student case studies often illustrate not only learning from personal reflection on one to one patient experiences, but also how they can influence changes in attitude or practice within the ward team. Pre-registration training is designed to produce a newly qualified nurse or midwife who is equipped with all the skills necessary to begin to lead small teams and support effective multidisciplinary patient care.

The ward sister is expected to lead on all these fronts simultaneously. The problem is, when do they find the time to engage in these leadership activities? Similarly, is there sufficient time and opportunity to be “free to care”?

Since the early 1990s, financially driven efficiency programmes have very often resulted in the ward sister being counted in the numbers of qualified staff on a shift or being excluded from the more expensive end of the working week - the very part of the week where relatives may be more able to visit and anxious to discuss their family member’s progress.

Increased paperwork is frequently cited as a major burden for all nurses - and I have seen some tortuous examples of so-called care assessment. Add to this off duty planning, student reports, staff appraisals and personal development plans, audits and returns, discharge summaries, ordering, attending sisters’ meetings/wards rounds/mandatory training and so on and there really is very little time to either lead or care.
So the key word in achieving the desired outcome of empowering the ward sister must not be “lead” or “care” but “FREE”.

I was talking recently with a senior nurse manager about a group of medical ward sisters who had been reviewing their daily routine with the programme leaders at the Welsh National Leadership and Innovation in Healthcare. From the diaries that these ward sisters kept, it was evident that from the time that they came on duty, there was no distinction between what they and, say, the staff nurses did. Their day rolled on inexorably, caught up on the conveyor belt that passed as “the patient’s day”. In the 1960s, a great deal of effort went in to planning patients’ days to ensure that they were able to benefit from the care that had been prescribed.

Since then, however, nurses have had their day eroded. We may have shaken off the trappings of task orientation in favour of patient allocation, but we have replaced it with indistinct lines of authority and accountability. No wonder there is the current drive to regain some of the former role of the ward sister. Somehow, we need to build in the freedom for them both to lead their teams and to provide the care that their personal knowledge and experience brings.

The fight is on to ensure not only that those nurses who aspire to become ward sisters/charge nurses are educated and equipped with the skills to undertake this vital role, and are supported by their managers to do so, but also that they are freed up - without an allocated clinical caseload - so that they can: come on duty after the initial handover period; take an in depth report from the most senior member of the ward team on duty; plan collective and individual nursing care; allocate time and resources; greet each patient personally; supervise junior staff; work with the medical consultant to oversee care plans; maintain standards of cleanliness and nutrition; and ensure that there is good communication all round.

This may seem like a tall order - and believe me, it is not for the faint-hearted - but it is what being a ward sister/charge nurse is all about and will result in far greater job satisfaction and professional pride that will, in turn, enhance the patient’s safety and experience.

Rosemary Kennedy is chief nursing officer for Wales

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