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Review

How nurses can lead from the frontline

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Organisations should introduce key nurse roles so that, over the course of a shift, patients have one nurse who is their main port of call

Citation: Entwistle F (2013) How nurses can lead from the frontline. Nursing Times; 109: 12, 15.

Author: Fran Entwistle is assistant practice and web editor at Nursing Times.

Introduction

In his inquiry into Mid Staffordshire Foundation Trust, Robert Francis QC identified what he describes as “a completely unacceptable standard of nursing care” (Francis , 2013). From the evidence given to the inquiry he concluded that the decline in standards was associated with inadequate staffing levels and skills, as well as a lack of effective leadership and support.

To address this, Mr Francis has made several recommendations on changes to the way nurses work in order to improve the quality of care offered by frontline NHS staff.

Recommendations

“Key nurses” should be responsible for coordinating provision of care

The report recommends that patients should be allocated key nurses on a shift-by-shift basis to ensure that patients have a specific nurse who is responsible for their care at all times. A lack of someone to take direct responsibility for the provision of care was one of the main failings found at Mid Staffs. This differs from the “named nurse” or “key worker” role, whereby patients are assigned to a nurse for the duration of their admission. Instead, nurses will be allocated at the start of each shift as the main port of call for a patient and their family.

Key nurses would have to accompany doctors during ward rounds and any other interaction with their allocated patients. This will keep nurses updated on everything that is happening and allow them to communicate decisions and progress confidently to patients and family members.

Nurses’ role in ward rounds to be extended

This recommendation relates to nurses acting as “a central point of communication between the patient and medical staff”. Mr Francis wants senior nurses to be in attendance at all ward rounds so the senior nursing team are kept informed of, and have a say in, all key decisions.

As well as improving communication between medical and nursing teams, this recommendation aims to place nurses in a position where they are better able to advocate on behalf of patients. Nurses are likely to spend more time with patients than other members of the multidisciplinary team so they need to be present to pass on information from the preceeding 24 hours of the patient’s care that only the nursing staff will know.

The initial inquiry found that often there were difficulties in locating nurses who were available to attend ward rounds. Mr Francis argues that nurses’ active involvement in ward rounds is essential to be incorporated into best practice, and that a nurse should always be present. He also stresses the importance of full and comprehensive handovers between shifts and to the rest of the multidisciplinary team.

All members of the multidisciplinary team to prioritise ward rounds

This recommendation is inspired by a publication from Royal College of Physicians and the Royal College of Nursing, Ward Rounds in Medicine: Principles for Best Practice, which was published in October 2012. It highlights the importance of ward rounds - these give the multidisciplinary team an opportunity to review a patient’s condition from different specialist angles, and the information can then be used to develop a multifaceted plan of care.

The recommendation suggests that all members of the team who care for a patient recognise ward rounds as an important part of care and attend as a priority. The initial inquiry found that often ward rounds happened early in the morning, a time of day when nurses in particular tended to be busy. Part of prioritising ward rounds could involve considering the timing to make it easier for all members of the team to attend. Mr Francis stresses that the team should ensure that patients’ ward rounds allow full engagement of the patient and/or their carer to enable shared decisions about care to be made.

Summary

These recommendations aim to develop a health service with frontline leadership by improving the flow of information between members of the healthcare team. The recommendation of key nurses should improve patient care by making sure someone is responsible for each patient at all times. By enhancing the importance of ward rounds, everyone involved should be kept informed of the plan of care for each patient and know who is responsible for ensuring it is carried out. The recommendations encourage a multidisciplinary approach, centred on patients so they receive specialist care that is tailored to their specific needs.

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