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Improving practice with limited resources

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VOL: 97, ISSUE: 36, PAGE NO: 43

Linda Phillips, RGN, RSCN, DipN, is senior clinical nurse to child health directorate

Jo Arnold, RGN, RSCN, is ward manager of the medical unit, Southampton General Hospital

The 30-bed child health medical unit at Southampton General Hospital wanted the benefits of a high-dependency unit, but the money was not available. The unit had been under pressure for some time, with increasing numbers of highly dependent children being transferred from a regional specialist paediatric intensive care unit.

The 30-bed child health medical unit at Southampton General Hospital wanted the benefits of a high-dependency unit, but the money was not available. The unit had been under pressure for some time, with increasing numbers of highly dependent children being transferred from a regional specialist paediatric intensive care unit.

Things came to a head in the winter of 1999/2000, with heavy workloads, high staff sickness rates and low morale. We submitted a bid for an HDU to channel the management of children with higher levels of need into one area, but knew it would take time. In the interim we had to find more effective ways to manage nursing resources and patients.

After a great deal of discussion, senior nurses agreed to group high-dependency patients into a discrete six-bed observation area. Close to the nurses' station, it opened last December and has its own internal telephone and dedicated medical equipment, such as a portable patient monitor.

Nursing resources were reallocated so that three nurses (at least one senior) staffed the six-bed observation area, and four nurses (one senior) and two health care assistants attended to the rest of the unit. After a few weeks we realised that the workload was too much for staff in the rest of the unit, so we moved one of the nurses from the observation area back to the main medical unit.

Segregating patients in the greatest need meant that junior nurses in the main unit were under less pressure and could concentrate on caring for those more suited to their level of skill. They were given the opportunity to be rotated into the observation area to work under the supervision of a senior nurse and develop new skills.

Patients are assessed daily to decide if they should be cared for in the observation area (see box).

The feedback to date shows that the separate observation area has improved both nursing care and staff morale. Identified benefits include:

- Reduced stress for less experienced nurses. They no longer have to care for very sick patients without appropriate support and training;

- An opportunity for staff to expand their skills. A number of senior nurses are doing specialist training in the care of high-dependency children at the University of Plymouth, while junior nurses can develop their skills in the observation area through the rotation programme.

Our main problem is staffing levels. As the observation area had to be set up using existing nursing resources, the nurse-patient ratio and workload in the rest of the unit has increased.

The initiative was a compromise. Constrained to having to use existing resources, we felt it was the most effective way to manage the care of very sick children on a busy ward. In an effort to ease these workloads, nurses can request longer periods of time off through 12-hour shifts.

We have since received funding to upgrade the acute observation area to a regional four-bed HDU, including £130,000 for more nurses. The acute observation area highlighted the need for such a unit and provided a valuable stepping stone towards its establishment.

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