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Are ward sisters and charge nurses able to fulfil their role?

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AIM: To investigate the self-reported duties carried out by sisters and charge nurses working on the wards and to assess the attitudes of these health care professionals towards their management role.

Abstract

VOL: 101, ISSUE: 29, PAGE NO: 38

Andy McEwen, MSc, RMN, is senior research nurse, St George’s Healthcare NHS Trust, London

Sue Cooper, MSc, BSc, RN, DipN, CMS, is deputy director of nursing, St George’s Healthcare NHS Trust, London;Sonja Clayworth, BSc, RGN, is critical care manager, Queen Mary’s Sidcup NHS Trust

AIM: To investigate the self-reported duties carried out by sisters and charge nurses working on the wards and to assess the attitudes of these health care professionals towards their management role. METHOD: Questionnaire. RESULTS: Sisters/charge nurses were allocated patients in addition to being in charge of their ward for, on average, half of their shifts each week. Most of them did not have time to complete their managerial duties, which included supporting and supervising other staff on patient care issues. More than 50 per cent of the sisters/charge nurses did not have the time to attend clinical supervision. CONCLUSION: Sisters/charge nurses treat clinical care - both delivering it directly themselves and advising other staff on its delivery - as a higher priority than their managerial and administrative duties; lack of time is a barrier to the successful fulfilment of their role. Ward sisters/charge nurses play a central role in the ward team and good clinical leadership is seen as paramount when it comes to providing high-quality nursing care (Department of Health, 2000). Since 2000 the NHS Leadership Centre, which incorporates the national nursing leadership programme, has made leadership development courses available for nurses. Nurses have also taken part in the Leading Empowered Organisations (LEO) course and been trained through the RCN clinical leadership programme. It is clear that the role of the ward sister/charge nurse is seen as pivotal in setting the standards in clinical care and leading improvements to enhance patients’ experiences while they are in hospital. However, it may be that there has not been a parallel focus on developing organisations’ infrastructure to allow these practitioners to perform their clinical leadership role effectively (Allen, 2001). The mix of clinical, managerial and educational roles of ward sisters/charge nurses needs to be re-evaluated in response to developments in advanced nursing practice, the focus on developing leadership skills among nurses and to changes in the NHS as a whole. This article reports on a study examining the ability of ward sisters and charges nurses in an NHS trust to fulfil the different aspects of their role, and the support they received in doing this. Method
Themes for investigation, including barriers to successful role fulfilment, were identified at two workshops for ward sisters/charge nurses held in 2003 at St George’s Healthcare NHS Trust in London. The workshops were organised to address issues highlighted by the National Patient Survey (Picker Institute, 2002). A 34-item questionnaire was designed to identify sisters’/charge nurses’ views about carrying out their duties and was then piloted within the nursing research team. The questionnaire asked how much time sisters/charge nurses spent working on ward business each week outside of their contracted hours and what percentage of their patients they managed to see during a typical shift. A number of statements were then proposed, to which respondents were asked to agree or disagree on a five-point Likert scale. The statements related to managerial, administrative, clinical and educational duties and to issues of support, time management and professional development opportunities. The questionnaire was supplied as an attachment to an e-mail with an accompanying message encouraging recipients to return the questionnaire via the internal post if they were a sister or charge nurse with responsibility for nursing teams working on the wards, in A&E or intensive care units. Results
The questionnaires were collected and collated: - There was a 48 per cent response rate (45 out of 93 questionnaires distributed), with all the nursing specialties represented; - Nearly all (91 per cent) of the sample were employed on a G grade; - Eighty-four per cent were female; - Approximately half of the subjects in the sample were aged 30-40; - Respondents had been qualified for an average of 17 years; - They had been in their current post for an average of five years. The results were analysed under three headings: clinical, management and professional duties. Clinical duties Sisters/charge nurses reported directly assessing on average 75 per cent of patients on their ward during a typical shift. They were allocated patients for whom they had not planned to take primary responsibility in addition to being in charge of the ward a mean of 2.5 shifts per week. On average they reported spending almost six hours a week outside of their contracted hours on ward business. When asked about ward organisation: - Forty-two per cent of respondents said their ward was organised using a team nursing system; - Twenty-four per cent said they used a patient allocation system; - Twenty per cent used the named nurse system. Table 1, p38 shows that 87 per cent of sisters/charge nurses agreed that they were aware of the standards of clinical practice in their area, although nearly one-third agreed that they did not have the time to evaluate these practices. Over three-quarters of respondents agreed that providing direct clinical care is one of the most important roles of a ward sister/charge nurse. A majority of respondents reported that they directly assessed all patients on their ward every shift, but nearly one-third said they did not have enough time to fully advise and support other staff on patient care issues. Managerial duties More than two-thirds of respondents believed they did not have sufficient time to teach, assess and develop junior staff (Table 2, p39). Only 11 per cent thought they had sufficient time to complete all their managerial duties each shift and only one-third agreed that they had the necessary skills, training, experience and time to manage their team effectively. A majority (54 per cent) felt that senior nurses and trust managers fully supported them, although they were evenly split on whether the trust valued their role. Fifty-eight per cent said they had a clear vision for the future of their clinical area, and the same percentage felt they had the authority and support to make changes in their clinical area. Professional issues One-third of respondents disagreed that their role allowed them to maintain their ongoing personal and professional development. In addition 33 per cent agreed that their skills and experience were not being fully utilised in their present role. Table 3 also shows that over half of the respondents agreed that they did not have the time or the opportunity to attend regular clinical supervision, although almost half said they were part of a network of ward sisters and charge nurses who supported each other and shared innovations. Discussion
Principal findings The sisters/charge nurses responding to this survey represented an experienced staff group. They were typically allocated patients, in addition to being in charge of their wards, on half of the shifts they worked. They reported that during each shift they were able to clinically assess three-quarters of the patients on their ward themselves, and believed that the provision of direct clinical care was one of the most important elements of their role. Time was a major constraint in carrying out managerial duties, advising and supporting staff, teaching and assessing junior staff, evaluating clinical practice and attending clinical supervision. Implications for practice Approximately a third of the sisters/charge nurses who completed the questionnaire reported having insufficient time to evaluate current practice in their clinical area or to directly assess all the patients on their ward every shift. This is of some concern. The fact that almost two-thirds of respondents did not have enough time to fully advise and support other staff on patient care issues is further evidence that, while they agree in principle that clinical care on their wards is their top priority, sisters/charge nurses do not have the time to fulfil this role adequately. Perhaps unsurprisingly, lack of time also appeared to be a barrier to sisters/charge nurses being able to teach and assess junior staff and complete their managerial duties. It is possible that some guidance on prioritising their duties and on time management may assist them with balancing their multifaceted roles. Initially, an obvious arena for such discussions would be in regular clinical supervision sessions. However, the majority of respondents reported not having the time or the opportunity to attend regular clinical supervision. Nevertheless, clinical supervision is essential for individual nurses as a means of maintaining and developing their clinical practice, and it is vital as a means of assuring the quality of care being delivered. A combination of time pressure and the absence of regular clinical supervision may go some way towards explaining why one-third of the sisters/charge nurses who responded to this survey felt their skills and experience were underutilised, that they were not valued and that they were unable to maintain their ongoing personal and professional development. Just over half of the respondents did not have access to a network of sisters and charge nurses providing mutual support and sharing innovations as an alternative or adjunct to regular clinical supervision. Thus, another means must be found to support these practitioners and maintain their professional development. Ensuring all sisters/charge nurses are able to attend regular clinical supervision should be a clinical and management necessity, and may have an additional benefit in terms of improving morale in this group. Latest developments Since this survey was carried out, St George’s Healthcare NHS Trust has committed to working with its sisters/charge nurses to enable them to devote more time to clinical care. In an attempt to further extend their clinical focus, the trust has changed the role of modern matrons in order to free sisters/charge nurses from some of the managerial components of their role. It has also engaged in an external review of trust budgeting and ward establishments. In addition, the majority of sisters/charge nurses have been through the RCN clinical leadership programme, while regular ward sister/charge nurse meetings have been significantly extended to ensure there is time for clinical updates, policy-making, debate and networking. Limitations This study was limited by the fact that it relied on self-reports and that the response rate was modest for surveys of nursing staff. Further research is needed to confirm whether the findings of the study can be generalised to other trusts. It would also be useful to quantify the time demands of current duties carried out by sisters/charge nurses and to identify barriers to successful fulfilment of their role. The survey could also be undertaken again at St George’s at a later date to assess whether changes made by the trust in response to the findings of this study have been effective. Comparisons with the literature It is reassuring that despite the fact that ward sisters/charge nurses are having to develop more complex managerial roles, possibly at the cost of clinical and professional functions (Allen, 2001), those taking part in this survey still placed a high priority on their clinical responsibilities. However, it is clear that the complex and often conflicting demands that face today’s ward sisters/charge nurses are nothing new (Kitson, 2001). Organisational changes are needed if they are to be effectively supported in fulfilling their role (Kelsey, 2004). Conclusion
Sisters/charge nurses appear to treat clinical care - both in terms of directly delivering it themselves and advising other staff on issues related to it - as a higher priority than their managerial and administrative duties. It is of some concern that these practitioners are regularly allocated patients in an unplanned way in addition to being in charge of their ward, and that a majority do not have time to directly assess all the patients on their ward during each shift. - This article has been double-blind peer-reviewed. For related articles on this subject and links to relevant websites see www.nursingtimes.net

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