Two senior charge nurses at NHS Ayrshire and Arran won a case for recruiting an administrative assistant, allowing them to be more visible and active as clinical leaders
Two senior charge nurses at University Hospital Crosshouse in Scotland, working in the acute stroke unit and on a general medical ward respectively, found that they were overwhelmed by admin tasks impacting on their ability to be visible clinical leaders for patients and staff. An administrative support role was piloted for six months and then made permanent. Each senior charge nurse now has 15 hours of administrative support per week, which allows them to be visible clinical leaders and has brought significant improvements for staff and patients. This article discusses the pilot, its background, implementation and outcomes.
Citation: Somerville C, Morrison V (2018) Freeing up senior charge nurses’ time through admin support. Nursing Times [online]; 114: 3, 27-29.
Authors: Christine Somerville and Victoria Morrison are senior charge nurses at University Hospital Crosshouse, NHS Ayrshire and Arran.
- This article has been double-blind peer reviewed
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Most nurses will have experienced waking up in the middle of the night worrying about a patient care issue. Back in 2015, what was keeping me awake at night was a growing to-do list of admin jobs relating to staff roster, annual leave, training, risk assessments and absences.
As senior charge nurse (SCN) in the acute stroke unit at University Hospital Crosshouse, NHS Ayrshire and Arran, I was spending more and more time away from patients, stuck at a desk and completing admin work. My passion for delivering safe, effective and person-centred care while supporting and leading a team was becoming increasingly difficult to fulfil and my stress levels were soaring.
I could either reduce my clinical involvement and become office-based (which I did not want); work more than 50 hours per week (with the risk of burnout); or come up with an innovative solution. This article describes how a colleague and I were able to reclaim our roles as SCNs by recruiting a part-time administrative assistant.
SCNs as the leader of the team are accountable for the standards of care within their area, with a need to be visible to patients, relatives and staff. Despite this being my passion and vision since my student nurse days, over 20 years later, I found this to be increasingly difficult. In contrast to the ever-growing role of the SCN, many other jobs have disappeared, including the administrative roles that used to deal with nurses’ wages, absences and training. This has resulted in SCNs taking on many admin tasks by default.
The Francis report highlighted that SCNs should have a supervisory role, drive up standards of care, and certainly not be office-based (Francis, 2013). They must have the capacity, resources, time and authority to fulfil a role that combines being responsible for the standard of patient care with line-managing those who deliver that care (Royal College of Nursing, 2009).
NHS Scotland supports the idea that SCNs are there to ensure safe and effective clinical practice, enhance patients’ experience, and manage their team’s performance (NHS Education for Scotland, Leading better care).
A review by Locke et al (2011) showed that, when ward managers had admin support, they were able to spend more time with patients. These findings are supported by a pilot undertaken by Mazengarb (2013), where clerical support helped the ward sister to work clinically, lead the team and focus on patient care.
No additional money
With 71 staff across two sites reporting directly to me, and a budget in excess of £1 million, increasing admin was making it harder and harder for me to fulfil my role as SCN. A review of the admin tasks I completed showed that 70% of them could be done by an administrative assistant. The job was estimated to take 20 hours a week, but only 15 hours if it was to be done by a trained administrative assistant, who would be more efficient. In my eyes, the need for admin support was evident.
However, there was no additional money and, at the same time as we demonstrated the need for admin support, we also demonstrated the need for more nurses at the bedside, so the idea of using the nursing budget to pay for an admin role was not going to be easy to sell. On the other hand, paying a band 7 nurse to spend 20 hours of her working week to complete admin tasks that an administrative assistant could do more effectively did not seem a good use of limited funds.
At a time of increasing financial scrutiny, we needed to move to a better use of resources and to new ways of working. As Shuldham (2017) highlights, the idea that, in times of pressure, there is no time or money to transform existing ways of doing things needs to be challenged.
A shared vision
Unknown to me, one of my SCN colleagues in a general ward was facing the same issues. Fortunately, our clinical nurse manager and associate nurse director were willing to take risks and encouraged us to think outside the box.
My colleague and I shared the same vision, both of our own roles and of the SCN administrative assistant role. Our idea was that the administrative assistant would take over tasks such as inputting audit data; arranging and monitoring staff training; managing staff attendance; managing diaries; developing and maintaining databases; entering the staff roster into the electronic system; and dealing with staff requests.
This would free up our time, allowing us to focus on leading and supporting our teams, ensuring safe, effective and person-centred care, and enhancing patient and family experience. We would be able to do more role modelling for staff, deliver more scenario-based teaching, lead consultant ward rounds, and spend more time with patients and relatives – to name but a few core components of the SCN role.
The outcomes of the new role would be reviewed in the light of patient, family and staff feedback, audit results, staff attendance management, personal development review, and preventable harm from falls and pressure ulcers.
Having presented our shared vision of the envisaged role, we secured six months of funding to pilot its introduction. The job was advertised as a 30-hour post shared between us. It attracted a lot of interest and, in December 2015, we recruited the first SCN administrative assistant at NHS Ayrshire and Arran, a motivated and trained ward clerk keen to help us deliver the best possible care.
Impact of the admin role
The introduction of the administrative assistant role has had a positive impact on all aspects of our roles. Admin tasks are now completed more efficiently and effectively, and we are able to play a supervisory role and be more visible on the wards, legitimising our roles as clinical leaders.
In the acute stroke unit, I now undertake a daily safety round including a 2pm ‘stop and check’, as well as daily consultant ward round incorporating a review of nursing care. During that review, I check care plans, risk assessments, food and fluid charts, peripheral venous cannula (PVC) charts, early warning scores, care and comfort rounding, and SSKIN care bundle charts for pressure ulcer prevention.
I also undertake a daily multidisciplinary team (MDT) round to review patients’ goals and outcomes, with a focus on achieving earliest possible discharge. Before the introduction of the admin role there were no MDT daily reviews. Review of nursing care was undertaken less frequently and there was no 2pm ‘stop and check’. Care is now reviewed in real time, rather than retrospectively, and avoidable harm is proactively prevented.
Clinical quality indicators relating to food and fluid intake, falls, PVC sites and hand hygiene are audited weekly and results displayed on the unit’s performance board. We are now consistently above 95% for all indicators.
Since January 2015 there have been fewer falls (Fig 1), no falls with harm to patients and no avoidable pressure ulcers – despite the fact that our patients are in the high-risk category for falls and pressure ulcers. The patient feedback in Box 1 shows a high level of satisfaction with care on the acute stroke unit.
Box 1. Patient feedback on the stroke unit
- “I can’t get over how nice the staff were in ward 3E. They were amazing and kept you up-to-date with everything that was happening, and took the time to get to know your likes and dislikes.”
- “Brought into 3E room 321 on the Monday pm and immediately impressed by politeness and capabilities of staff. Patients’ comforts and concerns taken care of. Easy to talk to and knowledgeable. All in all stay was very pleasant.”
- “I was (…) referred to Kilmarnock Crosshouse ward 3E for specialised treatment. I have received very good medical and personal treatment administered in a professional and caring manner. If this is the way the rest of the NHS is performing, things are pretty good with little to worry about.”
From less than 50% in June 2013, the percentage of acute stroke unit staff undergoing mandatory and statutory training reached 87% in April 2017. Personal development review (PDR) data shows that compliance is now above the HEAT target (Fig 2); our local target for completed PDR plan activity is 60%, the national standard being 80%. This is having a positive impact on staff, who have had a face-to-face review during which 12-month objectives and a personal development plan were agreed.
Admin tasks associated with staff attendance are now entirely managed by the administrative assistant, which has released time for me to focus on individual staff members’ health and wellbeing, and identifying any support they may need. As a result, staff absence is at an all-time low, having fallen from 3.8% in January 2017 to 1.78% in May 2017 (Fig 3). I also have more time to do role modeling with junior staff and provide scenario-based learning – for example, on breaking bad news or managing difficult conversations.
In partnership with our occupational health department, we have launched a project called ‘Getting to know your numbers’, which involves monitoring staff’s blood pressure and helping them manage their weight, reducing their stress levels and stopping smoking. The aim is to promote staff’s health and wellbeing, and make them feel supported and cared for.
Similar improvements as those described above have been seen in the general ward. The fact that my colleague and I are more visible and more involved has not only resulted in improved outcomes, but also in a culture change and the development of highly motivated teams. Staff are more engaged and actively participating in quality improvement projects such as #endPJparalysis (Box 2).
Box 2. #endPJparalysis
As part of the #endPJparalysis project, staff in the acute stroke unit assist patients to get washed and dressed in day clothes. Patients are encouraged to move around the ward or go for a walk supported by staff. Leaflets provided on admission advise families to bring their relative’s suitable clothes and footwear. Staff use their judgement to identify patients who are able to get up and about. All commodes have been removed from the unit, which supports patients’ recovery and also their dignity. Data shows that we have moved from less than 4% in November 2016 of appropriate patients wearing day clothes to over 83% in April 2017.
The administrative assistant post has been made permanent and is funded by the nursing budget. To find the money, nurse handover times have been reduced by 15 minutes from 30 to 15 minutes, which has resulted in more focused and structured handovers as well as a weekly staff saving of 19.25 hours. Crucially, the role remained within the nursing management structure and is line-managed by the two SCNs. With positive results demonstrated across every domain, the nurse director and associate nurse director has supported the role to be introduced for all SCNs within in-patient wards.
Our roles have been transformed, with more emphasis on continuous quality improvement. We have moved from an office setting to the front line and from words to action. We both feel energised by the presence of an administrative assistant, and are delighted to contribute to better outcomes for patients, relatives and staff across Ayrshire and Arran.
- The role of senior charge nurse combines being responsible for the standard of care with line managing those who deliver that care
- Senior charge nurses need to be visible on the wards and involved with patients and staff
- Relieving them of administrative tasks gives them more time to focus on ensuring safe and effective care and managing their teams
- At NHS Ayrshire and Arran, an administrative assistant was recruited to support two senior charge nurses in their roles as clinical leaders
- Acknowledgements – The authors would like to thank Mary Harper, clinical nurse manager, Angela O’Neill, associate nurse director, and Hayley Paterson, SCN administrative assistant, all at University Hospital Crosshouse, NHS Ayrshire and Arran.
Francis R (2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: Stationary Office.
Locke R et al (2011) The impact on the workload of the ward manager with the introduction of administrative assistants. Journal of Nursing Management; 19: 2, 177-185.
Mazengarb S (2013) Using clerical staff to free up ward sister time. Nursing Times; 109: 29, 12-13.
Royal College of Nursing (2009) Breaking down Barriers, Driving up Standards: The Role of the Ward Sister and Charge Nurse. London: Royal College of Nursing.
Shuldham C (2017) How nurses can improve quality while controlling costs. Nursing Standard; 31: 35, 29.