Calls to improve support for nurse leadership

A new report from the Royal College of Nursing (RCN) has warned that some ward sisters are prevented from offering the leadership their role requires because they have a high clinical load of their own, they have to do too much paperwork and are not given enough authority over the ward environment. Breaking Down Barriers, Driving up Standards: The Role of the Ward Sister and Charge Nurse is based on research with nurses across England and looks at their current roles, best practice, and areas where more support is needed. One example featured in the report showed the problems which arise when nurses are not given the necessary authority to lead on their ward. Nurses on one ward had to go and buy their own batteries for medical equipment because they did not have the authority to get them delivered through the hospital system. Dr Peter Carter, RCN chief executive and general secretary, commented:“This is not an effective way for a ward to be run, and there are few other industries where this would be tolerated. Talented nurses should be free to lead and to nurse, and good nurses should be encouraged to take a career route where they can lead, educate and oversee care as ward sisters. “Lord Darzi knows this, and he recognises the vital contribution made by ward sisters to delivering high quality treatment. Where the ward sisters are nurse leaders, who can educate staff and oversee patient care, wards run more effectively, and this should happen across the country. Talented nurses should be able to benefit more patients than those they treat directly.” Louise Boden, chief nurse at UCLH Foundation Trust, said: “Ward sisters are the key to delivering the best possible care. We know that when a patient comes into hospital, they need to know who is in charge. They also want to know that person has all the necessary skills, resources and authority to produce a good care environment, appropriately trained staff and well organised care. At UCLH we are committed to supporting ward sisters and charge nurses to be able to supervise care delivery, and deliver results for patients.” The report pointed out that ward sisters have a huge breadth of responsibilities, encompassing leadership and management, clinical practice, and education and teaching. To carry out all of these roles they must supervise nursing on all shifts, rather than taking on heavy clinical loads themselves. However, the roles ward sisters actually fulfil are often unclear, and the aims, purpose and function of a ward sister vary in different settings. Patients want to know who is in charge and that this person has the necessary authority to deliver high quality care. RCN recommended that more clarity in this area would encourage more talented nurses to take this route. Ward sisters reported a lack of formal preparation and skills development for ward sisters and aspiring ward sisters, despite some excellent examples of training in some Trusts. These programmes, such as the one at Imperial College Healthcare NHS Trust, should be made available to ward sisters across all Trusts, the RCN concluded. It added that ward sisters are constantly balancing roles as professional nurses and the front line of management for the largest group of NHS staff. The report found that ward sisters were motivated to manage their ward team by a passion for nursing, rather than an aspiration or desire to be a manager per se.

Authority
Another issue raised related to the authority of the ward sister role to actually manage the ward and ward staff. In theory, ward sisters hold responsibility for the management of the ward and ward staff, yet many said they did not actually have adequate authority to effectively carry this out. The report stated that they felt they were being held responsible for ward management issues that they could not control, because the responsibility had not been fully devolved to them and they still needed the signature and agreement of line managers for even small-scale decisions or change. One nurse highlighted the problem, commenting: “We do have any weighing scales that work at the moment… each day we ring facilities. They just say it will be sorted… meantime the nurses are trawling the other wards to borrow, beg or steal some scales. Why can’t I just ring up the company and get them to come and repair them?” Ward sisters are also theoretically responsible for key factors affecting nursing standards, such as cleanliness and nutrition, but often in practice are unable to control them. The report recommended that Trusts should ensure that clinical staff are able to deliver care in an appropriate environment with all the necessary resources. The report also highlighted evidence that effective ward leadership correlates with patient outcomes and staff performance in terms of lower rates of medication errors, higher levels of patient satisfaction, and lower ward absence and sickness rates. It warned that the nursing profession must take some “clear and firm decisions to shape, support and strengthen the role of the ward sister”, adding that current pressures and competing priorities have rendered their role almost “impossible” – resulting in excessive workloads and extra unpaid hours worked every week. The RCN pointed out that some pressures stem from system issues, which require rapid patient turnover and patient throughput, and high levels of bed occupancy, which have increased demands on nursing time. However, the most significant finding from the RCN investigation was the pressure placed on ward sisters from looking after and nursing a group of allocated patients on every working shift, in addition to their ward leader responsibilities. This has made it impossible for them to appropriately lead, manage and supervise clinical practice and the ward environment. The report stated that this is “not acceptable and needs to be swiftly remedied”. The support function of the human resources (HR) departments was also a key issue raised by many ward sisters. They said they were often unsupported when managing complex performance issues, such as sickness absence policies and disciplinary procedures, but also recruitment processes – from writing job descriptions and placing advertisements through to the selection process. Ward sisters viewed such work as “poor use of their time and skills”, since others with a more appropriate qualification could undertake this. They also perceived the lack of non-clinical support and the expectation that they would absorb such work as an indication that their role was not valued. The RCN added that pay and salary, which is one expression of how much a role is valued, was an area of considerable disgruntlement. The College was “surprised and concerned” to find that some ward sisters appeared to be inappropriately banded and paid at Agenda for Change (AfC) band 6 instead of the minimum AfC band 7 that correlates to the ward sister profile. It was uncertain how widespread inappropriate banding of ward sisters was and said it would be investigating this further. In addition, many participants pointed out that their take-home pay had actually decreased on their appointment to a ward sister post, since some no longer worked “unsocial hours” and therefore earned less than they had previously as staff nurses. Some suggested the ward sister role was no longer seen as attractive by many staff nurses, because they could achieve the same pay and a perceived higher status by becoming a nurse specialist. It was felt that specialist posts were valued more by NHS Trusts but also more by the nursing profession itself.

Recommendations
The RCN concluded that it is necessary to find ways to reward and value the role of the ward sister with commensurate professional status so that nursing excellence can be recruited, retained and developed at ward level. The RCN recommended that all ward sisters become supervisory to shifts so that ward sisters can: fulfil their ward leadership responsibilities; supervise clinical care; oversee and maintain nursing care standards; teach clinical  practice and procedures; be a role model for good professional practice and behaviours; oversee the ward environment, and assume high visibility as nurse leader for the ward. It also suggested that ward sisters and charge nurses should assume a title that conveys a clear identity as the nurse leader of the ward. Nurse directors need to review the remit of ward sisters in each NHS Trust to ensure they have the appropriate authority for key issues that underpin care quality – such as ward cleanliness and nutrition – and the appropriate administrative, housekeeping, and HR support to enable them to manage the ward team and ward environment. The RCN will host a joint summit with the Chief Nursing Officer (CNO) for England of key stakeholders to clarify and agree: the purpose and key functions of the ward sister role; the skills, competencies and knowledge needed to fulfil this role; the requirements for education and skills support to achieve these; and career pathways for ward sisters. The College will also host joint events with the CNO team for England in every strategic health authority to enable ward sisters and matrons to discuss the policy and professional context for care quality, the measures that can be used to improve it, and receive feedback on how to develop this further.