Posted by: ayrshirehealth | March 26, 2014

Reflections of a Senior Charge Nurse by @maureenfleming0

Reflections on the care of older people

When I was asked to be involved in writing this Blog my initial thoughts were “what do I do that I could write about that people would be interested in reading”. Having thought about it for a few weeks I decided I would write my reflections on the care of older people highlighting the wide spectrum of knowledge, skills and behaviours that are required to carry out the key role of Senior Charge Nurse.SCN

screen-capture-20I am the senior charge nurse in a 30 bedded Medicine for the older adult ward at Crosshouse Hospital in Kilmarnock. I have held this post for more than 15 years, prior to that I was the Charge Nurse in a day hospital for older adult.

The specialism of older adult nursing is always where I wanted to work, I feel that I personally gain more satisfaction from caring for people in this speciality rather than any other.

Much frailer condition

Last week a research report from Glasgow University indicated that in NHS Scotland

  • More than 30% of elderly people admitted to hospital died within a year, this increased as they got older
  • 10% of people admitted died within that admission
  • Nearly 50% of admitted men over 85 died within a year

My comment from the ward perspective is that unfortunately this is a true reflection. We seem to be seeing patients admitted in a much frailer condition at the latter stages of a period of illness.

So why is this happening? Are Hospitals getting it right by admitting the sickest people? And what does this mean for the nursing staff caring for this group of patients?

What could we be doing to improve these facts and figures?

Local NHS Ayrshire and Arran pieces of work developing frailty and delirium pathways aim to ensure that patients receive the best possible care in environments that are most beneficial for them whether these are at home or within the hospital environment. Whilst our community wards developments are targeting patients with a history of hospital admission and chronic conditions to actively manage these conditions better at home and potentially prevent future hospital admissions. The development of anticipatory care plans supports staff in providing more effective long term management and end of life care. These 4 initiatives will go a long way in improving the experience for patients and families.

So with our patients admitted with increased frailty and more complex needs in the latter stages of their illnesses. What does this mean for the day to day role of the senior charge nurse and the nursing team?

Nursing TeamPatients in the ward may present with an acute episode e.g. Chest infection but also may have 2 or 3 other chronic medical conditions like diabetes, heart failure, Parkinson’s disease and possibly associated dementia or delirium. This makes the medical and nursing management of the patient complex as there may be many contributing factors as well as poly-pharmacy. This of course means that the knowledge and skills of both the nursing and Multi-disciplinary team need to be able to identify and manage these complex presentations.

The increasing pressure on staff has been highlighted by our senior team and we have been able to recruit a number of new staff to support the provision of patient care. This has been a challenge with a number of new staff starting in a short period of time. Each of the new staff members will be allocated a mentor who will support them in the transitional period. The mentor and I are able to work with them to identify any learning needs, key challenges and opportunities to improve their clinical practice This provides them with a named person to support them.

The additional pressure on staff also has the potential to increase their stress levels which of course has an impact on their attendance at work. I like to think that my supportive behaviours that I exhibit encourages staff to come to me with any concerns that they have about how they are coping with their workloads ( and sometimes their family lives) at an early stage. I can then initiate supportive measures and activate any Human Resource Policies to assist them.SCN 2

Ensuring the quality of safe person centred nursing care

I see my key role in the ward as ensuring the quality of the provision of safe person centred nursing care provided to patients.

It is my role to ensure we complete the audits of the key clinical quality indicators. Examples include an analysis of falls management, food fluid and nutrition, tissue viability, peripheral vascular cannulation, MEWS etc.  These audits allow me to measure the performance of our staff against these standards. It also allows me to develop action plans for improvement if we fall below the standards and demonstrate where good clinical practice is being achieved. The results are displayed for visitors to the ward to see how we are performing. We are currently exploring different ways to capture the views of patients experience in the ward to replace our “you said- we did” tool – the results of which are also displayed for visitors.

Quality circleThe nurses in the ward area are the main healthcare personnel that both the patient and their family will come face to face with. It is my view that the key to ensuring that the experience of the patient and their carers is good effective communication. In this I mean effective communication between the nurses (and other clinicians providing care) in the form of effective records and handovers and effective communication with the patient and their families. If we get this communication right the patient and carers experience is much improved and potential concerns and complaints can be dealt with quickly and effectively.Wordle records

Two examples of how I promote this are

  • Daily audit tools analyse the quality of the record keeping and SBAR handovers. This allows me to better identify the record keeping issues and work closely with individual members of staff to improve their skills in this area.
  • I encourage all nurses to be visible in the ward areas during visiting time and to actively engage with patients and carers to update them on the patients’ progress. I also make myself available during these times to meet with families where necessary.

Conclusion

CareThis reflection is merely a snippet of the challenges faced by a senior charge nurse in this type of ward environment on a day to day basis. The pace of the workload has increased immensely and sometimes I see nurses “running” in the ward as they have so many things to do.

The ward environment has changed also, even though we have protected meal times to ensure patients receive support to meet their nutritional and fluid needs, outwith this we see staff constantly interrupted in their tasks to answer phones and respond to requests from others on the ward. I feel it would be good to have the opportunity to explore how the use of additional support staff e.g. administration and more volunteers to support nurses in providing more focussed care with less interruptions.

Leadership skills and behaviours are essential for the senior charge nurse to create a culture of care and compassion within the ward area and to share their own knowledge and skills with staff to help them develop.

I have always and continue to love the job that I do and I am so proud of the team I have and the difference that they make on a day to day basis for older people in acute hospital care.

This week’s blog is by @maureenfleming0 (Maureen Fleming) who is a Senior Charge Nurse in Crosshouse Hospital, NHS Ayrshire & Arran

 

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Responses

  1. I am an A&E nurse (as you know, partnered with our ‘sister’ ward – AMU, acute medical unit – where many of the elderly patients go first, at least as outliers until care of the elderly beds become available) and I have noticed that the paperwork has increased enormously over the past five years. In the main, I would say most of it is about safeguarding (falls, nutrition guarantees, pressure sores, etc), and it is all working to reducing risk and preventing accidents. However, I don’t think anyone, except the nursing staff, understand the extent to which this has put a huge amount of new tasks into a standard 12hr shift, for which there was never an abundance of ‘extra’ time to begin with.
    I work in a busy London hospital (originally from Glasgow/Ayrshire) and part of my role, over and above my PAYE job, is Bank work, as night practitioner (night-time site management). Over the past 6months, I see the absence levels have shot through the roof; much of it related to illness and some of it to do with disputes (not related to professional errors, but more and more disciplinaries involving compliance regarding paper trail issues).
    At the grass roots level, this means I start my night practitioner shift – not focussed on clinical needs of patients (canulas, catheters, clinical liaison, drug chart issues, fire alarms, thefts on the ward, etc) – but firefighting troubles on the wards at handover times: i.e. wards calling to say they are short handed and I need to call Bank or Agency, at the last minute, to find last minute labour, to come and work and fill shifts.
    The main, general medicine wing, of our hospital has 500 inpatients. We’re usually full by the time 8pm comes around. At 20:30hrs the other night, I had phone calls to say a total of 50no. band 5-band 6.5s were absent from night duty. This left our coverage on one branch of our Care of the Elderly ward as two registered nurses covering 35 patients. So, 17 patients each, approx.
    As soon as I arrived on that ward, there was utter chaos. One nurse was in the drugs room trying, for about 30minutes to get someone to come and sign out CDs with her, and she’d all but had a melt down. I spent time supporting her, professionally, and another 10minutes trying to prevent her walking off the job.
    I then managed to convince the senior site manager to pull other ‘extra’ hands from other wards to come and help. The priorities are always patient safety. Whilst that includes IV Abx for 22:00hrs, it includes dispensing general medicines, observations, turning (bed sore prevention), getting patients ready for bed (making sure the pads are changed, urometers are emptied and measured, PCAs are working and SATs are maintained), basically, everyone is dry, comfortable and healthy for the night in front of us. Technically, all of this should be achieved by around 23:00hrs, at the latest. We are lucky if we slow down and get on top of things by about 3am these days.
    If you aren’t mentally and physically exhausted by 3am, chances are you are dehydrated and hungry having not stopped since 8pm to have a drink or go to the bathroom.
    In August to November 2013, 22 people resigned from A&E. About 25% came back as bank workers. The rest of the short fall is made of agency workers, unfamiliar with new paperwork, new practices, new Trust policy, let alone not knowing the bleeps, the names of their colleagues, where the supplies are. Many of the 22 people have gone into the community, where the salaries are more generous, the benefits are higher (e.g. car allowances) and the workload a little lighter and more straightforward. That includes working hours. Some ex staff have gone into private hospitals where there has been a huge spike in foreign visitors using private treatments centres in the big cities of England and Wales.
    Australian and Kiwi nurses remind us that it is against the law to have more than 4 patients per nurse. If my nursing colleagues in the UK had that kind of level of engagement with their patients, there would be an abundance of time or flexibility for doing more paperwork and focussing on initiatives that increase the quality of care and reduction of errors.
    To date, I am proud to say that most of new and extra paperwork in A&E has been put to great use. I like the new NICE observation alert scoring. The SKIN bundle paperwork for measuring and treating and processing imported pressure sores (that we catch coming through the door) has initiated a process that continues, from arrival in A&E, through the whole hospital, of having successfully reduced pressure sore incidents to ONE incident for the entire month of February 2014. The paperwork, is working!!!!
    But for how much longer? We always say we are at our limits, and then manage, to senior management’s delight, to do a little more. But the sharp rise is absenteeism, as well as resignations, the collapse in enthusiasm and moral, is the price for the rise in standards.
    We will go on. We have to. But the NHS is heading towards a total catastrophic failure on Mid-Staffs levels. It won’t be, like Mid-Staffs, a rise in clinical incidents and a failure of reporting. It will be the lack of people wanting to actually turn up to do the work. Not so much a failure of good nursing practice, under pressure, but a lack of high level insight of who wants to work in healthcare and under what circumstances.

  2. […] Reflections of a Senior Charge Nurse (on the Ayrshirehealth blog) – Maureen Fleming writes about her work as a senior charge nurse in an older adult ward in a hospital, and the complex challenges of caring for frail older people with several health issues. […]


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