NHS Board Dumfries and Galloway

Contact Alice Wilson

Email alice.wilson@nhs.net

Title Senior Charge Nurse Supervisory Status

Category Workforce

Background/

context

The role of the Senior Change Nurse (SCN) is:

• to ensure safe and effective clinical practice

• to enhance the patients experience

• to manage and develop the performance of the team

• to ensure effective contribution to the delivery of the

organisation’s objectives

There is clear evidence that activity and acuity levels within the

general wards have increased significantly over recent years. As a

result the main focus of the SCN role has been to deliver hands on

care to patients.

Implementing this proposal will ensure on-going management of

risk for the organisation whilst also continuing to improve quality

and performance outcomes, reflected by an improvement in:

• patient experience, outcomes and safety

• health and wellbeing of staff

• increased productivity

• delivery of key performance indicators

Problem As a clinical leader, patient advocate and the person responsible

and accountable for the standards of care in the ward or

department, the SCN shoulders a burden of expectation

unparalleled on the front line of the NHS. All aspects of care

delivery, people and financial management of the ward or

department rests squarely with the SCN. In NHS Dumfries and

Galloway SCNs are almost fully clinical case holding which puts an

added burden as they have little dedicated time to deliver on all

that is expected from them

It would be easy to argue, on the grounds of this alone, that the

nature of this role demands supervisory status, however it is

important to outline some of the anticipated benefits, to the

organisation, in supporting this test of change.

Aim To test the impact and benefit of introducing supervisory status

for the Senior Charge Nurse (SCN) role for the purpose of

maintaining and improving quality and consistency of care

experienced by patients, along with supporting the delivery of key

performance indicators. In order to fulfil the supervisory role

there will be the requirement for the SCN to be additional to the

funded nursing establishment, increasing from the current one

day per week to five.

The project will run in two ward areas in DGRI for until the end of

2013-14 and will be used to quantify the potential benefits of the

supervisory

Summary of Key Performance Indicators

• reduction in complaints

• patient safety indicators consistently at appropriate

compliance

• Clinical Quality Indicators consistently at 95 per cent

compliance

• full completion of all documentation (audit)

• evidence of reduction in adverse events and

demonstration of learning

• Reduction in delayed discharges

• Reduction in sickness/absence (1 per cent)

• mandatory training and annual development reviews

(ADR) consistently up to date

• full implementation of quality rostering policy and

erostering system

• implementation and sustainment of change in practice

Action taken

Two SCNs were given an additional 30 hours supervisory time per

week to test whether this would impact on the quality of patient

care.

Given that this is a very different model for NHS Dumfries and

Galloway both SCNs were given external coaching and regular

support from their Nurse Manager and Associate Nurse Director

Regular measurement of KPIs was carried out as well as audit of

practice and outcomes in one another’s areas in conjunction with

the Nurse Manager.

Results

Key Performance Indicators

Complaints:

There has been a clear reduction in the number of complaints:

• Jan-May 2013 – 13 complaints

• Jan-May 2014 – 6 complaints

In addition to the number of complaints there has been a change

in the types of complaints received with very few now

commenting on staff attitude or poor nursing care experience.

Patient Safety Indicators:

There are three Clinical Quality Indictors:

• Falls

• Pressure Ulcers

• Food, Fluid and Nutrition

Both areas have achieved and maintained a consistent score of 95

per cent or above for all three Clinical Quality Indicators. This

covers elements of assessment, prevention and management of

risk.

Whilst it is relatively simple to reach 95% in the Clinical Quality

Indicators it is, like many other areas, difficult to maintain and the

opportunity presented in the pilot allows the SCN to get

underneath the scoring and look at what influences compliance.

This has allowed them to work with staff, challenging and

supporting them to deliver.

Completion of all documentation:

There has been a steady improvement in the compliance with

completion of documentation: specifically Active Patient Care

documentation shows a steady improvement, over a seven month

period till March 2014:

• Sept 74 per cent

• Oct 80 per cent

• Nov 73 per cent

• Dec 91 per cent

• Jan 98 per cent

• Feb 95 per cent

• Mar 100 per cent

Reduction in adverse events:

Responding to the majority adverse incidents sits with the SCN,

only the most significant ward based events are expected to be

led by a wider team, which will include the SCN. Keeping on top of

incidents, including slips, trips and falls and ensuring outcomes

and learning are shared with staff is a difficult task. This is evident

in the time taken to close incidents prior to the pilot. Ward 16

SCN has managed to reduce the length of time to closure of

incidents from average 18 days to an average of eight days. The

type and severity of incidents has also change as evidenced in the

table below; demonstrating a clear reduction in incidents.

Ward 16

1 October 2012 to 31 May

2013

1 October 2013 to 31 May

2014

Category A 13 Category A 12

Category B 69 Category B 4

Category C 29 Category C 5

Category D 19 Category D 4

Category E 16 Category E 11

Category F 41 Category F 5

Category G No incidents Category G None closed, 1

outstanding

Category H No incidents Category H No incidents

Category I No incidents Category I No incidents

Delayed discharges:

Delayed discharges are complex and multifactonal and there have

been specific issues in relation to cottage hospital beds and of

carers in the community which has had a knock-on effect on

Dumfries and Galloway Royal Infirmary (DGRI). However, there

has been an overall reduction in delayed discharges with the

notable exception of discharges to Annan Hospital and to a lesser

extent Castle Douglas Hospital.

Ward 9 Jan – Oct 2013 Nov – May 2014

Allanbank 6 5

Castle Douglas 3 2

Moffat 2 2

Annan 3 4

Lochmaben 1 2

Awaiting a Care

Package

6 2

Transfer to NHS

England

1

Total 21 18

Ward 16 Jan – Oct 2013 Nov – May 2014

Allanbank 15 12

Thornhill 3 1

Castle Douglas 2 6

Kirkcudbright 2 1

Moffat 2 2

Annan 6 17

Efficiency savings

and productive

gains

These have been set out in the results above.

Sustainability

The Board is continuing with the pilot at present and will make a

decision on the long term direction regarding the status of the

supervisory charge nurse in due course.

Lessons learned

Essential to have a clear idea of metrics at the outset in order to

be clear about the impact of the project before and after.