The patient was admitted to the hospital for bowel surgery and later minor surgery. His condition deteriorated in the hospital. He was operated on without identification and his family was asked to identify him. On the ward, he was not cleaned or dressed and staff discussed his low chances of survival in front of him. Five days later, he died. The document discusses the need for ward sisters to have a supervisory role and be present in the clinical area to oversee standards of care and provide leadership. It provides the RCN's definition of a supervisory role and discusses benefits seen at one hospital where ward sisters were given full release from providing direct care.

1. Facing the Care Challenge
Leadership – The Ward
Sisters Role

2. “ Having been an
employee at the
hospital I feel
very embarrassed
and ashamed to
have worked
there… there was
not a day went by
that I didn’t go
home in tears.”
The patient, whose daughter in law was an employee at Stafford Hospital,
was admitted to hospital following bowel surgery for unexplained bleeding.
His condition began to deteriorate and he was admitted for minor surgery.
Hours later his family were asked to identify him as he had been operated on
without any wrist identification or notes. The nurse told the family, who were
extremely upset, ‘don’t worry, he is not dead’.
On the ward the patient was not cleaned or dressed. Often he was left
exposed in view of other patients and nursing staff talked of his low chance
of survival in front of him.
Five days after being admitted to hospital the patient died.
Source: Direct contact
When the patient stayed at the Emergency Assessment Unit at Stafford
Hospital for three days he received excellent nursing and medical care.
Despite the negative reports he continues to have the ‘highest regard’ for the
hospital.
Source: Direct contact

3. The RCN’s Definition of Supervisory
Breakings Down Barriers, Driving up standards (RCN, 2009)
recommends that all ward sisters and Team leaders become
supervisory for the purpose of maintaining and improving the quality
and consistency of health care experienced by patients and service
users.
The RCN has subsequently defined supervisory[1] in the context of the
ward sister/team leader role in all settings as the presence of the
following attributes;
[1] Supervisory is used in preference to ‘supernumerary’ as
‘supernumerary’ implies being ‘extra’ to the establishment numbers
within a clinical team. Whereas ‘supervisory’ encompasses the purpose
for which this time would be used; acknowledgement that time is
required to undertake supervision over and above the provision of
direct care; and a range of strategies for achieving supervision that may
involve the provision of direct care with other team members.

4. The RCN’s Definition of Supervisory
Being visible and accessible in the clinical area to the clinical team, patients and
service users e.g. being approachable to visitors; enabling team members to ask
questions
Working alongside the team in different ways e.g. supporting junior colleagues in
the provision of direct care; facilitating learning in and from practice at the same
time as working alongside; undertaking a care plan review
Monitoring and evaluating standards of care provided by the clinical team e.g.
enabling reflective review at staff handover; bringing staff together to review
clinical and workforce data for example balanced score cards
Providing regular feedback to the clinical team on standards of nursing care
provided to, and experienced by, patients and service users e.g. providing
feedback at the end of each interaction with staff members, at the end of the
shift or in staff handover
Creating a culture for learning and development that will sustain person-centred,
safe and effective care e.g. through ensuring there are systems in place to
ensure evaluation of practice, clinical supervision and shared
governance/decision-making, as well as a focus on patterns of behaviour and
the provision of high challenge and high support

5. Breaking down barriers –Breaking down barriers –
Driving up standards:Driving up standards:
Supervisory ward sistersSupervisory ward sisters
The Dartford and Gravesham NHSThe Dartford and Gravesham NHS
Trust experienceTrust experience

6. ContextContext
 New PFI 460 bed DGHNew PFI 460 bed DGH
 ‘‘Good’ CQC ratings for quality, ‘excellent’ forGood’ CQC ratings for quality, ‘excellent’ for
financefinance
 Very ‘flat’ nursing hierarchyVery ‘flat’ nursing hierarchy
 Top ten Nursing Times rating for nursingTop ten Nursing Times rating for nursing
satisfactionsatisfaction
 But…. below average staffing levels (AuditBut…. below average staffing levels (Audit
Commission benchmarking / Dr Foster).Commission benchmarking / Dr Foster).

7. RCN ‘ Breaking Down Barriers’RCN ‘ Breaking Down Barriers’
 Resonated for us….Resonated for us….
 Ward sisters felt disempoweredWard sisters felt disempowered
 Part of ‘rostered’ numbersPart of ‘rostered’ numbers
 Crisis management – not proactive leadershipCrisis management – not proactive leadership
 PDR rate low…PDR rate low…
 Role confusion and conflictRole confusion and conflict
 Matrons ‘acted down’ to Band 7 roleMatrons ‘acted down’ to Band 7 role
 Difficult to recruit Band 7s.Difficult to recruit Band 7s.
 Complaints showed lack of ward leadershipComplaints showed lack of ward leadership
 Quality wasn’t being monitoredQuality wasn’t being monitored

8. Business caseBusiness case
 Phase 1 – (09/10) release ward sisters 2 days a weekPhase 1 – (09/10) release ward sisters 2 days a week
 Some investment in ward numbers (small)Some investment in ward numbers (small)
 Phase 2 – (10/11) release ward sisters full timePhase 2 – (10/11) release ward sisters full time
 Phase 3 – increase ward staffing levels to average for ‘peer’Phase 3 – increase ward staffing levels to average for ‘peer’
group (?2011)group (?2011)
 Total investment c £1.5 millionTotal investment c £1.5 million

9. Why was business case accepted?Why was business case accepted?
 Clinicians as decision makers – business case sub-group of theClinicians as decision makers – business case sub-group of the
Clinical Directors’ Board – chaired by a CD.Clinical Directors’ Board – chaired by a CD.
 Supportive Exec and Board teamsSupportive Exec and Board teams
 The ‘case’ made itself:The ‘case’ made itself:
 Maidstone and Tunbridge Wells is next doorMaidstone and Tunbridge Wells is next door
 Mid StaffsMid Staffs
 Foundation Trust application – Monitor focus on qualityFoundation Trust application – Monitor focus on quality
 Realisation that ward nursing care wasn’t all it should beRealisation that ward nursing care wasn’t all it should be
 Realisation that ward sisters had a complex management andRealisation that ward sisters had a complex management and
leadership task…leadership task…
 Recognition of below average staffing levelsRecognition of below average staffing levels
 Context of financial and activity growthContext of financial and activity growth

10. Nursing strategyNursing strategy
 Focus on wards – not other areasFocus on wards – not other areas
 Focus on accountability of ward sisterFocus on accountability of ward sister
 Clinical Fridays – metricsClinical Fridays – metrics
 Agreed Trust wide job descriptionAgreed Trust wide job description
 Formal delegation of ward budgetsFormal delegation of ward budgets
 E-rosteringE-rostering
 Delegation of people managementDelegation of people management
 Need for personal developmentNeed for personal development

11. Role of ward sister:Role of ward sister:
 ‘‘The Ward Sister/Charge Nurse remains the key nurseThe Ward Sister/Charge Nurse remains the key nurse
in negotiating the care of the patient because she/he isin negotiating the care of the patient because she/he is
the only person in the nursing structure who actuallythe only person in the nursing structure who actually
and symbolically represents continuity of care to theand symbolically represents continuity of care to the
patient. She/he is also the only nurse who haspatient. She/he is also the only nurse who has
managerial responsibilities for both patients andmanagerial responsibilities for both patients and
nurses. It is this combination of continuity in a patientnurses. It is this combination of continuity in a patient
area together with direct authority in relation toarea together with direct authority in relation to
patients and nurses which makes the role so uniquepatients and nurses which makes the role so unique
and so important in nursing’ (Susan Pembrey, 1980)and so important in nursing’ (Susan Pembrey, 1980)

12. What has improved?What has improved?
 Fewer nursing complaintsFewer nursing complaints
 Better ‘collegiate’ team of wardBetter ‘collegiate’ team of ward
sisterssisters
 Fewer in hospital fractured femursFewer in hospital fractured femurs
and pressure ulcersand pressure ulcers
 Better MRSA and C Diff ratesBetter MRSA and C Diff rates
 Fewer Band 7 vacanciesFewer Band 7 vacancies
 ?? Summer effect???? Summer effect??

13. Learning pointsLearning points
 Matrons roles have to changeMatrons roles have to change
 Awaydays for both matrons and ward sistersAwaydays for both matrons and ward sisters
 Formal ‘performance management’ of ward sistersFormal ‘performance management’ of ward sisters
 Not all ward sisters will ‘get it’ – some will grasp the newNot all ward sisters will ‘get it’ – some will grasp the new
opportunities, some won’t..opportunities, some won’t..
 Must stay in uniform and be visibleMust stay in uniform and be visible
 Challenges of staffing problems, vacancies and agencyChallenges of staffing problems, vacancies and agency
ban – ‘supervisory role’ can get lost…ban – ‘supervisory role’ can get lost…

14. FinallyFinally
‘‘Get off the dance-floor –Get off the dance-floor –
onto the balcony’onto the balcony’
Thank you to the RCNThank you to the RCN

15. Group work
1. What should Ward Managers be called?
2. Should Ward Managers undergo compulsory
management training?
3. Do you believe Ward Managers have the right level of
authority to go with their level of responsibility?
4. Is it time to make all Ward Managers clinical
supervisors/supervisory?
5. Consensus Statement

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