Leading Better Care: Report of the Senior Charge Nurse Review and Clinical Quality Indicators Project

Section 2

Senior Charge Nurse Review

The aim of the SCN Review was to create a modern clinical leadership role to enable frontline senior charge nurses to maximise their contribution to delivering safe and effective care by developing their leadership capacity and capability. The scope of the review included all nurses and midwives who lead a team that provides care to patients within hospitals.

The review's objectives were to:

• seek stakeholder views on the role and its potential for development
• describe the clinical coordination, leadership and management functions of Senior Charge Nurses
• develop a framework for the SCN role
• provide guidance for NHS boards on developing SCN roles locally (this will be outlined in the Implementation section).

Outcomes of Stakeholder Views of Senior Charge Nurse Role

At the outset of this review we already understood that Senior Charge Nurses have a key role in determining quality of care within wards and departments. However, as health service management structures have changed, SCN roles and responsibilities have become multifaceted and now tend to vary in scope across NHSScotland. For some senior charge nurses, this has meant a shift away from the focus of providing clinical coordination and managing patient care in their areas of clinical responsibility.

The early stages of the project examined how the SCN role was perceived both in the literature and by stakeholders. The key findings of this are outlined in Table 1.

There was consensus among stakeholders that NHSScotland should recognise and value the SCN role. Stakeholders felt that standardisation of the role across NHSScotland, with key responsibilities defined, core competencies described and an exemplar job description and Knowledge and Skills Framework ( KSF) outlines agreed, would be beneficial in this regard.

To complement the stakeholder perspective, an activity analysis of senior charge nurses within development sites was completed. This demonstrated that SCN time was distributed equally between:

• ensuring safe and effective clinical practice
• enhancing patient experience
• managing and developing the performance of the team.

This analysis also found little SCN time spent on explicitly contributing to the delivery of the organisation's objectives. Indeed, the disengagement between the strategic direction of NHS organisations and senior charge nurses as frontline clinical leaders was a key theme that emerged throughout the review process.

Table 1. Perceptions of role of SCN

Source/stakeholders	Perceptions/findings
Patients and public	Leadership and development of team is one of the most important roles of SCNs Concerned about amount of time SCNs spend on administrative duties 46% of patients interviewed were unable to identify the SCN from other nurses on the wards Expect SCNs to assume responsibility for the coordination of direct and indirect care Regard SCN as representing the hospital to patients and their families View SCNs as being pivotal to effective ward management and the delivery of high-quality patient care Find the job title confusing and believe levels of responsibility within the role are ill-defined
Stakeholder workshops	Public and health professionals find it difficult to identify the SCN from other nursing and midwifery staff Individual SCNs spend a significant proportion of their time on general administrative duties There is a perceived gap in providing a range of development opportunities for SCNs related to their key responsibilities
Survey of SCNs	Feel they have limited access to opportunities for development, information, support and resources Feel they have limited impact on their organisations Have confidence to undertake their role with a degree of autonomy 37% are educated to degree level or above 75% have undertaken leadership development
Learning and development needs analysis of SCNs	A range of development across the dimensions of the role is required Education needs to be tailored to meet individual needs
Interviews with executive directors and chief executives	Standardisation of the SCN role across NHSScotland would be beneficial Need to have succession g in place Need to provide a range of development opportunities including management and leadership programmes SCNs influence departmental culture and team dynamics
Literature review (Prof. N Kearney,University of Stirling)	Role lacks clear performance criteria and expectations Patients, public and staff hold misconceptions about the complexity of the role and the skills necessary to carry it out effectively
Literature review (Eileen McKenna, Project Manager)	Determine context and culture of care within their wards and departments Significant impact on job satisfaction of staff Significant impact on quality of patient experience Influence patient outcomes

Clinical coordination, leadership and management functions of the Senior Charge Nurse

The outcomes of the stakeholder consultation and activity analysis informed the development of the description of the clinical coordination, leadership and management functions of senior charge nurses. These outcomes are outlined below.

Clinical coordination

From their consideration of the SCN role, stakeholders were able not only to define the elements of the role they believed to be crucial, but also to identify current role components they believed were not essential parts of their function. Stakeholders' concerns over parts of the current role were highlighted by the outcomes of the SCN activity analysis, which demonstrated that a lot of SCN time was spent on general administrative duties, with a small number also providing hospital or directorate cover and a significant number providing direct clinical care to a caseload of patients.

The clinical coordination aspect of the role has generated a great deal of discussion and there is a risk that this may be misunderstood. To define the role of clinical coordination, it may help to identify some of what this does and does not encompass (Table 2).

Leadership

Senior charge nurses across Scotland already have a good platform to continue to build on their leadership skills as 75% of those responding to the SCN survey have been involved in a leadership programme. It is clear from the views gathered from patients and public that they perceive senior charge nurses as having a clear leadership role. They want then to be:

• visible
• identifiable
• accessible
• approachable
• authoritative.

Table 2. Scope of clinical coordination

Aspects of SCN role in clinical coordination

Not part of SCN role in clinical coordination

Clinical expert and coordinator for all patients in the ward/area Inspiring patient confidence Setting and maintaining high standards of care Monitoring quality of care Ensuring consistency of care for all patients Resolving clinical issues Communication with patients and relatives Communication with multidisciplinary team Responding to patients concerns and acting on them Role model for their team Ensuring delivery of safe and effective care

Providing care by having a direct clinical case load Participating in management of hospital site Having responsibility for allied health professionals Spending significant amount of time on administrative duties

The senior charge nurse has a significant clinical leadership role that includes:

• developing a culture of person-centred care
• leading the delivery of clinically excellent, high-quality services
• ensuring a culture of continuous quality improvement
• influencing and facilitating change.

Management function

Senior charge nurses also carry the functions of manager for their ward/department. These include:

• efficient and effective use of resources
• managing the performance of the team
• planning and monitoring staffing levels to match requirements of workload
• ensuring compliance with local and national standards, policies and legislation.

Framework for SCN Role

The views and consensus from the extensive stakeholder involvement, literature review and the SCN activity analysis were used to inform the development of a framework for the SCN role. The starting point for this was the identification of areas of responsibility:

• to ensure safe and effective clinical practice
• to enhance patient experience
• to manage and develop the performance of the team
• to contribute to the delivery of the organisation's objectives.

The key result areas linking to these four main areas of responsibility are highlighted below (see Figure 2). The details relating to these areas of responsibility are defined in Table 3.

Figure 2. Responsibilities and key result areas of SCN role

Table 3. Details of SCN Role Framework

1. Ensure safe and effective clinical practice

1.1 Clinical leadership and team working

As clinical leader, promote teamwork within a multiprofessional environment, demonstrating critical analysis and decision-making skills; lead the delivery of a clinically excellent, high-quality service; influence and facilitate change within the ward/department and, where appropriate, the organisation.

1.2 Evidence-based, clinically effective practice

Act as a change agent, lead the development of clinically effective practice through the effective use and integration of evidence; set, implement and monitor evidence-based policies, procedures and protocols.

1.3 Continuous quality improvement

Ensure a culture of continuous quality improvement through the use of audit, patient feedback and reflection on practice by self and other members of the team.

1.4 Patient safety

Promote a clean and safe environment for staff, patients and visitors by ensuring compliance with legislation, policies and protocols, including health and safety, healthcare associated infection, risk management and critical incident reporting and analysis; assess and manage actual and potential risks to health and well-being.

Ensure a high standard of record keeping in accordance with Nursing and Midwifery Council requirements, national legislation and local standards, facilitating effective communication with the multi-professional team regarding patient care.

2. Enhance patients' experiences

2.1 Coordination of the patient journey

Ensure coordination of the patient's journey by planning and coordinating the episode of care, including the smooth transition to other settings, promoting effective discharge and communicating with multidisciplinary and interagency teams as required.

2.2 Clinical expertise

Coordinate nursing/midwifery interventions, influencing clinical decisions and monitoring the quality of patient care provided through using expert clinical knowledge relevant to their own field of practice, underpinned by theory and experience.

2.3 Promote a culture of person-centred care

Within a multidisciplinary team environment, develop a culture of person-centred care; maintain high visiblity within the ward/department; communicate regularly with patients, relatives and/or carers; promote a caring environment where equality and diversity issues are respected and patients are enabled to be partners in their care.

Identify opportunities to develop care and services by ensuring that there are effective systems in place to access patients and carer experience/feedback and ensure complaints are managed in line with organisational policy, including the dissemination of learning points.

3. Manage and develop the performance of the team

3.1 Role modelling

Act as a role model, creating a supportive ethos to empower staff to contribute to the delivery of high-quality, person-centred care.

3.2 Learning and development

Support the learning and development of all staff; create a learning environment that ensures effective learning opportunities for staff and students, including appropriate orientation and induction programmes and a range of clinical support strategies (mentoring, coaching, clinical supervision and action learning) and planning ongoing mandatory training and relevant education/development opportunities.

Support the career pathway of individual team members by ensuring all staff have opportunities for individual performance review and personal development plans and maintain an up-to-date knowledge of current clinical, professional and legal issues.

3.3 Manage the practice setting

Manage the practice setting, ensuring effective use of resources and workforce planning by monitoring workload and, through efficient rostering, maintain appropriate staffing levels and skill mix, taking account of role and competence of staff when delegating work; contribute to the management of the ward/department budget.

Manage the nursing/midwifery team, ensuring compliance by self and others with professional standards, legislation, national and organisational policies; leading recruitment, selection and attendance management initiatives; ensure grievance and disciplinary matters within own department are identified, actioned and reported to the appropriate manager.

4. Contribute to the delivery of the organisation's objectives

4.1 Networking

Network with peers across professional groups, promoting the exchange of knowledge, skills and resources.

4.2 Service development

Work in partnership with a range of clinicians and managers in the planning or development of own service, promoting the involvement of patients and the public.

4.3 Political and strategic awareness

Develop and maintain a working knowledge of local, national and professional strategy and policy; ensure that organisational goals are reflected in personal objectives and in ward/department development plans and demonstrate the ability to contribute to policy and strategy development at departmental and organisational levels and, where appropriate, national level.

Table 4 demonstrates how the four key functions within the Framework for the SCN link with the Knowledge and Skills Framework.

Table 4. Links to Knowledge and Skills Framework of the four dimensions of the SCN Role

Framework for the Senior Charge Nurse Role	NHSKSF
1. Ensure safe and effective clinical practice 1.1 clinical leadership and teamwork 1.2 evidence-based, clinically effective practice 1.3 continuous quality improvement 1.4 patient safety	1.1 Core 1, Core 4, Core 5 1.2 Core 4, Core 5 1.3 Core 5, IK2 1.4 Core 1, Core 3, HWB2
2. Enhancing patients' experiences 2.1 co-ordination of the patient journey 2.2 clinical experience 2.3 promote a culture of person-centred care	2.1 Core 1, HWB2 2.2 Core 2, Core 5, HWB2 2.3 Core 1, Core 4, Core 6, HWB2
3. Manage and developing team performance 3.1 role model 3.2 facilitating learning and development 3.3 managing the practice setting	3.1 Core 2, Core 5 3.2 Core 2 3.3 G4, G6, IK2
4. Contribute to the delivery of the organisation's objectives 4.1 networking 4.2 service development 4.3 political and strategic awareness	4.1 Core 1, Core 4 4.2 Core 4 4.3 Core 2, Core 4

The publication of the Education and Development Framework for Senior Charge Nurses ( NHS Education for Scotland, 2008) will equip senior charge nurses with a tool to guide and support them in their development journey. This can be accessed at www.nes.scot.uk .

Summary of SCN Review

Senior charge nurses have an important role in providing clinical leadership to their teams to ensure that patients in their wards/departments receive high-quality care. This is not just about how they perform as individuals, but also how their teams are developed. The framework developed during the course of the SCN Review, which is outlined in detail above, will contribute to ensuring that there is a consistent approach to the role across NHSScotland.

Senior charge nurses across NHSScotland are motivated to continue to build on the quality of care and experience for patients in their areas of responsibility. The SCN Review will assure senior charge nurses that they are valued in this role and that their significant contribution to health care is recognised. This focus on quality is also supported by the results of the CQI project.