Having defined your workload (see Ch. 2), you may find that you can spend only four half-days a week on the ward in a clinical capacity, so you should make the most of this time.

Accessing up-to-date information

Make sure you have full access to appropriate up-to-date textbooks on your specialty. Keep them in your office for you and your staff to refer to when necessary. You can source funding for textbooks through:

your stationery budget

ward funds

one of the hospital charities, e.g. League of Friends.

You should have full access to professional journals through the NHS library. The NHS Evidence Web site is accessible to all: http://www.evidence.nhs.uk. Plus, you should have full access to the following:

NHS Athens if you work in England: http://www.openathens.net

Health on the Net in Northern Ireland (honni): http://www.honni.qub.ac.uk

The Knowledge Network for those in Scotland: http://www.knowledge.scot.nhs.uk/home.aspx

NHS Wales e-Library for Health: http://www.wales.nhs.uk/sitesplus/878.

In addition, you should be regularly accessing all sites which offer evidence-based clinical guidelines such as those produced by the National Institute for Health and Clinical Excellence for England and Wales: http://www.nice.org.uk and the Scottish Intercollegiate Guidelines Network: http://www.sign.ac.uk.

Print off any pertinent articles/relevant research and leave copies on the coffee table in the staff room. It’s a simple way of enabling both yourself and your staff to keep up-to-date.

Clinical supervision

Having an appropriate clinical supervisor is essential for you to help maintain your professional competence and credibility. Find someone who is more experienced and expert than you. One of the senior consultants (nurse or doctor) linked with your ward is a good option. Another more experienced ward manager or perhaps the link lecturer may be suitable. Meet with them regularly to reflect and learn from your experiences. Regular clinical supervision will enable you to:

stop picking up bad habits

challenge yourself and think more deeply about certain areas of practice

get advice and support.

If you cannot find anyone more experienced than you, then the next best option is to set up a group of people and meet once per month to reflect on practice together (see p. 177).

Learning through teaching others

Invite staff or student nurses to shadow you regularly for a shift. This not only gives them valuable experience but their enquiring minds will help stimulate your thinking and question your practice. Giving regular teaching sessions also keeps you ‘on the ball’. Teaching is a valuable learning experience for the teacher as well as the student. And if you find you are unable to answer any questions, go and find out the answer together.

Ensure that all patients have a full assessment and care plan

Care planning is an essential part of patient care, but in times of staffing shortages or increased workload it becomes low on the priority list for some. Yet without a specific document outlining the plan of care, important issues are likely to be missed. Care planning provides a guide to all who are involved with the patient’s care, including temporary staff.

It is essential that all patients are fully assessed using an appropriate nursing model, not a tick sheet. The written plan of care should be based on that assessment. This may seem basic but it’s still known for some patients to be discharged without having had a nursing assessment or written plan of care throughout their hospital stay.

Care plans save so much time, particularly if you have to use bank and agency nurses regularly. They ensure handovers are safe and efficient. Staff do not have to keep explaining what needs to be done for the patient if it’s written in the care plan. Bank and agency nurses don’t have to keep interrupting other staff during the course of their shift to ask questions about their patients’ care.

If a patient does not have a care plan, nurses have little defence against allegations of negligence. Legally, it will be assumed that the nursing care was not planned if there is no evidence of a care plan.

Which model?

Roper, Logan and Tierney’s model of nursing still appears to be the most popular method in the UK as it incorporates all activities of daily living. Orem’s self-care deficit model and the Neuman systems model are still in use in some areas. More recent models being introduced include the Gloucester Patient Profile, which focuses solely on physical aspects of care. It is becoming more popular because of its usefulness in auditing and as a trigger tool (Thompson and Wright 2003).

It’s entirely up to you and your team which model you use; just make sure that you choose one that is relevant to your patients’ needs, and don’t be ‘brow-beaten’ into replacing it by paperwork based on ‘performance indicators’ only. (For a good overview of nursing models in practice, read Barrett et al 2009.) You must have some sort of nursing assessment system in place that identifies the patients’ nursing requirements, followed by a written plan of care.

Standardised care plans

Standardised care plans save time but try to ensure that your team adapt them to an individual patient’s needs. Sometimes with standardised care plans, people can get used to seeing the same old thing. As a result, you may find that they tend not to read or refer to them. If you specify to your team that they must write the patients’ individual needs on the care plan in addition to the routine predicted needs, it will increase the likelihood of them being read.

Some nurses are under the misconception that writing the patient’s name under each problem heading is individualising the standardised care plan. This is unnecessary and serves no useful purpose other than to waste precious time. The patient’s name only has to be written once on each sheet of paper.

Accountability

As the ward manager, you are responsible for ensuring the systems are in place to ensure that every single patient in your ward receives a full nursing assessment and care plan. The registered nurses in your team are responsible for the content of the assessment, care plan and subsequent evaluations. The Nursing and Midwifery Council (NMC) code clearly states for nurses that: ‘You must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been’ (NMC 2008).

Get your team together and use their skills and experience to decide on which model is the most appropriate for assessing and planning care for the type of patients you have on your ward. If they have taken part in choosing which model to use, they are more likely to be willing to use that model in their day-to-day practice.

Care plans as teaching tools

Make sure your staff write clear care plans. The goals and actions should be specific and measurable. For example, a goal for a post-surgical patient such as ‘to prevent a chest infection’ is not specific. A goal such as ‘to remain free from chest infection as evidenced by T < 37 °C, WBC between 4–11, lungs clear on auscultation and negative sputum culture’ is a lot more meaningful. When care plans are used this way, they can also be invaluable teaching tools.

Care plans as communication tools

The ultimate purpose of care plans is to inform everyone in the team of the patients’ care needs. Any nurse coming back from ‘days off’ or annual leave and unfamiliar with the patient should be able to find all the information they need in the care plan. If there is no care plan, they will waste time trying to find out.

To condone the non-use of care plans on your ward equates to allowing poor standards of communication and patient care. Lack of care plans increases the risk of untoward incidents and unintentional neglect. Around 10% of NMC hearings concerning fitness to practise are due to allegations of ‘failure to maintain accurate records’ (NMC 2011), which includes the lack of care plans.

Be clear about what health care assistants can and cannot do

The role of the health care assistant (HCA) in supporting registered nurses has always been a contentious issue. The main concern is usually around the nurses’ accountability for the actions of HCAs. The NMC code states clearly that it is up to the individual nurse delegating the task to decide in each situation whether the HCA has the appropriate skills and competence (NMC 2008):

You must establish that anyone you delegate to is able to carry out your instructions.

You must confirm that the outcome of any delegated task meets required standards.

You must make sure that everyone you are responsible for is supervised and supported.

HCAs are as much a part of the team as registered nurses. Unfortunately, there are some managers who insist on having separate handovers for registered staff, and some that don’t include HCAs in the handover process at all. Handovers must include the whole team. The registered nurses and HCAs can then plan the care of their patients together.

Give HCAs responsibility, not tasks

Delegating tasks creates a ‘them and us’ atmosphere. With the emphasis on achieving competencies for diploma (equivalent to NVQ) levels 2, 3 and 4, HCAs are becoming more highly skilled. Rather than delegate a series of tasks to HCAs, it is more appropriate to delegate a small case load of patients with supervision. This maximises the use of their skills and abilities by enabling them to carry out the care as prescribed in the care plans. It enables HCAs to use their initiative rather than complete a set of delegated tasks. The registered nurses remain available to assist in areas where the HCAs do not have the competence to carry out a nursing task.

HCAs should also be included in all team and decision-making processes. At the time of writing this book, HCAs are not a regulated profession although in Scotland they are required to comply with the HCA code of conduct, which is regulated through their employing organisation (NHS Scotland 2011). Given the current trend towards reducing the number of registered nurses while correspondingly increasing the reliance on HCAs, it is likely that some form of regulation will be introduced across the UK in the future, even if it is simply a code of conduct that is implemented at organisational level. In the meantime, if the registered nurse has ensured that care is delegated according to the specifications of the NMC code as outlined previously, the HCA is then accountable for the care (RCN 2008).