Chapter 16 Question External Directives

Is another link nurse role really needed?

Prioritise and reprioritise 

Getting the most from the link nurse role 

Monitor effectiveness of the link nurse role 

Has the bed manager considered all other options?

Explain your situation clearly 

Work together with the other ward managers 

Don’t use the dayroom 

Are you managing a team of nurses or auditors?

Financial and professional implications 

Audits that are not part of continuous quality monitoring 

Has your line manager questioned the decision?

Do some quality indicators actually lower the quality of care?

Putting patient care first 

Challenge unreasonable quality indicators 

Are senior managers aware of the implications of their decision?

Point out the implications of the decision 

Are consultant/specialist decisions always appropriate?

Teach your staff the art of diplomacy 

What if the consultant/specialist is wrong but goes ahead anyway? 

Reporting concerns about another health professional 

Does your union steward know?

What help are unions? 

Getting your voice heard 

Is the chief executive aware of what is happening?

Statutory duty for maintaining quality 

Inappropriate decisions need to be highlighted 

Rely on your own common sense

Sometimes other health care professionals or managers make decisions which adversely affect patient care or staff. Sometimes you may feel that you are pressured into making decisions which you do not feel are appropriate. The message here is don’t always accept that others’ decisions are the right ones.

Don’t hesitate to challenge people just because they are more senior or are more knowledgeable in certain subjects than you. Trust your instincts. You are an experienced professional, and sometimes have more insight than they do. Often it is not what you say but how you say it that makes sure you are heard. If you find that certain performance indicators are reducing the standard of patient care or that undertaking audits is taking your staff away from patient care, you have a duty to speak up: ‘You are personally accountable for actions and omissions in your practice and must always be able to justify your decisions’ (Nursing and Midwifery Council (NMC) 2008).

Is another link nurse role really needed?

Link nurses are a good way of maintaining links between the ward and various nurse specialists and people who are employed to enable the organisation to meet a particular quality indicator. The problem is that the number of nurse specialists and quality indicators is continually increasing. Some ward managers are now finding themselves in the position where the number of link nurse roles required is far greater than the number of staff they have on their team. Box 16.1 includes a small selection of the link nurse roles required from today’s nurses.

Box 16.1 A Small Selection of the Link Roles Required From Today’s Ward Nurses

Productive ward

Infection control

Falls

Safeguarding

Transfusion

Medicines management

Nutrition

Palliative care

Risk management

Manual handling

Fire, health and safety

Diabetes

Tissue viability

Continence

Education

Child protection

Pain

Prioritise and reprioritise

Keep an up-to-date list of who is doing which link nurse role. Each time you are asked for another link nurse, don’t automatically allocate the role to one of your staff. Get your team together first and reprioritise. Ask yourselves if this new link role is more important than the link roles you currently have. If it is, then identify which is the least important and drop it from your list. Find some other way of maintaining communication about the subject.

Try not to say to the person requiring the link roles that ‘we are too busy and do not have the capacity to take on another role’. Be more specific. Show them the list of link roles you already have and explain why they are more important. Work out a compromise with them; it is in your best interests to maintain a good relationship with all nurse specialists.

Don’t overburden your team with more than one link nurse role. Give each one the time and resources to gain full benefit from the work involved. The rest of your team and patients will also benefit.

Getting the most from the link nurse role

The role of the link nurse usually entails the following:

1. Attending and contributing to regular meetings and study sessions.

2. Making information available to the rest of the team.

3. Keeping all patient and staff information sources up-to-date.

4. Helping to set and implement standards in the subject.

5. Evaluating and monitoring practice on the ward.

6. Identifying educational needs of the team.

7. Contributing to induction packages and staff teaching programmes.

8. Assisting with monitoring standards and auditing where necessary.

9. Identifying own educational needs and maintaining a high standard of professional competence in the subject area.

It takes time to be able to carry out these duties, so you should ascertain exactly how many hours per week or month will be required to undertake the role. Don’t expect your staff to meet the demands of the link nurse role in their own time. It should be seen as a development opportunity, not a chore. Ensure the link roles are included in job descriptions and the budgeted staff establishment takes the role demands into account.

Monitor effectiveness of the link nurse role

Monitor how these link roles are enhancing patient care on your ward. Are they making a difference, or are the link nurses being used as administrators to do work not directly involving or affecting patient care within your own ward? Do this by making sure that link nurses report back to you regularly regarding the additional work they are undertaking.

Has the bed manager considered all other options?

Work with your bed manager. You may dread them coming on to your ward or ringing you up every 5 minutes, but they have to know what is going on everywhere and place patients in beds as soon as possible. They are under constant pressure and sometimes do not realise the pressures you have, especially those who do not have a clinical background.

Explain your situation clearly

Never accept administrative decisions that compromise patient care. Your patients’ welfare should always come first. Obviously you cannot refuse admissions in emergency situations when it is clear that there is nothing else available, but you must not routinely accept additional patients knowing that the quality of care that they or your existing patients receive will be compromised.

If you have said to the bed manager that you do not have the staff required to care for a new patient appropriately at that time but they still insist on sending the patient to you, you must explain clearly the implications of their decision, and put this in writing. It is usually preferable to do this by e-mail, sending a copy to your line manager and the appropriate duty manager.

Work together with the other ward managers

Bed managers are used to nurses-in-charge saying that they do not have enough staff. It can get to the situation where the bed manager has to decide which short-staffed ward is worse off. The decision is sometimes based on the persuasiveness of the nurse-in-charge. It would help a lot more if you were to use your leadership skills of influencing and negotiating, to get all the wards to work together in these situations.

Use your close network with the other ward managers to create alternative solutions to these problems. You are the managers with the most clinical knowledge within the hospital and are probably in a better position to generate other options. The bed manager tends to work in isolation and does not have the knowledge and authority generated by a group of ward managers who communicate closely.

Working together as a group of ward managers alongside the bed manager will help reduce the problem of wards working against each other with regards to admissions. It may also help to stop some wards getting all the heavily dependent patients and makes sure that nurses get to care for patients in their specialty rather than struggling to nurse patients with illnesses of which they have little knowledge and who should probably be on another ward.

Don’t use the dayroom

For those who still have a dayroom, remember that caring for extra patients in the dayroom, in addition to those on the ward, is not usually costed within your staffing establishment and therefore should not be encouraged. The dayroom is not a waiting room to be used for those waiting to be admitted or discharged.

You cannot leave patients waiting for transport in the dayroom unless you have the appropriate staffing levels to monitor them. That is the role of the discharge lounge. Explain to the bed manager that you expect the bed to be available at a certain time, but will not accept a new patient until the previous patient has left.

If you are having your decision overturned by senior managers in your absence because of the pressure on waiting lists, make sure your staff book extra cover to look after the patients in the dayroom. Cost up the extra expense with your finance advisor and let your managers know in writing how much the decision is costing you. Unless you spell it out to managers and administrators, they may have no idea of the implications. Be specific: don’t use vague terms, such as ‘we are too busy’ or ‘we do not have enough staff’ or ‘it is affecting quality of care’. These phrases are heard every day and people become immune to such language. Use their language, such as ‘we need an extra £2000 per month to cover staffing costs with patients waiting in the dayroom, which amounts to an extra £24 000 per year’.

Are you managing a team of nurses or auditors?

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