ROLE OF OUT-OF-HOURS NURSE CO-ORDINATORS IN A CHILDREN S HOSPITAL

Art & science The synthesis of art and science is lived by the nurse in the nursing act JOSEPHINE G PATERSON ROLE OF OUT-OF-HOURS NURSE CO-ORDINATORS IN A CHILDREN S HOSPITAL Amy Hensman and colleagues explain why nurses with advanced skills can enable timelier patient care Correspondence samantha.wright@sch.nhs.uk; kerry.nathan@sch.nhs.uk Amy Hensman, Samantha Wright and Kerry Nathan are senior staff nurses, Sheffield Children s NHS Foundation Trust, Sheffield Date of submission August 3 2015 Date of acceptance September 18 2015 Peer review This article has been subject to open peer review and has been checked using antiplagiarism software Author guidelines journals.rcni.com/r/ ncyp-author-guidelines Pictured opposite (left to right): Samantha Wright and Kerry Nathan Abstract In a hospital, a high proportion of working time occurs outside the traditional working day, affecting patient safety as staffing levels are at their lowest out of hours. A service evaluation audit was used to evaluate the effectiveness of a clinical out-of-hours nurse co-ordinator (COHNC) pilot role in a tertiary children s hospital. The COHNC role was trialled over a six-month period. During the pilot, the COHNC carried the junior paediatrician s bleep and prioritised all phone calls and tasks. Following a patient assessment, the COHNC either performed the investigations and treatments within their scope of practice or escalated these to the appropriate multidisciplinary team member. A description of how the COHNC role has developed and its implications to nursing practice are presented in this article, along with an overview of the quantitative and qualitative data obtained during the audit. Keywords child health, emergency nursing, out-of-hours, paediatrics, nurse co-ordinators THE FINAL report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013) highlighted systematic failures in the NHS and focused on positive leadership initiatives to contribute to improved patient care. In addition, the Care Quality Commission (CQC) (2014) reported a need for improvement and change throughout emergency and medical departments. Most of the failings identified by Francis (2013) at Mid Staffordshire Hospital between 2005 and 2009 related to poor patient care; lack of management and leadership throughout the NHS trust; poor communication between patients, staff and management; and failure to achieve national targets. However, the CQC (2014) focused on medical service improvement, innovation by senior staff and the availability of the appropriate competency and skill mix of staff. Impetus behind the initiative Using the recommendations of Francis (2013) and CQC (2014) as evidence, Sheffield Children s NHS Foundation Trust (NHS FT) implemented a range of service improvements, including the establishment of the clinical out-of-hours nurse co-ordinator (COHNC) role. Beckett et al (2009) and Shulkin (2009) identified that 75% of working time in a hospital occurs out-of-hours and, during this time, the total number of nurses and doctors often reduces dramatically while the number of patients and resulting workload often remains the same or increases. These factors all have an effect on the ongoing challenges facing the acute services in relation to patient care and service flow due to an ever-growing demand on services (King s Fund 2013, NHS England 2013). Therefore, patient safety and the quality of care provided can be a significant problem in the out-of-hours period. To alleviate the growing demands on acute services, a Hospital at Night ethos has been 16 December 2015 Volume 27 Number 10 NURSING CHILDREN AND YOUNG PEOPLE

John Houlihan

Art & science emergency care 18 Box 1 December 2015 Volume 27 Number 10 Emergency department nurse criteria Advanced paediatric life support Triage Venepuncture/cannulation Patient group directions concerning paracetamol, ibuprofen, topical anaesthesia, oral re-hydration salts, chlorphenamine Entonox Electrocardiography evidenced and successfully embedded within adult services (Beckett et al 2009). However, this is a relatively new area of development in children s services. Pilot aims and objectives The aim of the Hospital at Night ethos is to deliver better patient care by using the available skill mix and competencies of a centralised multidisciplinary team. This involves consultants from all specialties agreeing that their teams will work together, providing support and sharing the workload. The Sheffield Children s NHS FT developed the Hospital at Night ethos and subsequently founded the pilot COHNC role to work between 6pm and 2am. The COHNC role was established to co-ordinate and delegate the workload to the most suitably skilled member of the Hospital at Night team. The objectives of this pilot were to provide more organisation, support, leadership and accountability. The main aim was to improve efficiency, reduce the workload of the paediatric out-of-hours team Figure 1 14 Procedures Reviews Analysis of bleep requests 15 24 47 Prescriptions Miscellaneous and improve the service for children and families. The results and the outcome of the pilot role were then audited by the COHNC. Recruitment The COHNC role was based on existing models from various paediatric trusts, including Birmingham and Alder Hey Children s Hospital at Night teams. Using these models, Sheffield Children s NHS FT developed a hybrid model that was designed to specifically meet the requirements of the NHS trust. The hospital out-of-hours working group had consultant and nursing representation from a range of specialties across the trust, including medicine, surgery, anaesthesia and the emergency department (ED). The NHS trust agreed that the COHNC role would consist of senior staff nurses selected from the ED because of their skills and experience in recognising and treating sick children. It was decided to allocate the existing ED manager the line management and overseeing of the COHNC role, as it involved ED staff so shift rotation and organisation would be easier to roster. The clinical skills criteria that the senior ED nurses had to meet are listed in Box 1. An advertisement and full interview process took place and eight successful candidates were appointed in September 2013. The eight appointees made up two full-time equivalent posts; this allowed an equal opportunity for more senior ED nurses to gain further management and leadership experience, as well as develop their clinical skills. Subsequently, the nurses continued to work in the ED in conjunction with their COHNC role. Audit The COHNC role began in November 2013 and ran for six months, between the hours of 6pm and 2am until April 2014. Due to the service and role evaluation being continuously audited over the six-month period, a full research project was not feasible. The audit used a quantitative audit tool and a qualitative questionnaire. The quantitative audit tool was the COHNC job list which identified the reasons for the bleeps received, and whether the task requested was successfully completed or required escalation to a more appropriate professional. The qualitative questionnaire, which was distributed throughout the NHS trust, was to gain feedback from the medical, surgical and nursing teams. Ethical considerations were taken into account during the audit. To maintain confidentiality, all the results from both data collection methods were anonymous. To ensure the success of the COHNC NURSING CHILDREN AND YOUNG PEOPLE

Figure 2 Procedure request results 300-250 - Number of procedures 200-150 - 100-50 - 0 - November December January February March April Month Peripherally-inserted central catheter removal Entonox Port deaccess Port access Catheter Electrocardiogram Bloods Cannula role and improve overall patient services, the results were monitored and assessed continuously. This meant that changes and improvements were implemented as they arose. A total of 45 study hours were provided to the COHNC team during the course of the pilot to enhance individual skills and development. This involved learning to interpret blood gas results, auscultation, accessing and de-accessing implanted ports, catheter training and administration of drugs via central lines. There was continuous learning throughout the six-month pilot, with each staff nurse being responsible for the organisation of their learning and development as well as the completion of a competency package for newly learned skills. This approach also enhanced personal leadership and management skills. The decision about which clinical skills to learn was taken from areas highlighted in the audit tool as well as assessing the individual limitations of each nurse. The aim was for the COHNC to complete relevant training in order to perform further tasks and therefore reduce the workload of the multidisciplinary team (MDT). Quantitative results The quantitative results show that over the 174 consecutive days of the audit, 3,209 bleeps were received and recorded. These would normally have been directed through to the junior paediatrician. Out of the 3,209 bleeps, n=1,508 (47%) were for procedure requests, n=770 (24%) were for patient reviews, n=449 (14%) were for drugs prescribing, and n=482 (15%) were for miscellaneous (Figure1). Procedure requests Procedural requests contributed to the largest group of bleeps received, n=1,508 (47%). These are outlined in Box 2. The data consistently showed that cannulation and venepuncture were the largest category of requests throughout the six months (Figure 2). Out of the 47% of requests for procedures, the COHNC only had to escalate n=347 (23%) to relevant members of the MDT. On reflection, these escalations mainly involved medication and fluid prescriptions which were a limitation of the COHNC role due to the absence of the nurse prescribing qualification. The COHNC role successfully completed n=1,161 (77%) of the overall procedural requests, representing a significant proportion Box 2 Procedures requested Cannulation Venepuncture Catheterisation Electrocardiogram Accessing/de-accessing of implanted ports Central line removal Entonox NURSING CHILDREN AND YOUNG PEOPLE December 2015 Volume 27 Number 10 19

Art & science emergency care 20 December 2015 Volume 27 Number 10 of the workload and was considered a good achievement. The COHNC team was able to use its advanced clinical skills and alleviate pressures from the paediatric out-of-hours teams, while providing a timelier standard of care to patients and families. Reviews The second largest proportion of bleeps received n=770 (24%) related to patient reviews. It is evident that the most successful topic of review carried out by the COHNC was inhaler spacing. This is due to the COHNC service being an advanced paediatric life support provider. The team identified sick children and developed auscultation skills successfully through the six months of the pilot role. Results were the next largest group of reviews, most likely due to the fact that the COHNC team had access to appropriate medical reporting systems. This demonstrates the initiative of the COHNC role and highlights what a time-consuming task collecting results usually is something that was alleviated from the medical and surgical teams workload during the six-month period. Finally, gastroenterology reviews were the thirdlargest number of reviews and again, on reflection, this fact is largely influenced by the COHNC team all having emergency nursing experience in fluid and feed management due to their expertise in the ED. However, n=462 (60%) of the requested reviews had to be escalated to an appropriate MDT member, the majority to junior doctors. This is felt to be due to the fact that they were mostly non-acute reviews and, because the COHNC were not advanced nurse practitioners (ANPs), they could not successfully and competently complete the requested reviews. This influenced the number of escalated reviews and was a big limitation to the role. However, it should be highlighted that n=308 (40%) of the reviews were undertaken successfully by the COHNC team, which was still a substantial percentage and significantly decreased the paediatric out-of-hours workload. Prescriptions Requests for prescriptions made up 14% of the total bleeps as outlined in Box 3. Box 3 Drug and fluid prescriptions Ibuprofen Paracetamol Analgesia Inhalers Antibiotics Intravenous fluids Take home medicines Others (chlorphenamine) Rewriting of drug record The COHNC was able to competently prescribe some of these drugs due to adhering to hospital patient group directions (PGDs), such as in paracetamol, ibuprofen and chlorphenamine, therefore completing n=121 (27%) of the requests for prescribing. However, n=328 (73%) had to be escalated due to the absence of the nurse prescribing qualification. Miscellaneous Finally, n=481 (15%) of the bleeps related to miscellaneous issues including: communication between staff, helping in the resuscitation room, accessing the out-of-hours drugs cupboard, contributing to nursing duties to help with staff shortages, and non-clinical issues for example attending fire alarms. Overall, the quantitative data from the audit highlights that the COHNC role successfully completed n=1,756 (55%) of the paediatric out-of-hours overall workload throughout the six month period. Qualitative results The qualitative results were obtained from a questionnaire distributed in the NHS trust at the end of the first month and sixth month. A hundred questionnaires were sent out in total (50 at the end of the first month and 50 at the end of the six months). Thirteen were completed by medical staff and 12 were completed by nursing staff. This was to allow improvements to be identified and implemented and to evaluate the overall effectiveness of the role. The returned anonymous questionnaires from the medical and surgical teams compromised of n=13 (100%) positive feedback with comments such as: Gave the doctors more time to carry out other tasks without interruption. The returned anonymous questionnaires from nurses throughout the hospital contained n=9 (75%) positive feedback with comments that included: It enables more direct patient care to be provided. Discussion The main limitation of the audit was the variation in documentation styles among the COHNC, which is plausible considering the COHNC role was made up of eight staff nurses. This affected the accuracy and the interpretation of the data, which subsequently affected the quantitative results when audited. Yet the role was established quickly so limitations were inevitable. Role development and funding Sheffield Children s NHS FT developed the COHNC role following the CQC (2014) and the Francis Report (2013), with the suggestion that out-of-hours NURSING CHILDREN AND YOUNG PEOPLE

low staffing levels often led to delays in patients being seen and treated efficiently. The NHS trust identified that the group most affected was general medical patients. As a result, it meant inpatient consultations, treatments and patient reviews were often delayed. Factors contributing to these medical delays included: emergencies in the resuscitation room; clerking in acutely unwell children or a review of a child deteriorating; patients requiring intricate investigations and responding to time-consuming bleeps due to an increased number of referrals from GPs and the ED. These delays led to complaints from parents and staff which contributed further to evidence for the COHNC role. The overall aims of the pilot role were to alleviate some of the medical teams workload by providing timely treatments and reviews, to provide optimal care to patients and offer support and leadership to the MDT. Following the six-month pilot period, the COHNC role has resumed permanently with the team now consisting of four senior staff nurses working permanent night shifts and covering seven days a week. The NHS trust also incorporated bedmanagement into the role of the COHNC. This alleviates that responsibility from the senior charge nurse in the ED who, due to increased patient workload during night shifts, had previously undertaken that role in addition to clinical duties. The NHS trust has also proposed the implementation of the ANP role by providing funding for the COHNC nurses to study for this qualification. Furthermore, the NHS trust has developed an out-of-hours phlebotomy service staffed by healthcare assistants between the hours 5pm and 10pm. Subsequently, patient safety and the delivery of care have both improved out-of-hours. The vision is that this improvement will continue and progress further when the COHNC nurses all become fully qualified ANPs and can undertake more of the common tasks that are extremely time consuming for the medical and surgical teams. This post still continues to be funded by the medical team and is managed by the modern matrons under the Hospital at Night. Conclusion In summary, this audit highlights a n=1,765 (55% of total number of bleeps) reduction in the paediatric out-of-hours teams workload since the COHNC role was started. This was an enormous achievement for the COHNC, as it allowed the expansion of their clinical and leadership skills while, at the same time, facilitated nursing development opportunities as recommended in the final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013). In addition, this was a substantial percentage of workload that was alleviated from medical staff; doctors were able to provide an increased quality of consultations and examinations to their patients without interruption. They were also able to have sufficient time to complete priority tasks, within an acceptable time frame, at a time when staffing numbers decreased dramatically (Beckett et al 2009, Shulkin 2009). As evident in the audit results, the overall aim of the COHNC role was successfully achieved. This pilot role has highlighted the need and benefits of additional advanced out-of-hours clinical staff to provide optimal patient care. Points for practice Nurses have the ability to undertake a role which has traditionally been in the domain of medical staff Nurses taking on advanced practice, or extended roles, must carefully consider their own accountability and autonomy as defined in the Nursing and Midwifery Council s The Code (2015). Clear role boundaries must be in place between medical staff and nurses taking on these extended roles Nurses with advanced skills must be trained appropriately and ensure they remain clinically competent with annual updates The overall patient experience improved because the standard of care was more timely and efficient. This was a result of the advanced role and responsibilities that the clinical out-of-hours nurse co-ordinator successfully accomplished References Beckett DJ et al (2009) Improvement in out-of-hours outcomes following the implementation of Hospital at Night. Quarterly Journal of Medicine. 102, 8, 539-546. Care Quality Commission (2014) Sheffield Children s Hospital NHS Foundation Trust Quality Report. tinyurl.com/pwj36oc (Last accessed: November 11 2015.) Francis R (2013) The Final Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. tinyurl.com/anb9zme (Last accessed: November 11 2015.) King s Fund (2013) The Increasing Demands on Accident and Emergency Departments: No Easy Answers. tinyurl.com/p4hkpjb (Last accessed: November 11 2015.) NHS England (2013) Transforming Urgent and Emergency Care Services in England. tinyurl.com/prx9qtg (Last accessed: November 11 2015.) Nursing and Midwifery Council (2015) The Code. Professional Standards of Practice and Behaviour of Nurses and Midwives. NMC, London. Shulkin DJ (2009) Assessing hospital safety on nights and weekends: the SWAN tool. Journal of Patient Safety. 5, 2, 75-78. Online archive For related information, visit our online archive and search using the keywords Conflict of interest None declared NURSING CHILDREN AND YOUNG PEOPLE December 2015 Volume 27 Number 10 21