Freeing charge nurses of caseloads ‘not appropriate or sustainable’

Green MSP Alison Johnstone fought for it to be written into the law that all clinical teams must have a senior charge nurse (SCN) who did not carry a caseload to allow them to focus on leadership duties.

Working alongside the Royal College of Nursing, Ms Johnstone secured an amendment under section 12IAD of the Health and Care (Staffing) Scotland Bill during its second and penultimate phase of consideration in Scottish parliament.

However, health secretary Jeane Freeman blocked the proposal at the final stage yesterday, saying it would not be would not be “appropriate” or “sustainable” to fully rid SCNs of caseloads.

The bill has now been passed into law after receiving unanimous support from MSPs.

It is the first safe staffing legislation of its kind in the UK to apply to all clinical groups and to cover both the NHS and social care.

Speaking in a debate on the final amendments to the bill yesterday, Ms Freeman told MSPs: “I fully recognise the unique role of the SCN and agree it is important that this is protected

“But I do not believe that the existing wording of section 12IAD, which does not take account of the multidisciplinary teams or allow for flexibility regarding the size of the team and the service delivery model, is the best way to achieve this,” said Ms Freeman.

She said it was “not always appropriate” to require health boards to make SCNs – equivalent to ward sisters in England – 100% non-caseload holding.

“You might need the experience or expertise of the SCN to be able to step in”

Emma Harper

Giving an example, Ms Freeman highlighted how the Shetland Islands was served by a number of community nursing teams made up of between two and eight staff members.

The teams are collectively led by two SCNs but Ms Freeman said if Ms Johnstone’s amendment was approved this would not be allowed and each team would need to have a supernumerary senior nurse who would also need to be backfilled.

“This is not sustainable and would not allow health boards to develop models of care to suit their local needs and their patients,” said Ms Freeman.

In addition, the Scottish National Party health secretary said an “unintended consequence” of the amendment could be that resources were diverted from other clinical team leaders from different disciplines.  

Scottish government

Jeane Freeman

Source: Andrew Cowan/Scottish Parliament

Jeane Freeman

Former NHS nurse Emma Harper, now an SNP MSP who helped develop the safe staffing legislation, spoke out to back Ms Freeman, saying there may be circumstances where it would be necessary for SCNs to get involved in direct patient care. 

Giving another example, Ms Harper said: “In the perioperative environment where surgery is extended, complications occur and you might need the experience or expertise of the SCN to be able to step in and provide the immediate care assistance that is needed when someone’s belly is open on the operating table.” 

An alternative amendment was agreed to replace 12IAD that means all senior clinical staff with responsibility for a team of staff must be given “sufficient time and resources” to carry out their leadership role alongside other professional duties. 

Ms Johnstone said she was “pleased” with the compromise but warned that SCNs must be freed of caseloads “when is it appropriate”.

“There are many occasions when it is entirely appropriate for SCNs to be non-caseload holding”

Alison Johnstone

She highlighted research carried out by the RCN that revealed out of 911 whole-time equivalent SCNs in September 2017, only 115 were non-caseload holding.

“There are many occasions when it is entirely appropriate for SCNs to be non-caseload holding and we must make sure that that is the case where it is appropriate,” she told MSPs.

“I am pleased that we have now reached a proposal that all healthcare professionals are content with, but I was pleased to push my earlier amendment at stage two because nurses do make up 42% of the NHS workforce,” she added.

RCN Scotland has vowed to continue to fight for the removal of caseloads for SCNs in the development of guidance that will sit alongside the Health and Care (Staffing) Scotland Bill.

Eileen McKenna, associate director of professional practice of RCN Scotland, said the college had championed the role of the SCN and the need for them to not have a direct patient caseload for more than a decade.

”We are clear that nursing teams in our acute hospitals and communities need a leader who has the clinical expertise and capacity to develop their team and oversee the quality of care and safety of all patients in the team’s care,” she added. 

“It’s important to remember that as a direct result of our lobbying we have secured a legal requirement for clinical leaders to have the time and resources they need to lead their teams.

“While it is disappointing that the requirement to have a non-caseload holding senior registered nurse was not maintained at the final stage, the cabinet secretary did acknowledge the need to protect the unique role of the SCN during the debate,” she added. ”We will be pushing to have this recognised in the guidance that accompanies the final act.”