Christopher Andrewes Ward is part of the Infection and Immunity Clinical Group, and is located on the St. Bartholomew's Site. It opened in June 1992 as a ward designated for the care of patients with Immunological Disorders.  It was originally located in a 'temporary' facility refurbished to create eight side-rooms.  In May 1996, owing to an increase in clinical caseload, the ward re-located to a twelve-bedded area with four-bedded bays and two side-rooms. Team Nursing is in operation, and the Named Nurse Concept is also practised. In order to meet the complicated and varied needs of our clients, it is important that there is a good skill mix on each shift, with the establishment reflecting the level of care that is needed to ensure the safety and well-being of the client group. 

The notion of self-rostering was introduced into Christopher Andrewes Ward in March 1996, at the request of a member of the nursing staff. The idea arose after a period when staff were making requests which, if granted, would have left the ward understaffed particularly at the weekend and on some night shifts. There were also periods where requests left little balance between the two nursing teams.  It was felt by implementing a system of self-rostering, staff were more likely to have a clearer appreciation of the off-duty requirements. It was hoped that by being able to visualise what the off-duty looked like in draft form as opposed to only one page at a time, (as in the request book) they would be more inclined to take account of the requests of colleagues in relation to the demands of the duty rota. The idea was discussed with the Senior Nurse for the Clinical Group, who gave his consent for the trial to start, and raised on an informal basis initially with the ward staff by placing a notice in the staff-room, and more formally with individuals by the Ward Manager.  With all staff in agreement the trial began.

Managing staff during periods of change can present major challenges (Bolton et al 1992). The management and personnel structure of the Clinical Group underwent significant changes in the latter six months of 1995, which involved the re-deployment of some of the more senior nursing staff within the Clinical Group.  The introduction of any change is often met with resistance (Klein 1968). It is felt that "the introduction of any innovation is far more likely to become adopted if the nurses behind them adopt tactics which involve planning and management of the change, and if the nurses themselves develop their own roles as change agents"  (Wright 1989). With this in mind, the introduction of the change, and the resultant process did not present any major problems. The need for change was identified by the staff themselves, and it was generally felt that self-rostering would give individuals more autonomy and choice in their duty rota.

The benefits of implementing such a system were considered before starting the trial.   It has been documented that self-rostering can assist in the recruitment and retention of staff (Miller 1984) and can significantly decrease the amount of management time spent writing the duty rota. Herzberg (1974) contends that "allowing the worker input into his or her schedule rather than a system which in which a schedule is developed by someone else, leads towards greater responsibility for the work to be done."  It was accepted that were the trial period deemed successful, that effective implementation could take longer than three months, as the system involved a certain amount of negotiation, and would involve providing guidance to some staff to enable them to develop the confidence and skills necessary to negotiate with their colleagues. To assist in this process, a set of guidelines was drawn up by the Ward Manager (Appendix 1).  These were designed in order to eliminate as many problems as possible,  with  core guidelines stipulating  basic requirements necessary for reasons of patient safety and skill mix, aimed at ensuring that no member of staff felt pressured into working a line of off-duty that was unacceptable.

The first attempt at self-rostering needed considerable managerial input before an acceptable skill mix was available on every shift. After the first two months, it was evident that although staff were diligent at filling in lines of off-duty, some were paying little attention to the requests of their colleagues, and rather than negotiate to ensure that there were sufficient people on a shift, merely requested what they wanted and hoped for the best.  It was felt that the most effective method of tackling this problem was for one of the Sister/Charge Nurses to write a list two weeks before the off-duty was formalised, detailing the shortfalls that  needed attention.   The more common areas that needed attention were night duty and the weekends. On certain days in the week, when ward rounds and other multidisciplinary team work took place, there was a need for a greater number of staff.

Although the trial period highlighted the need for continued managerial input to meet minimum safety requirements, at the request of the staff, it was agreed to continue with self-rostering on a permanent basis. Following the trial period, staff became slowly more aware of the needs of their colleagues, and the incidence of problems began to reduce. At the time of writing, it is still necessary for the Sister/Charge Nurses to have some input to ensure that guidelines are met All staff members were given a questionnaire asking them various questions about elements of self-rostering There were some common themes in the answers namely:

1)  Staff felt that if they were the last person to fill in their line of off-duty, it was often difficult to negotiate an acceptable line of off-duty with their colleagues.

2)  It was generally felt that there were a minority of people who did not appear to refer to the guidelines when making their requests. This made it difficult to balance the staff numbers and ensure that there was a good skill mix.

3)  It was generally felt that unless the guidelines were adhered to, the planning of the off-duty in this way could not be deemed more constructive.

4)  It was generally felt that it was worth carrying on with the system of self-rostering, with staff feeling that it gave them more choice and autonomy.

Research has shown that there are definite benefits in implementing a system of self-rostering. In a study (Miller 1984) carried out at an American hospital, the Senior Nurse Manager found that there was a 55% reduction in staff turnover following its implementation. The system has been place for almost seven months on Christopher Andrewes Ward, and although it has proved popular with the staff, it requires more structured work in order to ensure that the system is not weighted unfairly against individuals, and that the ethos of the system is upheld.  SeIf-rostering increases autonomy amongst staff, and if implemented effectively should minimise the time spent on the off-duty. It is yet to be evaluated against the effectiveness of recruitment and retention.

Daily staffing needs for a twelve-bedded immunology ward

N.B. Health Care Support Workers work every other weekend and rotate to night duty on a monthly basis or as per acute need