THE ROLE OF THE UNIT SISTER — EMPHASIS ON QUALITY OF CARE AND ACCOUNTABILITY Lecture sponsored by the South African Nursing Association , Johannesburg , September , 1982

Drie belangrike konsepte word bespreek, naamlik die rol van die eenheidsuster, die gehalte van sorg en verantwoordbaarheid. ’n Model word voorsien waarin die rolle van die eenheidsuster uitgebeeld word — die fokus van haar werk (die pasiënt, span, agentskap, genteenskap en die professie) word aangetoon sowel as die inhoudsgebiede (kliniese sorg, bestuur, onderwys en beleidsbepaling). Die doelwit van gehaltesorg is eie aan al haar rolle — wat fokus sowel as inhoud betref. As professionele in wie groot vertroue gestel word, moet die eenheidsuster vir haar eie werkverrigting en van dié oor wie sy toesig hou, verantwoordbaar wees. Om dit te kan doen, moet sy die nodige vermoë, verantwoordelikheid en gesag hê.


INTRODUCTION
The subject of this paper includes three important concepts. They are: role of the unit sister (or head nurse), quality of care and account ability. Each of these will be dealt with briefly and an attem pt made to show the interrelationship between them.

THE UNIT SISTER
The sister or head nurse, whether she is in a hospital ward, ambulat ory clinic, public health centre or long-term institution, plays a car dinal role in the effectiveness and efficiency of patient care. She also has a m ajor impact on the satisfac tion, morale and general well-being of patients, staff, and families. The ward sister serves as the primary link between patient and care-giver, staff and administration nursing and other professionals. She also co-ordinates her unit with the total institution as well as with the extra mural community. H er heteroge neous functions include provision of patient care as well as management of human and material resources.
Many questions have been raised about the unit sister's role. Should the management of the facility be her responsibility, or can these duties be carried by non-nurse m an agers, thus permitting the sister to concentrate on patient care and staff supervision? Should she be an expert clinician and participate in direct patient care -particularly for patients needing complex nurs ing care? How much of her time should be given to teaching of staff, students, patients and families? What are her responsibilities for continuity of care of patients after they leave the unit? Should she be concerned with people in the com munity who are potential con sumers of nursing -in line with the concept of outreach? Should she accept policy and procedures as they are, or function as a change agent? What is her role in relation to agency policy making? Some people have even raised doubts about whether the sister is needed at all in the primary nursing system where each nurse carries full re sponsibility for a group of patients.
These questions, as well as the CURATIONIS difficulty of attracting candidates to management positions in Israel, led to a research project to examine the unit head nurse role in Israel. Answers were sought to the follow ing questions: What is the desired role of the unit head nurse?
What criteria should be used in selecting the unit head nurse?
How should the candidate be pre pared for the desired role?
W hat factors impede employ ment of suitable candidates and im plementation of the desired role?
This paper deals with the first question only -the desired role of the unit head nurse.
Based on an extensive review of the literature, observations in va rious types of units and discussions with nurses, we envisioned the unit head nurse's role as two-dimensional. These dimensions were: the focus (or for whom) of the unit head nurse's activities -patient, team, agency, com m unity, profession, and the area (or content) of her w o rk -c li n ic a l , m a n a g e r i a l, human relations, educational.
The interview instrument was de VOL.5 NO. 4 veloped on the basis of this concept. It was decided to seek answers by learning how this role was per ceived by the unit head nurse her self, those whom she supervises, and the people who supervise her and make policy. Accordingly 279 people from different settings were interviewed according to the model shown in figure 1.
Early in the interview, the re spondents were asked to spon taneously state the three most im portant roles of the unit head nurse. Next they were presented with a series of 36 real-life situations, re presenting various roles concerned with who (focus) and content (area), and they were asked to grade how important it was that the unit head nurse carry out these roles.
In the first set of spontaneous answers the main focus was the team (40 %) and the main content was administration (44 %). The second approach (situations) pro duced much more importance for the roles related to education and clinical care and the need for the unit head nurse to also be con cerned with the community and the profession.
We assumed that the first spon taneous responses were drawn from what the unit head nurse does now, while the second set, which was in reaction to specific situations, re vealed a much broader approach.
Of interest is the high value given to clinical patient care by the unit head nurses themselves and the nursing supervisors while nurses at staff level and doctors felt that this was not her realm. Possibly each was claiming the patient for his own domain.
As a result of the study findings, a model of five concentric circles and an encompassing frame for the role was developed. (See figure 2). In it the patient (individual, family, group; sick or well) and his care are the purpose of the system. The unit is the major arena of the unit head nurse's activities which are team fo cused, utilising management and education as the media to serve the patient through the team. The unit head nurse has reciprocal relation ships with the agency (institution) in developing and implementing policy and in co-ordination with other professions and services. The community is a recipient of unit head nurse outreach activities and is also a provider of resources, such as volunteers, to the unit. The unit head nurse is a citizen and functions as such in the community. The pro fession draws upon and contributes to the unit head nurse in setting standards and expanding nursing knowledge. All of these interac tions take place within a frame of human relations which is integral to every human endeavour.
By use of this model, the activi ties of the unit head nurse are mainly with the team, but these and other activities eminate from, and are directly related to the patient-/client and his needs. Examples of the implementation of the model of unit head nurse roles are given in table 1.

QUALITY OF CARE
The second concept which appears in the title, is quality of care. The author hopes that assuring quality of care has been implicit in the unit head nurse role as discussed up to this point. What is missing, per haps, is a concrete approach on how to put this concept into operation. An example from Israel will be used for this purpose.
In the light of the increased lon gevity, accompanied by a greater need for care of the aged popu lation in Israel, an inter-agency committee was set up to study methods by which quality care could be promoted. Most of the conclusions are relevant to patients in all age-groups and are an indivisable part of the role of the unit sister.
The committee first formulated a statement of belief with the follow ing points: • Quality of care is comprehensive in nature and should be exam ined in terms of: -psycho-social and physical as pects; -the individual and the envi ronment -structure, process and out come of services. • Measures for assessing quality of care should include both objec tive measures and subjective im- -needs or purpose of those examining the quality of care (aged client, his family, the care giver, owner or adminis trator, funding or authorising agency, educational or re search body); -setting in which the care is provided (home, clinic, hos pital, long term institution). • Quality of care is primarily de pendent on the caregivers who to a large degree control the human environment and manipulate the material resources. Special atten tion must therefore be given to the selection, preparation, roles, satisfaction and work conditions of the personnel. • Assessment of care should exa mine the degree of flexibility of the services and programs in order to meet the varied and changing individual and group needs (routine must be adapted to individual and group needs). • Sufficient resources should be 6 available and accessible so that those who need them can select services appropriate for their needs and not be dependent on a specific institution or agency. • A sim ple, w orkable tool is needed to evaluate care: -to be acceptable such a tool should be developed and re commended by a well-quali fied, recognised, objective authority; -the tool could be used for p l a n n i n g a n d d e c i s i o n making; -it could be used in various set tings such as home care, am bulatory care, short and long term institutional care; -it should list indicators 01 cues to be considered in the light of each specific situ ation, as well as accepted measures; -the cues should be catego rised in several m ajor do mains to permit an overview of the various areas of care. These domains include the p h y s i c a l e n v i r o n m e n t , psycho-social environm ent, basic personal care, health CURATIONIS care, family involvement and manpower. The first six points in the state ment of philosophy were operation alised in the seventh item which called for the development of an ap propriate tool, and this became the next task of the committee.
The tool included six domains to be examined for quality, each with many sub-categories.
Examples of sub-categories by domain are: -physical environment: safety, comfort, private space, com munal space, equipm ent, heat ing and ventilation, transporta tion, aesthetics; -psycho-social environment: indi vidualised approach, tone of speech, common language; en couragement of independence, p a r t i c i p a t i o n in d e c is io n m aking; m eaningful activity; leisure time recreation; inter personal relationships between clients and staff, among clients, and among staff; -basic personal care: hygiene of skin, mouth, feet, nails, hair etc; nutrition-quantity, quality and aesthetics of food and feeding; rest and mobility; clothingcleanliness, suitability, aesthe tics; body discharges -regula tion and care; health care: prevention of illness and complications, continuity of care, rehabilitation, pain con trol, terminal care and comfort; family involvement: family as a client -dealing with stress, g u i lt , d e t e r i o r a t e d h e a lt h ; family as a care-giver -teach ing families, involving them in care and decisions; -manpower: ratio of staff to clients, level of staff, super vision, work organisation, inter staff relationships, career de velopment opportunities, work conditions and rewards, satisfac tion and attrition.
As it is impossible to present the complete cue table within the scope of this paper, one example will be given of a sub-category in each domain, with cues to be considered in short and long term in stitu tio n a l settings.
Privacy (physical environment domain) was perceived by the work-VOL. 5 NO. 4   group as cardinal for evaluating quality of care. Hayter (1981) states that patients should be helped to protect their privacy as long as they remain in their homes. If hospital ised, the nurse should help the patient establish a temporary terri tory of physical and personal space. Evaluation of privacy in the various settings include the following cues: -for short-term care -privacy during examination, interview, treatm ent, toileting; -in long-term care -personal space for private belongings, area to receive guests, place to be quiet and alone when so de sired. Meaningful activity is used to il lustrate the domain of psycho-social environment. Zyl (1980) states that the optimal aged, according to the activity theory, is the person who stays active and manages to resist the shrinkage o f his world. A s roles change the individual finds substi tutes fo r the activities involved in these roles. Activity throughout the life span seems to be an important determinant o f life satisfaction.
-In short-term institutional care, the patient can participate in ac tivities related to his recovery, such as breathing exercises, physical therapy, learning to m anage his m edication and treatm ent regime. -In the long-term setting he can take part in group cultural acti vities as a teacher or learner, work in the occupational pro gramme to earn pocket money or prepare gifts for his family. Volunteer work with retarded children is an area that has reaped benefits for both parties. Nutrition is given as an example of a cue to be examined in the domain of basic personal care. Food is a m ajor source of energy, tissue b u ild in g a n d m a in te n a n c e of physiological equilibrium. In speci fic health conditions such as dia betes, food may be an important mode of treatm ent. It is often a source of sensory stimulation and cultural gratification. Food selec tion may be one of the few areas where the patient can make choices and express his independence. As such, it should be seen as a measure of quality of care. Examples of quality of nutrition in different set tings are: -s h o rt-te rm c a re : su fficie n t fluids, easy access to bedside tray, help in feeding if needed; -long-term care: variation of diet, selection of menu, aes thetic, social environment for m e a ls , c u tl e r y a n d d is h e s adapted to individual abilities, early morning drink and evening snack, facilities to purchase and store fruits, sweets, etc. In the health domain, prevention of illness and complications was chosen as the subject to be illus trated.
-Short-term care: provision of health education, specific to the condition for which the patient was hospitalised, which will help him avoid a recurrence or exa cerbation of his illness. -Long-term institutionalisation: routine health examinations in cluding an assessment of ADL functional level, review of use of medications. The domain of family involve ment is often neglected. The family as a client was selected as the example. Families often have guilt feelings about their aged m ember, especially if he has been institution alised. They have to deal with new roles for themselves and the older person, as well as emotional, physi cal and financial burdens.
-In short-term care the family may be exhausted by the need to visit and make the required ad m in is tra tiv e a rra n g e m e n ts .
They may be worried about im pending death or serious handi caps. A measure of quality will be the readiness of staff to listen to families, to encourage them to express their needs and to provide guidance or referral. -The family of the long-term in stitutionalised patient will need continuing support as th eir family m em ber deteriorates. Over-identification with or re jection of the aged person by the family are frequently encoun tered . Strow and M acK ieth (1980) describe a programme of group work with families to create a more open and more mutually accepting bond be tween a nursing home and m em bers o f patients' families. In the domain of manpower the level of staff can illustrate cues of quality of care. -In the short-term setting, avail ability of expert staff during 24hours is essential. -In th e lo n g -te r m s e tt in g humanistic characteristics take predominance, with a back-up of specialists at a good profess ional level. These examples point to the kinds of items to be measured. Someone has to observe, listen, ask questions. Someone has to analyse the data, and see where quality is good and where it needs to be im proved. Someone also has to make plans, find resources, and imple ment the desired changes to im prove quality. The author submits that the key someone is the unit sister. It is part and parcel of her roles as practitioner, teacher, ma nager, researcher and policy maker.

ACCOUNTABILITY
The last of the three concepts with which this article deals is account ability. Murray and Z entner in their book Nursing Concepts fo r Health Promotion (1975) defined accoun tability as 1) being responsible fo r one's acts, and 2) being able to ex plain, and 3) to define or measure the results o f decision making.
The author believes that in order to be accountable there are several preconditions that must be fulfilled. They can be visualised as a pyra mid, each forming a base for the higher levels as illustrated in figure 3.
-The basic precondition is to have the ability (knowledge, skill, values) to decide and act on a specific issue; -then you must be given, or take, the responsibility to carry out that action; -next you need the authority, that is formal backing and legal right, to carry the responsibility; -then, with the preconditions, you can be accountable for the action you take. All too often nurses are given re sponsibility (and expected to be ac countable for same) when they are lacking the ability base and/or the formal authority.
W hat are the preconditions for a unit sister of an oncological unit, for example, to be accountable for her role in preparing the staff to deal with problems of death and dying?
First she must have the ability. This means knowledge of the m ean ing of dying for the patient, the family and the staff. She also needs skill as a clinician in working with such patients, and as a teacher to convey the theory and practice to her staff. She must clarify what her values are -for instance, when does dying with dignity take pre cedence over prolonging life? What does she believe about truth telling regarding impending death?
Next, is the unit head nurse ready to undertake responsibility for this task which will draw heavily on her em otional and in tellectual re sources, as well as take time from other aspects of her work and her private life? Is she ready to organise the logistics, implement the teach ing, plan and evaluate outcomes?
Does she have the authority to set up such an inservice pro gramme? Does this plan conflict with the functions of the director of nursing or the school of nursing? Will the medical staff object to the content (such as truth telling) if it is not in line with their philosophy?
Only when these three precondi tions have been satisfied, can the unit sister undertake the p ro gramme and be accountable for it.
Other questions of accountability are: who is accountable, to whom, for what? The who-to-whom have almost endless combinations. The unit sister is accountable to the patient, his family, the nursing staff, her nursing peers, the doctor, other professionals in the ward, stu dents, teachers, her supervisors, the employment agency, society and the nursing profession. All of these relationships are two-directionalthat is from unit sister to staff and vice versa. They may also have a triad relationship, with ongoing ac countability between the sister, staff nurse, and the patient.
The patient-sister diad is prob ably one of the most important realms of accountability. Patients are no longer blindly submissive to whatever staff decide to do with them. They want and should be partners in care. The ward sister has to be a patient advocate and make sure that patients are fully informed of their care and given every oppor tunity to share in decision making. The sister is responsible to the patient for ensuring a high level of nursing care. The patient is account able to the sister, via the nursing staff, for informing her of his needs and his reaction to treatm ent and for carrying out those aspects of care that are within his abilities.
The ward sister is accountable to the nursing staff for many of her roles. This includes informing staff about ward policy and giving them opportunities to contribute to same. She should assist staff in keeping up-to-date in clinical knowledge and skills. She is responsible for providing a physical and emotional work environm ent that enables them to give quality nursing care. Staff are accountable to the sister for carrying out their assignments, for showing initiative and for con tinued growth.
As an educator, the sister is ac countable to learners' as a role model and formal teacher. Students are responsible for selecting and fulfilling the programme.
The ward sister is also account able to the profession, through the N urses' A ssociation and other channels. She must contribute to setting standards of quality care in nursing practice. It is her duty to contribute to the body of nursing knowledge by analysing and report ing experiences of nursing practice and administration, and by co-ope rating in nursing research. The pro fession -as an organised body, in return, is responsible to its mem bers for serving as the unified voice of nursing and providing a support system for nurses individually and collectively.

CONCLUSION
In summary, a model has been pre sented which depicts the roles of the unit sister -showing the focus of her w ork (the p a tie n t, team , agency, community and the profes sion) and the content areas of clini cal care, management, education and policy setting. Inherent in all her roles, in both focus and content, is the objective of quality care.
The unit sister, as a professional in whom great trust has been placed, must be accountable for her own perform ance and of those whom she supervises. To fulfill this purpose she must have the necess ary abilities, responsibility and authority.
Role fulfillment, quality of care and accountability are within the scope of our p o te n tia l. They demand our continuous interest, in vestment of intellectual, emotional and physical resources, as well as the support and co-operation of col leagues and administrators. These are a challenge to all of usw hether practitioners, teachers, supervisors, administrators or re searchers. It is a challenge in which each accomplishment is not the end of the road, but the entrance into new vistas. Our roles continuously change and expand to adjust to social and scientific progress. Qual ity has no limits, and accountability grows with professional advance ment. This is the nature of professional nursing in today's and tomorrow's world. We have chosen this profes sion and we will achieve its ends.