Plan and Profile. Waikato District Health Board Nursing and Midwifery. Sue Hayward Director of Nursing and Midwifery

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1 Waikato District Health Board Nursing and Midwifery Plan and Profile Sue Hayward Director of Nursing and Midwifery Waikato District Health Board 2012 Te Hanga Whaioranga Mo- Te Iwi Building Healthy Communities

2 The Nursing and Midwifery Profile and Plan The Nursing and Midwifery directorate provides Sue Hayward - Director of Nursing & Midwifery professional advice, support, direction and leadership for nursing and midwifery across the Waikato District Health Board. The directorate, under the leadership of the director of nursing and midwifery, aims to improve patient experience and health outcomes through evidentially Corli Roodt - Clinical Midwife Director based clinical practice standards, education, resource utilisation, access to expert nursing and midwifery, professional behaviour standards and risk management. The Nursing and Midwifery plan gives the direction that will support these aims. Erina Morrison - Clinical Nurse Director, Mental Health & Addiction Services This document is divided into the nursing profile and the plan with a corresponding midwifery profile and plan. Suzanne Lawes - Nurse Director, Waikato Hospital Michael Bland - Clinical Nurse Director, Professional Development Unit Belinda Macfie - Clinical Nurse Director, Community, OP&R and Rural Hospitals G3119HWF

3 N&M Strategic Plan/One document Page 1

4 Nursing profile of Waikato District Health Board The purpose of this section is to provide information and descriptions around: Specific senior nursing roles How nursing numbers are set at ward or department level The education and training which is available to nurses to ensure they are exposed to evidence based practice. The model of nursing care utilised. Expected knowledge and skill acquisition Career pathways for nurses. Professional development pathway for nurses Director of nursing and midwifery Waikato DHB The director of nursing & midwifery reports to the chief executive, works in partnership with the chief operating officer, chief medical advisor, and is responsible and accountable for: the overall management and delivery of nursing /midwifery practice education and professional development overseeing the development and renewal of relevant policies engaging with the educational sector around service requirements. The role is responsible for implementing and monitoring clinical quality and risk approaches for nursing and midwifery. It provides professional (nursing and midwifery) advice and direction for both strategic planning and funding decisions and ensures that workforce planning reflects local, national and international trends and research. The director of nursing and midwifery works across the sector ensuring that primary, aged care and non-government organisations have access to current nursing research, professional development, educational programmes and nursing leadership. The director of nursing and midwifery is responsible to ensure frameworks are developed and implemented that allow nurses and midwives to provide patient/client care utilising skills and knowledge associated with their level of seniority. N&M Strategic Plan/One document Page 2

5 Clinical Nurse/Midwife Directors (CND/CMD) These senior nursing and midwifery roles form, under the direction of the director of nursing and midwifery the nursing and midwifery directorate. The roles are primarily responsible for the professional oversight and direction of nurses and midwives within their defined area of responsibility. They provide a link between all disciplines and work across these disciplines to achieve the outcomes as detailed through the Nursing and Midwifery Profile and Plan and the Waikato DHB Annual Plan. These roles have alliances with all the members of the Nursing and Midwifery directorate, which are inter-linked under a common purpose to ensure that nurses provide quality health care to those using nursing services across the continuum of care. They provide a link between all disciplines and work across these disciplines to achieve the outcomes as detailed through the Nursing and Midwifery Profile and Plan and the Waikato DHB annual plan. There are four positions and each CND and CMD has a clear area of responsibility with some components of their roles being unique to that area. CND Professional Development This role works with the Nursing and Midwifery directorate to ensure education programmes, professional development processes and research supports are available and linked appropriately to nursing services. The role is responsible for the continuation of the Nurse Entry to Practice programmes, and is the primary link with tertiary educational organisations. The team sitting in the Professional Development Unit and under the leadership of the CND: Professional Development, manage the NETP (Nurse Entry To Practice) programme, PDRP (Professional Development and Recognition Programme, oversight of research, practice development, and generic nursing education requirements. N&M Strategic Plan/One document Page 3

6 CND Primary, Community, OP&R and Rural Hospitals This role works alongside a wide range of primary, community and rural nursing groups and services, as well as the continuum of older persons and rehabilitation services. These include the rural hospitals, older persons and rehabilitation, continuing care facilities, public health and district nurses, population health, sexual health, population health and community nurse specialists across the region. The role also links with nurses from practice nursing, well-child, disease state management, rural, aged care, schools, occupational health, prisons, family planning, hospice, and health promotion. The main functions of the CND: Primary are to: Provide, role-model and develop professional nursing leadership Support, lead, inform and monitor clinical and professional and operational effectiveness, quality and efficiency. Optimise and improve clinical practice standards, policies and systems/processes. Advocate for appropriate education, workforce development, funding and support structures to be developed and maintained in primary, rural and community settings. Support nurses to work collegially and effectively as teams across the continuum of care, while building and sustaining nursing capability, capacity and competence. Provide strategic advice that progresses nursing and health systems/workforce issues within services and across sectors. CND Mental Health and Addiction Services The Clinical Nurse Director for Mental Health and Addictions provides professional nursing leadership and direction for the three service areas which are based either in the community or in the Henry Rongomau Bennett Centre. Additionally the CND Mental Health and Addictions is available to mental health and addictions nurses across the sector for professional issues and advice. N&M Strategic Plan/One document Page 4

7 This is done by: Developing, facilitating and promoting nursing leadership, and nursing workforce development in Mental Health and Addictions settings. Supporting clinical and operational effectiveness, quality and efficiency, by monitoring and improving clinical practice standards, policies and systems/processes. Advocating for appropriate education, workforce development, funding and support structures to be developed and maintained in Mental Health and Addictions settings. Supporting nurses to work collegially and effectively as teams across the continuum of care, to address the causes of health inequalities. Building and sustaining nursing capability, capacity and competence. CMD Clinical Midwife Director The purpose of this position is to provide strategic midwifery advice, effective professional leadership and direction for midwifery within Waikato DHB, which enhances the professional midwifery reputation and profile of midwifery within the DHB, regionally and nationally, by: Providing professional direction and strategic advice to the director of nursing and midwifery, the group managers, women s midwifery manager, rural facilities managers and participating as a member of the Women s Health management team. Being actively involved in the development of clinical services plans and strategic and annual business plans. Providing professional leadership and role modelling to the midwifery workforce which enhances the quality of midwifery services delivered and optimises standards of care consistent with a continuous improvement philosophy. Providing leadership, promotion and implementation of a protocol and procedural framework for the delivery of midwifery services throughout the DHB, which are of a standard equivalent to internationally recognised standards of best practice. Establishing and maintaining links nationally within Women s Health midwifery forums and academically within tertiary education networks. N&M Strategic Plan/One document Page 5

8 The clinical midwife director is responsible for the overall level of midwifery standards, including such aspects of midwifery as quality and accreditation, education and research and career development. The clinical midwife director provides professional input into the development and implementation of processes for the recruitment, training and professional development, performance management and retention of midwifery staff. Nurse Director, Waikato Hospital This role, while being line managed by the group manager of Waikato and Thames hospitals, is professionally accountable to the director of nursing and midwifery and also sits within the nursing and midwifery directorate. The role covers the Waiora Waikato Hospital campus but does not include Mental Health and Addictions or Older Persons and Rehabilitation. With the exception of the older persons and rehabilitation nurse manager, all nurse/midwife managers within Waikato Hospital report to the nurse director, Waikato Hospital. The main functions of the nurse director, Waikato Hospital, are: Nursing resources are appropriate for patient demand and activity. Ensuring rostering processes match patient activity. Skill mix and dispersion match patient activity. Operationalising components of the nursing and midwifery profile and plan that affect quality of patient care. Support, inform and monitor clinical and operational effectiveness, quality and efficiency. Educational and training opportunities are accessed by nursing staff. Along with the nursing & midwifery directorate, develop and maintain supportive professional working environment. Ensuring that audits carried out against quality and patient safety are developed as needed into achievable action plans. Providing management support to the nurse managers and, with the support, and as delegated by the director of nursing and midwifery, professional advice and development to this group. Provide leadership role modelling. N&M Strategic Plan/One document Page 6

9 Nurse manager These managers are responsible for more than one ward or unit with different subspecialists. The role covers across the hospital continuum i.e. inpatient, through to outpatient. They are responsible for the efficient and effective professional and operational management of these services. The nurse manager is required to be a registered nurse and have completed a post graduate diploma, be an expert on the professional development and recognition programme ( PDRP) (or equivalent) and have had significant leadership experience, led service changes and be able to demonstrate innovation delivery. Once in the role they are expected to transition onto the senior nurse PDRP. The nurse manager has a major responsibility for the implementation of the vision, values, evidence based practice and standards of the organisation and those of the Nursing and Midwifery directorate. The nurse manager is expected to support the creation and maintenance of a learning environment, promoting the sharing of expertise across their area and the wider organisation. The nurse manager is expected to collaborate with other nurse managers, be involved in the wider health team and engaged particularly with organisational planning, innovation and implementation of change. To fulfil these responsibilities the nurse manager is expected to lead and or be actively involved in: participating in nursing and organisational policy formation and decision making involving nursing staff. coordinate nursing care with other healthcare professionals and assist in integrating services across the continuum of health care. participate in the recruitment process be responsible for ensuring rosters of nursing across the service is appropriate to patient acuity and demand. be involved with budget setting against the nursing service and then be accountable for that. support and encourage access to ongoing education. N&M Strategic Plan/One document Page 7

10 Charge nurse manager This group of senior nurses are responsible for one specific area and report to a nurse manager or, in Mental Health and Addictions, they report to an operational manager. Once in the role they are expected to transition onto the senior nurse PDRP. The charge nurse manager is required to have a post graduate certificate, has been on the expert level of PDRP (or equivalent) and has demonstrated significant clinical experience. This role is expected to manage the systems, processes and resources that enable the nursing staff in that area to meet the needs of patients. They are expected to be actively involved in providing information to the nurse manager around safe staffing needs, educational and training needs so that optimal care by an appropriate level and educationally prepared number of nurses matches patient demand. The charge nurse manager is responsible for the activation or operationalisation of the systems and processes that support timely and appropriate admission and discharge of patients within their ward/department. To fulfil these responsibilities the clinical nurse manager is expected to contribute to: policy formation and decision making involving nursing staff coordinate the nursing care of their area and link in with other health professionals achieve effective communication between nursing and other health professionals manage the admission and discharge processes as outlined by the organisational requirements and as directed by the nurse manager. the provision of an environment that supports and encourages ongoing nursing education. be responsible for the recruitment process in their ward. Associate Charge Nurse Manager The associate charge nurse manager is a supportive role to the charge nurse manager and required to be working towards a post graduate certificate qualification. They provide continuing clinical coordination and expertise to enable an effective practice environment. They have delegated ongoing responsibilities from the charge nurse manager and provide direct care as required and clinical leadership for staff with coaching and supervision. N&M Strategic Plan/One document Page 8

11 Nurse educator The nurse educator provides nursing education as opposed to patient education (which all nurses do as a daily component of their role). The nurse educator develops and delivers educational programmes for a specific service and supports the generic component of educational requirements as set by the director of nursing and midwifery. The nurse educator is a registered nurse with a post graduate qualification, and a certificate in adult teaching, and achieved expert status on the PDRP. Once in the role they are expected to transition onto the senior nurses PDRP. The nurse educator while reporting to the nurse manager or clinical nurse director of the cluster will have strong links with the professional development unit (PDU). These links will allow for coordinated and consistent planning and adoption of key priorities for education. The nurse educator will inform and can be involved with the developing of post graduate papers, and with approval from the director of nursing and midwifery can be involved with the delivery of these papers at a tertiary education facility. Nurse practitioner As expert nurses working within a specific area of practice, the nurse practitioner employed within the Waikato DHB is aligned to identified clinical and population need. This most senior of clinical nursing roles is expected to have achieved prescribing rights and to diagnose, assess and manage peoples health needs, and have access to appropriate diagnostic procedures in their own right as a nurse practitioner. The nurse practitioner is also expected, as part of their scope, to provide leadership as consultants, educators and researchers. Clinical nurse specialist The clinical nurse specialist role is focused on patient care. The role provides for specialty nursing knowledge, skills and expertise to be delivered to a defined group of patients. This can be direct care or by supporting others to provide this care or a combination. The clinical nurse specialist is registered nurse with a significant clinical experience and at least the last two years being within the specific speciality. They will have achieved a post graduate qualification in that speciality and will continue to be N&M Strategic Plan/One document Page 9

12 involved in nursing research, and had been on the expert level of PDRP. Once in the role they are expected to transition onto the senior nurses PDRP. The clinical nurse specialist leads the development of patient care planning nursing protocols and is involved in any patient pathways or specific guidelines. The clinical nurse specialist may report to either a nurse manager or a charge nurse manager depending on the size and breadth of the speciality. Specialty clinical nurse Specialty clinical nurses are nurses who have a greater level and depth of knowledge in a specific area of practice than the registered nurse. This role focuses on direct patient care and is included in the skill mix and numbers. The speciality clinical nurse provides assessment, clinical care and education to a specific group of patients, whose complexity require this level of in-depth nursing skill. While involved in contributing to pathway and research based protocol development, it is the clinical nurse specialist who leads and drives this area practice. The speciality clinical nurse is expected to have achieved expert status on the PDRP and has commenced post graduate study, and will move on to the senior nurses PDRP. Other Senior Nursing Roles A small number of other appointed senior nursing roles are in place within the DHB. A description of these can be found in the DHB/NZNO MECA agreement. Model of nursing care A model of nursing care describes the way nurses organise their working environment in order to deliver patient care. Over the years many models have been developed and used. At Waikato DHB the model is that of patient focused team nursing called partnership care. Each team of nurses (can be two to three) is allocated a number of patients, and then within this team individual patient allocation occurs. The team may be supported by the health care assistant role either placed in the team or across a number of teams. The whole team has a superficial knowledge of all the patients but individual nurses have an in depth knowledge of their allocated patients. N&M Strategic Plan/One document Page 10

13 The team must organise and plan their breaks, high acuity procedures requiring support from the team, hourly patient rounds checking on pain, toileting requirements, and any issues causing concern for the patient participation in bedside handover and doctors rounds. Geographical co-location of patients must be considered and given priority. Ward handovers (these must be brief) are to be given to the oncoming staff, with the team receiving a more in depth handover individually at the patient bedside involving the patient. This of course needs to be modified for the night duty handover. The SBARR tool (Situation Background Assessment Recommendation Response) for communication is to be used as a guideline that supports succinct appropriate information is delivered. When the team consists of roles such as enrolled nurse and health care assistant, then appropriate patient allocation to the enrolled nurse must be carried out and direction given to the health care assistant around what is expected of them. The registered nurse and enrolled nurse must know and work within their scope of practice. Each team does not need to have the same number of patients but rather the acuity of the patient determines how many patients are in each team. Partnership and collaborative models of care underpin Mental Health and Addictions inpatient and community services. Inpatient wards offer a model of care based on key worker/primary nursing care and this is supported by psychiatric assistants and multi-disciplinary team treatment care planning. Community mental health nurses provide case coordination as key workers in partnership with consumer and family/whanau. N&M Strategic Plan/One document Page 11

14 Registered nurses / Novice to Expert Within the Waikato DHB there are formal processes that support nurses career development. 1) Nurse Entry to Practice programme (NETP), 2) BEST programme (first year of clinical practice for nurses into Mental Health & Addictions), 3) Professional Development and Recognition Programme (PDRP). These programmes have been credentialed by the Nursing Council as achieving expected educational and professional standards. To support the expectation that life long learning for nurses is available, accessible and achievable, study leave and financial support is provided for approved programmes of post-graduate study, seminars, workshops and conference attendance. These must be supported by the line manager of the nurse and linked to organisational priorities and requirements. On entering the profession, nurses will develop and acquire levels of skill, knowledge and increased vigilance of a situation that follow a pathway as described by Patricia Benner - novice to expert. (Novice to Expert 1985, 2001). Divided into five levels: novice, advanced beginner, competent, proficient and expert, reflect changes in three general aspects of skilled performance and are based on the Dreyfus model of skill acquisition. 1. Movement from reliance on abstract principles to the use of past concrete experience as paradigms. 2. The second is movement in the learner s perception of the demand situation, in which the situation is seen less and less as a compilation of equally relevant bits, and more and more as a complete whole in which only certain parts are relevant. 3. The third is a passage from detached observation to involved performer. The performer no longer stands outside the situation but is now engaged in the situation. Involvement with the Waikato DHB PDRP supports this ongoing development of skill acquisition and critical thinking. Increased ability to perform tasks, evaluate results of patient observations, vigilance and critical thinking when planning and evaluating patient care develops and improves also with exposure to clinical situations, professional development and education. N&M Strategic Plan/One document Page 12

15 The skill set and knowledge nurses have, can and does, lead them into many different roles both within and outside health. As an over-riding statement for registered nurses intending to move into designated senior roles, successful placement on the expert level of the PDRP is an expected pre-requisite. Depending on what roles at the senior level, post-graduate completion of a qualification. Each role is supported through education funded by either Health Workforce NZ funds (Formally CTA) or the nursing and midwifery education fund. There is progression between roles. eg. SCN CNS ACNM CNM Each role requires a specific degree of skill sets and qualifications that contribute to organisational outcomes in different ways, however there are also some constant expectations assigned to these senior roles around behaviour, commitment and ongoing development. Each senior nursing role has a set of specific key performance indicators attached to the role, these are measured and reported on. While only senior nursing roles have been described, they exist for the sole purpose of ensuring nurses working at the bedside are given the right environment, education support and leadership that allows for optimal nursing care to be delivered. All nurses contribute collectively and individually to the patient experience and to quality outcomes for patients and their families/whanau. Expected Skill Level of the Registered Nurse All registered nurses working within the provider arm of Waikato DHB must attain and maintain certain skills in order to carry out essential functions. Knowledge and skill acquisition must be a continuing process and at the very least, match years of employment. The registered nurse must have IV certification, be able to work volumetric syringe and subcutaneous pumps. Nurses working in areas using patient controlled angelsia will be capable and competent to work and manage this method of patient pain management. Epidural, central line and pereutaneous intravenous catheter competency is expected of nurses working with this treatment modality. N&M Strategic Plan/One document Page 13

16 Registered nurses are to be encouraged to develop the ability to cannulate and venapunture. For wards that have a high number of intravenous treatments, then it is expected that the majority of the nursing staff should be capable of carrying out cannulation. Competency is validated via educational and training in-service with a certification process. Point of care testing equipment is available to ensure patient diagnostic tests are carried out in a timely manner and results then inform ongoing care delivery. All registered nurses are expected to be competent in using the equipment in the areas they primarily work in. All registered nurses are expected to engage in comprehensive assessment of the patient on admission and then ongoing as needed. The use of the standard observation form, (in this DHB it is the Adult Deterioration Detection process), evaluate results of the observations and intervene appropriately, is an expected function the registered nurse has the ability to carry out. Nurses are to be engaged and involved with ensuring this organisation meets the health targets as directed by the Ministry of Health. Being involved and actively engaged with ward/department operational processes, eg. Coordination, projects, education programmes, is part of every registered nurse s role. The level of this varies depending on experience, hours worked and general competence. As each year in practice passes, it is expected that the level of competence will also increase. N&M Strategic Plan/One document Page 14

17 Enrolled nurse Enrolled nurses practise in a variety of settings and always work under the direction and delegation of a registered nurse or nurse practitioner. The enrolled nurse contributes to nursing assessments, care planning, implementation of care plans and then evaluation of that care. The enrolled nurse forms a very valuable component of the team when working in the Partnership Care model. Enrolled nurses are expected to participate in further training and professional development in order to build on technical skills and clinical aptitude. Professional Development Pathway The following diagrams provide an outline of the various responsibilities each level of registered nurse from step 1 through to step 5 is expected to undertake. Underpinning this is the assumption that there is involvement with the PDRP, as this will support acquisition of the skills needed and knowledge required to move through the steps. Participation in these work activities is not over and above work as a nurse, but is an inherent responsibility of nursing and provides evidence that nurses hold and display a unique body of knowledge that influences the patient experience and outcome while supporting the continuation of the nursing profession. N&M Strategic Plan/One document Page 15

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20 Strategic Aim 1: Develop a nursing culture which acknowledges and values the contribution of nurses and enhances leadership and management potential Key Objectives Outcome Measures Develop leadership competencies for senior nurses that meet organisational requirements Achieve succession planning and provide support for leadership position development Competencies have been identified and inserted in position descriptions. Key performance indicators attached to senior nursing roles are monitored. Senior nurses are enrolled in Midland Advanced Leadership Programme. Senior nurses gaining post graduate qualifications have been supported. Personal career planning inclusive of post-graduate education have been developed. PDU programmes PEBBLES and Kohatu will continue remaining committed to leadership development and implementing: Recommendations from evaluation report (2011) Action learning sets are established and populated by Charge Nurse/Midwife Managers. Associate CNM roles have been developed in key agreed areas, according to organisational needs. Succession plans are in place for senior roles. Processes that will support the aging nursing & midwifery workforce are documented and implemented.

21 Strategic Aim 1: contd Develop a nursing culture which acknowledges and values the contribution of nurses and enhances leadership and management potential Key Objectives Outcome Measures Establish measures that indicate productivity of nurses Nursing productive measure will show ratio of output (Hours Per Patient Day) to input (salary paid) linked to outcomes (Nurse Sensitive Indicators). Within Hours Per Patient Day the skill mix is defined and this matches patient demand (throughput) and acuity or dependency. Nurse Sensitive Indicators falls, hospital acquired pressure ulcers, urinary tract infections, pneumonias, are benchmarked against national and international levels and show optimal outcomes. Productive series is implemented in a way that will show an increase in direct patient care.

22 Strategic Aim 2: Build workforce capability, readiness and capacity Key Objectives Outcome Measures Establish where advanced and expanded roles would meet organisation requirements. Differences between senior nursing roles are documented and service requirements relating to roles needed have been identified. The expanded registered nurse role has been developed. The implementation of nurse practitioner in areas as identified in the Annual Plan has been achieved. (2010, 2011) Establish the entry workforce numbers, types and processes needed to sustain employment Evidence of collaboration with Wintec to ensure student numbers and quality reflect the population need. A sustainable process that allows yearly intake of an agreed number of NETPs has been established. Decisions about where newly registered enrolled nurses can be employed with Waikato DHB have been made. Describe the Nursing and midwifery workforce so the organisation has a consistent understanding around titles, roles expectations. Service workforce plans describing roles required to meet patient/service needs have been written and actioned. Skills for each level of RN (RN1 RN5) have been identified and described and are used to inform roster management. NETP numbers, student numbers and preceptor numbers needed to support them are matched. A training programme for the HCA that will enable them to support the RN, EN and RM has been established.

23 Strategic Aim 3: Advocate for high quality best practice in nursing through judicious use of evidence, research and practice development Key Objectives Outcome Measures Develop, influence and advocate for processes that ensures patients will receive safe and effective care Patient safety programmes have been implemented inclusive of: - Productive Wards - Productive Communities - Falls Minimisation - Adult Deterioration Detection System (ADDS) - Care Essentials - Organisational Audits - Role KPIs - Hand Hygiene practices - Medication Safety - Hospital acquired pressure ulcers Education plans are linked to the PDU and in place within each service. Training resources (e.g. simulation) have been made available to primary, NGO s and aged residential care sector. Maximum use of staffing resources will be achieved A standardised tool is used to measure nursing hours/acuity against patient demands. Centralised roster matches patient demand, skills needed and MECA requirements.

24 Strategic Aim 3: contd Advocate for high quality best practice in nursing through judicious use of evidence, research and practice development Key Objectives Outcome Measures Implement key initiatives and improvements which demonstrate that nursing practice is based in contemporary best practice Staff have access to policies and procedures that are up to date, consistent across the DHB/s and based on evidence. Access to procedures is available to primary and aged care sector. Care essential audits will be carried out twice a year, results reported and action plans developed against lower compliant areas. Results from the patient safety programme reflect acceptable outcomes as per national and international benchmarking.

25 Strategic Aim 4: Improve care coordination across the health continuum to enhance timely access to health care for the Waikato population Key Objectives Outcome Measures In collaboration with key stakeholders, develop and implement rural and primary nursing strategies to meet key requirements of communities and new models of care Develop and implement regionalised programmes of work that improve patient access to nursing care A model and workforce plan for a sustainable and flexible nursing workforce working within the rural sector has been developed. Strong alliances have been built across the nursing sector, (incl. education), that promotes a reduction in siloing of nursing services/specialties and employment models. Integrated collaborative nursing models have been implemented (e.g. DN inclusion in IFHCs) and agreed role transition plan has been progressed. The nurse practitioner role in Rural is integrated into the rural team with clear documented outcomes. Directorate reports show that Midland clinical services plan has driven service development. Recommendations of the Aged Residential Care s Clinical Assurance Group have been implemented as agree. Implement better, sooner, more convenient access to appropriate services Nurse led discharge (criteria based) is utilised. Nurse led clinics have been developed and there is evidence that patient wait times are reduced. Nurse roles developed to see, treat and discharge in the EDs of Waikato & Thames Hospitals are implemented. Shared nursing roles with primary that will coordinate complete care requirements are explored and developed as agreed.

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27 Strategic Aim 4: Improve care coordination across the health continuum to enhance timely access to health care for the Waikato population Key Objectives Outcome Measures Development of models of care which acknowledge and support the continuity of care model of maternity service delivery and enhance access to all women in the district Develop and implement regionalised programmes of work that improve access to maternity care Implementing better, sooner, more convenient access to appropriate services Develop and implement rural primary maternity models of care in conjunction with LMCs and key stakeholders founded on continuity of care as well as meeting the needs of the secondary/tertiary maternity service. Develop processes that support ambulatory care and avoid unnecessary admissions during pregnancy. Develop a sustainable and flexible midwifery workforce. Build and strengthen alliances across and within the maternity sector (including education, professional body and private providers). Active participation in the Midland Maternity clinical services plan. Implement the Ministry of Health s Maternity Quality and Safety Programme. Midwifery-led discharge developed and utilised. Implement midwifery led clinics. Inter / Intra-hospital transfers/retrievals occur in a timely way.

28 Strategic Aim 3: Advocate for high quality best practice in midwifery through judicious use of evidence, research and practice development Key Objectives Outcome Measures Women and their babies will receive safe and effective care Implement patient safety programme inclusive of: - Productive Wards - Falls Minimisation - EWS (maternity early warning score observation chart) - Care Essentials - Organisational Audits, KPIs and role - Hand Hygiene - Medication Safety Effective use of staffing resources Implement the midwifery recommendations around demand management care capacity as determined when the MERAS/SSHWP work is completed. Centralised roster matches patient demand, skills needed and MECA requirements. Midwifery practice based in contemporary best practice Easy access to policies, protocols, procedures and guideline, which are shared across the district.

29 Strategic Aim 2: Build workforce capability, readiness and capacity Key Objectives Outcome Measures Identify areas of changing clinical practice to enable education development to address changing needs Professional development and education opportunities are responsive to changing needs and are accessible to all midwives in the district. Develop advanced midwifery roles and midwifery-led services to meet service delivery requirements Support newly graduated midwives: To enable a smooth transition to providing secondary/tertiary care If a graduate LMC midwife, to be confident providing care in the secondary environment New roles are developed to address clinical need and improve patient safety. Wrap support around the graduate midwife through preceptorship, education and mentoring. Support is given to graduate LMCs when they access secondary facilities. Defining the employed midwifery workforce A skill mix profile of the workforce will be developed making expectations to the levels of midwives (RM1 RM5) and then these in designated senior roles. Identify the clinical areas of practice where role support can enhance care and to release midwives to focus on providing midwifery care Develop a midwifery model of care for maternity staff who provide care to women and their babies.

30 Strategic Aim 1: Develop a midwifery culture which acknowledges and values the contribution of midwives and enhances leadership and management potential Key Objectives Outcome Measures Leadership competencies for midwives in designated roles and their potential successors developed to meet organisational requirements Key requirements identified and inserted in position descriptions. Senior midwives enrolled in Midland leadership Programmes. Personal career planning inclusive of post-graduate education. Leadership Enabling programme for Midwives ( PEBBLES ) with PDU support to develop midwifery leadership Associate CMM roles developed in key areas as appropriate. Succession planning & support for leadership positions Leadership roles are supported by education, training and mentorship. Succession planning strategies in place; Recruitment and retention strategies in place to track and proactively address vacancies, exit interviews, primary/secondary interface.

31 CLINICAL After hours Coordinator Clinical Midwife Coordinator Specialty Clinical Midwife Clinical Midwife Specialist Career pathway for midwives CLINICAL After hours Coordinator Clinical Midwife Coordinator Specialty Clinical Midwife Clinical Midwife CAREER PATHWAY FOR MIDWIVES Acting in senior roles Lead projects Serve on committees / hold portfolios Retrieval team Preceptor QLP assessor Expert secondary / tertiary care Shift coordinators PPG development MSR reviewer RESEARCH Midwife Researcher Professor of Midwifery RESEARCH Midwife Researcher Professor of Midwifery EDUCATION Midwife Educator EDUCATION Midwife Educator ADVISORY / PROFESSIONAL LEADERSHIP Clinical Midwife Director Director of Midwifery ADVISORY / PROFESSIONAL LEADERSHIP Clinical Midwife Director Director of Midwifery MANAGEMENT Associate Charge Midwife Manager Charge Midwife Manager Midwife Manager MANAGEMENT Associate Charge Midwife Manager Charge Midwife Manager Midwife Manager Senior Midwifery Roles Leadership Midwife Year 3 5 Steps 4 & 5 Preceptor Quality rep Infection control rep Complex care course Caseload midwife Auditing Confident Midwife Year 3 4 Step 4 & 5 Competent Midwife Year 2 3 Step 2 & 3 MFYP / MGPS Step 1 Employed as hospital midwife or as caseload midwife Complex care course Preceptor Mentor QLP assessor Shift coordinator Lactation Consultant PPG development MSR reviewer Ward Champion Caseload Midwife The circles in the diagram parallel the growth and maturity that is marked within a tree. These circles contain the domains of practice for midwifery professional development. Each Domain builds on the one previous; each practitioner adds value to the service and the organisation.

32 Registered employed midwives As employees of the Waikato DHB, midwives have access to formal processes and education to develop their careers. The formal processes include the midwifery Graduate Programme of Support (M-GPS) that function alongside the national Midwifery First Year of Practice Programme (MFYP) and the midwifery Quality and Leadership programme (QLP). Life-long learning is an expectation and to this end financial support and professional development leave can be applied for. It is expected that the midwife has a discussion with her manager and educator prior to apply for support. The midwife s line manager needs to support the application prior to consideration for approval. Employed midwives may enter their professional career as a newly graduated midwife. This group of midwives have to be enrolled in the nationally run MFYP alongside the local support programme. The graduates enter a rotation programme in their first year of practice in order to be able to function across their scope of midwifery practice and to work as a team member in all areas of the maternity service. Employed graduates can also be a caseload midwife and work within a team whilst enrolled in the MFYP. The QLP is an incentive for employed midwives to extend professionally around quality and leadership domains. It is expected that all midwives will engage professionally in the recertification requirements of the Midwifery Council of New Zealand to maintain competency based practising certificates. The following diagram provides an overview of how employed can develop and grow their involvement in the practice environment. CAREER DEVELOPMENT Within Waikato District Health Board there are formal processes that support midwives career development and skill acquisition. 1. Midwifery First Year Clinical Practice (MYFP) 2. Midwifery Qualification & Leadership Programme (QLP) In order to support the expectation that life long learning for midwives is accessible and achievable, midwifery study leave and financial support is provided for approved programmes of post graduate study, seminars, workshops and conference attendance. These must be supported by the line manager of the midwife and linked to organisational priorities and requirements.

33 Geographical location of clients must be considered and given priority. Ward handovers are brief and are given to the oncoming staff. Following the general handover, the team receive a more in depth handover individually at the client bedside involving the client. This is modified for the night duty handover. The SBARR tool for communication is used as a framework that supports succinct appropriate clinical information in care delivery and in escalating clinical concerns. Where the team consists of roles such as enrolled nurse (EN), obstetric nurses and health care assistant (HCA), the team members are allocated appropriately to match the acuity and complexity of the client group and enable direction and delegation as per policy and professional requirements. Each RM, RN and EN must know and work within their scopes of practice. The midwife leads the team as the expert in the maternity setting. Where a junior midwife is expected to lead the team, she should be supported, directly or indirectly by a more experienced midwife. Hours per patient day acuity and budget setting A maternity appropriate acuity tool is in the process of being developed nationally. In the interim, the hours per patient day (HPPD) tool is applied to maternity in-patient settings. The delivery suite and women s assessment unit areas have no acuity tool at present to benchmark staffing levels against. HPPD is the nursing process adopted by Health Waikato to establish the number of midwives, nurses required to provide care for the client. This number is then matched to the predicted client activity through the CapPlan predictive tool. HPPD does not take into account individual clients acuity but rather arranges different hours according to the service speciality. HPPD is the average number of clinical hours per patient a midwife/nurse is required to give over a 24 hour period. Midwifery/Nursing positions not included in this establishment are charge midwife/nurse manager, midwife/nurse educator, and clinical midwife/nurse specialist (unless they are included in direct client care). The HPPD against client demand plus those positions not included in HPPD, and the total number of hours a midwife/nurse is available for, set the midwifery/nursing budget. Each full time equivalent midwife/nurse is available for 1637 clinical hours per year after annual leave, professional development and sick leave is removed. The total hours of a full time equivalent is 2,080 per year. The budget is set against total hours, but the FTE employed should only be to a level of clinical hours. The difference between budget (total nurse/midwife hours) and employed FTE (total clinical midwife/nurse hours) allows midwives/nurses from casual, part time or internal agency (nursing only) to be used to cover A/L, study leave or sick leave.

34 Specialty Clinical Midwives Specialty clinical midwives (SCM) are midwives who have a greater level and depth of knowledge in a specific area of practice than the RM. This role focuses on direct client care and is included in the skill mix and numbers. The SCM provides assessment, clinical care and education to a specific group of clients, whose complexity require this level of in-depth midwifery skill. While involved in contributing to pathway and research based protocol development, it is the Clinical Midwife Specialist (CMS) who leads and drives this area practice. The SCM is expected to have achieved leadership domain on the QLP and has commenced post graduate study. Model of midwifery care At Health Waikato the model of nursing care is delivered through a concept called team nursing. In the maternity setting, midwifery care is delivered depending on the setting, e.g. primary (predominantly rural) or secondary/tertiary. In the primary maternity setting, midwifery care is delivered as lead maternity carers and/or core midwives providing facility support to lead maternity carers and in-patient midwifery care. In the secondary/tertiary service midwifery care is delivered as part of the multi-disciplinary team. Midwives provide midwifery care across the scope of practice, e.g. antenatal, intrapartum and postnatal. The care is delivered across the maternity unit and midwives are deployed across the unit depending on the need of the service. In the antenatal and intrapartum settings, midwives work in partnership with the medical team and provide midwifery care on their own account. In the postnatal setting midwives and nurses work together as a team to deliver maternity care. Whilst the team care concept loosely exists, it requires further formalisation. The team should consist of a midwife and nurses (can be 2-3) who is allocated a number of clients. Within this team individual client allocation occurs. In the maternity setting, the midwife is leading the team and the nurses provide obstetric nursing care within their scope of practice. The team may be supported by the HCA role either placed in the team or across a number teams. The whole team has a superficial knowledge of all the clients but individuals have an in depth knowledge of their allocated clients. Depending on the midwifery staffing levels, the midwife may work across several teams to provide the midwifery input. The team must organise and plan their breaks, high acuity procedures that will require support from the team, hourly client rounds checking on pain, PV bleeding, breastfeeding requirements, toileting requirements, and any issues causing concern for the client.

35 Midwife educator The midwife educator provides midwifery education as opposed to client education (which all midwives and nurses do as a daily component of their role). The midwife educator develops and delivers educational programmes for the service as per Midwifery Council - and service requirements in consultation with the midwife manager, clinical midwife director and charge midwife/nurse managers. The midwife educator supports the generic component of organisational educational requirements as appropriate as set by the director of nursing and midwifery. The midwife educator is a registered midwife with a post graduate qualification, and a certificate in adult teaching, and is on the leadership domain on the QLP. The midwife educator while reporting to the midwife manager of the cluster will maintain a close working relationship with the clinical midwife director and have strong links with the professional development unit (PDU). These links will allow for midwifery to be included as appropriate in coordinated and consistent planning and adoption of key priorities for education. The midwife educators provide education to nurses working in maternity settings across the district. The midwife educator will inform and can be involved with the developing of post graduate papers, and with approval from the DON/M and the service be involved with the delivery of these papers at a tertiary education facility. Clinical midwife specialist The clinical midwife specialist role is focused on client care and staff education in their specialty. The role provides for specialty midwifery knowledge, skills and expertise to be delivered to a defined group of clients. This can be direct care and/or by supporting others to provide specialist clinical care. The clinical midwife specialist is a registered midwife with a significant clinical experience and at least prior 2 years engaging in the specific speciality. They will have achieved a post graduate qualification in that speciality and will continue to be involved in midwifery research, and be on the leadership domain of the QLP. The clinical midwife specialist leads the development of client care planning; midwifery protocols and is clinically involved in client pathways and/or specific guidelines. The clinical midwife specialist may report to either the midwife manager or a clinical midwife manager depending on the size and breadth of the speciality.