Mid-program evaluation of take the lead

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1 Report of the Mid-program evaluation of take the lead Centre for Clinical Governance Research Australian Institute of Health Innovation

2 Produced in 2011 by the Centre for Clinical Governance Research in Health, Australian Institute of Health Innovation, Faculty of Medicine, University of New South Wales, Sydney, NSW Travaglia J, Debono D, Erez-Rein N, Milne J, Plumb J, Wiley J, Callaway A, Dunn A, Johnson J, Braithwaite J This report is copyright. Apart from fair dealing for the purpose of private study, research, criticism or review, as permitted under the Copyright Act, 1968, no part of this publication may be reproduced by any process without the written permission of the copyright owners and the publisher. National Library of Australia Cataloguing-in-Publication data: Title: Report of the mid program evaluation of take the lead 1. Report of the mid program evaluation of take the lead 2. University of New South Wales, Centre for Clinical Governance Research in Health Australian Institute of Health Innovation Centre for Clinical Governance Research Australian Institute of Health Innovation University of New South Wales, Sydney Australia i

3 TABLE OF CONTENTS Abbreviations and definitions... 3 Executive summary... 5 Recommendations INTRODUCTION Method Introduction Evaluation tools Literature review N/MUM interviews N/MUM manager interviews Staff survey Case studies CSO survey Data analysis Approval Literature review Introduction Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals ( The Garling Report ) Caring Together: The health action plan for NSW Context for ttl The role of the Nursing/Midwifery Unit Manager within NSW Health The role of the CSO Take the lead ( ttl ) Factors supporting and inhibiting workplace change Results Demographic and background data Implementation of changes post ttl

4 4.3 Implementation of demonstrable changes in the capabilities and skills of N/MUMs post ttl Key factors affecting changes implemented as a result of ttl Quantitative improvements at the unit level Barriers to the program s implementation Strategies required to ensure the sustainability of changes Essentials of Care and Caring Together: The health action plan for NSW Conceptual Framework for the Nursing/Midwifery Unit Manager Role Strengthening of role as N/MUM Introduction of the Clinical Service Officer s position Impact of the CSO role on the clinical team Unexpected impacts/outcomes of the CSO role Case studies Reflections on ttl Discussion Overall findings Positive benefits Key factors Conclusion References Appendices Evaluation tools Literature review Demographic characteristics of participants Changes to N/MUMs capabilities and skills since ttl Improvements at the unit level since ttl CSO Survey Details of case study

5 ABBREVIATIONS AND DEFINITIONS Abbreviations ACRONYM AHS AIHI CCGR CGU CI CEC CPI CSO PHO SDM NMO NUM MUM N/MUM ttl FULL TERM Area Health Service Australian Institute of Health Innovation at University of NSW Centre for Clinical Governance Research at University of NSW Clinical Governance Unit Clinical Indicator Clinical Excellence Commission Clinical Practice Improvement Clinical Support Officer Public Health Organisation Service Delivery Model Nursing and Midwifery Office (NSW Health) Nursing Unit Manager Midwifery Unit Manager Nursing/Midwifery Unit Manager take the lead 3

6 Definitions TERM Clinical Practice Improvement Culture Ethnography Evaluation Formative evaluation Health services research Innovation Organisational change Organisational culture Summative evaluation Triangulation DEFINITION A combination of tools, techniques, skills and attributes designed to enhance care inputs, structures, cultures, processes, outputs or outcomes. The configuration of attitudes, values, beliefs, meanings, behaviours and practices which together can be seen to be definitive of what people are or where people come from. Culture can be seen as a state or something people possess; it can be seen as performance; and also as a process. A research technique used for describing and analysing what human beings do in selected settings, usually comprising participantobservation, fieldnotes, narrative accounts, temporal-spatial mapping, interviews, and other qualitative research methods. The systematic examination of a policy, program or project aimed at assessing its merit, value, worth, relevance or contribution. Evaluation conducted during the course of a policy s, program s or project s life. The systematic examination of health care settings, institutions or organisations including quality, safety, structures, politics, cultures, financing, resource allocation and delivery systems. The rate, propensity, capacity and effectiveness in adopting new ideas, practices or behaviours. Macro (organisational-wide), meso (divisional or departmental) or micro (small-scale) adaptations and adjustments to institutionalised processes, procedures, structures and strategies. The collective set of relationships in organisations that differentiate one group from another in terms of dress, attitudes, values, behaviours, beliefs, language and shared meaning. Evaluation conducted at the end of a policy s, program s or project s life. A multi-method research or evaluation design which adduces converging or diverging evidence drawn from pluralist sources to illuminate an object of inquiry. 4

7 EXECUTIVE SUMMARY This report presents the results of a mid-term evaluation of the take the lead ( ttl ) Nursing/Midwifery Unit Manager (N/MUM) program, conducted by the Centre for Clinical Governance Research (CCGR) in the Australian Institute of Health Innovation (AIHI), Faculty of Medicine, University of New South Wales (UNSW). The evaluation was commissioned by NSW Health, to assess the progress and achievements of the ttl program. ttl involved a series of strategies designed to develop, support and facilitate the role of N/MUMs The ultimate is that N/MUMs are able to provide highly co-ordinated care at the unit level, resulting in a well-managed unit and the improvement of the patients journey and their patients care experiences. The evaluation was conducted in the second half of A multi-method, triangulated research methodology was undertaken, involving seven inter-related studies and a literature review. Data were collected from participants across eight Area Health Services (AHS) and two state-wide services in New South Wales (NSW). Methods included: interviews with N/MUMs; interviews with managers of N/MUMs; two case studies; an online survey of staff; an online survey of Clinical Support Officers (CSOs); and document analysis. All of the participants in this evaluation recognised that the role of N/MUMs has changed significantly over the last three decades, and that this change has involved increased managerial and administrative responsibilities. Most N/MUMs and their managers commented on the lack of preparation for N/MUMs to pursue their managerial and leadership roles. The changes suggested or supported by the Garling Inquiry, including the formalisation of the role of N/MUMs, programs for their professional development, and the facilitation of their increased presence in their units and away from their desks was seen to form a new phase in this development. We found that there was general agreement amongst all participating groups that ttl had contributed to some degree to the skills development of N/MUMs. This was considered, by those who felt that ttl had had an impact, to have enabled and empowered N/MUMs to implement changes in the workplace. It is important to note this distinction however: not all N/MUMs, N/MUM managers or staff considered that ttl had had an impact on N/MUMs. Some participants were unable to identify whether it was ttl specifically that had contributed to the N/MUM s development or not. A range of confounding factors, including professional maturity, other development and change programs in the workplace, and the N/MUM s own educational background and experience made it difficult to attribute the impact. 5

8 Even though individual cases differ (both in response to the program and in assessing its subsequent impact), the results overall show that for those N/MUMs who were able to implement changes in the workplace, ttl was an important contributing factor. This is particularly, but not only, in cases where N/MUMs had little prior training and or experience. N/MUMs have put in place a wide range of changes as a result of their participation in ttl. The most common changes involved implementation of some aspect of lean thinking: this may be because, in the view of one participant, that model allows for small incremental changes which are highly visible and quick wins. However, many N/MUMs have implemented other changes ranging from the modification of their individual communication styles, to new approaches to the rostering of staff, to the creation of multi-method team based approaches to the improved co-ordination of care. Differences in the sophistication and range of changes meant that their impact was difficult to measure; however individual participants indicated cost and time savings as a major impact. Changes in N/MUMs capabilities and skills varied. However, across all participants groups, there were indications of improved communication, particularly in critical contexts. Several N/MUM managers noted that one of the positive impacts on their own work of their N/MUMs participation in ttl was a reduction in the number of performance reviews which progress up the ladder for their attention. The success of, and barriers to, N/MUMs attempts at change were attributed to a range of structural, cultural, organisational and relational factors. These factors complemented the findings from the literature review. The three key elements to the successful transfer of learning into action were a combination of: the clinicians own personal commitments and characteristics; the way in which the training did or did not prepare them for the transfer of that learning; and workplace climate and organisational support. Participants gave consistent examples of the importance of these factors. The last of these factors, workplace climate and organisational support, was also said to be critical for the sustainability of the changes implemented. Although individual circumstances differ, overall, the role of the CSOs was said to have made a significant contribution to reducing the administrative workload of most N/MUMs. From the CSOs perspective, undertaking a new and at times not clearly defined role has posed some challenges, particularly for CSOs who are geographically or organisationally isolated, or whose work extends over more than one location. 6

9 This evaluation shows that the introduction of ttl, along with other improvement mechanisms, such as the Essentials of Care program and the introduction of CSOs, has enabled some N/MUMs to develop, implement and sustain changes to their workplace. In cases where N/MUMs have been able to transfer their learning from ttl effectively, these changes have resulted in improvements in finances, staff satisfaction and morale, and patient care. 7

10 RECOMMENDATIONS Recommendation 1: ttl should continue to be implemented On the whole, ttl is perceived to have strengthened the role of the N/MUM, particularly new N/MUMs, and to have had positive impacts in many workplaces. However, it has been identified that there are some ways in which ttl could be strengthened. As discussed networking and sharing of ideas was identified as very helpful. Therefore, implementation of ttl should continue, particularly for new N/MUMs. Recommendations are proposed to enhance ttl and so maximise its potential impact. Recommendation 1.1 Future implementation of ttl programs should cater for divergent levels of experience, geographical location, existing localised and state-wide systems requirements, and role demands of N/MUMs. Recommendation 1.2 Future implementation of ttl should recognise and acknowledge prior learning. Alternative modules designed to build on prior knowledge should be included as an alternative for those N/MUMs with prior postgraduate management qualifications. Recommendation 1.3 Recommendation 1.4 Recommendation 1.5 Recommendation 1.6 Recommendation 1.7 Recommendation 1.8 A module on Change Management should be included to equip N/MUMs to lead and manage change in their units. Following ttl an advanced program should be introduced to encourage further development of N/MUMs in their leadership role. A ttl refresher module would be helpful to consolidate what has been learnt during ttl especially for less experienced N/MUMs. This would also provide an opportunity to share experiences of overcoming barriers to change. Methods should be established by which networking and sharing of experiences and ideas can be encouraged among N/MUMs. This may include regular debriefing sessions, links, and group discussion boards. A mentorship program for N/MUMs who have undertaken ttl should be introduced. An equivalent program to ttl should be introduced for other managers. 8

11 Recommendation 2 The CSO role should be developed and more CSOs employed The CSO role is perceived to have impacted positively on the work of N/MUMs largely through freeing them up from administrative duties to concentrate on their leadership role. However, shortcomings in the introduction of the CSO role have been identified. Recommendations are proposed to address some of these issues. Recommendation 2.1 Recommendation 2.2 Recommendation 2.3 Recommendation 2.4 Recommendation 2.5 Recommendation 2.6 Recommendation 2.7 A clearer job description for the CSO should be developed. Input from N/MUMs and their managers should inform the development of the job description for CSOs. The CSO job description should be clearly defined while allowing room for local adaptation. A generic training and orientation program for CSOs should be introduced. CSOs should be required to undertake this program prior to commencing their role. N/MUMs should be involved in the recruitment process for the CSO role. A development session on the role of CSOs should be held so that N/MUMs are better informed about how to utilise the CSO role effectively. Methods should be established by which networking and sharing of experiences and ideas can be encouraged among CSOs. This may include regular debriefing sessions, links, and group discussion boards. Ongoing evaluation of the introduction of the CSO role should be conducted. Input from CSOs, N/MUMs, managers, and other staff should inform further development of the role description, reporting lines and outcomes of the introduction of the CSO role. Further exploration of the role of CSOs in non acute services is warranted. 9

12 1. INTRODUCTION This report presents the results of a mid-term evaluation of the take the lead ( ttl ) The Nursing/Midwifery Unit Manager (N/MUM) program, conducted by the Centre for Clinical Governance Research (CCGR), Australian Institute of Health Innovation (AIHI), Faculty of Medicine, University of New South Wales (UNSW). The evaluation was commissioned by NSW Health, to assess the progress and achievements of the ttl program. ttl involves a series of strategies designed to develop, support and facilitate the role of N/MUMs, so that they are able to provide highly co-ordinated care at the unit level, resulting in a well-managed unit and the improvement of the patients journey and patients care experiences. The project examined and reports on the outcomes of ttl across ten Area or statewide Health Services including Sydney Children s Hospital, Westmead and Justice Health. The Ambulance Service was excluded from the evaluation because no staff had participated in ttl. The evaluation used a comprehensive and sophisticated multi-method, triangulated research methodology. The evaluation investigated the identified outcomes of ttl and in so doing answered the central questions: has the role of the Nursing/Midwifery Unit Manager been strengthened and are there identifiable improvements in patient care and flow? The framework for the evaluation took the form of eight inter-related studies (Figure 1). This report presents our findings. It begins with a brief history of ttl within a wider context of health system reform in NSW subsequent to the Garling Inquiry (Garling, 2008). This is followed by a review of the literature on the role and development of nurse managers, reflecting in particular on the transfer of learning about, and for, change within health systems. The findings section presents the results of interviews and surveys gathered from N/MUMs, their managers, and clinical and administrative staff, relating to the impact of ttl on the management of units and outcomes for patients across NSW. These results deal with various factors, including individual capacity development and structural support, which have contributed to, or hindered, the success and sustainability of changes N/MUMs wish to implement as a result of ttl. The report then considers how the introduction of the role of Clinical Services Officers (CSOs) has affected work of the N/MUMs and other staff of health services. 10

13 Figure 1: Evaluation studies 1. Literature review 2. Changes put in place by N/MUMs as a result of participation in ttl 3. Demonstrable changes in the capabilities and skills of Nursing and Midwifery Unit Managers from the perspective of individual Nursing and Midwifery Unit Managers, the staff they manage, the staff to whom they report 8. Examine the impact of the introduction of the Clinical Services Officers position What is the progress made by, and achievements of, the take the lead program? 4. Identify the key factor described by N/MUMs in any change they have been able to achieve 7. Identify strategies required to ensure sustainability of any changes achieved 6. Identify barriers to the program s implementation 5. Identify and measure quantitative improvements at the unit level to demonstrate change as a result of take the lead 11

14 Each study had a core question and set of tasks. These are presented in Table 1. Table 1: Key research tasks, studies conducted and core questions asked relevant ttl STUDY RESEARCH TASKS CONDUCTED CORE QUESTIONS ASKED 1. Review of the literature 2. Identify changes put in place by N/MUMs as a result of participation in ttl 3. Identify demonstrable changes in the capabilities and skills of N/MUMs 4. Identify the key factors described by N/MUMs in any change they have been able to achieve 5. Identify and measure quantitative improvements at the unit level to demonstrate change as a result of ttl 1.1 Identification and classification of the literature on nurse managers 1.2 Content analysis of the literature 1.3 Review of the key themes in the research literature. 2.1 Interview of N/MUMs 2.2 Interviews with managers of N/MUMS 2.3 Case studies of N/MUMs 2.4 Questionnaire survey of staff. 3.1 Interviews with N/MUMs 3.2 Interviews with managers of N/MUMs 3.3 Case studies of N/MUMs 3.4 Questionnaire survey of staff. 4.1 Interviews with N/MUMs 4.2 Interviews with managers of N/MUMs 4.3 Case studies of N/MUMs 4.4 Questionnaire survey of staff. 5.1 Interviews with N/MUMs 5.2 Interviews with managers of N/MUMs 5.3 Questionnaire survey of staff 5.4 Case studies of N/MUMs. What is known about the development of the role of nurse managers, and their ability to implement change? What changes have N/MUMS been able to put in place as result of their participation in ttl What changes have occurred in the capabilities and skills of N/MUMS from the perspective of individual N/MUMs the staff they manage, the staff to whom they report What key factors contribute to N/MUMs ability to implement successful changes supported by ttl? What types of improvements in care have N/MUMs been able to achieve as a result of ttl. Including: decreased adverse event; improved staff satisfaction; implementation of lean methodologies; improved communication and management of difficult situations; improved patient satisfaction; reduced proportion of time spent on 12

15 STUDY RESEARCH TASKS CONDUCTED CORE QUESTIONS ASKED 6. Identify barriers to the program s implementation 6.1 Interviews with N/MUMs 6.2 Interviews with managers of N/MUMs 6.3 Case studies of N/MUMs 6.4 Questionnaire survey of staff. transactional administrative tasks; improvements in financial management; any other improvements in line with relevant recommendations in Caring Together What factors acted as barriers to N/MUMs ability to implement successful changes in line with ttl? 7. Identify strategies required to ensure sustainability of any changes achieved 8. Examine the impact of the introduction of the CSOs position 7.1 Interviews with N/MUMs 7.2 Interviews with managers of N/MUMs 7.3 Case studies of N/MUMs 7.4 Questionnaire survey of staff. 8.1 Interviews with N/MUMs 8.2 Interviews with managers of N/MUMs 8.3 Case studies of N/MUMs 8.4 Questionnaire survey of staff 8.5 Questionnaire survey of CSOs 8.6 Document review of CSOs job descriptions. What factors have and will contribute to N/MUMs ability to implement sustainable changes in line with ttl? What differences are discernable in the way the CSOs position has been introduced across AHSs? What is their location within AHSs and units? What are their roles and lines of responsibility? What impact has the introduction of the CSOs had on the work of N/MUMs, other staff and on patients? In order to answer the evaluation questions, the findings from the studies have been structured in eight sections. Most of the data used in the studies comes from four larger studies. These were: a) interview survey of N/MUMs across eight AHSs, the Children s Hospital Westmead and Justice Health; b) interview survey of managers of N/MUMs across eight AHSs, the Children s Hospital Westmead and Justice Health; c) questionnaire survey of staff of the eight AHSs, the Children s Hospital Westmead and Justice Health; and d) questionnaire survey of CSOs in the eight AHSs, the 13

16 Children s Hospital Westmead and Justice Health. In addition to the collection of these data, we conducted a literature review and analysis and a document review of CSOs job descriptions. The original proposal had not included the study of CSOs, but had included a content analysis and focus group analysis of patient complaints and incidents pre and post ttl. The study of CSOs was added in response to a request from the NMO. In discussion with NMO it was decided that that given the length of time it had taken some participants to undertake all five modules of ttl (up to two years) that these latter tasks would not contribute any useful additional data. In the next section we describe our methodology in greater detail, followed by the literature review. Sections four to six outline the findings, a discussion of their implications, and then our conclusions. 14

17 2. METHOD 2.1 Introduction As outlined in the introduction, the mid-term evaluation of ttl utilises a multimethod approach. This type of approach allows for triangulation of results, and therefore increased assurance of their validity. Triangulation is essentially a method of cross-checking data from multiple sources to search for regularities in the research data" (O'Donoghue et al., 2003: 78). Various types of triangulation are possible, including data triangulation (ie gathering different data sets), investigator triangulation (deploying more than one researcher), and methodology triangulation (across-method, that is qualitative and quantitative, or within-method, that is different forms of qualitative such as questionnaires and interviews) (Denzin, 1989). This evaluation uses all three types of triangulation. Data triangulation is achieved across location (AHSs, rural compared to metropolitan) and persons (individuals from various backgrounds and roles were interviewed). This allowed for data sets of different types to be analysed. Investigator triangulation was achieved through the use of a team approach to the research. The team included researchers with nursing, organisational psychology, medicine, social work, and health services management backgrounds. They came from academic disciplines including health services research, health policy research, organisational psychology, anthropology and sociology. Both across- and within-method triangulation was employed. Across-method triangulation was achieved through the quantitative analysis of Likert scale data on improvements achieved through ttl. Within-method triangulation was achieved through: thematic analysis of interview and survey results; thematic analysis of case studies; and document analysis of CSOs job descriptions. The evaluation also had some specific stipulations. In order to ensure that what was evaluated was the overall impact of ttl and not the performance of individual N/MUMs certain parameters were set in regards to the selection of participants. These included: the random selection of N/MUMs for interviews; and ensuring that if an N/MUM was interviewed, then neither their direct managers nor their direct staff were interviewed or surveyed. Two limitations affected the second stipulation. First, in some instances (small hospitals, or hospitals with an N/MUM manager responsible for all N/MUMs) it was difficult to identify an N/MUMs manager who did not cover most or all of the N/MUMs who had participated in ttl. In the case of staff reporting 15

18 directly to N/MUMs we surveyed all CSOs whose contact details were supplied by AHSs, so there is a possibility that some CSOs of N/MUMSs who were interviewed replied. However, as not all CSOs details were supplied, and as the focus of that research was primarily the CSOs themselves, it was felt that there would be minimal impact, and certainly no adverse consequences, from the design of the study. 2.2 Evaluation tools An inter-related set of tools was developed specifically for the ttl evaluation (Appendix 8.1). The tools include: An interview schedule for N/MUMs An interview schedule for managers of N/MUMs A case study interview schedule A survey questionnaire for staff A survey questionnaire for CSOs. The tools were developed based on: the NSW Health Nursing and Midwifery Unit (NMU) briefing; meetings with the Director and staff of the NMU; the literature review; and the expertise of the researchers. Each tool was piloted, reviewed and modified as required. 2.3 Literature review The literature review was conducted using two methods. The first drew on existing literature relating to: the ttl program; workplace and health service reform in Australia and New South Wales; changes in the role of N/MUMS in NSW; the impact of the introduction of new roles in the workplace; health systems capacity to absorb and respond to change; and transferability of training into the workplace. In addition to the review of this literature, a second targeted analysis was conducted of the international literature on the development of nurse-manager roles and strategies for developing this role. This literature was identified through a search of key databases including: Medline, EMBASE (general medicine) and CINAHL (nursing and allied health). 2.4 N/MUM interviews NSW Health provided a list of all participants of ttl (n = 1610). It was decided that in order to assess the full impact of ttl only participants who had attended all five 16

19 modules; Facilitating Critical Communication (two days), Lean Thing and Leadership (two days), Financial Management (two days), Rostering for Patient Care (one day) and Leadership Making it Happen (two days), would be included in the evaluation (n = 186). These individuals were then divided by their AHS and numbered. There were no participants from the Ambulance Service. Each N/MUM was randomly assigned using a random number generator (http://www.random.org/). They were then contacted in the order of their random assignment. Attempts were made to contact forty-nine N/MUMs. Eleven were on leave (long service, annual and maternity), four had changed jobs, four were un-contactable, and one was unable to participate due to workload. Subsequently, thirty telephone interviews were conducted with three N/MUMs from each Area Health Service. Phone interviews were held with each of the participating N/MUMs. Each interview lasted from three quarters to one and a half hours. Researchers took notes of the interviews, and these notes were later transcribed. Open ended responses were coded for key themes and concepts by two teams of independent researchers. Any disputes in interpretation were resolved by discussion. Likert-scale responses are reported using descriptive statistics. 2.5 N/MUM manager interviews Upon completion of the NUM selection, the random ranking of N/MUMs was further used to identify the managers of N/MUMs who had undertaken ttl and had not participated in the N/MUM interview. These were contacted individually. As with the N/MUM interview, open ended responses were coded for key themes and concepts by two teams of independent researchers. Any disputes were resolved by discussion. Likert-scale responses are reported using descriptive statistics. A total of 30 interviews were conducted with N/MUM managers. 2.6 Staff survey Staff were contacted through the agreement of the managers of those N/MUMs who had completed ttl but who had not been interviewed as part of this study. Attempts were made to contact ten staff from each AHS. A number of survey contact s (n = 16) were returned as undeliverable. The remaining participants were then ed and asked to complete an online survey. A follow-up reminder was sent after three days. Of the contactable participants, a total of 23 participants (36%) completed the staff survey. Only one respondent indicated that they were sure that 17

20 the changes made by their N/MUM were universally not attributable to ttl. A number indicated throughout their responses that they were not sure of the impact for one or more elements of the survey. These uncertainties are indicated in the text. 2.7 Case studies In addition to the N/MUM interviews two case studies were undertaken. Participants in the cases were interviewed in depth. In two cases the interviews were recorded and transcribed. The transcripts were coded for key themes and concepts by two independent researchers and differences resolved by discussion. The participants were contacted by researchers from the evaluation project and were informed that they had been chosen to participate in an in-depth interview of their experiences in regards to ttl. The participants were advised that the interviews would take between hours. The main focus of the interviews was participants perceptions of the changes that occurred both in their own professional development and the unit practices, processes and culture as a result of ttl and the introduction of the CSOs role. The interview questions were similar to the questions asked in the N/MUMs' interviews. In the questions directly regarding ttl the researchers attempted to identify contextual details regarding the NUM and the unit pre and post ttl. NUMs were asked to relate how their perceptions of the program before attending and how or if their perceptions changed while attending or after attending the modules. Similar to the regular N/MUM interviews, the NUMs were asked to identify changes they had made and whether those changes were attributed to ttl or other interventions. The NUMs were asked to identify barriers to successful implementation of changes as well as what enabled them to make sustainable changes. 2.8 CSO survey CSOs were contacted via and invited to complete an online survey. A central contact list for all CSOs was not available. Access to CSO addresses was requested by the Nursing and Midwifery Unit. A total of 207 contact names (of a possible estimated 500 CSOs) were supplied by the AHSs. Of these, 15 messages were returned undeliverable, two were away during the survey period, and one was not a CSO, making a final total of 189 CSOs contacted. Potential participants received one asking them to participate, and follow up s. A total of 92 responded, giving a 48% response rate. 18

21 2.9 Data analysis Descriptive statistics were used to examine the demographic items in interviews and surveys. Interview and case study responses and free text survey results were interrogated using content analysis, with two independent researchers reviewing the results for key themes independently, and then resolving differences through discussion. Comparisons of thematic results were made across groups (N/MUMs, managers of N/MUMs, staff and CSOs) in the same manner. Responses to several items were formulated using five (1 increased significantly to 5 decreased significantly or 1 improved significantly to worsened significantly) or six (1 increased significantly to 5 decreased significantly or 1 improved significantly to worsened significantly 6 don t know) point Likert scales. In answering some different questions, including Likert scale responses, a number of respondents reported that while positive and negative changes had occurred, these, in their opinion were not directly attributable to their participation in ttl. Where an interviewee said that they did not or could not attribute their response to ttl, or where they were unsure whether it was attributable, or if they stated that the effect was attributable to another factor, this was marked as a zero response on the Likert scale. Only the remaining responses were included in the data set. Each set of Likert scale responses were validated by an additional question at the end of each set. Participants were asked if the changes were attributable to ttl. Where the response was no, the set of responses was removed Approval Ethics approval for the project was applied for, and granted by, the Human Ethics Research Committee of the University of New South Wales. The approval number was: HREC (PI)/Panel ref:

22 3. LITERATURE REVIEW 3.1 Introduction This literature review provides a context for ttl and the evaluation. We review the origins of Nursing and Midwifery Unit project, including the impact of the Garling Inquiry and the NSW Health Action Plan and the development of ttl and related programs. We then consider how the role of N/MUMs has changed in NSW and why the role required clarification and formalisation. We conclude the review with a consideration of the factors affecting the implementation and success of changes, such as those intended by ttl, in health systems. 3.2 Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals ( The Garling Report ) In January 2008, a Special Commission of Inquiry into Acute Care Services NSW Public Hospitals was commenced by Commissioner Peter Garling SC. The Inquiry followed a coronial investigation into the death of a young patient in a public hospital in New South Wales and reported growing public concern about the safety and quality of care provided in public hospitals in New South Wales. The Inquiry was the most comprehensive review ever undertaken of the acute care services in New South Wales (Garling, 2008: 39). In the Commission s final report (the Garling Report), publicly released on 27 November 2008, Garling recognised a paradoxical finding. Although application of the usual international criteria suggested the NSW public health care system was of a high standard, regular and alarming media reports of incidents in NSW public hospitals continued. The NSW public health system, he suggested, had entered a period of crisis and but for the goodwill and dedication of the public hospital system workforce, the reduction in quality of care would not only have been much greater but would have occurred sooner. Garling urged that patients be kept at the centre of care and noted that clinical staff were taken away from caring for their patients by an increasing burden of administrative tasks. The report s 139 recommendations were directed at clinical leadership; interdisciplinary health care teams; medical workforce planning and management; clinical education; supervision, training and communication; information technology; use of evidence based protocols or models of care; quality and safety; use of collected health information; and equipment and infrastructure (Garling, 2008). 20

23 Findings of the Special Commission of Inquiry recognised the pivotal role of the N/MUM in the provision of highly co-ordinated and safe care at a unit level. Specifically related to the role of the N/MUM, Garling made the following recommendations: Recommendation 23 NSW Health should, as a matter of priority, review and redesign the role of the nurse unit manager ( NUM ) so as to enable the NUM to undertake clinical leadership in the supervision of patients and the enforcement of appropriate standards of safety and quality in treatment and care of patients in the unit or ward for which they are responsible. This redesign needs to encompass either the transfer of a range of duties from the NUM to other existing staff members or alternatively the creation of a role of clinical assistant to the NUM to undertake those tasks. The aim of the redesign is to ensure that at least 70% of the NUM s time is applied to clinical duties and no more than 30% of the time is applied to administration, management and transactional duties. Recommendation 24 (Garling, 2008: 39) All hospitals employing nurse unit managers report within 6 months to the Chief Nurse of NSW Health how they will re-allocate the duties currently being undertaken by the NUM in line with my earlier recommendation and all hospitals employing NUMs should complete the implementation of the redesigned role within 2 years. 3.3 Caring Together: The health action plan for NSW (Garling, 2008: 39) Caring Together: The health action plan for NSW (the Action Plan) documented the New South Wales Government s response to the recommendations in the Garling Report. Informed by the results of an extensive consultation process that canvassed input from over 12,000 health workers and community members, the New South Wales Government indicated its acceptance of 134 of the 139 recommendations made by Commissioner Garling. Two of the recommendations were not accepted and decisions on the remaining three recommendations were held over, requiring further consultation. The recommendations that were accepted were to be implemented in three stages with some measures introduced immediately, aimed to 21

24 improve not only clinical care, but the environment and way with which it is delivered (NSW Department of Health, 2009). The first of the three stage approach is the Action Plan, an immediate response that focuses on the patient and includes their carers, the clinicians, managers and support staff. This stage aims to demonstrate the New South Wales Government s commitment to building a better health care system. At stage two (six months), a sustainability plan will require a progress report from the New South Wales Government and specified changes to build a stronger health care system. During the third stage (at 18 months), an intergenerational health care system, the New South Wales Government will report on further progress and describe their plan for changing thinking and culture to create a future sustainable health care system. Six major strategies though which the Stage One response will be delivered are outlined in the Action Plan. These strategies include: 1. Creating better experiences for patients 2. Safety 3. Education for future generations 4. New ways of caring 5. Strengthening local decision making 6. Monitoring our progress. (NSW Department of Health, 2009: 6) In implementing these strategies, the action plan emphasised the clinical leadership role of the N/MUMs. Furthermore it recognised that critical role of the N/MUM in the provision of safe care and in the successful implementation of responses to a wide range of the recommendations of the Garling Report. The following are the New South Wales Government s responses to Recommendations 23 and 24 of the Garling Report (those that pertain to the role of the N/MUM). Recommendation 23 New South Wales Government Response: (Stage One Supported) NSW Health will review and redesign the role of the Nursing/Midwifery Unit Manager as part of the move to the new Nurse/Midwife in Charge. Patients and 22

25 families will better recognise the Nurse/Midwife in Charge through a prominently displayed ward photo. Already NSW Health has surveyed over 750 nurses and midwives to identify their views about the key capabilities required for the role and started the Take the Lead program for these positions. A Conceptual Framework has already been developed to outline the purpose of the role, the personal capabilities that should be able to be demonstrated and the broad core functions that are the responsibility and accountability of the role. The Nurse/ Midwife in Charge will provide leadership to ensure safer patient care, the right skill mix of staff on the ward, improved hand hygiene and coordination of ward rounds. Recommendation 24 a & b (a) (NSW Department of Health, 2009: 19) New South Wales Government Response: (Stage One Supported) The Chief Nursing and Midwifery Officer will annually report progress on the reallocation of administrative duties currently undertaken by Nursing/Midwifery Unit Managers so that they can provide a stronger focus on clinical care. (NSW Department of Health, 2009: 19) The New South Wales Government s decisions to strengthen the clinical leadership role of the N/MUMs and to reduce their administrative load by employing clinical support officers was strongly supported by the New South Wales Nurses Association (NSW Nurses' Association, 2009). The ttl was identified as a key strategy in supporting this initiative. 3.4 Context for ttl By way of providing context to ttl we summarise here a range of initiatives and background that we deal with more fully in Appendix 8.2. There are currently multiple improvement strategies and programs underway across NSW Health. These provide positively reinforcing loops for ttl initiatives. They include the: Essentials of Care (EOC) program (NSW Health Nursing and Midwifery Office, 2008); Between the Flags program (Clinical Excellence Commission et al., 2010); and the key principles for clinical handover initiative (NSW Health, 2009). 23

26 3.5 The role of the Nursing/Midwifery Unit Manager within NSW Health N/MUMs must straddle technical, managerial and clinical demands in a complex and continuously changing environment. While aiming to provide compassionate care and clinical leadership they are simultaneously required to manage finances, administrative demands, performance manage and staff their unit often within the context of staff shortages, and increasingly complex patient needs. The role of the N/MUM within NSW Health is essentially one of leadership and management. This role has changed over time and is now defined in the NSW Public Health System Nurses and Midwives (State) Award as a registered nurse in charge of a ward or unit or group of wards or units in a public hospital or health service or public health organisation (NSW Health, 2010b: 4). A brief summary of the evolutionary course of the N/MUM role in NSW is provided below as it provides a context for the implementation of ttl. Appendix 8.2 provides a summary of the literature on the role and professional development of the N/MUM. The Charge Sister role was based on clinical experience and expertise until 1986 when in NSW the N/MUM role was created to replace this role. The Clinical Nurse Specialist role was simultaneously introduced to take over the clinical leadership role that was surrendered by the N/MUM for a focus on managerial responsibilities (Duffield et al., 2001). A recognised difficulty for N/MUMs was the lack of formalised training in management skills and an absence of role models, particularly given the dominance of role model based learning in nursing (Duffield et al., 2001). Decentralisation and the introduction of primary nursing affected the role of nurse unit manager requiring new types of managerial skills (Duffield, 1991). Uncertainty over role definition and a perceived gap in management skills has been identified as problematic not only in Australia (Duffield et al., 1994) but internationally (e.g. New Zealand (McCallin et al., 2010), South Africa (Pillay, 2009) and the United Kingdom (Gould et al., 2001). 3.6 The role of the CSO Linked to changes to the N/MUM s roles, and also emerging from the Garling Inquiry, was the introduction across NSW of the CSOs. Their role was envisaged to support clinical and managerial staff in acute hospital settings, N/MUMs, nurses, midwives, medical staff and allied health personnel. Although most often located at ward or unit level, CSOs are able to work across multiple wards and units, or a whole service. CSOs were not intended to replace existing administrative staff such as ward clerks and communication officers, but rather to complement them. As part 24

27 of the Action Plan, funds for 500 full time equivalent (FTE) CSOs were allocated, most of whom have now been employed. The CSOs usually work under the direction of a N/MUM at unit or ward level. Their role is intended to provide a range of administrative and or transactional services, with the possibility of a degree of independent initiatives and actions. The introduction of CSOs and the implementation of ttl had the joint policy objective of freeing up time for N/MUMs to become more involved in clinical co-ordination and spend less time on purely administrative tasks. 3.7 Take the lead ( ttl ) ttl is a series of strategies to enhance the capabilities and skills of N/MUMs across NSW. Its ultimate goal is that of improving patient care and flow. ttl develops the skills required by N/MUMs to provide co-ordinated care at the unit level by identifying strategies to support N/MUMs in achieving this role, recognising the pivotal part the N/MUM has in coordinating patient care (Hawe, 2009: 4). Although the Garling Inquiry and the NSW Actin plan contributed to the impetus for ttl, the origins of the program pre-date both reports. The project began as a collaborative between the Nursing and Midwifery Office (NMO) and the Health Service Improvement Branch at NSW Health, and is funded by the NSW Government. It was initiated in 2007, in response to patient and carer feedback and anecdotal information about the N/MUMs experiences (Hawe, 2009: 4). Early stages of the project were presented to Commissioner Garling. As a result of the recommendations (specifically 23 and 24) made by Garling, ttl moved from being a voluntary, to a required program, for N/MUMs. Between August 2007 and February 2008, the NMO used a multi-method strategy to examine the experiences and expectations of N/MUMs. Data were collected on the activities, barriers and enablers, required skills and attributes that were perceived by N/MUMS to constitute both the ideal N/MUM role, and observed behaviours of a successful N/MUM. As a result of that study, the NMO created three streams of work. These were to: clarify and define the purpose and core function of the N/MUM role in NSW; identify strategies to support and strengthen the N/MUM role through education and professional development; and propose strategies to reduce the number of administrative tasks undertaken by the N/MUM that are not aligned with the purpose and core function of the role (Hawe, 2009: 4). Other related activities 25

28 included workshops for N/MUMs and Directors of Nursing to increase understanding of the work being conducted in relation to ttl and other projects. The aims of ttl are that: There is clarity and standardisation around the purpose and core functions of the N/MUM role N/MUMs have the appropriate capacity and capability in order to fulfil their role N/MUMs are enabled and facilitate highly co-ordinated patient care reflective of their role and patient and carer expectations (NSW Health, 2008). A Conceptual Framework for the N/MUM role has been developed as part of the ttl project. This framework identifies the purpose and broad functions of a N/MUM as defined by the State Award as well as the personal capabilities and core broad functions of the N/MUM role (NSW Health, 2010a). 3.8 Factors supporting and inhibiting workplace change Fundamental to the evaluation of ttl is an identification of changes to practice and outcomes resulting from ttl, as well as the enablers and barriers to such changes. It is therefore useful to understand how the spread of innovation in healthcare organisations is reported within the literature. A brief overview of the literature on the spread of innovation in healthcare organisations is provided in Appendix 8.2 with key points summarised below. A key managerial role in healthcare is a constant striving for change and improvement (Braithwaite et al., forthcoming). Change may occur at a system-wide, organisational, group/team, or individual level and is influenced by formal and informal hierarchies within the organisation. The distribution of innovation within health service organisations is complex and affected by the interaction of multiple components including: the innovation itself; the adopter; the readiness of the system; the process chosen for implementation; the external context; the type of communication and influence used to transfer the innovation; and the linkages (Greenhalgh et al., 2004). The existence or lack of a certain characteristic does not guarantee the adoption or rejection of an innovation. It is imperative that change agents remember that the attributes are neither stable features of the innovation nor sure determinants of their adoption or assimilation. Rather, it is the interaction among the innovation, the intended adopter(s), and a particular context that determines the adoption rate. (Greenhalgh et al., 2004: 598). 26

29 4. RESULTS 4.1 Demographic and background data Demographic data Input from a wide variety of clinicians and staff members were sought. Appendix 8.3 provides demographic details. These include the gender of participants; their age; their work and employment patterns; their professions and occupations; their organisational roles; and the number of years they occupied their current position. The demographic questions were included on the basis of their relevance to the aim of the evaluation Background to N/MUMs participation in ttl In order to establish the context for their participation in ttl N/MUMs were asked a series of questions relating to their attendance in ttl. These included their reasons for participating, Table 2 below, and the perceived benefits of their involvement. Table 2: reasons for participating in ttl REASONS FOR PARTICIPATING IN ttl NUMBER OF RESPONSES Mandatory 16 Mandatory, but participated willingly 4 Own initiative 4 Strongly encouraged 3 Result of work appraisal or needs identified 2 Mandatory and did not want to go 1 N/MUMs were asked about their experience of participating in ttl. Of the 30 respondents, 18 (60%) indicated that their experiences were positive in some way, ten (33%) indicated that their experiences were variable (experiences varied with the module or the interactions), and two (7%) that their experiences were negative. Apart from content, N/MUMs specifically mentioned networking (n = 11), new ideas or reflecting on their existing knowledge in new ways (n = 4), discussions, problem solving or gaining advice from peers (n = 4) and reflection on their own roles (n = 2) as adding value to their participation. Two N/MUMs stated that participation in ttl had empowered them, or given them the skills to empower their staff. An additional 27

30 five N/MUMs mentioned support provided by the organisation as a positive factor in their experience of ttl. Both rural and metropolitan staff identified the opportunity to compare experiences across locations as being beneficial. I really enjoyed meeting NUMs from other areas and hearing their experiences and gaining tips and advice on how to deal with certain issues. [N/MUM, metropolitan hospital] Respondents who felt their experiences were variable noted that a number of the modules were more suited to less experienced N/MUMs. This was also the case with N/MUMs who indicated their experience of the program was negative one and who described the content as childish. A total of 12 N/MUMs nominated one or more specific modules as not meeting their needs. There appeared to be no difference in positive or variable attitudes for N/MUMs based on their: participation in Essentials of Care; years since graduation; years as a N/MUM; or number of staff reporting to them. N/MUMs who had positive attitudes towards ttl were more likely to be positive about the experience, rather than negative or variable. N/MUM s positive attitudes about their experience in ttl did not appear to be affected by whether they worked in a rural/regional hospital, or a metropolitan institution. Negative factors included; content already known (n = 3); content useless or inappropriate (eg rostering centralised so not under control of N/MUM) (n = 2); one size fits all approach (n = 1); and difficulty of implementing what was learnt (n = 1). There were three common suggestions made in relation to N/MUMs experience of ttl. These were that some modification was required based on N/MUMs level of experience (n = 6); consideration was needed of the difference between rural and metropolitan N/MUMs resources and experience (n = 2); and the possibility of arranging the modules in different ways, for example as a one week session (n = 2). 28

31 4.2 Implementation of changes post ttl Changes made as a result of participation in ttl N/MUMs were asked several times through the survey whether they had made changes due to their participation in ttl. Of the 30 N/MUMs interviewed, three people (10%) said they had not. One of these respondents went on to note although they had not made changes, they had used the skills they had gained in staff management and communication, including being able to successfully negotiate and introduce change, and get staff to take ownership of changes made. Table 3 outlines the types of changes participants said they had made. Table 3: changes implemented as a result of ttl (from perspective of N/MUMs)* CHANGES RESPONSES EXAMPLES OF CHANGES Implemented principles of lean thinking Communication/critical thinking 20 Changes to shift handovers and data collection Patient transportation streamlined Equipment packs streamlined Re-organisation of resources and equipment Better utilisation of storerooms Clean up of storerooms and general environment Removal of out dated forms Modification of office layout Only keep stock which is needed now Set up a new unit using lean thinking principles Introduced auditing and survey 7 Development of business plan Communication book with ideas for discussion Checklists for nursing staff in waiting area New and quicker methods of capturing patient information Niggle board established Changed communication style with staff and managers ing of educational material to 29

32 CHANGES RESPONSES EXAMPLES OF CHANGES staff Rostering 4 Method of distribution of roster Leadership or management Computerised rostering Six months of rostering available in advance Set up a roster which took into account patterns of sick leave 3 Developed a business plan Encourage staff to take leadership roles Helped implement CSO role Budgeting 1 Staff made more aware of, and increased ownership in, budgeting processes No changes 3 ttl aimed at a lower level *More than one response possible per participant No changes, but brought more of what I knew to the ward No specific changes but gained skills in staff management Communication module helped with introduction of change DON runs staff through budgets Although asked about specific changes they had made as a result of their participation in ttl a number of participants spoke about outcomes of their attendance and outcomes of changes they had instigated, rather than the changes per se. Incidental or flow-on outcomes are listed in Table 4 below. Table 4: outcomes as a result of ttl from perspective of N/MUMs* AREA Efficiency TYPES OF OUTCOMES Workload easier Save time More patient information captured Rostering improved Avoided what could have become an industrial issue through effective communication and negotiation Reduced manual and double handling 30

33 AREA Patient outcomes Change management Staff outcomes Capabilities skills and TYPES OF OUTCOMES Patient care improved Improved patient flow Better outcomes for patients Patient care is the focus Able to successfully introduce and implement changes to unit Gained ownership from staff of changes Able to implement change by getting stakeholders on board Better at negotiation with staff and managers Team approach to problem solving Passed onto staff knowledge and skills learnt Staff take ownership of rostering Staff take a leadership role Staff take greater accountability for approaching N/MUM over issues of concern Staff aware that change is possible Better at giving and receiving feedback More aware of emotions, moods and body language Better at seeing bigger picture More politically aware Improvements in general communication style and skills Calmer in responses *More than one response possible per participant Increased understanding of, and confidence in, role as manager N/MUMs were asked if they had evaluated any of the changes they had made. Two participants said that they had not yet evaluated the changes, but were hoping to do so. One N/MUM indicated that her unit was measuring patient flow at the moment. The rest of the respondents described informal methods of evaluation: Environmental changes (ie visible elimination of clutter, more equipment) (n = 2) Increased staff involvement (ie staff more involved in projects leading to a decrease in budget, staff more aware of budget constraints) (n = 2) 31

34 Staff feedback demonstrating increased satisfaction (n = 2) Staff proactive in requesting equipment or advising N/MUM of issues Decrease in the number of incidents between staff Decrease in amount of time taken to resolve issues New ward set up with lean thinking, and running efficiently from day one Consultation increased with both staff and patients and relatives. N/MUMs managers were also asked about the types of changes made by the N/MUMs under their supervision. The majority of N/MUM managers (90%) reported changes as a result of N/MUMs participation in ttl. As with the N/MUMs themselves, a range of changes were reported, some minor, others reflecting large scale changes to the organisation of the ward. Table 5 lists the changes made by N/MUMs as identified by their managers, and some examples of outcomes. Table 5: changes implemented as a result of ttl (N/MUMs managers)* CHANGES RESPONSES EXAMPLES OF CHANGES Implemented principles of lean thinking Communication and critical thinking 24 Store room audits and redesign Reviewed and updated use of folders Introducing new organising system, ttl helped prepare for changes Streamlining of processes in ward 18 Range of communication tools (e.g. whiteboard) Group huddles instigated Problem solving has EXAMPLES OF OUTCOMES Application of principle to other context More user friendly and easier to do the stores and easier for new staff to find things, plus it has saved the unit some money Easier and safer access to equipment N/MUM had intended to make changes to unit, ttl enabled her to do so Communication/critical thinking Improved exchange of information Improved problem solving 32

35 CHANGES RESPONSES EXAMPLES OF CHANGES become more solution based rather than problem based Rostering 5 N/MUMS collaborate in rostering process Finances budgeting and Staff involved in self-rostering Improved planning for skill mix 7 Improved budgeting Improved awareness Combination 5 Change was due to a combination of factors, but ttl provided the tools to make it possible Falls reduction program resulted in fewer adverse events Introduced staggered meal breaks so that staff are on the floor at meal times EXAMPLES OF OUTCOMES NMUM talks to staff and focuses them to think of patient needs and not personal rostering preferences: changing a shift need to swap with someone at own level NUM more proactive, thinking outside the square, and thinking what will be needed and rostering for it More financially aware Scrutinise FTEs and Financial Reports and offer comments Staff morale has improved and there are better patient outcomes. Staff are smiling and they re happy Patient outcomes have improved tracked (no. of falls; medication errors) There are less complaints More positive attitude of N/MUMS N/MUM felt empowered to make changes ttl cements changes that are already underway Skills development 33

36 CHANGES RESPONSES EXAMPLES OF CHANGES Values clarification 3 Were able to clarify unit values *More than one response possible per participant EXAMPLES OF OUTCOMES Used as tool for focusing service provision Although the majority of responses identified positive changes as a result of ttl, three N/MUM managers reported that there had been no changes implemented as a result of N/MUMs participation in ttl. However, while they could not identify specific changes, two of these managers identified that ttl had reinforced aspects of good management and leadership and participating N/MUMs had returned from ttl with renewed enthusiasm and motivation. One N/MUM manager reported that ttl had not catalysed changes because there was mentoring and professional skills development in place at their hospital pre ttl. Other N/MUM managers (n=4) noted that the impact of participation in ttl varied, with some N/MUMs demonstrating changes while others did not. It was suggested that this may be explained in part by individual attributes or that the effect may be delayed ( it takes time *for some of the concepts+ to sink in ). Other N/MUM managers proposed that ttl was particularly beneficial for newer N/MUMs : For the newer NUM it has given her skills to fulfill the role, development and growth. The more experienced NUMs had the knowledge. [N/MUM Manager, rural hospital] One N/MUM manager raised possible unintended consequences of attendance at the program. Their description highlights the contextual factors which affect N/MUMs ability to meet expectations, even with training: On the other hand, one of my NUMs went to ttl and will probably leave nursing because he has realised that it is very hard. At ttl he met likeminded people and found that his situation is like other N/MUMs so asked himself why he is staying in nursing? As a result of ttl he dissected the role. He realised that it won t get any better and everyone is in the same boat he is disillusioned.... the nurse in charge they need to be everything it is the schizophrenic nature of the role they need to be everything, asking them to manage (e.g. staffing, budget) but also to be out there with the patients and their families. The expectations are that they are a clinical coordinator, they do rounds for each of the specialists, they manage staff, beds, finances etc. 34

37 We have big wards They run with 76% occupancy. We have over [a dozen] VMOs who all want the NUM to do rounds with them between 7-9am. [N/MUM, metropolitan hospital] Of the 22 staff who responded to the online survey, 11 participants (41%) identified changes their N/MUMs had made as result of their participation in ttl. These included: establishing or facilitating a weekly multidisciplinary round (n = 2); decluttering and reorganising the unit (n = 2); inviting input and comments on issues involving patient care and service delivery; a patient handover initiative; implementing self rostering; a teamwork and organisation initiative; developing a holistic approach to leadership and management; increasing staff morale and team leadership; and developing a more proactive approach to the management of staff issues. One staff member said that as a result of ttl their N/MUM was more innovative and confident [and] reviewed the use and ordering of ward stock, saving a significant amount of money. 35

38 4.3 Implementation of demonstrable changes in the capabilities and skills of N/MUMs post ttl The evaluation sought to measure N/MUMs, their managers and staff s perceptions about changes in their capabilities and skills. Two types of indicators were chosen: the first was a Likert scale measure and the second qualitative comments and reflections by participants. A full set of figures representing these responses is presented in Appendix 8.4. In this, and in subsequent sections, we need to remember that responses reported are only from participants who indicated that they could be attributed to ttl. All other responses were removed. To clarify, respondents may have felt that there was an impact from ttl overall on their or their N/MUMs work, but may have felt that this impact differed according to the variable Changes in capabilities and skills as assessed by N/MUMs and N/MUM managers Participants were asked to rate the changes to N/MUMs job performance and capabilities post ttl on several indicators. These were: overall job performance; communication; ability to handle complex situations; and management skills. Job performance Most N/MUMs felt that their job performance improved significantly, or somewhat (67%). A third of respondents (33%) felt that it had stayed the same, and no N/MUM felt that their performance had deteriorated. One N/MUM said ttl had no impact on their job performance overall. There were 67% of N/MUMs managers who thought that ttl had had a positive impact, and felt that there had been some improvement to N/MUMs job performance. There were 13% who believed that an improvement in N/MUMs job performance was due to ttl in combination with other initiatives. The remaining 20% felt that the ttl had no impact or that N/MUMs performance had remained the same. Managers were also asked to provide free text responses to changes in the N/MUMs job performance as a result of ttl. Respondents felt that as a result of ttl several positive effects had occurred. This included N/MUMs : confidence had improved; they were better able to make decisions; they were better able to provide effective 36

39 feedback to staff; they could operate more effectively and efficiently; they had created a virtuous circle of ongoing learning and self-confidence; and they were less anxious about staff management. One manager described the change between N/MUMs who had attended a ttl module (leadership) and those who had not: Those who have done the leadership module have started to piece all the bits of ttl together. Also it improved their morale and motivation and means they are now looking for opportunities for change [N/MUM manager, metropolitan community health service] Communication Participants rated changes to three aspects of their communication. This included their ability to communicate with their own staff; their ability to communicate with other staff; and their ability to communicate with patients and their families. None of the N/MUMs felt that their ability to communicate with their own staff or patients had reduced, although 4% felt that their ability to communicate with other staff had decreased somewhat. The majority (81%) of N/MUMs felt that their ability to communicate with their own staff, with other staff (63%) and patients and family (59%) had improved. The remainder felt that their ability to communicate with their own staff (19%), other staff (33%) and patients (41%) had stayed the same. For managers of N/MUMs, no participant felt that N/MUMs communication skills had worsened in any way. The greatest increase was in N/MUMs ability to communicate with staff: 80% of their managers felt there had been an improvement of some kind; 88% of those who identified an improvement reported that the improvements were due to ttl ; 12% indicated that improvements were due to ttl in combination with other co-occurring programs. With respect to N/MUMs ability to communicate with other staff, 43% identified an improvement due to ttl. Among these managers, 25% reported that improvement as significant and 75% indicating that it had improved somewhat. Of those who did not report a change, the majority attributed this to extraneous variables such as: Growing problems with staff being managed off site. It creates new difficulties. Not ttl. [N/MUM Manager, metropolitan hospital] Fewer N/MUMs managers identified a change in N/MUMs ability to communicate with patients and their families (40%). All managers who reported a change in N/MUMs communication skills with patients and their relatives indicated that the 37

40 change was positive with 82% of these respondents attributing these positive changes to ttl. One manager of an N/MUM said that their N/MUMs were now: more out on the floor, participating with staff and patient outcomes. [N/MUM manager, regional hospital] Of those who reported no change, 90% identified that this was not attributable to ttl. Seven of these managers suggested that a lack of change was because this is core business anyway ; we do this every day anyway - daily contact with families ; already good at it. Ability to handle complex situations Three characteristics were measured in relation to N/MUM s ability to manage complex situations. These included: management of difficult situations; negotiation; and problem solving. No N/MUMs felt that their abilities in any of these areas had deteriorated. Of the participants interviewed, four felt that their participation in ttl had had no impact on their ability to manage difficult situations. No-one felt that it had had no effect on their negotiation or problem solving skills. Of the majority of participants who felt that ttl had had an impact, 80% felt their ability to manage difficult situations and negotiation skills (71%) had improved. In relation to problem solving skills slightly more (58%) felt their problem solving skills had improved and 42% felt that these had remained the same. Of the N/MUM managers 65% felt that their N/MUM s ability to manage difficult situations had improved since ttl, with 55% attributing the improvement solely to ttl, 10% reporting that the improvement was due to a combination of ttl and other factors and 3.5% attributing a change to factors other than ttl. There were 31.5% of managers who reported no change; 28% identified that the lack of change in the N/MUMs ability to manage difficult situations was due to external factors not ttl. There were 62% of N/MUM managers who felt that their N/MUMs negotiation skills had improved since ttl : 55% attributed this improvement to ttl ; 3% to ttl and other factors; and 3% to factors other than ttl. An improvement in N/MUMs problem solving skills since ttl was reported by 63% of N/MUM managers; 52% attributed the improvement solely to ttl ; 7% partly to ttl ; and 4% due to factors other than ttl. In the case of the last two categories 38% and 36% of managers reported that their N/MUM s ability had stayed the same. A lack of change in ability to problem solve (28%) and negotiate (31%) was predominantly attributed to factors other than ttl. 38

41 Almost equal numbers of staff felt that their manager s ability deal with difficult situations had improved (45%) or stayed the same (46%). The remainder were unsure. Management Participants were asked to gauge changes to several aspects of their management skills. These included their ability to manage staff, their ability to lead, and their ability to manage resources (including staff, through rostering, as well as finances and resources, and their ability to apply lean thinking). Most N/MUMs indicated that there had been changes in their ability to manage staff. A total of 82% of participants felt that their ability to manage staff had improved. The remaining participants felt that their ability had remained the same. No participant felt that their ability had been impaired. A slightly lower number of managers (75.5%) thought that their N/MUM s ability to manage staff had improved; 65% due to ttl ; 7% due in part to ttl ; and 3.5% not due to ttl. The remainder, 24.5%, believed that their ability had remained the same. A similar pattern was demonstrated when N/MUMs were asked to rate changes in their leadership abilities. A total of 77% indicated that they felt that their leadership abilities had increased to some degree. The rest (23%) indicated that they felt these abilities had remained the same. The majority of N/MUMs managers skills (80%) also indicated that their N/MUMs leadership had improved; 74% due to ttl ; 3% due to a combination of ttl and other initiatives; and 3% due to factors other than ttl. The rest felt that their skills had remained the same. Of the three remaining indicators of N/MUM s management skills, their ability to apply lean thinking showed the greatest increase, with 86% of participants indicating that their ability in this aspect had improved either somewhat or significantly, and 14% saying it had stayed in the same. In relation to their ability to manage finances and resources, had 50% of respondents said that their abilities had increased, and 38% felt their rostering ability had improved. In these last two indicators 50% and 62% felt that their ability had stayed the same. No-one felt their abilities had become poorer. Rostering and finances were the modules which were most commonly criticised by N/MUMs. In the case of rostering this was because it either did not meet N/MUMs needs, or because they had a centralised rostering system and therefore it was not applicable. Similar criticisms were made of the finance module. 39

42 As with the N/MUMs themselves, most managers of N/MUMs attributed the greatest impact of ttl to lean thinking (83%). For N/MUM managers, this was followed by financial management (54%). Improvement in N/MUMs ability to roster staff was noted by (50%) of participating N/MUM managers. There were 32% of managers who identified that a lack of change in abilities to manage finances or rostering was due to factors other than ttl such as central rostering and financial constraints beyond their control. None of the participants felt that the N/MUMs abilities had decreased in any way due to participation in ttl. Of the staff who responded to this question, 48% felt their manager s ability to manage finances had remained the same, 14% felt it had improved somewhat, and the rest were unsure Descriptions of changes in capabilities and skills Examples of improvements to capabilities and skills As well as rating the changes to their skills and abilities, N/MUMs were asked to describe any specific skills they had developed. Of the 30 respondents, six said that they could not identify any specific or additional skills and capabilities which they had developed and four indicated that they had either refreshed previous capabilities or enhanced others. Overall, the skills and capabilities identified by N/MUMs fell into two distinct groups: communication and the role of the N/MUM. Table 6 highlights these improvements and provides indicative examples. Table 6: examples of improvements in capabilities and skills of N/MUMS* CAPABILITY OR SKILL EXAMPLE Communication (n = 27) Communication Negotiation Communication with medical teams/doctors More measured/tolerant responses Widened range of communication techniques/tools Effect of communication on others Feedback Handling difficult conversations with staff Improved conversations with families and patients 40

43 CAPABILITY OR SKILL EXAMPLE Role of N/MUM (n = 14) Renewed sense of enthusiasm Increased confidence in abilities Improved leadership skills Assertiveness Managing difficult staff Empowering staff Improved organisational skills Research skills Financial management Increased computer literacy * More than one response possible per participant Impact on day to day work A number of participants identified the ways in which ttl had impacted on the day to day work in their unit. Of the 30 respondents, 14 either could not articulate the day to day impact of their participation in ttl as separate it from other improvement strategies and changes or did not respond to the question. For those who could, the examples of the impact included: better negotiation skills; improvements in time and other forms of management; better relationships with staff; improved organisation of ward; increased skills in prioritising; increased focus on patients; improved ability to sell change to staff; thing working better in unit in general; staff ownership of problems and empowerment; better temper and less stressed; and better communication with managers. Management of staff Several participants (n = 3) did not answer this open-ended interview question (as opposed to the Likert scale) about changes in their management of staff. Of the remaining participants, seven (26%) said that ttl had had no or minimal impact on their management of staff. The remaining participants identified that their involvement had resulted in a number of improvements in the way they manage staff (Table 7). 41

44 Table 7: improvements in staff management as a result of ttl * IMPROVEMENTS IN STAFF MANAGEMENT Improvements in reflective listening More insight into own behaviour Better communication skills Enhances staff ownership of and accountability to, unit Improved handover Improved management of difficult conversations Improved management of difficult staff Confidence with staff appraisals More inclusive of and less prescriptive with staff, decrease of barriers Increased assertiveness Improved understanding of staff needs, expectations and motivations Better time management * More than one response possible per participant Improvements to care of patients Half of the respondents, when asked if their participation in ttl had changed the way they responded to the needs of patients, said that it had not. However, most of these responses were qualified by statements that the N/MUM had always been patient focused anyway. An additional three people did not answer the question. Of the remaining 11, examples of improvements to care of patients are outlined in Table 8. Table 8: improvements in response to needs of patients IMPROVEMENTS IN RESPONSES TO NEEDS OF PATIENTS See things from patients experience, and aim to make their experience more efficient and less traumatic Increased focus on patient care and outcomes Listens to, and tries to meet patients needs: requires a different type of nursing Spends more time with patients and discussing their problems, needs, complaints, home situation Better management means happier staff, and therefore better care to patients Improved communication increased staff satisfaction which in turn leads to better patient care 42

45 IMPROVEMENTS IN RESPONSES TO NEEDS OF PATIENTS Improved budgeting means new equipment could be purchased Increased efficiency leading to better patient care Increased number of family conferences Increased patient compliments which are displayed for staff to see Gift register and sharing of gifts Complaints register Increased awareness amongst staff of opportunities for improvement More time spent by N/MUM in ward Changes in N/MUM s work Many of the changes to the N/MUM s work had been addressed in previous questions. Over half (n = 22) of the participants said either that ttl had not changed their work, did not respond, or said that they had nothing to add. Of the participants who said ttl had affected their work: six had more time to undertake clinical work or time on the wards through better prioritising and management; two had more time to spend with staff; and one felt that the N/MUMs Conceptual Framework allowed them to delineate their role more clearly. Changes to work of team Half of the respondents to this question indicated that ttl had not resulted in changes to the work of their team, or they did not respond to the question. Table 9 summarises the impact ttl has had on the teams of the remaining participants. Table 9: changes to the work of N/MUM s team as a result of ttl * CHANGES TO WORK OF TEAM Increase staff participation in problem solving and decision making (n = 4) Improvements in staff morale (n = 3) Higher quality care for patients (n = 2) Improved team work (n = 2) Improved handover (n = 1) Increased delegation (n = 1) * More than one response possible per participant 43

46 4.3.3 Impact of ttl on N/MUM s role One of the elements considered in the evaluation of ttl was its impact on the role of N/MUMs. It was perceived to be largely positive. Of the 30 participants, two said ttl had not had an impact on their role and another two did not answer the question. Of the remaining participants, all indicated that ttl had had some impact. The types of impact are presented in Table 10. In addition to the improvements outlined below, N/MUMs also raised several issues in relation to ttl. These included: networking being as important as the content of the modules; and the modules being too long. Table 10: impact of ttl on the role of N/MUMs* IMPACT OF ttl ON ROLE OF N/MUM Able to apply content of some or all of the modules (n = 9) Increased confidence in and or enthusiasm for role as N/MUM (n = 6) Networking (n = 5) Better understanding of role (n = 3) Improved coping mechanisms (n = 1) Improved status of N/MUM in view of staff (n = 1) * More than one response possible per participant Attitude towards being a N/MUM Participants were asked whether their participation in ttl had affected the way they felt about being an N/MUM. A total of seven participants said no and an additional six did not answer. Participants said that they: felt more positive about the role (n = 3); clarified expectations of the role (n = 3); decreased feelings of isolation (n = 2); gained insight into the contributions they made; felt more empowered; increased their enthusiasm for the role; reinforced current activities; staff more appreciative of role; felt valued by NSW Health (n = 1 for all the latter). One participant indicated that they had left the course with a greater enthusiasm for the role of N/MUM, but that this had waned subsequently N/MUMs managers and staff perceptions of capabilities and skills development in N/MUMs Managers of N/MUMs were asked to reflect on the capabilities and skills which they had seen their N/MUMs gain as a result of their participation in ttl in open ended questions. They identified the following improvements in their staff s skills: 44

47 Communication skills in dealing with staff and managers (n = 14) Improved understanding budgeting and rostering (n = 8) Embraced other initiatives and new ideas, increased lateral and or lean thinking (n = 11) Built team work and peer support amongst the N/MUMs (n = 3) Improved management and leadership skills (n = 14) Time management (n = 2) Improved performance management (n = 2) More outcome focused (n = 1) More staff focused (n = 1) Increased empathy (n = 1) Improved ability to support staff (n = 1) Increased professionalism (n = 1) Changed approach to data and improved knowledge base (n=4). Changes to N/MUMs ability to manage as identified by staff included: more collaborative; implemented a series of improvement initiatives; increased attendance at ward rounds; delineated and delegated more; improved communication between N/MUM and staff, and between staff; increased accountability. One respondent noted that as a result of the: ward NUM spending more time with patients [there have been] fewer complaints. [Medical staff, tertiary hospital] 45

48 4.4 Key factors affecting changes implemented as a result of ttl Participants were asked about factors which affect the successful implementation of changes. Questions included: which changes N/MUMs had been able to implement successfully; whether some changes had been easier to implement than others; and what were the factors that enabled or formed barriers to change Successful implementation of changes Of the 30 N/MUMs interviewed three did not implement changes. Of the remaining 27, three participants indicated that assessing the success of the changes was difficult: one because the change was undertaken in a new hospital and therefore it was difficult to assess the change from what had occurred previously; the second participant found it difficult to differentiate between the impact of the changes they had made post ttl and the impact of the Essentials of Care program; and the last participant found it difficult to assess the impact of change in a unit with high staff turnover. One additional participant felt that the success was 50:50 but noted that there were improvements both in her staff s abilities and her own. Table 11 presents changes which have been successfully implemented by N/MUMs. Table 11: changes successfully implemented as a result of ttl * SUCCESSFUL CHANGES Improved feedback from and communication with staff, improved relationships with staff, increased staff satisfaction (n = 18) Increased confidence and skills as manager (n = 8) Staff in control, more responsible, empowered and proactive (n = 7) Improved processes (handover, transport, flow management, rostering, organisation of equipment)(n = 5) Increased effectiveness and or productivity of staff (n = 3) Cost saving in storeroom supplies by applying lean thinking (n = 2) Development of improvements/innovations by staff (n = 2) Time saved in service delivery (n = 2) Increased patient satisfaction (n = 1) Increased interest in patients (n = 1) * More than one response possible per participant 46

49 The following statement paraphrases the response of one N/MUM to the question about the successful implementation of changes. In their opinion, ttl : allows you to be more transparent in your decisions. This leads to an increase in the trust that staff have of your decisions I was already doing some of the things so this was more about developing my understanding of it, now I don t just do what my role entails because I have been told to do it, I now understand why I do it. [It has] given me more opportunities to communicate with staff why I do things this has developed relationships with my staff. My relationships with my staff have improved because I am now confident and understand why and I can build the staff understanding of why. Being able to say I learnt this at ttl gives it more credibility and credence and therefore my managers are more supportive. Lean thinking [has been] successfully implemented. [N/MUM, state-wide service] As each interview progressed, participants often provided more details about changes which they had made as a result of their participation in ttl. These are not counted above, as they appear irregularly throughout various interview questions. They are, however, important examples of change. The following are spontaneous examples of change which were reported: Process mapping, changing paper work for patient going into day surgery are examples [of changes]. We removed duplication and unnecessary tasks in Day Surgery Unit. Also, eliminated some things not needed for patients being admitted, streamlining, so patients came in later and went home earlier, reducing ward times. Better communication with families and carers regarding patient care after surgery. Improved communication if surgery is cancelled. Whole skills got developed which gave confidence other NUMS concur. [N/MUM, metropolitan service] Factors affecting implementation of changes N/MUMs opinions varied as to whether some of the changes they had implemented were easier to change than others. Of the participants who responded (n = 23), factors said to increase the ease of implementation included: Increased confidence as a manager (n = 2) Patient centred approach (n = 2) Champions of change (n = 1) 47

50 Selling the change as a benefit to staff (n = 1) Establishing a new ward (n = 1) Team approach to change (n = 1). Factors making the implementation of changes more difficult included: Changing old habits/changing culture in others (n = 5) Lack of resources including staff (n = 2) Lack of development opportunities (n = 1) Difficulty in sustainability of change (n = 1) Need for follow up after courses such as ttl (n = 1) Lacking in leadership skills required (n = 1) Difficulty in seeing results of change for staff (n = 1) Time required to be inclusive (n = 1) Physical environment (n = 1). A number (n = 5) of participants identified lean thinking specifically as being an easier change to implement. The response of this participant provides important insight as to why this may be: lean thinking changes [are] easier but still need to be driven. Easier because [they are] practical and [you can] chip away at it and do even without a CSO. Staff feel overwhelmed with workload [and] so [are] resistant to evaluation of other projects. [N/MUM, regional hospital] The managers of N/MUMs identified a wide range of factors which affected their N/MUMs ability to implement change. These included: Support from senior management (n = 11) Support from staff (n = 7) Team work (n = 3) Timing/time (n = 4) Culture of unit and organisation (n = 2) Staff resistance (n=1) Understaffing/ workload (n = 4) 48

51 Impact of organisational structures (n = 1) Small scale, incremental changes (n = 1) Concurrence with Essentials of Care and or other change strategies (n = 1) Practice development workshop (n = 1) Support from CSO position (n = 2) Effective communication (n = 1) Showing relevance of change to staff (n = 1) Reduced sense of isolation (n = 1) Clinical champions of ttl (n = 1) Sharing learning (n = 2) Willingness to change (n = 1) Passion (n = 1) Effectiveness of ttl tools (n = 1) Skills to make changes (n = 1). The perspective of staff was closely aligned to that of the N/MUMs and managers. Factors which enable their N/MUMs to successful implement changes include: being positive about change themselves; implementing new practices over a period of time; introducing changes with increased confidence and collegiality, including team involvement, meetings and ongoing staff input (n = 2); strong support from the Executive and Senior Management; meeting a need; co-ordinated implementation strategy; and good leadership and communication skills (all the latter are n = 1). Factors which hindered successful implementation included: workload; the same project being undertaken by several departments simultaneously; lack of time; lack of ongoing organisational support; and change fatigue, because so many changes implemented at once. 49

52 4.5 Quantitative improvements at the unit level This section reports on quantitative improvements at the level of N/MUM s units as a result of their participation in ttl. A full list of figures is presented in Appendix Unit performance N/MUMs were asked to rate the quantitative improvements in their workplace as a result of their participation in ttl. Indicators examined included: perceptions of their unit s overall performance; perception of their unit s overall efficiency; and rate of adverse events. Unit performance and efficiency Just over half of the N/MUMs (58%) indicated that both their unit s performance had improved significantly or somewhat, and 42% that it had remained the same. In relation to their unit s efficiency, 67% felt that it had improved to some degree. No N/MUMs believed that their unit s performance or its efficiency had worsened by any measure. Of the N/MUMs managers, 62% reported that their unit s performance had improved significantly or somewhat, and 52% reported that their unit s efficiency had increased since the N/MUMs had participated in ttl. There were 14% and 7% who indicated that these improvements may be partly attributable to other initiatives. A total of 38% of N/MUMs managers felt that their N/MUMs units performance had stayed the same, and 41% that their efficiency had stayed the same. There were 31% and 38% respectively who attributed the lack of change in these variables to factors other than ttl. No manager felt that their N/MUM s unit s performance or its efficiency had worsened by any measure. Exactly half of the staff (50%) indicated that the unit s performance had improved, and the rest through it had stayed the same. A slightly lower proportion (46%) believed that their unit s efficiency had stayed the same, with 45% reporting that it had improved either somewhat or significantly. The remaining 9% felt that it had decreased somewhat. Adverse events The majority of N/MUMs (72%) indicated that the number of adverse events since their participation had largely stayed the same. No participants indicated that adverse events had increased. The remaining participants (28%) indicated that 50

53 adverse events had either decreased somewhat, or decreased significantly, in concert with ttl. A similar response was received from managers of N/MUMs participating in ttl. Two participants indicated that they were not sure that a decrease in adverse events could be attributed entirely to ttl. Of those who attributed a change to ttl, 27% identified that adverse events had decreased somewhat. Overall, 77% of managers reported that there had been no change in adverse events since ttl, with 50% identifying that the lack of change was not attributable to ttl (e.g. we don t get that many anyway ). Of the staff that responded 59% felt that adverse events had stayed the same or decreased somewhat, 23% that they had increased somewhat. The rest were unsure. Patient flow A slightly higher number of N/MUMs (48%) felt that patient flow had improved either significantly or somewhat, compared to those who felt it had stayed the same (42%). An additional 10% indicated that patient flow had worsened somewhat or significantly. Overall, 37% of N/MUM managers reported a change in patient flow since N/MUMs participated in ttl. There was 22% of participating N/MUM managers who attributed an effect on patient flow to their N/MUMs participation in ttl. Of these 27% reported a significant improvement and 59% a slight (somewhat) improvement. While 56% of N/MUM managers reported no change in patient flow, 48% reported that the lack of change was due to factors outside ttl. Of the staff who replied to this question, 32% reported that patient flow had improved to some degree, 50% that it had stayed the same, and the rest indicated it has worsened somewhat. Time spent on administrative tasks N/MUMs were asked a series of questions relating to their performance and capacity. The first question related to changes in the time spent on administrative tasks. No participant identified that the time spent on administrative tasks had either increased or decreased significantly. The remaining participants accounted that it had either: increased somewhat (25%), stayed the same (35%) or decreased somewhat (40%). In the perception of N/MUM s managers, 29% reported that the time spent on administration by their N/MUMs had stayed the same. A further 51% suggested that the time their N/MUMs spent on administration had decreased to some degree, although most of these attributed the decrease to a combination of the potential 51

54 effect of ttl and the introduction of CSOs, a similar response was made by the N/MUMs themselves. The remaining 16% reported that it had increased somewhat but that this was due to factors other than ttl (e.g. [there are] a lot of projects rolling through increasing admin time ). Of the N/MUM s staff that responded, 41% felt that the amount of time their N/MUMs spent on administrative tasks had decreased either somewhat or significantly. Of the rest, 27% felt it had stayed the same, 14% that it has increased somewhat and the rest did not know Staff performance The majority of N/MUM participants, 62%, thought that staff performance had improved, and 38% that it had stayed the same. No participant suggested that it had worsened. N/MUMs managers had similar perceptions, with 51% believing that staff performance had improved: 41% attributed this improvement to ttl ; 3% to a possible combination of ttl with other factors; and 7% was attributed to factors other than ttl. Most of the surveyed staff (50%) specified that staff performance had stayed the same, or that it had improved slightly (32%). The rest of the staff denoted that it had decreased somewhat (18%). N/MUMs were asked about impacts of their changes post ttl on the behaviour of their staff. Positive indicators were staff satisfaction and staff retention, negative indicators were staff absenteeism. Amongst N/MUMs the greatest increase identified was in staff satisfaction, where 69% of participants reported that staff satisfaction had increased either significantly or somewhat since ttl. No participants advised that staff satisfaction had decreased. A total of 26% of participants also believed that staff retention had increased; with most participants (70%) indicating that staff retention had stayed the same, and a further 4% that it had decreased. Of the N/MUMs managers 49% thought that staff satisfaction had increased somewhat (23% attributed this improvement to ttl ; 20% attributed changes to ttl in part or were unsure of the cause; and 6% did not attribute this change to ttl ). Of the remaining N/MUM managers, 40% thought that staff satisfaction had stayed the same and 6% that it had worsened significantly (participants noted that this was not due to ttl but factors such as workload issues ). Almost all (90%) of N/MUM managers thought that staff retention had stayed the same, with 7% stating that it had increased somewhat due to ttl. Of the N/MUMs staff, 41% felt that staff satisfaction had improved. Of the remaining respondents, 23% said that it had stayed the same, 27% indicated that it 52

55 had worsened either significantly (4%) or somewhat, and the rest were unsure. Most (41%) reported that staff retention had stayed the same, or that it had improved slightly (14%). The remaining staff were either unsure, or held that it had worsened (36%). Staff absenteeism was largely considered by N/MUMs to have stayed the same (70%). Of the remaining participants, 17% felt it has increased somewhat, and 13% that it had decreased either somewhat or significantly. Of the N/MUMs managers interviewed, 83% proposed that absenteeism had stayed the same and 3% that it had decreased somewhat (due to ttl ). There were 14% who indicated that absenteeism had increased but that this was not attributable to ttl. The majority of N/MUMs staff indicated that staff absenteeism had stayed the same (45%). Of the rest, 9% stated that it has improved somewhat, 23% that it had decreased somewhat or significantly, and the remainder unsure. As well as staff satisfaction and retention, N/MUM participants were asked about changes to staff morale. Half of the N/MUMs, 52%, felt that staff morale had improved. The remaining 48% thought that it had stayed the same. Amongst N/MUM managers, 60% felt that staff morale had improved. Of those N/MUM managers who attributed the improvement to ttl (37%), 8% identified a significant improvement and 83% reporting the improvement as somewhat. There were 10% who reported that staff morale had worsened somewhat but that this was due factors other than ttl. Of staff who completed the survey, 32% perceived that staff morale had stayed the same, 26% that it had improved somewhat, 37% that it had decreased to some degree, and the rest were unsure Impact on patients Three measures of patient impact were taken. These included: patient satisfaction, patient complaints and patient compliments. A total of 44% of N/MUMs estimated that patient satisfaction had increased and 41% believed that patient compliments had increased. No participant felt that either of these measures had decreased significantly, although 4% recorded that patient satisfaction had decreased somewhat. Most N/MUMs felt that both these measures, satisfaction (52%) and compliments (59%), had stayed the same. A further 64% indicated that patient complaints had also stayed the same. Of the remaining participants, 31% stated that patient complaints had decreased either somewhat or significantly and 5% that they had increased somewhat. No participant indicated that patient complaints had increased significantly. 53

56 Of N/MUM s managers, 37% indicated that patient satisfaction had increased (24% due to ttl ; 10% partly ttl ; 3% not ttl ), and 33% said that patient compliments had increased (20% due to ttl ; 6% partly ttl ; 7% not ttl ). Managers differed from N/MUMs on which of these measures had remained the same (62% for satisfaction, 67% for compliments and 61% for complaints). The majority of the respondents who reported that these variables had remained the same, identified that factors other than ttl were responsible; (38%, 43%, 37% respectively). A total of 27%, however, felt that patient complaints had decreased due to ttl. Of the staff surveyed, 52% recorded that patient satisfaction had stayed the same, and 38% that it had improved to some degree and 10% were not sure Examples of improvements As well as rating their improvements, participants were asked for specific examples of improvements at a unit level. Questions addressed the issues of patient flow; reduction in errors and adverse events. Patient care and flow A total of 14 participants said that ttl had not had a direct impact on patient care or flow or that the improvements were not directly or solely attributable to ttl. There were, in addition, four no responses. Of the remaining participants, respondents asserted that ttl had contributed to: Improvements in patient day surgery journey Improvements in patient flow as a result of improved communication with staff Improvements due to review of patient satisfaction surveys Increased focus on patient safety Increased focus on patients leading to improvements in continuity of care More time on wards by N/MUM improved patient care. Errors and adverse events Half of the participants indicated that there had not been a reduction in errors as a result of ttl and a further three did not respond. Of the participants who had indicated that errors had not reduced, one stated that there weren t any problems with regards to errors anyway, so there were no changes. 54

57 In comparison, one participant claimed that errors had been reduced by 40% because of their participation in ttl and another noted that there had been an increase in the error rate because staff were now more aware of the need to report. The remaining participants indicated that errors had been reduced by: Reduced errors through better communication Increased N/MUM presence on ward Improved retention of staff and fewer casual staff has contributed to reduction of errors Impact on day to day work of ttl Impact of ttl on day to day work of N/MUMs N/MUMs managers were asked about the impact of ttl strategies on the day to day work of N/MUMs. A number (n = 6) reported that ttl had not had a direct impact, or that the impact was mitigated or enhanced by other. The remaining respondents identified the following impacts: Improvement in N/MUMs capabilities overall (n = 4) Built team work amongst N/MUMs (n = 2) Improved ability to manage staff (n = 7) Improved communication skills (n = 4) Increased awareness of self and wider issues (n = 3) Increased confidence in their work (n = 3) Ability to translate ideas into action (n = 2). Factors prohibiting impact on day to day work included: Too many barriers to implement change (n = 1) No mechanism for changing staff (n = 1) Still cannot spend enough time on ward (n = 1) Expectations of the organisation (n = 1). 55

58 Impact on N/MUM managers As well as the impact of ttl on the N/MUMs themselves and their direct staff, changes to the N/MUMs skills were identified as having an impact on their managers. Not all N/MUMs managers perceived that changes to their N/MUMs had impacted on their daily work (n = 12), and others considered that it was too early to tell or that they were unsure (n = 4), a number of impacts (both positive and negative) were identified. These included: Better communication and management by N/MUMs means better handling of performance management issues before they become critical (n = 9) N/MUMs have become more independent and better at problem solving, reducing dependence on N/MUM manager (n = 9) Increased visibility of N/MUMs on wards means that their managers have picked up more of their administrative load (n = 3) Increased confidence, empowerment and more skills in their toolkit (n = 2) Less reliance on the Director of Nursing (DON) to initiate change at a unit level, although support still required (n = 3) Shorter meetings and less time needed to sell projects and less time spent chasing reports More resources needed for increased number of projects (viewed positively). 56

59 4.6 Barriers to the program s implementation Participants were asked about several aspects of the barriers which may have impeded N/MUM s ability to implement changes after participation in ttl. These included changes they would have liked to have made, but were unable to do so. Only a few N/MUMs identified changes which they would have liked to have made, but were unable to. Of 30 participants, 11 said explicitly that there was nothing they wished to implement that they could not. The others indicated a small number of specific projects they could not get underway, but most identified areas of further training or input. A few participants identified barriers to implementation of changes which N/MUMs would like to have made. These included: obstruction from medical staff (n = 1); lack of cross institutional collaboration (n = 1); need for more involvement of staff, including CSOs, in quality improvement (n = 2); time constraints (n = 2); and a lack of resources, both human and equipment (n = 4). The managers of N/MUMs identified a similar list of barriers. These included: time (n = 3); local courses already provided at a higher level (n = 2); inability to implement ideas in the workplace due to workload (n=3); participation seen as tick box training ; lack of preparation of, and information provided to, DONs; structural limitations; staff resistance; antagonistic culture; and interdependence with other organisations (all the latter responses are n = 1). Overall, however, most comments from N/MUMs managers were positive about the impact of ttl. One participant gave a clear summation of the barriers affecting implementation of changes. They said that the biggest barrier to implementing change was the [the] stark reality that you come back to work and you are straight back in and up to your elbows in hard work. [N/MUM manager, regional hospital] Surveyed staff also identified a series of barriers to improvement initiatives at a unit level. These included: staff attitudes (n = 1); cultural aversion or reluctance to change (n = 2); initial organisational support for the initiative which then petered out (n = 1) ; workload (n = 1); and several changes being implemented at once (n = 2). 57

60 4.7 Strategies required to ensure the sustainability of changes N/MUMs perceptions of sustainability of change One element of the evaluation was to identify the factors which influenced the sustainability of changes made by N/MUMs after their participation in ttl. All participants responded to this question. A total of 25 said that the changes they had put in place had been sustainable. Of these participants four noted the changes were sustainable so far and several indicated that the changes had been made were successful but did not relate the reasons why they thought this was so. Factors identified as affecting the sustainability of changes included: N/MUMs ability to drive and reinforce changes (n = 5) Difficulty in attaining and sustaining cultural and behaviour change (n = 2) The loudness of change resistors (n = 1) Evidence of success and benefits, including results of audits (n = 4) Patient centred focus (n = 1) Staff becoming part of the process (n = 1) Positive feedback to staff (n = 1) Reducing negative messages to staff (n = 1) Support of management (n = 1) Cohesive teams (n = 1) Clear plans and processes (n = 1). An example of the factors needed to sustain changes is presented in the following quotation from an N/MUM. They describe the process of implementing changes as a result of the lean thinking module in the following way: Yes the changes have been sustainable especially Lean Thinking. It worked because of supportive managers e.g. from the Leadership module (learning how to lead) enabled me to develop ideas e.g. I took the staff on a planning day at which we developed values (explicitly stated and shared) and we did team building activities. This has led to great changes on the ward that have come from the staff. The managers supported me. When I started ttl I had a group of new staff who were very keen to change. Now the staff are stuck in their 58

61 ways. It comes down to communication and how you communicate the need to change. The value of the changes need to be communicated - this could have been better covered (perhaps a module incorporated re the skills to communicate the value of change). Health is a constant change. An element in the communication module that focuses on change management would have been really useful. As there is change fatigue among nurses and staff, keeping interest in new things in the light of constant change is very difficult e.g. changes from Garling etc. [N/MUM, state-wide service] N/MUM managers and staff perspectives on the sustainability of change Managers of N/MUMs identified a number of factors which they felt contributed to the sustainability of changes implemented by N/MUMs. These include: Practical approaches that can be applied in many areas (n = 3) Support from local managers (n = 2) Collaborative decision making and implementation (n = 3) Effective communication between staff at all levels (n = 3) Increased confidence (n = 2) Support of staff (n = 2) Identification of clear benefits for staff (n = 2) Small changes which are easily sustainable (n = 1) Need to maintain enthusiasm once returned from course (n = 1) Removal of systems and resources act like a barrier (n = 1) Peer support (n = 2) Resources including CSOs (n = 1) Coaching (n = 1) Pre-planning and integration into routine practice (n = 1) Focus on staff (n = 1) Focus on patient care (n = 1). 59

62 N/MUMs staff were also able to identify a series of factors which they believed contributed to the sustainability of change within their units. These are presented in Table 12, below. Table 12: factors affecting the sustainability of change from staff perspective FACTOR Support and recognition Structural and resources issues Quality improvement Training N/MUM capabilities EXAMPLE Support from the AHS in getting medical officers to change practice to fit in with the AHS priorities Support from management Resourcing ratios fairly and at benchmarked levels Ongoing financial support and support from organisational management and time to develop and implement staff and patient education programs Decrease workload. Increase CSO equitable across regional and rural sites Measurement of the changes and positive feedback from senior management Continuously review the unit performance and stakeholders' comments Training in change management and leadership Education on managing change and how to work with resistance Good communication, team approach, quality activities Interpersonal skills, conflict resolution, people management skills 60

63 4.8 Essentials of Care and Caring Together: The health action plan for NSW Essentials of Care (EOC) EOC is being implemented in every ward in NSW over a three year period. In the current study, the prevalence of implementation and perceived effect of EOC was examined. Of the N/MUMs who were interviewed, 17% stated that EOC had been introduced in their wards, 20% indicated that implementation had begun (and were at various stages of that implementation) and 63% had not begun implementing EOC. Within the group for whom EOC had been introduced, 100% (n=5) identified that there had been changes made at least some of which could be attributed to EOC. One N/MUM stated that all of the changes they had made had been due to EOC rather than ttl. Those who said that EOC had stimulated changes in their wards noted that the changes arising from EOC were focused on patient care (clinical) needs and driven by staff on the ward. These changes included the introduction of multidisciplinary ward rounds, handover, changes in medication administration process and the development of values and mission statement by staff. One N/MUM captured the difference between the effects of ttl and EOC as one of focus. That is that while ttl focused on the skills of the N/MUM (e.g. communication and leadership), EOC had a clinical focus. Another N/MUM reported that the effects of EOC included an: increased culture of staff wanting challenge and change [and an] increase in the amount of open discussion about change and attempting change as a team. [N/MUM, tertiary hospital] Approximately half of the N/MUM managers (57%) and staff (48%) stated that EOC had been introduced in their organisations. Managers were able to identify the changes that the staff had made that were due to ttl and those that were due to EOC. Table 13 depicts key elements of the managers responses that support their claim. Table 13: Key elements of managers comments about how they identified between effects due to EOC and ttl * KEY ELEMENTS RESPONDENTS EOC is more about the bedside care 2 EOC is patient focused 1 61

64 KEY ELEMENTS RESPONDENTS ttl is leadership focused and patient focused 2 EOC supports staff initiatives and staff driven change 4 ttl supports N/MUMs to make change 1 * More than one response possible per participant ttl was purely managerial, EOC is purely basic nursing care related so it is not difficult to distinguish management of practice development... need to know more about change management. This module was not included but should have been [N/MUM manager, metropolitan hospital] Caring Together: The health action plan for NSW The N/MUMs (47%) identified improvements that had been made in their ward in line with Caring Together. Examples of some of these initiatives other than attending ttl, introducing EOC or the employment of a CSO have been depicted below (Table 14). Some N/MUMs reported more than one improvement as a result of Caring Together. The most frequently cited changes included alternations in processes for handover and patient care plans and those stimulated by Between the Flags. It was noted by one N/MUM that: Some [changes] are directly due to ttl, others a combination of Caring Together and Between the Flags... [N/MUM, tertiary hospital] Table 14: Examples of improvements identified by N/MUMs to have been made in line with Caring Together* EXAMPLES OF IMPROVEMENTS MADE Handover changes, introduction of ISBAR (n=2) 7 Nursing case review/care plan/models of care 5 Between the Flags 4 Implemented patient/staff ratios and will not open beds if there are not enough staff according to this ratio Gendered bathrooms 1 * More than one response possible per participant RESPONDENTS 1 62

65 N/MUMs managers (70%) identified improvements that had been made in their ward in line with Caring Together. Examples of some of these initiatives other than attending ttl, introducing EOC or the employment of a CSO are presented below (Table 15). Usually N/MUMs managers reported more than one improvement as a result of Caring Together. The most frequently cited changes included changes in processes for handover and hand hygiene. Table 15: Examples of areas of improvement in line with Caring Together reported by managers* IMPROVEMENTS RESPONDENTS Handover changes, introduction of ISBAR 12 Hand hygiene 8 Between the Flags 5 Deteriorating patient 4 Picture of managers and staff in ward 4 Early DETECT program 3 Staff ID and colour coding 3 Normalising change 2 Discharge planning 2 Multidisciplinary rounds 2 Peer nursing review 1 Improved partnership with community service providers 1 Clinical check list 1 Equipment modifications 1 Improved communication 1 Team nursing 1 Peer nursing review meeting 1 Medication safety 1 Patient moved through ED within 4 hours 1 TLC program 1 Job description updates 1 * More than one response possible per participant 63

66 4.9 Conceptual Framework for the Nursing/Midwifery Unit Manager Role The Conceptual Framework for the Nursing/Midwifery Unit Manager Role had been read by 70% (n = 21) of the N/MUMs interviewed. Of those N/MUMs who had read it, 38% (n = 8) reported that the Conceptual Framework accurately represents the purpose, capabilities and core functions of the N/MUM s role, 33% (n = 7) articulated that the Conceptual Framework could be strengthened, and 9% (n = 2) stated that it was not an accurate representation. One N/MUM asked about the Conceptual Framework evaluated it as very clear and good, fitting and appropriate [N/MUM, metropolitan hospital]. However, at the other end of the spectrum, another N/MUM stated that it undervalued N/MUMs, there is no sense of how pivotal N/MUMs are [N/MUM, tertiary hospital]. Suggestions of ways in which the Conceptual Framework could be improved fall into three overlapping categories. The first category proposes that the Conceptual Framework is too open and needs to define the role of the N/MUM more specifically. Comments in the second category suggest that the pivotal role of the N/MUM is not recognised, that the role of the N/MUM is undervalued and that administrative time demands of the role are not reflected. The third category included the comment that the Conceptual Framework for the N/MUM role was more relevant in some locations (rural versus metropolitan) than in others. Of the N/MUM managers interviewed, 66% had read the Conceptual Framework and thought that it accurately represented the role of the N/MUM. Some Managers described the document as very helpful: Absolutely fantastic document. Cements all N/MUMs. *We are+ creating new job descriptions for positions based on the Framework [Manager, rural hospital] Other managers had not read it (31%) or did not feel that it was a good representation of the role (3%), some describing it as too broad. In this N/MUM manager s opinion, the Conceptual Framework is: very worthy but quite broad, too broad, N/MUMs are expected to do too much. [Manager, state-wide service] 64

67 4.10 Strengthening of role as N/MUM Participation in ttl was perceived to have strengthened their role as an N/MUM by 80% (n=24) of the N/MUMs interviewed. The comments and examples of how ttl strengthened the role of the N/MUM were categorised into six groups (Table 16). An improvement in skills, clarification of the role, and increased confidence in their ability to perform the role were identified as ways in which the interviewed N/MUMs had been strengthened in their role as an N/MUM. The importance of networking and sharing ideas was also identified as important in strengthening the N/MUM role. Table 16: Ways in which the N/MUM role was strengthened by ttl (N/MUMs)* WAYS IN WHICH THE N/MUM ROLE WAS STRENGTHENED BY ttl RESPONDENTS Skills improvement e.g. communication, lean thinking 8 Increased confidence in ability to perform role 6 Networking and sharing of ideas 6 Clarified role 5 Increase in staff respect and expectation of leadership 3 Reinforced existing skills, practices and knowledge 3 * More than one response possible per participant While the majority of N/MUMs perceived that their role had been strengthened through participation in ttl, 17% did not hold this view. According to one of these N/MUMs interviewed ttl was: pitched too low, the topics were relevant topics but not content. [N/MUM, tertiary hospital] N/MUMs managers reported that participation in ttl was perceived to have strengthened the role of the N/MUM (90%). While 3% of the managers interviewed stated that they did not perceive that ttl had strengthened the role of N/MUM, 7% reported being unsure if a strengthening of the role could be attributed to ttl' or whether it was due to experience. N/MUMs managers gave examples of how they perceived that the N/MUM role had been strengthened through participation in ttl. Managers may have provided more than one example. An improvement in skills, increased confidence to in their ability to perform the role, and feeling valued and supported, were identified as ways in which ttl strengthened in the N/MUM in their role. The importance of networking and sharing ideas was also identified as important in strengthening the N/MUM role. 65

68 A renewed focus and invigoration, and sense of ownership of the unit in N/MUMs were also proposed as ways ttl strengthened the role: More confidence, more time on the floor, a role model. The more the person walks the walk the more it increases confidence [N/MUM manager, state-wide service] Made them leaders and taking accountability [N/MUM manager, Rural/Regional Hospital] The comments and examples of how ttl strengthened the role of the N/MUM were categorised into six groups. These are presented in Table 17. Table 17: Ways in which the N/MUM role was strengthened by ttl (managers)* WAYS IN WHICH THE N/MUM ROLE WAS STRENGTHENED BY ttl Skills improvement and strengthening existing skills e.g. communication, lean thinking RESPONDENTS Increased confidence in ability to perform role 9 Networking and sharing of ideas 9 Clarified role 5 Invigorated and refocused 4 Supported and valued 3 Increased ownership of role/unit 4 * More than one response possible per participant 10 66

69 4.11 Introduction of the Clinical Service Officer s position This section presents the N/MUMs views on the introduction of the CSO. Additional data from the perspective of the CSOs are presented in Appendix Introduction of the CSOs A CSO had been allocated to 20 (66.7%) of the N/MUMs interviewed. One N/MUM had been allocated but did not use the CSO. In light of this, the results are reported on the basis of 19 N/MUMs experience of utilising the CSO role. Of those N/MUMs five had been allocated a CSO who had since resigned, with (n=2) or without (n=3) being replaced at the time of interview. The length of time the same CSO had been employed for their unit ranged between one week and 12 months (average length of time = 7 months). All but one of the N/MUMs allocated a CSO identified that the CSOs reported to them with 45% of those CSOs also reporting to at least one other N/MUM or N/MUM manager. Of the NUMs to whom a CSO had been allocated, the CSO was employed on a full time basis. The hours of employment of the CSOs employed part time ranged between 12 to 32 hours per week. The recruitment process did not involve 74% of the N/MUMs who had been allocated a CSO and of those 43% stated that they would have liked to have been or that it was important that they were involved in the recruitment process. Of the five N/MUMs for whom the CSO position had to be refilled, three were not involved in the initial recruitment process but would be or were involved in the subsequent recruitment of a CSO. When asked if there was a CSO job description, two were unsure, six (32%) considered the position description to be too generic requiring local adaptation or development as the role unfolded. The N/MUMs to whom the CSO reported were responsible for the allocation their duties for 100% of CSOs. Two of the CSOs also had input into the allocation of their duties and for one CSO, the Deputy Director of Nursing allocated duties with the N/MUMs. Of the N/MUMs managers interviewed, 22 (73%) indicated that there had been a CSO employed in their organisation. The results reported in the remainder of this section in relation to the CSO role are based on the responses of those 22 managers. The number of CSOs employed was identified in FTEs. This ranged from 0.5 FTE to 14.4 FTEs. The length of time that the CSO had been employed ranged from two to 14 months with the average length of time being nine months. A similar percentage of N/MUMs staff (70%) stated that their organisation had CSOs. 67

70 While 83% of the managers stated that the CSO duties were allocated by the N/MUM in their organisations, only 63% noted that the CSOs also reported to the N/MUM. Among the CSOs identified as reporting to the Director of Nursing (DON), Assistant or Deputy Director of Nursing (A/DON or D/DON), manager, and administrative supervisor (n=8), only one manager noted the tasks were allocated by someone other than the N/MUM. In this case, the CSO role was shared across two hospitals with two CSOs (job sharing, 1.47 FTE) reporting to the D/DON. Among the managers interviewed, 64% reported that the N/MUM with whom the CSO would work was involved in the selection process for the CSO position. Among the managers who reported that the N/MUM had not been involved, one commented that it was very important for the N/MUM to be involved in that process. The N/MUMs were asked to indicate whether or not the CSO was undertook a range of duties including data entry and reporting, workforce matters, resource management, documentation/records management, or general administrative activities. They were also asked to indicate any other activities that the CSO undertakes in their unit (Table 18). Table 18: Percentage of CSOs undertaking duties DUTY TYPE YES NO UNSURE/NOT YET Data entry and reporting Workforce matters (rostering, recruitment, leave, payroll) 19 (100%) (89%) 3 (16%) 0 Resource management 14 (74%) 3 (16%) 2 (10%) Documentation/records management General administrative activities 15 (79%) 3 (16%) 1 CSO did documentation for one N/MUM to whom they reported but not the other 19 (100%) 0 0 Other activities 17 (89%) 3 (16%) 0 The N/MUMs were asked to identify whether there were any additional duties undertaken by the CSO allocated to their unit. The additional role of the CSO in recording staff performance appraisal data, organising staff training in-services, 68

71 Occupational Health and Safety activities, non-clinical audits and quality improvement documentation were reported by several of the N/MUMs (Table 19). Table 19: Types of additional duties undertaken by CSOs* ADDITIONAL AREAS IN WHICH CSOS ASSISTED RESPONDENTS Staff training and performance appraisal data 6 Non clinical audits and quality improvement documentation Occupational Health and Safety activities 4 Check equipment e.g. buzzers 2 Liaise with donor families and organizes flight requisitions for patients Mandatory reporting documentation 1 EQUIP documentation 1 Assistance with organization of referrals 1 Chases results 1 Assist with fundraising activities 1 * More than one response possible per participant While 91% of the N/MUMs managers interviewed indicated that the CSOs had had a positive impact on the work that the N/MUMs undertook, one N/MUM manager (4.5%) was ambivalent and one (4.5%) indicated no effect. However, 14% (n=3) of the managers stated that the impact had been limited. The reason offered was that they were not a large enough resource to make a big difference. Examples of types of duties the CSOs performed that impacted on the role of the N/MUM were volunteered by 64% of the interviewees. These are presented in Table 20 below. The most commonly identified duty impacting on the N/MUMs work was administrative assistance followed by duties associated with rostering and staffing. Stock ordering and duties associated with audits and KPI reports were also identified. Table 20: Examples duties the CSOs performed that impacted on the role of the N/MUM* EXAMPLES OF TYPES OF CSO DUTIES THAT IMPACTED ON N/MUMS WORK Administrative (e.g. minutes, organizing meetings, data entry) 5 2 RESPONDENTS Rostering and staffing duties 8 Stock ordering

72 EXAMPLES OF TYPES OF CSO DUTIES THAT IMPACTED ON N/MUMS WORK RESPONDENTS Audits, KPI reports, report writing 3 Bed board and organizing patient transport 2 * More than one response possible per participant When specifically asked to identify whether the employment of the CSO had affected the amount of time the N/MUMs spent on administrative tasks, 82% of managers articulated that there had been a positive impact. Of these, there were two managers who claimed a limited impact on administrative tasks. No impact on the N/MUMs administrative tasks was reported by 9% of the interviewees and 9% were unsure (Table 21). Most (43%) of N/MUMs staff where the unit had a CSO, indicated that the CSO had had an impact on the N/MUMs time spent on administrative staff. The rest either felt that there had been no impact (13%) or were unsure (54%). Table 21: Impact of the CSO on administrative duties of N/MUM reported by managers IMPACT OF THE CSO ON TIME SPENT ON ADMINISTRATIVE DUTIES BY N/MUM RESPONDENTS PERCENTAGE Yes 16 73% Yes but limited 2 9% Unsure 2 9% No 2 9% N/MUM s perspective of the impact of CSOs on their role The majority of N/MUMs interviewed (63%) reported that the introduction of the CSO role had impacted on the type of work that they did and that this had been helpful particularly in relation to reducing the time they had previously spent doing administrative tasks, allowing more time to be spent: to co-ordinate patient care and on higher level management tasks. [N/MUM, tertiary hospital] The impact of the role was described by some of the N/MUMs as dramatic, massive, fantastic, excellent, and huge. There were 26% of the N/MUMs who were ambivalent about whether or not the CSO role had impacted on the type of work they do. Reasons offered included a lack of infrastructure and resources to support the work of the CSO (e.g. desk, computer) and the initial intensive training required. Two N/MUMs reported that the introduction of the CSO had not positively 70

73 impacted on their work, with one explaining that a non-health professional was not helpful in the role. When asked whether the CSO role had decreased the amount of time the N/MUM spent specifically on administrative tasks, 15 (79%) responded that it had reduced the amount of time they spent on administrative tasks. I have gone from being able to relieve staff on breaks for only one hour to about three hours... I no longer have to work late. [N/MUM, metropolitan hospital] Two of these N/MUMs indicated that while the time they had spent on administrative tasks had decreased, their workload had increased in the initial period of the CSO employment due to the training requirements. When the CSO left there was further time investment required to train the new CSO. Four of the N/MUMs reported that the employment of the CSO had not reduced their administrative workload with three of them stating that the CSO had caused an increase in their administrative workload because while the CSO role is valuable, the process of implementation was not and the wrong person for the role had been chosen (n=2) or the way the role had been set up was not helpful (e.g. the lines of reporting were not clear) Impact of the CSO role on the clinical team In order to identify whether the CSO role also supported the work activities of nursing, medical and allied health staff, the N/MUMs were asked what, if any, impact they thought there had been on the work of these members of the clinical team. There were seven N/MUMs (37%) who reported that there had been no impact of the CSO role on the work of these members of the clinical team. Twelve N/MUMs (63%) recounted that there had been a positive impact of the CSO role particularly in relation to assistance they provided to allied health personnel. Educators, doctors, and nurses were also noted to have been positively affected by the CSO role. Some of the N/MUMs (21%) noted that in freeing them up to be more available the other members of the clinical team benefited from the CSO role. In order to identify whether the CSO role supported the work activities of nursing, medical and allied health staff, the N/MUMs managers were asked what, if any, support they thought there had been on the work of these members of the clinical team. There were five managers (28%) who reported that there had been no impact of the CSO role on the work of these members of the clinical team. A supportive impact of the CSO role on the work of other members of the clinical team 71

74 was affirmed by 41% of the interviewed managers. A limited effect on the role of the clinical team was suggested by a further 18% of the managers interviewed. The CSO role was reported to indirectly support work activities of nursing, medical or allied health staff by 9% of N/MUM managers (Table 22). Of the staff themselves, 48% reported that the CSO contributed to their work, 22% said they did not, and the rest were either unsure (n = 1) or did not reply. Table 22: N/MUM managers perception of impact of the CSO on the role of the clinical team SUPPORT OF THE CSO ROLE ON THE WORK OF THE CLINICAL TEAM RESPONDENTS PERCENTAGE Yes 9 41% Yes but limited 5 18% Indirectly 2 9% No 5 28% No response 1 4% Impact of the CSO role on patient care There were 37% of N/MUMs who reported that the CSO role had not impacted patient care. However, the CSO role was considered by the majority of N/MUMs to have positively impacted on patient care. The ways in which they suggested this occurred are tabulated below. They fall into two categories that can be summarised as streamlined processes or releasing the N/MUM for clinical care (Table 23). Table 23: The ways in which the CSO role impacts patient care THE WAYS IN WHICH THE CSO ROLE IMPACTS PATIENT CARE EXAMPLES Stream line processes: Discharge summaries faxed improved efficiency of patient Nurses not looking for care documentation At weekly case conferences the CSO makes action items and so there is quicker follow up EDDs behind beds patients are RESPONDENTS 4 72

75 THE WAYS IN WHICH THE CSO ROLE IMPACTS PATIENT CARE Releasing N/MUM and nurses for clinical care EXAMPLES more involved Co-ordination of care improved Fewer loose ends Fewer things get missed More time to focus on patient care N/MUM has more time on the floor with patients N/MUM is on the floor during morning rounds RESPONDENTS 8 The majority of interviewed N/MUMs managers (73%) reported that the CSO role had positively impacted patient care. Three of the managers (14%) claimed that there had been no impact and 14% were unsure or ambivalent about the impact of the CSO role on patient care. Managers identified ways in which the CSO role affected patient care. These fall into two categories summarised as administrative focus or N/MUM clinical supervision (Table 24). For example, responses when asked if they perceived an impact on patient care as a result of the introduction of the CSO included: Yes the NUMs are out there. If there is an issue with a patient, clinical or non clinical, they re there. The can solve the problem because they are the most senior person on that ward. [N/MUM manager, regional hospital] Table 24: The ways managers perceive that the CSO role impacts patient care* THE WAYS IN WHICH THE CSO EXAMPLES ROLE IMPACTS PATIENT CARE Administrative focus Auditing gets done RESPONDENTS 4 Releasing N/MUM and nurses for clinical care Better patient flow Better staffing and rostering More time to focus on patient care 15 73

76 THE WAYS IN WHICH THE CSO EXAMPLES ROLE IMPACTS PATIENT CARE Better clinical management and supervision RESPONDENTS N/MUM available and more visible * More than one response possible per participant Just over a third of N/MUM s staff (39%) said that CSOs had contributed positively to patient care, while 7% said that they did not. The rest either were unsure of the impact (23% or simply did not respond. Where the staff indicated that the CSO had had a positive impact on patient care the reasons provided included: N/MUMs spend more time on ward (n=2) and CSO had taken over administrative work, or is more efficient at administrative work (n=3). The following two comments were made by participants who indicated that the CSO had had a positive impact on patient care, and reflect the complexity of the situation. Only for one NUM. We have one FTE CSO for 2 hospitals and 5 NUMs and 2 NM. It is ludicrous to think they are going to make a substantial difference. [Staff member, regional health service] CSO's have been very effective in providing useful support and assistance to the NUM. The role will grow further with time. [Staff member, metropolitan service] 4.13 Unexpected impacts/outcomes of the CSO role There were no unexpected impacts of the CSO role reported by 47% of the N/MUMs interviewed. However, 53% reported both positive and negative unexpected impacts. Perceived negative impacts included the time spent training the new CSOs, the high turnover of CSOs, feeling out of the loop, and having no control over what the role of the CSO is. The positive unexpected impacts were a decrease in the number of lost items, assistance provided to other staff members including the ward clerk, and the support of consistency across units. To illustrate this latter point, one of the N/MUMs reported the following unintended consequence of the introduction of the CSO role: The CSO is part time for two N/MUMs. She has played a role in connecting the N/MUMs and coordinating things around the hospital which has led to increased consistency e.g. if she sees one NUM doing something she reminds the other. 74

77 [N/MUM, state-wide service] While 50% of interviewed N/MUM managers reported that there were no unexpected impacts of the introduction of the CSO role, and 14% who identified unanticipated negative outcomes including friction with other staff (e.g. ward clerks) and an unrealistic expectation that as a result of the CSO position, (e.g. the expectation that the N/MUM would [now] be available to be on the floor all of the time). There were 14% of N/MUM managers who identified unexpected benefits and offered suggestions about the CSO role (Table 25). In particular, managers identified benefits related to the aspect of the CSO role that allows them to share ideas across wards. This is illustrated by the comment of a Manager in a Tertiary Hospital: Forces N/MUMs to consider whether their practices are optimal on account of CSOs who share wards and report back on how things are done differently. [N/MUM manager, tertiary hospital] Table 25: Unexpected impacts of the introduction of the CSO role and managers suggestions about the role UNEXPECTED OUTCOMES Better communication Standardisation of on administrative tasks across wards Sharing of ideas on administrative tasks across wards SUGGESTIONS The job is too big for the number of hours allocated The efficacy of the CSO role is very dependent on the characteristics of the individual The expectations of the role must be kept in check with the N/MUM to retain managerial tasks In relation to the N/MUMs staff, 13% stated that there had been an unexpected impact as a result of the introduction of the CSOs, 22% felt that there had not been. All of the staff who reported there had been no unexpected impact, and who provided further information, said that this was because the CSOs were spread too thin to have any impact. For staff who said there had been an unexpected impact, all except for one ( increase in need for NUMS to be double checking roster and reroster staff ) were positive. Better management of casual pool staff, prompt entry of rosters, second set of eyes to detect errors in rosters or documents, reduced time spent typing up data, documents created faster and delivered to appropriate places on time. 75

78 [Staff member, regional health service] My personal recognition of tasks that can be completed by CSO and not myself. CSO is invaluable to allow time to not only spend with pts but also with the staff. [Staff member, regional health service] Ways in which the CSO role could be improved The N/MUMs identified ways in which aspects of the introduction of and the CSO role itself could be improved. The most frequently cited changes were an increase in the N/MUM-to-CSO ratio and hours that the CSO worked, and more input by N/MUMs into the position description for the CSO. Other suggestions included a training program for all CSOs before they commenced in the unit and a development of the aspect of the CSO role that co-ordinates and links units/wards. The N/MUM managers made recommendations of ways in which the CSO role could be improved. The most frequently made recommendations were to increase the number of CSOs and the hours that CSOs were available (27%) and to give them more training (18%). Other suggestions included that the role of the CSO be adapted to better suit the needs of the units (9%), that the CSO be included as a member of the unit team (4.5%) and that the position be better budgeted for (4.5%). Staff, in addition to N/MUMs and their managers had specific suggestions about improvements to the role of CSOs. Most of the suggestions related to increasing the CSOs time, or their distributed across services (n = 5): All clinician managers should have access to a CSO. A competent CSO can double to productivity of a Clinician Manager. [Staff member, regional health service] Excellent position should have leave relief and we need to ensure they do not get taken up by other departments- some CSO are working primarily for Medical officers- not NUMs, need more we have only 2 for 7 NUMS. [Staff member, regional health service] They need to support more clinical departments than just nursing. There are a large number of other departments with the same issues of clinical staff doing administrative tasks that they are inefficient at and therefore make lots of mistakes that take even longer to fix. [Staff member, regional health service] 76

79 Two respondents mentioned that CSOs would benefit from additional training. Only one respondent, who knew about the role felt that it was unclear if initiative is cost effective Case studies The following section will describe the affect ttl has had on two NUMS and their units that were identified as potential participants for an in-depth interview by NSW Health. The information the participants gave is of their personal experience and perspective. It is an opportunity to view two experiences of NUMs who have completed all five modules and what effect if any it has had on them and their units. A discussion follows the comparison that will attempt to tease out potential themes, whilst recognising the limits of generalisability of information. The two cases are briefly described, and a comparison follows in Appendix 8.6. N/MUM1 and N/MUM2 work in large hospitals, the former in a regional area and the latter in a metropolitan setting. Both have a similar number of staff, including a CSO, reporting to them Case 1 It was something that had to happen to be honest (N/MUM1) When N/MUM1 began her role on the ward, the ward was in disarray. Patient and staff satisfaction was low. Recruitment and retention was low. Her role was mainly administrative and had very few engaging characteristics or as N/MUM1 described it - this is seriously one of the shittiest positions in the hospital, I do have to tell you and it's quite recognised for that. As she spent more and more time in her office she became more disengaged with staff and patients. This had a number of consequences that will be discussed in the analysis. Amongst them was exhaustion: I was looking a bit beat and battered. ttl was an initiative that she perceived as necessary not only for herself, but for N/MUMs in general. N/MUMs had evolved into the role without formal and standardised training and there was a clear need for definition and clarity of the role, but also of providing management skills to nurses whom had clinical training and limited managerial training. She was initially identified to be a part of the piloting of the program and eventually became a champion for ttl. She was amongst the first to enrol in the program. 77

80 Case 2 I did think it was a good program, and it's not often that you get together with other N/MUMs (N/MUM2) N/MUM2 likens her unit to a revolving door, there's people coming and going the whole time. So it's very hard to maintain any kind of practise or have standards, or have continuity in care. This structural characteristic has strong implications on staff and patients. She describes a ward that has numerous managers across multiple levels of management and that it's an environment where nobody knows what the rules are, the goalposts keep changing, and there's too many people... it's like 'who is in charge?'. N/MUM2 describes ttl as a positive experience and was one of the first to enrol and participate. She believes that although the content was not beneficial to her, as she had already gained this knowledge in her post-graduate studies, it was important and relevant to N/MUM practice. The networking was what she found to be both interesting and beneficial. Overall, she sums the impact ttl has had on her personally by stating that I kind of felt that take the lead thing, maybe did not so much affect how I am a manager, but I think it's affected the management environment Comparison N/MUM1 describes the factors that enabled her to create successful and sustainable change in her unit as: 1) having more time due to the implementation of the CSO; 2) having a better understanding of her role and where it fits in within the organisation; 3) increased confidence gained from the skills she learnt and were reinforced; 4) increased motivation that she felt as a result of participating in the program 5) increased awareness and ability to reflect on the impact her and others action have on patients and staff 6) ongoing support from N/MUMs that was achieved through networking at the workshops and as a result of her coaching role 7) ongoing support from her management team and staff. N/MUM2 describes ttl as having less of an immediate impact on her everyday work, but the change it had made in the managerial environment, where N/MUMs now have a common language and an ability and opportunity to voice their needs and concerns as important. She describes leading her team to become more autonomous and capable to impact their work environment and patient care. This was achieved through participating in the EOC program that gave staff the structure through which to reflect, identify and initiate changes. 78

81 Both N/MUMs describe this as an ongoing process that requires navigating complex systems with limited time and financial resources. Both have recognised the influence of their role as leaders and not just managers and have noted changes that have disseminated through the ward gradually through conversations and a change of attitude (e.g. the push for staff to be more self-sufficient in problem solving) and not only through formalised planned changes Discussion As was evident in the description above, at times, the N/MUMs discussed ttl and EOC as both having a combined impact on their work and unit. A strong impression that arises from the interviews is that at times it will be impossible to tease out which intervention ttl, EOC or other initiatives is the stimulus for changes. Many times the N/MUMs stated that it is a combination of ttl and EOC or other clinical interventions. Some changes had been identified through internal initiatives or organisational directives before either ttl or EOC. It is the combination of initiatives that created the strong impact described. On both these accounts the units are a better place to work and patients are receiving higher quality care. Both N/MUMs state that there is still much to do. They both feel confident that they have the skills to meet the challenges and have a clearer understanding of their role. They both believe that that there is more support and a shared language with the different stakeholders. They both note that there are issues that need to be addressed systemically and cannot be influenced directly. They agree that they have more ability and forums to voice those needs and concerns. 79

82 4.15 Reflections on ttl Has participation changed how you feel about being a N/MUM? When asked whether participation had changed the way they felt about being a N/MUM, 40% reported that there had been no change, 7% did not comment and 53% reported that it had positively changed the way they felt about being a N/MUM. To illustrate, one N/MUM stated that originally from a clinical background, they now feel: more empowered... managing staff is different from managing patients. [N/MUM, state-wide service] Reported changes in how they felt about being an N/MUM were grouped according to similarity of concepts (Table 26). The two most salient changes centred on perceived empowerment and confidence in their role as an N/MUM and feeling less isolated in that role. One N/MUM noted: I have more job satisfaction because there is more clarity in what I should be doing. If you know what your goals are it is easier to know when you are doing a good job and this leads to improved satisfaction. [N/MUM, state-wide service] Table 26: Changes in how N/MUMs perceived being an N/MUM following ttl * CHANGES IN N/MUM S PERCEPTION OF BEING A N/MUM RESPONDENTS Feel more empowered/confident/clear/proud about my role 7 Don t feel as isolated 5 Renewed enthusiasm 2 Feel more appreciated (e.g. by staff and NSW Health) 2 Improved skills increased job satisfaction 1 * More than one response possible per participant N/MUM managers reflection on their participation in ttl Those managers who had participated in ttl were asked to reflect on their experiences participating in ttl. They identified improved leadership, consolidated knowledge, learning new skills, networking and refocussing as factors they found to be important. Some managers reported being better able to understand and support 80

83 the N/MUMs who had done ttl. Much was enabled through their participation in ttl. It gave them a common language and put them on the same page as the N/MUMs. Some of the NUMs had gone so we weren t on the same page they came back with great ideas. It was helpful that I went because when the others were going I could encourage them more and the conversations we then had about take the lead were on the same page. [N/MUM manager, state-wide service] Final insights on ttl from N/MUMs When offered an opportunity for additional comments about ttl, only 20% of interviewed N/MUMs declined. The comments from the remaining N/MUMs (80%) were diverse and included suggestions for the way in which the delivery of ttl could be improved including running the program over a shorter time span and tailoring the program for the different needs of N/MUMs and to include topics such as NSW Health s principles on EEO. Other suggestions included the introduction of post ttl refresher or regular debriefing sessions, and a greater focus on change management to better equip N/MUMs to help staff manage the many changes that are being made in their wards. Several N/MUMs proposed that it would be worthwhile designing a separate course or requiring managers of N/MUMs to attend so that they will be more supportive of the changes that the N/MUMs try to make as a result of ttl. The most frequently occurring comments were about the benefits of opportunities to network with other N/MUMs provided by ttl Final insights on ttl and recommendations from N/MUM managers When offered an opportunity for additional comments about ttl, 91% of interviewed managers offered comments. These comments ranged from suggestions about increasing the number of CSOs and developing their role to the suggestion that there should be an equivalent program introduced for managers. The comments were grouped according to similarity of key points and are presented in Table 27 below. The comment offered the most frequently was that ttl was an excellent program that should continue. Table 27: Managers comments and suggestions following ttl * COMMENTS AND SUGGESTIONS RESPONDENTS ttl is an excellent program that should continue 13 CSO role needs to be developed and more CSOs employed 4 81

84 COMMENTS AND SUGGESTIONS Revise content e.g. include clinical skill coordination and include a component on change management RESPONDENTS Recognise prior learning with ttl 2 Follow up with an advanced program post ttl 3 Follow up with a refresher 2 ttl was particularly helpful for new N/MUMs 2 Encourage continued networking post ttl 1 N/MUMs found the networking very helpful 3 Introduce an equivalent program for managers 1 Consistent approach and standardisation of role is excellent 2 Logistical problems with travel and accommodation 2 ttl was more helpful for the N/MUMs of some units than others 1 * More than one response possible per participant 3 82

85 5. DISCUSSION 5.1 Overall findings The participants in this evaluation recognised that the role of N/MUMs has changed significantly over the last three decades, and that this change has involved increased managerial and administrative responsibilities. Most N/MUMs and their managers commented on the lack of preparation for N/MUMs to pursue their managerial and leadership roles. The changes suggested by the Garling Inquiry, including the formalisation of the role of N/MUMs, programs for their professional development, and the facilitation of their increased presence in their units, and away from their desks was seen to form a new phase in this development. We found that ttl had contributed to a considerable degree to the skills development of some of the participating N/MUMs. Of the N/MUM respondents, 60% said that ttl was of some value to them. The value of each module, however, differed greatly. In some cases this was a structural issue: N/MUMs whose staff were centrally rostered found that module contributed little to their work. The financial module was open to the same criticisms. In several cases, participants noted that these were a waste of time. One of the most recounted determining factors of value of the ttl modules was how much prior education or experience the N/MUM already had. This was not a universal however: individual attitudes and the manner in which the module presented meant that some people with extensive experience were able to gain value from the program. This general point is supported in educational studies and the literature (Leimbach, 2010, Kirkpatrick et al., 2006, Nijman et al., 2006, Alvarez et al., 2004). For those for whom ttl was of value, the program was seen to have enabled and or empowered N/MUMs to implement changes in the workplace. It is important to note this distinction however: not all N/MUMs, N/MUMs managers or staff considered that ttl had had an impact on N/MUMs. More common than the no impact response, however, was respondents inability to identify whether ttl had contributed to the N/MUM s development or not: a range of confounding factors, including professional maturity, other development and change programs in the workplace, and the N/MUMs own background made it difficult to quantify the impact. Caution therefore has to be placed on too strong a representation of the Likert results. Almost half (n = 14) of the N/MUMs interviewed said that they could not identify a day to day impact of their participation in ttl. However, less than 20% of N/MUMs and N/MUM managers who participated in this evaluation stated either 83

86 that they were unsure whether ttl had strengthened or contributed to the role of N/MUMs, or that it had not. Respondents were more comfortable providing examples rather than quantitative measures of outcomes. Where ttl had an impact, it appears to have influenced N/MUMs ability to change and in their own perceptions to improve, many aspects of their workplace, including efficiency, patient outcomes, change management, staff outcomes and capabilities and skills. Even though individual cases differ (both in response to the program and in its subsequent impact), the results overall show that for those N/MUMs who were able to implement changes in the workplace, ttl was an important contributing factor. This is particularly, but not only, in cases where N/MUMs had little prior training and or experience. 5.2 Positive benefits N/MUMs have put in place identifiable changes as a result of their participation in ttl. The most commonly noted changes, by all participants (N/MUMs, their managers and staff) involved implementation of some aspect of lean thinking: this may be because, in the view of one participant, that model allows for small incremental changes which are highly visible. However, many N/MUMs have implemented a range of other changes ranging from the modification of their individual communication styles, to new approaches to the rostering of staff, to the creation of multi-method team based approaches to the co-ordination of care. Differences in the sophistication and range of changes meant that their impact was difficult to measure for many participants; however individual participants indicated cost and time savings as a benefit. Changes in N/MUMs capabilities and skills varied with individuals across the several measures which were taken. Of those N/MUMs who felt that ttl had had an impact on their work, 67% believed that their job performance had improved to some degree since their participation in ttl. In comparison, 83% of N/MUMs managers felt that their job performance had improved (67% due to ttl, 13% due partly to ttl and 3% due to other factors). A majority of N/MUMs (62%) recognised that their staff s performance had improved also. However, across all participant groups, there were indications of improved communication by N/MUMs, particularly in critical contexts. This was reflected in the changes which were deemed to have been successfully implemented: the most common change related to N/MUMs ability to communicate with, and provide feedback to, their staff reportedly resulting in increased staff satisfaction. 84

87 This was mirrored in their ability to handle complex situations: 80% of N/MUMs who felt ttl had had an impact, thought that their ability to manage difficult situations had improved, and 71% said that their negotiation skills had improved. Supporting this, 82% N/MUMs and 65% of N/MUM managers felt that N/MUMs ability to manage staff had improved. This was borne out by several of the N/MUM managers who noted that one of the impacts on their own work as a result of their participation in ttl was a reduction in the number of performance reviews which progress up the ladder for attention. Other measures varied. Even with the N/MUMs who felt ttl had had an impact, around 58% felt that their unit s performance or efficiency had improved. Fewer felt that adverse events had changed: 72% indicated that post ttl they had stayed the same, although some participants noted this was for reasons other than a lack of impact of ttl. About 49% of NUMs and 22% of N/MUMs managers claimed that patient flow had improved to any degree. There appeared to be minimal impact on patient satisfaction, compliments or complaints attributable to ttl. 5.3 Key factors The success of, and barriers to, N/MUMs attempts at change were attributed to a range of structural, cultural, organisational and relational factors. These factors were supported by the findings from the literature review. The three key elements to the successful transfer of learning into action relies on a combination of the clinicians own personal commitments and characteristics; the way in which the training did or did not prepare them for the transfer of that learning; and workplace climate and organisational support. Participants gave consistent examples of the importance of these factors across all participating respondent groups. The last of these factors, workplace climate and organisational support, were also said to support the sustainability of the changes implemented. This was also true of their perceptions of the sustainability of changes they had made. A combination of senior management, peer and staff support is considered essential to ensuring the continuation of change efforts. One of the intangible benefits of participation in ttl emerges from the opportunity for N/MUMs to network and share solutions to common problems. Related to this, and identified both by the N/MUMs themselves and their managers, is an increase in their self-confidence. These are key future success factors. Overall, the role of the CSOs was said to have had a positive impact on reducing the administrative workload of most N/MUMs, although in some cases this was 85

88 considered to be limited. From the CSOs perspective, undertaking a new, and at times not clearly defined role has posed some challenges, particularly for CSOs who are geographically or organisationally isolated, or those who are spread over several locations. This evaluation shows that the introduction of ttl, along with other improvement mechanisms, such as the Essentials of Care program and the introduction of CSOs, has enabled a range of N/MUMs to develop, implement and sustain changes to their workplace. In the cases where N/MUMs have been able to transfer their learning from ttl effectively, these changes have resulted in improvements in finances, staff satisfaction and morale, and patient care. 86

89 6. CONCLUSION The mid program evaluation of ttl shows clearly that while ttl has had some impact and a range of positive effects, in some areas this impact is mixed. To use a metaphor from patient safety, much of the low hanging fruit the small incremental workplace changes and engagement of N/MUMs have been picked. Nonetheless, ttl shows clearly the potential of a program to prompt and support workplace changes, even in the midst of major restructuring. While caution is required in interpreting the Likert scale responses too positively, across the board, in staff, N/MUM manager and N/MUM interviews, it is clear that ttl has influenced change at a unit level and proven to be a catalyst for a range of improvement initiatives. The potential next steps are indicated in the recommendations. The major recommendation is that, like most development programs, ttl must grow with its constituents and be subject to continuous improvement. 87

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97 8. APPENDICES 8.1 Evaluation tools N/MUMs interview schedule Interviews were opened with a scripted introductory statement. The researchers then asked the following questions: In these first questions, I would like to ask you about your overall impressions of the take the lead project. 1. Can you tell me about how your participation in the ttl workshops came about? 2. Can you tell me about your experience of participating in the ttl program? 3. Has participating in the ttl program been useful to you in your role as a N/MUM? 4. Have you made any changes in your unit as a result of your participation in the ttl program? a. If they answer yes ask: Can you please describe them? b. If they answer no ask: If you have not made any changes, could you tell me why? 5. Were the changes implemented successfully? a. What helped implement the change successfully? b. Have some changes been easier to make than others? Why do you think this is so? 6. Have the changes you have implemented so far proven to be sustainable? Why do you think this is so? 7. What changes would you have liked to have made but have been unable to implement? 8. Can you tell me about any specific skills that you developed as a result of taking part in ttl? a. How has your participation in the ttl program affected how you go about your day to day work in your unit? 9. Do you think that taking part in ttl has changed your job performance? How? 95

98 a. Has it changed the way you manage your staff? How? b. Has it changed the way you respond to the needs of patients? How? c. Has taking part in ttl led to any changes in the type of work you do? Can you please tell me about them? d. Has your participation resulted in any changes to the type of work your team does? Can you please tell me about them? 10. Following each statement that I am about to make, I would like you to respond by answering, on a scale of one to five. Please give your immediate response. Thinking about your unit since you did the ttl modules: Script Have the number of adverse events in your unit: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Has staff satisfaction: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Has staff retention: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Has staff absenteeism: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Has patient satisfaction: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Have the number of patient complaints: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Have the number of patient compliments: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Answer (circle) 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 96

99 Script Has the amount of time you spend on administrative tasks: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Answer (circle) 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly a. Can you attribute any of these changes to your participation in ttl (if they can t remember, the modules were critical communication; lean thinking and leadership; financial management; rostering for patient care). How and why? b. If you have made changes to the way you manage adverse events, staff, patient complaints or administrative tasks as a result of your participation in ttl have you evaluated any of the changes? If so, can you tell me about the findings? 11. Following each statement that I am about to make, I would like you to respond by answering, on a scale of one to five. Please give your immediate response. Please note the scale has changed. Thinking about your unit since you did the ttl modules has: Script Your unit s performance: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your unit s overall efficiency: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Patient flow: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Staff performance: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Answer (circle) 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 97

100 Script Staff morale: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Answer (circle) 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly a. Can you attribute any of these changes to your participation in ttl (if they can t remember, the modules were critical communication; lean thinking and leadership; financial management; rostering for patient care). How and why? b. If you have made changes to the way you manage adverse events, staff, patient complaints or administrative tasks as a result of your participation in ttl have you evaluated any of the changes? If so, can you tell me about the findings? 12. Following each statement that I am about to make, I would like you to respond by answering, on a scale of one to five. Please give your immediate response. Please note the scale has changed. Thinking about you since you did the ttl modules has: Script Your overall job performance: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your ability to communicate with staff: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your ability to communicate with patients and their families: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your ability to communicate with other (non-nursing) staff: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your ability to manage difficult situations: one improved significantly, two improved somewhat, three stayed the Answer (circle) 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 98

101 Script same, four worsened somewhat or five worsened significantly? Your ability to manage staff: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your ability to negotiate: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your ability to lead: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your ability to solve problems: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your ability to manage the finances and resources of your unit: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Your ability to manage the rostering of staff: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Has your ability to implement the principles of lean thinking: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Answer (circle) 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly a. Can you attribute any of these changes to your participation in ttl. How and why? b. If you have made changes to the way you manage adverse events, staff, patient complaints or administrative tasks as a result of your participation in ttl have you evaluated any of the changes? If so, can you tell me about the findings? 99

102 13. Has a CSO been allocated to assist you in your role? YES/NO a. When did the CSO begin their work? b. Does the CSO report directly to you? If not, then to whom do they report? Is this satisfactory from your perspective? c. What are their typical hours of duty? d. Were you involved in their recruitment? Do they have a position description? (can you send us their duty statement?) Is it based on the one issued by NSW Health? e. Who allocates their duties and tasks (you, centrally allocated) f. Do their duties involve: Data entry and reporting (rosters, HR) Yes No Workforce matters (rostering, recruitment, leave, payroll) Yes No Resource management Yes No Documentation/records management Yes No General administrative activities Yes No Are there any other duties they undertake? g. Has the employment of the CSO had any impact on the type or amount of work you undertake? h. Has the employment of the CSO affected the amount of time you spend on administrative tasks? If not, why not? If so, how? i. From your perspective, what has been the impact of the introduction of the CSO s role on the work of other members of the clinical team ie doctors, nurses, allied health? j. Do you think there has there been any impact on patient care as a result of the introduction of the CSOs role? k. Have there been any unexpected outcomes/impacts as a result of the introduction of the CSO s position? l. Please describe how the role of the CSO can be changed to further support you in your work and more specifically in successfully implementing change? 100

103 14. Has your unit has participated in the Essentials of Care program? Yes/No a. Can you tell me about changes in your practice that are a result of your participation in the ttl program and those that are due to your unit s participation in the Essentials of Care program? b. Can you tell me about any other improvements you have implemented which are in line with relevant recommendations in Caring Together? 15. Have you read the Conceptual Framework for the Nursing/Midwifery Unit Manager Role? Yes/ No 16. Do you feel it accurately represents the purpose, capabilities and core functions of the N/MUM s role? Could you tell me more? 17. Has your participation in ttl led to a strengthening of your role as a N/MUM? How? 18. Has your participation in ttl led to any identifiable improvements in patient care and flow? How? 19. Has your participation in ttl led to a reduction in errors in your unit? By what percentage? Ho 20. Has your participation in ttl changed the way you feel about being a N/MUM? If so how? 21. Is there anything else you would like to say? 101

104 8.1.2 N/MUMs manager interview schedule How many N/MUMs report to you? What level are the N/MUMs who report to you? In these first questions, I would like to ask you about your overall impressions of the take the lead project. 1. Can you tell me what you know about the ttl program? 2. Have any of your N/MUMs participated in ttl? a. Have you participated in ttl? 3. Do you know of any changes that your N/MUMs have made as result of their participation in the ttl program? a. If they answer YES ask: Can you please describe them and were they successful? b. If they answer NO ask: If they have not made any changes, could you tell me why you think they have not made any changes? 4. What do you think helped your or your N/MUMs implement the change successfully (Prompt: management support, staff support, other N/MUMS, resources). Has/have the NUM/s discussed any particular enablers or barriers to implementing changes? 5. Have the changes implemented so far proven to be sustainable? Why do you think this is so? 6. Can you tell me about any specific skills that you saw your N/MUMS develop as a result of taking part in ttl? a. Do you think your N/MUMS participation in ttl program has affected how they go about their day to day work of their units? b. Do you think that your N/MUMs participation in ttl has affected YOUR work? If so how? 7. Following each statement that I am about to make, I would like you to respond by answering, on a scale of one to five. Please give your immediate response. Thinking about units where the N/MUMs have undertaken the ttl modules has: 102

105 Script Have the number of adverse events: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Is this attributable to ttl? How has this change been measured? Has staff satisfaction: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Is this attributable to ttl? How has this change been measured? Has staff retention: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Is this attributable to ttl? How has this change been measured? Has staff absenteeism: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Is this attributable to ttl? How has this change been measured? Has patient satisfaction: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Is this attributable to ttl? How has this change been measured? Have the number of patient complaints: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Is this attributable to ttl? How has this change been measured? Have the number of patient compliments: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Is this attributable to ttl? How has this change been measured? Has the amount of time the N/MUMS spend on administrative tasks: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Answer (circle) 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly 1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 103

106 Script Is this attributable to ttl? How has this change been measured? Answer (circle) 5: Decreased significantly 8. Following each statement that I am about to make, I would like you to respond by answering, on a scale of one to five. Please give your immediate response. Please note the scale has changed. Thinking about units where the N/MUMs have undertaken the ttl modules has: Script The unit(s) performance: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? The unit s overall efficiency: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Patient flow: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Staff performance: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Staff morale: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Answer (circle) 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 104

107 9. Following each statement that I am about to make, I would like you to respond by answering, on a scale of one to five. Please give your immediate response. Thinking about units where the N/MUMs have undertaken the ttl modules has: Script Their overall job performance: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to communicate with staff: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to communicate with patients and their families: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to communicate with other (non-nursing) staff: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to manage difficult situations: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to manage staff: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Answer (circle) 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 105

108 Script Their ability to negotiate: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to lead: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to solve problems: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to manage the finances and resources of the unit: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to manage the rostering of staff: one improved significantly, two improved somewhat, three stayed the same, four worsened somewhat or five worsened significantly? Is this attributable to ttl? How has this change been measured? Their ability to implement the principles of lean thinking: one increased significantly, two increased somewhat, three stayed the same, four decreased somewhat or five decreased significantly? Is this attributable to ttl? How has this change been measured? Answer (circle) 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly 10. Have you noticed any differences in these areas between N/MUMs who have and those who haven t completed ttl? 11. Have you employed CSOs in your service? If so, how many? a. When did the CSOs begin their work? 106

109 b. To whom does the CSO report? Is this satisfactory from your perspective? c. Who allocates their duties and tasks (you, centrally allocated) d. Do you think the employment of the CSO had any impact on the type or amount of work your N/MUMs undertake? e. Has the employment of the CSO affected the amount of time your N/MUMs spend on administrative tasks? f. From your perspective, what has been the impact of the introduction of the CSO s role on the work of other members of the clinical team ie doctors, nurses, allied health? g. Do you think there has there been any impact on patient care as a result of the introduction of the CSOs role? h. Have there been any unexpected outcomes/impacts as a result of the introduction of the CSO s position? i. Please describe how the role of the CSO can be changed to further support you in your N/MUMs and more specifically in successfully implementing change? j. Was the N/MUM with whom the CSO works involved in the selection process of the CSO? 12. Has your service participated in the Essentials of Care program? Yes/No a. We are trying to tease out whether changes that your N/MUMs have made are due to their participation in ttl or their unit s participation in the Essentials of Care program b. Can you tell me about any other improvements your N/MUMs have implemented which are in line with relevant recommendations in Caring Together? 13. Do you feel that the Conceptual Framework for the Nursing/Midwifery Unit Manager Role accurately represents the purpose, capabilities and core functions of the N/MUM s role? 14. Has the participation of your N/MUMs in ttl led to a strengthening and developing of their role as a N/MUM? How? 107

110 15. Has their participation in ttl led to a reduction in errors? By what percentage? How? 16. Would it be possible for our team to examine your IIMS and complaints data pre and post your N/MUMS having undertaken ttl? 17. Has their participation in ttl led to any savings in terms of resources or costs? If so how much? 18. If you participated in ttl can you reflect on your experiences as a result of your participation? 19. Is there anything else you would like to say? 108

111 8.1.3 Staff survey questionnaire Demographics 1. Are you male or female? 2. What is your age? 3. In which Area Health Service do you primarily work? Greater Southern AHS Greater Western AHS Hunter New England AHS North Coast AHS North Sydney Central Coast AHS South Eastern Sydney Illawarra AHS Sydney South West AHS Sydney West AHS Children s Hospital Westmead Ambulance Services NSW Justice Health 4. What is your professional background? Medicine Nursing Allied Health (please specify) Other (please specify) 5. How many years have you worked in health care post-graduation? (since you gained your initial qualification) 6. Where do you do most of your work? Tertiary referral hospital Regional hospital Rural health facility Community Health Centre Area Health Service (Office) 109

112 Ambulance service Justice Health Other (please specify) 7. How many years have you worked in health care post-graduation? (since you gained your initial qualification) 8. Where do you do most of your work? Tertiary referral hospital Regional hospital Rural health facility Community Health Centre Area Health Service (Office) Ambulance service Justice Health Other (please specify) 9. What is your current position in your organisation? Please specify: Questionnaire 1. Have the any of the N/MUMs with whom you work completed the ttl program? Facilitating Critical Communication Lean Thinking and Leadership Financial Management Rostering for Patient Care Leadership making it happen Yes/No/Don t know Yes/No/Don t know Yes/No/Don t know Yes/No/Don t know Yes/No/Don t know a. Thinking about the N/MUM s you work with and in your personal opinion: Have any of the N/MUMs implemented changes to the way their unit operates as a result of their attendance at these courses? Yes/No/Don t know b. If they have made one or more changes, could you please describe at least one change? 110

113 c. Do you think these changes benefited the unit? Yes/No/Don t know 2. Is your unit or service participating in the Essentials of Care Program? Yes/No/Don t know a. Can you briefly describe what this participation has involved? 3. Do you think that your N/MUM s ability to manage the unit has changed? Yes/No/Don t know a. Do you think your N/NUM s work practices have changed? Yes/No/Don t know b. Has this led to any changes in your work practices? Yes/No/Don t know c. Could you please give us one example of how you think your unit s performance has changed as a result of changes made by your M/NUM? Yes/No/Don t know d. Have the changes in your N/MUMs work practices led to any changes in how your team works? Yes/No/Don t know e. Has your unit s performance changed as a result of changes in your M/NUMs work practices? (eg management of resources, efficiency, financial performance, error rates) Yes/No/Don t know f. Could you please give us one example of how you think your unit s performance has changed as a result of changes made by your N/MUM? g. What type of impact do you think that any changes made to work practices by your N/MUM over the last year have had on patients? (eg patient satisfaction, complaints and compliments, patient centred care) 4. Think about a specific change to work practices which you N/MUM has attempted to implement over the last year. Were they successful in doing so? Yes/No/Don t know a. Briefly describe the change the N/MUM tried to implement b. Why do you think your N/MUM was successful or unsuccessful in implementing this change? c. How did you, as a staff member, measure the effect of the change your unit? 111

114 5. Thinking about your unit over the last year (or as long as you have been at the unit) please rate each statement on the following scale, for example: The number of days leave taken has decreased significantly (Presented as a Likert scale with radio buttons) Have the number of adverse events changed? Has staff satisfaction changed? Has staff retention changed? Has staff absenteeism changed? Has the proportion of your N/MUMs time spent on transactional administrative tasks changed? a. In your opinion in what way, if any, are these changes attributable to your N/MUM(s) participation in the take the lead program? 6. Thinking about your unit over the last year (or as long as you have been at the unit) please rate each statement on the following scale, for example: (Presented as a Likert scale with radio buttons) Has your unit s performance overall changed? Has your unit s efficiency overall changed? Has patient flow has changed? Has staff performance changed? Has staff morale changed? Has the communication and the management of difficult situations between the N/MUM and staff changed? Has patient satisfaction has changed? Has the financial management of your unit changed? a. In your opinion in what way, if any, are these changes attributable to your N/MUM(s) participation in the take the lead program? 7. What do you think will assist N/MUMs (including future N/MUMs) to be able to identify and successfully implement needed changes to work practices? Yes/No/Don t know 112

115 8. Do you have Clinical Support Officer (CSO) working in your unit(s)? a. Does the CSO contribute to your work? Yes/No/Don t know b. Has the employment of the CSO affected the amount of time your N/MUM spends on administrative tasks? c. Do you think there has there been any impact to patient care as a result of the introduction of the CSO role? d. If yes, how? If not, why not? e. Have there been any unexpected outcomes/impacts as a result of the introduction of the CSO? Yes/No/Don t know f. If yes, how? If not, why not? g. Has anything hindered the CSO s ability to support your or your N/MUM s work? h. If yes, how? If not, why not? 9. NSW Health is interested in supporting and developing the role of N/MUMs. 10. Is there anything else you would like to add about the role of CSOs? 11. Is there anything else you would like to add in general? 113

116 8.1.4 CSO survey Demographics 1. Are you male or female? 2. What is your age? 3. In which Area Health Service do you primarily work? Greater Southern AHS Greater Western AHS Hunter New England AHS North Coast AHS North Sydney Central Coast AHS South Eastern Sydney Illawarra AHS Sydney South West AHS Sydney West AHS Children s Hospital Westmead Ambulance Services NSW Justice Health 4. What is your professional background? Clerical Other (please speciy) 5. What is your highest qualification? Year 12 or certificate II Certificate III Certificate IV Diploma Advanced Diploma Bachelor Degree Other (please specify) 6. Please specify the title of your highest qualification. 7. How many years have you worked in health care? 114

117 Questionnaire 8. How long have you worked in the role of CSO? Less than one year One year Two years More than two years 9. Are you allocated to a single or multiple ward/area/services? a. Which one(s)? 10. How long have you worked in your current position? 11. What role did you have prior to coming into this position? a. To whom do you report? (please use position titles only and not individuals names) b. Is this satisfactory from a work perspective? (Yes/No) c. Can you please describe why this arrangement is satisfactory or unsatisfactory? 12. What are your typical hours of duty? Less than five hours 5-10 hours hours hours hours hours hours hours More than 40 hours a. On which days of the week do you typically work? Monday Tuesday Wednesday Thursday 115

118 Friday Saturday Sunday b. Do you work outside of office hours? If so, when do you typically work these hours (eg Sunday 4pm to 8pm)? 13. On average what percentage of your time do you spend each week working with or for the following people/groups? The N/MUM(s) of your unit(s): % Other N/MUMS (or senior nursing staff): % Medical staff: % Nursing staff: % Allied health: % Other (please specify): % 14. What are your typical duties/tasks? 15. Please indicate which of the following are part of your roles and responsibilities (indicate as many as you wish) Data entry and reporting Data entry for ward/unit rosters into relevant IT system Updating the roster in line with any approved changes ie sick leave etc Entering information onto HR IT system once approved Entering information onto HR IT system once approved Data entry activities that relate to patient care activities and support any member of the health care team Registering births to the NSW Registry of Births, Deaths and Marriages Assisting the N/NUM in producing reports on finance and quality parameters/indicators Other, please specify: What percentage of your time (on a weekly basis) do you spend on data entry and reporting? : % 116

119 Workforce matters Rostering Recruitment Leave Payroll Liaising with Health Support Services to clarify pay and leave enquiries Providing support for the recruitment of staff to the ward/unit Undertaking administrative activities related to the management of performance reviews for staff that the N/MUM and other ward based medical and allied health staff line manage within the unit Assisting with the replacement of staff as directed by the N/MUM Other, please specify: What percentage of your time (on a weekly basis) do you spend on workforce matters?: % Resource management Ensuring the ward/unit has adequate stock of medical supplies and equipment required by staff to perform their day to day duties in delivery of patient care. Purchasing and receiving new equipment for the ward/unit and equipment maintenance. Uniform ordering Other, please specify: What percentage of your time (on a weekly basis) do you spend on resource management? : % Documentation/records management Supporting and participating in the administrative aspects of activities Numerical profiling Quality accreditation processes Incident management Maintaining staff credentialing register Monitoring of nurses and midwives registration and enrolment 117

120 Assisting the health care team in obtaining information, reports or correspondence related to patient care What percentage of your time (on a weekly basis) do you spend on documentation/records management? : % General administration activities Undertaking administrative tasks related to meetings that are held on the ward/unit involving medical, nursing and allied health staff including Scheduling Ensuring all relevant documents are available for the meeting Progression of action items where appropriate Assisting with the daily schedule for the health care team at ward/unit level Ensuring that multidisciplinary ward rounds are completed in a timely manner Ensuring relevant material is available to support the ward round Organising travel and accommodation for ward/unit staff where required Other general administrative tasks to support (please specify): What percentage of your time (on a weekly basis) do you spend on resource management? : % Any other tasks (please specify) What percentage of your time (on a weekly basis) do you spend on other tasks? : % 16. If you have access to your job description could you please upload it now? We are only interested in the scope of scope of tasks and duties across all CSOs and not in individuals. All information will be de-identified 17. Do you feel your job/position description accurately represents the purpose, capabilities and core functions of your role? Yes/No, if no, why not? 18. Has your role changed since you were first employed as a CSO? If so how? 19. Were you actively involved in the deciding how your role was to change? Can you describe how you were involved? Yes/No 20. Have you taken over tasks/duties that were once undertaken by the N/MUM? Yes/No 118

121 21. Can you briefly list the tasks that you now do, that were once undertaken by the M/NUM? 22. Can you briefly describe any tasks that you now do, that you know were once undertaken by other members of staff (e.g. doctors, allied health professionals, nurses)? 23. Are you undertaking activities/tasks allocated from somewhere other than the unit ward within which you work? (e.g. are you undertaking centralised rostering?) a. Can you briefly list the tasks that are allocated from outside your unit and who allocates them? b. How much of your time, on a weekly basis, is taken up by tasks allocated from outside your unit? 24. What type of tasks do you undertake that specifically support N/MUM(s)? 25. Do you think that the introduction of your role has reduced the amount of time your N/MUM spend on administrative tasks? Yes/No a. What type of tasks do you undertake that specifically support the doctors work? b. What type of tasks do you undertake that specifically support the nurses work? c. What impact do you think the introduction of your role on the allied health professionals work? (eg physiotherapists, psychologists, social workers, pharmacists etc) d. What impact do you think the introduction of your role on the work of other staff?(please specify which staff) 26. Do you think there has there been any impact on patient care as a result of the introduction of your role? Yes/No 27. What type of impact? 28. From your perspective there been any unexpected outcomes/impacts as a result of the introduction of your role? Yes/No a. Can you please describe these? 119

122 29. What, if anything, helps or hinders your ability to support your unit s work? 30. Is your unit participating in the Essentials of Care Program? Yes/No/Don t know 31. Can you briefly describe what this participation has involved? 32. Thinking about your unit over the last year (or as long as you have been at the unit) please rate each statement: (Presented as a Likert scale with radio buttons) Number of adverse events Staff satisfaction Patient satisfaction Staff retention Staff absenteeism Number of patient complaints Number of patient compliments 33. Thinking about your unit over the last year (or as long as you have been at the unit) please rate each statement: (Presented as a Likert scale with radio buttons) Your unit s performance Your unit s overall efficiency Patient flow Staff performance Staff morale Communication and management of difficult situations with staff Communication with patients and their families Management of staff Rostering of staff Financial management 34. What are the three biggest barriers you face doing your work? 35. What are the three things that might make your job easier or more effective? 120

123 36. Do you have the opportunity to meet with other CSOs in order to share information and provide support to each other? Yes/No 37. Have you undertaken any training to prepare you or develop you in your role as a CSO? Yes/No If yes, what kind of training? 38. Is there any other comment you would like to make specifically about the role of CSO? 39. Is there any other comment you would like to make? 121

124 8.2 Literature review In this section we provide further discussion of the issues raised in the literature review. These are presented in order to provide a context for readers who may not be familiar with the origins of the ttl program and factors affecting its implementation Examples of concurrent initiatives to improve patient safety During the implementation period of the take the lead other initiatives, also aiming to improving patient care, have been introduced. These initiatives have stimulated change and so it is important to recognise the potential effect of these initiatives when evaluating the take the lead project. As there have been numerous initiatives, only a sample of these are briefly outlined below. The Essentials of Care Program The New South Wales Government declared stage one support for Recommendation 38 in the Garling Report through the implementation of the Essentials of Care Program over a three year period in every ward in New South Wales. The Essentials of Care (EOC) Program commenced in February EOC is an evaluation framework to develop, support and continuously evaluate essential patient care that is fundamental to each patient s health and wellbeing. Involvement of the patient and their carers in discussions and decisions about their care is pivotal to achieving effective essential care. EOC utilises transformational practice development methodologies and aims to improve patient safety and outcomes, and enhance the experiences of patients and all involved in their care. It aims to enable nurses and midwives to focus on the development of clinical environments that enhance patient care, teamwork and individual satisfaction. (NSW Health Nursing and Midwifery Office, 2008). Recommendation 38 The Chief Nursing and Midwifery Officer of NSW Health should supervise the preparation within 6 months of and ensure over a 2 year period the implementation of a program across all public hospitals in NSW which is designed to achieve an improvement in the efficiency and design of nursing work practices in each ward or unit having regard to the principles of shared care and team-based work practices. The NSW program should take into account the improvements made by the Productive Ward Program in the United Kingdom and the Essentials of Care Program. (Garling, 2008: 43) 122

125 Recommendation 38 New South Wales Government Response: (Stage One Supported) The Essentials of Care program provides nurses and other health professionals with a method to explore and understand current clinical practice and practice environments and to develop ways to further enhance them. It is already being established across Area Health Services with a focus on patients experience, as well as what the patients, their families and health professionals value about effective and relevant patient care. Building on this, the Chief Nursing and Midwifery Officer will supervise a program designed to achieve greater efficiency and design of nursing work practices, giving consideration to shared care and teamwork principles. To ensure successful implementation, NSW Health will achieve this in every ward over a 3 year period. (NSW Department of Health, 2009: 25) Between the Flags Initiative Between the Flags, an initiative of the Clinical Excellence Commission, has been implemented in hospitals across New South Wales (Clinical Excellence Commission et al., 2010). This initiative aims to improve and standardise the response to and the identification of the deteriorating patient. Standardised colour coded observation charts have been introduced to track observations and trigger a response when observations fall within identified parameters. If the patient s observations fall within the yellow and red zones on the observation chart, the need for initiation of assessment or rapid response is indicated. Safe Clinical Handover The Garling Report specifically addressed the need to improve policies and procedures on clinical handover. Specifically, Garling recommended that a mandatory shift handover policy be designed and introduced in each hospital. The handover policy must require that part of the handover is to be conducted at the bedside, sufficient time for handover be incorporated when rostering, that required information is included in handover, and that an electronic or written record be made of the handover (Recommendation 56, Garling Report 2008). These recommendations were supported and an action plan developed including the development of key principles and strategies for clinical handover (NSW Health, 2009). 123

126 8.2.2 The role of the Nursing/Midwifery Unit Manager within NSW Health NSW Health comprises the Department of Health, eight Area Health Services, statutory health corporations and affiliated health organisations. Public hospitals contain patient ward areas or units. N/MUMs are in charge of all aspects of designated ward or unit environments and are responsible for the standard of patient care in those wards or units. He or she coordinates patient services, unit management, and nursing/midwifery staff management to ensure efficient use of resources and delivery of high quality patient care. N/MUMs have a key role in influencing the culture of a unit, the satisfaction of their staff, the quality of care patients receive, and the experience of the patient and their carer. As a result, expectations of N/MUMs are increasing. They are now expected to provide not only clinical leadership within their units but also deal with an increasing number of organisational and administrative requirements and at the same time ensure the maintenance of high standards of nursing and midwifery care (Hawe, 2009: 2). i. NSW Public Health System Nurses and Midwives State Award Within the New South Wales public health system, Nursing/Midwifery Unit Managers are defined as the registered nurse in charge of a ward or unit or group of wards or units in a public hospital or health service or public health organisation (NSW Health, 2010b:4). The NSW Public Health System Nurses and Midwives State Award classifies NUM/MUMs as Level 1, 2 or 3. The responsibilities of the Nursing/Midwifery Unit Manager Level 1 include: (a) CO-ORDINATION OF PATIENT SERVICES liaison with all health care disciplines for the provision of services to meet patient needs: the orchestration of services to meet patient needs after discharge; monitoring catering and transport services. (b) UNIT MANAGEMENT implementation of hospital/health service policy: dissemination of information to all personnel; ensuring environmental safety; monitoring the use and maintenance of equipment; monitoring the supply and use of stock and supplies; 124

127 monitoring cleaning services. (c) NURSING STAFF MANAGEMENT direction, co-ordination and supervision of nursing activities; training, appraisal and counselling of nursing staff; rostering and/or allocation of nursing staff; development and/or implementation of new nursing practice according to patient need. Provided that the classification of Nursing/Midwifery Unit Manager Level 1 shall include those registered nurses who, as at 27 June 1986, were appointed as Charge Nurses or Supervisors of 20 but less than 50 beds or who were appointed at a rate of pay equal to the latter. Nursing/Midwifery Unit Manager Level 2 whose responsibilities in relation to patient services, ward or unit management and staff management are in excess of those of a Nursing/Midwifery Unit Manager Level 1. Nursing/Midwifery Unit Manager Level 3 whose responsibilities in relation to patient services, ward or unit management and staff management are in excess of those of a Nursing/Midwifery Unit Manager Level 2. Provided further, in relation to those nurses classified in accordance with this definition as Nursing/Midwifery Unit Managers on the basis of their former appointment as Charge Nurses or Supervisors, as the case may be, that nothing in this definition shall prevent them from being considered for regrading at any time after 27 June (NSW Health, 2010b:6) From Charge Sister to Nursing/Midwifery Unit Manager As the demands on, and from, the health workforce have changed over the last decade, so too have the demands placed on nurse managers (Productivity Commission, 2005). An overview of the literature reports the evolution of the nurse manager role from the traditional head nurse role ( ), through early expansion of the role ( ) to an expanded nurse manager role ( ) (Shirey, 2006). While the role of Nurse/Midwifery Unit Managers was originally intended to provide clinical leadership, increasing expectations to undertake administrative tasks has detracted from this important role (NSW Nurses' Association, 2009). Nursing leadership is essential in developing and sustaining a healthy work environment (Pearson et al., 2007) and is correlated with productivity, 125

128 organisational commitment (Chiok Foong Loke, 2001) and job satisfaction (Duffield et al., 2009). In particular, knowledge of leadership principles, an ability to communicate, motivate and manage conflict among staff, a commitment to personal and staff professional development, and being honest and supportive of staff, are important characteristics of the successful nurse leader (Pearson et al., 2007). As early as the mid 1990s graduate programs designed to prepare nurse managers for the leadership positions were introduced or being developed in Sweden and the United Kingdom (Kleinman, 2003). The N/MUM roles and responsibilities have changed extensively over the last 25 years as nursing increasingly bases its claim to professional status upon a managerialist discourse: it seeks legitimacy and power by embracing both a managerial ideology and management practices (Brooks, 1999: 41). The clinical leadership role on a ward or unit was once fulfilled by the Charge Sister. This role was based on clinical experience and expertise until 1986 when in New South Wales, the N/MUM role was created to replace the Charge Sister role. The Clinical Nurse Specialist role was simultaneously introduced to take over the clinical role leadership role that was surrendered by the Nurse Unit Manager for a focus on managerial responsibilities (Duffield et al., 2001). The shift from hospital to tertiary based nursing education underscored the emphasis on clinical autonomy among nurses and a resultant perceived decrease in the need for clinical expertise among their managers (Duffield et al., 2001). This has led to the development of a nursing managerial role that is less and less traditional and more diverse, encompassing more and more non-nursing responsibilities with the risk that with an increasing span of control, nurse managers may become ineffective with their clinical credibility eroded (Duffield et al., 2001). A recognised difficulty for Nurse Unit Managers was the lack of formalised training in management skills and an absence of role models, particularly given the dominance of role model based learning in nursing (Duffield et al., 2001). Decentralisation and the introduction of primary nursing impacted the role of nurse unit manager requiring new types of managerial skills (Duffield, 1991). Uncertainty over role definition and a perceived gap in management skills is problematic not only in Australia (Duffield et al., 1994) but internationally (e.g. New Zealand (McCallin et al., 2010), South Africa (Pillay, 2009), and the United Kingdom (Gould et al., 2001). The development of leadership and management skills have replaced clinical skills identified as necessary for the nurse unit manager role (Oroviogoicoechea, 1996, Gould et al., 2001) and concern about whether individuals in healthcare are adequately prepared for their management role has been expressed (Kleinman, 2003). A priceless contribution that a nurse brings to the N/MUM role is undoubtedly 126

129 their ability to factor in the intricate complexities and demands of patient care in management decisions (Duffield et al., 2001). An overview of the literature reports the evolution of the nurse manager role from the traditional head nurse role ( ) through early expansion of the role ( ) to an expanded nurse manager role ( ) (Shirey, 2006). Stress among nurse managers is understood in relation to the staff shortages, increased responsibility and exigent work environment (Shirey, 2006). In summary, concerns for NUMs identified in the literature include: a lack of recognition, overtime, isolation, staff shortages, numerous meetings, increasing administrative load, lack of training for managerial role, competing clinical and managerial responsibilities (Hillier, 2005). The nurse manager role continues to evolve and in Australia managing the competing demands of clinical leadership and managerial roles poses ongoing challenges for nurse/midwifery unit managers. N/MUMs must straddle technical, managerial and clinical demands in a highly demanding and continuously and rapidly changing environment. While aiming to provide compassionate care and clinical leadership they are simultaneously required to manage finances, administrative demands, performance manage, and staff their unit often within the context of staff shortages, increasing litigation, demand for decreased elective waiting lists, publicised adverse events (e.g. Vanessa Anderson, St George Hospital epidural event), disquiet among their nursing staff (e.g. industrial action over patient to staff ratios (NSW, Nov 2010)) and financial restraints. They are required to ensure and measure the delivery of quality care in their unit quantified with indicators such as adverse events, patient complaints, patient compliments, length of stay and patient flow. The literature identifies that when financial restrictions are imposed, the work life concerns of nurses are often the first to be sacrificed (Duffield et al., 2002) catalysing an exodus of nurses further compromising staff satisfaction. Nurse shortages contribute to job dissatisfaction and negatively impact quality of care. Research suggests that patients in environments where there is a high nurse turnover are more physically and emotionally compromised (Hayes et al., 2006). Appropriate staff skill mix based patient needs is significantly correlated with patient outcomes (Twigg et al., (in press)). It is within this context that N/MUMs are navigating the competing demands of their role Ongoing development of nurse managers As the role of N/MUMs developed both in Australia and internationally, so too did the range of mechanisms utilised to facilitate that development. In many cases, 127

130 including the United Kingdom (Sprinks, 2010, Kellagher et al., 2010), Canada (MacPhee et al., 2010) and New Zealand (McCallin et al., 2010) development strategies are intended to address very similar issues to those identified by ttl. Most common among these are issues relating to N/MUMs (or their equivalents ) role ambiguity, workload and appropriate preparation for, and development of, their role, including competencies relating to management and leadership skills (MacMillan-Finlayson, 2010, Lewis et al., 2010, Kennedy, 2008). As part of the formalisation of nurse managers roles, there is an ongoing international interest in the development of specific sets of nurse manager competencies (Thomas et al., 2008, Chase, 1994). Competencies provide two functions for professional development: they act both as the basis for the development of educational/training strategies, and as the basis for assessments and reviews (Sutto et al., 2008, Care et al., 2003, Donaher et al., 2007). As the development of specific nurse manager competencies progresses, so too has the sophistication of the competencies themselves (Lin et al., 2007). Ireland, for example, now has specific nurse manager competencies aimed at managers-director, middle manager and front line manager levels (McCarthy et al., 2009). Although each competency set varies, reflecting national priorities as much as professional requirements, they generally include elements such as: ethical behaviour and integrity, effective decision making skills, change management, leadership, human and financial management skills, lifelong learning, communication skills, conflict resolution and negotiation skills (Sutto et al., 2008, Palarca et al., 2008, Jennings et al., 2007, Krejci et al., 1997, Care et al., 2003, Davis, 2005). While a range of nurse manager development strategies currently being implemented in health services around the world, the most common include: role induction (McCallin et al., 2010, Hawkins et al., 2009); in-house, hands-on training(maguire et al., 2004, Kowalski, 2004), coaching or mentoring programs (Karsten, 2010, Cashin et al., 2010, Rosati, 2009, McLarty et al., 2009); clinical supervision; succession planning (Ponti, 2009, Mass et al., 2006); and postgraduate training (McCallin et al., 2010, Joyce, 2005, Duffield, 2005) Transfer of learning to the workplace The transfer of learning, from training and educational contexts, into the workplace remains a central concern for health and other industries. This is partly because estimates that the effective transfer of learning (as measured by behavioural change) occurs only in between 10 20% of cases, with about 40% of trainees failing to transfer what they learn once they return to the workplace, growing to about 70% a 128

131 year after their attendance at a training program. It is generally accepted that only 50% of training investments actually result in improvements for either the individuals or the organisation (Leimbach, 2010, Burke et al., 2007, Georgenson, 1982, Saks, 1995). Three key characteristics are said to affect learners abilities to transfer what they learn into their workplace. These include: learner characteristics and readiness; training design and delivery; and the workplace environment (Leimbach, 2010, Kirkpatrick et al., 2006, Nijman et al., 2006, Alvarez et al., 2004). At an individual level, characteristics said to predict the transfer of learning include cognitive ability, self-efficacy, motivation (both to attend and to transfer what is learnt) openness to experience, perceived utility of the training and career planning. There is mixed evidence for the influence of extrinsic versus intrinsic motivation, conscientiousness, and internal versus external control (Blume et al., 2010, Burke et al., 2007, Colquitt et al., 2000, Holladay et al., 2003, Quiñones, 1995). At the intervention level, predictors included appropriate learning goals, content relevance, practice and feedback behavioural-modelling, and error based examples. There is some evidence for the influence of self-management strategies (Blume et al., 2010, Burke et al., 2007, Taylor et al., 2005, Locke et al., 2002). There were a number of predictors of learning transfer at an organisational level. These include: a supportive work environment, a strong transfer climate, supervisory support, peer support, opportunity to perform and organisational commitment (Blume et al., 2010, Burke et al., 2007, Colquitt et al., 2000) Factors supporting and inhibiting workplace change Healthcare environments are busy, complex and chaotic (Grimshaw et al., 2004). Managerial responsibilities in healthcare environments include pressures additional to those in most other industries, such as as life and death decisions, clinical complexities and strong autonomy of individual professionals (Braithwaite et al., forthcoming). Researchers have tried to identify and describe the manager s role and more specifically, how managers conduct their work (Fayol, 1949, Carlson, 1951, Mintzberg, 1971, Kotter, 1982, Stewart, 1998). Managing change is a particularly important element of the healthcare managerial routine (Braithwaite, 2004). Managers can be viewed as continuously attempting to make sense of their complex professional environments, whilst initiating and spearheading progress and improvement (Braithwaite et al., forthcoming). This constant striving for change and improvement is at the core of all managerial work. Change takes on different forms 129

132 from implementing new IT solutions to managing a budget or dealing with staff performance. In this context, change can be defined as an innovation in service delivery and organization as a novel set of behaviours, routines, and ways of working that are directed at improving health outcomes, administrative efficiency, cost effectiveness, or users' experience and that are implemented by planned and coordinated actions (Greenhalgh et al., 2004: 582). In order for change to be implemented successfully the intervention chosen needs to be tailored to the specific situation. It is essential that in each and every intervention, the potential barriers for implementation are identified and addressed (Flottrop et al., 2003) Four levels of change in health care have been identified: the whole healthcare system; institutional/organisational level; groups and teams; and the individual (Ferlie et al., 2001). Multiple hierarchical domains are a part of the context that underpins the management of change in healthcare (Braithwaite et al., forthcoming). On the one hand there is the formal hierarchy as depicted by the organisational chart, on the other an informal, internal hierarchy within and across professions. This less formal hierarchy can be based on political and professional rankings according to status, reputation, power or importance, or a combination of these (Braithwaite et al., forthcoming). For example, doctors often outrank nurses in terms of power. In order to coordinate and implement change, managers need to navigate this complex environment. In the past, it was commonly assumed that most barriers to implementation of change were at an individual level (e.g. negative attitudes or lack of knowledge and skills). There is now increasing recognition that there are multiple levels in which barriers exist, many of which are not within the control of the individual (Grimshaw et al., 2004). Greenhalgh, Robert, Macfarlane, Bate, Kyriakidou (2004) provide a comprehensive description and analysis of how innovation is distributed within service organisations. The authors describe a model that includes multiple components that interact with each other. These components include characteristics of: the innovation itself; the adopter; the readiness of the system; the process chosen for implementation; the external context; the type of communication and influence used to transfer the innovation; and the linkages (see model). The existence or lack of a certain characteristic does not guarantee the adoption or rejection of an innovation. It is imperative that change agents remember that the attributes are neither stable features of the innovation nor sure determinants of their adoption or assimilation. Rather, it is the interaction among the innovation, the intended adopter(s), and a particular context that determines the adoption rate. (Greenhalgh et al., 2004: 598). 130

133 There is variance with the rate at which change is adopted. This can be ascribed to a number of different attributes of the innovation itself. For example, innovations that have a clear relative advantage in effectiveness or cost effectiveness are more easily and more willingly adopted. If the advantage of the innovation is not clear to the individuals involved there is no chance that the innovation will be adopted. On the other hand, there is no guarantee that when the advantage is clear, that adoption will be widespread. Other examples that increase the chance that an innovation will be adopted are low complexity; high compatibility with the norms and values and needs of potential adopters; high visibility; easy to trial; and high relevance to the task. (Greenhalgh et al., 2004). The adoption of innovations by individuals is an interactive process. Individuals are not passive recipients of change. Individuals negotiate, experiment, evaluate, emotionally react to,, and modify innovations. Greenhalgh et al (2004) argue against applying wide adopter categories as there is little support for them in the literature. The authors articulate seven adopter categories that influence uptake of innovations. For example the meaning of the innovation for the individual has been shown to impact on the likelihood of change. When there is congruence between the meaning intended by the managerial level initiating the innovation and the meaning perceived by the individual, there is more chance that the innovation will be adopted. The meaning can also be negotiated and reframed within and between organisational levels (Greenhalgh et al., 2004). Other examples of individual attributes that increase the chance of adoption are psychological antecedents such as traits that increase the likelihood an individual will try and use innovations; context-specific psychological antecedents such as strong motivation and congruence with values, goals and skills; having a say in the decision process; awareness of concerns regarding the innovation or its consequences and an ability to address them; having information, training and support during early stages of adoption; when feedback regarding implications of the innovation are communicated to users and that the individuals can adapt the innovation according to the feedback (Greenhalgh et al., 2004). 131

134 8.3 Demographic characteristics of participants Table 28: demographic characteristics of participants~ DEMOGRAPHIC VARIABLES N/MUM INTERVIEWS N = 30 CASE STUDIES N=2 MANAGER INTERVIEWS N = 30 M = 4 F = 26 STAFF SURVEY N = 23 CSO SURVEY N=92 Gender M = 3 F = 27 M = 0 F = 2 M=7 F=16 M=6 F=86 Number of ttl 5 5 (N=2) n/a n/a n/a modules completed Participation in n/a Essentials of Care Current role N/MUM N/MUM, N/MUM Level 3 CSO Nurse to DON Manager Years in health post graduation Years in current role Years in current unit/hospital Years in current role in current unit/hospital Range: 8-40 years Average: 24 years Range: 2-20 Average: 6 years Range: 1-34 years Average: 8 years Range: 1-15 years Average: 5 years Range: years Average: 16 years Range: 5-9 years Average: 7 years Range: 7-11 years Average: 9 years Range: 1-7 years Average: 4 years Range: Average: 80 Range: 1-40 Average: 20 Range: 8-45 Average: 26 years Range: 1-26 years Average: 9 years Range: 1-35 years Average: 11 years Range: 1-15 years Average: 5 years Nursing/ Midwifery (13) Medicine (4) Allied Health (6) Range: 1-42 Average: 22 years n/a n/a Range: 1-37* Average: 7 years Less than one year = 79 One year= 12 Two years = 1 n/a n/a Range: 1 25 months Average: 8 months % of work on Range: n/a n/a n/a management Average: 56 % of work on Range: 1-80 n/a n/a n/a clinical duties Average: 44 ~ all years rounded up to the nearest whole year (except for CSOs), *Years in health total TOTAL N = 177 M= 20 F=

135 8.4 Changes to N/MUMs capabilities and skills since ttl NUMS responses to changes in their capabilities and skills since ttl Figure 2: changes in N/MUM s job performance since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Job performance Figure 3: changes in N/MUMs communication skills since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Ability to communicate with own staff Ability to communicate with other staff Ability to communicate with patients and family 133

136 Figure 4: changes in N/MUMs ability to manage complex situations since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Management of difficult situations Negotiation skills Problem solving Figure 5: changes in N/MUMs ability to manage staff since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Ability to manage staff 134

137 Figure 6: changes in N/MUMs leadership abilities since ttl \ Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Leadership abilities Figure 7: changes in N/MUMs management skills since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Application of lean thinking Management of finances and resources Rostering of staff 135

138 8.4.2 NUMS managers responses to N/MUMs changes in their capabilities and skills since ttl Figure 8: Managers perceptions of changes in N/MUM s job performance since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 9: Managers perceptions of changes in N/MUMs communication skills with staff Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 136

139 Figure 10: Managers perceptions of changes in N/MUMs communication skills with patients and their families since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 11: Managers perceptions of changes in N/MUMs communication skills with other staff since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 137

140 Figure 12: Managers perceptions of changes in N/MUMs ability to manage difficult situations since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 13: Managers perceptions of changes in N/MUMs negotiation skills since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 138

141 Figure 14: Managers perceptions of changes in N/MUMs ability to problem solve since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 15: Managers perceptions of changes in N/MUMs ability to manage staff since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 139

142 Figure 16: Managers perceptions of changes in N/MUMs leadership abilities since ttl \ Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 17: Managers perceptions of changes in N/MUMs management skills since ttl : application of lean thinking Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 140

143 Figure 18: Managers perceptions of changes in N/MUMs management skills since ttl : ability to manage finances Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 19: Managers perceptions of changes in N/MUMs management skills since ttl : ability to manage rostering Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 141

144 8.5 Improvements at the unit level since ttl N/MUMs perceptions of improvements at unit level since ttl Figure 20: N/MUMs perceptions of unit performance and efficiency since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Unit's performance Unit's efficiency Figure 21: N/MUMs perceptions of changes in number of adverse events since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Number of adverse events 142

145 Figure 22: N/MUMs perceptions of changes to patient flow since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Patient flow Figure 23: N/MUMs perceptions of time spent of administrative tasks since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased signficantly Time spent on administrative tasks 143

146 Figure 24: N/MUMs perceptions of changes in staff performance since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Staff performance Figure 25: N/MUMs perceptions of staff satisfaction and retention since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Staff satisfaction Staff retention 144

147 Figure 26: N/MUMs perceptions of staff morale since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Staff morale Figure 27: N/MUMs perceptions of staff absenteeism since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased signficantly staff absenteeism 145

148 Figure 28: N/MUMs perceptions of patient measures since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly patient satisfaction patient compliments patient complaints Managers of N/MUMs perceptions of improvements at unit level since ttl Figure 29: Manager s perceptions of unit performance since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 146

149 Figure 30: Manager s perceptions of unit efficiency since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 31: Managers perceptions of changes in number of adverse events since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 147

150 Figure 32: Manager s perceptions of changes to patient flow since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 33: Manager s perceptions of time spent of administrative tasks since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Due to ttl Due to ttl + CSO Due to CSO alone Unsure of cause Not due to ttl 148

151 Figure 34: Managers perceptions of changes in staff performance since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 35: Managers perceptions of staff satisfaction since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 149

152 Figure 35: Managers perceptions of staff retention since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 36: Manager s perceptions of staff absenteeism since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 150

153 Figure 37: Manager s perceptions of staff morale since ttl Improved significantly Improved somewhat Stayed the same Worsened somewhat Worsened significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 38: Managers perceptions of patient compliments since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 151

154 Figure 39: Managers perceptions of patient satisfaction since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl Figure 40: Managers perceptions of patient complaints since ttl Increased significantly Increased somewhat Stayed the same Decreased somewhat Decreased significantly Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl 152

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