First report on the models of care project. February April 2005

Transcription

1 First report on the models of care project February April 2005

2 Compiled by Professor Mary Chiarella Centre for Health Services Management University of Technology, Sydney and Dr Cecilia Lau Nursing and Midwifery Office NSW Health NSW DEPARTMENT OF HEALTH 73 Miller Street NORTH SYDNEY NSW 2060 Tel. (02) Fax. (02) TTY. (02) This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires written permission from the NSW Department of Health. NSW Department of Health 2006 SHPN (NMO) ISBN For further copies of this document please contact: Better Health Centre Publications Warehouse Locked Mail Bag 5003 Gladesville NSW 2111 Tel. (02) Fax. (02) Further copies of this document can be downloaded from the NSW Health website: February 2006

3 Foreword It gives me great pleasure to introduce this report, as I believe it illustrates the commitment, ingenuity, drive, resourcefulness and promise for the future that is evident in today s nursing and midwifery workforce in NSW. Maternity models of care, including primary maternity service models, are being addressed within the work plan of the Maternal and Perinatal Health Priority Taskforce. Some elements of this work plan will be achieved through the Midwifery Strategic Plan. The concept of taking a series of workshops around NSW had its genesis in the NSW Ministerial Standing Committee on the Nursing Workforce Action Plan (September 2001). This plan identified strategies designed to create a supportive, adaptable and sustainable environment that would achieve positive outcomes for clinicians and consumers. Since that time, a great deal of initiative and innovation regarding recruitment and retention has achieved significant steps forward and in 2004, the Joint Strategic Reference Group Nursing and Midwifery developed that concept further. This group recognised that within the framework of statewide health system reform, the essential inter-relatedness of workforce to health care services required roles and models of care to be reviewed. The opportunity to share information and showcase ideas across NSW about changing thinking around roles and models of care was seized, and the roadshow as the vehicle for this undertaking was born. I highly recommend this report, as it is evidence of the wealth of wisdom and imagination that was generated throughout this project, while it highlights the intrinsic value of nurses and midwives to the continued provision of safe, high standards of health care to the people of NSW. Adjunct Professor Kathy Baker Honorary Fellow Chief Nursing Officer New South Wales First report on the models of care project i

4 Contents Executive Summary...1 Recommendations Background The Roadshow Program and timetable The profile of the attendees The virtual toolkit The literature review The Presentations The impact of the safety and quality agenda on models of care Reflective Practice Analysis of Practice Implementation of evidence-based practice and innovations Measurement and evaluation of patient-centred outcomes Evaluation of Roadshow Key issues arising from the Roadshow evaluations for participants The need for further education Nurses roles and scope of practice Clinical leadership development Clinical supervision Safety and quality Research utilisation and development Barriers Key recommendations Conclusion...27 References...28 PowerPoint Presentations...30 Appendix. Evaluation form Measurement and evaluation of staff-centred outcomes Changes in skill mix Changes to models of care delivery Changes to organisation of care Changes in rostering...20 ii First report on the models of care project

5 Executive Summary The Joint Strategic Reference Group for Nursing and Midwifery, established to advise the Chief Nursing Officer (CNO), identified the need to undertake a major review of models of care and nurses roles as one of its four key priorities. A Working Group was established and determined that the review should be an iterative process in consultation with the nursing profession working in public sector health in NSW. The first step in this process was to undertake a statewide Roadshow which would showcase existing examples of innovation and engage the profession in debate around the way in which nursing and midwifery care is practised and delivered and the current and future roles of nurses and midwives. Adjunct Professor Kathy Baker, CNO, asked Professor Mary Chiarella to undertake the review, commencing with the Roadshow. The Roadshow was conducted from February to April 2005 inclusive. Twenty-two venues were visited from Bega in the south of the state to Ballina and Moree in the north and across to Broken Hill in the west. In addition to the presentations on workforce modelling by the CNO and a review of the literature pertaining to models of care and nurses roles by Professor Chiarella, thirty-nine different groups of nurses presented their work. At each venue there were one or two speakers from the local area and one or two presenters were invited from other Area Health Services. In addition, the CNO identified four additional groups to whom presentations were made. These were the Nursing Unit Managers (NUMs) group, the Directors of Nursing (DONs) group, and the Clinical Placement Coordinators group. It was intended to include a session with the Clinical Chairs of Nursing, but this session has not yet been held. Approximately 1,140 nurses attended the workshops overall either in person or by teleconference and the evaluations were overwhelmingly positive. A Virtual Toolkit which contains a selection of tools to aid with problem analysis, hot links to other sites eg NHS Essence of Care, a reference list from the literature review (in PDF and as an EndNote bibliography) and all PowerPoint presentations from the Roadshow was established on the Nursing and Midwifery Office website. The emergent themes from the Roadshow presentations discussed in detail in this report are: reflective practice, analysis of practice measurement and evaluation of patient-centered outcomes measurement and evaluation of staff-centered outcomes implementation of evidence-based practice adaptations of innovations changes in skill mix changes in care delivery practices and changes in rostering. The Roadshow and this report clearly demonstrate that across NSW, clinical nurses and midwives are delivering excellent standards of evidence-based patient care and they are using a range of analytical tools and measurement and evaluation techniques in short, they are undertaking clinical nursing research as an integral part of their clinical roles. The Roadshow also clearly demonstrated that there are many nurses and midwives in the system who derive enormous satisfaction from their work, their colleagues and their patients. Key recommendations and actions emerging from the evaluation are set out over the page. First report on the models of care project 1

6 Executive Summary Recommendations Recommendation 1 Further work in relation to models of care to improve patient care and patient outcomes will require education in management of change, teamwork, skill mix changes and flexible work practices. This education will be addressed by the following actions: 1.1 Wide distribution of this report to provide information to all health and/or nurse professionals to facilitate ongoing development of improved models of care. 1.2 Clinical nurses will be the target audience in the next round of statewide education in relation to models of care development. 1.3 Follow-up and feedback from the CNO to all attendees will be provided via appropriate mechanisms to ascertain progress and encourage development of models to best suit the local environment. 1.4 Scholarships will be offered for clinical nurses involved in practice development to improve patient care. 1.5 The virtual toolkit will be expanded and marketed to provide a venue for ongoing publication and to promote communication about innovation in models of care development. 1.6 A website feedback mechanism will be developed so that progress on models developed can be monitored and evaluated. 1.7 Educational development opportunities will be facilitated for Nursing Unit Managers that includes performance management. Recommendation 2 The Nursing and Midwifery Office continues to work closely with other sections of the NSW Department of Health, particularly Clinical Redesign, Safety and Quality, and the Workforce Development and Leadership Branches and also the Clinical Excellence Commission in order to maximise synergies and avoid duplication by: 2.1 Expanding the Clinical Leadership Program as an arm of the Clinical Excellence Commission (CEC), to include a wider diversity of clinicians in order to foster improved teamwork and care delivery innovations. 2.2 Exploring opportunities for inter-professional learning to ensure a multi-disciplinary approach to models of care innovations. 2.3 Supporting education to ensure health professionals are conversant with change management strategies, personal and professional development to enable them to work collaboratively and supportively with the inter-disciplinary team. Recommendation 3 Ensure patient safety by providing a framework for nurses role and scope of practice by: 3.1 Developing guidelines that nurses can use to inform management of skill mix to provide safe patient care. 3.2 Working with universities and educational bodies to facilitate program review and adaptation that will include the recognition of new and changing models of care and the value of challenging set practices. 3.3 Reviewing the clinical teaching role of nurses in conjunction with the Clinical Placement project currently being undertaken. 3.4 Providing resources that support a systematic, rigorous and analytic approach to reviewing practice (eg reflective practice, clinical supervision) as an integral aspect to retention and clinical redesign. 3.5 Exploring opportunities for inter-professional clinical supervision. Recommendation 4 Increased support for research activities in the workplace by: 4.1 Encouraging stronger links between academic and clinical nurses to facilitate rigorous implementation of practice development work and follow-up and publication of results. 4.2 Promoting, encouraging and supporting clinical nurses to undertake short courses on writing for publication and encouraging various educational facilities to provide more of these courses and greater ease of access to them. 2 First report on the models of care project

7 Background 1 In August 2003, a group of key nurse and midwifery leaders, titled the Joint Strategic Reference Group for Nursing and Midwifery (JSRG), was convened by the (then) Chief Nursing Officer (CNO) for NSW, Professor Mary Chiarella. The group continues to meet today under the auspices of the current CNO, Adjunct Professor Kathy Baker and comprises all of the Area Directors of Nursing and Midwifery, all the Deans of Nursing and Midwifery for NSW, the General Secretary of the New South Wales Nurses Association, the Director of Nurse Education for TAFE (NSW), the Executive Director of The College of Nursing, the Executive Officer of the Nurses and Midwives Board NSW and a representative from the NSW Midwives Association. The group was asked to agree on key priorities for NSW nursing and midwifery that they would be prepared to drive forward from their relevant perspectives. The Nursing and Midwifery Office (NaMO) of NSW Health would steer the top four priorities and funding would either be allocated where possible or sought if not available. The top four priorities identified by the JSRG were to: develop a leadership program for clinicians map and make recommendations about the ongoing problems associated with clinical placements for both undergraduate and postgraduate nursing and midwifery students undertake a major review of models of patient care delivery and nurses roles undertake a major review of clinical professional career paths. Working parties were established to determine the format and processes required to address these priorities. The Models of Care Working Party identified the need for a program of consultation and workshops with nurses and midwives across the state. A number of reasons were identified for needing to re-examine patient care delivery systems and the ways in which nurses and midwives practice. These reasons included the following issues: The much-needed increases in nursing undergraduates, trainee enrolled nurses, enrolled nurses and new graduates being recruited to meet the projected shortfall of nurses in the future will mean significantly greater numbers of staff in the workplace, who in their early days will require education and support. The introduction of nurse practitioner and other specialist advanced practice roles will mean greater numbers of highly specialised staff across the workforce. Changes to care delivery patterns eg clinical streaming, outreach and in-reach programs will mean geographical and structural shifts to the nature and location of teams. The growing focus on multidisciplinary workforce development may mean changes to the allocation and ownership of work and will certainly require a more interdisciplinary approach to problem solving. In addition to these actual and projected changes to work practices and skill mix, a number of key initiatives locally and globally highlighted the value of reflecting upon and reviewing practice and analysing the processes of care delivery from a range of perspectives, most particularly those of the patient. Two significant local initiatives were the Patient Flow and Safety Collaborative and the Chronic and Complex Care Collaborative funded and implemented by the former Institute of Clinical Excellence, whose role has now been expanded to become the Clinical Excellence Commission. First report on the models of care project 3

8 Background In addition, some key nurse leaders in NSW have been involved in the introduction and implementation of the clinical practice development movement, which has been highly successful in improving quality of care in the UK. Clinical practice development has been defined as: A continuous piece of improvement designed to increase effectiveness in patient-centred care. It is brought about by enabling health care teams to develop their knowledge and skills and in doing so, transform the culture and context of care. It is enabled and supported by facilitators who are committed to systematic, rigorous and continuous processes of change that will free practitioners to act in new ways that better reflect the perspectives of both service users and service providers. (Garbett & McCormack, 2002) There was much anecdotal evidence that significant innovation was occurring in NSW. The question was how to stimulate other nurses and midwives to take up the challenge of improving and changing their care delivery practices and to encourage them to increase their engagement with multidisciplinary groups. It was also recognised that an ongoing need exists to disseminate information about innovative models of care amongst health care professionals. To this end a secondary goal of the Models of Care project over the next four years was to encourage NSW nurses and midwives to publish their innovations. The first step in the process of dissemination was to conduct a workshop program across the state. This report details the process and evaluation of the workshop program, known as the Models of Care Roadshow. 4 First report on the models of care project

9 The Roadshow Program and timetable It was agreed that the Roadshow needed to be undertaken as soon as reasonably possible in 2005, in order to enable nurses and midwives to be prepared for some of the imminent changes that might be created by the Area Health Service restructure and the planned increases in the number of undergraduates and trainee enrolled nurses. It was anticipated that exposure to best practice models of care from their peers would both inspire and build morale. The need to share information about best practice in order to maximize the opportunities for collaboration and benchmarking is critical, as is the need to avoid duplication. The aims of each workshop program was to: provide the first step in an iterative process to assist clinical and academic nurses to benefit and profit from the changes which are occurring due to increased recruitment of staff direct clinical and academic nurses towards a range of tools to help them to evaluate the effectiveness of existing practices offer support and stimulate questions. The content of the one-day program was as follows: overview of the current workforce shortfall predictions and strategies to address them discussion about the impact of these strategies on skill mix and models of care presentations from nurses who are already successfully implementing innovative models of care review of literature on elements of innovative models of care open discussion facilitated to identify key issues, problems, opportunities and potential solutions exploration of tools to analyse models of care and practice identify and provide exemplars of best practice next steps. workshop difficult issues in relation to models of nursing and midwifery care and practice be a forum for exploring ideas and generating discussion provide clinical and academic nurses with opportunities to think about analysing practice The PowerPoint presentations of the current workforce predictions and the literature review are included in the Virtual Toolkit at The program ran for three months (February to April inclusive) and was held at 22 venues across the state. These are set out below in Table 1. Table 1 Timetable and Itinerary for Models of Care Roadshow February March April 8 St George Hospital 4 POW/RHW 4 Dubbo 17 RPAH/Concord 7 Campbelltown 5 Orange 18 RNSH 14 Coffs Harbour 11 Tamworth 23 Wagga Wagga 15 Coraki 13 Moree 24 Griffith 16 Ballina 18 John Hunter 28 Goulburn 21 Port Macquarie 21 Broken Hill 23 Nepean 27 Bega 30 Westmead 31 Liverpool First report on the models of care project 5

10 The Roadshow In addition to the Roadshow workshops, the CNO and Professor Chiarella conducted similar, condensed sessions with representative groups from the Directors of Nursing (DONs) (3rd May), the Nurse Unit Managers and Clinical Placement Coordinators (15th April). The session for the Clinical Professors and other relevant academics has not yet taken place. The DONs workshop was conducted by videoconference but due to technical failure, the NUMs and clinical placement coordinators workshops had to be conducted via teleconference. Approximately 1,140 nurses attended the workshops either in person or by teleconference/videoconference overall. As academic nurses were not the target audience for these workshops, Adj/Professor Baker has offered the Deans of Nursing and Midwifery the opportunity to invite Professor Chiarella to run individual workshops for academics. These are currently being organised. 2.2 The profile of the attendees A description of the staff attending the workshops follows. Table 2 identifies the attendees by specialty areas. Table 3 identifies the relative percentages of rural and metropolitan based nurses and midwives attending. Table 4 identifies the nurses by categories. Not all nurses who attended are included in these demographics, as only 60 percent of nurses (n = 677) provided demographic information on their evaluation forms. Table 2 demonstrates that the largest single specialist group represented was from nursing management, although clearly clinical nurses are in the majority if community health, surgical, medical, midwifery, ICU/high dependency and generalist numbers are combined. Whilst a number of nurses expressed disappointment in their evaluations that more clinicians were not present at the workshops, it was equally important to have strong representation from nursing management, as organisational support is considered to be critical for practice development to occur (Unsworth, 2000). Table 2 Nurses and midwives attending the workshops by specialty areas (n =677) Not stated Administration/Management Community Health Surgical Medical Other Midwifery ICU High Dep General Education First report on the models of care project

11 The Roadshow Table 3 demonstrates a strong attendance from rural sites, which is gratifying, given the difficulties encountered releasing staff in some rural facilities and the distances rural nurses have to travel to attend. Table 3 Nurses who attended from metropolitan or rural sites (n=677) Rural 44% Metro 56% Table 4 demonstrates that the single largest group identified were Nursing Unit Managers (NUMs) (n=190) followed by Nurse Managers (n=110) with more senior clinicians such as Clinical Nurse Consultants (n=70), Clinical Nurse Specialists (n=58) and Clinical Nurse Educators (n=42) also providing a strong presence. Only 70 attendees identified themselves as Registered Nurses (RNs) and only eight as Enrolled Nurses (ENs). A consistent refrain in the evaluations (n=119) was the need for more education on models of care for grass roots clinicians. Whilst it is vital that clinicians such as enrolled and registered nurses are completely involved in practice development work and changes to models of care delivery, change such as this will not happen unless senior clinicians lead it. Furthermore, there is significant evidence that changes to care delivery practices and ward organisation are influenced most by the personality of the NUM (Adams & Bond, 2003; Jones & Fairbrother, 2004), thus the engagement and motivation of the NUMs is critical to the success of any change management process. Table 4 Nurses attending by category (n=677) NUM NM CNC RN Not stated CNS NE CNE Other DON EN NP First report on the models of care project 7

12 The Roadshow 2.3 The Virtual Toolkit A virtual toolkit was developed to enable all nurses and midwives across the state to have access to information generated as a result of the Roadshow. The Toolkit contains a selection of tools to aid with problem analysis, such as process mapping tools, work sampling information and work satisfaction questionnaires. In addition, it features hot links to other websites such as the NHS Essence of Care website and the Queensland Nursing Council Scope of Practice and Decision Making Framework, the reference list from the literature review (which is also contained in an EndNote bibliography) all PowerPoint presentations from the Roadshow with contact details for each presenter and other documents of interest that nurses submitted during the Roadshow. The toolkit is available at Literature review A literature review was undertaken looking at English language refereed journal literature relating to models of care from CINAHL and Medline from 2002 onwards in order to generate the most current literature. A number of other earlier key seminal articles and a few local articles in non-refereed journals were also added. Relevant information from the emergent themes was identified and presented as trigger points for discussion and the workshop discussions developed according to take-up by each audience, although all points were covered by the completion of the workshop. The audience was encouraged to explore issues arising from the literature in relation to their own practice and, as will be evidenced from the key issues arising from the workshops in the evaluation section of this report, this aspect of the workshop was highly successful and stimulated considerable discussion during the workshops. It has also been the subject of correspondence and follow-up since completion of the workshops. Emergent themes are listed in Box 1. Box 1 Emergent themes from the literature review Nursing philosophy Patient centeredness The role and nature of practice development Changes in thinking around the importance of certain roles, namely matrons and generalist nurses Advanced practice Ward organisation and care delivery practices Nurse staffing and skill mix Clinical education, educating for clinical practice Ensuring staff satisfaction As previously stated, the themes emerging from the literature formed the content of the afternoon discussion in the workshops. Selected findings from the literature were presented to the workshop participants as a means of stimulating discussion. Some workshops were highly interactive, although as a general rule those held in tiered lecture theatres tended to be much less interactive than those in level rooms where the relationship between speaker and audience was more intimate. The size of the audience did not seem to affect the discussion. 8 First report on the models of care project

13 The Presentations 3 Overall the quality of the presentations was excellent and the evaluations were extremely positive. The presentations are listed by title and author at the end of the report. The CNO was able to attend both Royal Prince Alfred and Liverpool Hospital workshops and presented the overview of the current workforce shortfall predictions, strategies to address them and the ensuing discussion about the impact these strategies will have on skill mix and models of care. Professor Chiarella conducted this session on behalf of the CNO where she was unable to attend. On all occasions the attendees, who found the information on workforce predictions and recruitment and retention strategies most informative, evaluated this presentation enthusiastically. 3.1 The impact of the safety and quality agenda on models of care The impact of the safety and quality agenda in NSW as a stimulus for change cannot be underestimated in relation to the incentive for innovation and changes to practice. This agenda is exemplified by the Framework for Managing the Quality of Health Care Services in NSW (NSW Health, 1999); and the Safety Improvement Program, initiated by the Institute for Clinical Excellence (ICE) in 2001 which has now been further developed into the NSW Health Patient Safety and Clinical Quality Program (NSW Health, 2004) by the Clinical Excellence Commission (CEC). For example, the analysis of adverse events through root cause analysis was introduced as part of the education for the Safety Improvement Program; the use of analytical tools such as the Ishikawa diagram and nominal group technique are explained within the Clinician s Toolkit (NSW Health, 2001) and the use of process mapping as a means of analysing patient care delivery was taught to participants in the Patient Flow and Safety Collaborative (CEC, 2005). However, there is a risk that such activities could be described as routine quality improvement activities, whereas in reality they provide important examples of secondary research activities (Department of Health and Ageing 2005), grounded in practice, utilising available data, measuring and evaluating the impact of practice development and changes on a range of patient and nurse sensitive outcomes. Each workshop featured three to four presentations on models of care and/or care delivery innovations, with at least one being a local presenter and at least one presenter coming from another Area Health Service to facilitate exchange of ideas. Presenters were requested to focus on the process of change and to include evaluation data where they were available. Key themes that emerged from the presentations are presented in Box 2. Box 2 Key themes emerging from clinical presentations Reflective practice Analysis of practice Implementation of evidence-based practice and adaptation of innovations Measurement and evaluation of patient-centered outcomes Measurement and evaluation of staff-centered outcomes Changes in skill mix Changes in care delivery practices Changes in rostering 3.2 Reflective practice Reflective practice, the process of taking structured time-out to review and consider issues of importance in relation to care delivery practices, was identified both within the literature review (Marrow, 1997; McCormack, 1999; Unsworth, 2000) and within the presentations as being critical to professional development and practice improvement. Reflective practice can either occur through a structured mentoring process, through individual clinical supervision or through group activities. In one of the seminal texts on reflective practice, it is defined as: The throwing back of thoughts and memories, in cognitive acts such as thinking, contemplation, meditation and any other form of attentive consideration, in order to make sense of them, and to make contextually appropriate changes if they are required. (Taylor, 2000, p.3) First report on the models of care project 9

14 The Presentations Examples of reflective practice in the presentations included but were not confined to individual reflection on practice through mentoring (Spring, 2005, Cooma; Griffith; Jones, Rivas & Fairbrother, 2005, Prince of Wales); individual reflection through journaling (Bothe, Donoghue & Hawley, 2005, St George; Dempsey, 2005, Gosford; Penning, Claven & Wild, 2005, John Hunter & Rankin Park); individual reflection through reviews of incident reports and complaints (Eather, 2005, St George; Zirckler & Taylor, 2005, Macksville); group reflection through focus groups (Woodhouse, 2005, Braidwood); group reflection through reviews of incident reports and complaints (Dengate, Maher, Miller & Tapfield, 2005, Mona Vale; Eather, 2005, St George; Freeman, Harper & Davies, 2005, Kempsey; Kemsley, 2005, Liverpool); group reflection through practice development (Middleton & Griffiths, 2005, Bankstown; Dempsey, 2005, Gosford; Jones, Rivas & Fairbrother, 2005, Prince of Wales); and group reflection prompted as a result of root cause analysis (RCA) (McDonald, 2005, John Hunter Hospital; Eather, 2005, St George). Reflection inevitably stimulated a review of the relevant literature, in order to ascertain what was already known about the issue that had arisen from reflection. Examples include, but are not limited to, a review of randomised controlled trials on asthma management (McDonald, 2005, John Hunter); a review of the literature on efficacy and methods of establishing community based wound clinics (Hallam, 2005, Goulburn); a search of the literature on orientation into the recovery room (Ashworth, 2005, Bega); a review of the literature on care delivery systems in the acute sector (Summers, Lo & Maguire, 2005, Westmead); an extensive analysis of the literature relating to nurses and patients attitudes to changing care delivery models resulting in a published paper (Gullick, Shepherd & Ronald, 2004, Royal Prince Alfred); and a review of studies identifying those patients most likely to benefit from day surgery procedures (Bothe, Donoghue & Hawley, 2005, St George). Data gathered in the St George day surgery study included research literature on the surgical procedures performed as day surgery outcomes, complications, cost benefit analyses; literature on anaesthetics most appropriate for day surgery; and best practice evidence for the management of pain, nausea and vomiting. Clinical information data were also available from St George Hospital and NSW Department of Health in relation to: The number of patients having surgery for specific procedures eg hernia repair, cholecystectomy Patients ages and genders The length of patients hospital stay (by surgeon at SGH) Readmission rates of patients (within 30 days) Time in operating room for these procedures. 3.3 Analysis of practice The majority of presenters not only identified that problems or difficulties existed through the use of a range of reflective practices, but also took time out to describe and quantify the extent of the problem or difficulty. This strategy was essential to establish baseline data in order to measure improvement, and also enabled staff to ascertain whether or not they had an accurate analysis of the real issue. Observation techniques were taught and developed in a range of settings: as generic tools to assess general care practices such as oxygen delivery (Eather, 2005, St George) and general care and management of mental health patients (Freeman, Harper & Davies, 2005, Kempsey); and also as specialist tools to observe dementia care in the acute and rehabilitation settings (Penning & Claven, 2005 John Hunter & Rankin Park). Work sampling was used to identify the amount of time spent by nurses on direct and indirect care (Dempsey, Gosford; Walker, 2005, St Vincent s Private; Brown, 2005, Royal North Shore Hospital). Process mapping techniques, in relation to care management and delivery practices and patient experiences, were used extensively throughout the Patient Flow and Safety Collaborative, and Dubbo Base Hospital (Dombkins, 2005) and Mona Vale Hospital (Dengate, Maher, Miller & Tapfield, 2005) are identified as successful examples of this technique in the presentations. Similarly, patient journey analysis was used to investigate the difficulties encountered with access block at Nepean Hospital (Crowe, 2005). Brainstorming was described in two presentations as a means of identifying a wide range of possibilities for problem solving (Eather, 2005, St George; Daley, Lynott, McCallum & Bennet, 2005, Broken Hill Base). A PowerPoint presentation on brainstorming has been 10 First report on the models of care project

15 The Presentations provided in the virtual toolkit to assist staff who might wish to use this technique as part of their problem analysis strategy. The Ishikawa or fishbone diagram was also used by Eather to sort and categorise the ideas and issues arising from their brainstorming exercise relating to oxygen therapy administration. Both Eather (St George) and Dombkins (Dubbo) used the Pareto technique to assist the staff to identify their most frequently recurring problems. This technique enabled the team at St George to focus on the most critical issues in their safety and quality improvement activities and the team at Dubbo Base to focus on the most critical issues for their patient flow and safety program. Nominal group technique was used by Dempsey at Gosford Hospital as a consensus planning tool that helped prioritise issues in terms of developing strategies for efficiency and time management to assist with their falls prevention program. Analytical tools were also used to quantify and plan for improvements in management structure and organisational culture. For example, Kemsley at Liverpool Hospital chemotherapy service used a Y analysis technique where participants were asked to identify what they would like to see, hear and feel in their workplace. 3.4 Implementation of evidence-based practice and adaptation of innovations The interventions used to address identified problems drew on best available evidence to improve patient outcomes. For example, a review of the literature on best practice in post-operative oxygen delivery practices was used when staff at St George Hospital identified that patients were becoming hypoxaemic post-operatively following major colo-rectal surgery. Although initially they believed the cause to be poor compliance due to poorly fitting masks, careful investigation and application of evidence-based practice demonstrated that this was not the case. An audit of post-operative patients demonstrated that masks were correctly fitted, but were not worn for the appropriate period or time. The literature revealed that there is a high incidence of hypoxaemia during the 2nd and 3rd post-operative nights, when masks had traditionally been removed to allow patients to sleep because oxygen saturations were significantly improving during the day (Eather, 2005, St George). Other examples of innovation and implementation with evidence-based practice included: nurse-managed clinics for asthma management (McDonald, 2005, John Hunter) walking programs for elderly and demented patients to reduce the incidence of osteoporosis and poor balance following bed rest and anaesthesia and also wandering in dementia patients (Ari, 2005, Port Macquarie) utilisation of discharge planning tools (Winkworth & Barret, 2005, Tweed Heads; Johnson & Toft, 2005, Pambula) the use of dialectical behavioural therapy (Linehan, 1993) in the management of borderline personality disorder patients (Pfizner & Liersch, 2005, Chisholm Ross Centre) the introduction of falls assessment in ED prior to admission in order to facilitate timely handover back into the community (Cooper & Johnson, 2005, Dareton). Adaptations were also evident with: the introduction of dementia mapping tools originally developed in Bradford for dementia care facilities into the acute sector (Penning, Claven & Wild, 2005, John Hunter & Rankin Park) the use of Medical Early Warning Systems (Pittard 2002) to enable inexperienced nurses to identify and act upon gradual deterioration of patients (Eather, 2005, St (George) the education and use of volunteers in a medical ward to feed stroke and other elderly patients (Dengate, Maher, Miller & Tapfield, 2005, Mona Vale) other project leaders developing their own measurement instruments following a review of best practice. For example: Dempsey adapted and validated a falls assessment tool (2004, Gosford) Jones and Fairbrother tested and validated their own self-developed staff satisfaction questionnaire (Jones & Fairbrother, 2004, Prince of Wales). First report on the models of care project 11

16 The Presentations Table 5 Nursing Care Plan completion audit (Rivas, Murray, Davis & Butler, 2005) Percentage May 2004 June 2004 July 2004 August 2004 May 2004 June 2004 August 2004 signature of nurse assessing care 89% 90% 100% mobility needs drawn from plan 93% 100% 100% investigation and process documented 0% 14% 100% dietary needs 74% 71% 100% 3.5 Measurement and evaluation of patient-centred outcomes In terms of patient centred-outcomes, which emerged as a result of the observations and analyses undertaken, wide ranges of data were collected before and after the implementation of innovative strategies. Improvements in patient centred-outcomes included better documentation, reduced numbers of falls and medication errors, reduced numbers of re-presentations to emergency departments (ED) and readmissions, increased numbers of attendance at health promotion activities and primary health care facilities, improvements in a range of mental health outcomes and generic measures of improvements such as reduced numbers of complaints and critical incidents. In terms of documentation, a number of innovations used patient data documentation as a measure of improvement, reporting significant improvements. The nursing care plan completion audit by Rivas et al at Prince of Wales Hospital following the introduction of 12-hour shifts is set out above in Table 5. Audits were also undertaken in this project of bowel habit documentation and armband compliance with similar satisfactory results. Discharge risk screening and estimated date of discharge documentation was audited following the implementation of a major discharge planning quality improvement project at Tweed Heads which demonstrated an improvement in the completeness of the documentation from 76 percent in September 2004 to 95 percent in January 2005 for discharge risk screening and from 62 percent in October 2004 to 91 percent in January 2005 for estimated date of discharge rates (Winkworth & Barret, 2005). Falls risk assessment and the incidence of falls was examined in both in-patient (Dempsey, 2005, Gosford) and out-patient (Cooper & Johnson, 2005, Dareton) settings, with the incidence of falls in the Gosford study falling for the first time in five years as a result of the interventions introduced through practice development. A structured walking and mobility program reduced the monthly incidence of falls by 50 percent at Port Macquarie Hospital (Ari, 2005, Port Macquarie). The introduction of dementia care mapping in acute immunology and respiratory units resulted in a reduction in falls from 10 per month in August 2003 to four per month in August 2004 (Penning, Claven & Wild, 2005, John Hunter & Rankin Park). Medication errors were analysed and shown to reduce following the implementation of team nursing at Broken Hill Base Hospital (Daley, Lynott, McCallum & Bennet, 2005, Broken Hill Base), and safety of medication storage was analysed following 12-hour shift implementation in a medical ward by Rivas et al at Prince of Wales Hospital. Following a major review of infection control strategies at Grafton Base 12 First report on the models of care project

17 The Presentations (Nichols, 2005), improvements were observed in infection control clinical indicators and MRSA audits. Generalist clinical services, usually from discharge planning, local health service or GP referral Re-presentations both to acute and community care were measured. Significant reductions in readmission rates were observed following implementation of discharge planning strategies at Macksville with a reduction in readmission from 12 percent to 3 percent (Zirkler & Taylor, 2005) and early notification of chronic clients to community nurses in Dareton (Cooper & Johnson, 2005). Similarly, following implementation of an At risk assessment, a Well Clinic at Braidwood MPS and the introduction of a case management model (Woodhouse, 2005), reductions in the presentation of the frail aged to the Emergency Department (ED) were recorded. A best practice, nurse-led, wound management clinic implemented by Goulburn community nursing service (Hallam, 2005) resulted in a major reduction (from 20 percent to 3.5 percent) of patients representing to the clinic with wound breakdown and a concomitant reduction in home visiting requirements. This innovation also led to improvements in leg ulcer healing times (from 21 percent to 14.5 percent being treated for less than 6 months) and reduction in overall costs. At the health promotion/illness prevention end of the spectrum, referrals directly from ED to the Goulburn Community Wound Management Clinic increased from 12 percent to 39 percent. Referrals to the pulmonary and cardiac rehabilitation programs at Tweed Heads following implementation of discharge planning strategies (Winkworth & Barret, 2005) also improved. The Regional Health Services Program across the Hunter New England Area Health Service (Abingdon, Mills & Lawrence, 2005, HNEAHS), which provides a Primary Health Care focus to 33 small remote rural communities, has introduced primary health care drop-in centres in these communities. As these centres are a completely new initiative the increase in attendance is self-explanatory, but the drop-in clinics provide a range of preventative services, which include the following: Wellness checks Blood pressure (BP), Blood sugar levels (BSL), and full Personal health (PH) assessment Monitoring of existing health issues, include care planning and support of self-management of chronic disease Health information, education, promotion and support to individuals and groups Information about other service providers Referral to other service providers, GP, Physiotherapy, Women s Health, Diabetes Educator, Pulmonary and Cardiac Educators Working with communities to identify needs and wants Working with groups in the community. Since the introduction of this service, immunisation levels have now been established at 100 percent in the communities serviced and significant improvements in health promotion and illness prevention activities has occurred. Another successful primary health care program is the John Hunter Hospital Asthma Management Service (McDonald, 2005). This is a 2-phase service whereby patients are referred either to the asthma management clinic where they are assessed and taught by an asthma nurse educator or to the severe asthma clinic where they are reviewed by a doctor until stable and then referred to the asthma management clinic. The role of the nurse in the asthma management service is the provision of education, assessment of the level of asthma control in terms of symptoms, and FEV1 and peak flow measurements; assessment of the patient s willingness and ability to self manage and to provide self management support; assessment and correction of skills such as inhaler technique, self monitoring, written action plans, adherence knowledge of medications, trigger avoidance and management. Since the introduction of the program, patient knowledge about asthma management has increased from 70 percent of all patients understanding their disease to 100 percent; from 28 percent to 85 percent of all patients attending the clinic performing regular peak flow monitoring; and from 9 percent to 89 percent of all patients being able to recognise and monitor symptoms of asthma. A range of innovative measures undertaken to improve mental health patient outcomes was presented. A project introducing dementia care mapping (previously First report on the models of care project 13

18 The Presentations only undertaken in dementia specific units) into acute general and rehabilitation units, in addition to the reduction in falls previously mentioned, also resulted in a reduction in incidents of aggression and absconding from the ward (Penning, Claven & Wild, 2005, John Hunter & Rankin Park). The introduction of Dialectical Behaviour Therapy (DBT) for clients diagnosed with borderline personality disorder at the Chisholm Ross Centre at Goulburn resulted in a reduction on para-suicidal behaviour amongst the client group (Pfizner & Liersch, 2005). A walking program introduced at Port Macquarie Hospital has totally eradicated reports of wandering dementia patients since its inception (Ari, 2005, Port Macquarie). Following a major practice review and skill mix restructure at Kempsey Hospital, increased time for group work and therapeutic interventions by staff have been observed (Freeman, Harper & Davies, 2005). More generic undertakings include measurements of patient satisfaction (Hallam, 2005, Goulburn Community; Ari, 2005, Port Macquarie; Wall, 2005, Coolamon Ganmain MPS; Walker, 2005, St Vincent s Private; Woodhouse, 2005, Braidwood MPS) and family/carer satisfaction (Dengate, Maher, Miller & Tapfield, 2005 Mona Vale Hospital; Walker, 2005, St Vincent s Private). To give but one example, a significant improvement in patient and family satisfaction was achieved through the introduction of a nurse-run activity program at Coolamon Ganmain MPS (Wall, 2005). Similarly, the level of patient or family complaints was used as an indicator, with a decrease in complaints being recorded in a number of projects (Dengate, Maher, Miller & Tapfield, 2005; Freeman, Harper & Davies, 2005, Kempsey; Kemsley, 2005, Liverpool; Penning, Claven & Wild, 2005, John Hunter & Rankin Park; Walker, 2005, St Vincent s Private). Other facilities also used a reduction in the number of incident reports as an indicator of success (Kemsley, 2005, Liverpool; Ari, 2005, Port Macquarie). Livingstone at Port Macquarie Base reported a 15 percent reduction in patient complaints on one ward and Perry reported a 23 percent decrease in critical incident reports on another ward following the introduction of changes to staffing levels pursuant to a workload review Measurement and evaluation of staff-centred outcomes Given the need to not only recruit greater numbers of nursing staff, but also and more importantly to retain them, measures of staff-centred outcomes are critical for developing and fostering a culture of retention and staff stability. A recent economic modeling study undertaken by the University of North Carolina demonstrated that the per RN turnover cost estimated in this study ranged from approximately $US 62,100 to $US 67,100, with four cost categories vacancy, orientation and training, newly hired RN productivity, and advertising and recruiting costs accounting for more than 90 percent of the total and per RN costs of turnover (Jones, 2005). On occasions an identified lack of staff satisfaction was the motivator for implementing change (Kemsley, 2005, Liverpool; Ward & Wallace, 2005, Liverpool). However, more frequently the lack of satisfaction was evidenced by vacancies and resignations and staff satisfaction surveys were undertaken in order to provide base line data prior to implementing changes to skill mix and supplemental staffing strategies (Freeman, Harper & Taylor, 2005, Kempsey; Jones & Fairbrother 2004, Prince of Wales; Ronald & Gray, 2005, Royal North Shore; Walker, 2005, St Vincent s Private). In relation to vacancies, a review of the literature demonstrates that the negative reasons why nurses leave the workforce can be crystallised into two main categories: they feel they are not valued and/or they feel unable to deliver the quality of care they would like to provide (Chiarella, 2002). Both of these issues arose in terms of staff dissatisfaction within the presentations and both were successfully addressed through a range of strategies. Many of the negative feelings relating to being valued were often resolved through the emancipatory processes inherent in reflective practice (Penning, Claven & Wild, 2005, John Hunter & Rankin Park) practice development (Dempsey, 2005, Gosford) and action research cycles (Bothe et al, 2005, St George; Daley, Lynott, McCallum & Bennet, 2005, Broken Hill Base and others). Once the nurses believed they could make significant changes to patient management they gained confidence. They developed from task-focused workers who lacked accountability and had a poor sense of professional esteem to a mature group of health professionals who were autonomous, accountable, knowledgeable and engaged. (Bothe, Donoghue & Hawley, 2005) First report on the models of care project

19 The Presentations Similarly, resolution of workload issues (Livingstone & Perry, 2005, Port Macquarie; Kemsley, 2005, Liverpool) and addressing scarce specialist nurse resources in rural areas such as palliative care nurses (Spring, 2005, Cooma), community nurses with expertise in leg ulcer care (Hallam, 2005, Goulburn); infection control specialists (Nichols, 2005, Grafton); and nurse educators (Hutchinson, 2005, Coffs Harbour; Freeman, Harper & Taylor, 2005, Kempsey), also led to improved staff satisfaction and concomitant improvements to service delivery. Workload issues were also resolved by the introduction of both patient free senior staff positions and by increasing the numbers of less-qualified staff, and these will be discussed in greater detail under changes to skill mix (p. 17). On occasions increased patient turnover and reduced length of stay has lessened the opportunity for nurses in traditional models of care to enjoy the connectedness they used to have with their patients and to ensure that their patients receive the quality of care they wish to deliver. This has necessitated a review of care delivery models and patterns. Connectedness with patients has been identified by Manion (2003) as one of the elements that gives nurses joy at work. Indeed, nurses dissatisfaction with the quality and comprehensive nature of care due to changes in service modes was the driving factor in a number of innovative care delivery models. Although these changes were nurse-initiated and affected primarily the work of nurses, the changes were developed with and supported by the medical and allied health staff working in the units. For example, prior to the introduction of a continuity of care model involving the pre-admission clinic and follow-up care for patients undergoing laparoscopic hernia repair and cholecystectomy, the nurses working in the Day Surgery Unit at St George Hospital likened their work to factory floor work. The introduction of these innovations not only improved staff satisfaction, but significant reductions in re-admissions occurred following these types of surgery due to improved pre-operative education and post-operative follow up. The nursing staff in the Chemotherapy Unit at Liverpool Cancer Day Centre described themselves as chemotherapy robots and the unit staffing was down to only 2.4 FTEs out of a potential 16 FTE positions. Exit interview data and the Y analysis previously mentioned were used to identify the issues in relation to dissatisfaction with care delivery. A range of new nursing roles were developed to meet identified and previously unmet patient needs. These roles included specialist chemotherapy administration, in which the nurses educating patients about chemotherapy and side effects undertook holistic care of the patient involving the compilation of a care plan, administering of the chemotherapy and follow up of the patients during and after their treatment. A team leader position was established to give the nurses the opportunity to be in charge of the Day Centre, to ensure efficient workflow, to trouble shoot and problem solve, to facilitate effective and safe nursing practice and to lead by example. A radiation nurse was introduced to attend to dressings, assist with minor procedures, facilitate the efficient flow of patients and provide holistic care to the patients, who had the expertise as a vascular access nurse to insert percutaneous intravenous catheter (PIC) lines. Nurses have also been introduced into the new clinics to provide education to patients, to act as patient advocates and to be developed to run follow-up and treatment review clinics. In addition, new graduates and undergraduate AINs have been introduced into the Centre as a key plank of their succession planning and recruitment strategies. These strategies, coupled with a workload review, have increased the permanent staffing levels to 15.1 FTEs and the unit now has an 88 percent retention rate, increased staff satisfaction, decreased patient complaints and decreased adverse incidents. Both these examples demonstrate the strong association between patient satisfaction and progress and nurse satisfaction. This information is not new. Foley (2002) reports that the literature on hospital employment supports that the same practices that create a positive working environment for nurses are also critical to securing standards of quality patient care. There is now a body of research that supports that the so-called Magnet hospitals have lower complication rates, lower morbidity and mortality rates, higher patient satisfaction, higher staff job satisfaction and lower overall costs (Aiken et al 1994, 1997, 2000). Other measures of staff satisfaction reported in the presentations included recruitment to the unit (Wilson & O Connor, 2005, Campbelltown; Jones & Fairbrother, 2004, Prince of Wales); reduction in the incidence of work-related injuries (Daley, Lynott, McCallum & Bennet, 2005, Broken Hill Base; Freeman, Harper & Taylor, 2005, First report on the models of care project 15

20 The Presentations Kempsey); and engagement in continuing education and updating of skills (Rivas, Murray, Davis & Butler, 2005, Prince of Wales). Reduction in sick leave was also monitored with significant improvement noted at Port Macquarie Hospital (Livingstone, 2005) following introduction of skill mix changes and staffing enhancement following reasonable workloads readjustment (see Table 6). Table 6 Reduction in sick leave on Ward 1C at Port Macquarie Hospital following implementation of Reasonable Workloads strategies (July s high figures due to an infection amongst staff) Percentage July August September October November Changes in skill mix Perhaps some of the most challenging issues addressed and discussed in the Roadshow were the changes to skill mix and to care delivery models. Whilst the shortage of nurses has been well documented in the past (DEST, 2002), there is currently an improvement in workforce numbers, with a 10.2 percent increase in nursing numbers occurring in NSW between January 2002 and December 2004 (Baker, 2004). This number has continued to rise into Furthermore, there is now no difficulty attracting people to take up nursing as a career, both at university as undergraduates (U/G) and at Technical and Further Education institutions (TAFE) at trainee enrolled nurse (TEN) level. However, the difficulty with undergraduate places is that they are Commonwealth funded and whilst there has been some increase in funded undergraduate places to NSW this year, the numbers were insufficient to meet either the demand for undergraduate places (Baker, 2004) or the need for extra funded undergraduate places calculated in the Report of the National Review of Nursing Education Our Duty of Care (DEST 2002). In order to supplement the registered nurse (RN) workforce, and in light of the very recent changes to TEN education in NSW where enrolled nurses (ENs) are now being educated to administer medications, a decision was made to increase TEN numbers in 2005 and to offer ongoing contracts to TENs as ENs on completion of their course. This clearly has the potential to alter the predominantly all-rn skill mix, particularly in metropolitan areas. In rural base hospitals there is a much higher representation of ENs in the workforce. However, as TENs are not supernumerary and are counted in workforce numbers, the potential for dissent was still present, as all novice nurses need careful mentoring and preceptorship in order to consolidate nursing theory and practice and develop their clinical nursing skills. To this end, additional funding has been allocated to areas where extra TENs are being employed to assist with mentoring and preceptorship. Another change in skill mix has been the introduction of specific positions for undergraduates to work as Assistants in Nursing (AINs). Undergraduates from all disciplines have always taken part-time employment in a range of industries in order to support themselves during university. Whilst some nursing students worked in retail employment and other fields, many were already working as AINs, particularly in the aged care sector. Where hospitals have employed undergraduates as AINs they found that good relationships developed between the students and permanent staff and a level of brand loyalty resulted, with these AIN undergraduates often returning to their employing hospital on graduation. Working with the New South Wales Nurses Association (NSWNA), NSW Health has developed a policy Employment of Undergraduate Nursing Students as Assistants in Nursing in the Public Sector, PD2005_214, which details the environment in which these undergraduate AINs must function. This approach is a relatively recent innovation and is only now beginning to be more widely adopted, thus one intent of the Roadshow was to showcase successful models of changed skill mix in order to inform about the factors that needed to be in place for such changes to succeed. The presentations demonstrated a wide range of skill mix changes, all of which were ultimately highly successful and popular. 16 First report on the models of care project

21 The Presentations All skill mix changes presented were undertaken following one or more of the emancipatory processes discussed earlier, such as reflective practice, practice development and focus group work. However, the adjustments required were on occasions both challenging and far-reaching and necessitated an iterative approach to developing the new models of care delivery practice, with ongoing consultation and support to the staff. Where funding was available, independent facilitators or project leaders were used to assist with research and group work, particularly where contentious issues were being discussed and this was strongly recommended by presenters. Several sites had made links with universities in order to achieve these outcomes (Bothe, Eather (UTS), 2005, St George; Brown (UTS), 2005, RNSH; Dempsey (UTS), 2004, Gosford; Griffiths (UWS), 2005, Liverpool; Jones & Fairbrother (USyd), 2004, Prince of Wales; Middleton & Griffiths (UWS); 2005, Bankstown; O Connor & Wilson (UWS), 2005, Campbelltown). As previously discussed, decisions to effect skill mix changes often came about due to shortages of permanent registered nurses, either full or part time. A further driving force was a level of dissatisfaction with a lack of staff stability and the workload created by repeatedly having to orientate new casual staff, often from agencies, but also on loan from other wards to relieve shortages. In a UK study examining the relationships between grade mix, staff stability and features of ward organisational environment, Adams & Bond (2003b) identified that the number of staff on the ward, rather than the skill mix, had the greatest impact on nurse satisfaction, devolving organisational structures and clinical innovation. Further, they reported that stability of staff was the single most important influence on professional practice. Professional practice was described as an amalgam of factors including clinical education, mentoring, performance appraisal and staff development. In order to effect such changes, there was inevitably a need to understand the work of the organisation and the teams used a range of the evaluative processes described earlier such as work sampling, process mapping and observational techniques to identify how work could be done differently and by whom. The changes to models of care and ward organisation will be described, but innovations in RN skill mix included identifying a patient free shift co-ordinator or team leader to free up the remainder of the staff to deliver patient care without having to worry about discharges, admissions and transfers (Freeman, Harper & Davies, 2005, Kempsey; Jones, Rivas & Fairbrother, 2005, Prince of Wales; Kemsley, 2005, Liverpool), teaching generalist RNs skills formerly only performed by specialist nurses in order to form generalist/specialist partnerships in community care (Hallam, 2005, Goulburn Community; Spring, 2005, Cooma) and investing in RN staff development to ensure competent multiskilled professionals, particularly in small rural sites (York, 2005, Byron Bay; Hanna, 2005, Nimbin). Changes relating to EN skill mix included the introduction of ENs for the first time into an all-rn workforce (Freeman, Harper & Davies, 2005, Kempsey; Walker, 2005, St Vincent s Private), increasing permanent EN numbers to improve staff stability in the workforce (Livingstone & Perry, 2005, Port Macquarie) and extending the roles of ENs to include medication administration (Freeman, Harper & Davies, 2005, Kempsey; Kemsley, 2005, Liverpool; Jones, Rivas & Fairbrother, 2005, Prince of Wales; York, 2005, Byron Bay). In terms of the introduction of AINs, there was a significant shift towards introducing U/G AINs, not only into general wards where the majority had formerly been introduced, but also into specialist areas such as ICU (O Connor & Bolsom, 2005, Campbelltown), Paediatric Emergency Department (Wilson, 2005, Campbelltown) and Cancer Day Care Centre (Kemsley, 2005, Liverpool). Whilst U/G AINs were seen by the majority of presenters to offer greater potential in terms of recruitment and retention of future RN staff, some areas also opted to introduce AINs with Certificate III (Ronald & Gray, 2005, RNSH; Walker, 2005, St Vincent s Private). The positive aspect of recruiting Certificate III AINs was that they were regularly available, whereas the U/G AINs, although having more knowledge and expertise than the Certificate III AINs, were sometimes unavailable due to study and practicum commitments. Certificate III AINs were also used for specific tasks, such as mobility assistants at Port Macquarie Hospital (Ari, 2005) and for collecting and checking patients into theatre at Dubbo Base Hospital (Dombkins, 2005). First report on the models of care project 17

22 The Presentations All presenters who introduced increased numbers of inexperienced staff endorsed the need for sufficient preceptors and/or educators to support and supervise the new staff (see Gullick, 2004, Royal Prince Alfred for a review of the literature). This need is also one of the key resource issues that emerged from the analysis of the evaluations. Other important additions to ward staffing included after hours ward clerks to answer telephones and thus avoid staff having to leave patients who might be at risk of falling (Dempsey, 2005, Gosford). 3.8 Changes to models of care delivery Perhaps the most consistent shift in changes to models of patient care delivery occasioned by the changing skill mix was a move away from patient allocation towards some form of team nursing model. The major forms of patient care delivery models are task nursing, also known as functional nursing; team nursing, also known as mixed mode nursing and patient allocation, also known as total patient care and primary nursing, also sometimes described as case management (Gullick, Shepherd & Ronald, 2004; Tiedeman & Lookinland, 2004). Patient allocation has been the primary model of patient care delivery since the move to the tertiary sector and a whole generation of graduates have been educated to deliver patient care in this way. It was introduced in response to a growing recognition of the need for total patient care, whereby nurses cared for and thus got to know the whole patient, rather than the patient s care being fragmented into a series of tasks. Whilst the patient allocation system works well when there are sufficient numbers of highly qualified RNs to deliver patient care, Gullick s review of the literature (2004) demonstrated that most studies fail to show superiority of any one of the above models in terms of patient satisfaction. (Courtney & Berger 2000; Sago 1999; Gardner 1991). Furthermore, the patient allocation model does not deliver continuity of care or improved knowledge of the patient if patient allocation is changed on a regular basis or there is little staff stability due to agency and casual usage. In addition, there is little facility for supervising or teaching inexperienced or new staff in a patient allocation system, which could compromise safety and quality of patient care. From the patient s point of view, the actual model of care delivery is not the issue, but patient satisfaction is high when continuity of care and communication are maintained (Tiedman & Lookinland, 2004). Rather than return to a purely functional or task-focused model, the presenters described a range of models based on teaming experienced permanent nursing staff (both RN and EN) with less experienced or casual staff. Team Nursing is based on a philosophy that supports the achievement of goals through group action. Each member is encouraged to make suggestions and share ideas. When team members see their suggestions implemented, their job satisfaction increases, and they are motivated to give better care. Mariner-Tomey (1996) A wide range of teaming systems were described, ranging from establishing two or more evenly matched teams (Jones & Fairbrother, 2004, Prince of Wales; Daley, Lynott, McCallum & Bennet, 2005, Broken Hill Base); establishing partnerships in care of RNs with ENs and AINs (Walker, 2005, St Vincent s Private) and organising the ward and concomitant staff allocation into zones according to patient acuity (Perry, 2005, Port Macquarie; Summers, Lo & Maguire, 2005, Westmead). Despite initial readjustment difficulties, which invariably required further group work and facilitation, the outcomes across a range of patient and staff measures were consistently positive. Improvements were noted in terms of staff satisfaction and work enjoyment (Jones & Fairbrother, 2004, Prince of Wales); recruitment and retention of staff and reduction in sick leave (Livingstone, 2005, Port Macquarie); improved team spirit and a cleaner ward environment (Summers, Lo & Maguire, 2005, Westmead) and a reduction in vacancies by 50 percent (Walker, 2005, St Vincent s Private). In terms of patient outcomes, Livingstone (2005, Port Macquarie) reported a reduction in clinical incidents by 23 percent and a reduction in patient complaints by 15 percent. These findings are consistent with the literature, which shows that patient satisfaction, job satisfaction and motivation have been shown to improve with a change from patient allocation to allocation within a team framework (Gollard & Soo Hoo 1993; McGillis Hall & Doran, 2003; O Connor 1994). 18 First report on the models of care project

23 The Presentations The challenges experienced by the RNs through the introduction of teaming programs related to their skills in performance management, clinical education and delegation. Patient allocation does not facilitate clinical education, as RNs work in comparative isolation, with sole responsibility for a group of patients and little contact with other staff members. In the patient allocation model, education of inexperienced staff was perceived to be the responsibility of clinical educators and academics, while RNs were expected to deliver all aspects of patient care. In reality, because the RN staff provide a 24-hour presence with patients in hospitals, much work which does not fall within the domain of nursing care also falls to them. Identifying what work ought to be the domain of RNs and what work could be allocated to other levels of nursing staff and/or non-nursing staff has provided an important focus within the models of care work to date. These issues will require further discussion as they also emerged as key issues from the evaluations. In terms of staff satisfaction, team nursing provided improved satisfaction for all levels of staff, but most particularly for new graduates (Jones & Fairbrother, 2004, Prince of Wales). Jones and Fairbrother also identified that initially ENs experienced less satisfaction with the shift to team nursing, as there was a risk of tasks being allocated on a hierarchical basis. Other studies have also shown that inexperienced nurses like team nursing, but not task allocation (Coates & Gormley, 1997, AUTC, 2002). However, following further facilitated group work, an improved balance of work and recognition of the skills of experienced ENs has created improved work satisfaction for them. Jones & Fairbrother s study also revealed that work satisfaction decreased with years of experience as an RN and this has important implications for the future co-ordination and organisation of models of care. For example, Dempsey (2004, Gosford) identified that experienced nurses perceived a tension between technical work, which they identified as must do work, and caring work, which they identified as should do work. However, they derived their greatest job satisfaction from the caring work, whereas inexperienced nurses focused on and derived satisfaction from achieving the more technical aspects of patient care (Gustafsson & Fagerberg, 2004). Consideration needs to be given to the way work is allocated to nurses in order to achieve maximum staff satisfaction coupled with improved patient outcomes. In a review of models of care in a major teaching hospital in another state, Fitzgerald et al (2003) identified that there was a need for better recognition and utilisation of advanced clinical nursing skills. A review undertaken in the UK also highlighted the need to examine closely the way in which the skills of nurses in advanced practice roles are used to complement the team (Dewing & Reid, 2003). The question of the clinical teaching role of the RN was also regularly raised both in discussion and in the evaluations. Jones and Fairbrother identify that team nursing is better for teaching clinical decision-making and skills, but clinical teaching has not been considered an integral part of the RN role under a patient allocation model. The issues around the re-emerging clinical teaching roles for experienced RNs require further deliberation, as strong mentorship has been identified as essential to learning clinical practice (Coates & Gormley, 1997) and clinical decision-making is recognised as being best taught and articulated by experienced clinicians (Boney & Baker, 1997). However, Clifford (1997) points out that many RNs do not have a research background and therefore feel at a disadvantage teaching graduates and do not feel fully conversant with topics such as evidence-based practice. In addition to the clinical teaching role, the issue of research competence has emerged within the evaluations as an ongoing major theme and will be addressed within the recommendations. 3.9 Changes to organisation of care As part of the work of reviewing practices to improve patient flow and safety and/or to find time to introduce new strategies to improve patient care delivery practices, many aspects of nursing care organisation were reviewed and changed. Perhaps one of the most controversial (and as yet unresolved in some areas) was the question of shower times and frequency. There is no doubt that attending to a patient s personal hygiene is seen as a critical and integral part of nursing work, providing a time to interact with the patient and to obtain a careful visual assessment of the patient s skin integrity and condition, as well as their response to First report on the models of care project 19

24 The Presentations physical exertion. Traditionally, patients have been showered or given bed baths early in the morning, to coincide with bed making and to set the patient up for the day ahead. However, with decreased length of stay, day of surgery admission and increasing transfers and movements from the wards for tests and examinations, there is not the same stability of the early morning ward environment. Indeed, Jones & Cheek, in a review of care practices across Australia, make the observation that no longer is there such a thing as a typical patient day (2003). For such reasons a number of wards reported having explored the issue of shower times (Dempsey, 2004, Gosford; Dombkins, 2005, Dubbo) and patients were surveyed to ascertain how frequently and at what times of the day they wished to be showered. The results demonstrated that overall the patients were not as concerned as the nursing staff about having their showers or washes first thing in the morning, but Dempsey (2005) demonstrated that changing this practice was difficult for nurses, as having patients feeling clean and tidy gave the nursing staff a sense of achievement and satisfaction. Achievement correlated strongly with nurses finding joy at work in a study undertaken by Manion (2003), along with connectedness, enjoyment of the work and recognition for work well done Changes in rostering Following such changes in work re-design, changes in rostering also occurred to facilitate the workload hotspots and to provide support for permanent staff when it was most needed. Such changes ranged from the highly successful introduction of 12-hour shifts at Prince of Wales Hospital (Rivas et al, 2005) and in the Surgical Intensive Nursing Unit at Port Macquarie (Perry, 2005) to the introduction of short school-friendly shifts (10am to 2pm with workload organised accordingly) at Dubbo (Dombkins, 2005). Other shifts introduced varied widely, with one of the most unusual, but most successful, being a 6pm to 2.30am shift at Port Macquarie (Perry, 2005). Many other aspects of work organisation that might have formerly been considered to have fallen into somewhat ritualistic practice had been explored by the presenters and their teams, including handover (Dempsey, 2004, Gosford; Daley, Lynott, McCallum & Bennet, 2005, Broken Hill Base); falls assessment (Cooper & Johnson, 2005, Dareton; Dempsey, 2004, Gosford); discharge assessment (Winkworth & Barret, 2005, Tweed Heads) and medication ordering and systems (Dempsey, 2004, Gosford). In addition, work was examined to see if other categories of staff might perform different aspects, for example medication administration by ENs (Kemsley, 2005, Liverpool; York, 2005, Byron Bay); ECG recording by Certificate III AINs (Walker, 2005, St Vincent s Private); collection of paediatric admission data by U/G AINs (Wilson, 2005, Campbelltown); experienced ENs taking team leader/ supernumerary co-ordinator position (Jones, Rivas & Fairbrother, 2005, Prince of Wales) and having after hours ward clerks to answer the telephones. 20 First report on the models of care project

25 Evaluation of Roadshow 4 After each workshop, an evaluation form was distributed to the participants. One of the aims of the evaluation was to identify to what extent the sessions were felt to be of value to the participants. The participants were asked to rate on a Likert scale of 1 5 (1 = of no value, 5 = extremely valuable). See Appendix A. The second aim was to stimulate debate and discussion in relation to models of care delivery. Three open-ended questions were asked: list the three major issues or ideas the workshop raised for you (these can be positive or negative) comment on any future directions or future issues you would like to see explored further other comments 4.1 Key issues arising from the Roadshow evaluations for participants The evaluations from the Roadshow have been set out in two concept maps. Concept Map 1 (p. 25) identifies the key issues and ideas arising from discussions in the Roadshow and Concept Map 2 (p. 26) groups comments on future directions and initiatives for the Models of Care project. Seven key issues emerged from the Roadshow discussions for the participants. These were categorised as: the need for further education in models of care and practice development (n=525) the need for clinical supervision (n=149) issues relating to research (n=149) Response rate Six hundred and seventy-seven (677) participants completed the evaluation form, a response rate of 76 percent. Of the 677 returned forms, 56 percent were from metropolitan workshops while the remaining 44 percent were from rural sites. leadership development (n=102) safety and quality (n=76) nurses roles/scope of practice/multidisciplinary workforce (n=57) barriers (n=50). Data analysis Responses were entered into an Access database. Thematic analysis of qualitative responses was undertaken and the results were coded before being entered into the database. Statistical Package for Social Sciences (SPSS) was used to summarise the data. While analysis was undertaken after each workshop to assess the usefulness of the sessions, this analysis is not presented in this report because the content of each workshop session was different. Categories were used to summarise the qualitative responses and then further condensed into themes. As previously stated, the evaluations were extremely enthusiastic and positive overall, with comments such as inspirational, motivational and encouraged me to think outside the square being very much the norm. However, the key purpose of the evaluation was not to ascertain whether or not the participants had enjoyed the workshop, but rather to try to understand what key issues the Roadshow discussions raised for participants and what future directions and initiatives they would like to see considered in the Models of Care project. Nine suggestions for future direction were made. These were: nurses roles/scope of practice/multidisciplinary workforce (n=167) the need for further education in models of care and practice development (n=119) the need for clinical leadership development (n=122) the need for clinical supervision (n=114) miscellaneous ideas for future (n=68) workload (n=37) barriers (n=31) research education and utilisation for clinicians (n=22) make website interactive (n=6). The items are assigned within categories, but in reality almost all of the issues have significant overlap. Similarly, there is significant overlap between the ideas that arose within the workshop and the suggested future directions. For this reason, the ensuing discussion of the evaluation will address the issues First report on the models of care project 21

26 Evaluation of Roadshow arising from the Roadshow and any overlapping future direction together The need for further education in relation to models of care and practice development This was overwhelmingly the largest category in the evaluations and comments relating to this need are set out in the concept map. In particular, the need to engage and involve more ward-based clinical nurses was highlighted. There will undoubtedly be a need for a second round of the Roadshow, probably at the beginning of It is recommended that the original workshop program would need to be repeated, but the audience would need to be more clinically based RNs and ENs. In addition, a more strategic workshop will need to be held with the original attendees to ascertain progress and to provide the impetus for more widespread local practice development. By this stage it is anticipated that links will have been made with academics to enhance facilitation and outcome measurement. In addition, key themes that dominated the categories around the need for further information included the management of change, teamwork, skill mix changes and flexible work practices. Reference was repeatedly made to elements of practice development work in terms of the need to learn more about the philosophy of care development, reflective practice, introduction of evidence-based practice and greater emphasis on patient-focused care delivery models. The evaluations demonstrated that, although the work being undertaken across the state was sometimes quite new and challenging to other clinicians, they often had no prior awareness of such innovations taking place and were keen to learn more. This lack of awareness can in part be attributed to the fact that clinical nurses tend not to publish their work, as publication is largely seen as the work of academics and too time consuming. There is a need for much stronger and co-ordinated links between academic and clinical nurses and between sites of innovation to enable larger cohorts for evaluation and benchmarking. Such links and ongoing work in models of care will require strong local support and leadership and must be a key role for Area Directors and Directors of Nursing and Midwifery Nurses roles and scope of practice There was considerable comment around this topic both within the workshops and in the evaluations. Issues relating to roles, scope of practice and delegation of work were flagged both in relation to differing grades of staff, eg RNs, ENs and AINs, but also in relation to differing specialties such as community nurses, rural and remote nurses, midwives and mental health nurses. Delegation, clinical teaching and performance management of other grades of clinicians were identified as areas in need of further development and guidance. The Chief Nursing Officer, NSW (CNO) is a member of the National Nursing and Nurse Education Taskforce (N3ET) which is already exploring the issue of scope of practice. The Queensland Nursing Council Scope of Practice and Decision-Making Framework has already been adapted and used by the Western Australian Government and is strongly supported by a number of national nursing organisations for its flexibility and adaptability. The CNO has recommended that this Framework be utilised to provide effective guidance and leadership for the profession in NSW until the question is resolved nationally. The clinical teaching role of RNs received significant scrutiny in the workshops and was the subject of some heated debate. Whilst some RNs have taken on a teaching and mentoring role within a team-nursing framework, others situate this work firmly within the ambit of clinical nurse educators and preceptors employed by the university. However, the Australian Nursing and Midwifery Council identifies that RNs ought to contribute to the learning experiences and professional development of others as part of the RN National Competency Standards (ANMC, 2002). There is a need for careful negotiation and analysis of the workload associated with taking back this clinical teaching role, as at one end of the spectrum the role of the RN in the clinical teaching of inexperienced staff is essential for safe and effective delivery of patient care. However, it is equally important that such work does not impact on the RN s own ability to deliver safe and effective patient care. This debate resonates/articulates with the review currently being undertaken in relation to clinical placements and requires further co-ordination and deliberation. 22 First report on the models of care project

27 Evaluation of Roadshow Clinical leadership development The importance of clinical leadership in both introducing and supporting practice development and clinical improvement was strongly identified by nurses. Senior management needs to be supportive of clinically driven change, but for the change to occur, the clinical leaders Nursing Unit Managers, Clinical Nurse Consultants and Specialists, Nurse Practitioners and Clinical Educators need to be confident in and conversant with change management strategies, facilitation and differing, innovative models of care. This requires and needs education about practice development and skills in clinical teaching as discussed above, as well as personal and professional development to enable them to work collaboratively and supportively with intra and inter-disciplinary teams. The Clinical Leadership Program (CLP) is currently being sponsored by the Nursing Midwifery Office, NSW Department of Health and evaluation of the CLP is underway. The CLP was described enthusiastically by participants at almost every workshop as being a key vehicle for personal and professional development and for patient care delivery improvement. The CLP and the Models of Care Project both resonate with the recommendations of the Australian Council for Safety and Quality in Health Care regarding safe staffing, in relation to understanding the impact on patient safety of skill mix, staffing numbers and role delineation, the need to explore different ways of meeting the staffing needs of the system with the available and potential workforce and in relation to the need for improved team work (ACSQHC, 2003) Clinical supervision In addition to the need for clinical education and leadership, the participants identified the need for clinical supervision and other formal strategies for assisting with reflective practice and mentoring. Such strategies foster professional and clinical development for less experienced staff and address work-related issues in a structured and timely manner. Clinical supervision has been defined as a support mechanism for practising professionals within which they can share clinical, organisational, developmental and emotional experiences with another professional in a secure, confidential environment in order to enhance knowledge and skills. This process will lead to an increased awareness of other concepts including accountability and reflective practice (Lyth, 2000, p.728). Clinical supervision has been demonstrated to be an effective format for exploring issues concerning professional practice, allowing nurses to learn from each other, offer support, recognise how others see and esteem them as fellow workers, and moderate concerns and anxiety related to their work (Jones, 2003, p.224). Managing stressful situations through reflection and support has been demonstrated to reduce turnover and improve retention and well being amongst nursing staff (Thomas, 2004). Given the need to retain new graduates, new ENs and a more experienced nursing workforce, support in a rapidly changing health environment is critical (Lumby, 2001) Safety and quality The models of care work, clinical leadership, clinical supervision, resolution of workload issues and practice development all impact positively on recruitment and retention and improvement in care delivery. Many of the strategies and changes that were presented in the Models of Care Roadshow had their genesis in safety and quality improvement activities. The Models of Care agenda is inextricably linked to the safety and quality agenda, and strong links should be further fostered between the two. The work identified through the Models of Care Roadshow is entirely consistent with the work being undertaken within the Health Systems Performance Division and will provide a valuable basis for the work of the Clinical Redesign Project Research utilisation and development The need to use and understand research findings and methods was identified in the evaluations by a significant number of participants and highlights a growing interest amongst clinical nurses. Certainly the range of research methods used in the analysis and evaluation of the innovative Models of Care presented during the Roadshow indicates a level of confidence and familiarity with research that is most encouraging and reflects the number of clinical nurses currently undertaking postgraduate studies, with a sizeable number studying at doctoral level. However, as previously stated, there is still a real need for nurses to publish their work, and for the use of evidence based practice to be supported and encouraged in the workplace through the provision of access to computers and structured time to facilitate the access. Publishing the work of clinical nurses and midwives 23

28 Evaluation of Roadshow can also be supported through stronger links with universities and other educational bodies Barriers A number of barriers were identified in terms of difficulties in implementing innovative models of care. The first was the need for adequate resources to support staff in terms of access to education and support and education for new staff. This barrier has already been addressed in previous recommendations. The second is an issue that is regularly raised by nurses at clinical fora, which is the requirement for nurses to be re-accredited annually in clinical skills such as venepuncture. In addition to annual reaccredidation, nurses also have to be reaccredited when they move from AHS to AHS, meaning that a RN who might have been competent in venepuncture in one AHS yesterday is not permitted to perform it the following day should the RN change employers. The traditional approach to clinical skills education in nursing has been that pre-registration education prepared nurses for the necessary skills for safe practice at entry point to the profession. Any widening of that range and enhancement of the nurse s practice requires official extension of that role by certification. The policy setting out that requirement has been unchanged in NSW since the publication of HC 91/22 Guidelines for the hospitals seeking to extend the practice of health professionals. However, the ANC Code of Conduct (2003) states that nurses are personally accountable for the provision of safe and competent nursing care and that each nurse is responsible for maintaining the competence necessary for current practice. In addition, the Queensland Nursing Council (QNC) has commissioned research into the scope of nursing practice and has published a Scope of Nursing Practice - Decision-Making Framework. This document is described as a tool that provides guidance for individual nurses, the nursing profession, other health care personnel, health service providers and the public in making decisions about the scope of practice in a variety of health care settings (QNC 2000). This Decision- Making Framework has been discussed previously in terms of delegation of duties to other grades of staff. However, individual nurses could also use this Framework to identify the limitations of their competence and to seek reaccreditation or education if they felt they were not competent to perform a particular skill. If the onus of responsibility were placed on the professional to ensure ongoing competence and the employer to provide opportunities for updating and developing clinical skills, much duplication and waste could be avoided. 4.2 Key recommendations Four key recommendations have been identified from the evaluations, which are set out at the beginning of this report with recommendations for action contained within them. Firstly, the Report recommends the need for further work to be undertaken in relation to models of care to improve patient outcomes. It recognises that such work will require education in management of change, teamwork, skill mix changes and flexible work practices in order to ensure spread and sustainability of innovation. Specific actions are identified to achieve this recommendation. Secondly, the Report recommends that, in order to maximise synergies and avoid duplication, the Nursing and Midwifery Office continue to work closely with other sections of NSW Department of Health, particularly the Clinical Redesign, Safety and Quality, and the Workforce and Leadership Branches and also the Clinical Excellence Commission. Thirdly, the Report recommends that, in light of the many changes occurring within patient care delivery systems, a clear but flexible framework be developed for nurses roles and scope of practice in order to ensure patient safety. Fourthly, the Report recommends increased support for research and analytical activities in the workplace as these are clearly demonstrated to improve patient safety but also staff satisfaction, stability and retention. 24 First report on the models of care project

29 First Report on the Models of Care Project Models of care show comments on issues/ideas arising from the workshop. Concept Map 1 Conceptual representation on comments on issues/ideas from the Models of Care Workshops Need for Nurse education in PD/MOC (n=525) Nurses roles/scope of practice/multidisciplinary workforce (n=57) Leadership development (n=102) Role expansion, flexibility, approaches of MOC/zoning, scope of work practice...81 Acceptance of AIN in acute nursing; nurturing AIN into areas of need...21 Encourage/support other professionals to engage in change eg MO, allied health...12 Replacement of RN with inexperience staff... Bedside nursing is still valued/reinforce patient oriented service...7 Clinical teaching /supervision as part of the RN s role...7 Importance of clinical leadership/mentorship...27 Help to develop NUMs in order to support MOC concept...24 Need strong nurse leaders to stand up for nurses...13 Need for public awareness...9 What is success/measure success...9 Some NM cannot empower staff/delegation issue...7 Socio pathological phenomenon of oppression...6 Nurses becoming more political/nurses to become more vocal...4 Need to raise profile of community nursing...3 Importance and strategies to manage skill mix, flexible work practices, team work Exchange ideas, think outside the square, sharing of knowledge...89 Reflective practice/imperative to use reflective practice...62 MOC possibilities, effective mover for change, need to explore MOC...47 Methods of how to implement or bring about change/how to convince RNs...38 Change value of research to bring about change...28 To be creative try new MOC in ward/ new values...27 Acceptance of AIN in acute nursing; nurturing AIN into areas of need...21 Importance of philosophy/nursing values and standard of care/nursing ideology...23 Empowering nursing thinking...22 Re-affirming (action research, change model, research into practice)...20 Team nursing implication for staff; concern x quality of education for ENs & AINs...13 Need to be patient focused instead of nurse focused/ who are we here for...12 Team nursing may be an effective MOC/is the flavour of MOC...8 Reiterate importance of consumer focused care/patient focus..4 Clinical Supervision (n=76) Safey & Quality (n=76) Importance of recruitment and retention and implementation strategies...31 Recruitment/retention; state is addressing the problem...19 Need to/how to support and educate new staff and RN...17 Communication major issue/an issue for the workplace...7 Improve discharge planning process...2 Respect, caring for others: valuing ourselves and our profession...50 Importance of self-care...49 More support to improve workplace culture/ difficulty in changing culture highlighted...36 Importance of Job satisfaction Barriers (n=50) Research (n=149) Note: Numbers in the boxes are number of responses (Total no.=189). Number of nurses responsed to this question = 568 Need to explore resource issues and funding for nursing...27 Need funding/resources to drive MOC...14 More in-service for staff...4 Constant reaccreditation as an RN -yearly assessment, PCA etc....2 Need national/state interface to provide health care...3 Importance of safety & quality/ process mapping...74 Review of literature/need for educating nurses on literature review...21 Research to identify appropriate models/partnership with Universities in research/incorporate into unit...20 Use of language, language frames reality/articulate our practice...20 Need to look at different definitions of success, and evaluate MOC...6 Use of sampling tool kits...5 Evaluate clinical supervision programs and their effectiveness...3

30 26 First report on the models of care project Models of care Roadshow comments on future directions or future issues arising from the workshops. Concept Map 2 Conceptual representation on comments on future directions or ideas from the Models of Care Workshops More Education on PD & MOC (n= 119) Nurses roles/scope of practice/multidisciplinary workforce (n=167) Clinical Supervision (n=114) Leadership (n=122) Research for clinicians utilisation/education (n=22) Barriers (n=31) Workload (n=37) Make website interactive (n=6) Ideas for future (n=68) Clinical career paths...32 More EN/TEN Issues; MOC practical approach at a ward level...29 Explore issues on community nursing (not able to utilise AINs) primary healtcare in community...18 Collaborative care nurses work with GP, MO/involve other disciplines...13 Strategy addressing midwives shortage/moc for midwifery...10 Enhance EN role/ens as mentors or assessors for TENs...10 Increase recognition of generalist expert nurses...6 Regulation of AINs...6 Increase recognition of generalist MOC to include ward assistants to perform non-nursing duties...4 Midwives sharing their roles (with ENs, AINs)...4 More realistic view of NP/focus on NP generalist role...3 Integrate hospital and community care in nurses' mind...3 Articulate AIN to EN as a traineeship...3 Communication ward rounds by modern matron connecting with staff...2 MOC for mental health...2 Utilising undergrad AINs/award framework...2 MOC that integrates acute and community care...1 Address staff's fear/resistance to change and motivate staff/ how to actually implement change...30 Clinical leadership program/ for RN/increase no. of clinical leaders...30 support senior managers/rns to promote and support innovation/change...24 Empower nurses/ how to help fellow workers feel better about themselves/value, respect...19 Staff education to be a priority/ce must be supportive to change...13 Educate nurses on issues of aggression by means of CD...4 More secondments to other AHS...2 More funding for nurse education within hospital...18 Standardisation of policies and forms...8 Short term accommodation for nurses/childcare availability...5 Develop a website where Qs and As can be posted/discussion forum on the website..5 Use of website to facilitate mentoring of managers...1 Engage nurses on the floor (in decision making, change, and road show for them)...46 More time allocated for discussion in future forums...9 Follow up workshops...8 Follow up road show with focus groups...5 Need to analyse/explore MOC (results, perspective, practical applications, values)...29 More on practice development...18 Practical workshop on how to develop MOC...16 Communication/continuous feedback from nurses involved in successful changes...11 Educate undergraduates about MOC...9 Promotion of values in all work places...7 Use volunteer programs to free up nurses...4 Focus more on consumer satisfaction...2 Use MOC to attribute accountability etc....2 Further data on 12-hour shifts to see if excellent improvements are sustained...1 Clinical supervision model/more funding to support AINs and undergraduates in workplace...35 Need mentor at ground level/importance of preceptorship...27 Need to support staff better in team work...21 More Clinical Educators for wards...16 Internship for new graduates to consolidate clinical practice/ increase clinical practicum for undergraduates...9 Consider emphasis on self-care...3 Evaluate Re-connect strategy level of clinical and theory support offered to Re-connect nurses...3 Strengthen clinical research priorities/more resources for evaluation/research...16 Language as a key to change/to describe MOC/to describe what we do...6 Need to understand workload/explore workload issues...24 How do we argue positive points to get more NHPPD (Nursing Hours Per Patient Day)...4 Impact of Workload tool on Models of Care...3 Increase workload on educating "new staff"...3 Shorter working week for nurses...2 Increase workload computerised system (Cerner/PAS, IIMS)...1 Note: Numbers in the boxes are number of responses (Total no.=666). Number of nurses responsed to this question = 414

31 Conclusion 5 The Roadshow was an extraordinary event at a time of significant upheaval due to the restructure of the NSW Area Health Services. Notwithstanding the significant changes and uncertainty that any restructure brings, professionalism, enthusiasm for their work and passion for patient care was repeatedly demonstrated throughout the presentations by the nurses listed at the end of this report. This Report is a celebration of the calibre and professionalism of the nursing workforce in NSW. It has been one of the greatest privileges of my professional career to have engaged in the discussions and debates about nursing practice with my peers and I would like to thank the nurses and midwives of NSW for their generosity and enthusiasm; Kathy Baker, the Chief Nursing Officer for the opportunity to run the Roadshow; and the staff of the Nursing and Midwifery Office for all the hard work and logistical support they gave me in the planning and organisation of the program. First report on the models of care project 27

32 References Adams, A., & Bond, S. (2003a). Staffing in acute hospital wards: part 1. The relationship between the number of nurses and ward organisational environment. Journal of Nursing Management, 11, Adams, A., & Bond, S. (2003b). Staffing in acute hospital wards: part 2. Relationships between grade mix, staff stability and features of ward organizational environment. Journal of Nursing Management, 11, Aiken, L.H., Smith, H.L., & Lake, E.T. (1994) Lower Medicare mortality among a set of hospitals known for good nursing care, Medical Care, 32, Aiken, L.H., & Havens, D.S. (2000) The Magnet Nursing Services Recognition Program: A comparison of two groups of Magnet hospitals, American Journal of Nursing, 100 (3), Aiken, L.H., Sloane, D.M., & Lake, E.T. (1997) Satisfaction with inpatient AIDS care: A national comparison of dedicated and scattered-bed units Medical Care, 35, Australian Council for Safety & Quality in Health Care (2003) Safe staffing: a discussion paper. ACSQHC, Canberra. Australian Nursing & Midwifery Council (2002) National competency standards for the registered nurse. ANMC: Canberra. Baker K (2004) NaMO Update Spring Boney, J., & Baker, J., (1997). Strategies for teaching clinical decision-making. Nurse Education Today, 17, Chiarella, E.M. (2002) The legal and professional status of nursing. Churchill Livingstone, Edinburgh. Clare J., Edwards, H., Brown, D., & White, J. (2003) Evaluating Clinical Learning Environments: Creating Education-Practice Partnerships and Clinical Education Benchmarks for Nursing learning outcomes and curriculum development in major disciplines: Nursing Phase 2 final report Clifford, C. (1997). Nurse teachers and research. Nurse Education Today, 17, Clinical Excellence Commission (2005). Improving patient access to acute care services: a practical toolkit for use in public hospitals. CEC, Sydney. Coates, V., & Gormley, E., (1997). Learning the practice of nursing: views about preceptorship. Nurse Education Today, 17, Dempsey, J. (2004). Falls prevention revisited: a call for a new approach. Journal of Clinical Nursing, 13, Garbett R. & McCormack B. (2002) A concept analysis f practice development. NT Research 7(2), Gollard, L.T., & Soo Hoo, W.E. (1993) Maximising limited resources through TEAMCARE Nursing Management 24(11);36 8, 40 3 Gullick, J., Shepherd, M., & Ronald, T.,. (2004). The effect of an organisational model on the standard of care. Nursing Times, 100, Foley BJ. Kee CC. Minick P. Harvey SS. Jennings BM. (2002) Characteristics of nurses and hospital work environments that foster satisfaction and clinical expertise. Journal of Nursing Administration. May; 32(5): Jones, A. (2003) Some benefits experienced by hospice nurses from group clinical supervision. European Journal of Cancer Care. 12 (3), 224. Jones, A., & Fairbrother, G., (2004). Development of a new style team nursing on an acute care ward. Monograph, Prince Henry & Prince of Wales Hospitals. Jones, J., Cheek, J., (2003). The scope of nursing in Australia: a snapshot of the challenges and skills needed. Journal of Nursing Management, 11, Jones CB. The costs of nurse turnover, part 2: application of the nursing turnover cost calculation methodology. Journal of Nursing Administration Jan; 35(1): Linehan, M. M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press. Lumby, J. (2001) Who cares? The changing health care system. Allen & Unwin, Sydney. 28 First report on the models of care project

33 References Lyth, G.M. (2000) Clinical supervision: A concept analysis. Journal of Advanced Nursing.. 31: Manion, J. (2003). Joy at work!: creating a positive workplace. Journal of Nursing Administration, 33, Mariner-Tomey Ann (1996) Fifth Ed Nursing Management and Leadership CV Mosby Co: St Louis McGillis Hall, L. (2003). Nursing intellectual capital: a theoretical approach for analysing nursing productivity. Nursing economics, 21, National Review of Nursing Education (2002) The Nursing Workforce JS McMillan Printing Group Canberra National Review of Nursing Education (2002) Our Duty of Care JS McMillan Printing Group Canberra NSW Health (1999) A Framework for Managing the Quality of Health Care Services in NSW. Better Health Centre, Sydney. NSW Health (2001). The clinician s toolkit for improving patient care. Better Health Centre, Sydney. NSW Health (2002). Easy guide to clinical practice improvement: a guide for health professionals. Better Health Centre, Sydney NSW Health (2004) Patient Safety and Clinical Quality Program. Better Health Centre, Sydney. O Connor, S. (1994). A reorganisation that improves patient care: an evaluation of team nursing in acute clinical settings. Professional Nurse September: Pittard, A.J (2002) Out of our reach? Assessing the impact of a critical care outreach service Anaesthetics 58 (9) Thomas, S.P. (2004) Transforming nurses stress and anger: steps towards healing (2nd ed). Springer Publishing Company, New York. Tiedeman, M.E., & Lookinland, S., (2004). Traditional models of care delivery: what have we learned? Journal of Nursing Administration, 34, First report on the models of care project 29

34 PowerPoint Presentations All PowerPoint presentations are available at and can be cited as they are listed here by author and title. Abbingdon, P., Mills, T & Lawrence, N. (2005) Hunter New England Health Service Regional Health Services Program Ashworth, J. (2005) Development of the recovery room orientation manual Ari, H. (2005) Mobility enhancement program: Port Macquarie Base Hospital: commenced in February Bothe, J., Donoghue, J., & Hawley, K. (2005) Patient-centred, safe and effective model of care: Day Surgery Unit, St George Hospital Brown, D. (2005) Work sampling and practice development in Northern Sydney AHS. Cooper, S & Johnson, R. (2005) Early notification of complex clients (ENOCC) & mandatory aged falls (MAF) reporting Crowe, C. (2005) A sea change in the Emergency Department. Daley, J., Lynott, L., McCallum, D., & Bennet, C. (2005) Team nursing: medical ward, Broken Hill Base Hospital. Dempsey, J. (2005) Fighting falls with action research: a practice development project Dengate, B., Maher, C., Miller, H., & Tapfield, M. (2005) Mona Vale Hospital volunteer feeding program Level 3 Medical UnitDombkins, A. (2005) Process mapping: models of care. Freeman, P., Harper P., & Davies, L. (2005) Evolving mental health practice in rural New South Wales. Eather, B. (2005) Management of post-operative patients. Gullick, J. (2005) Organisational models of nursing care. Hallam, J. (2005) Goulburn Community Health community nursing clinic. Hanna, L., (2005) Tapping into staff potential. Hutchinson, D. (2005) Re-thinking nurse education. Johnson, C., & Toft, R. (2005) Restoration/discharge focus at Pambula Hospital. Jones, A., Rivas, K., & Fairbrother G., The Prince of Wales Hospital Models of Care Project: moving toward team based acute care nursing models a hospital wide Action Research Project. Kemsley, J. (2005) When the going gets tough... Livingstone, G. (2005) Reasonable workloads: Ward 1C Port Macquarie Base Hospital. Middleton, S., & Griffith, R. (2005) Partnership models at Bankstown Hospital. McDonald, V. (2005) Model of care: asthma. Nichols, J. (2005) Ironing out the bugs: through innovation. O Connor, C., & Bolsom, S. (2005) Catch them and keep them: the introduction of undergraduate AINs into Intensive Care. Penning, C., Claven, S., & Wild, K. (2005) Person-centred approach: March September Perry, L. (2005) Reasonable workloads: Ward 2C Port Macquarie Base Hospital. Pfizner, J., & Liersch, S. (2005) Dialectical Behaviour Therapy for clients diagnosed with Borderline Personality Disorder. Rivas, K., Murray, S., Davis, J., & Butler, S. (2005) 12 Hour Shift Trial Respiratory & Infectious Diseases Unit POWH.Ronald, T., & Gray, T. (2005) Introduction of Certificate III AINs into an acute care setting. Spring, J. (2005) Managing cancer care and palliation in a small rural community. Summers, P., Lo, K., & Maguire, D. (2005) Zone Allocation. Wall, R. (2005) Aged care provision in a public health setting: a multi-purpose service model. Wallace J & Ward, K. (2005) The introduction of assistants in nursing certificate III in the tertiary hospital setting. Walker, K. (2005) Project Possibility: from patient allocation to partnerships in care: introducing Wilson, R. (2005) Introduction of undergraduate AINs into the emergency department. Winkworth, K., & Barrett, P. (2005) I wanna go home: Discharge planning in the medical/cardiac care unit. Woodhouse, G. (2005) Community focused service provision: Braidwood Multi-Purpose Health Service. York, K. (2005) Byron District Hospital model of care Zirckler, J., & Taylor, J. (2005) Leaving with confidence: Discharge planning/chronic care framework. 30 First report on the models of care project

35 Appendix. Evaluation form Designation of staff: (please circle) CNC, CNE, CNS, EN, NE, NM, NUM, RN, Other (state): Facility: Specialty (in which you work): eg general medical ward, community health centre, intensive care unit etc) The aims of the workshop were as follows: 1. To provide nurses with information relating to nurse staffing projections and shortfalls and strategies in place to address them. 2. To provide nurses with exemplars of analysis and innovation in care delivery models. 3. To provide nurses with tools for analysis and innovation in care delivery models. 4. To stimulate debate and discussion in relation to models of care delivery. We would be grateful for your feedback on the workshop and input into future directions. A. Value of workshop in terms of meeting the workshop aims The Likert scale below is to identify to what extent the sessions were felt to be of value in meeting the aims of the workshop. List the names of the presenters for each session below as this is a generic questionnaire and for most sessions the presenters will vary. Session 1: Staffing requirements and strategies to address them Session 2: Clinical presentation 1 Session 3: Clinical presentation 2 Session 4: Clinical presentation 3 Session 5: Facilitated discussion Professor Mary Chiarella Score the sessions from 1 5, 1 being of no value in meeting the aims, 5 being extremely valuable in meeting the aims. Session (of no value) (extremely valuable) 1. Staffing requirements 2. Clinical Presentation 1 3. Clinical Presentation 2 4. Clinical Presentation 3 5. Facilitated workshop First report on the models of care project 31

36 Appendix. Evaluation questionnaire B. Issues arising within the workshop List the three major issues or ideas the workshop raised for you. These can be positive or negative C. Future directions Comment on any future directions or future issues you would like to see explored further. D. Other comments Thank you for attending the workshop and completing the questionnaire. I really appreciate your feedback and input. Professor Mary Chiarella (Models of Care workshop facilitator) 32 First report on the models of care project

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40 SHPN (HSPI)