Setting priorities for the safe staffing unit: the Safe Staffing/Healthy Workplaces Unit is up and running. What are the priorities for 2008?
It has taken some time to understand these disparate pieces, their significance and to make sense of where they fit in the work of the unit. But slowly a clearer picture is emerging.
"It has taken time to read all the documents that informed the report; to fully understand the complexities of the report; to make sense of the expectations surrounding the unit. It has definitely been a challenge but slowly the pieces are fitting together," Brewer said.
"The conduit, not the activist'
She well knows one person cannot meet all the expectations placed on the unit but is clear about her role--"I am the conduit, not the activist. I can bring people together and foster collaboration and partnership but I can't do the work at local level."
Each of the country's 21 DHBs has provided the unit with a self assessment of where it stands in relation to the 15 recommendations in the Col report, in its hospital, community and mental health services. Broadly, the report's recommendations aim to strengthen nursing and midwifery leadership, develop processes for unsafe staffing situations, improve workplace culture, involve nurses and midwives in change, gather information on the national nursing and midwifery workforce and support a national post-entry education framework.
The DHB information has provided the foundation from which Brewer will launch an action plan for the unit. The information has revealed where the gaps are, notably in collaboration between DHBs and NZNO, in freeing clinical leaders from patient toads, particularly at ward level, and in clinical input into escalation processes once nurses/midwives on the floor have declared staffing unsafe. Nursing and midwifery workforce data is also patchy and there are differences over position titles and definitions among the DHBs. Of the DHBs which had escalation processes in place, a number stated they were not embedded or had not been developed in collaboration with NZNO. Incident reporting systems were well established but many DHBs reported that feedback loops needed to be improved.
Education and training frameworks are well established in the majority of DHBs. Most DHBs did not have toolkits of best practice for nurses or models to determine nursing numbers in place. Of those that did, Trendcare was the most widely used.
Workforce data was collected, usually via the Nursing/Midwifery Councils or the Health Workforce Information Programme, with human resource departments holding the information. Only a small number of nursing services collate and report their own data.
Strategies to work with nurses and midwives to develop a supportive workplace culture were not well embedded in most DHBs and worked on an ad-hoc basis only.
From the welter of information, Brewer, in consultation with the unit governance group, has developed three work priorities: local collaboration; escalation processes; and workforce data. Collaboration between NZNO and DHBs was expected and the joint action committee, agreed at the latest NZNO/DHB multi-employer collective agreement negotiations, reinforced that. "DHBs and NZNO are expected to work together locally and one of my roles is to guide people towards that goal."
Brewer said the unit would take a "principles-based approach" to escalation processes which in many cases still had to be developed. The principle is that each nurse and midwife has the clinical authority commensurate with their level of responsibility.
Brewer is establishing links with the range of organisations which gather health workforce data. District Health Board New Zealand, the Nursing Council, the Health Workforce Action Committee, various nursing researchers, individual DHBs and nursing schools were all sources of information on the nursing workforce. But there are significant gaps. "No information is collected nationally on nursing vacancy rates. We don't know what the workforce movement actually is--how many nurses/midwives are training, how many are staying in New Zealand, how many are heading overseas, what their qualifications are. There are bits of that information but the rest is anybody's guess. We want to connect with everybody involved in collecting and collating workforce data to ensure the most robust data is available and to contribute to it."
Nurses must get involved
So how will these priorities improve the lot of nurses/midwives at the bedside? While acknowledging the toll of continuing staff shortages--"I know exactly how it feels to have no staff day after day"--she encourages nurses to get involved locally in the work required to make the report recommendations a reality.
She believes ensuring clinical input into decisions regarding unsafe staffing and improving "feedback loops" will help. "If nurses know their concerns are going to places and people that matter and not into some black hole, that their concerns are registering on the agendas of important committees within the DHBs, it will help nurses believe their voices are being heard."
Changing a workplace culture is hard but it can't and won't happen without input from many nurses and midwives.
Brewer is nothing if not a pragmatist. While she knows the unit's priorities won't put more staff on the floor in the short-term, she believes they will all contribute to incremental change.
"All I hope for at this stage is to give nurses small glimmers of hope. As unit director, I cannot single handedly change the situation. But I can encourage nurses, midwives and DHBs to collaborate on fundamental issues to ensure that, over time, sustainable change will occur.".
By co-editor Teresa O'Connor