Turning a nursing vision into a working reality: positive practice environments is the theme of International Nurses' Day next month. But how do you turn the vision of a positive practice environment into the reality of satisfied nurses and quality care for patients? The director of nursing services at Christchurch Hospital has a few ideas.

When Sue Hayward became the director of nursing services at Christchurch Hospital in 2002, one of her priorities was to ensure nurses never again "sank into the mire of the victim mentality" she encountered on arrival at the hospital. This mentality manifested in various ways. "There was always a 'but' in every sentence, nurses felt down trodden and nurses were not engaged in anything that was going on," Hayward said.

It was a daunting task to enable and empower a workforce still suffering the after effects of the mid '90s, when the nursing structure was tipped apart, with senior positions disestalished, and the series of preventable deaths in the winter of 1996. These events eventually ted to the report by then Health and Disability Commissioner Robyn Stent, released in April 1998, which confirmed the sorry state of affairs at Canterbury Health. Stent referred to Christchurch Hospital as "a dysfunctional and grief-stricken health system". (1) But in her trademark optimistic fashion, Hayward was not daunted by the task. She is affable, approachable and determined to implement her vision. Her determination may well have been honed during her nursing training which began at Dunedin Hospital and nearly foundered at Hutt Hospital to where she had transferred in her last year. In the days of no parental leave, her pregnancy meant she had to resign just before hospital finals. After the birth of her child, the matron Vera Hall rang her and said to lose her from nursing was a "ridiculous waste" She suggested, in a way that brooked no argument, that Hayward return to work full-time as a student nurse and sit State finals at the end of that year. Her husband took leave without pay to look after the baby and Hayward completed her nursing training. "I remain eternally grateful to that matron for her direction." From Hutt Hospital, she moved to Whangarei and into the special care baby unit (SCBU). Neonatal nursing became her passion and she became nurse manager of the SCBU. In 1993 she transferred to the neonatal unit at Christchurch Women's Hospital From a staff nurse position, she became a clinical nurse coordinator and then neonatal service manager. In 2000 she took up the rote of assistant director of nursing at Christchurch Hospital and in 2002 she became director of nursing services at the hospital

On taking up that rote, Hayward focused on getting the right nursing structure. That involved appointing nursing directors to work in partnership with clinical directors at the top of each of the four dusters, ie medical, surgical, child health and oncology/haematology. The foundation for such a structure had been laid by former incumbent Jeanetta Skiba. Hayward refocused the role of the nursing directors, each of whom now has "professional, operational and budgetary responsibility" for nurses in their cluster.

"It was important to clearly define the rote of the nursing directors. There was some resistance from other staff at that level a fear of encroachment. But it is the rote of the service managers to deal with the contracts and for the nursing directors to set up the right nursing services to meet those contractual obligations." While ever mindful of the budget, Hayward says it is very important that professional requirements drive the budgetary responsibility and accountability, not the other way round.

Refocusing the charge nurse role

After giving the top tier of the nursing structure time to bed in, Hayward turned her attention to the charge nurse (CN) role. This was a considerable challenge. Again, the hospital's recent history played a part, as the CN rote had been disestablished and replaced by clinical facilitators. When the rote was change back to CN, the clinical focus remained with the title being clinical CN. Now Hayward wanted to take away the clinical component of the role. "I wanted to refocus the rote on administrative, budgetary and management/leadership responsibilities. The role of the CN is to manage and lead the ward and allow the staff nurses to do the clinical work and expand their practice capabilities," Hayward said.

The change in focus is a work in progress. "I was aware it would take time to overcome resistance. I encouraged and got a great deal of feedback and took note of that feedback. The CN job descriptions went through many drafts. And I've used CNs who have 'got' the vision to talk with their peers and colleagues."

Hayward understood the fears of CNs. "They loved the clinical involvement and felt very comfortable with it. They were afraid they would no longer be seen as real nurses and that the new rote would be focused entirety on staying within budget."

But her clarity about her rote and vision did not waiver. She sees the CN rote as absolutely pivotal to "ward culture and organisational capability and to ensure the nursing voice is heard in a professional and meaningful way". The 41 CNs are a great group for whom things have been "extremely pressured and tough" for the last eight months. Hayward had scheduled a "state of the nation" meeting with CNs earlier this month to hear their concerns and try to work out solutions.

One of the major causes of the pressure has been a reduction in bed numbers from 29 to 22 across wards and a big jump in patient demand. "The CNs are dealing with that situation every single minute of every single day and that's stressful." Ironically, one of the spin-offs of the new nursing structure and a number of other nursing initiatives, has been a reduction in the overall number of bed days.

Another initiative Hayward has presided over is the introduction of a collaborative model of nursing care, replacing primary nursing care. "The collaborative model combines the best attributes of primary and team nursing and was phased in from 2005, with a great deal of education for staff to support its introduction. You've got to put in the supports for any new initiatives otherwise they will fail."

A transit nursing service has proved invaluable, as has the increase in the permanent pool to 30 Full-time equivalent experienced nurses.

Nurse-initiated discharge has been rotted out across the hospital but Hayward says there has been some "slippage" and further support and discussion is needed. "It's about nurses becoming confident in their own competence," she said. The acute assessment medical unit, part of the over arching 'Improving the patient journey' project throughout Canterbury District Health Board (CDHB), is another nursing success story (See story below.)

Relationships with medical staff are good. "I have always focused on the importance of those relationships. I don't agree with nurses reporting to doctors but I do agree with doctors and nurses working together."

A "grow your own" approach to recruitment sees 80 new graduates a year taken into the new graduate entry to practice programme. She also works closely with Christchurch Polytechnic Institute of Technology's nursing department to attract back nurses who have been out of the workforce for more than five years.

Hayward's vision of the right nursing structure--"nursing leadership from corporate level [executive nursing director Mary Gordon] through to the bedside"--has been achieved. So what attributes does Hayward bring to her readership? "I have an optimism about the profession, and my life has been based on feminist ideals. As students we fought for equal pay and I've fought for parental leave. Some people say I am too 'Pollyannaish' at times, but I feel privileged to be paid to do a job I love in a profession I love. I'm not into power and control; I'm into influencing and I'm told pretty quickly if something isn't right. Nurses obviously feet comfortable giving me that feedback."

She is grateful to her DoN colleagues in CDHB, with whom she discusses issues, shares concerns and asks for advice. She says there are many areas in which she does not have strengths and a team of skilled project managers in the Department of Nursing play a vital rote in assisting turning her vision into reality.

What Hayward has done and continues to do at Christchurch Hospital is having positive effects, both on the $76 million annual nursing budget and on staff morale. Hard data shows a reduction in bed days; a decrease in the cost of agency staff from between $300,000 and $400,000 a month to $45,000 a month; and a decrease in staff turnover from 21 percent to ten percent. Harder to measure are the intangibles of staff morale and job satisfaction, although reduced turnover could be an indicator. Other indicators are tow turnover of CNs and the fact nurses are included in all projects related to the working environment, quality outcomes and patient flow. Hayward believes the "victim mentality" has been replaced with a far more positive attitude among nurses.

Hayward was a member of the committee of inquiry into safe staffing and healthy workplaces and is utterly committed to the committee's recommendations. "Its recommendations are applicable right across the health sector. And the Minister [Pete Hodgson] has agreed to fund the safe staffing unit, so he must have confidence in the recommendations. The unit will not be a 'boss of anybody' unit but a supportive unit, facilitating sharing ideas and information." She says CDHB is further down the track laid out in the recommendations than many DHBs. She stresses the "no blame" culture regarding drug errors as an example.

The right nursing structure and leadership; the right number and skill mix of nurses; and the engagement of nurses in the operation side of the hospital, from executive level to the bedside, are the three crucial elements in creating a positive practice environment that benefits both patients and nurses, according to Hayward. On the evidence from Christchurch Hospital, it's a formula that appears to be working.

Reference

(1) Stent, R. (1998) Canterbury Health Ltd. A report by the Health and Disabilty Commissioner. Wellington: Office of the Health and Disability Commissioner.

RELATED ARTICLE: Managing change effectively.

The gap between a nursing vision and the reality at the bedside can sometimes be considerable. It is also inevitable. The vision is the goal; the reality of everyday work, part of the journey towards that goal.

Sue Hayward understands the evolutionary nature of change but believes the journey is well under way at Christchurch Hospital. How do some of those charged with making the vision real--charge nurses (CN)--experience the journey? Allison Partridge is the CN of the acute medical assessment unit (AMAU), part of the improving the patient journey project within CDHB, driven by nurse consultant Brian Nolan with the blessing of Mary Gordon.

The unit takes most of the acutely unwell medical patients who come through the doors of the emergency department (ED).The project was mooted early last year and a steering group established to get the unit up and running. Ward 24, of which Partridge was the CN, was suggested as the appropriate place. The ward, which had an immunology/rheumatology focus, had a reputation for innovation because of its successful special nursing unit (SNU) for seriously unwell general medical patients. It also had stable staffing.

Partridge said the idea of AMAU caused some anxiety among her colleagues. "It was a big practice change and nurses were concerned they would lose their specialty and continuity of patient care.

But nurses get on and do things, particularly if they can see it will benefit patients. The nurses were prepared to accept the challenge and then assess the situation based on their experience of the new way of working."

They also had faith in their CN, who understood the concept and believed it could work.

Partridge moved to Christchurch Hospital when it was that dysfunctional and grief-stricken health system. "When I came to this ward, it was an acute admitting unit, it was without a CN, things were chaotic, it was unresourced and unsafe. As a clinical nurse facilitator, I was very aware I was coming into a position that replaced the CN. The CN position had been dis-established. It was really difficult and I decided to tread pretty carefully."

Slowly, Partridge put her own stamp on the en vironment, making some practical changes to support nurses in their work. A major change was from an acute admitting unit to a "home ward", a change that upset some nurses. "I lost nearly the entire night staff. But overtime the ward staff became very stable, with little turnover and people wanted to work here."

The development of the SNU was a nursing initiative. "The nurses, using their judgement, knowledge and skills, developed criteria for deciding who would be cared for in the SNU and when they could be discharged. When the AMAU came about, nurses already had a tot of the skirls needed," Partridge explained.

"The AMAU is about improving care for patients. It is about getting them into the system immediately, not having them lying on trolleys in the emergency department (ED), and beginning assessment and treatment immediately." Patients are triaged in ED and, if their medical early warning (MEW) score is over 5, they are seen by a registrar in ED, who will initiate treatment.

Patients with MEWs of five and under go directly to the AMAU. The 25-bed unit is getting busier all the time. It is almost always furl and, on a recent aftenoon shift, there were 16 transfers and discharges and 25 admissions. To support this patient throughput, the staff have had to develop robust systems, processes and protocols. "The nurses have developed the systems and we have clear boundaries and patient pathways in place as to who is admitted and who isn't. This protects both patients and staff," Partridge said.

The AMAU is up and running so quickly and so well because of the calibre of her colleagues, according to Partridge. "I don't have to worry about the nursing on the unit. Some colleagues have experienced working in the previous dysfunctional acute admitting system. We did not want a chaotic system; we wanted a calm, safe environment for our patients and staff." The subdued lighting in her office is a small indicator of the pervasive atmosphere.

The unit is continually developing and the team considers it a work in progress. Some of the latest developments are a shift co-ordinator, a rote shared among the senior staff. Another proposal is for admissions directly from the community through GPs.

Describing herself as a "general medical and clinical junkie", Partridge says she does not want to move further away from clinical practice than the CN rote. "There has been a de-skilling of CNs, as far as hands-on clinical work is concerned. The role is more a management one now and a tot of that is invisible work."

Partridge says the cluster system at CDHB is the best system she has worked in. There are strong communication lines, eg CNs in the medical duster and medical nursing director Pam Kiesanowski meet daily to review staffing for the next 24 hours and discuss any issues. The budget is an ever-present concern but Partridge said her approach had always been "to do the best you can with what you've got. I enjoy the challenge of turning constraints into opportunities, of thinking about how we can get a bit more out of what we have."

A greater frustration than any budget constraints is the process needed to replace a staff member. "It is a hugely time consuming process. We have to argue the loss art the time. The 'approval-to-appoint-and-replace staff form' is unwieldy, undermines our rote, and demonstrates a tack of trust that we work in a fiscally responsible manner," Partridge says.

The is plenty of evidence of fiscal responsibility at the AMAU. A review of the unit six months after its establishment has shown, among other things, bed day savings of $215,000 and a reduction in the time patients spent under all hospital services from 5.3 days to 4.7 days.

While acutely aware of budgetary responsibilities and accountability, Partridge is not driven by them. "The patient will always be the most important concern. I feel the ongoing success of AMAU will be attributable in great part to the nursing contribution, not just nurses' knowledge and skill, but their respect for nursing and what we can achieve when we work in a functional team and nursing environment."