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Ward embraces CCDM: leading the adoption of CCDM in her ward has given one charge nurse manager a great deal of professional satisfaction.

In 2012, TrendCare was well-embedded in an acute 32-bed medical ward at Palmerston North Hospital. Activity and acuity for the ward showed it was consistently understaffed, often up to 30 hours negative over a 24-hour-period. Rostering practices were entrenched and did not recognise peaks and troughs in workload. Care rationing and missed nursing care had become the norm.

Then the opportunity arose for our ward to become the first to undertake work analysis and data collection to inform the care capacity demand management (CCDM) programme. We had two NZNO delegates working on the ward, both of whom were active in change management and quality improvement initiatives.

Some positive changes had already occurred. A room had been established to care for patients with delirium, new smoking cessation forms were being trialled and implemented, along with a new care plan format, and the new electronic rostering and payroll system Microster.

Nursing was led by a dynamic leadership and management action group, and education and research group. We also had vigorous but very efficient "word of mouth" communication processes through "what's on top" discussions at every shift handover. This helped overcome potential barriers to implementing CCDM through negativity created by high acuity and workload.

Initial interest in CCDM was gauged through conversations with the nursing team (including union delegates), allied health staff, and operational and clinical leaders. All responded positively to the idea. I saw my role as providing supportive oversight, ensuring full compliance with CCDM requirements.

Data collection was hard work, as I had anticipated--ironing out teething problems, ensuring everyone was on the same page, encouraging the negative staff and fence-sitters, keeping the momentum going when enthusiasm flagged. However, by the end of the two weeks, staff had become quite attached to their diaries and appreciated the fact they were able to clearly articulate care rationing--especially the missed nursing care that had become "business as usual".

Then came a period of stasis while the data was analysed. Because the analysis took some time, staff began to wonder if their hard work had been in vain. During this time, we implemented the "releasing time to care" (RTC) programme. This helped keep a sense of momentum for change, although staff remained very interested to hear the outcome of the data analysis.

New model of care developed

As soon as the results were confirmed, we swung into action and developed a new model of care based on input from the entire nursing team. We used butcher's paper and models, felt pens and timetables, arranging and rearranging the full-time-equivalent (FTE) hours and the roster to meet the peaks and troughs of work over the entire 24-hour day and seven-day week. The team divided up the available FTE into the most efficient and effective spread of qualified and non-qualified staff, thinking outside the square and breaking down traditional shift time barriers.

The model of care introduced a new role of "admission and discharge nurse", who straddled the morning and afternoon shifts. This nurse did not have a patient load, but focused on timely discharges and active "pulling" of patients from the medical assessment and planning unit and emergency department. The model of care in the delirium room also changed - instead of being staffed by a registered nurse (RN) and a bureau health care assistant (HCA), we had our own ward HCA who knew the patients and provided them with continuity of care.

The difference to staff morale and motivation as a result of CCDM was immense. While the ward remained very busy, it operated efficiently and effectively. Complaints, incidents, falls and medication errors reduced, staff turnover was practically zero and productivity improved. The ward also managed to implement RTC at the same time as CCDM--an amazing achievement. We found the two programmes supported and enhanced each other.

User-friendly process

The natural progression from mix and match (now known as staffing methodology) was developing variance response management (VRM). While implementing staffing methodology across other acute wards lost momentum at times, the push to develop the VRM tools used an organisation-wide collaborative approach, in partnership with NZNO. It has replaced a problematic and cumbersome safe staffing process and is moving towards a more visible and user-friendly process. It still cannot produce nurses out of thin air, but it raises awareness of areas under pressure to all the right people and allows a hospital-wide approach to pooling resources to provide support where it is needed. Everyone is talking the same language and, much like the "early warning system" used to detect the deteriorating patient, VRM triggers a response before a crisis develops, rather than after the event.

Nurses have recorded many comments about how they have found moving to CCDM. They appreciated having their opinions listened to, they said; and being able to show how many times they were interrupted during their shifts, thus demonstrating the need for more staff. We now have our own HCA, an extra RN at night and a dedicated admission/discharge nurse. However, the comment that resonated most with me, and which I think really sums up the benefit of CCDM to nurses, is: "Since CCDM, it feels like I've actually met the patients, and I don't go home with that horrible feeling that I've missed something."

As the CNM for this ward, I take some pride in making CCDM happen. We need senior managers to influence change at the executive table, but the CNM is responsible for driving change at ward level. If s/he can do this with enthusiasm and passion, leading from the front and never giving up, adopting CCDM should go smoothly.

For more about CCDM, go to www.nzno.org.nz/get_involved/campaigns/care_point.

Caroline Dodsworth, RN, RM, is now charge nurse manager of inpatient oncology at Palmerston North Hospital.
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Title Annotation:professional focus; care capacity demand management
Author:Dodsworth, Caroline
Publication:Kai Tiaki: Nursing New Zealand
Date:Jul 1, 2016
Words:962
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