think.change.do uts:centre for health services management growing a legacy: looking after our future...

UTS:CENTRE FOR HEALTH SERVICES MANAGEMENT

THINK.CHANGE.DO

Growing a legacy: looking after our future

Paper to Nurse Managers’ Interest GroupAustralian College of Health Service Executives

27th September 2007Professor Mary Chiarella

Faculty of Nursing, Midwifery & HealthUniversity of Technology, Sydney

Nursing and Midwifery Office, NSW Health


Growing a legacy: looking after our future

> Setting the scene – on the shoulders of giants– Environmental overview

> Looking after our future– NaMO Modelling Care Project– Clinical nursing and midwifery research– Our clinical nursing and midwifery staff

> Growing the legacy– For clinical staff– For nurses and midwives in general

> Positioning nursing and midwifery knowledge – what do we offer?> Growing the legacy


Setting the scene – on the shoulders of giants

> A huge thank you to those of our profession who are no longer working but who had the vision to see a very different future for nursing and midwifery

> Just some of their successes – lessons still to be learnt from these (and work still to be done)– University education (NSW went first)– Professional rates of pay– Clinical career paths– The gift of nursing and midwifery research– Coalitions of the willing (and able)


Environmental overview –professional development(Chiarella, 2002)

Pre Nightingale

Nightingale/ Victorian

Early to mid 20th century

Mid to late 20th century

Late 20th century to current

Autonomous professional

Subordinate professional

Subordinate professional

Doctor’s handmaiden



Ministering angel

Ministering angel

Ministering angel

Ministering angel

Domestic worker

Domestic worker

Domestic worker

Domestic worker

Domestic worker


Environmental overview – responses to challenge(Chiarella, 2007)

Ethos

of collective

non-responsibility

Practice zone of abrogation

Ethos of

Individual accountability

Practice

zone of isolation

or alienation

Practice zone of

mutual trust and

Collaboration

Ethos of collegial

generosity


Our current clinical leaders –the NaMO Modelling Care Project Prerequisites for inclusion in the presentations (Years 1 & 2)

> A preparedness to reflect on and examine current practice> Patient focus – this is the purpose of clinical nursing and

midwifery work> Data – good decisions are made on good data> Rigour – measure, observe, record> A preparedness to try something different> Flexibility to adapt if necessary> Evidence of collaboration (Year 2)> “What we see in this report is the result of 20 years of

university education for nurses” Mr J Hatzistergos, NSW Minister for Health, February 2006


Our current clinical leaders-outcomes of analysis of Modelling Care presentations 2006

> Growing synergies through the NaMO Modelling Care Project (note change of name: double entendre);

> Growing synergies through other statewide initiatives; > Changing and developing nursing and midwifery

roles; focus on clinical specialities; > Growth in Practice Development and > Identified and ongoing challenges.


Growing synergies through the NaMO Modelling Care Project

> Ongoing progress of local work –Rivas, 12 hour shifts to action learning sets, Dempsey, falls to patient stories, observations of care

> Developing synergies across NSW – between AHSs and universities and across AHSs (Harman + UnN’castle, Hartz + UTS; Crisp & Ind + CSU)

> Accessing funds and other resources – scholarships (19 Innovations + 10 MH), EAP (Ronald), grants, equipment (Bevan)

> Growth of and emphasis on teamwork (Marshall, De Cressac, Wand)


Growing synergies through other statewide initiatives

> Clinical Services Redesign Project presentations • Marshall -23 hour ward• Cort- orthopaedic long wait• Coote - APNs for JMOs• King – Acute Care of the Elderly• Gradidge - Older Persons Evaluation Review and Assessment

Project (OPERA) • McPhail – dementia care

> Clinical Leadership Program presentations• Jones, Rivas, Hamilton, Cutler& Griffin, Bristow

> Clinical Excellence presentations> TASC Samuels (Cardiac Assessment Nurse)


Changing and developing nursing and midwifery roles; focus on clinical specialities

> Advanced practice roles: N/MPs – Wand, Asimus• CN/MCs – Puckett, Hallam & Leaver• APN - Coote

> EENs: Sutherland-Fraser –OR• Lucas – haemodialysis• Mulhearn- neonatal nursery

> AINs: Ronald – acute aged care • Jones – acute medical surgical

> Specialty: Community, MH, aged care & midwifery> In-house education (lots of sharing)


Growth in Practice Development

> Values clarification • Clarkson & Hooke, Dempsey & Mangone, de Cressac,

Crameri> Person –centred models

• Demspey & Mangone, Peek & Higgins> Reflective Practice

• Puckett, Hallam & Leaver> Action learning sets

• Davis, Murray & Rivas> Case studies

• Puckett, Hallam & Leaver> Mentoring

• Mulhearn


Current MoC activity reported in 2006

> Work practice changes (41 sites – often more than one report per site)

> Maggie project (19 sites)> Skill mix changes (38 sites)> Introduction of team nursing (54 sites)> Improving communication and handover(11 sites)> Introduction of clinical pathways and guidelines (16 sites)> NB: 242 descriptions of work nurses wanted to undertake in the

near future


Looking after our future: clinical nursing and midwifery research

> NSW Professors of Nursing and Midwifery have obtained significant competitive ( & some of the highest scoring) NHMRC and ARC grants in the past decade

> Examples of current clinical research– Mothering skills for incarcerated women– Management of temperature in very low birth neonates– Physiological impact of stress of bereaved relatives of ICU

patients– Dementia mapping in the elderly– Optimal management of the perineum in childbirth– Home-based care for people dying with HIV/AIDS in

Mozambique


Looking after our future – clinical nursing and midwifery research

> Knowledge such as this provides us with language to describe our practice – that way we can help our novice nurses and midwives to practise well

> Work such as this gives us a place of authority from which to improve, discuss and influence clinical care

> Data such as these are invaluable to those planning and coordinating health services and give us a place at tables that otherwise might be denied

> Research training and communities give us fora to talk about and explore nursing and midwifery practice and work


Challenges for clinical nurses and midwives: growing a legacy

> Patient engagement> Sustaining memory > Confidence to be challenged and scrutinised > Role clarity, scope of practice, integration of new roles> Reflection and mentoring as a way of life> Teamwork skills – performance management, craft transfer,

communication, generosity> Maintenance of cultural environment -risk of default under pressure> Lack of knowledge about each other’s work> Re-defining success


Challenges for clinical nurses and midwives- support required

> Additional strategies for disseminating information about existing and proposed activities;

> Analysis of practice, including skills (inter alia) such as process mapping, audit, patients’ stories;

> Ongoing education for clinicians, managers, educators and academics on models of care development;

> Support for and extension of Practice Development, both technical and emancipatory;

> The development and piloting of strategies to address issues of delegation, scope of practice and challenges of peer performance experienced by many clinical nurses and midwives;

> The canvassing of strategies to develop skills for clinical nurses and midwives to share their craft with other less experienced nurses or midwives (craft transfer);

> Support and education in writing for publication.


A word about clinical nursing and midwifery practice: how do we know what to do?

> Through our theoretical education> Through our practical education> Through practice itself> Through reflection on practice> Through good role models who we want to emulate> Through poor role models we decide to be different

from> Through craft transfer


Memory exercise

> Think of an incident in your clinical practice where a clinical nurse shared her knowledge and skill with you (not an educator)

> Jot down any key memories you have of the experience eg– How did the incident occur?– What knowledge or skill did (s)he share with you? – What did (s)he do?– What did (s)he say?– How did (s)he engage the patient?


This process is what I have called craft transfer

> What factors need to be in place for it to be the norm, rather than the exception?– In terms of working structure and organisation– In terms of culture– In terms of the skills of clinical staff


The value of craft transfer

> Builds collegiality generosity> Fosters a sense of professional pride> Encourages the development of language to describe

practice> Encourages reflective practice as a way of being in

the clinical environment> Role models for future generations> Will ensure our legacy and our identity


What lessons can we learn from our current clinical leaders?

> Adjusting to living with uncertainty

> Taking the step back

> Being careful about how we define success

> Developing collegial generosity


“As far as Edward Bear knew, it was the only way of coming downstairs, although he sometimes felt there was another way, if only he could stop bumping for a moment and think about it”

(AA Milne)

Taking the step back


Re-defining success

> Research offers two main reasons why nurses leave –– Feel they are not valued or respected– Feel unable to deliver the quality of care they wish to deliver

> The 1970s/80s mentality in a 2006 world> Jones & Cheek (2002) –”no such thing as a typical nursing day”> Need to understand that routine was part of our comfort zone “at least I

got my showers done”> If they are applying a 1980s formula to a 2006 nursing world, they will

always feel that they have failed> Working with new professional grades of nurses and midwives–proper

recognition of the contribution of the different roles> Need for reflection on practice> Need to measure and evaluate our practice


Strategic areas for 2007/2008 in Modelling Care work

> Sustainability- ensure that no one person carries the project, that it can go on if someone “falls over”

> Synergy – try to maximise resources through linkages between clinicians and academics

> Synchronicity – try to organise innovations with research grant rounds/ scholarship applications

> Spread – need to publish the work, need to enable people to know or at least be able to find out who is doing what

> Self-belief –need to feel that they have the ability to improve their environment or their patient’s environment and to know how to go about it


Growing a legacy for nursing and midwifery in general – then and nowNursing and midwifery leadership –apartheid or secession?

> We cannot withdraw into nursing or midwifery> If we are competent to manage and deliver nursing and

midwifery services, we are competent to manage and deliver health services

> Our experienced, educated, skilled clinicians are competent to lead debates about health care, not just nursing or midwifery care

> The nurses and midwives engaged in modelling care work are more than capable of leading debate – we just need to get them from the tea room to the Board room

> We already have senior colleagues using their skills in very senior generic positions – DG, DMS, DCOps etc: we need to ensure they continue to feel like nursesand/or midwives and feel proud of the skills that took them there: that is the part of the legacy we need to build for the future


Growing a legacy for nursing and midwifery in general – leadership

> “Nursing – born in the church and bred in the army” (Gillespie, 1990)

> Expectation of individual militaristic leadership styles – Chief Nursing “Officer” an example

> Difficulty with this militaristic sense of leadership is that it carries with it an expectation of obedience and loyalty as the primary behavioural states

> From a clinician’s perspective an obligation of obedience will do nothing to foster a sense of entitlement

> From a patient’s perspective loyalty is not the same as integrity, and will not necessarily improve patient safety and quality


Looking after our future - workforce

> A lack of a formal nursing or midwifery management structure runs the risk of depleting senior nursing leadership

> In turn this could mean a lack of advocacy for nursing/ midwifery views and issues

> Nursing unions are unhappy about the lack of senior leadership through the restructures: this is conveyed through their journals to clinical nurses

> Turnover of itinerant workers can create instability of the workforce and reduce the potential for developing senior clinical nursing/ midwifery leadership in the absence of senior nursing/midwifery management leadership

> These factors can create a dispirited and/or docile clinical workforce and a lack of clinical nursing/midwifery leadership


Positioning clinical nursing knowledge for the future what do we offer?

What health services need (Pearson, 2000)

“There is little doubt that health services will always need a generic worker who is client-focused, possesses multidisciplinary skills, manages the care environment, delivers all but the most highly specialized services to the client, humanizes the system at the point of contact, and acts therapeutically as the experience is lived by the client. This is historically the broad, flexible role ascribed to those titled 'nurse'.”


Positioning nursing knowledge for the future what do we offer?

> Currently a strong 24/7 operational perspective –constancy (this has implications for nurse education and staff deployment)

> Understanding (because of proximity/ intimacy) of the key issues affecting patients and their families (may be lost if nurses do not deliver front-line care) –our practice has a strong relational base

> Historically a flexible attitude to nursing work due to changes in technology and consequent task transfer

> Comfort (by and large) with discussing intimate and/or difficult issues (this is useful for managing challenging behaviours)

> Clear eyed understanding that life is often neither rational nor fair (this is useful for realism)

> Knowledge that ordinary people are capable of greatness (this helps us not to despair)


Positioning nursing knowledge for the future– what do we offer?

> What we have to offer that is unique stems from our prolonged, intimate and regular contact with patients on a 24/7 basis – constancy, intimacy & flexibility (Chiarella, 1992)

> Our craft is an amalgam of informed clinical skill and professional compassionate care gained through a mix of education and experience

> Our ability to transmit this craft is contingent on our capacity to describe it

> Who else might be able to offer what we do?> Possibly unregulated health care workers and possibly other health care

professionals> Possibly patients/consumers and carers themselves – need for much

stronger coalitions


Growing the legacy– what might we do?

> Work in real partnerships with the public – co-production of health, constructed communities of care

> Use our high standing in the community to take a vocal stance on key health issues –the impact of poverty on health status, indigenous health, mental health, prisoner and refugee health

> Take advantage of every opportunity to put our differences aside and campaign on a united front for changes to the “big picture” health services issues

> Decide to be winners -remember the words of Steve Biko –”the greatest weapon in the hands of an oppressor is the mind of the oppressed”

> These behaviours would contribute significantly to professional cultural change


In conclusion

> Nursing and midwifery have the capacity to take a strong and active leadership role in future health care delivery, despite current trends and prevailing mantra

> We have committed skilled clinicians and researchers able to provide vital insights into health care delivery

> What modern nursing and midwifery might offer is what health care needs

> BUT> We need to be sure why leadership matters to us> We need to re-conceptualise what our leaders might look like> We need to decide and agree what we want nursing and midwifery

work to be concerned with –growing our future leaders means we have to offer something that matters to them

> We need to be able to strategise and manoeuvre and this requires language and models

> Thank you


References

> Alderfer, C.P. (1980), "Consulting to underbounded systems", in Alderfer, C.P., Cooper,C.L. (Eds),Advances in Experiential Social Processes, Wiley, New York, Vol. 2 pp.267-95.

> Chiarella M (2002) The legal and professional status of nursing Churchill Livingstone: Edinburgh

> Chiarella M (2007) Redesigning models of patient care delivery and organisation: building collegial generosity in response to workplace challenges Australian Health Review

> Diers D (2004) Speaking of Nursing…Jones & Bartlett: New York> Gillespie R. Handmaidens & battleaxes. ABC television program. True Stories.

10 June 1990.> Pearson A (2000) The Joan Durdin Annual Oration. University of Adelaide> Walker K. (1993) On what it might be to be a nurse: a discursive ethnography.

Unpublished PhD thesis. La Trobe University

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