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We have the science, now we need the staff to keep patients safe

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NZNO champions the use of Care Capacity Demand Management (CCDM) in our hospitals. CCDM tools and processes uses patient acuity data to determine how many staff hours are needed for each shift. CCDM is the first of its kind and is available in some, but not all DHBs, and in certain wards and units of these DHBs. CCDM results in safer patient care and a better working environment for staff. CCDM enables staffing levels (capacity) to meet incoming need (demand).

To find out more about CCDM, see: http://www.nzno.org.nz/get_involved/campaigns/care_point/what_is_ccdm

 This blog is by Lisa Taylor, Registered Nurse and NZNO Delegate

‘It’s the challenge that gets me out of bed in the mornings, I love my job caring for patients and there’s always so much to learn.

I am a nurse working in an acute surgical ward with a high acuity. Many patients every day go to and from surgery, ED, ICU, other hospitals and home. We have a big turnover of patients.

Regardless of patient numbers, in the last two years we have gone from having a Care Assistant and a Health Care Assistant on each morning shift, to having one or the other but not both. Having only one out of the two assistants has resulted in delays in patient care.

As an example, the more specialised Registered Nurse tasks such as clinical assessments and complex wound dressings are often delayed so we can attend to patients more ‘immediate’ needs, such as toileting and mobilising. This can result in ‘care rationing’ for this really important patient care.

If we were to have a Care Capacity Demand Management (CCDM) Work Analysis completed on our ward, which calculates in detailed the work that is completed by our nursing team, we would be able to show who was doing what work and when that work was being done. Work analysis is really specific and gives us the opportunity to analyse the information.

We use CCDM Response Management tools within our hospital and in our ward. This is a programme telling us when we should increase or decrease each type of nursing team staff rostered on as patient demand goes up and down outside of what we have planned. However, when we do go into yellow – which means we need assistance as the patient care requirements outweigh the staff resource on the ward – we are often told there is no more help. This is a difficult situation, as the Clinical Nurse Managers and the Duty Nurse Managers do want to help, but when there is no one to help, there is nothing they can do.

If health funding was appropriate, it’s more likely there would be better help available for our patients. Having confidence that the resources were available to provide the right care at the right time would make for a safer workplace for patients and staff.

TrendCare, the patient acuity system that shows how much nursing care each patient will probably need, has made a difference to us on our ward. We understand that we often have a ‘negative variance’. This means patient care requirements outweigh the staff resource on the ward. We are working to further improve our data. I feel optimistic that once the data is absolute correct we will be able to do the calculations for how many full time equivalent staff we need, and it will be accurate.

TrendCare data is really powerful in getting the right staffing, but the staff also actually need to be available. If health funding was increased we would always be able to have the right staff, at the right time, delivering the right care, all the time.’


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A day in the life of a mental health nurse in New Zealand

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This blog was sent to us by a NZNO member who works in mental health. We are choosing to keep their details anonymous because of the intense scrutiny that mental health services are currently under. This blog is a personal reflection on their own experience, rather than NZNO’s view, but we are sure it resonates with many of you who work in the sector. We really appreciate them sharing their story, and hope it gives some context to the recent media coverage of our mental health services. 

It is 7am and I am off to see a patient in the emergency department. It is a young man who has self-harmed overnight. This scenario is becoming all too common in today’s mental health setting. You see, mental illness is the invisible disease. Presenting to the emergency department in emotional distress, the only visible signs are an unkempt man with a frightened look on his face.

Coming into the cubicle I see a young man in obvious distress. A feeling of hopelessness comes from him. I walk in and introduce myself. We begin to talk. Eyes downcast, feeling somewhat embarrassed as he shares his story with me. He talks to me in a quiet voice. He knows he needs help but does not know where to obtain the help he needs. His relationship with his family has become strained. They have tried to help, but are unable to provide the support he requires.

This man begins to articulate his struggle with schizophrenia. His self harm is due to despair: a belief that life holds nothing for him.  By the end of the interview I know I have several options open to me as a clinician:

  • We could send him home to his parents. But evidently his parents are unable to cope anymore with his distress.
  • We could suggest his GP follow up and maybe a visit from the already over-stretched crisis team.
  • Another option is to find a community respite bed for a few days. But we know that these are few and far between. I will have to telephone and “sell” his case to the respite coordinator if I am to make this happen.
  • Another option is to try and organise for him to be admitted into the inpatient ward. But I know they are nearly always full or over capacity. This is yet another hard sell to find this young man a place to be safe and be supported.

I go to discuss treatment options within the consult liaison team and the decision is made to admit the young man to the inpatient unit. I call the ward coordinator.  “What are his risks they ask?” Not, ‘who he is’, but, what logistical problems might he bring to the unit.

This is mental health nursing today. There is now a ‘risk adverse’ culture that always errs on the side of organisational safety: a system characterised by a lack of choices due to limited resourcing.

This is the young man’s first time in an inpatient unit. I try and reassure him, but as soon we get to the unit the door closes.  People are busy. I try and find a nurse. They are few and far between. I eventually find the nurse assigned to my client. A brief introduction is shared, but I know the nurse is trying to get the paperwork done. Admission note, risk assessment, interview with the psychiatrist, place them on the observation board and a host of other tasks. This leaves little time to begin getting to know, understand and work alongside my client to better support them.

I leave my client and return to the ED, there is another case on the board.

This time another young person in a self-harm situation – they were bullied at school and decided to end their life.

Nurses do care, but we are not being given the time or resources to provide the level of service and care that I would want or expect if it was my family member presenting to mental health services.

We do not want to restrict or deny the people we care for their freedoms. Too often the concept of least restrictive practice is sidelined by lack of resources.

The organisations we work for are worried. Worried about risk and what could be in the papers tomorrow. So much so they seem to have forgotten about the core reason we are here – we are here to help.

I as a clinician welcome the reviews and public scrutiny. The current structure needs looking at so we mental health professionals are able to provide the service, care and support that our clients deserve.

 

 


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It’s time to shout out for health

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I’ve spent a long time working in health, and have seen a lot of change. Governments come and they go, budgets change, policies shift. But what doesn’t change is the reason we are attracted to health careers- it comes from a deeply felt desire to make a difference, and change the lives of others for the better.

What you’ve been telling us over the last few years is that it’s becoming harder to connect to that feeling in your everyday working life.

Of course, we still do good. Nursing, like all people-centred jobs is about getting creative, working with what you’ve got and accepting what you can’t change. But the more workarounds our members have to do to give good care, the less time they actually have to provide that care. Nursing SHOULD be a job where you can go home at the end of the day with a satisfied feeling that you were able to make the difference, not frustrated about what you couldn’t do. Nursing is a job we should be able to love.

You have told us you want:

  • “A health system we can be proud of, where everyone can get the healthcare they need when and where they need it.”
  • “To feel proud of the care we provide, and be confident that we have the resources to provide safe, quality care at all times.”
  • “We want satisfying careers with pay that values our work and is enough to thrive on, and ongoing professional development.”

And that’s what NZNO is also pushing for. But we need your help!

Right now, the effects of healthcare funding are all around us- on the ward, in the community, and in the news. In just the last few weeks, we’ve seen news reports about

And the list could go on. The best management and policy in the world can’t make 1+1 = 3. Healthcare underfunding affects almost every aspect of our working lives, and is starting to impact on patient care. I know we all want better. That’s why we are running a campaign programme led by YOU, our members, called Shout out for health. Shout out for health will take action on health funding to push for a health system we are all proud of. Sometimes it will be about a particular service, like our petition on funding for Smokefree services.

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And sometimes it will be about a local issue, that you let us know is happening. The important thing is we need confident, passionate members to make it a success.

If you are an NZNO delegate or NZNO champion, you should have received an email inviting you to a special Shout out leadership training programme. You need to let us know now if you are in- so check your emails please!

If you are ready to stand up and take action to make health funding a priority for all politicians, sign up to be a supporter of the campaign here.

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We are a professional association and union of 47,000 people who care deeply about others. If we use our voice to say ‘health matters’, we have the power to make it better for patients, but also for ourselves.

Memo Musa

NZNO Chief Executive

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CCDM from a Charge Nurse Perspective

By Caroline Dodsworth, charge nurse, Palmerston North Hospital

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As an NZNO member working in a DHB, I know that getting Care Capacity Demand Management (CCDM) working in all our DHBs is a priority in our multi-employer collective agreement (PDF pg 66).

I know that it has been started in most DHBs and I think the implementation has actually been completed in only one so far. It is good work to be doing and it’s important to do it right – better to take the time to get every step correct than to rush it and not get the benefits.

We all want patients to have the best possible outcome. This is most likely to be achieved when patients have the care they need when they need it.

CCDM is the programme that has been developed by the Safe Staffing Healthy Workplaces Unit, NZNO and district health boards (DHBs) to make sure we can actually do this every day (not just on those random, lucky days…).

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Working in partnership is the key to CCDM’s success; NZNO members and staff working together with DHBs to make safe staffing a reality. It’s about making sure base staffing is right every day. It’s about making sure there are workable strategies in place if the match between demand (what patients need), and capacity (our resources) is not right. And to do that there has got to be good quality data available to everyone so we can see on the day and over time if the programme is working. The whole system depends on the information we provide.

You can find out more about CCDM here: www.nzno.org.nz/carepoint

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I thought I’d share my experience of CCDM at Palmerston North Hospital, so you can get an idea of what to expect when your DHB gets the programme (if it hasn’t already).

In 2012 I was charge nurse manager of an acute 32 bed medical ward. TrendCare showed that we consistently didn’t have enough staff to complete the care required; often between 20 and 30 hours short over a 24 hour period! Rosters were pretty much set in concrete and didn’t (and couldn’t) respond to the peaks and troughs in workload. We knew care rationing was happening but there was no way to “see” it or prove it.

The opportunity to become the first ward to undertake work analysis and data collection to inform the CCDM programme was floated and our application was successful.

There was excellent communication during the process; ward staff were included and actively involved. It was a great example of working in partnership with close collaboration between charge nurse, NZNO and ward staff. Ward staff were given every opportunity to express their concerns and listened to in a non-judgmental manner. Facts and figures were explained and we were given time to digest and seek clarification if we weren’t sure about anything. Unfamiliar data was explained in language that we could all understand. Charge nurse, associate charge nurses, management and NZNO delegates were professional and supportive, and assisted with propelling the process forward – staff joined in at “grass roots” level.

The data collection process was difficult and hard work, as I had anticipated; ironing out teething problems, ensuring everyone was on the same page, encouraging the negative staff and the fence-sitters, keeping the momentum going when enthusiasm flagged.

The data collection process was generally seen as “just another data gathering exercise”. But as the process developed it was an eye-opener to be able to quantify the many interruptions during each shift. It also highlighted and reinforced what nurses already know; many interruptions means less time for patient care. We also gained further insight into the peaks and troughs of ward work.

By the end of the two weeks we had become quite attached to our diaries! Finally, we were able to show care rationing – especially the missed nursing care that had become “business as usual”.

It took quite a while for the information we collected to be analysed and some wondered if their hard work had all been for nothing. During this time we implemented Releasing time to care which helped keep a sense of momentum.

As soon as the results were confirmed we swung into action and developed a new model of care. The entire nursing team got together, and with butchers paper and models, felt pens and timetables, we arranged and rearranged the FTE and the roster to meet workload over the entire 24 hour day and seven day week.

We divided up the available FTE into the most efficient and effective spread of regulated and un-regulated staff, thinking outside the square and breaking down traditional shift time barriers. Our new model of care implemented a new role of “admission and discharge nurse” who straddles the morning and afternoon shifts without a patient load, but instead focuses on timely discharges and active “pulling” of patients from MAPU and ED.

This means less pressure on the qualified staff, especially on the morning shift. Discharges happen in a more timely manner, and the discharge of complex patients requiring a lot of registered nurse time is now smoother. Patients feel more informed and new admissions are seen and assessed early without having to wait for a busy nurse.

The model of care for patients with delirium also changed – instead of being staffed by a ward RN and a bureau Health Care Assistant (HCA) we have our own ward HCA who knows the patients and provides continuity of care for them. To have our own HCA caring for these patients is amazing. The benefits to the patient outcomes, and working relationships between the team are invaluable.

The staffing numbers across all three shifts are well thought out. Patient safety has improved significantly with an extra registered nurse at night.

The difference to staff morale and motivation as a result of CCDM has been immense! While the ward remains very busy it now operates efficiently and effectively.  Complaints, incidents, falls and medication errors have reduced, staff turnover is practically zero and productivity has improved.

Since then we have developed a hospital-wide response to variance in collaboration with NZNO. The CCDM variance response management (VRM) tool is a 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 an organisation-wide approach to pooling resources and to providing support where it is needed. Everyone is talking the same language and the tool triggers a response at the top of the cliff instead of the bottom.

I’ve heard a lot of feedback about CCDM over the last couple of years but the comment that has had a lasting impression, and the thing that I think CCDM stands for above all else for 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 charge nurse for that ward I take pride in the fact that I was responsible for making that happen. We need senior managers to influence change at the executive table, but the charge nurse is responsible for driving change at ward level with enthusiasm and passion, leading from the front and never giving up.

If you are involved with CCDM in your ward or unit, I’d love to hear how it’s going. You can leave a comment by clicking the “leave the comment” link to the left of this article.

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If you would like to know more about CCDM please talk with your local NZNO delegate or organiser, or visit www.nzno.org.nz/carepoint or centraltas.co.nz/strategic-workforce-services/safe-staffing-health-workplace

 


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What we want for health

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The Government’s 2016 Budget will be announced in a couple of weeks so we thought we’d set out now what NZNO wants for health. Here’s hoping that is what the Government delivers.

What we want is a health system where everybody can access the health care they need, where and when they need it.

It’s not an outrageous ask, and we’ve never met anyone who disagrees. So, let’s unpick it and see what lies beneath the words.

  • We want a health system that is funded to provide equitable and universal health care.
  • We need the right people to make it happen; nurses, doctors, kaimahi hauora, kaiāwhina, administrators, cooks, cleaners and clinical leaders.
  • Those people must be trained and paid appropriately and be provided with safe work environments.

Last years’ Budget does not provide enough funding to meet the health needs of New Zealanders. Nor did the Budget the year before, or the year before that… In fact economist Bill Rosenberg estimated last year that the funding allocated for health was at least $260 million short. This year will be worse. Rosenberg says that in the eight months to February 2016, District Health Boards were already $27.9 million in deficit.

Funding for the primary health services we so desperately need are being squeezed and cut and services are closing. It just doesn’t make sense – primary care is the way to make our vision for a healthy New Zealand happen. Attacking small services as they begin to make headway into our communities is completely counter-intuitive.

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The Minister of Health is famous for saying “We must live within our means” – implying that health funding is a finite pool. It’s not. This Government could prioritise health if it wanted to.

The Government could say, for example, it’s worth spending more on health for the next 10 years until the massive benefits of focusing on primary care start showing in the system. It could say, more spending now means spending less in future.

If there was a plan, we would know how many nurses to train and we’d be able to support and mentor them after graduation appropriately.

It would be recognised that short term “savings” often don’t yield long term rewards, for people or for budgets.

Nurses, midwives, caregivers and other health care workers tell us they are stretched to the limit. Some are having to sacrifice tea and lunch breaks and working unpaid overtime just to keep up with the care they need to give to ensure needs of patients are met. Support for training and development is decreasing. Stress levels are rising and morale is low.

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A healthy health system would train and employ the right number and skill mix of staff so that people aren’t burning out and/or making mistakes and/or rationing care.

So, that’s what we want in the Budget. New Zealanders deserve it and, as the largest health workforce, we expect to be heard. We are putting it out there that we will fight for it, for all New Zealanders.

A healthy health system should be a top priority for any Government. We want a health system where everybody can access the health care they need, where and when they need it.


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Give me the tools to do a good job

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A fast red car or nursing degree in my middle age? I decided on my long held dream of the nursing degree. So now, I’m part of a team of extraordinary professionals who remind me every day that flagging the fast car was the right decision. I love my job, I love and respect the people I work with and I care passionately about those I am charged to care for.

But, every day it’s getting harder. Harder to care the way I want to, the way I know I should and to care to the standard that my job description and Nursing Council expect of me.

This sounds emotive – it’s meant to be! Last time I looked I’d signed up for the ‘caring profession’, I’m paid to care – not to short change my patients. I didn’t for one moment, while studying, consider that I would have to factor ‘care rationing’ into my day. Care and rationing don’t even belong in the same sentence – It messes with a nurse’s head, it shouldn’t even be a concept!!

Most people have no idea how much these constant budget cuts impact on my ability to do my job. A few get a snapshot, when they are unwell and require medical help. If I’m lucky they are empathetic and understanding of the difficulties nurses face every day, they appreciate what we do and how hard we work.”

If the Minister of Health, Dr Coleman is going to name and shame hospitals who fail to meet the ‘ED Six Hour Target’, then he should be obliged to give the public the full story – the reasons why this is happening in the first place! Perhaps explaining that some EDs have increasing, unprecedented presentations – some patients very unwell, needing massive resource input, so others sit for hours waiting to be seen because there aren’t enough nurses or medical staff to keep the patient flow going. Or maybe that the hospital is in ‘bed lock’ – not a single bed, until hurried discharges are made – a short term solution, because some of those patients will be back in ED, sicker- requiring a higher level of care and  another admission. Or maybe that some days ED waiting rooms are full of patients who could have gone to their GP, but have left it too late, or couldn’t get an appointment, or didn’t have the money.

Nurses were voted the ‘most respected profession’ survey this year. I don’t feel respected by our government. If the government respected us and our work, they would make sure that nurses had the tools to do their job, and to do it well.  Our health service is being stripped so bare, many nurses are walking away or planning to. They’re done with the stress, the shifts that end in tears, not wanting to go back tomorrow.

I just want to be able to do my job properly, safely and go home knowing I’ve done a good job. Our health system should be given a realistic budget that allows it to function properly.

If we want things to change then it’s up to nurses to say so – nobody else is going to! So do we wait until the next pay round?  Do we wait for a nurse to make that error we all dread? Do we keep waiting… for what? It’s time to use the strength of our union to give the public the full story of what is happening to our health system and why that system is letting them down. To say nothing is negligent!

By NZNO member Ady Piesse

Photo credit under Creative Commons licence.


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Working to stay safe

Fb picYou’ve probably heard a lot in the news recently about the Government’s back-track on improving health and safety laws. After the Pike River tragedy the Government promised to improve health and safety legislation – so that no family would ever need to have the police turn up and tell them that their loved one was killed on the job – but instead they’re doing the opposite.

We speak to a nurse about what health and safety means to her.

Why does Health and Safety mean so much to you as a nurse?

Firstly, for us in hospitals, I know lots of colleagues that have had accidents at work, twisted knees and backs from lifting. There’s an immediate loss of earnings for that person, they’re down to 80 percent of their earnings on ACC, because our DHB doesn’t top them up, unless we use our sick leave allowance. And then someone on ACC isn’t usually replaced with another staff member, so we get short on the wards.

What happens then?

The first thing to go is meal and tea breaks. Nurses are terrible about working through without taking a break and just running between patients. Then, they’re likely to have more accidents because they are rushing, or even make medication errors or errors of judgement. So it starts having an impact on patient care too. And care rationing definitely happens when you have a staff member off injured. That’s when you decide what is going to keep people alive versus the best care you could give someone.

Can you give us an example?

Like, if you have someone who needs a shower, an elderly patient who hasn’t showered, giving that gentleman a shower might take 40 minutes, but you just can’t afford the time. Basic care like that could get missed. It’s so much easier to prevent accidents from happening than dealing with the flow-on effects of when they’ve happened. That’s why having effective Health and Safety strategies is so critical for everyone. Not just in big workplaces too but in all healthcare settings.

You deal with workplace accidents when people come in as patients too, right?

What people have to understand is that Health and Safety matters to nurses not just for our own workplace but because after a workplace death or accident, we have to come in to fix up the mess. It’s incredibly stressful dealing with a workplace death. When you clock off at the end of the day, it goes home with you. Every accident or death like that has ripples that go far afield and affect many people. And they come back to us too.

What you mean by ‘coming back to you?’

Oh, nurses treat the aftermath of those things with grieving friends and family too, in areas like addiction or depression. Or even poverty, some whole families have to deal with the grief and being thrown into sudden poverty. And then they’re back in the health service with stress and diseases that wouldn’t have happened if their family member wasn’t killed or injured. It’s never just one person affected, and it’s health staff as well.

It’s not just deaths, it’s accidents. Not everyone is covered by ACC so sometimes it’s a choice between their health and their income. When you see a bad employer that thinks workers lives don’t matter a lot it’s really disgusting and you know they think it’s going to cost less in dollar terms to just replace a killed or harmed worker than to invest in health. It costs the rest of us though, we pick up the tab.

There was a case recently, a woman who worked for a really well known New Zealand company, one that’s won awards, that you’d think could do better. She’d hurt herself at work. The operation was the only chance to avoid a permanent disability, but it entailed time off.  She told me that she couldn’t take time off because her boss wouldn’t keep the job open, and she wouldn’t get another one.  She had a family to support and felt she had no choice.  I’m pretty sure she would have gone straight back to work, and as a result of that will have an avoidable and permanent disability.

Do you have a message for the Government about the Health and Safety Reform Bill?

‘Yeah but you can’t print it! No, seriously, good health and safety reps can prevent these kinds of accidents when the attitude to them is positive and constructive and management takes them seriously. The Government has to give the message that they’re important and can’t be removed if they’re a ‘nuisance’ to bad management. We have to look at workplaces where they have health and safety committees that work and where there is a good record of improvement. What works is when unions and workers and employers are doing it right and engaging together. We didn’t have to lose all those lives and Pike River and we shouldn’t be losing any more in other industries now. Everyone has a responsibility.