Sadly, nurses and midwives often report an inability to deliver the standard of care they are trained to provide due to constraints within their workplace - including poor workplace culture, unreasonable restrictions determined by management, or an inability for nurses and midwives to get their voices heard.
We know the benefits of safe staffing levels are only fully realised when nurses and midwives are working in Positive Practice Environments.
As part of the QNMU’s Ratios Save Lives and Money campaign, nurses and midwives are seeking to have a minimum care standard mandated across all nursing and midwifery services - our Positive Practice Environment Standards.
What are the Standards?
Standard 1: Safe staffing levels
Minimum safe staffing and skill mix is essential for safe workloads in nursing and midwifery practice. Nurses, midwives, and carers should:
- Work in an environment that has minimum safe staffing and skill mix in place
- Have a process in place within the organisation to escalate workload issues.
Case study: Boosting staffing in EDs
QNMU members at an Emergency Department had been dealing with excessive workloads for years. In particular, there was a significant reduction in nurses on night shifts, despite a consistent flow of patient presentations, leading to increased wait times and safety concerns.
One QNMU Delegate, who helped lead the case for more staffing, said the unit as a whole agreed something needed to be done to fix their workloads.
“We contacted the QNMU and started filling in workload forms, then escalated it to a stage 3 grievance. We met regularly with management and there was a core group of us that rotated through all the meetings. We kept everyone else updated by talking on shift handovers, we ran some surveys to get feedback from nurses and ensured we were presenting everyone’s views. We tried really hard to keep everyone informed so that we didn’t lose the momentum. It certainly helped that we were dealing with co-operative management. Both parties worked well together to find a solution that helped our patients.”
In alignment with the QNMU’s Ratios Saves Lives Phase 2 claims document and CENA staffing standards, members determined an additional 13.2 FTE nurses were required. Ultimately, management committed to delivering these extra FTE, and members have since reported improved patient flow on night shifts, better communication between teams, and a dramatic reduction in workload forms. Most importantly, staff feel they can now provide better quality care to their patients.
Standard 2: Physical, psychological and cultural safety
Nurses, midwives, and carers' wellbeing is increased when a system of safe, high-quality health or aged care is established that focuses on evidence-based consumer centred care. Nurses and midwives should also provide an evidence-based primary focus on the delivery of safe, high-quality care, that is consumer centred.
Case study 1: Reviewing workplace culture
At one unit in a Brisbane hospital, members reported that divisions within the ward were affecting their ability to do their work. A culture of fear had spread across the ward, and stress levels were only intensified through unmanageable workloads that posed a danger to staff and patient safety.
Much has changed since then, with an independent review investigating workplace culture. Over 90 nurses took part in interviews and provided more than 300 suggestions on how to improve the ward. Among other things, the review emphasised the importance of providing psychological support for nursing staff. Now, with management recruiting a significant additional nurse FTEs to the ward, and a genuine commitment from management to engage with nurses, members report the ward is much safer. There has also been an increase in Health and Safety Representatives (all nurses), which is great for everyone’s safety.
Case study 2: Health and Safety Representatives
One of the ways that nurses and midwives can raise issues and concerns that they determine pose a health and safety risk (either to themselves or to their patients or residents) is to elect a Health and Safety Representative (HSR).
HSRs play a significant role in keeping staff safe by ensuring employers adequately consult with staff on matters relating to health and safety. Among other responsibilities, HSRs can inspect a workplace, investigate complaints, request a health and safety committee be established, and monitor compliance measures.
They can also issue provisional improvement notices (PIN) – which is exactly what one QNMU member and HSR did.
“There were ongoing issues relating to a patient relative whereby interference, questioning staff and clinical judgements along with other behavioural issues were impacting patient safety to the point where some staff were second guessing their judgements and putting the patient’s safety at risk. As a HSR, it was my job to act and fulfil the purpose of the role, which is to maintain a safe work environment. A provisional improvement notice (PIN) was submitted on consultation, outlining details of contravention to the Work Health and Safety Act to support and justify this action. Management implemented various measures, resulting in a safer workplace.
“So with the additional training and responsibilities that come with being a HSR, the role enables you to escalate things in a way that other staff may not feel confident or empowered enough to do – the use of a ‘PIN’, although as a last resort, enables the HSR to address matters that pose a direct threat to workplace safety. This process was very helpful in this particular case.”
The QNMU is currently working with members in various health facilities to increase the presence and education of HSRs. For more information on HSRs, members can view this HSR information sheet or contact their Organiser.
Standard 3: Autonomous and collaborative practice
Nurses, midwives, and carers have varying skill sets that allow us to provide different levels of care. The autonomous practice of registered nurses and midwives must be recognised and respected. Importantly:
- Registered nurses and midwives must work autonomously within their scope of practice.
- Carers must work under the delegation of a named and accessible registered nurse or midwife, and under the supervision of a nurse or midwife.
Case study 1: Quarantining time to upskill and collaborate
More time for training, upskilling and planning. That’s the intention behind an hour and a half crossover between the morning and afternoon shifts at an acute mental health unit in SEQ – a rostering strategy that, while not widely utilised in health facilities across the state, is a precious source of time for many nurses to grow their autonomy and collaborate with their colleagues. By having 10-hour night shifts, afternoon shifts are moved forward, creating a greater overlap during the middle of the day where more staff are rostered together, affording nurses an important opportunity to grow.
One QNMU member and mental health Clinical Nurse said her ward quarantines this time for education and planning, allowing nurses time to upskill and complete care plans.
“Over the last couple of years, mental health educators became quite proactive in providing a program for in-service sessions, which was really great, but it’s no good if we can’t get to it. So our NUM quarantined that overlapping hour and said that’s when you do your online training and attend in-service education. The nurses also often identify particular topics or issues, such as suicide prevention, med safety … when the RQI Cart for basic life support was around, pretty much the whole team got their mandatory training done in an afternoon during that hour.
“By having that time set aside, your focus during the shift is much more on the patient, you’re able to spend more time with them and actually do your care planning. I think our training is more up-to-date as well.
“The other thing is that I’m able to step in and do much more coaching and mentoring on the floor with other staff. So it’s a gift of time for us to take the space we need to do the things that allow us to work to our full potential.”
Case study 2: Nurse Practitioners: Pushing the scope of practice
Nurse Practitioners are, in many ways, the true clinical leaders within the broader health care team. They are able to work both autonomously and directly with their patients to assess, diagnosis, teach, treat and provide expert care, as well as develop and implement a person-centred plan of care, including referrals to other health professionals.
One Nurse Practitioner who specialises in aged care and dementia spoke about her six-year journey caring for one of her patients living with dementia.
“I initially saw Margaret* every two to three months, which is fairly standard, and over a period of six years I built up a relationship and trust with her husband, who was her primary carer, about what I was able to offer that would benefit both him and his wife. Three years in, when it was becoming more difficult for Margaret to leave the home, the local GP said they were no longer able to do home visits. I was able to explain my role to the GP, and we agreed I would continue my support and also prescribe the patient’s medications.
“Through discussions with the family and with updates to the GP, we were able to decrease a lot of Margaret’s medications – she went from taking six to two medications a day. But most significantly, we were able to keep Margaret in her home right until the very end. She had a Level 4 community service, whose staff were wonderful, and I was able to provide support from the side as Margaret’s husband and family were able to do all the care. As Margaret’s condition became end stage, I prescribed relevant pain relief and all oral medications were ceased. Her husband rang me a few times afterhours and said he thought Margaret needed to go to the hospital, I listened and talked him through what was happening and educated the family further on the normal dying process and what would happen if we sent Margaret to the hospital.
“He made the decision to keep her at home and continue to manage the situation, which was a better outcome for Margaret, her husband and their family.”
Through her specialised role and ability to work autonomously, the Nurse Practitioner ensured her patient’s end of life was dignified, comfortable and, ultimately, led by the family themselves.
*Not patient’s real name
Standard 4: Shared governance and decision-making
When nurses and midwives have a seat at the table, our voices are heard and factored into decisions that directly influence our everyday work. Nurses and midwives should:
- Work in an environment that empowers all levels of nursing and midwifery to work in shared governance models.
- Work in an environment that allows professional visibility and authority.
- Apply the NMBA Decision Making Framework in practice.
Case study 1 – Listening to the nursing expertise
A complete lack of nursing or clinical expertise in key management roles at a not-for-profit alcohol and drugs service has led to safety concerns, which have been ongoing for years. With no nursing representatives on the management team, management struggled to understand why nurses were constantly escalating their safety concerns.
One QNMU member said nurses felt like their clinical expertise was constantly being questioned by management.
“The main concerns were our lack of clinical governance and the assessment process not involving nurses. So patients with very complex medical and mental health issues were being assessed by non-clinical people with a Cert 4 qualification. The nurses would then decline the admission of a client after that initial assessment because they were too high-needs for our service. Unfortunately, this sort of clinical decision-making was constantly questioned and not backed up by management. The accuracy of assessments was consistently poor and nurses were being asked to make important clinical decisions with little or inaccurate assessment information.”
Fortunately, nurses, with the support of the QNMU, were able to get management to agree to an independent review to assess the problems and put forward recommendations. One of these recommendations was that a working committee be formed and include a nurse representative from each site.
“I’m hoping a lot of the safety issues will be resolved. But it may not be an immediate thing – it might be 12, 18 months. But we nurses have the clinical knowledge, we’ve studied for this, we’ve got years of clinical and mental health experience. We possess the knowledge and skills to assess our clients, and nurses know how to run these facilities safely.”
Case study 2 – IeMR rollout
The rollout of new digital technologies is often fraught with difficulties. Whether or not these new technologies elevate or frustrate our ability to deliver patient care – and therefore whether the technology succeeds in its intention to create a more efficient and safer health system – largely depends on whether nurses and midwives are adequately consulted throughout all stages.
For staff at one particular midwifery ward, a new IeMR system rolled out with minimal consultation with the midwives. One QNMU member said the lack of meaningful consultation meant issues with the technology were still ongoing today, despite the technology being introduced years ago.
“The system was brought in, we were pulled into a meeting, but it was a fair accompli – that’s to say it’s going to happen no matter what. So we had to make the best of it. We engaged in the training, we identified problems with the system, in particular things that didn’t cover maternity because it’s a stock-standard, one size fits all system.
“The observation machines weren’t talking to the system, so we’d have to write them down on a piece of paper and translate. It was time-consuming to be face-to-face with the computer that took you away from patient care. We continue to this day to have both paper and electronic systems.
“We’re now three years down the track and we’re still having problems with this system. The midwives have adapted to the system as best we can, and slowly we’re getting things changed, but it costs money every time they make a change to the system. If they’d consulted properly from the beginning, I think we would’ve ironed out so many of the problems that keep popping up all the time.”
The QNMU member described what she thought “genuine and proper consultation” should look like between management and staff on the floor.
“So much consultation is just rhetoric. They consult at different levels and will often choose who they consult with. Meaningful consultation means getting small groups of people in safe, face-to-face, relaxed environments to provide feedback as a starting point. Not in a formal way or via surveys – things get lost in translation with surveys. I think consultation should also include actually walking the floor and speaking to staff on days that aren’t going to be super busy and getting true feedback that way.”
Standard 5: Research and innovation
Nurses and midwives are the key to unlocking an innovative and more efficient health system that provides patients with timely access to the care they need. While nursing and midwifery research and innovation within the practice environment is broad and wide ranging, nurses and midwives should:
- Conduct evidence-based practice research.
- Lead and contribute to health and aged care service research and innovation.
- Participate in innovative quality improvement and accreditation processes.
- Develop health policies, practices, systems, products, and technologies.
Case study: Child Development CNC reduces wait times
As part of an Enterprise Bargaining innovation fund, a new role called the Child Development CNC was trialled in a regional district.
One QNMU member, who led the project, said the role was introduced to address the large cohort of triage category three patients on the paediatric or child development service waiting list with behavioural concerns.
“It was brought about to see if nurses could start to address the behaviour and parenting concerns of these families that generally sit on our wait list for periods of up to 12 months, despite not all of them needing to be medically managed.
“If the position becomes permanent, it would hopefully be moving to a model where the CNC would assess the patient or family first and based on this assessment commence early intervention, referrals and individualised support, which may/may not resolve their concerns. It will allow a more time-efficient appointment if paediatric input is required and earlier access to care for all families.”
Early findings from the trial have already resulted in more timely care (including early access to specialised services for rural clients) and high engagement from a large number of eligible clients across the four centres. Long-term benefits are also anticipated, including minimising impact of developmental issues, increased health literacy and parenting capabilities, and reductions in wait times and failure to attend.
The member said the project changed how she saw innovation in nursing.
“Now that I see the early results of this role, I just think, how come we didn’t do this earlier? This model could be replicated in many different settings. If it’s about improving patients’ access to care then it’s only going to be a good thing.
“Nurses are at the forefront to be able to deliver innovative ideas, but we often don’t work to our full scope. Innovation helps increase our value and highlights what amazing things we can do to make positive change in health care.”
Standard 6: Transformational leadership
Transformational leadership is about ensuring nurses and midwives show leadership at all levels – not just at the executive level, but also at the beside. This kind of leadership is about recognising that we all have a role to play in bringing about the change we want to see to achieve the best practice environment, including:
- Motivating and inspiring others to act as role models for their professions.
- Leading innovative contemporary models of nursing and midwifery care.
Case study: Nurse leaders recognised through Awards
One of the categories in the QNMU’s Professional Practice Awards is Excellence in Leadership and Governance. The award recognises QNMU members who:
- demonstrate excellence in safety and quality
- actively encourage work-life balance through advocating industrial and professional entitlements
- role model positive practice behaviour
- promote a culture of professional elevation of nursing/midwifery through peer support, mentoring and supervision
- motivate productivity and performance
- demonstrate collaborative decision-making.
The 2020 finalists included:
- Mary English (winner), who actively raises the profile of nursing in a rural setting and fosters confidence in new grads to help create a culture that supports best practice and excellent workplace relations.
- Belinda Henderson, who showcases and promotes the importance of infection prevention control nurses. She is a voice for her peers in small, rural and remote centres that don’t have access to infectious diseases physicians, clinical microbiologist and public health staff.
- Mark Crocker, who established Australia’s first Interventional Clinical Nurse Consultant of Ophthalmology position – a nurse-led injection service for WET AMD (Australia’s leading cause of blindness) and Diabetic Retinopathy.
Read more about the finalists on our Professional Practice Awards website.
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