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Report of the

Mid-program evaluation of ‘take the lead’

Centre for Clinical Governance Research

Australian Institute of Health Innovation

Report of the mid program evaluation of ‘take the lead’

i

Produced in 2011 by the Centre for Clinical Governance Research in Health, Australian

Institute of Health Innovation, Faculty of Medicine, University of New South Wales,

Sydney, NSW 2052.

© Travaglia J, Debono D, Erez-Rein N, Milne J, Plumb J, Wiley J, Callaway A, Dunn A,

Johnson J, Braithwaite J. 2011

This report is copyright. Apart from fair dealing for the purpose of private study,

research, criticism or review, as permitted under the Copyright Act, 1968, no part of this

publication may be reproduced by any process without the written permission of the

copyright owners and the publisher.

National Library of Australia

Cataloguing-in-Publication data:

Title: Report of the mid program evaluation of ‘take the lead’

1. Report of the mid program evaluation of ‘take the lead’

2. University of New South Wales, Centre for Clinical Governance Research in Health –


Centre for Clinical Governance Research


University of New South Wales, Sydney Australia

http://www.med.unsw.edu.au/medweb.nsf/page/ClinGov_About


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TABLE OF CONTENTS

Abbreviations and definitions ..................................................................................... 3

Executive summary ..................................................................................................... 5

Recommendations ...................................................................................................... 8

1. INTRODUCTION .................................................................................................. 10

2. Method .............................................................................................................. 15

2.1 Introduction ....................................................................................................... 15

2.2 Evaluation tools .................................................................................................. 16

2.3 Literature review ................................................................................................ 16

2.4 N/MUM interviews ............................................................................................ 16

2.5 N/MUM manager interviews ............................................................................. 17

2.6 Staff survey ......................................................................................................... 17

2.7 Case studies ........................................................................................................ 18

2.8 CSO survey ......................................................................................................... 18

2.9 Data analysis ...................................................................................................... 19

2.10 Approval ........................................................................................................... 19

3. Literature review ................................................................................................ 20

3.1 Introduction ....................................................................................................... 20

3.2 Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals

(‘The Garling Report’) ................................................................................................. 20

3.3 Caring Together: The health action plan for NSW ............................................. 21

3.4 Context for ‘ttl’ ................................................................................................... 23

3.5 The role of the Nursing/Midwifery Unit Manager within NSW Health ............. 24

3.6 The role of the CSO ............................................................................................ 24

3.7 Take the lead (‘ttl’) ............................................................................................. 25

3.8 Factors supporting and inhibiting workplace change ........................................ 26

4. Results ............................................................................................................... 27

4.1 Demographic and background data ................................................................... 27

4.2 Implementation of changes post ‘ttl’ ................................................................. 29


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4.3 Implementation of demonstrable changes in the capabilities and skills of

N/MUMs post ‘ttl’ ...................................................................................................... 36

4.4 Key factors affecting changes implemented as a result of ‘ttl’ ......................... 46

4.5 Quantitative improvements at the unit level .................................................... 50

4.6 Barriers to the program’s implementation ........................................................ 57

4.7 Strategies required to ensure the sustainability of changes ............................. 58

4.8 Essentials of Care and Caring Together: The health action plan for NSW ......... 61

4.9 Conceptual Framework for the Nursing/Midwifery Unit Manager Role ........... 64

4.10 Strengthening of role as N/MUM .................................................................... 65

4.11 Introduction of the Clinical Service Officer’s position ..................................... 67

4.12 Impact of the CSO role on the clinical team .................................................... 71

4.13 Unexpected impacts/outcomes of the CSO role.............................................. 74

4.14 Case studies ...................................................................................................... 77

4.15 Reflections on ‘ttl’ ............................................................................................ 80

5. Discussion .......................................................................................................... 83

5.1 Overall findings .................................................................................................. 83

5.2 Positive benefits ................................................................................................. 84

5.3 Key factors .......................................................................................................... 85

6. Conclusion ......................................................................................................... 87

7. References ......................................................................................................... 88

8. Appendices ........................................................................................................ 95

8.1 Evaluation tools .................................................................................................. 95

8.2 Literature review .............................................................................................. 122

8.3 Demographic characteristics of participants ................................................... 132

8.4 Changes to N/MUMs’ capabilities and skills since ‘ttl’ .................................... 133

8.5 Improvements at the unit level since ‘ttl’ ........................................................ 142

8.6 CSO Survey ....................................................................................................... 153

8.7 Details of case study ........................................................................................ 167


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ABBREVIATIONS AND DEFINITIONS

Abbreviations

ACRONYM FULL TERM

AHS Area Health Service

AIHI Australian Institute of Health Innovation at University of NSW

CCGR Centre for Clinical Governance Research at University of NSW

CGU Clinical Governance Unit

CI Clinical Indicator

CEC Clinical Excellence Commission

CPI Clinical Practice Improvement

CSO Clinical Support Officer

PHO Public Health Organisation

SDM Service Delivery Model

NMO Nursing and Midwifery Office (NSW Health)

NUM Nursing Unit Manager

MUM Midwifery Unit Manager

N/MUM Nursing/Midwifery Unit Manager

‘ttl’ take the lead


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Definitions

TERM DEFINITION

Clinical Practice Improvement

A combination of tools, techniques, skills and attributes designed to enhance care inputs, structures, cultures, processes, outputs or outcomes.

Culture The configuration of attitudes, values, beliefs, meanings, behaviours and practices which together can be seen to be definitive of ‘what people are’ or ‘where people come from’. Culture can be seen as a ‘state’ or something people possess; it can be seen as performance; and also as a process.

Ethnography A research technique used for describing and analysing what human beings do in selected settings, usually comprising ‘participant-observation’, fieldnotes, narrative accounts, temporal-spatial mapping, interviews, and other qualitative research methods.

Evaluation The systematic examination of a policy, program or project aimed at assessing its merit, value, worth, relevance or contribution.

Formative evaluation

Evaluation conducted during the course of a policy’s, program’s or project’s life.

Health services research

The systematic examination of health care settings, institutions or organisations including quality, safety, structures, politics, cultures, financing, resource allocation and delivery systems .

Innovation The rate, propensity, capacity and effectiveness in adopting new ideas, practices or behaviours.

Organisational change

Macro (organisational-wide), meso (divisional or departmental) or micro (small-scale) adaptations and adjustments to institutionalised processes, procedures, structures and strategies.

Organisational culture

The collective set of relationships in organisations that differentiate one group from another in terms of dress, attitudes, values, behaviours, beliefs, language and shared meaning.

Summative evaluation

Evaluation conducted at the end of a policy’s, program’s or project’s life.

Triangulation A multi-method research or evaluation design which adduces converging or diverging evidence drawn from pluralist sources to illuminate an object of inquiry.


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EXECUTIVE SUMMARY

This report presents the results of a mid-term evaluation of the ‘take the lead’ (‘ttl’)

Nursing/Midwifery Unit Manager (N/MUM) program, conducted by the Centre for

Clinical Governance Research (CCGR) in the Australian Institute of Health Innovation

(AIHI), Faculty of Medicine, University of New South Wales (UNSW). The evaluation

was commissioned by NSW Health, to assess the progress and achievements of the

‘ttl’ program. ‘ttl’ involved a series of strategies designed to develop, support and

facilitate the role of N/MUMs The ultimate is that N/MUMs are able to provide

highly co-ordinated care at the unit level, resulting in a well-managed unit and the

improvement of the patients’ journey and their patients’ care experiences.

The evaluation was conducted in the second half of 2010. A multi-method,

triangulated research methodology was undertaken, involving seven inter-related

studies and a literature review. Data were collected from participants across eight

Area Health Services (AHS) and two state-wide services in New South Wales (NSW).

Methods included: interviews with N/MUMs; interviews with managers of N/MUMs;

two case studies; an online survey of staff; an online survey of Clinical Support

Officers (CSOs); and document analysis.

All of the participants in this evaluation recognised that the role of N/MUMs has

changed significantly over the last three decades, and that this change has involved

increased managerial and administrative responsibilities. Most N/MUMs and their

managers commented on the lack of preparation for N/MUMs to pursue their

managerial and leadership roles. The changes suggested or supported by the Garling

Inquiry, including the formalisation of the role of N/MUMs, programs for their

professional development, and the facilitation of their increased presence in their

units and ‘away from their desks’ was seen to form a new phase in this development.

We found that there was general agreement amongst all participating groups that

‘ttl’ had contributed to some degree to the skills development of N/MUMs. This was

considered, by those who felt that ‘ttl’ had had an impact, to have enabled and

empowered N/MUMs to implement changes in the workplace. It is important to

note this distinction however: not all N/MUMs, N/MUM managers or staff

considered that ‘ttl’ had had an impact on N/MUMs. Some participants were unable

to identify whether it was ‘ttl’ specifically that had contributed to the N/MUM’s

development or not. A range of confounding factors, including professional maturity,

other development and change programs in the workplace, and the N/MUM’s own

educational background and experience made it difficult to attribute the impact.


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Even though individual cases differ (both in response to the program and in assessing

its subsequent impact), the results overall show that for those N/MUMs who were

able to implement changes in the workplace, ‘ttl’ was an important contributing

factor. This is particularly, but not only, in cases where N/MUMs had little prior

training and or experience.

N/MUMs have put in place a wide range of changes as a result of their participation

in ‘ttl’. The most common changes involved implementation of some aspect of lean

thinking: this may be because, in the view of one participant, that model allows for

small incremental changes which are highly visible and ‘quick wins’. However, many

N/MUMs have implemented other changes ranging from the modification of their

individual communication styles, to new approaches to the rostering of staff, to the

creation of multi-method team based approaches to the improved co-ordination of

care. Differences in the sophistication and range of changes meant that their impact

was difficult to measure; however individual participants indicated cost and time

savings as a major impact.

Changes in N/MUMs’ capabilities and skills varied. However, across all participants

groups, there were indications of improved communication, particularly in critical

contexts. Several N/MUM managers noted that one of the positive impacts on their

own work of their N/MUMs participation in ‘ttl’ was a reduction in the number of

performance reviews which ‘progress up’ the ladder for their attention.

The success of, and barriers to, N/MUMs’ attempts at change were attributed to a

range of structural, cultural, organisational and relational factors. These factors

complemented the findings from the literature review. The three key elements to

the successful transfer of learning into action were a combination of: the clinicians’

own personal commitments and characteristics; the way in which the training did or

did not prepare them for the transfer of that learning; and workplace climate and

organisational support. Participants gave consistent examples of the importance of

these factors. The last of these factors, workplace climate and organisational

support, was also said to be critical for the sustainability of the changes

implemented.

Although individual circumstances differ, overall, the role of the CSOs was said to

have made a significant contribution to reducing the administrative workload of

most N/MUMs. From the CSOs’ perspective, undertaking a new and at times not

clearly defined role has posed some challenges, particularly for CSOs who are

geographically or organisationally isolated, or whose work extends over more than

one location.


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This evaluation shows that the introduction of ‘ttl’, along with other improvement

mechanisms, such as the Essentials of Care program and the introduction of CSOs,

has enabled some N/MUMs to develop, implement and sustain changes to their

workplace. In cases where N/MUMs have been able to transfer their learning from

‘ttl’ effectively, these changes have resulted in improvements in finances, staff

satisfaction and morale, and patient care.


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RECOMMENDATIONS

Recommendation 1: ‘ttl’ should continue to be implemented

On the whole, ‘ttl’ is perceived to have strengthened the role of the N/MUM, particularly new N/MUMs, and to have had positive impacts in many workplaces. However, it has been identified that there are some ways in which ‘ttl’ could be strengthened. As discussed networking and sharing of ideas was identified as very helpful. Therefore, implementation of ‘ttl’ should continue, particularly for new N/MUMs. Recommendations 1.1 – 1.8 are proposed to enhance ‘ttl’ and so maximise its potential impact.

Recommendation 1.1 Future implementation of ‘ttl’ programs should cater for divergent levels of experience, geographical location, existing localised and state-wide systems requirements, and role demands of N/MUMs.

Recommendation 1.2 Future implementation of ‘ttl’ should recognise and acknowledge prior learning. Alternative modules designed to build on prior knowledge should be included as an alternative for those N/MUMs with prior postgraduate management qualifications.

Recommendation 1.3 A module on Change Management should be included to equip N/MUMs to lead and manage change in their units.

Recommendation 1.4 Following ‘ttl’ an advanced program should be introduced to encourage further development of N/MUMs in their leadership role.

Recommendation 1.5 A ‘ttl’ ‘refresher’ module would be helpful to consolidate what has been learnt during ‘ttl’ especially for less experienced N/MUMs. This would also provide an opportunity to share experiences of overcoming barriers to change.

Recommendation 1.6 Methods should be established by which networking and sharing of experiences and ideas can be encouraged among N/MUMs. This may include regular debriefing sessions, email links, and group discussion boards.

Recommendation 1.7 A mentorship program for N/MUMs who have undertaken ‘ttl’ should be introduced.

Recommendation 1.8 An equivalent program to ‘ttl’ should be introduced for other managers.


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Recommendation 2 The CSO role should be developed and more CSOs employed

The CSO role is perceived to have impacted positively on the work of N/MUMs largely through freeing them up from administrative duties to concentrate on their leadership role. However, shortcomings in the introduction of the CSO role have been identified. Recommendations 2.1 – 2.7 are proposed to address some of these issues.

Recommendation 2.1 A clearer job description for the CSO should be developed. Input from N/MUMs and their managers should inform the development of the job description for CSOs. The CSO job

description should be clearly defined while allowing room for local adaptation.

Recommendation 2.2 A generic training and orientation program for CSOs should be introduced. CSOs should be required to undertake this program prior to commencing their role.

Recommendation 2.3 N/MUMs should be involved in the recruitment process for the CSO role.

Recommendation 2.4 A development session on the role of CSOs should be held so that N/MUMs are better informed about how to utilise the CSO role effectively.

Recommendation 2.5 Methods should be established by which networking and sharing of experiences and ideas can be encouraged among CSOs. This may include regular debriefing sessions, email links, and group discussion boards.

Recommendation 2.6 Ongoing evaluation of the introduction of the CSO role should be conducted. Input from CSOs, N/MUMs, managers, and other staff should inform further development of the role description, reporting lines and outcomes of the introduction of the CSO role.

Recommendation 2.7 Further exploration of the role of CSOs in non acute services is

warranted.


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1. INTRODUCTION

This report presents the results of a mid-term evaluation of the ‘take the lead’ (‘ttl’)

– The Nursing/Midwifery Unit Manager (N/MUM) program, conducted by the Centre

for Clinical Governance Research (CCGR), Australian Institute of Health Innovation

(AIHI), Faculty of Medicine, University of New South Wales (UNSW). The evaluation

was commissioned by NSW Health, to assess the progress and achievements of the

‘ttl’ program. ‘ttl’ involves a series of strategies designed to develop, support and

facilitate the role of N/MUMs, so that they are able to provide highly co-ordinated

care at the unit level, resulting in a well-managed unit and the improvement of the

patients’ journey and patients’ care experiences.

The project examined and reports on the outcomes of ‘ttl’ across ten Area or state-

wide Health Services including Sydney Children’s Hospital, Westmead and Justice

Health. The Ambulance Service was excluded from the evaluation because no staff

had participated in ‘ttl’. The evaluation used a comprehensive and sophisticated

multi-method, triangulated research methodology. The evaluation investigated the

identified outcomes of ‘ttl’ and in so doing answered the central questions: has the

role of the Nursing/Midwifery Unit Manager been strengthened and are there

identifiable improvements in patient care and flow? The framework for the

evaluation took the form of eight inter-related studies (Figure 1).

This report presents our findings. It begins with a brief history of ‘ttl’ within a wider

context of health system reform in NSW subsequent to the Garling Inquiry (Garling,

2008). This is followed by a review of the literature on the role and development of

nurse managers, reflecting in particular on the transfer of learning about, and for,

change within health systems. The findings section presents the results of interviews

and surveys gathered from N/MUMs, their managers, and clinical and administrative

staff, relating to the impact of ‘ttl’ on the management of units and outcomes for

patients across NSW. These results deal with various factors, including individual

capacity development and structural support, which have contributed to, or

hindered, the success and sustainability of changes N/MUMs wish to implement as a

result of ‘ttl’. The report then considers how the introduction of the role of Clinical

Services Officers (CSOs) has affected work of the N/MUMs and other staff of health

services.


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Figure 1: Evaluation studies

1. Literature review2. Changes put in place

by N/MUMs as a result of participation in ’ttl’

3. Demonstrable changes in the capabilities and skills of Nursing and

Midwifery Unit Managers from the perspective of individual Nursing and

Midwifery Unit Managers, the staff they

manage, the staff to whom they report

4. Identify the key factor described by N/MUMs in

any change they have been able to achieve

5. Identify and measure quantitative

improvements at the unit level to demonstrate

change as a result of ‘take the lead’

8. Examine the impact of the introduction of the

Clinical Services Officers’ position

7. Identify strategies required to ensure

sustainability of any changes achieved

6. Identify barriers to the program’s

implementation

What is the progress made by, and

achievements of, the ‘take the lead’

program?


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Each study had a core question and set of tasks. These are presented in Table 1.

Table 1: Key research tasks, studies conducted and core questions asked relevant ‘ttl’

STUDY RESEARCH TASKS CONDUCTED CORE QUESTIONS ASKED

1. Review of the literature

1.1 Identification and classification of the literature on nurse managers

1.2 Content analysis of the literature

1.3 Review of the key themes in the research literature.

What is known about the development of the role of nurse managers, and their ability to implement change?

2. Identify changes put in place by N/MUMs as a result of participation in ’ttl’

2.1 Interview of N/MUMs

2.2 Interviews with managers of N/MUMS

2.3 Case studies of N/MUMs

2.4 Questionnaire survey of staff.

What changes have N/MUMS been able to put in place as result of their participation in ‘ttl’

3. Identify demonstrable changes in the capabilities and skills of N/MUMs

3.1 Interviews with N/MUMs

3.2 Interviews with managers of N/MUMs



What changes have occurred in the capabilities and skills of N/MUMS from the perspective of individual N/MUMs the staff they manage, the staff to whom they report

4. Identify the key factors described by N/MUMs in any change they have been able to achieve





What key factors contribute to N/MUMs’ ability to implement successful changes supported by ‘ttl’?

5. Identify and measure quantitative improvements at the unit level to demonstrate change as a result of ‘ttl’



5.3 Questionnaire survey of staff

5.4 Case studies of N/MUMs.

What types of improvements in care have N/MUMs been able to achieve as a result of ‘ttl’. Including: decreased adverse event; improved staff satisfaction; implementation of lean methodologies; improved communication and management of difficult situations; improved patient satisfaction; reduced proportion of time spent on


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STUDY RESEARCH TASKS CONDUCTED CORE QUESTIONS ASKED

transactional administrative tasks; improvements in financial management; any other improvements in line with relevant recommendations in Caring Together

6. Identify barriers to the program’s implementation





What factors acted as barriers to N/MUMs ability to implement successful changes in line with ‘ttl’?

7. Identify strategies required to ensure sustainability of any changes achieved





What factors have and will contribute to N/MUMs ability to implement sustainable changes in line with ‘ttl’?

8. Examine the impact of the introduction of the CSOs position




8.4 Questionnaire survey of staff

8.5 Questionnaire survey of CSOs

8.6 Document review of CSOs job descriptions.

What differences are discernable in the way the CSOs position has been introduced across AHSs? What is their location within AHSs and units? What are their roles and lines of responsibility? What impact has the introduction of the CSOs had on the work of N/MUMs, other staff and on patients?

In order to answer the evaluation questions, the findings from the studies have been

structured in eight sections. Most of the data used in the studies comes from four

larger studies. These were: a) interview survey of N/MUMs across eight AHSs, the

Children’s Hospital Westmead and Justice Health; b) interview survey of managers of

N/MUMs across eight AHSs, the Children’s Hospital Westmead and Justice Health; c)

questionnaire survey of staff of the eight AHSs, the Children’s Hospital Westmead

and Justice Health; and d) questionnaire survey of CSOs in the eight AHSs, the


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Children’s Hospital Westmead and Justice Health. In addition to the collection of

these data, we conducted a literature review and analysis and a document review of

CSOs’ job descriptions.

The original proposal had not included the study of CSOs, but had included a content

analysis and focus group analysis of patient complaints and incidents pre and post

‘ttl’. The study of CSOs was added in response to a request from the NMO. In

discussion with NMO it was decided that that given the length of time it had taken

some participants to undertake all five modules of ‘ttl’ (up to two years) that these

latter tasks would not contribute any useful additional data.

In the next section we describe our methodology in greater detail, followed by the

literature review. Sections four to six outline the findings, a discussion of their

implications, and then our conclusions.


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2. METHOD

2.1 Introduction

As outlined in the introduction, the mid-term evaluation of ‘ttl’ utilises a multi-

method approach. This type of approach allows for triangulation of results, and

therefore increased assurance of their validity. Triangulation is essentially a “…

method of cross-checking data from multiple sources to search for regularities in the

research data" (O'Donoghue et al., 2003: 78).

Various types of triangulation are possible, including data triangulation (ie gathering

different data sets), investigator triangulation (deploying more than one researcher),

and methodology triangulation (across-method, that is qualitative and quantitative,

or within-method, that is different forms of qualitative such as questionnaires and

interviews) (Denzin, 1989). This evaluation uses all three types of triangulation.

Data triangulation is achieved across location (AHSs, rural compared to

metropolitan) and persons (individuals from various backgrounds and roles were

interviewed). This allowed for data sets of different types to be analysed.

Investigator triangulation was achieved through the use of a team approach to the

research. The team included researchers with nursing, organisational psychology,

medicine, social work, and health services management backgrounds. They came

from academic disciplines including health services research, health policy research,

organisational psychology, anthropology and sociology.

Both across- and within-method triangulation was employed. Across-method

triangulation was achieved through the quantitative analysis of Likert scale data on

improvements achieved through ‘ttl’. Within-method triangulation was achieved

through: thematic analysis of interview and survey results; thematic analysis of case

studies; and document analysis of CSOs job descriptions.

The evaluation also had some specific stipulations. In order to ensure that what was

evaluated was the overall impact of ‘ttl’ and not the performance of individual

N/MUMs certain parameters were set in regards to the selection of participants.

These included: the random selection of N/MUMs for interviews; and ensuring that if

an N/MUM was interviewed, then neither their direct managers nor their direct staff

were interviewed or surveyed. Two limitations affected the second stipulation. First,

in some instances (small hospitals, or hospitals with an N/MUM manager responsible

for all N/MUMs) it was difficult to identify an N/MUMs’ manager who did not cover

most or all of the N/MUMs who had participated in ‘ttl’. In the case of staff reporting


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directly to N/MUMs we surveyed all CSOs whose contact details were supplied by

AHSs, so there is a possibility that some CSOs of N/MUMSs who were interviewed

replied. However, as not all CSOs’ details were supplied, and as the focus of that

research was primarily the CSOs themselves, it was felt that there would be minimal

impact, and certainly no adverse consequences, from the design of the study.

2.2 Evaluation tools

An inter-related set of tools was developed specifically for the ‘ttl’ evaluation

(Appendix 8.1). The tools include:

An interview schedule for N/MUMs

An interview schedule for managers of N/MUMs

A case study interview schedule

A survey questionnaire for staff

A survey questionnaire for CSOs.

The tools were developed based on: the NSW Health Nursing and Midwifery Unit

(NMU) briefing; meetings with the Director and staff of the NMU; the literature

review; and the expertise of the researchers. Each tool was piloted, reviewed and

modified as required.

2.3 Literature review

The literature review was conducted using two methods. The first drew on existing

literature relating to: the ‘ttl’ program; workplace and health service reform in

Australia and New South Wales; changes in the role of N/MUMS in NSW; the impact

of the introduction of new roles in the workplace; health systems’ capacity to absorb

and respond to change; and transferability of training into the workplace.

In addition to the review of this literature, a second targeted analysis was conducted

of the international literature on the development of nurse-manager roles and

strategies for developing this role. This literature was identified through a search of

key databases including: Medline, EMBASE (general medicine) and CINAHL (nursing

and allied health).

2.4 N/MUM interviews

NSW Health provided a list of all participants of ‘ttl’ (n = 1610). It was decided that in

order to assess the full impact of ‘ttl’ only participants who had attended all five


17

modules; ‘Facilitating Critical Communication” (two days), “Lean Thing and

Leadership” (two days), “Financial Management” (two days), “Rostering for Patient

Care” (one day) and “Leadership – Making it Happen” (two days), would be included

in the evaluation (n = 186).

These individuals were then divided by their AHS and numbered. There were no

participants from the Ambulance Service. Each N/MUM was randomly assigned using

a random number generator (http://www.random.org/). They were then contacted

in the order of their random assignment. Attempts were made to contact forty-nine

N/MUMs. Eleven were on leave (long service, annual and maternity), four had

changed jobs, four were un-contactable, and one was unable to participate due to

workload. Subsequently, thirty telephone interviews were conducted with three

N/MUMs from each Area Health Service.

Phone interviews were held with each of the participating N/MUMs. Each interview

lasted from three quarters to one and a half hours. Researchers took notes of the

interviews, and these notes were later transcribed. Open ended responses were

coded for key themes and concepts by two teams of independent researchers. Any

disputes in interpretation were resolved by discussion. Likert-scale responses are

reported using descriptive statistics.

2.5 N/MUM manager interviews

Upon completion of the NUM selection, the random ranking of N/MUMs was further

used to identify the managers of N/MUMs who had undertaken ‘ttl’ and had not

participated in the N/MUM interview. These were contacted individually. As with the

N/MUM interview, open ended responses were coded for key themes and concepts

by two teams of independent researchers. Any disputes were resolved by discussion.

Likert-scale responses are reported using descriptive statistics. A total of 30

interviews were conducted with N/MUM managers.

2.6 Staff survey

Staff were contacted through the agreement of the managers of those N/MUMs who

had completed ‘ttl’ but who had not been interviewed as part of this study. Attempts

were made to contact ten staff from each AHS. A number of survey contact emails (n

= 16) were returned as undeliverable. The remaining participants were then emailed

and asked to complete an online survey. A follow-up reminder email was sent after

three days. Of the contactable participants, a total of 23 participants (36%)

completed the staff survey. Only one respondent indicated that they were sure that


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the changes made by their N/MUM were universally not attributable to ‘ttl’. A

number indicated throughout their responses that they were not sure of the impact

for one or more elements of the survey. These uncertainties are indicated in the text.

2.7 Case studies

In addition to the N/MUM interviews two case studies were undertaken. Participants

in the cases were interviewed in depth. In two cases the interviews were recorded

and transcribed. The transcripts were coded for key themes and concepts by two

independent researchers and differences resolved by discussion. The participants

were contacted by researchers from the evaluation project and were informed that

they had been chosen to participate in an in-depth interview of their experiences in

regards to ‘ttl’. The participants were advised that the interviews would take

between 1-1.5 hours. The main focus of the interviews was participants’ perceptions

of the changes that occurred both in their own professional development and the

unit practices, processes and culture as a result of ‘ttl’ and the introduction of the

CSOs’ role.

The interview questions were similar to the questions asked in the N/MUMs'

interviews. In the questions directly regarding ‘ttl’ the researchers attempted to

identify contextual details regarding the NUM and the unit pre and post ‘ttl’. NUMs

were asked to relate how their perceptions of the program before attending and

how or if their perceptions changed while attending or after attending the modules.

Similar to the regular N/MUM interviews, the NUMs were asked to identify changes

they had made and whether those changes were attributed to ‘ttl’ or other

interventions. The NUMs were asked to identify barriers to successful

implementation of changes as well as what enabled them to make sustainable

changes.

2.8 CSO survey

CSOs were contacted via email and invited to complete an online survey. A central

contact list for all CSOs was not available. Access to CSO email addresses was

requested by the Nursing and Midwifery Unit. A total of 207 contact names (of a

possible estimated 500 CSOs) were supplied by the AHSs. Of these, 15 messages

were returned undeliverable, two were away during the survey period, and one was

not a CSO, making a final total of 189 CSOs contacted. Potential participants received

one email asking them to participate, and follow up emails. A total of 92 responded,

giving a 48% response rate.


19

2.9 Data analysis

Descriptive statistics were used to examine the demographic items in interviews and

surveys. Interview and case study responses and free text survey results were

interrogated using content analysis, with two independent researchers reviewing the

results for key themes independently, and then resolving differences through

discussion. Comparisons of thematic results were made across groups (N/MUMs,

managers of N/MUMs, staff and CSOs) in the same manner. Responses to several

items were formulated using five (1 increased significantly to 5 decreased

significantly or 1 improved significantly to worsened significantly) or six (1 increased

significantly to 5 decreased significantly or 1 improved significantly to worsened

significantly 6 don’t know) point Likert scales.

In answering some different questions, including Likert scale responses, a number of

respondents reported that while positive and negative changes had occurred, these,

in their opinion were not directly attributable to their participation in ‘ttl’. Where an

interviewee said that they did not or could not attribute their response to ‘ttl’, or

where they were unsure whether it was attributable, or if they stated that the effect

was attributable to another factor, this was marked as a zero response on the Likert

scale. Only the remaining responses were included in the data set.

Each set of Likert scale responses were validated by an additional question at the

end of each set. Participants were asked if the changes were attributable to ‘ttl’.

Where the response was no, the set of responses was removed.

2.10 Approval

Ethics approval for the project was applied for, and granted by, the Human Ethics

Research Committee of the University of New South Wales. The approval number

was: HREC 10289 (PI)/Panel ref: 9-10-029.


20

3. LITERATURE REVIEW

3.1 Introduction

This literature review provides a context for ‘ttl’ and the evaluation. We review the

origins of Nursing and Midwifery Unit project, including the impact of the Garling

Inquiry and the NSW Health Action Plan and the development of ‘ttl’ and related

programs. We then consider how the role of N/MUMs has changed in NSW and why

the role required clarification and formalisation. We conclude the review with a

consideration of the factors affecting the implementation and success of changes,

such as those intended by ‘ttl’, in health systems.

3.2 Special Commission of Inquiry into Acute Care Services in NSW Public

Hospitals (‘The Garling Report’)

In January 2008, a Special Commission of Inquiry into Acute Care Services NSW

Public Hospitals was commenced by Commissioner Peter Garling SC. The Inquiry

followed a coronial investigation into the death of a young patient in a public

hospital in New South Wales and reported growing public concern about the safety

and quality of care provided in public hospitals in New South Wales. The Inquiry was

the most comprehensive review ever undertaken of the acute care services in New

South Wales (Garling, 2008: 39).

In the Commission’s final report (the Garling Report), publicly released on 27

November 2008, Garling recognised a paradoxical finding. Although application of

the usual international criteria suggested the NSW public health care system was of a

high standard, regular and alarming media reports of incidents in NSW public

hospitals continued. The NSW public health system, he suggested, had entered a

period of crisis and but for the goodwill and dedication of the public hospital system

workforce, the reduction in quality of care would not only have been much greater

but would have occurred sooner. Garling urged that patients be kept at the centre of

care and noted that clinical staff were taken away from caring for their patients by

an increasing burden of administrative tasks.

The report’s 139 recommendations were directed at clinical leadership;

interdisciplinary health care teams; medical workforce planning and management;

clinical education; supervision, training and communication; information technology;

use of evidence based protocols or models of care; quality and safety; use of

collected health information; and equipment and infrastructure (Garling, 2008).


21

Findings of the Special Commission of Inquiry recognised the pivotal role of the

N/MUM in the provision of highly co-ordinated and safe care at a unit level.

Specifically related to the role of the N/MUM, Garling made the following

recommendations:

“Recommendation 23

NSW Health should, as a matter of priority, review and redesign the role of the

nurse unit manager (“NUM”) so as to enable the NUM to undertake clinical

leadership in the supervision of patients and the enforcement of appropriate

standards of safety and quality in treatment and care of patients in the unit or

ward for which they are responsible. This redesign needs to encompass either the

transfer of a range of duties from the NUM to other existing staff members or

alternatively the creation of a role of clinical assistant to the NUM to undertake

those tasks. The aim of the redesign is to ensure that at least 70% of the NUM’s

time is applied to clinical duties and no more than 30% of the time is applied to

administration, management and transactional duties.”

(Garling, 2008: 39)


“All hospitals employing nurse unit managers report within 6 months to the Chief

Nurse of NSW Health how they will re-allocate the duties currently being

undertaken by the NUM in line with my earlier recommendation and all hospitals

employing NUMs should complete the implementation of the redesigned role

within 2 years.”

(Garling, 2008: 39)

3.3 Caring Together: The health action plan for NSW

Caring Together: The health action plan for NSW (the Action Plan) documented the

New South Wales Government’s response to the recommendations in the Garling

Report. Informed by the results of an extensive consultation process that canvassed

input from over 12,000 health workers and community members, the New South

Wales Government indicated its acceptance of 134 of the 139 recommendations

made by Commissioner Garling. Two of the recommendations were not accepted

and decisions on the remaining three recommendations were held over, requiring

further consultation. The recommendations that were accepted were to be

implemented in three stages with some measures introduced immediately, aimed to


22

improve not only clinical care, but the environment and way with which it is

delivered (NSW Department of Health, 2009).

The first of the three stage approach is the Action Plan, an immediate response that

focuses on the patient and includes their carers, the clinicians, managers and support

staff. This stage aims to demonstrate the New South Wales Government’s

commitment to building a better health care system. At stage two (six months), a

sustainability plan will require a progress report from the New South Wales

Government and specified changes to build a stronger health care system. During

the third stage (at 18 months), an intergenerational health care system, the New

South Wales Government will report on further progress and describe their plan for

changing thinking and culture to create a future sustainable health care system.

Six major strategies though which the Stage One response will be delivered are

outlined in the Action Plan. These strategies include:

“1. Creating better experiences for patients

2. Safety

3. Education for future generations

4. New ways of caring

5. Strengthening local decision making

6. Monitoring our progress.”

(NSW Department of Health, 2009: 6)

In implementing these strategies, the action plan emphasised the clinical leadership

role of the N/MUMs. Furthermore it recognised that critical role of the N/MUM in

the provision of safe care and in the successful implementation of responses to a

wide range of the recommendations of the Garling Report. The following are the

New South Wales’ Government’s responses to Recommendations 23 and 24 of the

Garling Report (those that pertain to the role of the N/MUM).


New South Wales Government Response: (Stage One Supported)

NSW Health will review and redesign the role of the Nursing/Midwifery Unit

Manager as part of the move to the new Nurse/Midwife in Charge. Patients and


23

families will better recognise the Nurse/Midwife in Charge through a prominently

displayed ward photo.

Already NSW Health has surveyed over 750 nurses and midwives to identify their

views about the key capabilities required for the role and started the Take the

Lead program for these positions. A Conceptual Framework has already been

developed to outline the purpose of the role, the personal capabilities that should

be able to be demonstrated and the broad core functions that are the

responsibility and accountability of the role. The Nurse/ Midwife in Charge will

provide leadership to ensure safer patient care, the right skill mix of staff on the

ward, improved hand hygiene and coordination of ward rounds.”


“Recommendation 24 a & b (a)


The Chief Nursing and Midwifery Officer will annually report progress on the

reallocation of administrative duties currently undertaken by Nursing/Midwifery

Unit Managers so that they can provide a stronger focus on clinical care.”


The New South Wales Government’s decisions to strengthen the clinical leadership

role of the N/MUMs and to reduce their administrative load by employing clinical

support officers was strongly supported by the New South Wales Nurses’ Association

(NSW Nurses' Association, 2009). The ‘ttl’ was identified as a key strategy in

supporting this initiative.

3.4 Context for ‘ttl’

By way of providing context to ‘ttl’ we summarise here a range of initiatives and

background that we deal with more fully in Appendix 8.2. There are currently

multiple improvement strategies and programs underway across NSW Health. These

provide positively reinforcing loops for ‘ttl’ initiatives. They include the: Essentials of

Care (EOC) program (NSW Health Nursing and Midwifery Office, 2008); Between the

Flags program (Clinical Excellence Commission et al., 2010); and the key principles

for clinical handover initiative (NSW Health, 2009).


24

3.5 The role of the Nursing/Midwifery Unit Manager within NSW Health

N/MUMs must straddle technical, managerial and clinical demands in a complex and

continuously changing environment. While aiming to provide compassionate care

and clinical leadership they are simultaneously required to manage finances,

administrative demands, performance manage and staff their unit often within the

context of staff shortages, and increasingly complex patient needs. The role of the

N/MUM within NSW Health is essentially one of leadership and management. This

role has changed over time and is now defined in the NSW Public Health System

Nurses’ and Midwives’ (State) Award as a ‘registered nurse in charge of a ward or

unit or group of wards or units in a public hospital or health service or public health

organisation’ (NSW Health, 2010b: 4). A brief summary of the evolutionary course of

the N/MUM role in NSW is provided below as it provides a context for the

implementation of ‘ttl’. Appendix 8.2 provides a summary of the literature on the

role and professional development of the N/MUM.

The Charge Sister role was based on clinical experience and expertise until 1986

when in NSW the N/MUM role was created to replace this role. The Clinical Nurse

Specialist role was simultaneously introduced to take over the clinical leadership role

that was surrendered by the N/MUM for a focus on managerial responsibilities

(Duffield et al., 2001). A recognised difficulty for N/MUMs was the lack of formalised

training in management skills and an absence of role models, particularly given the

dominance of role model based learning in nursing (Duffield et al., 2001).

Decentralisation and the introduction of primary nursing affected the role of nurse

unit manager requiring new types of managerial skills (Duffield, 1991). Uncertainty

over role definition and a perceived gap in management skills has been identified as

problematic not only in Australia (Duffield et al., 1994) but internationally (e.g. New

Zealand (McCallin et al., 2010), South Africa (Pillay, 2009) and the United Kingdom

(Gould et al., 2001).

3.6 The role of the CSO

Linked to changes to the N/MUM’s roles, and also emerging from the Garling Inquiry,

was the introduction across NSW of the CSOs. Their role was envisaged to support

clinical and managerial staff in acute hospital settings, N/MUMs, nurses, midwives,

medical staff and allied health personnel. Although most often located at ward or

unit level, CSOs are able to work across multiple wards and units, or a whole

service. CSOs were not intended to replace existing administrative staff such as

ward clerks and communication officers, but rather to complement them. As part


25

of the Action Plan, funds for 500 full time equivalent (FTE) CSOs were allocated,

most of whom have now been employed.

The CSOs usually work under the direction of a N/MUM at unit or ward level.

Their role is intended to provide a range of administrative and or transactional

services, with the possibility of a degree of independent initiatives and actions. The

introduction of CSOs and the implementation of ‘ttl’ had the joint policy objective of

freeing up time for N/MUMs to become more involved in clinical co-ordination and

spend less time on purely administrative tasks.

3.7 Take the lead (‘ttl’)

‘ttl’ is a series of strategies to enhance the capabilities and skills of N/MUMs across

NSW. Its ultimate goal is that of improving patient care and flow. ‘ttl’ develops the

skills required by N/MUMs to provide co-ordinated care at the unit level by

identifying ‘… strategies to support N/MUMs in achieving this role, recognising the

pivotal part the N/MUM has in coordinating patient care’ (Hawe, 2009: 4).

Although the Garling Inquiry and the NSW Actin plan contributed to the impetus for

‘ttl’, the origins of the program pre-date both reports. The project began as a

collaborative between the Nursing and Midwifery Office (NMO) and the Health

Service Improvement Branch at NSW Health, and is funded by the NSW Government.

It was initiated in 2007, ‘… in response to patient and carer feedback and anecdotal

information about the N/MUMs’ experiences’ (Hawe, 2009: 4). Early stages of the

project were presented to Commissioner Garling. As a result of the

recommendations (specifically 23 and 24) made by Garling, ‘ttl’ moved from being a

voluntary, to a required program, for N/MUMs.

Between August 2007 and February 2008, the NMO used a multi-method strategy to

examine the experiences and expectations of N/MUMs. Data were collected on the

activities, barriers and enablers, required skills and attributes that were perceived by

N/MUMS to constitute both the ideal N/MUM role, and observed behaviours of a

successful N/MUM.

As a result of that study, the NMO created three streams of work. These were to:

clarify and define the purpose and core function of the N/MUM role in NSW; identify

strategies to support and strengthen the N/MUM role through education and

professional development; and propose strategies to reduce the number of

administrative tasks undertaken by the N/MUM that are not aligned with the

purpose and core function of the role (Hawe, 2009: 4). Other related activities


26

included workshops for N/MUMs and Directors of Nursing to increase understanding

of the work being conducted in relation to ‘ttl’ and other projects.

The aims of ‘ttl’ are that:

There is clarity and standardisation around the purpose and core functions of the

N/MUM role

N/MUMs have the appropriate capacity and capability in order to fulfil their role

N/MUMs are enabled and facilitate highly co-ordinated patient care reflective of

their role and patient and carer expectations (NSW Health, 2008).

A Conceptual Framework for the N/MUM role has been developed as part of the ‘ttl’

project. This framework identifies the purpose and broad functions of a N/MUM as

defined by the State Award as well as the personal capabilities and core broad

functions of the N/MUM role (NSW Health, 2010a).

3.8 Factors supporting and inhibiting workplace change

Fundamental to the evaluation of ‘ttl’ is an identification of changes to practice and

outcomes resulting from ‘ttl’, as well as the enablers and barriers to such changes. It

is therefore useful to understand how the spread of innovation in healthcare

organisations is reported within the literature. A brief overview of the literature on

the spread of innovation in healthcare organisations is provided in Appendix 8.2 with

key points summarised below.

A key managerial role in healthcare is a constant striving for change and

improvement (Braithwaite et al., forthcoming). Change may occur at a system-wide,

organisational, group/team, or individual level and is influenced by formal and

informal hierarchies within the organisation. The distribution of innovation within

health service organisations is complex and affected by the interaction of multiple

components including: the innovation itself; the adopter; the readiness of the

system; the process chosen for implementation; the external context; the type of

communication and influence used to transfer the innovation; and the linkages

(Greenhalgh et al., 2004). The existence or lack of a certain characteristic does not

guarantee the adoption or rejection of an innovation. It is imperative that change

agents remember that “the attributes are neither stable features of the innovation

nor sure determinants of their adoption or assimilation. Rather, it is the interaction

among the innovation, the intended adopter(s), and a particular context that

determines the adoption rate.” (Greenhalgh et al., 2004: 598).


27

4. RESULTS

4.1 Demographic and background data

4.1.1 Demographic data

Input from a wide variety of clinicians and staff members were sought. Appendix 8.3

provides demographic details. These include the gender of participants; their age;

their work and employment patterns; their professions and occupations; their

organisational roles; and the number of years they occupied their current position.

The demographic questions were included on the basis of their relevance to the aim

of the evaluation.

4.1.2 Background to N/MUMs’ participation in ‘ttl’

In order to establish the context for their participation in ‘ttl’ N/MUMs were asked a

series of questions relating to their attendance in ‘ttl’. These included their reasons

for participating, Table 2 below, and the perceived benefits of their involvement.

Table 2: reasons for participating in ‘ttl’

REASONS FOR PARTICIPATING IN ‘ttl’ NUMBER OF RESPONSES

Mandatory 16

Mandatory, but participated willingly 4

Own initiative 4

Strongly encouraged 3

Result of work appraisal or needs identified 2

Mandatory and did not want to go 1

N/MUMs were asked about their experience of participating in ‘ttl’. Of the 30

respondents, 18 (60%) indicated that their experiences were positive in some way,

ten (33%) indicated that their experiences were variable (experiences varied with the

module or the interactions), and two (7%) that their experiences were negative.

Apart from content, N/MUMs specifically mentioned networking (n = 11), new ideas

or reflecting on their existing knowledge in new ways (n = 4), discussions, problem

solving or gaining advice from peers (n = 4) and reflection on their own roles (n = 2)

as adding value to their participation. Two N/MUMs stated that participation in ‘ttl’

had empowered them, or given them the skills to empower their staff. An additional


28

five N/MUMs mentioned support provided by the organisation as a positive factor in

their experience of ‘ttl’. Both rural and metropolitan staff identified the opportunity

to compare experiences across locations as being beneficial.

“I really enjoyed meeting NUMs from other areas and hearing their experiences

and gaining “tips” and advice on how to deal with certain issues.”

[N/MUM, metropolitan hospital]

Respondents who felt their experiences were variable noted that a number of the

modules were more suited to less experienced N/MUMs. This was also the case with

N/MUMs who indicated their experience of the program was negative one and who

described the content as “childish”. A total of 12 N/MUMs nominated one or more

specific modules as not meeting their needs. There appeared to be no difference in

positive or variable attitudes for N/MUMs based on their: participation in Essentials

of Care; years since graduation; years as a N/MUM; or number of staff reporting to

them. N/MUMs who had positive attitudes towards ‘ttl’ were more likely to be

positive about the experience, rather than negative or variable. N/MUM’s positive

attitudes about their experience in ‘ttl’ did not appear to be affected by whether

they worked in a rural/regional hospital, or a metropolitan institution. Negative

factors included; content already known (n = 3); content ‘useless’ or inappropriate

(eg rostering centralised so not under control of N/MUM) (n = 2); ‘one size fits all

approach’ (n = 1); and difficulty of implementing what was learnt (n = 1).

There were three common suggestions made in relation to N/MUMs’ experience of

‘ttl’. These were that some modification was required based on N/MUMs’ level of

experience (n = 6); consideration was needed of the difference between rural and

metropolitan N/MUMs’ resources and experience (n = 2); and the possibility of

arranging the modules in different ways, for example as a one week session (n = 2).


29

4.2 Implementation of changes post ‘ttl’

4.2.1 Changes made as a result of participation in ‘ttl’

N/MUMs were asked several times through the survey whether they had made

changes due to their participation in ‘ttl’. Of the 30 N/MUMs interviewed, three

people (10%) said they had not. One of these respondents went on to note although

they had not made changes, they had used the skills they had gained in staff

management and communication, including being able to successfully negotiate and

introduce change, and get staff to take ownership of changes made. Table 3 outlines

the types of changes participants said they had made.

Table 3: changes implemented as a result of ‘ttl’ (from perspective of N/MUMs)*

CHANGES RESPONSES EXAMPLES OF CHANGES

Implemented principles of lean thinking

20 Changes to shift handovers and data collection

Patient transportation streamlined

Equipment packs streamlined

Re-organisation of resources and equipment

Better utilisation of storerooms

Clean up of storerooms and general environment

Removal of out dated forms

Modification of office layout

Only keep stock which is needed now

Set up a new unit using ‘lean thinking’ principles

Introduced auditing and survey

Communication/critical thinking

7 Development of business plan

Communication book with ideas for discussion

Checklists for nursing staff in waiting area

New and quicker methods of capturing patient information

Niggle board established

Changed communication style with staff and managers

Emailing of educational material to


30


staff

Rostering 4 Method of distribution of roster

Computerised rostering

Six months of rostering available in advance

Set up a roster which took into account patterns of sick leave

Leadership or management

3 Developed a business plan

Encourage staff to take leadership roles

Helped implement CSO role

Budgeting 1 Staff made more aware of, and increased ownership in, budgeting processes

No changes 3 ‘ttl’ aimed at a lower level

No changes, but brought more of what I knew to the ward

No specific changes but gained skills in staff management

Communication module helped with introduction of change

DON runs staff through budgets

*More than one response possible per participant

Although asked about specific changes they had made as a result of their

participation in ‘ttl’ a number of participants spoke about outcomes of their

attendance and outcomes of changes they had instigated, rather than the changes

per se. Incidental or flow-on outcomes are listed in Table 4 below.

Table 4: outcomes as a result of ‘ttl’ from perspective of N/MUMs*

AREA TYPES OF OUTCOMES

Efficiency

Workload easier

Save time

More patient information captured

Rostering improved

Avoided what could have become an industrial issue through effective communication and negotiation

Reduced manual and double handling


31

AREA TYPES OF OUTCOMES

Patient outcomes

Patient care improved

Improved patient flow

Better outcomes for patients

Patient care is the focus

Change management

Able to successfully introduce and implement changes to unit

Gained ownership from staff of changes

Able to implement change by getting stakeholders on board

Better at negotiation with staff and managers

Staff outcomes

Team approach to problem solving

Passed onto staff knowledge and skills learnt

Staff take ownership of rostering

Staff take a leadership role

Staff take greater accountability for approaching N/MUM over issues of concern

Staff aware that change is possible

Capabilities and skills

Better at giving and receiving feedback

More aware of emotions, moods and body language

Better at seeing bigger picture

More politically aware

Improvements in general communication style and skills

Calmer in responses

Increased understanding of, and confidence in, role as manager


N/MUMs were asked if they had evaluated any of the changes they had made. Two

participants said that they had not yet evaluated the changes, but were hoping to do

so. One N/MUM indicated that her unit was measuring patient flow at the moment.

The rest of the respondents described informal methods of evaluation:

Environmental changes (ie visible elimination of clutter, more equipment) (n =

2)

Increased staff involvement (ie staff more involved in projects leading to a

decrease in budget, staff more aware of budget constraints) (n = 2)


32

Staff feedback demonstrating increased satisfaction (n = 2)

Staff proactive in requesting equipment or advising N/MUM of issues

Decrease in the number of incidents between staff

Decrease in amount of time taken to resolve issues

New ward set up with lean thinking, and running efficiently from day one

Consultation increased with both staff and patients and relatives.

N/MUMs’ managers were also asked about the types of changes made by the

N/MUMs under their supervision. The majority of N/MUM managers (90%) reported

changes as a result of N/MUMs’ participation in ‘ttl’. As with the N/MUMs

themselves, a range of changes were reported, some minor, others reflecting large

scale changes to the organisation of the ward. Table 5 lists the changes made by

N/MUMs as identified by their managers, and some examples of outcomes.

Table 5: changes implemented as a result of ‘ttl’ (N/MUMs’ managers)*


EXAMPLES OF OUTCOMES

Implemented principles of lean thinking

24 Store room audits and redesign

Reviewed and updated use of folders

Introducing new organising system, ‘ttl’ helped prepare for changes

Streamlining of processes in ward

Application of principle to other context

More user friendly and easier to do the stores and easier for new staff to find things, plus it has saved the unit some money

Easier and safer access to equipment

N/MUM had intended to make changes to unit, ‘ttl’ enabled her to do so

Communication and critical thinking

18 Range of communication tools (e.g. whiteboard)

Group huddles instigated

Problem solving has

Communication/critical thinking

Improved exchange of information

Improved problem solving


33



become more solution based rather than problem based

Rostering 5 N/MUMS collaborate in rostering process

Staff involved in self-rostering

Improved planning for skill mix

NMUM talks to staff and focuses them to think of patient needs and not personal rostering preferences: changing a shift need to swap with someone at own level

NUM more proactive, thinking outside the square, and thinking what will be needed and rostering for it

Finances and budgeting

7 Improved budgeting

Improved awareness

More financially aware

Scrutinise FTEs and Financial Reports and offer comments

Combination 5 Change was due to a combination of factors, but ‘ttl’ provided the tools to make it possible

Falls reduction program resulted in fewer adverse events

Introduced staggered meal breaks so that staff are on the floor at meal times

Staff morale has improved and there are better patient outcomes. Staff are smiling and they’re happy

Patient outcomes have improved – tracked (no. of falls; medication errors)

There are less complaints

More positive attitude of N/MUMS

N/MUM felt empowered to make changes

‘ttl’ cements changes that are already underway

Skills development


34



Values clarification

3 Were able to clarify unit values

Used as tool for focusing service provision


Although the majority of responses identified positive changes as a result of ‘ttl’,

three N/MUM managers reported that there had been no changes implemented as a

result of N/MUMs’ participation in ‘ttl’. However, while they could not identify

specific changes, two of these managers identified that ‘ttl’ had ‘reinforced aspects

of good management and leadership’ and participating N/MUMs had returned from

‘ttl’ with ‘renewed enthusiasm and motivation’. One N/MUM manager reported that

‘ttl’ had not catalysed changes because there was mentoring and professional skills

development in place at their hospital pre ‘ttl’. Other N/MUM managers (n=4) noted

that the impact of participation in ‘ttl’ varied, with some N/MUMs demonstrating

changes while others did not. It was suggested that this may be explained in part by

‘individual attributes’ or that the effect may be delayed (‘it takes time *for some of

the concepts+ to sink in’). Other N/MUM managers proposed that ‘ttl’ was

particularly beneficial for “newer N/MUMs”:

“For the newer NUM it has given her skills to fulfill the role, development and

growth. The more experienced NUMs had the knowledge.”

[N/MUM Manager, rural hospital]

One N/MUM manager raised possible unintended consequences of attendance at

the program. Their description highlights the contextual factors which affect

N/MUMs’ ability to meet expectations, even with training:

“On the other hand, one of my NUMs went to ‘ttl’ and will probably leave

nursing because he has realised that it is very hard. At ‘ttl’ he met likeminded

people and found that his situation is like other N/MUMs so asked himself

why he is staying in nursing? As a result of ‘ttl’ he dissected the role. He

realised that it won’t get any better and everyone is in the same boat – he is

disillusioned. ... the nurse in charge – they need to be everything – it is the

schizophrenic nature of the role – they need to be everything, asking them to

manage (e.g. staffing, budget) but also to be out there with the patients and

their families. The expectations are that they are a clinical coordinator, they

do rounds for each of the specialists, they manage staff, beds, finances etc.


35

We have big wards … They run with 76% occupancy. We have over [a dozen]

VMOs who all want the NUM to do rounds with them between 7-9am.”


Of the 22 staff who responded to the online survey, 11 participants (41%) identified

changes their N/MUMs had made as result of their participation in ‘ttl’. These

included: establishing or facilitating a weekly multidisciplinary round (n = 2); de-

cluttering and reorganising the unit (n = 2); inviting input and comments on issues

involving patient care and service delivery; a patient handover initiative;

implementing self rostering; a teamwork and organisation initiative; developing a

holistic approach to leadership and management; increasing staff morale and team

leadership; and developing a more proactive approach to the management of staff

issues. One staff member said that as a result of ‘ttl’ their N/MUM was “more

innovative and confident [and] reviewed the use and ordering of ward stock, saving a

significant amount of money”.


36

4.3 Implementation of demonstrable changes in the capabilities and skills of

N/MUMs post ‘ttl’

The evaluation sought to measure N/MUMs’, their managers and staff’s perceptions

about changes in their capabilities and skills. Two types of indicators were chosen:

the first was a Likert scale measure and the second qualitative comments and

reflections by participants. A full set of figures representing these responses is

presented in Appendix 8.4.

In this, and in subsequent sections, we need to remember that responses reported

are only from participants who indicated that they could be attributed to ‘ttl’. All

other responses were removed. To clarify, respondents may have felt that there was

an impact from ‘ttl’ overall on their or their N/MUMs work, but may have felt that

this impact differed according to the variable.

4.3.1 Changes in capabilities and skills as assessed by N/MUMs and N/MUM

managers

Participants were asked to rate the changes to N/MUMs’ job performance and

capabilities post ‘ttl’ on several indicators. These were: overall job performance;

communication; ability to handle complex situations; and management skills.

Job performance

Most N/MUMs felt that their job performance improved significantly, or somewhat

(67%). A third of respondents (33%) felt that it had stayed the same, and no N/MUM

felt that their performance had deteriorated. One N/MUM said ‘ttl’ had no impact on

their job performance overall.

There were 67% of N/MUMs’ managers who thought that ‘ttl’ had had a positive

impact, and felt that there had been some improvement to N/MUMs’ job

performance. There were 13% who believed that an improvement in N/MUMs’ job

performance was due to ‘ttl’ in combination with other initiatives. The remaining

20% felt that the ‘ttl’ had no impact or that N/MUMs’ performance had remained

the same.

Managers were also asked to provide free text responses to changes in the N/MUMs’

job performance as a result of ‘ttl’. Respondents felt that as a result of ‘ttl’ several

positive effects had occurred. This included N/MUMs’: confidence had improved;

they were better able to make decisions; they were better able to provide effective


37

feedback to staff; they could operate more effectively and efficiently; they had

created a virtuous circle of ongoing learning and self-confidence; and they were less

anxious about staff management. One manager described the change between

N/MUMs who had attended a ‘ttl’ module (leadership) and those who had not:

“Those who have done the leadership module have started to piece all the bits of

‘ttl’ together. Also it improved their morale and motivation and means they are

now looking for opportunities for change…”

[N/MUM manager, metropolitan community health service]

Communication

Participants rated changes to three aspects of their communication. This included

their ability to communicate with their own staff; their ability to communicate with

other staff; and their ability to communicate with patients and their families.

None of the N/MUMs felt that their ability to communicate with their own staff or

patients had reduced, although 4% felt that their ability to communicate with other

staff had decreased somewhat. The majority (81%) of N/MUMs felt that their ability

to communicate with their own staff, with other staff (63%) and patients and family

(59%) had improved. The remainder felt that their ability to communicate with their

own staff (19%), other staff (33%) and patients (41%) had stayed the same.

For managers of N/MUMs, no participant felt that N/MUMs’ communication skills

had worsened in any way. The greatest increase was in N/MUMs’ ability to

communicate with staff: 80% of their managers felt there had been an improvement

of some kind; 88% of those who identified an improvement reported that the

improvements were due to ‘ttl’; 12% indicated that improvements were due to ‘ttl’

in combination with other co-occurring programs.

With respect to N/MUMs’ ability to communicate with other staff, 43% identified an

improvement due to ‘ttl’. Among these managers, 25% reported that improvement

as significant and 75% indicating that it had improved somewhat. Of those who did

not report a change, the majority attributed this to extraneous variables such as:

‘Growing problems with staff being managed off site. It creates new difficulties. Not

‘ttl’.

[N/MUM Manager, metropolitan hospital]

Fewer N/MUMs’ managers identified a change in N/MUMs’ ability to communicate

with patients and their families (40%). All managers who reported a change in

N/MUMs’ communication skills with patients and their relatives indicated that the


38

change was positive with 82% of these respondents attributing these positive

changes to ‘ttl’. One manager of an N/MUM said that their N/MUMs were now:

“more out on the floor, participating with staff and patient outcomes.”

[N/MUM manager, regional hospital]

Of those who reported no change, 90% identified that this was not attributable to

‘ttl’. Seven of these managers suggested that a lack of change was because ‘this is

core business anyway’; we ‘do this every day anyway - daily contact with families’;

‘already good at it’.

Ability to handle complex situations

Three characteristics were measured in relation to N/MUM’s ability to manage

complex situations. These included: management of difficult situations; negotiation;

and problem solving. No N/MUMs felt that their abilities in any of these areas had

deteriorated. Of the participants interviewed, four felt that their participation in ‘ttl’

had had no impact on their ability to manage difficult situations. No-one felt that it

had had no effect on their negotiation or problem solving skills. Of the majority of

participants who felt that ‘ttl’ had had an impact, 80% felt their ability to manage

difficult situations and negotiation skills (71%) had improved. In relation to problem

solving skills slightly more (58%) felt their problem solving skills had improved and

42% felt that these had remained the same.

Of the N/MUM managers 65% felt that their N/MUM’s ability to manage difficult

situations had improved since ‘ttl’, with 55% attributing the improvement solely to

‘ttl’, 10% reporting that the improvement was due to a combination of ‘ttl’ and other

factors and 3.5% attributing a change to factors other than ‘ttl’. There were 31.5% of

managers who reported no change; 28% identified that the lack of change in the

N/MUMs’ ability to manage difficult situations was due to external factors not ‘ttl’.

There were 62% of N/MUM managers who felt that their N/MUMs’ negotiation skills

had improved since ‘ttl’: 55% attributed this improvement to ‘ttl’; 3% to ‘ttl’ and

other factors; and 3% to factors other than ‘ttl’. An improvement in N/MUMs’

problem solving skills since ‘ttl’ was reported by 63% of N/MUM managers; 52%

attributed the improvement solely to ‘ttl’; 7% partly to ‘ttl’; and 4% due to factors

other than ’ttl’. In the case of the last two categories 38% and 36% of managers

reported that their N/MUM’s ability had stayed the same. A lack of change in ability

to problem solve (28%) and negotiate (31%) was predominantly attributed to factors

other than ‘ttl’.


39

Almost equal numbers of staff felt that their manager’s ability deal with difficult

situations had improved (45%) or stayed the same (46%). The remainder were

unsure.

Management

Participants were asked to gauge changes to several aspects of their management

skills. These included their ability to manage staff, their ability to lead, and their

ability to manage resources (including staff, through rostering, as well as finances

and resources, and their ability to apply lean thinking).

Most N/MUMs indicated that there had been changes in their ability to manage

staff. A total of 82% of participants felt that their ability to manage staff had

improved. The remaining participants felt that their ability had remained the same.

No participant felt that their ability had been impaired.

A slightly lower number of managers (75.5%) thought that their N/MUM’s ability to

manage staff had improved; 65% due to ‘ttl’; 7% due in part to ‘ttl’; and 3.5% not due

to ‘ttl’. The remainder, 24.5%, believed that their ability had remained the same.

A similar pattern was demonstrated when N/MUMs were asked to rate changes in

their leadership abilities. A total of 77% indicated that they felt that their leadership

abilities had increased to some degree. The rest (23%) indicated that they felt these

abilities had remained the same. The majority of N/MUMs’ managers skills (80%)

also indicated that their N/MUMs’ leadership had improved; 74% due to ‘ttl’; 3% due

to a combination of ‘ttl’ and other initiatives; and 3% due to factors other than ‘ttl’.

The rest felt that their skills had remained the same.

Of the three remaining indicators of N/MUM’s management skills, their ability to

apply lean thinking showed the greatest increase, with 86% of participants indicating

that their ability in this aspect had improved either somewhat or significantly, and

14% saying it had stayed in the same. In relation to their ability to manage finances

and resources, had 50% of respondents said that their abilities had increased, and

38% felt their rostering ability had improved. In these last two indicators 50% and

62% felt that their ability had stayed the same. No-one felt their abilities had become

poorer. Rostering and finances were the modules which were most commonly

criticised by N/MUMs. In the case of rostering this was because it either did not

meet N/MUMs needs, or because they had a centralised rostering system and

therefore it was not applicable. Similar criticisms were made of the finance module.


40

As with the N/MUMs themselves, most managers of N/MUMs attributed the

greatest impact of ‘ttl’ to lean thinking (83%). For N/MUM managers, this was

followed by financial management (54%). Improvement in N/MUMs’ ability to roster

staff was noted by (50%) of participating N/MUM managers.

There were 32% of managers who identified that a lack of change in abilities to

manage finances or rostering was due to factors other than ‘ttl’ such as central

rostering and financial constraints beyond their control. None of the participants felt

that the N/MUMs’ abilities had decreased in any way due to participation in ‘ttl’. Of

the staff who responded to this question, 48% felt their manager’s ability to manage

finances had remained the same, 14% felt it had improved somewhat, and the rest

were unsure.

4.3.2 Descriptions of changes in capabilities and skills

Examples of improvements to capabilities and skills

As well as rating the changes to their skills and abilities, N/MUMs were asked to

describe any specific skills they had developed. Of the 30 respondents, six said that

they could not identify any specific or additional skills and capabilities which they

had developed and four indicated that they had either refreshed previous

capabilities or enhanced others. Overall, the skills and capabilities identified by

N/MUMs fell into two distinct groups: communication and the role of the N/MUM.

Table 6 highlights these improvements and provides indicative examples.

Table 6: examples of improvements in capabilities and skills of N/MUMS*

CAPABILITY OR SKILL EXAMPLE

Communication (n = 27) Communication

Negotiation

Communication with medical teams/doctors

More measured/tolerant responses

Widened range of communication techniques/tools

Effect of communication on others

Feedback

Handling difficult conversations with staff

Improved conversations with families and patients


41

CAPABILITY OR SKILL EXAMPLE

Role of N/MUM (n = 14) Renewed sense of enthusiasm

Increased confidence in abilities

Improved leadership skills

Assertiveness

Managing difficult staff

Empowering staff

Improved organisational skills

Research skills

Financial management

Increased computer literacy

* More than one response possible per participant

Impact on day to day work

A number of participants identified the ways in which ‘ttl’ had impacted on the day

to day work in their unit. Of the 30 respondents, 14 either could not articulate the

day to day impact of their participation in ‘ttl’ as separate it from other improvement

strategies and changes or did not respond to the question. For those who could, the

examples of the impact included: better negotiation skills; improvements in time and

other forms of management; better relationships with staff; improved organisation

of ward; increased skills in prioritising; increased focus on patients; improved ability

to sell change to staff; thing working better in unit in general; staff ownership of

problems and empowerment; better temper and less stressed; and better

communication with managers.

Management of staff

Several participants (n = 3) did not answer this open-ended interview question (as

opposed to the Likert scale) about changes in their management of staff. Of the

remaining participants, seven (26%) said that ‘ttl’ had had no or minimal impact on

their management of staff. The remaining participants identified that their

involvement had resulted in a number of improvements in the way they manage

staff (Table 7).


42

Table 7: improvements in staff management as a result of ‘ttl’*

IMPROVEMENTS IN STAFF MANAGEMENT

Improvements in reflective listening

More insight into own behaviour

Better communication skills

Enhances staff ownership of and accountability to, unit

Improved handover

Improved management of difficult conversations

Improved management of difficult staff

Confidence with staff appraisals

More inclusive of and less prescriptive with staff, decrease of barriers

Increased assertiveness

Improved understanding of staff needs, expectations and motivations

Better time management


Improvements to care of patients

Half of the respondents, when asked if their participation in ‘ttl’ had changed the

way they responded to the needs of patients, said that it had not. However, most of

these responses were qualified by statements that the N/MUM had ‘always been

patient focused anyway’. An additional three people did not answer the question. Of

the remaining 11, examples of improvements to care of patients are outlined in

Table 8.

Table 8: improvements in response to needs of patients

IMPROVEMENTS IN RESPONSES TO NEEDS OF PATIENTS

See things from patients’ experience, and aim to make their experience more efficient and less traumatic

Increased focus on patient care and outcomes

Listens to, and tries to meet patients’ needs: requires a different type of nursing

Spends more time with patients and discussing their problems, needs, complaints, home situation

Better management means happier staff, and therefore better care to patients

Improved communication increased staff satisfaction which in turn leads to better patient care


43

IMPROVEMENTS IN RESPONSES TO NEEDS OF PATIENTS

Improved budgeting means new equipment could be purchased

Increased efficiency leading to better patient care

Increased number of family conferences

Increased patient compliments which are displayed for staff to see

Gift register and sharing of gifts

Complaints register

Increased awareness amongst staff of opportunities for improvement

More time spent by N/MUM in ward

Changes in N/MUM’s work

Many of the changes to the N/MUM’s work had been addressed in previous

questions. Over half (n = 22) of the participants said either that ‘ttl’ had not changed

their work, did not respond, or said that they had nothing to add. Of the participants

who said ‘ttl’ had affected their work: six had more time to undertake clinical work

or time on the wards through better prioritising and management; two had more

time to spend with staff; and one felt that the N/MUMs’ Conceptual Framework

allowed them to delineate their role more clearly.

Changes to work of team

Half of the respondents to this question indicated that ‘ttl’ had not resulted in

changes to the work of their team, or they did not respond to the question. Table 9

summarises the impact ‘ttl’ has had on the teams of the remaining participants.

Table 9: changes to the work of N/MUM’s team as a result of ‘ttl’*

CHANGES TO WORK OF TEAM

Increase staff participation in problem solving and decision making (n = 4)

Improvements in staff morale (n = 3)

Higher quality care for patients (n = 2)

Improved team work (n = 2)

Improved handover (n = 1)

Increased delegation (n = 1)



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4.3.3 Impact of ‘ttl’ on N/MUM’s role

One of the elements considered in the evaluation of ‘ttl’ was its impact on the role of

N/MUMs. It was perceived to be largely positive. Of the 30 participants, two said ‘ttl’

had not had an impact on their role and another two did not answer the question. Of

the remaining participants, all indicated that ‘ttl’ had had some impact. The types of

impact are presented in Table 10. In addition to the improvements outlined below,

N/MUMs also raised several issues in relation to ‘ttl’. These included: networking

being as important as the content of the modules; and the modules being too long.

Table 10: impact of ‘ttl’ on the role of N/MUMs*

IMPACT OF ‘ttl’ ON ROLE OF N/MUM

Able to apply content of some or all of the modules (n = 9)

Increased confidence in and or enthusiasm for role as N/MUM (n = 6)

Networking (n = 5)

Better understanding of role (n = 3)

Improved coping mechanisms (n = 1)

Improved status of N/MUM in view of staff (n = 1)


Attitude towards being a N/MUM

Participants were asked whether their participation in ‘ttl’ had affected the way they

felt about being an N/MUM. A total of seven participants said no and an additional

six did not answer. Participants said that they: felt more positive about the role (n =

3); clarified expectations of the role (n = 3); decreased feelings of isolation (n = 2);

gained insight into the contributions they made; felt more empowered; increased

their enthusiasm for the role; reinforced current activities; staff more appreciative of

role; felt valued by NSW Health (n = 1 for all the latter). One participant indicated

that they had left the course with a greater enthusiasm for the role of N/MUM, but

that this had waned subsequently.

4.3.4 N/MUMs’ managers and staff perceptions of capabilities and skills

development in N/MUMs

Managers of N/MUMs were asked to reflect on the capabilities and skills which they

had seen their N/MUMs gain as a result of their participation in ‘ttl’ in open ended

questions. They identified the following improvements in their staff’s skills:


45

Communication skills in dealing with staff and managers (n = 14)

Improved understanding budgeting and rostering (n = 8)

Embraced other initiatives and new ideas, increased lateral and or lean thinking

(n = 11)

Built team work and peer support amongst the N/MUMs (n = 3)

Improved management and leadership skills (n = 14)

Time management (n = 2)

Improved performance management (n = 2)

More outcome focused (n = 1)

More staff focused (n = 1)

Increased empathy (n = 1)

Improved ability to support staff (n = 1)

Increased professionalism (n = 1)

Changed approach to data and improved knowledge base (n=4).

Changes to N/MUMs’ ability to manage as identified by staff included: more

collaborative; implemented a series of improvement initiatives; increased

attendance at ward rounds; delineated and delegated more; improved

communication between N/MUM and staff, and between staff; increased

accountability. One respondent noted that as a result of the:

”… ward NUM spending more time with patients [there have been] fewer

complaints.”

[Medical staff, tertiary hospital]


46

4.4 Key factors affecting changes implemented as a result of ‘ttl’

Participants were asked about factors which affect the successful implementation of

changes. Questions included: which changes N/MUMs had been able to implement

successfully; whether some changes had been easier to implement than others; and

what were the factors that enabled or formed barriers to change.

4.4.1 Successful implementation of changes

Of the 30 N/MUMs interviewed three did not implement changes. Of the remaining

27, three participants indicated that assessing the success of the changes was

difficult: one because the change was undertaken in a new hospital and therefore it

was difficult to assess the change from what had occurred previously; the second

participant found it difficult to differentiate between the impact of the changes they

had made post ‘ttl’ and the impact of the Essentials of Care program; and the last

participant found it difficult to assess the impact of change in a unit with high staff

turnover. One additional participant felt that the success was “50:50” but noted that

there were improvements both in her staff’s abilities and her own. Table 11 presents

changes which have been successfully implemented by N/MUMs.

Table 11: changes successfully implemented as a result of ‘ttl’*

SUCCESSFUL CHANGES

Improved feedback from and communication with staff, improved relationships with staff, increased staff satisfaction (n = 18)

Increased confidence and skills as manager (n = 8)

Staff in control, more responsible, empowered and proactive (n = 7)

Improved processes (handover, transport, flow management, rostering, organisation of equipment)(n = 5)

Increased effectiveness and or productivity of staff (n = 3)

Cost saving in storeroom supplies by applying lean thinking (n = 2)

Development of improvements/innovations by staff (n = 2)

Time saved in service delivery (n = 2)

Increased patient satisfaction (n = 1)

Increased interest in patients (n = 1)



47

The following statement paraphrases the response of one N/MUM to the question

about the successful implementation of changes. In their opinion, “ttl”:

“… allows you to be more transparent in your decisions. This leads to an

increase in the trust that staff have of your decisions … I was already doing

some of the things so this was more about developing my understanding of it,

now I don’t just do what my role entails because I have been told to do it, I

now understand why I do it. [It has] given me more opportunities to

communicate with staff why I do things – this has developed relationships

with my staff. My relationships with my staff have improved because I am

now confident and understand why and I can build the staff understanding of

why. Being able to say “I learnt this at ttl” gives it more credibility and

credence and therefore my managers are more supportive. Lean thinking [has

been] successfully implemented.”

[N/MUM, state-wide service]

As each interview progressed, participants often provided more details about

changes which they had made as a result of their participation in ‘ttl’. These are not

counted above, as they appear irregularly throughout various interview questions.

They are, however, important examples of change. The following are spontaneous

examples of change which were reported:

“Process mapping, changing paper work for patient going into day surgery

are examples [of changes]. We removed duplication and unnecessary tasks in

Day Surgery Unit. Also, eliminated some things not needed for patients being

admitted, streamlining, so patients came in later and went home earlier,

reducing ward times. Better communication with families and carers

regarding patient care after surgery. Improved communication if surgery is

cancelled. Whole skills got developed which gave confidence other NUMS

concur.

[N/MUM, metropolitan service]

4.4.2 Factors affecting implementation of changes

N/MUMs’ opinions varied as to whether some of the changes they had implemented

were easier to change than others. Of the participants who responded (n = 23),

factors said to increase the ease of implementation included:

Increased confidence as a manager (n = 2)

Patient centred approach (n = 2)

Champions of change (n = 1)


48

‘Selling’ the change as a benefit to staff (n = 1)

Establishing a new ward (n = 1)

Team approach to change (n = 1).

Factors making the implementation of changes more difficult included:

Changing old habits/changing culture in others (n = 5)

Lack of resources including staff (n = 2)

Lack of development opportunities (n = 1)

Difficulty in sustainability of change (n = 1)

Need for follow up after courses such as ‘ttl’(n = 1)

Lacking in leadership skills required (n = 1)

Difficulty in seeing results of change for staff (n = 1)

Time required to be inclusive (n = 1)

Physical environment (n = 1).

A number (n = 5) of participants identified lean thinking specifically as being an

easier change to implement. The response of this participant provides important

insight as to why this may be: “lean thinking changes [are] easier but still need to be

driven. Easier because [they are] practical and [you can] chip away at it and do even

without a CSO. Staff feel overwhelmed with workload [and] so [are] resistant to

evaluation of other projects.’ [N/MUM, regional hospital]

The managers of N/MUMs identified a wide range of factors which affected their

N/MUMs’ ability to implement change. These included:

Support from senior management (n = 11)

Support from staff (n = 7)

Team work (n = 3)

Timing/time (n = 4)

Culture of unit and organisation (n = 2)

Staff resistance (n=1)

Understaffing/ workload (n = 4)


49

Impact of organisational structures (n = 1)

Small scale, incremental changes (n = 1)

Concurrence with Essentials of Care and or other change strategies (n = 1)

Practice development workshop (n = 1)

Support from CSO position (n = 2)

Effective communication (n = 1)

Showing relevance of change to staff (n = 1)

Reduced sense of isolation (n = 1)

Clinical champions of ‘ttl’ (n = 1)

Sharing learning (n = 2)

Willingness to change (n = 1)

Passion (n = 1)

Effectiveness of ‘ttl’ tools (n = 1)

Skills to make changes (n = 1).

The perspective of staff was closely aligned to that of the N/MUMs and managers.

Factors which enable their N/MUMs to successful implement changes include: being

positive about change themselves; implementing new practices over a period of

time; introducing changes with increased confidence and collegiality, including team

involvement, meetings and ongoing staff input (n = 2); strong support from the

Executive and Senior Management; meeting a need; co-ordinated implementation

strategy; and good leadership and communication skills (all the latter are n = 1).

Factors which hindered successful implementation included: workload; the same

project being undertaken by several departments simultaneously; lack of time; lack

of ongoing organisational support; and change fatigue, because so many changes

implemented at once.


50

4.5 Quantitative improvements at the unit level

This section reports on quantitative improvements at the level of N/MUM’s units as

a result of their participation in ‘ttl’. A full list of figures is presented in Appendix 8.4.

4.5.1 Unit performance

N/MUMs were asked to rate the quantitative improvements in their workplace as a

result of their participation in ‘ttl’. Indicators examined included: perceptions of their

unit’s overall performance; perception of their unit’s overall efficiency; and rate of

adverse events.

Unit performance and efficiency

Just over half of the N/MUMs (58%) indicated that both their unit’s performance had

improved significantly or somewhat, and 42% that it had remained the same. In

relation to their unit’s efficiency, 67% felt that it had improved to some degree. No

N/MUMs believed that their unit’s performance or its efficiency had worsened by

any measure.

Of the N/MUMs’ managers, 62% reported that their unit’s performance had

improved significantly or somewhat, and 52% reported that their unit’s efficiency

had increased since the N/MUMs’ had participated in ‘ttl’. There were 14% and 7%

who indicated that these improvements may be partly attributable to other

initiatives. A total of 38% of N/MUMs’ managers felt that their N/MUMs’ units’

performance had stayed the same, and 41% that their efficiency had stayed the

same. There were 31% and 38% respectively who attributed the lack of change in

these variables to factors other than ‘ttl’. No manager felt that their N/MUM’s unit’s

performance or its efficiency had worsened by any measure.

Exactly half of the staff (50%) indicated that the unit’s performance had improved,

and the rest through it had stayed the same. A slightly lower proportion (46%)

believed that their unit’s efficiency had stayed the same, with 45% reporting that it

had improved either somewhat or significantly. The remaining 9% felt that it had

decreased somewhat.

Adverse events

The majority of N/MUMs (72%) indicated that the number of adverse events since

their participation had largely stayed the same. No participants indicated that

adverse events had increased. The remaining participants (28%) indicated that


51

adverse events had either decreased somewhat, or decreased significantly, in

concert with ‘ttl’.

A similar response was received from managers of N/MUMs participating in ‘ttl’. Two

participants indicated that they were not sure that a decrease in adverse events

could be attributed entirely to ‘ttl’. Of those who attributed a change to ‘ttl’, 27%

identified that adverse events had decreased somewhat. Overall, 77% of managers

reported that there had been no change in adverse events since ‘ttl’, with 50%

identifying that the lack of change was not attributable to ‘ttl’ (e.g. “we don’t get

that many anyway”). Of the staff that responded 59% felt that adverse events had

stayed the same or decreased somewhat, 23% that they had increased somewhat.

The rest were unsure.

Patient flow

A slightly higher number of N/MUMs (48%) felt that patient flow had improved

either significantly or somewhat, compared to those who felt it had stayed the same

(42%). An additional 10% indicated that patient flow had worsened somewhat or

significantly.

Overall, 37% of N/MUM managers reported a change in patient flow since N/MUMs

participated in ‘ttl’. There was 22% of participating N/MUM managers who

attributed an effect on patient flow to their N/MUMs’ participation in ‘ttl’. Of these

27% reported a significant improvement and 59% a slight (somewhat) improvement.

While 56% of N/MUM managers reported no change in patient flow, 48% reported

that the lack of change was due to factors outside ‘ttl’. Of the staff who replied to

this question, 32% reported that patient flow had improved to some degree, 50%

that it had stayed the same, and the rest indicated it has worsened somewhat.

Time spent on administrative tasks

N/MUMs were asked a series of questions relating to their performance and

capacity. The first question related to changes in the time spent on administrative

tasks. No participant identified that the time spent on administrative tasks had either

increased or decreased significantly. The remaining participants accounted that it

had either: increased somewhat (25%), stayed the same (35%) or decreased

somewhat (40%).

In the perception of N/MUM’s managers, 29% reported that the time spent on

administration by their N/MUMs had stayed the same. A further 51% suggested that

the time their N/MUMs spent on administration had decreased to some degree,

although most of these attributed the decrease to a combination of the potential


52

effect of ‘ttl’ and the introduction of CSOs, a similar response was made by the

N/MUMs themselves. The remaining 16% reported that it had increased somewhat

but that this was due to factors other than ‘ttl’ (e.g. ‘[there are] a lot of projects

rolling through increasing admin time’). Of the N/MUM’s staff that responded, 41%

felt that the amount of time their N/MUMs spent on administrative tasks had

decreased either somewhat or significantly. Of the rest, 27% felt it had stayed the

same, 14% that it has increased somewhat and the rest did not know.

4.5.2 Staff performance

The majority of N/MUM participants, 62%, thought that staff performance had

improved, and 38% that it had stayed the same. No participant suggested that it had

worsened. N/MUMs’ managers had similar perceptions, with 51% believing that staff

performance had improved: 41% attributed this improvement to ‘ttl’; 3% to a

possible combination of ‘ttl’ with other factors; and 7% was attributed to factors

other than ‘ttl’. Most of the surveyed staff (50%) specified that staff performance

had stayed the same, or that it had improved slightly (32%). The rest of the staff

denoted that it had decreased somewhat (18%).

N/MUMs were asked about impacts of their changes post ‘ttl’ on the behaviour of

their staff. Positive indicators were staff satisfaction and staff retention, negative

indicators were staff absenteeism.

Amongst N/MUMs the greatest increase identified was in staff satisfaction, where

69% of participants reported that staff satisfaction had increased either significantly

or somewhat since ‘ttl’. No participants advised that staff satisfaction had decreased.

A total of 26% of participants also believed that staff retention had increased; with

most participants (70%) indicating that staff retention had stayed the same, and a

further 4% that it had decreased.

Of the N/MUMs’ managers 49% thought that staff satisfaction had increased

somewhat (23% attributed this improvement to ‘ttl’; 20% attributed changes to ‘ttl’

in part or were unsure of the cause; and 6% did not attribute this change to ‘ttl’). Of

the remaining N/MUM managers, 40% thought that staff satisfaction had stayed the

same and 6% that it had worsened significantly (participants noted that this was not

due to ‘ttl’ but factors such as ‘workload issues’). Almost all (90%) of N/MUM

managers thought that staff retention had stayed the same, with 7% stating that it

had increased somewhat due to ‘ttl’.

Of the N/MUMs’ staff, 41% felt that staff satisfaction had improved. Of the

remaining respondents, 23% said that it had stayed the same, 27% indicated that it


53

had worsened either significantly (4%) or somewhat, and the rest were unsure. Most

(41%) reported that staff retention had stayed the same, or that it had improved

slightly (14%). The remaining staff were either unsure, or held that it had worsened

(36%).

Staff absenteeism was largely considered by N/MUMs to have stayed the same

(70%). Of the remaining participants, 17% felt it has increased somewhat, and 13%

that it had decreased either somewhat or significantly. Of the N/MUMs’ managers

interviewed, 83% proposed that absenteeism had stayed the same and 3% that it

had decreased somewhat (due to ‘ttl’). There were 14% who indicated that

absenteeism had increased but that this was not attributable to ‘ttl’. The majority of

N/MUMs’ staff indicated that staff absenteeism had stayed the same (45%). Of the

rest, 9% stated that it has improved somewhat, 23% that it had decreased somewhat

or significantly, and the remainder unsure.

As well as staff satisfaction and retention, N/MUM participants were asked about

changes to staff morale. Half of the N/MUMs, 52%, felt that staff morale had

improved. The remaining 48% thought that it had stayed the same.

Amongst N/MUM managers, 60% felt that staff morale had improved. Of those

N/MUM managers who attributed the improvement to ‘ttl’ (37%), 8% identified a

significant improvement and 83% reporting the improvement as ‘somewhat’. There

were 10% who reported that staff morale had worsened somewhat but that this was

due factors other than ‘ttl’. Of staff who completed the survey, 32% perceived that

staff morale had stayed the same, 26% that it had improved somewhat, 37% that it

had decreased to some degree, and the rest were unsure.

4.5.3 Impact on patients

Three measures of patient impact were taken. These included: patient satisfaction,

patient complaints and patient compliments. A total of 44% of N/MUMs estimated

that patient satisfaction had increased and 41% believed that patient compliments

had increased. No participant felt that either of these measures had decreased

significantly, although 4% recorded that patient satisfaction had decreased

somewhat. Most N/MUMs felt that both these measures, satisfaction (52%) and

compliments (59%), had stayed the same. A further 64% indicated that patient

complaints had also stayed the same. Of the remaining participants, 31% stated that

patient complaints had decreased either somewhat or significantly and 5% that they

had increased somewhat. No participant indicated that patient complaints had

increased significantly.


54

Of N/MUM’s managers, 37% indicated that patient satisfaction had increased (24%

due to ‘ttl’; 10% partly ‘ttl’; 3% not ‘ttl’), and 33% said that patient compliments had

increased (20% due to ‘ttl’; 6% partly ‘ttl’; 7% not ‘ttl’). Managers differed from

N/MUMs on which of these measures had remained the same (62% for satisfaction,

67% for compliments and 61% for complaints). The majority of the respondents who

reported that these variables had remained the same, identified that factors other

than ‘ttl’ were responsible; (38%, 43%, 37% respectively). A total of 27%, however,

felt that patient complaints had decreased due to ‘ttl’. Of the staff surveyed, 52%

recorded that patient satisfaction had stayed the same, and 38% that it had

improved to some degree and 10% were not sure.

4.5.4 Examples of improvements

As well as rating their improvements, participants were asked for specific examples

of improvements at a unit level. Questions addressed the issues of patient flow;

reduction in errors and adverse events.

Patient care and flow

A total of 14 participants said that ‘ttl’ had not had a direct impact on patient care or

flow or that the improvements were not directly or solely attributable to ‘ttl’. There

were, in addition, four ‘no’ responses. Of the remaining participants, respondents

asserted that ‘ttl’ had contributed to:

Improvements in patient day surgery journey

Improvements in patient flow as a result of improved communication with

staff

Improvements due to review of patient satisfaction surveys

Increased focus on patient safety

Increased focus on patients leading to improvements in continuity of care

More time on wards by N/MUM improved patient care.

Errors and adverse events

Half of the participants indicated that there had not been a reduction in errors as a

result of ‘ttl’ and a further three did not respond. Of the participants who had

indicated that errors had not reduced, one stated that ‘there weren’t any problems

with regards to errors anyway, so there were no changes’.


55

In comparison, one participant claimed that errors had been reduced by 40%

because of their participation in ‘ttl’ and another noted that there had been an

increase in the error rate because staff were now more aware of the need to report.

The remaining participants indicated that errors had been reduced by:

Reduced errors through better communication

Increased N/MUM presence on ward

Improved retention of staff and fewer casual staff has contributed to

reduction of errors.

4.5.5 Impact on day to day work of ‘ttl’

Impact of ‘ttl’ on day to day work of N/MUMs

N/MUMs’ managers were asked about the impact of ‘ttl’ strategies on the day to day

work of N/MUMs. A number (n = 6) reported that ‘ttl’ had not had a direct impact, or

that the impact was mitigated or enhanced by other. The remaining respondents

identified the following impacts:

Improvement in N/MUMs’ capabilities overall (n = 4)

Built team work amongst N/MUMs (n = 2)

Improved ability to manage staff (n = 7)

Improved communication skills (n = 4)

Increased awareness of self and wider issues (n = 3)

Increased confidence in their work (n = 3)

Ability to translate ideas into action (n = 2).

Factors prohibiting impact on day to day work included:

Too many barriers to implement change (n = 1)

No mechanism for changing staff (n = 1)

Still cannot spend enough time on ward (n = 1)

Expectations of the organisation (n = 1).


56

Impact on N/MUM managers

As well as the impact of ‘ttl’ on the N/MUMs themselves and their direct staff,

changes to the N/MUMs’ skills were identified as having an impact on their

managers. Not all N/MUMs’ managers perceived that changes to their N/MUMs had

impacted on their daily work (n = 12), and others considered that it was too early to

tell or that they were unsure (n = 4), a number of impacts (both positive and

negative) were identified. These included:

Better communication and management by N/MUMs means better handling

of performance management issues before they become critical (n = 9)

N/MUMs have become more independent and better at problem solving,

reducing dependence on N/MUM manager (n = 9)

Increased visibility of N/MUMs on wards means that their managers have

picked up more of their administrative load (n = 3)

Increased confidence, empowerment and more skills in their toolkit (n = 2)

Less reliance on the Director of Nursing (DON) to initiate change at a unit

level, although support still required (n = 3)

Shorter meetings and less time needed to “sell projects” and less time spent

chasing reports

More resources needed for increased number of projects (viewed positively).


57

4.6 Barriers to the program’s implementation

Participants were asked about several aspects of the barriers which may have

impeded N/MUM’s ability to implement changes after participation in ‘ttl’. These

included changes they would have liked to have made, but were unable to do so.

Only a few N/MUMs identified changes which they would have liked to have made,

but were unable to. Of 30 participants, 11 said explicitly that there was nothing they

wished to implement that they could not. The others indicated a small number of

specific projects they could not get underway, but most identified areas of further

training or input. A few participants identified barriers to implementation of changes

which N/MUMs would like to have made. These included: obstruction from medical

staff (n = 1); lack of cross institutional collaboration (n = 1); need for more

involvement of staff, including CSOs, in quality improvement (n = 2); time constraints

(n = 2); and a lack of resources, both human and equipment (n = 4).

The managers of N/MUMs identified a similar list of barriers. These included: time (n

= 3); local courses already provided at a higher level (n = 2); inability to implement

ideas in the workplace due to workload (n=3); participation seen as ‘tick box

training’; lack of preparation of, and information provided to, DONs; structural

limitations; staff resistance; antagonistic culture; and interdependence with other

organisations (all the latter responses are n = 1). Overall, however, most comments

from N/MUMs’ managers were positive about the impact of ‘ttl’. One participant

gave a clear summation of the barriers affecting implementation of changes. They

said that the biggest barrier to implementing change was the

“… [the] stark reality that you come back to work and you are straight back in

and up to your elbows in hard work.”


Surveyed staff also identified a series of barriers to improvement initiatives at a unit

level. These included: staff attitudes (n = 1); ‘cultural aversion’ or reluctance to

change (n = 2); initial organisational support for the initiative which then ‘petered

out’ (n = 1) ; workload (n = 1); and several changes being implemented at once (n =

2).


58

4.7 Strategies required to ensure the sustainability of changes

4.7.1 N/MUMs’ perceptions of sustainability of change

One element of the evaluation was to identify the factors which influenced the

sustainability of changes made by N/MUMs after their participation in ‘ttl’. All

participants responded to this question. A total of 25 said that the changes they had

put in place had been sustainable. Of these participants four noted the changes were

‘sustainable so far’ and several indicated that the changes had been made were

successful but did not relate the reasons why they thought this was so. Factors

identified as affecting the sustainability of changes included:

N/MUMs’ ability to drive and reinforce changes (n = 5)

Difficulty in attaining and sustaining cultural and behaviour change (n = 2)

The loudness of ‘change resistors’ (n = 1)

Evidence of success and benefits, including results of audits (n = 4)

Patient centred focus (n = 1)

Staff becoming part of the process (n = 1)

Positive feedback to staff (n = 1)

Reducing negative messages to staff (n = 1)

Support of management (n = 1)

Cohesive teams (n = 1)

Clear plans and processes (n = 1).

An example of the factors needed to sustain changes is presented in the following

quotation from an N/MUM. They describe the process of implementing changes as a

result of the lean thinking module in the following way:

“Yes the changes have been sustainable especially Lean Thinking. It worked

because of supportive managers e.g. from the Leadership module (learning

how to lead) enabled me to develop ideas e.g. I took the staff on a planning day

at which we developed values (explicitly stated and shared) and we did team

building activities. This has led to great changes on the ward that have come

from the staff. The managers supported me. When I started ‘ttl’ I had a group

of new staff who were very keen to change. Now the staff are stuck in their


59

ways. It comes down to communication and how you communicate the need to

change. The value of the changes need to be communicated - this could have

been better covered (perhaps a module incorporated re the skills to

communicate the value of change). Health is a constant change. An element in

the communication module that focuses on change management would have

been really useful. As there is ‘change fatigue’ among nurses and staff, keeping

interest in new things in the light of constant change is very difficult e.g.

changes from Garling etc.”


4.7.2 N/MUM managers’ and staff perspectives on the sustainability of change

Managers of N/MUMs identified a number of factors which they felt contributed to

the sustainability of changes implemented by N/MUMs. These include:

Practical approaches that can be applied in many areas (n = 3)

Support from local managers (n = 2)

Collaborative decision making and implementation (n = 3)

Effective communication between staff at all levels (n = 3)

Increased confidence (n = 2)

Support of staff (n = 2)

Identification of clear benefits for staff (n = 2)

Small changes which are easily sustainable (n = 1)

Need to maintain enthusiasm once returned from course (n = 1)

Removal of systems and resources act like a barrier (n = 1)

Peer support (n = 2)

Resources including CSOs (n = 1)

Coaching (n = 1)

Pre-planning and integration into routine practice (n = 1)

Focus on staff (n = 1)

Focus on patient care (n = 1).


60

N/MUMs’ staff were also able to identify a series of factors which they believed

contributed to the sustainability of change within their units. These are presented in

Table 12, below.

Table 12: factors affecting the sustainability of change from staff perspective

FACTOR EXAMPLE

Support and recognition

Support from the AHS in getting medical officers to change practice to fit in with the AHS priorities

Support from management

Structural and resources issues

Resourcing ratios fairly and at benchmarked levels

Ongoing financial support and support from organisational management and time to develop and implement staff and patient education programs

Decrease workload. Increase CSO equitable across regional and rural sites

Quality improvement

Measurement of the changes and positive feedback from senior management

Continuously review the unit performance and stakeholders' comments

Training Training in change management and leadership

Education on managing change and how to work with resistance

N/MUM capabilities

Good communication, team approach , quality activities

Interpersonal skills, conflict resolution, people management skills


61

4.8 Essentials of Care and Caring Together: The health action plan for NSW

4.8.1 Essentials of Care (EOC)

EOC is being implemented in every ward in NSW over a three year period. In the

current study, the prevalence of implementation and perceived effect of EOC was

examined.

Of the N/MUMs who were interviewed, 17% stated that EOC had been introduced in

their wards, 20% indicated that implementation had begun (and were at various

stages of that implementation) and 63% had not begun implementing EOC. Within

the group for whom EOC had been introduced, 100% (n=5) identified that there had

been changes made at least some of which could be attributed to EOC. One N/MUM

stated that all of the changes they had made had been due to EOC rather than ‘ttl’.

Those who said that EOC had stimulated changes in their wards noted that the

changes arising from EOC were focused on patient care (clinical) needs and driven by

staff on the ward. These changes included the introduction of multidisciplinary ward

rounds, handover, changes in medication administration process and the

development of values and mission statement by staff. One N/MUM captured the

difference between the effects of ‘ttl’ and EOC as one of focus. That is that while ‘ttl’

focused on the skills of the N/MUM (e.g. communication and leadership), EOC had a

clinical focus. Another N/MUM reported that the effects of EOC included an:

“… increased culture of staff wanting challenge and change [and an]

increase in the amount of open discussion about change and attempting

change as a team.”

[N/MUM, tertiary hospital]

Approximately half of the N/MUM managers (57%) and staff (48%) stated that EOC

had been introduced in their organisations. Managers were able to identify the

changes that the staff had made that were due to ‘ttl’ and those that were due to

EOC. Table 13 depicts key elements of the managers’ responses that support their

claim.

Table 13: Key elements of managers’ comments about how they identified between effects due to EOC and ‘ttl’*

KEY ELEMENTS RESPONDENTS

EOC is more about the bedside care 2

EOC is patient focused 1


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KEY ELEMENTS RESPONDENTS

‘ttl’ is leadership focused and patient focused 2

EOC supports staff initiatives and staff driven change 4

‘ttl’ supports N/MUMs to make change 1


“’ttl’ was purely managerial, EOC is purely basic nursing care related so it is not

difficult to distinguish management of practice development ... need to know

more about change management. This module was not included but should have

been”

[N/MUM manager, metropolitan hospital]

4.8.2 Caring Together: The health action plan for NSW

The N/MUMs (47%) identified improvements that had been made in their ward in

line with Caring Together. Examples of some of these initiatives other than attending

‘ttl’, introducing EOC or the employment of a CSO have been depicted below (Table

14). Some N/MUMs reported more than one improvement as a result of Caring

Together. The most frequently cited changes included alternations in processes for

handover and patient care plans and those stimulated by Between the Flags. It was

noted by one N/MUM that:

“Some [changes] are directly due to ‘ttl’, others a combination of Caring

Together and Between the Flags...”


Table 14: Examples of improvements identified by N/MUMs to have been made in line

with Caring Together*

EXAMPLES OF IMPROVEMENTS MADE RESPONDENTS

Handover changes, introduction of ISBAR (n=2) 7

Nursing case review/care plan/models of care 5

Between the Flags 4

Implemented patient/staff ratios and will not open beds if there are not enough staff according to this ratio

1

Gendered bathrooms 1



63

N/MUMs’ managers (70%) identified improvements that had been made in their

ward in line with Caring Together. Examples of some of these initiatives other than

attending ‘ttl’, introducing EOC or the employment of a CSO are presented below

(Table 15). Usually N/MUMs’ managers reported more than one improvement as a

result of Caring Together. The most frequently cited changes included changes in

processes for handover and hand hygiene.

Table 15: Examples of areas of improvement in line with Caring Together reported by

managers*

IMPROVEMENTS RESPONDENTS

Handover changes, introduction of ISBAR 12

Hand hygiene 8

Between the Flags 5

Deteriorating patient 4

Picture of managers and staff in ward 4

Early DETECT program 3

Staff ID and colour coding 3

Normalising change 2

Discharge planning 2

Multidisciplinary rounds 2

Peer nursing review 1

Improved partnership with community service providers 1

Clinical check list 1

Equipment modifications 1

Improved communication 1

Team nursing 1

Peer nursing review meeting 1

Medication safety 1

Patient moved through ED within 4 hours 1

TLC program 1

Job description updates 1



64

4.9 Conceptual Framework for the Nursing/Midwifery Unit Manager Role

The Conceptual Framework for the Nursing/Midwifery Unit Manager Role had been

read by 70% (n = 21) of the N/MUMs interviewed. Of those N/MUMs who had read

it, 38% (n = 8) reported that the Conceptual Framework accurately represents the

purpose, capabilities and core functions of the N/MUM’s role, 33% (n = 7) articulated

that the Conceptual Framework could be strengthened, and 9% (n = 2) stated that it

was not an accurate representation.

One N/MUM asked about the Conceptual Framework evaluated it as “very clear and

good, fitting and appropriate” [N/MUM, metropolitan hospital]. However, at the

other end of the spectrum, another N/MUM stated that it “undervalued N/MUMs,

there is no sense of how pivotal N/MUMs are” [N/MUM, tertiary hospital].

Suggestions of ways in which the Conceptual Framework could be improved fall into

three overlapping categories. The first category proposes that the Conceptual

Framework is too open and needs to define the role of the N/MUM more

specifically. Comments in the second category suggest that the pivotal role of the

N/MUM is not recognised, that the role of the N/MUM is undervalued and that

administrative time demands of the role are not reflected. The third category

included the comment that the Conceptual Framework for the N/MUM role was

more relevant in some locations (rural versus metropolitan) than in others.

Of the N/MUM managers interviewed, 66% had read the Conceptual Framework and

thought that it accurately represented the role of the N/MUM. Some Managers

described the document as very helpful:

“Absolutely fantastic document. Cements all N/MUMs. *We are+ creating new

job descriptions for positions based on the Framework”

[Manager, rural hospital]

Other managers had not read it (31%) or did not feel that it was a good

representation of the role (3%), some describing it as too broad. In this

N/MUM manager’s opinion, the Conceptual Framework is:

“very worthy but quite broad, too broad, N/MUMs are expected to do too

much.”

[Manager, state-wide service]


65

4.10 Strengthening of role as N/MUM

Participation in ‘ttl’ was perceived to have strengthened their role as an N/MUM by

80% (n=24) of the N/MUMs interviewed. The comments and examples of how ‘ttl’

strengthened the role of the N/MUM were categorised into six groups (Table 16). An

improvement in skills, clarification of the role, and increased confidence in their

ability to perform the role were identified as ways in which the interviewed N/MUMs

had been strengthened in their role as an N/MUM. The importance of networking

and sharing ideas was also identified as important in strengthening the N/MUM role.

Table 16: Ways in which the N/MUM role was strengthened by ‘ttl’ (N/MUMs)*

WAYS IN WHICH THE N/MUM ROLE WAS STRENGTHENED BY ‘ttl’ RESPONDENTS

Skills improvement e.g. communication, lean thinking 8

Increased confidence in ability to perform role 6

Networking and sharing of ideas 6

Clarified role 5

Increase in staff respect and expectation of leadership 3

Reinforced existing skills, practices and knowledge 3


While the majority of N/MUMs perceived that their role had been strengthened

through participation in ‘ttl’, 17% did not hold this view. According to one of these

N/MUMs’ interviewed ttl’ was:

“pitched too low, the topics were relevant topics but not content.”


N/MUMs’ managers reported that participation in ‘ttl’ was perceived to have

strengthened the role of the N/MUM (90%). While 3% of the managers interviewed

stated that they did not perceive that ‘ttl’ had strengthened the role of N/MUM, 7%

reported being unsure if a strengthening of the role could be attributed to ‘ttl' or

whether it was due to experience.

N/MUMs’ managers gave examples of how they perceived that the N/MUM role had

been strengthened through participation in ‘ttl’. Managers may have provided more

than one example. An improvement in skills, increased confidence to in their ability

to perform the role, and feeling valued and supported, were identified as ways in

which ‘ttl’ strengthened in the N/MUM in their role. The importance of networking

and sharing ideas was also identified as important in strengthening the N/MUM role.


66

A renewed focus and invigoration, and sense of ownership of the unit in N/MUMs

were also proposed as ways ‘ttl’ strengthened the role:

“More confidence, more time on the floor, a role model. The more the person

“walks the walk” the more it increases confidence”

[N/MUM manager, state-wide service]

“Made them leaders and taking accountability”

[N/MUM manager, Rural/Regional Hospital]

The comments and examples of how ‘ttl’ strengthened the role of the N/MUM were

categorised into six groups. These are presented in Table 17.

Table 17: Ways in which the N/MUM role was strengthened by ‘ttl’ (managers)*

WAYS IN WHICH THE N/MUM ROLE WAS STRENGTHENED BY ‘ttl’ RESPONDENTS

Skills improvement and strengthening existing skills e.g. communication, lean thinking

10

Increased confidence in ability to perform role 9

Networking and sharing of ideas 9

Clarified role 5

Invigorated and refocused 4

Supported and valued 3

Increased ownership of role/unit 4



67

4.11 Introduction of the Clinical Service Officer’s position

This section presents the N/MUMs’ views on the introduction of the CSO. Additional

data from the perspective of the CSOs are presented in Appendix 8.5.

4.11.1 Introduction of the CSOs

A CSO had been allocated to 20 (66.7%) of the N/MUMs interviewed. One N/MUM

had been allocated but did not use the CSO. In light of this, the results are reported

on the basis of 19 N/MUMs experience of utilising the CSO role. Of those N/MUMs

five had been allocated a CSO who had since resigned, with (n=2) or without (n=3)

being replaced at the time of interview. The length of time the same CSO had been

employed for their unit ranged between one week and 12 months (average length of

time = 7 months). All but one of the N/MUMs allocated a CSO identified that the

CSOs reported to them with 45% of those CSOs also reporting to at least one other

N/MUM or N/MUM manager.

Of the NUMs to whom a CSO had been allocated, the CSO was employed on a full

time basis. The hours of employment of the CSOs employed part time ranged

between 12 to 32 hours per week. The recruitment process did not involve 74% of

the N/MUMs who had been allocated a CSO and of those 43% stated that they

would have liked to have been or that it was important that they were involved in

the recruitment process. Of the five N/MUMs for whom the CSO position had to be

refilled, three were not involved in the initial recruitment process but would be or

were involved in the subsequent recruitment of a CSO. When asked if there was a

CSO job description, two were unsure, six (32%) considered the position description

to be too generic requiring local adaptation or development as the role unfolded.

The N/MUMs to whom the CSO reported were responsible for the allocation their

duties for 100% of CSOs. Two of the CSOs also had input into the allocation of their

duties and for one CSO, the Deputy Director of Nursing allocated duties with the

N/MUMs.

Of the N/MUMs’ managers interviewed, 22 (73%) indicated that there had been a

CSO employed in their organisation. The results reported in the remainder of this

section in relation to the CSO role are based on the responses of those 22 managers.

The number of CSOs employed was identified in FTEs. This ranged from 0.5 FTE to

14.4 FTEs. The length of time that the CSO had been employed ranged from two to

14 months with the average length of time being nine months. A similar percentage

of N/MUMs’ staff (70%) stated that their organisation had CSOs.


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While 83% of the managers stated that the CSO duties were allocated by the

N/MUM in their organisations, only 63% noted that the CSOs also reported to the

N/MUM. Among the CSOs identified as reporting to the Director of Nursing (DON),

Assistant or Deputy Director of Nursing (A/DON or D/DON), manager, and

administrative supervisor (n=8), only one manager noted the tasks were allocated by

someone other than the N/MUM. In this case, the CSO role was shared across two

hospitals with two CSOs (job sharing, 1.47 FTE) reporting to the D/DON.

Among the managers interviewed, 64% reported that the N/MUM with whom the

CSO would work was involved in the selection process for the CSO position. Among

the managers who reported that the N/MUM had not been involved, one

commented that it was very important for the N/MUM to be involved in that

process.

The N/MUMs were asked to indicate whether or not the CSO was undertook a range

of duties including data entry and reporting, workforce matters, resource

management, documentation/records management, or general administrative

activities. They were also asked to indicate any other activities that the CSO

undertakes in their unit (Table 18).

Table 18: Percentage of CSOs undertaking duties

DUTY TYPE YES NO UNSURE/NOT YET

Data entry and reporting

19 (100%) 0 0

Workforce matters (rostering, recruitment, leave, payroll)

17 (89%) 3 (16%) 0

Resource management 14 (74%) 3 (16%) 2 (10%)

Documentation/records management

15 (79%)

3 (16%) 1 CSO did documentation for

one N/MUM to whom they reported

but not the other

General administrative activities

19 (100%) 0 0

Other activities 17 (89%) 3 (16%) 0

The N/MUMs were asked to identify whether there were any additional duties

undertaken by the CSO allocated to their unit. The additional role of the CSO in

recording staff performance appraisal data, organising staff training in-services,


69

Occupational Health and Safety activities, non-clinical audits and quality

improvement documentation were reported by several of the N/MUMs (Table 19).

Table 19: Types of additional duties undertaken by CSOs*

ADDITIONAL AREAS IN WHICH CSOS ASSISTED RESPONDENTS

Staff training and performance appraisal data 6

Non clinical audits and quality improvement documentation

5

Occupational Health and Safety activities 4

Check equipment e.g. buzzers 2

Liaise with donor families and organizes flight requisitions for patients

2

Mandatory reporting documentation 1

EQUIP documentation 1

Assistance with organization of referrals 1

Chases results 1

Assist with fundraising activities 1


While 91% of the N/MUMs’ managers interviewed indicated that the CSOs had had a

positive impact on the work that the N/MUMs undertook, one N/MUM manager

(4.5%) was ambivalent and one (4.5%) indicated no effect. However, 14% (n=3) of

the managers stated that the impact had been limited. The reason offered was that

they were not a large enough resource to make a big difference. Examples of types

of duties the CSOs performed that impacted on the role of the N/MUM were

volunteered by 64% of the interviewees. These are presented in Table 20 below. The

most commonly identified duty impacting on the N/MUMs’ work was administrative

assistance followed by duties associated with rostering and staffing. Stock ordering

and duties associated with audits and KPI reports were also identified.

Table 20: Examples duties the CSOs performed that impacted on the role of the N/MUM*

EXAMPLES OF TYPES OF CSO DUTIES THAT IMPACTED ON N/MUMS’WORK

RESPONDENTS

Administrative (e.g. minutes, organizing meetings, data entry)

10

Rostering and staffing duties 8

Stock ordering 3


70

EXAMPLES OF TYPES OF CSO DUTIES THAT IMPACTED ON N/MUMS’WORK

RESPONDENTS

Audits, KPI reports, report writing 3

Bed board and organizing patient transport 2


When specifically asked to identify whether the employment of the CSO had affected

the amount of time the N/MUMs spent on administrative tasks, 82% of managers

articulated that there had been a positive impact. Of these, there were two

managers who claimed a limited impact on administrative tasks. No impact on the

N/MUMs’ administrative tasks was reported by 9% of the interviewees and 9% were

unsure (Table 21). Most (43%) of N/MUMs’ staff where the unit had a CSO, indicated

that the CSO had had an impact on the N/MUMs’ time spent on administrative staff.

The rest either felt that there had been no impact (13%) or were unsure (54%).

Table 21: Impact of the CSO on administrative duties of N/MUM reported by managers

IMPACT OF THE CSO ON TIME SPENT ON ADMINISTRATIVE DUTIES BY N/MUM

RESPONDENTS PERCENTAGE

Yes 16 73%

Yes but limited 2 9%

Unsure 2 9%

No 2 9%

4.11.2 N/MUM’s perspective of the impact of CSOs on their role

The majority of N/MUMs’ interviewed (63%) reported that the introduction of the

CSO role had impacted on the type of work that they did and that this had been

helpful particularly in relation to reducing the time they had previously spent doing

administrative tasks, allowing more time to be spent:

“to co-ordinate patient care and on higher level management tasks.”


The impact of the role was described by some of the N/MUMs as “dramatic”,

“massive”, “fantastic”, “excellent”, and “huge”. There were 26% of the N/MUMs who

were ambivalent about whether or not the CSO role had impacted on the type of

work they do. Reasons offered included a lack of infrastructure and resources to

support the work of the CSO (e.g. desk, computer) and the initial intensive training

required. Two N/MUMs reported that the introduction of the CSO had not positively


71

impacted on their work, with one explaining that a non-health professional was not

helpful in the role.

When asked whether the CSO role had decreased the amount of time the N/MUM

spent specifically on administrative tasks, 15 (79%) responded that it had reduced

the amount of time they spent on administrative tasks.

“I have gone from being able to relieve staff on breaks for only one hour to about

three hours ... I no longer have to work late.”


Two of these N/MUMs indicated that while the time they had spent on

administrative tasks had decreased, their workload had increased in the initial period

of the CSO employment due to the training requirements. When the CSO left there

was further time investment required to train the new CSO. Four of the N/MUMs

reported that the employment of the CSO had not reduced their administrative

workload with three of them stating that the CSO had caused an increase in their

administrative workload because while the CSO role is valuable, the process of

implementation was not and the wrong person for the role had been chosen (n=2) or

the way the role had been set up was not helpful (e.g. the lines of reporting were not

clear).

4.12 Impact of the CSO role on the clinical team

In order to identify whether the CSO role also supported the work activities of

nursing, medical and allied health staff, the N/MUMs were asked what, if any,

impact they thought there had been on the work of these members of the clinical

team. There were seven N/MUMs (37%) who reported that there had been no

impact of the CSO role on the work of these members of the clinical team. Twelve

N/MUMs (63%) recounted that there had been a positive impact of the CSO role

particularly in relation to assistance they provided to allied health personnel.

Educators, doctors, and nurses were also noted to have been positively affected by

the CSO role. Some of the N/MUMs (21%) noted that in freeing them up to be more

available the other members of the clinical team benefited from the CSO role.

In order to identify whether the CSO role supported the work activities of

nursing, medical and allied health staff, the N/MUMs’ managers were asked

what, if any, support they thought there had been on the work of these members of

the clinical team. There were five managers (28%) who reported that there had been

no impact of the CSO role on the work of these members of the clinical team. A

supportive impact of the CSO role on the work of other members of the clinical team


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was affirmed by 41% of the interviewed managers. A limited effect on the role of the

clinical team was suggested by a further 18% of the managers interviewed. The CSO

role was reported to indirectly support work activities of nursing, medical or allied

health staff by 9% of N/MUM managers (Table 22). Of the staff themselves, 48%

reported that the CSO contributed to their work, 22% said they did not, and the rest

were either unsure (n = 1) or did not reply.

Table 22: N/MUM managers’ perception of impact of the CSO on the role of the clinical

team

SUPPORT OF THE CSO ROLE ON THE WORK OF THE CLINICAL TEAM

RESPONDENTS PERCENTAGE

Yes 9 41%

Yes but limited 5 18%

Indirectly 2 9%

No 5 28%

No response 1 4%

4.12.1 Impact of the CSO role on patient care

There were 37% of N/MUMs who reported that the CSO role had not impacted

patient care. However, the CSO role was considered by the majority of N/MUMs to

have positively impacted on patient care. The ways in which they suggested this

occurred are tabulated below. They fall into two categories that can be summarised

as ‘streamlined processes’ or ‘releasing the N/MUM for clinical care’ (Table 23).

Table 23: The ways in which the CSO role impacts patient care

THE WAYS IN WHICH THE CSO ROLE IMPACTS PATIENT CARE

EXAMPLES RESPONDENTS

Stream line processes: improved efficiency of patient care

Discharge summaries faxed

Nurses not looking for

documentation

At weekly case conferences the CSO

makes action items and so there is

quicker follow up

EDDs behind beds – patients are

4


73



more involved

Co-ordination of care improved

Fewer loose ends

Fewer things get missed

Releasing N/MUM and nurses for clinical care

More time to focus on patient care

N/MUM has more time on the floor

with patients

N/MUM is on the floor during

morning rounds

8

The majority of interviewed N/MUMs’ managers (73%) reported that the CSO role

had positively impacted patient care. Three of the managers (14%) claimed that

there had been no impact and 14% were unsure or ambivalent about the impact of

the CSO role on patient care. Managers identified ways in which the CSO role

affected patient care. These fall into two categories summarised as ‘administrative

focus’ or ‘N/MUM clinical supervision’ (Table 24). For example, responses when

asked if they perceived an impact on patient care as a result of the introduction of

the CSO included:

“Yes the NUMs are out there. If there is an issue with a patient, clinical or non

clinical, they’re there. The can solve the problem because they are the most

senior person on that ward.”


Table 24: The ways managers perceive that the CSO role impacts patient care*



Administrative focus Auditing gets done

Better patient flow

Better staffing and rostering

4

Releasing N/MUM and

nurses for clinical care More time to focus on patient

care

15


74



Better clinical management and

supervision

N/MUM available and more

visible


Just over a third of N/MUM’s staff (39%) said that CSOs had contributed positively to

patient care, while 7% said that they did not. The rest either were unsure of the

impact (23% or simply did not respond. Where the staff indicated that the CSO had

had a positive impact on patient care the reasons provided included: N/MUMs spend

more time on ward (n=2) and CSO had taken over administrative work, or is more

efficient at administrative work (n=3). The following two comments were made by

participants who indicated that the CSO had had a positive impact on patient care,

and reflect the complexity of the situation.

“Only for one NUM. We have one FTE CSO for 2 hospitals and 5 NUMs and 2 NM.

It is ludicrous to think they are going to make a substantial difference.”

[Staff member, regional health service]

“CSO's have been very effective in providing useful support and assistance to the

NUM. The role will grow further with time.”

[Staff member, metropolitan service]

4.13 Unexpected impacts/outcomes of the CSO role

There were no unexpected impacts of the CSO role reported by 47% of the N/MUMs

interviewed. However, 53% reported both positive and negative unexpected

impacts. Perceived negative impacts included the time spent training the new CSOs,

the high turnover of CSOs, feeling out of the loop, and having no control over what

the role of the CSO is. The positive unexpected impacts were a decrease in the

number of lost items, assistance provided to other staff members including the ward

clerk, and the support of consistency across units. To illustrate this latter point, one

of the N/MUMs reported the following unintended consequence of the introduction

of the CSO role:

“The CSO is part time for two N/MUMs. She has played a role in connecting the

N/MUMs and coordinating things around the hospital which has led to increased

consistency e.g. if she sees one NUM doing something she reminds the other.”


75


While 50% of interviewed N/MUM managers reported that there were no

unexpected impacts of the introduction of the CSO role, and 14% who identified

unanticipated negative outcomes including friction with other staff (e.g. ward clerks)

and an unrealistic expectation that as a result of the CSO position, (e.g. the

expectation that ‘the N/MUM would [now] be available to be on the floor all of the

time)’. There were 14% of N/MUM managers who identified unexpected benefits

and offered suggestions about the CSO role (Table 25). In particular, managers

identified benefits related to the aspect of the CSO role that allows them to share

ideas across wards. This is illustrated by the comment of a Manager in a Tertiary

Hospital:

“Forces N/MUMs to consider whether their practices are optimal on account of

CSOs who share wards and report back on how things are done differently.”

[N/MUM manager, tertiary hospital]

Table 25: Unexpected impacts of the introduction of the CSO role and managers’ suggestions about the role

UNEXPECTED OUTCOMES

Better communication

Standardisation of on administrative tasks across wards

Sharing of ideas on administrative tasks across wards

SUGGESTIONS

The job is too big for the number of hours allocated

The efficacy of the CSO role is very dependent on the characteristics of the individual

The expectations of the role must be kept in check with the N/MUM to retain managerial tasks

In relation to the N/MUMs’ staff, 13% stated that there had been an unexpected

impact as a result of the introduction of the CSOs, 22% felt that there had not been.

All of the staff who reported there had been no unexpected impact, and who

provided further information, said that this was because the CSOs were “spread too

thin” to have any impact. For staff who said there had been an unexpected impact,

all except for one (“increase in need for NUMS to be double checking roster and re-

roster staff“) were positive.

“Better management of casual pool staff, prompt entry of rosters, second set of

eyes to detect errors in rosters or documents, reduced time spent typing up data,

documents created faster and delivered to appropriate places on time.”


76


“My personal recognition of tasks that can be completed by CSO and not myself.

CSO is invaluable to allow time to not only spend with pts but also with the

staff.”


4.13.1 Ways in which the CSO role could be improved

The N/MUMs identified ways in which aspects of the introduction of and the CSO

role itself could be improved. The most frequently cited changes were an increase in

the N/MUM-to-CSO ratio and hours that the CSO worked, and more input by

N/MUMs into the position description for the CSO. Other suggestions included a

training program for all CSOs before they commenced in the unit and a development

of the aspect of the CSO role that co-ordinates and links units/wards.

The N/MUM managers made recommendations of ways in which the CSO role could

be improved. The most frequently made recommendations were to increase the

number of CSOs and the hours that CSOs were available (27%) and to give them

more training (18%). Other suggestions included that the role of the CSO be adapted

to better suit the needs of the units (9%), that the CSO be included as a member of

the unit team (4.5%) and that the position be better budgeted for (4.5%).

Staff, in addition to N/MUMs and their managers had specific suggestions about

improvements to the role of CSOs. Most of the suggestions related to increasing the

CSOs time, or their distributed across services (n = 5):

“All clinician managers should have access to a CSO. A competent CSO can

double to productivity of a Clinician Manager.”


“Excellent position should have leave relief and we need to ensure they do not

get taken up by other departments- some CSO are working primarily for Medical

officers- not NUMs, need more we have only 2 for 7 NUMS.”


“They need to support more clinical departments than just nursing. There are a

large number of other departments with the same issues of clinical staff doing

administrative tasks that they are inefficient at and therefore make lots of

mistakes that take even longer to fix.”



77

Two respondents mentioned that CSOs would benefit from additional training. Only

one respondent, who knew about the role felt that it was “unclear if initiative is cost

effective”.

4.14 Case studies

The following section will describe the affect ‘ttl’ has had on two NUMS and their

units that were identified as potential participants for an in-depth interview by NSW

Health. The information the participants gave is of their personal experience and

perspective. It is an opportunity to view two experiences of NUMs who have

completed all five modules and what effect if any it has had on them and their units.

A discussion follows the comparison that will attempt to tease out potential themes,

whilst recognising the limits of generalisability of information. The two cases are

briefly described, and a comparison follows in Appendix 8.6.

N/MUM1 and N/MUM2 work in large hospitals, the former in a regional area and the

latter in a metropolitan setting. Both have a similar number of staff, including a CSO,

reporting to them.

4.14.1 Case 1

“It was something that had to happen to be honest” (N/MUM1)

When N/MUM1 began her role on the ward, the ward was in disarray. Patient and

staff satisfaction was low. Recruitment and retention was low. Her role was mainly

administrative and had very few engaging characteristics or as N/MUM1 described it

- “this is seriously one of the shittiest positions in the hospital, I do have to tell you –

and it's quite recognised for that”. As she spent more and more time in her office she

became more disengaged with staff and patients. This had a number of

consequences that will be discussed in the analysis. Amongst them was exhaustion:

“I was looking a bit beat and battered”.

‘ttl’ was an initiative that she perceived as necessary not only for herself, but for

N/MUMs in general. N/MUMs had evolved into the role without formal and

standardised training and there was a clear need for definition and clarity of the role,

but also of providing management skills to nurses whom had clinical training and

limited managerial training. She was initially identified to be a part of the piloting of

the program and eventually became a champion for ‘ttl’. She was amongst the first

to enrol in the program.


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4.14.2 Case 2

“I did think it was a good program, and it's not often that you get together with other

N/MUMs” (N/MUM2)

N/MUM2 likens her unit to “a revolving door, there's people coming and going the

whole time. So it's very hard to maintain any kind of practise or have standards, or

have continuity in care”. This structural characteristic has strong implications on staff

and patients. She describes a ward that has numerous managers across multiple

levels of management and that “it's an environment where nobody knows what the

rules are, the goalposts keep changing, and there's too many people ... it's like 'who is

in charge?'””.

N/MUM2 describes ‘ttl’ as a positive experience and was one of the first to enrol and

participate. She believes that although the content was not beneficial to her, as she

had already gained this knowledge in her post-graduate studies, it was important

and relevant to N/MUM practice. The networking was what she found to be both

interesting and beneficial. Overall, she sums the impact ‘ttl’ has had on her

personally by stating that “I kind of felt that take the lead thing, maybe did not so

much affect how I am a manager, but I think it's affected the management

environment”.

4.14.3 Comparison

N/MUM1 describes the factors that enabled her to create successful and sustainable

change in her unit as: 1) having more time due to the implementation of the CSO; 2)

having a better understanding of her role and where it fits in within the organisation;

3) increased confidence gained from the skills she learnt and were reinforced; 4)

increased motivation that she felt as a result of participating in the program 5)

increased awareness and ability to reflect on the impact her and others action have

on patients and staff 6) ongoing support from N/MUMs that was achieved through

networking at the workshops and as a result of her coaching role 7) ongoing support

from her management team and staff.

N/MUM2 describes ‘ttl’ as having less of an immediate impact on her everyday work,

but the change it had made in the managerial environment, where N/MUMs now

have a common language and an ability and opportunity to voice their needs and

concerns as important. She describes leading her team to become more autonomous

and capable to impact their work environment and patient care. This was achieved

through participating in the EOC program that gave staff the structure through which

to reflect, identify and initiate changes.


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Both N/MUMs describe this as an ongoing process that requires navigating complex

systems with limited time and financial resources. Both have recognised the

influence of their role as leaders and not just managers and have noted changes that

have disseminated through the ward gradually through conversations and a change

of attitude (e.g. the push for staff to be more self-sufficient in problem solving) and

not only through formalised planned changes.

4.14.4 Discussion

As was evident in the description above, at times, the N/MUMs discussed ‘ttl’ and

EOC as both having a combined impact on their work and unit. A strong impression

that arises from the interviews is that at times it will be impossible to tease out

which intervention – ‘ttl’, EOC or other initiatives is the stimulus for changes. Many

times the N/MUMs stated that it is a combination of ‘ttl’ and EOC or other clinical

interventions. Some changes had been identified through internal initiatives or

organisational directives before either ‘ttl’ or EOC. It is the combination of initiatives

that created the strong impact described.

On both these accounts the units are a better place to work and patients are

receiving higher quality care. Both N/MUMs state that there is still much to do. They

both feel confident that they have the skills to meet the challenges and have a

clearer understanding of their role. They both believe that that there is more support

and a shared language with the different stakeholders. They both note that there are

issues that need to be addressed systemically and cannot be influenced directly.

They agree that they have more ability and forums to voice those needs and

concerns.


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4.15 Reflections on ‘ttl’

4.15.1 Has participation changed how you feel about being a N/MUM?

When asked whether participation had changed the way they felt about being a

N/MUM, 40% reported that there had been no change, 7% did not comment and

53% reported that it had positively changed the way they felt about being a N/MUM.

To illustrate, one N/MUM stated that originally from a clinical background, they now

feel:

“… more empowered ... managing staff is different from managing patients.”


Reported changes in how they felt about being an N/MUM were grouped according

to similarity of concepts (Table 26). The two most salient changes centred on

perceived empowerment and confidence in their role as an N/MUM and feeling less

isolated in that role. One N/MUM noted:

“I have more job satisfaction because there is more clarity in what I should be

doing. If you know what your goals are it is easier to know when you are doing a

good job and this leads to improved satisfaction.”


Table 26: Changes in how N/MUMs perceived being an N/MUM following ‘ttl’*

CHANGES IN N/MUM’S PERCEPTION OF BEING A N/MUM RESPONDENTS

Feel more empowered/confident/clear/proud about my role 7

Don’t feel as isolated 5

Renewed enthusiasm 2

Feel more appreciated (e.g. by staff and NSW Health) 2

Improved skills increased job satisfaction 1


4.15.2 N/MUM managers’ reflection on their participation in ‘ttl’

Those managers who had participated in ‘ttl’ were asked to reflect on their

experiences participating in ‘ttl’. They identified improved leadership, consolidated

knowledge, learning new skills, networking and refocussing as factors they found to

be important. Some managers reported being better able to understand and support


81

the N/MUMs who had done ‘ttl’. Much was enabled through their participation in

‘ttl’. It gave them a ‘common language’ and put them on the ‘same page’ as the

N/MUMs.

“Some of the NUMs had gone so we weren’t on the same page – they came back

with great ideas. It was helpful that I went because when the others were going I

could encourage them more and the conversations we then had about take the

lead were on the same page.”

[N/MUM manager, state-wide service]

4.15.3 Final insights on ‘ttl’ from N/MUMs

When offered an opportunity for additional comments about ‘ttl’, only 20% of

interviewed N/MUMs declined. The comments from the remaining N/MUMs (80%)

were diverse and included suggestions for the way in which the delivery of ‘ttl’ could

be improved including running the program over a shorter time span and tailoring

the program for the different needs of N/MUMs and to include topics such as NSW

Health’s principles on EEO. Other suggestions included the introduction of post ‘ttl’

refresher or regular debriefing sessions, and a greater focus on change management

to better equip N/MUMs to help staff manage the many changes that are being

made in their wards. Several N/MUMs proposed that it would be worthwhile

designing a separate course or requiring managers of N/MUMs to attend so that

they will be more supportive of the changes that the N/MUMs try to make as a result

of ‘ttl’. The most frequently occurring comments were about the benefits of

opportunities to network with other N/MUMs provided by ‘ttl’.

4.15.4 Final insights on ‘ttl’ and recommendations from N/MUM managers

When offered an opportunity for additional comments about ‘ttl’, 91% of

interviewed managers offered comments. These comments ranged from suggestions

about increasing the number of CSOs and developing their role to the suggestion

that there should be an equivalent program introduced for managers. The comments

were grouped according to similarity of key points and are presented in Table 27

below. The comment offered the most frequently was that ‘ttl’ was an excellent

program that should continue.

Table 27: Managers’ comments and suggestions following ‘ttl’*

COMMENTS AND SUGGESTIONS RESPONDENTS

‘ttl’ is an excellent program that should continue 13

CSO role needs to be developed and more CSOs employed 4


82

COMMENTS AND SUGGESTIONS RESPONDENTS

Revise content e.g. include clinical skill coordination and include a component on change management

3

Recognise prior learning with ‘ttl’ 2

Follow up with an advanced program post ‘ttl’ 3

Follow up with a ‘refresher’ 2

‘ttl’ was particularly helpful for new N/MUMs 2

Encourage continued networking post ‘ttl’ 1

N/MUMs found the networking very helpful 3

Introduce an equivalent program for managers 1

Consistent approach and standardisation of role is excellent 2

Logistical problems with travel and accommodation 2

‘ttl’ was more helpful for the N/MUMs of some units than others 1



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5. DISCUSSION

5.1 Overall findings

The participants in this evaluation recognised that the role of N/MUMs has changed

significantly over the last three decades, and that this change has involved increased

managerial and administrative responsibilities. Most N/MUMs and their managers

commented on the lack of preparation for N/MUMs to pursue their managerial and

leadership roles. The changes suggested by the Garling Inquiry, including the

formalisation of the role of N/MUMs, programs for their professional development,

and the facilitation of their increased presence in their units, and ‘away from their

desks’ was seen to form a new phase in this development.

We found that ‘ttl’ had contributed to a considerable degree to the skills

development of some of the participating N/MUMs. Of the N/MUM respondents,

60% said that ‘ttl’ was of some value to them. The value of each module, however,

differed greatly. In some cases this was a structural issue: N/MUMs whose staff were

centrally rostered found that module contributed little to their work. The financial

module was open to the same criticisms. In several cases, participants noted that

these were ‘a waste of time’. One of the most recounted determining factors of

value of the ‘ttl’ modules was how much prior education or experience the N/MUM

already had. This was not a universal however: individual attitudes and the manner

in which the module presented meant that some people with extensive experience

were able to gain value from the program. This general point is supported in

educational studies and the literature (Leimbach, 2010, Kirkpatrick et al., 2006,

Nijman et al., 2006, Alvarez et al., 2004).

For those for whom ‘ttl’ was of value, the program was seen to have enabled and or

empowered N/MUMs to implement changes in the workplace. It is important to

note this distinction however: not all N/MUMs, N/MUMs’ managers or staff

considered that ‘ttl’ had had an impact on N/MUMs. More common than the ‘no

impact’ response, however, was respondents’ inability to identify whether ‘ttl’ had

contributed to the N/MUM’s development or not: a range of confounding factors,

including professional maturity, other development and change programs in the

workplace, and the N/MUMs own background made it difficult to quantify the

impact. Caution therefore has to be placed on too strong a representation of the

Likert results. Almost half (n = 14) of the N/MUMs interviewed said that they could

not identify a day to day impact of their participation in ‘ttl’. However, less than 20%

of N/MUMs and N/MUM managers who participated in this evaluation stated either


84

that they were unsure whether ‘ttl’ had strengthened or contributed to the role of

N/MUMs, or that it had not.

Respondents were more comfortable providing examples rather than quantitative

measures of outcomes. Where ‘ttl’ had an impact, it appears to have influenced

N/MUMs’ ability to change and in their own perceptions to improve, many aspects

of their workplace, including efficiency, patient outcomes, change management,

staff outcomes and capabilities and skills. Even though individual cases differ (both in

response to the program and in its subsequent impact), the results overall show that

for those N/MUMs who were able to implement changes in the workplace, ‘ttl’ was

an important contributing factor. This is particularly, but not only, in cases where

N/MUMs had little prior training and or experience.

5.2 Positive benefits

N/MUMs have put in place identifiable changes as a result of their participation in

‘ttl’. The most commonly noted changes, by all participants (N/MUMs, their

managers and staff) involved implementation of some aspect of lean thinking: this

may be because, in the view of one participant, that model allows for small

incremental changes which are highly visible. However, many N/MUMs have

implemented a range of other changes ranging from the modification of their

individual communication styles, to new approaches to the rostering of staff, to the

creation of multi-method team based approaches to the co-ordination of care.

Differences in the sophistication and range of changes meant that their impact was

difficult to measure for many participants; however individual participants indicated

cost and time savings as a benefit.

Changes in N/MUMs’ capabilities and skills varied with individuals across the several

measures which were taken. Of those N/MUMs who felt that ‘ttl’ had had an impact

on their work, 67% believed that their job performance had improved to some

degree since their participation in ‘ttl’. In comparison, 83% of N/MUMs’ managers

felt that their job performance had improved (67% due to ‘ttl’, 13% due partly to ‘ttl’

and 3% due to other factors). A majority of N/MUMs (62%) recognised that their

staff’s performance had improved also. However, across all participant groups, there

were indications of improved communication by N/MUMs, particularly in critical

contexts. This was reflected in the changes which were deemed to have been

successfully implemented: the most common change related to N/MUMs ability to

communicate with, and provide feedback to, their staff reportedly resulting in

increased staff satisfaction.


85

This was mirrored in their ability to handle complex situations: 80% of N/MUMs who

felt ‘ttl’ had had an impact, thought that their ability to manage difficult situations

had improved, and 71% said that their negotiation skills had improved. Supporting

this, 82% N/MUMs and 65% of N/MUM managers felt that N/MUMs’ ability to

manage staff had improved. This was borne out by several of the N/MUM managers

who noted that one of the impacts on their own work as a result of their

participation in ‘ttl’ was a reduction in the number of performance reviews which

‘progress up’ the ladder for attention.

Other measures varied. Even with the N/MUMs who felt ‘ttl’ had had an impact,

around 58% felt that their unit’s performance or efficiency had improved. Fewer felt

that adverse events had changed: 72% indicated that post ‘ttl’ they had stayed the

same, although some participants noted this was for reasons other than a lack of

impact of ‘ttl’. About 49% of NUMs and 22% of N/MUMs’ managers claimed that

patient flow had improved to any degree. There appeared to be minimal impact on

patient satisfaction, compliments or complaints attributable to ‘ttl’.

5.3 Key factors

The success of, and barriers to, N/MUMs attempts at change were attributed to a

range of structural, cultural, organisational and relational factors. These factors were

supported by the findings from the literature review. The three key elements to the

successful transfer of learning into action relies on a combination of the clinicians’

own personal commitments and characteristics; the way in which the training did or

did not prepare them for the transfer of that learning; and workplace climate and

organisational support.

Participants gave consistent examples of the importance of these factors across all

participating respondent groups. The last of these factors, workplace climate and

organisational support, were also said to support the sustainability of the changes

implemented. This was also true of their perceptions of the sustainability of changes

they had made. A combination of senior management, peer and staff support is

considered essential to ensuring the continuation of change efforts.

One of the intangible benefits of participation in ‘ttl’ emerges from the opportunity

for N/MUMs to network and share solutions to common problems. Related to this,

and identified both by the N/MUMs themselves and their managers, is an increase in

their self-confidence. These are key future success factors.

Overall, the role of the CSOs was said to have had a positive impact on reducing the

administrative workload of most N/MUMs, although in some cases this was


86

considered to be limited. From the CSOs perspective, undertaking a new, and at

times not clearly defined role has posed some challenges, particularly for CSOs who

are geographically or organisationally isolated, or those who are spread over several

locations.

This evaluation shows that the introduction of ‘ttl’, along with other improvement

mechanisms, such as the Essentials of Care program and the introduction of CSOs,

has enabled a range of N/MUMs to develop, implement and sustain changes to their

workplace. In the cases where N/MUMs have been able to transfer their learning

from ‘ttl’ effectively, these changes have resulted in improvements in finances, staff

satisfaction and morale, and patient care.


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6. CONCLUSION

The mid program evaluation of ‘ttl’ shows clearly that while ‘ttl’ has had some impact

and a range of positive effects, in some areas this impact is mixed. To use a

metaphor from patient safety, much of the ‘low hanging fruit’ – the small

incremental workplace changes and engagement of N/MUMs have been ‘picked’.

Nonetheless, ‘ttl’ shows clearly the potential of a program to prompt and support

workplace changes, even in the midst of major restructuring. While caution is

required in interpreting the Likert scale responses too positively, across the board, in

staff, N/MUM manager and N/MUM interviews, it is clear that ‘ttl’ has influenced

change at a unit level and proven to be a catalyst for a range of improvement

initiatives. The potential next steps are indicated in the recommendations. The major

recommendation is that, like most development programs, ‘ttl’ must grow with its

constituents and be subject to continuous improvement.


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8. APPENDICES

8.1 Evaluation tools

8.1.1 N/MUMs interview schedule

Interviews were opened with a scripted introductory statement. The researchers then

asked the following questions:

In these first questions, I would like to ask you about your overall impressions of the

take the lead project.

1. Can you tell me about how your participation in the ‘ttl’ workshops came about?

2. Can you tell me about your experience of participating in the ‘ttl’ program?

3. Has participating in the ‘ttl’ program been useful to you in your role as a

N/MUM?

4. Have you made any changes in your unit as a result of your participation in the

‘ttl’ program?

a. If they answer yes ask: Can you please describe them?

b. If they answer no ask: If you have not made any changes, could you tell

me why?

5. Were the changes implemented successfully?

a. What helped implement the change successfully ?

b. Have some changes been easier to make than others? Why do you think

this is so?

6. Have the changes you have implemented so far proven to be sustainable? Why

do you think this is so?

7. What changes would you have liked to have made but have been unable to

implement?

8. Can you tell me about any specific skills that you developed as a result of taking

part in ttl?

a. How has your participation in the ‘ttl’ program affected how you go about

your day to day work in your unit?

9. Do you think that taking part in ‘ttl’ has changed your job performance? How?


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a. Has it changed the way you manage your staff? How?

b. Has it changed the way you respond to the needs of patients? How?

c. Has taking part in ‘ttl’ led to any changes in the type of work you do? Can

you please tell me about them?

d. Has your participation resulted in any changes to the type of work your

team does? Can you please tell me about them?

10. Following each statement that I am about to make, I would like you to respond

by answering, on a scale of one to five. Please give your immediate response.

Thinking about your unit since you did the ‘ttl’ modules:

Script Answer (circle)

Have the number of adverse events in your unit: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?

1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat 5: Decreased significantly

Has staff satisfaction: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?


Has staff retention: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?


Has staff absenteeism: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?


Has patient satisfaction: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?


Have the number of patient complaints: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?


Have the number of patient compliments: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?



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Has the amount of time you spend on administrative tasks: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?


a. Can you attribute any of these changes to your participation in ‘ttl’ (if they

can’t remember, the modules were critical communication; lean thinking

and leadership; financial management; rostering for patient care). How

and why?

b. If you have made changes to the way you manage adverse events, staff,

patient complaints or administrative tasks as a result of your participation

in ‘ttl’ have you evaluated any of the changes? If so, can you tell me about

the findings?



Please note the scale has changed.

Thinking about your unit since you did the ttl modules has:


Your unit’s performance: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?

1: Improved significantly 2: Improved somewhat 3: Stayed the same 4: Worsened somewhat 5: Worsened significantly

Your unit’s overall efficiency: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Patient flow: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Staff performance: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?



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Staff morale: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


a. Can you attribute any of these changes to your participation in ‘ttl’ (if they

can’t remember, the modules were critical communication; lean thinking

and leadership; financial management; rostering for patient care). How

and why?




the findings?




Thinking about you since you did the ttl modules has:


Your overall job performance: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Your ability to communicate with staff: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Your ability to communicate with patients and their families: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Your ability to communicate with other (non-nursing) staff: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Your ability to manage difficult situations: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the

1: Improved significantly 2: Improved somewhat


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same’, four ‘worsened somewhat’ or five ‘worsened significantly’?

3: Stayed the same 4: Worsened somewhat 5: Worsened significantly

Your ability to manage staff: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Your ability to negotiate: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Your ability to lead: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Your ability to solve problems: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Your ability to manage the finances and resources of your unit: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Your ability to manage the rostering of staff: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?


Has your ability to implement the principles of lean thinking: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?


a. Can you attribute any of these changes to your participation in ‘ttl’. How

and why?




the findings?


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13. Has a CSO been allocated to assist you in your role? YES/NO

a. When did the CSO begin their work?

b. Does the CSO report directly to you? If not, then to whom do they report?

Is this satisfactory from your perspective?

c. What are their typical hours of duty?

d. Were you involved in their recruitment? Do they have a position

description? (can you send us their duty statement?) Is it based on the

one issued by NSW Health?

e. Who allocates their duties and tasks (you, centrally allocated)

f. Do their duties involve:

Data entry and reporting (rosters, HR) Yes No

Workforce matters (rostering, recruitment, leave, payroll) Yes No

Resource management Yes No

Documentation/records management Yes No

General administrative activities Yes No

Are there any other duties they undertake?

g. Has the employment of the CSO had any impact on the type or amount of

work you undertake?

h. Has the employment of the CSO affected the amount of time you spend

on administrative tasks? If not, why not? If so, how?

i. From your perspective, what has been the impact of the introduction of

the CSO’s role on the work of other members of the clinical team ie

doctors, nurses, allied health?

j. Do you think there has there been any impact on patient care as a result

of the introduction of the CSOs role?

k. Have there been any unexpected outcomes/impacts as a result of the

introduction of the CSO’s position?

l. Please describe how the role of the CSO can be changed to further

support you in your work and more specifically in successfully

implementing change?


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14. Has your unit has participated in the Essentials of Care program? Yes/No

a. Can you tell me about changes in your practice that are a result of your

participation in the ‘ttl’ program and those that are due to your unit’s

participation in the Essentials of Care program?

b. Can you tell me about any other improvements you have implemented

which are in line with relevant recommendations in Caring Together?

15. Have you read the Conceptual Framework for the Nursing/Midwifery Unit

Manager Role? Yes/ No

16. Do you feel it accurately represents the purpose, capabilities and core functions

of the N/MUM’s role? Could you tell me more?

17. Has your participation in ‘ttl’ led to a strengthening of your role as a N/MUM?

How?

18. Has your participation in ‘ttl’ led to any identifiable improvements in patient care

and flow? How?

19. Has your participation in ‘ttl’ led to a reduction in errors in your unit? By what

percentage? Ho

20. Has your participation in ‘ttl’ changed the way you feel about being a N/MUM? If

so how?

21. Is there anything else you would like to say?


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8.1.2 N/MUMs’ manager interview schedule

How many N/MUMs report to you? _____________________________________

What level are the N/MUMs who report to you? __________________________

In these first questions, I would like to ask you about your overall impressions of the

take the lead project.

1. Can you tell me what you know about the ‘ttl’ program?

2. Have any of your N/MUMs participated in ‘ttl’?

a. Have you participated in ‘ttl’?

3. Do you know of any changes that your N/MUMs have made as result of their

participation in the ‘ttl’ program?

a. If they answer YES ask: Can you please describe them and were they

successful?

b. If they answer NO ask: If they have not made any changes, could you tell

me why you think they have not made any changes?

4. What do you think helped your or your N/MUMs implement the change

successfully (Prompt: management support, staff support, other N/MUMS,

resources). Has/have the NUM/s discussed any particular enablers or barriers to

implementing changes?

5. Have the changes implemented so far proven to be sustainable? Why do you

think this is so?

6. Can you tell me about any specific skills that you saw your N/MUMS develop as a

result of taking part in ‘ttl’?

a. Do you think your N/MUMS participation in ‘ttl’ program has affected

how they go about their day to day work of their units?

b. Do you think that your N/MUMs participation in ttl has affected YOUR

work? If so how?



Thinking about units where the N/MUMs have undertaken the ‘ttl’ modules has:


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Have the number of adverse events: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Has staff satisfaction: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Has staff retention: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Has staff absenteeism: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Has patient satisfaction: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Have the number of patient complaints: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Have the number of patient compliments: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Has the amount of time the N/MUMS spend on administrative tasks: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’?

1: Increased significantly 2: Increased somewhat 3: Stayed the same 4: Decreased somewhat


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Is this attributable to ‘ttl’? How has this change been measured?

5: Decreased significantly






The unit(s) performance: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’?

Is this attributable to ‘ttl’? How has this change been measured?


The unit’s overall efficiency: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Patient flow: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Staff performance: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Staff morale: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?



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Their overall job performance: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to communicate with staff: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to communicate with patients and their families: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to communicate with other (non-nursing) staff: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to manage difficult situations: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to manage staff: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?



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Their ability to negotiate: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to lead: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to solve problems: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to manage the finances and resources of the unit: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to manage the rostering of staff: one ‘improved significantly’, two ‘improved somewhat’, three ‘stayed the same’, four ‘worsened somewhat’ or five ‘worsened significantly’? Is this attributable to ‘ttl’? How has this change been measured?


Their ability to implement the principles of lean thinking: one ‘increased significantly’, two ‘increased somewhat’, three ‘stayed the same’, four ‘decreased somewhat’ or five ‘decreased significantly’? Is this attributable to ‘ttl’? How has this change been measured?


10. Have you noticed any differences in these areas between N/MUMs who have

and those who haven’t completed ‘ttl’?

11. Have you employed CSOs in your service? If so, how many?

a. When did the CSOs begin their work?


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b. To whom does the CSO report? Is this satisfactory from your perspective?

c. Who allocates their duties and tasks (you, centrally allocated)

d. Do you think the employment of the CSO had any impact on the type or

amount of work your N/MUMs undertake?

e. Has the employment of the CSO affected the amount of time your

N/MUMs spend on administrative tasks?

f. From your perspective, what has been the impact of the introduction of

the CSO’s role on the work of other members of the clinical team ie

doctors, nurses, allied health?

g. Do you think there has there been any impact on patient care as a result

of the introduction of the CSOs role?

h. Have there been any unexpected outcomes/impacts as a result of the

introduction of the CSO’s position?

i. Please describe how the role of the CSO can be changed to further

support you in your N/MUMs and more specifically in successfully

implementing change?

j. Was the N/MUM with whom the CSO works involved in the selection

process of the CSO?

12. Has your service participated in the Essentials of Care program? Yes/No

a. We are trying to tease out whether changes that your N/MUMs have

made are due to their participation in ‘ttl’ or their unit’s participation in

the Essentials of Care program

b. Can you tell me about any other improvements your N/MUMs have

implemented which are in line with relevant recommendations in Caring

Together?

13. Do you feel that the Conceptual Framework for the Nursing/Midwifery Unit

Manager Role accurately represents the purpose, capabilities and core functions

of the N/MUM’s role?

14. Has the participation of your N/MUMs in ‘ttl’ led to a strengthening and

developing of their role as a N/MUM? How?


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15. Has their participation in ‘ttl’ led to a reduction in errors? By what percentage?

How?

16. Would it be possible for our team to examine your IIMS and complaints data pre

and post your N/MUMS having undertaken ‘ttl’?

17. Has their participation in ‘ttl’ led to any savings in terms of resources or costs? If

so how much?

18. If you participated in ‘ttl’ can you reflect on your experiences as a result of your

participation?

19. Is there anything else you would like to say?


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8.1.3 Staff survey questionnaire

Demographics

1. Are you male or female?

2. What is your age?

3. In which Area Health Service do you primarily work?

Greater Southern AHS

Greater Western AHS

Hunter New England AHS

North Coast AHS

North Sydney Central Coast AHS

South Eastern Sydney Illawarra AHS

Sydney South West AHS

Sydney West AHS

Children’s Hospital Westmead

Ambulance Services NSW

Justice Health

4. What is your professional background?

Medicine

Nursing

Allied Health (please specify)

Other (please specify)

5. How many years have you worked in health care post-graduation? (since you

gained your initial qualification)

6. Where do you do most of your work?

Tertiary referral hospital

Regional hospital

Rural health facility

Community Health Centre

Area Health Service (Office)


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Ambulance service

Justice Health


7. How many years have you worked in health care post-graduation? (since you

gained your initial qualification)

8. Where do you do most of your work?

Tertiary referral hospital

Regional hospital

Rural health facility

Community Health Centre

Area Health Service (Office)

Ambulance service

Justice Health


9. What is your current position in your organisation?

Please specify:

Questionnaire

1. Have the any of the N/MUMs with whom you work completed the ‘ttl’ program?

Facilitating Critical Communication Yes/No/Don’t know

Lean Thinking and Leadership Yes/No/Don’t know

Financial Management Yes/No/Don’t know

Rostering for Patient Care Yes/No/Don’t know

Leadership – making it happen Yes/No/Don’t know

a. Thinking about the N/MUM’s you work with and in your personal opinion:

Have any of the N/MUMs implemented changes to the way their unit

operates as a result of their attendance at these courses? Yes/No/Don’t know

b. If they have made one or more changes, could you please describe at least

one change?


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c. Do you think these changes benefited the unit? Yes/No/Don’t know

2. Is your unit or service participating in the Essentials of Care Program?

Yes/No/Don’t know

a. Can you briefly describe what this participation has involved?

3. Do you think that your N/MUM’s ability to manage the unit has changed?

Yes/No/Don’t know

a. Do you think your N/NUM’s work practices have changed? Yes/No/Don’t

know

b. Has this led to any changes in your work practices? Yes/No/Don’t know

c. Could you please give us one example of how you think your unit’s

performance has changed as a result of changes made by your M/NUM?

Yes/No/Don’t know

d. Have the changes in your N/MUMs work practices led to any changes in how

your team works? Yes/No/Don’t know

e. Has your unit’s performance changed as a result of changes in your M/NUMs

work practices? (eg management of resources, efficiency, financial

performance, error rates) Yes/No/Don’t know

f. Could you please give us one example of how you think your unit’s

performance has changed as a result of changes made by your N/MUM?

g. What type of impact do you think that any changes made to work practices

by your N/MUM over the last year have had on patients? (eg patient

satisfaction, complaints and compliments, patient centred care)

4. Think about a specific change to work practices which you N/MUM has

attempted to implement over the last year. Were they successful in doing so?

Yes/No/Don’t know

a. Briefly describe the change the N/MUM tried to implement

b. Why do you think your N/MUM was successful or unsuccessful in

implementing this change?

c. How did you, as a staff member, measure the effect of the change your

unit?


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5. Thinking about your unit over the last year (or as long as you have been at the

unit) please rate each statement on the following scale, for example: “The

number of days leave taken has decreased significantly”

(Presented as a Likert scale with radio buttons)

Have the number of adverse events changed?

Has staff satisfaction changed?

Has staff retention changed?

Has staff absenteeism changed?

Has the proportion of your N/MUMs’ time spent on transactional

administrative tasks changed?

a. In your opinion in what way, if any, are these changes attributable to your

N/MUM(s) participation in the ‘take the lead’ program?


unit) please rate each statement on the following scale, for example:


Has your unit’s performance overall changed?

Has your unit’s efficiency overall changed?

Has patient flow has changed?

Has staff performance changed?

Has staff morale changed?

Has the communication and the management of difficult situations between

the N/MUM and staff changed?

Has patient satisfaction has changed?

Has the financial management of your unit changed?

a. In your opinion in what way, if any, are these changes attributable to your

N/MUM(s) participation in the ‘take the lead’ program?

7. What do you think will assist N/MUMs (including future N/MUMs) to be able to

identify and successfully implement needed changes to work practices?

Yes/No/Don’t know


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8. Do you have Clinical Support Officer (CSO) working in your unit(s)?

a. Does the CSO contribute to your work? Yes/No/Don’t know

b. Has the employment of the CSO affected the amount of time your N/MUM

spends on administrative tasks?

c. Do you think there has there been any impact to patient care as a result of

the introduction of the CSO role?

d. If yes, how? If not, why not?

e. Have there been any unexpected outcomes/impacts as a result of the

introduction of the CSO? Yes/No/Don’t know

f. If yes, how? If not, why not?

g. Has anything hindered the CSO’s ability to support your or your N/MUM’s

work?

h. If yes, how? If not, why not?

9. NSW Health is interested in supporting and developing the role of N/MUMs.

10. Is there anything else you would like to add about the role of CSOs?

11. Is there anything else you would like to add in general?


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8.1.4 CSO survey

Demographics

1. Are you male or female?

2. What is your age?

3. In which Area Health Service do you primarily work?

Greater Southern AHS

Greater Western AHS

Hunter New England AHS

North Coast AHS

North Sydney Central Coast AHS

South Eastern Sydney Illawarra AHS

Sydney South West AHS

Sydney West AHS

Children’s Hospital Westmead

Ambulance Services NSW

Justice Health

4. What is your professional background?

Clerical

Other (please speciy)

5. What is your highest qualification?

Year 12 or certificate II

Certificate III

Certificate IV

Diploma

Advanced Diploma

Bachelor Degree


6. Please specify the title of your highest qualification.

7. How many years have you worked in health care?


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Questionnaire

8. How long have you worked in the role of CSO?

Less than one year

One year

Two years

More than two years

9. Are you allocated to a single or multiple ward/area/services?

a. Which one(s)?

10. How long have you worked in your current position?

11. What role did you have prior to coming into this position?

a. To whom do you report? (please use position titles only and not individuals’

names)

b. Is this satisfactory from a work perspective? (Yes/No)

c. Can you please describe why this arrangement is satisfactory or

unsatisfactory?

12. What are your typical hours of duty?

Less than five hours

5-10 hours

10-15 hours

15-20 hours

20-25 hours

25-30 hours

30-35 hours

35-40 hours

More than 40 hours

a. On which days of the week do you typically work?

Monday

Tuesday

Wednesday

Thursday


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Friday

Saturday

Sunday

b. Do you work outside of office hours? If so, when do you typically work these

hours (eg Sunday 4pm to 8pm)?

13. On average what percentage of your time do you spend each week working with

or for the following people/groups?

The N/MUM(s) of your unit(s): _____%

Other N/MUMS (or senior nursing staff): _____%

Medical staff: _____%

Nursing staff: _____%

Allied health: _____%

Other (please specify): _____%

14. What are your typical duties/tasks?

15. Please indicate which of the following are part of your roles and responsibilities

(indicate as many as you wish)

Data entry and reporting

Data entry for ward/unit rosters into relevant IT system

Updating the roster in line with any approved changes ie sick leave etc

Entering information onto HR IT system once approved


Data entry activities that relate to patient care activities and support any

member of the health care team

Registering births to the NSW Registry of Births, Deaths and Marriages

Assisting the N/NUM in producing reports on finance and quality

parameters/indicators

Other, please specify:

What percentage of your time (on a weekly basis) do you spend on data entry

and reporting? : _____%


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Workforce matters

Rostering

Recruitment

Leave

Payroll

Liaising with Health Support Services to clarify pay and leave enquiries

Providing support for the recruitment of staff to the ward/unit

Undertaking administrative activities related to the management of

performance reviews for staff that the N/MUM and other ward based medical

and allied health staff line manage within the unit

Assisting with the replacement of staff as directed by the N/MUM


What percentage of your time (on a weekly basis) do you spend on workforce

matters?: _____%

Resource management

Ensuring the ward/unit has adequate stock of medical supplies and equipment

required by staff to perform their day to day duties in delivery of patient care.

Purchasing and receiving new equipment for the ward/unit and equipment

maintenance.

Uniform ordering


What percentage of your time (on a weekly basis) do you spend on resource

management? : _____%

Documentation/records management

Supporting and participating in the administrative aspects of activities

Numerical profiling

Quality accreditation processes

Incident management

Maintaining staff credentialing register

Monitoring of nurses and midwives registration and enrolment


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Assisting the health care team in obtaining information, reports or

correspondence related to patient care

What percentage of your time (on a weekly basis) do you spend on

documentation/records management? :_____%

General administration activities

Undertaking administrative tasks related to meetings that are held on the

ward/unit involving medical, nursing and allied health staff including

Scheduling

Ensuring all relevant documents are available for the meeting

Progression of action items where appropriate

Assisting with the daily schedule for the health care team at ward/unit level

Ensuring that multidisciplinary ward rounds are completed in a timely manner

Ensuring relevant material is available to support the ward round

Organising travel and accommodation for ward/unit staff where required

Other general administrative tasks to support (please specify):

What percentage of your time (on a weekly basis) do you spend on resource

management? : _____%

Any other tasks (please specify)

What percentage of your time (on a weekly basis) do you spend on other tasks? :

_____%

16. If you have access to your job description could you please upload it now? We

are only interested in the scope of scope of tasks and duties across all CSOs and

not in individuals. All information will be de-identified

17. Do you feel your job/position description accurately represents the purpose,

capabilities and core functions of your role? Yes/No, if no, why not?

18. Has your role changed since you were first employed as a CSO? If so how?

19. Were you actively involved in the deciding how your role was to change? Can you

describe how you were involved? Yes/No

20. Have you taken over tasks/duties that were once undertaken by the N/MUM?

Yes/No


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21. Can you briefly list the tasks that you now do, that were once undertaken by the

M/NUM?

22. Can you briefly describe any tasks that you now do, that you know were once

undertaken by other members of staff (e.g. doctors, allied health professionals,

nurses)?

23. Are you undertaking activities/tasks allocated from somewhere other than the

unit ward within which you work? (e.g. are you undertaking centralised

rostering?)

a. Can you briefly list the tasks that are allocated from outside your unit and

who allocates them?

b. How much of your time, on a weekly basis, is taken up by tasks allocated

from outside your unit?

24. What type of tasks do you undertake that specifically support N/MUM(s)?

25. Do you think that the introduction of your role has reduced the amount of time

your N/MUM spend on administrative tasks? Yes/No

a. What type of tasks do you undertake that specifically support the doctors’

work?

b. What type of tasks do you undertake that specifically support the nurses’

work?

c. What impact do you think the introduction of your role on the allied health

professionals’ work? (eg physiotherapists, psychologists, social workers,

pharmacists etc)

d. What impact do you think the introduction of your role on the work of other

staff ?(please specify which staff)

26. Do you think there has there been any impact on patient care as a result of the

introduction of your role? Yes/No

27. What type of impact?

28. From your perspective there been any unexpected outcomes/impacts as a result

of the introduction of your role? Yes/No

a. Can you please describe these?


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29. What, if anything, helps or hinders your ability to support your unit’s work?

30. Is your unit participating in the Essentials of Care Program? Yes/No/Don’t know

31. Can you briefly describe what this participation has involved?


unit) please rate each statement:


Number of adverse events

Staff satisfaction

Patient satisfaction

Staff retention

Staff absenteeism

Number of patient complaints

Number of patient compliments


unit) please rate each statement:


Your unit’s performance

Your unit’s overall efficiency

Patient flow

Staff performance

Staff morale

Communication and management of difficult situations with staff

Communication with patients and their families

Management of staff

Rostering of staff

Financial management

34. What are the three biggest barriers you face doing your work?

35. What are the three things that might make your job easier or more effective?


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36. Do you have the opportunity to meet with other CSOs in order to share

information and provide support to each other? Yes/No

37. Have you undertaken any training to prepare you or develop you in your role as a

CSO? Yes/No If yes, what kind of training?

38. Is there any other comment you would like to make specifically about the role of

CSO?

39. Is there any other comment you would like to make?


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8.2 Literature review

In this section we provide further discussion of the issues raised in the literature

review. These are presented in order to provide a context for readers who may not

be familiar with the origins of the ‘ttl’ program and factors affecting its

implementation.

8.2.1 Examples of concurrent initiatives to improve patient safety

During the implementation period of the ‘take the lead’ other initiatives, also aiming

to improving patient care, have been introduced. These initiatives have stimulated

change and so it is important to recognise the potential effect of these initiatives

when evaluating the ‘take the lead’ project. As there have been numerous initiatives,

only a sample of these are briefly outlined below.

The Essentials of Care Program

The New South Wales Government declared stage one support for Recommendation

38 in the Garling Report through the implementation of the Essentials of Care

Program over a three year period in every ward in New South Wales. The Essentials

of Care (EOC) Program commenced in February 2008. EOC is an evaluation

framework to develop, support and continuously evaluate essential patient care that

is fundamental to each patient’s health and wellbeing. Involvement of the patient

and their carers in discussions and decisions about their care is pivotal to achieving

effective essential care. EOC utilises transformational practice development

methodologies and aims to improve patient safety and outcomes, and enhance the

experiences of patients and all involved in their care. It aims to enable nurses and

midwives to “focus on the development of clinical environments that enhance

patient care, teamwork and individual satisfaction.” (NSW Health Nursing and

Midwifery Office, 2008).

Recommendation 38

“The Chief Nursing and Midwifery Officer of NSW Health should supervise the

preparation within 6 months of and ensure over a 2 year period the

implementation of a program across all public hospitals in NSW which is

designed to achieve an improvement in the efficiency and design of nursing

work practices in each ward or unit having regard to the principles of shared

care and team-based work practices. The NSW program should take into

account the improvements made by the Productive Ward Program in the

United Kingdom and the Essentials of Care Program.” (Garling, 2008: 43)


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Recommendation 38


“The Essentials of Care program provides nurses and other health

professionals with a method to explore and understand current clinical

practice and practice environments and to develop ways to further enhance

them. It is already being established across Area Health Services with a focus

on patients’ experience, as well as what the patients, their families and health

professionals value about effective and relevant patient care.

Building on this, the Chief Nursing and Midwifery Officer will supervise a

program designed to achieve greater efficiency and design of nursing work

practices, giving consideration to shared care and teamwork principles. To

ensure successful implementation, NSW Health will achieve this in every ward

over a 3 year period.”(NSW Department of Health, 2009: 25)

Between the Flags Initiative

Between the Flags, an initiative of the Clinical Excellence Commission, has been

implemented in hospitals across New South Wales (Clinical Excellence Commission et

al., 2010). This initiative aims to improve and standardise the response to and the

identification of the deteriorating patient. Standardised colour coded observation

charts have been introduced to track observations and trigger a response when

observations fall within identified parameters. If the patient’s observations fall

within the yellow and red zones on the observation chart, the need for initiation of

assessment or rapid response is indicated.

Safe Clinical Handover

The Garling Report specifically addressed the need to improve policies and

procedures on clinical handover. Specifically, Garling recommended that a

mandatory shift handover policy be designed and introduced in each hospital. The

handover policy must require that part of the handover is to be conducted at the

bedside, sufficient time for handover be incorporated when rostering, that required

information is included in handover, and that an electronic or written record be

made of the handover (Recommendation 56, Garling Report 2008). These

recommendations were supported and an action plan developed including the

development of key principles and strategies for clinical handover (NSW Health,

2009).


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8.2.2 The role of the Nursing/Midwifery Unit Manager within NSW Health

NSW Health comprises the Department of Health, eight Area Health Services,

statutory health corporations and affiliated health organisations. Public hospitals

contain patient ward areas or units. N/MUMs are in charge of all aspects of

designated ward or unit environments and are responsible for the standard of

patient care in those wards or units. He or she coordinates patient services, unit

management, and nursing/midwifery staff management to ensure efficient use of

resources and delivery of high quality patient care. N/MUMs have a key role in

influencing the culture of a unit, the satisfaction of their staff, the quality of care

patients receive, and the experience of the patient and their carer. As a result,

expectations of N/MUMs are increasing. They are now ‘expected to provide not only

clinical leadership within their units but also deal with an increasing number of

organisational and administrative requirements and at the same time ensure the

maintenance of high standards of nursing and midwifery care’ (Hawe, 2009: 2).

i. NSW Public Health System Nurses’ and Midwives’ State Award

Within the New South Wales public health system, Nursing/Midwifery Unit

Managers are defined as the “registered nurse in charge of a ward or unit or group of

wards or units in a public hospital or health service or public health organisation”

(NSW Health, 2010b:4). The NSW Public Health System Nurses’ and Midwives’ State

Award classifies NUM/MUMs as Level 1, 2 or 3.

The responsibilities of the Nursing/Midwifery Unit Manager Level 1 include:

(a) CO-ORDINATION OF PATIENT SERVICES

liaison with all health care disciplines for the provision of services to meet

patient needs:

the orchestration of services to meet patient needs after discharge;

monitoring catering and transport services.

(b) UNIT MANAGEMENT

implementation of hospital/health service policy:

dissemination of information to all personnel;

ensuring environmental safety;

monitoring the use and maintenance of equipment;

monitoring the supply and use of stock and supplies;


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monitoring cleaning services.

(c) NURSING STAFF MANAGEMENT

direction, co-ordination and supervision of nursing activities;

training, appraisal and counselling of nursing staff;

rostering and/or allocation of nursing staff;

development and/or implementation of new nursing practice

according to patient need.

Provided that the classification of Nursing/Midwifery Unit Manager Level 1 shall

include those registered nurses who, as at 27 June 1986, were appointed as Charge

Nurses or Supervisors of 20 but less than 50 beds or who were appointed at a rate of

pay equal to the latter.

Nursing/Midwifery Unit Manager Level 2 whose responsibilities in relation to patient

services, ward or unit management and staff management are in excess of those of a

Nursing/Midwifery Unit Manager Level 1.

Nursing/Midwifery Unit Manager Level 3 whose responsibilities in relation to patient

services, ward or unit management and staff management are in excess of those of a

Nursing/Midwifery Unit Manager Level 2.

Provided further, in relation to those nurses classified in accordance with this

definition as Nursing/Midwifery Unit Managers on the basis of their former

appointment as Charge Nurses or Supervisors, as the case may be, that nothing in

this definition shall prevent them from being considered for regrading at any time

after 27 June 1986.” (NSW Health, 2010b:6)

8.2.3 From Charge Sister to Nursing/Midwifery Unit Manager

As the demands on, and from, the health workforce have changed over the last

decade, so too have the demands placed on nurse managers (Productivity

Commission, 2005). An overview of the literature reports the evolution of the nurse

manager role from the traditional head nurse role (1980-1991), through early

expansion of the role (1992-1999) to an expanded nurse manager role (2000-2003)

(Shirey, 2006). While the role of Nurse/Midwifery Unit Managers was originally

intended to provide clinical leadership, increasing expectations to undertake

administrative tasks has detracted from this important role (NSW Nurses'

Association, 2009). Nursing leadership is essential in developing and sustaining a

healthy work environment (Pearson et al., 2007) and is correlated with productivity,


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organisational commitment (Chiok Foong Loke, 2001) and job satisfaction (Duffield

et al., 2009). In particular, knowledge of leadership principles, an ability to

communicate, motivate and manage conflict among staff, a commitment to personal

and staff professional development, and being honest and supportive of staff, are

important characteristics of the successful nurse leader (Pearson et al., 2007). As

early as the mid 1990s graduate programs designed to prepare nurse managers for

the leadership positions were introduced or being developed in Sweden and the

United Kingdom (Kleinman, 2003).

The N/MUM roles and responsibilities have changed extensively over the last 25

years as “nursing increasingly bases its claim to professional status upon a

managerialist discourse: it seeks legitimacy and power by embracing both a

managerial ideology and management practices” (Brooks, 1999: 41). The clinical

leadership role on a ward or unit was once fulfilled by the Charge Sister. This role

was based on clinical experience and expertise until 1986 when in New South Wales,

the N/MUM role was created to replace the Charge Sister role. The Clinical Nurse

Specialist role was simultaneously introduced to take over the clinical role leadership

role that was surrendered by the Nurse Unit Manager for a focus on managerial

responsibilities (Duffield et al., 2001). The shift from hospital to tertiary based

nursing education underscored the emphasis on clinical autonomy among nurses

and a resultant perceived decrease in the need for clinical expertise among their

managers (Duffield et al., 2001). This has led to the development of a nursing

managerial role that is less and less traditional and more diverse, encompassing

more and more non-nursing responsibilities with the risk that with an increasing

span of control, nurse managers may become ineffective with their clinical credibility

eroded (Duffield et al., 2001).

A recognised difficulty for Nurse Unit Managers was the lack of formalised training in

management skills and an absence of role models, particularly given the dominance

of role model based learning in nursing (Duffield et al., 2001). Decentralisation and

the introduction of primary nursing impacted the role of nurse unit manager

requiring new types of managerial skills (Duffield, 1991). Uncertainty over role

definition and a perceived gap in management skills is problematic not only in

Australia (Duffield et al., 1994) but internationally (e.g. New Zealand (McCallin et al.,

2010), South Africa (Pillay, 2009), and the United Kingdom (Gould et al., 2001). The

development of leadership and management skills have replaced clinical skills

identified as necessary for the nurse unit manager role (Oroviogoicoechea, 1996,

Gould et al., 2001) and concern about whether individuals in healthcare are

adequately prepared for their management role has been expressed (Kleinman,

2003). A priceless contribution that a nurse brings to the N/MUM role is undoubtedly


127

their ability to factor in the intricate complexities and demands of patient care in

management decisions (Duffield et al., 2001).

An overview of the literature reports the evolution of the nurse manager role from

the traditional head nurse role (1980-1991) through early expansion of the role

(1992-1999) to an expanded nurse manager role (2000-2003) (Shirey, 2006). Stress

among nurse managers is understood in relation to the staff shortages, increased

responsibility and exigent work environment (Shirey, 2006).

In summary, concerns for NUMs identified in the literature include: a lack of

recognition, overtime, isolation, staff shortages, numerous meetings, increasing

administrative load, lack of training for managerial role, competing clinical and

managerial responsibilities (Hillier, 2005). The nurse manager role continues to

evolve and in Australia managing the competing demands of clinical leadership and

managerial roles poses ongoing challenges for nurse/midwifery unit managers.

N/MUMs must straddle technical, managerial and clinical demands in a highly

demanding and continuously and rapidly changing environment. While aiming to

provide compassionate care and clinical leadership they are simultaneously required

to manage finances, administrative demands, performance manage, and staff their

unit often within the context of staff shortages, increasing litigation, demand for

decreased elective waiting lists, publicised adverse events (e.g. Vanessa Anderson, St

George Hospital epidural event), disquiet among their nursing staff (e.g. industrial

action over patient to staff ratios (NSW, Nov 2010)) and financial restraints. They are

required to ensure and measure the delivery of quality care in their unit quantified

with indicators such as adverse events, patient complaints, patient compliments,

length of stay and patient flow.

The literature identifies that when financial restrictions are imposed, the work life

concerns of nurses are often the first to be sacrificed (Duffield et al., 2002) catalysing

an exodus of nurses further compromising staff satisfaction. Nurse shortages

contribute to job dissatisfaction and negatively impact quality of care. Research

suggests that patients in environments where there is a high nurse turnover are

more physically and emotionally compromised (Hayes et al., 2006). Appropriate staff

skill mix based patient needs is significantly correlated with patient outcomes (Twigg

et al., (in press)). It is within this context that N/MUMs are navigating the competing

demands of their role.

8.2.4 Ongoing development of nurse managers

As the role of N/MUMs developed both in Australia and internationally, so too did

the range of mechanisms utilised to facilitate that development. In many cases,


128

including the United Kingdom (Sprinks, 2010, Kellagher et al., 2010), Canada

(MacPhee et al., 2010) and New Zealand (McCallin et al., 2010) development

strategies are intended to address very similar issues to those identified by ‘ttl’. Most

common among these are issues relating to N/MUMs (or their equivalents’) role

ambiguity, workload and appropriate preparation for, and development of, their

role, including competencies relating to management and leadership skills

(MacMillan-Finlayson, 2010, Lewis et al., 2010, Kennedy, 2008).

As part of the formalisation of nurse managers’ roles, there is an ongoing

international interest in the development of specific sets of nurse manager

competencies (Thomas et al., 2008, Chase, 1994). Competencies provide two

functions for professional development: they act both as the basis for the

development of educational/training strategies, and as the basis for assessments and

reviews (Sutto et al., 2008, Care et al., 2003, Donaher et al., 2007).

As the development of specific nurse manager competencies progresses, so too has

the sophistication of the competencies themselves (Lin et al., 2007). Ireland, for

example, now has specific nurse manager competencies aimed at managers-director,

middle manager and front line manager levels (McCarthy et al., 2009). Although each

competency set varies, reflecting national priorities as much as professional

requirements, they generally include elements such as: ethical behaviour and

integrity, effective decision making skills, change management, leadership, human

and financial management skills, lifelong learning, communication skills, conflict

resolution and negotiation skills (Sutto et al., 2008, Palarca et al., 2008, Jennings et

al., 2007, Krejci et al., 1997, Care et al., 2003, Davis, 2005).

While a range of nurse manager development strategies currently being

implemented in health services around the world, the most common include: role

induction (McCallin et al., 2010, Hawkins et al., 2009); in-house, ‘hands-on’

training(Maguire et al., 2004, Kowalski, 2004), coaching or mentoring programs

(Karsten, 2010, Cashin et al., 2010, Rosati, 2009, McLarty et al., 2009); clinical

supervision; succession planning (Ponti, 2009, Mass et al., 2006); and postgraduate

training (McCallin et al., 2010, Joyce, 2005, Duffield, 2005).

8.2.5 Transfer of learning to the workplace

The transfer of learning, from training and educational contexts, into the workplace

remains a central concern for health and other industries. This is partly because

estimates that the effective transfer of learning (as measured by behavioural change)

occurs only in between 10 – 20% of cases, with about 40% of trainees failing to

transfer what they learn once they return to the workplace, growing to about 70% a


129

year after their attendance at a training program. It is generally accepted that only

50% of training investments actually result in improvements for either the individuals

or the organisation (Leimbach, 2010, Burke et al., 2007, Georgenson, 1982, Saks,

1995).

Three key characteristics are said to affect learners’ abilities to transfer what they

learn into their workplace. These include: learner characteristics and readiness;

training design and delivery; and the workplace environment (Leimbach, 2010,

Kirkpatrick et al., 2006, Nijman et al., 2006, Alvarez et al., 2004).

At an individual level, characteristics said to predict the transfer of learning include

cognitive ability, self-efficacy, motivation (both to attend and to transfer what is

learnt) openness to experience, perceived utility of the training and career planning.

There is mixed evidence for the influence of extrinsic versus intrinsic motivation,

conscientiousness, and internal versus external control (Blume et al., 2010, Burke et

al., 2007, Colquitt et al., 2000, Holladay et al., 2003, Quiñones, 1995).

At the intervention level, predictors included appropriate learning goals, content

relevance, practice and feedback behavioural-modelling, and error based examples.

There is some evidence for the influence of self-management strategies (Blume et

al., 2010, Burke et al., 2007, Taylor et al., 2005, Locke et al., 2002).

There were a number of predictors of learning transfer at an organisational level.

These include: a supportive work environment, a strong transfer climate, supervisory

support, peer support, opportunity to perform and organisational commitment

(Blume et al., 2010, Burke et al., 2007, Colquitt et al., 2000).

8.2.6 Factors supporting and inhibiting workplace change

Healthcare environments are ‘busy, complex and chaotic’ (Grimshaw et al., 2004).

Managerial responsibilities in healthcare environments include pressures additional

to those in most other industries, such as as life and death decisions, clinical

complexities and strong autonomy of individual professionals (Braithwaite et al.,

forthcoming). Researchers have tried to identify and describe the manager’s role and

more specifically, how managers conduct their work (Fayol, 1949, Carlson, 1951,

Mintzberg, 1971, Kotter, 1982, Stewart, 1998). Managing change is a particularly

important element of the healthcare ‘managerial routine’ (Braithwaite, 2004).

Managers can be viewed as continuously attempting to make sense of their complex

professional environments, whilst initiating and spearheading progress and

improvement (Braithwaite et al., forthcoming). This constant striving for change and

improvement is at the core of all managerial work. Change takes on different forms


130

from implementing new IT solutions to managing a budget or dealing with staff

performance. In this context, change can be defined as an “innovation in service

delivery and organization as a novel set of behaviours, routines, and ways of working

that are directed at improving health outcomes, administrative efficiency, cost

effectiveness, or users' experience and that are implemented by planned and

coordinated actions” (Greenhalgh et al., 2004: 582). In order for change to be

implemented successfully the intervention chosen needs to be tailored to the

specific situation. It is essential that in each and every intervention, the potential

barriers for implementation are identified and addressed (Flottrop et al., 2003)

Four levels of change in health care have been identified: the whole healthcare

system; institutional/organisational level; groups and teams; and the individual

(Ferlie et al., 2001). Multiple hierarchical domains are a part of the context that

underpins the management of change in healthcare (Braithwaite et al., forthcoming).

On the one hand there is the formal hierarchy as depicted by the organisational

chart, on the other an informal, internal hierarchy within and across professions. This

less formal hierarchy can be based on “political and professional rankings according

to status, reputation, power or importance, or a combination of these” (Braithwaite

et al., forthcoming). For example, doctors often outrank nurses in terms of power. In

order to coordinate and implement change, managers need to navigate this complex

environment.

In the past, it was commonly assumed that most barriers to implementation of

change were at an individual level (e.g. negative attitudes or lack of knowledge and

skills). There is now increasing recognition that there are multiple levels in which

barriers exist, many of which are not within the control of the individual (Grimshaw

et al., 2004).

Greenhalgh, Robert, Macfarlane, Bate, Kyriakidou (2004) provide a comprehensive

description and analysis of how innovation is distributed within service

organisations. The authors describe a model that includes multiple components that

interact with each other. These components include characteristics of: the

innovation itself; the adopter; the readiness of the system; the process chosen for

implementation; the external context; the type of communication and influence

used to transfer the innovation; and the linkages (see model). The existence or lack

of a certain characteristic does not guarantee the adoption or rejection of an

innovation. It is imperative that change agents remember that “the attributes are

neither stable features of the innovation nor sure determinants of their adoption or

assimilation. Rather, it is the interaction among the innovation, the intended

adopter(s), and a particular context that determines the adoption rate.” (Greenhalgh

et al., 2004: 598).


131

There is variance with the rate at which change is adopted. This can be ascribed to a

number of different attributes of the innovation itself. For example, innovations that

have a clear relative advantage in effectiveness or cost effectiveness are more easily

and more willingly adopted. If the advantage of the innovation is not clear to the

individuals involved there is no chance that the innovation will be adopted. On the

other hand, there is no guarantee that when the advantage is clear, that adoption

will be widespread. Other examples that increase the chance that an innovation will

be adopted are low complexity; high compatibility with the norms and values and

needs of potential adopters; high visibility; easy to trial; and high relevance to the

task. (Greenhalgh et al., 2004).

The adoption of innovations by individuals is an interactive process. Individuals are

not passive recipients of change. Individuals negotiate, experiment, evaluate,

emotionally react to,, and modify innovations. Greenhalgh et al (2004) argue against

applying wide ‘adopter categories’ as there is little support for them in the literature.

The authors articulate seven adopter categories that influence uptake of

innovations. For example the meaning of the innovation for the individual has been

shown to impact on the likelihood of change. When there is congruence between the

meaning intended by the managerial level initiating the innovation and the meaning

perceived by the individual, there is more chance that the innovation will be

adopted. The meaning can also be negotiated and reframed within and between

organisational levels (Greenhalgh et al., 2004).

Other examples of individual attributes that increase the chance of adoption are

psychological antecedents such as traits that increase the likelihood an individual will

try and use innovations; context-specific psychological antecedents such as strong

motivation and congruence with values, goals and skills; having a say in the decision

process; awareness of concerns regarding the innovation or its consequences and an

ability to address them; having information, training and support during early stages

of adoption; when feedback regarding implications of the innovation are

communicated to users and that the individuals can adapt the innovation according

to the feedback (Greenhalgh et al., 2004).


132

8.3 Demographic characteristics of participants

Table 28: demographic characteristics of participants~

DEMOGRAPHIC VARIABLES

N/MUM INTERVIEWS

N = 30

CASE STUDIES N=2

MANAGER INTERVIEWS

N = 30

STAFF SURVEY N = 23

CSO SURVEY N=92

TOTAL N = 177

Gender M = 3 F = 27

M = 0 F = 2

M = 4 F = 26

M=7 F=16

M=6 F=86

M= 20 F= 157

Number of ‘ttl’ modules completed

5 5 (N=2) n/a n/a n/a

Participation in Essentials of Care

10 2 12 11 n/a

Current role N/MUM N/MUM, Nurse

Manager

N/MUM Level 3 to DON

Nursing/ Midwifery (13) Medicine (4) Allied Health

(6)

CSO

Years in health post graduation

Range: 8-40 years

Average: 24 years

Range: 10-26 years

Average: 16 years

Range: 8-45 Average: 26

years


years

Range: 1 -37* Average: 7

years

Years in current role

Range: 2-20 Average: 6 years

Range: 5-9 years

Average: 7 years

Range: 1-26 years

Average: 9 years

n/a Less than one year = 79

One year= 12 Two years = 1

Years in current unit/hospital

Range: 1-34 years

Average: 8 years

Range: 7-11 years

Average: 9 years

Range: 1-35 years

Average: 11 years

n/a n/a

Years in current role in current unit/hospital

Range: 1-15 years

Average: 5 years

Range: 1-7 years

Average: 4 years

Range: 1-15 years

Average: 5 years

n/a Range: 1 – 25 months

Average: 8 months

% of work on management



n/a n/a n/a

% of work on clinical duties



n/a n/a n/a

~ all years rounded up to the nearest whole year (except for CSOs), *Years in health total


133

8.4 Changes to N/MUMs’ capabilities and skills since ‘ttl’

8.4.1 NUMS’ responses to changes in their capabilities and skills since ‘ttl’

Figure 2: changes in N/MUM’s job performance since ‘ttl’

Figure 3: changes in N/MUMs communication skills since ‘ttl’

0

10

20

30

40

50

60

Increased significantly

Increased somewhat

Stayed the same

Decreased somewhat

Decreased significantly

Job performance

0

10

20

30

40

50

60


Increased somewhat

Stayed the same

Decreased somewhat


Ability to communicate with own staff

Ability to communicate with other staff

Ability to communicate with patients and family


134

Figure 4: changes in N/MUMs ability to manage complex situations since ‘ttl’

Figure 5: changes in N/MUMs ability to manage staff since ‘ttl’

0

10

20

30

40

50

60

70


Increased somewhat

Stayed the same

Decreased somewhat


Management of difficult situations Negotiation skills Problem solving

0

10

20

30

40

50

60


Increased somewhat

Stayed the same

Decreased somewhat


Ability to manage staff


135

Figure 6: changes in N/MUMs’ leadership abilities since ‘ttl’

\

Figure 7: changes in N/MUMs’ management skills since ‘ttl’

0

10

20

30

40

50

60


Increased somewhat

Stayed the same

Decreased somewhat


Leadership abilities

0

10

20

30

40

50

60

70


Increased somewhat

Stayed the same

Decreased somewhat


Application of lean thinkingManagement of finances and resourcesRostering of staff


136

8.4.2 NUMS’ managers’ responses to N/MUMs changes in their capabilities and

skills since ‘ttl’

Figure 8: Managers’ perceptions of changes in N/MUM’s job performance since ‘ttl’

Figure 9: Managers’ perceptions of changes in N/MUMs communication skills with staff

0

5

10

15

20

25

30

35

40

Improved significantly

Improved somewhat

Stayed the same

Worsened somewhat

Worsened significantly

Due to ttl Unsure of cause or partly due to 'ttl' Not due to ttl

0

5

10

15

20

25

30

35

40

45

50


Improved somewhat

Stayed the same

Worsened somewhat




137

Figure 10: Managers’ perceptions of changes in N/MUMs communication skills with

patients and their families since ‘ttl’

Figure 11: Managers’ perceptions of changes in N/MUMs communication skills with other

staff since ‘ttl’

0

10

20

30

40

50

60


Improved somewhat

Stayed the same

Worsened somewhat



0

5

10

15

20

25

30

35

40

45

50


Improved somewhat

Stayed the same

Worsened somewhat




138

Figure 12: Managers’ perceptions of changes in N/MUMs ability to manage difficult

situations since ‘ttl’

Figure 13: Managers’ perceptions of changes in N/MUMs negotiation skills since ‘ttl’

0

5

10

15

20

25

30

35

40

45


Improved somewhat

Stayed the same

Worsened somewhat



0

5

10

15

20

25

30

35

40

45

50


Improved somewhat

Stayed the same

Worsened somewhat




139

Figure 14: Managers’ perceptions of changes in N/MUMs ability to problem solve since ‘ttl’

Figure 15: Managers’ perceptions of changes in N/MUMs ability to manage staff since ‘ttl’

0

5

10

15

20

25

30

35

40

45


Improved somewhat

Stayed the same

Worsened somewhat



0

5

10

15

20

25

30

35


Improved somewhat

Stayed the same

Worsened somewhat




140

Figure 16: Managers’ perceptions of changes in N/MUMs’ leadership abilities since ‘ttl’

\

Figure 17: Managers’ perceptions of changes in N/MUMs’ management skills since ‘ttl’:

application of lean thinking

0

10

20

30

40

50

60


Improved somewhat

Stayed the same

Worsened somewhat



0

10

20

30

40

50

60


Improved somewhat

Stayed the same

Worsened somewhat




141


ability to manage finances


ability to manage rostering

0

5

10

15

20

25

30

35

40

45


Improved somewhat

Stayed the same

Worsened somewhat



0

5

10

15

20

25

30

35


Improved somewhat

Stayed the same

Worsened somewhat




142

8.5 Improvements at the unit level since ‘ttl’

8.5.1 N/MUMs’ perceptions of improvements at unit level since ‘ttl’

Figure 20: N/MUMs’ perceptions of unit performance and efficiency since ‘ttl’

Figure 21: N/MUMs’ perceptions of changes in number of adverse events since ‘ttl’

0

10

20

30

40

50

60


Improved somewhat

Stayed the same

Worsened somewhat


Unit's performance Unit's efficiency

0

10

20

30

40

50

60

70

80


Increased somewhat

Stayed the same

Decreased somewhat


Number of adverse events


143

Figure 22: N/MUMs’ perceptions of changes to patient flow since ‘ttl’

Figure 23: N/MUMs’ perceptions of time spent of administrative tasks since ‘ttl’

0

5

10

15

20

25

30

35

40

45


Improved somewhat

Stayed the same

Worsened somewhat


Patient flow

0

5

10

15

20

25

30

35

40


Increased somewhat

Stayed the same

Decreased somewhat

Decreased signficantly

Time spent on administrative tasks


144

Figure 24: N/MUMs’ perceptions of changes in staff performance since ‘ttl’

Figure 25: N/MUMs’ perceptions of staff satisfaction and retention since ‘ttl’

0

5

10

15

20

25

30

35

40

45

50


Improved somewhat

Stayed the same

Worsened somewhat


Staff performance

0

10

20

30

40

50

60

70


Increased somewhat

Stayed the same

Decreased somewhat


Staff satisfaction Staff retention


145

Figure 26: N/MUMs’ perceptions of staff morale since ‘ttl’

Figure 27: N/MUMs’ perceptions of staff absenteeism since ‘ttl’

0

10

20

30

40

50


Improved somewhat

Stayed the same

Worsened somewhat


Staff morale

0

10

20

30

40

50

60

70


Increased somewhat

Stayed the same

Decreased somewhat

Decreased signficantly

staff absenteeism


146

Figure 28: N/MUMs’ perceptions of patient measures since ‘ttl’

8.5.2 Managers of N/MUMs’ perceptions of improvements at unit level since ‘ttl’

Figure 29: Manager’s perceptions of unit performance since ‘ttl’

0

5

10

15

20

25

30

35

40


Improved somewhat

Stayed the same

Worsened somewhat



0

10

20

30

40

50

60

70


Increased somewhat

Stayed the same

Decreased somewhat


patient satisfaction patient compliments patient complaints


147

Figure 30: Manager’s perceptions of unit efficiency since ‘ttl’

Figure 31: Managers’ perceptions of changes in number of adverse events since ‘ttl’

0

5

10

15

20

25

30

35

40

45

50


Increased somewhat

Stayed the same

Decreased somewhat



0

5

10

15

20

25

30

35

40


Improved somewhat

Stayed the same

Worsened somewhat




148

Figure 32: Manager’s perceptions of changes to patient flow since ‘ttl’

Figure 33: Manager’s perceptions of time spent of administrative tasks since ‘ttl’

0

5

10

15

20

25

30

35

40

45

50


Improved somewhat

Stayed the same

Worsened somewhat



0

5

10

15

20

25


Increased somewhat

Stayed the same

Decreased somewhat


Due to ttl Due to ttl + CSO Due to CSO alone Unsure of cause Not due to ttl


149

Figure 34: Managers’ perceptions of changes in staff performance since ‘ttl’

Figure 35: Managers’ perceptions of staff satisfaction since ‘ttl’

0

5

10

15

20

25

30

35


Improved somewhat

Stayed the same

Worsened somewhat



0

5

10

15

20

25


Increased somewhat

Stayed the same

Decreased somewhat




150

Figure 35: Managers’ perceptions of staff retention since ‘ttl’

Figure 36: Manager’s perceptions of staff absenteeism since ‘ttl’

0

10

20

30

40

50

60


Increased somewhat

Stayed the same

Decreased somewhat



0

10

20

30

40

50

60

70

80


Increased somewhat

Stayed the same

Decreased somewhat




151

Figure 37: Manager’s perceptions of staff morale since ‘ttl’

Figure 38: Managers’ perceptions of patient compliments since ‘ttl’

0

5

10

15

20

25

30

35

40

45


Increased somewhat

Stayed the same

Decreased somewhat



0

5

10

15

20

25

30

35


Improved somewhat

Stayed the same

Worsened somewhat




152

Figure 39: Managers’ perceptions of patient satisfaction since ‘ttl’

Figure 40: Managers’ perceptions of patient complaints since ‘ttl’

0

5

10

15

20

25

30

35

40


Increased somewhat

Stayed the same

Decreased somewhat



0

5

10

15

20

25

30

35

40


Increased somewhat

Stayed the same

Decreased somewhat




153

8.6 CSO Survey

8.6.1 Background

The CSO survey explored the introduction of the CSOs from their perspective. This is

a preliminary analysis of the results. A total of 92 CSOs who were invited to

participate, responded to the survey (48%).

CSOs have a range of educational backgrounds and qualifications. Of the 90 CSOs

who responded, 73% indicated that they had clerical backgrounds. Of the remainder,

two had previously worked as nurses; four had worked in welfare or education; and

the rest (n = 18) had a combination of customer service, administration, business and

legal backgrounds. Table 29 lists the CSO’s current qualifications.

Table 29: CSO’s qualifications

QUALIFICATION RESPONDENTS (n = 70)

Advanced diploma N = 3, (4%)

Bachelor degree N = 14, (20%)

Certificate III N = 24, (34%)

Certificate IV N = 15, (22%)

Diploma N = 7, (10%)

Post graduate degree N = 3, (4%)

Other N = 4, (6%)

8.6.2 Allocation to wards

Slightly more of the CSOs were allocated to a single (58%) rather than multiple

wards. All except two of the CSOs who responded (n = 89) said that they were

allocated to direct care units (eg theatres, geriatrics, surgical, Emergency and Allied

Health Departments etc). The two remaining CSOs were allocated to a centralised

staff unit. An accurate summary of locations is difficult, because many respondents

simply identified the number of the unit, such as Ward 10e or Rose Unit.

8.6.3 Satisfaction with reporting arrangements

Most CSOs who responded currently respond directly to one or more N/MUMs (n =

57). The remaining CSOs report to senior nursing managers (DONMs) (n = 8), other

senior managers (n = 1), mixed nursing (eg N/MUM and DONM) (n = 12), mixed

nursing and non-nursing managers (n = 7) and other managers (n = 4).


154

A number (n = 7) of the CSOs said they were not satisfied with their lines of

reporting. Of these, one did not give a reason for their dissatisfaction. Table 30

outlines reasons for CSOs dissatisfaction with current lines of reporting.

Table 30: Reasons for dissatisfaction with lines of reporting

SUPERVISOR(S) REASON FOR DISATISFCATION

N/MUM(s) The NUM was not interested in handing over the required tasks of the CSO. The DON is not interested in any progression of the CSO role and allows the NUM's to work as per usual prior to the introduction of the CSO role

Senior staff member, nursing

Many more skills are need than what I have

Senior staff member (non-nursing)

I do not feel that I am progressing in the role of CSO as I had originally anticipated.

Senior (staffing) They're focussed on staffing, and doesn't have the skills nor the time to manage staff

Multiple (nursing and non-nursing)

It seems to be cumbersome and messages can be crossed or mixed.

Other manager (clinical information)

I think it would be better to report to the NUM as she can see what is happening on the job

Six participants who report to N/MUMs, three that report to senior staff, two that

report to other managers and one that reports to multiple staff did not give a reason

for their satisfaction. Table 31 provides a sample of the reasons given by CSOs for

their satisfaction with current lines of reporting.

Table 31: Reasons for satisfaction with lines of reporting

SUPERVISOR(S)* REASON FOR SATISFACTION

N/MUM(s) Relationships

I report directly to the NUM, from whom I receive most of my direction regarding the flow and type of work she wants me to accomplish in any given day. I have developed a wonderful working relationship with her and that was important in my role

Because I have worked with this person previously and have a good relationship with her

I work with a wonderful team who have made me feel welcome

Very supportive , hands on always available


155


I am happy to report to my NUM

Normal manager/subordinate relationship

My NUM is very helpful and friendly

They seem to appreciate my skills.

Access/communication

She is always accessible and nearby when needed

I am grouped with the other Support services & Nursing staff on the ward

Direct communication

It is satisfactory as the NUM is the most in charge on the ward and I am working under them also available to give direction

Easily able to prioritise workload in consultation with manager

I can discuss work directly with the [department] head and their specific requirements

My office is situated 5 metres from NUM's office on the ward so I am close to the NUM, Allied Health, doctors and staff if they need my assistance

It is satisfactory as she is close by and approachable

I spend 80% of my time here

Because I work in direct contact with NUM on a daily basis- good feedback available

NUM is my manager and we work closely together

Most of my duties are carried out on behalf of the NUM - therefore reporting back to same maintains communication flow.

Structural issues

It is satisfactory because most of my work is to assist the NUM

The NUM provides me with all my jobs to do

Because I am working under NUM supervision so for me it's satisfactory

It suits me and my workload to report to the one person

Multi tasking, lots of opportunities

The NUM of [the department] has held the position for many years and has vast knowledge and experience in all areas of this department

My direct supervisor whom I obtain my daily workload from

My job is divided between the two units and the NUMs are my direct supervisors/managers

They are the people who see me on a regular basis and know what work I am doing

It's satisfactory because I support the NUM in most of her duties

The NUM is the in charge on the ward she knows what is going on and what needs to be done this makes her the best person


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to direct the CSO in her duties

The NUM manages the ward

They provide the majority of tasks

NUM allocates task for me to complete. Role

The purpose of the role is to take the burden of administration off the NUMs. Any other arrangement would be unsatisfactory

I work closely with my NUM's daily and assist in all areas of their working load when able

It is simple and clear and therefore easy to communicate and manage workload/expectations

There is a clear line of management and they are approachable and reasonable

Working on a ward the NUM is the person in charge of the ward and therefore they are also the person who you assist

I have a mix of duties which overlap as well. It is challenging and rewarding

The NUM is in control of the smooth running of the ward, so she directs me to help her with that.

Senior Nursing Because I am allocated to multiple wards and multiple hospital having one manager is better as there is less conflict when I am given instruction on how to deal with Issues

Full support from the DoNM.

Multiple managers

(nursing)

Both managers work together

It is satisfactory because these are the people that provide me with work

Communicate well with both managers.

Multiple managers

(Nursing and non nursing)

Work mostly with the NUM

Depending on what role I am doing for the day depends on which manager I report to

Variety of work

Work well with each other

As there are two people to report to it gives the opportunity to be able to speak to the most appropriate person with regards to any issues; due to their different positions within the hospital

It covers both the aspect of pay etc and work locations

Report directly to NUMs, who allocate tasks, and Executive Unit who hold administrative resources

They are my boss - who else could I report to?

It is satisfactory as if helps the NUM so that they have more time with patients, nurses and doctors.

Other manager(s) I am a relief CSO: manager covers all clerical areas.


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* Supervisor as N/MUMs refers to CSOs who report to one or more N/MUMs at the same level.

Multiple managers (nursing) refers to CSOs who stated they reported to N/MUMs and DONs or other

senior nursing staff as well as N/MUMS.

A small number of respondents said that they were happy with their lines of

reporting, but made qualifying statements. These provide some insight into the

tensions in the role:

Reporting to N/MUMs

It is satisfactory but it would be good to have a general person to go to about issues

Satisfactory because answering to nursing staff would be too confusing

Mostly ok, but re definition of work a bit problematic some times, as no precedence.

Reporting to multiple managers (nursing)

Only two now, used to reporting to more - it gets difficult at times when too

many bosses.

8.6.4 Hours and days of work

Most CSOs worked between five and 40 hours a week. Only six of the CSOs work on

weekends: three CSOs work both Saturdays and Sundays, two work on Saturdays and

one indicated that they work on Sundays in addition to weekdays.

Table 32: Hours of work

HOURS PER WEEK RESPONDENTS (n = 81)

5-10 N = 20, (25%)

15 -20 N = 4, (5%)

20-25 N = 5, (6%)

25-30 N = 1, (1%)

30-35 N = 7, (9%)

35 – 40 N = 40, (49%)

More than 40 hours N = 4, (n = 5%)

CSOs were asked about the proportion of time each week they spend working with

different professional groups. Table 33 outlines the results.


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Table 33: Hours of work

OWN N/MUM

OTHER N/MUMS

MEDICAL STAFF

NURSING STAFF

ALLIED HEALTH

OTHER

Mean* 65% 11% 4% 13% 2% 5%

Median 70% 5% 0% 10% 0% 0%

Mode 80% 5% 0% 0% 0% 0%

Highest percentage

100%

(n = 6)

80%

(n = 1)

50%

(n = 1)

60%

(n = 1)

20%

(n = 1)

95%

(n = 1)

Lowest percentage

0%

(n = 1)

0

(n = 37)

0

(n = 52)

0

(n = 23)

0

(n = 58)

0

(n = 65)

8.6.5 CSOs’ duties

In addition to these questions, a sample of 27 CSOs duty statements were collected

and reviewed. All of these closely mirrored the NSW Health duty statement for CSOs,

with only minor differences (whether the CSO was to have a Certificate III or

Certificate IV, some additional duties). More information about duties was gained

through the survey questions below.

Participants were asked about their roles and responsibilities, based on the NSW

Health statement of duties for CSOs. Tables 34 to 38 outline the number of

participants undertaking each task.

Table 34: Number of CSOs undertaking data entry and reporting*

ROLE OR RESPONSIBILITY NUMBER OF RESPONDENTS

(N = 82)

Data entry for ward/unit rosters into relevant IT system

N = 73, (89%)

Updating the roster in line with any approved changes ie sick leave etc

N = 75, (91%)


N = 33, (40%)

Data entry activities that relate to patient care activities and support any member of the health care team

N = 48, (59%)

Registering births to the NSW Registry of Births, Deaths and Marriages

N = 6, (7%)


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(N = 82)

Assisting the N/NUM in producing reports on finance and quality parameters/indicators

N = 55, (67%)


Table 35: Number of CSOs undertaking duties relating to workforce matters*


(N = 85)

Rostering N = 64, (75%)

Recruitment N = 58, (68%)

Leave N = 73, (86%)

Payroll N = 49, (58%)

Liaising with Health Support Services to clarify pay and leave enquiries

N = 64, (75%)

Providing support for the recruitment of staff to the ward/unit

N = 57, (67%)

Undertaking administrative activities related to the management of performance reviews for staff that the N/MUM and other ward based medical and allied health staff line manage within the unit

N = 52, (61%)

Assisting with the replacement of staff as directed by the N/MUM

N = 57, (67%)


Table 36: Number of CSOs undertaking duties relating to resource management*


(N = 69)

Ensuring the ward/unit has adequate stock of medical supplies and equipment required by staff to perform their day to day duties in delivery of patient care

N = 53, (77%)

Purchasing and receiving new equipment for the ward/unit and equipment maintenance.

N = 61, (88%)

Uniform ordering N = 28, (41%)



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Table 37: Number of CSOs undertaking duties relating to documentation/records management*


(N = 85)

Supporting and participating in the administrative aspects of activities

N = 78, (92%)

Numerical profiling N = 29, (34%)

Quality accreditation processes N = 42, (49%)

Incident management N = 30, (35%)

Maintaining staff credentialing register N = 39, (46%)

Monitoring of nurses and midwives registration and enrolment

N = 56, (66%)

Assisting the health care team in obtaining information, reports or correspondence related to patient care

N = 43, (51%)


Table 38: Number of CSOs undertaking duties relating general administration activities *


(N = 72)

Undertaking administrative tasks related to meetings that are held on the ward/unit involving medical, nursing and allied health staff

N =62, (86%)

Scheduling N = 43 (60%)

Ensuring all relevant documents are available for the meeting

N = 62, (86%)

Progression of action items where appropriate N = 47, (65%)

Assisting with the daily schedule for the health care team at ward/unit level

N = 29, (40%)

Ensuring that multidisciplinary ward rounds are completed in a timely manner

N = 8, (11%)

Ensuring relevant material is available to support the ward round

N = 24, (33%)

Organising travel and accommodation for ward/unit staff where required

N = 18, (25%)



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8.6.6 Impact of CSOs

CSOs were asked if they had taken over tasks which had once been undertaken by

their N/MUMs. Of the 76 CSOs who replied, 63 (83%) said they now undertook tasks

which were once completed by their N/MUMs, and 89% thought that they had

reduced the amount of time their N/MUMs spent on administrative tasks. Most of

the tasks indicated reflected those outlined in the previous tables, for example

rostering and entering Kronos.

CSOs were also asked if they believed that their work had an impact on patient care.

Of the 69 who replied, 59 (86%) felt that their work had not impacted on patient

care.

8.6.7 Impact of CSOs on the work of other staff

CSOs were asked about the duties that they were undertaking that supported the

work of other (non N/MUM) staff. Examples are presented in Table 39.

Table 39: Duties undertaken by CSOs

EXAMPLES OF DUTIES CONDUCTED BY CSOS PREVIOUSLY UNDERTAKEN BY OTHER STAFF

Allied health minutes. Allied health databases, allied health stock/stationery ordering. Database for Medical staff. Stay tuned, more to come

Arrange family conferences for social worker. Do Pathlore database entry and other admin tasks to support CNE

As a CSO in nursing admin, we have assumed roles that previous and current admin officers were/are doing

Clinical ordering, they come to me when needing anything

Entering courses into Pathlore, talking to nursing administration

Faxing; Minutes; Filing; Booking venue; organising appointments

Go to meeting and taking minutes for the health professionals

Hand hygiene audits; updating Pathlore; updating registrations; taking minutes; typing minutes; web requisition orders; office max orders.

Helping out the nurse educator, producing staff accreditation booklets for each staff member, keeping records of their training, basic admin tasks I have taken over for her

I act as backstop to the Ward Clerk and to a lesser extent Ward Assistant. Answering telephones, cleaning wards, general running around

I support the Ward Secretary by answering phones and liaising with relatives when required. I support Allied Health in regard to updating FIMs (Functional Independence Monitoring assessment forms)on a daily basis - this is particular to Aged Care and Rehabilitation


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EXAMPLES OF DUTIES CONDUCTED BY CSOS PREVIOUSLY UNDERTAKEN BY OTHER STAFF

Minutes, ordering, communication between different staff, booking transport, ordering supplies, calling up for maintenance

Ordering stock used to be undertaken by the ward clerk on one ward. The ID audit used to be undertaken by the CNE on one ward. Taking minutes of the falls meeting used to be taken by the CNC. Audit reports used to be prepared by the CNE on one ward

Ordering stock. Updating staff health on Riskmate

Ordering/tracking stock, performance reporting, data collation

Photocopying; booking out staff; faxing documents; obtaining medical records

Send request to and follow up with BIMS for the repair of medical equipments

Signage, minutes, documentations, ordering, tracking

Stores orders; retrieval of medical records; clerical support to other staff

Surveys, flyers

Taking minutes of meeting, entering request rosters

Taking minutes of meetings, creating spreadsheet for Diabetes data

There are many tasks as mentioned above once done by nurses now regularly undertaken by me: updating patient results and filing, culling old results, task spreadsheets, shift replacements for in charge when NUM is not working, typing a variety of documents for nurses, answering the telephone and assisting with non clinical enquires and delegating clinical enquiries, departmental systems and equipment rearranging for staff, communication and information support for Nurses

Update bed summary sheets, Pathlore, order dressings and keep dressing trolley updated

Updating the pt boards, stationary orders, multidisciplinary meeting stickers

CSOs were then asked about the specific tasks that they perform to support the work

of doctors, nurses and allied. Of the three groups, allied health received the most

comments, rather than descriptions of tasks. CSOs were quite clear as to their

contribution (or not) for doctors and nurses: they either gave examples, or indicated

that they did not work with these groups. In relation to allied health, however, CSOs

provided a number of reflective responses: either providing examples of tasks, or

reflecting on why they have not contributed to the work of this group. Examples are

presented in Tables 40 to 42 below.

Table 40: Examples of tasks undertaken by CSOs to support medical staff

SUPPORT OF MEDICAL STAFF

Booking transport

Complete the Intern roster on a 10 week rotation


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SUPPORT OF MEDICAL STAFF

Creation of printed material - Signage, pamphlets, brochures

Data collation for reporting and research

Discharge scripts taken to pharmacy, collating notes and getting patient information for doctors

Faxing pathology/Xray and ultrasound request forms

I have only assisting one doctor the whole time I have worked here. It involved preparing a data sheet to which the doctors complete. I enter the results of the data sheet into a data base that

If in rehabilitation I prepare paperwork for case conference

Keep track of patients going to operating theatre, keep track of patient information coming through fax

Library requests; faxing; organising new laptop, telephone

Ordering medical stock

Patient discharges, liaising with pharmacy, organising follow-up consultations

Preparation of results for signing, liaison with Nursing staff on behalf of the doctors for follow throughs required. Maintenance of an orderly and efficient filing system

Printing bedlists, ordering other tests

Providing forms, making sure computer room is tidy and functional for the doctors

This does not occur in theatres as such. By supporting the theatre manager I support the doctor's work by default (i.e. prosthesis reports, VMO payments)

Word processing where necessary, some purchasing

Table 41: Examples of tasks undertaken by CSOs to support nursing staff

SUPPORT OF NURSING STAFF

Ad hoc matters relating to pay and leave etc. Also ensuring the registration is updated. Organise performance reviews

Alleviating the NUM of administrative tasks gives them more time to spend on the floor therefore supports the nurses

Answering phone enquiries

Any administrative queries re rosters, sick, FACS or A/L.

Assisting in printing labels, getting patient folders, taking scripts to pharmacy, changing Diets for patients

Check their roster and pay, make sure overtimes are noted by nursing salaries, support them with registration, filling out of forms, ordering medical supplies, help them to find information on the intra or internet


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Conduct audits; format forms, leaflets, policies etc; follow up on HR issues; IT support and advice

Co-coordinating vacant shifts with casual and part-time staff looking for extra hours. Proacting specific shifts for CNE's, ie. EOC hours. Assisting new employees with recruitment documentation, orientation etc. Maintaining and updating an availability spreadsheet for casual staff

Daily staffing, laminating. love laminating. Creating signs and posters, pay queries. Leave queries

Data collation, organise maintenance, transcribe/write minutes, order/track stock

EMS , phototyping , phone answering , filing patient notes

I help them with any general pay questions; finding forms online; making signs ; ordering transport/meal etc online

I help with their portfolios and anything they need

I report maintenance problems. I regularly check that supplies are orderly and check general supplies around the patient beds eg gloves and cleaners

Locating products, suppliers and purchasing details of equipment and supplies, maintenance issues on ward

Make sure there are stethoscopes, signs for falls risks/fluid restriction/nil by mouth signs are put up

Only organising the ward, having emergency bags clearly marked and labelled next to every bed, have charts labelled easier for bed changes

Ordering clinical stock, notification of educational programs available to them, management of portfolios etc

Ordering medical stock/ensuring obstetrics and midwife data collection data are correct

Ordering, collecting and preparing notes for patients who have presented. Stock is available for their use

Photocopying and printing of front sheet once patient being transferred to our ward, transferring/discharging patients, transport booking.

Powerchart, patient discharges and taking patients to discharge lounge

Purchasing medical supplies, payroll talk, keeping track of their accreditation/training/registration

Queries they may have about their pay and entitlements. ; Print off information they make require for education or day to day tasks

Supero uniforms courses

Typing whatever they may need, and compiling and updating relevant work as needed.


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Updating roster on both hard copy and electronic systems with changes (ie sick leave, OT, filling shifts), adding staff to roster, changing shifts for nurses following approval by NUM) to ensure they are paid correctly. Assist them with the completion of forms such as sick leave, annual and study leave forms are all completed accurately and in a timely manner. Assisting them with pay queries, assisting casuals to work shifts

Updating the patient boards

Table 42: Examples of tasks undertaken by CSOs to support allied health staff

SUPPORT OF ALLIED HEALTH STAFF

A little help dependent on where I work - if there is an bedboard meeting where all the professionals go I prepare paperwork to assist them daily

Administration cover for holiday leave

Allied health professionals never asked me to help a lot but I helped whenever they need any

As I am not fully covering the CSO role my contact with the above professionals is the same as it was as a ward clerk I support them as best I can administratively when asked

Assist in purchasing

Better relationship between NUM and all this professional workers

Depends on how/if they use CSO. Slight but minimal impact

Good documentation due to maintain acceptable level of stationery especially stock of form for documentation

Has provided them with more clerical support so they are able to spend more time with patients and patient care

I assist with ordering for the physiotherapists and other than that I don't help allied health at all

I have had no impact on the role of allied health

I have not really done too much work for the allied health team. I'm not sure why, maybe they don't that they can approach me. I have booked meetings for them

I haven’t been involved with allied staff at all

I suppose it reduces their work load

It has some impact as all of these link in with our department and all are part of the multidisciplinary team. I am able to assist at all levels with provision of information and there are benefits to those staff also

More time is spent on the patients instead of administrative tasks

Not enough - they would like to use me more but I have been limited in the amount of time I am allowed to give them


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SUPPORT OF ALLIED HEALTH STAFF

Not much in regards to my role

Not much, I am present at Allied Health Bed Board meetings and make sure referrals are entered on the Ward Summary sheet.

Ordering stock for the physiotherapy department, collecting patient information for discharges

Prepare case conference info, arrange family conferences / occasionally assist with ad hoc tasks or projects

Smoothing communication between NUM and allied health professionals

The NUM is available and on the floor for allied health professionals to speak to. Access easier. NUM is in greater touch with what is going on in the ward

There isn't much of an impact. I powerchart requests for them when they have been given a referral by the NUM in either the daily morning meeting or the allied health meeting - once a week

Timely communication

Try to assist where I can, sometimes order things, get notes communicate details etc.


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8.7 Details of case study

Similarities

Both NUMs describe the program as having a positive impact on them and their

units. The impact they described:

1) ‘ttl’ identified and addressed core skills that NUMs need to succeed in their

role.

Both NUMs describe the process of nurses moving into the role of the NUM as an

evolutionary process. “Nearly every NUM has come from a nursing background, and

they have been a bedside nurse at some point or another – and then through a whole

pile of reasons, whether it's natural progression, or whether they've done extra

courses, or for what people have gone on maternity leave, or whatever happens –

they find themselves in the nurse unit manager role. Some people actively seek it, but

I think it happens to a lot of people…” (NUM1).

This process left a gap in the skills that are required for management. “There's no

training and there's really no guidelines and you know, a job description is just that,

it's just a job description, but it doesn't tell you what the job is... it was interesting

listening to a lot of them say, yeah, that they hadn't had any educational training or

support – somebody says to them, 'where's your (whatever you call it) – Nets, or

whatever, and they're like 'well what's that'….” (NUM2).

One example of a learning opportunity was the role of leadership in the NUMs role.

Previously NUM1, for example, had not realised the impact of organisational politics

on her performance. “The thing I really liked about leadership, and I think again

that's something that is very foreign to nurses now, is we do have to become a bit

politically savvy. We do have to…. and I'd be the worst offender of that – I have

absolutely no interest in politics, whatsoever, but I've realised that through having an

increased awareness and being impressed by some of these people I've seen be

involved in this course in running it, being involved in it and some of the NUMs you

meet in the process of it – that you know you need to pick up your game was the

message for me in that area. You can't just stick your head in the sand and think it's

not going to impact on you – because as bedside nurses it doesn't, it doesn't impact

on us in any shape or form, or not that we're aware of…. I'm sure it does to a degree,

but we're completely unaware of it – but as managers you have to become a bit

politically savvy. And you have to be able to have those talks – if you want to be

heard, you need to present yourself professionally and educationally, and you know


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you can't do that if you're going to stay in the dark about it…. so I must admit when I

left leadership, I thought 'I need to pick up my game a bit”.

This skill gap had some obvious consequences, such as lower efficiency in running

the wards. But it also brought unintended consequences such as lack of clarity of role

and authority, as in the situation NUM2 described in her unit. But also as NUM1

describes it limits your power and influence in the organisation. “So you can go in

there and have an opinion, because what happens if you don't feel comfortable with

the knowledge that you have or if you have a lack of knowledge, or you feel like you

can professionally present, then you don't seem so, and everybody else's voice gets

heard and yours doesn't – and I think as nurses we under-estimate our power

sometimes. You know we are the biggest workforce in the health and I think we can

influence a lot of things, and I think we need to be aware of that, and raise that a bit

more, but we need to be able to do that in a succinct and educated way – which we

haven't been good at in the past I don't think” (NUM1).

Both NUMs described modules that were more or less beneficial to them. NUM1, for

example has been in her role for several years and has had a lot of experience

handling the financial aspects of the unit. NUM2 has recently finished her post-

graduate degree and felt that she received the information she needed through

those studies. Overall, both accepted that ‘ttl’ had a different impact on each

participant based on individual differences (such as breadth of managerial

experience, previous knowledge and personality) and different unit needs and

characteristics, but that it did not diminish the value of the program. “And I think

look the difference has been that there were 700 and something NUMs I think across

the state if I remember rightly at the time, and it was like, you were never going to be

able --- there were going to be people in there that didn't need rostering, and there

were people in there that didn't need financial management, because they'd been

doing it to death for several years, and they were comfortable with it – but there was

also going to be probably an equally large, if not larger group of people that were

new to positions that didn't know that its format had changed who were being asked

to take on extra things that they didn't know how to do, so they were desperate for

rostering and financial management” (NUM1).

2) ‘ttl’ has reinforced and focused attention on concepts that have always been a

part of nursing and health care management.

One such example was the organisation skills that were discussed as a part of the

lean thinking module.“...so I guess with the Take the Lead, it was interesting that

other people started to see the concepts that have probably been around, you know

have always been there, that they just haven't taken note of…. So even just going to


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the first one, one of the first things they said was about cleaning up – you know what

I mean. Like just cleaning up and organising your work environment, and I've always

been clean and tidy. But now when I go around the other areas are now clean and

tidy and their marking their floors as a place for this, and so it's interesting – perhaps

it's not affecting in my environment, but it's certainly taking effect in the areas

around me” (NUM2).

NUM1 expressed a similar view regarding her communication skills... “I think I had

very good approachable communication skills, that stuff was all there basically, but

it's that higher finesse thing like bigger bang for your buck I suppose. I felt quite

comfortable having conversations and things with my staff and my patients, but

perhaps not so much with hierarchy, and not so much on a major area level for

example. Definitely through Take the Lead and EOC, my profile has been raised in this

area health service, and I have been asked to step up and present at quite a few

things I would have found reasonably intimidating before – but I can do that quite

confidently now, and I feel quite comfortable with that, it doesn't concern me at all”.

It was not only the skill that was reinforced but an awareness of unintended

consequences of behaviours, such as the example given by NUM1 that described

increased awareness regarding communicating style with patients and families. “...

and I think when you have those conversations with patients or relatives that can be

angry….. Like I was okay at that already, but I guess it's more teaching those skills to

be still and listen. And one of the biggest things I learned was about being present in

the room with the person you're with. That was a big thing for me. I would be a

typical NUM, I'd be sitting here listening to someone, but I'd also have one eye on the

computer and so on – and one on the floor to see what they're up to – so that was a

big learning thing for me.”

The program reinforced that knowledge and education can equate to more power in

the organisation. For example NUM2 stated “I think if people have the knowledge

and the skills, I think it puts them in a better position not to be that 'yes' person all

the time, and often people want to argue, or don't agree with the decisions that are

made and the things they're told to do, or feel that they have the capacity to argue a

point or voice an opinion or express a different point of view – so I think the more

educated and more skilled that people are…..”.

Another concept that was reinforced by ‘ttl’ and EOC was that of prioritising and

continuously striving for excellence in patient care. Both NUMs stated, that while

patient care has always been at the heart of their role, the attitude toward care and

interaction with patients and families has changed for the better: “I think the


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attitude, the patient care has changed, and I think it is great and there's a lot of

interaction with families and patients ...“ (NUM2).

3) ‘ttl’ gave N/MUMs recognition and acknowledgement of the importance and

contribution of their role.

Both NUMs describe their role as one that was previously not overtly visible or

recognised in the organisation. It was suggested that this could be because of the

gradual evolution from charge nurse to NUM, but that the role and workload kept

growing without any change in support or training. ‘ttl’ was the first time that NUMs

needs and impact as leaders was recognised and brought to the forefront. “Yes, I

think that was the first and foremost thing, someone had recognised that NUMs

around the place were drowning, absolutely drowning, but you know the upshot of

that is that I believe patient care was suffering in a lot of places” (NUM1).

The NUMs were also recognised by other professional disciplines that work with the

unit. “There was this total recognition from other disciplinarians as well and I think in

particular medical staff here I would have to say, and I'm sure it's the same in other

places, where they just wanted this person, this charge nurse that they knew to be

able to run this, with no recognition of how much that role has changed and evolved

and what else was being required from that person. You know, the time had gone

where you could just be here to see every doctor that was associated with your unit

…. So yeah… I think it was a process that had to happen, and I think the recognition

from the nursing and midwifery office is really positive” (NUM1).

One dimension of the recognition was the fact that considerable resources had been

put towards this program. This manifested itself, for example, in the fact that rural

NUMs were flown into metropolitan centres and provided accommodation. Another

issue was that wards had to find replacements for the NUM while she was away.

Whilst this created certain upheaval for the units, it also highlighted that the NUMs

education and training is a priority to NSW Health, which added to the recognition of

their importance to the organisation.

4) ‘ttl’ provided increased role clarity, shared experiences and a shared language

for participating NUMs and also their colleagues and their managers.

The ‘ttl’ program, along with the role definition and EOC gave the NUMs a shared

understanding and clarity of their role despite unit and organisational specific

differences. The fact that the program was mandatory meant that many (eventually

all) NUMs had gone through a similar experience. This gave the NUMs a common

language. NUM2 described how this effected her interactions with management: “...

a lot of the things we've been doing is we've been saying to management, we don't


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like this, this is why we don't like it, and this is how it impacts on us, and this is how it

impacts on our care, and until recently there's been no forum for that, because as I

say with management it's top heavy - with the whole Take the Lead and introduction

of the Essentials of Care, they're recognising that at various levels, you do need to

listen…. so we've managed to get some changes, but I think had we tried to do this a

year ago, before Essentials of Care, there's no way they would have listened”.

One example of shared language was the prioritisation of patient care. As discussed

in the section describing reinforcement, patient care was always a part of the unit

and its’ priorities, for both NUMs. NUM1 describes how when issues arise the focus

is on problem solving so that patient care is enhanced. Through ‘ttl’ and the EOC

programs it has become a part of the ‘language’ of the unit. “There is always a

patient focus for some staff, not necessarily for all staff. What we've done is a lot of

work around values and things through EOC and one of the amazing things that

came out I think for the staff is that when you brought them all together, they were

all here for the same reason, and they all wanted the same outcome. So whether or

not they liked each other, they actually all had this common thing that they wanted

to reach, and that was good patient outcomes and patient care and all of those

things. Even that recognition of bringing that enormous amount of people together

and saying 'this is what you said, you're all on the same pay, you all want the same

outcome, so why don't you all work together to get there' and so I think that's

probably raised that a lot. What you find is that people are less tolerant of staff who

don't have that focus” (NUM1).

The recognition, together with the increased awareness of their roles not just as

managers, but as influential leaders also had an effect on empowering the NUMs to

take more initiative to represent their perspective on patient care, staff needs and

their own needs. NUM1 commented that “It's definitely given me, and it's made me

realise that it's a reasonably powerful position, it didn't feel like that before, but it is

you influence a lot of people by how you manage yourself really, and I guess I didn't

realise the impact that that had beforehand. You know you think you come in here

and you do a job and that's it, but you know the way you speak, the way you speak to

patients, the way you speak to staff the way you speak to visitors, the way you speak

to other departments, the working relationships you build with those different people

and departments, you set the standard very much I think, and you're actually very

influential on a lot of peoples' lives and you don't realise that. I certainly didn't realise

that before. So it's made me much more aware of that, and much more respectful of

that”.

5) Networking was identified as one of the strong benefits of the program


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Both NUMs identified that the N/NUM role is very isolated and that it is difficult to

ascertain whether you are doing your job well or not. The NUM support network

that resulted from the program was a safe place to ask questions and a source of

ideas and information.

6) CSO were a much needed addition to enable and sustain the ability of the NUM

to engage with core clinical and managerial roles rather than administrative

tasks.

Although, each NUM had a different experience with their CSO, both NUMs viewed

the impact of the CSO as a positive one. NUM1, who has had a full time CSO for the

last 10 months stated that once the CSOs were deployed “you'd never get a NUM to

give one back, that's for sure” and maybe even more convincingly that “I'd give you

my child before I gave you my CSO…”. NUM2 that shares her CSO with another unit,

and has only had the position filled recently, is still learning how to best utilise the

CSO in her specific situation. “I guess it's been, we're just trying to work out what we

can give her. It's very hard to give over some of the tasks that you do when you've

been doing them for so long, and often you don't realise that these are tasks that you

could…”.

Both have had less administrative tasks to do which has freed them up to do other

things like being on the ward more and interact with staff and patients.

Differences

The differences identified in the interviews were in the perceived source of the

change catalyst and the types of changes made.

1) Source of change -NUM2 believes that she had previously gained the content

knowledge that was in ‘ttl’ from post-graduate studies, and that ‘ttl’ did not

directly influence any specific changes in her unit. Most of the changes are

attributed to EOC and staff initiatives that resulted from it. NUM1 has instituted

a number of ‘simple changes that have had a big impact’ that she attributes to

‘ttl’. She too recognises the benefits of other programs on the positive changes

in her unit.

2) Changes implemented and sustained – each of the units had different challenges

and different needs that stem from, amongst other things, their function, their

organisation, their staff characteristics and their managers’ leadership style.

Time and staff were resources that were scarce in both cases, but both describe

multiple changes that have occurred since ‘ttl’ and EOC. Below are some


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examples from each unit. Some examples of the changes that were

implemented in NUM2’s unit are:

Better collaboration between her and her staff – “I think there's definitely

much more, as I said, yes, better collaboration, and I think that I feel like I

have a goal for them, which I want them to achieve... and I think that my

approach is to try and work towards that goal”.

Empowers and encourages her staff to be more autonomous – “My ultimate

goal is to have a completely, well not completely, but a nursing driven unit

that is autonomous and self-sufficient, and can function with/without me, and

is not dependant on individual members ... And I guess having that in mind,

I've changed…like I feel like I'm endeavouring to give them more autonomy on

how the unit functions”.

A number of staff initiatives were described, such as a unit ‘think tank and

employee of the month was created as an initiative to boost

morale...”because as I said, morale was so bad. And now employee of the

month is like, like a status ... the doctors are even wanting to know are they,

can they be voted employee of the month”.

Other initiatives were instigated through discussing issues that the ward

could improve and by “Letting them talk about how they want to, how they're

going to drive it – so they have done 101 things that are ultimately influencing

how they practise. So they've done a mission statement. They've come up

with new ideas all the time to consider what are issues, so for instance, simple

things like ---- you know the bed areas weren't being cleaned properly after a

patient was discharged and before a new patient came in, so they did these

little admission packs – so basically even when they're pushed for time, they

can bin everything, they've got an admission pack ready to go….. um, so basic

stuff like that”.

Overall, NUM2 feels that there has been considerable change in the unit and in her

managerial style. “There's been a huge change in my work… like in my unit, and I

don't know if that's related to the take the lead. I don't feel that my management

technique, or style, or whatever has changed – but I do feel that the environment in

the last 12 months has started to change, and I mean I still do what I do, but I kind of

let the staff --- my idea of management is not telling people what to do, but letting,

you know, letting them do what… letting them run the show”.

Some examples of changes made in NUM1s’ unit are:

Lean thinking – this module is described as having had a huge impact on her

work and unit. Firstly it was about awareness and reflection on practices that

part of the day to day in the unit. “There was a lot of wastage. There was a


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lot of waste of time, there was a lot of stuff we did, just because we always

did it like that, or you know where you were bombarded with these things

that you thought that you had to do, because that's what you were told you

had to do…. So being able to realise that that may not be the case, and

realising that you can have the power to say 'well I'm not doing it that way it's

a bit of a waste of time, can't we do it that way' that sort of stuff. So that was

good” (NUM1).

The change she describes she made is simple, she now begins her day on the

ward and does not turn her computer on until 10am in the morning. Before

‘ttl’ she was overwhelmed with the office work and emails. The module

initially made her aware of the impact of prioritising different roles and more

importantly, it gave her the confidence and opportunity to try and change it.

“So you know that was something very simple to change and very easy to

change, and you know why did I not think of that before. I think I was so

bogged in it, and it just was this thing of giving you the time to look at it from

outside, giving you some skills to look at it with, and making a decision to do

something and see how it went. Because it was quite frightening. I know that

sounds stupid, but you think to yourself, 'oh if I'm not there on the emails I'll

get a 'bolicking' and I'm meant to be somewhere where I'm not'”.

“...but certainly I guess that was the big thing and big change for me when I

first came back from Take the Lead, that simple making that contact with my

staff and patients in the morning, as opposed to being completely office

driven”. The impact was significant as there have been less staff complaints,

less patient and family complaints and more compliments.

Personally, her job satisfaction rose and importantly “the other thing that

that did for me was made me remember why I was a nurse in the first place.

Why I wanted to do that. Because you know I think nearly everyone becomes

a nurse for the same reason. Nobody wants to do any harm, and people want

to help people and you know it's a privilege to be a nurse and to be involved

with people, intimately at times, in peoples' lives – but as a manager you

become more and more disengaged from that, and more and more

dissatisfied I think – because that's not why you came into nursing, and you

forget those bits, so it's so nice to go out there and chat to patients, and chat

to staff and realise they're not all wicked witches who're trying to make your

life unbearable...” .

Through ongoing communication with staff regarding her experience in the

program, especially around critical communication, some staff were inspired

to try and increase communication with the ward and began an internal

newsletter. This caught on and has created a more open team environment.


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Leadership and succession planning had always been an issue in her ward, as

her role is very difficult. The leadership module encouraged creating a

succession plan so that if she needs to be away from the unit, there are

people who can take over seamlessly. This is currently a work in progress but

as she stated: “when I first started in this job there was nobody who wanted

to relieve as the NUM 3 and there was nobody who wanted to relieve as the

NUM 1, and I now have two people who have expressed interest to relieve as

the NUM 3, and we have four people who have had expressions of interest to

relieve as the NUM 1 ---- so that succinct planning is starting to happen, and

people are starting to recognise, because we try to set it up so that people

don't fail”.

This is a part of a slowly evolving change in attitude towards professional

development and training. Whereas previously the attitude was that

professional development was negative, as it will lead to extra work and

responsibilities, now there is a shift in attitude as discussed previously, that

knowledge is power and provides opportunities.

Coaching- a local initiative that began in their regional area was to have

continued support through coaching for NUMs that have finished the ‘ttl’

modules. NUM1 was one of the first in the program and currently coaches 6

other NUMs that have finished ‘ttl’. “I got a coach out of it as well, which I

find invaluable. But certainly the feedback from the coachees I've had as well,

and it's really nice to watch people start to develop through their issues and

come up with the solution themselves, you know it's very powerful for you

personally, but it's very gratifying when you can help someone else do that

too. So that's been a fantastic thing as well”.

This initiative is a result of the need that was identified for continued support

in order to identify, enable and sustain change initiatives as well as to

maintain the high levels of motivation that follow the program. NUM1 relates

this network support to the powerful impact that the networking aspect has

had on her motivation and work. “I think a sharing of knowledge will come

out of it …. Because sometimes what happens is in my experience, my own

personal and other peoples' is when you've worked in a place for a while and

you've moved up into these positions, you feel very unable to ask for help

maybe in that environment. Like if it's an environment that's reasonably

intimate, and it's very difficult to look like the dumb, dumb, NUM for a while,

once you go to work and go 'I don't know what you're talking about', or 'I

don't know how to do that' and people can feel quite threatened by that.

Sometimes it's much easier when it's a face that you've met at something,

that you've networked with that doesn't directly work with you, that's not in


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your same hospital, and lots of cases not in your area health services, you can

be much more open and honest with those people I think in some cases. So I

definitely think there's a sharing of knowledge about that. I've had several

phone calls from other NUMS in this stage that I've met through Take the

Lead myself”.

The descriptions above have focused on the impact that ‘ttl’ has had on two NUMs

and their units. It has attempted to compare the experiences of the two, by

identifying differences and similarities.

It is clear from both NUMs, that ‘ttl’ has had a positive impact on them and their

units. They differ in the perceived personal impact. NUM1 identified several

significant changes that she made that were due to ‘ttl’ and described how they

were related to the program. NUM2 felt that it was important as it enabled much

needed attitude and cultural change regarding the N/MUM position.

Change is a multi-faceted process and both NUMs describe the need for change in

their role and in their units. Each was experiencing multiple challenges due to

organisational and situational characteristics of their units. To both it was clear that

change was and still is needed.

report of the mid-program evaluation of ‘take the lead’ · report of the mid-program evaluation...

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