Health Assistant (Nursing) implementation in Victoria

Shane Crowe Senior Project Coordinator Department of Health Victoria

Victorian context

•  ‘Nurse/Patient Ratios’ determines staffing levels in public hospital settings

•  No provision in the Victorian Public Sector Nurses and Midwives Agreement for AINs – this remains the case in the current agreement

•  2 initial pilots undertaken in 2009 at Austin Health and Bendigo Health

•  AIN role called Health Assistant (Nursing) in Victoria

•  Traditionally strong opposition by ANMF to the introduction of AINs in any setting

Key principles of Health Assistant (Nursing) role

Within Victoria:

•  Work as part of the ward team

•  Complements existing roles

•  Work under the supervision of the registered nurse

•  Bound by enterprise agreement (nurse/patient ratios) – not replacing nurses

•  Support the highly skilled nurses with appropriately trained staff

•  Focused on activities of daily living and other related duties – role clarity

Initial Pilots

Methodology utilised by Austin Health:

•  Executive sponsorship

•  Project officer to oversee implementation

•  Dedicated clinical support

•  Recruitment and selection process

•  Pilot wards – 2 per ward and part of ward team

•  TAFE partner - Cert III in Health Service Assistant – with focus on acute care

Initial Pilots

Stakeholder engagement

•  Early engagement with NUMs

•  Local ward working groups

•  Comprehensive communication strategy with all stakeholders, including nursing staff across all sites and all shifts

•  Education of nursing staff around supervision and delegation

•  Support for nursing staff on how to work with new role and integrate into the team.

•  Engagement and consultation with industrial groups and staff

External Evaluation – Initial Pilots

Independent external evaluation undertaken by PwC demonstrated:

Efficiency:

•  A reduction in agency costs across the pilot wards

•  A reduction in specialling costs by 30% over the 12 month pilot (362 hours)

•  Austin Health pilot demonstrated that role is almost cost neutral

Effectiveness:

•  A positive impact on the nurses’ time to provide patient care

•  A sense of the role enabling the team to provide the “care our patients deserve”

External Evaluation – Initial Pilots

•  A positive impact on staff morale on the pilot wards

•  Feel valued and that their employer cares

Sustainability: •  Reduction in workload and stress levels for nurses, may lead

to improved retention

Feasibility: •  Evaluation found the role/model to be appropriate for

consideration of future workforce reform and feasible for broader roll out to other suitable hospitals and wards across the State

Nurses’ comments

•  “I get more time to assess patient and able to provide more acute care”

•  “Able to administer meds and IV antis on time, follow up doctors orders sooner”

•  “Feel less pressured – able to really concentrate on patient assessment”

•  “More time to focus on medications, vital signs and general overall well-being”

Consumer/patient feedback

•  Clear communication of roles and responsibilities of all staff

•  Patients commented that they had increased access to assistance with personal care needs

•  48% drop in patient complaints on pilot wards following introduction of HAN role in first 12 months

0 1 2 3 4 5 6 7 8 9

10

Jul-0

8 A

ug-0

8 S

ep-0

8 O

ct-0

8 N

ov-0

8 D

ec-0

8 Ja

n-09

Fe

b-09

M

ar-0

9 A

pr-0

9 M

ay-0

9 Ju

n-09

Ju

l-09

Aug

-09

Sep

-09

Oct

-09

Nov

-09

Dec

-09

Jan-

10

Feb-

10

Mar

-10

Apr

-10

May

-10

Jun-

10

Number of Patient Complaints Pilot Wards - Pre and Post HAN Implementation

Pre-HAN Patient Complaints (pilot wards)

Post-HAN Patient Compliants (pilot wards)

Alternate entry pathway into nursing

•  A number of the HAN’s from initial pilot have been inspired to continue their learning

Ongoing education

Undertaking RN degree

Undertaking EN diploma

Undertaking other healthcare undergraduate course Undertaking non-healthcare undergraduate course

No further study post-Cert III

•  At Austin Health 25% from initial pilot are currently studying Nursing Degrees or Diplomas

Initial Pilots – Key Learning

•  Dedicated clinical support vital for both trainees and nurses

•  Communication strategy with all nursing staff

•  Delegation and supervision education vital

•  Complement the role of the nursing staff – not replacing nursing staff – ratios

•  Consultation with stakeholders, particularly the ward staff

•  Part of ward team – nursing culture

•  Executive leadership +++++

Subsequent Projects

•  In 2011 Austin Health independently introduced HANs into all of their acute inpatient wards

•  Based on success of initial pilots, in 2013 the Department of Health Victoria supported additional implementation projects:

Acute care:

•  Barwon Health

•  Eastern Health

•  Monash Health

Sub-acute care:

•  Austin Health all wards

•  Monash Health – 1 sub-acute ward.

Implementation Guide

•  As role is still new to Victoria, robust implementation is vital.

•  Initial pilots and subsequent projects have demonstrated that implementation methodology is sound.

•  Learning gained from pilots, projects and literature has been consolidated into an implementation guide.

•  Aims to support and guide health services in planning, implementing and evaluating the HAN role.

Implementation Guide

Provides guidance on:

•  Establishing governance arrangements •  Role and scope of activities •  Assessing needs and capacities of workplaces •  Establishing delegation and supervision arrangements •  Recruitment, orientation and employment •  Education and training options •  Reviewing project outcomes

Supporting a team approach

•  It is well established that good teamwork is an important part of providing high-quality care, with tangible benefits to patients, staff and health services.

•  The guide supports integration of health assistants (nursing) as part of the nursing team.

•  Role works with registered staff to support and facilitate the provision of the highest standards of patient care.

Example of shared aspects of care

Different roles within the nursing team share various aspects of care to fulfil the clinical care requirements of the patients under their care.

Role and scope of activities

•  Work under clearly defined parameters, with a mixture of direct patient care and other activities that support the nursing team.

•  Position descriptions and duty lists established, ensuring role clarity. Examples given in appendices of guideline.

Indicative Duty List

Hygiene   Communica.on  Mouth  clean   Answering  call  bells  including  “staff  assist”  Basic  eye  care   Clerical  (answering  and  transferring  calls)  Brushing  hair   Communica>on  conduit  (Verbal  and  wri@en)  Showering   Report  unexpected  events  Shaving A@end  handover  

Sponging   Report  to  Team  Leader  Toile.ng   Documenta.on  Changing  incon>nence  pad   Fluid  balance  Chart  (oral  input  and  urine  output)  Replacing  bo@le/commode   Food  Chart  Emptying  IDC   Bowel  Chart  Emptying  and  delivering  urinal  pans     Weight  Manual  Handling   Maintenance  Transfer/siNng  out  of  bed   Restock  supplies  

Changing  tubing/suc>on  equipment  Mobilising  pa>ents  Nutri>on   Emergency  response  Feeding  pa>ents/assis>ng  oral  nutri>onal  needs   Other  Du.es  

Environment   Assis>ng  with  deceased  pa>ents  Maintain  safe  pa>ent  environment   Escor>ng  to  appointments  where  appropriate  Assist  with  flowers/vases   Packing  and  unpacking  pa>ent  belongings  Making  beds  (not  on  admission  or  discharge)   Weighing  pa>ents  

Pre-­‐opera>ve  shaves  

Getting Started

To establish the role, the document provides guidance on:

•  Establishing project governance

•  Project management and resourcing

•  Assessing need for role and capacity

•  Project planning

•  Establishing role governance

•  Developing a communication strategy – Austin Health case study outlined.

Change Management

New to most health services in Victoria, so an effective change management essential to support everyone through the change process, including: •  A clear reason for the change and a shared vision •  Consistent messaging – clear communication •  Executive support •  Consultation and involving stakeholders •  Set objectives and congratulate team when it is

achieved •  Gaining people’s commitment

Delegation and supervision

•  Must be a clear and shared understanding of the:

o  role that the HAN plays within the team.

o  skills and competencies that a HAN will be expected to demonstrate

•  Establishing an effective delegation and supervision framework is essential.

•  Document provides guidance on:

o  Delegation – delegator and delegatee

o  Supervision – direct and indirect

o  HAN specific case scenarios outlined

Delegation and supervision

•  These projects and other work has highlighted the need to support a heightened awareness and education of delegation and supervision principles.

•  New Delegation and Supervision guidelines for Victorian nurses and midwives just released.

•  Seeks to reinforce the NMBA publications around decision making, by making practical recommendations and a framework.

Recruitment, education and evaluation

Recruitment: •  Recruitment of right staff essential to this new role •  All projects have demonstrated large untapped pool of people

interested in working in health at this level •  Document provides guidance on selection, induction and

management arrangements Education: •  Currently mainly traineeship based •  Outlines traineeship requirements, competency assessment

and where to find out about potential incentives •  Specifies the Certificate III (HLT32512) course core and

recommended units for Victorian public health services •  Provision of appropriate support

Measuring outcomes and impact

Evaluation: •  Implementation Guide outlines the evaluation framework

utilised for these projects within Victoria. •  Victorian Innovation and Reform Impact Assessment

Framework evaluates the efficiency, effectiveness and sustainability of initiatives.

•  External independent evaluation of subsequent projects currently underway.

Resources and further reading

•  Implementation guide: http://docs.health.vic.gov.au/docs/doc/Health-assistant-nursing-implementation-guide

•  Delegation and supervision guideline for Victorian nurses and midwives: http://docs.health.vic.gov.au/docs/doc/Delegation-and-supervision-guidelines-for-Victorian-nurses-and-midwives

•  PwC external evaluation of HAN role and implementation: http://docs.health.vic.gov.au/docs/doc/Evaluation-of-three-Better-Skills-Best-Care-pilot-projects

•  Contact: shane.crowe@health.vic.gov.au