The New Right Way: Introducing New Staffing Models on Vancouver Island Talk to any nurse and you ll probably hear the same thing: patients they ain t what they used to be! Aging baby boomers have changed not just the face of our average patient, but the care we need to offer. On Vancouver Island, home of an increasing number of Canada s retirees, we see this change every day in our Emergency Departments, homecare services, ambulatory clinics, and inpatient units. One result of this is that in the Vancouver Island Health Authority (VIHA) staff members were becoming frustrated by their workloads and we all found ourselves asking: why isn t this working? We knew we needed to change. And so we worked with our staff to understand our current care environment better and to design and implement care and staffing models that better meet our patients needs. This new model of care not only means better care for patients, but better work environments for nurses and the other members of the care team. The case for change Well known as a retirement destination in Canada, Vancouver Island is experiencing the gray tsunami. In 2010, 9% of the population we served was over the age of 75 years, and used 49% of available inpatient days in our hospitals. Compare this to just nine years earlier when in 2001 when these numbers were 8% and 43%. All indications are that this trend will continue to rise as baby boomers age. When these older adults come into hospital they are generally frailer than their younger cohorts and have more complicated care needs related to factors such as co-morbidities, age related functional and physical changes, and family, social, and behavioral characteristics. In short, they not only have different care needs than the majority of patients had in the 1980 s and 1990 s (when our current care models were developed), but those care needs are best met by different staffing models that take advantage of roles of different providers. The changing patient population was reason enough to do this work, but this became even more urgent when we considered that a significant portion of our nurses were also baby boomers nearing retirement. Like others, we were worried about a pending nursing shortage. This may seem obvious to us now, but we were assisted with coming to this understanding by our Care Delivery Model Redesign (CDMR) work which began in 2007/8 in our acute care sectors. Through a series of observational studies, called Function Analysis (FA), we were able to capture an in-depth picture of how staff members were providing care in our medical and 1 P a g e
surgical units. Plus, we could see what staff were doing with patients, how they used their time, and the barriers to providing good care. The FA studies made it clear that our patients needs have changed greatly over the last decade, while the ways in which our care staff worked, communicated with each other, and provided care had not. In fact, this analysis highlighted that many of the activities occupying most of our nurses and other health care professionals time had drifted significantly from the intended scope of practice they had 2 P a g e The activities performed by frontline care providers are drifting away from the intended scope of practice. been educated to work within. This drift had happened so gradually that most staff members weren t able to see it happen. This observation is reflected in the adage that fish can t see the water they swim in. The challenge of changing from the old right way The FA studies showed that existing staffing models resulted in overlap and duplication across multiple roles and providers; and that there were gaps in 12 care, especially in our patients perception. We learned that most of nurses work time was consumed by the need to complete discrete tasks tasks that often occurred without the focus of a care plan, or integration with other care professionals. Many nurses saw their role as a collection of tasks, rather than the role of health promoter and coordinator of care. Understanding the current state was a key motivator for change: to find a new right way to engage nurses at their full scope of practice, and to achieve a balance of workload between and among the individual members in care teams to meet the care needs of patients. The planning phase of each FA study provided nurses and the other care providers on the team with a forum to describe what good care looks and sounds like. Their ideas were then translated into data dictionaries that were used to describe what the observers were observing. The results of the studies pointed to lots of opportunities for change, which were readily apparent to both staff and VIHA s leaders. For example, they showed that significant amount (60%) of their time was spent in 3 key categories of activities: Travel: especially between the nurse s station, supply rooms and patient rooms to get supplies and answer call bells; Communication: primarily one on one communication among individual nurses, and these communications often occurred while nurses were performing tasks that required their undivided attention such as during medication preparation and delivery; Documentation: often of the same information in multiple places, but not necessarily resulting in a coherent and up to date care plan.
Relatively small amounts of time were spent in activities such as care planning and patient and family education. It became apparent that what we required were changes to how we actually provide care as well as different staffing models so that we could optimize the roles, scopes and functions of all care providers. It also showed that we needed some different care providers on the units. Frontline nurses found it easier to see the need for a renewed staffing model once they experienced how their time could to be used to better meet patients needs. It was a chicken and egg situation. The FA data also showed that we needed to work with our educational institutions to change some components of how students are educated. Lastly, we noted where there were opportunities for streamlining documentation and organizing work environments to be more efficient, and today we continue to make progress on all of these work streams. Practice changes: enabler and precursor for staffing model changes Based on feedback from our care teams, we started with making practice changes in three areas. These included: Initial care assessments; The ways nurses communicated with patients, each other and other team members; and The processes used for care planning including care rounding. Each of these practice changes were grounded in principles of elder-friendly care, interprofessional team-based care and communication strategies and standards. New processes that were introduced included standardized white boards at the bed side, One of the first changes we made on our medical unit was to actively involve the staff from therapy services in our morning huddles. By sharing information on patient goals all at the same time, I saw the staff on the unit become much more of a united team; one that better understood how they could use the skills and abilities of all of the staff available, to more effectively help patients achieve their goals. Tracy Martell, RN planning rounds and conversations that were focused on meeting client care goals (including discharge), and regular brief team huddles, and performance support tools such as the acuity and intensity matrix. Changing to the New Right Way via our staffing model The staffing models in VIHA are guided by meeting the care needs of the patients and optimizing the roles, scopes and functions of the care providers. By focusing on the care needs of the patients, staff members were able to describe who should be responsible for designing care for each patient and who would be responsible for delivering care. We found that design and deliver was a useful way for delineating responsibilities and roles. We also engaged the expertise and guidelines established by the licensing bodies for Registered Nurses and Licensed Practical Nurses to assist with distinguishing responsibilities related to design and deliver for these two nursing professions as well as unregulated providers such as patient care aides (PCA). 3 P a g e
This was further supported by team building activities and support tools related to introducing new types of workers into care teams. In the new right way patients needs and goals are at the centre of decision making. In order to do that nurses need to get know each of their It can be a challenge to easily identify which patients are within, and which patients are beyond my scope of practice. The introduction of the high acuity and high intensity tool has eased this challenge greatly for me by instantly alerting me when I am assigned a patient with a high acuity designation, and that I should look further into the specifics of that patient and determine if it is an appropriate assignment for me as an LPN. It also guides me to know when I need to share information with my RN colleagues if I notice changes in the patients I am working with. Tools such as this make me feel comfortable working as an LPN on a busy surgical floor knowing that I can safely care for my patients in an environment of constantly changing patient demographics and need. Erin Ballard, LPN "I joined this team because I was wanting work that I felt challenged by, and where I could really be making a difference for people. On this unit, our patients are discharged home much faster than where I worked before. One of the main ways that I help them get ready for discharge is by helping them to mobilize as soon as the team tells me it is safe to do so. Because I work here fulltime, I am able to see how each patient gets a little stronger every day. There are times that I am the member of the team who knows a particular patient and their abilities best; it is great to be able to share this information with the nurses and the physio staff and watch how they use it to plan care that meets the unique needs of patients. When I first started here, one of the really helpful things for me was being able to spend some time one-on-one with the physiotherapist. I was able to learn a lot from her about the types of patients I would be working with and she was able to spend time confirming with me that I knew how to work safely with patients who had hip surgery." Meredith Kaplycz, PCA patients. When a nurse learns all that he/she can about their patient, they can guide the development of appropriate goals that include physical symptom resolution and a focus on functional ability, while teaching about health and self-care in a person-centered way. They can The nurses I work with are looking forward to moving to a much more supported work environment of collaborative care. They will not feel 'alone' with the challenge of meeting the needs of complex patients, who always seem to have intense hands-on care needs. The move towards a more even sharing of this responsibility is reassuring and everyone should feel much more supported to be able to do what is right to proactively meet the needs of our patients. Shari MacFarlane, RN 4 P a g e
also focus on providing direction to patient care aides as part of the care design role while other care providers such as practical nurses and patient care aides deliver care based on factors such as the acuity of the care needs. Sustaining the change The implementation of the new staffing model is a work in progress. We are striving to achieve more than just a rotation change; we are working towards a transformational culture change to maximize the full potential of all staff. We want to ensure that we have a model that is sustainable into the future. That means we have skilled nurses working where we need their skills and knowledge; and we incorporate new graduate nurses so that we do not have the expected shortages in the near future. Time and resources to engage staff and incorporate lessons and feedback have been built into the implementation; true transformation takes time, and thanks to the ongoing dedication and hard work of our staff, the new right way is being put into action every day. The Journey of Transformation Current Reality Vision 1 Rita den Otter, MA, BScOT Director, Care Delivery Model Redesign Vancouver Health Authority Rita.denotter@viha.ca Robyne Maxwell, RN, BSN Project Director Care Delivery Model Redesign Vancouver Island Health Authority Robyne.maxwell@viha.ca 5 P a g e