Essential Care and Team Nursing

Health Issues Group: Essential Care and Team Nursing 30 June 2015

Guest Speaker: Chief Nurse of the ACT Veronica Croome

On the 30^th of June Veronica (Ronnie) Croome, Chief Nurse of the ACT, came to talk at the HCCA Issues Group. These events are public forums where HCCA hosts members of ACT Health staff and other health professionals or service providers to come and provide insight into different aspects of our health system. These sessions are a great opportunity to learn more about our health system and also to ask questions of a range of people expert in their area of practice.

ACT Chief Nurse Ronnie Croome with HCCA President Sue Andrews

What follows is an overview of the discussion with the ACT Chief Nurse.

Ronnie started by introducing herself and her role. She has been Chief Nurse of the Act for six years. She explained, Chief Nurse is a very hierarchical title which reflects the military roots of nursing profession.

The session began with a question: why would the chief nurse have to talk about the two elements that seem essential to nursing? The answer is clear: it seems that the nursing profession has lost sight of some the principles of what fundamental nursing care is and how to work in teams.

So what is the Essential Care Program at Canberra Hospital?  It all started with a patient journey about nursing care at The Canberra Hospital.  Ronnie recounted the experience of one family. The attitude of staff in the wards was poor, and care and dignity seemed to be missing.  There was poor communication and a loss of personal integrity. Staff did not ever seem to smile and did not look like they wanted to be at work. This story really impacted Ronnie and she was determined to discuss it with the family effected and use this as a starting point for systemic change. Four main issues were identified:
·         poor communication between teams, nursing staff, shift to shift handover
·         little evidence of caring, the care was mechanical and the family felt that they needed to be with the patient from 6.30am – 9.30pm to ensure that he received appropriate care.
·         lack of empathy and dignity
·         treatment was not patient focussed

Many patient complaints reflect these issues. This seemed to be in part due to the attitude of ‘this is not my patient’ and the patient allocation model of nursing.

But as Ronnie pointed out, in the words of Florence Nightingale: ‘They are all our patients in one way or another’-  .

So how have we manage to get to this point? This is partly due to the fact that in Australia we have developed a nursing model of care which is about nursing in isolation. The way in which patients were allocated to nurses they were fostering the isolation of patients and nurses. Universities, who now train our nursing workforce, call it Total Patient Care but it is more about care in isolation. Nurses need the support of others and are at their best when they work collaboratively with others. There are also skill mix issues that need to be considered, as some care may be beyond what individual nurses are able to do and they need to use the skills of their peers.

How did we get here?

Put simply, one could argue that we have lost the balance between the art and science of nursing. It shifted the balance from the art (caring) in favour of the science (evidence). Nurses see themselves as deliverers of evidence based care and have lost sight of the art of caring. They are now going about trying to correct this balance and refocus on essential care.

This was also in the content of the Mid-Staffordshire Review where there was major systemic failure of nursing staff to address the basic concerns of essential care. Canberra Hospital did not want this to happen in the ACT.

They conducted four audits looking at fundamental care principles For example: teeth cleaned each day, wash hands after going to the toilet and wash their hands before they have their meals.

Canberra Hospital has also introduced the Patient Care and Accountability Plan.  This is a comprehensive document that the nurse (who admits the patient) uses it to identify risks and then everyone who is involved in the care of that patient has a part of the form that they need to complete. It becomes part of the record and it sets out the risks and critical issues around care including falls, skin integrity, weight, and nutrition. Nursing staff have embraced the form and they are about to make changes based on feedback and it will then be in place to identify essential care requirements. This in combination with team nursing will address the level of nursing care.

We also heard from a range of ACT community members and HCCA Consumer Representatives who raised questions or shared their experiences with nursing care. The questions and discussion broadly covered;

·         The importance of good communication to consumer experience of nursing care. How is improvement in communication skills measured in this new model and audits?

·         How do you instil ‘good nursing values’ and empathy into graduate nurses and all nurses?

·         How can we provide better supervision and reflective practice for nurses? and;

·         A general discussion about workforce and systemic pressure that impacts the roles nurses play today in Australian Healthcare.

We are grateful for Ronnie coming out to talk at our HCCA Health Issues Group and talking so openly with us.

Darlene Cox

Executive Director

Tour of the Royal Melbourne Hospital

On Friday 12 June Darlene Cox and I went on a tour of the Royal Melbourne Hospital (RMH) in North Melbourne.

We were interested in a tour of the hospital as it is in a similar situation as the Canberra Hospital. The campus is landlocked, meaning roads surround the hospital and there is nowhere to expand on the current campus. Also RMH has undergone and continues to undergo a series of infrastructure upgrades to improve the ageing facility and to accommodate the increasing demand in services.

The RMH has been upgrading older parts of the hospital with various projects completed and include the construction of additional Inpatient Units; Helipad; new buildings and refurbishment of some of the existing building. Some recent upgrades have been the intensive care unit, 300 inpatient beds, as well as upgrades to pathology and medical imaging facilities. The most recent projects are the allied health building and the Emergency Department (ED) refurbishment.

The Community Engagement manager and Director Capital Works, both from Melbourne Health, were our tour guides for the day. We met them both at the main entrance where our tour was to begin.

MAIN ENTRANCE

The main entrance to the hospital was located just off busy Flemington Road. The drop off zone was on street. This is not ideal, however the RMH is completely land locked.

You are greeted at the main foyer with a volunteer’s desk, where they can assist patients and visitors. There seemed to be a very good use of volunteers at the hospital. The main foyer also had a café (café Zouki), bank, florist and gift shop. Even through the space felt cramped with the low roofing it still felt alive and spacious. 

Main entrance to the Royal Melbourne Hospital

EMERGENCY DEPARTMENT

We were very interested in the ED, as it underwent a $53 million redevelopment upgrade in July 2009. It was good to see what was able to be done with a space that could not be extended, only refurbished. It was also useful for the planning of the refurbishment and extension of the existing ED at the Canberra Hospital. 

Triage/administration main desk

The triage/administration desk had cables across the counter rather than glass perspex. Both the patients and the staff preferred the cables over the glass as it was easier to talk to one another and felt less like a compound. The marble front counter was five years old, although you wouldn’t know it. Our tour guide said that the front desk has held up very well to wear and tear over the years. Also the wooden roofing soften both the feel of the waiting room and absorbed a lot of the sound.

The ED has a total of 107 treatment stations, however there was no paediatric stream in the ED as there was an ED at the children’s hospital just down the road. Visitors in ED also had stickers with visitor written on them. This was a great idea, as when in ED it can sometimes feel like as a visitor you are not meant to be there. The sticker provides reassurance.

ED also had write up stations in acute rooms, allowing the wirte up to be done at the bedside. However this is currently only available in ED. There were also smaller write up stations in the corridors of ED, as theses station locations allowed improved line of sight for clinical staff.

Wayfinding through ED was not very clear and we felt there was a need for improvement. It was a bit confusing as to where you were.

ED bedside write up in treatment bay

ED hallway write up station

AMBULATORY CARE (OUTPATIENTS)

RMH has also rolled out a Q flow system similar to the system ACT Health is about to roll out. This was located at outpatients/day services. The system had been in place for about 12 months, there has been very little issues with the system and is making it easier for patients to check in for appointments and go to the sub waiting rooms. These rooms are all colour coded, making it easier to find. Hopefully this is a good sign for the new Q Flow system that ACT Health will be rolling out in the coming months.

Q Flow machine

Outpatient waiting room

Once you got a ticket from the Q Flow system it would tell you to wait in sub wait rooms in outpatients. Each sub wait room was colour coded making it easier to find. We really liked the combination of seating in the waiting rooms. Not only were there the standard single seats you see in all waiting rooms there were also double and single lounge chairs. This meant that if you needed a little more space or had a family member with you the seating arrangement would be able to accommodate this. 

The ambulatory care reception desk also had cables across the counter with some parts covered with glass perspex

NEW HOSPITAL TOWER

The RMH has recently completed a new allied health building that opened in October 2012. It is a three storey building connected to the North Wing of the hospital that provides allied health services for both inpatients and outpatients. This new allied health building is home to rehabilitation services such as speech pathology and a gym. 

Rehabilitation gymnasium

The Gym was bright with floor to ceiling windows surrounding almost the whole room. Although the gym was not massive, it seemed to use the space proved quite well. Also the flooring in the gym was colour coded for different types of exercises, this was incorporated into the design quit well.

The image cover the whole wall as you walk into allied health. The people featured are people who had used the services previously.

Entrance into a speech 
pathology room, with a nice 
use of people on the sign 
who have been using the 
service 

Occupational Therapy 

Entrance

One of the Allied Health sub waiting rooms, with different seating

The new allied health building also incorporated some great signs for services. The inclusion of people in the signs makes it that much easier and relatable. Particularly the sign that has great messages on it such as achieving better health and respecting our community, as you can see in the pictures.

YOU MAKE A DIFFERENCE AWARD

We came across the You Made a Difference Awards on our tour and were interested in what the award meant. The You Made a Difference Awards recognise individuals or teams for making a difference for patients, visitors or staff. We thought this was a great idea as it promotes and shows appreciation to those who most deserve it, as nominations are provided by patients, visitors and staff. Simple things such as this award promotes better care and can be very rewarding to staff and volunteers.

Pictures of past and present winners of the You Make a Difference Award

MUSIC THERAPY

On our tour we came past a group playing some great live music. RMH has been running music therapy almost daily since 1997 with great results. We definitely noticed a positive difference around the live music, everyone seemed more relaxed and had a smile on their face. This is certainly something health services in Canberra need more of. 

The live band playing some great songs with a piano accordion and all

INPATIENT UNIT

The inpatient units were refurbished about 10 years ago. These units where divided into 32 bed pods, there were single bed rooms in this arrangement but unfortunately we could not find out what the ratio was for single bed to multi-bed rooms.  The room layout for both single and multi-bed rooms were a standard layout, similar to the current layout at the Canberra Hospital. There seemed to be limited future proofing done at the time of refurbishment, this includes no bedside write up infrastructure and a large central nursing station with poor line of site to rooms. There was also the constraints of the old building layout. The 32 bed inpatient units were shaped liked a capital T, making it very difficult to design nursing stations that maintain line of site to rooms. In a situation such as this it might had been better to work off a decentralised nurse station model.

There were clocks in each room at the end of the beds with dates and days on them. This was a great idea, as it allowed patents to keep track of what day and date it is. This was in responses to feedback from consumers and carers.

Inpatient clock at the end of patients beds

There were also very informative messages on porters through the hospital such as fall prevention and how you rate your exerances with the health services. What was even better about them was the amount of different languages these signs were in. All in all the hospital provided a lot of information in several different languages.

One of the many posters around the hospital with messages in several different languages and interpreter services

LESSONS LEARNT

We gained a lot from the tour of RMH and it would be worth noting a with a few key points that in the case of RMH need to be kept in mind when planning for both refurbishment and constructing new facilities:

• Always plan for the future, not for what you providing currently. This means including future proofing in design.

• You need evidence base design to work with spatial constraints to gain the best outcomes.

• The use of colour and green spaces are very important.

• Line of site from nursing stations needs better incorporation with the design of inpatient units.

• Incorporating a wide range of languages with all information and clearly mark interpreter services 

• Adaptable seating arrangements in waiting rooms are very important.

• The use of people in signs provides a greater message than just words.

• Volunteers are very valuable and can be used for more than just finding your way around the hospital

HIP Project Officer

Nicholas Wales

Dementia Care in Hospitals Program

It’s 10am on the morning of 25 June, and I am in the auditorium of The Canberra Hospital (TCH) listening to Associate Professor MarkYates of the Ballarat Health Services Dementia Care in Hospitals Program explain what this program is about to the assembled TCH staff. He’s clearly practised at it, which might be expected, since the program has been embedded in no less than 25 Victorian health care providers to date. It’s been so successful at improving the experience of treatment in hospital for patients with cognitive impairment that it’s pretty much standard in Victoria.  Mark is here today to kick off the program’s national rollout. TCH is one of four pilot sites across Australia selected to introduce the program and 18 months later, comprehensively evaluate its effect.

Prior to Mark Yates, we hear from Jane Allen, the CEO of Alzheimer’sAustralia ACT. She tells us that ‘dementia’ is a catch-all term for a range of symptoms and types of cognitive impairment, of which the most common is Alzheimer’s, but it is only one of over one hundred possible diagnoses. It’s most common in the over-65 age group, but its prevalence is increasing amongst younger people, although no one is sure why. It’s the single greatest cause of disability for older Australians. While people don’t often present to hospital with dementia as their primary issue, people with dementia are prone to a range of injuries and illnesses, and therefore more likely than those without dementia to be in hospital. For these people, the busy hospital environment is a confusing and stressful place, and can cause challenging behaviours as they try to cope.

Dr Anil Paramadhathil is the Director of Geriatric Medicine at TCH, and the man leading the introduction of the Dementia Care program here. He shows us data from some research he did recently, which looked at the proportion of the total people admitted to TCH over 6 months who had some form of cognitive impairment noted on their record. He had expected 20-30%, a proportion which would be in line with what the Ballarat team’s research has found. He found less than 1% had this information on their record. This backs Mark Yate’s assertion, that 1 in 5 families feel that the hospital has no idea that they are caring for someone with cognitive impairment.

This morning session is about what the program does and how it helps. It’s a simple program with three main elements. The first, and to my mind most radical, is that all adult patients admitted to hospital are screened for cognitive impairment. It’s not as onerous as it sounds, because it’s not a diagnosis, but one or more simple tests of function. For example, request the patient to draw a clock face, and then draw on the hands of the clock to show ten past eleven. I learn that the ability to carry out this apparently simple task says a lot about the absence or presence of cognitive impairment.

Step two, once cognitive impairment is found, is placing a symbol at the patient’s bedside to alert staff, in much the same way as a hearing or sight impairment would be identified. The beauty of a simple, visible symbol is that any of the staff approaching the bedside, from the food service staff to the clinical team, will receive the same message, and providing they have been effectively trained in caring for people with cognitive impairment, a systemic dementia-appropriate response should occur. Mark shows us the symbol, which was developed with a consumer focus group. To me it looks like someone radiating superpowers, but apparently explaining what the abstract symbol means has become an opportunity for staff education, and that’s got to be a good thing. Mark assures us that when this program is in full swing, we’ll see that symbol above one in three of all adult beds in TCH. 

The last part of this program is staff training in how to care for and communicate with patients with a cognitive impairment and their carers, so that staff know how to modify their own behaviour and responses in these circumstances.

The afternoon session of staff training begins with the story of Joan, whose husband Kyle was hospitalised  at an unnamed hospital for a minor operation. Kyle suffered from Alzheimer’s, and when he was hospitalised Joan asked that this information was clearly marked on his notes. The information seemed to have gone missing fairly soon after admission however, and things went downhill from there. Kyle’s Alzheimer’s wasn’t necessarily obvious to a casual observer, and when Joan witnessed, among other things, a nurse presenting Kyle with his medication, asking him to take it and then leaving him to it, she realised that although she hadn’t planned to stay, she would have to, as there was no way he could follow such instructions by himself.  Things came to a head when a family member noticed that Kyle had removed his patient ID band because it was bothering him. Joan advised the hospital that he needed another one but before this was done, and in one of Joan’s absences, he disappeared. I’m sure I wasn’t imagining the discomfited seat shifting in the nursing staff around me as we listened to this tale. Fortunately the situation resolved without further drama, as Kyle turned up on foot at his son’s house 3km away, but not before the police were involved and a procedural hole a mile wide was clear for all to see.

I have a different perspective when I leave the auditorium. As I emerge into the foyer I am momentarily disorientated and it takes a few seconds to see which way I need to go. I notice it is noisy, and those bright artificial lights are a bit stressful. All around me are strangers dashing, limping, wheeling hither and yon. I’m OK though; I know where I am and I’m pretty sure I can still draw a clock face and place the time on it. It’d be good if I could also remember where I parked the car though.

Kate Gorman

Consumer Representatives Program