Growing a legacy: looking after our future

1
Growing a legacy looking after our future

• Paper to Nurse Managers Interest Group
• Australian College of Health Service Executives
• 27th September 2007
• Professor Mary Chiarella
• Faculty of Nursing, Midwifery Health
• University of Technology, Sydney
• Nursing and Midwifery Office, NSW Health

2
Growing a legacy looking after our future

• Setting the scene
• on the shoulders of giants
• Environmental overview
• Looking after our future
• NaMO Modelling Care Project
• Clinical nursing and midwifery research
• Our clinical nursing and midwifery staff
• Growing the legacy
• For clinical staff
• For nurses and midwives in general
• Positioning nursing and midwifery knowledge
  what do we offer?
• Growing the legacy

3
Setting the scene on the shoulders of giants

• A huge thank you to those of our profession who
  are no longer working but who had the vision to
  see a very different future for nursing and
  midwifery
• Just some of their successes lessons still to
  be learnt from these (and work still to be done)
• University education (NSW went first)
• Professional rates of pay
• Clinical career paths
• The gift of nursing and midwifery research
• Coalitions of the willing (and able)

4
Environmental overview professional
development(Chiarella, 2002)
5
Environmental overview responses to
challenge(Chiarella, 2007)
Ethos of collective non-responsibility
Ethos of Individual accountability
Ethos of collegial generosity
Practice zone of isolation or alienation
Practice zone of mutual trust and Collaboration
Practice zone of abrogation
6
Our current clinical leaders the NaMO Modelling
Care Project Prerequisites for inclusion in the
presentations (Years 1 2)

• A preparedness to reflect on and examine current
  practice
• Patient focus this is the purpose of clinical
  nursing and midwifery work
• Data good decisions are made on good data
• Rigour measure, observe, record
• A preparedness to try something different
• Flexibility to adapt if necessary
• Evidence of collaboration (Year 2)
• What we see in this report is the result of 20
  years of university education for nurses Mr J
  Hatzistergos, NSW Minister for Health, February
  2006

7
Our current clinical leaders-outcomes of analysis
of Modelling Care presentations 2006

• Growing synergies through the NaMO Modelling Care
  Project (note change of name double entendre)
• Growing synergies through other statewide
  initiatives
• Changing and developing nursing and midwifery
  roles focus on clinical specialities
• Growth in Practice Development and
• Identified and ongoing challenges.

8
Growing synergies through the NaMO Modelling Care
Project

• Ongoing progress of local work Rivas, 12 hour
  shifts to action learning sets, Dempsey, falls to
  patient stories, observations of care
• Developing synergies across NSW between AHSs
  and universities and across AHSs (Harman
  UnNcastle, Hartz UTS Crisp Ind CSU)
• Accessing funds and other resources
  scholarships (19 Innovations 10 MH), EAP
  (Ronald), grants, equipment (Bevan)
• Growth of and emphasis on teamwork (Marshall, De
  Cressac, Wand)

9
Growing synergies through other statewide
initiatives

• Clinical Services Redesign Project presentations
• Marshall -23 hour ward
• Cort- orthopaedic long wait
• Coote - APNs for JMOs
• King Acute Care of the Elderly
• Gradidge - Older Persons Evaluation Review and
  Assessment Project (OPERA)
• McPhail dementia care
• Clinical Leadership Program presentations
• Jones, Rivas, Hamilton, Cutler Griffin, Bristow
• Clinical Excellence presentations
• TASC Samuels (Cardiac Assessment Nurse)

10
Changing and developing nursing and midwifery
roles focus on clinical specialities

• Advanced practice roles N/MPs Wand, Asimus
• CN/MCs Puckett, Hallam Leaver
• APN - Coote
• EENs Sutherland-Fraser OR
• Lucas haemodialysis
• Mulhearn- neonatal nursery
• AINs Ronald acute aged care
• Jones acute medical surgical
• Specialty Community, MH, aged care midwifery
• In-house education (lots of sharing)

11
Growth in Practice Development

• Values clarification
• Clarkson Hooke, Dempsey Mangone, de Cressac,
  Crameri
• Person centred models
• Demspey Mangone, Peek Higgins
• Reflective Practice
• Puckett, Hallam Leaver
• Action learning sets
• Davis, Murray Rivas
• Case studies
• Puckett, Hallam Leaver
• Mentoring
• Mulhearn

12
Current MoC activity reported in 2006

• Work practice changes (41 sites often more than
  one report per site)
• Maggie project (19 sites)
• Skill mix changes (38 sites)
• Introduction of team nursing (54 sites)
• Improving communication and handover(11 sites)
• Introduction of clinical pathways and guidelines
  (16 sites)
• NB 242 descriptions of work nurses wanted to
  undertake in the near future

13
Looking after our future clinical nursing and
midwifery research

• NSW Professors of Nursing and Midwifery have
  obtained significant competitive ( some of the
  highest scoring) NHMRC and ARC grants in the past
  decade
• Examples of current clinical research
• Mothering skills for incarcerated women
• Management of temperature in very low birth
  neonates
• Physiological impact of stress of bereaved
  relatives of ICU patients
• Dementia mapping in the elderly
• Optimal management of the perineum in childbirth
• Home-based care for people dying with HIV/AIDS in
  Mozambique

14
Looking after our future clinical nursing and
midwifery research

• Knowledge such as this provides us with language
  to describe our practice that way we can help
  our novice nurses and midwives to practise well
• Work such as this gives us a place of authority
  from which to improve, discuss and influence
  clinical care
• Data such as these are invaluable to those
  planning and coordinating health services and
  give us a place at tables that otherwise might be
  denied
• Research training and communities give us fora to
  talk about and explore nursing and midwifery
  practice and work

15
Challenges for clinical nurses and midwives
growing a legacy

• Patient engagement
• Sustaining memory
• Confidence to be challenged and scrutinised
• Role clarity, scope of practice, integration of
  new roles
• Reflection and mentoring as a way of life
• Teamwork skills performance management, craft
  transfer, communication, generosity
• Maintenance of cultural environment -risk of
  default under pressure
• Lack of knowledge about each others work
• Re-defining success

16
Challenges for clinical nurses and midwives-
support required

• Additional strategies for disseminating
  information about existing and proposed
  activities
• Analysis of practice, including skills (inter
  alia) such as process mapping, audit, patients
  stories
• Ongoing education for clinicians, managers,
  educators and academics on models of care
  development
• Support for and extension of Practice
  Development, both technical and emancipatory
• The development and piloting of strategies to
  address issues of delegation, scope of practice
  and challenges of peer performance experienced by
  many clinical nurses and midwives
• The canvassing of strategies to develop skills
  for clinical nurses and midwives to share their
  craft with other less experienced nurses or
  midwives (craft transfer)
• Support and education in writing for publication.

17
A word about clinical nursing and midwifery
practice how do we know what to do?

• Through our theoretical education
• Through our practical education
• Through practice itself
• Through reflection on practice
• Through good role models who we want to emulate
• Through poor role models we decide to be
  different from
• Through craft transfer

18
Memory exercise

• Think of an incident in your clinical practice
  where a clinical nurse shared her knowledge and
  skill with you (not an educator)
• Jot down any key memories you have of the
  experience eg
• How did the incident occur?
• What knowledge or skill did (s)he share with you?
  
• What did (s)he do?
• What did (s)he say?
• How did (s)he engage the patient?

19
This process is what I have called craft transfer

• What factors need to be in place for it to be the
  norm, rather than the exception?
• In terms of working structure and organisation
• In terms of culture
• In terms of the skills of clinical staff

20
The value of craft transfer

• Builds collegiality generosity
• Fosters a sense of professional pride
• Encourages the development of language to
  describe practice
• Encourages reflective practice as a way of being
  in the clinical environment
• Role models for future generations
• Will ensure our legacy and our identity

21
What lessons can we learn from our current
clinical leaders?

• Adjusting to living with uncertainty
• Taking the step back
• Being careful about how we define success
• Developing collegial generosity

22
As far as Edward Bear knew, it was the only way
of coming downstairs, although he sometimes felt
there was another way, if only he could stop
bumping for a moment and think about it (AA
Milne)
Taking the step back
23
Re-defining success

• Research offers two main reasons why nurses leave
  
• Feel they are not valued or respected
• Feel unable to deliver the quality of care they
  wish to deliver
• The 1970s/80s mentality in a 2006 world
• Jones Cheek (2002) no such thing as a typical
  nursing day
• Need to understand that routine was part of our
  comfort zone at least I got my showers done
• If they are applying a 1980s formula to a 2006
  nursing world, they will always feel that they
  have failed
• Working with new professional grades of nurses
  and midwivesproper recognition of the
  contribution of the different roles
• Need for reflection on practice
• Need to measure and evaluate our practice

24
Strategic areas for 2007/2008 in Modelling Care
work

• Sustainability- ensure that no one person carries
  the project, that it can go on if someone falls
  over
• Synergy try to maximise resources through
  linkages between clinicians and academics
• Synchronicity try to organise innovations with
  research grant rounds/ scholarship applications
• Spread need to publish the work, need to enable
  people to know or at least be able to find out
  who is doing what
• Self-belief need to feel that they have the
  ability to improve their environment or their
  patients environment and to know how to go about
  it

25
Growing a legacy for nursing and midwifery in
general then and nowNursing and midwifery
leadership apartheid or secession?

• We cannot withdraw into nursing or midwifery
• If we are competent to manage and deliver nursing
  and midwifery services, we are competent to
  manage and deliver health services
• Our experienced, educated, skilled clinicians are
  competent to lead debates about health care, not
  just nursing or midwifery care
• The nurses and midwives engaged in modelling care
  work are more than capable of leading debate we
  just need to get them from the tea room to the
  Board room
• We already have senior colleagues using their
  skills in very senior generic positions DG,
  DMS, DCOps etc we need to ensure they continue
  to feel like nursesand/or midwives and feel proud
  of the skills that took them there that is the
  part of the legacy we need to build for the
  future

26
Growing a legacy for nursing and midwifery in
general leadership

• Nursing born in the church and bred in the
  army (Gillespie, 1990)
• Expectation of individual militaristic leadership
  styles Chief Nursing Officer an example
• Difficulty with this militaristic sense of
  leadership is that it carries with it an
  expectation of obedience and loyalty as the
  primary behavioural states
• From a clinicians perspective an obligation of
  obedience will do nothing to foster a sense of
  entitlement
• From a patients perspective loyalty is not the
  same as integrity, and will not necessarily
  improve patient safety and quality

27
Looking after our future - workforce

• A lack of a formal nursing or midwifery
  management structure runs the risk of depleting
  senior nursing leadership
• In turn this could mean a lack of advocacy for
  nursing/ midwifery views and issues
• Nursing unions are unhappy about the lack of
  senior leadership through the restructures this
  is conveyed through their journals to clinical
  nurses
• Turnover of itinerant workers can create
  instability of the workforce and reduce the
  potential for developing senior clinical nursing/
  midwifery leadership in the absence of senior
  nursing/midwifery management leadership
• These factors can create a dispirited and/or
  docile clinical workforce and a lack of clinical
  nursing/midwifery leadership

28
Positioning clinical nursing knowledge for the
future what do we offer?

• What health services need (Pearson, 2000)
• There is little doubt that health services will
  always need a generic worker who is
  client-focused, possesses multidisciplinary
  skills, manages the care environment, delivers
  all but the most highly specialized services to
  the client, humanizes the system at the point of
  contact, and acts therapeutically as the
  experience is lived by the client. This is
  historically the broad, flexible role ascribed to
  those titled 'nurse'.

29
Positioning nursing knowledge for the future
what do we offer?

• Currently a strong 24/7 operational perspective
  constancy (this has implications for nurse
  education and staff deployment)
• Understanding (because of proximity/ intimacy) of
  the key issues affecting patients and their
  families (may be lost if nurses do not deliver
  front-line care) our practice has a strong
  relational base
• Historically a flexible attitude to nursing work
  due to changes in technology and consequent task
  transfer
• Comfort (by and large) with discussing intimate
  and/or difficult issues (this is useful for
  managing challenging behaviours)
• Clear eyed understanding that life is often
  neither rational nor fair (this is useful for
  realism)
• Knowledge that ordinary people are capable of
  greatness (this helps us not to despair)

30
Positioning nursing knowledge for the future
what do we offer?

• What we have to offer that is unique stems from
  our prolonged, intimate and regular contact with
  patients on a 24/7 basis constancy, intimacy
  flexibility (Chiarella, 1992)
• Our craft is an amalgam of informed clinical
  skill and professional compassionate care gained
  through a mix of education and experience
• Our ability to transmit this craft is contingent
  on our capacity to describe it
• Who else might be able to offer what we do?
• Possibly unregulated health care workers and
  possibly other health care professionals
• Possibly patients/consumers and carers themselves
  need for much stronger coalitions

31
Growing the legacy what might we do?

• Work in real partnerships with the public
  co-production of health, constructed communities
  of care
• Use our high standing in the community to take a
  vocal stance on key health issues the impact of
  poverty on health status, indigenous health,
  mental health, prisoner and refugee health
• Take advantage of every opportunity to put our
  differences aside and campaign on a united front
  for changes to the big picture health services
  issues
• Decide to be winners -remember the words of Steve
  Biko the greatest weapon in the hands of an
  oppressor is the mind of the oppressed
• These behaviours would contribute significantly
  to professional cultural change

32
In conclusion

• Nursing and midwifery have the capacity to take a
  strong and active leadership role in future
  health care delivery, despite current trends and
  prevailing mantra
• We have committed skilled clinicians and
  researchers able to provide vital insights into
  health care delivery
• What modern nursing and midwifery might offer is
  what health care needs
• BUT
• We need to be sure why leadership matters to us
• We need to re-conceptualise what our leaders
  might look like
• We need to decide and agree what we want nursing
  and midwifery work to be concerned with growing
  our future leaders means we have to offer
  something that matters to them
• We need to be able to strategise and manoeuvre
  and this requires language and models
• Thank you

33
References

• Alderfer, C.P. (1980), "Consulting to
  underbounded systems", in Alderfer, C.P.,
  Cooper,C.L. (Eds),Advances in Experiential Social
  Processes, Wiley, New York, Vol. 2 pp.267-95.
• Chiarella M (2002) The legal and professional
  status of nursing Churchill Livingstone
  Edinburgh
• Chiarella M (2007) Redesigning models of patient
  care delivery and organisation building
  collegial generosity in response to workplace
  challenges Australian Health Review
• Diers D (2004) Speaking of NursingJones
  Bartlett New York
• Gillespie R. Handmaidens battleaxes. ABC
  television program. True Stories. 10 June 1990.
• Pearson A (2000) The Joan Durdin Annual Oration.
  University of Adelaide
• Walker K. (1993) On what it might be to be a
  nurse a discursive ethnography. Unpublished PhD
  thesis. La Trobe University