Improving Clinical Review in the Northern Sydney Home Nursing Service

This project defined the role of the resource representative and increased awareness of this role among staff at Northern Sydney Home Nursing Service (NSHNS), to ensure patients are referred to the most appropriate clinician.

Aim

To reduce delays to specialist access for clinicians and patients, by 30% by July 2017.

Benefits

• Reduces delays to specialist advice.
• Enhances staff and patient understanding of roles within the organisation.
• Increases collaboration between Clinical Nurse Coordinators (CNCs), Nurse Practitioners (NPs) and resource representatives.
• Provides appropriate care to patients in a timely manner.

Background

The NSHNS and Acute Post-Acute Care (APAC) teams are community-based nursing and allied health organisations that operate from nine dedicated locations in NSLHD. Each organisation has a specialist resource committee in place, which is led by a CNC, NP or manager. These committees include resource representatives who work across all sites and represent their specialty group. The purpose of resource representatives is to build a connection between specialist and generalist staff, as well as enhance the knowledge of the nursing workforce, which in turn improves clinical practice and patient outcomes. While it is not a Clinical Nurse Specialist (CNS) role, it does have the capacity to support staff in their application for a CNS 1 grading.

Resource committees reported that between 2015 and 2016, waiting lists for advice and community consultations had increased, due to the increasing complexity of patients who were cared for at home. A review of waiting times for CNC and NP consultations indicated waiting times up to one month for non-urgent reviews. Normally, urgent reviews are triaged and a consultation booked the next day. However, during this period patients were waiting up to a week for an urgent review.

In addition, feedback from specialist staff indicated that resource representatives were not always fulfilling what was thought to be the expectations of the role. Committee meetings were cancelled due to lack of attendance and some representatives rarely attended meetings at all. All meetings are held at the head office, which requires members to drive from their local site to attend. Issues raised by committee members, committee chairs and senior staff included the following.

• Representatives were not seen as a resource by clinical staff, and so were not encouraged to fulfil their role.
• Some representatives did not appear to be engaged in their committees.
• Less complex referrals could be managed onsite via consultation with the resource representative in the first instance. This would allow CNCs and NPs to focus on more complex patients and reduce delays in reviews.

A survey of clinicians, nurses and managers in July 2016 showed a lack of clarity around the function of the resource representative, with less than 50% of staff reporting a true understanding of the role. It also showed that resource committees did not encourage best practice, due to poor information flow between specialist CNC and NP staff and clinicians. It was determined that defining the role of the resource representative and increasing awareness of the role among clinicians and patients would increase the number of referrals directed to the resource representative, leaving the CNCs and NPs to focus on patients with complex conditions. This would reduce the delays in specialist reviews and provide patients with the most appropriate care in a timely manner.

Implementation

• A clear definition of the resource representative role was developed and disseminated to staff for consultation and engagement. Once feedback was received, the definition was updated to further clarify the role.
• A feedback action plan was developed, to help resource representatives take feedback from committee meetings back to their team, or deliver any education requested by the committee to their sites. The resource representative can use the same action plan to add feedback from their team and take this back to the next committee meeting.
• The frequency of meetings was reviewed to ensure each meeting had an appropriate number of attendees from a range of sites. Following consultation with committee chairs, a reduced schedule of meetings was trialled from January 2017, with a clear expectation that all representatives (or a delegate) must attend all meetings to ensure ongoing education and feedback to sites.
• A mentoring program for resource representatives was launched in March 2017. This is a voluntary program that aims to increase the confidence of representatives when providing advice and support to colleagues on education delivered to sites or individual patient cases.

Project status

Implementation - The initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

July 2016 – July 2017

Implementation sites

This project was implemented in seven NSHNS sites and three APAC sites in NSLHD.

Partnerships

Clinical Leadership Program

Evaluation

A full evaluation will be undertaken in July 2017, with measurement of the following outcomes:

• understanding of the resource representative role, measured by staff and resource representative surveys (target 90% improvement)
• impact of the project on engagement with resource representatives, measured by a staff survey
• waiting time for CNC and NP reviews
• resource representative attendance at meetings
• cancellation of meetings due to a lack of attendance by resource representatives.

A staff survey conducted in December 2016, following implementation of the new resource representative definition, showed that close to 100% of staff had a good understanding of this role.

Lessons learnt

• Staff can behave in surprising ways, but if a project directly relates to what they do, eventually they will be more interested and involved in the change.
• Using a Driver Diagram to guide the project was very helpful and will be used as a tool to achieve future clinical practice improvements within NSHNS and APAC.
• It can be challenging to implement a change process across a decentralised service, when there is limited time for the team to collaborate.
• It’s possible for a project to become too big to continue. In this case, a new direction may be required.

Further reading

• Fletcher M. Assessing the value of specialist nurses. Nursing Times 2011; 107(30-31): 12-14.
• LaSala CA, Connors PM, Pedro JT et al. The role of the clinical nurse specialist in promoting evidence-based practice and effecting positive patient outcomes. The Journal of Continuing Education in Nursing 2007; 38(6): 262-270.
• McHugh GA, Horne M, Chalmers KI et al. Specialist community nurses: a critical analysis of their role in the management of long-term conditions. International Journal of Environmental Research and Public Health 2009; 6(10): 2550-2567.

Contact

Karen Femia
Nurse Manager, Northern Sydney Home Nursing Service
Northern Sydney Local Health District
Phone: 02 9887 5444
karen.femia@health.nsw.gov.au