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Growing a legacy: looking after our future


... on teamwork (Marshall, De Cressac, Wand) ... Advanced practice roles: N/MPs Wand, Asimus. CN/MCs Puckett, Hallam ... ABC television program. True ... – PowerPoint PPT presentation

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Title: Growing a legacy: looking after our future

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

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

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
  • 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)

Environmental overview professional
development(Chiarella, 2002)
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
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
  • 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

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
  • Changing and developing nursing and midwifery
    roles focus on clinical specialities
  • Growth in Practice Development and
  • Identified and ongoing challenges.

Growing synergies through the NaMO Modelling Care
  • 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)

Growing synergies through other statewide
  • 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)

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)

Growth in Practice Development
  • Values clarification
  • Clarkson Hooke, Dempsey Mangone, de Cressac,
  • 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

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

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
  • Examples of current clinical research
  • Mothering skills for incarcerated women
  • Management of temperature in very low birth
  • 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

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
  • Research training and communities give us fora to
    talk about and explore nursing and midwifery
    practice and work

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

Challenges for clinical nurses and midwives-
support required
  • Additional strategies for disseminating
    information about existing and proposed
  • Analysis of practice, including skills (inter
    alia) such as process mapping, audit, patients
  • Ongoing education for clinicians, managers,
    educators and academics on models of care
  • 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.

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

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?

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

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

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

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
Taking the step back
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

Strategic areas for 2007/2008 in Modelling Care
  • Sustainability- ensure that no one person carries
    the project, that it can go on if someone falls
  • 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

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

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
  • From a patients perspective loyalty is not the
    same as integrity, and will not necessarily
    improve patient safety and quality

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
  • 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

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'.

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
  • 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
  • Knowledge that ordinary people are capable of
    greatness (this helps us not to despair)

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

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
  • 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

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

  • 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
  • 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