North Shore Hospital report - New Zealand Doctor

Health and Disability Commissionercarrying out the delegated activities maintains the relevant standards and outcomes.‖(p.9)In the Waitemata ECC where the nurses are all registered, the registered nurse beingdelegated the care retains professional responsibility for their own practice. The NursingCouncil of New Zealand competency 1.1 states, ―Accepts responsibility for ensuring thathis/her nursing practice and conduct meet the standards of the professional, ethical andrelevant legislated requirements.‖ The indicators are: ―Practises nursing in accord withrelevant legislation/codes/policies and upholds client rights derived from that legislation;Accepts responsibility for actions and decision making within scope of practice;Demonstrates knowledge of, and accesses, policies and procedural guidelines that haveimplications for practice; uses professional standards of practice.‖Further guidance is given to the registered nurse in the team in Competency 2.8 which states,―Reflects upon, and evaluates with peers and experienced nurses, the effectiveness of nursingcare.‖ The indicators are: ―Identifies one‘s own level of competence and seeks assistance andknowledge as necessary; Determines the level of care required by individual clients; Accessesadvice, assistance, debriefing and direction as necessary.‖ The registered nurse must decide toaccept the delegation and work within the model of care.The Council guideline goes on to say ―Factors influencing a registered nurse‘s ability todelegate are: his/her level of experience, staffing levels, the acuity of patients, the number ofstaff, the workload, the policy, quality and risk management frameworks and access to otherhealth professionals to support delegation and direction. Workload calculations need toinclude the time factored to safely delegate‖ (p.15).While it is not an unusual expectation for an experienced nurse to have a patient load at thesame time as managing the system, s/he also has to oversee the overall quality of care andsupport/guide all the nursing staff, to meet their professional responsibilities as laid down bythe Nursing Council. The Safe Staffing Inquiry Report 2005 says, ―There is an assigned roleto co-ordinate and manage workflow and provide clinical support for each ward, unit orservice 24 hours a day, seven days a week. Generally, for most acute areas, this role wouldinvolve a reduced or nil case-load‖ (p.11), it is context dependent. The ECC management hasdetermined units within the ECC (acute, monitoring and observation) that require TeamLeaders to oversee the shift. Adequate staffing levels and leadership responsiveness needs totake into account the variable skills mix of some experienced, junior or casual staff; and theunpredictable nature of client conditions in the ECC, as well as the need to establish baselineassessments to promptly initiate protocol treatments, to keep patients safe until they areexamined, and implement treatment plans promptly.Benner (1984) describes what is involved for nurses new to practice to acquire ―a sense ofsalience — of perceiving that some things are more important than others‖ (p.146). [The ECCnurse] pointed out that some of the new graduates ―are rather quickly orientated to monitoredarea‖. She believes experienced nurses should be allocated to the monitoring area. Currentpractice causes more pressure on the senior nurse there as the ―inexperienced person does notnecessarily have the ability to assess someone immediately‖.Given the skills mix (RN skill level) in the ECC, the other factor to take into account isWaitemata District Health Board‘s responsibilities in its contract with the Clinical TrainingAgency for the Nursing Entry to Practice Programme. The requirements to be met are laid outin the Nursing Council Standards for Nurse Entry to Practice Programme. In particular,Standard Four states, ―Appropriate resources are available to support theprogramme….Criterion 4.3, the programme is appropriately supported in terms of timeallowance for preceptors working with the new graduates.‖ (p.5)As per the Safe Staffing Healthy Workplace Recommendations and in line with ED Victorianstaffing, the Team Leaders should have no patient loads when the team includes significant94April 2009