A conversation about nursing management Jennifer Rowe talks with Jane Etchells, Nursing Unit Manager at Royal North Shore Hospital, Sydney.
Jane Etchells, Nursing Unit Manager at Royal North Shore Hospital, Sydney.
Jane Etchells is the nursing unit manager (NUMJ of the spinal unit at Royal North Shore Hospital (RNSH) in Sydney. We met on a busy weekday morning and discussed her nursing role and contributions to this unit. Throughout our conversation, I was struck by how clearly Jane understood and was able to articulate the links between managing, facilitating clinical nursing, and good patient experiences. Jane began nursing after she finished high scbool, coming to Sydney from Canberra and training at RNSH. It was a means of leaving home but Jane described herself as 'terrified the whole time I was doing my nurses' training, really shy. It was terrible and everyone would tell you the worst stories about the wards you were going to next. No one would ever say "oh that's a really great place to go".' She persevered, completing her training and taking the well-worn path of overseas travel before working as an RN in Canberra for about three years. Here she worked as a surgical nurse, specialising in stoma nursing. Looking for a change, she returned to Sydney where she ended up back at RNSH after failing to find somewhere to park her car at either Royal Prince Alfred or St Vincent's hospitals. To cut a long and interesting story short, she ended up some ten years later, agreeing to be NUM in the spinal unit for a short term - six months. Some two and a half years
later, she remains in this position. In ballpark numbers, the unit is capable of housing 25 patients. Normally there will be four or five non-spinal injured patients and potentially two ventilator dependent quadriplegic patients among those with spinal injuries. There is a staff of around 40 nurses and seven personal care assistants as well as support from surgical dressers. Jennifer: What do you think made you the fight person for this job? Jane: I'm a pretty definite sort of person and I think they were looking to make some changes in the unit not that the unit was a bad place but I think as a very specialised area, it had become quite isolated from the rest of the hospital. I brought a totally different perspective or way of looking at patients and how we manage patients. Jennifer: A sort or re-orientation? Jane: Yes. Also I don't want our unit to be isolated from the rest of the hospital. I actually want our unit to be leading the rest Df the hospital, that's what I want to see and I think that we have achieved that in some respects. Jane described a number of initiatives that illustrated her approach to managing and being a change agent.
Jane: There are two types of patients that we have on the unit. First we have the acute spinal injury patients who need acute spinal management and beginning rehabilitation. We have only six to eight of those types of patients in the unit at any one time. The rest of the patient population are those with existing spinal injury, patients who come back to our unit for other reasons. It may be for a medical reason,.such as when they have a chest pain or abdominal pain. Or they have UTIs (urinary tract infections) or they may be coming in for elective surgery or some such thing. The change that I've made is that I have brought a surgical perspective to all of those patients, in that they are now treated like a normal person coming in for a surgical procedure as opposed to a spinal person with something else wrong. If you or I were coming in for say a cystoscopy, we'd come in on the day of surgery, have the surgery and go home. What was happening for such patients in the unit and had been happening for a long time was; you'd be admitted by a spinal specialist, they'd say you'd need a cystoscopy, you'd sit in the unit 'til we could get urology consult which might take two or three days. They'd come along and agree you'd need a cystoscopy, but say, 'can't do it this week, possibly could do it next week. We'll add you to the list'. You'd wait for a
week, they'd come in and say. 'look the list is full, sorry bumped off, wait 'til next week'. So a procedure that should take a normal person eight hours in hospital was taking a week to maybe even three weeks to achieve. For me that's not good enough. If you're a spinal injured person you deserve exactly the same care as an able bodied person. So spinal injured patients, particularly within the city area, not so much from the country, go to pre-admission and they see the doctors from preadmission. They're booked in when they come in for their surgery, day of surgery, or if they're a quadriplegic and they need care early in the morning, they might come the night before. They'll have their surgery and they'll go home on the same day, as happens with elective surgery patients. And they love it because now they have a date and they come in on that date and they have surgery on that date and they go home and back to their life, which is how it should be. Jennifer: I am sure as people who have more than their fair share of encounters with health services, this must be a good thing and less disruptive. Jane: Yes. I would say that the spinal injury patients that I have dealt with would be the most patient group of people or patients. They are so used to waiting - for everything to happen. That's normal for them. So they wait very patiently and it's not good enough. So I think that is one difference. In another example of change that focussed on improving outcomes for patients. Jane discussed
changes in discharge planning, par- patients going on to rehab. We have one guy in now who's been ticularly for the acute spinal injured patients. waiting for a rehab bed for three months, which is really appalling. But the problems continue down Jane: When I first came here, there the track. Patients can't get out of were these discharge planning the rehab unit because of care meetings but never ever mention of issues or community or housing discharge dates. I sat there in the issues. That's something that we first meeting thinking, 'hmm, I wonneed to look at. der why they're doing this'. So the
was one activity mentioned, a fundraiser conducted soon after Jane's arrival on the unit. This money had helped with a much overdue interior paint job for the unit, smartening up the walls, upon which a series of paintings produced through a hospital art scheme, were then hung.
next week, I went to the meeting and I said, 'When is this person actually going to be discharged?' and the others looked at me in a, 'that's a novel idea Jane' way and said, 'Oh, we don't know'. I said, 'Well you must have some idea when they might be going to go on to rehab or home' and the response was, 'Oh, you know things are different here' etc etc and I said, 'Well look, give me a ball park figure, two months? three months? four months?'. So they would somewhat reluctantly give me a 'you know, maybe four months time'. I then had a piece of paper on which I put a discharge date and then I'd go back to my diary and work out a date in four months time and I'd go to the meeting the following week and I'd say, last week you said this person was going home in...' and I'd suggest such and such a date and I'd keep going with dates. Anyway by doing this, we'd eventually get to a date that they were all satisfied with. Now I go and say, 'So when will this person be discharged home?', and they say, 'Oh, in six weeks'. You know it's really worthwhile.
Jane: We just had another fundraiser again a couple of months ago. So we've bought five new wheel chairs, new commodes, a new alternating pressure relieving device.
Jennifer: ft gives your staff and the patients something to work towards. Jane: Yes exactly. But it is complicated. We do have difficulties with
Jennifer: Yes, that's a tough one isn't it and I imagine it concerns funding issues in part. Jane: Yes. / asked Jane how she judged her capacity, within her role, to influence decisions about funding and resource distribution. Jane: I don't think there is an awful lot that I can do. I feel pretty powerless in some ways. I wish there was. We have written to the Minister before about the issues. You end up getting a ministerial reply to your own letter, so that doesn't work very well. I am not sure who you would lobby and I know that the director of the spinal rehab unit has agitated in many different areas but without much success. In the situation I was describing, we've talked as a team about trying to do more of the rehabilitation here. It may be that getting housing issues and those sorts of things started at an earlier stage will help. But there are issues with allied health. They will probably need more staff here. Fundraising is one aspect of life for the team working in the spinal unit as they search for funds for resources, and equipment. Absailing from the Harbour Bridge
Jennifer: It's interesting isn't it because this sort of activity is where people start to get a sense of ownership over the work place, yet in the back of my mind is a concern that you have to raise your own money to get this sort of equipment. It seems difficult to consolidate. Jane: It is. I resent it a bit too, but then on the other hand, I see that it has improved the work environment. I gave up one Saturday and as long as they never make me abseil off the top of the bridge, that's fine. I suppose it's not a big price to pay. / am starting to get some insight into this role. But there is so much more. Jane discussed her clinical knowledge and how this fitted in her role. Jane: Spinal's not my speciality at all. I don't think I need to know about spinal injuries. My nursing staff is very, very good. They are clinical experts but I'm not and I don't need to be a clinical expert because that's what they're there for. I've learned a lot in two years
and I could probably make an awful lot of clinical decisions but I choose not to because I think that it's important that staff feel that that's their role and I defer to them on most clinical issues. Jennifer: So what do you see as being the main components of this role? Jane: For me the main thing is to empower my nursing staff to make the right decisions. That's the thing that I think is the most important and to keep the nursing staff and invest in their level of knowledge so that they give as good quality care as they possibly can. A lot of my time is taken up with the rostering and dealing with staff issues. Trouble shooting. A lot of the human resource workforce planning has been devolved down to the NUM level. So it's being aware of who is about to resign, making sure that you've advertised in time so that you can recruit to the position, knowing who's going on long service leave and so on. There is all the performance review linked to the staff. And the staffing budget. Then there is stock management. As you can imagine we use an incredible amount of stock. The budget here is just about impossible to manage because we use a lot of very expensive equipment, much of it • imported and the Australian dollar is down the tube. So what can we do? I keep an eye on it, Jennifer: If you had to assess your own performance what would you like to see? Jane: I guess I really want to see that I am retaining staff. The
staffing in the unit has definitely improved since I've been managing it so I think I must be doing something right. We run a new graduate program at RNSH and I take seven students on any rotation. I think this is a fantastic area for new graduates to learn time managing and also lots of skills. Spinal nurses are still multi-skilled and think about multi-systems. So yes, it is a good place for new nurses to come and spend some time. If they stay with me at the end of the year, I'm delighted and if they stay with me for a further year, I'm really very happy. One initiative Jane is working on with other members of staff, and in collaboration with one of the metropolitan universities, is the development of a postgraduate certificate in spinal nursing. Jane. hopes such initiatives will assist staff retention as well as utilise the expertise of the clinical staff and forge strong links with the tertiary sector. All ways of advancing spinal nursing care. Jane talked about other key nursing roles in the unit.
• I ; ; I • ; ; \ I I : ; \
injuries unit. The clinical nurse consultant spends quite a lot of time looking at that as well as educating the university students and the staff on the unit. And she is supposed to do research as well. It's a very, very big role. It's probably too much for one person to do really. I'm lucky enough to have a ward-based nurse educator. Since I've had that position, the clinical nurse consultant's been able to pull back a bit on her education role with the staff.
Teamwork is an obvious feature of \ success in this unit and one that is \ evident in Jane's description of her '•• everyday activities. She engages in ; an important ritual at the start of \ each day, known as 'her time' by \ the staff, arriving an hour before \ she is due. She uses this time, I among other things, to order her thoughts, read emails and update •: daily records.
\ ; j \ ; ; Jane: In this particular unit, the I clinical nurse consultant almost ! works as a registrar if you ask me. | She does an awful lot of liaison I with the outpatients and has a big \ rale in managing crisis and preven- : tion with patients that are in the : community, giving them advice I over the telephone, visiting them in I. their homes. She also has a big i role in sexuality and fertility coun- ! selling. We have a big sexuality I and fertility service here and we • do semen retrieval and IVF and • that sort of thing, which we do ; more of than the other spinal :
Jane: I make sure everyone's pays are correct. I am absolutely fanatical about that because I think the staff work hard enough that they should be paid correctly at the end of the week. I'll speak to the night staff, just a 'how was the night?' and if they have had a bad night, I like them to throw that at me. If they throw that at the day staff, you can find that the day staff think they're going to have a bad day before they even know that they're going to have a good day. Anyway I can use the information to allocate the staff. For some reason the staff like me to allocate the patients in the morning. On Monday, we have a big ward round which is the staff specialists, the registrars, myself and the case co-ordinator, another nursing
position. We see all the patients, which might take two to two and a half hours. On Wednesday, I do a nursing round with the clinical nurse consultant and case co-ordinator, That's my time for asking the patients about how they are finding the nursing care in the unit, if there is anything that the nurses can do differently for them, if there is anything they need, are they satisfied with their nursing care. I ask every patient that question every Wednesday. It's useful. Sometimes they say, 'oh yeah I've got a problem' but usually they say 'no, your nurses are terrific carers, fantastic'. It's really positive reinforcement for what is happening in the unit and I think it probably gets rid of an awful lot of potential complaints. On Thursday, we have a big rehab meeting. The multi-disciplinary team sits down and discusses patient planning. Jane discussed nursing and the multi-disciplinary team, an area where she has advocated for the nurses to be more enabled. Jane: When I first came here, I felt that the nurses were at the bottom of the rung in terms of the multi-disciplinary team. Basically, they deferred everything to someone else and all the other team members seemed to have the final say instead of the nurses saying, 'I know this is right and this is how I'm going to do if they would be, 'Can I do that, can I do the other?'. So in some ways, I've been a negative force with multi-disciplinary teams saying, 'No, you guys [medical and allied health practitioners] aren't making those decisions anymore. That's a nursing decision. No you don't change trache tubes
because you are a physiotherapist]. A nurse manages the airway - and so on. Jane's role is clearly a managing and leadership one. How does she describe the way she leads? Jane: I'd like to think that I lead by example realfy. I might be a bit bossy but I think sometimes you have to be. Certainly, I think that the things I've implemented in the unit have been to empower the nursing staff with the knowledge and the ability and the professionalism to get on with the job and to have a caring approach. If we get rid of that word 'care', then we function as robots. I am very passionate about caring and nursing care. I think being a nursing unit manager is one of the most influ-
ential positions in nursing, both in the fact that you do influence the guaiity of care that a patient gets and you set the standard and can ensure that the standard is maintained. You influence new nurses coming in. If you yourself have a passion for nursing, you can show that and you can get people to stay and be passionate and interested also. in closing, I would like to present a story that Jane told about the nurses who work on the unit and tbeir caring ability. We were discussing the intensity of nursing spinal injured patients, particularly ventilator dependent patients - not only the challenging emotional and social aspects'of care but also the demanding physical and technical requirements of helping people
who can do nothing for themselves. they would have managed it with such expertise, say if the trachea Jane: When I first came here we had blocked off or if they had to change the trache tube. If the venhad two fairly newly injured, ventilator dependent patients. One was tilator had packed it in, they would a Kiwi and one was an Aussie. have bagged the patient. They Some of the staff managed to get would have managed, whatever tickets through the rugby union for had happened. And I satthereand the patients. They took the two my little heart was thumping and I ventilated patients to the rugby, to was thinking, 'Those are my nursthe Bledisloe Cup. I had tickets es over there'. You know it was and I was going with a friend and I just - they really are very, very, just happened to be sitting not very special people. And these two very far from where they had guys? They had a really nice time. seats. I was just sitting around and when I saw them, I tell you, Jennifer Rowe my heart was pounding and I PhD MPhil GradDipEd BA DipEd almost had tears in my eyes RN, Lecturer and Postgraduate watching these nurses. The experStudies Coordinator, School of tise of someone to take someone Nursing Griffith University. on a ventilator out of the hospital, Email: to a huge venue like that, knowing [email protected]
anything could have happened. But
Book Review Nurse Practitioner Manual of Clinical Skills Edited by Sue Cross and Myfanwy Rimmer. Published by Bailliere Tindall, London, in association with the Royal College of Nursing From a primary health care focus, the content of this book is thorough. It is not voluminous, making it easy to take with you wherever you work, but is a wonderful guide and concise compilation for any nurse, particularly for senior clinical nurses at the level of Clinical Nurse Consultant or Nurse Practitioner, It approaches Health
Assessment in a systematic manner and the chapters deal mainly with body systems but also address Mental Health in Primary Care, Health Promotion and Health Assessment through the life span. This book is easy to read and use as e reference and guide is facilitated by the way the content has been systematised. The "Red Flags" and "Top Tips" sections in each chapter are relevant and very helpful. The tables and diagrams are plentiful and pertinent and subject matter on each page is significant and comprehensive. Each chapter is put together in a standardised format that focuses on health assessment, use of equipment, techniques for
assessment and some advanced assessment skills. An overview of anatomy and physiology starts the chapters and specific complaints are described covering subjective and objective findings, investigations, management, therapeutic intervention, patient education, referral, complications and prognosis. This book is an excellent resource, particularly as it has been written by a group of British nurse practitioners and nurse consultants who are clinical and current in their practice. Until the nurse practitioner movement in Australia has gathered more momentum, and we have similar positions in the numbers that are
evident overseas, editions such as this are important to help us advance our nursing practice. The focus of this book on advancing the role of the nurse in health care particularly primary health can not be overstated. I thoroughly recommend this book for all clinical nurses but particularly for advanced practice nurses with a primary care focus. Reviewer: JaneO'ConnellRNMNNP Director, Government Action Plan Unit NSW Health Seconded from substantive position as Clinical Nurse Consultant, Emergency Department, Concord Repatriation Hospital, NSW