The NA role was introduced with the intention that it would form “part of our nursing team and part of our nursing culture” (20906). As part of the nursing team, the NA “report to the nurse unit manager however in day-to-day work they’re obviously responsible and accountable to any registered nurse who can delegate them [the NA] activities” (20906). Beyond the individual ward supervision and management structures, the NA had “the same direct line as the nursing staff” (20904) for reporting purposes. Figure 6.1 displays the lines of reporting at the hospital organisation, as described by the nurse leader participants.
60“The Victorian Quality Council has identified the following guiding principles for implementing change:
Have a plan for the project implementation but be prepared to adapt it if the outcomes at different stages show this to be necessary.
Executive (or senior) support is essential for the success of a project, but recognise that change will come from the bottom up.
Set objectives and congratulate the team when each objective is achieved, but remember that improvement is an ongoing process.
Recognise that a plan for introducing change and monitoring the effects of the change is important, but gaining people’s commitment is vital to the project’s success” (DHHS Vic, 2015, p. 7).
148 Figure 6. 1 Lines of reporting within the hospital organisation
The NA were able to access ward educators “who may be able to speak on their behalf” (20904), or the Human Relations Department, if they had difficulties communicating with or reaching a satisfactory outcome with their NUM. As part of the structures for
supervision of the NA, the DoH representative suggested that the NA would “be performance monitored and managed in the way that every staff member is” (10202), to ensure that they are “qualified and understand what they’re doing” (10202).
It was strongly emphasised by members of the nurse leadership that the NA “can’t practice autonomously and they’re always under the supervision and delegation of a
registered nurse, their activities for the day are identified for them” (20907). The distinction between nursing and NA workload allocation was clearly identified as: “[NAs] are not allocated ever to a patient they’re allocated to a task and nurses are never allocated to a task they’re allocated to a patient” (20304).
NA RN/ EN delegating the activity RN in Charge of Shift ANUM NUM Clinical Specialty Unit Director Nursing Executive Director Human Resources Ward Nursing Educators
149 Evidence produced from the 2009 NA pilot program at the hospital under study
determined “that the allocation of work [for the NA] needed to have a defined model”
(20906). This was to ensure the NAs “were helping out the areas of most need on the ward … the [NAs] had variety of work … to make sure the [NAs] weren’t completely run of their feet by ten nurses barking orders at them” (20906). To enable this:
Either the nurse in charge of the ward or a team leader needed to be the people who were actually delegating responsibilities to the [NAs] because they had broader oversight as to the activities of the ward, they knew which nurses were busier than others. That way it sorted out needy from greedy (20906).
The model of NA workload allocation varied between wards, depending on the specific needs of the individual wards and the models of care they employed, such as team nursing or
patient allocation nursing, as previously described.
It was noted in the BSBC evaluation of the NA pilot program, that “as the [NA] gained more experience in their role and progressed through the traineeship the assignment and reporting processes evolved” (PwC, 2011, p. 40). Contrary to the assertion that the NA’s “activities for the day are identified for them” (20907) by the organisation, it was “reported that some [NA] were able to independently manage their own day” (PwC, 2011, p. 40). This finding was verified in the findings of this case when participants from each stakeholder group discussed autonomy in the NA role. The BSBC evaluation report further stated, “that all nursing staff are cognisant of the ongoing requirement for appropriate supervision for [NA] including any new nursing staff that may join the team” (PwC, 2011, p. 40). This was not found in this case, which will be discussed in the subsequent results chapters.
150 At the time of data collection for this case study, NA were restricted to working Monday to Friday, day and evening shifts, as determined by the ward. This scheduling structure was criticised by many participants in this case study, due to the reasoning that nursing care is required 24 hours a day, 7 days a week, and the acuity and the needs of the patients does not decrease on the weekend. The justification provided for the NAs only working week days by a senior manager was that “we wanted them [nurses (RN/EN)] to remember what life was like pre [NA]” (20906). The nurse leaders recalled that some wards trialled different scheduling patterns for the NAs; however, in most situations the NA returned to the morning shift as it was perceived they could provide the most assistance during this shift. In addition to scheduling issues, the leadership group also acknowledged that “there’s currently no backfill, there’s no replacements” (21110) for the NA position, in terms of training and leave. They recognised the potential benefits of the introduction of a pool of NAs, which could be accessed when NAs are on leave or absent from a shift.