Patients
5 (8. 1 9%) participants made patient related comments
We must decrease the length of stay. We 've have no choice in that. Any health care system in the world stands or falls on how well they can deliver for reducing revenue
[4]
Because of the more acute nature of the clientele . . . you need the expertise of the registered nurse to make assessments and decisions [24]
I think because patient length of stay is decreasing so rapidly and because acuity and the needs of the patients they are getting in the system are changing so rapidly
everything is being compacted into 2-3 days. Compounded by increasing technologies [34]
On the whole patients are a lot sicker than they used to be [36]
The issue for us at the moment is how are we going to reduce our average length of stay [50]
Information
4 (6.55%) participants made reference to information
One of the things we need here in New Zealand is a reliable dependency system [ 17]
Lots of computer work and paper work coming in [2 1 ]
The power user of information systems is going to be a major influence in any unit. There 's an issue of the availability of highly skilled people for advice and that goes back to care delivery design [57]
I can 't get them to see if it takes 20 minutes to enter the data and you have 4 patients that's one and a half hours they are not available to be with patients [59]
Information is a primary resource for executives and health care professionals. In a eRE where some health professional staff members may be absent from work for days or weeks at a time and much of the information is confidential the collection, management and transfer of patient, organisation and profession related information poses a significant challenge. That only 7 ( 1 1 .47%) participants made a comment directly related to information suggests that the information was not seem as an integral part of the care delivery.
Finance
6 (9.83%) participants referred to financial matters:
Part of it is economic [3]
I believe a lot of what they are introducing is going to cost more. They have fragment services greatly and are being encouraged by the RHA to be taskfocused [8]
Well it 's really the only one we can afford. We can 't afford primary nursing any more. We just don 't have enough people. Historically we have a skill mix problem . . .
And so we are talking lead nurse and all that business and that increases resources
[ 1 0]
Resource implications are actually important as one of the ways to get nursing staff to stay here is to pay them more. You 're paying a premium for certain skills but you have to lose it somewhere else and that affects service provision. [3 1 ]
It 's a sad fact that we have to use more [financial] resources on same or fewer people because they [nurses] want to be territorial [X]
There 's absolutely no need for a nurse with a masters degree to be cleaning wards, making beds or delivering meals. We 've got over priced people making us totally un competitive. [X]
The resource implications for me are that we can 't actually do anything different without putting in huge [financial] resources [42]
Plant and equipment
Only 2 (3.27%) participants commented on plant or equipment Beds decreased in response to purchase of less cases [2]
Resource implications to do with equipment and physical layout [40]
The two most capital intensive items of plant and equipment in the CHE context were buildings and medical technology. B oth have significant resource implications terms of capital expenditure, ongoing maintenance and staffing. Physical layout and the nursing care delivery system are interrelated. B uilding structures and the placement within the building of some medical technology influence nursing care delivery, as does the presence or absence of electronic monitoring and call systems.
At the time of the interviews some CHEs were considering a move to patient focused or patient centred care. With the patient as the focus of care building layout would where possible, be changed to facilitate care delivery. So little known about the way nurses are working that the full impact of building layout and medical and communication technologies, particularly after hours, is yet to be fully explored. Because nursing is not generally associated with expensive equipment and the
adaptability of nurses assists them to cope in a variety of environments, plant and equipment may not be readily seen to be a critical resource.
Staff
Safety
Only 4 (6.55%) participants raised safety issues
Well there 's always a minimum number isn 't there in a lot of areas because of safety
[6]
You have to consider the safety of the nurses [25]
They 've got to be spot on after hours because resources are less and it takes longer to get assistance so assessment and planning skills have to be really good [5 1 ] and [39]
Safety of patients and staff is an important consideration in any public health care organisation. In terms of the patient and nursing care delivery systems safety is of paramount importance. All health professionals have a duty to give safe care. CEOs have responsibility for ensuring a safe environment for patients and staff. The NCDS should ensure the provision of safe, effective nursing care to patients. Staff is the maj or component of any nursing care delivery systems. Adequate and appropriate staffing is therefore central to the effective and efficient delivery of nursing care.
1 9 ( 3 1 . 14 %) participants made staff related comments:
Workforce
1 6 (26.22%) participants made workforce related comments:
People are likely to leave within 5-10 years of each other [aging workforce] [2]
I'm told the funding is there if I need to call extra people .. .. That's fine but where do I find them ? Where 's the young ones coming through ? [5]
The demands and requirements within the service [nursing] the dynamics of it, the technology and the changing clinical practice, the huge requirement to manage public expectation is driving us to a more highly sophisticated nursing workforce
rather than a less skilled nursing workforce. We are looking at some of the resource implications because nursing is [$X] over budget [ 1 5]
Resource implications are in terms of skills and nurses maintaining their skills [ 1 9] We 're expecting all our general nurses to be specialists [20]
Problem with expert nurses taken out to cover in other areas where they 're being overwhelmed and not in their area of expertise anyway [26]
One of the significant issues within this organisation is the lack of skill, education and professional maturity of the nursing workforce [28]
Difficulties employing new grads in specialist areas [29] We have a problem getting staff to study days [37]
An issue for us is getting skilled registered staff [4 1 ]
Biggest problem is attracting new grads [43]
Expertise is something that experience gives you to some degree [27]
It 's difficult to break the mould when people [staff] have become institutionalised
[30]
We 're short of nurses particularly nurses with experience. There 's resource implications with getting enough trainers. [Nurses] need to be more up to date, better trained, more refreshed all the time on practice [40]
There are a number of nurses [registered] who like a low level of responsibility and who do not want to take more responsibility [52]
Need experienced registered nurses on every unit, especially at night [55]
Casual staff
3 (4.9 1 %) participants commented on the use of casual staff Once again it gets down to personnel. Use lots of casuals [2 1 ]
I try to push for permanent [as opposed to casual] staff I think it's safer and more practical [32]
Recently we have been filling the gaps with casual staff which is a worry [54]
While these participants recognised some important staff resource issues they did not follow through to discuss the implications of these, for example the implications of an aging workforce, the expectation that every nurse be a specialist, or 'filling the
gaps' with casual staff. The important interface with the education sector as the provider of new graduates does not appear to be appreciated. The source of experienced nurse/s who join the CRE and destination of nurses who leave the CRE is not mentioned.
Future
4 (6.55%) participants commented on future plans
We have a sort of clearly mapped out path in terms of people resource implications and there are pressures on the organisation in terms of resources. In each ward you need a wide range of skills [9]
In future we will need to look at the whole concept of multi and interdisciplinary teams ... Looking at multi-skilling and cross-skilling [ 14]
The next step being looked at here is multi-skilling. We 've got an aging workforce. The question is how can you get the most out of any particular resource delivering your system ? This means you are constantly challenged in terms of innovative ways of doing this [ 1 8]
I believe you employ staff for their day to day abilities, for their operational abilities and their ability to deliver safe care but also to think further than that. You want them to think the future and see how it's going to impact on their practice [39]
Geography
3 (4.9 1 %) participants commented on the implications of geography
Part of it is geographic [3]
Geography has a bit to do with what happened as well [ 1 6]
The physical component [geography] has to be considered [33]
Changing roles
2 (2.37%) participants commented on changing roles for nurses
Nurses are trying to take over or assume some of the responsibilities that were medical and the reason I assume is that nurses want to earn money and so perceive that by getting further skills and logically degree skills are the ones people gather to make themselves more valuable and more attractive packages [22]
Who is going to take on the nursing work off nurses if you 're going to ask them to pick up medical work? [48]
Remaining
We 're just implementing new acuity system . . . to match nurses with demand I don 't believe you can always measure or quantify what nursing is all about [6]
The resource implications of primary nursing were considerable and I don 't know that we made the best use of nurses ' time talent or skills [ 1 6]
The resource implications are huge. I think we waste a lot of health dollars protecting what we have always done [23]
With new grads having to develop them. We are having increasing difficulties employing nurses [3 1 ]
Most of the nurses have been born and brought up here. The days are gone when you can visit a little old person because you know they are lonely [38]
Ideally we would like a generalist but I appreciate that 's not what a lot of people want for themselves [52]
The thing that saddens me the most is the lack of understanding that if you invest in staff you get returns in the long run [53]
I find sometimes you give nurse a specialty, she learns it all then hangs on to it and won 't share it [58]
The nature of the beast has changed and we have become a heap more technical [6 1 ]
Answered question in term of a system
3 (4.9 1 %) answered the question in terms of a system:
We get major pre-occupation with what they [nurses] can do and can 't do and we 're right back into divvying up nurses work into tasks. The resource implications of implementing this particular system have never been evaluated [44]
People have changed the system of doing things from desperation. Like this is not working for us anymore. How are we going to survive ? [47]
The amount of double work I've seen people doing under this system . . . I 've observed that they spend an awful lot of time doing non nurse things [60]
Answered question in terms of a model
1 ( 1 .63%) participant answered in terms of a model but seemed to be indicating a system:
The new model turned out to have problems with continuity. They felt they could staff this well enough to prevent this [lack of continuity] but it didn 't happen and it turned to custard [ 1 2]
The NCDS is a major subsystem of the PCDS. Its primary function is the delivery of safe, effective nursing care to patients within available resources. Participants' answers to the questions about the NCDS are time and context specific. Together they indicate a NCDS that is not well understood by senior staff members. They also indicate a lack of sophisticated resource management and evaluation skills.