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SUPPORTING THE INTEGRATION
OF NURSING ASSISTANTS
INTO ESTABLISHED REGISTERED
NURSE TEAMS
Astride Bazile B.Sc.N M.Ed. CON(C) Susan Drouin RN MSc(A) Doctor Soc. Sc. Monday June 15th 2015
MUHC
Disclosure
We have no actual or potential
conflict of interest
in relation to this presentation
Learning objectives
Recognize the processes put in place to integrate
Nursing Assistants as new members of the nursing
staff
Identify the key elements in a successful team
approach to integration of new staff
Profile of the Nursing Assistant
Or
Be at least 18 years of age and have completed the Test de development Général
( TDG ) and 5th year of High School
To enrol in the SASI Program
Hold a High school diploma or be 16 years of age as of Sept 30th of the
year of enrolment in the program and completed secondary 5 level
Nursing Assistant
Complete 1800 hours of Santé Assistance et soins Infirmiers (SASI )Program 18months Program = Diploma of Professional Studies (DEP)
No current licensing exam / coming in 2016
OIIAQ (2015)
Reserved Activities for Nursing
Assistants
Bill 90 (2002)
Profile of the Registered Nurse
Registered Nurse
Initial Entry to Practice
3 years in CEGEP
General duty nurse
2 years in CEGEP
+ 3 years in
University
Nurse Clinician
3 years in the Direct entry to Masters in Nursing Program with a previous
Bachelor in Arts or Science
Opportunities for advanced roles
OIIQ (2015)
The McGill University THE McGill UNIVERSITY HEALTH CENTRE-MUHC
BEFORE JUNE 2015
HC
before June 2015
The McGill University Health Centre – The
THE McGill UNIVERSITY HEALTH CENTRE
THE GLEN
Integration of Nursing Assistants
(INA)
The Context: Large Scale Optimization Project “Grand Projet d’Optimisation” (GPO)
Goal and objectives of the INA Project
Governance structure
Engaging the Leadership team and Staff
Challenges and Successes
Evaluation
Where are we now?
Large Scale Optimization Project
Operating rooms
Adult medical imaging
Medical labs
Lachine Hospital
Staff mix on inpatient units
Ambulatory care
Integration of
Nursing Assistant
project
Large Scale Optimization Project
GPO: “Grand Projet d’optimisation”
Nursing Staff Mix GPO given clear financial
targets to be met:
3 pronged approach:
1. Nurse-patient ratio
2. Review of quotas of:
Clinical Nurse Specialists (CNS)
Nursing Professional Development Educators (NPDE)
3. Integration of Nursing Assistants
Integration of Nursing Assistant Project
Goal of the INA Project:
Integration of 42 NAs*in part-time positions into designated in-patient units within the MUHC by ensuring:
No compromise of patient care
NAs to become valued and permanent members of the nursing team
Meet financial targets of Staff Mix GPO
INA Project’s objectives:
Establish a model of care
Integrate successfully the Nursing Assistants
within the nursing teams
Determine mechanisms to ensure ongoing
evaluation
Develop a recruitment and a retention plan
Governance structure
Nursing Staff Mix GPO Chair: Director of Nursing
Human Resources Manager
Steering Committee Chairs: Associate Director of
Nursing of Staff Development and Surgery
Coordination Committee
Clinical Practice and Education Workgroup
Chairs: Nurse Practice Consultant and Educator
Logistics Workgroup Chair: ADON Surgery
Communications Workgroup
Chair: ADON of Staff Development
Evaluation Workgroup Chair: DON
Supporting resources: Clinical Leader
Change Management Advisor Project Manager
Coordinator Media Relations
Project Charter
Governance Structure
Governance structure
Nursing Staff Mix GPO Chair: Director of Nursing
Human Resources Manager
Steering Committee Chairs: Associate Director of
Nursing for Staff Development and Surgery
Coordination Committee
Clinical Practice and Education Workgroup
Chairs: Nurse Practice Consultant and Educator
Logistics Workgroup Chair: ADON Surgery
Communications Workgroup
Chair: ADON of Staff Development
Evaluation Workgroup
Chair: DON
Supporting resources: Clinical Leader
Change Management Advisor Project Manager
Coordinator Media Relations
Clinical Practice and Education Workgroup
Mandate:
Define the scope of practice of the NA
Prepare and assist leadership teams with integration of the NAs
Provide knowledge about roles, teamwork and assistance at the unit level
Members:
Nursing Professional Development Educators
Clinical Nurse Specialists
Assistant Nurse Managers
Nurse Managers
Clinical Practice and Education Workgroup
Documents developed:
Job description and Performance Appraisal tool
Reference Guide regarding the reserved activities for Nursing Assistants
Orientation Process for Nursing Assistant 6 weeks of orientation
Standardized Competency based Checklist for Orientation and Evaluation tool
Timeline for teams integrating Nursing Assistants
Clinical Practice and Education Workgroup
Adopt a conceptual framework for collaboration
and Delegation using the dyad model
Follow an Evidenced Based Approach : Kalisch and
the concept of Missed Care
Provide teaching to Staff and Leadership teams
Kalisch and the Concept of Missed
Care
The purpose : determine nursing care regularly
missed on medical-surgical units and reasons for
missed care
Ineffective delegation
Lack of collaborative planning for patient care
between Nurse and Nursing Assistant
Nurses delegating without retaining accountability
Denial
Denial of missed care
Kalisch (2006)
Delegation Model
Role and accountability of the nurse in delegation
process to Nursing Assistants
Initial Assessment of patients
Decision to delegate to the NA
Shared goals to be met with the NA
Clear directions to the NA
Follow up on completion and feedback with further
delegation as required
Hansten and
Jackson ( 2009)
Logistics Workgroup
Mandate:
Develop clear and efficient guidelines and processes
for the implementation of NAs into the system
Determine the number of NAs per unit
Members:
Human Resources Representative
Nurse Managers
Associate Director of Nursing
Communications Workgroup
Mandate:
Maintain constant and consistent internal nursing
communication
Answer all questions from the staff on the units
Post the answers for all staff members to access as needed
Support each workgroup to develop messages for their
respective team
Members:
Associate Director of Nursing for Clinical and Professional
Staff Development
Coordinator for Media Relations
Evaluation Workgroup
Mandate:
Obtain feedback from the teams regarding their
experience with the integration process
Conduct evaluation of chosen indicators related to
integration of NAs.
Members:
Director of Nursing
Nurse Practice Consultant
Associate Professor from McGill Nursing School
INA Project: Phases of Integration
Wave 1: 20 new NAs on January 6th 2014 Site 1: 4 units
Site 2: 1 units
Site 3: 1 unit
Site 5: 1 unit
Wave 2: 22 new NAs on April 1st 2014
Site 1: 1 unit
Site 2: 2 unit
Site 4: 2 units
Wave 1: January 2014 Wave 2: April 2014
INA Project: Phase of Integration
Wave 2B: site 1: 1 unit Wave 2B: site 3: 1 unit
Wave 2B: July 2014 Wave 2B: October 2014
Evaluation workgroup
In April 2014 follow-up post Wave 1
Focus groups with members of the Leadership Teams
N=11
Focus groups with Nursing Assistants N=17
Individual interviews with Preceptors N=12
Evaluation Workgroup
Report from focus groups:
Overall good level of satisfaction from NAs,
Preceptors and Leadership members regarding
the integration process
NAs felt welcomed
All groups appreciated tools provided from
orientation
Duration of 6 weeks of orientation was
appropriate
Evaluation Workgroup
Preceptors reported lack of use of the tools
especially the competency checklist due to its
length
NAs reported lack of preparation on the part of
some preceptors
Lack of knowledge identified by NAs from the
staff regarding their scope of practice
Difficulty in operationalizing the collaboration
delegation process when working in a dyad
reported by all team members
NA
• Some NAs did not ask a sufficient number of questions; therefore this impacted on their interaction with the preceptors
Team
• Unexpected change of preceptors during orientation/ Multiple preceptors
• Preceptors having poor knowledge of scope of practice of the NA
• Mistrust from preceptors
Pro
cess
• Poor use of the Competency checklist as an evaluation tool
• Poor communication between preceptors when multiple preceptors involved in the orientation
Wave 1 and 2 Lessons Learned exercise:
Challenges
NA
• NAs felt welcomed
• NAs had good knowledge of their scope of practice
Team
• Good support
from
Leadership
team
Pro
cess
• Good support
from the Staff
Development
Department
• Documents
clear/ well
written
• Competency
Based Checklist
helped with the
evaluation
process
Wave 1 and 2 Lessons Learned exercise:
Positive Outcomes
Evaluation Workgroup
Next Steps
2 years post integration/ 6 months post
move to the Glen site
Reassessing our indicators
Engaging the Leadership Team
and the Staff
Engaging the Leadership teams
Clarifying the mandate and the urgency of the
situation
Involving the teams in the process
Identifying the key role of each member
Providing structure for the process
Having a Change Management Advisor throughout
the process
Providing tools
Providing ongoing support
Engaging the Leadership teams
Weekly meetings for the members of the workgroups
Weekly memos from the Communication workgroup to
answer questions being asked by staff (FAQ)
Coverage of the INA project in the quarterly Nursing
newsletter
Bi-Monthly and ad hoc meetings of the Coordination
Committee
Monthly Steering Committee meetings with all
workgroups
Challenges
Timing- Upcoming move to the Glen site
Period of uncertainty
Circumstances around the integration the NA
Nursing Staff bombarded by new practice changes
Individual feelings regarding the role of the NA
Personal views on the role and value of NAs by
members of the Leadership teams
Short timeline to integrate the NAs
High Level timeline
Successes
Collaborative work between the various clinical
sectors of the Nursing Department
Opportunity to create a better partnership with
Human Resources
Out of the 42 NAs integrated ...only 1 failed
orientation
Change of perception regarding the contribution of
the Nursing Assistants to the nursing team
Overall Integration was a success
Where are we now?
Major restructuration of manpower planning at the
MUHC
In the process to integrate more Nursing Assistants
Move to the new site = reconfiguration of some units
Preparing new teams to work with NAs
Preparing to create a float team of NAs
Phase 2 of the Evaluation
Clinical and Practice Education Committee in place to
review the practice of the NAs
References
Hansten, I. Ruth & Jackson Marilynn(2009). Clinical Delegation
Skill a Handbook for Professional Practice, 4th edition Jones
and Bartlett Publishers
Kalisch, Beatrice J. ; Sallie J. Weaver, MS;, Eduardo Salas
(2009) What does Nursing Team Look like ?, Journal of
Nursing Care Quality Vol. 4 no. 24 pp. 298-307
Kalisch, Beatrice J. ( 2006) Missed Nursing Care a Qualitative
Study. Journal of Nursing Care Quality Vol. 21, no. 4, pp.
306-313
References
Bill 90 Bill 90 (2002, chapter 33) An Act to amend the
Professional Code and other legislative provisions as regards
the health sector
http://www.oiiaq.org/en/becoming-an-lpn
http://www.oiiq.org/admission-a-la-profession/la-
profession/infirmiere
Group/Team performance!!
Feedback and Questions
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