Ms. Sylvia FUNGImmediate past Chief Manager (Nursing)/Chief Nursing Executive

Hospital Authority, Hong Kong (Hon. DHS, MSc (Hosp. & Health Mgt), MBA, Dip Ed(Nursing), FAAN, FACSE, RN, RM)

HA Convention 16th May 2013

Building Magnetism in Hospital –

Local Perspective

Hospital Authority

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NTEC

NTWC

KWC

KEC

HKEC

KCC

HKWC

• Public Hospital Services

41 hospitals and institutions;

47 Specialist Out-patient Clinics;

74 General Out-patient Clinics; and

27,153 beds

Services in 2011/2012 1.5 Mn Inpatient & Day patient discharges; 2.2 Mn Accident & Emergency attendances; 8.9 Mn Specialist Outpatient Clinic attendances 1.9 Mn Community Outreach visits; 5.7 Mn Primary Care attendances;

• With a workforce of around 63,603 staff (full-time equivalents) (as for

2012/13)

– Doctors: 5,513

– Nurses: 21,747

– Allied Heath: 6,381

– Others: 29,962

Are we heading towards our Vision ?

• Nursing manpower shortage

• Looming patient volume

• Working under intensive pressure

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• Happy Staff

A survey on local nurses’ perception of their nursing work environment (Choi et al., in press)

Conducted in 2008 and involved 1271 registered nurses (response rate: 61.9%) working in 10 public hospitals

Results: 44.5% reported dissatisfied with their jobs, and over 60% had thought about leaving

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Improvement

Priorities

Engagement

Driver

Level of satisfaction

Total Satisfied Dissatisfied

NWE N=1259 n=677(55.4%) n=545(44.6%)

Scale and Subscales Mean ± SD Mean ± SD Mean ± SD p valuea

Overall perception 2.52 ± 0.41 2.70 ± 0.36 2.30 ± 0.36 .000*

Ward practice 1.84 ± 0.57 1.97 ± 0.57 1.66 ± 0.53 .000*

Staffing and resources 2.06 ± 0.79 2.22 ± 0.82 1.87 ± 0.72 .000*

Management 2.28 ± 0.78 2.52 ± 0.74 2.05 ± 0.68 .000*

Co-worker relationship 2.79 ± 0.81 3.00 ± 0.74 2.50 ± 0.80 .000*

Professionalism 3.38 ± 0.74 3.59 ± 0.66 3.13 ± 0.76 .000*a – t test; *p < 0.001

Quality of Care on In patient Wards Project (QOCP) in Hospital Authority, Hong Kong -

Employee Engagement as Intervention Strategies

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73 QOCP Wards In 19 Hospitals

Dec 2011 - Dec 2012

39 units with

material resources

34 unitswith

manpower support + material resources

Go

al d

irec

ted

n

urs

ing

in

itia

tive

s

Em

plo

yee

par

tici

pat

ory

in

terv

enti

on

s

United based

specific nurse and patient outcomes

Evaluation study

by Comparative Study

Improve Nurses’ Practice Environment(Bottom Up Approach for

Problem Identification and Solving)

Aims:

• Improve morale and job satisfaction of ward staff

• Enhance collaborative teamwork

Ward Staff developing ward improvement interventions e.g.

• Process redesign and other measures

• Care Process streamlining

• Improving work efficiency and service quality

• Staff mix review and work reform in releasing nursing time for providing quality and timely direct patient care

• Modernization of patient care equipment and facilities to address daily operations difficulties.

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ENVIRONMENT SETTING

EQUIPMENT FURNITURE AND MATERIAL

COMMUNICATION DEVICE

STAFFRECOGNITION

Renovation - Interview RoomModernization - Ward- Nursing Station- 2 mini-stations- Staff rest roomInstallation - Wall mounted

monitor- Ceiling mounted

monitor- Ceiling mounted

IV poles- Waterproof

cabinet in patient bathroom

- Storage cabinets- PA systems in

ward- Bedpan washer- Projector for

patient & staff training

• Bladder scan• BP monitor• Pulse Oximeter• Thermoscan• Mini Doppler• Doppler fetus

detector• ECG machine &

accessories• Snap Clip adaptor• Capnometer• Syringe/Infusion

pumps• Blood warmer• Oxylog• Neopuff• CVVH set for

Haemofiltration• Yankauers suckers• Endotracheal stylet• Pressure Alarm

pads• Physical Restrainer• Tube dryer• Mobile hoist• Emergency blanket

• Trolleys –Medication, injection, procedure, bathing

• Drug labeling and library for infusion systems

• Medication crusher

• Ampoule opener

• Low air loss mattress

• Geriatric chairs• Roll boards• Basin stand• Linen carrier• Scan cart• Cleansing

Wooden bed boards

• Foam pelvic holder

• foam/clothes• Thermal Cup• Warmer

• Patient pamphlet, teaching aids,

• DVD• Walkie-

talkie• Video

Intercoms• Hearing

aids

• Quality indicator board

Medication safety

Prevention of fall

Preventionof pressuresore

• Staff Spot Award

• Newsletter• Appreciation

certificate• Gimmicks

Types of Resources : Material resources

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Types of Resources – Manpower Resources

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Supporting Staff

• Transforming care at bedside• Forming a lifting team - Regular turning • Hourly ward round for patient and

environmental safety• Ward Orientation for newly admitted patients• Vital signs taking on admission• Assist patient toileting• Increase routine bathing• Enhance patient mobilization • Q&A during visiting hour• Telephone FU day after discharge• Trolley preparation for nursing procedures• Assist daily technical & patient care duty

Clerical Staff

• Clerical support • Order stock for medical consumable items

Ward Environment Warm & Caring

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Pre

Patient Cubicle

Ward CorridorPatient Rest Area

Interview Room

Saving space - Improve work efficiency

Well labeled cabinet Automatic Sliding Door in NICU

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Ward Environment Tidy & Safe

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AfterBefore

Ward Environment Organized & Comfortable

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AfterBefore

Treatment Room Organized & Accessible

Before After

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Store Room Organized & Accessible

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Before After

Bathing and Lifting Team and Materials

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Before

After

Lifting Team

Bathing Team

All in One Trolley

Process Redesign –work efficiency

Ceiling Mounted IV Drip Poles

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Ceiling Mounted Hoist

Transforming Care to Bedside – All in one

Access Control –> Safe & Efficient

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Door Alarm and IntercomVideo Phone with Remote ControlAt Main Entrance

Modernization of patient care equipment

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Bladder Scan

Bedpan Washer

Doppler Fetus Detector

BP Monitor

Medication Safety

Medication Cutter

PA System & Alert Sign

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Medication trolley

Enhancement of Infection Control

Before

After

UV Assessment Kit for auditing Hand

Hygiene

Designated Equipment for

MRSA Case

Disposable Bathing Wipe

All in One Trolley

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Resources Support

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Geriatric Chair

Pressure Relieving MattressRolling Board

Patient Transfer Aid

Bringing learning to staff

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Medication Safety Awareness

Occupational Safety and Health Awareness

Staff Recognition Enhance collaborative teamwork

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Quality of Care on In Patient Ward Project

Regular QOCP working group meetings to monitor the progress

Ward visits to show encouragement and strengthen staff engagement

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Pre- & Post-Implementation Comparative Study

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Staffing & Resource

Management

ProfessionalismCo-worker

relationship

Ward practice

Nursing Work Environment Inventory (NWEI)

modified to 62 items

SamplingAll staff nurses working full-time working in the QOCP units• 19 hospitals• 73 units

• 34 units received Manpower Support and Material Resources

• 39 units received Material Resources

Study DesignPre- and post-intervention studyThree time points

T0: Baseline in Dec 2011T1: 4 months after QOCP in April 2012T2: 12 months after QOCP in Dec 2012

Overall Ratings

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Improvement

Priorities

Engagement

Driver

Post-Implementation

Baseline T0 Post-test T1 Post-test T2

NWEn=1194(83%)

n=1123(77%)

n=1155(75%)

Scale and Subscales Mean ± SD Mean ± SD Mean ± SD p valuea

Overall perception 2.96 ± 0.46 2.98 ± 0.47 3.09 ± 0.47 .000**

Ward practice 2.52 ± 0.48 2.55 ± 0.50 2.69 ± 0.49 .000**

Staffing and resources 2.66 ± 0.59 2.71 ± 0.58 2.84 ± 0.59 .000**

Management 2.68 ± 0.65 2.72 ± 0.65 2.87 ± 0.62 .000**

Co-worker relationship 3.47 ± 0.68 3.42 ± 0.68 3.50 ± 0.66 .005**

Professionalism 3.52 ± 0.59 3.51 ± 0.61 3.56 ± 0.57 .089#

Note: a – One-way ANOVA test; SD: standard deviation; NWE: Nursing work

environment

*p < 0.05; **p < 0.01#Post-hoc analysis indicated significant difference (p < 0.05) between T0 and T2

Manpower & Material Resources

Material Resources Only

Baseline T0 Post-test T2 Baseline T0 Post-test T2

NWE n=586 N=609 n=608 n=546

Scale and Subscales

Mean ±SD

Mean ±SD

pvaluea Mean ± SD

Mean ±SD

pvaluea

Overall perception 2.93±0.45 3.08±0.48 .000** 3.01±0.46 3.10±0.46 .000**

Ward practice 2.50±0.49 2.69±0.51 .000** 2.54±0.48 2.69±0.47 .000**

Staffing & resources 2.63±0.55 2.83±0.60 .000** 2.69±0.61 2.85±0.59 .000**

Management 2.63±0.66 2.85±0.62 .000** 2.73±0.63 2.89±0.62 .000**

Co-worker relationship 3.44±0.70 3.50±0.66 .030* 3.51±0.67 3.51±0.66 .079

Professionalism 3.45±0.59 3.55±0.58 .014* 3.57±0.58 3.57±0.55 .454

Note : *p < 0.05; **p < 0.01

Ratings for the 2 Types of Resources Allocated

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Improvement

Priorities

Engagement

Driver

Baseline T0 Post-test T1 Baseline T2

2 p value

NWEN = 1194

(83%)

N = 1123

(77%)

N = 1155

(75%)

Scale and Subscales n (%) n (%) n (%)

Job satisfaction 21.343 .000**

Satisfied 858 (71.9) 790 (70.3) 896 (77.6)

Dissatisfied 312 (26.1) 310 (27.6) 229 (19.8)

Not specified 24 (2.0) 23 (2.0) 30 (2.6)

Having thought to leave the present work unit 28.218 .000**

No 596 (49.9) 513 (45.7) 644 (55.8)

Yes 560 (46.9) 587 (52.3) 477 (41.3)

Not specified 38 (3.2) 23 (2.0) 34 (2.9)

Having considered to resign

No 604 (50.6) 574 (51.1) 683 (59.1) 24.662 .000**

Yes 551 (46.1) 523 (46.6) 435 (37.7)

Not specified 39 (3.3) 26 (2.3) 37 (3.2)Note: a – chi-square *p < 0.05; **p < 0.01

Level of Job Satisfaction & Turnover Intention

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Predictors of Job Satisfaction & Turnover Intention

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Improvement

Priorities

Engagement

Driver

Level of job

satisfactionb

Intention to leave the

present work unitc

Intention to resign

from the current

positionc

NWE Adjusteda Adjusteda Adjusteda

Scale and Subscales Odds Ratio

95% CIOdds Ratio

95% CIOdds Ratio

95% CI

Ward practice 2.45** 1.24 – 4.83 0.79 0.48 – 1.30 0.74 0.44 – 1.24

Staffing & resources 3.12*** 1.72 – 5.65 0.65* 0.43 – 0.98 0.40*** 0.26 – 0.62

Management 1.36 0.78 – 2.37 0.61* 0.41 – 0.92 0.84 0.55 – 1.27

Co-worker relationship 3.39*** 2.22 – 5.19 0.39*** 0.29 – 0.54 0.54*** 0.39 – 0.73

Professionalism 2.92*** 1.83 – 4.68 0.96 0.69 – 1.34 0.55** 0.39 – 0.78

Note: *p<0.05, **p < 0.01, ***p < 0.001; CI: confidence intervala Adjusted for age, gender, rank, education level, duration working as a nurse and in the present work unitb Strongly satisfied and satisfied coded as 1 versus strongly dissatisfied and dissatisfied coded as 0c Not intending to leave/resign coded as 1 versus intending to leave/resign coded as 0.

Specific Unit-based Outcome Evaluation

Unit-based patient outcomes Unit-based nurse outcomes

↑ Patient satisfaction Unnecessary steps in wards

↑ Nurse-patient contact time ↑ Nurse-patient contact time

Unplanned admission ↑ Staff satisfaction

IV pump related problems

Physical restrain time

Fall incidence

Pressure ulcer incidence

Catheter-associated Urinary Tract Infection

Distraction during Administration of Medication

Measures included : Record Review, Observation & RecordingPre and Post Quality Indicator measures

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Nursing work environment attributes

Identified Strengths

Response (Percent)

T0

N=1194

T1

N=1123

T2

N=1155

(1) Professionalism

The nature of nursing work is enjoyable to me. 76.2 76.2 80.2

Nursing is not a suitable career for me. * 77.0 72.5 72.3It is challenging to face matters of illness and death

in the nursing profession. 76.1 72.6 75.4

The more one can do for the patient, the higher the job satisfaction. 70.9 67.6 70.9

Being able to gain experience from the hectic nature of work makes me happy. 60.4 58.0 63.6

One feels good because a broadened knowledge base increases the proficiency of patient care. 75.4 73.0 76.4

(2) Co-worker Relationship

There is good cooperation between colleagues. 72.0 69.2 71.3Colleagues help each other. 72.7 68.4 71.2There is trust between colleagues. 61.9 56.5 61.0In all areas of work, I feel accepted, respected and

supported 56.7 57.0 60.3

In all areas of work, good communication is maintained between colleagues. 62.1 59.2 61.9

(3) Ward Practice

When caring for patients, nurses can make decisions according to their professional judgment. 63.0 63.6 62.1

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Nursing work environment attributes

Improvement Priorities

Response (Percent)T0

N=1194T1

N=1123T2

N=1155

(1) Staffing & ResourcesSufficient staff is allocated for each team. 12.0 13.0 15.7

There is sufficient manpower in wards to maintain quality nursing work. 9.6 11.1 16.5

Work load in wards due to high patient turnover is difficult to handle. * 6.2 6.4 7.6Manpower shortage means staff requests for shifts that meet individual

needs are not possible. *9.0 9.9 11.0

(2) Ward PracticeDocumentation does not reflect the effectiveness of nursing. * 6.9 6.6 8.4Patient and patient relatives’ demands are greater than can be handled by

nurses. *5.1 5.6 7.8

Documentation and charting is often repetitive and redundant. * 6.6 7.9 9.4

Nurses are mistreated by patient relatives when dealing with their enquiries on patient matters. *

5.6 7.4 9.9

When medical incidents occur in wards, complaints are always pointed to be handled by nurses. *

4.0 4.3 5.6

Nurses need to spend time doing non-nursing work, e.g. clerical duties, maintaining equipment. *

5.6 7.0 7.0

Managing patient complaints are always prioritized in wards. * 3.4 5.0 6.4

Nurses feel the work load in wards is unmanageable. * 7.9 8.5 9.8

(3) Management

Senior management does not truly understand the needs of frontline staffs. * 11.4 14.1 15.8

Senior management is not sensitive enough to staff needs. * 8.1 10.4 12.4Senior management does not let staff do what they want. * 11.8 12.9 16.6

In auditing work, senior management makes decisions without considering relevant wards or colleagues. *

11.8 10.5 12.1

Work audit reflects nursing quality. 15.9 17.2 16.7

Conclusion

• The QOCP interventions developed using a

participatory approach demonstrated significant

positive changes in the overall levels of job

satisfaction, turnover intention, and nurses’

perception of their work environment as well as in

patient and nurse outcomes.

• The result findings have pointed to specific areas as

priorities for further improvement to enhancing nurse

and patient outcomes.

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34

NursesThank you

NursesThank you

Happy Staff