Nursing & Midwifery Crisis Model of Care

COVID - 19 Be Safe -- Be Smart -- Be Kind

Nursing & Midwifery Crisis Model of Care

October 2021


Situation & rationale for change

• We had a Crisis Model of Care in 2020, and thankfully the additional nursesthat we employed was able to meet demand.

• Unfortunately in 2021 the modeling predicts that the COVID-19 demand isgoing to be much higher, within an environment where the workforce isalready stretched.

• Once lockdown is lifted, this will likely lead to significantly more COVID casesas the unvaccinated population and the small percentages of vaccinatedpopulation need hospital care. We have seen this occur overseas.

• There is a need to establish workforce models that will be able to respond toboth the anticipated increase in the number of inpatients and the associatedincrease in personal leave directly due to COVID-19

• A nursing and midwifery crisis model of care and staffing profile for eachsurge level at Western Health has been developed to provide safe patientcare and to ensure that staff workloads are controlled as much as possible


Situation & rationale for change

• Our Crisis Model of Care is planning for the worst, and we hope that it will not need to be implemented.

• If it does need to be implemented, it will likely evolve on a ward/department basis – dependent upon the volume and nature of any surge in demand/activity and the levels of personal leave from nurses/midwives.

• Only in the worst case scenario will this need to be implemented across the whole health service.


Preparation

• The demand for nursing has never been as high, with nurses actively involved in all aspects of the COVID-19 pandemic management - including vaccination, contact tracing and testing. Combined, these take many hundreds of people to undertake these vital roles - and the majority are nurses.

• We have been actively recruiting for months now to build staffing capacity, and to date Western Health has recruited hundreds of additional nurses.

• There is no cap on the number of nurses that we are recruiting - we are trying to get as many staff to join our team to weather any COVID-19 storm that may come our way.

• We have also introduced a new COVID Vaccination Graduate Program, where we recruited an additional 220 graduates onto our team.

• We need to keep on vaccinating, as vaccination is our way out of this pandemic. Similarly testing and contact tracing are essential to identifying and managing outbreaks.

• Central to Western Health's Crisis Model of Care 2021 is having the right people, with right skills, in the right place at the right time.


Preparation

• Many of the roles being undertaken by nurses in Vaccination and Testing can be undertaken by others at the moment, and therefore over the past months Western Health has been actively employing hundreds of additional COVID-19 support roles including:

oRegistered Undergraduate Students of Nursing (RUSON)

oRegistered Undergraduate Students of Midwifery (RUSOM)

oAllied health students

oParamedic students

oPersonal Care Attendants.

• These roles are an ‘emergency authorised’ workforce that are able to be trained to work in the COVID Vaccination Hub and administer vaccine under the delegation and supervision of a nurse.


Details of the change

The introduction of the model may not be a whole of health service determination, butwill likely evolve on a ward/department basis – dependent upon the volume & nature ofany surge in demand/activity & the levels of personal leave (PL) from nurses/midwives.

• Surge 1 – Hospital Vacancy requests (excludes Vaccination and testing hubs) remainbelow 204 per day

• Surge 2 – Hospital vacancy rates are between 205 and 249 per day&/or clinicaldemand/activity dictates that additional beds are needed beyond what can beachieved through business as usual processes.

• Surge 3 – Hospital vacancy rates are above 250 per day &/or clinical demand/activitydictates that additional beds are needed substantially beyond what can be achievedthrough business as usual processes.


Surge 1

Our wards:

• Maintenance of Safe Patient Care Act staffing requirements through business as usualprocesses. Hospital vacancy requests are less than 204 per day, acuity is manageable& replacement of personal leave is achievable with either bank, pool or agency staff.

• Our nurses working in the Vaccination Hub and Testing sites be progressivelyredeployed into our wards and clinical departments when required. This will reducethe number of nurses in Vaccination and Testing to absolute minimum for servicedelivery.

• There will be continuous monitoring to ensure that this is undertaken in a balancedway, with the right timing, to ensure that our wards and clinical departments are keptsafe whilst we continue to vaccinate our community.

• We are working with these staff to educate and support them to make this change,and will put them on supernumerary time initially to help them get settled.


Surge 1

Our Specialty Areas:

• Nurses with post-graduate qualifications have been identified, andtraining is being provided to nurses with previous experience in ICUand ED, to be able to refresh their skills and knowledge.

• Additionally ward nurses that have volunteered to help out in ICUand/or ED are being given training and inducted to working inthe ICU and ED (within their scope of practice) to support ourcritical care and emergency nurses.


Surge 2

Surge 2

• The vacancy request is above 204 per day, together with increaseddemand & clinical acuity may mean that very limitednurses/midwives are available to meet demand.

• Western Health would be forced to implement measures to ensurethat patients continue to receive care.


12 hour shifts:• Night duty may convert to 12 hour shifts. Staff may nominate.• An equal number equivalent of AM shifts to night duty shifts may

convert to 12 hour shifts. Staff may nominate.• The change to 12 hour shifts for some of our staff decreases the overlap

time for double staffing therefore maximises staff social-distancing,increases the hours of direct care reducing pressure on night duty staffand maintains nursing/midwifery ratios for day and nights as long aspossible.

• The changes also increase ‘downtime’ for staff to assist with well-beingand rest between blocks of shifts.

Non-clinical nurse reassignment:• In this instance non-clinical nurses/midwives would be reassigned to

clinical roles where possible.

Surge 2 staffing


Reduction of supernumerary time

• We would look at optimising staff, which maydecrease supernumerary time.

COVID areas:

• We may look at shift times decreasing, whilst paying full shift tomanage fatigue.

Dialysis:

• Dialysis may move to 1:4 ratio

Other areas and departments:

• All other areas with consistent shift staffing requirements ICU,Emergency, Delivery Suite may move to a full 12 hour roster

Surge 2 staffing


May mean that no nurses/midwives are available to meet demand orcover vacancies.

• Western Health would be forced to implement measures to ensure thatpatients continue to receive care.

• Unfortunately, ratios may need to reduce to 1:6, 1:6, 1:8 across acutewards. If this needs to occur, we would attempt to send a COVIDsupport worker (where a nurse/midwife is not available) to work underthe nurses' delegation and supervision so our teams have the samenumber of people This would including RUSON, RUSOM and PCA rolesin wards, and ward nurses in ICU and ED.

• Staff would be working to top of scope, and delegating any aspects oftheir role that can be safely assigned to other roles (including membersof the COVID-19 Support Staff).

Surge 3 staffing


• Any delegated task would be undertaken under the supervision of theRegistered Nurse/Midwife.

• No role would be asked to work outside of their scope of practice oreducational preparation.

Shift times:

• AM eight hour shift shifts may be moved to commence at 06:00

• Afternoon eight hour shifts may commence at 14:30

Further reduction of supernumerary time:

• No supernumerary in charge on shifts

Surge 3 staffing


Registered Nurses role

Working at top of scope within the multidisciplinary team:

• Registered Nurses and Midwives delegate and supervise COVID-19 Support Staff roles in accordance with the NMBA Registered Nurse standards for practice (2016), NMBA Registered Midwife standards for practice (2018) and Decision-making framework for nursing and midwifery (2020)

• Registered Nurses and Midwives can only delegate aspects of care to a COVID-19 Support Staff role, which are consistent with the educational preparation, skill level and assessed competencies of the person being delegated the task.

• RUSONs/RUSOMs/PCAs and any other ‘COVID-19 Support Staff’ roles are not to be given sole allocation of patients


Working at Top of Scope of Practice

• Registered Nurses/Midwives in all areas practice at top of scope

• Move to a team model that is under the delegation and supervision of the RegisteredNurse/Midwife or Specialist Nurse

o Position descriptions developed for new roles

o Activity lists developed as a guidance for safe and appropriate delegation.

Resources are on the COVID-19 microsite


COVID-19 Support Staff roles

Area of care Activity

Hygiene Assist with oral hygiene – brushing teeth, dentures, mouth

wash/toilet

Assist with simple eye care – eye toilet

Toileting Change incontinence pads or aids

Empty, record and provide urinary bottle

Empty and record urinary catheter bag drainage

Manual handling & Mobility Assist with patient transfers, sitting patients out of bed/on

toilet/commode

Assist with provision of pressure area care

Nutrition Assist with safe meal set up, cut up food, adjusting table and

opening packages

Environment Ensure falls prevention strategies are in place – call bell, phone,

bedside table in reach, bed lowered, trip hazards removed

Communication Reporting and/or escalating all care and concerns to supervising

registered nurse/s

Clerical answering and transferring calls/intercom

Documentation Complete fluid balance chart: Oral input and urine output and

report to RN

Maintenance Cleaning and putting away equipment between use i.e. – infusion

pumps, bed frames

Other duties Assist in the care of the deceased patient

Packing and unpacking patient belongings

• Includes:o Staff previously without currency of practice that have

undertaken basic training packages. o Nurses reassigned to a specialty (e.g. ICU) without

formal training or qualifications in that specialty.o Registered Undergraduate Student of Nursing (RUSON)o Registered Undergraduate Student of Midwifery

(RUSOM), and o Personal care assistants (PCA)

• Undertake activities that have been delegated & supervised by a registered nurse

Example of COVID-19 Support Staff Role Activity List:


Hierarchy of delegation

Expert

Ward Nurse

COVID-19 Support Staff Role

Key characteristics of expert RNs and RMs

Possess in-depth clinicalknowledge and experience

• Demonstrate deep understandingof complex situations

• Base decisions on clinicalreasoning and expert intuition

• Address patients’ needsproactively and holistically

• Function as leadersamong bedside RNs, RMs & COVID-19 Support Staff roles

2019 Advisory Board

Move to a team model that is under the delegation and supervision of the Expert Nurse and/or Midwife


Activity lists have been prepared for:

• Medical wards

• Surgical wards

• Rehabilitation wards

• Palliative Care

• ICU

• ED

• CCU

• Dialysis

• Day Oncology

These are designed to support staff delegation and supervision.

COVID-19 Activity Lists


To support this education packages are available for:

• Delegation and supervision

• COVID upskill

• Ward refresher/induction

• ICU Refresher

• ICU (for ward nurses)

• ED

• Higher acuity

• Acute nursing (for subacute nurses)

• Maternity

• PPE Spotting (including Transmission Based Precautions)

Supernumerary placements occurring in areas to support induction, bedside learning and consolidation of skills and education.

Education


Clinical support plans are in place for:

• Increased presence of nursing and midwifery leadership in clinical areas

• Proning teams

• High Acuity Support Teams

• Critical Care Outreach

• Remote visiting support

• Relative Enquiry Line

Supports


Wellbeing and Support – Implemented and ongoing

Promoting Preventing Supporting

Wellbeing Hubs EAP (Expanded Contract) Daily Wellbeing surveillance and follow

up

Wellbeing webinars Manager Support Onsite Psychological Support for hot

spots

RU OK Day? Leading Recovery Program Manager support

Wellbeing Divisional Meetings Building Agility and Fortitude through

multiple targeted sessions

Translational Research

Leadership Development Programs Listening Circles Team development interventions

Wellbeing Inbox Implementing Leadership Capability

program including a focus on wellbeing

Coaching

Wellbeing Microsite A range of targeted nurse development

programs meeting nurses where they

are at in their career.

Wellbeing Newsletters Senior Leadership Group check ins

Weekly Raffle Peer Support Program

Remote work arrangements

Inspire Awards


Wellbeing and Support – Planned

Promoting Preventing Supporting

Bacchus Marsh Melton sites hampers Expansion of Peer support Partnership with Nurse & Midwife

Health Program Expanding pastoral care support Phase 2 Leadership Development

Program

Org wide Pulse 2021 survey

Leadership Capability Framework

include wellbeing

Opt out NUM MUM Manager support

bookings

New sessions recognising early

symptoms of PTSD, Vicarious trauma

etc.

Roving Coaching BMM site – Culture, Capability

Development

Regular structured Schwartz Debriefs

with COVID & SCOVID teams

Compassion Buddy calls Team support for work teams Decompression sessions

Expanding psychological support

services e.g. EAP onsite; Manager

support

Targeted team and manager support for

COVID and SCOVID

Documents

Nursing & Midwifery Crisis Model of Care