For quite some time we have been hearing about Island Health’s[1. Formerly Vancouver Island Health Authority] Care Delivery Model Redesign (CDMR)[2. CDMR is the acronym for Island Health’s Patient Care Model – similar models may be employed in other health authorities under different names], a patient care model that, according to Island Health:
“… not only improves patient care, it enhances the work environment for nursing staff by supporting nurses to work in collaborative teams. The Patient Care Model is based on nurses utilizing the full scope of their high level of training, knowledge and practice, and gives them a key role in health care planning and assessment."[3. http://www.viha.ca/NR/rdonlyres/63276A4E-5CD2-4755-892E-0E420089B75F/0/BoardQAMay2013.pdf]
While the intent behind the CDMR model is admirable, ARNBC has become increasingly concerned by the first-hand stories we have heard from point-of-care nurses working under CDMR. These nurses have indicated that they are struggling with several aspects of the CDMR program, and that staff and patients are suffering as a result.
Specifically, nurses have told us that under this model, their patient loads have increased to the point where they do not believe that they are able to deliver the safe, competent, compassionate and ethical care that their profession mandates. For example, nurses have told us that one RN may be responsible for managing the care of 10 or more acutely ill patients with inadequate professional nursing support because unregulated care aides have replaced so many RN and LPN positions.
Point-of-care nurses report that it is almost impossible to deliver an appropriate level of patient care when overseeing the needs of so many acutely ill patients.We have also heard that there are nurses in management positions who are navigating conflict and uncertainty as these changes unfold.
In other words, rather than helping nurses and other health providers to provide better patient care, what we are hearing is that this new CDMR model is causing nurses undue stress and may be putting patients at risk.
On February 27, 2014, ARNBC was pleased to participate on the panel of MLA Andrew Weaver’s Town Hall on CDMR along with nursing colleagues from the BCNU and the University of Victoria. We heard more first-hand stories from nurses as well as members of the public who are concerned about the impact CDMR is having on their communities. Along with our other nursing colleagues, we believe that it is time to speak up in support of good patient care and a healthcare system that values the health and well-being of its employees.
The Need for Evidence
As time has gone on, we have become increasingly concerned about the lack of evidence and outcome data that has been released by the Health Authority that either supports or refutes CDMR. At the Town Hall Meeting we heard that despite requests from nursing groups and at least one FOI (freedom of information) request, the nursing community in B.C. continues to have no official data to work with when analyzing the impact of CDMR on nurses and on patients. The only information we have to assess the situation is anecdotal stories from nurses who have been directly impacted.
It’s important that provincial research on CDMR be made publicly available so that nursing organizations, nurse researchers and others can thoughtfully and carefully analyze the impact of the program on nurses and other staff, as well as patients and their families. Through better transparency about the planning and evaluation of CDMR, nurses in B.C. would be in a stronger position to collaborate and support Island Health in their goals to improve patient care and enhance the work environment for nursing staff. The well-being of nurses is linked to the well-being of the patients and families they serve.[4. Rodney, P., Buckley, B., Street, A., Serrano, E., & Martin, L.A. (2013). The moral climate of nursing practice: Inquiry and action. In Storch, J., Rodney, P., & Starzomski, R. (Eds.) Toward a moral horizon: Nursing ethics for leadership and practice (2nd ed.; pp. 188-214 ). Toronto: Pearson-Prentice Hall]
There are currently warnings emerging from the United Kingdom about what can happen if we get nurse staffing and care delivery models wrong. A recent report from the United Kingdom discussed a series of public inquiries revealing serious breaches of duty on the part of the Mid Staffordshire NHS Foundation Trust.[5. Francis, R. (2013). Letter to the Secretary of State. In The Mid Staffordshire NHS Foundation Trust Public Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Executive summary (pp. 3-5). London: The Stationery Office]
One nurse expert stated that problems were “fuelled by the hospital management being driven by the achievement of targets – set centrally by the Department of Health – that were paper-based indicators of ‘quality care’ and ‘success’. These were inextricably linked to financial imperatives, which created a culture where, if the numbers look right, then it was assumed that the hospital was providing quality care."[6. Hayter, M. (2013). The UK Francis report: The key messages for nursing. Journal of Advanced Nursing, Vol. 69, No. 8, pages e1-e3, August 2013. Article first published online: 1 Jul 2013 DOI: 10.111/jan.12206]
In addition, a recent article published in The Lancet clearly identifies the significant problems that can arise when staffing mix decisions are not carefully thought out.[7. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study, February 26, 2014]
ARNBC’s Priorities for Staff Mix/Models of Care
Our main priorities as the professional association that represents B.C. Registered Nurses and Nurse Practitioners are to:
1) Ensure that the health of British Columbians is the first and foremost priority of all decision-makers and stakeholders as we work through the complexities of staff mix and care delivery models.
2) Ensure appropriate, evidence-informed decisions are being made about staff mix and care delivery models on the basis of planning and outcome data that are publicly accessible and peer reviewed.
3) Compel government and health authorities to collaborate with nurses around staff mix and care delivery models, and be transparent and accountable for the decisions they make.
4) Promote registered nurses to be supported in every aspect of their professional work and have a safe place to share their concerns.
Fortunately, there are some good national guidelines that can help. In February 2010, the CNA established the Staff Mix: Regulated Nurses and Unregulated Care Providers Working Group. This pan-Canadian group was comprised of RNs, licensed practical nurses (LPNs), registered psychiatric nurses (RPNs), unregulated care providers (UCPs) and a research consultant. The working group defined staff mix decision-making as the act of determining the mix of the different categories of health-care personnel employed for the provision of direct client care. The work resulted in the publication of the Staff Mix Framework which provides direct care nurses and nurse managers with excellent direction and identified five guiding principles that were agreed upon by all participants:
- Decisions concerning staff mix respond to clients’ health-care needs and enable the delivery of safe, competent, ethical, quality, evidence-informed care in the context of professional standards and staff competencies.
- Decision-making regarding staff mix is guided by nursing-care delivery models based on the best evidence related to (a) client, staff and organizational factors influencing quality care and work environments, and (b) client, staff and organizational outcomes.
- Staff mix decision-making is supported by the organizational structure, mission and vision and by all levels of leadership in the organization.
- Direct care nursing staff and nursing management are engaged in decision-making about the staff mix.
- Information and knowledge management systems support effective staff mix decision-making.
Next Steps for ARNBC and How You Can Help
While we have been monitoring the situation in Island Health and listening to the concerns of nurses, ARNBC has become increasingly aware that tensions and stress are rising. We have written about staff mix previously in our blog and with an issue statement, but we are increasingly concerned about the lack of availability of outcome data and related information around CDMR.
In the absence of actual evidence, we can only base our analysis of CDMR on the anecdotal evidence we hear from nurses.
Some components of the CDMR program are good for the healthcare system, good for patients and good for nurses and other team members. As a professional nursing association, ARNBC will work with Island Health and with nurses to have an honest, frank discussion about the program, the outcomes, the stories and the data – and we would hope this discussion could help Island Health to make changes and improvements to CDMR -- changes that would be a win-win for everyone.
ARNBC will undertake further policy work to explore, analyse and make recommendations around Staff Mix and CDMR. We anticipate that this work will further refine ARNBC’s position on staff mix and care delivery models, and will provide a number of recommendations for next steps that can be taken in British Columbia.
In the meanwhile, we invite nurses who have concerns about CDMR to share your stories anonymously in the comments section of this blog (you will be prompted to share your name and email address – please don’t hesitate to make up a name and email address if you are concerned about sharing your information). Or you can email us at email@example.com. Lastly, you can make an anonymous phone call to our Communications Director, Andrea Burton, by calling 604.730.7402. We believe that hearing your stories and impressions of what is happening under CDMR will contribute to ARNBC being better able to support quality health care delivery in British Columbia.
It is time to talk more openly about CDMR, and to take a balanced, thoughtful approach to finding the middle ground between the goals of health authorities and the needs of patients and healthcare providers.
Paddy Rodney, RN, is a nurse educator with a specialty in ethics. Paddy is currently an Associate Professor at the UBC School of Nursing and is affiliated with the UBC Centre for Applied Ethics and the Canadian Bioethics Society. Over the last 25 years, she has lectured and consulted on nursing ethics for nursing associations and unions. Paddy is on the ARNBC Board.