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Dr Michael Roche

Biography

Michael is a mental health nurse with experience in clinical, educational, information technology, and management positions in the New South Wales public health system. He has coordinated a number of large research studies, including a State-wide study of nursing workload and patient outcomes, and reviews of the mental health nursing practice environment and postgraduate education. He is currently one of the chief investigators on two ARC-Linkage funded multi-state studies, and a UTS Partnership grant. He is also involved with health services on several site-specific research projects. He has experience in survey research, the analysis of large datasets, and quantitative analysis methods.

Michael’s studies have investigated the links between the practice environment and patient, nurse and system outcomes, including his doctoral work that focused on influences on the therapeutic relationships of nurses working in mental health using a path modeling approach. He supervises PhD, Masters and Honours students studying aspects of the practice environment, mental health interventions, nurse outcomes and nursing leadership. He teaches in the Master of Health Services Management and Bachelor of Nursing programs along with post-graduate research subjects, and on the exploration of administrative data in health services.

Professional

Australian College of Mental Health Nurses

Sigma Theta Tau International

Image of Michael Roche
Senior Lecturer, Faculty of Health
Core Member, Health Services and Practice Research Strength
DipAppSc Nurs (SCAE), BSc Nurs (Syd), MHSc (CSU), PhD (UTS)
Member, Australian College of Mental Health Nurses
 
Phone
+61 2 9514 4811
Room
CB10.07.220

Research Interests

Practice environment
Large datasets
Therapeutic relationships
Mental health
Health services management

Can supervise: Yes

Analysis of routinely collected data
Research methods
Nursing self-awareness, communication and relationships
Working in groups
Fundamentals of quality and safety in the workplace
Information and communication technologies for practice

Chapters

Duffield, C.M., Roche, M.A., Diers, D. & Stasa, H. 2011, 'Australia: What has changed?' in Nelson, S. & Doran, D. (eds), Mapping the field: Nursing scholarship in health human resources, Lawrence S. Bloomberg Faculty of Nursing, Toronto, Ontario, Canada, pp. 25-37.
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This chapter will describe some of the recent changes to health services practice and policy in the Australian context, using as a basis a research study completed in 2007 in New South Wales (NSNSW) (Glueing it together: Nurses, their work environment and patient safety, hereafter referred to as 'The Glue Report'? [Duffield, Roche, O'Brien-Pallas, Diers, Aisbett, King, et al., 2007]) which built on the work of other researchers in health human resources for nursing, and in which Dr. Linda O'Brien-Pallas played a leading role.

Conferences

Roche, M.A., Duffield, C. & Twigg, D. 2015, 'The nursing practice environment 2004-2013', International Council of Nurses Conference, ICN, Seoul, Republic of Korea.
Positive practice environments have been linked to increased nurse satisfaction, nurse retention and better patient outcomes. Nursing workforce shortages have focused greater attention on the importance of retention, in which a positive work environment can play a significant role. This study aimed to examine nurses' perceptions of the quality of the nursing practice environment in Australia, over a ten-year period. In order to address the aim, a secondary analysis was undertaken of nurse survey data collected between 2004-2013, from six acute-care hospitals across three Australian states. Across the period, nurses report a marked increase in instability (being forced to change jobs), a lower intent to leave their current job but also fewer employment opportunities. Broadly, nurse satisfaction with the practice environment is, and remains, positive. However, a decline was noted over the past decade. With large future shortages projected, organizations that aim at improving the nursing work environment may benefit in the form of greater staff retention, higher nurse satisfaction and better quality patient care and outcomes.
Roche, M.A., Laschinger, H.K.S. & Duffield, C. 2015, 'Nursing worklife and turnover intention in Australia and Canada', International Council of Nurses, Seoul, Republic of Korea.
With the worldwide shortage of nurses, retaining staff within fiscally challenged health care systems is critical to sustaining the future of the nursing workforce, and ultimately to safe patient care. This study tests a model, derived from the Nursing Worklife Model, that links elements of a supportive practice environments to nurses' turnover intentions and behaviours in Canada and Australia. A secondary analysis of data collected in two cross-sectional studies in Canada and Australia (n=4816) was conducted. Multigroup structural equation modelling techniques were used to determine the validity of the theoretical model in both countries, and to identify differences between countries. The findings show that the hypothesized model relationships were supported in both countries with few differences between groups. Components of supportive professional practice work environments were significantly linked to nurses' turnover intentions and active search for new jobs. Leadership was a critical factor in shaping the pattern of relationships to other elements of supportive practice environments and turnover behaviours. The Nursing Worklife Model was shown to be valid in both countries.
Roche, M.A. & Duffield, C.M. 2014, 'Nursing Support Workers and Tasks Performed, Delayed or Not Completed', http://www.nursinglibrary.org/vhl/handle/10755/335156, Sigma Theta Tau International 25th International Nursing Research Congress, Hong Kong.
Purpose Direct patient care has been undertaken by a combination of licensed and unlicensed nurses for many years. However, persistent nursing workforce shortages and increased patient acuity and throughput has led to increased employment of large numbers of nursing support workers internationally (Bureau of Labor Statistics, 2013; Health Workforce Australia, 2012; NHS, 2013). Concurrently, tasks formerly completed by registered nurses have moved to the nursing support worker (Gillen & Graffin, 2010; Plawecki & Amrheim, 2010). This change has raised questions regarding the role and effective utilization of support workers. However, there has been limited research on the impact of these workers in the acute hospital workplace. This paper compares the nature of tasks performed, delayed or not completed by nursing support workers and licensed nurses, and the factors associated with these outcomes. Methods This paper reports a secondary analysis of data collected in three studies of medical and surgical units across three states of Australia. Data from a recently completed project were combined with that from two previously reported studies (Duffield et al., 2011; Roche, Duffield, Aisbett, Diers, & Stasa, 2012). In total, data were collected on 132 randomly selected units in 25 public general acute hospitals across three Australian states between 2004 and 2010. Data collection procedures in all studies were similar. All direct personal care workers on the selected wards were asked to complete a survey anonymously. An overall response rate of 60.4% was achieved (3945 of 6528 potential consenting respondents). The survey included demographic items, employment characteristics, six questions on specific tasks performed, and 11 questions on direct-care interventions delayed or left undone at the end of the most recent shift. The survey also included the Practice Environment Scale (Lake, 2002) and the Environmental Complexity Scale (O'Brien-Pallas, Irvine, Peereboom, & Mur...
Roche, M.A. & Duffield, C.M. 2013, 'Nurse Turnover, Patient, Nurse and System Outcomes', Sigma Theta Tau International 24th International Nursing Research Congress, Prague, Czech Republic.
Purpose Workforce shortages and retention are critical issues facing healthcare organizations. Turnover rates in Australia have been estimated at between 12% (Eley et al. 2007) and 38% (Garnett et al. 2008). This variation is also seen internationally, from 14% in the United Kingdom (Frijters, Shields & Wheatley Price 2004), 19.9% in Canada (O'Brien-Pallas et al. 2008), to 39.2% in New Zealand (North et al. 2006). Turnover costs have been estimated to account for 5% of an organisations annual operating budget (Waldman et al. 2004). Both individual and organisation factors have been linked to turnover intention (Duffield, et al. 2009), but the impact of turnover on nurse and patient outcomes have been less frequently examined (Hayes et al. 2012). This study describes the rate and costs of nurse turnover in Australia and investigated the impact of turnover. It is part of an international project to examine the cost of nurse turnover and the impact of turnover on patient safety and nurse health and safety outcomes. Methods Data were collected on 62 nursing units in 11 public general acute hospitals in three states of Australia, for two three-month periods, one year apart, between 2008 and 2010. Data included details of turnover, a unit profile, patient outcomes and demographics, and the nurse survey (Practice Environment Scale (Lake, 2002), job satisfaction (Mueller & McCloskey 1990) and other information). Turnover was defined as the voluntary transfer or resignation of nursing staff from their primary employment position. The turnover rate was calculated in accordance with previous studies (Jones 1990, OBrien-Pallas et al 2006). Ethics approval was granted by seven Human Research Ethics Committees representing the participating hospitals and the university. A total of 1673 Nurse Surveys were received (44% response rate) during this study and over 5000 patient files were audited. In accordance with previous research that found significant differences between nursi...
Baldwin, R.J., Duffield, C.M., Fry, M., Roche, M.A., Stasa, H. & Solman, A. 2013, 'What does a Clinical Nurse Consultant do', ACCCN NSW and ICCMU conference, Australian Critical Care Nurses Association, Sycney, pp. 1-1.
The research collected both quantitative and qualitative data to examine what CNCs do in their current roles It examined role and functions what CNCs did how they went about their jobs how they spent their time was focused more broadly than duties or tasks did not attempt to measure outcomes or validate claims The instrument developed has now been used in three studies into nurses with advance practice roles
Roche, M.A. 2012, 'AINs: Staffing, Skill Mix And Outcomes', Assistants in Nursing Conference, Sydney.
Roche, M.A. & Duffield, C.M. 2011, 'Environmental Influences on the Therapeutic Relationships of Nurses Working in Mental Health', Sigma Theta Tau International 22nd International Nursing Research Congress, Cancun, Mexico.
The therapeutic relationship is considered the central focus of nursing work in mental health and has been linked to patients? involvement in care and patient outcomes (Horvath, 2005). Therefore, factors that may improve or impeded the nurse?s ability to engage effectively in this relationship have the potential to have a corresponding influence on the patient and their outcomes. Studies in mental health and other nursing domains have identified a range of environmental factors that have an influence on nurses (Aiken, et al., 2008; Hanrahan et al., 2008, 2010). This study investigated the impact of characteristics of the work environment on the willingness and ability of nurses to engage in therapeutic relationships.
Roche, M.A., Diers, D. & Duffield, C.M. 2010, 'Nursing resources, workload, the work environment and patient outcomes', National Database of Nursing Quality Indicators 4th Annual Data Use Conference, New Orleans, United States.
Kelly, M.A., Forber, J., Conlon, L.S., Stasa, H. & Roche, M.A. 2010, 'Empowering the RNs of tomorrow: pre and post simulation analysis of clinical skill parameters related to deteriorating patients', SimTecT Health, Melbourne.
Final year Bachelor of Nursing students in an adult medical surgical subject engaged in a deteriorating patient simulation encounter. Local Ethics Review Committee approval was obtained for the study. Sixty two students agreed to participate in the study and completed consent and confidentiality forms. A pre-simulation survey consisting of ten questions, with a 4 point Likert scale response was completed immediately prior to the activity. Students participated either actively in predetermined roles or as observers with structured questions to address and discuss during the debriefing. A post-simulation survey, of identical questions, was completed immediately after the simulation encounter.
Roche, M.A. & Duffield, C.M. 2009, 'Aggression Towards Nurses', International Council of Nurses 24th Quadrennial Congress 2009, Durban, South Africa.
Roche, M. 2009, 'The mental health work environment and therapeutic relationships', INTERNATIONAL JOURNAL OF MENTAL HEALTH NURSING, pp. A21-A21.
Roche, M.A. & Duffield, C.M. 2005, 'Methods of measuring nursing workload in Australia', International Council of Nurses 23rd Quadrennial Congress, Taipei.
Sara, G., Gill, K., Pennock, J., Gomez, F., Woodland, L., Siggens, A. & Roche, M.A. 2002, 'Service Structures For Population Mental Health What Do We Need And Where Is The Evidence?', THE AUSTRALIAN AND NEW ZEALAND COLLEGE OF PSYCHIATRISTS 37TH ANNUAL CONGRESS, Blackwell Publishing Asia, Brisbane, pp. 846-849.
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Journal articles

Wise, S., Fry, M., Duffield, C., Roche, M. & Buchanan, J. 2015, 'Ratios and nurse staffing: The vexed case of emergency departments', Australasian Emergency Nursing Journal, vol. 18, no. 1, pp. 49-55.
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Background: Within Australia nursing unions are pursuing mandated nurse-patient ratios to safeguard patient outcomes and protect their members in healthcare systems where demand perpetually exceeds supply. Establishing ratios for an emergency department is more contentious than for hospital wards. The study's aim was to estimate average staffing levels, skill mix and patient presentations in all New South Wales (NSW) Emergency Departments (EDs). Methods: The design was a retrospective historical census audit. Nurse rosters and patient presentation data were collected for three randomly selected census days in May 2010. Twenty-six valid responses out of 44 were returned. A ratio of the number of beds per nurse was calculated as well as skill mix and bed occupancy. Results: The average beds per nurse ratios found were 3.8 (morning shift), 3.6 (evening), and 5.1 (night). However, ratios as high as 8.4 (morning), 7.3 (evening) and 16.0 (night) were identified on particular shifts. Overall a rich skill mix was found with an average of 90% of nursing hours being provided by Registered Nurses. The average daily bed occupancy of 4 patients per bed was similar across ED levels. Conclusions: The study adds to the limited literature on ED staffing and demonstrates the utility in the simplicity of ratios in flagging potential staffing problems. The audit revealed wide variation in staffing levels which was not always linked to patient activity. Of particular concern were the regional EDs (Level 5) which have the capacity to deal with all types of emergencies but where ratios as high as 7 beds per nurse were found during the day. Ratios cannot be used to determine the optimal staffing levels in every clinical situation; their purpose is to force an increase in nursing supply and to prevent individual units from becoming understaffed.
Elliott, D., Allen, E., Perry, L., Fry, M., Duffield, C., Gallagher, R., Iedema, R., McKinley, S. & Roche, M. 2015, 'Clinical user experiences of observation and response charts: Focus group findings of using a new format chart incorporating a track and trigger system', BMJ Quality and Safety, vol. 24, no. 1, pp. 65-75.
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Background: Optimising clinical responses to deteriorating patients is an international indicator of acute healthcare quality. Observation charts incorporating track and trigger systems are an initiative to improve early identification and response to clinical deterioration. A suite of track and trigger 'Observation and Response Charts' were designed in Australia and initially tested in simulated environments. This paper reports initial clinical user experiences and views following implementation of these charts in adult general medical-surgical wards. Methods: Across eight trial sites, 44 focus groups were conducted with 218 clinical ward staff, mostly nurses, who received training and had used the charts in routine clinical practice for the preceding 2-6 weeks. Transcripts of audio recordings were analysed for emergent themes using an inductive approach. Findings: In this exploration of initial user experiences, key emergent themes were: tensions between vital sign 'ranges versus precision' to support decision making; using a standardised 'generalist chart in a range of specialist practice' areas; issues of 'clinical credibility', 'professional autonomy' and 'influences of doctors' when communicating abnormal signs; and 'permission and autonomy' when escalating care according to the protocol. Across themes, participants presented a range of positive, negative or mixed views. Benefits were identified despite charts not always being used up to their optimal design function. Participants reported tensions between chart objectives and clinical practices, revealing mismatches between design characteristics and human staff experiences. Overall, an initial view of 'increased activity/uncertain benefit' was uncovered. Conclusions: Findings particularly reinforced the significant influences of organisational work-based cultures, disciplinary boundaries and interdisciplinary communication on implementation of this new practice chart. Optimal use of all chart design chara...
Roche, M.A., Laschinger, H.K.S. & Duffield, C. 2015, 'Testing the Nursing Worklife Model in Canada and Australia: A multi-group comparison study', International Journal of Nursing Studies, vol. 52, no. 2, pp. 525-534.
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Study aim: To test a model derived from the Nursing Worklife Model linking elements of supportive practice environments to nurses' turnover intentions and behaviours in Canada and Australia. Background: With the worldwide shortage of nurses, retaining nurses within fiscally challenged health care systems is critical to sustaining the future of the nursing workforce and ultimately safe patient care. The Nursing Worklife Model describes a pattern of relationships amongst environmental factors that support nursing practice and link to nurse turnover. This model has been tested in north American settings but not in other countries. Methods: A secondary analysis of data collected in two cross-sectional studies in Canadian and Australian hospitals ( N= 4816) was conducted to test our theoretical model. Multigroup structural equation modelling techniques were used to determine the validity of our model in both countries and to identify differences between countries. Results: The hypothesized model relationships were supported in both countries with few differences between groups. Components of supportive professional practice work environments, particularly resources, were significantly linked to nurses' turnover intentions and active search for new jobs. Leadership played a critical role in shaping the pattern of relationships to other components of supportive practice environments and ultimately turnover behaviours. Conclusion: The Nursing Worklife Model was shown to be valid in both countries, suggesting that management efforts to ensure that features of supportive practice environments are in place to promote the retention of valuable nursing resources.
Duffield, C.M., Roche, M.A., Dimitrelis, S., Homer, C. & Buchan, J. 2015, 'Instability in patient and nurse characteristics, unit complexity and patient and system outcomes.', J Adv Nurs, vol. 71, no. 6, pp. 1288-1298.
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AIMS: To explore key factors related to nursing unit instability, complexity and patient and system outcomes. BACKGROUND: The relationship between nurse staffing and quality of patient outcomes is well known. The nursing unit is an important but different aspect that links to complexity and to system and patient outcomes. The relationship between the instability, complexity and outcomes needs further exploration. DESIGN: Descriptive. METHODS: Data were collected via a nurse survey, unit profile and review of patient records on 62 nursing units (wards) across three states of Australia between 2008-2010. Two units with contrasting levels of patient and nurse instability and negative system and patient outcomes, were profiled in detail from the larger sample. RESULTS: Ward A presented with greater patient stability (low occupancy, high planned admissions, few ICU transfers, fewer changes to patient acuity/work re-sequencing) and greater nurse instability (nurses changing units, fewer full-time staff, more temporary/casual staff) impacting system outcomes negatively (high staff turnover). In contrast, Ward B had greater patient instability, however, more nurse stability (greater experienced and permanent staff, fewer casuals), resulting in high rates for falls, medication errors and other adverse patient outcomes with lower rates for system outcomes (lower intention to leave). CONCLUSION: Instability in patient and nurse factors can contribute to ward complexity with potentially negative patient outcomes. The findings highlight the variation of many aspects of the system where nurses work and the importance of nursing unit managers and senior nurse executives in managing ward complexity.
Zugai, J.S., Stein-Parbury, J. & Roche, M. 2015, 'Therapeutic Alliance in Mental Health Nursing: An Evolutionary Concept Analysis', ISSUES IN MENTAL HEALTH NURSING, vol. 36, no. 4, pp. 249-257.
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Roche, M.A., Duffield, C., Dimitrelis, S. & Frew, B. 2015, 'Leadership skills for nursing unit managers to decrease intention to leave', Nursing: Research and Reviews, vol. 5, pp. 57-64.
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Aim: To examine specific elements of nursing leadership linked to intention to leave, in public acute care hospitals. Background: Nurse turnover is a global issue receiving widespread attention due to prolonged and projected workforce shortages. Nurse management and leadership qualities have been associated with intention to leave and turnover of nurses. The role of the nurse unit managers in the retention of nurses is becoming increasingly important, particularly because of their strong influence on the quality and stability of the work environment. Methods: Data were collected from 62 medical, surgical, and mixed units across eleven public acute care hospitals in three Australian states (September 2008 to August 2010). A total of 1,673 nurses completed a nurse survey that included measures of intention to leave and leadership aspects of the practice environment. Analyses explored specific leadership characteristics that were associated with turnover intent. Results: The role of nursing unit managers was confirmed to be a major factor in nurses' intention to remain or leave their current workplace. Nurses valued 'human' skills more highly than other leadership characteristics, including their manager's connection with nurses' concerns, clarity, participation in decisions, and encouragement. Conclusion: Strong leadership qualities in the nursing unit manager have been associated with greater job satisfaction, reduced turnover intention among nursing staff, and improved patient outcomes. Nurse leaders need to be supported in an effort to retain nurses given ongoing workforce issues and to ensure high-quality patient care.
Kelly, M.A., Forber, J., Conlon, L., Roche, M. & Stasa, H. 2014, 'Empowering the registered nurses of tomorrow: Students' perspectives of a simulation experience for recognising and managing a deteriorating patient', Nurse Education Today, vol. 34, no. 5, pp. 724-729.
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Background: Recognising and responding to patients who are deteriorating are key aspects to improving outcomes. Simulations provide students with exposure to deteriorating patient scenarios and the role of nurses in such events. The number of programmes seeking to provide best possible simulation experiences is growing exponentially. Robust evaluation of these experiences is crucial to ensure maximum benefit. Objectives: To assess the impact of a deteriorating patient simulation experience on students' technical and communication skills; and to determine if differing study programmes and years of previous nursing experience influenced students' responses and experiences. Methods: A convenience sample of final year nursing students (N=57) in a medical-surgical course at a large urban university completed a descriptive pre/post simulation survey rating their technical skills and communication abilities in recognising and responding to patient deterioration. Changes in pre/post scores were analysed including influence of study programme (3-year, 2-year Enrolled Nurse, 2-year Graduate Entry); gender; and years nursing experience (beyond course clinical practicum). Results: Statistically significant improvements in post-simulation survey scores were demonstrated for combined student group data. Students with greater years of nursing experience had statistically higher scores than those with less experience in both pre- and post-surveys. Specific improvements were identified for: assessing a deteriorating patient; and in seeking help from the medical officer or external service. Conclusions: All student groups gained benefit in participating in a deteriorating patient simulation. For this group, greater years of prior nursing experience led to higher pre- and post-survey scores. The learning activity provided students an experience of the importance of recognising and responding to an acute situation in a timely manner which may be recalled in subsequent clinical situa...
Blay, N., Duffield, C.M., Gallagher, R. & Roche, M. 2014, 'A systematic review of time studies to assess the impact of patient transfers on nurse workload', International Journal of Nursing Practice, vol. 20, no. 6, pp. 662-673.
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Patients in hospital are increasingly being moved between clinical units and between bedspaces; however, the impact of patient transfers and bedspace moves on nurses' workload is not known. Time studies are an established observational research method that can be used to determine the duration of time taken to perform an activity or process. This review systematically searched four databases for literature published between 2000 and 2013 for observational time study techniques and patient transfers as a nurse activity. Eleven publications from three countries were included in the review. All studies used timing techniques to explore nurse work associated with the transfer process. The review highlights the duration of time spent by nurses on certain aspects of the transfer process. However, as few studies published results from timings, the impact on nurse time is likely to be higher than indicated. Further research is recommended.
Dawson, A.J., Stasa, H., Roche, M.A., Homer, C.S.E. & Duffield, C. 2014, 'Nursing churn and turnover in Australian hospitals: Nurses perceptions and suggestions for supportive strategies', BMC Nursing, vol. 13, no. 1.
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Background: This study aimed to reveal nurses' experiences and perceptions of turnover in Australian hospitals and identify strategies to improve retention, performance and job satisfaction. Nursing turnover is a serious issue that can compromise patient safety, increase health care costs and impact on staff morale. A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories.Method: A qualitative design was used to analyze responses from 362 nurses collected from a national survey of nurses from medical and surgical nursing units across 3 Australian States/Territories.Results: Key factors affecting nursing turnover were limited career opportunities; poor support; a lack of recognition; and negative staff attitudes. The nursing working environment is characterised by inappropriate skill-mix and inadequate patient-staff ratios; a lack of overseas qualified nurses with appropriate skills; low involvement in decision-making processes; and increased patient demands. These issues impacted upon heavy workloads and stress levels with nurses feeling undervalued and disempowered. Nurses described supportive strategies: improving performance appraisals, responsive preceptorship and flexible employment options.Conclusion: Nursing turnover is influenced by the experiences of nurses. Positive steps can be made towards improving workplace conditions and ensuring nurse retention. Improving performance management and work design are strategies that nurse managers could harness to reduce turnover. © 2014 Dawson et al.; licensee BioMed Central Ltd.
Duffield, C.M., Twigg, D.E., Pugh, J.D., Evans, G., Dimitrelis, S. & Roche, M.A. 2014, 'The Use of Unregulated Staff: Time for Regulation?', Policy, Politics, and Nursing Practice, vol. 15, no. 1-2, pp. 42-48.
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Internationally, shortages in the nursing workforce, escalating patient demands, and financial constraints within the health system have led to the growth of unlicensed nursing support workers. Recently, in relation to the largest publicly funded health system (National Health Service), it was reported that extensive substitution of registered nurses with unskilled nursing support workers resulted in inadequate patient care, increased morbidity and mortality rates, and negative nurse outcomes. We argue that it is timely to consider regulation of nursing support workers with their role and scope of practice clearly defined. Further, the addition of these workers in a complementary model of care (rather than substitutive model) should also be explored in future research, in terms of impact on patient and nurse outcomes. © The Author(s) 2014 Reprints and permissions:]br]sagepub.co.uk/journalsPermissions.nav.
Blay, N., Duffield, C.M., Gallagher, R.D. & Roche, M.A. 2014, 'A systematic review of time studies to assess the impact of patient transfers on nurse workload', International Journal of Nursing Practice, vol. 20, pp. 662-673.
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Patients in hospital are increasingly being moved between clinical units and between bedspaces; however, the impact of patient transfers and bedspace moves on nurses workload is not known. Time studies are an established observational research method that can be used to determine the duration of time taken to perform an activity or process. This review systematically searched four databases for literature published between 2000 and 2013 for observational time study techniques and patient transfers as a nurse activity. Eleven publications from three countries were included in the review. All studies used timing techniques to explore nurse work associated with the transfer process. The review highlights the duration of time spent by nurses on certain aspects of the transfer process. However, as few studies published results from timings, the impact on nurse time is likely to be higher than indicated. Further research is recommended.
Roche, M.A., Duffield, C.M., Homer, C., Buchan, J. & Dimitrelis, S. 2014, 'The rate and cost of nurse turnover in Australia', Collegian.
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Nurse turnover is a critical issue facing workforce planners across the globe, particularly in light of protracted and continuing workforce shortages. An ageing population coupled with the rise in complex and chronic diseases, have contributed to increased demands placed on the health system and importantly, nurses who themselves are ageing. Costs associated with nurse turnover are attracting more attention; however, existing measurements of turnover show inconsistent findings, which can be attributed to differences in study design, metrics used to calculate turnover and variations in definitions for turnover. This paper will report the rates and costs of nurse turnover across three States in Australia. © 2014.
Blay, N., Duffield, C.M., Gallagher, R. & Roche, M. 2014, 'Methodological integrative review of the work sampling technique used in nursing workload research', Journal of Advanced Nursing, vol. 70, no. 11, pp. 2434-2449.
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To critically review the work sampling technique used in nursing workload research. Background: Work sampling is a technique frequently used by researchers and managers to explore and measure nursing activities. However, work sampling methods used are diverse making comparisons of results between studies difficult. Design: Methodological integrative review. Data Sources: Four electronic databases were systematically searched for peer-reviewed articles published between 2002-2012. Manual scanning of reference lists and Rich Site Summary feeds from contemporary nursing journals were other sources of data. Review Methods: Articles published in the English language between 2002-2012 reporting on research which used work sampling to examine nursing workload. Results: Eighteen articles were reviewed. The review identified that the work sampling technique lacks a standardized approach, which may have an impact on the sharing or comparison of results. Specific areas needing a shared understanding included the training of observers and subjects who self-report, standardization of the techniques used to assess observer inter-rater reliability, sampling methods and reporting of outcomes. Conclusion: Work sampling is a technique that can be used to explore the many facets of nursing work. Standardized reporting measures would enable greater comparison between studies and contribute to knowledge more effectively. Author suggestions for the reporting of results may act as guidelines for researchers considering work sampling as a research method.
Elliott, D., McKinley, S., Perry, L., Duffield, C., Iedema, R., Gallagher, R., Fry, M., Roche, M. & Allen, E. 2014, 'Clinical utility of an observation and response chart with human factors design characteristics and a track and trigger system: Study protocol for a two-phase multisite multiple-methods design', Journal of Medical Internet Research, vol. 16, no. 8, pp. e40-e40.
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Background: Clinical deterioration of adult patients in acute medical-surgical wards continues to occur, despite a range of systems and processes designed to minimize this risk. In Australia, a standardized template for adult observation charts using human factors design principles and decision-support characteristics was developed to improve the detection of and response to abnormal vital signs. Objective: To describe the study protocol for the clinical testing of these observation and response charts (ORCs). Methods: We propose a two-phase multisite multiple-methods design to test the initial clinical utility of the charts in 10 hospitals of differing types and sizes across state jurisdictions in Australia. Data collection in the first phase includes user surveys, observations and field notes by project officers, handover de-briefs (short interviews with small groups of staff), and an audit of ORC documentation completion compared to the site's existing observation chart. For the second phase, data will be collected using a retrospective audit of observation documentation from the previous hospital observation chart, prospective audit of observation documentation following implementation of the selected ORC, user focus groups, observational field notes, and patient outcome data from routinely collected organizational data sources. Results: Site selection and preparation, project officer training, chart selection and implementation, participant recruitment, and data collection has been completed and the analysis of these results are in progress. Conclusions: This detailed description of these study methods and data collection approaches will enable a comprehensive assessment of the clinical utility of these newly developed track and trigger charts and will be useful for clinicians and researchers when planning and implementing similar studies. Potential methodological limitations are also noted.
Duffield, C.M., Roche, M.A., Homer, C., Buchan, J. & Dimitrelis, S. 2014, 'A comparative review of nurse turnover rates and costs across countries', Journal of Advanced Nursing, vol. 70, no. 12, pp. 2703-2712.
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Aims: To compare nurse turnover rates and costs from four studies in four countries (US, Canada, Australia, New Zealand) that have used the same costing methodology; the original Nursing Turnover Cost Calculation Methodology. Background: Measuring and comparing the costs and rates of turnover is difficult because of differences in definitions and methodologies. Design: Comparative review. Data Sources: Searches were carried out within CINAHL, Business Source Complete and Medline for studies that used the original Nursing Turnover Cost Calculation Methodology and reported on both costs and rates of nurse turnover, published from 2014 and prior. Methods: A comparative review of turnover data was conducted using four studies that employed the original Nursing Turnover Cost Calculation Methodology. Costing data items were converted to percentages, while total turnover costs were converted to US 2014 dollars and adjusted according to inflation rates, to permit cross-country comparisons. Results: Despite using the same methodology, Australia reported significantly higher turnover costs ($48,790) due to higher termination (~50% of indirect costs) and temporary replacement costs (~90% of direct costs). Costs were almost 50% lower in the US ($20,561), Canada ($26,652) and New Zealand ($23,711). Turnover rates also varied significantly across countries with the highest rate reported in New Zealand (443%) followed by the US (268%), Canada (199%) and Australia (151%). Conclusion: A significant proportion of turnover costs are attributed to temporary replacement, highlighting the importance of nurse retention. The authors suggest a minimum dataset is also required to eliminate potential variability across countries, states, hospitals and departments.
Mather, B., Roche, M. & Duffield, C. 2014, 'Disparities in Treatment of People With Mental Disorder in Non-Psychiatric Hospitals: A Review of the Literature', Archives of Psychiatric Nursing, vol. 28, no. 2, pp. 80-86.
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People with mental disorder experience a heavy burden of physical ill-health. This, alongside structural health-system changes, means more people with mental disorder are being cared for in non-psychiatric hospitals. This article reports on 32 studies that have investigated the care and outcomes of people with comorbid mental and physical health problems in non-psychiatric hospitals. Prevalence of mental disorder ranged between 4%-46%, and rates of psychiatric referral was 2%-10%. The receipt of invasive cardiac procedures was markedly reduced for those with mental disorder. Likelihood of experiencing an adverse event, post-operative complication or increased length of stay was also elevated for those with mental disorder. © 2014 Elsevier Inc.
Duffield, C., Baldwin, R., Roche, M. & Wise, S. 2014, 'Job enrichment: Creating meaningful career development opportunities for nurses', Journal of Nursing Management, vol. 22, no. 6, pp. 697-706.
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Aim: This paper presents an evaluation of a career development policy in South Australia which increased the number of senior staff nurse positions and provided senior registered nurses with time away from clinical duties to undertake agreed projects. We use Kanter's model of structural power and commitment theory to understand the dimensions of this policy. Background: Development strategies for experienced staff who wish to remain at the bedside are needed, especially in smaller health services with limited opportunities for horizontal or vertical mobility. Methods: Face-to-face semistructured interviews were conducted with 54 senior staff nurses who participated in the career structure arrangements. Results: The policy enhanced the structure of opportunity in three ways: by increasing the number of senior staff nurse positions, the ladder steps were improved; undertaking strategic projects developed new skills; and the job enrichment approach facilitated time out from the immediate pressures of ward work and challenged nurses in a different way. Conclusions: Through job enrichment, South Australia has found a novel way of providing meaningful career development opportunities for experienced nurses. Implications for nursing management: Methods of job enrichment need to be considered as part of career development policy, especially where movement between clinical facilities is limited and staff wish to remain at the bedside.
Gallagher, R., Gallagher, P., Roche, M., Fry, M., Chenoweth, L. & Stein-Parbury, J. 2014, 'Nurses' perspectives of the impact of the older person on nursing resources in the emergency department and their profile: A mixed methods study', International Emergency Nursing.
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Background: Nurses provide the majority of care in the ED, so increases in the number of older people (?60 years) may impact nursing workload and provision of care. Aim: To determine whom, of older people, emergency nurses perceive as using the most nursing resources and to profile this subgroup from the ED dataset, including illustrative cases. Method: A mixed-methods design study in a metropolitan hospital. Data were collected from focus group interviews with emergency nursing staff (n = 27), from the patient dataset for the corresponding year, and an audit of 13 patients' medical records. Results: Emergency nurses perceived that the highest demand for their resources came from the older persons representing multiple times in short timeframes (cluster presenter). Cluster presenters had a longer length of stay and required intensive nursing time and vigilance because they had one or more chronic illnesses and comorbid conditions such as limited mobility and dementia. Cluster presenters had to have a full assessment each presentation, were usually admitted to the hospital and admitting specialists were reluctant to assume care. Conclusion: Emergency nurses associate a high workload with cluster presenters for reasons including ED processes and availability of expertise. Further research should examine more objectively and precisely nursing workload in this area.
Fry, M., Duffield, C., Baldwin, R., Roche, M., Stasa, H. & Solman, A. 2013, 'Development of a tool to describe the role of the clinical nurse consultant in Australia', Journal of Clinical Nursing, vol. 22, no. 11-12, pp. 1531-1538.
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Aims and objectives. To develop a tool for defining and measuring the role characteristics and responsibilities of an advanced practice nursing role in Australia. Background. Internationally, there is considerable confusion about the precise role responsibilities of advanced practice nursing positions. In Australia, the clinical nurse consultant is an advanced practice role with five nominated domains of practice. However, there are no tools for measuring the performance of clinical nurse consultants against the listed domains. Design and methods. Participants were 56 clinical nurse consultants at a tertiary public hospital. The existing literature, an online survey, and position descriptions were used to generate the a priori themes for the initial template. Semi-structured interviews were conducted (in 2010) to test the template characteristics. The template underwent multiple iterations in its development. Results. A 50-item tool was devised, which consisted of five domains with a ten-point hierarchical scale within each domain. In preliminary testing, the revised template was found to provide greater clarity regarding roles and grades than the original position descriptions. Conclusions. Further testing and refinement of the modified rating scale is needed, but it offers the possibility of a new tool that can be used by health service managers to determine the grade of a clinical nurse consultant position and for evaluating role performance. Relevance to clinical practice. This preliminary study suggests that the tool provides a useful means of measuring advanced nursing practice and responsibilities across different domains and levels of appointment. The tool may be able to be adapted for use with other advanced practice nursing roles both within Australia and internationally. © 2012 Blackwell Publishing Ltd.
Fry, M., Horvat, L., Roche, M., Fong, J. & Plowes, J. 2013, 'A four month prospective descriptive exploratory study of patients receiving antibiotics in one Emergency Department', INTERNATIONAL EMERGENCY NURSING, vol. 21, no. 3, pp. 163-167.
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Baldwin, R., Duffield, C.M., Fry, M., Roche, M., Stasa, H. & Solman, A. 2013, 'The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study', International Journal of Nursing Studies, vol. 50, no. 3, pp. 326-334.
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Background: The NSW Health Policy Directive (NSW Department of Health, 2000) lists clinical service and consultancy; clinical leadership; research; education; clinical services planning and management as the five domains of practice for nurses appointed as Clinical Nurse Consultants (CNCs), an Australian advanced practice nurse (APN) role. However, there is no clear definition of what is meant by advanced practice in the Australian nursing context. Nowhere is this more evident than in differentiating between the roles of Clinical Nurse Consultants (CNCs) and Nurse Practitioners (NP) in NSW. To date, limited empirical research has been done to characterise or delineate CNC role activity and responsibility. Objectives: To investigate (i) the nature of CNC roles, activities and responsibilities, (ii) differentiate between CNCs by their work patterns and activities, and (iii) empirically conceptualise and differentiate ways CNCs practice in terms of an APN typology. Participants: The study sample was 56 CNCs at one tertiary level public hospital in Australia. Methods: A descriptive exploratory cohort study was conducted to explore CNC role characteristics and patterns of activity. Data were triangulated using an online survey, a follow-up survey, and semi-structured interviews. The data were analysed using descriptive statistics to examine differences between CNC work patterns and role activities. The survey data and the individual reports were thematically analysed to investigate for difference across the population of CNCs. Results: Interpretation of survey and interview data led to an analyst-developed CNC typology of four CNC categories based on the work patterns and activities of Sole Practitioner, Clinic Coordinator, Clinical Team Coordinator and Clinical Leader. The typology was based on the themes interprofessional, role focus, clinical focus and setting as these themes distinguished and differentiated CNC roles. Conclusions: The study provides evidence of gr...
Zugai, J., Stein-Parbury, J. & Roche, M. 2013, 'Effective nursing care of adolescents with anorexia nervosa: A consumer perspective', Journal of Clinical Nursing, vol. 22, no. 13-14, pp. 2020-2029.
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Aims and objectives: To establish how nurses ensure weight gain and a positive inpatient experience for the treatment of adolescents with anorexia nervosa by considering consumer perspectives. Background: Consumer perspective literature indicates approval and dissatisfaction with certain aspects of the inpatient experience, and there is a limited understanding of what consumers perceive to be effective nursing practice. Design: The design of this study was qualitative, the data being interpreted with a thematic analysis. Methods: This study sought the perspectives of eight (n = 8) recovered consumers through semi-structured interviews. Results: Nurses were considered highly influential over the inpatient experience. The findings of this study are characterised by three overall themes regarding nursing practice: (1) ensuring weight gain, (2) maintaining a therapeutic milieu, and (3) the nursing relationship. Conclusions: Consumers have clear perspectives of how nurses effectively ensure weight gain and how nurses ensure a positive inpatient experience. The quality of relationships between consumers and nurses had implications for both weight gain and the perceived quality of the inpatient experience. By relying on the strength of positive, thoughtful and well-timed interactions, nurses may contribute to productive physical outcomes and a positive inpatient experience. Consumers indicated that motivation to adhere to care was derived from strong relationships with nurses. Ensuring both weight gain and a positive experience involves achieving a productive 'balance of restrictions'. Consumers also valued nurses that created a comfortable and productive environment. Relevance to clinical practice: This study indicates that the process of weight gain may be enhanced when accompanied by a process of therapeutic engagement. Therapeutic alliance may be an effective way for nurses to ensure weight gain and an enhanced inpatient experience. Therapeutically beneficial relati...
Roche, M., Duffield, C., Wise, S., Baldwin, R., Fry, M. & Solman, A. 2013, 'Domains of practice and Advanced Practice Nursing in Australia', Nursing and Health Sciences, vol. 15, no. 4, pp. 497-503.
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A key component of workforce reform is the international growth in Advanced Practice Nursing (APN) roles. This study evaluated one APN role in Australia, the Clinical Nurse Consultant (CNC). All 56 CNCs employed in a tertiary hospital in New South Wales took part in the study. Demographic and work activity data were collected by an online questionnaire. Face-to-face interviews included the administration of a 50-point tool to score the level of practice of each CNC against five domains. The domains of practice did not appear to have played a central role in the design of these CNC roles despite being defined in the industrial legislation and linked to a pay structure. There was widespread variability in the level of practice both within and between the CNC grades as well as significant differences in job content. Few CNCs managed to achieve a moderate level of practice across all five domains. The findings suggest that the distinctive features of the CNC roles as articulated in the domains of practice are often not realized in practice. © 2013 Wiley Publishing Asia Pty Ltd.
Roche, M., Duffield, C., Aisbett, C., Diers, D. & Stasa, H. 2012, 'Nursing work directions in Australia: Does evidence drive the policy?', Collegian, vol. 19, no. 4, pp. 231-238.
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A significant body of research has shown a relationship between nurse staffing (in particular, skill-mix: the proportion of Registered Nurses [RNs]) and both morbidity and mortality. This relationship is typically investigated by measuring the incidence of Nursing Sensitive Outcomes (NSOs) under different skill-mix levels. Yet whilst the evidence suggests that richer skill-mix is associated with a lower incidence of NSOs, recent Australian policy reforms have proposed the replacement of Registered Nurses with less qualified staff. The present study sought to examine the relationship between staffing, skill-mix, and incidence of NSOs at two hospitals in one Australian state. The study sought to determine the rate of occurrence of several NSOs, the relationship of skill-mix to that rate, and the number of patients affected per annum. It was found that the current rate of NSOs across wards ranged from 0.17% to 1.05%, and that there was an inverse relationship between the proportion of hours worked by RNs and NSO rates: an increase of 10% in the proportion of hours worked by RNs was linked to a decrease in NSO rates by between 11% and 45%. It was estimated that increasing the RN staffing percentage by 10% would mean 160 fewer adverse outcomes for patients per year across these two hospitals. Importantly, increases in nursing hours overall (without increases in skill-mix) had no significant effect on patient outcomes. These findings challenge current policy recommendations, which propose increasing the number of unregistered staff without increasing skill-mix. © 2012 Royal College of Nursing, Australia.
Fry, M., Horvat, L., Roche, M.A., Fong, J. & Plowes, J. 2012, 'The prevalence and triage characteristics of patients presenting with infection to one tertiary referral hospital', Australasian Emergency Nursing Journal, vol. 15, pp. 127-132.
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Globally, severe infection and or sepsis is a problem that is costing billions of dollars, using hundreds of hospital beds, and often results in patient death. Any infection can potentially develop a sepsis health trajectory if left unrecognised and unmanaged. We conducted a 12 month retrospective descriptive exploratory study. Our research explored the prevalence and triage characteristics of patients presenting with infection to one tertiary referral hospital. Electronic medical records were reviewed to identify patients that had a primary diagnosis related to infection. The study identified that 16% (n = 7756) of adult presentations had a discharge diagnosis related to infection. A significant difference (X2 = 297.83, df = 4, p .001) in Triage Code allocation for the infection group was identified compared with the non-infection patient group. Thirty-nine percent (n = 3027) of patients with infections were admitted to hospital. Of the patients (n = 1930; 4%) admitted to a critical care area, 6% (n = 122) had a primary diagnosis related to infection. Of the ED deaths (n = 81), 12% (n = 10) had a primary diagnosis related to infection.
Duffield, C.M., Roche, M.A., Blay, N. & Stasa, H. 2011, 'Nursing unit managers, staff retention and the work environment', Journal of Clinical Nursing, vol. 20, no. 1-2, pp. 23-33.
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Aim and objective: This paper examined the impact of leadership characteristics of nursing unit managers, as perceived by staff nurses, on staff satisfaction and retention. Background. A positive work environment will increase levels of job satisfaction and staff retention. Nurse leaders play a critical role in creating a positive work environment. Important leadership characteristics of the front-line nurse manager include visibility, accessibility, consultation, recognition and support. Design: Secondary analysis of data collected on 94 randomly selected wards in 21 public hospitals across two Australian states between 2004-2006. Methods: All nurses (n = 2488, 803% response rate) on the selected wards were asked to complete a survey that included the 49-item Nursing Work Index-Revised [NWI-R] together with measures of job satisfaction, satisfaction with nursing and intention to leave. Subscales of the NWI-R were calculated. Leadership, the domain of interest, consisted of 12 items. Wards were divided into those reporting either positive or negative leadership. Data were analysed at the nurse level using spss version 16. Results: A nursing manager who was perceived to be a good leader, was visible, consulted with staff, provided praise and recognition and where flexible work schedules were available was found to distinguish the positive and negative wards. However, for a ward to be rated as positive overall, nurse leaders need to perform well on all the leadership items. Conclusion: An effective nursing unit manager who consults with staff and provides positive feedback and who is rated highly on a broad range of leadership items is instrumental in increasing job satisfaction and satisfaction with nursing. Relevance to clinical practice: Good nurse managers play an important role in staff retention and satisfaction. Improved retention will lead to savings for the organisation, which may be allocated to activities such as training and mentorship to assist nurse ...
Duffield, C., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M., King, M. & Aisbett, K. 2011, 'Nursing staffing, nursing workload, the work environment and patient outcomes', Applied Nursing Research, vol. 24, no. 4, pp. 244-255.
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Nurse staffing (fewer RNs), increased workload, and unstable nursing unit environments were linked to negative patient outcomes including falls and medication errors on medical/surgical units in a mixed method study combining longitudinal data (5 years) and primary data collection. © 2011 Elsevier Inc.
Duffield, C.M., Roche, M.A., Blay, N. & Stasa, H. 2011, 'Nursing unit managers, staff retention and the work environment', Journal Of Clinical Nursing, vol. 20, no. 1-2, pp. 23-33.
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Aim and objective. This paper examined the impact of leadership characteristics of nursing unit managers, as perceived by staff nurses, on staff satisfaction and retention. Background. A positive work environment will increase levels of job satisfaction and staff retention. Nurse leaders play a critical role in creating a positive work environment. Important leadership characteristics of the front-line nurse manager include visibility, accessibility, consultation, recognition and support. Design. Secondary analysis of data collected on 94 randomly selected wards in 21 public hospitals across two Australian states between 20042006. Methods. All nurses (n = 2488, 803% response rate) on the selected wards were asked to complete a survey that included the 49-item Nursing Work Index-Revised [NWI-R] together with measures of job satisfaction, satisfaction with nursing and intention to leave. Subscales of the NWI-R were calculated. Leadership, the domain of interest, consisted of 12 items. Wards were divided into those reporting either positive or negative leadership. Data were analysed at the nurse level using spss version 16.
Roche, M. 2011, 'Looking at the bigger picture.', Nursing standard (Royal College of Nursing (Great Britain) : 1987), vol. 26, no. 13, pp. 62-63.
Roche, M., Duffield, C. & White, E. 2011, 'Factors in the practice environment of nurses working in inpatient mental health: A partial least squares path modeling approach', International Journal of Nursing Studies, vol. 48, no. 12, pp. 1475-1486.
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Background: Developing a therapeutic relationship with consumers is considered as the central aspect of nursing work in mental health. The importance of this relationship stems from its association with enhanced patient care and improved patient outcomes. Factors within the practice environment may influence the nurse's ability to engage effectively in this relationship. Objective: This study explored a model that added characteristics of the individual and practice environment to a central framework incorporating therapeutic commitment: a nurse's ability and willingness to engage in a therapeutic relationship. Setting and participants: Data were collected at six mental health nursing units in five public general acute hospitals in New South Wales, Australia for 14 days per unit, between 2005 and 2006. All nurses in participating wards were invited to partake in the study. Seventy-six (51%) responses were analyzed. Method: The data were collected using a Nurse Survey inclusive of the Practice Environment Scale of the Nursing Work Index (NWI-PES), and the Mental Health Problems Perception Questionnaire (MHPPQ). A Unit Profile form was used concurrently to collect staffing, skill mix and patient turnover data. Partial least squares path modeling (PLS-PM) was chosen as the analytical method to test the model and identify the most influential factors. Results: Experienced nurses who perceived themselves to be competent and supported were more likely to express a willingness to engage therapeutically with patients. Environmental factors associated with these perceptions included foundations of quality nursing care, opportunities to participate in hospital affairs and clinical supervision. Not all elements in the proposed model were supported. Conclusion: Positive hospital practice environments can improve the capacity of nurses working in mental health to engage therapeutically with patients. Specific approaches may include access to preceptorship, continued education...
Duffield, C., Roche, M., Blay, N., Thoms, D. & Stasa, H. 2011, 'The consequences of executive turnover', Journal of Research in Nursing, vol. 16, no. 6, pp. 503-514.
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The high rate of executive turnover in the healthcare industry is a major issue for health service organisations and their staff both in Australia and internationally. In the course of planning a research project examining nurse turnover at the clinical level within three Australian States/Territories, the researchers became aware of frequent executive turnover at all levels (State Department of Health, Area Health Service, hospital). Over a period of approximately 2 years there were 41 executives occupying 18 different positions, highlighting the scope of this issue in Australia. Few studies have examined the causes and consequences of this phenomenon in depth. Factors such as age, gender, education, lack of career advancement opportunities and remuneration have all been identified in the literature as important contributors to executive turnover. High turnover rates have been found to be associated with a number of negative consequences, including organisational instability, high financial costs, loss of human capital and adverse effects on staff morale and patient care. While the use of 'acting' roles may assist in filling executive positions on a temporary basis, consequences for the rest of the organisation are associated with their extended use. Steps which health services planners may take to attempt to minimise executive turnover include providing staff members with appropriate challenges and opportunities for growth and ensuring that a clear succession plan is in place to minimise the impact for the organisation and its staff. © The Author(s) 2011.
Duffield, C., Roche, M., Blay, N., Thoms, D. & Stasa, H. 2011, 'The consequences of executive turnover', Journal of Research in Nursing, vol. 16, no. 6, pp. 503-514.
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The high rate of executive turnover in the healthcare industry is a major issue for health service organisations and their staff both in Australia and internationally. In the course of planning a research project examining nurse turnover at the clinical level within three Australian States/Territories, the researchers became aware of frequent executive turnover at all levels (State Department of Health, Area Health Service, hospital). Over a period of approximately 2 years there were 41 executives occupying 18 different positions, highlighting the scope of this issue in Australia. Few studies have examined the causes and consequences of this phenomenon in depth. Factors such as age, gender, education, lack of career advancement opportunities and remuneration have all been identified in the literature as important contributors to executive turnover. High turnover rates have been found to be associated with a number of negative consequences, including organisational instability, high financial costs, loss of human capital and adverse effects on staff morale and patient care. While the use of 'acting' roles may assist in filling executive positions on a temporary basis, consequences for the rest of the organisation are associated with their extended use. Steps which health services planners may take to attempt to minimise executive turnover include providing staff members with appropriate challenges and opportunities for growth and ensuring that a clear succession plan is in place to minimise the impact for the organisation and its staff. © The Author(s) 2011.
Roche, M., Diers, D., Duffield, C. & Catling-Paull, C. 2010, 'Violence toward nurses, the work environment, and patient outcomes', Journal of Nursing Scholarship, vol. 42, no. 1, pp. 13-22.
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Purpose: To relate nurses' self-rated perceptions of violence (emotional abuse, threat, or actual violence) on medical-surgical units to the nursing working environment and to patient outcomes.Design: Cross-sectional collection of data by surveys and primary data collection for 1-week periods on 94 nursing wards in 21 hospitals in two states of Australia.Methods: Nursing Work Index-Revised (NWI-R); Environmental Complexity Scale (ECS) PRN-80 (a measure of patient acuity); and a nursing survey with three questions on workplace violence; combined with primary data collection for staffing, skill mix, and patient outcomes (falls, medication errors).Findings: About one third of nurses participating (N=2,487, 80.3% response rate) perceived emotional abuse during the last five shifts worked. Reports of threats (14%) or actual violence (20%) were lower, but there was great variation among nursing units with some unit rates as high as 65%. Reported violence was associated with increased ward instability (lack of leadership; difficult MD and RN relationships). Violence was associated with unit operations: unanticipated changes in patient mix; proportion of patients awaiting placement; the discrepancy between nursing resources required from acuity measurement and those supplied; more tasks delayed; and increases in medication errors. Higher skill mix (percentage of registered nurses) and percentage of nurses with a bachelor of science in nursing degrees were associated with fewer reported perceptions of violence at the ward level. Intent to leave the present position was associated with perceptions of emotional violence but not with threat or actual assault.Conclusions: Violence is a fact of working life for nurses. Perceptions of violence were related to adverse patient outcomes through unstable or negative qualities of the working environment. Perceptions of violence affect job satisfaction.Clinical Relevance: In order to manage effectively the delivery of nursing care in...
Roche, M.A. & Duffield, C.M. 2010, 'A comparison of the nursing practice environment in mental health and medical-surgical settings', Journal of Nursing Scholarship, vol. 42, no. 2, pp. 195-206.
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Purpose: To examine the differences between characteristics of the work environment of nurses working in mental health and general acute inpatient nursing settings.Design: Secondary analysis of data collected on 96 randomly selected medical and surgical (general) wards and six mental health wards in 24 public acute general hospitals across two Australian states between 2004 and 2006.Methods: All nurses on the participating wards were asked to complete a survey that included the Practice Environment Scale of the Nursing Work Index (NWI-PES). Responses were received from 2,556 nurses (76.3% response rate). Using the five-domain structure, comparisons were made between mental health and general nurses.Findings: Across the entire sample of nurses, those working in mental health settings scored more highly in regard to nurse-doctor relationships and staffing adequacy. Nurses in general wards reported more participation in hospital affairs, stronger leadership, and the presence of more of the foundations of nursing quality care such as access to continued education. Differences between the groups on each of the domains was statistically significant at p=05 or greater, but not for the composite practice environment scale. A wide range of responses was seen when data were aggregated to the ward level.Conclusions: The work environment of mental health nurses is different from that of their colleagues working in general settings. Specific areas of the mental health environment, such as participation in the hospital, leadership, and the foundations of quality, may be enhanced to improve nurses' job satisfaction and, potentially, other nurse and patient outcomes.Clinical Relevance: Factors in the medical and surgical nursing practice environment have been established as significant influences on nurse and patient outcomes. It is important to understand the existence and potential impact of these factors in mental health inpatient settings. © 2010 Sigma Theta Tau Internationa...
Duffield, C., Roche, M., Diers, D., Catling-Paull, C. & Blay, N. 2010, 'Staffing, skill mix and the model of care', Journal of Clinical Nursing, vol. 19, no. 15-16, pp. 2242-2251.
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Aims and objectives: The study aimed to explore whether nurse staffing, experience and skill mix influenced the model of nursing care in medical-surgical wards. Background: Methods of allocating nurses to patients are typically divided into four types: primary nursing, patient allocation, task assignment and team nursing. Research findings are varied in regard to the relationship between these models of care and outcomes such as satisfaction and quality. Skill mix has been associated with various models, with implications for collegial support, teamwork and patient outcomes. Design: Secondary analysis of data collected on 80 randomly selected medical-surgical wards in 19 public hospitals in New South Wales, Australia during 2004-2005. Methods: Nurses (n = 2278, 809% response rate) were surveyed using The Nursing Care Delivery System and the Nursing Work Index-Revised. Staffing and skill mix was obtained from the ward roster and other data from the patient record. Models of care were examined in relation to these practice environment and organisational variables. Results: The models of nursing care most frequently reported by nurses in medical-surgical wards in this study were patient allocation (91%) and team nursing (80%). Primary nursing and task based models were unlikely to be practised. Skill mix, nurse experience, nursing workload and factors in the ward environment significantly influenced the model of care in use. Wards with a higher ratio of degree qualified, experienced registered nurses, working on their 'usual' ward were more likely to practice patient allocation while wards with greater variability in staffing levels and skill mix were more likely to practice team nursing. Conclusions: Models of care are not prescriptive but are varied according to ward circumstances and staffing levels based on complex clinical decision making skills. Relevance to clinical practice: Variability in the models of care reported by ward nurses indicates that nurses ada...
Duffield, C., Roche, M., O'brien-Pallas, L. & Catling-Paull, C. 2009, 'The implications of staff 'churn' for nurse managers, staff, and patients', Nursing Economics, vol. 27, no. 2, pp. 103-110.
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? In this article, the term "churn" is used not only because of the degree of change to staffing, but also because some of the reasons for staff movement are not classified as voluntary turnover. ? The difficulties for the nurse managing a unit with the degree of "churn" should not be under-estimated. ? Changes to skill mix and the proportions of full-time, agency, and temporary staff present challenges in providing clinical leadership, scheduling staff, performance management, and supervision. ? Perhaps more importantly, it is likely that there is an impact on the continuity of care provided in the absence of continuity of staffing. ? A greater understanding of the human and financial costs and consequences, and a willingness to change established practices at the institutional and ward level, are needed.
Duffield, C., Diers, D., Aisbett, C. & Roche, M. 2009, 'Churn: Patient turnover and mix', Nursing Economics, vol. 27, no. 3, pp. 185-191.
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Patient throughput and casemix changes on nursing wards are little understood aspects of nursing's responsibility for nursing wards/units as hospital operations. In this study, the movement of patients on and off wards in 27 Australian public hospitals (286 wards) were analyzed over a 5-year period. Casemix change at the nursing unit level was also examined. In the data here, medical/surgical patients moved on average more than twice in an average hospital stay of only about 4 days. The absence of ward-level metrics compromises the ability of nursing unit/ward managers to meet their own efficiency and quality standards. Measurements of churn would give nurses another way to talk about the work of nursing to senior management and would give nurse executives a way to describe hospital operations and throughput and the impact on staff, patients, and resource allocation.
Duffield, C., Roche, M., O'Brien-Pallas, L., Catling-Paull, C. & King, M. 2009, 'Staff satisfaction and retention and the role of the Nursing Unit Manager', Collegian, vol. 16, no. 1, pp. 11-17.
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Despite recent increases in nursing recruitment in Australia, participation in the workforce is still below the numbers predicted to meet future needs. This paper discusses factors impacting on nurses' job satisfaction, satisfaction with nursing and intention to leave in public sector hospitals in New South Wales (NSW), Australia. Staffing and patient data were collected on 80 medical and surgical units during 2004/5. This included a wide range of individual nurse data from a Nurse Survey; detailed and comprehensive staffing data including skill mix variables; patient characteristics; workload data; a profile of the ward's characteristics; and adverse event patient data. Nurses who were intending to remain in their job were more likely to be satisfied, be older, and have dependents. They were also likely to be experiencing good leadership and to have allied health support on the ward. Most nurses reported being satisfied with their profession, while a lower proportion reported satisfaction with their current position. Work environment factors such as nurses' autonomy, control over their practice and nursing leadership on the ward were statistically significant predictors of job satisfaction. This study will inform decision-making and policy for managers in both the public and private hospital sectors. This is the first large study which explored the work environment at the ward/unit level in public hospitals in NSW (Australia). It illustrates that there are no typical wards; each ward functions differently. The importance of nursing leadership at the ward level to job satisfaction, satisfaction with nursing and intention to leave, cannot be overstated. Crown Copyright © 2009.
Roche, M. & Duffield, C. 2007, 'Issues and challenges in the mental health workforce development', Contemporary Nurse, vol. 25, no. 1-2, pp. 94-103.
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As in many other developed countries, the proportion of the population in Australia that will experience a mental health disorder is increasing. To respond adequately and appropriately to what some might say is an epidemic will require not only an available workforce but also one which is highly skilled. Unfortunately the current protracted shortage of nurses generally, and which is projected to worsen over the next few years, will also have a significant impact on the provision of care for a large and vulnerable portion of the population, those who experience mental illness. This article will provide an overview of the issues and challenges confronting the development of a sustainable mental health nursing workforce. Copyright © eContent Management Pty Ltd.
Roche, M. & Duffield, C. 2007, 'Issues and challenges in the mental health workforce development', CONTEMPORARY NURSE, vol. 25, no. 1-2, pp. 94-103.
Duffield, C., Roche, M. & Merrick, E.T. 2006, 'Methods of measuring nursing workload in Australia.', Collegian (Royal College of Nursing, Australia), vol. 13, no. 1, pp. 16-22.
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Continuing and worsening nurse shortages nationally and internationally have reignited the debate in Australia about the methods of measuring nursing workload. As workload is one of the most significant factors in nursing retention, measuring nursing workload reliably is the critical initial step to understanding the relationship between workload, nursing retention and patient safety. In Australia, some states and territories have no measure of nursing workload and those states that have introduced measurement methods are inconsistent in their approach. This paper provides a critical review of the methods of measuring nursing workload with particular reference to Australia. It also explores the strengths and limitations of each approach in terms of its reliability and utility. This review highlights the implications of not understanding fully the impact of excessive workload on patient and nurse safety outcomes.
Duffield, C., O'Brien Pallas, L., Aitken, L.M., Roche, M. & Merrick, E.T. 2006, 'Recruitment of nurses working outside nursing', Journal of Nursing Administration, vol. 36, no. 2, pp. 58-62.
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Nurses have always left nursing for other jobs and careers. However, there is some evidence that suggests this occurs now more than ever before as new generations join the workforce, and non-health employers recognize the skills that nurses gain in the profession. The authors provide data on the movement of nurses to careers outside the nursing profession in Australia and reasons for this occurrence and propose solutions. ©2006, Lippincott Williams & Wilkins, Inc.
White, E. & Roche, M. 2006, 'A selective review of mental health nursing in New South Wales, Australia, in relation to clinical supervision', INTERNATIONAL JOURNAL OF MENTAL HEALTH NURSING, vol. 15, no. 3, pp. 209-219.
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Forrester, K., Duffield, C., Roche, M. & Merrick, E.T. 2005, 'Clinical handover: can we afford the time?', Journal of law and medicine, vol. 13, no. 2, pp. 176-179.
Duffield, C., Forbes, J., Fallon, A., Roche, M., Wise, W. & Merrick, E.T. 2005, 'Nursing skill mix and nursing time: The roles of registered nurses and clinical nurse specialists', Australian Journal of Advanced Nursing, vol. 23, no. 2, pp. 14-21.
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Objective: The roles of clinical nurse specialists (CNS) and registered nurses, while similar, should also be quite different, with the CNS functioning as an advanced practice nurse. Differences in roles can be partially explained and understood by examining the use of their time. Adjustments to skill mix usually involve using more plentiful but less-skilled workers, and there is a growing body of overseas research in this field. In contrast, little research has examined and compared the use of nursing time for the RN and CNS role, particularly in an Australian context. Comparing work activities enables employers to begin to answer the question: Are skilled nursing personnel being used effectively and efficiently? Design: A work-sampling study conducted over eight weeks. Data were analysed descriptively using SPSS, v.9. Setting: Six wards in a large private not-for-profit hospital. Main outcome measure: To determine whether there is a differentiation in the roles of CNS and RN by examining the percentage of time spent in 25 specific activities. Results: In some activities it is not possible to distinguish differences in the amount of time spent by RNs and CNSs. In other activities such as clerical, meetings and administration, CNSs are spending more time than anticipated. Consideration needs to be given to employing clerical staff to relieve the CNS of these non-clinical aspects. Conclusion: The study extends the understanding of the roles of registered nurses and clinical nurse specialists and provides a basis on which to begin to understand similarities and differences in their roles.

Reports

Duffield, C.M., Roche, M.A., O'Brien-Pallas, L., Diers, D., Aisbett, C., Aisbett, K. & Homer, C.S. University of Technology, Sydney 2009, Nursing workload and staffing: Impact on patients and staff, pp. 1-161.
Duffield, C.M., Roche, M.A., O'Brien-Pallas, L., Diers, D., Aisbett, C., King, M.T., Aisbett, K. & Hall, J.P. Centre for Health Services Management, UTS 2007, Glueing it together: nurses, their work environment and patient safety., pp. 1-243, Sydney.