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Aims: To investigate the experience of nursing assistants being delegated nursing tasks by registered nurses., Design: Mixed method explanatory sequential design., Methods: A total of 79 nursing assistants working in an acute hospital in Australia completed surveys that aimed to identify their experience of working with nurses and the activities they were delegated. The survey data were analysed using descriptive statistics. Interviews with 11 nursing assistants were conducted and analysed using Braun and Clarke's thematic analysis. Results were triangulated to provide a richer understanding of the phenomena., Results: Most nursing assistants felt supported completing delegated care activities. However, there was confusion around their scope of practice, some felt overworked and believed that they did not have the right to refuse a delegation. Factors impacting the nursing assistant's decision to accept a delegation included the attitude of the nurses, wanting to be part of the team and the culture of the ward. Nursing assistants who were studying to be nurses felt more supported than those who were not., Conclusions: Delegation is a two-way relationship and both parties need to be cognisant of their roles and responsibilities to ensure safe and effective nursing care is provided. Incorrectly accepting or refusing delegated activities may impact patient safety., Implications for the Profession And/or Patient Care: Highlights the need for implementing strategies to support safe delegation practices between the registered and unregulated workforce to promote patient safety., Impact: Describes the experiences of nursing assistants working in the acute care environment when accepting delegated care from nurses. Reports a range of factors that inhibit or facilitate effective delegation practices between nurses and nursing assistants. Provides evidence to support the need for stronger education and policy development regarding delegation practices between nurses and unregulated staff., Reporting Method: Complied with the APA Style JARS-MIXED reporting criteria for mixed method research., Patient or Public Contribution: No patient or public contribution., (© 2024 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Aims and Objectives: To explore the relationship between patient obesity and nursing workload, and discuss the nursing activities most affected by patient obesity., Background: The increasing number of patients with obesity, and the severity of obesity, impacts the healthcare workforce, particularly to nurses who provide most direct care to patients. There is growing evidence to suggest that patient obesity may increase nursing workload and time taken for clinical care., Design: Integrative review., Methods: A comprehensive search of academic databases for primary research related to patient obesity and nursing workload, published since 2000, was conducted. References of relevant articles were hand-searched., Results: 27 articles were analysed. Analysis was undertaken at the levels of patient characteristics, nursing work and the healthcare system. The increasing number of patients with obesity, and the severity of patient obesity, increases nursing workload by affecting nursing time needed to deliver care. An increased number of nurses, particularly with increased clinical skill, are needed to deliver care meeting these increased needs. Organisational change is required to provide infrastructure and bariatric equipment that enables effective nursing care of patients with obesity. Organisations must consider additional time and staff needs when delivering care for patients with obesity., Conclusions: The current health system is not established to address the challenge of providing nursing care to the increasing numbers of patients with obesity. Further research on accurately and objectively quantifying the impact and severity of patient obesity on nursing clinical activities is required., Relevance to Clinical Practice: When determining staffing, healthcare organisations must consider the increased nursing staff, time and clinical skill required to provide care for patients with obesity. Healthcare organisations should implement policies that ensure sufficient staffing in areas where care of patients with obesity is prevalent, and provide training for and workplace availability of bariatric equipment., (© 2021 John Wiley & Sons Ltd.)

Aims: To highlight the need for the development of effective and realistic workforce strategies for critical care nurses, in both a steady state and pandemic., Background: In acute care settings, there is an inverse relationship between nurse staffing and iatrogenesis, including mortality. Despite this, there remains a lack of consensus on how to determine safe staffing levels. Intensive care units (ICU) provide highly specialised complex healthcare treatments. In developed countries, mortality rates in the ICU setting are high and significantly varied after adjustment for diagnosis. The variability has been attributed to systems, patient and provider issues including the workload of critical care nurses., Design: Discursive paper., Findings: Nursing workforce is the single most influential mediating variable on ICU patient outcomes. Numerous systematic reviews have been undertaken in an effort to quantify the effect of critical care nurses on mortality and morbidity, invariably leading to the conclusion that the association is similar to that reported in acute care studies. This is a consequence of methodological limitations, inconsistent operational definitions and variability in endpoint measures. We evaluated the impact inadequate measurement has had on capturing relevant critical care data, and we argue for the need to develop effective and realistic ICU workforce measures., Conclusion: COVID-19 has placed an unprecedented demand on providing health care in the ICU. Mortality associated with ICU admission has been startling during the pandemic. While ICU systems have largely remained static, the context in which care is provided is profoundly dynamic and the role and impact of the critical care nurse needs to be measured accordingly. Often, nurses are passive recipients of unplanned and under-resourced changes to workload, and this has been brought into stark visibility with the current COVID-19 situation. Unless critical care nurses are engaged in systems management, achieving consistently optimal ICU patient outcomes will remain elusive., Relevance to Clinical Practice: Objective measures commonly fail to capture the complexity of the critical care nurses' role despite evidence to indicate that as workload increases so does risk of patient mortality, job stress and attrition. Critical care nurses must lead system change to develop and evaluate valid and reliable workforce measures., (© 2021 John Wiley & Sons Ltd.)

Aims and Objectives: To explore the impact of an initiative to add unregulated nursing support workers to wards in acute care hospitals., Background: Adding nursing support workers to existing nurse staffing may be one solution to reduce nursing workloads and improve outcomes. However, the effects of this addition on nurse, patient and system outcomes are not well documented. In one state of Australia, a trial deployment of nursing support workers to wards across the public health system provided opportunity for the exploration of their impact in a natural, real-world, environment., Design: Cross-sectional study., Methods: A sample of five wards where nursing support workers had been added matched to a group of five wards where there were no nursing support workers. Data were collected via patient survey (n = 141) and nurse survey (n = 154). Analysis was comparative with regression models constructed for the different ward types., Results: Nursing leadership, staffing and resources, and nurse experience were linked to outcomes on both ward types. Instability was a significant predictor of reduced quality of care and increased turnover intention on wards where support workers were added., Conclusion: Adding nursing support workers to ward staffing did not lead to improvements in patient care. Findings suggest that staffing a nursing ward is a complex activity and that a simple approach to staffing is unlikely to be successful. Future research should explore the process of implementation and the conditions under which this strategy is likely to be successful., Relevance to Clinical Practice: Ward-level factors are key in making appropriate staffing and skill mix choices to limit instability and to consequently avoid negative patient, staff and system outcomes. Consideration of the ward context, alongside effective delegation processes and integration into the care team are imperative when adding nursing support workers., (© 2018 John Wiley & Sons Ltd.)

Aims and Objectives: To determine whether there was an association between intra-hospital transfers and adverse outcomes., Background: Transfers between clinical units and between beds on the same unit are routine aspects of an episode of care in acute hospitals. The rate of these transfers per episode has increased in response to high occupancy levels, a decline in bed numbers, and increased demand for hospital services. The impact of the number of transfers between both wards and beds on patient outcomes is not widely explored., Design: Retrospective cross sectional design using hospital administrative data., Method: Data were extracted from existing hospital administrative datasets for one large metropolitan hospital for the financial year 2008-09 in Australia (n = 14,133). Descriptive analyses and logistic regression models were developed for each of 3 selected patient outcomes., Results: Nearly one-tenth of patients (9.2%) experienced a fall with injury, 3.8% of surgical patients a wound infection and 0.1% a complication from medication errors. For each bed or ward transfer, the odds of falls and wound infections increased. Medication errors were not associated with either bed or ward moves., Conclusion: Hospitals should minimise the number of bed and ward transfers per episode of care in order to reduce the likelihood of adverse patient outcomes. Current bed management policies and practices should be evaluated and further refined to address this need. Additional strategies include improving coordination and communication during and after transfer., Relevance to Clinical Practice: Nurses must consider the potential cost of intrahospital transfers on patients, length of stay and bed availability., (© 2017 John Wiley & Sons Ltd.)

Aims and Objectives: To determine the rate of patient moves and the impact on nurses' time., Background: Bed shortages and strategies designed to increase patient flow have led to a global increase in patient transfers between wards. The impact of transferring patients between wards and between beds within a ward on nurses' workload has not previously been measured., Design: A two-stage sequential study. Retrospective analysis of hospital data and a prospective observational-timing study., Methods: Secondary analysis of an administrative data set to inform the rate of ward and bed transfers (n = 34,715) was undertaken followed by an observational-timing study of nurses' activities associated with patient transfers (n = 75)., Results: Over 10,000 patients were moved 34,715 times in 1 year which equates to an average of 2.4 transfers per patient. On average, patient transfers took 42 min and bed transfers took 11 min of nurses' time. Based on the frequency of patient moves, 11.3 full-time equivalent nurses are needed to move patients within the site hospital each month., Conclusion: Transferring patients is workload intensive on nurses' time and should be included in nursing workload measurement systems., Relevance to Clinical Practice: Nurses at the site hospital spend over 1700 hr each month on activities associated with transferring patients, meaning that less time is available for nursing care., (© 2017 John Wiley & Sons Ltd.)

Aims and Objectives: To examine user acceptance with a new format of charts for recording observations and as a prompt for responding to episodes of clinical deterioration in adult medical-surgical patients., Background: Improving recognition and response to clinical deterioration remains a challenge for acute healthcare institutions globally. Five chart templates were developed in Australia, combining human factors design principles with a track and trigger system for escalation of care. Two chart templates were previously tested in simulations, but none had been evaluated in clinical practice., Design: Prospective multisite survey of user acceptance of the charts in practice., Methods: New observation and response charts were trialled in parallel with existing charts for 24 hours across 36 adult acute medical-surgical wards, covering 108 shifts, in five Australian states. Surveys were completed by 477 staff respondents, with open-ended comments and narrative from short informal feedback groups providing elaboration and context of user experiences., Results: Respondents were broadly supportive of the chart format and content for monitoring patients, and as a prompt for escalating care. Some concerns were noted for chart size and style, use of ranges to graph vital signs and with specific human factors design features. Information and training issues were identified to improve usability and adherence to chart guidelines and to support improved detection and response for patients with clinical deterioration., Conclusions: This initial evaluation demonstrated that the charts were perceived as appropriate for documenting observations and as a prompt to detect clinical deterioration. Further evaluation after some minor modifications to the chart is recommended., Relevance to Clinical Practice: Explicit training on the principles and rationale of human factors chart design, use of embedded change management strategies and addressing practical issues will improve authentic engagement, staff acceptance and adoption by all clinical users when implementing a similar observation and response chart into practice., (© 2016 John Wiley & Sons Ltd.)

Aims: Investigate the number and type of tasks performed, delayed or not completed by regulated and unregulated (assistant) nurses., Background: Assistants in Nursing change the work environment of the nurses with whom they work. As the number of Assistants in Nursing working on acute units grows, it is important to understand how their presence influences nursing care., Design: Descriptive analysis of survey data from 62 acute nursing units across three Australian states between 2008-2010., Methods: All staff providing nursing care to patients were asked to complete a survey that included demographics, the number of tasks delayed/incomplete and the completion of six specific tasks. Nonparametric tests compared Assistants in Nursing (n = 25) to regulated nurses (n = 1630), and regulated nurses on units with no Assistants in Nursing (n = 1356) to those on units with up to 5% assistants (n = 76) and over 5% assistants (n = 198)., Results: More regulated nurses on units with zero, or up to 5% Assistants in Nursing, completed tasks usually associated with assistants' scope of practice, relative to those on units with over 5% Assistants in Nursing. Statistically significant differences were found between the units in delays responding to the patient bell and in the planning of nursing care., Conclusion: This study suggests that Assistants in Nursing have an impact on the nature and timeliness of care provided in acute hospital units, that is relative to the proportion of staffing they comprise, to the effectiveness of integration and to the clarity of their scope of practice and associated delegation., Relevance to Clinical Practice: With increasing employment of Assistants in Nursing in acute hospital settings comes the requirement to optimise their use. This needs to include a well-articulated scope of practice, clear delegation of tasks and effective integration with the rest of the care team., (© 2015 John Wiley & Sons Ltd.)

Aims and Objectives: To identify factors that motivate older nurses to leave the workforce., Background: As many older nurses are now reaching retirement age and will be eligible for government-funded pensions, governments are concerned about the impending financial burden. To prepare for this scenario, many are looking at increasing the age of retirement to 67 or 70 years. Little is known about how this will affect the continuing employment of older nurses and the consequences for employers and the nurses themselves if they remain longer in the workforce., Design: Prospective randomised quantitative survey study., Methods: The Mature Age Workers Questionnaire, Job Descriptive Index and Job in General Scale were used to measure job satisfaction, intention to retire and factors encouraging retirement in registered nurses aged 45 years and over (n = 352) in Australia (July-August 2007)., Results: There were 319 respondents. The mean age proposed for leaving the workforce was 61·7 years. Key motivators were: financial considerations (40·1%), primarily financial security; nurse health (17·4%) and retirement age of partner (13·3%)., Conclusions: Older nurses are leaving the workforce prior to retirement or pension age, primarily for financial, social and health reasons, taking with them significant experience and knowledge. As financial considerations are important in older nurses decisions to continue to work, increasing the age of retirement may retain them. However, consideration will need to be given to ensure that they continue to experience job satisfaction and are physically and mentally able to undertake demanding work., Relevance to Clinical Practice: Increasing retirement age may retain older nurses in the workforce, however, the impact on the health of older nurses is not known, nor is the impact for employers of older nurses continuing to work known. Employers must facilitate workplace changes to accommodate older nurses., (© 2014 John Wiley & Sons Ltd.)

Aims and Objectives: To explore whether or not the context of Australian practice nursing supports collaborative decision-making about organisation and delivery of patient care., Background: Positive patient outcomes depend on Australian practice nurses participating in collaborative and interprofessional services, particularly for patients with chronic disease(s). It is unclear whether Australian practice nurses have the opportunity to collaborate in decision-making or how traditional organisational structures may support or hinder collaboration., Design: This is a descriptive exploratory study. Semi-structured interviews were conducted using a purposive sample of practice nurses (n = 15). Thematic analysis was used to provide meaningful and contextual insights into how practice nurses participate in decision-making., Method: An interview tool, based on available literature, was developed and consisted of thirty open-ended questions to direct discussion during telephone interviews. Transcribed data were imported into NVivo(tm) for analysis and interpretation. The collection, analysis and thematic interpretation of data were an iterative process., Findings: Participants fostered trusting interprofessional relationships, which enabled them to influence medical decision-making and thereby advocate for patient need. Trusting interprofessional relationships were perceived to alter the relative roles of the medical practitioner and practice nurse and enhance the opportunities for collaborative decision-making., Conclusions and Relevance to Clinical Practice: Collaborative interprofessional care in Australian general practice must occur if increased demands for care are to be met. It is timely to consider how government policy, financial regulations and the organisation of Australian general practice can better support and enhance a collaborative contribution to care by practice nurses., (© 2014 John Wiley & Sons Ltd.)

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.)

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, 80.9% 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 adapt the model of nursing care on a daily or shift basis, according to patients' needs, skill mix and individual ward environments.

Aim: To find that changes in models of service delivery together with the dynamic nature of the contemporary health care context have changed the direction and focus of nurses' work. The aim of this paper is to explore some of the drivers for change and their impact and recommend a way forward to optimising nurses' work in the hospital environment., Background: The healthcare workplace has been transformed over the past 20 years in response to economic and service pressures. However, some of these reforms have had undesirable consequences for nurses' work in hospitals and the use of their time and skills., Results: As the pace and complexity of hospital care increases, nursing work is expanding at both ends of the complexity continuum. Nurses often undertake tasks which less qualified staff could do while at the other end of the continuum, are unable to use their high level skills and expertise. This inefficiency in the use of nursing time may also impact negatively on patient outcomes., Conclusions: Nurses' work that does not directly contribute to patient care, engage higher order cognitive skills or provide opportunity for role expansion may decrease retention of well-qualified and highly skilled nurses in the health workforce., Relevance to Clinical Practice: In this climate of nursing shortages, we need to use nurses in a cost-effective but also, intellectually satisfying manner, to achieve a sustainable nursing workforce.