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"All hands on deck" - an autonomous collaborative practice model to sustain emergency care in rural Victoria.
thesisposted on 05.12.2016, 02:26 by Sullivan, Elise
Background This study is set in rural Victoria, Australia, during the period of 2006 to 2012. In 2006, as a consequence of the contracting medical workforce in rural areas, the number of doctors willing and able to provide on-call service to rural hospitals was diminishing. The doctors remaining were increasingly dissatisfied with the impost that on-call rosters had on their private lives and preferred not to be called in, particularly for less-urgent, non-complicated patient conditions. In order to develop and test a model in which nurses could practice more autonomously and call the doctor less frequently, the Queensland Rural and Isolated Practice Registered Nursing (RIPRN) model was trialled as part of the government funded Rural Collaborative Practice Model Pilot. This PhD study was based on the Rural Collaborative Practice Model Pilot. Aim and research questions This study aimed “To pilot a collaborative approach to enhancing nurses’ ability to practice autonomously” in order to answer the question: “What are the conditions required to establish the model and does this model improve access to emergency care in rural Victoria?” Methodology Action research design was adopted and included qualitative and quantitative data generation and analysis methods. The study focused on emergency departments in four rural health services and a Bush Nursing Centre, and involved twenty-nine people including clinical nurses, hospital managers, General Practitioner Visiting Medical Officers, pharmacists and a paramedic. From early 2007 until April 2008, there were four action research cycles which commenced with the initial diagnosis of the current situation, followed by the first 2-day planning forum and thereafter three full-day action learning sets held at approximately 2-monthly intervals. While the data were collected during this period of time, the changes that resulted from this study extended into 2012 and have been included in this study. Results The results of this action research study relate to four key elements: 1. Firstly, diagnosis of the existing emergency care situation in the participating organisations, which confirmed that General Practitioner Visiting Medical Officers were attending most emergency presentations regardless of their level of medical urgency or complexity. 2. Secondly, the factors impeding nursing autonomy were identified as relating to the individual nurse, the clinical team and structures within which nurses work (culture, policy and legislation). 3. Thirdly, the strategies planned and implemented to create the conditions needed to improve nursing autonomy. The preparation for the new advanced nursing role, the development of clinical guidelines and providing legal authority were central features of the Queensland Rural and Isolated Practice Registered Nursing model. While these factors are important, they were not sufficient on their own to support nurses to practice within the Autonomous Collaborative Practice Model developed in this study. A key strategy implemented as a result of this study was the change to the Victorian Drugs, Poisons and Controlled Substances Act to authorize these nurses to supply drugs without a medical practitioner’s order. 4. Fourthly, this study measured the impact of the Autonomous Collaborative Practice Model, which included an increase in nurses’ autonomy and a concomitant reduction in the call on the local General Practice Visiting Medical Officer. Conclusion This study confirmed that nurses have a central role in creating a better emergency care service system in rural Victoria. This study found that the Autonomous Collaborative Practice Model delivered a more sustainable model of emergency care in rural health services by reducing the call on the local General Practitioner Visiting Medical Officer and possibly improving service access. Integral to the success of this model is the ability of nurses to practice autonomously in collaboration with other health professionals and their managers. The conditions needed to support this more sustainable model are 1) clinically confident and competent clinicians working collaboratively, where 2) their roles are flexible, but their individual responsibility clear, within 3) cultural, organisational and state structures that engender authority and support for autonomous and collaborative practice.