Professor Carol Gaston
ISBN Number: 0 86396 826 0
The University of Adelaide
Department of Clinical Nursing
Joan Durdin Oration
Paper Series Number 8
Professor Carol Gaston left the South Australian Health Commission in late 1996 after 10 years in various senior executive positions and 30 years in the public health system. Carol has worked as a nurse clinician with the Aborigines in a remote area in Western Australia; as a volunteer in Bangladesh and Sabah, Malaysia; and as a health consultant in Nigeria and Mauritius. She has also worked as a clinician, educator, researcher and manager in the Victorian, Western Australian and South Australian health systems.
Carol has recently retired her position as Chair of the Royal District Nursing Service, and is a member of the Board of the Adelaide Community Healthcare Alliance (ACHA), Catherine House, Shelter for Homeless Women, and is Deputy Chair of the Cancer Council (SA). Carol is also a Governor of the Adelaide Bank Charitable Foundation.
Carol is now self-employed and acts as an advisor to human service industries public, private and not-for-profit organisations predominantly in South Australia and the Northern Territory. She is currently working on two long-term projects for the World Health Organisation and is Deputy Chair and Executive Officer for the SA Generational Health Review.
Carol is an Adjunct Professor of the University of South Australia.
The University of Adelaide , Department of Clinical Nursing was established in 1995 in collaboration with Royal Adelaide Hospital.
The Department continues to thrive and grow meeting the needs of the health sector in providing high quality post graduate education to nurses in Australia and through its international teaching programs. Research output through higher degree courses and activities such as The Joanna Briggs Institute, are recognised for their high calibre and relevance to clinical practice. The success of these programs relies on the continued collaboration of the Department and the organisations that provide health care.
Clinical practice remains the major focus of all research and teaching programs, it is therefore fitting that the Department of Clinical Nursing host the Joan Durdin Oration that celebrates the practice of nursing.
Professor Carol Gaston
Three experiences in the last 2 years have contributed to this evening's presentation. The first was the opportunity to co-author a paper on leadership in nursing and midwifery with Prof Sally Borbasi; the second was developing a Tool Kit for the World Health Organisation to assist nurses and midwives advocate for their inclusion in policy development and decision making; and finally being directly involved in the Generational Health Review of the South Australian health system.
All three activities have been a privilege to be part of and have added to my commitment to the reform of the health system in South Australia and to the role nurses and midwives must, I repeat must play if the system is to be more equitable and if we are to help make a difference to the most disadvantaged.
World Health Organisation (WHO) and its Assembly (WHA) recognised the need to further strengthen nursing and midwifery services when in 1992 resolution 45.5 was passed. This resolution recommended to member countries and WHO's Director General to undertake a number of initiatives to strengthen nursing and midwifery services for primary care. A Global Advisory Group (GAG) to the Director General of WHO was formed and over its 4 year term (1992-1996) has made numerous recommendations to member countries and WHO to strengthen nursing services.
At the 49th World Health Assembly resolution 49.1 was passed which urged member states to:
Involve nurses and midwives more closely in health care reform and in the development of national policy.
The 54th World Health Assembly held in May 2001 reinforced its position by urging member states amongst other things to:
Further the development of their health systems to pursue health sector reform by involving nurses and midwives in the framing, planning and implementation of health policy at all levels.
The World Health Organisation is recognising that reform in the health system cannot occur effectively if nurses and midwives are not involved. This is recognition of the proximity of nurses and midwives to individuals, their families and their communities and consequently their deeper understanding of the communities health needs.
South Australia is well served by talented and dedicated people who work in the health care system. By national standards there appears to be a good level of health care resources and in many respects we have an enviable health system when compared with the 191 member states monitored by the World Health Organization.
Nevertheless, the system is under increasing pressure:
• the population is ageing, increasing the level of demand for health and support services
• the role of hospitals is changing - many conditions no longer require hospital admission
• previously “institutionalised” people are now in the community - such as people who previously would be resident in a nursing home or mental health facility
• there is an expectation that people with chronic illness and disability, or the frail, should be supported in the community
• given the current rate of growth, demand for health and support services would increase in the future if a more prevention-oriented approach is not taken.
The Canadian Institute for Health Information, through the National Consensus Conference on Population Health Indicators has developed a Health Indicators Framework. This framework is based on a set of thematic dimensions which are based on other works such as the World Health Organisation's International Classification of Functioning and Disability (ICIDH-2 Beta 2 Version) and the Canadian Council on Health Services Accreditation (CCHSA). The major categories are:
1. Health Status
2. Social Determinants of Health
3. Health System Performance
There are significant levels of unmet need and inequities of access across geographic areas and population groups for health services, including primary health care, dental services, allied health and counselling.
Our indigenous population living in rural areas live 20-24% years less than the non-indigenous population. They use hospital services twice as much as the non-indigenous population but are low users of primary health care. (SA DHS 2000-2001)
The focus of ‘western' models of service delivery has been on separate service agencies which operate in silos and, in the case of remote communities, ‘fly in, fly out' with little integration or joint planning in partnership with Aboriginal communities. Only quite recently in South Australia has there been recognition that these approaches are failing Aboriginal children, families and communities as they do not acknowledge ‘the time honoured institutions that have sustained communities over time'. A ‘different' service model is required and we have a responsibility to advocate with our indigenous people for this change.
Data from hospitals in South Australia shows that people in Adelaide's poorest areas are more likely to be admitted to hospital than those from the more advantaged areas. This and other data demonstrates that the more disadvantaged people are, the poorer their health and the more likely they will be admitted to hospital for more episodes of care. (SA DHS 2000-2001)
Regardless of the propensity of the most well off to be admitted to private hospitals as well as to public, the poorest people in Adelaide are more likely to be waiting longer for their public hospital elective admission than are the well off.
A view of health capable of encompassing the social, economic and biological components requires a whole of government commitment since many of the determinants of inequalities and poor health are outside the scope of the health sector to influence and cross the responsibilities of many departments. It also requires a population health approach, prioritising the needs of those with the poorest health and increasing the focus on prevention of illness and disability.
Local regions and communities can better address their health care issues by focusing on the development of a strong primary health care system. This could include action to ameliorate the negative effects of socio-economic factors or to assist the community to change those socio-economic factors. For example, a whole of government early intervention strategy focused on vulnerable and overburdened families can help ameliorate future negative health consequences for children. Similarly a primary health care focus on community participation can enable and support local communities to take action on social and environmental issues affecting their health. Nurse and midwives must become involved in advocating for whole of government consideration of these issues.
Health care services have been streamlined and cost has become the defining factor in the treatment of human disease. Services have been cut to a bare minimum and the quality of care is constantly under threat.
The most significant indications of pressures within hospitals are becoming evident in the most concerning way. Hospitals are now experiencing serious quality issues. These include:
• An increase in the incidence of sick leave amongst nursing staff. In one hospital this has grown by 20% over the past 12 months. Increases in sick leave can be attributed to the additional stress of working long hours with limited resources.
• An increase in the rate of MRSA and other antibiotic resistant organisms. Again this can be attributed in part to the increased demands on limited clinical staff.
• An increase in ‘sentinel events'. A sentinel event is a unique, unexpected serious adverse event that has the potential to or caused the death of a patient. Whilst it is acknowledged that improved reporting mechanisms are now in place there is concern about possible increase in such events.
• An increase in patient complaints. In one hospital this has risen by 40% in the past 12 months.
• An increase in patient incidents. A rise of 25% has been experienced in one hospital over the past 12 months.
A significant patient/consumer centred indicator of efficiency in the health system is that of patient safety.
Demonstrations of strong and consistent relationships between professional nurse staffing levels and patient/consumer related adverse events are well documented in the literature (Fedoruk, M & Gaston, C 2001). Silber and Rosenbaum (1997) found that failure to rescue is governed by personnel mixes rather than case mix. Pronovost et al. (2001) found that fewer nurses in intensive care units resulted in an increase in medical complications such as pulmonary compromise that could require re-intubation.
Kovner and Gergen (1998) report significant relationships between hospital acquired urinary tract infections (UTI) pneumonia and thrombosis from examining discharge data from 589 acute-bed hospitals in 10 states in the USA. These authors found that minimal increases in nurse staffing hours resulted in a 4.5 % decrease in UTI, a 4.2 % decrease in pneumonia and a 2.6% decrease in thrombosis.
Sovie (1999) reported by Fagin (2001) in a study conducted in 32 university teaching hospitals in the United States found that higher registered nurse staffing levels reduced serious injuries to patients.
It would appear from the research-based evidence now available that there are significant relationships between a professional nursing presence and patient/ consumer safety because registered nurses are the “primary surveillance system in hospitals” 24 hours a day, 7 days per week (Fagin, 2001:18).
Currently the system is under stress due to dependence on acute hospitals to service health care needs. The acute care sector should be supported to focus on the areas where it is most effective – acute care. The growth in chronic disease requires community structures to enable the management and maintenance of people with chronic conditions at the local level. This means changing the profiles and roles of hospitals to provide for a networked hierarchy of services, and redeveloping some hospitals to provide sites, for example, for short-term stays and community rehabilitation. Linked to acute services via specialists in the community, it may be possible to shift the health system focus to creating healthy communities, maintaining people within their local area and freeing up acute hospitals to deal with speciality acute needs. Good primary prevention programs will help prevent ill health in the future and therefore may assist in reducing the demand on our hospitals.
Making these changes will take time and will require strong leadership to lead a change management process. Leaders across the health system will need to make a commitment to a better way of doing business, have the courage to challenge existing power bases and norms, and be willing to take the initiative to go beyond defined boundaries. This will include taking responsibility for the health of a population and not just the health of a health unit.
There is increasing evidence, from other parts of Australia and countries overseas to support a reorientation towards primary health care.
Primary health care services are the usual point of contact with the health system for people seeking assistance with a health problem, support for living with chronic illness or disability, or for health advice.
General practitioners comprise the largest service sector of the primary health and community support service system, usually operating independently through private practices and providing services which are publicly funded through the Commonwealth Medicare Benefits Schedule (MBS). Community pharmacists are another significant sector. The remainder of the primary health and community support sector is made up of a vast number of different organisations and small private providers. Community Health Services provide a common platform for many State-purchased services.
Primary health care should be available to all people, regardless of where they live, their income or their health and related problems. Increasingly primary health care is being recognised as the cornerstone of modern health care and as the ‘gatekeeper' for specialist services.
A recent study of 13 industrialised nations, found that the stronger a country's network of primary health care providers, the lower the health care costs and generally the better the health of the population. The more robust systems of primary health care had the most favourable health outcomes for all ages and particularly for the health of children. The research found several policy characteristics to be related to better population health levels.
The Discussion Paper released recently by the Generational Health Review provides a vision for the future. The South Australian health care system would have a strong primary health focus with more integrated, coordinated and responsive services that address both intensive and complex needs. It would more strongly pursue opportunities for population health promotion, illness prevention and early intervention. This would involve building partnerships between the primary health care and acute hospital sectors to develop and implement strategies to reduce preventable hospital admissions and to bridge the gaps that can exist when a person is discharged from hospital.
The health care system should:
• Offer a “seamless” service focused on the provision of continuity of care for the individual
• Deliver services as conveniently as possible to the person, predominantly in a primary health care setting, in the home or an easily accessible local facility wherever this is possible
• Deliver services that are accessible to all people, including those from different cultural backgrounds
• Provide services with extended hours (evenings and weekends) to aid accessibility, and provide local services which are an alternative to locum and hospital ‘walk-in' services
• Promote services that are designed to enable people to be treated in the community rather than in hospital
• Provide systematic quality care for people with chronic illnesses in a local setting
• Provide for the needs of an ageing population, by support in the home, early intervention strategies, improved recuperation (“step down”) and rehabilitation facilities and, where necessary, respite beds
• Provide high quality and efficient hospital services but accessed by only those in an acute phase of illness requiring specialist treatment
• Balance the need to centralise complex, expensive or rare treatments and procedures, with the decentralisation made possible by information technology, telemedicine, community care and rehabilitation
• Ensure the delivery of high quality services through networked clinical services designed to deliver care in local, regional and central settings
• Enable cooperation and coordination across the system
• Provide adequate data collection processes which reflect the health needs on a local and statewide basis, and which show outcomes of health service provision. Adequate resources are required for the collection of this information.
The majority of resources and attention in South Australia are currently focused on solving individual health crises that require people to seek help in a major hospital. South Australians fortunately have high standard hospital services, but these are increasingly under stress. There will always be a need for acute complex hospital care and a health care model for the future will ensure that such facilities are appropriately supported and resourced, both in infrastructure and personnel.
However, evidence consistently shows that many people in hospitals could have avoided an admission had there been a greater level of community support services or alternatives sites in which to receive their required level of care.
The hospitals of the future will have a different role to the hospitals of the past. Services such as minor elective surgery, chemotherapy, dialysis, allied health and outpatient services would be provided much closer to where people live, and with more community input into service planning and delivery. There is also clearly a need for increased facilities to provide for respite, rehabilitation, palliative care and recuperation (“step down”) beds - the aim being that acute hospital beds are therefore free for people who need a high level of care.
The voluntary workforce is shrinking and community based health systems are now required to provide many of the core services which were formerly provided by family members and the extended family. This would require a major reorientation of health funding models to enable a focus on community based care, including the capacity for the realignment of Commonwealth and State funding to cover the continuum of care.
Rural health services should be more formally networked to metropolitan health services with both specialist staff as well as clients moving more freely within such a network. These networks would also provide professional support and development, working in both the public and private health sectors, to assist in the retention of staff in the rural areas.
For these reforms to occur there needs to be a strong voice. This voice can and should be nurses and midwives.
The role of nurses and midwives in advocacy is to mobilise all interested parties around an issue which evidence shows will impact positively on health system performance. Nurse and midwives need to build relationships to get messages through to decision-makers at all levels about the need to take action, what actions are possible, and what benefits can be gained from the actions.
Some people see advocacy as organising marches and demonstrations, others see advocacy as involvement in political campaigns or lobbying in the corridors of powers while some see it as editorial comment in the mass media. Advocacy may require all of these tools.
Advocacy is a combination of individual and social actions designed to gain political and community support for a particular health goal or program. Action may be taken by, or on behalf of, individuals and groups to create living conditions which promote health and healthy lifestyles
Advocacy by nurses and midwives should involve securing political action which will improve health outcomes and health system performance. A critical starting point for advocacy is knowledge – that is, having a good understanding of the problem and the appropriate responses. So, advocates for nurses and midwives should understand:
• How the problem or issue is experienced;
• Both common and uncommon experiences;
• The extent to which cultural, social and economic forces impact on the problem; and
• Appropriate solutions which are effective given diverse cultural, social and economic conditions.
Advocacy is required at all levels of the health system. Whether it be registered nurses or midwives in remote clinics needing to advocate for funding for a particular community development program; nurses or midwives in hospital settings requiring new technology or altered staff mix; Directors of Nursing in hospital, community or
aged care settings requiring additional funding to manage increased demand; or simply advocating for a change of practice amongst colleagues.
Advocacy requires sustained action with multiple players. Advocacy needs to be well planned. Previous advocacy efforts provide well-worn tracks and it is important to take the lessons from earlier endeavours. These include:
• Be Focused and Relevant: Be clear about what you are advocating for; establish common themes and messages; don't stray from your message; and make it local and keep it relevant
• Work in Partnership: Target individuals and organisations that can get your message across; get other peoples forums and use them for your own; recruit corporate allies; and develop media contacts (including those outside health care).
• Be Credible and Appealing: Know the facts and the numbers; do your homework and document your findings; use icons who have credibility; and use interesting stories
• Be Tactical: Be passionate and persistent; set realistic goals; plan for small wins; be opportunistic and creative; employ multiple strategies; and be willing to compromise.
I close with a quote:
“Nurses are no different from the rest of the community in their urgent need for articulate and committed leaders. And yet, leaders are said to only emerge if they are encouraged and rewarded and if others are interested in following their leadership. The current view is that contemporary society expects too much from its leaders. It is hardly surprising therefore that a community that is too cynical and distrusting of those who accept the responsibility to lead finds itself with insufficient leadership. Nurses long for strong leaders, but then criticise such leaders in unrealistic ways. Few clinicians speak of their local leaders with high regard; nurses are cautious about the motives of current power holders and people who are leaders by virtue of their positions; nurses are scornful about the use of power by power holders in nursing. It may well be the case that many talented able, creative and energetic nurses have rejected opportunities to lead.”
(Borbasi & Gaston 2002)
Borbasi, S & Gaston, C. (2002) ‘Nursing and the 21st Century: what's happened to leadership?' Collegian, vol. 9, no. 1, pp. 31-35.
Canadian Institute for Health Information Health Indicators Framework (1999) www.cihi.ca
Fagin, C. (2001). When care becomes a burden. Diminishing access to adequate nursing. Milbank Memorial Fund, New York.
Fedoruk, M & Gaston, C (2001) Nurse Effectiveness: A Literature Review. Unpublished Paper World Health Organisation
Generational Health Review of South Australian Health System, Discussion Paper (2002) www.dhs.sa.gov.au/generational-health-review
Kovner & Gergen (1998)- Nurse staffing levels and adverse events following surgery in U.S: Journal of Nursing Scholarship
Pronovost, P. J. Dang, D. Dorman, et al. (2001). ‘Intensive Care Unit Nurse Staffing and the risk for complications after abdominal aortic surgery,' Effective Clinical Practice, 4:199-206.
Silber, J. H & Rosenbaum, P.R. (1997). ‘A spurious correlation between hospital mortality and complication rates.' Medical Care, 35 (10):OS77-92.
South Australian Department of Human Services (2000-2001). Unpublished data.
World Health Organisation, 54th World Health Assembly (2001) http://www.who.int/health-services-delivery/nursing/background.htm