Winter can be a challenging time to be nice on the ward. Demand for beds can go up and staff numbers go down as winter illnesses hit.
It is the second winter for Mikaela Shannon as nurse manager of inpatient services at Kenepuru Hospital, which is 18 months into a ‘Care with Dignity’ project that morphed from focusing on staff being kind to patients to nurses being kinder to each other.
Shannon says this winter, when wards are short-staffed and flag they need help, it may well be a team manager who arrives to work on the floor beside them.
“All my managers are in uniform now. They used to be in their own clothes. At the end of the day we are all nurses and we are slowly getting that culture that we are all there to help. And I too can make a bed and take a patient to a toilet.”
Shannon believes “absolutely” that if you want culture change you need to “get on the floor and role model it”.
And when she arrived nearly two years ago to take up the post of managing around 100 nurses and healthcare assistants in Kenepuru’s five inpatient wards, a culture change was being called for by Capital & Coast District Health Board’s head office. There was concern about some ‘unpleasant’ online patient feedback and a series of complaints to the Health and Disability Commissioner, says Shannon.
Working with the director of nursing’s office, it was decided to adapt the United Kingdom’s ‘Dignity in Care’ approach and the Royal College of Nursing’s related ‘Dignity: At the heart of everything we do’ campaign to form the basis of Kenepuru’s Care with Dignity programme, which was held last year and underwent an independent evaluation by Whitireia New Zealand.
Shannon says the campaign started simply with wearing name badges and taking a “Hello my name is” approach to communicating with patients. It then moved on to an education workshop looking at dignity, patients’ rights and ideas for improving patient care, which were supported by appointing ‘dignity advocates’ in each ward to highlight and champion putting the improvements into action.
The project focused on treating patients with dignity and respect but it got some staff questioning how respectful staff were of each other. And amongst the Whitireia evaluation report recommendations – including management providing the resources, time and environment to put the Care with Dignity philosophy into action – was a call for all healthcare workers themselves to “model a culture of care with dignity”.
“Over 18 months we probably had four or five events where people had not been very nice to each other … really harsh, ‘eat your own’ type stuff,” says Shannon.
Some events involved new graduate registered nurses or new enrolled nurse staff being snapped at when asking a question or for help, leaving them in tears.
The dignity training meant staff were ready to speak up about unkind behaviour, including one healthcare assistant reporting, “Yes, I’m under direction and delegation, but I don’t need to be shouted or screamed at.” “People can have a bad day,” says Shannon. “But they still need to communicate respectfully to each other.”
Some staff also expressed concern about patients having to hear the “silly banter” of staff being disrespectful to each, including the incoming shift’s nurses sniping about what the previous shift had left undone.
The result is that this year there is a follow-up pilot Care with Dignity project for fostering respect and dignity between nursing staff that got underway in April to build on the groundwork of last year’s patient-focused programme.
It’s early days yet but Shannon says things are changing and nearly 60 per cent of staff are on board, with feedback indicating that the dignity advocates, focus groups and ward teams are working on developing a ‘culture for caring’ and a zero tolerance for bullying-type behaviour (see sidebar).
All her senior team staff are trained and supported in conflict management, including giving staff feedback and assessing ward culture. Work has also been done with staff whose actions prompted the call for more kindness, including using a ‘coach and buddy’ system, role reversal discussions and peer mediation, plus making sure that staff have the appropriate professional language and strategies to use when things go wrong. They are also encouraged to come to meetings with not only problems but also possible solutions.
Shannon says she once had new grads and ENs coming to her in tears but now she believes that the former ‘I’m not helping you’ or ‘we’re not working as a team’ vibe is very much gone.
Work pressure and rostering stress
Shannon acknowledges that the stresses and strains of the modern health system also take their toll on a nurse’s capacity to be caring.
“Most people don’t come to work to be unprofessional – they come because they want to do a good job but they get stressed and snap or say the wrong thing.”
She believes what is helping is having the dignity advocacy groups where people can talk about some of the pressures and issues that make them act unprofessionally.
“It is not perfect yet by a long shot – don’t get me wrong.” But she feels Kenepuru is now on the right track.
Part of the move to “being nicer to each other” is Kenepuru’s new approach to rostered and rotating shifts. Shannon says the roster may have been a source of tension before but there is now a push towards a ‘self-rostering’ model with the aim of allocating shifts fairly and “looking after each other like a team”.
“It is no longer ‘my way or no way’. [For example] we had an awful lot of nurses who had had their families and worked mornings but their families had now left home and they were still working mornings – that kind of thing.”
Roster discussions start at ward meetings and while some people request shifts online there is still a paper roster in the staffroom where people can negotiate and swap shifts before the roster is finalised and published.
Shannon says it can be hard work role-modelling a culture change and she needs to be mindful that she may not always get it right.
But while it may take longer to get some staff on board with the new philosophy than others, she says a Dignity Week in March was a turning point for her as positive things happened on wards not just because she or her senior managers were around or had initiated them.
“We now have a platform where dignity is business as usual,” says Shannon. And, “touch wood”, after 22 months in the job, staff turnover is very low and she has not had to deal with any serious patient complaints. “Which, for me, says volumes.”
Care with Dignity
- Initiating and participating in workplace celebrations.
- Complimenting colleagues.
- Respecting each other’s ideas.
- Thinking before responding.
- Supporting colleagues who are struggling with personal or workplace issues.
- Disrespecting feedback.
- Being emotionally reactive.
- Not sharing information or resources.
- Isolating peers.
- Changing information (written or verbal) without delegation.
- Poor attitudes.
- Screaming or shouting.
- Unrealistic expectations of each other.
Behaviour and values guidelines developed by Kenepuru nurses to foster respect and dignity between nursing staff.