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Introduction
Hunter New England Local Health District (HNELHD) provides
a comprehensive range of public health care services for a
population of approximately 840,000 people from the Hunter,
New England and Lower Mid North Coast Regions. Clinicians
work in a range of facilities, including public hospitals, community
health centres and mental health facilities.
The Local Health District (LHD) has a large workforce of
approximately 14,500 staff or 10,500 FTEs (full time equivalents),
which include approximately 7,200 nurses and midwives (50% of
the HNELHD workforce).
In addition to this organisational structure, HNELHD has
implemented Clinical Networks that link acute hospital and
community services across metropolitan, regional and rural areas.
Ensuring contemporary clinical resources are available in all clinical
settings has been a challenge since the LHD was established in
2005, but significant progress has been made.
Background
While the system for developing clinical resources for specialised
clinical services had been established, making those resources
available to all clinical staff has remained problematic. In the past,
smaller facilities have relied on a range of resources, including
those purchased from external providers to support the provision
of clinical care.
TheLHDhasimplementedClinicalNetworksthatlinkacutehospital
and community services across metropolitan, regional and rural
areas. The networks and their associated streams use their clinical
expertstodevelopandmaintainclinicalproceduresandguidelines
which are relevant to their target patient population and strive
to have these available in all contexts. Clinical procedures and
guidelines which are not the responsibility of specialist networks
or streams have been delegated to the Nursing and Midwifery
Service.
To address the gaps the Nursing and Midwifery Service established
a Clinical Guidelines and Procedures Coordinator position, a
governance framework and a working group with representatives
from across the LHD. This governance framework allows the
Nursing and Midwifery Service to authorise and manage Nursing
and/or Midwifery related clinical guidelines and procedures that
do not fit under other Clinical Networks, Streams and Services. The
Senior Nursing and Midwifery Managers Collaborative Committee
(SNMMCC) and the Director of Nursing and Midwifery approve
and authorise final nursing documents that are placed in the
Nursing and Midwifery Portfolio and which may also be applicable
to midwives or medical officers.
The goal is to provide evidence based clinical practice resources
for clinicians in all settings within a large Local Health District,
ensuring broad consultation and a rigorous governance structure.
This development and governance will ensure a nurse working in
a small rural hospital, faced with a clinical challenge which they
have not seen for some time, can find the required resources to
allow them to manage the patient safely without transferring
them to a larger facility.
Nursing and Midwifery Clinical Guidelines and Procedures
Governance
The development of an agreed purpose and governance
structure for the role of HNELHD Nursing and Midwifery Clinical
Guidelines and Procedures Coordinator and body of work was
achieved through consultation with stakeholders, using Practice
Development methodology. These included Values Clarification
and Claims, Concerns and Issues. These techniques were chosen
to ensure participatory decision making and to provide a point
of reference for the group when challenged about their role and
function.
The Nursing and Midwifery Clinical Guidelines and Procedures
Coordinator and working group are responsible for:
• standardisation of clinical guidelines and procedures
wherever possible;
• ensuring clinical guidelines and procedures are evidence
based and support best practice;
• identifying gaps in available resources;
• establishing a governance structure for ongoing
development, review, approval and authorisation of
documents and resources;
• maintaining wide consultation with nurses and
midwives, senior nurse managers and other clinical
managers, networks and streams;
• working collaboratively across areas, networks
and streams, community health networks and the
multidisciplinary teams to improve patient outcomes;
• ensuring the clinical governance framework is followed
for clinical guidelines and/or procedures;
• ensuring documents and resources are accessible
electronically to all nurses and midwives regardless of
location in the Local Health District to inform clinical
practice.
ESTABLISHING A GOVERNANCE FRAMEWORK FOR NURSING AND
MIDWIFERY CLINICAL GUIDELINES, PROCEDURES AND RESOURCES
IN A LARGE, COMPLEX ORGANISATION
Catherine Turner
Nursing & Midwifery Services
Hunter New England Local Health District, New South Wales, Australia
Sheryl Davis
Nursing & Midwifery Services
Hunter New England Local Health District, New South Wales, Australia

2. 48
Since the establishment of the role in 2011, the Coordinator
provides support, advice and assistance for nurses and midwives
to develop or review policies, clinical guidelines and procedures
and direction on where to get help in working through the policy
process across a variety of rural and urban settings. Additionally,
this role manages development, dissemination, collation and
approval processes of any Ministry of Health Policy Directives
or HNELHD policies that require mandatory compliance and
which are referred to the Director of Nursing and Midwifery for
implementation across the LHD.
The Coordinator role also provides advice and assistance to the
HNELHD Women’s Health, Maternity and Gynaecology Policy and
Forms Group and submission of final documents to the relevant
portfolio sponsor for authorisation. This group is responsible
for document review and development specific to Maternity
and Gynaecology (including Women’s Health). Documents are
reviewed and final versions approved by the Women’s Health and
Maternity Network (WHaM).
Challenges
Since the merging of area health services in 2005, there has been
some reluctance to share or publish clinical resources which
have been developed for specific sites, resulting in duplication
of effort and lack of standardisation of practice. Some nurses and
midwives at smaller sites within the HNELHD have previously
relied on externally purchased resources which may not have
been applicable in their context of work. The revised coordination
and governance processes have enhanced the quality of clinical
resources by ensuring that they are developed and reviewed by
the appropriate clinical experts in context and based on current
evidence.
Benefits of Electronic Resources
Nurses and midwives are able to access HNELHD clinical guidelines,
procedures and other appropriate resources e.g. forms and
learning packages, from any HNELHD networked computer at any
facility/service across the district. The HNELHD Policy, Procedures
and Guidelines directory (PPG) enables searching using keywords
contained in each document e. g. the keyword ‘maternity’ is used
in all maternity documents to enable midwives to search and
access all relevant documents easily.
Only one current copy of each document is stored on the
policy directory at any one time and versioning is controlled by
the HNELHD Policy Officer (Clinical Governance) or local policy
site administrators. The PPG directory is designated as the one
authoritative and primary source of policies and procedures
affecting the LHD. Related documents can be linked in the
guideline or procedure and accessed electronically. Due to the
constant revision of documents, either local or district wide, staff
are strongly advised to access the online version of a document
rather than keeping printed copies.
Maintaining paper versions requires effort at each site, especially
when several amendments are required. If keeping printed copies
is unavoidable, it is the responsibility of the manager to ensure the
documentsarekeptup-to-date.Staffcanstillprintcopiesifneeded
and are encouraged to review when undertaking procedures with
which they are less familiar or confident.
Risk Management
Nurses and midwives’ increased familiarity with the use of
computers to find resources, combined with increasing confidence
inthereliabilityoftheintranetandpolicydirectory,hasencouraged
more sites to remove hard copy manuals and to educate staff to
access the PPG directory. This ensures that all staff are using the
most current versions for clinical care. A large number of Ministry
of Health documents, local and LHD documents/resources are
now accessible via the PPG directory.
Documents commonly needed in a patient emergency need to
be on hand, but for the majority of users, the risks around using
an out-dated hardcopy of a procedure over the risks of not having
access to the PPG directory is probably greater. Some sites have
opted to print their most common top ten documents as a back-
up and it is the responsibility of the manager to ensure these
documents are kept up-to-date if the version is changed.
Progress and Collaboration
Prior to the establishment of the Coordinator role, limited
progress had been made on the development of procedures and
guidelines for the range of issues not covered by specialist clinical
groups. Networks and Streams were reporting challenges with
ensuring broad nursing and midwifery consultation for specialist
documents.
Since the development of a governance framework and
establishment of a Coordinator position in 2011 for Nursing and
Midwifery, significant progress has been made which has resulted
in the improved access to more than 70 relevant revised or new
District-wide clinical documents/resources for nursing, maternity
or gynaecology via the PPG directory.
Conclusion
The Coordinator provides a central point of contact for enquiries
and comments about documents under development or
review and is able to provide direction for clinicians trying to
source available clinical documents. A culture of collaboration
now exists and the organisation has a viable system for the
development, review and maintenance of nursing and midwifery
clinical guidelines and procedures. Communication to all relevant
managers has improved the implementation of the contents of
documents.
The continued collaborative work by all stakeholders across
such a large geographical area has improved evidence based
standardisation of care and improved patient care outcomes.
Clinicians are involved in review and development and therefore
have ownership and commitment.
The challenge of ensuring that all clinicians are aware of changes
in clinical practice remains significant across this diverse LHD.
The need to provide appropriate, clinically relevant resources
which are based on the most current evidence will ensure that
the work of the coordinator and the group is ongoing. Current
challenges include the need to develop other documentation
which is standardised across the area and meets the needs of
nurses and midwives, including assessment forms and care plans
and raising the awareness of all clinicians of the array of resources
now available online.