Nursing care has been undertaken by a combination of licensed nurses and nursing support workers (unlicensed assistive personnel, nurse aides, nurse assistants) for many years, with a recent increase in the number of nursing support workers across healthcare systems (Bureau of Labor Statistics, 2013; Health Workforce Australia, 2012; NHS, 2013). Where these workers have been introduced in acute general hospital settings, direct care activities increase overall, with the bulk of these tasks undertaken by support workers (Roche, Friedman, Duffield, Twigg, & Cook, 2017). However, working outside of scope of practice, delays in care, and task duplication have also been noted (Roche, Duffield, Friedman, Dimitrelis, & Rowbotham, 2016), suggesting inconsistencies in clarity of scope, delegation, and integration (Duffield et al., 2014). Services have addressed these issues with frameworks describing scope of practice and delegation procedures, usually defined for the acute general setting (e.g. New South Wales Health, 2009, 2010). However, acute general frameworks provide limited guidance to mental health nursing, and research has identified a lack of role clarity and under-utilisation of nursing support workers in that setting (Cleary et al., 2012; Cowan, Frame, Brunero, Lamont, & Joyce, 2015). Consequently, a set of context-specific care activities for mental health nursing was developed and implemented in 2013 (Cowan, Brunero, Lamont, & Joyce, 2015). This paper reports on a follow-up study to review, revise, and extend this baseline set of care activities.
Methods:This study was undertaken between April and July 2016 using a modified Delphi approach that combined voting rounds with consensus conferencing, an approach used previously to address similar issues (Kizawa et al., 2012). A panel of key stakeholders (n=10) was established, with expertise and experience of working with, teaching or supervising nursing support workers. The study was undertaken in 4 phases: Phase 1 was an initial voting round on 22 care activities that extended current practice, with respondents also given the opportunity to suggest modifications or additions to the list. Phase 2 was a conference where voting results were presented, and consensus was sought. Phase 3 was a second voting round on the revised and expanded list of 29 activities, and Phase 4 a conference where final consensus was sought. Throughout the process, consensus on each activity was set at 70% (Hasson, Keeney, & McKenna, 2000; Sumsion, 1998).
Results:Phase 1 voting indicated support for five of the 22 proposed activities, suggested modifications to six, and proposed an additional seven activities. Phase 2, the first conference, confirmed support for a total of 17 activities: the five initial items, the seven new activities, and five activities where consensus was not reached in Phase 1. Second round voting in Phase 3 was similar although one of the original activities, and two of those up-voted during Phase 2, did not reach consensus. These 14 items were reviewed in Phase 4 with no change to consensus, providing an extended set of care activities that could be performed by nursing support workers in mental health inpatient settings. This final list of activities included the escorting of clinically stable patients, acting as a preceptor to less experienced nursing support workers and conducting, but not interpreting, electrocardiograms. Activities not supported included the scoring of patient pain, alcohol withdrawal scale, neurovascular observations, and complex dressings. Participants in the study also identified requirements for ongoing education programs for nursing support workers, and effective communication of the final list of care activities.
Conclusion:The ongoing shortage of registered nurses and increased use of support workers challenges health service managers to effectively integrate these staff into their workplace and to confirm these support workers are operating within their defined scope of practice. This study developed a set of extended care activities to guide the practice of nursing support workers in inpatient mental health services, expanding the basic set of mental health duties that were initially built on those from acute general hospital frameworks. Clarification of the nursing support worker role in mental health should reduce the role ambiguity noted in previous work and provide a basis for safe, effective, and efficient utilisation of these positions. The findings of the present study have been incorporated into new position statements, and developed into posters that clearly outline the activities, placed in nurse meeting rooms and stations. Future work will evaluate the implementation of these extended care activities and associated education from nurse, manager, consumer, and carer perspectives.