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IntroductionHunter 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.

BackgroundWhile 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.

The LHD has implemented Clinical Networks that link acute hospital and community services across metropolitan, regional and rural areas. The networks and their associated streams use their clinical experts to develop and maintain clinical procedures and guidelines 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 ORGANISATIONCatherine Turner Nursing & Midwifery ServicesHunter New England Local Health District, New South Wales, Australia

Sheryl DavisNursing & Midwifery ServicesHunter New England Local Health District, New South Wales, Australia

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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 documents are kept up-to-date. Staff can still print copies if needed 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 in the reliability of the intranet and policy directory, has encouraged 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.

ConclusionThe 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.