Research at the Centre

Health services research is a multidisciplinary field of scientific inquiry into questions about the appropriateness, equity, effectiveness and efficiency of different means of improving the health status of individuals and populations.

Both internationally and in Australia, there is a demand for high quality interventions delivered at the most reasonable cost, which leads to greater reliance on evidence from health services research. As with other key health care policy areas, research can contribute to resolving existing dilemmas and can provide innovatory ideas for the future and the CHSM is committed to providing sound evidence upon which health policy and planning decisions can be made.

Research projects

The Centre is involved in a broad range of collaborative research and cross-disciplinary research activity with a strong emphasis on human resource development and information management.

The main focus of the research program of the UTS Centre for Health Services Management for the past three years has been the ARC-Linkage funded study, examining patient and nurse outcomes and the cost of nurses' turnover, in collaboration with health services across NSW, ACT and Western Australia.

Other active research interests within the CHSM include:

• Research into the costing of specialist health services
• Organisation of health care, such as the systematisation of clinical care for specific, disease, treatment and case types
• Turnover costs for staff and patients
• Development of tools to evaluate the resiliency of clinical handover
• Use of electronic medication records and the impact on work
• Policy development in the area of aged care
• Policy analysis in end-of-life care
• Review and development of innovative models of nursing care
• Review and analysis of advanced practice roles
• Evaluation of initiatives in coordinated care
• Economic modelling of the nursing workforce
• Evaluation of clinical quality programs and training program in quality improvement
• Health policy development and implementation

Current research projects

Advancing understanding of health professionals’ work and communication patterns and the effectiveness of work reform initiatives

ARC Discovery ($512,051 2011-2013) Investigators Westbrook J Dunsmuir W Duffield C.

This cross university research partnership looks at the health systems internationally need to improve productivity and the way in which hospital staff work together. These three researchers will focus on delivering new methods, information and theoretical advances to support the design and evaluation of future health care workforce reform initiatives.

Effective clinical handover communication: improving patient safety, experiences and outcomes

ARC Linkage ($718,245 2011-2013) Investigators Slade, D.M., Manias, E., Battersby, M., Scheeres, H.B., Della, P.R., Jureidini, J.N., Jones, D.A., Sorensen, R., Farrell, L.E., Watson, B.M.

This project aims to contribute new knowledge for improvements in handover communication which will be shared across hospitals and health departments nationally to improve patient safety and reduce healthcare costs. This project brings together the collaborative work of a large number of leading researchers both nationally and internationally.

Observation and Response Charts: Usability Testing and Piloting

Tender awards by the Australian Commission on Safety and Quality in Health Care ($167,486 2010-2011) Investigators Elliott D, McKinley S, Perry L, Duffield C, Roche M, Sorensen R, Iedema R, Gallagher R, Fry M.

This study will assess the performance of four types of Observation and Response Charts (ORC) in a clinical environment. The focus is on usability testing to examine whether the ORCs are appropriate tools for managing patients in a clinical environment. This study is a component of a larger program of work being conducted by the Australian Commission on Safety and Quality in Health Care (ACSQHC) that focuses on ensuring that hospital patients whose clinical condition deteriorates receive appropriate and timely care and treatment.

Economic Modelling of the Nurses' Labour Market in Australia.

ARC Linkage ($410,239 for 2007-2010) with Department of Human Services Victoria. Chief Investigator Professor A Scott (University of Melbourne) with Shields M, Creedy J, Kalb G, Duffield C and McCarty M.

Being able to devise policies that aid recruitment and retention is a key issue for government and other nurse employers. Given the moderate role played by wages shown in overseas literature, this research will focus on the non-wage aspects of nurses' jobs that influence nurse turnover. A survey of nurses will be conducted, and an already established economic model of factors influencing labour supply will be extended. The results will be used to influence pay and non-pay policies to reduce nurse shortages in Australia.

Patient and nurse outcomes and the cost of nurses' turnover in Australian hospitals.

ARC Linkage ($350,000 for 2007-2010) with Northern Sydney Central Coast Health, ACT Health and WA Health. Chief Investigator Professor C Duffield with Roche M, Homer C, O'Brien-Pallas L, Buchan J and Shamian J.

This research focuses on the costs and outcomes of nursing turnover for patients and staff. The overall aim of this study is to determine how the rate and intensity of nursing turnover (the loss of human capital as providers leave and the lost productivity as new hires are oriented) impact patient health and safety outcomes, nurse satisfaction, health and safety, and system outcomes (turnover costs). It is anticipated that the project will provide a turnover costing methodology for use with other health disciplines.

Newsletter 1 (PDF, 72kB) - July 09

Completed research projects

Determining nurse-patient ratios in NSW public hospitals

New South Wales Nurses Association ($126,000 2010) Investigators Buchanan J, Duffield C.

Excessive workload has been identified as a major cause of stress and dissatisfaction in the nursing workforce. Increased acuity, throughput and patient complexity, combined with new types of tasks, overextended work jurisdictions, increasing pace of work, and scope, role and task expansion have intensified the work done by nurses. This project provided advice to the NSW Nurses Association on the design and methods of data collection to determine current nurse to patient ratios in NSW Public Hospitals.

Review of the roles of the Clinical Nurse Consultants (CNC) at a large teaching hospital (2009)

Investigators Duffield, C, Baldwin, R, Roche, M.

The review was commissioned by the Director of Nursing as part of the overall review of nursing staffing and roles at the Hospital. The review consisted of the collection and analysis of data from two electronic surveys, interviews with all CNCs, selected managers and clinicians, and analysis of data on occasions of services provided.

Analysis of staff feedback on the proposed organisational restructuring (2009)

Investigators Duffield, C, Fry, M, Stasa, H.

A review was commissioned to analyse feedback from staff about the proposed hospital restructuring. The scope of the review was to analyse and identify themes from staff feedback to the proposal, and to provide a summary of the comments and issues raised by the respondents.

Review of the Aged Care Accreditation Standards for Residential Aged Care

Department of Health and Ageing (2009) Investigator Baldwin, R.

The review provided a number of services including general expert advice, assistance with the development and review of the report and participation in workshops conducted by PwC on behalf of the Department of Health and Ageing.

NSW Treasury Workforce Productivity: Hospital nurse practitioners

On behalf of the Sax Institute NSW and NSW Treasury Department (2009 $12,000) Investigator Fry, M.

This review was undertaken in the context of the Garling Commission Report, the National Health and Hospital Review Commission and additional funds to support reform. The reviews were for Treasury in the first instance and will be discussed with NSW Health and the Department of Premier and Cabinet. The objective was to provide an evidence base for discussions about potential reform options. The review scoped studies examining the potential for nurse practitioners in hospital settings to undertake a wider scope of tasks than are currently part of medical practitioner roles and to increase organisational efficiencies.

The impact of providing after hours care on acute care utilisation

On behalf of the Sax Institute NSW and Department of Health (2009 $12,000) Investigator Fry, M.

The purpose of the review was to guide policy decisions by the NSW Department of Health in the context of the Area of Need Program and the new co-location of afterhours primary care clinics with Hospital emergency departments. The Area of Need Program aimed to address medical workforce shortages primarily in rural and remote locations of NSW.

The impact of electronic medication administration records (e-MAR) on medication administration safety and nurses' work

NHMRC Project Grant ($641,125 2007-2009) Investigators: Westbrook JI, Dean-Franklin B, Day R, Duffield C, Coiera E, Williamson M.

The aims of this project were to determine how e-MARs impact upon medication safety by measuring changes in the types, rates and severity of medication administration errors (MAEs) following implementation of an e-MAR; assess changes in the time nurses spend in medication administration following implementation of an e-MAR, and identify by nurse classification if more or less time is spent on other work tasks as a consequence; provide recommendations to reduce MAEs and improve the design of e-MARs. This project was the first of its kind in the world and the results are of national and international significance in establishing the role e-MARs play in improving medication administration safety and their impact on nurses' work.

Building capacity for workplace governance: Evaluating a clinical-led improvement strategy to implement an end-of-life care pathway

This research was the result of a collaboration between academics at UTS and clinicians and clinical academics at St George Hospital supported by a grant from UTS.

The findings strongly suggest that clinicians have the capacity to implement clinical governance processes in clinical units that underpin improvements in the quality of care. Further work is recommended to investigate the type of systems that are needed to support clinicians in this endeavour, particularly data feedback and multidisciplinary team review.

This report was finalised in December 2008.

Report (PDF, 832kB)

The Nursing Workload, Skill Mix and Patient Outcomes Study

The Nursing Workload, Skill Mix and Patient Outcomes Study was commissioned by the NSW Minister for Health to better understand the impact of nursing workload and skill mix on patient outcomes ($1,200,000 for 2004 - 2007). Chief Investigator Professor C Duffield with L O'Brien-Pallas, D Diers, C Aisbett, M King and J Hall. The project was coordinated by M Roche.

The project was established to answer two key questions:

• Has nursing workload changed over time given increased in-patient acuity and shortened length of stay?
• What is the relationship between the number and mix of staff, nursing workload, nursing environment and patient safety outcomes, including adverse events?

Data accessed to answer these questions included retrospective collection of five years of patient and workforce data from NSW Health, Area Health Services and hospital sources across all NSW clinical facilities. In addition, primary data collection was undertaken on eighty acute care nursing units in 19 public hospitals in NSW. This study captured the complexity of the health care environment and revealed links between nursing skill mix and patient outcomes.

Key amongst the many findings of the study were:

• Wards with a 'richer skill mix' (a higher proportion of Registered Nurses) and the support of nurse educators had fewer negative patient outcomes such as falls, medication errors, bedsores, sepsis and shock.
• Wards with a lower proportion of Registered Nurses, high workload and increased aggression towards nurses had more negative patient outcomes such as urinary tract infections.
• Overall, this study suggests that approaches to manage skill mix, workload and the work environment are best undertaken at the ward level and will lead to improved patient outcomes.

This project was finalised in 2007 and the report Glueing it Together: Nurses, Their Work Environment and Patient Safety (opens an external site) is available for download from the NSW Health website.

The National Clinical Handover Program: Tools for ongoing observation, monitoring and evaluation of handover in order to ensure handover practices are resilient in the workplace.

Tender awarded by the Australian Commission for Safety and Quality in Health Care ($202,000, 2007). Investigators: Iedema R, Manias E, Duffield C, Homer C, White L, Crisp J, Scheeres H, Lee B, Kerridge R, Sorensen R, Gerdtz M, Carroll K, Thomas V, Mallock N.

This project focuses on designing a clinical handover monitoring tool using video-based simulation technologies. The products from this work will include: a governance document that will set out the parameters of use of video technologies for hospital quality improvement projects used by clinical staff themselves; a video-based monitoring tool that engages with informational as well as affective dimensions of clinical hand-over; a procedural model for using video technologies for hand-over monitoring, and (visual) examples and evaluations of video-reflexivity applications for the purpose of establishing a data bank that legitimises the tool and captures its successes.

Making nursing work - Development of an operational model for assigning advanced nursing roles

QNC Experienced Researcher Grant ($30,000 - 2007) - Chief Investigator Professor A Chang (QUT) with Gardner G and Duffield C.

Advances in health care practice and technology as well as changes in consumer demographics necessitate more innovative approaches to nursing workforce. Nursing roles have proliferated and there is a confusing array of titles. Clarity in definition and service application of the advanced practice nursing role (APN) role is paramount given the increasing demands for and diversification of nursing roles. Definition of the role of a nurse practitioner (NP) in Australia has left many managers in Queensland and throughout Australia unclear whether their service needs can and should be met by a NP or an Advanced Practice Nurse (APN). This study will provide a reference framework for service providers to understand the operational potential of advanced nursing roles; validate role domains on which to base educational master's programs for the APN; and operationally will distinguish between the APN and NP roles.

Nursing workload measurement and staffing

A grant of was awarded through ACT Health Research Open Tender ($226,000 for 2007 - 2008). Chief Investigator Professor C Duffield with Homer C, O'Brien-Pallas L, Diers D, Aisbett C, Roche M and King M).

This project examined the components of nursing work and the impact of nursing workload on the ACT Health workforce and environment, patient/client outcomes and safety, and staff outcomes. The results should assist in making recommendations on the most appropriate way to understand the factors which generate work for nurses and contribute to their workload and how best to measure this and its impact.

This project was finalised in early 2009 and the report Nursing Workload and Staffing: Impact on Patients and Staff (pdf, 4mb) is available for download.

Developing Evidence-Based Workforce Models for Nursing Services in Acute Care Hospitals

An ARC Linkage Project (2005-2007 $115,000) with additional funding from Affinity Foundation 2005-2007:$25,000 Queensland Nursing Council $40,000, Gold Coast Hospital $10,000, Princess Alexandra Hospital $10,000. Partner Organisation(s): Queensland Nursing Council; Princess Alexandra Hospital; Gold Coast Hospital

Investigators: Duffield, C.M., Chaboyer, W., Fox-Young, S., Winch, S., Kachel, P., Courtney, M., Burgess, D., Stockler, J.P. The aims of this study are to document the current activities undertaken by differing levels of nursing staff in hospitals and develop evidence-based guidelines for future service delivery.