Citation

Material Information

Title:
A baseline study of human resources in the health care sector Commonwealth of the Bahamas
Creator:
Cynthia Carver
Place of Publication:
Nassau, Bahamas
Publisher:
Ministry of Health
Publication Date:
Language:
English
Physical Description:
86 p. ; 28 cm
Physical Location:
HBL Main Collection

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Subjects / Keywords:
Nurses -- Supply and demand -- Bahamas
Genre:
technical report ( marcgt )
federal government publication ( marcgt )
Target Audience:
specialized ( marctarget )

Notes

Statement of Responsibility:
Cynthia Carver

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Source Institution:
University of The Bahamas
Holding Location:
University of The Bahamas
Rights Management:
This item is licensed with the Creative Commons Attribution No Derivatives License. This license allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author.
Classification:
RT89 C27 1986

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A BASELINE STUDY OF HUMAN RESOURCES IN TliE HEALTH CARE SECTOR C OMMONWEALTH OF THE BAHA MAS I -RT89 C27 19ts6 copf Carver, M D., t986 ... ,.,..,.,-..:a-...:.=-

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I . / A BASELINE STUDY OF HUMAN RESOURCES IN THE HEALTH CARE SECTOR COMMONWEALTH OF THE BAHAMAS Cynthia Carver, M.D., M.P.H

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I I TABLE OF CONTENTS I. INTRODUCTION AND RATIONALE II. BASELINE DATA NURSING NUMBERS AND DEPLOYMENT III. JOB CONTENT AND PRODUCTIVITY , 1 3 21 IV. SYSTEMIC LOSSES 32 V. WORKING CONDITIONS, NURSING MORALE AND PRODUCTIVITY 45 VI CONCLUSIONS 59 VII. RECOMMENDATIONS 68 APPENDIX I METHODOLOGY 77 APPENDIX II OTHER INSTITUTIONS 80

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A BASELINE STUDY OF HUMAN RESOURCES IN THE HEALTH CARE SECTOR COMMONWEALTH OF THE BAHAMAS I. INTRODUCTION AND RATIONALE The Ministry of Health Commonwealth of the Bahamas, has determined that there is an urgent need to examine the human resources witbin the health sector and to project manpower requirementes for the period 1986-1990. To assist with preliminary planning for this endeavour, Dr. Betty I Lockett and Dr. Asher Segall from PAHO/WHO v{sited the Bahamas in January 1986 and obtained an overview of the health care system, methods and locations of service delivery, staffing and general problems. They recommended that a health manpower study be undertaken and that it have two tracks as follows: "a) The current situation in terms of utilization of personnel (in Princess Margaret Hospital and the deployment of personnel to Sandilands in particular) needs to be analyzed in terms of cost efectiveness and productivity. b) The overall health manpower planning study could be carried out at the same time with a time frame of 1990". {1) {1) from PAHO Trip Report 1 Bahamas, January 26-31, 1986 by Dr. B. Lockett.

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-2 -The rationale for a preliminary or baseline study of health manpower includes two important components. First, if future human resource projections are based on extrapolations from present staffing patterns they will perpetuate and even multiply existing inefficiencies where.they exist. It therefore is only prudent to evaluate numbers and deployment of present staff before beginning any projections. The second factor is that the Ministry of Health has become increasingly aware of dissatisfaction among the ranks of nursing. This dissatisfaction has manifested itself in reports on nursing from Senior staff, perceptions that absenteeism is high among nurses and that nursing morale is low. It was recognized that if these perceptions were true, it I might also be true that productivity could less than optimal. As a result of these considerations, it was decided to immediately undertake this Baseline Study for the specific purpose of examining the present numbers, deployment and productivity of health care personnel. Since Nurses represent by far the majority of health care personnel, and are essentially the backbone of the health care delivery system, it was decided to concentrate on Nurse manpower for the study. It was further decided to focus on nursing at Princess Margaret H ospita 1 since it is the major employer of Nurses in the Bahamas. Hence the format of this study and report will be firs t documentation and evaluation of nursing numbers, deployment and productivity at Princess Margaret Hospital in depth, followed by a more cursory examination of nursing outside of Princess Margaret. The report will enumerate, evaluate and make recommendations for improvement where warranted. The focus will be on present and future efficiency, efficacy and cost-effectiveness of human resource utilization in the Health Sector in the Bahamas.

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/ -3 -II. BASELINE DATANURSING NUMBERS AND DEPLOYMENT. A. Total Number of Nurses in the Bahamas Before beginning an in-depth examination of nursing in Princess Margaret Hospital, a brief look at overall Bahamian nursing numbers seems warranted. Table I shows the total number of nurses and nurses per 10,000 population for the Commonwealth of the Bahamas as compared with other Caribbean countries, the United States, Canada and selected Latin American countries. It can be seen that itt'' the Caribbean sub-region the Bahamian ratio of 42.9 nurses per 10,000 population is higher than that for other countries, except for Bermuda (93. 7) and the Virgin Islands (45.4). Canada and the United States have much higher Nurse ratios (71.0 and 83.1, respectively). The Latin American countries have far lower ratios of nurses per 10,000 population, ranging from 1.2 and 1.7/10,000 for Brazil and Bolivia, respectively, to 10.4 and 7.8/ 10 000 in Panama and Peru. It must be noted that the figures come from various years for different countries. Nonetheless, the magnitude of the differences is likely to be reasonably accurate. The level of education of nurses is not stipulated and hence questions can a lso be raised about productivity and scope of activity. The .overall conclusion, however, must be that the Bahamas ranks extremely well alongside its neighbors 1n total numbers of Nurses, given its population.

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-4 -TABLE I Nurses -Total Number and Number per 10,000 population (PAHO Statistics) Nurses Total per Anguila Antigua & Barbuda Bahamas Barbados Bermuda Caytnan Islands Cuba Dominica Dominican Republic Grenada Guadalupe Haiti Jamaica Hartinique Monserrat St. Christopher & Nevis St. Lucia St. Vincent & The Grenadines Trinidad & Tobago Turks & Caicos Virgin ISlands Canada United States Panama Peru Bolivia Brazil Year 1985 1983 1983 1983 1984 1985 1983 1983 1982 1983 1983 1983 1984 1984 1983 1983 1983 1983 1983 1985 1985 1983 1983 1983 1985 1985 1980 Number Nurses r 19 145 944 744 562 82 26,194 204 509 162 977 973 3,594 1,091 33 140 229 327 3,346 32 59 174,768 1, 943,700 2,172 14,900 1,066 15, 1 '58 10,000 population 27.1 18.6 42.9 29.8 93.7 41.0 26.5 27.1 0.9 14.7 30.3 1.9 15.7 33.1 25.4 26.9 18.2 32. 1 29.1 40.0 45. 4 71.0 83.1 10 4* 7.8* 1. 7** 1.2** highest ratios and ** lowest ratios in Latin America.

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5 -B. Number of Nurses -Princess Margaret Hospital. There are many factors 'to be considered in an evaluation of nursing numbers. Nursing in a hospital environment is generally a twenty-four hour service. The major exceptions to this are Out-Patient (Ambulatory Care) Clinics and Operating Theatres. This means that three shifts of nurses are required to provide services through-out the day. Furthermore, the three shifts require different levels of staffing. The early shift, 8 A.M. -4:30 P.M. in PMH, generally requires the most staff since the hosp{tal day is structured such that more activities occur during this time period than in/ any other: admissions and discharges, surgery, doctors' rounds, most meals and housekeeping, medications, dressings, procedures and tests, etc. The night shift, when most patients sleep and few procedures are done, requires the ewes t staff. Another factor that must be considered in evaluating staff levels is days off, including regular days off, vacation leave, public holidays, study leave, sickness, disability (limited capacity to function), leave without pay and so on. Training and experience of staff will affect the kind of work individuals can do and the amount of supervision they will require. Extra work, such as supervising students, running errands or doing the work of maids, porters and clerks when these staff are unavailable, will all impact on the actual numbers of staff required on any given ward at a particular time. Hence, the total number of nurses actually on staff should never be viewed only in the context of number of beds and occupancy rates, but rather in the context of the day to day working conditions.

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-6 -Table II shows the Approved Nursing Establishment in March 1985 and the actual Nurse Staffing as of December 1985. If the approved Nursing Establishment is meant to refer to the number of nurses of various categories that the Ministry of Health is willing and able to fund, then it is difficult to understand why, in all but two categories, the actual staffing is at a considerably lower level than that of the establishment list. Of particular concern here is the apparently unfilled senior nursing positions, including PNO, SNO, NOI and NOli. The reality is that the positions are filled, with nurses accepting full responsibility for the jobs, but lacking both recognition and pay for the work they are I performing. It is not clear to the investigator why these promotions have not been completed, except that there have been major administrative delays. For the reasons given above, the total number of Nurses tells little about the adequacy of staffing. However, the Table does give information about the numbers in different categories of nurses, and hence the potential for adequate supervision. C. Supervisory Ratios Supervisory ratios are an area of some concern, particularly when a significant amount of developmental work is required within groups of Nurses. If goal setting, program development, work planning, evaluation and team building are not at a relatively high level of operation, then the numbers of workers supervised by one manager should be reduced. There is no set ratio for optimal management, but it would appear that (as will be seen later in this Report) much developmental activity is required from supervisors ln nursing in the Hospita 1. Therefore, a ratio of one manager to about 6 nurses is probably reasonable, with a range of 1 : 5 -1:8, depending on location of work, level of skill, etc.

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--7 -TABLE II Establishment by Institution and Staff Category as of 31 December, 1985 PRINCESS MARGARET HOSPITAL GRADE ESTABLISHMENT PRESENT STAFF VACANCIES Principal Nursing Officer 1. Deputy Principal Nursing Officer Senior Nursing Officer 6 Nursing Officer I 9 Nursing Officer II 45 Nursing Officer III 10 Staff Nurse 274 Senior Trained Clinical Course 4 Trained Clinical Nurse 262 Midwives Nursing Auxiliary and Attendant 85 Total 696 Midwives -Work as T_rained Clinical Nurses, but paid as Nursing Auxiliaries. 0 1 3 3 5 4 40 5 6 4 270 4 0 4 231 31 2* 176 91 773

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-8 -Table II shows the numbers of supervisory nurses (Nursing Officers) and the numbers of Staff Nurses and Trained Clinical Nurses. The Principal Nursing (P.N.O.) directly supervises Senior Nursing Officers (SNO), and in the (theoretical) Establishment List,, a 1:6 ratio is observed. In reality, this is what is occurring at present (although there is also an Assistant to the PNO) despite the "Actual Staffing" list. The Senior Nursing Officers are responsible for functional areas of the hospital (medical wards, surgical wards, pediatrics, maternity, operating theatres and the ambulatory care department). They supervise 64 Nursing Officers (NOs) I, II, and III, which is an average of almost 11 NOs per SNO. The 1:11 ratio of SNO:NOs probably does not allow for adequate supervision unless the NO-lis and 'NO-IIIs report to NO-Is. In addition, with only 6 SNOs, there cannot be Senior Nursing Officers supervising on all shifts. With only 6 SNOs, there cannot be senior nursing supervisors on all shifts. Examination of the next level of overall staffing shows one Nursing Officer to between 4.3 (establishment list) and 5.3 (actual list) Staff Nurses, or 1:8.4 or 1:9.9 Staff Nurses plus TCNs. If the TCNs receive all of their supervision from NOs (and none from Staff Nurses), then this supervisory r ation may be less than adequate. On the other hand, one NO supervising 4-5 Staff Nurses probably represents oversupervision. Similarly, if Nursing Auxilliaries (NAs) receive a significant amount of supervision from NOs, then they must be included in the team count. Staffing supervision ratios must be closely studied and considered in the light of supervisory roles in the future as compared the present and with clearly defined areas of responsibility. In particular the question of who supervises the TCNs and NAs must be resolved.

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-9 -D. Shift Deployment Tables III-VIII show the total staff assigned to each of the major areas in the hospital. The beds and occupancy rates are given by Ward, and typical staffing of the various shifts is shown. Two important qualifications about these tables must be made. First, total staff numbers for each area (bottom table on each page) include nurses who are away on study leave, maternity leave and sick leave and thus they are an over-statement of the numbers actually working. Secondly, while the numbers of nurses present on each shift represent actual numbers working, the occupartcy rates are an.average for the year. The actual number of beds occupied at the time these "typical shifts" were staffed is not known. However, a number of aspects of Nurse deployment can be seen in these Tables. The Tables indicate that there are no Nursing Officers on duty on the late or night shifts for Areas: Surgical I, Medical, Pediatrics or Maternity. It seems obvious that if supervision of Staff Nurses and TCNs is required during the day shift it should also be required on the late and night shifts. Tables III-VI, cover the major Ward Areas (Medical, Surgical I and Paediatrics). They show the numbers of Staff Nurses and Trained Clinical Nurses by shift and the Area totals. In general there are more Staff Nurses than Trained Clinical Nurses. This is an area worthy of consideration which direction is more desirable for the Bahamas: to move towards phasing out the TCN, to maintain the approximate 1:1 ratio, or to move towards deployment of more TCNs in relation to SNs. The degree of supervision of TCNs by SNs is important to this equation as is the kind of teamwork in operation and the specific capabilities of each type of nurse.

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Ward Private Medical Female Medical I Female Medical II Male Medical I Male Medical II Male and F emale Chest Shift Totals Private Medical Male Medical I Male Medical II Female Medical I Female Medical II Male Chest Female Chest Area Office 10 -TABLE III Typical Staff'Shifting March 1986 Area: M edical No. % 0 Earl I Shift Late Shift .. Beds OccuE NO SN TCN NA NO SN TCN NA NO SN 12-15 81 1 2 1 1 1 1 1 1 0 . . . . 24 1 2 2 2 2 1 2 1 ... . . . .... ................. 16 103.6 2 1 1 ; ... 1 . 1 1 1 l5 65.3 1 2 1 1 1 1 1 1 0 16 1 2 2 1 1 1 1 1 0 0 ...... 25 42.6 2 1 3 1 1 2 1 14 31.8 4 12 8 9 7 6 8 6 Total Staff -All Shifts Dec. 1985 NO 1 1 1 0 1 2 3 SN TCN 7 5 5+1* 6 8 7 8 7 7+1* 4 4 6 1 1nfection 1 relief control Shift TCN NA 1 1 2 1 1 1 1 1 1 1 1 1 7 6 NA 5 6 6 7 5 9 Medical Area Totals 9 42 36 38 Away on leave -2 nurses.

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11 -TABLE IV Shift Staffing March 1986 Area: I Ward No. % Early Shift Late Shift Night Shift Beds Occup NO SN TCN NA NO SN TCN NA NO SN TCN NA . ...... Female Surg. 32 81.4 1 4 3 1 -2 2 1 2 2 1 ... . . Male Surg 48 88.7 2 4 3 3 3 3 3 3 3 3 ....... . .... Private Surg 30 81.8 1 3 2 2 2 2 1 2 1 1 . . r Eye Wing 24 37 3 1 1 1 1 1 1 1 1 Area Office 1 1 Shift Totals 5 14 9 7 8 8 6 8 7 6 . I Total Staff -All Shifts Dec. 1985 NO SN TCN NA Female Surger y 3 12 12 8 Male Surgery 3 19 16 12 Private Surgery 1 13 9 7 Eye Wing 0 7 5 6 Area Office 1 Surgical Area I Totals 8 51 42 33

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1 2 -TABLE V Shift Staffin& March 1986 Area: Paediatrics Ward No. % Ear l l Shift Late Shift Nisht Shift Beds Occup. NO SN TCN NA NO SN TCN NA NO SN TCN NA Children' s 88 70.7 1 7 6 7 5 6 5 -5 7 3 Wards (4) Paediatric 15 78. 8 1 1 1 1 1 1 1 1 Sur ical Special Car e 20 124. 4 1 4 2 { 3 2 2 2 1 Unit Formul a -1 2 ---Room Area Office 1 --Shift Total s 3 1 2 1 0 1 1 9 9 6 -8 10 4 Total Staff -All Shifts Dec. 1985 NO SN TCN N A Chi ldren's Wards 3 28 40 30 Paediatric Surgical 2 4 5 3 Spec i a l Car e 1 1 5 10 5 Area Office 1 Paediatric Area Totals 7 47 55 38

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-13 -TABLE VI T:nical Shift Staffing March 1986 Area: Maternity Ward No. % Earll:: Shift Late Shift Night Shift Beds Occup NO SN TCN NA NO SN TCN NA NO SN TCN NA Antenatal 16 63 1 2 1 -1 1 1 -1 1 Postnatal 24 63 1 1 1 1 -1 1 1 1 Labour and 3 63 1 3 1 -r' 2 1 1 2 1 1 Delivery 1 1 MW MW Nursery 20 99.6 1 1 --1 1 --1 Gyne 24 58.9 1 1 1 2 -1 1 1 1 1 1 Area Office 1 Shift Totals 5 8 3 5 5 5 4 5 3 4 lNW 1 MW Total Staff -All Shifts Dec. 1985 NO SN TCN NA MW Post Natal O.P. 1 2 Gynecology 2 7 6 7 Maternity 6 36 14 16 2 Area Office 1 Maternity Area Totals 10 43 22 23 2

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14 -TABLE VII Typical Shift Staffing March 1986 Area: Surgical II Ward No. % Occup. Early Shift Late Shift Night Shift Beds NO SN TCN NA NO SN TCN NA NO SN TCN NA I C U 8 7 6.4 1 4 1 1 1 3 2 1 3 1 1 Main Theatre 3 2 5 5 3 -3 4 2 -1 1 1 Ext. Theatre 4 3 lt' --& Recovery Main Recovery 2 1 1 1 --Burns Unit 1 1 1 2 ---Area Office 1 Shift Totals 5 16 11 7 1 7 7 3 4 2 2 1 MW Total Staff -All Shifts Dec. 1985 I C U Theatres/Recovery Burns Night Duty Surgical Area II Totals -Away on leaves NO 3 4 1 8 SN 22+4* ** 20+1* ** 2 44+5 TCN NA 8 4 19 10+1* 2 3 1 30 17+1 ** includes 1 part-time nurse.

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15 -TABLE VIII Sh.ift Staff March 1986 Area: Ambulatory Care Department Ward No. % Shift Late Shift Shift Beds Occup. NO SN TCN NA NO SN TCN NA NO SN TCN NA Accident and 2 6 3 3 1 6 3 3 3 3+1 1 General Practice 1 1 8 7 Clinics Dressing 5 2 Room Injection 1 Room Fanngton 1 2 2 rHouse ........ Specialty 1 7 7 3 Clinics Sh ift Totals 4 1 5 26 1 7 1 6 3 3 1 3 4 1 . . Total Staff -All Shifts 1985 NO SN TCN NA Area Office 2 General Practice 1 2 15+1 9 Accident & Emergency 3 19+ 1 9 5 Accident & Emergency 6 8 Ni hts Spec i alty Clinics 2 7 1 0 3 lnJectl.on Unit 1 D U 1 Hospital 2 Farrington House 1 2 2 ACP Area Totals 11 40+1 45+1 19 -Away on leaves **-includes 1 part-t ime nurse.

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-16 The deployment of Nurses is important not only from a supervisory perspective -related to the to manage -but more fundamentally in terms of the ability to provide excellence in patient care. At the most basic level, decisions must be made as to how many patients, on average, a good Nurse for. Such decisions require assumptions as to the average amount of nursing care and maintenance care (feeding, washing, toiletting) required by patients, the level of productivity of professional and support staff, and the types of staff and numbers available. I I' Using the typical shift staffing from the tables it is possible to calculate average numbers of patients per nurse. Table IX shows a few examples of the staff patient ratios in 3 major patient areas and by shift. These ratios include Staff Nurses and Trained Clinical Nurses but not Nursing Officers. The average bed census is used to obtain patient numbers per ward. It can be seen, that on the early shift the ratios of patients per Nurse range from 3 per nurse to 6 per nurse on the Medical and Surgical Wards On the late and night shifts, 5 to 8 patients per nurse is more the norm. In interviews with several senior nurses, the question was asked: with good support staff, and a mix of patients from quite sick to ready-for-discharge, how many patients can a highly competant staff Nurse look after and offer optimal care? The responses ranged from 8 to 12. In the calculations of the ratios above, TCNs were included, and they probably cannot look after as many patients as a staff Nurse. In addition, there are some tasks that are reserved to Staff including dispensing of medications and complex dressings among others. Finally, the amount bf supervision required by TCNs must be considered. Under present conditions a ratio of 6 patients per nurse on average is probably reasonable. Three to four patients per nurse, unless all are quite ill, seems like over-staffing.

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17 -TABLE IX Number o f Patients per Nurse (SN & TCN) by Areas & Shifts I Area Early Shift Late Shift Night Ward Average No. Patients No. Patients No. Patients Nurses per Nurses Per Nurses Nurse Nurse i .... ....... Female Surgical 26 7 3 7 4 6.5 4 Male Surgical 43 7 6.1 6 7.2 6 Private Surgical 25 5 5.0 4 6 3 3 I ,. Medical Area Early Shift Late Shift Night Ward Average No. Patients No. Patients No. Patients Nurses per Nurses Per Nurses Nurse Nurse Female Medical 41 7 5.9 5 8 2 5 Male Medical 20 7 2.9 4 s o 4 Private Medical 10 3 3.3 2 s o 2 Pediatrics Area ... . Early Shift Late Shift Night Ward Average No. Patients No. Patients No. Patients Nurses per Nurses Per Nurses Nurse Nurse Children' s Wards 62 13 4.8 11 5.6 12 Paed. Surgery 12 2 6.0 2 6.0 2 Special Care 25 6 4.2 5 5.0 4 Shift Patients per Nurse 6.5 7.2 8.3 Shift Patients per Nurse 8 2 5 0 5.0 Shift Patients per Nurse 5 2 6.0 6 3

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-18 -E. Overall Deployment In 1980 a Nursing report was submitted to the Minister of Health by Mrs. Phillips. The title was: "Ministry of Health, Commonwealth of the Bahamas, Nurse Staffing, Princess Margaret Hospital." The report examined closely the actual nursing requirements of each ward in the Hospital based on the average hours of nursing care needed by each patient. From these assessments, an average number of I hours per patient per ward was calculated. Finally, calculations were made of the number of nurses needed to provide adequate care on each ward. Table X shows the s tafflng levels recommended by the 1980 study and compares them with the actual staffing levels of 1985. The far right column contains the results of the comparison, taking into account the differences in bed numbers and occupancy rates for the two periods, 1980 and 1985. Of the 19 wards considered, 4 had staffing levels in 1985 which were the same as those recommended in 1980; 5 wards were understaffed by comparison with the 1980 recoounendations; and 10 were overstaffed by comparison with 1980. F. Summary Overall, then, the recommendations made in 1980 by senior nursing supervisors in a careful study have now been fulfilled. In general, Nurse staffing should now have adequate numbers and the capacity for reasonable deployment. From the perspective of numbers of Staff Nurses and Trained Clinical Nurses, it seems clear that the supply presently available should be adequate to provide competant nursing care to the patients of Princess Margaret Hospital.

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'_. '" Surgical I Female Surgical Hale Surgical Private Surgical Eye Wing Medical FlNale Medical I & II Male Medical I & II Private Medical Chest Warda Pediatdca Medical Surgical Special Care Maternity Maternity Cyne Surgical II ICU Theatres & Recovery Burna ACD CP Clinics Visits A 6 E Spec Clinics I I I I I I -19 Aver. Beds Occup 32 20 49 37 30 25 24 8 33 30 39 30 12 10 39 9 88 81 17 16 20 16 43 31 25 16 8 5 5 --(Visits) 112 700 1 46,200 3 41 000 1 TABLE X NURSE STAFFING COMPARISONS 1980 Studl Recommended Staff Aver. tiO SN ICN NA Beds Occup, 1 10 10 7 32 26 2 15 14 9 48 43 2 12 9 7 30 26 1 3 5 2 24 9 3 12 12 8 40 41 3 12 10 8 31 20 1 8 4 6 12-15 11 1 4 4 5 39 15 4 24 40 14 88 62 -6 6 3 15 12 2 16 9 2 I 20 25 6 36 12 10 I 43 27 2 7 7 6 l 24 14 l 2 L5 7 2 8 6 4 18 14 1 5 -1 2 -1 --(1984) 3 18 6 133,800 22 12 9 I 49,800 7 10 4 31,200 1985 Preaent Nursing -etaff copared with Actual Staff reco.aendation, coneider NO SN ICN NA ing preeent occupancy --3 12 12 8 SAM!: 3 19 16 12 SAME 1 13 9 7 SAM u 7 5 6 OVER 5T 42 33 I ---16 11 12 UNDER 14 13 12 OVER 7 5 5 UN'DER I 4 6 9 UNDER I I 6 4f 38 u --I 28 40 30 OVER 4 5 3 I OVER 15 10 5 UNDER 6 49 55 38 -6 36 14 1t;-OVER 2 7 6 7 SAME 8 43 To 23 3 26 8 4 OVER 4 )t 19 11 1 ovu 2 2 3 I OVER 8 49 29 TB 1 2 16 9 J UtroER 3 26 17 5 OVER 2 7 10 2 OVER 6 35 53 TI

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20 -If there is a perception among staff and supervisors that more nurses are needed, then it seems likely that something other than actual numbers .is the problem. ,.

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., -21 -III. JOB CONTENT AND PRODUCTIVITY A n important factor whi ch can have major impact on efficiency and effectiveness is the degree t o which Nurses are filling their assigned The job description and the day t o day reality must both be considered i n evaluating actual and potent i a l productivity. A Supervisors The principal responsibility of nursing supervisors from the Principal Nursing her assistant through the Nursing Officers supervising the wards appears to be persQnnel matters. These run the ,. gamut from maintaining a ttendance records, through monitoring holiday and other leave time, to last minute staffing du e to absences, to counselling of staff. The Nursing supervisors also monitor the activities of the various level s of nursing staff Staff Nurses, Trained Clinical Nurses, and Nursing Auxiliaries. Al t hough they do not have the official responsibility for the activities of maids, porters and dietary staff, in order to oversee general ward function, they must to some extent supervise these employees as well. Area Supervisors generally make rounds of all the wards and patient s from one to three times each day in order to assess any special problems and. t o reassign staff if needed. If there are unexpected absences, they may have to arrange for Nurses to come in as relief or to remain on duty for an extra shift. They order supplies and follow up on these, and receive Nurses' requests for vacation and other leaves. Since the Area Supervisors maintain the attendance records, when Nurses have questions as to the status of their sick days or holiday time, Area Supervisors must deal with them.

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'. -22 -Area Supervisors at times must cover the position of Principal Nursing Officer. On shifts other than the early shift, this means that the Nurse is essentially responsible for the entire hospita 1 operation, since the administrative staff does not usually work outside of normal working hours. Area Supervisors generally do not deliver bedside care. They have responsibility for the Nursing Students present on their wards, and since these students may not be direct supervision from the School of Nursing, adequate supervision and teaching must be ensured by the Area Supervisor. I r Area Supervisors should have the rank of Senior Nursing Officer, but due to delays in effecting a number of promotions, some of them still have the rank (and pay) of Nursing Officers I. Each Area Supervisor has an Assistant who is an NO I or NO II but who also supervises a ward or wards. Nursing Officers I and II are generally assigned the supervision of one or more wards. They may also provide direct patient care. They are responsible for ensuring adequate staffing and patient care and must replace the Area Supervisor when she is off duty. As with the Area Supervisor, Nursing Officers have de facto responsibility for ensuring that maids, porters, etc. are present and functioning adequately. Nursing Officers monitor supplies and equipment, patients with special needs, staffing, and offer counselling to Nurses under their supervision. The Job Description of the Senior Nursing Officer and the NOI are almost identical, and include*: Job Descriptions are all from: Ministry of Health-Rand Memorial Hospital.

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-23 Professional 1. Assist in all matters to the improvement of nursing. 2. Day to day management and to give advice to the officers in the area which she is responsible. l. Performs other duties as Administrative Supervises and coordinates the planning of the administrative activities of the area within the context of the whole. Personnel 1. Responsible for orientation, development and evaluation. I' work performance, personnel 2. Functional conununication with persons of allied services with whom she must come in contact for the efficient and effective execution of her duties. The only differences between the two job descriptions are: (1) that the SNO reports to the PNO and the NO! to the SNO; and (2) under Administrative the NO! "supervises and coordinates in the area (for) which she is responsible". The investigator interviewed all six Senior Nursing Officers. While their problems varied with area of responsibility, several cormnon themes emerged. (1) Most SNOs spent great amounts of keeping staff attendance records and dealing with requests for attendance information and for leaves. At least one SNO said that up to 75% of her time was spent on attendance and personnel matters.

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(2) Staff much 24 -shortages, especially last time in trying to find schedules. minute absences, replacements and consumed rearrange (3) Supplies ordering and procurement was a source of frustration and took much time. Basic supplies often were unavailable, had to be borrowed from other areas or were of poor quality. (4) Staff disciplitie was a problem for several SNos: There were gross examples of lateness for work (20-60 times per year per employee) in some Areas, yet. the SNO had no authority to discipline, only to talk with the offender and send a letter of censure. More forceful measures could only be taken at the Ministry level. Even in a case of clear dereliction of duty, the SNO had no authority to act in 'decisive way. (5) Much SNO time was spent in areas extraneous to her major responsibilities, including: -supervising and monitoring construction and repairs; -supervising maidi, porters and other ancillary staff; allocating and providing overall supervision of nursing students; divising questions for and/or marking national nursing exams; attendance on a variety of committees. (6) Supervision of Nursing Officers for some SNOs took more time than warranted, since a few of the NOs seemed unable or unwilling to accept and fulfill their responsibilities. This also meant that the SNO often was meeting with or counselling junior staff who should have been able to get their help from NOs. (7) Meetings and/or rounds with the many consultants attached to the hospital, which occur if and when the physician appears, can be quite disruptive to the daily schedule: Supervisors seemed very aware of the areas of dissatisfaction among more junior staff (see section on Morale) as well as being able to

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25 -articulate their own areas of frustration. However, among many, there was a sense of impotence, partly resulting from a feeling that they were not permitted to exercise their full authority and partly from recognition that many of the changes and improvements required were outside the authority of the Hospital, in the hands of the Ministry. But with so much of their time spent on attendance and staffing, and on matters not directly under their control or not relevant to Area Nursing, the SNOs were limited in their ability to play a positive leadership role. Several expressed the desire to work to upgrade Nurses' report writing and development of patient care plans; to provide more in-service education; to work on team building; or to engage in clinical I research. r Some SNOs were aware of much staff discontent within their Areas; others did not feel there was a problem. Some felt that the Principe 1 Nursing Officer needed to take a stronger leadership role, to fight for more independence from the Ministry and to provide more support to Area Supervisors. Others felt the PNO needed to make more contact with Junior Staff, to hear their problems directly and to fight for their concerns. In general, however, most Senior Nursing Officers considered the PNO to be supportive of them, but handicapped by her relative lack of autonomy. B. Staff Nurses Staff Nurses (and Trained Clinical Nurses, see below) provide the regular to day bedside nursing required by patients: In a normal day they will, upon arrriving for duty, take report from the previous shift, check the controlled drugs, delegate staff and begin the routine monitoring of patients. This will involve checking the Intravenous lines and any other equipment, reviewing input-output sheets, assessing the physical and mental condition of each patient, checking vital signs, writing and maintaining nursing notes and patient records. They will make rounds with the various consultants and receive instructions from them.

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-26 ':t' Staff ore p11rticulnrly responsible for thn giving out of medications and doing or overseeing any required dreulugs. rr Nurslng students are present, theii direct supervision will generally be by the Staff Nurse. As with the various supervisory nurses, some degree of direction of maids and porters may be required from Staff Nurses. Staff Nurses represent the mainstay of Nursing service within the hospital. Unfortunately staff nurses are frequently required to perform duties that should be the responsibility of others, and this detracts . from their ability to perform nursing duties. In some instances this may also contribute to poor morale. There are problems with the attendance, the training and the supervision of maids, porters, clerks and nurse I auxill.iaries, and Staff Nurses and Trained Clinical Nurses are often found doing the work of these other groups of employees. The Job Description for the Staff Nurse covers most standard nursing duties, including: Responsibilities and Duties (summary) observes and reports symptoms and conditions and temperature, pulse, respirations -administers medications and special therapies sets up treatment trays and assists HDs with treatments -maintains patient records bathes and feeds acutely ill patients assists .in teaching nursing students/pupils assists in teaching patients good health habits acts for NO in her absence. Relationships (summary) -Direct communication with other staff and/or male nurses

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-27 -Contact with patients in providing care Contact with doctor_ s in receiving orders Communication with administrative personnel -Direct Contact with superiors of other nursing departments Co-ordinates work with housekeeping; laundry, dietitian and maintenance. In an in-depth discussion with about forty staff nurses the following question was asked: in a 7 hour day, about how many hours are spent by you performing truly nursing functions: The consensus of the group was three hours. 1 There appeared to be three general reasons for this reduced nursing productivity: first, as mentioned earlier, nurses had to do many tasks that should have been (but were not) done by other Nurses and by support staff; second, a lack of supplies and equipment meant that much time was spent locating and procuring needed items; and third, that overall supervision of ward operations and of all staff was inadequate, leading to many inefficiencies. In essence, Staff Nurses concurred with the general perception that their productivity (at least with regard to Nursing functions) was low. (Further comments, by Nurses and observations on general morale appear in another section). C. Trained ClinicalNurses It is the impression of the investigator that in almost all areas of the hospital the experienced Trained Clinical Nurse is doing essentially the same work as Staff Nurses, with the exceptions of giving medication and doing more complex dressings and procedures. It may be that if staffing were more adequate, Staff Nurses would be doing more education and more patient care p tanning, and evaluation and that this

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. : -28 -would distinguish them from Trained Clinical Nureea, but at this time the distinction does not seem to be very marked between the roles of the two categories of nurses. The educational pre-requisites for entry into the TCN program are lower than those for registered nurses, and the nursing programs are eighteen months and three years, respectively, hence the Staff Nurse has a more academic background and should be capable of fulfilling a more complex role than is often the case at present: As with other nurses.,. the Trained Clinic Nurses are frequently found doing the tasks of maids, auxiliaries and porters. One of the I / supervisory problems repeatedly cited was the resentment of an experienced TCN being supervised by a relatively inexperienced Staff Nurse merely because of the existing hierarchy based on educational level. The Job Description for the Trained Clinical nurse states that she reports to the "Professional Nurse or Team Leader," and describes her Functions as follows: give safe and effective nursing care to patients -participate in preparation and execution of nursing care plan -perform simple nursing skills -assist in meeting the patients' physical, spiritual, social and emotional needs -handle materials and equipment correctly and assist with their care, maintenance and conservation -assist Staff with special procedures assist with instruction in health practices help the individual and his .family become adjusted to the situation which brings them in contact with the health services -report and record promptly pertinent information relating to the patient and his family

PAGE 32

29 -interpret available conununity resources with a view to guiding the patient and his family in making better use of these facilities promote and maintai n good interpersonal relationships and inspire public confidence in the health service -perform other duties as required. In general this Job Description is that of an assistant, not an independent health worker. With the exception of helping the patient/family adjust to illness, promoting community resources, and inspiring confidence in the health service, most other tasks are prefaced by "assist with." I' During a discussion with about 40 TCNs, two widely felt that divergent the Staff op1.n1.ons were expressed. Nurses regularly dumped tasks (bed pans, bathing, On the one hand, TCNs on them the most routine and least technical bed making, cleaning): On the other some TCNs felt thay were routinely left with more or less full responsibility for very sick patients, whose care was beyond their competance : Overall, the deployment and utilization of T CNs does not seem to be uniform nor designed to obtain maximum They may receive orders and supervision from several sources and most do not seem to feel that they have an appropriate amount of responsibility nor that they are part of a team. Future health human resource planning in the Bahamas must deal with the question of the most desirable role for the TCN and how to develop and optimize it.

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.. -' 30 -D. Nursing Auxiliaries The selection, role and training of nursing auxiliaries are problematic throughout the hospital. Appointments to these positions seem to be often the result of political favours rather than by any methodical selection process. Most training is "on the job" and there is a perception that these employees are very unreliable in attendance and in function. The tasks they perform are very like those of the maids, but they also sterilize and disinfect patient areas. Most Nursing Auxiliaries have little formal education and the general feeling among other nurses is that they have little commitm ent to their jobs or to the care-giving team. The of pay for the job is minimal and there is no career path for the It would seem that this position should either be up-graded or down-graded, but not remain as is. The position could be upgraded by providing a short training period before entry to the ward, and then a defined on-the-job continuation training: In this case, the Nursing Auxiliary would learn basic nursing skills, and could become a true support worker for the Staff Nurses and Trained Clinical Nurses. The other option is to assign them as maids, have all maids do disinfecting and the other chores now done by Nursing Auxiliaries. This study did not assess Nursing Auxiliaries in any depth and it did not seem that they were a part of the health care team. Innumerable comments b y Staff suggested that the deployment and function of NAs require major revision. E. Summary There is a problem with regard to job content and productivity. From Nursing Officers through Staff Nurses and Trained Clinical Nurses to Nursing Auxiliaries far too much time is spent in performing tasks well

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-31 -below the competance of the individual Nurse. In s om e cases the time consuming tasks are not even within the realm of Nursing. Means must be found of reducing the amount of routine attendance, staffing and monitoring now being done by Area Nursing supervisors. Staff Nurses and Trained Clinical Nurses should not be chasing after supplies or doing the jobs of Nursing au xiliaries, maids and porters. A re-evaluation of the roles and interactions of Nursing Officers, SNs, TCNs and NAs should be undertaken. The specific tasks and responsibilities of each require delineation. Supervisory Nurses require tntlulng lu lJULldJug, I !Vlllunlluu ttntl Lht-mtcluutlcu ul supervision and management. ,.

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32 IV. SYSTEMIC LOSSES A. Losses from Shift Organization The manner in which shifts are organized in Princess Margaret Hospital is a cause of reduced productivity on the part of Nurses. This feature of the system should be examined as a potential reservoir of increased productivity. 1. Night Shift Because of the perceived of night-shift work, attempts were made in the Bahamas to it more appealing by offering a bonus of extra time off. Another factor leading to the present arrangement is an attempt to avoid transportation to and from Hospita 1 during 11unsocial hours," which might require the Ministry to provide taxi cab fares or a special bus service. Mrs. Theda Godet, Principal Nursing Officer of Princess Margaret Hospital, submitted an excellent paper on the Off Duty System to the Deputy Permanent Secretary, Mr. L. Smith, in June of 1985. In the paper she pointed out that the present system of night duty, working four nights and having four nighta off, caused the hospital to use 43 full-time-equivalent persons on nights who would not be required if those on night duty worked five nights on and two off, .comparable to day shift hours. With this system, night workers would put in the same number of hours per week as day workers. Mrs. Godet 's calculation of 43 excess Nurses presently required with the existing night shift maybe an under-estimate. If she is correct, that approximately 94 staff members are on duty each night, then the following calculations should (approximately) apply.

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33 -'l'lar tltty Nut" Will hl '1:1 ft Wl,.lut ur urr ltfo Wt,.lttl (to Wl"tk :J., WC"f'kM tfttylt Ill" 2 WPIkiiiK Wrf'kll ur jtllltflt hull tiny II. o. WM,Itlll Cl r "I c k "'"Y") /16 Wt!t!kll x 5 nhlrta por wt k 2JU oltllt11. -There are 365 shifts to be worked each year to cover each position in Hospital. -It takes 1. 6 Nurses to cover each position if they work 230 shifts per year. However the night Nurse works four nights on and four nights off, in addition to which she recei-vea vncntion, public holidny11 nnd nick clnyn. / -she works 52-6 (holiday/sick) weeks off = 46 weeks 46 weeks x 7 322 nights or shifts she works 4 on, 4 off -therefore each night nurse works a total of 161 nights -it takes 365 2.3 Nurses to cover a single night position 161 At present then, to cover 94 nightly position requires 94 x 2.3 Nurses 216 Nurses If Night Nurses worked 5 on 2 off like day Nurses, the number required to fill 94 nightly positions would be 94 x 1.6 150 Nurses Thus 66 full time equivalent positions could be saved. Using Mrs. Godet's salary average of $10,000 per year, 66 x $10,000 $660,000 Excess is spent to achieve night coverage. Again, as Mrs. Godet rightly points out, this excess in Nurses and/or expenditure couid be reallocated to provide:

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-34 -(1) a bonus to Nurses working regular night shifts {2) transportation to and from hospital (3) provide a permanent, relief pool of Nurses to act as "floats" on each shift, to cover absences, provide special care for very sick patients, or to supplement on Wards with high occupancy. In summary, the system now in operation for night coverage is very wasteful. Further, most nurses dislike working nights when their regular shifts are in daytime, since alternating nights and days is highly disruptive to sleep patterns as well as to family life. (There is also a general perception that absenteeism on Nights is higher than on day I shifts, but it may simply be that it is harder to fill the positions of the absentees). 2. Day and Late Shifts There is considerable wastage in Day and Late Shift Coverage due to the hour and a half overlap of the two shifts. Day Shift 8 am 4:30 pm Late Shift 3 pm 11 pm overlap 3 4;30 a 1 1/2 hours For simplicity, if one assumes 100 Nurses a day on either Day or Late Shift, then 1.5 hrs. x 100 Nurses = 150 hours per day wasted in overlap, which is the equivalent of 18 nurses a day (150 )lost to the system 8.5 hr. shift each day or 29 regular staff nurses each year (18 shifts x 365 ) 230 ahifts/yr/nurse.

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35 -In addition, it is well known that Nurses tend to leave early during the overlap, knowing that they are not really needed. The argument has been made that the overlap time can conveniently be used for in-service education, meetings, counselling and the like. However, it would seem quite wasteful to provide this overlap every day for all Nurses in order to allow time for occasional meetings or in-service for limited numbers On the other hand a small overlap does seem warranted to provide time for full reporting and turnover of responsibility from one shift to the next. A fifteen minute overlap would seem adequate. Possible Shifts 7:45 am -4 pm 3:45 pm 12 pm 11:45 pm -8 am I r Some provision for transportation would have to be made, especially for those arriving or leaving around midnight and not having their own cars. It would also seem advisible to generally have Nurses always working the same shift (or at least for several months at a time). This would mean that they could formalize household arrangements, and also that they would be able to maintain constant working teams and supervisors. B. Losses from Absenteesm Illness is recognized as a legitimate cause for missing work, and the Bahamas has an extremely generous system of sick days and extended sick leaves. The worker is well protected by the sickness benefits in a

PAGE 39

36 -situation of serious and protracted disability. Indeed, sickness benefits in the Bahamas are considerably more generous than those in most of North America. On the other hand, sickness benefits are like other kinds of insurance, namely a safety net for those who are unlucky enough to fall seriously ill. These benefits are not in the same category as holidays and vacation which are automatic rights of all employees irrespective of need. . There is a clear among supervisory Nurses that many of their staff see sick days as days off due to them, rather than as I insurance against illness. Unfortunatefy, even the requirement for doctor's notes does not totally alleviate the It is very difficult for j doctor to prove one way or the other whether a patient "had a cold yesterday," or "had a terrible stomach ache, back pain, etc." The total 1985 sick days at Princess Margaret Hospital by category of Nurse were: Total Sick Days 1985 SNO NO-I NO-II NO-III SN TCN 31 11 322 87 3326 3176 Using the same figure as in the section on Night Duty, assume that each full time equivalent Nurse works 230 shifts (or days) per year, the number of Nurses required to fill in for the absentees is as followsi

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.. SNO -37 -Full Time Equivalent Replacement Nurses to Cover for Sick Days No-I No-II NO-III SN TCN 0.13 0.05 1.4 0.38 13.8 In other words it is as though 14 1/2 Staff Nurses and 14 TCNs had disappeared from the staff To make matters worse, when these missing overtime Nurses are replaced, it is usually by other Nurses working / and therefore receiving higher than normal pay. (The amount expended on Nursing overtime was not available at the time of writing:) When replacements for the absentees are not staff on duty must cover more This can lead to poorer patient care and resentment among Nurses who are on duty and having to overwork to compensate for their colleagues' absences. In addition, the process of finding a Nurse to replace an absentee takes a great deal of supervisors' time and contributes to their decreased productivity. It is generally recognized that high rates of absenteeism are related to low job satisfaction and poor morale among workers. This is certainly deemed to be case by all levels of Nurses, administrators and other Ministry personnel interviewed during this study. While more controls can be placed on Nurses' ability to claim sick days, such controls (more notes, phoning closer monitoring) will . incur administrative costs. It would be far more desirable to clarify the reasons for reduced morale and job satisfaction and improve the working conditions such that Nurses wanted to be on the job.

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39 -c. Losses from Resignations and Transfers In 1985 according to try of Health records, a total of 18 Staff Nurses resigned their positions. In addtion 21 Staff Nurses were transferred out of Princess Margaret Hospital. Using 275 as the total Staff Nurse complement this means that 6.5% of all staff nurses resigned, and an additional transferred o ut. Thus 14% of Staff Nurses had to be replaced during 1985 : The reasons for the resignations and transfers are not available, so it is not possible to conclude whether job dissatisfaction played a major or minor role in these decisions. Most of the resignations came from the ranks of I contract officers who had presumably fuffilled the terms of their contracts and decided to leave. Table XI shows the transfers, resignations and new appointments over the period 1982-1984. Whatever the reasons for these moves, the result is disruption of nursing team organization, frequent need to orient new staff to the hospital and the ward, and the integration of new individuals to existing teams of staff. Concern was often expressed during this study about senior nurses who had left nursing for administrative positions outside of nursing altogether, and more junior nurses who chose to enter the private sector. There are no figures presently available to confitlD or refute these perceptions, but this is an area worthy of follow-up. If experienced, senior nurses are leaving the. nursing public sector, and young nurses are not entering it, this suggests serious problems within public sector nursing and bodes ill for future staffing.

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. 140 120 100 80 60 :.o 20 0 -TABLE XI PMB NURSING STAFF: NEW APPOINTMENTS AND 1982 198G AND TRANSFEP.S ', \ \ \ \ TRANS FEltS OUT ."\ \ \ \ \ \. \ , 'NEW APYOINTNEI\TS ' " .-A .. ""-..___,; .::----1 ''' . --. -1-I._. t ;-::; .,,.. 11, __________ -; P.F.Sl -1=---..:.._ ____ __.J __ __ .. ___ __._ l 1982 1983 1984

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40Concern about nursing attrition led to a study by the Nursing Council chaired by Mrs. Ironaca Morris. The report on this study, entitled: "Attrition of "Nurses: A Study by the Nursing Counci 1 Commonwealth of the Bahamas" was completed in February, 1986. The objectives of the study were: (1) To gain information into the reasons why nurses leave the nursing service. (2) To identify factors which will cause nurses to leave the nursing profession. (3) To identify factors which will encourage nurses to return to nursing. I' The investigators had hoped to reach three categries of nurses: nurses in the Public Service; those practicing nursing outside the Public Service; and those who were non-practicing. Unfortunately, although 300 nurses were targetted for questionnaires (1 in 4 nurses on the Register and Roll), the response rate was not as high as was hoped for. Eighty two questionnaires were returned (27.3%), and of these nurses, 76 'Were working in the Public Service: Of the 76, all enjoyed working as nurses and 59 (78%) wanted to remain in nursing. Twelve (16%) did not wish to remain in Nursing. The Nurses in the Public Service were asked to identify the "area in your working environment needing improvement cited areas were: The most commonly

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Area Modern working Facilities Team Work Staff Attitude Space -(Larger working area) In-service Education Staff Shortage Building Maintenance 41 -% of Nurses choosing this area 53% 42% 32% 25% 21% 20% 20% Unfortunately only six respondents were nurses who had left the Public Service but were still practicing / as nurses. The reasons cited for leaving the Public Service were as follows: Insufficient Salary Poor Working Conditions Shift rotation/Working hours % of Nurses (n=6) 67% 67% 50% All six nurses wished to return to the Public Service. The responses to areas of the "working environment needing improvement" of the 12 nurses in the Public Service who did not wish to remain in the profession were compared with thoses who did want to remain Modern Working Facilities and Team Work ranked 1 and 2 for both groups, but the nurses not wishing to remain gave less emphasis to Staff Attitude, Space and building maintenance and more emphasis to salary increase and decreased work load. The conclusion of the study states:

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42 "It is interesting to note that the nurses's perception of the work conditions where improvement is needed correlate with the reasons given by nurses for leaving the service. These conditions apparently have not improved over the years." It goes on to say: "The poor attitudes of staff and the need for team work and i mpro ved comnunications among workers were mentioned frequently: The conditions which are identified predispose to the problems of staff morale, high absenteeism, frustration, which undoubtedly affect the quality of patient care." / In summary, nursing attrition appears to be a problem, although the full extent and reasons behind it are not yet completely documented. It is an area that deserves ongoing scrutiny by the Director of Nursing and/or the Nursing Council. D. Other Losses Aiside from those discussed ab ove, the Ministry shows other significant losses of Nursing days: 1983 Total Days Off PMH Maternity leave Away without leave Unpaid leave Seven eights pay Half pay Three quarter pay Special leave 1130 296 1412 470 413 105 "10 3836

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43 Using the same shifts (days) worked per Nurse each year, 230: 3836. 16.7 230 This means that, in effect, another 17 full time equivalent Nurses were lost to the system in the hospital during the year 1983. A look at the average days lost per Nurse per year for various types of leave, shows that between 1982 and 1985 ; the trend has been in the direction of a gradual increase. I Average No; Work Days Lost Per Nurse Per Year by Reas o n 1982 -85 PMH Reason 1982 1983 1984 1985 Sickness 10.2 9.0 12.1 12.1 Maternity Leave 1.8 1.6 1.4 1.6 Away Without Leave 0.5 0.4 0.3 0 4 Unpaid Leave 1.9 2.0 3.2 3.1 Seven Eighths Pay 0.5 0.7 1.5 1.8 Half Pay 0.5 0.6 0.1 1.5 Three Quarters Pay 0.1 0.2 0.5 0.2 Special Leave 0 04 0;01 0;1 Totals 15.54 14.51 19.1 20.8 Again, using the figure 230 shifts (or days) worked per Nurse per year, we find that 20.8 230.0 shifts lost p e r N urse/year average shifts work ed/year

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-44 The average Nurse ia away for 9% of her shifts aside from her earned vacation leave. E. Summary Between the present method of shift scheduling and the absenteeism of various kinds -but not including earned leave and public holidays -it can be seen that there is a great deal of working time lost to the system. The shifts as now organized probably waste about the equivalent of 75 Nurses per year. Absenteeism in sick day' costs the system about 28 Nurses per year, and other kinds of leave cost another 10 15 Nurses. Of these losses, the sick days are probably the most amenable to correction, through enhanced Nursing Altering of shifts also has great potential for improved Generally better working conditions might reduce the rate of transfer and resignation. there is broad scope for improvement of systemic losses.

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,. -45 V. WORKING CONDITIONSt NURSING MORALEAND PRODUCTIVITY Introduction There seems to be a general consensus that the morale of nurses is relatively low. This was expressed by nurses in all categories (supervisors, staff nurses and trained clinical nurses) as well as others in non-nursing positions within the In addition some supervisors felt that there was a lack of commitment to work among nurses, and this was variously described as an absence of discipline, loss of the work ethic, or just a general slackness. While it is I difficult to be definitive about the ,. causes of this suboptimal performance, indications are that a low level of morale as well as other factors are involved. In order to try to identify the cause of the low morale many of the interview questions dealt with working conditions which were suggested by interviewees as being largely responsible. The following areas were identified as presenting problems which contributed to the discontent of the nurses. A. Physical Facilities The general problems mentioned repeatedly by the nurses included inadequate maintenance of the ho spital as a whole; overcrowding in the wards; lack of basic amenities for staff and an overall sense that management was relatively unresponsive to problems in this area. Nurses described leaks that weren't fixed, cleaning that was only done sporadically, construction that was begun and then stopped as workers were called away to do some other task, and repairs that were poorly done

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. -46 -Overcrowding was reported as occurring either regularly or intermittantly in almost all wards. Overcrowding resulted not only in extra work for the staff, but beds placed in the wards reduced the space available for access to patients and increased the risk of transmission of infection from one patient to another. The investigator noted several instances of infants sharing cribs, babies placed in playpens because no cribs were available, and neonates doubled up in incubators. In adult wards beds were placed i n c entral aisles such that in the case of an emergency, entry and egress would be seriously hampered r There was no drinking water available for staff on the wards, and on many wards no facility for preparing a hot drink for patients. Most wards did not have toilet facilities for staff, necessitating departure from the ward in order to use these facilities. There was a general absence of secure storage areas resulting in the office of the Area Supervisor -not very large to begin with -being used as storage area as well as office and meeting room. The office of one Area Supervisor was dark and extremely cramped, apparently a former There seemed to be a general feeling. among the nurses that management did not fully appreciate the risks presented to patients by these deficiencies in the physical plant, let alone the difficulties inherent in working in such conditions. The overcrowding in the Intensive Care Unit, the Special Care Unit (neonatal intensive care unit), the Burns and the Paediatric ward would appear to present the greatest risk to patients. The laek of a special isolated space for AIDS patients may be accoiiUJlodated by the development of an infectious ward which is presently underway.

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-47 -If there is an overall Master Plan for the correction of the above-mentioned deficiencies, it does not seem to be known to the interviewed. On the contraty, they appeared quite pessimistic as to the likelihood of significant improvements occurring in the near future. B. Supplies and Equipment Immense frustration was expressed universally about the inadequacy of supplies and equipment and particularly about the process of ordering and procurement. Equipm ent maintenance was also generally identified as a 'problem. I Lack of even basic supplies IV fluids, etc.) often meant that nurses had to spend time finding which other ward might have the needed supplies and then going to collect them. Drugs, even antibiotics and drugs for common conditions such as diabetes and hypertension, sometimes were unavailable. The responses from central supply in the hospital were frequently unsatisfactory. At times, the basic items requested were out of stock; sometimes requests were denied; at other times the amount of an item provided was less than what requested, with no explanation for the discrepancy. When the request was for an item that had to be procured through the Ministry, the results were even less satisfactory and more frustrating. Nurses reported requests that they had made over a year ago and about which they had heard nothing: In the Ministry substitutions were made of lower quality goods than those requested. One ward reported that several new beds bad been received, but at least one was non-functional within a month of delivery.

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,. -48 -Several nurses expressed the notion that those ordering supplies 'from inside the Ministry had no knowledge about the conditions of use of the equipment, and hence no way of knowing a cheaper item might not be adequate. Indeed, the cheaper items in some instances represented a false economy, since they required more maintenance, were out of service often, and had to be replaced sooner than would a better quality equivalent. Difficulties were also mentioned about the ability of hospital repair personnel to care for sophisticated equipment such as monitors. This resulted in equipment being out of commission for long periods of time. C. SupervisionandAdministration I r Perhaps the predominant theme expressed about supervision and administration was that supervising nurses had responsibility without authority. The degree to which this bothered nursing supervisors varied, but it seemed quite clear to most that the real control over the operation of the hospital was in the offices of the Ministry of Health (and perhaps other Ministries as well) rather than in the hospital itself. The bulk of the time of most nursing supervisors was spent on personnel. This ranged from keeping records of attendance and leaves, to replacing sick nurses, to counselling staff. Frustration was expressed at the ability of the Ministry to overule decisions made at the ward even when the support of the Principal Nursing Officer had been received. For example. situations were described in which a staff nurse had requested leave, and this request was supported by supervisors with the proviso that the nurse be replaced in order to maintain a full complement of staff. The result. however. would be that the Ministry approved the leave without replacing the staff member, so that area was left understaffed.

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49 -A few of the supervising nurses expressed frustration that the time needed to handle all the matters left them with no time to develop research projects, or to work to improve area There was some resentment at the need for hospital staff to supervise nursing students.{At the same time the School of Nursing expressed concern about its inability to provide enough staff to supervise the students.) In general, from Administrators through all levels of nursing supervision -to varying -the idea that they were responsible for m aintaining the smooth operation of the hospital without having any significant control over staffing, supplies ,. and budget was noted as a major problem. The staff categories identified as causing the most problems were the nursing auxiliaries and porters. The factors suggested as contributing to this problem were universally low salaries and the fact that many of these workers were "political appointees." Staff Nurses, on the other hand, expressed the view that many Nursing Officers were poor managers and administrators. It was felt that they were inadequate in assigning tasks and responsibilities, did no team building and were out of touch with the day to day problems faced by staff. The supervisory system was seen as very much a "closed shop," with little involvement of ward staff in decision-making and with only minimal information sharing. D. Pay and Benefits There were general complaints about nurses salaries, in particular that they were too low, but also that when raises had been awarded these did not actually appear sometimes for many months (even years) after the raise had been recommended.

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50 -There was no time during this study to make comparisons with the salaries in the private sector or with jobs requiring similar levels of training and experience. Thus no conclusions will be drawn here about the relative fairness of nursing salaries. However, such a comparison should be made, since salaries are a source of nurses' complaint. Benefits, in terms of sick leave, holidays, earned leave, casual leave and partial pay sick leave are extremely g enerou s by North American standards. However, the regulations governing casual leave were seen by many as unfair. I E. Conflicts with Domestic Responsib{lities Shift work, e specially nursing shift-work: almost invariably conflicts with domestic To an outsider, it would seem that the nurses were constantly switching shifts, and that this would be more disruptive to home life than if they worked longer periods on any one shift. The night shifts appeared most difficult to staff, and apparently the problem of last minute absenteeism was greatest here. The scheduling system of four nights on duty and four nights off means that essentially double staffing is required for night shifts. Given the unpopularity of these shifts, the optimal situation would be to find staff who preferred working nights, and would provide more reliable coverage. F. Promotion Opportunities Slowness of promotion and the relative unavailability of promotion were frequently mentioned as a cause for nurses' discontent. In the case of senior nurses, there were several instances in which Nursing Officers had been recommended for promotion to Senior Nursing Officer or to Nursing Officer One more than a year ago, but neither the official

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-51 -designation nor the increased salary had actually been implemented. In these cases the nurses in questic;m had been fulfilling the more senior positions with all of the attendant responsiblitity, but without financial compensation or titular recognition. Among all groups of Nurses interviewed, there were repeated complaints about unfairness in promotion. Many felt that favouritism and "politics" played far more important role than In addition Nurses felt that the criteria for promotion were not well known by staff, and that, in any event, the criteria were frequently 1 At the level of the Staff NurS'e, the problem was that opportunities for advancement were seen to be extremely limited. In general the supervisory nurses at Princess Margaret Hospital are quite young and this is true throughout the nursing hierarchy. As a consequence, retirement is unlikely to make senior positions available in the near future. In addition, some of the other facilities utilizing nurses (Rand Hospital, Family Islands) are located out of New Providence Island which means that family relocation would be necessary in order for a nurse to take advantage of promotion to another workplace. As in so many other working situations, the only real scope for promotion or advancement is into This means, of course, that the Nurse who is promoted because of her excellence in nursing is moved into an administrative role in which service delivery is no longer significant component of her work. She may be poor at administration and even dislike it, but since this is the only route for advancement she is unlikely to turn such a promotion down. It would be worth considering other means of recongnizing nursing excellence. These could include awards of merit, pay raises not tied to promotion into administration, or the development of a hierarchy of nursing excellence a concept that is finding some acceptance in the

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1 .... '0 ., ... 0 0 -..: 1 ....... t. . -52 -field of education, where the same problems with promotion apply. Implementation of such a system involve the development of several levels of nursing based on nursing skills and experience and having as the highest level the category of "Master Nurse:" Such nurses might have special responsibilities such as supervision of nursing students; establishment of quality control programs; devising of research projects The general area of promotion, and how to recongnize and reward excellence is one which should be given serious consideration by Nursing Administration and the Minitry of Health. I t' Trained Clinical Nurses have the most serious problem as regards promotion. Essentially they have no career advancement track: This is very discouraging and demoralizing for some, as they watch young Staff Nurses move into positions of increasing authority over the years. At this time the only career advancement option available to the Trained Clinical Nurse is to enter the regular Nursing degree program, put in three years of education, and then restart at the bottom of the Staff Nurse hierarchy. She gets no credit or reduced academic load 1n recognition of her TCN training or her hospital experience. There is no exemption program to enable her to take competance exams and thus eliminate parts of the training. The development of a mechanism for gradual upgrading of TECNs, for competance exams and for a reduced duration Nursing course should be considered, not only as a means o f establishing a career path and a source of future nurses, but as a means of upgrading the educational level of a segment of the population that has already demonstrated a degree of commitment and attainment.

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. -53 -G. Training Opportunities The basic problem relating to training seemed to be that much advanced education could only be gained by attending courses outside the Bahamas, generally at the University of the West Indies, in England or in the United States/Canada. This, of course, would present special problems to women with young families, and might well prejudice their opportunities prerequisite for promotion, since extra levels of to advancement. In addition, there barriers which discriminate against some nurses. training can be are often financial While there are some provisions for Ministry financial support during out-of-country advanced education, this support may not be comprehensive or may be limited to selected individuals. Therefore, those women who have the financial resources to go abroad on their own, can return to the Bahamas with the extra training required for certain levels of promotion whereas tho'Se who cannot afford this education may have their promotional opportunities Training in midwifery has been available through the School of Nursing, and more recently a psychiatry training program has been developed. These are available in the Bahamas, and hence are more accessible to the majority of nurses. One problem described in relation to these training programs is that having completed such specialization, nurses often cannot then find work which uses their newly gained expertise. As a result they are unable to maintain their skills. Another frequent complaint was that favouritism and politics play a significant role in the process of selecting Nurses for advanced training or education.

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54 -H. Job Content Satisfaction As noted in Section III, there is cause for concern for at least some Nurses in the area of job content. Many Staff Nurses agreed that only about 3 hours a day are spent in true nursing activities: Some Area Supervisors that very large amounts of time are spent on attendance and personnel matters which could be dealt with by a knowledgeable clerk: Nurses feel frustrated that they are unable able to do as good a job as they could do because of the many problems mentioned in previous sections. The job they are supposed to be doing (see job descriptions) I is 'the job they would like to do, but workiJig conditions are such that they are prevented from working to capacity: In addition Nurses feel they do not get adequate credit or recognition for the work they do: I. Summary The conditions in which Nurses function at Princess Margaret Hospital are not conductive to high productivity. This is in part because much of their time is spent on non-nursing tasks and in part because morale in general is not high. The pages that follow contain the results of a questionnaire administered by the investigator to 47 Staff Nurses. (It is the intention of the Ministry to have it completed by all Nurses eventually.) To the question: "In general, how happy are you in your job?" the responses were: Very happy 4 Fairly happy 22 Not very happy 14 Quite unhappy 7

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. .. 55 -In a satisfactory and with a group of professionals, a much higher percentage should be rep lying very happy, and only a few should choose "not very happy" and "quite unhappy." Another question and responses read: "Attitudes of most Nurses to their work is:" Excellent/Good 15 Fair 19 Not very good/poor 13 I ,. This suggests that Nurses' perceptions of their colleagues is that only about 1/3 are highly motivated in their work. The other questions attempt to pinpoint problem areas for the Nurses. It is somewhat disheartening how few times the Excellent/Good colum has the largest number of responses. For most questions more responses are in the Not very good/Poor category than in Excellent/Good. It seems safe to conclude -as have many senior nurses now and 1n the past -that productivity of Nurses is low and that the cause is largely poor morale. This study suggests that the cause of the low morale is in the working conditions in the hospital and the operation of the Nursing system in general.

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56 SURVEY OF 47 STAFF NURSES PRINCESS MARGARET HOSPITAL Excellent/ Fair Not very NR good good/poor I ( 1) The Hospital's degree of concern about its employees is: ( 2) As an organization to for your Hospital is: 1 ( 3) Working conditions generally are: 1 ( 4) The reputation of your Hospital for patient care is: < 5) Overall management of your hospital is: 6) As a people-oriented organization, your hospital is: ( 7) The care of patients' physical problem is: ( 8) The care of patients' emotional/ social problem is: 1 ( 9) Condition of the building, (10) '(ll) especially patient and staff working areas is: Building maintenance is: Given your qualifications and experience, your pay (including benefits) is: '(12) Given the work you do each day, your pay (including benefits) is: t(l3) Compared with nursing jobs in the I (14) I (15) I (16) I (17) ( 18) I ( 19) Bahamas private sector, your pay (including benefits) is: Cleanliness in your Hospital is: Space available for working is: Availability of equipment and supplies is: Functioning of equipment is: Opportunities for promotion are: Opportunities for further training are: 1 (20) The preparation (training) you had for your was, in general; (21) Relations between the Ministry of Health and Hospital Managers (Nursing, Medical, Admin.) seem: '(22) Relations between you and your supervisor are: 5 16 6 15 8 13 26 10 5 5 1 2 5 17 3 1 4 2 1 33 9 18 20 25 27 20 24 22 13 24 20 20 16 10 21 21 22 12 17 9 17 8 14 19 20 6 13 12 15 10 8 13 22 22 29 34 17 8 21 33 26 32 28 3 23 9 2 2 1 1 4 1 1 1 4 1 3 1 1

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57 -1 (23) Relation between you and those you supervise are: (24) Cooperation among SNs, TCNs, NAs in your Ward is: '(25) Relations between doctors and Nurses are: 1(26) Degree of friendship among Nurses is: 1(27) Communication between Nurses and supervisors is: / (28) Support provided to you by supervisors is: 1(29) Attitutes of most Nurses to their work is: (30) Relations between Nurse and maids, porters, etc. are: (31) Most of the work you do is: 1(32) The amount of responsibility and authority you have is: f (33) To what extent do you have freedom to decide how you will carry out your job? (34) How much pressure is put on you to perform your work? (35) To what extent do you get credit for the work you do? Excellent/ good Fair Not very good/poor 28 24 21 27 10 11 15 ,. 13 (a) (b) (c) (d) 15 3 14 9 21 5 16 4 25 12 14 22 19 13 11 22 challenging interesting but not challenging routine and not very interesting dull and boring No response NR 1 1 16 17 6 0 8 (a) less than it should be 15 (b) about right 21 (c) more than it should be 11 (a) very little freedom (b) a reasonable amount (c) almost complete freedom (a) a lot of pressure (b) some pressure (c) almost no pressure (a) almost always get credit (b) sometimes get credit (c) almost never get credit 8 32 7 5 26 16 2 14 31

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58 1 (36) In general, how happy are you in your job? 1 (37) To what extent does your job conflict with your domestic life Excellent/ good Fair Not very NR good/poor (a) very happy 4 {b) fairly happy 22 (c) not very happy 14 (d) quite unhappy 7 (a) (b) (c) (d) a lot 6 some 15 not very much little work -conflict I 17 home 9

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59 -VI. CONCLUSIONS A. Numbers Systemic Losses, Deployment and Productivity 1. Numbers The overall number of Nurses, including Officers, Staff Nurses, Trained Clinical Nurses, appears to be theoretically adequate to provide good care to patients in Princess Margaret Hospital. However the ability of this complement of Nurs e s 'to provide optimal care is highly contingent upon deployment and productivity. It the conclusion of the investigator that at the present time and under existing conditions optimal patient care is not being offered with the staffing now in place. It is also the impression of the investigator that increasing the numbers of staff will not improve patient care significantly without major changes in the operation of the hospital and the administration/supervision of the Nurses. 2. Systemic Losses Although the number of Nurses on staff is theoretically adequate, the actual number at work at any given time is significantly less than implied by staff lists. Table II lists 270 Staff Nurses and 231 TCNs for a total of 501 Nurses regularly involved in patient care. As calculated in Section IV, the equivalent of 28 Nurses is lost to the system through absenteeism, and another 17 through various kinds of leaves. This m eans that the actual working staff is about 9% less than on paper. The sick day absenteeism can probably be improved, but the other leaves cannot, and the latter group should n o t be included in the complement s of the Nursing Areas within the hospital.

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60 -In addition the exi.sting shift system uses about 50 excess full time equivalent nurses in the night system and another 29 from the overlap in day and late shifts. By reorganizing this system, the equivalent of about 80 nurses could be added to the system without actually hiring anyone. 3. Deployment As calculated in Table IX, the overall average number of patients per nurse on Medical/Surgical wards was about 5 on the early shift; 6 on the late shift; and 7 per Nurse on Nights. For the Paediatric wards, the averages were 4 -6 patients per Nurse. (As noted in the text, these averages do not take into account the actual patients present at the time.) The number of patients a Nurse can care for depends a great deal on the adequacy of support staff. The smooth function of SN, TCN and NA as a team will facilitate optimal patient care. This team does not appear to be fully functional at the moment. On day shifts on adult Medical/Surgical Wards 1 nurse to 6 or 7 patients is probably adequate, but on pediatrics 1 nurse to 4 would be more desirable. The deployment of Nursing Officers seems much more questionable. Almost none are on late and night duty (Table III -VIII) hence there can be little supervisory activity. On the early shift supervisory ratios range from one nursing officer to 3 ward nurses (SN + TCN) on Maternity, 1:5 on Medical, 1:6 Surgical I, to 1:7 in the remaining Areas. One superviser to 3 nurses is oversupervision, and one to 6 or 7 is only acceptable if TCNs are not receiving supervision from Staff Nurses. If TCNs are in Teams headed by SNs, then there should only be one Nursing Officer for every 5-6 Teams.

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-61 -4. Productivity Leaving aside the issues of numbers and deployment of Nurses, the question arises of the productivity of those Nurses actually on the job. There was neither time nor resources during this study to perform a time/motion study, or in any way to observe individual Nurses at their work. (Of course, such observation can in itself increase productivity markedly.) Therefore evidence for regarding productivity was indirect -anecdotal and circumstantial. / However the unanimity of the anecdotal evidence was overwhelming. At all levels of Nursing administration, and from the Staff Nurses and TCNs the investigator was told repeatedly that Nurses were not nearly as productive as they could be. This was described as "sitdown" disease, in which a Nurse did the basic necessary tasks and then found a corner in which to sit down. Other Nurses talked of "loss of the work ethic", "lack of dedication," "low morale." The circumstantial evidence for reduced productivity lies in excessive rates of absenteeism, lateness and the departure of highly qualified senior Nurses from the system. These are generally accepted signs of dissatisfaction with work. It can reasonably be inferred that if the commitment of Nurses is suffuciently low as to cause excess lateness, days off and Tesignations, it is very likely to also result in productivity on the job. Finally, a group of Staff Nurses told the investigator that it estimated the average Nurse did Nursing duties only 3 hours out of the standard 7 1/2 hour working :iay. Similarly, Senior Nursing Officers, reported up to 75% of their time involved in and related personnel matters.

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-62 -In the light of thes. e observations it can reasonably be assumed that Nursing productivity in Princess Margaret Hospital is less than optimal. Indeed, efficiency, efficacy an. d cost-effectiveness of Nursing operation are all compromised by this reduced productivity: B. Management 1. Introduction The fundamental problem underlying the efficiency and efficacy of the Nursing Service appears to be far less ctne of numbers than one of management. The management problem begins at the Ministry of Health (and other involved Ministeries) and permeates the entire system to the ward level. The heart of the problem is the lack of decentralization, delegation and autonomy on the one hand, and a relative absence of what might be called "creative and supportive leadership and supervision" on the other. It is unrealistic to expect the latter without the former. The top levels of hospital administration: the administrator, the Principal Nursing Officer and the Medical Director are given the responsibility for operating the hospital efficiently and effectively without being given the authority to control areas of operation which most directly affect the ability of the hospital to func.t ion. As a result, in the three areas most relevant to this study ..: personnel, procurement of supplies and equipment, and general budgetary control -the administration (Nursing, Medical and General) is unable to respond adequately to problems as they arise, or in many eases, even to those that have been simmering for long periods of time. Delegation of authority means that the Minister has sufficient confidence in his staff to permit them to make the decisions required to operate their programs/institutions. When this delegation does not occur, then the institutional administrators become timid, never knowing what they can or cannot do o r w h e n t heir decisions will be overturned

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-63 -They become particularly .afraid to undertake anything new, rightly suspecting that such endeavours are bound to be vetoed when half a dozen other individuals can overturn or undermine a decision to make change. 2. Personnel Hiring and firing, disciplinary action, changes in job description, working hours, pay rat&s and promotion are all out of the hands of hospital administrators. Yet promotions, low productivity, lateness, salaries are all major areas of dissatisfaction among nursing staff. I ,. Some personnel matters must move through five or six layers of authority before a decision can be made. For example a decision to recommend promotion of a nurse to NOI might originate with an Area Supervisor within the hospital. It will then require review and support from the Principal Nursing Officer in the hospital; in the Ministry of Health, from the Personnel Department, the Director of Nursing, the Permanent Secretary, the Minister; then the Department of Public Personnel and finally the Public Service Commission. Even if this approval process were capable of moving swiftly and smoothly, when inadequacies are found in the form of the reccommendation, it must move down the approval chain for correction, and finally back up again an ultimate decision. Some important promotions have been delayed for over a year by this process. It seems reasonable that only hospital staff can determine which individual can best be utilized in a given position, and assuming an applicant meets the requirements for hiring or promotion, the decision should be made by the PNO with a hiring or promotions committee, after a thorough evaluation of all applicants. Any other supports or approvals for the recommended party from within the Ministry should be purely rubber-stamp, and the Ministry itself should ensure speedy movement of personnel matters to completion.

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I [ 64 -The investigator learned of numerous instances of habitual lateness (20 to 60 times in a year ), chronic absenteeism, derelection of duty (leaving the ward), etc. in which, not only was the supervisor unable to implement a rapid and appropriate response, but was quite certain that little or no response would be forthcoming from the decision-makers 5 or 6 steps up the hierarchy. It is to be expected that when discipline is hard to implement, infractions will increase in number and general morale will decline as 80od workers are forced to carry the load for their less dedicated colleaguies. 3. Supplies and Equipment ,. The centralization of ordering and procurement of supplies and equipment can be cost effective by offering economies of scale in certain instances. In other cases it can be the cause of lengthy delays and result in the obtaining of inferior and/or inadequate material. In a hospital situation this can put patients at risk and cause staff immense frustration. It would seem that procurement of certain supplies, especially office supplies, furniture and equipment might well be centralized. However, the purchase of medical supplies and equipment requires the direct input of medical and nursing staff and should reside within the hospital. Buying second-rate medical supplies and equipment is a false economy ; since malfunction will result in loss of staff time in working with the inferior goods or in improvising modifications. among nursing/ medical staff is inevitable. Frustration Where several competitive products are available, it might be advantageous for the hospital administration to be able to call on central negotiators to supervise a bidding competition. But even this will only be useful if it can be done quickly and well.

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I l 65 -Nurses reported fr!quently running out of basic supplies such as intravenous fluids, antibiotics and the like. There must be adequate inventories of both medications and basic supplies at the ward level and in the central hospital supply area. Autonomy within the hospital is needed in order to maintain constant supply levels, to fill deficits such as the inadequate number of cribs and incubators, and to ensure'that equipment purchased is of good quality and unlikely to require frequent repairs. At the same time that full purchasing authority should be delegated 1 so should full responsibility for maintenance of the system. Thus the hospital administrator must answer to his colleagues in the hospital and at the Ministry for failures in the system. 4. The Budget To a extent, it is having budgetary control that permits an institution to exercise the authority and responsiveness which can yield creative solutions to problems. When administrators are locked in to line budgets that require approval for any expenditure over (for example) $1,000, and are unable to move monies from one line to another, they lack the flexibility to respond to day to day needs. There is no question that since the central Ministries are ultimately responsible for public monies they must regularly audit the accounts of the hospital. But the spending should be in the hands of the hospita l M ana gement Committee and so should full responsibitity for fiscal successes and failures. 5. Nursing Supervision Among the Nursing Officers interviewed there were varying responses to questions about their freedom to supervise as they saw fit.

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-66 Some nurses felt that thet had little authority to carry out optimal supervision; others said that although they had the authority, they had little time or energy for supervision because of the amount of attendance and oth.er personnel work they had to do; still others were quite content with the way they were able to supervise their areas. The Area Supervisors were asked to keep a two day record of how they spent their time, but these reoords had not been submitted at the time of the writing of this report. Such records from all Nursing Officers would be very usewl in order to begin a management review of nursing within the hospital. r There was little evidence of attempts to clarify problem areas on the wards or among staff and to develop programs to deal with them. It seemed that supervisors had their hands full simply ensuring a basic level of coverage and function. With the exception of a fairly new program of inservice education (almost universally praised) there did not appear to be plans afoot to upgrade areas where deficiencies had been previously indentified. A least one supervisor expressed the desire to engage in some clinical resarch on her wards, but was unable to begin due to lack of time. At a meeting held with about forty Staff Nurses supervisors present) the nurses were asked about encountered on the job. (and with no problems they whole flawed. Their almost unanimous and highly vocal response was that the process of supervision in their working areas was seriously Among their more prominant complaints were the following: not being asked for their input about how the w ards were being run; not being told or consul ted when changes were being made in ward/or hospital operation;

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-67 -having requests for cancelled without good reason; spending large amounts of time hunting up supplies and equipment from other wards; poor system of supervision of TCNs and ancillary staff; poor teamwork poor communication between supervisors and themselves; rarely receiving praise for gbod work, but frequently receiving censure for lapses perceived by supervisors; not having regular staff meetings either with direct supervisors or upper level administration; r supervisors showing little interest in the problems faced by Staff Nurses; favouritism being shown in promotions and in opportunities for advanced training; supervisors not being familiar with patients or with ward conditions. The staff nurses feel that some of the supervisors were very insecure in their roles and were filling them poorly. As one nurse expressed it: "this place is ready to explode." Others admitted that their level of commitment to the job was minimal, and all they wanted was to get the chores done and leave. Most agreed that morale was low and they seemed pessimistic about the likelihood of improvement.

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--68 -VII. RECOMMENDATIONS A. Nurse Recognition It would be highly desirable for Ministry of Health to take a few steps immediately in order to show appreciation and recognition of the Nurses in the Bahamas. The Nurses were aware of this study and cooperated with it in hopes of seeing improvementes in their working conditions. Immediate implementation of the f91lowing would demonstrate Ministerial support and recognition of Nurses as people and as dedicated health professionals. The items are not costly, and should come from the Ministry itself not the hospital budget. 1. Install drinking water in all wards 2. Install urns for preparation of hot drinks for patients 3. Make food and beverages available 24 hours a day for staff 4. Complete the promotions now in process. 5. Establish awards (and an awards dinner) for such meritorious practices as: a. perfect (or near perfect) attendance b. most dedicated Nurses c. nurse most helpful and supportive of other N'urses d. nurses making suggestions which improve patient care and or Nursing operations e. special merit (research, new procedures, etc. ) 6. Within a year provide staff toilets easily accessible to each Ward. 7. Provide locked storage capacity in each Area

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system 69 B. Management Recommendations As noted in the conclusion, is seriously flawed. Efforts the present management/supervisory should begin immediately on all fronts (from Ministry to Ward) to make improvements. General Management Give greater budgetary control to the hospital' especially for supplies' equipment' repairs and renovations 0 Within very broad guidelines, permit the Man. agement Committee at PMH to move monies from line to line., Consider making the hospital independent of the Ministry entirely, with its own Board of Directors. / 7; Nursing Administration Hiring, firing, promotion, discipline and training decisions within the hospital should be completely under the control of the Principal Nursing Officer (and her senior ataff). An appeal procedure should be established for grievances, but this should be at arms length from the political process. Members of parliament and senior MinistrY officials should be able to truthfully inform constituents and that they cannot influence these matters. (It should be noted that complaints of political favouritism and intervention are not limited to Nursing or to the Ministry of Health.) All routine personnel matters -attendance, records of leaves, sick days, holidays -should be removed Nursing Supervisors to a Nursing Personnel Officer in the Administration Office. This would free up the time of Supervisors for true supervision. 3. Nursing Supervision The basic unit of function in the Hospital I should be the Ward Team, and its membership should be fairly constant for periods of at least several months. Each Team should have a senior Sat Nurse who works with the Team to divide tasks and responsibilities. Depending on the number of beds (and average occupancy) the Team should consist of one or two Staff Nurses, one or two TCNs and one NA.

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I I I 70 Staff Nurses and TCNs should each have their own patients and be responsible for them from admission to discharge. The TCNs could probably manage about six patients each and Staff Nurses about 8 on general medical and surgical wards. The Senior Staff Nurse would have a slightly reduced patient load and could perform tasks (such as giving of medications) which TCNs cannot do. She would also review the charting, care plans and activities of all staff. Team meetings should be held regularly for the open discussion of roles and responsibilities of staff as well as for problems with patients. Four to six Teams should be supervised/ by a Nursing Officer. The role of the Nursing Officer should be to facilitate the activities of the Team. She should ensure the of supplies and equipment, deal with personnel conflicts and complaints and mediate between Senior Staff Nurses and others when problems arise. The philosophy most likely to improve morale and productivity is: the most important workers are those providing direct patient care, and the role of supervisors and administrators is to help remove obstacles to the provision of optimal care by these front-line workers. Thus the Nursing Officer might help Teams identify problem areas and arrange in-service training for them. This could range from workshops in Team-building, operation of new equipment, upgrading of TCNs and NAs, to report writing, improved patient record keeping and so on. Nursing Officers would meet together to discuss common problems and to find joint ways of dealing with them. The PNO would play the same facilitating role viz a viz the NOs as the NOs play with the Ward Teams.

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71 -4. Team Building The problem of morale and productivity in PMH will only be resolved if Nurses' fee1 respected and an integral part of decision-making in the hospital. If a decision is taken to beain a more cooperative system of operation, the first iteps need to be taken by the PNO. It is clear that many Nurses have grievances about the hospital, the system and their supervisors. The PNO can give direct evidence of a coming change by meeting with groups of SNs and TCNs to discuss their problems and get their about future. Such meetings should not include the direct supervisors of the Nurses, or there will not be open I and honest diicussion. J' Team building requires specialized skills and often actual training. If the Nursing Officers are not familiar with the techniques and/or lack the needed interpersonal skills, experts in this area could be brought into the hospital to work with groups of NOs or even with the Teams themselve. B. Other Recommendations 1. Promotions Circulate the "Criteria for Promotion" among all Establish a review of the Criteria to ensure that all Nurses have seen and understand them. whether changes should be made and make ttiem. This review should occur within PMH (and within other Nursing institutions) with conclusions brought to the Ministry (and Union?) for finalization. 2. Shifts and Deployment Begin examination of Night Shift system and overlap between day shifts to ascertain whether straight shifts can be instituted. Consider using a system in which Nurses work a given shift for several months at a time, and that the same people work together on a regular basis. This is essential for the Team building discussed above.

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-72 NOs should work nights (and lates) as well as day shift since supervision is required 24 hours a day. Completion of a period of a night supervision could be required for promotion. 3. Relief Pool Institute a pool of relief Nurses for each shift. These Nurses would not be on-call, but actually on duty. Perhaps six on each day shift and three or four on nights would be adequate. They would be used to replace .absentees, to 11special" very sick patients or to assist on over crowded wards. It be reasonable to make a six month period of relief work a part of the requirement for promotion. The .I rationale is that relief Nurses must learn to work in all hospital areas, I to fit easily into teams, and to adapt quicklf to last minute needs. 4. Training A review of the role of training is needed. To require advanced training in midwifery and/or psychiatry as a prerequisite to promotion is a waste of educational resources. In many instances Nurses who take such training are not subsequently put into positions where they can make use of it. This kind of specialized training should be utilized to train for vacancies or anticipated vacancies in Areas requiring the particular skills. It can also be used as a promotional requirement if a career track based on experience and skill is instituted (towards the Master Nurse). In-service training programs in special areas should be increased. The intensive care program for ICU Nurses is a good model, and Neonatal Intensive Care, Renal Dialysis, Emergency Nursing as well as others should be instituted. Such programs can either bring in specialists from out of country or send Nurses on courses elsewhere. A combination might be optimal, since in-house training permits the Nurse to continue in her post, thus minimizing staffing problems, whereas working elsewhere gives her the opportunity to return to the Bahamas with new ideas and methods.

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I ... -73 -s. Career Paths -Staff Nurses Introduce a new career path for rewarding expeiienced! extremely generalist and specialist Nurses with gradations leading to a "Master Nurse" designation and special responsibilities in improvement of patient care and quality of Nursing. Administrative skills and professional excellence are both important in Nursing and they are not necessarily found in the same individuals. Both should be fostered and honored, and a way found to integrate the two sets of skills for the benefit of Nurses and patients 6. Career Paths .I Trained / Clinical Nurses There should be a hierarchy within the ranks of TCNs with experienced and skilled TCNs providing functional supervision; consultation, and liaison for TCNs. But there must also be a clear and facilitated path for crosa-over for TCNs to move into the SN stream. This includes exemption exams for portions of the Nursing program, credit for experience and a mechanism for entry into regular Nursing that supports desires for self-improvement rather than inhibiting them. 7. TCNs Institute a review of the role and training of the TCN. Decide whether she is to be an assistant or an independent professional. In conjunction with an overall review of future nursing directions decide whether the TCN is to be maintained or phased out, so that training decisions can be made in accordance with future human resource needs. 8. Future Activities a. study feasibility of workplace day care b. examine Nurses' salaries and compare with the private sector and with other jobs requiring similar training, skill and experience.

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I. -74 -c. find other placements for "boarders" who are now occupying acute care d. continue study of attrition, institution of exit interviews and further interviews of those who have left the public service. e. either upgrade or down grade the NA. f. establish a counselling service for Nurses, including career guidance and personal counselling 9. Future Considerations For Health Care in the ,l The future of Nursing in the Bahamas will, to a great extent, depend on the directions taken by the health care system as a whole. The Bahamas is in a difficult situation, having a small but scattered population; In addition it has the health problems of both developed and less developed countries. At the same time that Princess Margaret Hospital has sophisticated equipment for life support, surgery, renal dialysis and neonatal intensive care, the Community Nursing Service and Ambulatory Care Department are dealing with diarrhoeas, communicable disease&j nutritional deficiencies, tropical diseases and the problems of pregnancy and child growth and development. It would seem optimal for the Bahamas to follow a two-stream approach for the next ten to. fifteen years in its health care delivery. There is a great risk that if resources become concentrated (as they do in many countries) in the high technology equipment and training required for tertiary care in hospital, then the problems causing the greatest morbidity in the country will not be adequately dealt with. The major focus for the Bahamas should be primary health care in communities, with a strong emphasis on health education/promotion, disease prevention, community participation in health care programming and

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--75 -delivery, and consumer health group activites. To maintain and expand this focus; priority should be given to Community Health Nursing. In particular, there should be more Community Health Visitors trained, and a component of education in diagnosis and basic treatment should be added to their curriculum. A strongly focussed program to prevent disease; promote health, and detect illness early and treat it promptly in the community can yield great in terms of decreased hospitalization and use of hospital clinics. The general ambulatory care clinics at Princess Margaret Hospital are now experiencing ;ery high demand. This could be greatly reduced with expanded community programming. the Family Islands, where hospitals are not available, there is a need for Nurses with a broader range of skills in basic diagnosis and treatment. The Bahamas is in an excellent position to target health conditions and monitor them closely over the coming years. Prenatal and child care, breast feeding, nutrition, oral rehydration, immunization, respiratory infections and tropical diseases are good candidates. With a focus on community services, expanded numbers and training of Community health Visitors; and increased co11111unity participation, morbidity and mortality from many of these common disorders could be rapidly reduced. At the same time, the second stream of tertiary care must be developed in a highly selective fashion. Hard decisions must be made as to which services can and should be provided within the country and which should be referred outside. It is unrealistic to expect that a small country can develop and maintain the human and technological resources required to provide all tertiary care services.

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\ I t l 76 Once these basic decisi. ons have been made, plans can be made for the training of the human resources. required for the health care system in the future. There are some specific questions related to Nurse education .that must also be dealt with. The role of the Trained Clinical Nurse, the Nursing Auxiliary, and the Staff Nurse should be reassessed and projected into the future. Furthermore, the trend in N orth America is towards Nursing as a Bachelors degree program, with many Nurse having Masters ,. level education. There is also a trend toward Nursing subspecialization, with training available in areas such as: cardiac intensive care, neurological intensive care, emergency medicine, acute care nursing, neonatal intensive psychiatric care, geriatric care, etc. The future of the School of Nursing will depend on many decisions that must be taken about the role of the Nurse in the Bahamas. Long range planning along these lines should begin immediately if the Bahamas is to develop a coherent health care system that can meet the needs of the country. Efficiency, efficacy and effectiveness can all be compromised if there is no overall plan capable of directing resources to areas where the greatest impacts can be made.

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I I { I I [ -77 APPENDIX I Data Collection This study took place over the course of a four week period. The methods of data collection included: observation, individual interviews, group interviews, review of existing documents about the health care system in the Bahamas. Tours and Observations of Operation-of I Princess Margaret Hospital -all Waras and areas. 2. Rand Memorial Hospital -overview tour 3. Sandilands Rehabilitation Center -overview tour. 4. Two Community Clinics on New Providence Island -tour and observation of operation. Individual Interviews 1. Ministry of Health -Deputy Permanent Secretary, Mrs. V. Brown -Director of Nursing, Mrs. I. Morris -Chief Medical Officer, Dr. V. Allen Personnel Officer Mrs. P. Johnson Chief Personnel Mrs. 0. Brown 2. Princess Margaret Hospital Mrs. T. Godet, PNO Mrs. M. Moss, Asst. PNO -Dr. Haddox, Chief of Medical Staff Mr. Thompson, Administrator

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{ \ I I -78 Senior Nursing Officers {Area Supervisors) -acutal, or acting. Mrs. Minnis Medical Area -Mrs. Coakley Surgery I Mrs. Ene Paediatrics Mrs. Comery -Maternity Mrs. Okpuno Surgery II Mrs. Thompson Ambulatory Care Department 3. Other -Mrs. Isaacs School of Nursing, Principal Nursing Officer Mrs. Prescod Community Nursing Service, PNO I Knowles Rand Memorial Hosp{tal, PNO Mrs. Ford Sandilands, PNO Mr. Davies Sandilands, Nursing Officer Mr. Davis -Administrator, Sandilands Mrs. Thompson -Administrator, Rand Hospital Meetings/Group Discussions/Group Interviews 1. Ministry of Health Union: Mr. Miller et al Meeting of Principal Nursing Officers Manpower Committee Debriefing with Senior Staff 2. Princess Margaret Hospital Senior Nursing Officers Nursing Officers, Medical Area 40 Staff Nurses -general discussion abou t problems 30 Trained Clinical Nurses -general discussion about problems

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I I I I I I l 79 -3. Other Community Nurs!ng Service 15 (about) Nursing Officers Community Nursing Service -4 Nursing Officers Rand Hospital -4 Maternity Nurses School of Nursing -about 10 Nursing Officers Documents from the Bahamas Background Material 1. Community Nursing Manual 2. Proposal for Minimum Staffing Requirements Community Nursing Service, by Mrs. E.M. Prescod, PNO. (1985) I t 3. Off Duty System for the Nursing Staff Princess Margaret Hospital by Mrs. T. Godet, PNO. (1985) 4. Ministry of Health, Commonwealth of Bahamas, Nurse Staffing, Princess Margaret Hospital (1980) Mrs. D. Phillips, PNO. 5. Attrition of Nurses: A Study by the Nursing Council, Commonwealth of the Bahamas, Chairman, Mrs. I. Morris, DON (Feb. 1986) 6. Ministry of Health: Health Policy (revised 1985) 1. Project for Funding Infrastructure Development for Ministry of Health June, 1985 8. Princess Margeret Hospital Management Committee Operational Guidelines. 9. Project Proposal for the Study of Health Manpower Needs of the Ministry of Health, Commonwealth of the Bahamas, June 1983.

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I l I [ I { I I I i 1 I It I ( ... 80 -APPENDIX II COMMUNITY NURSING SERVICE Future Directions Expansion and improvement of the Community Nursing Service can achieve several desirable goals: 1) decrease demand on ambulatory care unit PMH. 2) decrease morbidity and hospital admissions by preventive and early curative services in the communities. 3) extend health services to those most in need and least able 4) to access the private system. I move towards the World Health Organization's (and PAHO) concept of primary health care, a holistic approach, involving recognition of the multi-causality of ill health, the socio/econo/political context in which it exists, and the multifaceted approach required to improve it. Real improvements in health can only come from this approach. The investigator believes that expansion of cormnunity services, with major educational, health promotional and early diagnosis and treatment components is the optimal direction for the Bahamas in the future. Requirements for Improvement/Expansion 1) 2) 3) Nurse practitioner (diagnosis/treatment) training for all Community Health Visitors. Adequate staffing af all clinics -especially on Family Islands -with fully qualified CHVs. More emphasis on prevention/promotion. 4) Autonomy to the Nursing Service; to work with physicians, but not to report to them Independence from Ministry. 5) More training slots for CHV education.

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! I I \ I t I I l I I 1 -81 Problems 1) although improved recently, still inadequate equipment 2) inequity in promotion standards between Community Health Nurses supplies and hospital and 3) lateness and absenteeism among nurses and discipline in clinics 4) NOs need more experience in supervisory techniques, performance appraisal and team building 5) 6) 7) 8) 9) difficulties with interpersonal relations among some staff, and with organizing and scheduling risk bonuse s for visiting homes more availability for training post-partum home visit program needs more fully trained nurses interpreters and/or in-service training in Haitian languages ..

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l I I 1 I I 82 SANDILANDS REHABILITATION CENTRE Future Directions This Centre is seriously over-crowded, both with s::espect to floor space per patient (no room to turn around, store belongings, no privacy) and patients per Nurse. The result is that the institution operates in a custodial manner more than a rehabilitative one. Comparatively than through death. few geriatric and pediatric patients leave other Psychiatric patients often rotate in and out of the centre, prison and the community. I With the inevitable aging of the population, and the spread of drug and alcohol abuse, demand for this kind of institutional care will rise. The Centre must be expanded in the very near future. There can also be a connected program of home care for the handicapped and elderly, day care, halfway houses and group homes in the community. The costs of community based care are lower than those of full-time institutional care. However, the support services, staff and infrastructure must be fully developed in conjunction with establishment of sites and types of care. Otherwise the Bahamas will re-enact the US/Canadian experience of thousands of (for example) ex-psychiatric patie'nts homeless, wandering the streets and begging passers-by for money. Requirements for Improvement/Expansion 1) more staff move to more rehabilitation and less custodial care. 2) Lnmediate moves required to reduce over-crowding. 3) more staff training for patient care. 4) centre needs further autonomy -budgetary control, staffing, equipment and supplies. 5) begin consideration of integrated system of Rehabilitation Centre through Grouphomes, to Day Care, to home care.

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f r l l l \ I : t !jl I I' t l. I I 83 -Problems 1) overcrowding, understaffing 2) some absenteeism, lateness 3) bus system causes much lateness and uncertainty 4) better selection and training of Nursing Auxilliaries needed I t'

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I ; I I .,, ' :'l I l I .. t I l I I l t I l -84 -RAND MEMORIAL HOSPITAL Future Directions Many of the same problems arise at Rand as have been discussed in the Princess Margaret report. Staffing, salaries, lack of promotions, lack of autonomy, equipment maintenance, shift work were all raised as issues in discussion However, in general, by virtue of its location, Rand has had more freedom to operate and make decisions without going through Ministry Offices. In the future this de-centralization and autonomy should be in discipline, t' increased, particularly budgetary discretion. The question of enlarging the capacity of the hospital depends on population projections for island in the immediate and long term. Problems 1) short of staff 2) lack adequate number nursing supervisors 3) no promotions 4) absenteeism 5) ability to discipline 6) slow filling of vacancies by Ministry 7) equipment maintenance, supplies at end of fiscal year 8) more space required 9) team-work and supervision with porters, maids, food clerks 10) paediatrics often understaffed 11) delays in hiring to fill vacancies As in Princess Margaret, there is a perc,ption that the morale of Nurses is low and productivity suffers as a result.

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--as The School of Nursing Future Directions The future directions of the School of Nursing will depend to a large extent on the decisions made as to the directions and focuses of the health care system as a whole and Nursing in particular. As has been mentioned earlier, the role and training of both the TCN and NA require review. The results of such a reveiw might well require the Shool to meet new educational needs/ Efforts should begin to find ways to ease the movement of TCNs into regular nursing programs, with exemptions, credit for experience, and equivalency exams. Whether or not the School should become involved in specialty training for Nurses is another question that must be dealt with. Similarly the trend towards Bachelor's degree programs for Nurses may have to accommodated. The School will not be able to offer all the programs currently available to Nurses in larger countries, but it may wish to develop some of the specialties especially important and relevant in the Bahamas. Problems The major problem for the School of Nursing at the moment appears to be the same as for the other institutions. The School requires more autonomy from the Ministry. Broad guidelines shuld be given, but then the hiring/ firing of staff, curriculum development and program delivery should be left to the School itself. There are, at present, discrepancies in the promotion system between the hospitals and the shool, with more training and experience required for Officer positions in the School.

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I t l f { [ l I I I l l L ' ,. . ' I 86 -A review of the programs and staffing in the School is needed. There seems to be inadequate for student nurses placed in the hospital, but it is not clear whether the problem is one of staff numbers or deplorment. It may be that the School is having to fulfill too many roles at present. The system of having field nurses involved in writing questions for and grading the licensing exams is creating problems. Both the School and the field Nurses are complaining. It would seem that the School staff should draw up the questions and do the grading, but that a review committee should pr.ovide consultation. 4821H April 86 I r