Essentials of Care - a personal experience

Marc Johns, CNC Rehabilitation, David Berry & Shoalhaven Hospitals

In 27yrs as a practicing nurse, Essentials of Care (EOC) is possibly one of the best opportunities for nurses to effect meaningful change in day-to-day practice that I have witnessed.

Implementing EOC simultaneously across two separate rehabilitation sites has proven to be a challenge and what started out in the belief that both sites would mirror similar claims, concerns and issues, the reality is turning out to be quite different.

"I can really feel the momentum grow now that we have that spark of interest. The team should be commended as they have moved from a space of suspicion to one of participation."

(KP- RN, internal facilitator)

Particularly in the assessment phase, the benefits of the EOC program are apparent through the ownership of the process by the nurses at the coal-face. Across both sites, the areas chosen for auditing have been identified by the teams and during the observation sessions there has been total cooperation. The feedback processes have varied slightly, but participation by the teams in the analysis of the data has been positive with key themes surfacing, relevant to nursing practices on each unit.

The action plans have yet to be formalised, but they promise to reflect areas for improvement known to the teams for a while, but never before identified in a structured plan for change.

"As an EOC observer I was able to see the high quality of care provided by the team. As an educator it identified some learning needs of the team and helped me developed educational resources to assist with learning."

(KS-CNE & observer)

The nine EOC domains marry well with those of rehabilitation practice and each domain has had a high level of acceptance amongst the staff. Reflecting broad principles of general nursing practice, the EOC domains provide a platform for a multitude of clinical issues, whilst at the same time enabling the teams to highlight issues unique to their own setting – whilst 'Privacy & Dignity' might be a key issue on a nightingale ward, 'Documentation & Communication' might be more important for the team with skill-mix concerns.

Not only does EOC help to identify areas of concern, it also demonstrates what is done well.

Through the observations and audits, we have been able to make positive comments to each other and to colleagues from other departments. 'Promoting Self-management' and 'Personal Care' in particular have been two domains that have featured positively across both sites and feedback to individuals has had great impact on the team ethos.

As a facilitated process, EOC raises the bar for individuals who are keen for change, but who are unsure how to achieve it. The training days for internal facilitators are comprehensive and create a sound base from which to start the process at ward level. The EOC manual is a valuable resource with enough structure to support implementation of EOC in the clinical setting, whilst providing the facilitator with enough freedom to individualise his/her approach.

"EOC has enabled the team to take a step back, pause, and be more objective about their daily clinical practices."

(LH – NUM)

Through the facilitation process some staff have had the opportunity to observe on other wards and other hospitals, enabling them to gain a shared view of nursing practice. Having external facilitators act as observers has also provided each unit with a chance to showcase what we do well.

"During the feedback sessions the nurses were very engaged – there was no holding them back once they found their voice."

(MJ-CNC facilitator & external observer)

Externally, we benefitted from input by the EOC Coordinator who not only mentored our internal facilitators, but who also provided practical assistance with patient interviews and writing up notes from the observation sessions. The external support is invaluable during the natural lulls in enthusiasm by the team – a time when internal facilitation is at risk. This support demonstrated the value of the EOC structure and highlighted its effectiveness – facilitation at all levels.

Whilst not without potential pitfalls – staff reservations about findings, available time on a busy ward, rostering and leave issues, natural and other disasters, (one observation week was affected by major floods resulting in a full day of observations being cancelled, another was halted by an outbreak of norovirus) - there is flexibility built into EOC and unlike many change practices within healthcare, a very reasonable timeframe relieves some of the pressure, allowing the team to regroup, refocus and restart EOC after difficult times.

"The feedback from the staff has been positive. I’ve heard them talking about it on the ward, in the tearoom and even in the car park."

(RS-acting DDON/Nurse Manager)

The two rehabilitation sites started the EOC journey from the same point and will, no doubt, cross paths with some of the items on the action plan. To-date, the EOC experience has, however, been quite different, which is testament to the value of a program that claims to recognise nurses and "the integral role they play in the care provided to the community across a number of contexts and settings".

The final say goes to one who is new to nursing and our rehabilitation team. For a new graduate, the EOC program has provided an opportunity to focus on clinical practice and contribute to the development of the team even as a newcomer. EOC gives the established team many opportunities to reflect on clinical practice, but for the nurses of tomorrow,

"EOC promotes holistic care and encourages patient wellbeing by assisting the team to apply nursing philosophy to professional nursing practice"

(BH – New Grad RN & EOC participant).