Between the Flags (BTF) program introduction and resultant changes in nurses’ workplace culture Ms Cathy Maginnis Mrs Maryanne Podham Dr Judith Anderson Mrs Lyn Croxon

INTRODUCTION & AIM The Between the Flags (BTF) program was introduced in NSW public hospitals in 2010 to improve systems in healthcare related to responding to a deteriorating patient. The program is designed to support clinicians in the early recognition and management of a deteriorating patient. The aim was to explore the impact of the BTF program on the workplace culture regarding the perception of the registered nurses' role in the recognition and escalation of the deteriorating patient at a rural hospital in NSW.

LITERATURE REVIEW 2008-2016 using electronic databases, reference lists and key reports Focussed on perception of the role the RN plays in detection and escalation 80 reviewed and 30 met inclusion criteria PRISMA system adopted for literature review Results from the past several years highlight that initiation of this rapid response is predominantly nurse driven; a change from the traditional medically led response Research required on workplace culture and interactions between RN and rapid response team (RRT)- hence this project

METHODOLOGY Ethics approval from both organisations A qualitative interpretative approach was utilised Data was collected through a survey monkey link/hard copy questionnaire Phenomenological approach 16 / 70 questionnaires were completed and 7 interviews were conducted. Ethics approval obtained from CSU HREC Approval from WNSWLHD research ethics and governance unit

PARTICIPANTS- INCLUSION CRITERIA RN One year working in the identified medical or surgical ward as permanent employee Over 18 years of age 2 wards were identified as they were the initial project sites for the BTF program when it was introduced Recruited through flyers & information sessions Flyers put up in identified wards Flyer left in tea room Participant information provided to NUM’s to discuss at staff meeting Researchers conducted information session on each ward to staff

DATA COLLECTION 2 collection methods Online questionnaire with 20 questions approx. 20 minutes to complete Semi-structured interviews with volunteers who completed the questionnaire approx. 30-60 minutes duration Information recorded and de-identified when transcribed verbatim to maintain confidentiality and anonymity

RESULTS Themes identified included: improved patient outcomes the value of the program perception of BTF as a safety net and a set of clear guidelines improved communication role of management in supporting this program medical staff reaction to the nurse driven initiative need for ongoing education

PARTICIPANT QUOTES We were probably not, (comfortable to escalate before BTF) especially if there wasn’t anything you could put your finger on … it depends how senior you were, how approachable the medical staff were. (No.3) I feel that it's made a huge impact on patient safety … in my early nursing years … patients actually had a cardiac arrest and I find these days it's very rare that a patient gets to that stage”. (No 7).

PARTICIPANT QUOTES The biggest thing was knowing that we had goal posts and if they were outside of that, it was our responsibility to notify the doctor. No 4. BTF is really good … because when the doctors come ranting and raving we can just stand up and say … well okay that’s fine I will press the red button and we’ll get everybody here. No 5.

PARTICIPANT QUOTES It gives nurses a bit of an empowerment … particularly junior nurses who don’t often have the confidence to be assertive, something to follow and back them up. No 7. Between nurses and doctors there has been (a change in communication). I think the nurses are more willing to push a bit more when they ring the doctors with a problem….. you now need to clinically review this patient. I need immediate action No 2

CONCLUSION Introduction of BTF has led to a change in traditional cultural hierarchies. Nurses empowered in their decision making and ability to escalate concerns for a deteriorating patient. Recommendations: Orientation process for new staff- simulation scenario’s Need for ongoing education, Clarification of individual roles in a rapid response, Consideration of a two tiered RR calling criteria Workload consideration Nurses have gained empowerment in their decision making and knowledge in relation to escalating patient well being   The implementation of the BTF program, has led to positive changes in the culture of patient safety and shared responsibility of patient wellbeing