1. 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

2. 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.

3. LITERATURE REVIEW
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

4. 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

5. PARTICIPANTS- INCLUSION CRITERIARN
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

6. 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 minutes duration
Information recorded and de-identified when transcribed verbatim to maintain confidentiality and anonymity

7. 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

8. 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).

9. 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.

10. 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

11. 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