Professor Christine Duffield

Duffield, C.M., Roche, M.A., Diers, D. & Stasa, H. 2011, 'Australia: What has changed?' in Nelson, S & Doran, D (eds), Mapping the field: Nursing scholarship in health human resources, Lawrence S. Bloomberg Faculty of Nursing, Toronto, Ontario, Canada, pp. 25-37.
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This chapter will describe some of the recent changes to health services practice and policy in the Australian context, using as a basis a research study completed in 2007 in New South Wales (NSNSW) (Glueing it together: Nurses, their work environment and patient safety, hereafter referred to as 'The Glue Report' [Duffield, Roche, O'Brien-Pallas, Diers, Aisbett, King, et al., 2007]) which built on the work of other researchers in health human resources for nursing, and in which Dr. Linda O'Brien-Pallas played a leading role.

Baldwin, R.J., Duffield, C.M., Fry, M., Roche, M.A., Stasa, H. & Solman, A. 2013, 'The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study', International Journal of Nursing Studies, vol. 50, no. 3, pp. 326-334.
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The study provides evidence of great diversity and prioritisation within CNC roles. The CNC typology identified in this study is similar to the categorisation of the roles of APNs reported by other researchers. With further testing, the CNC typology could be useful to service managers and policy makers in making decision on the category of CNC required for a position and may also be able to be applied to other APN roles.

Fry, M., Duffield, C.M., Baldwin, R.J., Roche, M.A., Stasa, H. & Solman, A. 2013, 'Development of a tool to describe the role of the clinical nurse consultant in Australia', Journal Of Clinical Nursing, vol. INPRESS, pp. 1-11.
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Aims and objectives. This article is a report of a study that used template analysis to develop a tool for defining and measuring the role characteristics and responsibilities of an advanced practice nursing role in Australia. Background. Internationally, there is considerable confusion about the precise role responsibilities of advanced practice nursing positions. In Australia, the Clinical Nurse Consultant is an advanced practice role with five nominated domains of practice. However, there are no tools for measuring the performance of Clinical Nurse Consultants against the listed domains. Design and methods. Participants were 56 clinical nurse consultants at a tertiary public hospital. The existing literature, an online survey, and position descriptions were used to generate the a priori themes for the initial template. Semi-structured interviews were conducted (in 2010) to test the template characteristics. The template underwent multiple iterations in its development. Results. A 50-item tool was devised, which consisted of five domains with a ten-point hierarchical scale within each domain. In preliminary testing, the revised template was found to provide greater clarity regarding roles and grades than the original position descriptions. Conclusions. Further testing and refinement of the modified rating scale is needed, but it offers the possibility of a new tool that can be used by health service managers to determine the grade of a clinical nurse consultant position and for evaluating role performance.

Gardner, G., Chang, A.M., Duffield, C.M. & Doubrovsky, A. 2013, 'Delineating the practice profile of advanced practice nursing: a cross-sectional survey using the modified strong model of advanced practice', Journal of Advanced Nursing, vol. In Press.
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Aims. To test a model that delineates advanced practice nursing from the practice profile of other nursing roles and titles.

Blay, N., Duffield, C.M. & Gallagher, R.D. 2012, 'Patient transfers in Australia: implications for nursing workload and patient outcomes', Journal of Nursing Management, vol. 20, no. 3 Special issue, pp. 302-310.
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To discuss the impact of patient transfers on patient outcomes and nursing workload. Many patient transfers are essential and occur in response to patients. However, increasingly within Australia transfers are performed in response to reductions in bed numbers, resulting in 'bed block'. A discussion of the literature related to inpatient transfers, nursing workload and patient safety. Measures to increase patient flow such as short-stay units may result in an increase in patient transfers and nursing workload. Frequent patient transfers may also increase the risk of medication incidents, health-care acquired infections and patient falls. The continuing demand for health care has led to a reactionary bed management system that, in an attempt to accommodate patients, has resulted in increased transfers between wards. This can have a negative effect on nursing workload and affect patient outcomes. High nursing workload is cited as one reason for nurses leaving the profession. Reductions in non-essential transfers may reduce nurse workload, improve patient outcomes and enhance continuity of patient care.

Chang, A., Gardner, G., Duffield, C.M. & Ramis, M. 2012, 'Advanced Practice Nursing Role Development: Factor Analysis Of A Modified Role Delineation Tool', Journal of Advanced Nursing, vol. 68, no. 6, pp. 1369-1379.
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Aim. This study reports the use of exploratory factor analysis to determine construct validity of a modified advanced practice role delineation tool. Background. Little research exists on specific activities and domains of practice within advanced practice nursing roles, making it difficult to define service parameters of this level of nursing practice. A valid and reliable tool would assist those responsible for employing or deploying advanced practice nurses by identifying and defining their service profile. This is the third article from a multi-phase Australian study aimed at assigning advanced practice roles. Methods. A postal survey was conducted of a random sample of state government employed Registered Nurses and midwives, across various levels and grades of practice in the state of Queensland, Australia, using the modified Advanced Practice Role Delineation tool. Exploratory factor analysis, using principal axis factoring was undertaken to examine factors in the modified tool. Cronbach+s alpha coefficient determined reliability of the overall scale and identified factors. Results. There were 658 responses (42% response rate). The five factors found with loadings of =400 for 40 of the 41 APN activities were similar to the five domains in the Strong model. Cronbach+s alpha coefficient was 0À94 overall and for the factors ranged from 0À83 to 0À95. Conclusion. Exploratory factor analysis of the modified tool supports validity of the five domains of the original tool. Further investigation will identify use of the tool in a broader healthcare environment.

Clarke, E., Diers, D., Kunisch, J., Duffield, C.M., Thoms, D., Hawes, S., Stasa, H. & Fry, M. 2012, 'Strengthening the nursing and midwifery unit manager role: an interim programme evaluation', Journal of Nursing Management, vol. 20, no. 1, pp. 120-129.
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Aims: An interim evaluation was conducted on the professional development components of the New South Wales (NSW) Health 'take the lead' ('ttl') programme, an initiative aimed at enhancing nursing/midwifery unit managers' (N/MUM) skills. Background: Previous research has highlighted the importance of strong nurse leaders, and shown that training programmes may assist in improving leadership skills. The NSW Nursing and Midwifery Office (NaMO) developed the 'ttl' programme for N/MUMs with the intention of improving hospital quality by strengthening nurse leadership. The programme had three strands, with the professional development modules a key component. Method: Semi-structured interviews were conducted with 17 participants who had completed components of the 'ttl' programme. The interviews explored participants' perceptions of the programme, and suggestions for improvement. Qualitative analysis was conducted on the transcribed interviews. Results: The N/MUMs reported feeling increasingly empowered, knowledgeable and supported as a result of attending the 'ttl' workshops. Conclusions: The results suggest that the studied components of the 'ttl' programme may be effective in assisting nurse leaders gain new leadership skills and institute positive changes in the nursing work environment. Implications for Nursing Management: Leadership programmes such as 'ttl' may provide an effective tool for improving N/MUM performance and role confidence

Dignam, D.M., Duffield, C.M., Stasa, H., Gray, J.E., Jackson, D.E. & Daly, J. 2012, 'Management and leadership in nursing: an Australian educational perspective', Journal of Nursing Management, vol. 20, no. 1, pp. 65-71.
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Aim: In this article, we present an Australian perspective on issues influencing management and leadership education in nursing. Background: Nurse leaders and managers work in a context of high pressure, uncertainty and rapid change, and face unprecedented challenges on a daily basis. Evaluation and Key Issues: In the present paper, we reflect on the issues and challenges facing providers of management education for nursing, and consider these challenges in relationship to current trends and imperatives. Conclusions: Collaborative approaches between educational and clinical settings are needed to ensure quality, relevant educational support for managers and leaders, and enhance curriculum integrity. Implications for Nursing Management: There is a need for contemporaneous and relevant research to inform innovative models of collaborative education.

Hayes, L.J., O'Brien-Pallas, L., Duffield, C.M., Shamian, J., Buchan, J., Hughes, F.A., Laschinger, H. & North, N. 2012, 'Nurse turnover: A literature review - An update', International Journal of Nursing Studies, vol. 49, no. 7, pp. 887-905.
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Background: Concerns related to the complex issue of nursing turnover continue to challenge healthcare leaders in every sector of health care. Voluntary nurse turnover is shown to be influenced by a myriad of inter-related factors, and there is increasing evidence of its negative effects on nurses, patients and health care organizations. Objectives: The objectives were to conduct a comprehensive review of the related literature to examine recent findings related to the issue of nursing turnover and its causes and consequences, and to identify on methodological challenges and the implications of new evidence for future studies. Design: A comprehensive search of the recent literature related to nursing turnover was undertaken to summarize findings published in the past six years. Data sources: Electronic databases: MEDLINE, CINAHL and PubMed, reference lists of journal publications. Review methods: Keyword searches were conducted for publications published 2006 or later that examined turnover or turnover intention in employee populations of registered or practical/enrolled or assistant nurses working in the hospital, long-term or community care areas. Literature findings are presented using an integrative approach and a table format to report individual studies. Results: From about 330 citations or abstracts that were initially scanned for content relevance, 68 studies were included in this summary review. The predominance of studies continues to focus on determinants of nurse turnover in acute care settings. Recent studies offer insight into generational factors that should be considered in strategies to promote stable staffing in healthcare organizations. Conclusions: Nursing turnover continues to present serious challenges at all levels of health care. Longitudinal research is needed to produce new evidence of the relationships between nurse turnover and related costs, and the impact on patients and the health care team.

Merrick, E.T., Duffield, C.M., Baldwin, R.J., Fry, M. & Stasa, H. 2012, 'Expanding the role of practice nurses in Australia', Contemporary Nurse, vol. 41, no. 1, pp. 133-140.
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Like other countries, Australia is looking to reforms in the primary health care sector to meet the growing demand for care. Expansion of the role of practice nurses (PNs) is one way in which this demand may be met. To date the Federal Australian government has played a significant role in encouraging growth in the PN worforce. If the PNs tend to be GP directed, with little autonomy, care must be taken to consider whether to expand existing scopes of practice.

Merrick, E.T., Duffield, C.M., Baldwin, R.J. & Fry, M. 2012, 'Nursing in general practice: organizational possibilities for decision latitude, created skill, social support and identity derived from role', Journal of Advanced Nursing, vol. 68, no. 3, pp. 614-624.
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Abstract Aim. This article is a report of a study to describe the factors that support organizational opportunities for practice nurse decision-making and skill development for nurses employed in general practice in New South Wales, Australia. Background. Corresponding to the availability of subsidies from the Australian universal health insurer (Medicare), there has been an increase in the number of nurses employed in general practice. Currently, there is no Australian evidence as to the organizational possibilities for these practice nurses to make decisions, develop their own skills and abilities, derive identity from their role or how their role is influenced by social support. Methods. Over a 8-month period in 2008 practice, nurses employed in general practice in the State of New South Wales were invited to complete a 26-item selfadministered online questionnaire utilizing constructs from Karaseks (1998) Job Content Questionnaire (valid n = 160). Results. Confirmatory Factor Analysis indicated that all scales demonstrated acceptable levels of internal consistency. Sequential regression models revealed that social support exerts a weak influence on decision latitude (R2 = 0++07); the addition of self-identity through work significantly improved the predictive ability of the model (R2 = 0++16). Social support and self-identity through work exerted a negative influence on created skill (R2 = 0++347), whereas social support was effective in predicting self-identity through work (R2 = 0++148). Conclusions. Collegial and supervisory support in the work environment predicts organizational possibilities for practice nurse decision-making.

Roche, M.A., Duffield, C.M., Aisbett, C., Diers, D. & Stasa, H. 2012, 'Nursing work directions in Australia: Does evidence drive the policy?', Collegian, vol. 19, no. 4, pp. 231-238.
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A significant body of research has shown a relationship between nurse staffing (in particular, skill-mix: the proportion of Registered Nurses [RNs]) and both morbidity and mortality. This relationship is typically investigated by measuring the incidence of Nursing Sensitive Outcomes (NSOs) under different skill-mix levels. Yet whilst the evidence suggests that richer skill-mix is associated with a lower incidence of NSOs, recent Australian policy reforms have proposed the replacement of Registered Nurses with less qualified staff. The present study sought to examine the relationship between staffing, skill-mix, and incidence of NSOs at two hospitals in one Australian state. The study sought to determine the rate of occurrence of several NSOs, the relationship of skill-mix to that rate, and the number of patients affected per annum. It was found that the current rate of NSOs across wards ranged from 0.17% to 1.05%, and that there was an inverse relationship between the proportion of hours worked by RNs and NSO rates: an increase of 10% in the proportion of hours worked by RNs was linked to a decrease in NSO rates by between 11% and 45%. It was estimated that increasing the RN staffing percentage by 10% would mean 160 fewer adverse outcomes for patients per year across these two hospitals. Importantly, increases in nursing hours overall (without increases in skill-mix) had no significant effect on patient outcomes. These findings challenge current policy recommendations, which propose increasing the number of unregistered staff without increasing skill-mix.

Twigg, D.E., Duffield, C.M., Bremner, A., Rapley, P. & Finn, J. 2012, 'Impact of skill mix variations on patient outcomes following implementation of nursing hours per patient day staffing: a retrospective study', Journal of Advanced Nursing, vol. 68, no. 12, pp. 2710-2718.
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Aims. This article is a report of a study of the association between skill mix and 14 nursing-sensitive outcomes following implementation of the nursing hours per patient day staffing method in Western Australian public hospitals in 2002, which determined nursing hours by ward category but not skill mix. Background. Findings from previous studies indicate that higher nurse staffing levels and a richer skill mix are associated with improved patient outcomes. Measuring skill mix at a hospital level for specific staffing methods and associated nursing-sensitive patient outcomes are important in providing staffing for optimal patient care. Design. The research design for the larger study was retrospectively analysing patient and staffing administrative data from three adult tertiary hospitals in metropolitan Perth over 4 years. Methods. A subset of data was used to determine the impact of skill mix on nursing-sensitive outcomes following implementation of the staffing method. All patient records (N = 103,330) and nurse staffing records (N = 73,770) from nursing hours per patient day wards from October 2002Ô++June 2004 following implementation were included. Results. Increases in Registered Nurse hours were associated with important decreases in eight nursing-sensitive outcomes at hospital level and increases in three nursing-sensitive outcomes. The lowest skill mix saw the greatest reduction in nursing-sensitive outcome rates. Conclusions. The skill mix of nurses providing care could impact patient outcomes and is an important consideration in strategies to improve nurse staffing. Levels of hospital nurse staffing and skill mix are important organizational characteristics when predicting patient outcomes.

Daly, J., Davidson, P.M., Duffield, C.M., Campbell, T. & Ward, R. 2011, 'Interdisciplinary, cross- institutional collaborations: The Academic Health Sciences Centre as a key to addressing complex health problems and advancing research-based health care', Collegian, vol. 15, no. 1, pp. 1-2.
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Changes in disease patterns and the economic climate have created challenges for contemporary health care systems (Bennett, 2009). Meeting increased demands for care in a fiscally responsible manner requires new collaborative approaches involving not only health care professionals but also, managers, researchers, educators and basic scientists. In addition it is increasingly recognised that unless we engage consumers, policy makers and clinicians actively in the research process, the relevance, application and uptake of research findings are limited (Lavis et al., 2005). Unfortunately, efforts to ensure the collaboration and synergy required between all of these stakeholders are often challenged by organisational boundaries, and differences in research cultures and paradigms (Smith, Mitton,Peacock,Cornelissen, & MacLeod, 2009). It is not uncommon for researchers and clinicians working in the same organisation to have limited conversations and dialogue. Yet when they come together solutions to challenging problems are often enabled by merging unique perspectives and the sharing of knowledge (Boivin et al., 2009).

Davidson, P.M., Homer, C.S., Duffield, C.M. & Daly, J. 2011, 'A moment in history and a time for celebration: The performance of nursing and midwifery in Excellence in Research for Australia', Collegian, vol. 18, no. 2, pp. 43-44.
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The long awaited and much anticipated results of Australia's first national university system wide research evaluation exercise were delivered in February this year. The Excellence in Research Assessment (ERA) examined `research quality within Australia's higher education institutions using a combination of indicators and expert review by committees comprising experienced, internationally-recognised experts' (Australian Research Council, 2011). In the discipline review for nursing some twenty three universities were assessed. Midwifery was included in the Nursing category as the Field of Research (FoR) code (the way the groups were clustered together) for nursing includes midwifery. The results for nursing and midwifery were impressive and they demonstrated that nine of the twenty three research programs in this category that were assessed were world class or above world class. In fact, nursing and midwifery in the FoR code 1110 was noted to be a `particularly strong performer' (Australian Research Council, 2011). This demonstrates that nurses and midwives in Australia are engaged in high quality research which is influencing practice and policy and making a difference to the health care of Australians. In addition, the research of many nurses and midwives was also considered in other categories including public health, health services and clinical medicine. This shows that our disciplines are well represented across the health field and the commitment to interdisciplinary practice to solve complex health care problems.

Duffield, C.M., Gardner, G., Chang, A.M., Fry, M. & Stasa, H. 2011, 'National regulation in Australia: A time for standardisation in roles and titles', Collegian, vol. 18, no. 2, pp. 45-49.
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Background: The past few years has seen a growth in the number of new nursing roles and position titles in many countries, including Australia. The Australian situation is unique due to the lack of professional engagement and debate in determining the purpose of some of these new positions. Often these new roles have been poorly de?ned, and there is no national consistency in nomenclature. The recent move to a national nursing registration system provides an opportunity for change. Method: Discursive paper.

Duffield, C.M., Diers, D., O'Brien-Pallas, L., Aisbett, C., Roche, M.A., King, M.T. & Aisbett, K. 2011, 'Nursing Staffing, Nursing Workload, the Work Environment and Patient Outcomes', Applied Nursing Research, vol. 24, no. 4, pp. 244-255.
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Abstract: Nurse staffing (fewer RNs), increased workload and unstable ward environments were linked to negative patient outcomes including falls and medication errors on medical/surgical wards in a mixed method study combining longitudinal data (5 years) and primary data collection.

Duffield, C.M., Roche, M.A., Blay, N. & Stasa, H. 2011, 'Nursing unit managers, staff retention and the work environment', Journal Of Clinical Nursing, vol. 20, no. 1-2, pp. 23-33.
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Aim and objective. This paper examined the impact of leadership characteristics of nursing unit managers, as perceived by staff nurses, on staff satisfaction and retention. Background. A positive work environment will increase levels of job satisfaction and staff retention. Nurse leaders play a critical role in creating a positive work environment. Important leadership characteristics of the front-line nurse manager include visibility, accessibility, consultation, recognition and support. Design. Secondary analysis of data collected on 94 randomly selected wards in 21 public hospitals across two Australian states between 2004+2006. Methods. All nurses (n = 2488, 80À3% response rate) on the selected wards were asked to complete a survey that included the 49-item Nursing Work Index-Revised [NWI-R] together with measures of job satisfaction, satisfaction with nursing and intention to leave. Subscales of the NWI-R were calculated. Leadership, the domain of interest, consisted of 12 items. Wards were divided into those reporting either positive or negative leadership. Data were analysed at the nurse level using spss version 16.

Duffield, C.M., Roche, M.A., Blay, N., Thoms, D. & Stasa, H. 2011, 'The consequences of executive turnover', Journal of Research in Nursing, vol. 16, no. 6, pp. 503-514.
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The high rate of executive turnover in the healthcare industry is a major issue for health service organisations and their staff both in Australia and internationally. In the course of planning a research project examining nurse turnover at the clinical level within three Australian States/Territories, the researchers became aware of frequent executive turnover at all levels (State Department of Health, Area Health Service, hospital). Over a period of approximately 2 years there were 41 executives occupying 18 different positions, highlighting the scope of this issue in Australia. Few studies have examined the causes and consequences of this phenomenon in depth. Factors such as age, gender, education, lack of career advancement opportunities and remuneration have all been identified in the literature as important contributors to executive turnover. High turnover rates have been found to be associated with a number of negative consequences, including organisational instability, high financial costs, loss of human capital and adverse effects on staff morale and patient care.

McKenna, H., Daly, J., Davidson, P.M., Duffield, C.M. & Jackson, D.E. 2011, 'RAE and ERA-Spot the difference', International Journal of Nursing Studies, vol. 49, pp. 375-377.
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It is a given that university research underpins economic and social developments. In 2010, it was reported that -ú3.5 Billion of publicly funded research generates -ú45 Billion a year in job creation and new products (THE, 2010). However, the benefits are not limited to industrial innovation and products. In the United Kingdom (UK), the Arts and Humanities Research Council asserted that for every -ú1 spent on arts and humanities research each year, the UK reaps up to -ú10 in immediate benefit and another -ú15--ú20 in the long term (Owens, 2010). Similar metrics have been provided in Australia with similar returns on investment for research dollars spent. In Australia it has been estimated that there is a $5 AUD return for every $1 AUD invested in health and medical research (National Health & Medical Research Council, 2003).

Meyer, R.M., O'Brien-Pallas, L., Doran, D., Streiner, D., Ferguson-Pare, M. & Duffield, C.M. 2011, 'Front-line managers as boundary spanners: effects of span and time on nurse supervision satisfaction', Journal of Nursing Management, vol. 19, no. 5, pp. 611-622.
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Aim To examine the influence of nurse manager span (number of direct report staff), time in staff contact, transformational leadership practices and operational hours on nurse supervision satisfaction. Background Increasing role complexity has intensified the boundary spanning functions of managers. Because work demands and scope vary by management position, time in staff contact rather than span may better explain managersÔ++ capacity to support staff. Methods A descriptive, correlational design was used to collect cross-sectional survey and prospective work log and administrative data from a convenience sample of 558 nurses in 51 clinical areas and 31 front-line nurse managers from four acute care hospitals in 2007Ô++2008. Data were analysed using hierarchical linear modelling. Results Span, but not time in staff contact, interacted with leadership and operational hours to explain supervision satisfaction. Conclusions With compressed operational hours, supervision satisfaction was lower with highly transformational leadership in combination with wider spans. With extended operational hours, supervision satisfaction was higher with highly transformational leadership, and this effect was more pronounced under wider spans. Implications for Nursing Management Operational hours, which influence the managerÔ++s daily span (average number of direct report staff working per weekday), should be factored into the design of front-line management positions.

Moran, P.A., Duffield, C.M., Donoghue, J.M., Stasa, H. & Blay, N. 2011, 'Factors impacting on career progression for nurse executives', Advances in Contemporary Nursing, vol. 38, no. 1-2, pp. 45-55.
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This discursive paper examines recent research on career progression for nurse executives in Australia. In particular, it focuses on the personal, work-related and professional factors which influence progression. The role of gender, location and the provision of mentoring are also considered. It is suggested that family friendly policies (such as the option to job share or to perform an executive role on a part-time basis), the availability of a mentor, and the opportunity to pursue further education/training are vital in assisting nurses to progress in their executive careers.

Roche, M.A., Duffield, C.M. & White, E.G. 2011, 'Factors in the practice environment of nurses working in inpatient mental health: A partial least squares path modeling approach', International Journal of Nursing Studies, vol. 48, no. 12, pp. 1475-1486.
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Background: Developing a therapeutic relationship with consumers is considered as the central aspect of nursing work in mental health. The importance of this relationship stems from its association with enhanced patient care and improved patient outcomes. Factors within the practice environment may influence the nurse's ability to engage effectively in this relationship. Objective: This study explored a model that added characteristics of the individual and practice environment to a central framework incorporating therapeutic commitment: a nurse's ability and willingness to engage in a therapeutic relationship. Setting and participants: Data were collected at six mental health nursing units in five public general acute hospitals in New South Wales, Australia for 14 days per unit, between 2005 and 2006. All nurses in participating wards were invited to partake in the study. Seventy-six (51%) responses were analyzed. Method: The data were collected using a Nurse Survey inclusive of the Practice Environment Scale of the Nursing Work Index (NWI-PES), and the Mental Health Problems Perception Questionnaire (MHPPQ). A Unit Profile form was used concurrently to collect staffing, skill mix and patient turnover data. Partial least squares path modeling (PLS-PM) was chosen as the analytical method to test the model and identify the most influential factors. Results: Experienced nurses who perceived themselves to be competent and supported were more likely to express a willingness to engage therapeutically with patients. Environmental factors associated with these perceptions included foundations of quality nursing care, opportunities to participate in hospital affairs and clinical supervision. Not all elements in the proposed model were supported. Conclusion: Positive hospital practice environments can improve the capacity of nurses working in mental health to engage therapeutically with patients. Specific approaches may include access to preceptorship, continued education an career development opportunities, together with clinical supervision, improved continuity of care, and the involvement of mental health nurses in the governance of the hospital

Twigg, D.E., Duffield, C.M., Bremner, A., Rapley, P. & Finn, J. 2011, 'The Impact Of The Nursing Hours Per Patient Day (Nhppd) Staffing Method On Patient Outcomes: A Retrospective Analysis Of Patient And Staffing Data', International Journal of Nursing Studies, vol. 48, no. 5, pp. 540-548.
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Background: In March 2002 the Australian Industrial Relations Commission ordered the introduction of a new staffing method - nursing hours per patient day (NHPPD) - for implementation in Western Australia public hospitals. This method used a

Twigg, D.E., Duffield, C.M., Bremner, A., Rapley, P. & Finn, J. 2011, 'The characteristics of hospital nursing staff and patient outcomes: A response to Garland and Glenn (2011)', International Journal of Nursing Studies, vol. 48, no. 5, pp. 657-658.
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A reply to Garland and Glenn's (2011) critique of Twigg, D.,Duffield,C.,Thompson,P.L.,Rapley,P.,2010.Theimpactof nurses onpatientmorbidityandmortalityÔ++theneedforapolicy change inresponsetothenursingshortage.AustralianHealthReview 34, 312Ô++316.

Westbrook, J.I., Duffield, C.M., Li, L. & Creswick, N.J. 2011, 'How much time do nurses have for patients? a longitudinal study quantifying hospital nurses' patterns of task time distribution and interactions with health professionals', BMC Health Services Research, vol. 11, no. 319, pp. 1-12.
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Background: Time nurses spend with patients is associated with improved patient outcomes, reduced errors, and patient and nurse satisfaction. Few studies have measured how nurses distribute their time across tasks. We aimed to quantify how nurses distrib

Chang, A.M., Gardner, G., Duffield, C.M. & Ramis, M. 2010, 'A Delphi study to validate an Advanced Practice Nursing tool', Journal of Advanced Nursing, vol. 66, no. 10, pp. 2320-2330.
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Aim. This paper is a report of a study conducted to validate an instrument for measuring advanced practice nursing role delineation in an international contemporary health service context using the Delphi technique. Background. Although most countries now have clear definitions and competency standards for nurse practitioners, no such clarity exists for many advanced practice nurse roles, leaving healthcare providers uncertain whether their service needs can or should be met by an advanced practice nurse or a nurse practitioner. The validation of a tool depicting advanced practice nursing is essential for the appropriate deployment of advanced practice nurses. This paper is the second in a three-phase study to develop an operational framework for assigning advanced practice nursing roles. Method. An expert panel was established to review the activities in the Strong Model of Advanced Practice Role Delineation tool. Using the Delphi technique, data were collected via an on-line survey through a series of iterative rounds in 2008. Feedback and statistical summaries of responses were distributed to the panel until the 75% consensus cut-off was obtained. Results. After three rounds and modification of five activities, consensus was obtained for validation of the content of this tool. Conclusion. The Strong Model of Advanced Practice Role Delineation tool is valid for depicting the dimensions of practice of the advanced practice role in an international contemporary health service context thereby having the potential to optimize the utilization of the advanced practice nursing workforce.

Duffield, C.M., Roche, M.A., Blay, N. & Stasa, H. 2010, 'Nursing unit managers, staff retention and the work environmen', Journal Of Clinical Nursing, vol. 20, no. 1-2, pp. 23-33.
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This paper examined the impact of leadership characteristics of nursing unit managers, as perceived by staff nurses, on staff satisfaction and retention. Secondary analysis of data collected on 94 randomly selected wards in 21 public hospitals across two Australian states between 2004 and 2006.

Duffield, C.M., Roche, M.A., Diers, D., Catling-Paull, C. & Blay, N. 2010, 'Staffing, skill mix and the model of care', Journal Of Clinical Nursing, vol. 19, no. 15-16, pp. 2242-2251.
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The study explored whether nurse staffing, experience and skill mix influenced the model of nursing care in medical-surgical wards. Nurses (n=2278, 80.9% response rate) were surveyed using The Nursing Care Delivery System and the Nursing Work Index-Revised. Staffing and skill mix was obtained from the ward roster and other data from the patient record. Models of care were examined in relation to these practice environment and organisational variables.

Duffield, C.M., Conlon, L.S., Kelly, M.A., Catling-Paull, C. & Stasa, H. 2010, 'The Emergency Department Nursing Workforce: Local Solutions for Local Issues', International Emergency Nursing, vol. 18, no. 4, pp. 181-187.
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Demand for health services especially emergency services has increased substantially in recent years. As a consequence, Emergency Departments and hospitals have focused greater attention on the way they provide care using the workforce differently to meet efficiency targets. A strategy frequently implemented is either the initiation or restructuring of Emergency Nurse Practitioner roles. The future role of the emergency nurse is likely to be different from that of today, as health services adapt and evolve to meet demand. However, the authors caution against the notion of implementing new positions or restructuring existing positions without first analysing patient throughput, case-mix, staff competency levels, cross-professional boundaries and relevant local issues.

Gallagher, R.D., Fry, M. & Duffield, C.M. 2010, 'Nursing the future in Australia', Contemporary Nurse, vol. 36, no. 1-2.

Gardner, G., Gardner, A., Middleton, S., Gibb, M., Della, P.R. & Duffield, C.M. 2010, 'Development And Validation Of A Novel Approach To Work Sampling: A Study Of Nurse Practitioner Work Patterns', Australian Journal Of Advanced Nursing, vol. 27, no. 4, pp. 4-12.
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Objectives This methodological paper reports on the development and validation of a work sampling instrument and data collection processes to conduct a national study of nurse practitioners' work patterns. Design Published work sampling instruments provi

Graham, E.M. & Duffield, C.M. 2010, 'An Ageing Nursing Workforce', Australian Health Review, vol. 34, no. 1, pp. 44-48.
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There are well documented workforce shortages in nursing. Many strategies have been suggested to resolve the issue, including increasing migration or training places, changing skill mix or nursesÔ++ roles, redesigning nursing work, and greater use of unregulated or unlicensed workers. One of the contributing and growing factors is the ageing of the workforce, but methods of retaining older employees have been given very little attention. This paper examines the impact of ageing on individuals, the ageing nursing workforce and the implications for government policy given its current status.

Roche, M.A. & Duffield, C.M. 2010, 'A Comparison of the Nursing Practice Environment in Mental Health & Medical-Surgical Settings', Journal Of Nursing Scholarship, vol. 42, no. 2, pp. 195-206.
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Examined the differences between characteristics of the work environment of nurses working in mental health and general acute inpatient nursing settings. Analysis of data collected on randomly selected medical and surgical (general), and mental health wards in 24 public acute general hospitals across two Australian states between 2004 and 2006.

Roche, M.A., Diers, D., Duffield, C.M. & Catling-Paull, C. 2010, 'Violence toward nurses, the work environment, and patient outcomes', Journal Of Nursing Scholarship, vol. 42, no. 1, pp. 13-22.
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This study's purpose was to relate nurses' self-rated perceptions of violence (emotional abuse, threat or actual violence) on medical/surgical units to the nursing working environment and to patient outcomes. Cross sectional collection of data by surveys and primary data collection for one week periods on 94 nursing wards in 21 hospitals in two states of Australia.

Twigg, D.E., Duffield, C.M., Thompson, P.L. & Rapley, P. 2010, 'The impact of nurses on patient morbidity and mortality- the need for a policy change in response to the nursing shortage', Australian Health Review, vol. 34, no. 3, pp. 312-316.
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CONTEXT: Workforce projections indicate that by 2012 there will be a shortfall of 61,000 registered nurses in Australia. There is a growing body of evidence that links registered nurse staffing to better patient outcomes. PURPOSE: This article provides a comprehensive review of the research linking nurse staffing to patient outcomes at a time of growing shortages, highlighting that a policy response based on substituting registered nurses with lower skilled workers may have adverse effects on patient outcomes. METHOD: An electronic search of articles published in English using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Journals @ OVID and Medline was undertaken. FINDINGS: Robust evidence exists nationally and internationally that links nurse staffing to patient outcomes. Recent meta-analyses have found that there was a 3-12% reduction in adverse outcomes and a 16% reduction in the risk of mortality in surgical patients with higher registered nurse staffing. Evidence confirms that improvements in nurse staffing is a cost-effective investment for the health system but this is not fully appreciated by health policy advisors. CONCLUSIONS: An appropriate policy response demands that the evidence that patient safety is linked to nurse staffing be recognised. Policy makers must ensure there are sufficient registered nurses to guarantee patient safety.

Duffield, C.M., Gardner, G., Chang, A.M. & Catling-Paull, C. 2009, 'Advanced nursing practice: A global perspective', Collegian - Journal of Royal College of Nursing, Aust..., vol. 16, no. 2, pp. 55-62.
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To review the titles, roles and scope of practice of Advanced Practice Nurses internationally. Background: There is a worldwide shortage of nurses but there is also an increased demand for nurses with enhanced skills who can manage a more diverse, complex and acutely ill patient population than ever before. As a result, a variety of nurses in advanced practice positions has evolved around the world. The differences in nomenclature have led to confusion over the roles, scope of practice and professional boundaries of nurses in an international context. Method: CINAHL, MEDLINE, and the Cochrane database of Systematic Reviews were searched from 1987 to 2008. Information was also obtained through government health and professional organisation websites. All information in the literature regarding current and past status, and nomenclature of advanced practice nursing was considered relevant. Findings: There are many names for Advanced Practice Nurses, and although many of these roles are similar in their function, they can often have different titles. Conclusion: Advanced Practice Nurses are critical for the future, provide cost effective care and are highly regarded by patients/clients. They will be a constant and permanent feature of future health care provision. However, clarification regarding their classification and regulation is necessary in some countries.

Duffield, C.M. 2009, 'Bring back the veil', Journal Of Clinical Nursing, vol. 18, pp. 783-785.

Duffield, C.M., Diers, D., Aisbett, C. & Roche, M.A. 2009, 'Churn: Patient Turnover and Case Mix', Nursing Economic, vol. 27, no. 3, pp. 185-191.
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The article discusses a research study that examined the movement of patients on and off hospital wards in public hospitals in Australia. Case-mix changes on nursing wards were also examined. Researchers found that the absence of ward-level metrics compromises the ability of nursing unit managers to meet quality and efficiency standards. Researchers believe that measurements of turnover give nurses another way to talk to management about the work of nursing.

Duffield, C.M., Roche, M.A., O'Brien-Pallas, L., Catling-Paull, C. & King, M.T. 2009, 'Staff satisfaction and retention and the role of the Nursing Unit Manager', Collegian, vol. 16, no. 1, pp. 11-17.
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Despite recent increases in nursing recruitment in Australia, participation in the workforce is still below the numbers predicted to meet future needs. This paper discusses factors impacting on nurses' job satisfaction, satisfaction with nursing and intention to leave in public sector hospitals in New South Wales (NSW), Australia. Staffing and patient data were collected on 80 medical and surgical units during 2004/5. This included a wide range of individual nurse data from a Nurse Survey; detailed and comprehensive staffing data including skill mix variables; patient characteristics; workload data; a profile of the ward's characteristics; and adverse event patient data. Nurses who were intending to remain in their job were more likely to be satisfied, be older, and have dependents. They were also likely to be experiencing good leadership and to have allied health support on the ward. Most nurses reported being satisfied with their profession, while a lower proportion reported satisfaction with their current position. Work environment factors such as nurses' autonomy, control over their practice and nursing leadership on the ward were statistically significant predictors of job satisfaction. This study will inform decision-making and policy for managers in both the public and private hospital sectors. This is the first large study which explored the work environment at the ward/unit level in public hospitals in NSW (Australia). It illustrates that there are no typical wards; each ward functions differently. The importance of nursing leadership at the ward level to job satisfaction, satisfaction with nursing and intention to leave, cannot be overstated

Duffield, C.M., Roche, M.A., O'Brien-Pallas, L. & Catling-Paull, C. 2009, 'The Implications of Staff 'Churn' for Nurse Managers, Staff, and Patients', Nursing Economic, vol. 27, no. 2, pp. 103-110.
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The article discusses a study of 40 hospital wards that analyzed staff skills and patient outcomes. The author explores factors that influence staff turnover, the consequences and their effect on the quality of patient care, and the costs. The study found that the changes that occur during staff turnover have an impact on the continuity of patient care and present challenges to the nurse manager in areas such as scheduling, supervision, and leadership.

Hoffman, K.A., Aitken, L.M. & Duffield, C.M. 2009, 'A comparison of novice and expert nurses' cue collection during clinical decision-making: Verbal protocol analysis', International Journal of Nursing Studies, vol. 46, no. 10, pp. 1335-1344.
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The type of cues used during clinical decision-making contexts is not well understood. Further, there are conflicting findings in relation to how novice and expert nurses use cues. The aim of this study was to determine if there were differences between novice and expert nurses in the range and type of cues selected as well as how cues were clustered together when making clinical decisions while caring for post-operative patients in an Intensive Care Unit. Expert nurses collected a wider range of cues than novice nurses, almost twice as many different cues. The expert nurses also clustered more cues together to identify patient status when making decisions. Expert nurses were more proactive in collecting relevant cues and anticipating problems that may help identify patient problems. In the real world of practice expert nurses collect a broader range of cues to assess patient status than novice nurses. This differs to expert nurses cue collection in simulations where expert nurses may select only those cues that are necessary for the identified problem. This difference, if identified in other studies, may have important implications for nursing research and education.

Twigg, D.E. & Duffield, C.M. 2009, 'A review of workload measures: A context for a new staffing methodology in Western Australia', International Journal of Nursing Studies, vol. 46, no. 1, pp. 132-140.
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Objectives This paper critically reviews various approaches to measuring nursing workload to provide a context for the introduction of a different approach to staffing. Nurse hours per patient day (NHPPD), which classifies wards into various groupings, was applied to all public hospitals in Western Australia. Results This method was introduced in response to industrial imperatives to determine reasonable workloads for nurses. As a result, the limited evaluation has focused only on the impact on workload management; reporting target versus actual nurse hours, staff retention and nurse feedback. This method improved ward staffing significantly without imposing restrictive nurse-to-patient ratios and facilitates the use of professional discretion within ward groupings to enable diversion of resources to match reported acuity changes. Conclusion While successful in attracting nurses back into hospitals and increasing nursing numbers, there is no empirical evidence of the impact this method had on patient outcomes or whether the guiding principles used in the development of this method are appropriate. The model would also benefit from further refinement to be more sensitive to direct acuity measures.

Chaboyer, W., Wallis, M., Duffield, C.M., Courtney, M., Seaton, P., Holzhauser, K., Schluter, J. & Bost, N. 2008, 'A comparison of activities undertaken by enrolled and registered nurses on medical wards in Australia: An observational study', International Journal of Nursing Studies, vol. 45, no. 9, pp. 1274-1284.
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Background The past decade has seen increasing patient acuity and shortening lengths of stays in acute care hospitals, which has implications for how nursing staff organise and provide care to patients. Objective The aim of this study was to describe the activities undertaken by enrolled nurses (ENs) and registered nurses (RNs) on acute medical wards in two Australian hospitals. Design This study used structured observation, employing a work sampling technique, to identify the activities undertaken by nursing staff in four wards in two hospitals. Nursing staff were observed for two weeks. The data collection instrument identified 25 activities grouped into four categories, direct patient care, indirect care, unit related activities and personal activities. Setting Two hospitals in Queensland, Australia. Results A total of 114 nursing staff were observed undertaking 14,528 activities during 482 h of data collection. In total, 6870 (47.3%) indirect, 4826 (33.2%) direct, 1960 (13.5%) personal and 872 (6.0%) unit related activities were recorded. Within the direct patient care activities, the five most frequently observed activities (out of a total of 10 activities) for all classifications of nursing staff were quite similar (admission and assessment, hygiene and patient/family interaction, medication and IV administration and procedures), however the absolute proportion of Level 2 RN activities were much lower than the other two groups. In terms of indirect care, three of the four most commonly occurring activities (out of a total of eight activities) were similar among groups (patient rounds and team meetings, verbal report/handover and care planning and clinical pathways). The six unit related activities occurred rarely for all groups of nurses.

Duffield, C.M., Gardner, G. & Catling-Paull, C. 2008, 'Nursing work and the use of nursing time', Journal Of Clinical Nursing, vol. 17, no. 24, pp. 3269-3274.
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Aim: To find that changes in models of service delivery together with the dynamic nature of the contemporary health care context have changed the direction and focus of nurses' work. The aim of this paper is to explore some of the drivers for change and their impact and recommend a way forward to optimising nurses' work in the hospital environment. Background: The healthcare workplace has been transformed over the past 20 years in response to economic and service pressures. However, some of these reforms have had undesirable consequences for nurses' work in hospitals and the use of their time and skills. Results: As the pace and complexity of hospital care increases, nursing work is expanding at both ends of the complexity continuum. Nurses often undertake tasks which less qualified staff could do while at the other end of the continuum, are unable to use their high level skills and expertise. This inefficiency in the use of nursing time may also impact negatively on patient outcomes. Conclusions: Nurses' work that does not directly contribute to patient care, engage higher order cognitive skills or provide opportunity for role expansion may decrease retention of well-qualified and highly skilled nurses in the health workforce. Relevance to clinical practice: In this climate of nursing shortages, we need to use nurses in a cost-effective but also, intellectually satisfying manner, to achieve a sustainable nursing workforce.

Duffield, C.M. 2008, 'The Future Nursing Workforce: neonatal, paediatric and child health nurses', Neonatal, Paediatric and Child Health Nursing, vol. 11, no. 3, pp. 3-8.
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Modern technology and treatments are improving survival rates of children, but with the consequence of an increasing number of children growing up with chronic disease and disability. The increase in numbers will provide challenges for families caring for these children, the community, health services and the nursing workforce. This paper discusses some of the challenges facing the paediatric, neonatal and child health nursing workforce in meeting future demands. Issues such as increasing specialisation, direct entry and separate registration, disparity in nomenclature of positions, future role development and advanced nursing practice will be discussed.

Chiarella, E.M. & Duffield, C.M. 2007, 'Workforce Issues in Palliative and End-of-Life Care', Journal of Hospice and Palliative Nursing, vol. 9, no. 6, pp. 334-341.
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Policy development in palliative and end-of-life care has changed significantly since its origins as a "boutique" specialist area of hospice care in the 1960s and 1970s. International agencies have shifted the emphasis away from solely caring for cancer patients to a much broader definition of palliative care, which encompasses people with life-limiting illnesses who are not going to die immediately but still need to plan for death while undergoing life-prolonging treatment. This article explores the development of and demand for palliative and end-of life care in developed countries and the implications of this development for available workforce and future workforce planning. It argues that human resource planners in healthcare need to turn their attention to the growing demands of caring for the dying and the elderly and work closely with service planners to ensure that sufficient and qualified staff are available.

Duffield, C.M., Kearin, M., Johnston, J.L. & Leonard, J.M. 2007, 'The impact of hospital structure and restructuring on the nursing workforce', Australian Journal of Advanced Nursing, vol. 24, no. 4, pp. 42-46.
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OBJECTIVE: Health systems throughout much of the world have been subject to 'reform' in recent years as countries have attempted to contain the rapidly rising costs of health care. Changes to hospital structures (restructuring) have been an important part of these reforms. A significant impact of current approaches to restructuring is the loss of, or changes to, nursing management roles and functions. SETTING: Australian hospitals PRIMARY ARGUMENT: Little evaluation has been undertaken to determine the impact of hospital structure and organisational restructuring on the nursing workforce. CONCLUSIONS: There is some indication that nurses have experienced a loss of key management positions, which may impact on their capacity to ensure that adequate and safe care is provided at the ward level

Gardner, G., Chang, A. & Duffield, C.M. 2007, 'Making nursing work: breaking through the role confusion of advanced practice nursing', Journal of Advanced Nursing, vol. 57, no. 4, pp. 382-391.
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Roche, M.A. & Duffield, C.M. 2007, 'Issues and Challenges in the mental health workforce development', Contemporary Nurse, vol. 25, no. 1/2, pp. 94-103.
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As in many other developed countries, the proportion of the population in Australia that will experience a mental health disorder is increasing. To respond adequately and appropriately to what some might say is an epidemic will require not only an available workforce but also one which is highly skilled. Unfortunately the current protracted shortage of nurses generally, and which is projected to worsen over the next few years, will also have a significant impact on the provision of care for a large and vulnerable portion of the population, those who experience mental illness. This article will provide an overview of the issues and challenges confronting the development of a sustainable mental health nursing workforce.

Duffield, C.M., Roche, M.A. & Merrick, E.T. 2006, 'Methods of measuring nursing workload in Australia', Collegian, vol. 13, no. 1, pp. 16-22.
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Duffield, C.M., O'Brien-Pallas, L., Aitken, L.M., Roche, M.A. & Merrick, E.T. 2006, 'Recruitment of nurses working outside nursing', The Journal of Nursing Administration (JONA), vol. 36, no. 2, pp. 58-62.

Hayes, L.J., O'Brien-Pallas, L., Duffield, C.M., Shamian, J., Buchan, J., Hughes, F.A., Spence Laschinger, H.K., North, N. & Stone, P. 2006, 'Nurse turnover: A literature review', International Journal of Nursing Studies, vol. 43, no. 2, pp. 237-263.
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Ongoing instability in the nursing workforce is raising questions globally about the issue of nurse turnover. A comprehensive literature review was undertaken to examine the current state of knowledge about the scope of the nurse turnover problem, defini

O'Brien-Pallas, L., Duffield, C.M. & Hayes, L.J. 2006, 'Do we really understand how to retain nurses?', Journal of Nursing Management, vol. 14, no. 4, pp. 262-270.
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To compare views of nurse executives with those of nurses who have left the profession on the importance of retention strategies. Although much has been written about nursing turnover, there continues to be dissonance among decision makers as to why nurses leave the profession and what the most crucial issues are for retention. Factor analysis was undertaken to compare responses of nurse executives with those of nurses employed outside of nursing. Contract requirements represented the greatest discrepancy, 1.07, followed by legal and employer issues, 1.02; worklife/homelife balance, 0.91; external values and beliefs about nursing, 0.75; and professional practice, 0.29. A disparity exists between perceptions of nurse executives and those of nurses who have left the profession as to which issues are most critical in retention. We suggest that nurse executives ensure sufficient organizational support for nursing unit managers who are more likely to understand methods of retaining nurses at the clinical interface

O'Brien-Pallas, L., Griffin, P., Shamian, J., Buchan, J., Duffield, C.M., Hughes, F.A., Spence Laschinger, H.K., North, N. & Stone, P. 2006, 'The impact of nurse turnover on patient, nurse, and system outcomes: A pilot study and focus for a multicenter international study', Policy, Politics and Nursing, vol. 7, no. 3, pp. 169-179.
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Duffield, C.M. 2005, 'A master class for nursing unit managers: an Australian example', Journal of Nursing Management, vol. 13, no. 1, pp. 68-73.
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Duffield, C.M., O'Brien-Pallas, L. & Aitken, L.M. 2005, 'Are skills learned in nursing transferable to other careers?', Nursing Leadership (Canadian Journal of Nursing Leadership), vol. 18, no. 3, pp. 68-82.
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Objective: To determine the influence of skills gained in nursing on the transition to a non-nursing career. Background: Little is known about the impact that nursing skills have on the transition to new careers or about the transferability of nursing skills to professions outside nursing. Method: A postal questionnaire was mailed to respondents who had left nursing. The questionnaire included demographic, nursing education and practice information, reasons for entering and leaving nursing, perceptions of the skills gained in nursing and the ease of adjustment to a new career. Data analysis included exploratory and confirmatory factor analysis, Pearson product moment correlations and linear and multiple regression analysis. Results: Skills learned as a nurse that were valuable in acquiring a career outside nursing formed two factors, including "management of self and others" and "knowledge and skills learned," explaining 32% of the variation. The highest educational achievement while working as a nurse, choosing nursing as a "default choice," leaving nursing because of "worklife/homelife balance" and the skills of "management of self and others" and "knowledge and skills" had a significant relationship with difficulty adjusting to a non-nursing work role and, overall, explained 28% of the variation in this difficulty adjusting. Conclusion: General knowledge and skills learned in nursing prove beneficial in adjusting to roles outside nursing.

Duffield, C.M., Forbes, J.L., Fallon, A., Roche, M.A., Wise, W. & Merrick, E.T. 2005, 'Nursing skill mix and nursing time: the roles of registered nurses and clinical nurse specialists', Australian Journal of Advanced Nursing, vol. 23, no. 2, pp. 14-21.
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OBJECTIVE: The roles of clinical nurse specialists (CNS) and registered nurses, while similar, should also be quite different, with the CNS functioning as an advanced practice nurse. Differences in roles can be partially explained and understood by examining the use of their time. Adjustments to skill mix usually involve using more plentiful but less-skilled workers, and there is a growing body of overseas research in this field. In contrast, little research has examined and compared the use of nursing time for the RN and CNS role, particularly in an Australian context. Comparing work activities enables employers to begin to answer the question: Are skilled nursing personnel being used effectively and efficiently? DESIGN: A work-sampling study conducted over eight weeks. Data were analysed descriptively using SPSS, v.9. SETTING: Six wards in a large private not-for-profit hospital. MAIN OUTCOME MEASURE: To determine whether there is a differentiation in the roles of CNS and RN by examining the percentage of time spent in 25 specific activities. RESULTS: In some activities it is not possible to distinguish differences in the amount of time spent by RNs and CNSs. In other activities such as clerical, meetings and administration, CNSs are spending more time than anticipated. Consideration needs to be given to employing clerical staff to relieve the CNS of these non-clinical aspects. CONCLUSION: The study extends the understanding of the roles of registered nurses and clinical nurse specialists and provides a basis on which to begin to understand similarities and differences in their roles.

Duncan, J.A., Johnston, J.L. & Duffield, C.M. 2005, 'Nurse managers: An enhanced role in workforce shortages', Asian Journal of Nursing Studies, vol. 8, no. 3, pp. 25-30.

Forrester, K., Duffield, C.M., Roche, M.A. & Merrick, E.T. 2005, 'Clinical handover: Can we afford the time?', Journal of Law and Medicine, vol. 13, no. 2, pp. 176-179.

Pelletier, D.S., Duffield, C.M. & Donoghue, J.M. 2005, 'Documentation and transfer of clinical information in two aged care settings', Australian Journal of Advanced Nursing, vol. 22, no. 4, pp. 40-45.
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Increasingly, documentation, both formal and informal, is being undertaken by nurses using a range of modalities. In Australia there is a sense that the demand for this in the aged care sector is increasing in line with requirements of funding agencies. However, the scope of this activity and its impact on nursing workload in aged care facilities has not been rigorously investigated. Funding of aged care facilities in the public hospital system in Australia is dependent on documentation of care.

Pelletier, D.S., Donoghue, J.M. & Duffield, C.M. 2005, 'Understanding the nursing workforce: A longitudinal study of Australian nurses six years after graduate study concludes with a snapshot', Australian Journal of Advanced Nursing, vol. 23, no. 1, pp. 37-43.
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The challenge posed by the worldwide nursing shortage is significant not only for workforce and facility planners, but also for those who educate nurses for practice and nurses themselves. The provision of skilled and competent advanced nurses is clearly a goal of postgraduate education. An increasing shortage of skilled and qualified nursing staff to provide the required level of care is evident in Australia.

Algase, D.L., Beattie, E.R., Song, J., Milke, D.L., Duffield, C.M. & Cowan, B. 2004, 'Validation of the Algase Wandering Scale (Version 2) in a cross cultural sample', Ageing and Mental Health, vol. 8, no. 2, pp. 133-142.
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Duffield, C.M., O'Brien-Pallas, L. & Aitken, L.M. 2004, 'Nurses who work outside nursing', Journal of Advanced Nursing, vol. 47, no. 6, pp. 664-671.
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Duffield, C.M., Aitken, L.M., O'Brien-Pallas, L. & Wise, W. 2004, 'Nursing: a stepping stone to future careers.', Journal of Nursing Administration (JONA), vol. 34, no. 5, pp. 238-245.
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Hoffman, K.A., Duffield, C.M. & Donoghue, J.M. 2004, 'Barriers to clinical decision-making in nurses in Australia', Australian Journal of Advanced Nursing (AJAN), vol. 21, no. 3, pp. 8-13.
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Hoffman, K.A., Donoghue, J.M. & Duffield, C.M. 2004, 'Decision-making in clinical nursing: investigating contributing factors.', Journal of Advanced Nursing, vol. 45, no. 1, pp. 53-62.
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O'Brien-Pallas, L., Duffield, C.M. & Alksnis, C. 2004, 'Who will be there to nurse? Retention of nurses nearing retirement', Journal Of Nursing Administration, vol. 34, no. 6, pp. 298-302.
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Aims: To determine the impact on nursing work-force supply of delaying retirement. Background Data: The nursing workforce is aging, and the Baby Boomer generation is nearing retirement age. This potential loss of experienced nurses is likely to exacerbate current nursing shortages. Methods: An analysis of loss rates of nurses in New South Wales (Australia) is provided using 2 different retirement ages-58 and 65 years. Supply numbers were used and then aged to determine the impact of retirement on workforce numbers. The impact of potential retention strategies on the numbers who could be retained were determined if 100% of 50- to 55-year-old nurses was retained, 75% of those 56 to 60 years, and 50% of those 61 to 65 years.

Creegan, R., Duffield, C.M. & Forrester, K. 2003, 'Casualisation of the nursing workforce in Australia: driving forces and implications', Australian Health Review, vol. 26, no. 1, pp. 201-208.
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Duffield, C.M. & Wise, W. 2003, 'Tell me what we do. Using work sampling to find the answer.', Australian Journal of Advanced Nursing, vol. 20, no. 3, pp. 19-23.
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Duffield, C.M. & O'Brien-Pallas, L. 2003, 'The causes and consequences of nursing shortages: a helicopter view.', Australian Health Review, vol. 26, no. 1, pp. 186-193.
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Pelletier, D.S., Donoghue, J.M. & Duffield, C.M. 2003, 'Australian nurses' perception of the impact of their postgraduate studies on their patient care activities', Nurse Education Today, vol. 23, no. 6, pp. 434-442.
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Pelletier, D.S. & Duffield, C.M. 2003, 'Work sampling: Valuable methodology to define nursing practice patterns.', Nursing and Health Sciences, vol. 5, pp. 31-38.
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Song, J., Algase, D.L., Beattie, E.R., Milke, D.L., Duffield, C.M. & Cowan, B. 2003, 'Comparison of U.S., Canadian, and Australian participants' performance on the Algase Wandering Scale - Version 2 (AWS-V2).', Research and Theory for Nursing Practice: An International Journal, vol. 17, no. 3, pp. 241-256.
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Stone, P., Tourangeau, A., Duffield, C.M., Hughes, F.A., Jones, C.B., O'Brien-Pallas, L. & Shamian, J. 2003, 'Evidence of nurse working conditions: A global perspective.', Policy, Politics and Nursing Practice, vol. 4, no. 2, pp. 120-130.
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Donoghue, J.M., Pelletier, D.S., Adams, A.F. & Duffield, C.M. 2002, 'Recognition of prior learning as University entry criteria is successful in postgraduate nursing studies', Innovations and Eduation and Teaching International, vol. 39, no. 1, pp. 54-62.
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Duffield, C.M. & Franks, H. 2002, 'Career paths beyond nursing and the contribution of nursing experience and skills in attaining these positions.', International journal of nursing practice, vol. 39, no. N/A, pp. 601-609.
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Duffield, C.M. & Franks, H. 2002, 'Qualifications and experience: how well prepared are nurse managers compared to health service executives?', Australian Health Review, vol. 25, no. 2, pp. 182-190.
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Duffield, C.M. & O'Brien-Pallas, L. 2002, 'The nursing workforce in Canada and Australia: two sides of the same coin.', Australian Health Review, vol. 25, no. 2, pp. 136-190.
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Johnston, J.L. & Duffield, C.M. 2002, 'Strategic public governance in Australian health: the unsmart, incapacitated state?', Administrative Theory and Praxis, vol. 24, no. 1, pp. 125-144.
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Moran, P.A., Duffield, C.M., Beutel, J., Bunt, S., Thornton, A., Wills, J., Cahill, P. & Franks, H. 2002, 'Nurse Managers in Australia: Mentoring, Leadership and Career Progression', Canadian Journal of Nursing Leadership, vol. 15, no. 2, pp. 14-20.
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Duffield, C.M., Moran, P.A., Beutel, J., Bunt, S., Thornton, A., Wills, J., Cahill, P. & Franks, H. 2001, 'Profile of first-line managers in NSW, Australia in the 1990's', Journal of Advanced Nursing, vol. 36, pp. 785-793.
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Duffield, C.M. & Franks, H. 2001, 'The role and preparation of first-line nurse managers in Australia. Where are we going and how do we get there?', Journal of Nursing Management, vol. 9, pp. 87-91.
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Duffield, C.M., Wood, L.M., Franks, H. & Brisley, P. 2001, 'The role of nursing unit managers in eduation nurses', Contemporary Nurse, vol. 10, no. 3 & 4, pp. 244-250.
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Duffield, C.M. & Franks, H. 2000, 'The role and preparation of first-line nurse managers in Australia: where are we going and how do we get there?', Journal of Nursing Management, vol. 9, no. 0, pp. 87-91.

Pelletier, D.S., Donoghue, J.M., Duffield, C.M., Adams, A.F. & Brown, D.M. 1998, 'Why Undertake Higher Degrees In Nursing?', Journal Of Nursing Education, vol. 37, no. 9, pp. 422-424.
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NA

Crisp, J.M., Pelletier, D.S., Duffield, C.M., Adams, A.F. & Nagy, S.A. 1997, 'The Delphi Method?', Nursing Research, vol. 46, no. 2, pp. 116-118.
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NA

Duffield, C.M., Donoghue, J.M. & Pelletier, D.S. 1996, 'Do Clinical Nurse Specialists And Nursing Unit Managers Believe That The Provision Of Quality Care Is Important?', Journal Of Advanced Nursing, vol. 24, no. 2, pp. 334-340.
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The nursing profession has a long tradition of evaluating the quality of its product in order to ensure that the best possible care can be given. However, in the climate of economic rationalism which prevails worldwide, it is possible that the emphasis o

Pelletier, D.S., Duffield, C.M., Adams, A.F., Crisp, J.M., Nagy, S.A. & Murphy, J.E. 1996, 'The Impact Of The Technological Care Environment On The Nursing Role', International Journal Of Technology Assessment In Health Care, vol. 12, no. 2, pp. 358-366.
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Proliferation of acute health care technology creates problems and benefits for nurses and patients. In this paper the impact of technology on the nursing work role is reviewed through the international literature. The thrust of the nursing literature ha

Duffield, C.M., Baker, K. & Edwards, K. 1995, 'Nurse Managers And Their Future In New-south-wales', Journal Of Nursing Administration, vol. 25, no. 10, p. 9.
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The goal of International Perspectives is to share the views of nurse leaders, from countries other than the United states, on global healthcare issues. The focus is on identifying healthcare management problems and their implications, research prioritie

Duffield, C.M., Pelletier, D.S. & Donoghue, J.M. 1994, 'Role Overlap Between Clinical Nurse Specialists And Nursing Unit Managers', Journal Of Nursing Administration, vol. 24, no. 10, pp. 54-63.
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Role ambiguity is a serious and costly phenomenon that the healthcare delivery system can ill afford. Classically, it results from a lack of clarity or information concerning the expectations of a role, and it often results in several staff members unde

Pelletier, D.S., Duffield, C.M., Gallagher, R.D., Soars, L., Donoghue, J.M. & Adams, A.F. 1994, 'The Effects Of Graduate Nurse Education On Clinical-practice And Career Paths - A Pilot-study', Nurse Education Today, vol. 14, no. 4, pp. 314-321.
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The recent proliferation of graduate courses in nursing has increased the need for educational administrators to evaluate the impact of such programmes on clinical practice and the career of participants. 40 registered nurses undertaking graduate studies

Duffield, C.M. 1993, 'The Delphi Technique - A Comparison Of Results Obtained Using 2 Expert Panels', International Journal Of Nursing Studies, vol. 30, no. 3, pp. 227-237.
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The Delphi technique is a useful method of obtaining group consensus. However, 'consensus'' is not usually defined when this technique is used. This paper describes a study in which two panels of experts (registered nurses who were nurse managers or invo

Duffield, C.M. 1991, 'Maintaining Competence For 1st-line Nurse Managers - An Evaluation Of The Use Of The Literature', Journal Of Advanced Nursing, vol. 16, no. 1, pp. 55-62.
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NA

Donoghue, J.M., Duffield, C.M., Pelletier, D.S. & Adams, A.F. 1990, 'Health Promotion As A Nursing Function - Perceptions Held By University-students Of Nursing', International Journal Of Nursing Studies, vol. 27, no. 1, pp. 51-60.
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NA

Duffield, C.M. 1989, 'The Competencies Expected Of First-line Nursing Managers - An Australian Context', Journal Of Advanced Nursing, vol. 14, no. 12, pp. 997-1001.
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NA

Duffield, C.M. 1988, 'Nursing In The 1980s And 1990s - A Challenge For Managers', International Journal Of Nursing Studies, vol. 25, no. 2, pp. 125-134.
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NA

Duffield, C.M. 1986, 'Nursing In Australia Comes Of Age', International Journal Of Nursing Studies, vol. 23, no. 4, pp. 281-284.
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NA

Duffield, C.M. 2012, 'Nursing and midwifery workforce- skill mix and ratios', 2012 Professional Issues in Practice Conference: The Future is Now, Melbourne Convention and Exhibition Centre, September 2012.
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Australian Nurses Federation (Victoria Branch)

Duffield, C.M. 2012, 'Our Nursing and Midwifery Workforce: Key issues for managers', Have Your Say-We are listening, Terrigal, September 2012.
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New South Wales Nurses Association

Roche, M.A. & Duffield, C.M. 2011, 'Environmental Influences on the Therapeutic Relationships of Nurses Working in Mental Health', Sigma Theta Tau International 22nd International Nursing Research Congress, Cancun, Mexico, July 2011.
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The therapeutic relationship is considered the central focus of nursing work in mental health and has been linked to patients? involvement in care and patient outcomes (Horvath, 2005). Therefore, factors that may improve or impeded the nurse?s ability to engage effectively in this relationship have the potential to have a corresponding influence on the patient and their outcomes. Studies in mental health and other nursing domains have identified a range of environmental factors that have an influence on nurses (Aiken, et al., 2008; Hanrahan et al., 2008, 2010). This study investigated the impact of characteristics of the work environment on the willingness and ability of nurses to engage in therapeutic relationships.

Duffield, C.M. 2010, 'If you get too far in front....(Keynote address)', Australian College of Critical Care Nurses Annual Conference, Sydney, May 2010.

Roche, M.A., Diers, D. & Duffield, C.M. 2010, 'Nursing resources, workload, the work environment and patient outcomes', National Database of Nursing Quality Indicators 4th Annual Data Use Conference, New Orleans, United States, January 2010.

Duffield, C.M. 2009, 'Challenges and threats of nurse specialisation: The effects on our nursing identity (Keynote address)', Australian Nursing Federation (Victorian Branch) Professional Day: Am I Responsible? Responsibility, accountability and expectations placed on nurses, Melbourne, Australia, May 2009.

Duffield, C.M. 2009, 'Is anybody listening? Patient safety and the nursing and midwifery workforce (Keynote address)', Women's and Children's Hospitals Australasia Annual Conference: The times they are a-changin': Engaging in health care reform, Brisbane, Australia, November 2009.

Duffield, C.M. 2009, 'Leadership, decision-making and safe staffing (Keynote address)', Flinders Nurses' Education & Research Fund, Adelaide, January 2009.

Duffield, C.M. 2009, 'Nurse staffing and patient safety', Total nursing care and skillmix conference (Keynote address), Taichung City, Taiwan, January 2009.

Duffield, C.M. 2009, 'Nursing workforce: New roles for new times (Keynote address)', The International Council of Nurses 24th Quadrennial Conference, Durban, South Africa, June 2009.

Roche, M.A. & Duffield, C.M. 2009, 'Aggression Towards Nurses', International Council of Nurses 24th Quadrennial Congress 2009, Durban, South Africa, June 2009.

Duffield, C.M. 2008, 'Are we changing with the times?', Royal College of Nursing Australia Annual Conference, Perth, Australia, September 2008.

Duffield, C.M. 2008, 'Challenges for the nursing workforce: Staffing for patient safety. Globalization and social determinants of health: Implications for human resource development and health systems', Ribeirao Preto SP, Brazil, July 2008.

Duffield, C.M. 2008, 'Leadership is about action', Deakin University Leadership Conference, Melbourne, October 2008.

Duffield, C.M. 2008, 'Nurses: We are in a new place. Safety and quality is everyone's business', National Forum on Safety and Quality in Health Care, Adelaide, October 2008.

Duffield, C.M. 2008, 'Panel discussion: Getting recognition and policy action from research', Coalition of National Nursing Organisations National Nursing Research Symposium, Melbourne, Australia, August 2008.

Duffield, C.M. 2008, 'Utilising the nursing workforce appropriately', Australian Nursing Federation Annual Delegates Conference, Adelaide, August 2008.

Duffield, C.M. 2008, 'We are all children... (Keynote address)', 10th International Paediatric and Child Health Nursing Conference, Darwin, Australia, April 2008.

Roche, M.A. & Duffield, C.M. 2005, 'Methods of measuring nursing workload in Australia', International Council of Nurses 23rd Quadrennial Congress, Taipei, May 2005.

Duffield, C.M., Roche, M.A., O'Brien-Pallas, L., Diers, D., Aisbett, C., Aisbett, K. & Homer, C.S. 2009, 'Nursing workload and staffing: Impact on patients and staff', University of Technology, Sydney, pp. 1-161.

Duffield, C.M., Roche, M.A., O'Brien-Pallas, L., Diers, D., Aisbett, C., King, M.T., Aisbett, K. & Hall, J.P. 2007, 'Glueing it together: nurses, their work environment and patient safety.', Centre for Health Services Management, UTS, Sydney, pp. 1-243.

Duffield, C.M., O'Brien-Pallas, L., Tomblin-Murphy, G., Birch, S., Meyer, R. 2005, 'Nursing Workforce Planning: Mapping the Policy Trail', The Global Nursing Review Initiative, ICN - International Council of Nurses, Geneva, Switzerland, pp. 1-44.
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Planning for the efficient and effective delivery of health care services to meet the health needs of the populations is a significant challenge. Globally policy makers, educators, health service researchers, leaders of unions and professional associations, and other key stakeholders struggle with the best way to plan for a workforce to fulfill the health needs of populations. To meet this challenge, achieving the appropriate balance between human and non-human resources is important and requires continuous monitoring, careful attention to the country specific context in which policy decisions are made, and evidence-based decision-making. This paper provides an overview of current evidence and policy initiatives pertinent to the nursing workforce including: health human resource (HHR) planning, service planning and modelling; nursing workforce imbalances and internal migration; and approaches to nursing deployment and utilisation. Policy implications and recommendations are offered.