Duties performed by team leader
108That brings me to the other issue of whether Mr Pink's concession, that the clinical management role was undertaken by team leaders when he commenced in HACU in 2005, was soundly based. If it was, the change to the role in 2012 would not invalidate the concession for the period from 2012 onwards.
109 According to the evidence of Ms White, since about 2002, HACU has been co-located with MODU and the Stem Cell Transplant/Apheresis Team. Ms White stated that when co-location occurred in 2002 the previous arrangement, whereby HACU and MODU were each managed by a NUM1, was changed so that a single NUM2 was in charge of all three units. In 2005, the NUM2 position was upgraded to a NUM3 position. To the best of Ms White's recollection, the team leader positions in HACU have been in existence since about 2002, which would seem to coincide with the change from a NUM1 being in charge of each unit to a NUM2 taking over the management of the three units. This suggests that with a NUM2 taking over the three units, whereas previously each unit was managed by a NUM1, there was a need to insert an RN between the NUM and the nursing staff to perform the role of a team leader.
110Both Ms White and Ms Pink stated that the team leader duty list produced and published by Gabrielle Prest in July 2011 was generally an accurate description of the team leader duties in HACU over the period that they performed the role. Ms Prest had engaged in a "job swap" with Mr Pink for a period of months and it was during this time the list was prepared. Ms Prest was either a NUM2 or NUM3, but she had clinical experience in haematology and oncology. The list was circulated to nursing staff and placed on the "computer" as a desktop item from which it later, inexplicably, disappeared.
111The respondent submitted the Prest duty list and other lists produced by individuals over the years relating to Ground East were not formal job descriptions, but may have been used as informal guides to assist individuals undertaking the role. It was further submitted these documents had not been approved or endorsed by the Nursing Executive.
112That does not make the Prest duty list irrelevant. The evidence is that the duty list was generally an accurate description of the team leader duties in HACU. That being so, it is a question of whether the duties described in the list constitute a clinical management role.
113The main duties identified by the two team leaders from the Prest list were, in shorthand form, the following:
(1)Allocation and management of daily nurse to patient workload according to staffing levels and staff skill mix.
(2)Organising the meal breaks and the number of nursing staff on the floor during tea and lunch breaks to ensure adequate patient care.
(3)Allocation of all patients to chairs or beds.
(4)Ordering all blood tests online in accordance with doctors' instructions/standing orders.
(5)Checking the blood results of all haematology patients then conferring with the Resident Medical Officer (RMO) to prioritise patients for review.
(6)Co-ordinating doctors' reviews of patient test results, ensuring that treatment orders are written up, and then ensuring that appropriate prescriptions are written and obtained.
(7)Communicating with various medical teams, including immunology, neurology and sometimes renal and rheumatology, to update prescription orders or new treatment requirements, or patient reviews for patients who are unwell.
(8)Organising the admission of HACU patients presenting unwell after review by the RMO. This requires liaison with the Bed Manager, and Admissions and may require contacting the ward directly and organising transfers.
(9)Answering phone enquiries from patients, doctors, including staff doctors and general practitioners, other nursing staff, patients' relatives, allied health professionals, such as dieticians and physiotherapists, associated organisations such as Leukaemia Foundation, Red Cross Blood Bank.
(10)Managing all patient appointments to ensure an appropriate clinical workload for HACU.
114The general response of the respondent's witnesses (Mr Pink, Ms Antonio and Ms Hogan) to the duty list was that the NUM performs most of the duties and it was only "sometimes" team leaders carried out these tasks and/or much of what was described in the list was what was expected of all RNs, not just a team leader. This sits somewhat oddly with the fact that Ms Pink and Ms White do not have a patient load and are engaged full time during their shifts as team leader, directing and coordinating the other nursing staff.
115Mr Pink stated, "I do not consider that this list is reflective of what they are meant to do as Team Leaders." However, Mr Pink was aware of the existence of the list and took no steps to remove it or advise nursing staff it was not accurate.
116The witness' general response was not very helpful. Nevertheless, the response seemingly amounts to an acceptance that the team leader carried out the duties on the list. For instance, Ms Antonio agreed, as a general proposition, that the team leader's role would encompass all of the duties which are set out in the Prest list. The question is whether, in performing those duties, it amounts to the team leaders undertaking a "day to day clinical management role for the shift". I propose to consider each of the duties on the list.
117The first duty was the allocation of staff to patients. The team leaders performed this function until 2012 when Mr Pink was given an instruction by Ms Hogan that he was to undertake the task. As the instruction was given after the applicant lodged its claim for underpayment based on a list of duties that included the allocation of staff to patients, the inference is available that the task was removed from team leaders because it tended to indicate a clinical management role.
118According to the evidence of Ms Pink, the allocation of nursing staff to patients involves an analysis of scheduled patient treatments, individual patient needs and the skills of nursing staff rostered on duty. Ms Pink gave the following example:
For example the following clinical scenarios need to be managed by the Team Leader:
a. some patients have indwelling vascular access devices and only accredited nursing staff can access and perform dressings on these patients.
b. Some patients will be receiving chemotherapy which not all staff are trained and accredited to administer.
c. Some types of chemotherapy require the nurse to sit with the patient for approximately 45 minutes as the intravenous treatment is administered by gravity drip, not infusion pump as with many treatments, to monitor for signs of extravasation ie the leakage of the drug outside the vein.
119Until 2012, the team leader undertook the required analysis of skill mix of staff and the scheduled patient treatments and needs and the allocations were written on the white board at the end of each shift in preparation for the following day.
120It seems to me this duty intrinsically involved a clinical management role for the shift. The team leader, based on her knowledge of nursing staff accreditation and patient needs, makes the necessary allocations. The team leader is unquestionably involved in directing and coordinating nursing staff in the care and treatment of patients.
121Whilst team leaders ceased performing this duty in 2012, Ms White and Ms Pink gave evidence that the team leader frequently has to "re-do patient allocations during the shift when changes occur to treatments and staffing allocations". These would include reallocation to accommodate unscheduled patient arrivals or patients requiring admission. Another example mentioned was where patients had adverse reactions needing one-on-one care. Other patients of the nurse who is required to provide one-on-one care would then need to be reallocated. Mr Pink accepted in his oral evidence that team leaders will adjust staff allocations during the day from time to time to accommodate changes to workload. That would seem to me to involve the function of directing and coordinating patient care and treatment.
122The second duty was organising meal breaks. I do not think Ms Pink and Ms White put the role of the team leader any higher than the team leader monitors meal breaks to ensure all nurses get a break and that an adequate skill mix is maintained. Mr Pink's evidence was that nurses manage the times when they take meal breaks and there was no need for the team leader to be involved. However, he did concede if the team leader had any concern with nursing coverage the team leader could intervene.
123It was Ms Hogan's evidence that the organisation of meal breaks could be done between the nursing staff and did not necessarily need to be arranged by the NUM. Ms Hogan said
It is entirely appropriate that nursing staff organise their own breaks. The NUM would ensure that the skill mix during breaks was appropriate and that any concerns regarding break allocation were escalated to him to resolve.
124Like many aspects of the role of team leader, Ms Hogan relied on what she was told by Mr Pink. However, Ms Hogan eventually accepted in her oral evidence that the team leader had a role in organising meal breaks, but the NUM was also involved:
Q. As a general proposition, that role of ensuring breaks are properly covered is undertaken by the team leader?
A. Well, my understanding that they they do ensure that people are aware of when when to take their breaks, but that the NUM is also involved in that as well.
Q. Well, could I suggest to you that the only time that the NUM becomes involved is if, because of particular clinical events on the unit, there are insufficient staff
A. Right, okay.
Q. and there needs to be additional staff called in?
A. Okay.
Q. And leaving aside that contingency, it would be left to the team leader to oversee the taking of breaks?
A. Look, they could do that, but I do expect that the NUM is involved in organising the breaks. Particularly in ground east, where there is three different lots of staff four different lots of staff, and it does need to be coordinated.
125It seems inevitable that if a problem arises about coverage during meal breaks a person designated as team leader who has a responsibility, for example, to adjust staff allocations during the day from time to time to accommodate changes to workload - a matter conceded by Mr Pink - the team leader would deal with meal break issues. I accept the evidence of Ms Pink and Ms White in this respect.
126The third duty on the Prest list was the allocation of all patients to chairs or beds depending on patient needs and treatments. Ms Pink gave the following examples of clinical scenarios need to be managed by the team leader:
a. Patients who present unwell or post stem-cell transplant recipients who are expected to arrive unwell and often need urgent treatment and admission will need a bed, as do patients needing Hickman's catheters and portacaths accessed; and
b. Patients with potentially transmissible infections, have to be isolated from patients with lowered immune status, eg leukaemia or post chemotherapy patients.
127Ms White stated that the allocation of patients to beds or chairs involved the following:
i. allocation of patients in accordance with their needs, which requires knowledge of their condition, clinical treatment and length of treatment, and their mobility;
ii. ensuring that patients with infective pathogens or contagions, eg shingles, Vancomycin Resistant Enterococcus (VRE), are isolated from other patients;
iii. adjusting throughout the day to accommodate such things as delayed or extended treatments, unscheduled arrivals or treatments running over time; and
iv. liaising with the MODU Team Leader to access extra chairs or beds when needed;
128Mr Pink accepted in his oral evidence that as a general rule team leaders allocated patients to beds or chairs. Again, in my opinion, what is involved in allocating patients to beds or chairs is quintessentially a clinical management role.
129The fourth and fifth duties involved the ordering and checking of blood tests. In this respect, it was Ms Pink's evidence:
The Team Leader is responsible for reviewing all the blood test results for all patients and ordering blood or blood products from Concord Hospital Blood Bank as dictated by blood results so they can be administered to patients in a timely fashion. The Team Leader needs to check blood results as they become available on the computer to ensure that the haematology registrar or specialist looks at the blood results of patients who are likely to need blood products so treatments can be administered and completed the same day.
This is because haematology patients usually need to have blood tests on the day they come to HACU and depending on the results may be given a blood or platelet transfusion or both. Chemotherapy patients usually have blood tests on the day they arrive for treatment and depending on results treatment may be deferred. The Team Leader again needs to check for blood results becoming available so they can be reviewed by the haematology registrar as soon as possible and ensure chemotherapy charts are signed off by doctors to avoid delays in treatment.
130Mr Pink's evidence regarding blood tests included the following:
One is we have to get blood test results and have a look at that. If you start from the beginning of the day patients will be put in the chairs, they get cannulated, the blood tests come back, the team leaders usually look at that those blood tests and have a discussion yes or no go ahead for treatment with the doctor.
131In agreeing that the team leader role was a difficult one, Mr Pink stated, in part:
Answering questions from specialists and the like to actually organise what is going on throughout the unit. So it's not just that but if you're looking up your blood results for patients to go and have their chemotherapy, interacting with the doctors in the unit to see if it can go ahead.
132It is apparent that the team leader performs the task of ordering and checking blood. It requires clinical knowledge and is clearly an important coordinating role. Indeed, Mr Pink used it as an example of the difficult role team leaders perform. It is an aspect of a clinical management role.
133The sixth duty involved coordinating doctors' reviews of patient test results, ensuring that treatment orders are written up, and then ensuring that appropriate prescriptions are written and obtained. There appeared to be no exception taken by any of the respondent's witnesses to this duty, so I presume it is accepted by them that it is part of the role of a team leader. It is essentially a coordinating role, but nevertheless, an important one. Ms Pink stated:
[T]he Team Leader needs to check that medication and chemotherapy charts and prescriptions as needed are written up by medical staff and check what tests the specialist has requested. If the documentation is not up to date or not completed at all, which frequently happens, the Team Leader needs to assess based on experience which tests are required. All patient activities which occur in HACU need to be completed in order of priority to ensure patient flow is accelerated. This priority is managed by the Team Leader.
134The seventh duty on the list involved liaising with other health disciplines. In this respect, it was Ms Pink's evidence that:
The Team Leader is responsible for liaising with the haematology registrar, anaesthetic registrar, other specialists, the Ground East NUM, nursing staff and with multidisciplinary services within the hospital. There are six specialist haematologists employed at Concord Hospital who liaise with the Team Leader to arrange bookings for their patients' treatments in HACU.
If the specialist requests treatments for the same day, the Team Leader needs to assess whether HACU can accommodate this, depending on the needs of patients already booked in for treatment. This may require arranging admission for urgent treatment or liaising with both patients and specialists for treatment on a future date.
The Team Leader is responsible for ensuring medical staff are contacted for urgent review when patients having infusions develop symptoms of adverse reaction for example, shortness of breath, fever, hives, rigors, high or low blood pressure.
135There did not appear to be any disagreement with the claim that team leaders liaise with other health disciplines to arrange bookings for their patients' treatments in HACU. Nor was there any disagreement that the team leader contacted medical staff for urgent review when patients having infusions develop symptoms of adverse reaction. The respondent's witnesses appear to have taken the view, however, that these duties were also the responsibility of individual nurses. Nevertheless, it was not denied that the team leader had a coordinating role in liaising with other health professionals and was responsible for ensuring medical staff were contacted for urgent review when patients having infusions developed symptoms of adverse reaction. That would obviously be the case where an inexperienced nurse or nurse unfamiliar with the HACU environment and procedures was involved.
136The eighth duty involved organising the admission of HACU patients presenting unwell. Ms Pink said in her statement:
The Team Leader is responsible for managing the treatment of unscheduled patients who present to HACU because they are unwell. This usually involves liaising with specialist doctors, registrars, the bed manager and HACU staff to arrange extra treatment/tests or close monitoring of the patient. The Team Leader may need to change the staff to patient allocation if this occurs.
The Team Leader may need to direct the patient to either the Emergency Department(ED), HACU, or the Medical Assessment Unit depending on clinical needs.
The Team Leader is also responsible for managing patients who call HACU with medical problems. The Team Leader has to decide whether to consult the haematology registrar or haematology co-ordinator (the RN who co-ordinates care for haematology patients throughout Concord Hospital) or direct the patient to ED, their general practitioner or to HACU for review.
The Team Leader is responsible for liaising with the Bed Manager when a decision is made that a patient in HACU is to be admitted to the ward and involves frequent follow up with the Bed Manager and receiving ward staff to ensure a timely transfer of the patient from HACU by 4.30pm when the majority of staff finish their shift.
137Ms Antonio responded to Ms Pink's statement, saying:
This is standard work for this type of unit. As the Team Leader is co-ordinating patient flow, they will contact the doctor to see the patient and conduct their own observations. Unscheduled patients are part of the standard workload of this unit and similarly to the Emergency Department, a nurse assesses the patient and refers to a medical officer once the patient is assessed. The NUM should be informed by the Team Leader if the care of the unscheduled patient or patients will impact on the flow or treatment of booked patients for the unit.
...The Team Leader may direct a patient to attend the Emergency Department if they are unwell and HACU does not have capacity to see them at the time. They do not direct patients to the Medical Assessment Unit as this in an inpatient unit and beds are allocated by the Demand Management Unit once the patient has been accepted for an inpatient bed.
138On the question of admissions generally Mr Pink said in his statement:
In my role as NUM, I am responsible for facilitating the admission of patients from unit to ward. The transfer of patients should be discussed with me.
There are different ways for a patient to be admitted. If they are coming in as an admitted patient, the Care Co-ordinator would have done the admission, the patient would have their chemotherapy in HACU and would then be transferred up to the ward in the afternoon to complete their chemotherapy. The liaison in that situation would be confirming that the bed is ready. In this situation, I will know who is coming in and it will be the transfer of a patient from unit to unit.
On the other hand, when there is a walk in patient who is unwell that needs to be admitted, then this becomes an issue about what is best practice for the patient. In my opinion, it is the role of the nurse to facilitate that process. However, staff have been asked to notify me when these patients come in.
Staff will be required to fill in a Request for Admission (RFA) which is then faxed to Admissions who send it to the Bed Manager. If I am in the unit, I will contact the Bed Manager and tell them about the patient including whether they need a chemotherapy bed or whether they can go to a general ward. This does not happen daily but may happen a couple of times a week.
The Bed Manager is looking at where the beds are available and normally that will not happen until 2.00pm. If there is a bed needed in Ward 5 East, I will phone to see what is available. Sometimes the Team Leader may call, but it is not expected that they will do that. It is a courtesy call.
If there are admissions that need to occur after 4.30pm, by which time I am not there, then the Team Leader would do that themselves....
139In answer to a proposition put to her in cross-examination that whilst the NUM may be informed of admissions, it is the team leader actually does the liaison with bed managers, Ms Hogan replied:
A. Well, my directive to Mr Pink was that he was to be organising the beds for patients, and I will have to reinforce that with him.
140It would appear that Ms Hogan did not know, as a matter of fact, who liaised with the Bed Manager.
141In her reply statement, Ms Pink referred to the admissions process:
If I formed the view that a patient may need admission I would contact the appropriate doctors who would generally come to see the patient and write admission notes if they thought admission was appropriate. I would then contact the Bed Manager to request an inpatient bed. I would explain the reasons for the admission and provide documentation to the bed manager. I would generally advise the NUM that we had an admission but the NUM would not be involved in the process.
142My view of the evidence is that the team leader plays a significant role in admitting HACU patients presenting as unwell. In that respect I accept the evidence of Ms Pink and Ms White. Whilst it may be accepted Mr Pink is to be informed of admissions, that does not make him the clinical manager for the shift. And whilst Mr Pink may exercise an incidental role in the day to day process he agreed under cross-examination there were "many occasions" when he was not available to deal with unscheduled patients. He also agreed it was the usual practice for the team leader to liaise with the Bed Manager and the Ward Manager.
143Dealing with patients who present as unwell is an integral part of the clinical management role. The team leader is involved in liaising with specialist doctors, registrars, the bed manager and HACU staff to arrange extra treatment/tests or close monitoring of the patient. The team leader may need to change the staff to patient allocation if this occurs.
144The ninth duty on the Prest list was answering telephone inquiries from patients, doctors, other nursing staff, patients' relatives, allied health professionals and the like concerning patient treatments, clinical management and bookings. It was asserted by Mr Pink this was within the normal scope of duties of an RN. Nevertheless, it was not contested that team leaders performed this duty. Indeed, Mr Pink said that "answering questions from specialists and the like..." was a feature of the team leader's difficult role. Dealing with telephone inquiries is ancillary to clinical management.
145The tenth duty was managing patient appointments. Ms White explained this required an assessment of all scheduled treatments, their administration times and the condition of the patients. This included management of the following factors:
a. patients may ring to change appointments and the Team Leader needs to look at the daily schedule to see where they can be fitted in. This involves making clinical judgements based on the urgency of the treatment, the length of administration of the treatment, the condition of the patient, the skill mix and availability of nursing staff. The Team Leader also needs to assess whether patients are suitable for treatment as an outpatient in HACU;
b. the Team Leader is required to notify Admissions if urgent treatment is needed and HACU has no physical capacity to accommodate the patient/s. The Team Leader has to liaise with the NUM to see what can be arranged; and
c. the Team Leader may be required to call patients to re-schedule their treatments due to changes in the workload or changes to staffing skill mix issues and availability of staff.
146Ms Pink's evidence was as follows:
The Team Leader is responsible for managing bookings for all patient treatments as requested by haematology, neurology, immunology, rheumatology, dermatology, renal and gastroenterology. This requires an assessment of the clinical needs of the individual patients and knowledge of how long treatments are likely to take and variations that may occur due to drug dosages, patient tolerance and conditions requiring longer treatment times.
The Team Leader is responsible for reviewing and managing the daily patient load and rescheduling treatments if needed to aim for a reasonable workload. This requires assessment of urgency of treatments and knowledge of all patients' histories and needs.
For example if HACU is fully booked it is the responsibility of the Team Leader to discuss with the haematology registrar in the ward which patients' treatments can be re-scheduled where necessary.
147Mr Pink did not appear to disagree to any significant degree with the description of Ms Pink and Ms White regarding their role in scheduling patients and ensuring a smooth patient flow. For example, Mr Pink gave the following oral evidence:
Q. What do you mainly rely on the team leader for Mr Pink?
A. Moving the patients through the system. So a team leader in both units will make sure that the patient comes in for treatment. So they have been allocated a seat or a chair for treatment. So certain things have to happen. One is we have to get blood test results and have a look at that. If you start from the beginning of the day patients will be put in the chairs, they get cannulated, the blood tests come back, the team leaders usually look at that those blood tests and have a discussion yes or no go ahead for treatment with the doctor. Then they will either, if it is chemotherapy they will organise with pharmacy to have the chemotherapy make up if we are going ahead and then on the reverse side of that when they are finishing up, patients will have new appointments made and for the next set of treatments and that has a scheduling function so that will be done. So that appointment is made, made sure they are in the schedule properly. Towards the end of the day the team leader then will get the next day's files out, in HACU they do. (emphasis added)
...
Q. Just going over the page, it says that a recent decision in December '08 was made by the nurse in charge to allocate the team leader in two week blocks to mitigate some of these issues. To create consistency, part time RNs were ineligible to perform the role. Was it your decision that the team leaders would be allocated in two week blocks?
A. Yes there was a discussion we had with staff to see what best met the needs of the units.
Q. How did it assist to have a team leader allocated for a two week block?
A. If you have them on a day by day basis there are stuff that flows from day to day and the consequences of that. So if you are doing a job one day and then back on the floor the next day then there can be inconsistency that is not consistency of care.
Q. What kind of areas are you talking about now?
A. Scheduling appointments.
Q. I am sorry?
A. Scheduling and appointments are being booked. (emphasis added)
...
Q. Just looking at the next paragraph, you would agree with the proposition in the first sentence that the team leader role is generally described is a difficult and stressful one?
A. I would say difficult, not necessarily stressful.
Q. What makes you come to the conclusion that it is a difficult role?
A. It is a combination of a lot of things, just a lot of things in your head. Mainly the scheduling of patients and allocating them in and out of time slots and making sure treatments can be accommodated within that. Answering questions from specialists and the like to actually organise what is going on throughout the unit. (emphasis added)
...
Q. You have said essentially the rescheduling would simply involve looking at how long a procedure would take, and seeing whether there was a sufficient time slot?
A. It's not as simple as that.
Q. No?
A. The process for doing that is we patients are scheduled for treatments throughout the months, so we preload our schedules as much as possible. Where a patient gets delayed, or needs to have treatments and not scheduled, then we look at our how we put those into the schedule. If that means we can move people around, or change what people have been scheduled to that name, we can do that. That is one section of the schedule. So if there is no space available within the haematology unit, then usually the medical oncology unit can also be take on a load if that is required. But the scheduling, or rescheduling of where patients go, I would expect the team leaders to actually do the rescheduling of patients. Say if they can't go ahead with their chemotherapy, or whatever is wrong with them, the system at that time, or the person at that time, to reschedule them within an allotted time. If they cannot do that, then they have been asked to talk to me and see what they can do about moving between units.
Q. And to degree, making those assessments about whether you can or cannot accommodate rescheduling of particular patients, that will obviously depend on the nature of the procedure?
A. Yes.
Q. But it will also depend on the particular condition of the patient?
A. Well that's in totality isn't it? I mean you're doing that because you need to get something some medication to a patient, so you are going to have a whether or not a patient can wait one, two, three days, or weeks, that's something you have to do with each individual, as each individual patients comes through.
Q. That is an assessment in which the team leader will ordinarily make?
A. Well it's not unexpected them to do it, but I expect them to do that. (emphasis added)
148Ms Pink was asked in cross-examination about Mr Pink's role in scheduling patients:
Q. What about if there's no available spots in the schedule, though, and you have got a patient that's come in unexpectedly. You would have to let the NUM know of that?
A. If we don't have any space for the patient, and we can consult with the haematologist or haematology registrar to see what the best course of action is for that patient, whether they should go to the emergency department or otherwise, and we were unable to accommodate them in HACU, and the medical officer was insisting that we do accommodate the patient in HACU, then, yes, I would call Adrian to help us resolve
Q. To manage the issue?
A. to manage the issue, yep
149The issue of whether a patient should go to the emergency department because they could not be accommodated in HACU is a relatively minor aspect of the task of scheduling and rescheduling of patient treatment. It is not surprising that, where a medical officer insists on HACU accommodation when there is none, the issue should be referred to the NUM who has overall responsibility for the unit.
150It appears to me from the evidence that scheduling and rescheduling of treatment for patients is a critical part of the team leader's role to "ensure safe, accurate and appropriate flow of patient management". In my opinion, it is also a fundamental aspect of the clinical management role.