In April, on behalf of the NIHR CLAHRC Wessex, Portsmouth Hospitals NHS Trust, the Faculty of Health Sciences University of Southampton and our Wessex NHS partners I had the privilege of presenting at the 6th NETNEP International Nurse Education Conference in Brisbane, NSW, Australia. I demonstrated how our collaborative training programme is creating clinical academic leaders in nursing, midwifery and the allied health professionals (NMAHP) in Wessex. I focused on developing the critical NHS engagement with both the NIHR CLAHRC Wessex and the faculty needed to advance the agenda. The presentation demonstrated the benefits and impact for all organisations, our NMAHP workforce and our patients.
The conference focussed on transforming education through scholarship, development of academic leadership and evaluation research. Approximately 400 delegates attended from across the world including USA, New Zealand, Netherlands, Denmark, Canada, Singapore, Sweden, China, Finland, Pakistan, Norway, Hong Kong, Japan and 23 UK universities (Edinburgh Napier, Huddersfield, Coventry, Manchester, Glasgow Caledonian, Chester, City London, Stirling, Nottingham, Birmingham, Salford, Bournemouth, Birmingham City, Keele, West of Scotland, Oxford Brookes, Surrey, Cambridge, Glyndwr, Belfast, Huddersfield, Kings College and of course Southampton).
Professor Lisa Bayliss-Pratt, Director of Nursing, Health Education England, presented the development of the Associate/Assistant Nurse role as recommended in “The Shape of Caring” publication following the Willis Report. As a call for action, Lisa has now established an international community of practice (CoP) to consider how this role has developed across the world and learning that is applicable to the English model.
Colleagues from Bournemouth University, Professor Steve Tee and Dr Sue Way were also present.
Sue presented the work of a Portsmouth NHS Hospitals Trust Clinical Doctoral Midwife Research Fellow, Dana Colbourne “Leading with a SMiLE: Exploring a Student Midwife Integrated Learning Environment”. Our own Dame Professor Jill Macleod Clark also attended, a great support for me and provided current NMC nursing curriculum plans.
A thoroughly enjoyable 3 days in sunny, beautiful Brisbane. It was a great chance to network with colleagues and develop those important relationships. I feel terribly honoured to have presented our work to this international audience. I so was exhausted after I treated myself to a weeks leave in the totally beautiful North Queensland, careful of course of the saltwater crocs!
Yesterday saw the release of the Nuffield Trust’s report on “Reshaping the workforce to deliver the care patients need“. Asked to respond to news headlines that reported on this I responded to headlines that framed the reports conclusions as a solution to junior doctor shortages, for example on the BBC news. Of course, there is a […]
Primary care professionals have contributed a lot in recent years to meeting the medical needs of those with diabetes and other chronic illnesses. However, despite being viewed by commentators as the big hope for progressing patient education and self-management support our most recent paper suggests otherwise. We might need to think again whether it’s a good thing to use GPs and practice nurses more in this area.
Our research undertaken with *Greater Manchester CLAHRC shows that in terms of ‘work force’ that non-health professionals provide more valuable support to people’s self-management than primary health care professionals.
Partners and spouses provided most support in terms the amount and intensity of illness, emotional and every-day work whilst most support provided in primary care professional input is work related to illness specific management (medication etc.). The provision of emotional support in Primary care is lower than that obtained from other network members (family, spouses, friends, groups and pets)
The intensity of support was also found to be less than that received from other social network members. Primary care professionals can be described as providing essential but ‘minimally provided support’. This reinforces limited expectations and value about what primary care professionals can provide in terms of support for long-term condition management. That needs to be taken into consideration in looking at how we might look outside professionally dominated networks to think more imaginatively about exploring how extended self-care support could be enhanced out-with primary care.
A lot of unrecognised, imaginative and effective work is undertaken by the lay work force regarding long term condition management. Unlike the professional workforce it seems to operate with a positive care law – expanding and reacting to the changing needs of people.
So thinking about building, valuing and engaging a network to mobilise resources for self-management support. We should look to open settings and the broader community rather than assuming that more has to be done by professional health care workers.
Anne Rogers is Professor of Health Systems Implementation and Research Director CLAHRC Wessex at University of Southampton.
*Collaboration for Leadership in Applied Health Research and Care (Wessex) or CLAHRC Wessex is one of a network of research organisations supported and funded by the National Institute for Health Research which is the research arm of the NHS.
Ryan Buchanan is a specialist registrar doctor in liver disease and a PhD student supported by CLAHRC Wessex.
In my previous blog I described how a novel, award winning case-finding initiative was identifying some of the estimated 200 missing cases of Hepatitis C on the Isle of Wight and linking them directly to specialist care. The second part of this project, which I describe here, is an attempt to establish a more accurate estimation of the true number of missing cases in order to guide future service design and inform best practice elsewhere.
The main risk factor for Hepatitis C is injecting drug use and therefore we focused our survey on people who inject, or have ever injected drugs on the Isle of Wight. This as you can imagine is a difficult group to survey with people unwilling to come forward due to issues surrounding privacy, stigma and the illegal nature of drug use.
Other researchers have addressed these challenges by undertaking surveys in locations where people who have injected drugs frequent regularly and feel able to participate – for example, drug support or needle exchange centres. However, we chose not to do this because survey designs such as this only sample people who going to support services and are therefore likely to have different characteristics to those who are not. The results of such a survey would therefore not be a true representation of the whole local population of people who inject drugs.
We have used a survey method called respondent driven sampling. In this method survey participants are asked to invite two or three of their friends and associates, who might also be at risk of Hepatitis C, to come forward to the research team. In this way we are potentially reaching more of a cross-section of people who inject drugs and can therefore make a better judgment about how common Hepatitis C is in this population as a whole.
Diagram showing how respondent driven sampling works, participant 1 (green) is asked by the research team to invite friends and contacts to take part (blue), if these attend then that are also asked to invite friends to take part (orange). The survey continues in this way until a sufficient number of people have taken part to give meaningful results.
Respondent driven sampling has been used successfully before in people who have or are currently injecting drugs, usually as part of research looking at HIV. However, it has only been used in rural communities a handful of times and this brings unique challenges.
Our survey has now started, we began with a carefully selected sample of participants who were able and enthusiastic to take part in the research and thought they had friends who were also willing to do so. These initial participants have gone on to invite these friends to take part and these have gone on to invite others and so it has continued. We have faced challenges during the process particularly posed by the rural nature of the Island community where people who are eligible to take part often live a long way from their friends and the survey centre.
It is hoped that on completion of the survey we will have a better idea about how many cases of Hepatitis C are actually missing on the Isle of Wight and importantly the characteristics of those that are missing. This will allow us to tailor our case-finding initiative for Hepatitis C so that it is accessible to the people that really need it.
Almost a year on from my last post here and I’ve done a lot of work on my developing my research proposal – reading, learning, literature reviewing – but sadly not a lot has changed for people with dementia in acute hospitals. My desire to improve the quality of care, especially at meal times has certainly grown.
As part of my research training I have had the privilege of completing some observations for another large study in an acute setting. This involve observing acute hospital wards at different times of day – not specifically meal times, but some of my slots covered that period.
Why a privilege? Because it is so rare for anybody actually working on the wards to stop and watch for a prolonged period. It isn’t until you pause and observe that you realise the extent of the problem.
My observations and reflections:
- Lack of meaningful activity or social stimulation is visible to a much greater extent than I realised. Sitting in a bay for 2 hours mostly produced results of very few staff interactions often lasting less than 1 minute.
- The routine and culture is mostly task focused, allowing little flexibility from the rigidity of the organisational structure. I say “allowing” because I know there are thousands of nurses out there who are fantastic, who wish they could do more but are restricted by various pressures of the acute setting and the NHS.
- Again, I noticed how staff pressures result in inadequate assistance at meal times: people with food they cannot reach, sat in awkward positions in the bed unable to bring the food to their mouth, struggling with packets and wrappers eventually giving up, asleep throughout the whole period. People with dementia were seen to be particularly vulnerable at this time, often ignoring the food for whatever reason or not getting the assistance they needed meaning full or half empty plates taken away when the staff were scheduled to take it away.
The resounding complaint of being “short staffed” is constantly ringing in my ears – yes it is highly likely this does contribute to quality of care at meal times.
Is it going to change? I don’t know.
What I do know is, there is scope for better quality within what we already have– what I really want to do is work within our restricted, stretched, task focused, short staffed system and see how we can change with the resources we have.
So, here’s the summary of what I plan to do:
- Observations of meal times using Dementia Care Mapping. This will be used to measure people’s well-being and engagement during the meal time, and to gather and in-depth picture of what may influence the meal time experience. What a great opportunity to stop and stare.
- Build a model of areas which influence the eating process for people with dementia on acute hospital wards. This will aid in conceptualizing the problems. I hope it can be used to improve care through education and training for health care staff.
- Interview staff about the tools currently used to encourage eating and drinking, and what they see their roles as in this process. I look forward to developing from there.
Next step… ethics approval.
Naomi is a NIHR Clinical Doctoral Research Fellow in Dementia Care and Occupational Therapist supported by NIHR CLAHRC Wessex
Want to email Naomi?
This Blog has also been published on the UK care guide website
We have a shortage of registered nurses, hence nursing is once again on the occupational shortage list. With insufficient ‘home-grown’ registered nurses available, Trusts have had to resort to other measures: use bank and agency, recruit ‘ready-made’ RNs from other countries, run services with a high vacancy rate and try and ‘stretch’ the existing resource to cover the gaps.
The solutions are far from perfect – each bearing a financial cost and increasing pressure on existing staff, to manage temporary staff, accommodate staff from other countries, or bear the brunt of staffing shortages themselves. Increased pressure leads to sickness, absence, higher burnout, and staff leaving. Leading to more vacancies and more pressure. A downward spiral fuelled by too few RNs.
In December 2015, Health Education England published the national workforce investment plan. Confusingly, given the context of too few RNs, just 300 additional adult general nurse training places are to be funded, despite an assessment that suggested more than 3,000 more RNs were needed. In the same month came the announcement of a new role: the ‘nursing associate’.
So will introducing a nursing associate role help with the shortage on RNs?
No, in my view it cannot. The ensuing consultation stated that the proposed role is not intended to substitute for RNs, but to complement them. But consider how the introduction of the new role might work in practice.
Clover Ward, a 30 bed acute medical ward, has an agreed establishment of 30 RNs and 15 HCSWs that has been arrived at using the SNCT and professional judgement. All the HCSWs posts are currently filled – easy to do so as no training needed and ample supply in the local labour market. 10% of RN posts are currently vacant.
Then comes the plan to introduce nursing associates. So how does the establishment change?
- New money is provided for Clover ward to allow them to have 2 nursing associates on top of the funded establishment, to support RNs and existing HCSWs, and free up RN time? Unlikely. There is no new money.
- HCSWs are funded to become Nursing Associate’s? What many of us were hoping for. HCSWs have typically had no more than 2 weeks preparation for their roles, frequently working beyond their pay grade and their skill-set. But HEE says funding for education will have to be found by providers/employers.
- Or, does the finance director and HR manager and nursing director look at the empty RN posts and say – let’s not wait to find more RNs to recruit, we should switch those vacancies into nursing associate posts. It’s the nationally proposed and endorsed solution to increase capability and capacity of the nursing workforce. It will provide some much needed extra pairs of hands on the ward, and meanwhile save us money. And according to the Health Education England it will stop “RNs being dragged down by fundamental care”.
Which of these is likely to happen? There is only one option that in the current context can happen. The last one.
If we introduce the nursing associate role within the existing budget, it can only be as a replacement for RN posts, as anything else costs money. And so the nursing associate role will sometimes, as the CNO of NHS England acknowledged at the Deputy Director congress, be used as a substitute for RNs. Question 12 of HEE’s FAQ’s asks: ‘Will the new nurse role be introduced across the UK?’ Note the term already in use: the new nurse role.
The result is that patients will receive a higher proportion of their care from staff who are less well-equipped to do so: less knowledge, less training. A 30-bedded ward that rosters 5 RNs + 3 HCSWs, becomes a ward that only has enough RNs for 4 RNs plus 4 HCSWs. Each RN has one more patient to care for, plus more staff to support and supervise.
So who cares about who delivers care? We all should.
This isn’t a nursing issue. This is a fundamental issue about the level and quality of care we as a society want to be available to patients when they receive care in the NHS.
Insufficient investment in training enough RNs got us into this mess. Investment in the workforce is needed to get us out of it. Having established the number of RNs needed, we need to train and employ them, without compromise.
But can we afford to do that? Should we not accept that safe staffing levels is not a feasible objective in the current financial climate, and focus instead on “sustainable” staffing levels?
In my view, we cannot afford not to fund the level of RNs needed to provide care safely and effectively. Low RN staffing levels cause patients too die in hospital when they should have recovered and gone home. 86% of RNs on acute wards are leaving necessary care undone because they haven’t enough time. We cannot undo our knowledge of these things.
We can’t keep accepting compromises that patients ultimately pay the price for. When we ‘make do and mend’ its care quality and patient lives that suffer. These aren’t our compromises to make.
If there isn’t the money in the system to run this number of beds or to provide that range of services, then close some beds. Cut some services. Reduce what is covered by the NHS. Charge for some elements of it. Put a penny on taxes of higher paid for a health fund. Change the balance of resources so that a slightly higher percentage goes into nursing workforce rather than medicine.
I don’t know which of these are the right choices. I’m not a policy maker. I’m not a health economist. Nor am I a politician. But I do know that these are choices that need making. If we want a health care system that provides care safely, and that meets the first principle of medicine and nursing: do the patient no harm. Or else we need to be honest with ourselves, with the public and with patients, about the compromise we are making, and the risks we are being asked to take.
I’m Ryan Buchanan, a specialist registrar doctor in liver disease and a PhD student. My research is paid for by something called the National Institute for Health Research (it’s the research arm of the NHS and here in our region I work for the bit of it called CLAHRC Wessex).
Just over a year ago I wrote an article describing how I was part of a project to improve the care for patients living with Hepatitis C on the Isle of Wight. Hepatitis C is a pretty devastating virus that lives in the liver, and if untreated it can sometimes cause serious and potentially life-threatening damage over many years. It’s normally spread by blood to blood contact, so sharing needles or in some cases blood transfusions abroad.
My mission here on the island has two main goals; firstly to find people living in the community who don’t know they have Hepatitis C (we estimated there may be up to 200 such cases), and secondly to make sure those people get fast and efficient care in their local community to hopefully eradicate the virus.
The project has now been running for 18 months, we have won two national awards. Most recently our work was was recognised at the Isle of Wight NHS awards where we picked up the prize for excellence in research.
Our Hepatitis C awareness campaign has increased testing across the Island and a we have carried out more than 150 tests in local pharmacies. Through that along we have found 10 previously undiagnosed cases of Hepatitis C.
Thirteen of our patients with Hepatitis C related liver scarring (also known as cirrhosis) have begun treatment and last week the first patient to complete treatment was declared cured of the virus.
So progress is being made and in many respects the project has been a success, however, when asking ‘how good is it?’ the project needs to be considered within the context of the disease and the Island community. Most importantly we need a better idea of the true number of missing cases of Hepatitis C because if there are truly 200 missing cases then, even with the success of the pharmacy scheme, we have a long way to go.
We estimated the number of missing cases on the Island by doing some simple arithmetic. We identified all the known cases of Hepatitis C who had been diagnosed over the last 13 years and took that way from the Health Protection Agency (HPA) estimate for the number of cases thought to be on the Island. Even assuming we missed a few ‘known cases’ the answer left 200 unaccounted for, which, assuming the HPA estimate is accurate, are hidden within the Island community.
The next part of our project aims to gain a better understanding of how many cases of Hepatitis C are truly missing on the Isle of Wight and establish how best to reach them with testing and treatment services.
Across the UK 90% of new diagnoses of Hepatitis C are in people who currently or have previously injected drugs – So for us the challenge is to make sure we reach enough people this community on the Island.
The start of the month saw the publication of our latest research on nurse staffing levels in the BMJ Open . In most respects, the finding is not new and not surprising. Using administrative data from English acute NHS Trusts and the RN4CAST survey of hospital nurses, we found that hospitals with fewer nurses tended to have higher mortality rates. I recall similar findings a few years ago being greeted with a commentator on the NT website with the pithy phrase “…no s?!t Sherlock…” (or words to that effect). So, what was new and why is (another) study showing the same thing important?
Well, for one thing, the finding is not entirely obvious. Not all studies have found an association and it is certainly possible, even likely, that the medical staffing level, which tends to be closely related to nurse staffing levels, are more important when looking at mortality rates…
View original post 572 more words
So the BBC and others are reporting on the increasing numbers of vacancies for Drs and Nurses in the NHS. The governments bland response appears to be to simply say that we have more than we have ever had before. It’s all very well saying that the NHS now has more nurses and doctors but these figures clearly show that it does not have enough. Demands on services have increased and, certainly for nursing, we have known that we are not training enough to meet predicted demand for some time. The need to recruit overseas is entirely predictable and will we can get some excellent nurses research such as our BMJ Open paper (1) shows that this is not a simple and straightforward solution – people need proper support to adapt and don’t always get it.The government has recently abolished bursaries for student nurses and the NHS no longer directly…
View original post 184 more words