Bangor University Cardiff University Welsh Ambulance Service Hywel Dda Health Board Public Health Wales Cwm Taf Health Board Cardiff & Vale University Health Board Aneurin Bevan Health Board Velindre Cancer Centre Cardiff Metropolitan University Swansea University Abertawe Bro Morgannwg University Health Board Powys Teaching Health Board Betsi Cadwaladr University Health Board University of Glamorgan 1
Foreword It is now more than a decade since the introduction of consultant health professionals to the Welsh NHS and while they remain a small cadre of expert practitioners within the workforce their impact, as can be seen by this report, remains high. It is a testament to the hard work and commitment of the individuals who fulfil these demanding roles that their influence has touched so many people s lives, whether that is service user, carer/relative or fellow practitioner. All are strong professional role models and leaders within their fields and the health service in Wales is stronger as a result of their contributions. This year s report includes a selection of contributions from the members of the CNMHP Forum rather than reports from all members. The selected contributions cover a wide range of services and client/patient groups: young to old, physical and mental health care as well supporting those in childbirth or with learning disabilities. The potential for expansion of the consultant role as the Welsh health service continues to evolve remains great, and the case for developing additional posts is strengthened through the evidence presented here regarding the type and level of impact these roles can make. I encourage all who are considering how services can be modernised to reflect on the examples outlined in this report, specifically on the potential contribution consultant health professional roles can make. Again this year it is pleasing to see active involvement in the research and development agenda. It remains vitally important that we grow the evidence base to support how we deliver care to people. It is also important that the NHS in Wales is supported to make a full contribution to the wider innovation, research and development agenda needed to support the growth and prosperity of Wales. My congratulations and thanks to the contributors of this report for sharing your personal achievements this year. Professor Jean White Chief Nursing Officer (Wales)/ Nurse Director NHS Wales 2
CNMHP s Aim: To make a significant contribution to health & well being for the population of Wales Our Commitment: C N Collaboratively work across traditional boundaries, between organisations and agencies to ensure individuals, families and communities are at the centre of strategic planning and high quality service delivery. Nurture others to enable and empower personal growth and development in patients, carers and health care staff. Work with Universities and other educational establishment to help to ensure that courses are learner focused and that the impact of the courses/programmes will be of direct benefit to patients, their carers or health boards. M Maintain and develop standards of care that are underpinned by evidence based practice whilst leading and making a contribution to the research agenda to maximise on opportunities for patient, client, carers and other health care professionals H P Health protection and health promotion are high on our agenda. They will underpin our work and we will ensure that vulnerable children & adults, as well as excluded and disadvantaged people are considered as we continue to act as their advocates in health care delivery. Patient or client centred care is at the heart of our praxis and we will persevere to provide leadership & consultancy for health care thus making a significant contribution to health and wellbeing of the population of Wales 3
Contents: 1. CNMHP introduction 5 2. CNMHP history 6 3. CNMHP membership 6 3. CNMHP vision statement 7 4. CNMHP goals 7 5. Governance 7 6. Contributions 8 7. Examples of impact from specific work 9 8. Current priorities in relation to capturing impact 70 9. Appendix 1 membership list 84 4
Introductions from CNMHP s Chair Gemma Ellis and Chair Elect Sian Thomas We are delighted that you are taking the time to read or browse through our 2012-2014 report and are really pleased to be in a position to present our work over the last 2 years. In the last few years our Forum has gone from strength to strength with the development of new posts in Wales. We are collectively delivering care which is fit for the 21 st Century and making an impact on the care of patients throughout Wales and beyond despite the financial climate within the NHS. We are committed to the Health Ministers Prudent Healthcare vision that fits the needs and circumstances of patients and actively avoids wasteful care that is not to the patients benefit We are committed to helping NHS Wales to deliver expert care to meet the national agendas, provide professional leadership, educate others, and explore new ways of working and to develop the evidence base for practice. We do this on an individual basis and as a collective. Our report is produced using tools specifically developed by Dr Kate Gerrish to enable Consultant Nurses to capture their impact and we have specifically chosen activity 4 and 5 from the toolkit which is available here: http://research.shu.ac.uk/hwb/ncimpact/tool.html All members of the CNMHP have had the opportunity to contribute to the content of this report. 5
Who we are and what we do. 1. CNMHP History In Wales, consultant nurse and midwife posts were introduced in 2001 and consultant allied health professionals (AHP) in 2003. They were established to develop and modernise clinical practice across and beyond traditional and organisational boundaries and are well placed to provide the clinical leadership and partnership working to deliver the modernisation agenda as identified in Design for Life 1. Posts are created to maintain and develop clinical expertise within frontline patient care services. Since their introduction consultant practitioners (non-medical) have provided leadership and impacted on clinical care and have been at the forefront of consultations for reform through the Welsh Nursing Midwifery Committee and Welsh Government. Consultant roles have responsibilities across five domains of practice: Expert clinical practice Professional leadership and consultancy Education and training Practice and service development Research and evaluation CNMHP have produced a work plan reflecting the Doing Well Doing Better Standards for Health Service Wales 2010 2 using the tenets: Consultancy and Expert Clinical Practice; Leadership, Practice and Service Development; Education and Training, and Research and Development. 2. Current Membership CNMHP membership is open to all consultant practitioners (non-medical) whose job description has previously been agreed by the Consultant Practitioner (non medical) Scrutiny Panel or the now devolved local scrutiny panels. Membership includes consultant allied health professionals (AHPs), Consultant Nurses (CN) and Consultant Midwives (CMs). Currently we have 31 members (appendix 1). 1 http://www.wales.nhs.uk/documents/designed-for-life-e.pdf (accessed 11.08.14) 2 http://www.nhswalesgovernance.com/uploads/resources/pwihke4fu.pdf (accessed 11.08.14) 6
3. CNMHP Vision Statement Consultant Nurses, Midwives, Health Visitors and Allied Health Professionals will make a significant contribution to health and well-being of the population of Wales. We are well placed to help to improve the health and social care outcomes for excluded and disadvantaged people. Collaborative work across traditional boundaries, between organisations and agencies enables consultants to ensure individuals, families and communities are at the centre of strategic planning and high quality service delivery. 4. CNMHP Goals 4.1 To drive patient centred care initiatives through expert practice, practice development, multiprofessional /interprofessional education, developing the research base for practice and sharing information. 4.2 To develop, monitor, advocate and publicise the consultant role in nursing, midwifery, health visiting and allied health professions in Wales, in order to provide an expert clinical resource which supports practice, service development, education, training, and research within the particular fields across the expertise of members. 4.3 To inform, lead and influence public strategies affecting health, social care and well being by providing formal representation in key areas of strategy development in Wales, the UK and internationally. 4.4 To inform and influence the respective professional agenda maintaining a collaborative senior level forum to consider papers with a focus on health, social care and wellbeing strategy from Wales, the UK and internationally. 5. Governance CNMHP is governed by the following documents which can be accessed on the CNMHP website: 5.1. Terms of Reference 5.2. Strategic work plan 7
6. Contributions have been received from the following members of CNMHP: 1. Christopher Griffiths ABMUHB 2. Judith Morgan ABMUHB 3. Jackie Austin ABUHB 4. Elizabeth Candy ABUHB 5. Sian Thomas ABUHB 6. Steve Cottrell BCUHB 7. Gemma Ellis C&VUHB 8. Karen Jewell C&VUHB 9. Louise Poley C&VUHB 10. Julia Sanders C&VUHB 11. Denise Shanahan C&VUHB 12. Nicola West C&VUHB 13. Norman Young C&VUHB 14. Lynne Garwood CTUHB 15. Michelle Price PTHB 8
7. Examples of impact from work relating to the different areas. Christopher Griffiths Consultant Nurse Learning Disabilities: Abertawe Bro Morgannwg University Health Board Impact on Definition Examples Patients Physical and psychological wellbeing Individuals return to normal functioning or experience a change of symptoms Improved the patient and family/carer experience of healthcare through developing policy and guidance that promotes better care and support when using hospital services. Quality of life (QoL) and social wellbeing Patient behaviour Experience of healthcare Improving an individual s QoL and self-efficacy, specifically the impact the disease has on activities of daily living Influencing outcomes relating to patient behaviour Influencing patient experience of healthcare services Promotes patient involvement in their care and treatment. Working with Primary and Acute care staff to improve communication and promote understanding of health and health services. Encouraging patients to take a more active role in the management of their health care through improving their understanding of their health and health services. Enable patients with learning disabilities to better cope with their experience of hospital services by promoting good practice through a range of training and acute pathway work. The work helps patients through facilitating understanding, improving communication and reducing anxiety when using hospital services. Facilitate focus groups on Health Promotion for people with learning disabilities enabling individuals to change health behaviours and choose a healthier lifestyle. Improving the patient with learning disabilities experience of healthcare through acute hospital pathway development and staff education and training. This directly affects the patient s experience as staff are more adequately equipped and confident when working with people with learning disabilities. 9
Staff Competence Influence on the competence of the healthcare workforce Provide statutory/mandatory training to nurses across the Health Board on learning disabilities and the Acute Hospital Pathway/Bundle. Quality of working life Work distribution and workload Team working Influence on quality of work experience in the healthcare workforce Impact on staff societal outcomes such as the work distribution, turnover and workload of other staff. Impact on effective team working across organisational and professional boundaries leading to provision of high quality care. Provide bespoke training to specific clinical areas across the Health Board on matters relating to learning disabilities. Provide advice, guidance and consultancy to other Health Boards across Wales to promote the use of the Learning Disabilities Hospital Care Bundle. Contracted 1 day per week with Swansea University to provide pre and post registration education across the Adult, Child and Mental Health fields of practice. Provide academic supervision to pre and post registration nurses within Swansea University and across the University Health Board. Provide consultancy across 3 health board areas on matters related to learning disability policy and practice. The acute hospital pathway work has enabled acute colleagues to better understand the nature of learning disabilities and provides a framework that improves practice and promotes confidence in working with this complex patient group. The acute pathway work is organised through a pathway implementation group. This is made up of professionals from Health, Social Care and Third sector employees and importantly has carer and self advocacy representation. Worked in collaboration with Pain Team, Dementia Team and Palliative Care Team in 10
Organisation Organisational priorities and targets Development of policy Meeting targets set by commissioners such as length of stay, waiting times and other organisational priorities or strategies. Impact on the development of policy (local / national) adapting a Pain Assessment tool for people with cognitive impairments who have difficulty in self reporting their pain. This tool has been adopted for use across the Health Board. The acute hospital pathway work contributes to the compliance for the Standards for Healthcare Services in Wales, in particular: Standard 1 Governance and Accountability Standard 2 Equality, Diversity and Human Rights Standard 3 Health promotion and Protection Standard 7 Safe and Clinically Effective Care Standard 8 Care Planning and Provision Standard 9 Patient Information and Consent Standard 11 Safeguarding Children and Vulnerable Adults Standard 18 Communicating Effectively Worked closely with the Welsh Government and Public Health Wales to develop an All Wales Care Bundle for people with learning disabilities when using acute hospital services. Developed a Pathway and Care Bundle for people with learning disabilities when using hospital services for use across the Health Board. This work led on to the All Wales Care Bundle for people with learning disabilities referred to above. 11
Generation of new knowledge Impact on the generation of new knowledge through involvement in research Member of the Learning Disabilities Directorate Clinical Effectiveness, Audit and Research (CLEAR) group. Member of the Learning Disabilities Directorate Research group. Member of the Health Board s Nursing Education, Practice Innovation & Research Group. Worked with Bristol University Norah Fry Research Centre as part of an overview panel that carried out a confidential inquiry into the premature deaths of people with learning disabilities when admitted to acute hospitals (published 2013). Judith Morgan Consultant Nurse in Emergency Care: Abertawe Bro Morgannwg University Health Board Impact on Definition Examples Patients Physical and psychological wellbeing Individuals return to normal functioning or experience a change of symptoms I am the clinical lead for minor injury unit. In 2013 34143 new patients attended the unit of which 26263 presented with minor injuries and were treated by the emergency nurse practitioners (ENPs). Within my clinical role, I: Consulted with 1485 new patients On a daily basis consulted about patients by ENPs, triage nurses and HCSWs. This included offering reviewing x-rays, reviewing patients, advising on appropriate management of patients with minor injuries, deep vein thrombosis and conditions outside scope of the unit. Consulted with 1263 in my minor injury review clinic, held 3 times a week. Patients seen are those with potential fractures and injuries too acute to be 12
Quality of life (QoL) and social Improving an individual s QoL and self-efficacy, specifically the impact the disease has on activities of daily living examined on day of attendance. Part of the review includes assessing the quality of the ENP examination, documentation as well as reviewing the x-ray. Patients can be referred for bone scans, ultrasounds, MRI, CT scans or blood tests. Following the consultation the ENPs are provided with written feedback on every patient which includes patient outcomes, capture of pertinent information as well as highlighting deficits in documentation and assessments. During the reviews any clinical risks identified are managed and necessary actions taken such as informing staff of identified risk and actions to be taken, completing incident forms and raising concerns to senior managers. In 2014, patients are now asked about their impression of the service they received the finds will be presented in 2015 s report. Reviewed in excess of 2704 x-ray reports and took action as required which included calling patients to my clinic for review, ensuring patients attended the appropriate fracture clinic, identifying 59 missed fractures and recalling patients for treatments and referring to fracture clinic, maintaining a data base of missed fractures & informing ENP of the miss. Reviewed 372 cards of patient who re-attended the unit. The reason for re-visit included: casting problems such as cast too loose or became wet, dressing got wet or leak through. No recall of patient s was required following review. Investigate and provide opinion on complaints or incidents generated from the unit. Outcomes from which are reported to the individuals involved and are included in staff feedback at meetings and inform future training and service development. Continued to lead on the development and refining of the DVT pathway for lower limb clots. The pathway has: a) reduced number of attendances for patients b) reduced time delays for each visit c) prevented admissions as the pathway has developed in 5 stages and commenced in the GP service and involved community resource team, minor injury unit, 13
wellbeing consultant physician, pharmacy anticoagulation clinic. Patient behaviour Experience of healthcare Influencing outcomes relating to patient behaviour Influencing patient experience of healthcare services During the consultations, health & injury advice is provided written and oral which not only provides information for this injury but also informs management of future injuries. Developed patient information leaflets to ensure that advice supplied is up to date and evidence based; all developments are reviewed by patient experience team and translated into Welsh. This relates to the advice given above and would include management of further injuries and importance of application of ice, not delaying attendance for wound management; use of analgesia and anti-inflammatories, importance of exercise. In 2013, 2 patient satisfaction surveys: 1. Purposive survey of 39 consecutive patients in my clinic. Response rate 74.4%. Findings: 21 (72.4%) scored 10/10; all but 1 score 7/10 ; care commented on as very professional, caring, excellent, welcoming and friendly, quick, good quality. Things that could improve included increasing the number of consultant nurses; more toilets; provide drinks machine. 2. Purposive study 5 patients per day - 100 total. Response rate 69 (69%); 98% (n=51) stated they would recommend the service to others; 75% (n=57) scored 10/10; 100% scoring 6. Glowing report with comments: service excellent, could not be improved, NHS at best, nurses were professional, friendly, kind, considerate, good communicators, speedy and efficient. Things that could be improved: information on waiting times and switch on TV. In 2014, started to ask patients on discharge from my clinic what they felt about the 14
service, to date overwhelming satisfaction with the service they have received. Staff Competence Influence on the competence of the healthcare workforce In my role as educator I: Provide written feedback to ENPs, triage nurses and health care support workers on clinic patients: highlighting capture of important assessment and documentation criteria; patient outcome and patient satisfaction. This assists the practitioner to see the quality of the care that they provide, also documented are the comments from the patient about the care that they received. When approach for advice, consultations are used an opportunity to educate about patient care and management Provide sessions at Cardiff University for radiography students and radiographer reporting courses which look at a) history taking and mechanism of injury with common complaints b) role of consultant practitioner. Feedback from the students is that the sessions are good and I am consequently asked to repeat them yearly. Co-manage All Wales ENP Network, delivering quarterly educational days. Study days are attended by ENPs from all over south and west Wales and ENPs from North Wales have recently joined. The feedback is that the group value the sessions provided as well as having the opportunity to networking and share practice and learn from experiences. anonymised interesting cases, complaints and incidents are a regular feature of the day. Training programmes or sessions have been developed from findings of clinical incidents and complaint investigations. Sessions have been delivered for both emergency nurses and ward nurses and have been very well evaluated with 15
Quality of working life Work distribution and workload Influence on quality of work experience in the healthcare workforce Impact on staff societal outcomes such as the work distribution, turnover and workload of other staff. participants detailing the ways in which their practice has changed. Two trainee ENPs are developing very quickly into competent practitioners following an educational programme, clinical supervision and assistance in portfolio development. Quality of the consultations of both ENPs and triage nurses can be clearly visualised in their record keeping, patient satisfaction, low numbers of missed fractures and complaints. This has been achieved through continual assessment and feedback. Development of injury specific audit tools has provided a framework for trainee ENPs to use as guide for their consultation. These tools are used to assess the competence of the trainee ENPs. The mentors have stated that undertaking this process of structured assessment has highlighted weaknesses in their documentation and they too have improved capture in assessment and documentation. Provide both positive and constructive feedback to nursing team. Identify issues and try to solve or ease problems examples include streamline pathway for patient with deep vein thrombosis. It is well documented that there are an inadequate number of doctors specialising in emergency medicine to sustain the number of major emergency departments in Wales, if I was not providing the clinical lead for the minor injury unit then the unit would require a consultant in emergency medicine to function. The unit has no recruitment or retention problems, with most nurses having served more than 10 years in the unit. posts have recently become available due to retirement and increase in workforce. No EN, triage nurse or health care 16
support worker has left for a new appointment in the last 10 years. Team working Impact on effective team working across organisational and professional boundaries leading to provision of high quality care. Monthly ½ day ENP educational sessions are provided for across the health board covering 2 EDs and the MIU. The sessions are seen as valuable as there is an opportunity to discuss interesting cases, review recent literature on specific injuries to ensure practice is up to date, clinical portfolio development sessions and review of incidents and complaints with key learning points identified. Privileged to be asked to undertake root cause analysis and protection of vulnerable adult incidents across the health board. Feedback provides states the reports are of a high quality and valuable. The learning points and recommended actions have been considered in the risk strategy meetings and normally instigated. From these an essential nursing one day course has been developed for ward nurses of all grades and has been very well received with feedback that practice has resultantly improved. Organisation Organisational priorities and targets Meeting targets set by commissioners such as length of stay, waiting times and other organisational priorities or strategies. The targets of care for the unit are: 4h target from time of arrival to time of discharge : 99.5% achieved All patients should have first contact within 15 minutes; due to an exponential rise in number of attendances over 18 months (range 10 to 65% when comparing months 2031 to 2012 and range 30 to 70% when comparing first 6 months 2014 to 2012) this target has been adversely affected only around 30% meeting this target currently. A paper is currently being considered for extra staffing to enable this target to be met) 100% capture of assessment for domestic violence required. This has improved 17
Development of policy Impact on the development of policy (local / national) from 14% to 97% from Dec 2013 to June 2014. 100% of patients must have a pain score recorded on initial assessment: achieved: improved 6% to 73.5% from November 2013 to June 2014. 100% of patients who have a pain score of 2/3 recorded are offered pain relief. Represented CNMHP on the NLIAH Consultant Practitioner Review Steering Committee; a paper was developed which recommend that consultant practitioners were still required to enhance service development and practice. Represent CNMHP on RCN Life Long Learning Group which inform RCN Wales Council about initiatives and educational requirements. Board Member of the Faculty of Emergency Nursing, a national group that is defining competencies & accreditation for emergency nursing pan the UK. Co-lead for All Wales ENP Network Group which has agreed Standard for ENP Scope of practice, assessment document and audit tools for minor injuries for use pan Wales. Lead Nurse for Development of Patient Group Directives for Emergency Nurses within the Health Board. From this work I am now one of two nurse representatives on the PGD subgroup of Health Board Policy Medicines Group which review & agree PGD submitted from across the Health Board. As part of this work have developed an examination to ensure knowledge and understanding of using PGDs which meets NICE recommendations. Co Lead on an emergency care group from Welsh College of Emergency Medicine and emergency nurses determining the standard of education and practice for 18
advanced practitioners in emergency care. Generation of new knowledge Impact on the generation of new knowledge through involvement in research Lead on CNMHP research Delphi study into What Professionalism means for Nurses and Midwives in Wales from which a questionnaire has been developed that facilitates individuals and the organisation identifying how professional they and their services are. This research informed the Welsh Government Free to Care, Free to Lead Professionalism Subgroup. 4 papers have been identified for write up, from which Paper 1 has been submitted for publication. The questionnaires have been submitted to the NMC for consideration as a part of the re-registration process. 19
Jackie Austin Nurse Consultant Heart Failure and Cardiac Rehabilitation Services: Aneurin Bevan University Health Board Impact on Definition Examples Patients Physical and psychological wellbeing Individuals return to normal functioning or experience a change of symptoms During the last two years several projects have been used as a precursor to improving patient care for example;.1) A NC led Community Parenteral Diuretic Service for Patients with End Stage Heart Failure following referral criteria patients with decompensated heart failure are reviewed either at home or in an outpatient clinic by the Community Nurse Specialist for Heart Failure to see if they would benefit from an adjustment in oral medication or to receive parenteral diuretics (Furosemide IV/SC) at home. Distressing symptoms are resolved and anxiety is reduced through treatment and support targeted to keep patients within their home environment. Family members feel better supported and the anxiety of hospital visiting is absolved. Patients demonstrate Improved confidence and a reduction in distress through partnership working. The service works closely with palliative care, GP s, Frailty Teams and District Nurses 2) An externally funded two year project using an Acute HF Nurse Specialist at RGH: the aim of which is to reduce readmissions and length of stay of patients with heart failure by enhancing timely discharge and appropriate follow-up March 2013-15. The first year report demonstrated favourable results in terms of the delivery of evidence based care whilst the patient was in hospital and triaged follow up by the local HF Nurse. Quality of life (QoL) and social wellbeing Improving an individual s QoL and self-efficacy, specifically the impact the disease has on activities of daily living The majority of patients with stable heart failure (in four of the five Localities) now have the opportunity to attend Cardiac Rehabilitation; functional status improves along with the ability to undertake activities of daily living, return to work (if applicable) and enhance their QoL and reduce cardiac risk factors. NC led Service protocols and coherent patient pathway documentation underpin the 20
Patient behaviour Experience of healthcare Influencing outcomes relating to patient behaviour Influencing patient experience of healthcare services service Seen early after the diagnosis working in partnership with, and supporting the patient with self care is vitally important. Early detection and treatment of deterioration is an important component in keeping cardiac patients out of hospital. Patients are encouraged to use a locally designed traffic light tool against which they are able to monitor symptoms and know when to seek advice/help. Patient stories are used to improve the patient journey from diagnostics to NC led; inpatient care, clinics cardiac rehabilitation and home visits. Using a patient story application, patients are able to record their stories on an ipad using digital prompts. Transcribed into video format they have been shown to patients/ the public/ Executive Board and the Cardiac Network. Examples of service improvement incude 1) the main carer being present when patients receive results of Angiography 2) follow up by a member of the CR team within 48hrs following PCI 3) choice of where to attend for CR Staff Competence Influence on the competence of the healthcare workforce Enhanced skill of health care professionals caring for the cardiac patient through the provision of education locally using team involvement and as Lead Nurse through the Cardiac Network Annual Primary Care Conference. Enhanced staff skills through involvement with various projects 1) Six month project to evaluate the efficacy of two CR nurses trained in Cognitive Behavioural Therapy in counselling patients suffering from reactive depression and anxiety 2)The NC is PI for ReAblement in Chronic Heart Failure (REACH-HF) ( a multi centre RCT 21
Quality of working life Work distribution and workload Team working Influence on quality of work experience in the healthcare workforce Impact on staff societal outcomes such as the work distribution, turnover and workload of other staff. Impact on effective team working across organisational and professional boundaries leading to provision of high quality care. evaluating the delivery of an evidence based cardiac rehabilitation manual at home), one of the CR nurses and a physiotherapist are patient facilitators for this fully funded research. 3) the NC is the local PI for a feasibility study reviewing Spiritual Care Support in Patients with End stage Heart Failure using trained volunteers. HF and CR nurses are involved in the training and the recruitment of patients. Increased knowledge and skills of CR professionals through NC involvement in the national competency framework and the All Wales Cardiac Rehabilitation and Heart Failure Working Group The NC is a mentor for the Nurse Consultant for HF Services Oxford (John Radcliffe) Job satisfaction/ well being and confidence is supported through bi monthly clinical supervision/ quarterly nurse forums and individual 6 monthly informal reviews for all nurses. An across HB MDT is held quarterly and an ABUHB team away day arranged annually Improved team working has led to cross cover across ABUHB for CR and HF. Project work has led to seconded posts bringing new ideas to the service and positive development leading to an increase in CNS posts and subsequent improvement in patient care There is Low staff turnover and sickness levels Enhanced team working; has improved continuity of care, recognises the importance of contributing and responding to national clinical audit data. 22
Organisation Organisational priorities and targets Development of policy Generation of new knowledge Meeting targets set by commissioners such as length of stay, waiting times and other organisational priorities or strategies. Impact on the development of policy (local / national) Impact on the generation of new knowledge through involvement in research NC leads on the Heart Disease Delivery Plan specifics for HF and CR across ABUHB. NC as lead nurse for the S Wales Cardiac Network raises the importance of taking part in National Audits and works to improve care pathways Achievement of evidence based care and nationally set targets through the use of national audit and NWIS data as a reference. A nurse within each team is responsible for collating and presenting data twice a year. Patient flow data through CR and HF are presented annually A -reduced 30 day readmission rate and length of stay as a result of NC review of inpatient care, nurse led clinics, CR and home management leading to service redesign through project/ research work to realise positive outcomes. The NC has an Influence on the national agenda in relation to CR and HF through the Cardiac Network and as a member on the Implementation Group for the Heart Disease Delivery Plan. Development of local / regional protocols and guidelines in partnership with all stakeholders As above current PI on two research projects: 1) REACH-HF ( portfolio -NISCHR supported) In partnership with the Penninsula Medical School (Cornwall), York and Birmingham Universities; a multi centre UK based study exploring various issues related to Cardiac Rehabilitation for patients with Heart Failure successful in obtaining from the National Institute for Health Research RP PG 1210 12004 ReAblement in Chronic Heart Failure (REACH-HF) to commenced Sept 2012. PI for the Feasibility NISCHR Portfolio supported Study commenced April 2014. RCT to 23
commence Jan 2015 2) Feasibility study on the use of trained volunteers to support spiritual care for patients in end stage heart failure (in partnership with South Wales University - Dr Linda Ross). 3) The evaluation of Parenteral Diuretic Therapy for Patients with Decompensating Heart Failure in the Community. British Heart Foundation Funding 2 yr project may 2011-13. Publications Austin J, Hockey D, Williams R, Hutchison S. (2013) Assessing parenteral diuretic treatment of decompensated heart failure in the community. British Journal of Community Nursing Vol 18, No 11 Ross L and Austin J (2013). Spiritual needs and spiritual support preferences of people with end stage heart failure and their carers: Implications for nurse managers. Journal of Nursing Management. DOI: 10.1111/jonm.12087 Awards: MBE in 2003 for services to cardiac rehabilitation PhD in 2003 24
Elizabeth Candy Consultant Physiotherapist: Aneurin Bevan Health Board Impact on Definition Examples Patients Physical and psychological wellbeing Individuals return to normal functioning or experience a change of symptoms I am the clinical lead for a multi-professional musculoskeletal (MSK) interface assessment team (MSKI) team and an outpatient musculoskeletal physiotherapy team. The primary purpose of my role as lead for the MSKI team is to ensure that patients with MSK conditions are given the best advice and treatment to ensure that they maintain and improve their quality of life. In addition we ensure that if patients require diagnostic investigations, manipulation, soft tissue or joint injections to relieve their pain and discomfort they are made available. Referral onwards to secondary care orthopaedic, rheumatology, pain or other services is also a pathway to consider. My role in outpatient physiotherapy is to ensure the quality of care for patients within the service and maintain standards of MSK physiotherapy practice by not only treating and assessing patients myself but acting as a clinical mentor/educator for the rest of the team. Quality of life (QoL) and social wellbeing Improving an individual s QoL and self-efficacy, specifically the impact the disease has on activities of daily living In order to assess the impact of MSK conditions on patient s lives we have introduced the routine use of patient reported outcome measures (PROMS) and patient reported experience measures (PREMs). I have recently undertaken a retrospective review of the patients discharged by the MSKI team to investigate if they return to secondary care services following discharge. Only 2% were found to have been referred on to secondary care following discharge from MSKI and 18% (10 patients) were offered a referral to secondary care by MSKI before they were discharged. I undertake regular service evaluations such as the outcome of MSKI referrals to secondary 25
Patient behaviour Experience of healthcare Influencing outcomes relating to patient behaviour Influencing patient experience of healthcare services care and the effectiveness of soft tissue and joint injections. Recent initiatives in the physiotherapy department have increased the awareness of the public health agenda with regard to physical fitness, exercise, weight loss and cessation of smoking. Patient information in all physiotherapy departments has been increase to support this and all physiotherapists are supported to ask patients when they come for assessment about their participation in regular exercise, weight management etc. Links with the NERs referral scheme are encouraged and work on participation levels in Back to Fitness and other class activities is also encouraged. A major part of the physiotherapy remit is to improve patient s levels of fitness and thus their overall quality of life. I undertake eight monthly patient experience surveys of the patient s seen in MSKI and the results of these suggest that the majority of patients are satisfied with their care. We also ask for comments from the patients and these enable us to make patient driven improvements to our facilities and care. A recent example of this is the provision of a new waiting area at one of our MSKI sites. Staff Competence Influence on the competence of the healthcare workforce In my role as mentor/educator and support for the MSKI and physiotherapy team I: Provide regular MDT interactive training sessions with e.g. Radiology and other secondary care services sucj as orthopaedics, pain and rheumatology. Supervision and training of new clinical specialist to prepare them for working in extended role clinical situations. Observed practice and peer review with the team. 26
Clinical reasoning sessions with the team Quality of working life Work distribution and workload Team working Influence on quality of work experience in the healthcare workforce Impact on staff societal outcomes such as the work distribution, turnover and workload of other staff. Impact on effective team working across organisational and professional boundaries leading to provision of high quality care. In my role as team lead I have conducted a survey of clinicians, managers and directors perceptions of the roles of the MSKI clinics with a view to finding clarification of the role of the team members both within the clinics and the organisation as a whole. I provided additional support, mentoring and clinical reasoning to the mainstream team when there are team changes. The clinic structure is essentially stable but there are times when clinical need demands additional appointment time. This requires a degree of flexibility from both the staff and the administrative team in order that the team both meets the performance expectations but more importantly provides a high quality service for our patients. My role is to ensure that a balance between the clinical and operational demands it maintained. Locally We have quarterly team meeting for the MSKI team this ensures that the MSKI team are regularly updated on changes, results of evaluation and audit and provides a forum for all the professions in the clinical team to meet and exchange views. The Physiotherapy Musculoskeletal Executive Team also meet quarterly this team is both clinical and management and overviews both the MSKI team and the physiotherapy mainstream team. ABUHB are working on a pathway to improve patient quality for those people on the total knee replacement pathway and the physiotherapy role in this pathway is vital not just to ensure the right patients are seen in orthopaedic clinics but to improve their 27
Organisation Organisational priorities and targets Development of policy Meeting targets set by commissioners such as length of stay, waiting times and other organisational priorities or strategies. Impact on the development of policy (local / national) fitness for surgery and their recovery rate following surgery. Member of the ABUHB research scrutiny committee Nationally I am the chair of the UK physiotherapy consultants group which meets twice a year we have recently written a document giving an overview of the physiotherapy consultants nationally. I am a member of the Chartered Society of Physiotherapy Quality and Assurance group I am also of the Physiotherapy Welsh Board Physiotherapy Expert Clinical Advisor to the Parliamentary Ombudsman The internal target for the first assessment in the MSKI team is 6 weeks there are very few occasions when this target is not met. It is also hoped that reducing the demand for outpatient appointments on the secondary care MSK services allows the ABUHB to meet their targets. The target for an urgent mainstream physiotherapy department is 10 days which is now rarely exceeded and a WAG routine appointment time of 14 weeks is recognised as the target. Over the last few years the team has worked extremely hard and we are normally achieving our targets The development of a protocol for the physiotherapy management of suspected cauda equina. 28
Generation of new knowledge Impact on the generation of new knowledge through involvement in research Member of the ABUHB PGD implementation committee Member of the CSP QAE committee Member of CNMHP project team conducting a research Delphi study into What Professionalism means for Nurses and Midwives in Wales. Piloting a questionnaire on professionalism which has been developed that facilitates individuals for physiotherapists. Member of the ABUHB research scrutiny panel Peer reviewer for Physiotherapy Presentation at WCPT conferences 2007 and 2011- abstracts are being submitted for WCPT 2015 29
Sian Thomas Consultant Nurse Community Child Health: Aneurin Bevan Health Board Impact on Definition Examples Patients Physical and psychological wellbeing Individuals return to normal functioning or experience a change of symptoms Review of multi-agency assessment and agreement of respite nursing service for children with continuing care needs across ABUHB Scoping of health profile of LAC which will define the service specification for the LAC nursing service at ABHB thereby impacting on the physical and psychological health outcomes for LAC within ABUHB. Quality of life (QoL) and social wellbeing Patient behaviour Experience of healthcare Improving an individual s QoL and self-efficacy, specifically the impact the disease has on activities of daily living Influencing outcomes relating to patient behaviour Influencing patient experience of healthcare services As part of the Carers Strategies (Wales) Measure I am chair of the young carers multiagency sub group. Aim is to raise awareness of young carer needs and rights and provide appropriate information and advice to support young carers in their roles across ABUHB partnership area. This will hopefully make a positive difference to the young carer and their ability to cope with their caring role and influence their ability to engage with education and leisure activities. Raising awareness of the needs of young carers with professionals should impact on identification of carers and enable early intervention/support. Working with the Paediatric Specialist nurses for epilepsy on establishing outcome measures relating to patient behaviour and evidence impact of their role. Reviewing parent and professional view regarding joint assessment, planning and review process (that involve the parents/carers)for children/young people with a disability using the MAPIT tool to improve standard and develop a consistent approach across ABUHB thereby improving parent satisfaction and understanding of services and condition. Implemented the 15 Step Challenge in children and young people inpatient services - the 15 Steps Challenge is a tool to help staff, service users and others to work together to identify improvements that will enhance the patient experience. The Challenge involves a ward walk around, seeing the ward through the eyes of a child or young person and 30
parent/carer. The 15 step challenge team consists of a young person and /or a carer, a staff member from another clinical area and hospital board member; who undertake a walk around and take note of their first impressions of the care setting and whether this develops confidence and trust. Following the ward walk around. The 15 Steps Challenge team co-ordinator feeds back findings to the clinical leaders, which focuses on both good practice and areas for improvement. This process is then repeated on a regular basis. Developed a digital story of a mother s experience of the continuing care process and the respite service delivered by the CCNS and the impact on her family life has been shown to Senior managers in Health & Social Care, Children s Commissioner s office, CCNS staff and will be shown the Executive Board and used for teaching at Universities. Staff Competence Influence on the competence of the healthcare workforce Oversaw/influenced training for professionals on the rights and needs of young carers that is to be delivered to health, social care and education staff across the partnership. Quality of working life Work distribution Influence on quality of work experience in the healthcare workforce Impact on staff societal outcomes such as the work distribution, turnover and workload of Co-ordinated a workshop to launch and raise awareness of the ABUHB Continuing Care Policy for Children and Young in light of the publication of the Guidance for Children and Young People s Continuing Care (WG 2014). Working with specialist nurses to develop performance indicators in relation to their services. Work with staff well-being service to provide clinical supervision to a team who deliver a complex care package in the home to a child requiring long term ventilation covering aspects such as clinical skills, professionalism/ boundary issues, delivering care in community setting. The aim is to provide staff support, minimise staff issues and improve staff retention. Working with the paediatric epilepsy nurse specialist to review role, define criteria of service and establish outcome measures this will help re-define their workload, establish a 31
and workload other staff. clear pathway for a child with epilepsy and strengthen team working with acute and community nursing services and partners Team working Organisation Organisational priorities and targets Development of policy Generation of new knowledge Impact on effective team working across organisational and professional boundaries leading to provision of high quality care. Meeting targets set by commissioners such as length of stay, waiting times and other organisational priorities or strategies. Impact on the development of policy (local / national) Impact on the generation of new knowledge through involvement in research Reviewing parent and professional view regarding joint assessment, planning and review process (that involve the parents/carers)for children/young people with a disability using the MAPIT tool to improve standard and develop a consistent approach across ABUHB. Work with multi-agency partners to review complex care packages/multi-agency assessments for children/young people who have continuing care needs. As part of the Carers Strategies (Wales) Measure evidence and report to Welsh Government in relation to outcome measures for young carer services within ABHB Divisional lead (with Nurse Consultant colleagues) for collating the Family & Therapy Division response for elements of Standards for Health Services in Wales and ABUHB Nursing Strategy Led ABUHB response to WG in relation to the consultation for All Wales Continuing Care Guideline for Children and Young People Benchmarked nationally on HCSW guidance in relation to administering medication in community. Working on developing a policy within ABUHB regarding HCSW administering medication to continuing care children in community setting. Principal investigator undertaking a 3 yr study to evaluate family centred services delivered within an integrated children s centre for children with complex disability Completed a economic evaluation of a nursing innovation for children with continuing health care needs (RCN/OPM) 32