Susan Procter

Success and failure in integrated models of nursing for long term conditions: Multiple case studies of whole systems

BACKGROUND Current projections indicate that the UK faces a 252% increase in people aged over 65 with one or more long term conditions (LTC) by 2050. Nurses, managing their own caseloads and clinics, working across sectors and organisational boundaries and as part of a wider multi-disciplinary team, are frequently seen as key to managing this growing demand. However, the evidence base informing the nursing role in managing LTC, the most effective configuration of the multi-disciplinary team and the policy evidence relating to the infrastructure required to support cross organisational working, remains weak. OBJECTIVES To explore, identify and characterise the origins, processes and outcomes of effective chronic disease management models and the nursing contributions to such models. DESIGN Case study whole systems analysis using qualitative interview methods. SETTINGS Two community matron services, two primary care (GP) practice nursing services, two hospital based specialist nursing services were purposefully sampled from across England and Wales. PARTICIPANTS Selection criteria were derived using a consensus conference. The nurses in the service, all patients and carers on the caseload, members of the multi-disciplinary team and stakeholders were invited to participate. METHODS Semi-structured interviews with all participants, thematic analysis within a whole system framework. RESULTS The study found high levels of clinical nursing expertise which in the case of the community matrons was meeting the aim of reducing hospital admissions. Both the primary care and hospital nurse specialist indicate similar levels of clinical expertise which was highly valued by medical colleagues and patients. Patients continued to experience fragmented care determined by diagnostic categories rather than patient need and by the specific remit of the clinic or service the patient was using. Patient data systems are still organised around the impact on services and prevalence of disease at an individual level and not around the patient experience of disease. CONCLUSION Nurses are making a major contribution to meeting the policy objectives for long term conditions. Primary care nurses and hospital nurse specialists do broadly similar roles. The scope of the nursing roles and services studied were idiosyncratic, opportunistic and reactive, rather than planned and commissioned on an analysis of local population need.

A case study of asthma care in school age children using nurse-coordinated multidisciplinary collaborative practices

Aim To describe the role of school nursing in leading and coordinating a multidisciplinary networked system of support for children with asthma, and to analyze the strengths and challenges of undertaking and supporting multiagency interprofessional practice. Background The growth of networked and interprofessional collaborations arises from the recognition that a number of the most pressing public health problems cannot be addressed by single-discipline or -agency interventions. This paper identifies the potential of school nursing to provide the vision and multiagency leadership required to coordinate multidisciplinary collaboration. Method A mixed-method single-case study design using Yin’s approach, including focus groups, interviews, and analysis of policy documents and public health reports. Results A model that explains the integrated population approach to managing school-age asthma is described; the role of the lead school nurse coordinator was seen as critical to the development and sustainability of the model. Conclusion School nurses can provide strategic multidisciplinary leadership to address pressing public health issues. Health service managers and commissioners need to understand how to support clinicians working across multiagency boundaries and to identify how to develop leadership skills for collaborative interprofessional practice so that the capacity for nursing and other health care professionals to address public health issues does not rely on individual motivation. In England, this will be of particular importance to the commissioning of public health services by local authorities from 2015.

Professional Executive Committees: What Do They Do?

This article examines the contribution of Professional Executive Committees (PECs) to Primary Care Trusts (PCTs). It looks at the balance of clinical and corporate discussions in PEC meetings, and how their contribution and functions are perceived by PEC members and other PCT personnel.

Increasing systemic capacity to respond to child and adolescent mental health needs using reciprocal knowledge transfer with parents

Background: Knowledge is recognized as a crucial organizational resource, which it has been suggested, increases in value through use. However, tensions exist between applying generalized scientific and academic knowledge to practice and incorporating local, experiential and tacit understanding in our knowledge base for practice. Knowledge management and transfer are frequently advocated as the means to increase service capacity within existing resource levels. In the NHS knowledge management and transfer tends to adopt a social constructivist approach, which favours the application of scientific evidence to practice, consequently the tacit and experiential knowledge of practitioners and service users is often excluded from formal knowledge-transfer processes. Aim: This paper describes a systematic process that was used to formalize tacit nursing knowledge in child and adolescent mental health (CAMH) and link it into the pre-existing scientific and academic literature. Method: The paper goes on to describe how this process was modified and transferred to work with parents of children referred to CAMH services. Findings: The paper illustrates the differing strands of pre-existing scientific and academic knowledge valued by nurses and parents. It highlights how involving service users in identifying scientific and academic knowledge that they find useful can focus attention on strands of pre-existing knowledge previously overlooked by professionals and service providers and thus enhance the value of this knowledge as an organizational resource. The paper also demonstrates how the tacit and experiential knowledge of nurses and services users can be transformed into more formalized knowledge, which can then be incorporated into organizational knowledge-transfer processes.

Scoping the role and education needs of practice nurses in London

Aims To identify education priorities for practice nursing across eight London Clinical Commissioning Groups (CCGs); to identify the education, training, development and support needs of practice nurses in undertaking current and future roles. BACKGROUND The education needs of practice nurses have long been recognised but their employment status means that accessing education requires the support of their GP employer. This study scopes the educational requirements of the practice nurse workforce and working with educational providers and commissioners describes a coherent educational pathway for practice nurses. METHOD A survey of practice nurses to scope their educational attainment needs was undertaken. Focus groups were carried out which identified the education, training, development and support needs of practice nurses to fulfil current and future roles. Findings A total of 272 respondents completed the survey. Practice nurses took part in three focus groups (n=34) and one workshop (n=39). Findings from this research indicate a practice nurse workforce which lacked career progression, role autonomy or a coherent educational framework. Practice nurses recognised the strength of their role in building relationship-centred care with patients over an extended period of time. They valued this aspect of their role and would welcome opportunities to develop this to benefit patients. CONCLUSION This paper demonstrates an appetite for more advanced education among practice nurses, a leadership role by the CCGs in working across the whole system to address the education needs of practice nurses, and a willingness on the part of National Health Service education commissioners to commission education which meets the education needs of the practice nurse workforce. Evidence is still required, however, to inform the scope of the practice nurse role within an integrated system of care and to identify the impact of practice nursing on improving health outcomes and care of local populations.

General practice nurses report minimal support as one obstacle to implementing self-management strategies for long-term conditions

Commentary on: Kennedy ARogers ABowen Ret al. Implementing, embedding and integrating self-management support tools for people with long term conditions in primary care nursing: a qualitative study. Int J Nurs Stud 2014;51:1103-13. Implications for practice and research Self-management support for patients with long-term conditions is not seen as a priority within the current structures and procedures of primary care nursing. The few nurses who implement aspects of self-management support have been confident enough to disrupt the prevailing system and spend time on hidden work. However, they could only initiate conversations and were not able to sustain interactions sufficiently to support lifestyle change. Supporting patients with lifestyle changes necessary to self-manage long-term conditions requires changes in primary care nursing.

Models for quality improvement and assurance in English and Welsh primary care

Background: Various initiatives have been tried to improve the quality of primary care in England and Wales in the last fifteen years. Such initiatives can be divided into quality improvement (QI) and quality assurance (QA). Purpose: This paper looks at three contrasting models, drawn from data from 48 semistructured interviews with personnel from three primary care organisations (PCOs): two primary care trusts in England and one Local Health Board in Wales. Findings: The first model was collegiate, a voluntary doctor-led initiative begun during the period of GP fundholding. The second is clinical governance, a current government-imposed system administered by PCO officers, which has attracted limited engagement from GPs. The third is the Quality and Outcomes Framework of the new GP contract, which was generally described positively, although the process of administering it was experienced as bureaucratic. Discussion: The three models correspond with three organisational types: networks (which use peer relationships to achieve goals), hierarchy (which use ‘top-down’ requirements and monitoring) and market (which use contracts). Although doctors have traditionally preferred network-style arrangements, the success of these arrangements in sustained QA and QI has been questionable. The importance of hierarchical arrangements is inevitable, given the functions and constitution of PCOs, and the risk that GPs will disengage is similarly inevitable. However, it is important that PCO officers find ways to engage GPs as much as possible in quality initiatives if patient services are to improve.