Nursing notes on a scandal.

10 years on from the publication of the Francis report, the nursing profession is facing unprecedented challenges; Robert Francis has recently sounded the alarm that the NHS is currently facing 'the Mid Staffordshire scandal playing out on a national level'. In this perspective, we consider the opportunities missed in the last decade in the attempt to secure safe staffing in nursing.

Investigating the impact of financial concerns on symptoms of depression in UK healthcare workers: data from the UK-REACH nationwide cohort study.

BACKGROUND: Exploration of the association between financial concerns and depression in UK healthcare workers (HCWs) is paramount given the current 'cost of living crisis', ongoing strike action and recruitment/retention problems in the National Health Service. AIMS: To assess the impact of financial concerns on the risk of depression in HCWs, how these concerns have changed over time and what factors might predict financial concerns. METHOD: We used longitudinal survey data from a UK-wide cohort of HCWs to determine whether financial concerns at baseline (December 2020 to March 2021) were associated with depression (measured with the Public Health Questionnaire-2) at follow-up (June to October 2022). We used logistic regression to examine the association between financial concerns and depression, and ordinal logistic regression to establish predictors of developing financial concerns. RESULTS: A total of 3521 HCWs were included. Those concerned about their financial situation at baseline had higher odds of developing depressive symptoms at follow-up. Financial concerns increased in 43.8% of HCWs and decreased in 9%. Those in nursing, midwifery and other nursing roles had over twice the odds of developing financial concerns compared with those in medical roles. CONCLUSIONS: Financial concerns are increasing in prevalence and predict the later development of depressive symptoms in UK HCWs. Those in nursing, midwifery and other allied nursing roles may have been disproportionately affected. Our results are concerning given the potential effects on sickness absence and staff retention. Policy makers should act to alleviate financial concerns to reduce the impact this may have on a discontent workforce plagued by understaffing.

Implementation and perceived impact of the SWAN model of end-of-life and bereavement care: a realist evaluation.

OBJECTIVES: To evaluate the End-of-Life and Bereavement Care model (SWAN) from conception to current use. DESIGN: A realist evaluation was conducted to understand what works for whom and in what circumstances. The programme theory, derived from a scoping review, comprised: person and family centred care, institutional approaches and infrastructure. Data were collected across three stages (May 2021 to December 2021): semi-structured, online interviews and analysis of routinely collected local and national data. SETTING: Stage 1: Greater Manchester area of England where the SWAN model was developed and implemented. Stage 2: Midlands. Stage 3: National data. PARTICIPANTS: Twenty-three participants were interviewed: Trust SWAN leads, end-of-life care nurses, board members, bereavement services, faith leadership, quality improvement, medicine, nursing, patient transport, mortuary, police and coroners. RESULTS: Results from all three stages were integrated within themes, linked to the mechanisms, context and outcomes for the SWAN model. The mechanisms are: SWAN is a values-based model, promoting person/family-centred care and emphasising personhood after death. Key features are: memory-making, normalisation of death and 'one chance' to get things right. SWAN is an enablement and empowerment model for all involved. The branding is recognisable and raises the profile of end-of-life and bereavement care. The contextual factors for successful implementation and sustainability include leadership, organisational support, teamwork and integrated working, education and engagement and investment in resources and facilities. The outcomes are perceived to be: a consistent approach to end-of-life and bereavement care; a person/family-centred approach to care; empowered and creative staff; an organisational culture that prioritises end-of-life and bereavement care. CONCLUSION: The SWAN model is agile and has transferred to different settings and circumstances. This realist evaluation revealed the mechanisms of the SWAN model, the contextual factors supporting implementation and perceived outcomes for patients, families, staff and the organisation.

Do advanced clinical practitioners have the theoretical knowledge to authorise blood components for transfusion? A cross sectional survey Study.

AIM: The aim of this study is to investigate whether non-medical authorisers of blood component transfusion, in a single centre working at an advanced level, have the theoretical knowledge to potentially undertake this task safely. BACKGROUND: Authorisation of blood components for transfusion has predominantly been a medical role in the United Kingdom. Advanced Clinical Practitioners (ACP) are increasingly undertaking this role in order to maintain timely transfusion care. DESIGN: A cross sectional study design was utilised for this study which was conducted between 05th March 2018 and the 4th of April 2018. METHODS: A total of 81 participants (49 medical authorisers and 32 Advanced Clinical Practitioners of which 21 were nurses and 11 were Allied Healthcare Professionals) working in a single centre completed the BEST-TEST, a previously validated knowledge assessment tool (Transfusion, 54, 2014, 1225). This study's methods were compliant with the STROBE Checklist. RESULTS: The overall mean was 8.74 out of a possible 20 questions. Doctors scored higher within the basic science domain compared to Advanced Clinical Practitioners (p = .01). This study found the method of training received by its participants was statistically significant with those receiving formal training scoring more than those who had received on the job training from their colleagues (p = .02). When all specialities were compared for differences with the mean correct scores a statistically significant difference was found (p = .01). CONCLUSION: This study demonstrates there is no statistically significant difference in transfusion medicine knowledge between professional subgroups working in a single centre. Furthermore, there is deficits in the knowledge of all subgroups. RELEVANCE TO CLINICAL PRACTICE: With advanced practice roles expanding, it is essential that we realise their full potential. There is no current research examining knowledge of ACPs, who could potentially authorise blood components for transfusion, but there are some clear benefits for clinical practice such as providing safe, timely and patient centred care.

Examining the impact of Diabetes Inpatient Specialist Nursing in acute trusts in London.

AIMS: To examine if the introduction of Diabetes Inpatient Specialist Nurses impacted on length of stay and rates of readmission. DESIGN: Knowledge discovery through data mining as part of a larger realist evaluation of the role. METHODS: Data from January 2017 to January 2019 was extracted and examined. A subset of performance data from July 2017-November 2018 was analysed. This consisted of 7320 records for Hospital Episode Statistics and 272 incident reports (Datix). The data were analysed via Generalised Linear Model regression routines in R. Analysis of readmission rates utilized binary logistic regression, while for the Length of Stay a count regression method was employed. RESULTS: Four trusts were found to have complete and rich data sets. All Trusts that returned complete data were found to have varying decreased length of stay and reduced readmission rates. In two trusts there were significant decreases in patient readmissions and length of stay after the introduction of the Diabetes Inpatient Specialist Nurses. A marked decrease (approximately half) in patient length of stay was found in one London trust after the introduction of the post. Issues with data quality were noted. CONCLUSION: Reduced patient length of stay and rate of readmission were found since introduction of Diabetes Specialist Nurses. Patient safety data was incomplete and varied significantly between trusts. IMPACT: The project sought to understand the impact of employing Diabetes Inpatient Specialist Nurses in hospitals in London. Overall, the specialist nurses helped reduce length of stay and the rate of readmissions. The research will have an impact on the workforce in diabetes and also people with diabetes who need hospital care.

Modeling the Multiple Sclerosis Specialist Nurse Workforce by Determination of Optimum Caseloads in the United Kingdom.

BACKGROUND: It is estimated that there are more than 100,000 people in the United Kingdom who have multiple sclerosis (MS). Patient experience and outcome are improved by access to a specialist nursing service. The aim of this study was to perform demand modeling to understand the need for MS nursing interventions, and thus inform modeling of the future UK MS nursing workforce. METHODS: Existing national data and specific workload and service data were collected from 163 MS specialist nurses who completed a questionnaire on activity and complexity of work both done and left undone. RESULTS: Data were received from across all of the United Kingdom. Twenty-nine percent of respondents were specialist nurses in the field for 3 years or less. Unpaid overtime was regularly performed by 83.4% of respondents. The MS specialist nurse was part of all areas of the patient journey. Areas of work left undone were psychological interventions, physical assessments, social interventions/benefits, and recommending or prescribing medications. CONCLUSIONS: The current recommended caseload of 358 people with MS per full-time equivalent seems to be too high, with a considerable amount of work left undone, particularly psychosocial care. Factors such as travel time, complexity of caseload, changing drug therapies, and societal issues such as the benefits system contributed to driving demand/workload.

Implementation of advanced practice nursing for minor orthopedic injuries in the emergency care context: A non-inferiority study.

AIMS: To evaluate the implementation of advanced practice nursing for patients with minor orthopedic injuries, including comparison of outcomes in relation to advanced practice nurse versus standard (physician-led) care models. DESIGN: A non-inferiority study was performed in an emergency department in Norway, where advanced practice nursing is in an initial stage of implementation. The non-inferiority design was chosen to test whether the new advanced practice nursing model does not compromise quality of care compared to the standard care model already in use. METHODS: Patients with minor orthopedic injuries were assessed and treated by either advanced practice nursing or standard (physician-led) care models. Participating patients were assigned to the professional available at presentation. In the nursing model, registered nurses worked at an advanced level/applied advanced practice nursing following in-house-training. Senior orthopedic specialists evaluated the diagnostic and treatment accuracy in both models. Data were collected in a tool developed for this study, from May to October 2019. RESULTS: In total, 335 cases were included, of which 167 (49.9%) were assessed and treated in the nursing model. Overall, correct diagnosis was found in 97.3% (n = 326) of the cases, and correct treatment was found in 91.3% (n = 306) of the cases. In comparison of missed diagnosis between advanced practice nurse and the standard (physician-led) care model showed inconclusive results (risk ratio: 0.29, 95% CI: 0.06-1.36). In comparison of treatment outcomes, the results showed that the advanced practice nursing model was non-inferior (risk ratio: 0.45, 95% CI: 0.21-0.97). CONCLUSION: Advanced practice nursing care models can be used to diagnose and treat minor orthopedic injuries without compromising quality of care. Further implementation of the advanced practice nurse care model is encouraged.

Do working practices of cancer nurse specialists improve clinical outcomes? Retrospective cohort analysis from the English National Lung Cancer Audit.

BACKGROUND: Cancer nurse specialists are advanced practitioners who offer continuity of care and expert support for people diagnosed with specific cancers. Health Education England's Cancer Workforce Plan prioritises expansion of cancer nurse specialist numbers by 2021 as part of the Cancer Taskforce Strategy for England. OBJECTIVE: To assess whether working practices of advanced practice specialist nurses are associated with clinical outcomes for people with lung cancer. METHODS: Adults with non-small cell lung cancer followed from 30 days post-diagnosis in English secondary care were obtained from the English National Lung Cancer Audit, 2007 to 2011. A national survey of lung cancer nurse specialists provided information on self-reported working practices. Mortality and unplanned admissions from 30 days to 12 months post diagnosis were respectively analysed using Cox and Poisson regression. Outcomes were assessed according to patients' receipt of initial assessments by a lung cancer nurse specialist and according to trust-level reported working practices. Regression models were adjusted for individual sociodemographic and clinical characteristics, error adjusted for intracorrelations within regional cancer networks, and presented separately according to patients' treatment pathways (surgery, chemotherapy, radiotherapy, or no anti-cancer therapy). RESULTS: Data for 108,115 people with lung cancer were analysed and associations with mortality and unplanned admissions were infrequent. Among people receiving only radiotherapy, however, the hazard for death was 17% lower among those who received an assessment by a lung cancer nurse specialist, compared with no assessment (hazard ratio = 0.83, 95% confidence interval 0.73-0.94; p = 0.003). The hazard was also lower among those receiving surgery (hazard ratio = 0.91, 0.84-0.99; p = 0.028). Among those receiving radiotherapy, nurse specialists' reported confidence within multidisciplinary team settings was associated with a lower risk of death (hazard ratio = 0.88, 0.78-1.00; p = 0.049) and a lower rate of unplanned cancer-related admissions (incidence rate ratio = 0.83, 0.73-0.95; p = 0.007). Lung cancer nurse specialist assessments before/at diagnosis, were associated with a 5% lower rate of unplanned admissions, compared to when assessments occurred after diagnosis. CONCLUSION: The contribution of nurse specialist working practices was occasionally associated with better outcomes for people with lung cancer. These were not limited to a single treatment pathway, but do indicate discrete relationships within pathways. Our study provides initial measures of overall lung cancer nurse specialist working practices at trusts, however, more detailed studies with longitudinal measurement of lung cancer nurse specialist-patient interaction are needed to better ascertain impacts on long-term patient outcomes. The findings highlight opportunities for potential improvement in effectiveness of service and care management.

Workforce experience of the implementation of an advanced clinical practice framework in England: a mixed methods evaluation.

BACKGROUND: This study aims to understand how the implementation of the advanced clinical practice framework in England (2017) was experienced by the workforce to check assumptions for a national workforce modelling project. The advanced clinical practice framework was introduced in England in 2017 by Health Education England to clarify the role of advanced practice in the National Health Service. METHODS: As part of a large-scale workforce modelling project, a self-completed questionnaire was distributed via the Association of Advanced Practice Educators UK aimed at those studying to be an Advanced Clinical Practitioner or who are practicing at this level in order to check assumptions. Semi-structured phone interviews were carried out with this same group. Questionnaires were summarised using descriptive statistics in Excel for categorical responses and interviews and survey free-text were analysed using thematic analysis in NVivo 10. RESULTS: The questionnaire received over 500 respondents (ten times that expected) and 15 interviews were carried out. Advanced clinical practice was considered by many respondents the only viable clinical career progression. Respondents felt that employers were not clear about what practicing at this level involved or its future direction. 54% (287) thought that 'ACP' was the right job title for them. 19% (98) of respondents wanted their origin registered profession to be included in their title. Balancing advanced clinical practice education concurrently with a full-time role was challenging, participants underestimated the workload and expectations of employer's training. There is an apparent dichotomy that has developed from the implementation of the 2017 framework: that of advanced clinical practice as an advanced level of practice within a profession, and that of Advanced Clinical Practitioner as a new generic role in the medical model. CONCLUSIONS: Efforts to establish further clarity and structure around advanced clinical practice are needed for both the individuals practising at this level and their employers. A robust evaluation of the introduction of this role should take place.

Perceptions of the cancer care left undone in primary and community services: A mixed methods evaluation.

Primary and community care in the United Kingdom are under increasing workforce and time pressures. How these pressures affect the delivery of cancer care has rarely been explored. This service evaluation aimed to elucidate some of the views of the workforce in this sector of what work in cancer care is left undone, and what they would like to be able to offer more of. An exploratory sequential design was taken including a questionnaire and interviews asking primary and community care staff in London about their workload in cancer care. Surveys were analysed using descriptive statistics. The evaluation revealed a perception from primary and community care that there is work in cancer care that is currently being left undone. 64% of the workforce across all professions reported that they worked 10 or more hours of unpaid overtime per week. Respondents identified psychological care for people with cancer (PWC), and bereavement care for families and carers of PWC as the most common areas that were left undone. They would like to do more proactive work, in place of the current reactive 'fire-fighting' they are doing. For example, signposting available services to PWC and access to nutritional support. There was a desire for acknowledgement of the time and workforce pressures in primary and community care, and how these are hindering the delivery of care for PWC.

Using knowledge discovery through data mining to gain intelligence from routinely collected incident reporting in an acute English hospital.

PURPOSE: Incident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study explores if intelligence from such datasets could be used to improve quality, efficiency, and safety. DESIGN/METHODOLOGY/APPROACH: Incident reporting data recorded in one NHS acute Trust was mined for insight (n = 133,893 April 2005-July 2016 across 201 fields, 26,912,493 items). An a priori dataset was overlaid consisting of staffing, vital signs, and national safety indicators such as falls. Analysis was primarily nonlinear statistical approaches using Mathematica V11. FINDINGS: The organization developed a deeper understanding of the use of incident reporting systems both in terms of usability and possible reflection of culture. Signals emerged which focused areas of improvement or risk. An example of this is a deeper understanding of the timing and staffing levels associated with falls. Insight into the nature and grading of reporting was also gained. PRACTICAL IMPLICATIONS: Healthcare incident reporting data is underused and with a small amount of analysis can provide real insight and application to patient safety. ORIGINALITY/VALUE: This study shows that insight can be gained by mining incident reporting datasets, particularly when integrated with other routinely collected data.

An observational study on the rate of reporting of adverse event on healthcare staff in a mental health setting: An application of Poisson expectation maximisation analysis on nurse staffing data.

Evidence highlights the intrinsic link between nurse staffing and expertise, and outcomes for service users of healthcare, and that workforce retention is linked to the clinical and organisational experiences of employees. However, this understanding is less well established in mental health. This study comprises a retrospective observational study carried out on routinely collected data from a large mental healthcare provider. Two databases comprising nurse staffing levels and adverse events were modelled using latent variable methods to account for the presence of multiple underlying behaviours. The analysis reveals a strong dependence of the rate of adverse events on the location and perceived clinical demand of the wards, and a reduction in adverse events where registered nurses exceed 'clinically required levels'. In the first study of its kind, these findings present significant implications for nursing workforce policy and present an opportunity to not only improve safety but potentially impact nurse retention.

Implementation of advanced practice nursing for orthopaedic patients in the emergency care context - A study protocol for outcome studies.

AIM: To evaluate the implementation of advanced practice nursing in emergency care in Norway for patients with orthopaedic injuries, including hip fractures. The outcomes relate to quality of care and patient trust. DESIGN: A non-inferiority study comparing an advanced practice nursing care model with a standard (physician-led) care model. METHODS: Data will be collected from patient records and through the Patient Trust Questionnaire, completed by patients. The data will be analysed by descriptive and inferential statistics. Funding for the research was granted in 2015 and the regional ethical committee approved the current study in February 2019. DISCUSSION: In Norway and the other Nordic countries, advanced practice nursing is still in its infancy, especially in the emergency care context. This study will evaluate advanced practice nursing in this new context. IMPACT: The study will add to knowledge on the quality of care provided for orthopaedic patients with minor orthopaedic injuries or hip fractures as delivered by advanced practice nurses and physicians, respectively. It will also evaluate how well-advanced practice nursing is accepted by patients in this new context.

Does the Diabetes Specialist Nursing workforce impact the experiences and outcomes of people with diabetes? A hermeneutic review of the evidence.

OBJECTIVES: The aim of the hermeneutic review was to identify and clarify the mechanisms by which the Diabetes Specialist Nursing workforce affect the outcomes of diabetes patients, with a focus on those in the United Kingdom. A clarification of diabetes specialist nurses' work is necessary in understanding and improving diabetes inpatient care. DESIGN: The design is a hermeneutic evidence review and was part of a wider evaluation of Diabetes Inpatient Specialist Nurses for which the evidence was sourced. The literature search was limited to specialist nursing workforce caring for adults with diabetes. In order to gain global understanding of the impact of specialist nursing in diabetes, worldwide literature was included. METHODS: A hermeneutic literature review of 45 publications was carried out, which included citation analysis. Relevant literature was identified from 1990 to 2018. RESULTS: Evidence suggests that Diabetes Specialist Nurses educate patients and other healthcare professionals as well as delivering direct care. The outcomes of these actions include a reduced patient length of stay in hospital, reduced inpatient harms and complications, and improved patient satisfaction. Additionally, they are cost-effective. CONCLUSIONS: The Diabetes Specialist Nursing workforce is essential in diabetes care, particularly in hospital settings. They improve patient experience and outcomes.

Determining acute nurse staffing: a hermeneutic review of an evolving science.

BACKGROUND: Calculating nurse staffing in the acute hospital has become a key issue but solutions appear distant. Community, mental health and areas such as learning disability nursing have attracted less attention and remain intractable. This review aims to examine current approaches to the issue across many disciplines. DESIGN: The approach taken is iterative and in the form of a hermeneutic review. 769 pieces of evidence were reviewed from across disciplines such as nursing, medicine, engineering, statistics, population science, computer science and mathematics where hospital nurse staffing was the subject of the study. RESULTS: A number of themes emerged. The first iteration showed the predominance of unit base approaches (eg, nurse numbers, ratios, activity and workload) and the second was the development of methodologies. Subsequent iterations examined issues such as demand, safety, nurse education, turnover, patient outcomes, patient or staff satisfaction, workload and activity. The majority of studies examined (n=767) demonstrated some association between staffing (units or type/skill) and various factors such as staff or patient satisfaction, working conditions, safety parameters, outcomes complexity of work achieved, work left undone or other factors. Many potential areas such as operational safety research were not utilised. CONCLUSION: Although the relationship between staffing in acute care and factors such as units, safety or workload is complex, the evidence suggests an interdependent relationship which should only be dismissed with caution. The nature of these relationships should be further examined in order to determine nurse staffing. The body of knowledge appears substantial and complex yet appears to have little impact on policy.

Nursing pay by gender distribution in the UK - does the Glass Escalator still exist?

AIMS AND OBJECTIVES/BACKGROUND: Nursing is a predominantly female profession. This is reflected in the demographic of nursing around the world. Some authors have noted that despite being a gendered profession men are still advantaged in terms of pay and opportunity. The aim of this study was to examine if the so called glass escalator in which men are advantaged in female professionals still exists. DESIGN AND METHOD: Descriptive statistics of the routinely collected national workforce datasets from across the UK central repositories and mining of a bespoke data set that has been curated which focuses on the activity of specialist advanced practice clinical nurses. RESULTS: Even in a gendered occupation such as nursing the advantage of men in terms of pay is apparent with men being over-represented at senior Bands compared to their overall proportion in the UK nursing population. From the bespoke dataset there also seem to be an advantage in term of faster attainment of higher grades from the point of registration. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: Reward and remuneration are essential to the workforce. This work reveals a gender differential towards men in higher paid nursing work. The drivers for this are complex and further work is required to determine the factors associated with career progression with men in nursing, and the rate limiting factors with the female workforce.

Modelling the Inflammatory Bowel Disease Specialist Nurse Workforce Standards by Determination of Optimum Caseloads in the UK.

BACKGROUND AND AIMS: Crohn's disease and ulcerative colitis are the most common forms of inflammatory bowel disease [IBD], affecting 1 in 250 of the population in the UK. It is accepted that access to a specialist nurse service improves patient experience and outcome. National Standards for the Healthcare of People Who Have Inflammatory Bowel Disease [2013] defined the number of nurse specialists required at 1.5 full time equivalent per 250000 population. The aim of this study was to determine if these standards were being met and to publish a new, robust, validated standard optimising the UK nursing workforce model. METHODS: Existing national data and specific workload and service data were collected from 164 IBD specialist nurses who completed a questionnaire designed to collect information on activity and complexity of work both done and undone. RESULTS: Data were received from all of the UK; 36% of respondents were specialist nurses in the field for 3 years or less. A higher caseload than the recommended level was reported by 63% of respondents. Unpaid overtime was regularly carried out by 84% of respondents. The IBD specialist nurse was involved in all areas of the patient pathway. Areas of work left undone were psychological interventions, prescribing medicines and physical assessments. CONCLUSIONS: Compared with other specialties, IBD specialist nurses are less experienced. It is recommended that the current standard be increased to 2.5 full time equivalent specialist nurses per 250000 patients, to mitigate the increasing complexity of the role, care and the 'rookie' factor.