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.

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.

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.

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.

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.

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.

Variation in job titles within the nursing workforce.

AIMS AND OBJECTIVES/BACKGROUND: The work of specialist nursing has been under scrutiny for many years in the UK due to a perception that it is not cost-effective. A common issue is the lack of consistency of job titles, which causes confusion to the public, employing organisations, colleagues and commissioners of services. Lack of consistency has implications for the wider perception of advanced specialist practice in the worldwide community and the workforce more generally. This study aims to understand the variation in job titles in the UK population. METHODS: A pre-existing data set of accrued studies into the work of nurses working in specialisms was mined for insight (N = 17,960). This study used knowledge discovery through data and descriptive statistics to perform secondary analysis. RESULTS: Mining these data revealed 595 job titles in use in 17,960 specialist posts once the specialism had been removed. The most commonly used titles were Clinical Nurse Specialist, Nurse Specialist/Specialist Nurse, Advanced Nurse Practitioner and Nurse Practitioner. There were three other primary groupings. These were variants with a specialist or technical prefix of suffix, for example Nurse Endoscopist, variants of seniority such as trainee, senior nurse for [specialism] or variants of function such as Nurse Prescriber. The clustering was driven primarily by pay band. A total of 323 posts were recorded as holding titles such as Advanced Nurse Practitioner or Specialist Nurse who were not registered with the Nursing & Midwifery Council. RELEVANCE TO CLINICAL PRACTICE: In this data set, there is a large array of titles, which appear to have little relationship with other factors like education. This is confusing to the public, employers and those commissioning services. It also demonstrates that the previous assumptions by Council for Healthcare Regulatory Excellence that advanced practice labels are associated with career progression are unsound and should be addressed by the regulator.

Severe asthma: emergency care patient driven solutions.

Purpose Patients with severe asthma were choosing not to use the emergency department (ED) in extremis and were self-medicating when experiencing severe asthma, putting their lives at risk. This local issue reflected a nationwide situation. The purpose of this paper is to better understand the reasons behind patients' reluctance to attend ED and to consider practical solutions in a structured way. Design/methodology/approach Systems thinking (soft systems methodology) was used to examine the issues resulting in this reluctance to attend the ED. Once this tame (well-defined) problem was revealed, a potential solution was developed in co-production with patients. Findings Patients feared attending the ED and felt vulnerable while in the ED for several reasons. This appeared to be a well-defined and solvable problem. The solution proposed was an asthma patient passport (APP), which increased patient's confidence in their ability to communicate their needs while in severe distress. The APP decreases (from 12 to 5 steps) the work patients had to do to achieve care. The APP project is currently being evaluated. Practical implications The APP should be offered to all people with severe asthma. Originality/value By revisiting systems thinking and identifying problems, a solution was identified. Although methods such as soft systems methodology have limitations when used in wicked (difficult or impossible to resolve) problems, such methods still have merit in tame problems and were applicable in this case to fully understand the issues, and to design practical solutions.

Nurse staffing levels and outcomes - mining the UK national data sets for insight.

Purpose Despite the generation of mass data by the nursing workforce, determining the impact of the contribution to patient safety remains challenging. Several cross-sectional studies have indicated a relationship between staffing and safety. The purpose of this paper is to uncover possible associations and explore if a deeper understanding of relationships between staffing and other factors such as safety could be revealed within routinely collected national data sets. Design/methodology/approach Two longitudinal routinely collected data sets consisting of 30 years of UK nurse staffing data and seven years of National Health Service (NHS) benchmark data such as survey results, safety and other indicators were used. A correlation matrix was built and a linear correlation operation was applied (Pearson product-moment correlation coefficient). Findings A number of associations were revealed within both the UK staffing data set and the NHS benchmarking data set. However, the challenges of using these data sets soon became apparent. Practical implications Staff time and effort are required to collect these data. The limitations of these data sets include inconsistent data collection and quality. The mode of data collection and the itemset collected should be reviewed to generate a data set with robust clinical application. Originality/value This paper revealed that relationships are likely to be complex and non-linear; however, the main contribution of the paper is the identification of the limitations of routinely collected data. Much time and effort is expended in collecting this data; however, its validity, usefulness and method of routine national data collection appear to require re-examination.

Impact of lung cancer clinical nurse specialists on emergency admissions.

Clinical nurse specialists (CNS) in cancer perform a range of complex activities, including the management of care. However, they often report a high administrative burden for services, which makes providing expert nursing care challenging. Administrative work for a service can be seen as a priority for non-nurses, yet a high administrative burden allows less time for complex nursing care. A London trust admitted a mean of four lung cancer patients per month for symptom control in progressive disease or end-of-life care, with a mean stay of 6 days. This was often a default location: the acute hospital was not always the patient's preferred place of care for end of life. The CNS negotiated away the administrative burden, which occupied 38% of their working time, and adopted standard proactive case management in line with national standards. The CNS were also able to build a collaborative relationship with others, such as local GPs and community palliative care teams. Their proactive and vigilant case management resulted in fewer admissions for non-acute problems: a mean of four emergency admissions per month fell to a mean of fewer than one (0.3). For this service, the mean length of emergency admission was 6 days, so a reduction in the admission rate represented a significant saving in bed days (266 a year) and a higher rate of achieving the preferred place of end-of-life care. In conclusion, CNS who practise proactive case management and refocus services in line with best practice represent a good return on investment (ROI).

Do psychological interventions reduce preoperative anxiety?

The systematic review investigates whether, during preoperative assessments, nurse-delivered psychological interventions reduce anxiety levels preoperatively for patients undergoing elective surgery. Seventeen studies met the inclusion criteria for data extraction and in-depth critiquing. Of these, two were discarded due to lack of validity, while the remaining studies were organised thematically in a narrative synthesis, generating two principal results: patients' preoperative anxieties were lowered by nurse-delivered general preoperative psychological interventions; and patients valued individualised preoperative interventions delivered by nurses. However, the single oncology study in the review showed an elevation in preoperative anxiety, regardless of intervention, and highlights the need for more research in this under-reviewed area. In the meantime, the authors believe that service improvements should be implemented to ensure that, where possible, psychological preoperative interventions are individualised.

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.

Return on investment: workload, complexity and value of the CNS.

UNLABELLED: The rheumatology nurse specialist (RNS) has become an integral and vital part of the multidisciplinary team and is valued by patients. Yet, a number of challenges regularly face all clinical nurse specialists (CNS) in the UK. The perception that CNS are an expensive and poorly defined nursing resource results in regular threats to their sustainability, particularly that of the RNS. This study examined return on investment of the RNS. METHOD: An interrelational Structured Query Language (SQL) database collected data on the day-to-day activities of the RNS based on previous models of CNS and RNS work, and qualitative narrative data were then subjected to data mining. RESULTS: The RNS represented an excellent return on investment, in terms of income generation activity, patient safety and efficiency. These outcomes were achieved using key principles of proactive case management using vigilance, rescue work and brokering. The mean average per whole time equivalent (WTE) RNS per annum represents £ 175,168 in terms of income/savings to an employing NHS Trust. This figure is likely to be an underestimation, as calculations on reduction in bed days in hospital have not been included.

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.

Pediatric cancer and the quality of children's dyadic peer interactions.

OBJECTIVE: To use observational methods to assess the quality of peer relationships in 51 7- to 12-year-old acute lymphoblastic leukemia survivors as compared to healthy children. METHODS: Children were audiotaped as they engaged in free play with their best friend and interactions were coded to assess their ability to maintain engagement with one another during play as well as the affective dimension of their play. RESULTS: Results indicated that dyads with survivors of childhood cancer were less likely to be highly engaged with their best friend and more likely to experience disengagement than dyads with healthy participants. There were no group differences in positive or negative affect. CONCLUSIONS: Overall, these data suggest that survivors of childhood cancer's relationships with their best friend may be compromised in some specific areas when compared to the relations of healthy children. Implications for intervention are discussed.

Productivity gains by specialist nurses.

Workload analysis showed that the specialist nursing service in lung cancer in an acute hospital was being used primarily to support processes and administration rather than providing holistic cancer care. An analysis of the inpatient population showed that many people were being admitted for non-acute problems, such as symptom control in advanced disease. As the key workers for patients with lung cancer, the clinical nurse specialists negotiated away the administrative burden and adopted standard, proactive case management in line with national standards. Their proactive and vigilant case management resulted in a drop in admissions for non-acute problems from four to a mean of 0.3 per month. This represents a significant saving in bed days. Clinical nurse specialists who practise proactive case management and re-focus services in line with best practice represent a good return on investment.

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.

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.