FACING THE CARE CHALLENGE IN PRACTICE

- Reflections of a Chief Nurse

Mandie Sunderland

WELCOME TO MY WORLD!

- 5,000 Nurses & Midwives / 10,000 staff- 3 hospital sites- Breach of authorisation with Monitor – removed August

2010- 3 conditions with CQC Registration

• Staffing• Safeguarding• Appraisal

- Rule 43 (Coroner)• All have nursing involvement

- Reputation re standards of nursing care- Same commissioners as Mid Staffs

NURSING – OUR PROFESSION- Adverse media stories- Inquiries / Investigations / Reports - Public perception- ‘Fit for Purpose’ debate

- NMC Consultation- Media coverage ‘too posh to wash’!

- Personal experiences• SUI’s• Coroners Verdicts• Complaints• Disciplinaries• NMC Referrals

THEMES OF QUALIFIED NURSES & MIDWIVES DISCIPLINARY CASES 2008/10

1. Professional conduct – medicines - failure to follow policy (inc several fatalities- theft

2. Professional conduct – patient observations- failure to escalate (inc several fatalities)- failure to document

3. Professional conduct – personal- attitude / behaviour- communication- internet abuse

4. Professional conduct – other- documentation- confidentiality

ISSUES• Recruitment

- quality of applicants• Medicines Managements

- numeracy- standards / policy for medicines administration- basic knowledge of safe practice

• Provision of fundamental care- knowledge of ‘basics’- appetite for ‘basics’- inability to plan care

• Knowledge of accountability both professional / personal- aware of NMC but no in depth knowledge- ‘someone else’s fault’

HEFT SOLUTIONS• Pre interview tests re drug calculations for all RN’s

– original pass mark 100% (achieved by 10%)– given calculator and formula card– no time restraints imposed

• Pass rate revised Oct 2099– pass rate between 60 – 80% can proceed to appointment

if interview exceptional– Manager to develop PDP to ensure completion of

medicine administration competency– Score of 60% not employed– Assessments for adults / paediatrics / neonates

EXAMPLES OF QUESTIONS OF MEDICINES ASSESSMENT

• Patient A requires 30mg of oral Prednisolone; you have a stock of 5mg tablets. How many tablets do you need to give?

• Convert 400 micrograms into milligrams• If there is 80 mg of Gentamicin in 2 mls how much

Gentamicin is in 0.5ml?• You need to administer 40 mg the vial contains 50mg in 2

mls. How many mls do you need?• You need to give 100 mls of Metronidazole over 20 mins.

What is the hourly rate in mls?• Your patient weighs 65 kg the drug prescribed on 7mg per kg.

How many mg are required?

MEASURING FUNDAMENTALS OF CARE

• Development of Nursing & Patient Experience Metrics• Originally 8 indicators

– Medicines administration– Falls– Nutrition– Tissue Viability– Infection Prevention– Patient Observations– Pain Management– Continence Management

• Electronic real time reporting• Peer review – ‘Back to the Floor’• Assurance process in place• Consequence to poor performance / celebration of good practice

Progress – October 2010• Trust remains GREEN overall

and has stayed at 90%• 1 ‘RED’ ward October 2010 (2

‘RED’ wards September 2010)• 3 wards slipped from ‘GREEN’

to ‘AMBER’• GHH slipped from ‘GREEN’ to

‘AMBER’ overall• Pilot of Metrics 2 commencing

November 2010 - Additional indicators for Diabetes Management; Discharge Checklists and Assurance

Bar chart to demonstrateRed Wards : Green WardsJanuary 2010 – October 2010

0

5

10

15

20

25

30

35

40

Jan Feb Mar Apr May Jun Jul Aug Sep Oct

Month

Metrics results 2010

90% +

< 80%

METRICS RESULTS

OCTOBER 2010

Critical Care Theatres

NeonatesPaediatrics

?

QUESTION

Do we have a fundamental problemwith the knowledge base of ournursing workforce?

VITAL

• Virtual interactive teaching and learning Education tool to acquire knowledge and skills that confirm core standards for safe practice

• Profession / role specific modules in development

VITAL for nursing• E learning foundation module related to fundamental safe

practice• Integrated training needs analysis and learning intervention

VITAL - premise

• Registered nurses first• MS to write to every nurse• HEFT Context around professionalism promoted • Core safety - linked to metrics• Linked to other trusts• Probably badged• Life span – patient journey focused• VLE user support

ACCESS

• Access via HEFT Faculty website (www.)• Platform: MOODLE on-line virtual learning

environment • Trust specific reports produced• Will inform national research project on

current state of nursing knowledge led by HEFT Faculty in collaboration with participating partners

Medication Storage & Custody inc numeracy

End of LifePatient Observations inc MEWS /PEWS elements of SBAR and SepsisPain Management

Tissue Viability

Nutritional Assessment

Falls Assessment

Continence Assessment

Privacy & Dignity/elements of Communication SBAR Diabetes

Blood transfusion

Mentor update

Safeguarding children/adults

Discharge planning

INDICATIVE NURSING CONTENT TBC

STEP OFF / ORSTEP OFF / OR

Further face to face education and training modules as required

Further face to face education and training modules as required

VITAL for nursesProgramme Framework

VITAL – Proposed Assessment Scheme

GlossaryModule on MOODLE called VITALVITAL contains Units of learning e.g Safeguarding

Possible Outcomeongoing performance support.

- Congratulations -Successfully passed

VITAL Module

- Congratulations -Successfully passed

VITAL Module

VITAL-Ready to go

NEXT STEPS

• Inclusion of Midwifery 2011• Development of Trust badge to epitomise

‘HEFT’ Nurse/Midwife• Utilisation of VITAL pre recruitment?• Allow access from home to all nurses and

midwives• Assurance to Trust Board, Regulators, patients

and public that our nurses are knowledgeable and competent

THOUGHTS FOR THE FUTURE• Move to graduate status – excellent news!• Fit for purpose debate continues• Yet another review of pre reg curriculum??• Explore potential to enable mandatory training and competency

‘mania.’• Public confidence – jury remains out!• Recent events Recommendation 4

“The Trust, in conjunction with the Royal Colleges, the Deanery and the nursing school at Staffordshire University, should

review its training programmes for all staff to ensure that high-quality professional training and development is provided at all levels and that high-quality service is recognised and valued.”

The Mid Staffordshire NHS Foundation Trust Inquiry

BLASPHEMOUS THOUGHTS!• No pilot of P2K• Concerns over pre-reg practice experience/assessment of clinical

skills/progression to registration• HEFT Faculty of Nursing & Midwifery

- Pilot of 30 students (pre-reg training)- External evaluation of end product- Total ownership of whole experience- Work with academic partner- Academic credit given to practice- Ownership and commitment from practice- Value for money- Fits with new policy direction- Logistics becoming easier e.g. amalgamation with community

nursing- Appetite from patients / public / practitioners

• 4.32 – ‘Each year several billion pounds are spent on central funding of education and training for NHS staff through the Multi-Professional Education & Training levy, in addition to investment by NHS organisations in their own staff. A top-down management approach led by the DOH does not allow accountability for decisions affecting workforce supply and demand to sit in the right place. It is time to give employers greater autonomy and accountability for planning and developing the workforce, alongside greater professional ownership of the quality of education and training

- Healthcare employers and their staff will agree plans and funding for workforce development and training; their decisions will determine education plans.

- Education commissioning will be led locally and nationally by the healthcare professions ………. Mechanisms will be put in place for nurses and midwives and allied health professionals.

- The professions will have a leading role in deciding the structure and content of training and quality standards.

- All providers of healthcare services will pay to meet the costs of educatioin and training. Transparent funding flows for education and training will support the level playing field between providers.’

………………..

‘EQUITY AND EXCELLENCE – LIBERATING THE NHS’ JULY 2010