Nurse Consultant Impact: Newcastle upon Tyne Hospitals NHS Foundation Trust Workshop report

Background

Nurse Consultant (NC) posts were established in the United Kingdom in 2000 as part of the modernisation agenda for the NHS. The roles were intended to achieve better outcomes for patients by providing roles for senior nurses that would keep their clinical and managerial expertise at the bedside, and provide leadership in their teams. Across the UK there has been a strong interest in demonstrating the impact these posts have had on their patients and the professional community.

A two year research study funded by the Burdett Trust for Nursing developed a framework for assessing the impact of NCs (Gerrish et al 2013) and a toolkit to help NCs measure the impact of their work, and share these findings with managers and other stakeholders.

The toolkit, which can be downloaded from the project website http://research.shu.ac.uk/hwb/ncimpact/NC%20Toolkit%20final.pdf is based on an evidence-based framework which classifies the impact of Nurse Consultants into three domains: impact on patients, staff and the organisation. The toolkit includes a series of reflective exercises to help NCs identify their impact in each of these domains and prioritise which areas of impact are most important for them to capture at this moment in time. Practical guidance is given on the challenges of capturing impact together with tips on how to overcome or manage these challenges. Practical examples are given on how impact has been captured in each of the three domains as well as exercises and guidance to encourage NCs to consider who they might want to share evidence of their impact with and how to disseminate this information.

A number of tools are provided to help NCs to collect data to demonstrate their impact. NCs are free to choose tools that are relevant to their work, and adapt them as necessary.

After the toolkit was developed, the research team were approached by the Head of Research for Nursing and Midwifery at Newcastle Upon Tyne Hospitals NHS Foundation Trust with a request to work with her Trust to use the toolkit in practice in order to build on existing mechanisms to capture the impact of their nurse consultant roles. The nurse consultants offered to provide feedback in order to help the team further refine and develop the framework for capturing impact and the toolkit itself.

The Nurse Consultants at Newcastle upon Tyne Hospitals NHS Foundation Trust

The Nurse Consultants at Newcastle upon Tyne Hospitals NHS Foundation Trust consists of expert consultant nurses who cover the full spectrum of age ranges and work in specialisms such as critical care, vulnerable older adults, urogynaecology , cancer, chronic pain and respiratory At the time of the workshops there were 10 nurse consultants working within the Trust. Six of the consultants attended one of the workshops and used the toolkit in practice. Of these, two had been in post for over 10 years and three had been in post for over 5 years. The most recently appointed had been in post since 2011.

The toolkit had previously been developed with nurse consultants who worked in adult and neonatal services, including consultants working in gynaecology, urology, and respiratory (pulmonary hypertension), but working with the Newcastle Nurse Consultants gave the NC Impact team the opportunity to gather evidence about whether the toolkit was also useful for nurse consultants in a more diverse range of specialities (e.g. critical care, chronic pain, cancer).

Piloting and Workshops

Two workshops were held in Newcastle during 2013.

Prior to workshop 1, participants were asked to complete Activity 4 in the toolkit (to identify examples of their impact in three domains) and Activity 5 (to identify their current priorities in relation to capturing impact).

Workshop 1 took the form of a focus group where the discussion focused on the framework for capturing impact in in terms of its usability and applicability.

The workshop concluded with a group exercise to encourage participants to focus on the practicalities and challenges associated with capturing impact in relation to their current priorities.

Piloting in practice Over the next 6 months, participants used the toolkit in practice. They piloted the use of one or more tools from the toolkit to capture an aspect of their impact discussed at the workshop and were encouraged to use the information provided in the toolkit to guide them through this process.

Workshop 2 took the form of a focus group where participants fed back on what aspects of their work had benefited from the toolkit and any challenges they faced when using it. Participants were asked in what scenarios they had used the toolkit, how they had adapted it for their work, what data they had collected and how, and what they were intending to do with the data.

Participants

Participants included consultants in the following specialties:

o Vulnerable older adults

o Critical care

o Gynaecology & Urology

o Respiratory including cystic fibrosis

o Cancer

o Chronic pain

Learning from the workshops

Applicability of the framework for capturing impact

The nurse consultants liked how the framework was organised into the three domains of patients, staff and organisation:

“I quite like it split into patients, staff and organisation, because that’s what you have to think about”

The framework was considered easy to understand but one nurse consultant commented that it was especially helpful to have it explained further in a workshop such as this, in particular to hear how the framework/toolkit had been useful for others and how it could be used in practice.

In terms of the ability of the framework to capture the full range of impact, the consultants made a number of useful suggestions about where the framework could be extended or the description of the indicators could be improved in order to encapsulate the full breadth of impact relevant to their roles.

Firstly, in relation to the patient domain one nurse consultant felt that it was important to highlight that it might not always been possible to ‘improve’ or get patients back to ‘normal' functioning in terms of physical or psychological wellbeing. In some of the situations they were dealing with helping patients to accept the function that they had:

“Sometimes you can’t get people to normal functioning, it’s about accepting the function that they’re at, so it’s about coping, developing and coping despite physical problems… so returning to normal function suggests you can but you might not be able to”

One of the nurse consultants also queried whether the framework fully captured their work around quality of care and preventing harm, for example preventing infections:

“I spend quite a lot of time on improving the quality of care that we deliver and preventing harm, rather than preventing them from coming in or what their quality of life’s like after, it’s about the quality of care that we actually deliver. So it’s, I suppose where does that fit? I know it’s about the quality of life, but it’s also about prevention of harm related to the care we are actually delivering and I think that’s quite a big national topic, a lot of quality improvement is being cascaded all the way through. I mean people could have a very positive experience of the service but ended up with a complication so it’s important to also prevent complications "

It was discussed how the logical place for this might be within physical and psychological wellbeing, but that the definition for this indicator might need to be broadened out to reflect the ‘avoidance’ nature of this work, rather than only focusing on symptoms. However, it is also important to highlight that if this impact related to organisational targets such as CQUINS (e.g. prevention of infections) it could also fit within the organisational social significance category.

One nurse consultant also felt that the framework didn't fully cover the national work that she was involved in, so in this context the whole NHS is the organisation and she is involved in work that has an impact on the speciality nationally:

“Sometimes I think you can have a big impact on one patient can’t you…or you can develop guidelines for a department, or you can set some strategy for the Trust, and you can go on and on and on for the bigger and better wellbeing of everybody, so to me it just felt it’d covered it up to an organisational point of view but it didn’t take that wider”

One of the nurse consultants also talked about how she does a lot of research work but that she doesn't really think about that having an impact because you don’t know what impact it has. However, she commented that she was glad that the generation of new knowledge was included in the framework. The nurse consultants felt that this was similar to the national work above, in that it doesn't ‘just’ sit as an organisational impact - either impacting on the speciality or nursing generally. It was discussed that it might be helpful to change the organisational domain to make it broader or there might be a need for an additional area in the framework that looks at external, wider, national impact:

"You could argue as a nurse consultant you should be working more than just in your organisation, because otherwise you can't differentiate between a very highly experienced clinical nurse specialist and a nurse consultant, whereas clinical nurse specialist might just be dealing in their organisation and that would be expected, whereas the nurse consultant you tend to be expected to beyond the organisation I think"

Usability of the framework for capturing impact

One nurse consultant reflected that looking at the framework had made her recognise the areas that she tries to capture impact data on already and the areas she doesn't do this in:

"It's made me think about well why don't I try and demonstrate my impact in that area, and those are the kind of things that you think well I’ve been doing that for how ever long and nobody's queried it, and I know it has an impact, that's why I bother to spend time doing it"

Another nurse consultant agreed and felt she collected a lot of information about the impact on patients, whereas the framework made her think more about her impact on staff or organisation.

The Toolkit

The nurse consultants had tended to just focus on looking at the tools, rather than exploring the entire toolkit guidance and activities. One of the nurse consultants said:

“It is nice to have it all in one, and it’s, just listening to what people said today, there’s stuff that I’m going to go back and have a look at and see if there’s anything else that’s useful.”

One of the nurse consultants had looked at the logic model that was described on page 16 of the toolkit, which she felt was quite interesting. Knowing how others go about evaluating impact was seen as valuable.

Using the tools to capture impact in practice

In the first workshop the nurse consultants discussed how they currently go about capturing their impact and the potential added value of the toolkit and the integrated tools to offer new, varied ways of capturing impact. However, it was acknowledged that this work was time dependent and also influenced by the organisation’s agenda at the time:

"You don't have time to do it properly for everything that you do all of the time, so you're kind of a bit selective...and some of that is a bit political as well really, with a small "p" really, it does depend on your boss's agenda I think"

"I guess it's going through and finding what suits your role, what might add to what you're already doing or demonstrates something in a better way and using those tools, like I say it's beneficial for that"

One Nurse Consultant had considered giving Tool 1 the 'Generic 360° feedback tool' to her colleagues but felt that some staff might not fill it in because it required them to write comments. Her view was that these staff would prefer a tick box/rating scale feedback questionnaire, (with a section for free text) because it would be quicker for them to complete:

“I gave it to my Band 7 and he was, he said it would be easier if it was rating scales”

Some of the nurse consultants discussed how it is more difficult to analyse and collate free text responses. Rating scale type questionnaires were easier and also more useful to benchmark and monitor their ongoing development overtime. However, it was also discussed how free text comments were still important to tease out the reasons behind the scores. It was felt that this type of 360° information would be useful to present at their appraisal with their line manager, which is something that the group currently didn’t do:

“That is something that I think is very handy for appraisals because it’s something that we don’t do…I think it’s good to have that just so you have a bigger picture of things rather than its just hearsay, so that is something that I would look at using for future IPRs”

Furthermore, another nurse consultant commented that she often had to explain and give examples relating to the four dimensions of a nurse consultant role that are included in Tool 1 (e.g. expert practice, professional leadership), so giving the tool as it is would probably be difficult for others to complete:

“I can understand that if you give somebody that, not that I’ve tested this, that you might have a situation where they just say ‘I don’t know what to write’”

Therefore it might be that the tool needs some exemplars at each question to help those filling it in and make it clear to them, if they aren’t already familiar with the role, what is meant by the different elements that apply to the nurse consultant role.

Impact on Patients

The Respiratory Nurse Consultant felt that some of the questions in Tool 3 'Nurse Consultant Consultation Satisfaction Questionnaire' weren't appropriate for her group of patients. Although she recognised that the questionnaires could be tweaked, she felt the questions were not relevant to the focus of the consultations she undertakes which centre around shared decision-making:

“I will follow the nurse consultant’s advice because I think he/she was absolutely right’…I felt that it’s very old-fashioned and there’s not negotiation here…and I felt this didn’t reflect shared decision-making, which is what we’re pushing now”

However, the nurse consultant in Chronic Pain used the tool with 10 patients in an outpatient clinic setting where patients are either seen by her or a medical consultant. She chose this tool because it was a tick box questionnaire, it could be used in different ways (e.g. give to patient to complete afterwards or ask the healthcare assistant to help them complete it) and was quick and simple to use on a regular basis:

“We get a lot of feedback from PALS and about patient complaints and things, and we deal with those on a regular basis. What we don’t necessarily get is the positive side of things or the patient’s view…This captures things a little bit, the real picture if you like, the good and the bad, and it’s the patient’s there and then, so it’s their feedback”

There were a few things that the nurse consultant would change about the tool, particularly some of the terminology, and there were some extra items she would want to add, but overall she considered that her patients found it easy to complete:

“The beauty of it is its quick but there are a few questions that I would probably change, it’s something that would be useful, and if I could tweak it I would probably adapt it and use it”

The nurse consultant felt it would be fairly simple to collate the results from the tool herself, and that she might just get ‘snapshot’ view every now and then about the consultations by asking a few patients to complete it in order for it to be useful and not too onerous. The nurse consultant was happy to provide a copy of her adapted version relevant to her discipline of Chronic Pain.

The Nurse Consultant in Gynaecology and Urology used Tool 6 'Patient Experience Proforma' with her patients following their consultation. Some of the consultations also included other nursing colleagues working with her in the consultation who had also found it useful to receive the feedback from patients and simultaneously reflect on how they felt the consultation had gone. The nurse consultant received a mixture of responses, some specifically about the consultation, which were useful to her, but other patients used the form to feedback about general issues relating to the unit or outpatient area. The nurse consultant felt the wording of the tool needed to be adapted in order to highlight that they were looking for feedback on the consultation itself rather than their more general experiences. However the nurse consultant did highlight that the tool might not be the best one to disentangle her specific contribution:

“Am I evaluating the service or am I evaluating my impact on it? I think I was finding it a bit difficult to see whether that questionnaire would in fact help with measuring the impact that I have there, so I’m not sure whether that is the best tool for me to use…And because the change was made over time with a lot of people it sometimes is difficult to pick out what it is that you’ve had an impact on yourself rather than the whole team”

In relation to this, it was discussed whether the tool could be reworded in order to make it more specific to the consultation or the nurse consultant individually – e.g. “In terms of your experience today, what did the nurse consultant get right” “Is there anything the nurse consultant could have done better?”:

“Rather than we, because it does sound a bit like the royal we, it implies it’s all of us together and the environment and everything, rather than just the”

Another nurse consultant raised concerns about the use of Tool 6 with her patients, some of whom had poor education levels and literacy skills.

The same nurse consultant also looked at Tool 2 'Carer support group evaluation' and felt it would be useful to use with the carers support group she is considering running.

There was also a discussion at the end of workshop 2 about the other measures the Nurse Consultants currently routinely use to capture patient outcomes, for example Hospital Anxiety and Depression Scale (HADS), validated measures for pain, and incontinence QOL scales. It was considered that within the project website there could be reference to other patient measures that might be useful.

Impact on Staff

One of the nurse consultants considered using Tool 7a and 7b 'Training evaluation' and felt that it would be really useful to measure change in skills:

“I liked it I could really use that…. this was about motivational interviewing, ….I really like the fact that people rate cognitive therapy. If you rate your skills you’re hoping that by the end of the training they’ll have moved up the scale and that’s really good feedback for you”

One of the nurse consultants felt that Tool 9 'Higher Education Contribution Questionnaire' would be useful to collect for her professional development file:

"The higher education contribution, if I go and do something at the university I would be happy to give that, get the feedback and put it my file, so it would be useful to collect, whereas I might just get, you do get feedback and I might print that out and put that in, but that's some more evidence really"

Impact on the Organisation

Tool 13 'External Activity Proforma' was considered by 3 of the nurse consultants. One felt the form would capture a lot of what she did and might contribute to her annual appraisal as she recognised that she often didn’t record the details or outcomes of the meetings she attended:

“I go to meetings where I don’t even record them anywhere, or what the output from the, you know a stakeholder meeting, I might go to a commissioning meeting and I don’t record that anywhere, whereas it could go down here. Some good things come out of meetings, so I quite liked it, it’s all in one place, I could just pop that in my appraisal”

The nurse consultants also felt that the form might help them to articulate the value of these external activities to their organisation. One nurse consultant mentioned that external work might have a delayed impact on the organisation, so it might not be immediately obvious what the impact is but it gives the organisation a ‘head’s up’:

“Clinical reference groups, which will be in the future, the next couple of years, Quality Standards that will be coming in and the Trust…don’t need to necessarily know about that now but I think if you know about it in advance it’s an advantage. It’s not got to worry too much about them now but it will hopefully help have a better Quality Service in the future…You don’t necessarily directly come back and do something different tomorrow, but is more likely to happen in the next year or two”

Bringing kudos and raising the profile of the Trust was also mentioned as an important and valued impact for the organisation.

Three of the nurse consultants used Tool 15 the 'Project Leadership Questionnaire' and a fourth consultant was considering using it in the future.

The Vulnerable Older Adults Nurse Consultant used the tool in a project that was still ongoing, so she felt she might have been asking people for feedback a little too early. The project was developing multi-disciplinary guidelines for staff on clinical management of patients with cognitive impairment in terms of swallowing and nutritional needs. Eight questionnaires were emailed out by her secretary and two had been returned by email, but they were given the option to print, complete and return anonymously if they wished. The two responses were very positive and indicated that the individuals had found the tool easy to complete. She found the responses interesting in terms of looking at the ratings that were not the most positive/top values, which highlighted aspects she could try to develop further. There was nothing in the tool that she wouldn’t have wanted to ask, so she considered it comprehensive:

“I think it’s useful in terms of project manage and leadership in general, rather than in relation to the particular project…It was useful doing it”

The nurse consultant also discussed her thoughts about how to capture the impact of these guidelines once they are implemented (which would show an impact on staff) – perhaps a Survey Monkey questionnaire to the wards testing knowledge before they were implemented and after.

The Nurse Consultant in Cancer who doesn’t carry a clinical caseload but has a corporate/ Trust wide role also used Tool 15 within a project she is currently undertaking to review a care pathway. Ten surveys were sent out electronically to a range of disciplines and grades and five were returned as hard copies. She found the comments particularly helpful in terms of highlighting areas that she could improve. She didn’t feel she would pull the responses together into a report because there were only five responses but she would consider using it again when the project was further down the line to see if there was any change.

The Nurse Consultant in Critical Care also used this tool in a multi-disciplinary project she had led on a CQUIN target relating to central venous catheter bloodstream infections. The tool was sent electronically to around twelve individuals and seven hard copy anonymous responses were received back:

“I found it quite useful, sometimes you look down and think ‘it’s all about the same’ and I thought the comments were the most useful part because it pulled out the specifics…But I think there’s this tendency for them to just go down the columns, so I suppose for me it was one measure to measure the impact of that project. For me the most important part of that project was the data on central venous catheter infections, that actually showed a decrease over time, and the other thing we measured was compliance with evidence based practices and we showed over time that we demonstrated some improvements…So if this [Tool 15] looked fantastic and we hadn’t achieved any improvement in infection, what value, is that really measuring my impact?”

It was discussed how using Tool 15 allowed the nurse consultant to say that she had been a key contributor to the improvements in clinical outcomes demonstrated through being the project lead. However, it was highlighted that the tool only provides one perspective and might be most useful when combined with other outcome measures.

Taking the work forward

The group expressed a willingness to share the tools they had adapted to be included on the NC Impact Project website and contribute to a list about other patient outcome tools that they found useful and routinely used in their field to be listed on the project website.

NB. All activities and tools referred to in this report are downloadable from the project website: http://research.shu.ac.uk/hwb/ncimpact/tool.html