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Nursing – high impact actions

The High Impact Actions (HIAs) are lead by the Strategic Health Authority Chief Nurses and the NHS Institute for Innovation and Improvement.

This initiative aims to mobilise nurses and midwives throughout the health service to contribute to the quality and productivity agenda through the implementation of High Impact Actions that improve patient care and have the potential to release costs.

Eight High Impact Actions were identified and launched at the CNO conference in November 2009.
[toggle title="Fit and Well to Care"]

The aim: ‘to reduce sickness absence in the nursing and midwifery workforce to no more than 3%’.

HEFT Leads: Ann Edgar and Tracy Selsby

Without fit and well staff, how can we ensure quality? As a caring profession, we should ensure that we have strategies to ensure that staff are fit and well. Caring for our staff means supporting our staff, trying to understand what is causing levels of sickness absence and providing an environment that lets them know the positive impact they have by delivering patient care. It means ensuring staff feel valued and missed when they are not at work and that they realise their health and wellbeing is important to use.

Staff spend a lot of time at work and they need to feel that they are really contributing. Hardly any nurses would disagree with the suggestion that having more regular and consistent staffing therefore requiring fewer bank and agency requests results in enhanced team work and better care provision.

Having a focus on ‘fit and well to care’ will, without question, have an impact on quality and cost reduction, but more importantly needs to ensure that NHS staff feel valued and supported in their work.

Other large organisations such as BT and the Post Office have demonstrated that aiming to reduce absence by a third is a realistic and achievable target. Communication is the key to most areas of improvement and never more so than in staff wellbeing. It is important to empower staff to lead change and to make individuals matter. It is vital to empower ward managers and team leaders so they can provide support and information to staff about health and wellbeing.  This group should also be able to recognise signs of stress and anxiety especially when any change is happening. Whenever change is happening, staff need to be involved and be active participants in the decision-making process, inclusion helps people to feel more in control.  Regularly set aside time to review how the day went, a simple ‘what went well’ and ‘even better if’ approach helps to draw out both the positive and less positive aspects following a particularly difficult shift, training day and so on.

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[toggle title="Important Choices - Where to Die When the Time Comes"]

The aim: ‘to increase the numbers of people who are able to die in the place of their choice and avoid inappropriate admission to hospitals’.

HEFT Lead: Jo Harper
HEFT Support: Jackie Edwards

Improvements in medical interventions and treatments are advancing at a great pace, which means that populations are living for longer.

The Gold Standards Framework (2004) states that many people who are nearing the end of life, or who are known to need end of life care, are admitted to hospital rather than supported to die at home. The National Care of the Dying Audit (Marie Curie Cancer Care, 2007) notes that 55% of people with cancer would prefer to die at home but in fact only around 25% actually achieve this wish.

Sometimes, in our society, we still find it hard to talk about the subject of death. However, unless we discuss issues around the care of the dying, the NHS will not be able to respond to the challenge of reducing the existing level of variation in the care it currently provides and therefore it will not be able to improve the experience of patients and their families at this very important time.

Preparation is vital to getting end of life care right and to provide a seamless service for people and their families. Identifying people who are nearing the end of life is vital to unlocking the end of life pathway. Being able to discuss end of life care issues while patients are ‘well’ enough can greatly enhance their experience and that of their loved ones by helping them at this stage. Discussions with patients should include anything the person thinks is important including decisions about preferred place of death and do not attempt resuscitate (DNACPR) orders. Practical aspects such as providing equipment and anticipatory medication can be key to making the patient’s journey easier and avoiding crisis calls and emergency hospital admissions.

Community nursing teams already carry out a lot of end of life care – recognising this and providing support and robust systems to help provide care that is important. All staff working with people at the end of life need good levels of support to maintain high morale, which is key to reducing staff turnover and ensuring that patients receive a high quality service.

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[toggle title="Protection from Infection"]

The aim: ‘to demonstrate a dramatic reduction in the rate of urinary tract infections (UTIs) for patients in NHS provided care’.

HEFT Lead: Lorna Grinnell-Moore

Urinary Tract Infections (UTIs) make up a large proportion of healthcare-associated infections (HCAIs) in the UK – and four out of every five can be traced to indwelling catheters (Health Protection Agency, 2009). This means there is a massive scope for both improving the quality of patients’ lives and saving precious healthcare resources by reducing the occurrence of UTIs.

It is clear that, if we want to reduce the number of catheter associated urinary tract infections, then one simple thing that we can do is to catheterise patients only when absolutely necessary and, also, minimise the time that a catheter is in place. While catheterisation can be necessary for certain symptoms, such as acute retention and for monitoring urinary output, it should be the last resort for managing incontinence.

Catheterisation carries many risks, and these risks increase the longer the catheter is in situ. Responsibility for ensuring that there is a clinical need for catheterisation lies with all clinicians performing the procedure. Ongoing catheter care is the responsibility of nursing staff and forms part of basic nursing care provided for patients.

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[toggle title="Ready to Go - No Delays"]

The aim: ‘to increase the number of patients in NHS provided care who have their discharge managed and led by a nurse or midwife where appropriate’.

HEFT Leads: Andrea Field and Liz Lees

In recent years, discharge initiatives which aim to free up hospital beds have become common-place within hospitals. However, the development of new systems and roles such as bed management, can leave nurses feeling disengaged from the proactive management of patient admission and discharge. The increasing focus on bed capacity and turnover of patients can result in nurses feeling pressurised into speeding up discharge and removed from their role of caring for patients.

While new roles and initiatives can be valuable, changing the way nurses engage with discharge is key. Proactive management of patient discharge and embracing of nurse-led discharge will have a major impact on the flow of patients, faster discharge and less frustration for patients that are ready and waiting to go home.

Increasingly, nursing staff need to respond to this issue and increases in nurse-led discharge will meet the needs of patients and deliver the quality from admission to discharge that we inspire to.

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[toggle title="Staying Safe - Preventing Falls"]

The aim: ‘to demonstrate a year-on-year reduction in the number of falls sustained by older people in NHS provided care’. However, patient safety must always be carefully balanced with patient independence and their right to make informed choices.

HEFT Leads: Sue Hyland and Ann-Marie Riley
HEFT Support: Bridget Leach

Every nurse knows there is no such thing as a simple fall. Even a fall where there is no injury can cause a level of psychological damage to the patient often resulting in a loss of confidence and independence. This can lead to the need for increased or extended support from the NHS. Nurses are aware that there are things that can be done to prevent patients from falling, or at least to minimise the risk.  We all have a responsibility for ensuring that we try and take the appropriate action to keep our patients safe. To do this we need to have a co-ordinated approach with both organisational leaders and frontline staff playing their part.

There are many elements to falls prevention and it is a complex area that has many layers, which means no one method will work alone. Falls prevention needs to consider the patient’s individual needs and the different environmental factors in different settings, including home, care setting, and hospitals. All of this needs to be reviewed while balancing patient safety, independence and rehabilitation.

[/toggle]
[toggle title="Your Skin matters"]

The aim: ‘no avoidable pressure ulcers in NHS provided care’.

HEFT Lead: Fiona Burton
HEFT Operational Lead: Helen Roden

We know that pressure ulcers represent a major burden of sickness and reduced quality of life for patients. They create significant difficulties for patients, carers and families, as well as increasing the time in hospital and, therefore, cost to the NHS.

Most nurses will agree that the majority of pressure ulcers that develop in NHS provided care are avoidable. So why do they occur? Often it is the processes around their prevention that fail, for example not being able to get hold of the right equipment, or not finding the time to undertake an early assessment. Stopping pressure ulcers needs input from the multidisciplinary team that results in the creation of a simple process that works and that we all follow. As a nurse, why wouldn’t you want to lead on the work to stop your patients from developing pressure ulcers?

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[toggle title="Promoting Normal Birth"]

The aim: ‘to increase the normal birth rate and eliminate unnecessary caesarean sections through midwives taking the lead role in the care of normal pregnancy and labour, focusing on informing, educating and providing skilled support to first-time mothers and women who have had one previous caesarean section’.

HEFT Lead: Joy Payne

Maternity services in England offer care for mothers and babies that is the envy of many other countries. However, there are concerns that intervention rates are rising. The proportion of births by Caesarean section (c-section) has steadily increased in England over the past 20 years.

Clinicians currently working in services with low c-section rates believe that maternity units applying best practice to the management of pregnancy, labour and delivery can achieve consistent rates below 20% (NHS institute 2006, Focus On: Caesarean Section).

A focus on normalising birth results in better quality, safer care for mothers and their babies with an improved experience. Increasing normal births and reducing c-section deliveries is associated with shorter (or no) hospital stays, fewer adverse incidents and admissions to neonatal units and better health outcomes for mothers. It is also associated with higher rates of successful breastfeeding and a more positive birth experience.

These changes benefit, not only women and their families, but also maternity staff. Midwives are able to spend less time on non-clinical tasks and more on caring for women and their babies.

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[toggle title="Keeping Nourished - Getting Better"]

The aim: ‘to stop inappropriate weight loss and dehydration in NHS provided care’.

HEFT Leads: Diane Eltringham, Helen Reilly and Jo Richmond

Malnutrition is a cause and a consequence of disease leading to worse health and clinical outcomes in all social and NHS care settings. Yet most patients, carers, healthcare professionals, commissioners, senior managers and chief executives do not realise how common it is in the UK and so it goes unrecognised and untreated (BAPEN, malnutrition matters; 2010). Nurses and midwives have a responsibility to make sure people under their care are appropriately nourished and hydrated – they need to have food and drink. This is a basic human requirement and fundamental to the care and recovery process. To support and improve nutritional care we need to have an approach that is inclusive and ensure we have a joined up approach which crosses pathways in both acute and community settings. Clinical leadership and effective management structures in addition to robust multidisciplinary care is essential in order to provide nutritional care that is focussed on each individual and is comprehensive and seamless across all care settings.

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Click on the above links for more information and to find out who is leading on each of the eight areas at Heart of England Foundation NHS Trust (HEFT).

For further information and to read the case studies and literature reviews click here to visit the NHS Institute for Innovation and Improvement website.