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Designing a new patient centred nursing strategy.

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VOL: 102, ISSUE: 25, PAGE NO: 34

Maria Leader, MSc, DipN, RGN, is practice development nurse, General Surgery/Urology Directorate

Christine Pigford, BA, DipN, RGN, is practice development nurse, Obstetrics and Gynaecology Directorate; both at City Hospitals Sunderland NHS Foundation Trust

Making a Difference (Department of Health, 1999) and The NHS Plan (DH, 2000a) both outline plans for a modern nurse, responsible for the overall plan of patient care from admission to discharge, which coordinates and facilitates management where appropriate. The reduction in junior doctors' working hours (DH, 2000b) has resulted in role boundaries becoming blurred and tasks that were once considered the extended role of the nurse falling within normal practice (NMC, 2002).

Making a Difference (Department of Health, 1999) and The NHS Plan (DH, 2000a) both outline plans for a modern nurse, responsible for the overall plan of patient care from admission to discharge, which coordinates and facilitates management where appropriate. The reduction in junior doctors' working hours (DH, 2000b) has resulted in role boundaries becoming blurred and tasks that were once considered the extended role of the nurse falling within normal practice (NMC, 2002).

In order to achieve the full implementation of these initiatives, City Hospitals Sunderland NHS Foundation Trust introduced 'pen portraits' to ensure that the patient was at the centre of all new developments.

The project
Pen portrait is part of City Hospitals' nursing strategy. It is a written vision of the modern nurse identifying her or his roles and responsibilities. The term came from the trust with 'pen' referring to the 'vision' of the modern nurse role and 'portrait' identifying the list of skills/training each nurse would need to be able to perform the role within each specialty. For example, a nurse working in haematology would need skills including: Hickman line care; ability to administer cytotoxic drugs; venepuncture; and cannulation. These skills would be the pen portrait for that nurse. The pen portraits outline the future role and responsibilities of the modern nurse within the trust.

The strategy supports a number of national as well as local directives/initiatives, which include:

- The chief nursing officer's 10 key roles (DH, 2002);

- The named nurse system of care;

- The Critical Care Agenda (DH, 2000c);

- Essence of Care (DH, 2001).

It was anticipated that the nursing strategy would help the trust to achieve its modernisation agenda.

Achieving the pen portrait involves relevant training and education programmes for existing registered nurses and developing pre-registration training to deliver the modern nursing role at the point of registration. These proposed new roles and responsibilities would therefore enable nurses to provide patient care, utilising the full extent of their knowledge and skills. To help drive this agenda forward the practice development team was created.

Practice development team

It was the vision of the chief matron that the practice development team would have a pivotal role in driving the pen portrait forward to achieve excellence in patient care. Alongside the team a number of modern nursing roles were created to help delivery, including modern matrons, nurse practitioners and nurse consultants.

The practice development nurse role ensured:

- Implementation of the named nurse system of care to provide continuity and coordination of care in a timely fashion;

- That all nurses had undergone competency-based programmes relevant to their work;

- That action plans were developed to shatter old role demarcations that have potentially held back staff and slowed down care;

- Streamlining of patient care;

- Delivery of modern patient-centred services.

Implementation
Initially new roles for nurses were proposed by clinical directors, business managers, senior clinical nurses/midwives and ward/department managers. The individual directorate and the trust agreed these modern nursing roles. The practice development team facilitated the completion of nursing action plans within agreed timescales to meet the vision of the future modern nurse.

Once these roles were agreed it was necessary to develop competency-based assessments, accompanied by teaching outlines to ensure consistency in nursing knowledge and skills.

It was recognised that staff already possessed certain knowledge and skills to deliver part of the pen portrait requirements. However, there was a need to obtain support from local universities and to establish a continuing professional framework group and an educational forum.

Monitoring progress
The practice development team was responsible for monitoring the progress of the project. Skills grids were created (Table 1) indicating the specific skills required for each ward/department. These grids reflected the acquired competencies of each individual practitioner. Bimonthly reports were compiled to monitor progress in each ward, indicating any improvement/blockages in achieving competencies.

Roles and CPD
As a result of systematically identifying and meeting training needs many advances in clinical practice have occurred, including:

- A urology peripatetic service - allowing patients to receive treatment in their own homes, resulting in less occupancy within the hospital setting and also allowing directorate funds to be utilised more effectively in other areas of patient care;

- Midwifery-led care - promoting greater continuity for the woman, allowing her to be seen by a highly skilled midwife meeting her individual needs;

- Home chemotherapy service - allowing many patients with cancer to receive treatment in the comfort of their own homes by professionals trained to deliver their individual regimens;

- HCA roles - facilitating a more dynamic workforce, allowing care to be given by a multiprofessional team of highly trained individuals. Most HCAs within City Hospitals Sunderland have now completed the first level of the HCA course and this has led to the development of level two, which identifies more specialised skills;

- Emergency percutaneous endoscopic gastrostomy (PEG) reinsertion - allowing patients to receive timely care without having to wait for medical review;

- Nurses requesting radiological investigations - allowing nurses to order specific X-ray requests following a set criteria to provide holistic care and more efficient care delivery;

- Nurses administering medications via patient group directions (PGDs) - allowing patients to receive specific medications efficiently without having to contact medical staff;

- Development of standards, protocols and guidelines - supporting clinical practice with evidence-based research;

- Competency-based assessments - ensuring that staff possess the appropriate knowledge and skills in order to be able to deliver holistic care;

- Development of nurse-led discharge - empowering nursing staff to discharge patients in a more appropriate timely fashion;

- Progression of nurses - allowing verification of expected death in place of medical staff.

All of these developments have been shared within the trust at the annual modernisation day.

Where are we now?
As with all change innovation in clinical practice, audit and review are part of the ongoing process. As a result pen portraits have been reviewed and updated within all directorates and projected skill requirements/new roles identified for 2006-2007 (Box 1). These developments are reflective of the current challenges faced within the NHS. Healthcare roles are constantly changing and the demands of the service require staff to be adequately skilled to deal with this change.

Improving the patient's experience is a major initiative intended to help design the NHS around patients, where staff are equipped to deliver high-quality services that are accessible, responsive and appropriate to meet the needs of patients as individuals (DH, 2000a).

Discussion
Before pen portrait there was no robust system to ensure that training and education was prioritised and coordinated within each clinical area. This led to a disjointed approach in reviewing and evaluating the current individual ward and department skill requirements. Staff knowledge was not shared and skills were not utilised appropriately.

As the modernisation strategy progressed, changes occurred in the ward manager's role and senior clinical nurse posts were restructured, leading to the creation of new posts such as the modern matron and the practice development nurse.

Changes in practice would have occurred within the trust without the practice development team, however, the impact of the team has enabled practitioners to be appropriately skilled and knowledgeable in everyday practice, ensuring that care is delivered in a timely manner.

There was a necessity to ensure the nursing workforce was equipped to deliver the needs of the service appropriately, particularly due to the reduction in junior doctors' hours. This reduction led to a potential deficit in care delivery such as a lack of available medics to insert cannulas during the night resulting in fragmented care, as patients would potentially not receive vital medication as prescribed.

There was a requirement to bridge this gap and pen portrait shattered demarcations, developed health professionals and provided a more efficient service to patients.

This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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