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Leading the switch to patient-centred care

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NAME: Jonathan Webster

NAME: Jonathan Webster

JOB TITLE: Consultant Nurse for Older People, Western Sussex Primary Care Trust

CAREER HISTORY: After qualifying in 1990, worked first in general medicine in Portsmouth and then surgery in Australia. Returned to general medicine and completed a secondment as a project nurse in resource management. In 1994, became a senior staff nurse on an acute medical ward for older people, then a charge nurse on a stroke rehabilitation ward. In 1996, became a charge nurse on an acute medical ward for older people that included acute stroke assessment beds. In 1999, took the clinical lead in setting up a community stroke rehabilitation service at Eastbourne and County Healthcare NHS Trust, with subsequent responsibility for establishing a hospital-at-home service.

QUALIFICATIONS: MSc, BA (Hons), DPS(N), RGN

How the role evolved
Since my appointment to the post of consultant nurse working with older people in 2001 the role has evolved to reflect the diversity of need in my locality. Initially, I was employed to work in an acute hospital in the Royal West Sussex NHS Trust; it then became a joint appointment with community services and now I am employed solely by Western Sussex Primary Care Trust. This change reflects the development of the local older person's agenda.

My role places me in a good position to influence and inform operational and strategic development and expert therapeutic working with older people. Four elements underpin the consultant nurse role (NHS Executive, 1999):

- Expert practice

- Professional leadership and consultancy

- Education and development

- Practice and service development (linked to research and evaluation).

When the role was first announced in 1998, debate centred on its potential impact on clinical care and nursing as a whole (Castledine, 1999). I saw it as a chance to maintain a clear clinical focus, while aiding the development of expert therapeutic working with older people taking a person-centred approach. I felt that the broader focus would also enable me to integrate within one role key aspects such as practice development, clinical leadership, practitioner-centred research, education and service development (operational and strategic).

Working with older people requires practitioners to think and work creatively because older people can have a multitude of interrelated needs associated with the ageing process, and to reflect on their practice critically while challenging practices and ways of working that are not person centred. Key to the therapeutic relationship is working in partnership with the older person and their supporters.

One of the key challenges I faced when I started was in dealing with people's perceptions of the post. Unlike similar posts, my role is not disease-focused and while some people found this concept 'uncomfortable' and wanted me to work within a narrow scope, others recognised that my role should cross traditional boundaries and span different areas of clinical practice.

Work by Manley (1997) has greatly influenced my practice: her views validated and reaffirmed my own values about the potential of expert nursing and the role of consultancy in influencing and shaping clinical practice.

The key to developing expert, person-centred practice and implementing policy such as the National Service Framework for Older People (DH, 2001a), is working within both multiprofessional and multi-agency teams. If the role is to reach its full potential, it is vital to secure support from managers, peers and other professionals (Sturdy, 2004). With such support consultant nurses are ideally placed to facilitate local services and practice developments, while informing and influencing the national older person's agenda.

POLICY ON DEVELOPING THE NURSE CONSULTANT ROLE
NHS guidance that has been instrumental in shaping aspects of the post:

- The New NHS: Modern, dependable (DH, 1997) saw a change of focus and policy, replacing the internal market with an integrated approach to care

- Making a Difference (DH, 1999) outlines a range of clinical opportunities for nurses to stay within a clinically focused role

- The NHS Plan (DH, 2000) sets out a vision of an NHS centred on the needs of patients

- The National Service Framework for Older People (DH, 2001a) puts the needs of older people at the centre of the reform programme for health and social services. It focuses on four core themes: respecting the individual; intermediate care; providing evidence-based specialist care; and promoting an active, healthy life

- The Essence of Care (DH, 2001b) provides a benchmarking process and identifies the fundamentals of nursing care.

A NOT-SO-TYPICAL WEEK FOR A CONSULTANT NURSE FOR OLDER PEOPLE
'While the diary contains a number of regular clinical commitments, the rest of the week brings great variety. This may include meeting with patients and their families to agree a plan of care and organising staff visits to nurse-led units, as well as leading training sessions, taking part in advisory groups on gerontological nursing courses and supervising master's students'

There is no such thing as a typical week. I try to maintain my regular clinical commitments, but the rest of my time is spent prioritising other work. I aim to get to work at 8-8.30am, but this depends on traffic, as I have a 60-mile commute.

MONDAY
First thing, I attend a chronic disease steering group meeting. This is a multi-agency group that focuses on developing an integrated approach to chronic disease management - the group will be vital in supporting the new nurse practitioner posts for older people in the community we are developing in chronic disease management.

Most Monday afternoons, I attend a multidisciplinary team meeting at one of the three community hospitals. This time, I am asked to see a patient who has multiple health and social needs due to her age. I spend time talking with her about her life, desires and aspirations. We agree plans for her care.

I speak with a colleague who works for a voluntary agency and has been involved with the development of a good neighbourhood scheme. I arrange to meet up to find out more.

TUESDAY
I attend a multidisciplinary meeting at another community hospital. I've arranged to see a man and his family to talk about his current needs and their hopes as a family for the future. The issues we discuss are complex and multidimensional related to how he will be able to return home. I recognise the family is under strain and is having difficulty coping. The meeting offers an environment within which the family can air their perceived challenges. Everyone is honest and frank, and we agree a way forward.

I drive to Portsmouth University and take part in an advisory group meeting about the MSc course in gerontological practice run by the university.

WEDNESDAY
At a training session on the health-care support worker induction programme on 'Seeing the person and not the patient', which I lead, we explore some of the principles that underpin person-centred care. We conclude with a video we have made with the help of a local college of higher education that helps to put the session in the context of the 'real' world. Next, I catch up with a physiotherapist I am mentoring as part of his master's degree and we discuss his research proposal.

I spend the afternoon attending the older persons' leads meeting at the strategic health authority that covers Surrey and Sussex. We talk about local implementation and monitoring of the National Service Framework for Older People and work that is under way related to the older person's agenda across the authority. This includes discussion of progress against milestones and local developments and challenges.

THURSDAY
I spend a couple of hours working on a medical ward observing care as part of a programme of practice development that is modelled on the Essence of Care. I work alongside a staff nurse and work with two patients on her team. I am not only observing care as part of the programme, but I am also actively working as a team member. I initiate some key therapeutic activities that include strategies to promote comfort and to enable independence and talk through what I have done, and why.

I visit a patient on the orthopaedic ward: he appears exhausted, with complex physical and psychological needs. I make suggestions about how the team can address some of these, using the person-centred assessment I have carried out with him, and leave a message for his daughter to suggest we meet at her next visit.

Next, a couple of hours in the office to catch up on post and emails. I spend time reading and commenting on an integrated falls strategy produced by our NSF falls group. I speak with someone interested in applying for one of our nurse practitioner for older people posts. I also meet the intermediate care co-ordinator to discuss site visits to some nurse-led units that we have arranged for staff.

FRIDAY
At an early morning meeting with the director to whom I report we talk about some of the work I am leading and a report I am writing. It's a good opportunity to catch up on key priorities and to help me keep focused.

At lunchtime I meet staff from two clinical areas with whom I am working on a programme of practice development that focuses on 'Person-centred assessment with older people'. We have been meeting for the past eight weeks. Once the programme has been completed, I will have worked with six clinical areas. This work has been an integral part of my role, and I plan to use the data for my PhD research.

I return to the office mid-afternoon and receive a phone call from the daughter of the man I saw on the orthopaedic ward. After a discussion, I arrange to meet her the next week.

I also speak with a colleague working in mental health about the needs of older people with dementia receiving hospital care. We are keen to organise local training, but this will clearly need to link to practice. We discuss how this can be done, including the clinical support that will be necessary, as there is little purpose in training practitioners if they cannot apply what they have learnt in their clinical settings in their work with older people.

Four key elements for nurse consultants
- Expert practice

- Professional leadership and consultancy

- Education and development

- Practice and service development (linked to research and evaluation)

NHS Executive, 1999

Author's contact details
Jonathan Webster, Directorate of Community and Intermediate Care, Western Sussex Primary Care Trust, 9 College Lane, Chichester PO19 6FX. Email: jonathan.webster@wsx-pct.nhs.uk

Castledine, G. (1999) Nurse consultants herald new era for clinical nursing. British Journal of Nursing 8: 18, 1258.

Department of Health. (1997)The New NHS: Modern, dependable. London: Stationery Office.

Department of Health. (1999)Making a Difference. London: DH.

Department of Health. (2000)The NHS Plan. London: The Stationery Office.

Department of Health. (2001a)The National Service Framework for Older People. London: DH.

Department of Health. (2001b)The Essence of Care. London: DH.

Manley, K. (1997)A conceptual framework for advanced practice: an action research project operationalizing an advanced practitioner/consultant nurse role. Journal of Clinical Nursing 6: 3, 179-190.

NHS Executive. (1999)Nurse, Midwife and Health Visitor Consultants. Establishing new posts and making appointments. HSC1999/217. Leeds: NHSE.

Sturdy, D. (2004)Consultant nurses: changing the future? Age and Ageing 33: 4, 327-328.

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