VOL: 101, ISSUE: 09, PAGE NO: 28
Veronica Budgen, RGN, SEN, DEN, is community staff nurse and practice nurse, Judges Close Surgery, Mid Sussex Primary Care Trust
Research commissioned by Help the Aged has identified that older people can be resistant to falls prevention advice because they consider it relevant only to people older and frailer than them and that there is a stigma attached to being described as ‘at risk’ (Godfrey, 2005). It is suggested that the most successful health promotion strategies for older people focus on positive activities, take a holistic approach and account for the needs of the individual. Nurse-led initiatives to meet these needs are becoming common in primary care (Jones, 2000). One such project is based at a general practice surgery in a small market town in mid-Sussex and this article describes a health promotion project that was set up there.
Health promotion for older people
The importance of health promotion for older people was highlighted as part of the white paper The New NHS: Modern, Dependable (Department of Health, 1997) and health screening for all patients over 75 years was for some time part of the GP contract. The National Service Framework for Older People (DoH, 2001) sets priorities of care for older people. Clinical governance recommendations mean that older people need more than just their height, weight and blood pressure recorded but should receive structured health promotion advice (Nazarko, 2004).
The surgery has a practice population of almost 9,000 patients, 662 of whom are over 75. They have an established integrated nurse team that routinely evaluates and replans its nurse-led clinics to improve patient care.
The nursing team ran an assessment clinic for the over-75s for several years. This was set up in accordance with the government target for all patients over 75 to be offered an annual assessment and medication review. The assessment used a system of inviting all those in that age group for individual appointments with a nurse. However, audit showed low attendance and the nurses were finding these types of appointment repetitive.
Government and local policy has highlighted the importance of health promotion for older people and in light of this the nurses decided that the assessment system was not meeting patients’ needs.
The nurses and GPs agreed it was important to provide something different to meet the health needs of this patient group, and the integrated nurse team took on the management of this project.
An afternoon workshop was arranged by the nurse practitioner for the team to analyse the problems of the old system and come up with a new plan to provide a service for this client group.
The workshop used a variety of facilitation tools, the first of which was a brainstorming session to come up with ideas on how the health needs of this group of patients could be met in a different way. As is often the case when this technique is employed to generate creative solutions, a huge variety of ideas was generated. Some of these ideas were too extreme such as one involving a barcode system. However, there were other ideas that were more practical such as a very formalised session of health promotion, increasing exercise and medication reviews, and one that identified and addressed the social needs of the older people and involved a chat and cup of tea.
From this set of ideas group discussions took place and a consensus was reached that the over-75 clinics should be a combination of:
- Medical review;
- Health screening;
- Health promotion;
- Social aspects.
A new name was suggested by one of the team - medical opportunity with tea - which could be abbreviated to MOT and therefore the sessions could be promoted as being a routine annual check-up.
The commitment of the integrated nurse team to altering current practice was evident but a force-field analysis was undertaken to inform the development of the clinic.
The driving forces were identified as:
- The National Service Framework for Older People;
- Clinical governance;
- Provision of quality patient care;
- The nurse’s professional development;
- Improved workload planning.
The restraining forces were identified as:
- Staff cooperation;
- A previously low attendance rate;
- Established practice and attitudes.
The MOT idea was assessed against the force-field analysis and it was suggested that it successfully addressed and reduced some of the restraining factors, as well as providing interest for the nurses and holistic care for the patients. It is difficult in nursing to do anything about restraining factors such as time and resources, but nurses are often used to working under such conditions. In addition, the integrated nursing team was looking for a new collaborative project and welcomed the opportunity that the new sessions would offer.
The new sessions
The format of the new MOT clinics would be that all patients booked for each session would arrive at the same time and be offered tea and biscuits, provided by the Friends of the Surgery patient participation support group. During this time they would be given the opportunity to chat with fellow patients and members of the integrated nurse team. A health promotion talk would be given highlighting good dietary advice, ways to increase exercise and other relevant health education subjects. After this health screening would be offered as an individual, private consultation with one of the nurses.
The change in the way the clinics would be run would have a minimal effect on the organisation. The expense of sending out invitations and providing tea and biscuits would be negligible. The reception staff, practice manager and Friends of the Surgery cooperation were also identified as being important to the project, as they would be involved in the administration of the clinic.
Evaluating the quality of health care intervention should be an integral part of care provision. Therefore, the new- style MOT clinics were run as a pilot for six clinics (a total of 90 patients) during which time patients’ views were sought to see how successful and practical they felt the clinics were. The nurses involved had an additional meeting and examined feedback and opinions from the patients and reflected on how they thought the new clinics had worked.
A strengths, weaknesses, opportunities and threats (SWOT) analysis was used to evaluate the clinics.
It was discovered that the strengths of the clinics included job satisfaction, improved attendance, meeting the needs of the NSF and clinical governance, a high patient satisfaction rate and providing a broader, more holistic approach.
The weaknesses were difficulties in meeting the time commitment, room allocation and the practice not having enough teacups.
Patients had lots of questions about their medications and this revealed the team’s lack of knowledge regarding complex polypharmacy and drug interactions. A pharmacist was invited to join the team to address the lack of pharmacological skills in the group.
The introduction of the MOT clinics offered a multidisciplinary health promotion activity that meets the needs of older people. It provides a holistic approach to the health needs of older people and meets the requirements of both the NSF for older people as well as the falls prevention guidance from the National Institute for Clinical Excellence (Box 2).
By giving an opportunity for health education as a group activity it allows for discussion that enables individuals to see that they can make health-related changes following the example of others in the group. The individual assessment can follow up on any issues and consolidate the assessment of individual health needs.
Furthermore, the MOT clinic has increased the nurses’ enjoyment of their work. It enables interaction between nurses and patients in both a formal and a social setting, and enables the positive aspects of health accounting for the needs of each individual to be emphasised.
- This article has been double-blind peer-reviewed.
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