VOL: 96, ISSUE: 38, PAGE NO: 46
Colin Dugdale, BSc, RMN, RGN, dementia trailblazer, NHS Executive North WestAs a community mental health nurse team leader I was seconded to the NHS Executive North West for the role of dementia trailblazer to develop the Admiral Nurse Service in the north-west of England.
As a community mental health nurse team leader I was seconded to the NHS Executive North West for the role of dementia trailblazer to develop the Admiral Nurse Service in the north-west of England.
'Trailblazer' conjures up an image of Batman or the Lone Ranger. Certainly as I met people there appeared to be some disappointment that I did not wear cowboy boots and a black balaclava.
The transition from community mental health nurse to trailblazer, has involved understanding the priorities, complexities and cultures of two very different organisations - the NHS Executive and The Dementia Relief Trust, a national registered charity launched in 1995 to promote, develop and support the Admiral Nurse Service. DRT aims to provide a professional framework for Admiral nurses working in partnerships with host NHS trusts.
Although my clinical experience and knowledge have proved invaluable, as a non-clinical role, the trailblazer post requires a different set of skills - those of negotiation, presentation and collaboration.
Admiral nurses are RMNs who work with the carers of people with all forms of dementia and have a consultancy remit. The impetus for establishing the Admiral Nurse Service arose from the experience of the Levy family whose father, Joseph Levy, had been ill with vascular dementia. Although the family had plenty of financial resources and could afford to pay for as much care as Mr Levy needed, they discovered that few workers who came into the home had any specialist and that there appeared to be no support for family carers.
So, in the late 1980s, a group of carers and NHS staff set up the Admiral Nurse Service. The title 'Admiral' was in memory of Mr Levy, who was a keen yachtsman and nicknamed 'Admiral Joe'. The service originated from a pilot project, which took place at the Middlesex Hospital, London between 1989 and 1992, and was backed by charitable funding from the Levy foundation.
Admiral Nurses' role
Not only are Admiral nurses specialist nurses in the dementia field, they have a unique carer focus. There now exists a significant amount of evidence suggesting that caring for a person with dementia is not only stressful but can have a negative impact on the carer's own mental health status (Coope et al, 1995). In recent years, government policy has consistently stressed the importance of supporting carers. This has been further highlighted by the recent Audit Commission report examining mental health services for older people (2000).
While it could be argued that the majority of services already focus on carers, regarding the carer as a client alters the professional relationship. This shifts the emphasis from supporting the carer in their role to specifically identifying the carer's needs. These needs are, inevitably, linked to those of the person with dementia. Working with the carer may also involve joint work with the carer and person with dementia as well as direct work with the person with dementia. To assess the needs of carers, a 19-point holistic assessment tool is used, which provides the focus for the nursing interventions.
The Admiral Nurse model reflects the work of Zarit et al (1985) and Pearlin et al (1990). These authors have studied the nature of carers' stress and suggest that their needs fall into three broad categories: information, support, and practical skills. Needs that have been identified are worked through according to the priority ascribed by the carer and nurse, and will vary according to the unique nature of the caring relationship. The model takes account of the fact that caring is a career and that needs are dynamic. Research suggests that carers' needs are often multifaceted and that they need especially need support at times of transition, such as diagnosis, admission of the person they are caring for to residential care and the death of the person with dementia. (Aneshensel et al, 1995).
Interventions are likely to continue beyond the patient's admission to a residential facility and will include bereavement counselling and emotional support at the time of death.
The UKCC guidance on higher-level practice provides a useful framework for understanding the dual role of the Admiral nurse. Alongside clinical practice, the role involves consultancy, development, teaching and research. The Admiral Nurse Service aims to integrate training and research to assist in developing a thorough knowledge-base, be a point of reference for other professionals, and take an active role in training carers and paid workers.
DRT and Admiral Nurse Service are based in the south-east of England. Services have developed in closely geographically aligned clusters, which has strengthened the nurses' identity and facilitated support from DRT.
Developing the service outside south-west England, in the absence of supportive networks and where awareness of Admiral Nurses was likely to be more limited, required a great deal of work. To facilitate this development a unique partnership was formed between the NHS Executive North West and DRT - and the trailblazer post was created.
The first objective was to raise awareness about the Admiral Nurse Service. To achieve this a number of strategies have been used. These include press releases, radio interviews, presentations, the dissemination of written material and a forthcoming regional conference.
The NHS Executive North West, in acting as host and providing the opportunity to access NHS Trusts and health authorities at a regional level, has contributed significantly to raising awareness of the Admiral Nurse Service.
A great deal of interest has been shown in the service by clinicians, managers and purchasers. There is, however, a significant difference between interest and a commitment to develop a service. In addition, a new service, no matter how innovative, needs to be supported at the grass-roots level, meet local needs, and both complement and dovetail with existing services.
To this end, a joint document was drafted and forwarded to health authorities and trusts, detailing how they could apply for money to establish an Admiral Nurse Service.
The document sought detail on how Admiral nurses would work with local services and enhance the provision of carer support and education in the field. The successful applicants are to be announced shortly.
The next part of the project will be concerned with replicating the service, and the unique practice development framework provided by DRT. This will include induction, individual and peer-group supervision, practice development days, and support with training and research.
Multiagency steering groups will oversee the development of the new services, with representation from both the statutory and voluntary sector.
Education and Research
The need for more advanced training in the field of dementia care has been recognised for some time (Jones et al, 1997).
The north-west and northern and Yorkshire regional offices of the NHS Executive and DRT are exploring the possibility, along with essential stakeholders, of developing a skills-based interdisciplinary advanced diploma/BSc in dementia care.
Options for evaluating the Admiral Nurse Service in north-west England are being considered, and the RCN will soon undertake a piece of action research to assist current services in developing a competency framework for higher-level practice.