"Making the complexity of community nursing visible: The ...
The Cassandra Project- Building a Sustainable Workload Activity Model for Future Community and District Nursing Workforce Capacity Planning Carrie Jackson Director England Centre for Practice Development Acknowledging the team Professor Alison Leary, Chair Healthcare and Workforce Modelling, LSBU
Prof Kim Manley CBE, Chair Practice Development and Innovation, ECPD Dr Toni Wright, Principal Research Fellow Anne Martin, Research Fellow Tricia Leadbetter, Research Fellow Key: DCN- District & Community Nurses GCN General Community Nurses Presentation will cover 2 year mixed methods study to evaluate the impact of a community nursing workload
activity tool to underpin decisions about safe staffing levels. Funded by NHSE and HEE regional level Phase 1 Published BJCN March 2015 Setting the Scene- Background Background The DCN Workforce Issues
NHS Five Year Forward View Shift away from hospital care Care close to or in the home New models of care delivery Flexible high quality innovative workforce More District and Community Nurses needed
Different skill set Reality - Declining DCN Numbers Source: (HSCIC, 2014) DCN reduction from 13,000 to 7,500 in 10 yrs Over 4 years GCNs >by over 3,300- 2,000 are district nurses- 28% decrease 45% over the age of 45 approaching retirement Downgrading 1,545 band 7 and 1,317 band 8 nurses
Regional variations-East of England >903 DCNs >twice national average RCN Frontline First- The Fragile Frontline 2015 Understanding the role- clear as mud Poor understanding of DCN roles Wide variation in numbers of roles and bandings Lack of consensus around definitions
used to describe activities (1) service (what is being done, how frequently it involves contact with clients (2) population served (and its density) Further compounded by variation in how
caseloads are defined Size and skill mix of staffing levels determined historically based on custom around patient caseload Case Load Issues Large number of older people, with complex multimorbidities, polypharmacy
and myriad of psychosocial needs Higher levels of dependency -70% of the health service budget and time to manage Heavy caseloads -workload inconsistently distributed Poor/inappropriate referrals Inability to state when capacity has been reached
Contact time varies across the country not evidence based 25 clients per varying acuity caseload- Not possible to respond to variations in workload by redistributing nursing time to
where it is most needed Workforce Models -False Assumptions about (Community) Nursing We can rely on historical patterns to predict the future requirements Nursing is application of a simple linear task based physical skill set occupying time (Leary 2011, 2015, Jackson et al 2015) Most current IT systems e.g. RIO, System One are diary
based linear tools Linear methods do not capture complex work well (De Leon 1993; Raiborn 2004) Measuring workload based on counting patient contacts alone does not clearly demonstrate the full workload of nursesbulk of work unseen (QNI 2014) Missed Care Defined Required patient care that is omitted (either in part or in whole) or delayed in response to multiple
demands and inadequate resources. (Kalisch et al (2009: 1510) Negative consequences for patient outcomes Conclusion Need new capacity and demand tools to measure and reflect the complexity of workload and output, maximising the potential of the existing workforce to enable planned growth
The Cassandra Project Objectives 1. Adapt the Cassandra Matrix workload activity tool (Leary 2011) specifically for the community nursing context with DCNs 2. Pilot across 6 community organisations across Kent, Surrey and Sussex DCNs (bands 5-7) 3. Undertake a utility evaluation of the tool to provide proof of concept as a model to predict and plan for optimum community nursing caseload activity within a whole system. 4. Aggregate the data sets to identify patterns that might impact on caseload management including identification of care left
undone Our Assumptions Methodology Emancipatory Practice Development (ePD) Informed by critical realism to understand real world issues Formative implementation and process evaluation Strengthen or improve the tool being evaluated examine the delivery of the tool
quality of its implementation assessment of the organizational context, personnel procedures, inputs, processes and outputs alternative delivery procedures tool fidelity Methods Cassandra Matrix Workload Activity Tool (adapted) (Leary
2011) Pre and post workload activity survey to capture what difference it made to their self awareness of their role and contribution to care delivery. Process evaluation workshops with stakeholder organisations BOS survey pre and post workload activity using CCCIs framework (Guba and Lincoln 1989) What does the Cassandra Tool do?
Web based tool used in real time as practitioners carry out their daily work using computers, phones or tablets to input their activity Intervention, context, time, people, care left undone/activity left undone Six main categories of intervention:
1. Case management 2. Clinical admin 3. Non-clinical admin 4. Physical 5. Psychological 6. Social What does the tool look like? Input data for each care episode
Findings Approx. 11,000 points of data 7,629 interventions collected in 58 regularly used categories Issues with collection (not enough for a big data study) but shows complexity of care 112 examples of care left undone Intervention by Location 76 % of care delivered in the home
24% in other areas Spread across the intervention spectrum (2x context) Areas highlighted with less input? Continence management Falls assessment/prevention Advanced care planning Safeguarding Social needs assessment
Cannot generalise as you need big data to do this Tool does capture care missed/left undone so economic cost may be applied Why is this different? Models a complex system Relies on understanding relationships not just tasks that occupy time This includes modelling negative space ie work left undone Is more sensitive than averages
Can be used to construct optimum caseload blackbox Is iterative, takes longer and requires large amounts of data to look for patterns Mathematical Modelling Applied to Nursing Leary and Jackson 2015 in press Modelling is about building a representative whole system rather than trying to measure bits
What pilot sites said about its utility It shows what we are actually doing We had really enthusiastic motivated nurses who could see how they could use the tool to support their workload planning It is a good tool to use because it provides nurses with the systematic evidence needs to raise awareness of the impact that nurses are having at the front line as well as providing data that evidences skill mix and workforce development issues
Limitations Project timescale Winter pressures Gaining consistent membership of steering group and pilot sites from the start IT issues in one site- champions, web support Next Steps Develop data ontology for community nursing Data collection allowing for pattern recognition
through NIHR bid Optimum caseload calculations using stochastic methods Detailed analysis of workforce resourcing patterns and gap analysis Economic impact assessment through Burdett Trust programme at RCN NICE Safer Staffing guidelines Other developments Sophia workload activity tool for community mental health teams
Career Competence Framework ready to test (bands 5-8)- QNI CPD Impact Tool (Health Education England)- 4 theories of transformation Key References Jackson, C. et al. (2015) Making the complexity of community nursing visible: the Cassandra project. British Journal of Community Nursing, March, 20 (3), 126-133. Leary. A. (2011) Proving your worth: Alison Leary has tips on how nurse specialists can demonstrate added value. Nursing
Standard. 25 (31). Leary, A. et al. (2014) The work left undone. Understanding the challenge of providing holistic lung cancer nursing care in the UK. European Journal of Oncology Nursing. 18. 23-28. Thank you! @ECPDCarolyn @ECPD3 #WePracticeDevelopers http://www.canterbury.ac.uk/health-and wellbeing/england -centre-for-practice-development/england-centre-for-practice-develop
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