Background
Methods
Design
Participants
Job / Role | Number of participants |
---|---|
System leader | 4 |
Primary Care Team | 2 |
Care home manager | 4 |
Care home resident | 7 |
Family member | 6 |
Frailty Nurse | 3 |
GP | 3 |
Senior carer / carer | 13 |
Data collection
Results
Unanticipated implementation issues | Recruitment challenges Additional support and education |
Unintended outcomes | Misaligned role expectations Trust and relationship building |
Unanticipated implementation issues
Recruitment challenges
Consideration of these recruitment issues, alongside local budgets, and programme timescales, resulted in a strategic decision to re-advertise as ‘Trainee’ Frailty Nurse (TFN) posts at a lower level (UK NHS Band 6). Thus, the posts evolved to be training positions in which appointees could develop and grow to fit the local context. These unanticipated contextual factors changed the model from a FN-led model to a TFN-led model and prompted a series of unintended programme consequences.‘We advertised for [x number of] nurses … but it very quickly became apparent that the workforce wasn’t there, at that band seven, community matron-type level. … then over a shortish period of time we went out for further recruitment’ (FN-led Model, Participant 1: System Leader)
However, care staff seemed unaware of the subsequent change from FNs to TFNs and the additional educational element to the role that was needed because of these changing posts. This ‘mismatch’ of information disseminated originally and the evolution of the role to a training position led to unintended consequences, uncertainty, and confusion regarding the role parameters of TFNs. There was also a perception that recruitment of staff to TFN roles could have involved greater targeting of existing staff from within the care homes themselves.‘We had great expectations, because we were finding a lot of problems with contacting doctors’ (FN-led Model, Participant 15: Care Home Manager)
‘Whoever thought of the scheme, should maybe have gone round all the trial homes that they’re trying out in, and saying have you got anybody that you think fits the bill, that might like to do this role?’ (FN-led Model, Participant 15: Care Home Manager)
Additional support and education
TFNs were regularly mentored and for the first 6 months, were supported by the FN Lead to develop their role in context. This was also linked to preparing for future statutory national drives regarding specialty care requirements for the ageing cohort these nurses were working with. This support was helpful to all TFNs and the wider team, given they came to the posts without formal frailty training.‘Once I’ve done my clinical skills – my skill level will be higher than that of the current nursing staff. And I will then go and listen to the chests and say, yeah, I’ll get the GP to prescribe some antibiotics. But, at the minute, I don’t have any more skills than the nursing staff’ (FN-led Model, Participant 9: TFN)
‘ … Only one of them was from that [frailty] background. But they all have been looking after older people … It was getting one-to-ones, getting team meetings … Making them be safe from a nursing perspective. And … the way that they worked in this medically driven primary healthcare federation world’ (FN-led Model, Participant 11: Primary Care Team)
Unintended consequences
Misaligned role expectations
‘The very first time I [met the FN I] didn’t really understand what [the role] was. The next time I think it was… She explained what it is... that it’s not a GP, but it’s sort of a high… Like, she used to be a nurse... But then they do something like 98% of what a GP does or something’ (FN-led Model, Participant 22: Care staff)
Care staff from the TFN-led model felt misinformed about the role, remit, and responsibilities of the TFNs, which made them feel less trusting of decisions and judgments regarding residents’ care. Staff were mostly unaware of the educational and developmental requirements within the trainee’s role, and this led to unintended consequences of uncertainty and confusion. Some care staff expressed a preference for a GP-led model, as they perceived GPs as having the ability to provide immediate treatment and being unable to refuse requests to visit residents.‘[The FN] cannot put in any real input into the home…It’s a misleading perception to everybody…Frailty Nurses…The contents don’t do what the tin says. And for me… I find it misleading because if you went into a hospital and someone had on their badge that they were a nurse, and they were actually a carer... You know, they were working towards being a nurse, and you thought that person was a nurse - how would you feel about that?’ (FN-led Model, Participant 15: Care Home Manager)
The lack of understanding led to unintended consequences of mistrust regarding the (T)FN role, despite efforts of system leaders to provide a dedicated team to train the TFNs and disseminate information about their remit and development. Conversely, positive experiences of the existing GP-led model were perceived to be directly linked to GP credibility and familiarity with the GP role.‘I don’t think [the FN has] relieved us from doing anything. Now, I think if we had a GP coming into the home every day - oh, what a fantastic difference that would make to us. Because we could say to them, oh, we’ve got so-and-so, who we think is a bit poorly... Can you have a look at them? Now, I think that would be fantastic’ (Participant 16, Care Staff: FN-led Model)
Trust and relationship building variable
‘I know my client group. I know when they’re well, and I know when they’re not well. And because I know them and their family, I think I’m better positioned than the GP so that I can feedback’ (FN-led Model, Participant 9, FN)
Whilst the EHCH framework supported consistency through GP alignment, some inconsistencies were still experienced, particularly when GPs visited care homes on an ad-hoc basis.‘I can see if somebody is deteriorating. You know, if somebody with dementia is getting suddenly more confused - a GP that doesn’t know them might think, oh, they’re just getting worse dementia. Whereas I would know that probably there’s a delirium there. And... And it may need to be actioned with some investigations or, you know, sort of, checking things out. It’s great continuity. It means we can, as we’ve been saying, be more proactive with care’ (GP-led Model, Participant 25, GP)
Care staff, residents, and their families felt that relationships were developed because of regular and consistent visits made by the TFNs or GPs in each model.‘Because we used to get various GPs, and they didn’t know who the individual [resident] was.…So, now we’ve got a regular GP, we’re all on the same wavelength’ (GP-led Model, Locality B, Participant 37: Care Staff)
Relationship building was also central to staff development through improved information sharing and proactive care; central components of the EHCH framework. In the narrative below a TFN explained how their alignment to one care home enabled them to make change and reduce falls. This was made possible through familiarity with the care home, its staff, and residents.‘Not all of the residents are part of the surgery who’s aligned to us. So, we’ve got three other surgeries who... We find very difficult to get them to come in’ (GP-led Model, Locality B, Participant 12: Care Staff)
Not all information sharing was positive, sometimes a lack of consistency in communicating information which was felt to impact resident care negatively.‘You can see through the investigation of them if there’s any recurrent places that they fall. Or recurrent reasons. And the lounge was one of… It tended to be one of the main areas… And made the biggest impact…stuff’ (Participant 9, FN-led model)
This documentation was critical for residents’ care. As part of the GP-led model, GPs also suggested that frequent care staff changes, including Registered Managers, negatively impacted establishing key information about residents, for example, in Emergency Health Care Plans (EHCPs). It was felt that this was due to a lack of time care staff had spent with residents and this was why some care staff could not provide a comprehensive account of resident issues.‘If [the FN] doesn’t document, then that could lead to problems. So, I think she needs to keep up with documentation when she’s done anything at all, to writing the doctor’s notes, the MDT notes… the family notes. Or if there’s something she needs to handover – put it in the book for the nurse. Or leave a note for the nurse. You know if it’s not written down, it’s not done’ (Participant 15, Care Staff: FN-led Model)
Relationship building across the multi-disciplinary team also strengthened communication with residents and their families, as they fulfilled their requirements to complete EHCH documentation e.g., end of life care plans. There were reports of enhanced care for residents within both models. Care staff explained that a close working relationship with GPs helped them to understand their roles and responsibilities, but more significantly they were preparing observations and acting sooner to resident care needs because they were aware of GPs visiting regularly.‘[The watch and wait policy] quite a complex issue, the carers wouldn’t recognise early illness. So, then, the person would be quite poorly by the time they got a GP to come out and visit them’. (Participant 10: FN, FN-led model)
Unlike with the existing GP model, an issue that impacted relationship building and affected trust was the misalignment of the TFN role, as discussed above. Despite wider strategic efforts to promote preventative care and support TFNs within care homes, care staff were uncertain, and somewhat untrusting, of the trainee role. Judgements were questioned, and this created tensions between the care home and TFNs.‘So, working with them a bit closer, and more regular, it makes you understand what they’re do and what they can and can’t do’ (GP-led Model, Participant 37: Care Staff)
Uncertainty and mistrust were exacerbated by a lack of awareness or understanding regarding the evolution from the autonomous FN role initially portrayed to that of trainee.‘Yes, because we know what’s going on... But she seems to be looking after the wrong ones, instead of concentrating on the ones that are really poorly, you know. I don’t know what more I can say, really, because…’ (Participant 21, Care Staff: FN-led Model)
‘I think the staff really appreciate it. And there is an opportunity for a bit of education and support of them. Because they have a very heavy burden as well. You know, they’re dealing with some very poorly patients’ (GP-led Model, Participant 25: GP)