evidence and practice
Digital by choice: becoming part of a digitally ready general practice team
Ruth Chambers Professor of health care, Keele University, Keele, England
Rudy McKinney Practice nurse, Stoke-on-Trent, Staffordshire, England
Marc Schmid Digital expert, Redmoor Health, Chorley, Lancashire, England
Paul Beaney Evaluator, Keele University Medical School, Keele, England
Practice nurses from a sustainability and transformation partnership area participated in six action learning sets focused on digital upskilling. The evolving digital practice nurse champions shared their learning and experiences of technology-enabled care in their practices. As well as identifying barriers to deployment, they overcame these challenges and accelerated the transformation of the delivery of care in their practices to create a digitally ready workforce.
The action learning sets consisted of three sessions spanning approximately four months in the same location. All were led and supported by an experienced clinical telehealth practice nurse facilitator and an expert on applications of technology-enabled care, during and between the sessions, with one-to-one remote and in-practice support depending on the needs of participants and their practices, and preferences for technology-enabled care services.
This is the story of Rudy, one of the 38 nurses who participated in the six cohorts. Her path spans sharing her aims, the performance indicators of her practice pertaining to providing care for long-term conditions and adverse lifestyle habits, her digital literacy before action learning and after the third session, her completed action plan and her achievements.
Primary Health Care. doi: 10.7748/phc.2018.e1502Citation
Chambers R, McKinney R, Schmid M et al (2018) Digital by choice: becoming part of a digitally ready general practice team. Primary Health Care. doi: 10.7748/phc.2018.e1502Peer review
This article has been subject to external double-blind peer review and has been checked for plagiarism using automated softwareCorrespondence
Published online: 20 November 2018
Digital nurse champions from a sustainability and transformation partnership (STP) area are showcasing what is possible by creating six action learning sets for evolving digital practice nurse champions who can cascade their learning and experiences of technology-enabled care in their practices.
As well as identifying barriers that exist to deployment they promote ways to overcome such challenges and accelerate the digital transformation of the delivery of care in general practice. This learning can be shared with clinicians in primary care and other front-line settings to create a digitally ready workforce.
This is the story of Rudy, who was one of the 38 nurses who participated in six cohorts across Staffordshire. All practice nurses in the six Staffordshire clinical commissioning groups could apply to join an action learning set, which consisted of three sessions spanning about four months in the same location. All the sessions were led and supported by an experienced clinical telehealth practice nurse facilitator and an expert on the applications of technology-enabled care, during and between the sessions. They provided one-to-one remote and in-practice support, depending on the needs and preferences of participants and their practices for technology-enabled care services (TECS). A bursary paid for attendance at the three sessions, as well as reading and planning time to underpin application of learning in the participants’ practices.
• Practice nurses need protected time to plan and implement changes to modes of care delivery
• Making change happen at practice level requires the whole team to agree and support each other
• Once there is clinician confidence in digital delivery there are opportunities to provide digital modes of care delivery
The aims of action learning relating to technology-enabled care services
The aims of the action learning were to help practice nurses embed a range of TECS as part of usual service provision focused on health conditions and patients’ adverse lifestyle habits. It was anticipated that this would enhance patient engagement, increasing the likelihood of patients adhering to treatment and changing their behaviour to address adverse lifestyle habits, while also providing a viable path to more effective and productive working by practice nurses, which is the future for provision of care by the NHS (NHS England 2016a, 2017).
Box 1 shows Rudy’s personal aims. She defined these after the first session of her action learning set, which she attended with two other nurses from her practice.
Rudy’s aims over the period of action learning
• Improve digital literacy by becoming familiar with the Florence Simple Telehealth texting system, apps and Facebook
• Expand the use of these in practice to improve my effectiveness and productivity
• Empower my patients to take control of their conditions and improve their understanding, which in turn should improve their clinical outcomes
• Work alongside our practice nursing team to incorporate digital technology into our practice
Focusing technology-enabled care services on population needs and preferences
It is important to be able to justify any investment by the NHS in transformational change – in this case, to repay the costs and efforts required for digital upskilling, including the equipment needed to provide certain types of digital care. This equipment might include: a tablet with Wi-Fi to undertake video consultations on a home visit or show a recommended app to patients during consultations, or devices to lend to patients so they can record biometric measurements such as their blood pressure, weight or oxygen saturation blood levels.
Practice nurses can find it difficult to be released from work or to prioritise time at work to design and set up a new service with associated protocols and changes in usual practice. Thus, the nurses in these initial action learning sets required bursaries to cover their non-working hours to attend the learning sessions, read about and watch videos of good practice, read and adopt governance and delivery protocols, as well as make changes to systems in their practices. The bursaries also covered any necessary equipment. However, the bursaries were not received until each nurse had reached agreed achievements and answered final evaluation questions.
Also essential to the preparation for action learning was a practice performance plan for each nurse, relating to the latest quality and outcomes framework (QOF) indicators for providing care for selected long-term conditions and lifestyle habits, with suggested opportunities for several types of TECS. Table 1 shows the different TECS available, while Table 2 shows Rudy’s practice’s performance chart and which TECS could be used for each lifestyle.
Another element of learning to become digitally ready is for the nurse to analyse where they are now in terms of digital literacy in relation to TECS, so their action plan can be examined (Health Education England (HEE) and RCN 2017). Table 3 shows Rudy’s assessment of her digital literacy at her first session and then four months later after her third session.
Technology-enabled care services applications and achievements
Table 4 shows the action plan Rudy compiled after her first session and her update of it four months later.
It can be seen that her focus was on patients with hypertension and/or diabetes, and she describes using Florence Simple Telehealth and apps for a range of applications, such as enhancing medication adherence and blood pressure monitoring. She also describes the increased productivity that TECS gave her and other nurses in her practice team.
The Leading Change, Adding Value template (NHS England 2016b) proved a great way to capture Rudy’s achievements a couple of months after she completed the action learning set. The template underpins the national framework for all nursing, midwifery and care staff, which can be used to achieve the ‘triple aim’ measures of better outcomes, better experiences for patients and staff, and better use of resources.
Completing the template helped Rudy review her starting point and how she had put her learning into practice as a practice nurse and with nurse colleagues and the whole practice team:
• She described how she could see gaps in practice where digital technology could be used.
• She relayed how the practice team realised that times were changing and they needed to keep up with the times.
• She thought through the various digital technology options to support their current practice, focus on patient-centred care and encourage patients to take responsibility for their own health.
• She felt this would also make the nursing team more efficient.
Before she started the action learning, Rudy’s practice used very little digital technology. The team saw that their practice could be streamlined and made more efficient by using digital technology. Patients had already indicated they would welcome advice on using health-related apps. The nurses’ knowledge of these was poor, however. The nurses were aware that the use of TECS could improve patients’ compliance and health outcomes, reverse their adverse lifestyle habits, and help them take control of their own health journeys.
Rudy and three other members of the nursing team led the adoption of TECS in their practice. Each chose to lead in their main specialties – for one nurse it was respiratory and for another it was atrial fibrillation (AF). Rudy’s was hypertension and diabetes, while the practice matron supported management of housebound patients. They held a meeting with the GPs in the practice to educate them about TECS and how it could support their practice. The GPs took to it well, which resulted in TECS being used across the practice.
A significant achievement for Rudy was that TECS changed the practice’s management of patients with poorly controlled and newly diagnosed hypertension. Previously, the practice used many appointments with nurses for checks and management of blood pressure.
Any home monitoring was conducted using a sheet of paper that the patient had to return to the surgery. Compliance with home monitoring was poor for some patients, who would forget to bring back the sheet with the readings.
Doing much of the hypertension monitoring using Florence Simple Telehealth has:
• Improved compliance by sending twice-daily reminders.
• Saved on appointments, as follow-up of patients can be done by phone.
• Reduced time wasted on appointments when patients return0ed without their home readings.
• Reduced time wasted chasing patients to return their sheets.
Rudy also chose to use the Manage Your Health app. She strongly recommended it to patients newly diagnosed with diabetes and achieved a good response. She now routinely shows it to patients previously diagnosed with diabetes during their annual reviews. She uses Florence Simple Telehealth to regularly remind patients to administer medication such as inhalers or depot/B12 injections. She and other nurses also now use AliveCor to diagnose AF.
Rudy was asked to describe the success of the changes already made or still being made in relation to the triple aim measures. She and the other nurses measured success primarily based on feedback from patients and staff.
Patients’ feedback was positive. They reported that they found the app to be a useful resource that helped them to increase their knowledge and understanding of their condition at their own pace. They also responded very well to Florence Simple Telehealth – they liked the reminders as a way to keep control of their health. Most patients said they preferred to submit blood pressure readings using Florence Simple Telehealth rather than paper charts, as they often forgot to respond with the paper method and found it inconvenient to keep coming to the surgery, especially if they did not have their own transport.
Staff feedback was also positive. The nursing team and GPs felt TECS improved the patients’ experiences and long-term health outcomes, as it assisted them to take responsibility for managing their own health. Staff liked using the app to reiterate their advice, so patients could later consolidate the information given at their consultation in their own time at home. They also felt that it reduced the number of appointments needed and enabled more streamlined and efficient management.
The main challenge in using TECS that Rudy described was resistance from some patients – some felt they did not need the app as they already understood their condition well, while others did not use technology much and preferred to continue with their previous methods. However, Rudy recognised that TECS do not have to be for everyone: ‘If we can use TECS to support our willing patients then that is a huge step in the right direction.’
‘There is a big place for technology-enabled care services in consultations’
When we came to evaluate Rudy’s experience of the project overall, she expressed several ways in which she had progressed during and after the action learning. The most important learning she recognised was that despite her initial scepticism she realised there is a big place for TECS in consultations.
She was surprised that TECS could be so useful and that her patients would be so receptive. She also felt it had improved her patients’ ability to manage their long-term conditions, especially those who were newly diagnosed and found the apps she recommended to be trustworthy sources of information post-consultation, when it is easy to forget details and lose paper leaflets.
Overall, Rudy rated her action learning set training as improving her confidence to use TECS in caring for her patients ‘100 times’ more than she had before she started the course. The practical support and information provided by the programme has given her the knowledge and confidence in TECS to use it with her patients and has empowered her practice as a clinician by expanding her ‘toolkit’.
The advice Rudy would give to others is: ‘Try TECS to see what it can do for you. As our confidence as nurses in TECS is relayed to patients, they develop confidence too. My final piece of advice is to ask for support if you are unsure – TECS in practice is new to many of us and we all have varying knowledge, but we are here to support each other moving forward. Currently, we are all working together as a team with the nurses and GPs in our practice, all using TECS and promoting them equally. While we have varying levels of knowledge and confidence, we are working together and supporting each other moving forward and all feel confident about a future using TECS.’
Rudy had been sceptical but was prepared to try TECS in her practice and has become a clinical champion with a supportive and interested team. She has recognised the advantages of patients being empowered to take more responsibility for their own health conditions using TECS, and the general practice team has become more effective and productive in their provision of care. Rudy has become increasingly confident in providing care digitally from an action learning approach with other nurses inside and outside her practice team. She obviously now enthuses her patients, too – they embrace TECS organised for a specific purpose relevant to improving their health and well-being (Chambers et al 2018).
Chambers R, Schmid M, Al Jabbouri A et al (2018) Making Digital Healthcare Happen in Practice: A Practical Handbook. Otmoor Publishing, Bristol.
Health Education England (2017) Building a Digital Ready Workforce. http://hee.nhs.uk/our-work/building-digital-ready-workforce (Last accessed: 4 October 2018.)
Health Education England, RCN (2017) Improving Digital Literacy. http://www.rcn.org.uk/professional-development/publications/pub-006129 (Last accessed: 4 October 2018.)
NHS England (2016a) General Practice Forward View. http://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf (Last accessed: 4 October 2018.)
NHS England (2016b) Leading Change, Adding Value. http://www.england.nhs.uk/wp-content/uploads/2016/05/nursing-framework.pdf (Last accessed: 4 October 2018.)
NHS England (2017) General Practice – Developing Confidence, Capability and Capacity. A Ten Point Action Plan for General Practice Nursing. https://www.england.nhs.uk/wp-content/uploads/2018/01/general-practice-nursing-ten-point-plan-v17.pdf (Last accessed: 4 October 2018.)
RCN (2018) Every Nurse an E-Nurse. https://rcn.clevertogether.com/welcome (Last accessed: 4 October 2018.)
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