Evaluation

The following information was collected from each participant in the four cohorts for project evaluation:

A digitally ready workforce

The NHS is at the stage of the digital revolution when many TECS are available but are not in mainstream use. In 2014, only 2% of patients reported having digitally enabled transactions of healthcare (National Information Board 2014). More recent figures from a GP survey (NHS England and Ipsos MORI 2018) show little change: 41% of patients surveyed were aware they could book appointments online but only 13% used the service.

The aim of the GPN ALS programme was to bridge this gap from the ground up rather than top down, empowering GPNs to be the agents of digital transformational change, as envisaged in the NHS Long Term Plan (NHS England 2019) and recommended in the Topol Review (2019). This approach can be adapted to varying clinical needs in different localities with a broad spectrum of priorities, where a ‘one-size fits all’ strategy would be unacceptable.

The disconnection between the availability and adoption of TECS is clear from the lack of TECS used in practices before the nurses started the project. Furthermore, the TECS were not used to full effect, if at all. This may be due to reticence to change, poor awareness of the range of TECS, and lack of confidence and ability of practice teams to implement change, as illustrated by GPNs’ comments in the phone survey.

Enthusiasm for implementing TECS in healthcare was high among GPN participants, who could envisage the benefits for patients and practitioners despite their initial low confidence and ability in adopting the technology themselves. Following completion of the programme, and enhancement of GPNs’ confidence and ability with TECS, all practices were using at least two different modes, with many using five or more, generally and for specific LTCs. This shows how individuals who are enthusiastic about TECS can embed them into their own and colleagues’ everyday practice despite not being initially ‘TECS savvy’. A ground-up approach was effective because, when nurses have the knowledge and support to use TECS, their confidence to drive changes followed.

A recent UK-wide consultation by the Royal College of Nursing (RCN) (2018) on the digital future of healthcare concludes that nurses in all healthcare settings need to be ‘equipped to lead this change’.

One of the barriers highlighted by the consultation is the difference between the perspectives of clinical staff and those who commission digital systems. It was reported that this difference, as well as structural and infrastructural barriers, is holding back the digital revolution in UK healthcare.

Like the project participants, nurses consulted by the RCN favoured a digital future and could see the potential benefits for themselves, their patients and the health service. These findings reinforce the aim and scope of a ground-up approach to digital transformation in two ways.

First, nurses are ideally placed to identify the real needs and preferences of patients. As the ALS programme demonstrated, when equipped with a digital toolkit, they can select the right TECS for the right patient according to the availability of equipment and patients’ or carers’ skills. Second, nurses are passionate about providing good-quality care and positive about using new modes of delivery where beneficial. As the ALS programme showed, nurses make for effective digital champions in their practices.

When interviewed about why they chose specific TECS, nurses across the board described how they were influenced by practicality and day-to-day insight of clinical need rather than their general practice performance figures in certain LTC areas. This finding is supported by the modes of TECS chosen most widely for implementation, with the top three being the mobile device to detect atrial fibrillation, the public social media group and the interactive text messaging system. The mobile device and social media group were reportedly the simplest to use, while the text messaging system was deemed most versatile.

Only one of the participants reported a choice of TECS based on missed practice clinical-indicator targets. Most participants selected particular modes of TECS for pragmatic reasons, such as their benefits for patients with clinical needs and likely compliance. Essentially, the nurses had developed and expanded their delivery toolkit to address problems they saw in front of them for their perceived benefits, an agile approach that is driven by actual needs rather than targeted or organisational pressures. In other words, they had become a digitally ready workforce that could optimise productivity and minimise gaps in healthcare delivery for their patients.

Efficacy of the nurse cohorts

As champions, the digitally ready GPNs: seeded change in their practice teams; increased reported productivity, patient safety and compliance; and reduced avoidable practice face-to-face appointments and phone calls. Additionally, the results of the ALS programme provide evidence that initiatives adopted by just one member of a general practice team can evolve from a pilot to usual practice.

As an important part of the ALS process, participants were asked to identify areas for change and record best practice by completing LCAV documents. A common theme was participants’ empowerment. For example, they recorded how they held meetings with senior practice GPs to educate them about adopting digital modes of delivery of care.

One, who at the beginning of the course described herself as ‘not TECS-savvy’ but ended it as ‘TECS-happy’, described how she had spread what she had learned and her ‘can do’ attitude to her practice colleagues. Another wrote about the challenges she faced and said that the results of her TECS use had been mixed so she was adapting her implementation approach.

When interviewed by phone about the attitudes of their practice teams towards the adoption of TECS, more than 80% of participants reported that attitudes became more positive after their interventions. Even in practice teams where engagement was already high, participants’ application of learning to front-line care boosted adoption of TECS even further. As agents of change, the nurses proved themselves to be not only digitally ready, but resilient and empowered by becoming trusted practice champions for digital delivery of care.

Application to other branches of nursing

There are other branches of nursing where an individualised ALS programme would apply. For example, district nurses could find that remote access to their patients by video consultation, telehealth or social media enhances their productivity. One district nurse teacher at a recent digital nursing conference commented that this is already happening: ‘We use telehealth, digital photography and video conferencing to support, enhance and empower staff.’

As the two case studies show, ALSs can offer huge boosts to productivity and improve management of patient care in the community. Further links by digitally ready GPNs are being made in community and secondary care settings, with TECS for wound care along the tissue viability delivery pathway (RCN 2018).

Programme improvements

After the final session, five participants said they were still ‘digitally worried’ (Figure 2). However, by the time of the phone survey two months later, four of these had increased markedly in confidence so that only one of the 24 participants who completed the programme could still be described as ‘digitally worried’. This nurse described struggling with being the only GPN in her practice and felt isolated, despite support from the ALS team’s expert nurse facilitator.

Perhaps unsurprisingly, nurses tended to perform well when they initiated informal study groups using instant messaging and video consultation so that they could share learning, challenges, ideas and progress with one another. It is recommended that such instant messaging groups are encouraged in initial ALS sessions to ensure that all participants feel supported and can reach their full potential as the action learning progresses.

Although a closed social media group was created for the participants, there was little interaction and only three of the GPNs actively participated in it. The instant messaging group was regarded as much more accessible and beneficial for ongoing interactions.

Limitations

Although data demonstrate the use of TECS in practices before the start and at the end of the project, collecting more information about the uptake of TECS after the ALS sessions would have been useful to identify trends.

The project did not collect data from patients about how they felt using digital technology, so their perspectives could not be evaluated directly. Findings are limited due to the size of the project, with 27 volunteer nurses recruited from 21 practices across Staffordshire. Of these, 24 completed the programme, a small sample. However, it is worth noting that the nurses were all volunteers, and covered a range of experience and age, and their practices had varying registered patient population size and levels of deprivation.