Digital healthcare provision in England has been driven mainly by a ‘top-down’ approach and a focus on digital infrastructure rather than front-line delivery. This has laid the foundation, but digital care delivery still has a long way to go.
This article describes an action learning programme to create digitally ready nurses. The programme, which underpins action six of NHS England’s ten-point plan for general practice nursing, shows that a ‘ground-up’ approach to upskill and empower front-line clinicians is central to embedding technology-enabled care services (TECS).
Following completion of the action learning sets (ALSs), 24 general practice nursing digital champions across Staffordshire have used TECS to deliver a range of benefits for their practice teams. This has informed the introduction and extension of the programme, with national funding for a further 12 regional pilot ALSs across England in 2018-19. Importantly, the active learning individualised approach provides a digitally ready workforce with the ability and support to adopt TECS in areas of clinical need. This ability is central to the next stage in the digital transformation of healthcare.
Nursing Management. 26, 3, 27-35. doi: 10.7748/nm.2019.e1840Correspondence
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Published: 28 May 2019
Provision of digital healthcare in England has so far been driven largely by a ‘top-down’ approach focusing on digital infrastructure in healthcare systems rather than front-line delivery (Chambers and Schmid 2018). This has laid the foundations for the digital delivery of care, but this still has a long way to go before its potential is realised.
In line with action six of NHS England’s (2017) ten-point plan for general practice nursing and Health Education England (HEE) (2017) priorities, six action learning sets (ALSs) for upskilling digital general practice nurses (GPNs) and encouraging them to adopt technology-enabled care were set up across Staffordshire to ‘embed and deliver a radical upgrade in prevention’ of ill health. This involved the provision of training and resources to help GPNs develop as champions for technology-enabled care services (TECS), and thereby improve efficiency and clinical benefits. The process focused on enhancing patient engagement to increase patient concordance with their treatments and change adverse lifestyle habits, while providing viable solutions for more effective and productive working by GPNs (Topol 2019).
The main aims were:
» For GPN participants to become digital champions using at least two modes of TECS with patients for at least three months. This could involve using, for example, closed social media groups, telehealth, video consultation and trusted apps to support patients with long-term conditions (LTCs) and/or adverse lifestyle habits.
» To champion clinical engagement in the digital delivery of general practice care.
In March 2018, four cohorts of GPNs were recruited from across 21 general practices in Staffordshire. A total of 27 GPNs signed up to the programme, but three left due to ill health or unexpected additional work commitments so 24 GPNs in 19 practices completed the programme. To encourage practice engagement, practice managers co-signed the GPNs’ applications to participate in the programme and implement their learning in practice. This affirmed the practice team’s interest and involvement with their GPNs’ participation from the start. Most of the GPNs were in their fifties and band 6 practice nurses; four were advanced nurse practitioners. Registered patient population practice list sizes ranged from around 3,000 to 16,000 patients and levels of deprivation varied.
The programme involved three ALS sessions per cohort spanning four months, with content progressing from information giving to implementation. The first session introduced the project team, and the aims and scope of the programme, and connected the GPNs with one another through a closed social media group. Following the initial session, the GPNs drafted their action plans to identify the modes of TECS for the LTCs they would try. By session two they had finalised their individual action plans with the help and agreement of the nurse and digital expert facilitators involved in the project and their practice teams. They were given access to, and practical assistance with, their chosen modes of TECS. The final session allowed participants to reflect on their learning and experiences, and plan for future development and ways to embed TECS in front-line practice.
Before session one, participants were given access to comprehensive online educational resources, including practice performance figures for delivering care to patients with specific LTCs and information on which TECS could be useful for them. The expert facilitators also made practice-based visits to provide advice and practical support in, for example, setting up TECS, protocols and relevant information governance guidance.
Another important element of the GPNs’ project resources was a 7Cs tool (Table 1) for reflecting on learning and organisational needs in relation to adoption and delivery of TECS (Chambers et al 2018a). By progressing through the ALS programme the nurses could meet each of the tool’s seven areas. Where changes to organisations or infrastructure were required, participants could collaborate with their practice teams to embed their preferred modes of TECS.
|Competence||The ability to adopt of a range of modes of delivery of technology-enabled care services (TECS) for an agreed purpose and to feed in information or act on advice|
|Capability||Demonstrating best practice in a range of modes of delivery of TECS for an agreed purpose, and in feeding in information or acting on advice in daily professional life|
|Capacity||Protecting and prioritising time for initiating and participating in the remote delivery of care. Ensuring that the IT infrastructure is in place and that equipment is available and easily accessible by all service providers and users|
|Confidence||Ensuring that an organisational infrastructure in line with local TECS code of practice (Staffordshire Digital Design Authority 2017), including the reliability and validity of equipment and its outputs, is in place|
|Creativity||The ability to adopt and adapt agreed TECS for different purposes, or for patient or carer groups, in line with the Nursing and Midwifery Council (2018) code of professional standards of practice and behaviour|
|Communication||Sharing and disseminating digital modes of delivery and associated clinical protocols, as well as the evaluation of applications, outcomes and challenges, with other members of the team or organisation|
|Continuity||Interacting with patients through TECS along single pathways for long-term conditions or lifestyle habits. If the practitioner is away, cover should be arranged and agreed with patients in line with their shared care management plans|
|(Chambers et al 2018a)|
Further resources to support and motivate the evolving digital GPN champions included a bursary to apply the learning programme outside of work hours, a tablet with recommended apps, video-consultation options, various TECS and support equipment, including a mobile device for detecting atrial fibrillation.
A TECS code of practice with 23 elements, covering clinical indemnity, information governance, consent, quality and safety, and health and safety (Staffordshire Digital Design Authority 2017), was already in place. It had been endorsed by all health and care organisations in Staffordshire, including general practices.
The following information was collected from each participant in the four cohorts for project evaluation:
» Self-rated measures of competence, confidence and knowledge about TECS. This was gathered from a baseline survey at the first ALS session and was repeated at the final session.
» Progress in the programme. This was gathered through a phone survey conducted about two months after the final ALS session.
» Individual GPN action plans that specified aims, resources required and outcomes attained. These were completed by participants after the final session and covered progress, implementation, achievements and obstacles overcome.
» Areas of change, the form(s) of TECS that can ensure such change and self-assessed progress towards making change. This information was gathered using adapted leading change adding value (LCAV) questionnaires (NHS England 2016), completed by participants after the final session.
As the ALS programme progressed, GPNs self-rated their matches to statements about perceptions of using technology-enabled healthcare on the baseline survey at the first (n=27) and last (n=24) sessions. Three participants did not complete the programme due to personal issues, but they expressed determination to continue at a slower pace.
Most participants strongly agreed from the start that they could see benefits of using technology-enabled healthcare for patients (Figure 1).
GPNs were asked to rate what they thought about using digital technology by highlighting whether they were ‘digitally leading’, ‘digitally ready’, digitally worried’ or ‘digitally lost’. By session three, 19 of the 24 GPNs believed they were ‘digitally ready’ or ‘digitally leading’ compared with 14 out of 27 GPNs at session one (Figure 2).
The phone survey, which an independent evaluator conducted about two months after the final ALS session, identified that the 24 GPNs who completed the course found it beneficial for themselves and their patients. Many also noted there was support for the adoption of digital modes of delivery of care from their practice colleagues. Highlights from the phone evaluations are shown in Table 2.
|Phone survey question||Illustrative responses from general practice nurses|
|Have there been any changes in the practice team’s attitudes to technology-enabled care services (TECS) since they joined the action learning set programme?|
|What factors led you to choose the TECS you selected?|
|What was the most important thing you learned from the programme?|
Figure 3 shows the modes of TECS used in participants’ practices before the ALS programme, as well as the modes used by the digital GPN champions and practice team members after completing the programme. The evidence shows that practice teams increased their TECS adoption substantially.
Before ALS completion, 11 practices used a public social media group to enable services, and three of these also used video consultation. Figure 4 shows how the adoption and variety of TECS increased substantially after completion.
In the two case studies, GPN participants illustrate their experiences of adopting TECS with their practice teams, while Table 3 shows detailed completion of the LCAV template by another participant.
|Topic||Questions||Examples of responses|
|Where to look|
|What to change|
|How to change|
|Better outcomes, experiences or use of resources|
|Sharing the learning|
|What is happening now?|
|(Chambers et al 2018b)|
GPN participants reflected on the benefits and risks that they perceived and experienced as the ALS progressed from their own and patients’ perspectives and these were collated as themes (Table 4).
|Patient or carer – potential benefits|
|Patient or carer – potential risks or unintended consequences|
|Clinician – potential benefits|
|Improved clinical outcomes|
|Improved patient safety|
|Clinician – potential risks or unintended consequences|
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.
This participant, a general practice nurse (GPN), wanted to improve her interactions with people in a local care home and reduce her travel time by introducing video consultations.
Before her action learning set (ALS), she visited the care home weekly to see a group of patients registered with her practice and selected by home staff. Through the ALS, training to set up the equipment, and the appropriate protocols and governance documentation, were provided to the GPN and the care home manager. The training was cascaded to the wider care home team, which prepared the patients for the video consultation.
The GPN now holds video consultations on alternate weeks and has halved the number of routine visits to the care home. The patients receive an equivalent level of care and support, and the reduction in travel has freed up face-to-face appointment time for an extra 20 patients a week in the GPN’s clinic. She has also promoted apps to patients with specific long-term conditions.
The GPN reports that this shared management has strengthened clinical safety, improved patients’ experiences and encouraged them to access their own patient records, thus enabling medication reviews or investigations to be completed instantaneously.
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.
The main role of this participant is the care of older frail patients and those who are housebound or acutely ill. She chose to prioritise the use of apps and telehealth to improve patient engagement, and to monitor baseline observations, while assisting patients to manage their conditions independently.
She reported that using interactive text messaging reduced the need for face-to-face appointments with specific patient cohorts and found that around half could take part in follow-up consultations by remote digital delivery in line with an agreed shared management plan.
This has improved management of their conditions because they can now accurately monitor themselves and refer to their individual care plans. It has also allowed capacity for an additional ten face-to-face appointments a week.
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.
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).
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.
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.
By focusing on unwarranted variation and common local LTCs where change is most possible, clinicians can endorse applicable digital technology to deliver the right care at the right time, enhancing the effectiveness and efficiency of patient-centred care. When patients understand and own their LTCs, such as COPD, they should increase compliance and so have better health outcomes and lessen their use of healthcare (Collis et al 2014).
The design of this ALS programme shows that practical hands-on training with nurses who are committed to a digital future, even though some are ‘digitally worried’, is an effective way to create digital champions, who can implement TECS in general practice. This has resulted in benefits for practitioners and practice management, greater self-management and patient safety, better productivity and empowerment, enthused proactive team members and fewer avoidable face-to-face consultations and phone calls. If such supported action learning were introduced on a larger scale, a digitally ready workforce could be created at scale, and could prioritise TECS for the right patients according to clinical need. This could make huge improvements in healthcare delivery nationally, not only among GPNs, but among health and social care practitioners from different care settings.
The ALS programme is being introduced in other regions and will contribute to the next stage of the digital healthcare revolution, ensuring that TECS are firmly embedded in the NHS (NHS England 2019).
• This action learning set programme shows that practical training of nurses can create digital champions with the skills and confidence to implement technology-enabled care services (TECS) in general practice
• By focusing on unwarranted variation and locally important long-term conditions (LTCs), clinicians can use digital technology in delivering the right care at the right time, thereby enhancing the effectiveness and efficiency of patient-centred care
• If patients understand and ‘own’ their LTCs, their compliance with technology should increase and their health outcomes improve
• The programme has resulted in greater patient self-management and safety, better clinician productivity and empowerment, and fewer avoidable consultations
• Large-scale programmes such as this could create a digitally ready workforce that prioritises TECS for the right patients according to clinical need
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