CONFERENCE 29th and 30th November 2012

BOOK OF ABSTRACTS

Book of Abstract for 2012 Wales Centre for Practice Innovation (WCPI)
I would like to thank all the contributors to 2012 WCPI Conference Book of Abstracts which we have made available on line to ensure maximum distribution. Please note that some of the concurrent presentations are also replicated as posters and therefore do not figure twice in this book. The WCPI Conference Committee (Judith Bowen, Hywel Dda Health Board; Ruth Davies, CHHS and Louise Hughes, ABMU Health Board) were impressed with the standard of work submitted this year. We were delighted to see evidence of how Practice Innovation has been shared between Hywel Dda Health Board and ABMU Health Board since last years conference. The Butterfly Training Programme is a good example of how innovation in one board can be shared with another as exemplified in the lead plenary by Lisa Marshall and Tom Alexander (Hywel Dda HB) and the concurrent by Christine Williams et al., (ABMU HB). This years special themes were Dementia and End of Life Care. The incidence of dementia in the elderly population has been compared to a Tsunami and it has to be acknowledged that care and services are not always what they should be. Nevertheless, the submissions we received in relation to this show a real commitment to addressing these shortfalls including some imaginative practices as well as clinical leadership. End of Life Care is another area of care under the spotlight at the moment and we were pleased to have a number of excellent submissions under this theme which spans paediatric and adult palliative care in both the NHS and third sector. I hope you will enjoy the WCPI Conference, and even if you are unable to attend, you find this book of abstracts inspirational.

27th October 2012

Dr Ruth Davies, Email: R.E.Davies@swansea.ac.uk

PLENARIES Please note abstracts were only submitted for the following plenaries. Tom Alexander & Lisa Marshall Dementia Coordinator for Pembrokeshire BSc, MSc: Sister Ward 8 Withybush General Hospital E.mail: Thomas.alexander@wales.nhs.uk lisa.marshall@wales.nhs.uk The Implementation and Evaluation of the Butterfly Scheme in Withybush General Hospital and Hwyel Dda Health Board The aim of this plenary is to inform people of the scale of dementia in acute settings and the challenges that it brings. Also, to look at the Butterfly Scheme in this context and present findings on how effective it has been on patient care and staff competencies. The prevalence dementia is increasing (Alzheimers Society, 2012) and with this so are the numbers of those in acute/hospital settings with this diagnosis. Due to the nature of dementia these patients needs may not be addressed satisfactorily, which can result in increases in length of stay, challenging behaviours and complaints from the patient/carer. The Butterfly Scheme (BS) was designed to address these problems and aid all members of staff to provide more appropriate care for those with dementia in hospital settings. The aim of the investigation was to measure the impact of the BS on the care of those with dementia and staff competencies in dementia care at Withybush Hospital, Pembrokeshire. Quality of patient care was measured using the Quality of Care for those with Memory Impairment Questionnaire and Staff Competency was measured using the Shared Competencies in Dementia Care Questionnaire. The questionnaires were randomly allocated to either patients/carers or staff at Withybush hospital, one month before and one month after the introduction of the BS. Data from the staff competency questionnaires (73) was analysed using an independent t-test. Results indicated a significant increase in staff competencies with regard to a range of dementia care skills. It was concluded that the BS had a positive impact on staff competencies. Although more data needed to be collected with regard to patient care questionnaires (23) the trend indicated an increase in quality of care. Implications of findings discussed. Three intended learning outcomes: 1. Increased knowledge of prevalence of dementia in hospital settings 2. Introduce the theory and aims behind the Butterfly Scheme 3. Highlight the challenges in implementing the Butterfly Scheme

Andrea Higgins Senior Nurse, Mental Health & Learning Disabilities, Hywel Dda Health Board E.mail: Andrea.higgins@wales.nhs.uk Pulling Together - A Dementia Supportive Community Experiences of a Florence Nightingale Foundation Travel Scholarship of Dementia Services across India Visit Tour - October 26th 2012 The intention of the scholarship is to elaborate on research findings of the 10/66 Dementia Research Group (2000); a worldwide group of International experts providing a detailed evidence-base on dementia; setting out development and implementation of policies for improving the health and social welfare of older people in low and middle income countries. The aims of the study tour reflect both the Wales and UK Governments aspirations of community supportive approaches; and intend to translate the International lessons locally in Wales; the tour intends to clarify evidence through regions of India by information exchange and evidence gathering of; Approaches to community based programmes of dementia care Collaborative models between Alzheimers Society and government providers The dementia supportive community model in urban and rural settings delivered in diverse conditions Quantifying informal care and measures of support How dementia care is delivered in a developing country with its competing challenges

Local Background Projected growth within populations in Wales for dementia is to increase by 38% across Hywel Dda Health Board by 2021 (Alzheimers Society 2012); alternative models of dementia care need to be planned outside of inpatient and residential care settings. India professes to have a significant dementia supportive community which aspires to address the issue of limited residential services. Study Tour Question If a developing country can address some of the community challenges of dementia sufferers and carers; what are the lessons to be learnt within a developed country? Learning Opportunities Education and awareness of dementia is fundamental to understanding and delivering care. India delivers community awareness and training raising the profile within the health community, particularly with carers. This work is delivered via voluntary services along with government care. India has a community impact on dementia and other chronic health conditions specifically disability, dependency and care giver strain. The dementia supportive community infrastructure is of interest for future models for Wales. Three intended learning outcomes 1. Understand the international and local impact of dementia on society and care services 2. Consider alternative models of care in the community and in particular informal carer support 3. Shaping future workforce learning and development through alternative models of dementia training

The 10/66 Dementia Research Group. Methodological issues in population-based research into dementia in developing countries. A position paper from the 10/66 Dementia Research Group. International Journal of Geriatric Psychiatry 2000;15:21-30 Alzheimers Society Dementia Infographics 2012. Alzheimers Society. (2012) National Dementia Vision for Wales; Dementia Supportive Communities. Welsh Government. (May 2011)

Phil Collings and Phil McFadden Team Leader Assertive Outreach Team and Art Psychotherapist E.mail: phillip.collings@wales.nhs.uk & Phil.mcfadden@wales.nhs.uk Art Therapy Developments in Engaging Assertive Outreach Clients Arts therapies are the only interventions, both psychological and pharmacological, to demonstrate considerable efficacy in the reduction of negative symptoms (in people with schizophrenia)

History Assertive Outreach Teams (AOT) clients are typically treatment-resistant to Mental Health services. To engage clients we routinely ask them their needs and wishes, looking for possibilities to add to their individual medical and psychosocial interventions. Groupwork figures highly: Social integration and sports activity groups Healthy Living promotion groups (esp. smoking cessation) Walking & Talking groups

Art activities figured highly as common interest. Clients expressed a wish for a Landscape Drawing group. The team commissioned weekly sessions with an Art therapist: Participants discuss location options, with no obligation to display artwork. Galleries/museum visits alternative activity. Development Team members fed back requests for more guidance. Art Therapist trainee with Teaching qualifications joined group as part of Volunteering for Health programme.

How art activities are perceived by clients themselves: On days when we have the group I feel the sun is shining, colours are brighter and I can see more clearly: I'm more alive! Increased number requesting intervention new participants Negative symptoms improved -Emotional presentation: safe expression of humour, anger, sadness, hope, pride in achievements Trust toward Art therapist extended to other Team Members clients stated felt more listened-to and increased other contact Reduced inpatient time attendance continued during admissions, contributing to early discharge. Regular attendance Consequential benefits to families and communities. Increased awareness of physical well-being, better physical health Conclusions Following this project Art therapy is routinely offered where appropriate Open studio group is in planning stages.

Three intended learning outcomes 1. 2. 3. To raise awareness to the opportunities for Art Therapy To prompt opportunities for developing similar approaches within other patient groups To provide compelling evidence of patient partnership working to develop a new initiative

References: NICE guideline Core interventions in the treatment and management of schizophrenia in primary and secondary care (update), March 2009 Demetrea Michaelides 'An understanding of negative reflective functioning, the image and the art psychotherapeutic group' International Journal of Art Therapy 17(2); 45-53, Vanessa Jones, 'Practice Definition: Art Therapy Outdoors' British Association of Art Therapists' Journal 'Newsbriefing' June 2012, pp 14-15

CONCURRENTS

Tom Alexander Dementia Co-ordinator Pembrokeshire Sally Corlett Dementia Co-ordinator Brongalis Hospital Ceredigion Tammy Morris Dementia Co-ordinator Prince Phillip Hospital Carmarthenshire E.mail: Thomas.alexander@wales.nhs.uk; Tammy.morris@wales.nhs.uk Sally.collett@wales.nhs.uk Developing Dementia Friendly Communities The aim of this presentation is to introduce the concept of a dementia friendly community, look at examples of practice from UK/Europe and work together on how to create one in Wales. Dementia friendly communities (DFCs) have been identified as a key priority for dementia planning in the UK (Prime Ministers Challenge on Dementia, National Dementia Vision for Wales Dementia Action Alliance National Dementia Declaration, Ageing Well in Wales 2013 2018). This is unsurprising given that evidence suggests the financial and person centered care benefits community care provisions can bring to the NHS. Furthermore, due to the increased prevalence in dementia diagnosis year-on-year, the acute hospital services are looking more to the community for help managing these individuals with complex care needs. DFCs have been shown to be a success in England, as well as abroad and Welsh government now is actively encouraging their development in Wales. To create a successful DFC means that working partnerships need to be in place across health and social care, as well as with the voluntary and private sector, and with the general public. The idea behind this workshop is that we look at what health maybe able to offer in terms of support for a DFC as well as what is needed from the other agencies. In doing so we hope to not only increase general knowledge about dementia but also encourage staff to look at the disease from a holistic point of view. Three intended learning outcomes from oral session and/ or poster: 1. Increase knowledge of community provisions for dementia 2. Develop a model of a DFC for local services to work towards 3. Expand staff knowledge with regard to holistic care needs in dementia

Heidi Blofield E.mail: heidi.blofield@wales.nhs.uk

Out of the Blue Use of blue crockery to improve nutritional intake of patients with dementia According to a publication from Alzheimer's Society, people with dementia can experience a number of visioperceptual difficulties due to normal ageing, eye conditions, and sometimes from additional damage to the visual system caused by specific types of dementia. Visual perception is complex since, whether people have good vision or not, they try to interpret and understand what they see. Sometimes trying to understand what was 'poorly seen' involves making a 'best guess' at what was seen. If what we perceive seems real to us, it can directly affect our behaviour. Blue Crockery will help to reduce this difficulty at meal times by framing the food in front of themA study was conducted by Cumbria County Council where a residential home changed their crockery from patterned to plain blue. The colour blue was used as there are no other foods that are blue. The results showed a marked increase in the amount the patients ate. In view of this study it was decided that we would introduce the crockery for people that are either confused or diagnosed dementia. This would link in with the butterfly project that Towy ward are currently involved in.The plates have been given to a number of patients now and the improvement is visible. On one occasion, a confused patient was witnessed refusing porridge from a white bowl but when it was transferred to a blue bowl, she ate the whole portion.

Due to the shape of the bowls, people with poor dexterity find it easier to hold the bowl, in turn eating more of the food.

Following the positive outcome of the study on Towy Ward, the blue plates have started to be disseminated across the Hywel dda health board.For the future I suggest consideration is given to incorporating the blue plates scheme in the Butterfly project Three intended learning outcomes 1. Raise awareness 2. Disseminate area of good practice 3. Promote effective leadership

Catherine Cotter, Susan Peterson, Maureen Jones E.mail: Maureen.jones2@wales.nhs.uk A leader if one who knows the way , goes the way and shows the say. This presentation will show how with other members of the multidisciplinary team within the NHS & Education Department maternity services at Bronglais General Hospital have introduced a staff education program which is innovative, has changed midwifery practice and improved the quality of care given to women during childbirth

McCandlish (2010) states that responding to womens experiences of care will drive quality improvement and this will result in an increased focus on social models of care with women and families needs at the very heart of midwifery and maternity care. Following the publication of the document Midwifery 2020 Delivering Expectations in 2010, a small group of Supervisors of Midwives in Ceredigion decided to look at ways of modernising the maternity service following the recommendations included within the document. The role of the Supervisor of Midwives includes protection of mothers and babies by promoting best practice and excellence in care and preventing poor practice and intervening in unacceptable practice (NMC 2012). By listening to feedback from users of the service it became apparent that some women felt disappointed following their birth experience. Common themes were; not being able to have the choice of giving birth in water; feeling pressurised to accept interventions in labour and having to wait for a doctor to come to suture their perineum following birth. A training needs analysis demonstrated that midwives needed appropriate education and training to give them the skills to improve competence & confidence in promoting normality, water birth and perineal suturing. A midwife working within the maternity unit applied for the Royal College of Midwives Iolanthe Award and was successful on two occasions. By working together with the Learning and Development Department within Hywel Dda Health Board an education program for Midwives and Obstetricians was set up with eminent speakers coming to Aberystwyth to share their knowledge and skills. Following a recent case note audit by the Supervisors of Midwives it is apparent that more women have achieved a birth in water, more women are having a more natural birth if requested in their birth plan and that more midwives are performing suturing of the perineum following birth. Three intended learning outcomes 1. Recognize within your work area where improvements in service can be made by using user feed back and involving staff as part of a team approach 2. Identify what resources you need to make improvements in service which may include education and training for staff 3. Measure change in practice by undertaking an audit, has it made a difference?

References: Mc Candlish, R., 2010. Midwifery 2020 Delivering Expectations. London. Department of Health and Public Safety Nursing & Midwifery Council, 2012.,Supervisors of Midwives: How Can They Help You? (on line). Available from: http://www.nmc-uk.org/midwiferysupervision (accessed 25 September 2012)

Davies, Annette; Thomas, Louise; Wright, Karen & Carter, Yvonne annette.davies@wales.nhs.uk

Reducing Unscheduled Care Using An Interdisciplinary Practice Focus There is greater emphasis on community services for the delivery of care closer to home. There are a variety of Intermediate Care services across the UK. CIIS provides the Intermediate care Service in partnership with Neath Port Talbot County Borough Council for Neath Port Talbot (NPT). CIIS is constantly adapting to local needs and the pressures of unscheduled care. This has resulted in a range of innovative pathways being developed to further bridge the gap between primary and secondary care. The pathways include:

1. The Place for Physiotherapy in Admission Avoidance providing treatment at home for those
patients immobilized by acute musculoskeletal pain, and needing full care or are at high risk of being admitted into hospital due to the pain and its consequences.

2. CIIS Nurse Practitioners working with the Welsh Ambulance Service to develop Admission
Avoidance Pathways this involves inter professional working between the CIIS Nurse Practitioners and the Paramedics treating patients at home, improving outcomes for patients through reducing the need for their transfer to Emergency Departments.

3. CIIS Nursing Team Interaction with local Emergency Departments - this involves changing the
mindset of secondary care and historical working and in effect act as hospital base case finders identifying patients in Emergency Departments, Admission Units and the wards for immediate supported discharge.

4. Community Intravenous Antibiotic Therapy this involves the development of an Integrated

Care Pathway for Home Intravenous Antibiotic Therapy. This pathway will be used throughout ABMUHB as a standardized tool in reducing unnecessary hospital admissions and facilitating early discharge. Three intended learning outcomes: 1. To understand the role of the team in admission avoidance and the pivotal role that CIIS has developed between primary and secondary care. 2. To demonstrate that by good communication and close working across the traditional primary and secondary care boundaries seamless care can be delivered. 3. To be informed of the importance of providing an intermediate care service for patients in order to improve their independence and quality of life.

Davies, Karyn; Lambert, Helen & Turner, Alison. karyn.davies@wales.nhs.uk Championing The Champions: Dementia Care Training for Acute Hospital Settings The principal aim of the Championing the Champions initiative is to improve and enhance the care and support offered to people with dementia in the acute hospital setting, through delivery of specialist education and training initially for identified/nominated Dementia Champions across ABMU health board. This is a key priority from both a National and Local perspective supported by current policy, guidelines and key drivers. As part of ABMU response to the Wales Older Peoples Commissioners Dignified Care report (2011) Recommendation 2: Care of people with dementia; a priority area of staff training in specialist dementia care has been identified along with the identification of dementia

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champions from acute hospital ward and departmental settings. Dementia champions have subsequently been identified from across the Health Board.

The Dementia Care Training Team (DCTT) are employed by ABMU, are jointly funded and provide dementia care training to a range of health and social care staff. In 2011 the team were invited to design and pilot a four day specialist training and education programme for the identified dementia champions. The programme captured the key elements of caring for a person with dementia, with emphasis on linking theory to practice along with the National and Local policy perspective and the role and responsibilities of the dementia champion in practice. This was a successful pilot which evaluated very well. Subsequently, further funding has recently been secured for delivery of a five day training programme to a further 45 dementia champions Dementia champions have been identified within ABMU throughout the acute hospital settings. This education programme is therefore innovation in practice. Whilst it complements other recent local developments, such as the identification of people with dementia in the general hospital settings, this bespoke initiative provides the underpinning theoretical, knowledge base around dementia care and its application to practice.

Three intended learning outcomes: 1. To recognize the need for specialist dementia care training in the acute hospital setting. 2. To promote the role of the dementia care training team within ABMU/ Hywel Dda/Swansea University. 3. To share innovation in practice. References: Older Peoples Commissioner for Wales (2011). Dignified Care? The experiences of older people in hospital in Wales. Older peoples Commissioner for Wales, Cardiff

Margaret Devonald Morris E.mail: margaret.devonald-morris@wales.nhs.uk Hywel Dda Childrens Continuing Care Service Funding for Hywel Dda Childrens Continuing Care Service (CCCS) was secured from the Welsh Assembly Government in May 2009 based on bids that were approved by our then Three-Counties Overarching Continuing Care Group comprising of leaders from Health and the Local Authority. Total funding secured was 507,126 for a baseline service demand in January 2009 that identified 10 clients requiring a total of 672 hours per week. It was acknowledged that by investing in additional staff resources within Hywel Dda it would be possible to reduce the number of expensive care packages, and in particular unnecessary out of county placements. The funding has been used to enhance staffing levels across Hywel Dda establishing a service model that enables a more effective Childrens Continuing Care provision across the three counties of Carmarthenshire, Ceredigion, and Pembrokeshire:

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CCC Service Team Manager CCC Nurses CCC Service Administration Support Specialist CAMHS Dietetics Occupational Therapy Physiotherapy Speech and Language Therapy Psychologist

1.0wte Band 7 2.8wte 1.5wte 1.0wte 0.5wte 1.0wte 1.5wte 1.5wte 1.0wte Band 6 Band 3 Band 6 Band 7 Band 7 Band 6 Band 6 Band 8a

Aim of Hywel Dda CCCS To integrate with and strengthen core services as well as working in partnership with our third sector colleagues to support children and young people (CYP) with Continuing Care Needs. The practitioners employed by this service use their specialist knowledge and skills to assist parents and carers in managing complex health needs, enabling access to education and social activities in order to facilitate CYP to reach their potential. Current Service Provision To date the number of nursing care packages has increased to 19 (1158.5 hours/week). In addition to these packages, Speech and Language Therapy and Physiotherapy support a number of other CYP whose needs exceed the core service and specialist CAMHS have thirteen packages. Three intended learning outcomes 1. Hywel Dda Health Boards service model for children and young peoples continuing care. 2. Partnership arrangements with our third sector colleagues 3. Current measures in place to monitor the nursing care activity (Lewis and Pontin, 2008) Reference Lewis, M. Pontin, D. (2008) Caseload management in community childrens nursing. Paediatric Nursing, April, vol. 20, no. 3, 18-22.

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Dodds, Phedra Advanced Nurse Practitioner for Gastroenterology & Endoscopy phedra.dodds@wales.nhs.uk A Health Economic evaluation of the savings of an Advanced Nurse Practitioner Service Abstract In 2002 I commenced a role as ANP in Gastroenterology and Endoscopy. The vision for the role was implementation of open access via a telephone help-line, nurse led clinic and endoscopist role, underpinned by an electronic patient record providing immediate access to relevant demographic, clinicalyl coded and free-text details. The role has evolved, and in-line with service demand has diversified. The central tenets of the role remain; to provide open access for patients at time of need. The service has shown measurable savings. The potential for the role to be replicated is vast and may provide a cost effective and more patient centered approach to gastroenterology care, the provision of endoscopy services and wider ANP roles.

Three intended learning outcomes: 1. To discuss how use of innovative remote and open access services such as telephone helpline services and nurse led clinics can save a variety of services. 2. How use of the electronic patient record can speed decision making, support patient information retrieval and create a useable database for quantifying activity and services saved. 3. How health economic modeling can demonstrate tangible savings, identify where service savings can be made in future service modeling and provide rationale for expansion of services. References:

1. Curtis, L. (2011). PSSRU Unit Costs of Health and Social Care. Personal Social Services
Research Unit. www.pssru.ac.uk p. 91, 147, 149, 203, 2. Department of Health. (2011). National Schedule of reference costs 2010 2011 for NHS Trusts and PCTs combined. www.dh.gov.uk

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Fabb, Lisa lisa.fabb@wales.nhs.uk Opening Chests and Minds Cardiac Staff returned from the 2008 SCTS conference enthusiastic about the CALS course. The course deals with arrest and peri arrest situations following cardiac surgery in accordance European Association of Cardiothoracic Surgery (2009) guidelines. Joel Dunning author of guidelines and course organiser is keen to disseminate guidance and supported to running the course in Swansea. In January 2010 a new educator post was created, learning needs assessment suggested staff wanted clinical skills especially in high risk low frequency situations. Planning proved challenging, but in October 2011 the course ran smoothly was very well received. Attendees included a mix of intensive care nurses, doctors, surgical assistants and resuscitation officers. The faculty was supplemented by local consultant cardiac surgeons and one nurse. While evaluating the course the benefits of staff who work together learning together was realised. The Resuscitation council dedicates a chapter to Human Factors in the 2010 ALS manual. It discusses the importance of good communication and understanding of each others roles. DoH document Implementing Human Factors in Healthcare-How to guide discusses how human factors and improved team working directly improves patient safety. Holding courses such as CALS locally, and including all members of the multi disciplinary team is advantageous not only in terms of the skills learned and cost, but also for the invaluable team building opportunities. Collaborative learning needs to be examined further but for the clinical team it would seem to result in a safer journey for the patient. Dunning J, Fabbri A, Kohl PH et al (2009) Guideline for resuscitation in cardiac arrest after cardiac surgery. European Journal of Cardio-thoracic Surgery. 6872 Carthey J. (2010) Implementing Human Factors in Healthcare-How to guide. Patient Safety First Campaign, NHS Griffiths, Beth Nurse Practitioner beth.griffiths2@wales.nhs.uk Is there a better way? Areas to be expanded: Intermediate care has many definitions depending on its context, but the most important aspect in the context of this presentation is that it is patient centered care. Integration of health and social care creates a synergy which has very powerful outcomes for our clients. The Early Response Service (ERS) division of CIIS is responsible for prevention of hospital admission. It has been running now for 2 years in Bridgend, but much longer in other parts of ABMU. In Bridgend it is a nurse led service, with very limited resources. Over the course of the past year, this small team has prevented 1,940 bed days for our clients. Providing a single point of contact that can result in the right person providing the correct response at the right time produces great rewards for staff as well as clients.

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One of the most successful client groups are clients with dementia. The outcomes for this client group following admission to hospital are particularly poor. By providing support for the family or carer we have managed to maintain the client at home during the episode of illness, e.g. urinary tract infection and restore them to their normal activities of daily living. Preservation of dignity and person centred care planning underpins all aspects of the care we provide. The importance of multidisciplinary working including therapy and provision of equipment (albeit small and inexpensive) and expertise is essential to good outcomes. Intermediate care must span the medical boundary between primary and secondary care and liaising with other agencies is integral to its success. Patient stories will be used to demonstrate the effectiveness of the service.

Three intended learning outcomes: 1. Elderly care is not sexy but it is very rewarding. 2. Person centred care does not need to be costly. 3. Integrated services are essential for this client group.

Lesley Hill Email: Lesley.hill@wales.nhs.uk Sure Start Mentoring and Behaviour Support Team. Service Overview and Outcomes The Sure Start Team Provides supports to vulnerable families with children 0-10years. The service consists of two projects, Mentoring / Volunteer service and the Behaviour Support service.The presentation provides an overview of the service and demonstrates how the project has achieved the National Population Outcomes within the poverty agenda, helping families to move on, improve their well being, mental health and lifestyles.This is done by a multi skilled team of Professionals, support workers and volunteers working in family homes and in group setting with the aim of empowering parents, improving parents skills and confidence in effective parenting their children; Strengthening the parent and child relationship; Providing early intervention and support to improve attachment and promote infant mental health. The presentation demonstrates how changes have been made to the service to achieve the changing targets set out by the Welsh Government and evidence and outcomes through RBAs and case studies. Three intended learning outcomes 1. To increase awareness of the delivery of the Sure Start Mentoring and Behaviour Support Team. 2. To increase knowledge on the effectiveness of early intervention on service population and conditions of well being of early intervention 3. To have a better understanding of the RBA framework and how this demonstrates service outcomes in a logical easy to ready way. References: Friedman, M., (2005) Trying Hard is not enough. Bloomingham. Trafford Publishing.

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Cox & Bentovin (2000) Framework for the Assessment of Children in Need and their Families Department Of Health. Norwich ISBN 011 322426 5 Families First Welsh Governments Poverty Agenda hhtp:.//wales.gov.uk/topics/childrenyoungpeople/poverty/newcpstrategy/?lang=eng

Rowena Jones & Jayne Thomas E.mail: Rowena.jones2@wales.nhs.uk ; jayne.thomas@wales.nhs.uk The development of an integrated multidisciplinary Paediatric Palliative Care service to deliver high quality, end of life care to children, young people and families with a life limiting or life threatening condition within their own home. The Welsh Government (2012) as highlighted within their delivery plan that everyone in Wales should receive the highest standard of care at the end of life. High quality end of life care enables the child, young person and family to exercise true choice; focus on preparing for an anticipated death in a place of their choice and effectively manage the end stage of a terminal condition. This presentation will describe the historical back ground and process involved in establishing a paediatric registered nurse bank service within the Hywel Dda Health Board area in 2012 in order to provide high quality palliative care at home to children and young people and their families, 24 hours a day and 365 days of the year in the terminal stage of their illness. The Better Care Better Lives report (DH 2008) highlighted the importance of designing services around the palliative care needs of children, young people and their families. The report highlighted the need for high-quality, family-centred sustainable care and support with services provided in a setting of choice, according to the child and familys wishes and needs. The death of a child is one of the most painful and devastating experiences that families can face. Achieving high quality end of life care will impact positively on the health and well-being of children, young people and families however is one of the greatest challenges that nurses can encounter in practice. In 2002 there were 20 deaths in a year throughout South and West Wales, 12 occurred at home, 6 deaths in hospital, 1 in a hospice and 1 child was taken home to die in India. Out of the children that died in hospital 50% of parents given the choice expressed a wish that their child die at home if there was 24 hour medical and nursing support available. There is evidence to suggest that rate of hospitalization increases steadily as death grows near. There is a 2 fold rise in last 2 months of life and a 4 fold rise in last month of life. The vision and commitment is that children, young people and families have safe, accessible, sustainable, high quality end of life care in the setting of choice.

Three intended learning outcomes: McNamara-Goodger and Cooke (2008) maintain that well coordinated services are essential for true choice to be available to families. Well informed children, young people and families can exercise true choice by understanding the choices available. This should mean they have: Choice of place of care Choice of place of death Choice of bereavement care and support

This will impact positively on the health and wellbeing of children, young people and families within Hywel Dda.

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References: Department of Health. 2008. Better Care: Better Lives. London: Department of Health Publications. McNamara-Goodger, K., Cooke, R. 2008. Childrens and young peoples palliative care: good practice guidelines. Primary Health Care. 19 (2), pp. 40-47. Welsh Government. 2012. Together for Health Delivering End of Life Care. Cardiff: Welsh Government. Morgan, Judith Judith.Morgan4@wales.nhs.uk Improving care for patients with suspected and actual deep vein thombosis (DVT) through multi professional integrated cross boundary working. A DVT pathway was in existence but was cumbersome and patients waited many hours to be processed with the number of referrals increasing year on year. In September 2011, a multiprofessional team revised the pathway and made changes at three key stages: Stage 1: multiprofessional team: nurses, doctors & pharmacist devised secondary care integrated pathway for assessment of patients with DVT. Changes made: a) blood results obtained from the lab to near patient testing B) prescribing practices c) revised integrated pathway for documentation Stage 2: Consultation between project lead (consultant nurse ED) consultant physician, pharmacist, lead nurse for community integrated services & clinical lead. CIIS reviewed pathway and revised it to enable it to be used for frail patients in the community. CIIS team and district nurses: a) took blood for anticoagulation levels b) administered daily anticoagulant injections c) interpreted blood results and dosed daily oral anticoagulant d) referred & organised ambulance transport for attendance at anticoagulation outpatient clinic and consultant review at 6 weeks. Stage 3: Consultant nurse & lead nurse community integrated service met with the locality GPs. Agreement GPs would refer patients to CIIS team for investigation and subsequent management thus preventing initial A&E attendance, patients now only need to attend on the day that they have a Doppler ultrasound scan to determine presence of DVT. The CIIS team use their independent prescribing ability enable the anticoagulant injection & tablets. The outcome of the changes were audited for a 3 month period, year on year for 4 years (January to March) showed improvement across the board.

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Ransome, Alison & Hill, Frances CHC & Long Term Care Lead Nurse/CHC Deputy Team Manager alison.ransome@wales.nhs.uk frances.hill@wales.nhs.uk Redefining the Community Health Care Support Worker Role Continuing Care carries high financial jeopardy. There is a history of difficulty in providing a sustainable level of nursing care with associated problems in recruitment and retention and also the issue around de-skilling. We took an opportunity to challenge long standing ways of working within adult services and to review sustainability and appropriateness of the staff required to provide the patients care needs. After careful consideration and robust risk assessment, a decision was made not to pursue traditional methods of staffing complex packages with registered nurses. The development of a new Band 4 HCSW Role was considered to be the most appropriate way of meeting the identified needs. Sustainability, cost containment and meeting national workforce strategic objectives would also be facilitated by developing this new role Role Development New role benchmarked against existing Band 4 HCSW roles from other professions and from other NHS bodies. New Job Description & Person Specification created. Role matched at Band 4. 7 new staff successfully recruited to the post. A robust induction and competency programme developed. Ongoing support and supervision given by Band 5 Team Leader and Band 6 Care Coordinator. Clinical Supervision provided every 6 weeks.

Progress Update All clinical competencies completed. Further 2 WTE Band 4 HCSW recruited, surplus registered nursing staff moved to district nursing services to fill vacancies. Cost savings realised - 86,000 per annum. Positive Patient & Carer Feedback Positive staff wellbeing and personal development.

Key to success is accurate risk assessment, joint working and robust support, supervision and monitoring. The development of the Band 4 HCSW role in adult community services will support future planning for the increasing number of complex patients that require their health needs to be met in the home setting, and for those patients who require skilled health care that is difficult to sustain with a Band 5 registered nursing workforce. Three intended learning outcomes: 1. To share the role redesign process used to develop the new Band 4 HCSW role within Adult Community Services. 2. To present the extended roles and responsibilities of the new Band 4 HCSW Role. 3. To outline positive outcomes in service delivery, this includes patient and carers experiences and cost savings produced for department.

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Adele Roberts E.mail: adele.roberts@wales.nhs.uk Use of simulation concepts to support effective learning within the clinical environment The aim is to raise awareness and increase the use of simulation in clinical practice to support effective multi disciplinary learning during skills and drills training sessions for Obstetric emergencies. Skills and drills training has been a feature of practice development and incorporated into midwifery practice for over a decade. The challenge for trainers has been to deliver this in a different format utilizing clinicians existing knowledge and technical skills with new concepts insight and innovation. Over the last year the training we have developed has focused on these issues and supported scenario based simulation with a multidisciplinary approach on the labour ward. This has challenged many clinicians and supported a greater understanding amongst the clinicians of the human factors which contribute to human error (Carthey, Clarke and the Clinical Human Factors group 2010; CMACE, 2011; Sissakos, Crofts, Winter, Weiner, Draycott 2009). The aim was to develop midwives and obstetricians understanding of how the non technical skills in the management of obstetric emergencies need to complement and inform the technical skills to support the best management and outcome. Scenarios were created around obstetric emergencies to incorporate the technical as well as the non technical aspects to develop an understanding of situational awareness, leadership, communication, and decision making/problem solving and resource utilisation. These also included the use of reflective recorded material to facilitate analysis, self awareness and learning. The training supports current midwifery/obstetric practice and enables clinicians from their assessment and awareness processes to deliver safe effective reasoned actions and decisions incorporating realistic timings. It highlights the importance of accurate and efficient communication processes and tools such as the Situation, background, assessment and recommendations are used. The training has been primarily trialed in one area in the Health Board utilizing equipment resources and a simulation model which were already available. This has been evaluated very well by the midwives and doctors who have participated. From the evaluations the multi disciplinary teams are currently developing a simulation DVD of an Obstetric emergency and exploring the purchase of an obstetric simulation model. Three intended learning outcomes: 1. Understanding Human factors and the role these play in obstetric emergencies 2. Situational awareness and being able to communicate effectively the non technical as well as the technical information during an obstetric emergency 3. Using these concepts to enhance the learning experience in clinical practice References Carthey, J., Clarke, J., Clinical Human Factors Group (2010) Implementing Human Factors in Healthcare. London; N.P.S.A. Centre for Maternal and Child Enquires (2011) Lewis, G. (ed) Saving mothers' lives: reviewing maternal deaths to make motherhood safer, 20062008. The eighth report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. British Journal of Obstetrics and Gynaecology 118 (suppl 1): 1203.

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Siassakos D, Crofts J, Winter C, Weiner C, Draycott T. (2009) The active components of effective training in obstetric emergencies

Roberts, Patricia pat.roberts@wales.nhs.uk An Evaluation of Utilising the Tenovus Mobile Lymphoedema Unit Abstract Due to increasing lymphoedema referrals from a large geographical area meant patients were expected to travel long distances to attend the lymphoedema clinic. Patient attendance and non-compliance might improve if patients were seen closer to home (Welsh Government, 2011). Thus we needed to: Source a suitable location, facility reducing patient travel time Determine if the use of a large mobile unit ( 3 treatment areas/reception/waiting area) was a viable alternative to hospital accommodation Evaluate the attitudes of lymphoedema patients and staff utilising the unit

Methods Data for evaluation was collected using a mixed method approach. Information on patient numbers Socio-demographics Attitudinal data via surveys Interviews with lymphoedema patients Anonymous surveys with NHS staff using the mobile unit.

Surveys were completed by 57 lymphoedema patients and 10 health care professionals. Semistructured interviews were conducted with 16 patients. Patients were extremely positive about having their lymphoedema treatment on the mobile unit stating that it was convenient, clean, comfortable and cost effective. HCPs were very encouraging about the possibility of future use providing lymphoedema treatment across Wales.

Findings : These demonstrates that patients and HCPs are highly receptive to this model of lymphoedema service delivery and agree that the mobile unit is providing excellent clinical care to lymphoedema patients across Wales. We have been able to accommodate many patients locally thus being seen much quicker, travelling fewer miles spending less money. Therefore this new service development has proved to be successful. Three intended learning outcomes:

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1. Disseminate new service delivery 2. Inform clinical intervention 3. Transfer knowledge and information References: Welsh Government (2011), Rural Health Plan for Wales, Cardiff

Shill, Claire; Lever, Rose; Jones, Donna & Chilvers; Jane. Claire.shill@wales.nhs.uk Medicines Management for Health Care Support Workers in the Continuing Care Team Neath Port Talbot Locality Managing complex care effectively has become a major priority for the NHS and local Government in Wales. As medicines are the most common therapeutic intervention, medicines management has become an important yet often unrecognised part of a persons care. NPT Local Authority domiciliary care workers are trained to manage and administer medicines to service users whenever this is needed. However this development has not been introduced to HCSWs within community teams. It had been acknowledged that there had been duplication of the services attending the patients with complex health needs in NPT Locality. Patient discharges home were delayed whilst awaiting additional packages of care to provide medication administration ultimately leading to a nursing placement on a few occasions where a return to home would have been more desirable. In order to improve services and quality of care for the patient it was agreed that a pilot for medicine management should be initiated for the CHC Team. The aim was to improve the quality of care by providing a patient centered/holistic package of care by developing staff roles and also to provide a more cost effective service utilising available resources. A proposal was submitted to the Medicines Management group who agreed a pilot for HCSWs in the CHC Team to administer medication to patients eligible for CHC funding. Working in partnership with the Medicines Management Team Domiciliary Care (MMTDC) and NPT Local authority, training was attended by all HCSWs and both coordinators. Training complied with requirements of Qualification Framework (QCF) and was subject to Quality Assurance measures. All staff undertook a written and practical assessment. A written protocol and pathway was developed by the CHC Co-coordinators and the MMTDC and approved by the medical director. On completion of training the HCSWs have been deemed competent to administer, oral, topical, and inhaled medicines to patients with complex health care needs. An evaluation was carried out at 6 months and results will be discussed.

Three intended learning outcomes: 1. Development of new service models/ improving quality of care 2. Partnership working

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3. Development of extended role of HCSWs

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Desi Tait, CHHS, d.j.r.tait@swansea.ac.uk (Lead Presenter) Sandra Miles, Critical Care, GGG, HDHB, Sandra.Miles2@wales.nhs.uk Jane James, Department of Nursing, CHHS, Jane.James@swansea.ac.uk Julie Wickland, , Critical Care, Withybush, HDHB, Julie.Wickland@wales.nhs.uk David Blesovsky, Department of Nursing, CHHS, d.j.blesovsky@swan.ac.uk Enfys James-Camp, Critical Care, Bronglais, HDHB, Enfys.James-Camp@wales.nhs.uk John Kidby, Critical Care, Bronglais, HDHB, John.Kidby@Wales.nhs.uk

Presenting student feedback from an evaluation of a Collaborative Module Developed to Improve the Rapid Assessment and Management of Patients with Acute and Critical Illness

Situation The Rapid Response to Acute and Management of Critical Illness (RRAMCI) course was developed through collaborative working between the senior tutor for critical care in Swansea University and practice educators in critical care within Hywel Dda Health Board. The course, which ran concurrently between April and August 2012 within district general hospitals provided a standardised approach to the provision of critical care education for health care practitioners caring for patients with critical care dependency levels one to three. A research study was undertaken to evaluate the effectiveness of the module in terms of its impact on students and patient safety in clinical areas.

Background Inadequate and or inappropriate management of acutely ill ward patients' were highlighted throughout the 1990's (DOH 2000), and despite attempts to re-organise and develop quality standards within critical care (NICE 2007), this remains an issue. Failures to optimise key essential fundamentals such as airway, breathing & circulation together with ineffective communication and team working between health care professionals have been acknowledged as contributory factors associated to substandard care (Wales NHS, 2010).

Assessment A mixed method approach was taken to collecting data from students at module commencement, as it progressed and at completion. Provision findings suggest that initially students shared common concerns regarding inadequate knowledge, skills and confidence in caring for the acutely ill patients, however students stated that they felt that they could manage critically ill patients more effectively and confidently as the module progressed. Recommendation Research evidence collated from the RRAMCI course suggest that this module had a positive impact on student confidence and ability to manage critically ill patients level 1 to 3, which supports its ongoing use within Hywel Dda Health Board.

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References DOH (2000) Comprehensive Critical Care: A review of Adult Critical Care Services. accessed at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasse t/dh_4082872.pdf on 01.09.12 NICE (2007) Acutely Ill Patients in Hospital: Recognition and Response to Acute Illness in adult hospitals. accessed at: http://www.nice.org.uk/nicemedia/pdf/CG50FullGuidance.pdf on 01.09.12. Wales NHS (2010) 1000 Lives Plus: How to guide 6: rapid response to acute illness Wales NHS as part of 1000 lives plus accessed at: http://www.wales.nhs.uk/sites3/Documents/781/How%20to %20%286%29%20Rapid%20Response%20to%20Acute%20Illness%20%28Feb %202011%29%20Web.pdf on 01.09.12

Dawn Tapp Email: dawn.tapp@wales.nhs.uk Healthcare support worker handover at patient bedside This presentation will show how healthcare support workers (HCSWs) have been empowered to undertake handover at the patients bedside. Section 4 of the Code of Conduct for Healthcare Support Workers in Wales states that: HCSW must communicate in an open, transparent and effective way to promote the wellbeing of service users and carers. It also states that HCSWs must communicate effectively and consult with colleagues as appropriate and that HCSW must recognise the limits of their role, knowledge and competence when communicating with service users, carers and colleagues. Towy ward have taken an active part in Transforming Care. Part of the initiative was to improve the amount of time health care staff spent in direct patient care. Historically handovers on the ward had suffered from a number of shortcomings. They were taking to long and information given was often inconsistent or incomplete. Healthcare Support Workers indicated that handovers were far more detailed that they required to undertake their role. Therefore Towy ward piloted an initiative whereby HCSW undertook their own handover at the bedside and updated pre printed handover sheets and patient status at a glance board were fundamental to ensure that correct information was available. Initially HCSW were observed by a registered nurse when they were performing handover in order to ensure that the process was correct. This process has encouraged HCSW to recognise their own role and responsibilities. It has empowered them to make changes in relation to patient care and to ensure PSAG board etc. is kept up to date. Part of this initiative highlighted the need for HCSW team leaders and these have now been nominated and they will be taking an active role in the ward team leader meetings.

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Three intended learning outcomes: 1. Raise awareness 2. Disseminate area of good practice 3. Promote effective leadership

Julia Terry Email: j.terry@swan.ac.uk Development and evaluation of an educational module for mental health nurses regarding the physical health of mental health service users Background: People with severe mental health problems have high levels of morbidity and mortality (Royal College of Psychiatrists, 2009); and are less likely to get routine evidence based physical health interventions than other societal groups. Mental Health Nurses need to develop physical healthcare knowledge and assessment skills and actively engage in health promotion strategies with service users (Dept of Health, 2005); but feel illequipped to do so. There is little published evidence of the influence of healthcare professional educational programmes and their outcomes in physical health and serious mental illness research (Hardy et al, 2011). A new module was developed in partnership with health board staff and service users to address these knowledge and skill gaps for mental health staff. This evaluation relates to both the impact and process of the educational intervention, as perceived by the participants. Method: This pilot study had a mixed method design. Students (n=14) attending a stand-alone module completed pre and post module survey questionnaires, and participated in an end of module focus group. The survey incorporated a 39 item self-report questionnaire regarding perceptions of participants confidence levels regarding various physical health interventions. The focus group explored participants perspectives regarding educational outcomes. Findings: Participants reported that as a result of attending the module their confidence and knowledge about physical health issues had increased. Students perceived the taught content from a wide range of specialist speakers to be of high quality. Recommendations were made for increased practical skillsbased sessions for future modules. Conclusions: This pilot study suggests mental health nurses, who attended a physical health issues in mental health practice module, reported increased knowledge about physical health issues. Further research is required into educational programmes for health care staff relating to physical health issues for mental health service users, as the evidence base remains under-developed. Three intended learning outcomes: 1. An increased awareness of the rationale for, and development of a module on physical health issues in adult mental health practice 2. Be able to identify the reported experiences of participants who attended the module 3. Be able to discuss different educational models to improve the knowledge and skills of mental health nursing staff about physical health issues

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References: Dept of Health (2005) Choosing Health: Making Healthy Choices Easier. London: DH Hardy, S., White, J., Deane, K., Gray, R. (2011) Educating healthcare professionals to act on the physical health needs of people with serious mental illness: a systematic search for evidence. Journal of Psychiatric and Mental Health Nursing, 2011, 18, 721727 Howard, L., Gamble, C. (2011) Supporting mental health nurses to address the physical health needs of people with serious mental illness in acute inpatient care settings. Journal of Psychiatric and Mental Health Nursing, 18, 105-112

Carol Thomas, Sally-Ann Rolls & Catherine MacPhee E.mail: carol.thomas@wales.nhs.uk The Modafinil Study A foot in the door Research in palliative care is far behind other cancer areas, such as oncology. As a result, palliative treatment historically has not always been informed by research. To address this, and in accordance with the direction and funding received from NISCHR, the Cancer Registered Research Group is currently focused specifically on Palliative Care research development. Withybush General Hospital was one of just two hospitals in Wales which participated in the Modafinil Study (Modafinil for the treatment of fatigue in lung cancer: a multicentre, randomised, double-blinded, placebo-controlled trial). The study was funded by a National Cancer Research Institute (NCRI) Lung Cancer SuPaC Research Award and the Primary Objective was to assess the efficacy of modafinil in the management of fatigue in lung cancer. This was the first time the research team had supported a palliative care study and it was also the first time that the Palliative Care Consultant had taken on the role of Principal Investigator.This presentation will show some of the barriers/problems we faced running the trial at a district general hospital as opposed to a cancer centre or hospice, highlight some of the challenges faced with regard to recruitment of this vulnerable patient group, as well as sharing the steps we took to try to overcome those barriers and what we have learned that we can take forward for future palliative care trials. Three intended learning outcomes 1. Identify barriers to recruitment for a palliative care study in a district general hospital 2. Identify the benefits of involving other members of the multidisciplinary team 3. Identify strategies which can be used for future palliative care trials Thomas, Nicky & Kirtly, Helyn nicky.thomas2@wales.nhs.uk Empowering Employees to Manage their Wellbeing: The Success of Partnership Working Wellbeing through Work is a ground breaking service, demonstrating the benefits of partnership working to support the health & wellbeing of people in work. This partnership between ABMU Health Board, NLIAH and Remploy was established in October 2011 and is funded by the Welsh European Funding Office. The service targets employees and empowers individuals to manage their wellbeing, thus enabling them to sustain their employment or return to work following sickness absence.

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Wellbeing through Work compliments the recommendations made within Dame Carol Blacks Health at Work An Independent Review of Sickness Absence Report (2011) which highlighted the impact of presenteeism and sickness absence within the workplace. It is a community based service offering a flexible model of one to one support, telephone support and Managing Your Wellbeing Courses. The course utilises a self management approach and offers a combination of cognitive behavioural therapy, mindfulness, motivational interviewing and solutions focused techniques, which are offered as tools to enable participants to manage their own health. This presentation will summarise the history of the project and outline its innovative practice, including partnership working between Health Professionals and Employment Advisors and the diverse range of short term clinical interventions, delivered flexibly according to the needs of the individual. Interventions are regularly reviewed and updated accordingly to conform to evidence based practice. Standardised outcome measures are used to evaluate the service (Hospital Anxiety and Depression Scale (HADS) and Short Form 36v2 (SF36v2), a quality of life measure), and the changes in health status will be presented along with employment outcomes. Three intended learning outcomes: 1. To provide an insight into the benefits of health & employment partnership working

2. To provide an overview of clinical interventions utilised within the vocational rehabilitation setting 3. To demonstrate health & employment outcomes as a result of participating in the service. Reference Black, C. Frost, D. (2011) Health at Work an Independent Review of Sickness Absence. The Stationery Office Limited. London

Thomas, Ros rosalyn.thomas@wales.nhs.uk Faster Feet: The setting up and running of a Joint Multi Disciplinary Diabetic Foot Clinic

Diabetic foot ulcers are costly and are associated with considerable morbidity. Between 45-75% of non-traumatic amputations of lower limbs are due to diabetic foot problems which contribute to the largest numbers of patients with diabetes admissions to hospital and uptake of hospital beds (Edmonds 2000; Furguson et al. 1996). Foot ulcers precede more than 80% of non-traumatic below knee amputations (Pecoraro et al 1990). Incorporating foot care into a Podiatry-led multidisciplinary team (M.D.T.) can reduce the amputation rate by 40-44% (Coleman & Brand 1997). With todays Health Board structure and with the budgetary constraints, the need for a lean workforce without any detrimental effect on patients care is a priority. Achieving more for less and improving the patient pathway necessitated a review of clinic appointments for those utilizing hospital outpatient appointments the most. A multidisciplinary Joint foot clinic was established to reduce the numbers of visits to hospital for patients who have multiple co-morbidities i.e. a one stop shop. Discussing with appropriate

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consultants, this podiatry-led foot clinic has improved communication between the professionals involved in the management of diabetic foot problems. Out of 8 clinics, 5 patients were unable to attend and cancelled and rebooked at a later date Of the 58 seen in this clinic 25(48%) of these patients were fast tracked for surgical procedures, 30 in total, as some required two or more interventions at the same time. Nine patients admitted to hospital from their clinic appointment and 16 were given dates prior to leaving the foot clinic. The chosen treatment plan involved discussions with the patient and/or carer to give them an informed choice. The success of this foot clinic can only be achieved by working as a team with good communication skills and prior knowledge and understanding of each others limits or scope of practice.To date 17 patients have ulcerations that have resolved, 6 patients are ongoing with foot ulcerations, 2 patients are deceased and 1 patient declined surgery.

Three intended learning outcomes: 1. Awareness of MDT 2. Share best practice 3. Increase awareness of scope of practice of podiatry to other disciplines References Coleman, W. C. & Brand, P. W. (1997), "The Diabetic Foot," in Ellenberg & Rifkin's Diabetes Mellitus, 5 edn, D. Jr. Porte & R. S. Sherwin, eds., Prentice Hall International, London, pp. 1159-1182. Edmonds, M. E. & Foster, A. 2000, Managing The Diabetic Foot Blackwell Science, London.Furguson, M. W. J., Herrick, S. E., Spencer, M. J., Shaw, J. E., Bolton, A. J. M., & Sloan, P. 1996, "The Histology of Diabetic Foot Ulcers.", Diabetic Medicine, vol. 13, no. S, pp. 30-33.

Sophie Thomas E.mail: sophie@paulsartori.org Advance Care Planning: Person-centred support by trained volunteers; a new service for a wellestablished Hospice at Home service in Pembrokeshire There is a huge unmet preference for home death in the UK, with 50 - 70% (or more) wanting it, and only 20% achieving it. (Gomes et al. 2012). There is ample evidence that Advanced Care Planning (ACP) increases the likelihood of achieving end-of-life preferences. ACP has been widely adopted in other countries and there are numerous models for its provision (Thomas and Lobo 2011). It is recommended in several sets of professional guidelines, yet uptake in the UK is low - fewer than 5% of our patients have an ACP. The most commonly cited barrier to ACP is that it is time-consuming for professionals. A volunteerprovided service can address this, and has been shown to have potential in the UK (Seymour et al. 2011) and elsewhere.We have received funding for a pilot project that is enabling us to build on experiences elsewhere to design a service demonstrably acceptable to public and professionals in Pembrokeshire. The project started in May 2012. Three intended learning outcomes

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By November we will be able to present our early experiences with: 1. Engagement with the public and health and social care providers 2. Patient recruitment and Volunteer recruitment 3. The practicalities of completing plans References: Gomes, B., Calanzani, N. and Higginson, I. J. (2012) 'Reversal of the British trends in place of death: Time series analysis 2004-2010.', Palliat Med. Seymour, J. E., Almack, K., Kennedy, S. and Froggatt, K. (2011) 'Peer education for advance care planning: volunteers' perspectives on training and community engagement activities.', Health Expect. Thomas, K. and Lobo, B. (2011) Advance Care Planning in End-of-Life Care, Oxford: Oxford University Press.

Christine Williams, Helen Griffiths, Lesley Cook, Donella Davies and Kevin Jones, ABMU. Ruth Davies and Tessa Wales, CHHS Swansea University Email enquiries: Christine.Williams20@wales.nhs.uk Implementing the Butterfly Scheme in ABMU: The Big Bang Approach In April 2012 the Princess of Wales WCPI Unit held a seminar at which Sister Andrea Higgins and Tom Alexander spoke about how they had introduced the Butterfly programme to help improve care and support for patients with dementia in Withybush Hospital. Their presentation was inspirational and following a succession of meetings at ground and executive level the decision was taken to roll out the Butterfly Scheme, developed by Barbara Hodkinson (2011), across ABMU Health Board. The need to roll out this programme as soon as possible is compelling given concerns about the care of people with dementia in hospital by the public and health care workers themselves following media accounts of inappropriate care as well as the report by the Older Peoples Commissioner for Wales (2011), which recommended that better knowledge of the needs of older people with dementia in hospital is needed together with improved communication, training, support and standards of care. Likewise recent research by Tadd et al., has highlighted that older people in Welsh experience ageism and are often the recipients of undignified care (2011). The Butterfly programme which includes all health care workers including porters and domestic staff, allied professions (physiotherapists, dieticians etc), health care support workers as well as qualified nurses and medical staff should make a positive difference to the experience of hospital care for people with dementia. Three intended learning outcomes: 1. The challenges of implementing the Butterfly Scheme 2. How all levels of health care workers may access the Butterfly programme seminars and learning materials 3. The need to evaluate and research outcomes

References:

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Hodkinson B. (2011) Hospital Programme for Dementia Specific Care. Nursing Older People 23(7); 1417 Older Peoples Commissioner for Wales (2011) Dignified Care? The Experiences of older people in hospital in Wales. Tadd W., Hillman A., Calnan S., Calnan. M., Bayer T., Read S. (2011) Dignity in Practice : An Exploration of the Care of Older People in Acute NHS Trusts.

Wright, Gemma Occupational Therapist gemma.wright@wales.nhs.uk Urinary Incontinence in Older Women: Conservative Therapeutic Interventions and the Potential Role of the Occupational Therapist Urinary incontinence (UI) is a highly prevalent yet largely ignored condition that affects older women and can be exacerbated by admission to hospital (NICE, 2006).Conservative treatment options are widely underused and containment methods more widely prescribed. This presentation seeks to highlight the efficacy of conservative approaches and the potential role for Occupational Therapists (OT) in the management of these patients. The most widely used interventions (NICE,2006) form the framework for this presentation: pelvic floor muscle training, behavioural training, biofeedback, electrical stimulation, lifestyle changes and complementary therapy as well as the potential role for the Occupational Therapist. A critical appraisal of these conservative approaches has been completed and will be presented to identify which approaches could be widely recommended. A case study will then be used to demonstrate how the conservative therapeutic interventions were used on an acute medical ward to an older female patient with UI. In order to improve the patients continence management, the OT developed a programme to improve current practice on the ward and encourage the patients self management of the condition. The treatment plan was based on cognitivebehavioural, educational and functional approaches. Close collaboration with the multi-disciplinary team, the patient and the OT was essential. As a result of these interventions and collaboration the patient was discharged independently managing her daytime continence and was experiencing only mild and intermittent nocturia. The presentation and the case study combined aims to illustrate the potential role of the OT in promoting independent continence management and the need for increased awareness of the beneficial effects of conservative interventions. Three intended learning outcomes: 1. Increased knowledge of prevalence, epidemiology, impact and types of incontinence experienced by older women. 2. Increased knowledge of conservative treatment options for this patient group with an emphasis on active treatment of the condition as opposed to containment methods only. 3. Increased knowledge of the potential role for the occupational therapist in this area. References:

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National Institute for Health and Clinical Excellence. 2006. Urinary incontinence: The management of urinary incontinence in women [Online]. Available at: www.nice.org.uk/nicemedia/live/10996/30281/30281.pdf [Accessed: 22 Aug 2012]. POSTER PRESENTATIONS

Barton, Thomas Specialist Nurse Practitioner Thomas.barton@wales.nhs.uk Drug treatment monitoring in the cognitively impaired, an innovative approach to monitoring and assessment. Abstract This proposed project in its developmental stage is primarily concerned with the monitoring and assessment of pain of patients, particularly those with cognitive impairment. (It is a highly transferable concept and could be used in the monitoring of a number of symptoms and therapies). It consists of three main bodies of work firstly, an innovative symptom (in this case pain) mapping tool implemented within the drugs charts of the ward to provide side by side comparison of pain scores and the analgesia administered. It is proposed that this idea will improve the frequency of pain scores as the task coincides with drug administration. It also provides useful data and trends to assess the effectiveness of treatment. To ensure the implementation of the organisations standardised pain scoring tools as guided by the specialist pain teams. Thirdly, it is proposed that the above system form part of a research project to investigate whether its implementation has an impact on the experience of a predominately elderly population of patients in a non acute medical setting. Anecdotally, pain is poorly assessed in practice and there is an increased challenge in assessing pain within the cognitively impaired due to their impaired ability to recall the specific patterns and nuances of their pain. It is hoped that the project will provide an effective yet efficient, easy to use tool that will better monitor patients pain to allow swifter, more informed changes to treatment. Available literature describes conflicting conclusions as to whether pain assessment itself results in improved control of pain. However, locally there is significant lack of pain assessment and there is potential for improvements in pain control in a morbid population who may achieve better clinical and social outcomes in the absence or control of their pain. Three intended learning outcomes: To monitor and measure the effect of a pain tool in effecting pain relief in a cognitively impaired patient population in a non acute medical setting. Adapting and implementing existing knowledge to achieve a project goal. Developing research to evaluate the effectiveness of the innovation and project.

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Battle, Suzy & Gallagher, Elizabeth Suzy.Battle@wales.nhs.uk & Elizabeth.Gallagher3@wales.nhs.uk Introduction of a patient information leaflet; a change for the better? A decrease in pulmonary function is well known post cardiac surgery (60-75% of pre-operative pulmonary function) due to atelectasis, decreased lung volume and oxygenation (Westerdahl et al 2001). There are numerous methods of physiotherapy input which improve pulmonary function & prevent pulmonary complications which are a cause of morbidity (Crowe and Bradley 1997). Crowe & Bradley (1997) commented incentive spirometery is only effective if used regularly and adherence to this is an issue. At the cardiothoracic centre in Morriston hospital the physiotherapy team aimed to improve adherence to all aspects of physiotherapy treatments, to improve post operative outcomes. Method A 4 week audit of all post operative cardiac patients was carried out using a questionnaire, an exercise leaflet was designed and introduced and a 4 week re-audit was completed to assess any change in patient compliance & memory of physiotherapy input. Results The introduction of the leaflets showed an improvement throughout all aspects of physiotherapy Use of incentive spirometers improved by 27% Performance of breathing exercises improved by 37% Remembering how often exercises should be performed improved by 29% Performance of mobility exercises improved by 43%

Conclusion This study has demonstrated the need for an exercise sheet for post op cardiac patients, to improve compliance to physiotherapy post surgery. It improved patients memory of physiotherapy requirements. It also identifies areas of further audit & research. Three intended learning outcomes from oral session and/ or poster: 1. To understand why physiotherapy post cardiac surgery is vital for optimum recovery 2. To present a tool created to aid the continuity of treatment & demonstrate the ease of using a simple exercise leaflet to improve treatments & patient compliance 3. To inform others of the positive outcomes of the audit

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Claire Brimson Nursing Student, College of Human and Health Sciences, Swansea University, Wales and Diaconia University of Applied Sciences, Oulu, Finland. Email: 642746@swansea.ac.uk Common bacterial and viral hospital infections: The use of a poster to bring about positive change Patients frequently develop health care-associated infections (HCAI) when in hospital and are considered a global burden (WHO, 2012). Whilst in Finland on my critical care placement, I worked on a Neurology rehabilitation ward, and Intensive Care trauma and coronary units. Whilst on the Neurology rehabilitation ward, I observed poor practice in infection control issues being demonstrated by trained staff and support workers. Having looked into the common hospital infections in this ward environment, I decided to compile a poster to give information regarding the four most prevalent bacterial and viral hospital infections: Clostridium difficile, Extended-Spectrum BetaLactamases, Norovirus, and Vancomycin Resistant Enterococcus. Information about transmission and prevention of each organism was given, with the main emphasis being on the five stages of hand washing (WHO, 2012); this was important to help halt cross infection. Guidance from the poster was offered to the qualified nurses and allied health professionals regarding HCAIs. Although all staff are Finnish speaking, they also understand English because of Finnish health care policies, so the poster was compiled in English, although the option for Finnish translation was available. Following the simple information session in mixed English/Finnish using the guidance poster, it was noted that both hand washing and infection control had improved. This was demonstrated by fewer patients being barrier nursed, the increased use of personal protective clothing and infection control attitudes by all staff. The compiled poster was displayed for future reference for all staff. The poster was also given to Intensive Care trauma and coronary, although their infection control standard was already high. This illustrates how a simple informative poster can bring about positive change.

Dixon, Sharon & Jenkins, Claire Community Learning Disability Nurses Sharon.Dixon@wales,nhs.uk Claire.Jenkins@wales.nhs.uk Living Well, Dying Well: Palliative and End of Life Care for People with Learning Disabilities Abstract People with learning disabilities are living longer and have the same health needs as the general population. However, they had additional health needs associated with their learning disabilities; some cancers, hearth disease, respiratory disease, psychiatric disorders, challenging behaviours, dementia and epilepsy (Emerson and Baines 2010). They also have higher mortality rates than the general population and can experience delays in accessing primary and secondary health care including palliative care services (Mencap, 2007). Bridgend Community Support Team decided to choose

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Palliative Care for People with a Learning Disability as its annual team project for 2010 / 2011 and to develop a local palliative care pathway. As part of this project, Bridgend Community Learning Disability Nurses in conjunction with the Health Team Manager developed a poster and power point presentation to raise the awareness of the needs of people with learning disabilities with palliative and end of life care needs, titled Living Well, Dying Well. Key themes included; personcentred approach, collaborative working, empowerment, good quality of life and good symptom control, etc. The poster and presentation was presented at the ABMU HB Palliative Care Conference in November 2011. Three intended learning outcomes from oral session and/ or poster:

1. TO PROMOTE PERSON CENTERED PLANNING TO IMPROVE QUALITY OF LIFE. 2. TO INCREASE PEOPLES UNDERSTANDING REGARDING THE PALLITIVE CARE NEEDS OF INDIVIDUALLS WITH LEARNING DISABILITES. 3. TO PROMOTE COLLABORATE WORKING BETWEEN PRIMARY, SECONDARY AND SPECIALIST HEALTH CARE SERVICES. References E, Baines S (2010) Health Inequalities and people with learning disabilities in the UK 2010. Improving health and lives Learning Disability Observatory, Lancaster. Mencap (2007) Death by Indifference. Mencap, London. Scottish Government (2012) Strengthening the Commitment. The Report of the UK Modernising Learning Disability Nursing Review. Scottish Government.

Gadsden. Kirsty Senior Health Care Assistant kirstygadsden@talktalk.net Nutrition The aim of this poster is to inform people of the importance of nutrition and to give them a knowledge and understanding of the subject. The aim is also to promote nutrition and its effects on our patients. I hope that the poster will give people a greater awareness of nutrition/malnutrition, the signs to look out for and what we can do to help. I hope that this poster will give nutrition the priority it deserves in order to give our patients the care that they deserve. Three intended learning outcomes from poster: 1. What is nutrition? 2. Why is nutrition important? 3. Highlight some of the issues surrounding nutrition

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Goss, Louise Louise.Goss@Wales.nhs.uk Combating Poor Training Attendance How We Succeeded? The attendance of off ward training within Cardiac Intensive Care was poor and showed a significant deficit which did not meet the criteria for mandatory training within the Health Board. The unit Manager asked me to approach the Infection Control Team to ask if we could potentially run a ward based training scheme with myself as the ward based trainer given my experience in delivering Infection Control training. My training & presenting skills were assessed by the Infection Control team before we could undertake the Standard Infection Control Precautions Training (SICPs). The training commenced in April 2011, we had a total of 81 staff members including Health care support workers & ward receptionist. At the end of 2011 we had achieved 75 out of 81 staff trained which is 93%. Only 6 members of staff (7%) were not trained due to Maternity leave or part time workers who were not working on the day of training. This has been a successful innovation and importantly has brought us up to date with mandatory training and also increased both staff knowledge & awareness on a fundamental part of health care delivery to assist with better infection control practices. We are now on target for the 2012 training updates and in process of training a further 2 members off staff to be able to deliver the training to keep our records of attendance on target. References: Gould.D & Chamberlin A. 1997. The use of a ward-based educational teaching package to enhance nurses compliance with infection control procedures. Journal of Clinical Nursing, Jan 6(1) pp.55-67. Abstract only. Available through: Department of Nursing Studies, Kings College, London, UK. (Accessed 5 September 2012) Halstead T. 2002. Using research to improve a ward-based learning environment. Nursing Times. 98(47), p.36 London Deanery, 2012. Where to teach clinical skills. (Online) Available at: http://www.faculty.londondeanery.ac.uk/e-learning/teaching-clinical-skills/where-to-teach-clinical-skills. (Accessed 11 September 2012)

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Griffiths, John & Wilcox, Daniel john.griffiths@wales.nhs.uk Daniel.Wilcox@wales.nhs.uk INTRODUCING POSITIVE BEHAVIOURAL SUPPORT TO A PSYCHIATRIC INTENSIVE CARE UNIT Abstract The aims of positive behavioural support (PBS) is to equip and enable nursing staff to safely manage aggressive and challenging behaviours that can be displayed by our patient group. PBS emphasises positive engagement with the individual in an attempt to clarify the meaning behind any aggressive behaviours. The interactions are based around support and understanding of the individual rather than responding in a manner that results in sanctions as a deterrent against the actions. Having identified the perceived benefits of adopting this approach there follows an account of setting up the structure, delivering appropriate training and ongoing support for all clinicians involved. A first hand account of care delivery utilising the PBS approach is provided by a ward based charge nurse, reflecting upon their own challenges of managing a patient with a particular set of personal values and beliefs that presented the clinical environment with a series of unique challenges. Three intended learning outcomes from oral session and/ or poster: 1. Explain the reasons for adopting a PBS approach to a forensic ICU setting. 2. Highlight the challenges of managing a change in clinical practice at ward level. 3. Examine any benefits already gained by utilizing PBS at ward level. References: McClean B., Dench C., Grey I., Shanahan S., Fitzsimons E., Hendler J., & Corrigan M. (2005). Person Focused Training: a model for delivering positive behavioural supports to people with challenging behaviours. Journal of Intellectual Disability Research. 5, 340-352 Soothill, K., Rogers, P. & Dolan, M. (2008) Handbook of Forensic Mental Health. Devon: Willan Publishing

Hyde, Lindsay Lindsay.hyde@wales.nhs.uk Role of the Physiotherapist in the Pain Management programme A Pain Management Programme (PMP) is an educational programme, which offers practical ideas and techniques to help chronic pain sufferers cope with their pain. It consists of one session a week for 8 weeks and is delivered using a cognitive behavioral therapy approach by a specialist multi-disciplinary team. This team includes physiotherapists, Occupational therapists, Nurses and a psychologist who work closely together to address all aspects of living and coping with chronic pain. People who have chronic pain often find that they are not as active as before the pain started. Over time they can become de-conditioned, and everyday activities become harder. The aim of physiotherapy is to break the chronic pain cycle to enable the individual to reduce their level of Kinesiophobia (fear of movement) and achieve their goals.

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Improved fitness may allow the individual to achieve their personal goals, big or small. For example: Return to Work, Walk the dog, Socialise with friends. Exercise is an important component of the pain management programme. The physiotherapist can help the individual to establish a base level at which they are able to exercise. The programme is graded, which means that the exercises are gradually increased at a level which feels comfortable for the individual. Physical function is tested before and after the programme. Three tests are performed. 1. Two minute walk test 2. Upper limb endurance test 3. Sit to stand test

We have looked at the outcome data from 15 programmes which have been conducted over the past 3 years within the ABMU trust. They show significant improvements in fitness levels using the above measures. Three intended learning outcomes: 1. Improve understanding of a PMP 2. Highlight the role of the physiotherapist within a PMP 3. Demonstrate by the use of audit data that physical fitness can be improved in the chronic pain population by attending a PMP. Jones, Rhiannon Rhiannon.Jones9@wales.nhs.uk Scores on the Boards The National Confidential Enquiry into Patient Death and Outcome (NCEPOD) Time to intervene May 2012 takes a critical look at areas where the care of patients might have been improved, and factors which may have affected the decision to initiate a resuscitation attempt. Remediable factors have also been identified in the clinical and the organisational care of these patients. Unfortunately some areas have not changed since the NCEPOD 2005 report which was used to guide much of the NICE 50 guidance. I have looked at one area of the 2012 report in particular and how we have addressed it in our area. The report statesCare before the cardiac arrest Where patients continue to deteriorate after non-consultant review there should be escalation of patient care to a more senior doctor. If this is not done, the reasons for non escalation must be documented clearly in the case notes NCEPOD 2012 We have worked closely with NLIAHs 1000 lives + rapid response to acute illness campaign; they highlighted the need for four bundles admission, recognition, response & sepsis. These have been implemented using a 2 minute safety briefing and patient information board we collected data on compliance with the bundles see below.

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We hope to drill down and understand why although these patients are being recognized still there is no appropriate care instigated. Three intended learning outcomes: 1. Patient Safety 2. Service delivery 3. Improvements in knowledge

Sue Jordan and Amy Brown

Email: S.E.Jordan@swansea.ac.uk

Why are breastfeeding rates at 6-8 weeks not improving? A discussion paper

Background Breastfeeding rates are too low. In the UK, only 49% of women are breastfeeding at all by 6-8 weeks, a figure which has remained unchanged since 2009. The decline in breastfeeding initiation 1980 to 1990, the increase from 2000 and the unchanged breastfeeding rates at 6-8 weeks are incompletely explained. Aims We aim to broaden the discussion by considering the impact of obstetric interventions on breastfeeding. Methods Systematic reviews reporting infant feeding outcomes were identified from PubMed and Cochrane databases. Where these yielded little data, clinical trials, cohorts and studies describing biological mechanisms were reviewed. Results Initiatives to support breastfeeding have been extensively researched, but, in the UK, benefits are inconclusive. In contrast, Cochrane reviews indicate that infant feeding data has been collected in <25% of participants in trials of management of third stage of labour (1,447/ 6,486 women), and <3% of participants in trials of pain relief in labour (643/ 22,676). The only systematic review of Caesarean sections located indicates that pre-labour sections reduce breastfeeding rates. The 4 trials reporting the impact of epidural analgesia on breastfeeding, together with cohort work, suggest a dose-response relationship for the most commonly used analgesic, fentanyl. Intramuscular opioids also reduced breastfeeding. Suggestions that uterotonics, opioids and pre-labour sections reduce breastfeeding rates are supported by large, but not small, cohorts, and physiological studies.

Conclusion The UKs suboptimal breastfeeding rates are not fully explored. However, drugs administered in labour and pre-labour Caesarean sections may be disturbing the biology of breastfeeding. The benefits of breastfeeding are so substantial that work is needed to: remedy omissions of previous trials and explore

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all benefits and harms of drugs administered in labour; identify drug doses which make labour safe and tolerable without reducing breastfeeding rates; ensure breastfeeding support is targeted towards women receiving multiple obstetric interventions. Sue Jordan and Amy Brown on behalf of the PREGNANCY, CHILDBIRTH, INFANT FEEDING AND MEDICINES Research Development Group, funded by CYPRN/ NISCHR

Terina Kidby E.mail: t.kidby@wales.nhs.uk Skin Care Business, Everyones Business In October 2007, the National Hip Fracture Data base (NHFD) was established by the British Orthopaedic Association and the British Geriatrics Society it enabled staff in Bronglais Hospital to measure care against nationally agreed standards and benchmark to other sites. The integral audit tool helped to quantify the standards of care that has been provided to this vulnerable group. Data from Bronglais was included in the 2009/2010 report and at this stage our Pressure Sore rate for people who had been admitted with fractured hips was 17.6% against a Welsh average of 4.6%. Staff attended a 1000 lives workshop and subsequently established a local Health Board mini collaborative to focus interventions, keeping the patient at the forefront of our work. This, initiated the use of safety crosses, skin care bundles and local training The audit was repeated in 2011 disappointingly the pressure sore rate for Bronglais 12%. Effectively meaning 1 in 10 pts admitted with a fractured hip would develop a pressure sore while in our care.However the findings enabled us to identify causative factors for this unacceptably high score e.g.: Bronglais Hospital did not easy access to a Tissue Viability Nurse there was a lack of pressure relieving equipment, Nurses were not able to accurately risk assess Patients and subsequently assess and grade pressure sores; Pressure damage prevention was not owned by the wider multi-disciplinary team

Concurrently local staff were also engaging with the All Wales Hip Fracture pathway. The 2012 NHFD report identifies pressure damage rate as 5.8% against a national average of 3.6%. Although still too high, it must be acknowledged that changes to practice are still evolving an significantly there has not been a reportable pressure sore in this group of patients since November 2011. Three intended learning outcomes 1. To demonstrate how we have been able to enhance local accountable multi-disciplinary service delivery and clinical interventions. 2. To provide an example of improvements to patient centred care in a specific field of practice. 3. To provide a model for improvement that is transferable to other areas of practice

Littlehales, Sharon

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Sharon.littlehales@wales.nhs.uk Paediatric Skills Study Days This is the third year that the paediatric skills study days has been successfully implemented. The original aim was the facilitation and development of clinical based Registered Nursing staff within Child Health. To reflect a team approach to the care of the child patient in practice, the study day was also offered to Accident and Emergency staff and the Cleft Service. The study days have been held over an 11 month period, primarily targeting Registered Childrens Nurses (April through to March with the exception of December). With the NMC standards in mind, the programme was divided into teaching sessions that focused upon professional roles, responsibilities and to maintain/ advance technical clinical skills and knowledge for clinical practice and promote the overall competence of the Registered Nurse. The aim has been to facilitate the development of Registered Nurses in line with a model of development. To make the days inspirational differing teaching strategies have been utilised such as formal presentations followed by interactive methods. The interactive methods included participation in clinical skills session, scenarios and group work. Objectives of Programme Registered Childrens Nursing need to continually develop and improve the following: Promote leadership and assertiveness Identify professional issues in practice and resolution Work effectively as a team member and delegate effectively Actively participate in clinical skills sessions to advance clinical skills Promote clinical knowledge and best practice Safeguard children and manage risk

Evaluation Each study day has been evaluated and the comments have been very positive from each Registered Nurse who attended. The small numbers within the groups allowed the staff to speak freely and openly. The skills sessions were effective in providing opportunity for practice which was highly valued by the staff in attendance. To validate the quality of the study days a Child Health Swansea University Team have agreed to undertake an independent evaluation of the study days, which is in its early phase of development. Three intended learning outcomes from oral session and/ or poster: 1. Create a discussion about the design and development of training programmes within the service that is centered around the needs of nurses 2. Demonstrate that barriers to innovative concepts can be overcome when teams work together 3. Share this concept with colleagues from other domains of nursing practice References Benner, P. (1984) From novice to expert, excellence and power in clinical nursing. Menlo Park, CA:Addison-Wiley Publishing Nursing and Midwifery Council (2008, 2010) The Code. Standards of Conduct, Performance and Ethics for Nursing and Midwifery. London. NMC Littlehales, S. (2001) Competence of third year Student Nurses. Unpub masters dissertation

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Lynch, Colm Patrick Physiotherapist Colm.Lynch@wales.nhs.uk Patient Experiences of Hydrotherapy post-CVA Hydrotherapy may lead to improvements in strength, muscle extensibility, balance, cardiovascular endurance and ADL performance in CVA patients. There has been limited research into patients self reported experiences of hydrotherapy participation post CVA. The aim of the present study was to qualitatively identify patients experiences of hydrotherapy post CVA.

Methods All patients had confirmed CVA and were under physiotherapy treatment on a designated stroke rehab ward. Patient eligibility for hydrotherapy was identified based on established contraindications/suitability and patient agreement. Medical clearance was gained for all patients to participate. Following a course of hydrotherapy, patients experiences were collected via an individual semi-structured interview. This asked for comment on the patients overall experience of hydrotherapy, positive and negative aspects, and their opinion of how it contributed to their overall rehabilitation while on the ward.

Results Interviews were collated and transcribed and then analysed for recurring themes under the broad areas of physical effects and non-physical effects. These were further subdivided into general positive experiences, enabling of movement, confidence, enjoyment, other benefits, hard work, effect of balance and secondary benefits.

Discussion The breadth of comments received made thematic analysis difficult, but dividing into specific areas allowed easier categorization of responses. Patient experiences were very positive overall with a majority of patients expressing that they felt that hydrotherapy positively contributed to their recovery in both physical and non-physical ways. These results lent support to establishing an ongoing regular hydrotherapy service and highlight the importance of non-physical benefits in the rehab process. Three intended learning outcomes: 1. Increase awareness of the use and benefits of hydrotherapy post stroke 2. Increase awareness of the non physical benefits of a specific rehabilitation modality 3. Discuss benefits of exploring patient qualitative experiences of treatment

References: DK Noh, JY Lim, HI Shin, et al, (2008), The effect of aquatic therapy on postural balance and muscle strength in stroke survivors a randomized controlled pilot trial, Clinical Rehabilitation, 22(10-11): 966 976.

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Chu, K, Eng, J, Dawson, et al, (2004) Water-based exercise for cardiovascular fitness in people with chronic stroke: a randomized controlled trial. Archive Physical Medical Rehabilitation, 85, 870-874. Braun, V. and Clarke, V. (2006), Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2). pp. 77-101.

Mashlan, Wendy wendy.mashlan@wales.nhs.uk The development of the Advanced Nurse Practitioner rehab /care of the elderly medicine referral system has been ongoing for the past 8 years since the early inception of the roles within practice. Over the years the system has evolved and change in accordance with resource issues, demands for beds, and an ever increasing population of older people within the hospital setting. Historically all patients requiring rehabilitation or care of the elderly input would have been seen by a Consultant Geriatrician. Given the ANP roles mix of advanced skills of clinical assessment and traditional nursing knowledge, developing a dedicated ANP led referral system to replace the traditional consultant led service seemed a sensible move forward in service development The following will outline the journey within this evolving service that aims to demonstrate the innovative thinking that has enabled the system to progress and flourish within a demanding health service. This is considered to be a live and progressive project that meets no immediate end. Three intended learning outcomes 1. Understanding how alternative roles to the traditional medical doctor can deliver a service that is equal in delivery. 2. Understand the impact that a dedicated specialists can have on care and management of the care of the elderly patient. 3. To gain understanding of the elements that constitute the need for care of the elderly input.

Pawsey, Richard charles.r.pawsey@wales.nhs.uk A model for the screening and management of community brain-injured patients complaining of dizziness Dizziness is an extremely common symptom following traumatic brain injury, with up to 80% of patients reporting symptoms at some stage in their recovery. Commonly the associated symptoms of poor memory, limited cognitive skills and anxiety make it difficult for patients with brain injury to engage with generic services. The term dizziness is commonly used to describe vertigo, syncope or unsteadiness. Skilled assessment is required to identify which of these the patient is actually describing, as the management is different in each case. Vertigo requiring vestibular rehabilitation therapy and possibly canalith re-positioning maneuvers, syncope requiring review of their cardiovascular system, either by their GP, or medical consultant. Unsteadiness is managed by exercise prescriptions and provision of aids.

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One year ago the Traumatic Brain Injury Service (TBIS) secured physiotherapy input, to explore the difficulties experienced by this client group. Initial mapping of services indicated a fragmented referral process to Ear, Nose & Throat (ENT) Consultants, with waiting times varying from 2-3 months to over 6 months. Following process mapping a pathway was proposed, with an initial physiotherapy assessment within 2 weeks of contact with TBIS. Subsequent treatment is provided alongside the rest of the multidisciplinary team (MDT). Outcome profiles are presented which indicate the effectiveness of this service model, with some patients achieving complete resolution of their symptoms without referral to other departments or specialties. Three intended learning outcomes from oral session and/ or poster: 1. Earlier intervention is more effective 2. Co-ordinated team intervention is required to gain maximum reduction in symptoms 3. Dizziness may not be resolvable in all clients Pridmore, J. Hinkin, J. Gallimore, D. Warner G, Thomas H. Email: J.A.Pridmore@swansea.ac.uk Embedding Quality into the Nursing Curriculum 2012 Following the introduction of the Nursing and Midwifery Council (NMC) Standards (2010), HEIs within the UK were required to revise their curricula for nursing degrees .The new curriculum design is broadly based on Bruners constructivist spiral model (Bruner 1977). The need to redesign the curriculum presented an opportunity to introduce principles of quality improvement outlined by the NHS Wales (2012). The model for improvement adopted by the 1000 Lives Plus Campaign (NHS Wales 2012) was used to facilitate the changes required. The improvement proposal began by identifying the need to introduce the QI methodology as a theme running throughout the curriculum in accordance with the spiral design. Meetings and discussion took place to gain consensus for change. Next, specific elements of quality improvement were mapped to the module learning outcomes. PDSA cycles were used to test out the changes, refine the content, design and teaching approaches. It is expected that by 2015, all undergraduate nurses will undertake a final assessment requiring them to apply the QI methodology in a clinical practice setting; linked to clinical areas of excellence such as those identified as part of the Wales Centre for Practice Innovation.

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References Bruner JS(2006) In Search of Pedagogy Vol. 1 The Selected Works of Jerome S, Bruner 1957-1978. London, Routledge NHS Wales(2012) Achieving Excellence, The Quality Delivery Plan for the NHS in Wales Available at: http://wales.gov.uk/docs/dhss/publications/120517planen.pdf NHS Wales 1000 Lives Plus(2012) The Quality Improvement Guide for Educators and Students, available at: http://www.1000livesplus.wales.nhs.uk/educators-students-qi-guide Nursing and Midwifery Council(NMC)(2010) Standards for Nursing and Midwifery Education, available at: http://standards.nmc-uk.org/PreRegNursing/statutory/background/Pages/introduction.aspx

Protheroe Katharine Katharine.Protheroe@nhs.wales.uk Bringing the Outside In: The effect of the environment on dementia sufferers In May 2012, four elderly care wards moved into a brand new purpose built unit for dementia sufferers. The unit compromises of a core area and three individual wards. Each ward is large, airy and designed as a wandering loop. There are sixteen single ensuite bedrooms and two double bedrooms. The loop surrounds a garden that has been carefully planned to allow maximum use and enjoyment for the patients and their visitors. Each ward has three rooms, specifically for therapies, including a sensory room which has been fully equipped. The theme of the building is Bringing the Outside In, and has been designed to allow plenty of natural light, and is decorated in natural tones and colours. The effect on the patients has been noticeable. The building gives an air of calmness, and this has impacted positively on the patients, leading to a reduction is noise levels. Due to the individual rooms, patients are sleeping better and this has led to a reduction in medication usage. If a patient becomes agitated, staff are quick to use the sensory room to help alleviate and stress or anxiety. The improved facilities and a small increase in staffing levels has given staff more opportunity to focus on activities and has encouraged them to become more imaginative in dealing with individual patients. Families are now able to personalise the bedrooms with photos, flowers, throws, cushions etc, which previous wards could not allow due to limited space. Families often visit in the bedrooms, which encourages ownership of the rooms and maintains privacy. Pollock (2003) explains the importance of appropriate facilities. The building has only been open for five months, however the impact it has had has been remarkable, and the effect of the environment cannot be underestimated. This is supported by Pool (2010) and it is an opportunity to encourage innovation and research, leading to an improved future of care. Three intended learning outcomes from poster presentation: 1. To demonstrate the importance of the environment for dementia sufferers

2. To show how the environment can motivate staff

3. To highlight the importance of activities as a therapeutic intervention

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References Pool, J. (2010) Alzheimers society guide to the dementia care environment. 2nd ed. London: Alzheimers Society. Pollock, R. (2003) Designing interiors for people with dementia. Stirling: Dementia Services Development Centre

Roberts Patricia pat.roberts@wales.nhs.uk The effects of short stretch bandaging in lower limb oedema To disseminate that patients presenting with multifaceted problems including complex wounds, swelling, lymphorrhoea, maceration and cellulitis can often be mismanaged as a result of poor bandage selection and poor bandage technique. This report will illustrate the importance of utilising multilayer lymphoedema bandaging with short stretch bandages (Actico). Case Description Mrs X was referred to the Lymphoedema service as a last resort after previously being seen by numerous specialities. Problems commenced 20 years prior with a severe leg burn, resulting in extensive venous ulcers on legs, feet and toes, exudate level extremely high with gross odour. Previous management included the four layer bandaging system, double tubigrip and currently absorbent dressings with tubifast which provided no compression. This caused her legs to increase in size, wounds deteriorated and her quality of life suffered. On assessment from clinical history and physical examination the management of this severe complex bilateral lower leg lymphoedema required best practice of compression bandaging. The selection of choice was Actico with toe bandaging as previously inappropriate bandage choice and application had caused toe oedema and ulceration. Discussion Incorrect referral, treatment, bandage selection and technique can lead to an exacerbation of symptoms causing unnecessary damage and distress. Correct selection of multilayer lymphoedema bandaging is fundamental as well as adequate knowledge and skills. Had Mrs X been given the gold standard of compression bandaging which is one of the cornerstones of lymphoedema management? Then a good clinical outcome would have been achieved sooner. Three intended learning outcomes: 1. Disseminate best clinical practice 2. Share clinical interventions 3. Transfer knowledge and skills of lymphoedema and compression bandaging

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Ian Stevenson Email Ian.Stevenson@wales.nhs.uk Mental Health Triage: A New Service Development This research project will examine the impact of introducing mental health triage into the Mental Health Directorate in ABM University Health Board over 3 different phases. It is anticipated that mental health triage will provide the model for single point of access to secondary mental health services in 2013. Current traditional routes into mental health services provide variable access. Services between primary care and secondary mental health services in each of the localities make these transition points confusing for service users as well as General Practitioners. The research in Stage 1 will establish a baseline to evaluate current responses to mental health assessments across the 3 localities in the Mental Health Directorate over the next 12 months. Stage 2 will examine the impact of the mental health triage model when it is introduced in 2013/14 using cooperative enquiry methodology. Stage 3 will conclude in 2016/17 by applying outcomes and action to the cyclical evaluations. Mental Health Triage was introduced in Australia in 1998 and operates in hospital emergency departments and also as telephone based community mental health triage (Australian Health Ministers, 2006). It is a clinical intervention, assessment and support service that requires trained clinicians, predominantly nursing staff, to perform a number of roles that can and do overlap into face to face clinical practice (Sands 2004). In this context mental health triage can provide an opportunity for assessing suicide risk (Sands 2007) and by shortening the timescale of a normal referral, therefore reducing the period of risk. Mental Health Triage will be based on the model of service currently being used in the State of Victoria, Australia. Three intended learning outcomes: 1. Sharing and implementing practice 2. Managing change 3. Developing innovation References: Australian Health Ministers, 2006. Second National Mental Health plan. Available at http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-pubs-s-plan2. (Accessed 28 July 2012) Sands, N., 2004. Mental Health Triage Nursing: an Australian perspective. Journal of Psychiatric and Mental Health Nursing, 11(2), pp. 150-155

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Thomas, Gemma Gemma.Thomas3@wales.nhs.uk The Impact of Post-Operative Pulmonary Complications on Clinical Outcomes after Adult Cardiac Surgery The development of post-operative pulmonary complications (PPCs) in patients undergoing Cardiopulmonary By-pass (CPB) and its impact on mortality and morbidity has been well recognized. This study sought to identify factors that lead to PPCs in our cardiac surgical population and its impact on clinical outcomes. Methods: A Retrospective Audit Design that reviewed 736 consecutive adult cardiac surgical patients over a 2-year period. Patient profiles were constructed containing data collected for preoperative characteristics and post-operative clinical outcomes including length of stay. Results: 22.6% (n=166) of the study population developed PPCs, which is within range reported in previous studies. Patients who developed PPCs spend on average, 5 days longer on ITU, (5.04 days vs. 0.4 days, p=0.001) and had a post-operative stay of almost 3 times longer (p=0.001). Analysis of the patient characteristics demonstrated LV function to be the single isolated pre-operative characteristic that differs between those who developed PPCs and those who did not. Conclusion: In this cardiac surgical population, the impact of PPCs on clinical outcome is profound and poor left ventricular function was correlated with PPCs. This study opens opportunities for further research into therapeutic strategies to prevent PPCs in cardiac surgical patients with poor left ventricular function. Three intended learning outcomes: 1. To highlight the incidence of PPCs after adult cardiac surgery 2. To promote the transfer of knowledge into the possibility of a relationship between Left Ventricular function and the development of PPCs to facilitate further research into this domain. 3. To promote discussion into preoperative physiotherapy/MDT strategies that could possibly be implemented in the near future. Thomas, Helen Helen.Thomas20@wales.nhs.uk Cardiac ITUs Band 5 Development Program This program allows our candidates to explore the demanding role of coordinator in a busy clinical setting in a supportive atmosphere. It consists of a multiple approach of practical sessions, theoretical sessions with outside expert input, and lastly, a focus group for the mentors and mentees to share their experiences. Initially, they will be paired with an experienced Band 6 mentor and take charge on quieter shifts, as they become more confident and proficient, this is expanded to busier days where the stresses and demands are amplified. While it is anticipated our candidates will be stretched by these demands, they always will have the security of senior help at hand. There is strong emphasis on how the senior staff can foster staff development for all levels of expertise, while delivering a safe, clinically sound service to enhance the patients and relatives journey.

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Time is spent exploring Trust policies and protocols so the candidates have a sound, operational knowledge of how they impact on the day to day running of the service, such as the sickness policy, infection control issues, health and safety and so on. An important element of the course has been the time our senior management have contributed by attending the 6 weekly meetings and sharing their knowledge, on varied subjects including organisational structure and leadership. The scheme in part helps to address the problem of staff succession into a demanding role, and while it is acknowledged not all of the candidates will want to seek a permanent Band 6 role, all will have an insight into the organisation behind the bed area, and the way that they as individuals can affect their patients and colleagues potential. Three intended learning outcomes 1) To demonstrate the positive outcomes for all staff on the unit from running the Band 5 Development Program.

2) To guide team members in their practice and promote the focus of their knowledge and skills acquisition.

3) To acknowledge the positive impact on members of the team not enrolled on program

Thomas, Jane, Hopkins-Jones, Ira & Boyd, Jodie. Ty Waunarlwydd Jane.Thomas@swansea.gov.uk All Together Now The aim of the work in Ty Waunarlwydd care home is to challenge the traditional deficit and task based hotel model of care for people living with dementia and develop an interdependent and reciprocal model of shared living, which builds on the strengths and contributions of people living with dementia. People living with dementia are amongst the most discriminated and misunderstood group of individuals who receive health and social care services. Across the UK, the language of dementia care is all too often one of deficit and loss. For example, the elderly mentally infirm, sufferers, people who are damaged etc. Language like this was abolished in learning disability services many years ago and it is time that dementia services caught up. Research suggests that suffering for people living with dementia is more often a result of the environment they are placed in and the way they are treated, than as a result of the disease itself (Brooker, 2008, Sheard 2007). Furthermore, deficit, task based and risk averse approaches to care provision undermine the independence and well-being of people living with dementia, which can lead to so called challenging behaviour. The aim of the work in Ty Waunarlwydd care home is to challenge the traditional deficit and task based hotel model of care for people living with dementia and develop an interdependent and reciprocal model of shared living, which builds on the strengths and contributions of people living with dementia. The partnership project between ABMU HB and City & County of Swansea commenced in 2010 with a focus on life story work, cognitive functional assessment and an approach to organisational culture

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change using the Senses Framework (Nolan 2006), which suggests that an enriched environments of support can only achieved when older people, carers and staff all achieve a sense of security, continuity, belonging, purpose, achievement and significance. There has been a move away from task based care, towards a greater focus on feelings and emotions. An action learning approach is being taken to training and workforce development. Outcomes This work has had a profound affect on both residents and frontline staff, with a move away from a culture of us and them to one of we. The work has also evidenced that many people living with dementia who present so called challenging behaviour do not require residential nursing care, but rather an environment that supports their emotional well-being, strengths and contributions, whether this be in their own home or within a residential care home setting. References: Brooker, D. (2008): Person Centred Dementia Care: Making Services Better, London, Jessica Kingsley Nolan, M., Brown, J., Davies, S., Nolan, J. and Keady, J. (2006): The Senses Framework: Improving Care for Older People Through a Relationship-Centred Approach, Getting Research into Practice (GRiP) Report No 2, University of Sheffield. Sheard, D. (2007): Being; An Approach to Life and Dementia, London, Alzheimers Society

Weekes, Clare clare.weekes@wales.nhs.uk Assessing the Effect of a 10-Week Intra-dialytic Cycling Programme on Functional Ability and Quality of Life. Chronic Kidney Disease (CKD) is associated with physical inactivity and reduced ability to perform activities of daily living. A recent study has identified the minimum effective volume of physical activity needed to obtain health benefits in this sedentary population (Manfredini et al. 2012). There is ample evidence that exercise can improve fitness; however there is a lack of defined best programmes for (Haemodialysis) HD patients: this represents a barrier to the implementation of exercise to these patients (Johanssen 2008). It is suggested that treatment strategies in CKD could be optimised in patients who are often neglected in clinical trials. A framework for individualising treatment preferences was outlined to promote decision-making in older patients, thus allowing them to prioritise the outcomes that matter to them (Tamura et al. 2012). In response to this it was decided to study the effects of an individualised exercise programme on a single HD patient with a complex medical history. Method: A 76 year old gentleman started intra-dialytic exercise comprising of 15mins cycling 3/week for 10 weeks. PMH: CKD, Gout, Asthma, Hyperlipidaemia, Diabetes, Hypertension, Cardiovascular Disease, Right Total Hip Replacement, Severe degenerative disc disease (L2/L3), Spinal decompression surgery 2006, Osteoarthritis and right arthroplasty of ankles. Results and Discussion: Results, expressed with both subjective and objective outcome measures, showed a decrease in target weight and improvements in the following: number of Sit to Stands in 60 seconds; Dukes Activity Score Index; SF-36 QOL questionnaire and Self-Reported Exercise Tolerance.

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Ultimately whether these results correspond to clinical or scientific research or not, the patient in this study has expressed how this exercise programme has made life-changing differences to him. He quotes: I am now able to stand and make a cup of tea without falling over. This is the outcome that is important to this patient and we have achieved it with a simple low-intensity exercise programme. Three intended learning outcomes 1. A single patient case study can demonstrate how a clinically researched exercise protocol can be delivered to a complex renal patient who would normally be omitted from an exercise programme.

2. To demonstrate the effectiveness of a low intensity exercise programme on both selfreported and objective measures physical functioning and QOL. 3. To show how an individualised exercise programme can be effective in the absence of HDspecific exercise guidelines or recommendations. References: Johanssen K (2008): Exercise and dialysis (Scholarly Review). Haemodialysis International 12:290300. Manfredini F, Mallamaci F, Calizone L, Zoccali C (2012): The burden of physical inactivity in CKD. Nephrol. Dial. Transpl. 27(6): 2143-2145. Tamura MK, Tan JC, OHare AM (2012): Optimising RRT in Older Adults. Kidney International 82(3): 261-269.

Williams, Tracey tracey.williams4@wales.nhs.uk The introduction of knowledge distribution amongst multi-disciplinary members within a clinical environment. Our unit philosophy states, patients are individuals with unique identities and physical, psychological and spiritual needs which are achieved through a holistic care approach to aid recovery and independence or when not possible to ease their pain, prepare them for a peaceful death and help to ease grief. As a unit, it is paramount holistic care is at its highest which is achieved though team motivation and professional development. This highlights the importance shared knowledge amongst multidisciplinary members. The Board of knowledge was introduced in March 2011. The objective was to enhance quality of patient care by developing the management of care to aid recovery through the introduction of protocols, evidence based practice, staff training/education, early referrals and communication. The aim is for nurses and physiotherapists to share and enjoy knowledge, motivate individuals, encourage autonomy, teamwork, innovation, creativity and creation. I believe this concept is one of uniqueness within the Cardiac directorate.

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The success comprises of firstly, a static board displaying anatomy and physiology of the heart and lungs; secondly, nursing knowledge board and thirdly, physiotherapist knowledge board. The boards are generated from an established list of topics or by the team; topics flow from basic care through to more complex issues. The team display their topic for two months whilst the next team prepares theirs, this allows for a rolling programme of professional development and implementation of research. Once presentations have been displayed they are filed into a resource folder. The boards have allowed the multidisciplinary team to learn, share and enjoy knowledge and skills. Professionally, learning needs have been enhanced. The team appears motivated and confident within their practice from the knowledge gained. Collectively, it has enabled the delivery of quality holistic care at the highest of standards to all patients that pass through our doors. Three intended learning outcomes: 1. To guide team members in their practice and introduce what is expected of them. 2. To give focus on what they need to achieve in terms of knowledge and skills. 3. To provide a expected guide of knowledge that they must possess.

END OF BOOK OF ABSTRACTS

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