Leading change

A Staff Nurse at Dragon Square Community Unit, North Staffordshire Combined Healthcare NHS Trust led on improvements to the evidence based approach to service delivery and care for children aged 5 – 18 years. This approach has led to locally improved outcomes, experiences and use of resources by supporting staff to tailor approaches to meet the need of each individual child using the Short Breaks Service.

Where to look

The Department of Education (2012) state that all people who work with children and young people are expected to provide high-quality and safe care for the children they look after, whatever their role. The Dragon Square Community Unit service has very experienced nursing staff to support the children and young people who attend the Short Breaks Service. The NMC Code of Practice contains the professional standards that registered nurses, midwives and nursing associates must uphold within the limits of their competence. A key part of the code is that individuals must assess, deliver and advise on treatment to the best of their abilities, based on the evidence available and best practice. Individuals must make sure that they maintain the knowledge and skills need for safe and effective practice.

The staff nurse reviewed the education and training practice at the service and identified unwarranted variation in the lack of formal update training and continued professional development (CPD) for the nursing staff. The nurse saw the opportunity to lead change through creating a training package, CPD programme and guidance documentation to support staff in gaining confidence, clinically supporting the children and young people more effectively and providing evidence based practice.

What to change

Dragon Square Community Unit is a specialist service for children and young people (aged 5-18 years), with a severe learning disability and additional complex health needs, which require Registered Nursing Care whilst the child is away from home. These needs may include either severe and significant behavioural complexities, which requires therapeutic intervention and cannot be managed in other Short Break settings, or medical/physical conditions requiring regular and frequent nursing interventions. Prior to the change, nursing interventions were undertaken following guidance and demonstration from parents and families who routinely provided this care for their child. Formal training packages were available to staff but were not always undertaken. This unwarranted variation in practice meant there was an opportunity to provide specialist skills training courses as well as offer peer support from nursing staff at the nearby University Hospital of North Midlands NHS Trust (UHM). This would ensure training remained up-to-date, evidenced based and assessed for competence as well as working with parents and families more informally on personalised care for their child.

How to change

The staff nurse led a review of the training requirements working with the Dragon Square Community Unit nursing team, the parents and the specialist nursing teams from UHM. Key areas of training, education and development were highlighted for inclusion in the initial programme of development.

A training provider at UHM was identified. The specialist nursing team at UHM also routinely work with the parents of the children and young people utilising the Short Break Service. Indeed, the children were often seen in both settings. This gave additional continuity of care to local healthcare systems – a wrap-around care provision between the hospital, Short Break Service (Dragon Square Community Unit) and parental care – creating seamless and effective support for the children and young people.

The nursing leads at the Community Unit and UHM developed and agreed a bespoke package of training and peer support. The developed package of training included care such as:

• JEJ (Jejunostomy) and PEG feeding tubes;
• Tracheostomy training;
• BIPAP (Bilevel Positive Airway Pressure) and CPAP (Continuous Positive Airway Pressure);
• Inserting gastronomy devices;

Training was provided to the nursing staff employed within the service. A rolling training schedule and CPD programme has also been developed and integrated into the working year for all the nursing team and a week of specialist updates and training by the nursing staff at UHM is integrated into the service.

The nursing leads have also created of a suite of guidance documents to support and enable staff to refresh and check practice throughout the year and these are widely available within the service. In line with these training developments, the nurse leads have also developed a Standard Operating Procedure to improve physical health interventions for children with a severe learning disability and complex health needs, to enhance the understanding and awareness of care needs amongst staff.

Adding value

Better outcomes – Nursing staff have anecdotally reported they feel more empowered and confident in their skills and abilities when caring for children using the service. To date, approximately 80% of nurses within the service have been fully trained and effectively undertaken all relevant clinical procedures. This figure continues to increase as the roll out of the training continues. Physical health interventions are being delivered in a manner that supports best practice and evidence-based clinical guidance. A reduction in clinical incidents relating directly to the health needs of children who require in-situ feeding tubes has also been noted.

Better experience – Registered Nurse and Support Worker knowledge and awareness of the clinical procedures has increased. This includes recognition across the wider Trust of the specialist nature of the nursing care offered by the Short Breaks Services. Although there has been no direct feedback sought from patients regarding staff education and training, the new approach to care has been positively received by both staff and patients, their families and carers. Families have anecdotally reported they feel confident that nurses are delivering the best care to their children, as the service strives to have the right education and training and enhancing skills, knowledge and understanding.

Better use of resources – Following the programme, the nursing team report they are more confident in dealing with complex situations and know where to seek help if required. Feedback shows that they feel empowered to be more flexible with the medical support they provide to children and young people who use the service. Prior to the change, nursing staff may have supported specific children, guided by their needs, whereas the unit now has a more versatile and empowered nursing team who are able to support any of the children at any stage of their stay. An additional resource benefit has also been that the Short Break Service now works more closely in partnership with the specialist nursing teams at UHM, ensuring a better wrap-around service of evidence-based, high quality nursing practice which is helping to reduce duplication.

Challenges and lessons learnt for implementation

The value of partnership working and sharing good practice is crucial to success, so building local networks and relationships is a must.

It is important to undertake an effective training needs analysis and ensure that the commissioning of the training supports the longer term CPD requirements of the staff.

Finding the time to allow staff to access education, training and development can be challenging. However, it is essential to providing a high quality, safe and effective service.

Invest time in the nursing team to hear their voice, support them to understand the change and the benefits, and invest in asking them what they need.

Find out more

For more information contact:

• Jessica Robinson, Staff Nurse, Dragon Square Community Unit, North Staffordshire Combined Healthcare NHS Trust, jessica.robinson@combined.nhs.uk
• Julie Anne Murray, Deputy Director of Nursing, AHP and Quality, North Staffordshire Combined Healthcare NHS Trust, JulieAnne.Murray@combined.nhs.uk