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1NURSING AND MIDWIFERY VALUES IN PRACTICE CONFERENCE 2017 BURSARY AWARDS

The Office of the Nursing & Midwifery Services Director, HSE is pleased to announce the award of a bursary which will be presented at the Nursing and Midwifery Values in Practice Conference, Tuesday 16th May 2017. This bursary award is intended to recognise nurses and midwives who demonstrate a commitment to promoting the core values that underpin their practice Compassion, Care and Commitment. This booklet showcases the submissions for 2017 Bursary Award.

Office of the Nursing & Midwifery Services Director, HSE Bursary Award

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Office of the Nursing & MidwiferyServices Director

2 NURSING AND MIDWIFERY VALUES IN PRACTICE CONFERENCE 2017 BURSARY AWARDS

Nursing and Midwifery Values in Ireland Bursary Submissions 2017Nur

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Bursary Number Title of the Initiative Organisation Names of Team Members involved in the submission

NMVP1 Development and implementation of an Emergency Department (ED) Nursing Proforma

HSE (Emergency Department University Hospital Limerick

Sarah WatkinsBridget Hoctor

NMV B2 Caring for Staff + Caring for Patients = CBAS-I Midland Regional Hospital, Portlaoise, Co. Laois.

Sandra McGrath & Nicola McGlynn

NMV B3 Development and Implementation of Person-Centred Nursing Documentation

Cork/Kerry Community Healthcare Organisation CHO4

Susan Daly

NMV B4 Development of a “Pop-up” Acute Specialist Eating Disorders Service for the inpatient Management of Really Sick Patients with Anorexia Nervosa in Sligo/Leitrim.

Hse West, Sligo/Leitrim Mental Health Service

Mary Harron

NMV B5 End Pj Paralysis Cork University Hospital, HSE Aileen Horgan

NMV B6 Spread the word not the infection Ireland East Hospital Group and Dublin Mid Leinster Hospital Hospital Group

Grace Kinahan, Julie Cullen, Michelle Bergin, Liz Winters, Claire Dowling & Sarah Roche

NMV B7 The impact of an educational intervention on home support workers ability to detect pressure ulcer damage

Community Health Organisation 8, HSE

Mairead Clarke

NMV B8 Work-based Facilitators of Person-centred Practice – Realising nursing values within the midst of practice.

Galway Clinic Michele Hardiman; Nessa Gillen; Amanda Hastings; Orla Murphy; Maria O’Neill; Karen O’Connell; Marie Connolly; Brita Jordan; Teresa Mulhall; Laura McLoughlin; Louise Barrett; Alice Timlin; Aedemar Hyland; Claire Leese; Aoife Quinn

NMV B9 Realizing nursing values within a bespoke person-centred electronic nursing record. Development and implementation of the Galway Clinic Complete Electronic Nursing Record (GCCENR)

Galway Clinic Winnie O Neill; Michelle Casserly; Teresa Mulhall; Marie Connolly; Michele Hardiman; Sinead Hanley

NMV B10 Mindfulness & Self Compassion for Health Care Staff

Coombe Women & Infants University Hospital

Brid Shine

NMV B11 The development and psychometric evaluation of the Patient Knowledge of Pressure Ulcer Prevention Instrument (KPUP).

Royal College of Surgeons in Ireland & HSE

Emer Shanley, Zena Moore, and Declan Patton

NMV B12 Taking the Fear out of the Transition to Fatherhood

Primary Care Team, Macroom, Co. Cork

Mary O Regan-Hyde

NMV B13 The Introduction of the Growth Assessment Protocol for the first time in an Irish Maternity Unit.

Our Lady of Lourdes Hospital, Drogheda

Gráinne Milne, Mary Rowland, Bernadette Daly, Seosamh O’Coigligh

NMV B14 NMH Neonatal Web Camera System National Maternity Hospital, Holles Street, Dublin 2

Kim Ryan, Denise McGuinness, Dara Keeley, Martin Keane

NMV B15 Caring Behaviours Assurance System –Ireland, The Journey so far

Galway University Hospital, Saolta University Healthcare Group

Olive Gallagher, Jean Kelly, James Geoghegan, Eavan Higgins

NMV B16 Partners in Care: Bringing Compassion, Care and Commitment To Life Within a Shared Decision-Making Framework

Health Service Executive, CHO 8

Yvonne Delaney

NMV B17 Perinatal Hospice Care; A Different Journey. National Maternity Hospital Sarah Cullen, Heather Hughes, Brenda Casey, Barbara Cathcart


Bursary Number Title of the Initiative Organisation Names of Team Members involved in the submission

NMV B18 Quality Initiative to reduce incidences of incorrect placental sampling for cytogenetic testing post pregnancy or perinatal loss

RCSI Hospital Group Fiona Mulligan, Michelle Scanlon

NMV B19 What Matters to You St Vincents University Hospital (SVUH) and Midland Regional Hospital Portlaoise (MRHP)

SVUH: Lisa Murphy, Angela Smyth, Hepsy John, Martina Higgins, Carolyn Donohoe MRHP: Olivia Lafferty, Maura Rice, Geraldine Britton, Lorraine Cuddy

NMV B20 Pathway Granularity and solutions to Barriers to Sepsis diagnosis and treatment on a Surgical Ward

South/Southwest Hospital Group

Sinéad Horgan, Grace Reidy

NMV B21 Development of the first Irish Chapter of Sigma Theta Tau International Honor Society of Nursing and Midwifery.

SIA Honor Society of Nursing and Midwifery Ireland

Dawn Farrell, Nicola Cornally, Alice Coffey, Suzanne Denieffe, Catherine Buckley, Gerardina Harnett, Patrick Cotter, Agnes Walsh, Claire O’Gorman, Lisa Herrity, Ruth Lernihan and Fiona Willis.

NMV B22 Connecting Cardiology services through Advanced Nursing Practice - Nursing Values in Action

Tallaght Hospital & Naas General Hospital

Shirley Ingram, Jacqueline O’Toole, Niamh Kelly

NMV B23 The development of the Advanced Nurse Practitioner (Intellectual Disabilities) Services Galway

John Paul Services Galway, Brothers of Charity

Aoife O’Donohue, Maurice Healy, Ann Loughney, Tony Gallagher

NMV B24 The introducation of the Careful Nursing Philosophy & Professional Practice Model to a number of hospitals in the South/South West Hospital Group as part of a nursing documentation project

South/Southwest Hospital Group

Catherine (Kay) O’Mahony

NMV B25 Development and implementation of Adolescent section “Your Visit to Us”in hospital website

Cork University Hospital, HSE Bebhinn O’Sullivan

NMV B26 Team Sepsis - The Leadership Journey. Learn, Reflect, Apply

Cork University Hospital, HSE Eileen Kelly, Elaine O’Farrell & Claire Costigan

NMV B27 “What Matters to Me” St.Michael’s C Ward, Temple Street Children’s University Hospital, Dublin

Karen Cunningham, Lauren Clarke, Aoife Ryan

NMV B28 Back to Basics National Maternity Hospital Teresa Mc Creery

NMV B29 The Patient Journey – Improving Quality, Safety and Satisfaction.

Our Lady’s Hospital, Navan Agnes Connolly, Merica Dempsey and Caroline Carpenter

NMV B30 Providing holistic person centred care for adult patients with intellectual, physical and sensory disabilities requiring dental treatment under general anaesthetic in MGH

Mallow General Hospital Catherine McCarthy, Denise Kearney

NMV B31 Registered Nurse Prescribers’ (RNPs’) experiences of the benefits and challenges to Nurse Prescribing in Palliative Care, Primary Care in Ireland.

Laois/Offaly Palliative Care Team

Phyllis Howlin

NMV B32 Providing expert care and commitment to nursing in advanced practice- the experience of a nursing team in a five year implementation of the Clinical Care Programme in Epilepsy

Dublin Mid Leinster Epilepsy Service/ St James Hospital

Cara Synnott

Nursing and Midwifery Values in Ireland Bursary Submissions 2017



Bursary AwardsNursing & Midwifery Values in Practice 2017


NMV B1

The ED is a unique environment, an ‘exhilarating chaotic workplace caring for humanity at all levels’ (McClelland 2012, p. 112). It is essential that ED nurses are supported to perform competent care that is underpinned by sound analytical and judgment skills and best evidence. The ED Nursing Proforma:

1.Promotes high quality patient care that integrates the best evidence and places primacy on identifying individual patient needs and vulnerabilities

2.Showcases the contribution of ED nurses to the emergency service and advocates for nurses as critical thinkers who are proactive in seeking the best outcomes for their patients

3.Demonstrates the willingness of ED nurses to embrace change in pursuit of safe, professional care delivery and provision

Why the initiative was carried out In November of 2014 the first author carried out an audit of some 350 samples of emergency nursing documentation. The audit was part of a research project that was looking at the journey of the older person in the ED. The main objective was to highlight processes but also to gather evidence of the contribution of ED nurses in the journey of the older person in the ED. It became apparent very quickly that the system of nursing documentation at that time was unfit for purpose. Nursing documentation in 2014 consisted of stapled sheets of paper. Typically two progress sheets were used to document nursing care and then stapled to a fluid balance and/or observation chart. Such poor quality nursing documentation jeopardised patient safety because there was no coherent account of the patient journey and thus key omissions in critical data. This type of nursing documentation was a sad reflection of emergency nursing practice. Oftentimes there were only six lines written to reflect the nursing care of an older person with multiple care needs who had been in the ED for perhaps 30 to 40 hours. There was no evidence of a comprehensive nursing assessment or whether nurses were applying appropriate knowledge and logical reasoning to promote optimal outcomes for their patients. It appeared that the focus of the documentation at that time was not on promoting the key values that reflect emergency nursing but on completing tasks, documenting for example that a cannula had been inserted or an ECG had been recorded. Unfortunately there was no written account of human interactions, how nurses in the ED went the extra mile or had provided reassurance, comfort and compassion to patients and their families in times of distress. How the initiative was carried out Development of the ED Nursing Proforma took approximately eight months. Most nurses in the ED accepted that there was a need to re-establish professional pride. ED nurses were committed to improving nursing documentation so that it would reflect a work ethic of diligence and attention to detail. However the transition from stapled sheets of paper to a nursing proforma was no easy undertaking. Inevitably there was some apprehension about disrupting the status quo. The key to this project was communicating and engaging with ED nurses on the floor. The first author was keen to get the message across that this was an authentic collaboration, encouraging ED nurses to share insights and experiences to co-create a document that would work in such a challenging environment. Many hours were spent speaking to nurses on a one to one level. Pilot of the nursing proforma commenced in November 2015. This was a dynamic process that involved ED nurses feeding back what wasn’t working, amending the document as per the feedback and rolling out the next revision. The end result is a professional looking document that celebrates the uniqueness of nursing and displays the key skill sets and values of ED nurses. Crucially the proforma identifies the need to strike a balance between the task orientated technical components but also on those aspects of care such as understanding and establishing rapport, that are so vital in an emergency nursing context.

Title of the initiative Development and implementation of an Emergency Department (ED) Nursing Proforma

Names: Sarah Watkins, Bridget Hoctor

Organisation: Emergency Department, University Hospital Limerick


What is the impact for patients and service usersThe ED Nursing Proforma provides a framework that ensures that the nurse remains high-touch in a high-tech environment. In using the proforma, ED nurses are encouraged to prioritise the person’s interest, promote dignity and comfort and provide nursing care that is respectful and responsive. The ED Nursing Proforma pinpoints the critical aspects of patient management and assessment in the post triage phase of the patient journey in the ED. Research suggests that a proportion of patients presenting to the ED (older people with atypical symptoms) are susceptible to deterioration after the point of triage and before they are attended to by the ED doctor. The nursing proforma is a standardised and safe system that decreases the risk of errors in clinical judgement and re-affirms that excellence in ED nursing practice is crucial to maintaining patient safety and wellbeing. The ED Nursing Proforma incorporates the best evidence not only in detecting Sepsis for example but also in planning care that is underpinned by succinct and coherent information exchanges. The implementation of the ED Nursing Proforma will hopefully reassure patients that ED nurses are powerful advocates who know what to do and who to call, who are technically competent, explain procedures and options, are transparent and who carefully assess in order to make precise and appropriate clinical decisions.

What is the impact for nursing and midwifery practice The nursing proforma provides ED nurses with a framework to deliver comprehensive patient assessment. The ED Nursing Proforma:

• Integrates the best evidence• Promotes seamless care transitions• Benchmarks the standard of nursing required • Serves as a guide to new and inexperienced emergency nurses• Showcases the contribution of ED nurses• Facilitates the capture of data that is meaningful to nursing practice and performance

The ED Nursing Proforma has won two prestigious national awards. This has served to raise the profile and status of emergency nurses working in the ED University Hospital Limerick. The first author won the award for best oral presentation at the National Sepsis Summit Dublin Castle in September 2016. The presentation highlighted the impact of the nursing proforma and the skill of ED nurses in rapidly detecting patients with Sepsis. The ED Nursing Proforma has recently won an Irish Healthcare Award in March 2017. This award was presented in a multidisciplinary forum. Such high profile recognition has re-ignited nursing pride and the aspiration to create a culture where core nursing values can flourish.


NMV B2

CBAS-I values staff and patients equally CBAS-I is led by multi-disciplinary staff CBAS-I creates ownership of qualityion

Why the initiative was carried out Our work encompasses the values of caring, compassion and commitment. It is these values that help to provide high quality person centred care that is safe and delivered in a compassionate and kind manner in an environment that meets the needs of our staff and patients. The publication of the National Standards for Safer Better Healthcare (HIQA, 2012) and the Health Service Executive Corporate Plan 2015-2017 (HSE, 2015) have added an increased awareness and profile of the patient safety agenda and this underpins the values of Caring Behaviours Assurance System – Ireland (CBAS-I). CBAS-I is designed to include a multi-disciplinary team to explore our perceptions and our approach to patient safety & satisfaction and staff awareness of their work environment and the patients in our hospital. CBAS-I was introduced in the Saolta University Healthcare Group & was a resounding success with very positive evaluation. Our Director of Nursing, Ms Angela Dunne, encouraged us to participate in this initiative in Midland Regional Hospital, Portlaoise. We aimed to introduce & implement a system to assure patients and staff that the care experience in our hospital is safe and of high quality. “CBAS-I enables healthcare teams to have the confidence in the care and compassion they provide to patients, made possible by the tools and techniques of the programme” We wanted to be able to measure this & to celebrate our quality initiatives and valued care practices. We hoped to have an objective view on the areas that were not so positive and needed to be improved. We felt that CBAS-I would be an excellent method of highlighting areas of excellence in care & compassion and would assist us with areas for improvement. We felt that it would provide a boost for staff to show that they are valued and appreciated. How the initiative was carried out Information sessions about CBAS-I were delivered in the hospital in Feb 2016 and were very well attended by all groups of staff. Following on from this, 4 areas of the hospital were selected to complete a cycle of CBAS-I in their wards/departments.

• Theatres• Surgical/ICU• Paediatrics• Maternity

Each team consisted of 5 members of multi-disciplinary staff who volunteered to work as Quality Champions (QC). All staff attended a 3 day implementation programme to ensure that all staff had the required skills to complete a CBAS-I cycle in their own areas. During this programme, each area completed a quality framework assessment document to select items that were important to their team. They completed a CBAS-I cycle in their areas using the following techniques - observations, interviews and assessments in their areas and used the following CBAS-I formats of assessment: Caring Walk, Practice Observation, Patient Family Interview, Manager Conversation, Paperwork, Other (Staff Interview). All teams presented back to their Hospital Management Team on the last day of the programme.

Title of the initiative Caring for Staff + Caring for Patients = CBAS-I

Names: Sandra McGrath & Nicola McGlynn

Organisation: Midland Regional Hospital, Portlaoise, Co. Laois


What is the impact for patients and service usersWhen a patient is in hospital, both they and their families are in an unfamiliar and strange environment. Everything and everyone is different to their norm. CBAS-I helped to open the QC’s eyes to how the patient and service users react to the hospital environment. One exercise we completed was to go from the front door of the hospital to the ward in a wheelchair. This was very enlightening & helped us to appreciate the patient’s journey. Our patient conversations detailed the wonderful work that is carried out in our hospital. Patients all commented on how friendly our hospital is and how all staff are extremely kind and helpful. We asked them specific questions about their hospital stay relating to several areas including access, comfort, nutrition and communication. Our first cycle of CBAS-I helped identify the following • Difficulty in opening a set of double doors. • Interruptions during meal times• Absence of signs to various locations around the hospital• Uncomfortable fold-out beds for parents/carers• Unfamiliarity of who is their named Nurse or Doctor

Patients now can easily identify different staff types as their uniforms have been changed and nurses identify themselves to their patients at each shift change. Patients can now enjoy protected meal times as no visitors or ward rounds are permitted during meal times. It is quieter and focused on the nutritional needs of the patient.Signage has improved across the hospital, including coloured lines to different parts of the hospital and picture signs on toilets.New fold-out beds were purchased for parents & carers in the Paediatric Ward.An automatic door was installed and is much easier to enter or exit.

We found that patients and service users enjoy having the opportunity to give feedback and we endeavour to continue this communication cycle.

What is the impact for nursing and midwifery practice The staff wanted to view their department with ‘fresh eyes’. We saw and heard things about our wards that we had not noticed at all. The most positive finding was to re-enact the patient journey to see how some little things could make a big difference e.g accessibility, signage, and easily identifiable staff. The programme has given nursing & midwifery staff the empowerment and motivation to make small changes to their wards so that it is a happier place to work. We found that CBAS-I addresses Caring for Staff AND Caring for Patients in equal measure. As our staff are looked after, they are more content & confident in their work to provide kind, considerate & compassionate care to our patients and to each other.Our teams have demonstrated huge improvements to the quality of care provided in their wards and a happier environment to work in. CBAS-I has given us a tool to highlight that every member of staff is appreciated, valued and important. When staff are happy, they have a positive, caring and compassionate outlook and this is reciprocated by our patients positive feedback.


NMV B3

Commitment to promoting individualised person-centred care

Encouraging compassionate collaboration with each resident

Providing testament to the person-centred care being delivered

Why the initiative was carried out Irvine et al. (2006) assert structured documentation can improve resident care by limiting vague narrative style entries. Nevertheless, in practice the personal and individual aspects of care can only be recorded through a person-centred approach to care planning (Broderick & Coffey 2012, Butterworth 2012, Prideaux 2011). Nurses are therefore challenged to balance the factual, non-speculative principles of good record keeping with a person-centred approach to writing that acknowledges the residents perspective (Butterworth 2012).

The Cork/ Kerry Community Healthcare Organisation undertook a planned, gradual and inclusive process of change as a step towards providing testament to the compassionate and person-centred care being delivered. The process of change involved the redesign of structured nursing documentation into a nursing care record that promoted and facilitated the creation of individualised contemporaneous person-centred care plans. How the initiative was carried out The Lewins (1951) force –field analysis change model has been uti¬lised to support successful change.

Step 1: Unfreezing (2016)

• Stakeholders are made aware of the need to change (Nurses, Clinical Nurse Managers, Directors of Nursing and Area Manager)• Project team created to steer the change process• New document designed • Consultation with multi-disciplinary team• External review • 6 month trial commenced

Step 2: Moving (2016/ 2017)

• Supporting projects initiated• Collaborative consultative process with stakeholders • Internal and external education for nurses on the art of writing individualised person-centred care plans • Resource folder of sample care plans created• Laminated pocket guide on the working mechanism of the new document created for easy reference• Feedback report following completion of trial • Final edits directed by feedback report• Completion and rollout of supporting projects • Phased introduction of new document across all sites

Title of the initiative Development and Implementation of Person-Centred Nursing Documentation

Names: Susan Daly

Organisation: Cork/Kerry Community Healthcare Organisation CHO4


Step 3: Refreezing (2017/ 2018) • Reinforcing and integrating the change effective communication continuing care planning education• Sustained audit & review effectiveness of the new documentation in showcasing nurses core values of compassion, care and commitment through person-centred care plans • Residents satisfaction with the document• Stakeholders satisfaction with the documen What is the impact for patients and service usersThe comprehensive biopsychosocial assessment uses validated evidenced based tools that are essential in gathering, validating and analysing each resident’s health status (Okaisu et al. 2014). The assessment process seeks the residents’ perspective and promotes consultation with the resident (and / or a member of the residents’ family). The assessment process directly influences the nursing care plan developed, thus this new person-centred approach accentuates ability focused care rather than disability focused care. In addition, the assessment and care planning process outlines the residents’ perspective and preference rather than the nurses’ perspective or the organisations preference. Ultimately the care record promotes each residents personhood, irrespective of clinical diagnosis, which in turn promotes commitment, compassion and care.

“The new documentation is giving us an opportunity to put down how well we know our residents. I’ve learnt a lot about our residents reading other nurses care plans”. (Direct Quote by RGN taken from 6 month satisfaction survey in trial site)

What is the impact for nursing and midwifery practice The new person centred approach to assessment and care planning increased visibility of nursing values through quality documentation (Pearson 2003). Okaisu et al. (2014) highlight that nurses attitudes and perceptions towards documentation impact the quality of what and how they document. Education alone is insufficient to change practice; the cultural component of documentation practice must be addressed to achieve observable change. The change process therefore aimed to empower nurses, enhance nurses’ confidence and inspire a shared vision. Meaningful recognition of individual nurses’ engagement in and contribution to the change process, promoted authentic leadership and a healthy work environment. As a result, the commitment, compassion and care being delivered to residents throughout the organisation was reflected in each residents person-centred care plan.


NMV B4

Practice development is key to reaffirming the core values of compassion, care and commitment.

Compassion Vision for Change (2006) identified that accessing specialist mental health beds for the treatment of adults with eating disorders in Ireland has been historically difficult. It is widely acknowledged that little has changed for the cohort of patients since its publication. Many psychiatric services and or hospitals can refuse referrals based on arbitrary exclusion criteria that categorise body mass index as being too low to provide assessment, treatment and or care. The MARSIPAN Research has shown that many of those with the poorest outcomes present with severe Anorexia Nervosa to acute hospital beds with low Body Mass Index (<15 high risk, < 13 very high risk). In response to the needs of patients locally and in line with the recommendations of A Vision for Change (2006) existing staff with skills and experience from inpatient services in Sligo University Hospital and the local Adult CMHT were identified and training including MARSIPAN (Management of Really Sick Patients with Anorexia Nervosa) was undertaken. All team members who trained in MARSIPAN had experience of eating disorders – this may not be the case in all centres. Our goal was to provide a seamless service for individuals who present with eating disorders across the entire spectrum of severity, including those who present acutely in a high risk or life threatening way. Prioritising the interests of individuals is essential to provide compassionate nursing care, promoting dignity and comfort and responding anxiety and distress of individuals and their families.

CareSligo/Leitrim/West Cavan and South Donegal Adult Mental Health Service serves a population area of 107,659. It is comprised of a number of multidisciplinary teams working together collaboratively to provide evidence based care in both community and inpatient settings. It is a good example of how existing staff can work collaboratively to provide evidence based care and treatment locally to adults with complex eating disorders. This is a rural based service providing care across a large geographical area. The team was built from within existing staff from hospital, community and mental health settings but working in an integrated way to deliver evidenced based treatment. Audit indicates that the outcomes for eating disorders patients, carers and families have improved. Ensuring access to evidence based-approaches to care, advocating on behalf of the patient, being technically competent and providing quality and safe care are key elements of this project and are likewise emphasised as core values that enshrine and underpin core competencies and nursing and midwifery values that will contribute to enhance practice and provide safe, competent and quality patient care.

CommitmentDeveloping self as a reflective learner, being open to engaging in change and displaying professional courage are likewise highlighted in this project. To our knowledge, this project is the first of its kind in Ireland to adopt the MARSIPAN guidelines in the setting up of a “Pop-up SEDU” team. It is tailored to the nature of such presentations which are infrequent but extremely challenging and high-risk. It has been the experience of the project team that the knowledge of its existence and the successes we have had to date have transmitted a confidence and reassurance to all staff, particularly those working in the acute medical wards, emergency department, primary care and in mental health services. Referral pathways, treatment protocols, reflective practice, continuous professional development, education of healthcare staff and the public are established and ongoing. This is a “real world” response to a recognised need and gap in services which can be effectively addressed by dedication, organisation and training. The nature of the project is that the Pop-up team can be activated immediately once the need arises, even if there is a gap in time since the last patient needing the service.

Why the initiative was carried out Prior to development of the Sligo/Leitrim specialist eating disorders service in 2011, patients with a diagnosis of eating disorders were treated by several different healthcare professionals with varying degrees of knowledge, expertise and experience. There were no specific guidelines, policy or procedure as to multidisciplinary assessment, communication, treatment planning, coordination of roles, follow-up ect. As part of the overall strategic development of the Eating Disorders Service we undertook to address this problem. In 2011 a specialist nursing post was developed to provide individualised assessment, treatment and therapy utilising CBT-E (Enhanced Cognitive Behavioural Therapy for Individuals with Eating Disorders). However, in 2014 a

Title of the initiative Development of a “Pop-up” Acute Specialist Eating Disorders Service for the inpatient Management of Really Sick Patients with Anorexia Nervosa in Sligo/Leitrim

Names: Mary Harron

Organisation: Hse West, Sligo/Leitrim Mental Health Service


service review identified gaps in service provision for individuals with a diagnosis of eating disorders who were acutely ill with low body weight. Policies, procedures, protocol and guidelines were in place for individuals presenting with mild and moderate eating disorders. Those patients who were acutely unwell were excluded from service provision locally and were transferred to inpatient units in Dublin or the UK. The MARSIPAN project was developed to address these deficits.

A local service evaluation and simultaneous review of new evidence including guidelines from the National Institute of Clinical Excellence (NICE) (2014) and the Royal College of Pathologists, Royal College of Surgeons & Royal College of Psychiatrists (2004) concerning the Management of Really Sick Patients with Anorexia Nervosa (MARSIPAN) (2004) indicated a widespread disparity of skills, knowledge and training locally in the management of this cohort of patients. The National Council for the Professional Development of Nurses and Midwives (2004) identified deficits in professional development can impact negatively on patient care, service provision. Furthermore, these shortfalls can also lead to increased levels of staff stress and poor morale within the healthcare environment.

How the initiative was carried out A literature review revealed the best practice model was the MARSIPAN (RCPsych College Report CR189) guidelines as develop in the UK. A team travelled to Antrim in 2014 to train directly with Dr. Paul Robinson, initiator of the MARSIPAN project. The team decided to adopt the key principles of MARSIPAN and developed a protocol for use in Sligo University Hospital and Sligo/Leitrim Mental Health Service Settings and Primary Care when such patients present.

Members of the multi-disciplinary Eating Disorder team are notified as soon as a patient with anorexia is referred or admitted. A “Pop-Up Team”, made up of a Consultant Physician, Consultant Psychiatrist, Eating Disorders Practitioner and Senior Dietician work collaboratively with the patient and family members, nursing and care staff, whilst the patient is in the hospital. Patients are admitted to a medical observation ward with staff who have developed expertise in managing acute presentations of eating disorders. The team adheres closely to the principles of the MARSIPAN guidelines, including multidisciplinary team working devising and treatment planning designed to minimise risk and improve outcomes for patients. Discharge planning is detailed with aims which emphasis providing continuity of care when the patient moves from the inpatient to outpatient settings. What is the impact for patients and service usersThe aims and goals of the project were patient focused:

• To develop a planned approach to the care and management of individuals with eating disorders• Outlining a defined communication and referral pathway• Using international best practice guidelines• Acknowledging the absence of a local Specialist Eating Disorders Unit (SEDU) but recognising the many advantages to treating patients locally rather than referring to specialist services in Dublin.• Systematically identifying and managing potential complications from the outset.• Avoiding refeeding and underfeeding syndromes• Closer involvement of families and carers of those affected and the development of a structured support network through collaboration with Bodywhys. • Upskilling all healthcare professionals in dealing with this condition.• Education of students from all professions.• Increasing awareness of the project within the healthcare system and among the public, through a series of educational meetings and lectures.

The team recognised the need for education and support for families of patients with Eating Disorders. Discussions were held with the Chief Executive of Bodywhys, and 6 week (later shortened to 4 week) structured support programme of educational workshops for carers called “PiLaR: Peer Led Resilience” was developed with funding obtained from a GENIO grant.Feedback from patients and carers has been positive they have highlighted the patient centred aspects of choice of care and local service provision.

What is the impact for nursing and midwifery practice This project has enabled existing staff across services to work collaboratively to provide evidence based care and treatment locally to adults with complex eating disorders. This is a rural based service providing care across a large geographical area. The team was built from within existing staff from hospital, community and mental health settings but working in an integrated way to deliver evidenced based treatment. Feedback from staff working in acute medical wards, primary and community care settings and emergency services has been positive. Staff have expressed that multidisciplinary training and teamwork has conveyed confidence and support.

To our knowledge, this project was the first of its kind in Ireland to adopt the MARSIPAN guidelines in a rural setting in Ireland. The “Pop-up specialist.eating disorders team was developed by utilising and developing the skills and knowledge of existing staff to provide evidence based patient centred care. Staff from Sligo/Leitrim have been working with The National Clinical Programme for Ireland and the Office of Nursing and Midwifery Development as members of the advisory groups working to produce eating disorders nursing practice guidelines and a model of care for Ireland. Ongoing training for staff locally and nationally is provided by team members.


NMV B5

End PJ Paralysis is a simple change in hospital culture and attitude to care which involves helping people to stay independent, maximising wellbeing and improving health outcomesThe key points include:

• Care: Patient Centered: Promoting patients to maintain a normal routine by getting up out of bed, getting dressed in their own clothes and mobilising where possible, thus preventing decondition of muscles. • Compassion - Giving me your time: Promotes Independence by supporting patients to self-care. This may take a little more time but there are huge benefits for the patient.

• Commitment to Quality: Delivers Quality care as it is a person centered approach and values patient time.

Why the initiative was carried out “Teach us to live that we may dread unnecessary time in bed. Get people up and we may save our patients from an early grave” (Asher, 1947).Although enabled out of compassion and kindness, being in bed when not clinically necessary is bad for patients and being in pyjamas reinforces the ‘sick role’ that, leads to unintentional harm. Hospitalization can often be a devastating event for elderly patients. Elderly people frequently incur major functional setbacks resulting from inpatient treatment and immobilisation. Enforced bed rest and immobilisation can have considerable effects on nearly every system in the body, these effects are likely to be more pronounced in an elderly person with illness.

For people over the age of 80 ten days in bed ages muscles by 10 years. One week of bed rest results in 10% muscle loss. Loss of strength could make the difference between dependence and independence. It is of key importance to prevent excess loss of strength and to begin rehabilitation as soon as possible.

The ‘End PJ paralysis’ initiative highlights the fact that most patients are at a risk of deconditioning. If patients stay in their pyjamas or gowns for longer than they need to, they have a higher risk of infection, loss of mobility, fitness and strength and will ultimately stay in hospital longer. If we can help patients get back to their normal routine as quickly as possible this will mean a quicker recovery. End PJ Paralysis raises the awareness of the effects of bed rest amounts staff, patients and family. It aims to encourage all of us to take the lead in ending PJ paralysis in a safe and timely manner-to get up, get dressed and mobilise. How the initiative was carried out An idea that is starting to go viral on social media-#endpjparalysis. The initiative focuses on encouraging patients in hospital, where possible, to stop wearing their pyjamas or hospital gown when they don’t need to. The Director of Nursing in Cork University Hospital (CUH) embraced this ethos and promoted the nurse led project in CUH. The initiative was initially piloted in four wards in CUH, promoting a multidisciplinary approach. Cork University Hospital is the first hospital In Ireland to implement this initiative.

Title of the initiative End Pj Paralysis

Names: Aileen Horgan

Organisation: Cork University Hospital, Cork


Baseline measurements were taken on:

• Percentage of patients in pajamas/hospital gowns. • Average length of stay on each ward in 2016• Number of falls on each ward.

Each measurement is taken as a focus point for staff to encourage improvement. Educating relatives and carers is important to ensure they encourage their relative or friend to get dressed and move about. Poster and information cards are placed on wards (see attached) and a walking programme was commenced on the Transitional Care Unit, encouraging patients to reach their goals to sustain or improve their mobility. What is the impact for patients and service usersWearing pyjamas reinforces the ‘sick role’ and can prevent a speedier recovery. Enabling patients to get into their own clothes leads to enhanced mental wellbeing as they are encouraged to take greater responsibility for their own health and become active participants in their personal health journey.

Enabling patients to get into their own clothes enhances patient safety. It improves reports of patient satisfaction. The likely measures of success include more timely discharges and reduced length of stay.

What is the impact for nursing and midwifery practice While staff time is busy and important, patients’ time is scared and this culture of valuing patient’s time is a change in the culture of a very busy hospital. However more staff including all members of the MDT is accepting this change which clearly improves patient outcomes. Posters have helped with the implementation of this new priority.

In one ward - the Transitional Care Unit, staff were very proud that two patients who were awaiting placements in long term care, were discharged to their own homes as a result of End PJ Paralysis. Helping the patient get up, get dressed and get mobilising ensured these positive patient outcomes.


NMV B6

1- Caring involves prompt recognition of a patient with a healthcare associated infection in order to treat the patient and protect other patients, healthcare workers and other service users.

2- Commitment requires staff nurses to provide evidence based care that can be valued by the patient.

3- Compassion uses effective communication skills in order to care for the patient and treat the infection.

Why the initiative was carried out The decision to transfer a patient to another ward, for a procedure or to another hospital is made after an assessment of the potential risks and benefits to the patient. However it is evident from the research that the hectic hospital environment can make effective communication difficult. It is important that all healthcare staff be cognisant, clear and concise about what pieces of vital patient information can be compartmentalised, and what pieces should be prioritised. Highlighting that verbal communication of a patient’s welfare can be criticised and open to misinterpretation. Therefore an Infection Prevention and Control single communication strategy document would be particularly important in helping reduce healthcare-associated infections (HCAI) and improving patient safety. Globally, the most frequent adverse events in healthcare delivery are healthcare associated infections. In addition to this it has been recognised that an estimated 80 % of serious medical errors involve miscommunication between caregivers when patients are transferred or handed over. Similarly the research has recognised that despite the focus on quality care services we are falling short of some very basic standards such as the appropriate identification and placement of a patient with a HCAI. The prevention of healthcare associated infections decreases mortality, lengths of stay, the need for antimicrobial therapy, and surgical and other invasive interventions. Healthcare staff must identify that their astute clinical decisions must not be sub standard. Nursing care must remain, caring, compassionate and committed. The very root of nursing professionalism, decision making skills and evidence based practice can be made visible though the implementation of infection prevention and control programmes. In our current fiscal environment structured Infection Prevention and control programmes have repeatedly been shown to be effective. Driving high standards of infection prevention and control is crucial to improving the safety and quality of patient care. It is therefore essential to have a structured system in place that will address the evolving challenges of reducing and controlling healthcare associated infection. How the initiative was carried out As errors are caused by system or process failures, it is important to adopt various process-improvement techniques to identify inefficiencies, ineffective care, and preventable errors to then influence changes associated with systems. The primary function of the initiative was to develop a structure method of communicating that a patient had a healthcare associated infection. This tool was created in order to alert each ward, hospital and long term care home that a patient had a healthcare associated infection in order to provide the appropriate treatment for the patient , protect the other patients and protect each member of staff. A survey that compromised of 21 questions was developed with the input from six Infection Prevention and Control nurse specialists involving three hospital sites. Across the three hospital sites it was recognised that there are broad variations in how each hospital communicates that a patient has a healthcare associated infection. A patient transfer sticker was then developed with the aid of practice development. This sticker is at its infancy stage. All infection prevention control education sessions were updated to reflect this change. All cnm2 were advised about the sticker and all healthcare staff invited to attend updated education sessions. The research has also recognised that change can be slow but with effective change management and leaders in healthcare this single document can be rolled out nationally. The Infection control team are also going to show case the initiative at the yearly Infection Prevention and Control Ireland conference that is to held in May 2017.

Title of the initiative Spread the word not the infection

Names: Grace Kinahan, Julie Cullen, Michelle Bergin, Liz Winters, Claire Dowling & Sarah Roche

Organisation: Ireland East Hospital Group and Dublin Mid Leinster Hospital Hospital Group


What is the impact for patients and service usersIn order to address healthcare associated infections and improve the transfer process for patients and service users the impact of infection prevention and control processes for patient and service users must be addressed. Infection prevention and control in acute facilities has always had a righteous history alongside the values of nursing care. This can be echoed in Florence Nightingales words “the first requirement in a hospital is to do no harm”. These words are as relevant today as in the 19th Century. Patients with healthcare associated infections need appropriate identification of the infection and suitable placement in order to protect the patient, staff and other service users. The aim of this research is to improve the care that patients receive and empower healthcare staff with the information and tools to improve patient placement. Thus enabling healthcare staff to care for the patient and treat the infection. The impact on the service users themselves was equally important. The research identified that 100% of clinical nurse managers identified that their care is being delivered with care and compassion. Focusing on the patient care that was committed was a fundamental aspect of this research. This was made evident by staff involvement in the survey. Staff identified that they had more direct time with patients. Current plans for evaluation of this research include completing a patient survey or patient interviews in order to identify if service users felt that their hospital experience was improved for them.

What is the impact for nursing and midwifery practice Assessing clinical nurse managers role in appropriate identification and placement of patients with healthcare associated infections, with the goal of improving the quality and outcomes of care, presented many challenges. Infection prevention and control nurses must ensure that they are competent in addressing the challenges they face and are equipped to develop infection prevention and control (IPC) services that will have a positive outcome for patients. As healthcare is delivered in a dynamic environment with frequent changes in populations, methods, equipment and settings the patient may be left disillusioned with the healthcare process. Therefore improving the actual communication process of infection control may lead to better compliance with precautions for service users and thus reduce the frequency of the transition of healthcare associated infections. The evidence based care is necessary in order to provide valued care to the patient that can be measured. In parallel with the advances in healthcare technology the increasing awareness of the gap between healthcare delivery and the use of health care technology became evident. It was also evident that senior managers needed to understand the impact of high level decisions on certain work processes such as the transferring of patients to unsuitable wards and at off peak hours. If patients are not receiving all the evidence-based care that is indicated, then clinical nurse managers have a professional obligation to demonstrate leadership to develop the methods to improve that care. The challenge is how to develop and sustain the change necessary to translate infection prevention knowledge into everyday clinical practice and continue to provide care that is committed and compassionate.


NMV B7

Title of the initiative The impact of an educational intervention on home support workers’ ability to detect pressure ulcer damage

Names: Mairead Clarke

Organisation: Community Health Organisation 8, HSE

1. Care: Providing quality and safe care This study provides a unique exploration of Home Support Workers (HSW) knowledge relating to competence in completing skin assessment. This study has shown that currently HSWs ability to complete skin assessment is inadequate. These findings have indicated that presently HSWs are being sent into homes with inadequate or no training, and that currently there is minimal supervision to monitor if current practices for care delivery are safe. 2. Compassion :Being non-judgmentalThe finding of low health literacy adds a layer of complexity to the task of achieving educational attainment for this workforce and thus requires further research. Therefore, the educators involved in health and social care education, need to adapt to the growing needs of the HSW in terms of how and what they learn and what they need to know. However, low health literacy can prevent HSWs from obtaining vital information needed to prevent harmful ritualistic practices.

3. Commitment :Working within his/her scope of practiceThe inconsistencies in visual skin assessment have been outlined in the research and in this study. This means that nurses should be mindful when delegating this care provision to HSWs, as these staffs’ skill levels might not be adequate to meet patients’ needs. As professionals, nurses are accountable for the delegation of care delivery to HSWs’. Nurses should be mindful when delegating this care provision, as HSW skill levels might not be adequate to meet patient needs.

Why the initiative was carried out The pressure on community nursing in Ireland has increased due to the economic downturn; demographic changes; an ageing population with multifaceted needs; and swifter discharges with enhanced and intense packages of care being put in place². However, the resources and systems necessary to implement this increased workload have not kept pace. Nonetheless, pressure ulcers are prevalent in primary care, and therefore it is essential that clinicians are prepared for this increase in demand on the clinical aspect of nursing³.

Skin assessment is an essential component in pressure ulcer prevention, however, there is evidence to suggest that patients may not always receive the correct level of care to maintain their skin integrity⁴. Home Support Workers (HSWs) are directly involved in patient care, and they have a pivotal role to play in skin assessment⁵. All health care workers require education to fulfil this role. Yet, despite their regular involvement in supporting registered nurses in pressure ulcer prevention, little research to date has considered HSWs’ educational needs if they are to be enabled to competently complete a comprehensive skin assessment.

Undeniably, the evolution of the HSW role in the 21st century has been guided by changes in healthcare delivery, fiscal limitations and attrition of the qualified nurse workforce⁶. In reality, inconsistency surrounds their job title, role boundary, recruitment procedures, professional development and degree of training. It is evident from the research that if unaddressed, it will affect patient safety⁷. Indeed, to liberate this care role to provide greater healthcare, increased investigation, analysis and planning are critical. Yet, currently within the literature very little attention is being focused on their role in pressure ulcer management.


How the initiative was carried out A repeated measure design was employed to quantify the effectiveness of an educational intervention, consisting of one pre-test and two post-tests. This was followed by a workshop, tasked with reflecting on the educational intervention. To capture participant issues following the educational intervention, words used by them were recorded, as they represented the terms and language used to articulate their main concerns and affirmations.

Education was provided to Home Support Workers and this was followed by an assessment of their ability to correctly classify 20 photographs detailing varying stages of skin damage severity. Permission to use the PUCLAS e-learning tool was granted by Professor Dimitri Beeckman. At the baseline (pre-education), 58% of the photographs were classified correctly. The post-test 1 results were lower, with 55% of the photographs being classified correctly. In post-test 2 findings, results increased to 58%, achieving the original baseline scores. There was a moderate negative relationship between pre-training and post-test 2 scores (r=-.44; n=27; p=0.02).

What is the impact for patients and service usersThe educational intervention has been shown not to have a statistically significant positive effect on Home Support Workers’ ability to detect early pressure ulcer damage. The moderate negative relationship between pre-training and post-test 2 scores can be principally explained by low health literacy among the participants. The workshop group findings exposed educational issues relating to participant ability to understand theoretical health concepts. These difficulties were fundamentally linked to low health literacy among the participants.

Presently, in the community setting, visual skin assessment remains a key trigger for the initiation of preventative measures⁴. The inconsistencies are a worry for nurses working in the community and create risk for the delivery of effective strategies which involve the delegation of care. As professionals, nurses are accountable for delegation of care delivery to HSWs¹. Delegation requires experienced clinical judgement. Such delegation must never compromise the patient’s safety and must always serve the patient’s best interest. Therefore, it is imperative that the Registered Nurse is involved in some way in the training and assessment of HSW competencies.

Currently there is a wide variation in educational standards and knowledge attainment. Worryingly, throughout the literature, educational intervention and training is firmly placed within a ‘one size fits all’ approach. This questions the value that organisations place on HSWs and shines a spotlight on the lack of shared learning at a local level. The HSW role is currently placed within social care⁸. An integrated rather than fragmented service is urgently required, one that allows the patient to have a continuum of care delivered by a professional, competent and confident workforce⁹. Therefore, this study recommends ensuring that the HSW education programmes are fit for purpose, and that those completing programmes are fit to practice, with clearly defined roles. For HSWs, the topic of career progression and remuneration to match any accreditation also needs to be addressed. Regulation of this element of the workforce has been mooted, this would also help to support better practice.

References 1. Nursing and Midwifery Board of Ireland (2014). Code of Professional Conduct and Ethics for Registered Nurses and Registered Midwives. Nursing and Midwifery Board of Ireland, Dublin.2. Pye, V (2015). Reshaping Public Health Nursing in the Republic of Ireland. British Journal Of Community Nursing. 20, 7, p. 348.3. Skerritt, L, & Moore, Z (2014). The prevalence, aetiology and management of wounds in a community care area in Ireland. British Journal Of Community Nursing. 19, Sup3, pp. S11-7 1p.4. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel & Pan Pacific Pressure Injury Alliance (2014) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.) Perth, Australia.5. Samuriwo, R (2010). The impact of nurses’ values on the prevention of pressure ulcers. British Journal Of Nursing.19, 15, pp. S4-S14.6. Kyle, G, McLoughlin, R, Browne, V, & Greene, C (2015). Developing and validating a national education programme for healthcare assistants in Ireland: a collaborative project. British Journal Of Healthcare Assistants. 9, 6, pp. 288-294 7p.7. Swedberg, L, Chiriac, E, TÖRnkvist, L, & Hylander, I (2013). From risky to safer home care: health care assistants striving to overcome a lack of training, supervision, and support. International Journal Of Qualitative Studies On Health & Well-Being. 8, pp. 1-11 11p.8. Health Service Executive (2014). Annual Report and Financial Statements 2014. Health Service Executive. Dublin.9. Department of Health (2016) Interim Report and Recommendations by the Taskforce on Staffing and Skill Mix for Nursing on a Framework for Safe Nurse Staffing and Skill Mix in General and Specialist Medical and Surgical Care Settings in Adult Hospitals in Ireland. Dublin. Stationary Office.


NMV B8

a. Development of novice work-based facilitators of person-centred practice using Critical Allies and Critical Friends Framework (Hardiman 2016).

b. Establishment of Community of Practice who meet weekly for 30 mins to ensure continuous participatory process.

c. Driven and enabled by nursing values coming to life in practice.

Why the initiative was carried out In 2014 the Nursing team in the Galway Clinic set a new vision for nursing through the development of person-centred cultures. The enablement of person-centred cultures is supported by the realisation of nursing values of compassion, person-centred care and commitment in every day practice. Realising our vision requires focused development of staff who delivers care in our hospital.

The Work-based Facilitators initiative (WBF) follows and builds on existing research conducted as part of a doctoral study in the hospital and uses a framework to develop the facilitation skills of nurses within the workplace (Hardiman 2016). The WBF initiative commenced in September 2016 with the first in a series of facilitated workshops to explore values and beliefs of the nursing staff wishing to become facilitators of others.Aims and Objectives

• Develop work-based facilitators of person-centred practice through the enhancement of facilitation skills to enable team working and staff well-being.

• Explore values and beliefs of nurses within the workplace, agree a shared purpose and develop action plans through shared decision making.

• Sustain and support values project through a Community of Practice

• Examine what is happening in practice, collaborate and listen to patients and their families and identify gaps between what we say and what we do.

• Commit to learning in and from practice

• Celebrate success and continue momentum

How the initiative was carried out The initiative further builds on existing Person-centred programmes within the Clinic. The programme commenced with a facilitated workshop to explore values and beliefs and vision for care and for the workplace. Work-based Facilitators were provided with resources and practical skills for novice facilitators of person-centred learning. The new work-based facilitators were then in turn brought back to the workplace using the Claims Concerns and Issues (Guba and Lincon, 1989) exercise encouraging all staff to participate in evaluating their workplace. This informed action plans for each individual area. The action plans are shared, discussed and progressed at a weekly Community of Practice huddle which starts and stops on time to demonstrate how facilitation of person-centred practice can be achieve in a short space of time. Workshops are organised to augment weekly community huddles every 10 weeks with guest co-facilitators attending from other areas. This provides an opportunity to work with nurses from other areas and countries and discusses shared values relating to nursing practice.

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Title of the initiative Work-based Facilitators of Person-centred Practice – Realising nursing values within the midst of practice

Names: Michele Hardiman; Nessa Gillen; Amanda Hastings; Orla Murphy; Maria O’Neill; Karen O’Connell; Marie Connolly; Brita Jordan; Teresa Mulhall; Laura McLoughlin; Louise Barrett; Alice Timlin; Aedemar Hyland; Claire Leese; Aoife Quinn

Organisation: Ireland East Hospital Group and Dublin Mid Leinster Hospital Hospital Group


What is the impact for patients and service usersThe development of person-centred cultures requires focused facilitated actions. Novice facilitators can be developed within the workplace to achieve this goal if supported to do so (Hardiman and Dewing 2014). Since commencing the programme greater awareness of unique and individual needs of patients and their families have been incorporated into everyday engagement. Focus on the four outcomes for Person-centred Care (1) Satisfaction with Care (2) Involvement with Care (3) feeling of well-being (4) Creation of a therapeutic culture (McCormack and McCance 2010) are being measured and collated as part of the evaluation of the programme. Using evidence based tools such as the Workplace Cultural Analysis Tools ( McCormack et al 2009) we are observing and recording how we are ‘living’ our values and vision and how this impacts on the patients in our care. Discussing as we discover new understandings how we can address and transform to achieve human flourishing

What is the impact for nursing and midwifery practice The work-based facilitators are becoming embedded into everyday practice which has the effect of ‘normalising’ facilitation of person-centred practice. The workshops have helped nurses explore previously hidden or unspoken concerns which are supported by the team. One participant in her evaluation expressed this by writing this was ‘helpful to re-focus on the values of nursing and why we become nurses in the first place’. Recognising that as nurses we can get busy and distracted which can be a barrier to living our values. Nurses need to ensure we take time for mindfulness and allow ourselves the capacity to be compassionate in our interactions. Having the capacity to be compassionate is an important pre-requisite for being authentically present and communicating using gentle language. When the group was comfortable with their shared understanding regarding their own practice they were then challenged to change their lens from patient care to interacting with challenging colleagues and consider how they lived their values and beliefs when highly challenged. One of the nurses wrote in her evaluation that the workshop ‘changed my perspective on working within a team’ and another stated that it was ‘very reflective and informative (and) that (it) facilitated different ways of thinking’.


NMV B9

1. Team working to develop an electronic nursing record that is person-centred and captures the unique relationship between the nurse and her patient. 2. Driven by nursing values and a shared vision. 3. Has led to other initiatives to develop and sustain person-centred cultures.

Why the initiative was carried out The Galway Clinic have used an electronic patient record since opening in 2004, since that time nurses have been proactive in adjusting the system to enable nurses to capture the role and activity involved in nursing practice. In 2014, the nursing team developed using a collaborative process the Philosophy and Vision for nursing which was underpinned by a philosophy of person-centred practice (McCormack, McCance 2010) . In 2015, the Galway Clinic decided to upgrade their existing Electronic patient record (EPR) which presented an opportunity to develop nursing documentation that embodies the values and vision for nursing practice and captures the relationship between the nurse and his/her patient.

Maintaining the integrity of the nursing process within an electronic patient record is challenging both in complexity of process within a pre-set forma, but also in supporting nurses to assess, plan and evaluate care in a way that is unique to the individual patient. Intrinsic to nursing practice is the relationship between the nurse and the patient and others involved in their care, providing documentation that captures the healthful relationship is a craft of nursing practice. The nursing team decided to use the opportunity presented through the upgrade of the EPR to build from scratch a nursing document that would achieve this, we called this the Galway Clinic Complete Electronic Nursing Record (GCCENR).

The aims of the project were:

• Provision of comprehensive, holistic record of assessment, planning care and evaluation of the care that supports evidence based decision making and compassionate care • Documentation that meets the legal and professional requirements criteria defined in legislation, guidelines and standards and incorporates international Nursing Language • Provides evidence of person-centred nursing practice and metrics measurement.

• Includes the use of person-centred language in pre-set content that will in turn support person-centred practice. How the initiative was carried out The team named above agreed to use a Practice Development methodology (Manley and McCormack 2008) to tease out the salient elements of an EPR. The team used creative analysis to determine values and vision underpinning the project. The values and vision for the project were to: Develop and introduce person-centred nursing documentation within an Electronic Patient Record to encourage and support meaningful relationships and improved quality outcomes and positive patient experience of care.

The work began by undertaking a literature review and best practice related to the development of holistic record and we found that there is a dearth of literature available to guide practice in the Irish or UK context. The team consisting of nursing and IT staff proceeded to write in its entirety a holistic and person-centred document which would be then incorporated into an EPR.

Title of the initiative Realizing nursing values within a bespoke person-centred electronic nursing record. Development and implementation of the Galway Clinic Complete Electronic Nursing Record (GCCENR)

Names: eCúram PCS Team; Winnie O Neill; Michelle Casserly; Teresa Mulhall; Marie Connolly; Michele Hardiman; Sinead Hanley

Organisation: Galway Clinic


Using the principles of Collaboration, Inclusion and Participation nurses from all areas critiqued and reviewed the draft content which imbued a sense of ownership for the wider nursing team. This also commenced a dialogue about living the underpinning values in practice which in turn led to the development of work-based facilitators (Hardiman 2016) of person-centred practice now in place in all areas in the Clinic.

What is the impact for patients and service usersThe recording of nursing care has always posed a challenge to nurses due to the complexity in nature and is both an art and a science. Primarily, electronic documentation must serve the needs of the patient, the nurses and the organisation (RCN, 2012). In addition nursing documentation must be functional and easy to write and retrieve. The use of GCCENR ensures that all nursing and other disciplines involved in the care of the patient have easy access to all relevant data on any enabled computer in real time, providing both transparency and aids clear clinical decision making. Evidence suggests that the use of a nursing electronic health record enhances patient safety and is a tool that can be used to support care evaluation.

A key challenge rarely achieved however, is to provide an evaluation framework consistent with the complexity of nursing practice that will present the information in a way that follows the process of nursing and incorporates the standards required of comprehensive and holistic assessment , plan of care, record of interventions (An Bord Altranais 2002). Incorporating person-centred language and prompts toward person centred care processes adds additional challenge to the team.

In addition the project has raised awareness and encouraged dialogue about the culture and context of care and how to enhance the patient experience and deliver safe, effective and compassionate care.

What is the impact for nursing and midwifery practice Through the process nurses have examined their own values and beliefs and developed a shared understanding and vision for nursing practice and for care delivery in the Galway Clinic.

The project intentionally set about to write an electronic nursing record that would not only record technical care and treatment but would also encourage and empower nurses to develop a person-centred relationship with each and every patient in their care.

Even before the go-live on 1st of May. Nurses have already stared to transform their practice and approach to the delivery and documentation of care. Leaders have emerged who are facilitating others to reflect on and in the midst of practice.


NMV B10

1. Learning to care authentically for ourselves is imperative, in order to provide sustained compassionate care for others, in the current challenging health care system.

2. Meditative & Compassionate care practices underpin “true presence” in patient care and improve meaningful human connections between staff and the patients they serve.

3. This type of initiative holds the potential to revolutionise care within Nursing. We are likely to hear less and less about the inevitable stress and burnout within the caring profession. Instead collectively as a professional body we are more likely to reflect on how better we can serve humanity. Why the initiative was carried out As part of the authors work in perinatal Mental Health & Bereavement she undertook both an MSc in Bereavement Studies and trained as a Mindfulness teacher. Part of these trainings required her to do staff training.

Bearing witness to the stress experienced by staff on a day to day basis in her shared work within the MDT she felt compelled to support staff by introducing training programmes on Mindfulness & Self Compassion. In certifying as a Mindfulness teacher she was asked to teach an eight week programme entitled “Mindfulness Based Stress Reduction” (MBSR) under supervision. The author chose to offer this to Healthcare staff where she worked.

The initiative began because on a daily basis the author was inspired by the deep and heartfelt compassion of staff who worked in often under resourced challenging clinical environments. Bearing witness to staff’s evident stress, secondary traumatisation and often intense distress in response to a clients grief/sadness, indicated to the author, that Nurses & Midwives were themselves worthy recipients of Compassionate Care. Beginning with training for staff on issues of Self Compassion was in truth ‘tending to the grass roots of patient care’ in an effort to provide sustainable compassion for patients coming through our maternity care service. How the initiative was carried out The author approached the Director of Nursing & Midwifery to seek buy in as well as support for the initiative from senior management. The authors supervisor overviewed the recruitment process which began in a formal letter of invitation to managers of the following key Clinical Areas. Delivery Suite, Neonatal Unit, Outpatients, Day centre, Gynaecology Ward (Where Bereaved Parents are cared for), Practice Development, Obstetrics department, Administration. Each Head of Department either applied to attend, or nominated a member of the team from their department to attend. Pre Interviews were carried out to examine compassionately the suitability of each individual at that time, and their expressed commitment to the proposed programme was sought. A local Holistic Centre was secured as a suitable venue. This was a short ten minute walk from the Hospital, and being outside the clinical environment proved to be very supportive and nurturing to the staff who attended. Training Materials were given to staff in advance and throughout the course CDs to support the required daily meditative practices were given. No cost was involved to staff for the course or its materials. Staff attended 1 evening/week x 8 weeks (2.5 hrs) and between week 6 and 7 they also attended one full day of guided silent practice, (9-5) with support. The author went on to run 8 individual one day workshops entitled “Introduction to MBSR & Self Compassion” for health care staff. These were aimed at Nurses / Midwives across the three Dublin Maternity Hospitals with support from the Centre of Midwifery Education. All workshops were evaluated positively.

Title of the initiative Mindfulness & Self Compassion for Health Care Staff

Names: Brid Shine

Organisation: Coombe Women & Infants University Hospital


What is the impact for patients and service usersThe research is abundant and robust. Health care staff who are trained in the use of mindfulness meditation have greater empathy and compassion both for others as well as for themselves. It impacts positively on their therapeutic relationships with clients and they are less likely to experience stress and burnout.

A growing body of evidence suggests that the practice of mindfulness meditation improves the overall health and well being of individuals. Healthy staff has to impact patient care as staff arriving to work with vibrant health are ready to engage wholeheartedly with the clients they serve. During the training programmes, staff learned to respond rather than habitually react to stress in their lives. They learned to engage more deeply with clients by being present in an authentic manner.

Staff who are truly present to their patients greatly enhance that patient’s care, as compassion and presence are a felt experience. Present moments arise between carer and patient that are rarely talked about and positive appraisals of care tend to result.

What is the impact for nursing and midwifery practice The very essence of nursing is to care, to be present and to experience the immense joy of watching the broken and wounded respond to our expressed compassion and heartfelt care. “Being with” women is the very definition of midwifery, and this includes patients and their families. Nurses & Midwives came to understand more fully that it is the simple acts of kindness and love that sustains us all as human beings, particularly when we find we have become vulnerable in our physical or mental health.

The practises taught place emphasis on our shared humanity which serves to humble us in our work and keep our motivation to care sincere and genuine.

It is timely now, as staff increasingly leave the deeply rewarding work of caring, to introduce programmes whereby staff themselves experience compassion.

Nurses & Midwives need education and support in maintaining their own self care to keep them committed to their work and be proud of their professional role within our health care services.

It has been the author’s direct experience, that staff trained in these practices can role model the benefits of their practice and inspire patients who are struggling to cope in difficult times.

We need to under pin our highly academic nurse & midwifery training with these meditative practices in order to sustain our staffing and remind our upcoming generation of nurses of the deeply rewarding work we began and continue to do, amidst much change and challenge. We have the potential to become visionary leaders in a new emerging era of healthcare.

Compassion begins at home with ourselves, and whether we are offering or seeking care- as human beings, we are all equally vulnerable. Yet we all have that innate ability to return to wholeness when cared for compassionately by others who bear witness to our life challenges. As nurses & midwives we are deeply privileged to do the work that we do, so let us begin with ourselves in terms of our commitment to compassionate self care.


NMV B11

1) Care:In undertaking this research careful consideration was given to identifying a patient cohort that would potentially benefit from structured education that would positively impact on these patient’s health outcomes and quality of life. The Shanley Pressure Ulcer Prevention Programme (SPUPP) was designed to empower patient’s to become involved in his or her own care by providing access to a structured education programme for preventing pressure ulcers. This is in keeping with a key component of the positing ageing strategy in Ireland, which relates to the prevention of disability, chronic disease and premature mortality as people age. 2) Commitment:As we were committed to producing an education program with quantifiable findings, which could be easily evaluated, we searched the literature extensively and found no pre-existing validated tool. Thus the development and psychometric evaluation of the Patient Knowledge of Pressure Ulcer Prevention Instrument (KPUP) was necessary. The KPUP can be used in further research, clinical practice and education to evaluate patient’s knowledge of, and attitudes and behaviours towards pressure ulcer prevention. 3) Compassion:Pressure ulcers have a significant impact on patients health related quality of life, with studies demonstrating that compared with similarly aged people, patients living with pressure ulcers have a lower quality of life. The aim of this program is to improve quality of life and health outcomes for this patient cohort. By involving patients in their own care we can empower them in their right to have a central role in the prevention process. The programme will also be a valuable tool for assisting health care professionals to provide structured education. The KPUP will be used to measure the impact of the education programme. Why the initiative was carried out Emer is undertaking her PhD at the School of Nursing and Midwifery, RCSI, whilst also practising as a Clinical Nurse Specialist in Tissue Viability and Wound Management in the West Cork Community care area. She is focussing on older persons living at home, because a key component of the positing ageing strategy in Ireland, relates to the prevention of disability, chronic disease and premature mortality as people age. Emer set out to explore the impact of a structured pressure ulcer prevention education programme “Shanley Pressure Ulcer Prevention Programme (SPUPP)” (1), on older persons’ knowledge of and attitudes and behaviours towards pressure ulcer prevention, in addition to the impact of the programme on pressure ulcer incidence. The SPUPP is based on the SSKIN (2) principles and is delivered via multimedia. To evaluate the outcomes of the planned patient led pressure ulcer prevention clinical trial, a validated tool to measure patient knowledge was essential. However, we found no pre-existing validated tool and thus the development and psychometric evaluation of the Patient Knowledge of Pressure Ulcer Prevention Instrument (KPUP) (3) was necessary. The KPUP consists of three sections:

a. Section 1 focuses on participant knowledge of pressure ulcers b. Section 2 consists of questions relating to the participants health care practices c. Section 3 contains questions relating to participants attitude to pressure ulcer prevention

Given the dearth of evidence pertaining to patient led pressure ulcer prevention within the community setting this work may provide a significant advancement for the practise of pressure ulcer prevention, where patient involvement is the central tenet of person centred care.

Title of the initiative The development and psychometric evaluation of the Patient Knowledge of Pressure Ulcer Prevention Instrument (KPUP)

Names: Emer Shanley, Zena Moore, and Declan Patton

Organisation: Coombe Women & Infants University Hospital


How the initiative was carried out Following ethical approval, the KPUP (3) was sent to two groups of researchers (n=39) in a Delphi procedure, to assess for content validity. The experts independently reviewed each question and answer, for appropriateness and relevance in assessing patient’s knowledge of, and attitudes and behaviours towards pressure ulcer prevention, using a Likert scale. The KPUP (3) was then administered to 200 older adults living independently in the community, but attending either day care centres or retirement groups. This was done on a test /retest basis in order to assess stability and reliability, with one week between each administration of the questionnaire. Statistical analysis of the data found the KPUP (3) to be a valid instrument for assessing patient’s knowledge of, and attitudes and behaviours towards ulcer prevention.

Thus, Emer has developed and validated an instrument for the assessment of patient knowledge, attitudes and behaviours, and, to date, no other such instrument exists. As a result, clinicians will have access to the means to assess patient knowledge of and attitudes and behaviours towards pressure ulcer prevention.

What is the impact for patients and service usersThe rights of patients to have a central part in the pressure ulcer prevention process are an important aspect of health care provision (4-6). The benefits include enhanced motivation and knowledge about health and illness, resulting in patients having increased capacity to monitor and look after themselves (5, 6). From a PU perspective, patient involvement in prevention tends to be limited as this aspect of care has been largely viewed as being in the domain of the trained health care professional. However, patient involvement in their healthcare improves their experience and satisfaction and yields enhanced clinical and economic benefit (6). A WHO healthcare workforce report suggests that there will be a shortage of 12.9 million healthcare workers by the year 2035 (7). Furthermore, in developed countries, 40% of nurses will leave health employment in the next decade (7). With the strive for increased capacity within primary healthcare, the desire for people to remain in their own homes for as long as possible, coupled with the ever increasing reduction in available trained health professionals, it is now more important than ever that patients are empowered to take a leading role in their own health care (4). We envision that this programme will empower older persons at risk of serious PU development residing in the community care setting. Given that patients are central in the process of all healthcare delivery, including pressure ulcer prevention, this work is of great significance for improving our understanding of pressure wounds and pressure care. Thus, the provision of a validated instrument, which has to date been unavailable, is of significant value to the pressure ulcer prevention community.

What is the impact for nursing and midwifery practice The underlying premise of person centred care is that individuals who engage with the health service should be seen as equal partners in the assessment, planning and evaluation of care delivery (8). In order to ensure that needs are met, it is essential to evaluate the outcomes of care delivery (9). Given that patients have a right to education in pressure ulcer prevention, so that they may more readily engage in prevention strategies, any education endeavors need to be evaluated to determine impact (10). Recent research at the Royal College of Surgeons in Ireland, exploring patient and carer involvement in a “Pressure Ulcer to Zero Campaign” identified that patients and carers’ had limited involvement in PU prevention within the campaign, yet expressed a desire for greater involvement (11).The KPUP (3) is a rigorously developed reliable and valid instrument, which can be used in further research, clinical practice and education to evaluate patient’s knowledge of, and attitudes and behaviours towards pressure ulcer prevention. It is designed as a reasonably short tool for ease of administration and scoring, and could be used to evaluate the efficacy of educational interventions in the field of pressure ulcer prevention.

References 1. Royal College of Surgeons in Ireland, School of Nursing & Midwifery, Shanley E, Moore Z, Patton D. Shanley Pressure Ulcer Prevention Programme (SPUPP). In: Royal College of Surgeons in Ireland, editor. Print and Electronic Format. Dublin RCSI Publications; 2016.2. Gibbons W, Shanks H, Kleinhelter P, Jones P. Eliminating facility-acquired pressure ulcers at Ascension Health. Journal of Quality and Patient Safety 2006;32(9):488-96.3. Royal College of Surgeons in Ireland, School of Nursing & Midwifery, Shanley E, Moore Z, Patton D. Shanley Pressure Ulcer Prevention Programme (SPUPP) [Supplemental Questionnaire –Knowledge of Pressure Ulcer Prevention [KPUP] v.1. In: Royal College of Surgeons in Ireland, editor. Print and Electronic Format. Dublin RCSI Publications; 2016.4. World Health Organisation. Right to Health 2012 19/1/2013. Available from: http://www.who.int/mediacentre/factsheets/fs323/en/index.html#.UPrSuSNE5mw.email.5. European Commission. Eurobarometer Qualitative study: Patient involvement. In: Directorate-General for Communication, editor. Brussels: European Commission; 2012.6. Coulter A, Parsons S, Askham J. Where are the patients in decision-making about their own care? In: World Health Organization 2008 and World Health Organization on behalf of the European Observatory on Health Systems and Policies, editor. Copenhagen, Denmark: WHO Regional Office for Europe; 2008.7. World Health Organisation. A universal truth: no health without a workforce. In: World Health Organisation, editor. Geneva: WHO Press; 2014.8. McCormack B. A conceptual framework for person-centred practice with older people. Int J Nurs Pract. 2003;9(3):202-9.9. Saleh M, Anthony D, Parboteeah S. The impact of pressure ulcer risk assessment on patient outcomes among hospitalised patients. Journal of Clinical Nursing. 2009;18:1923-9.10. O’Connor T, Moore ZEH, Dumville JC, Patton D. Patient and lay carer education for preventing pressure ulceration in at-risk populations. Cochrane Database of Systematic Reviews. 2015(12).11. Flemming E, Moore Z, Condell S. Patient and family/carer experiences and involvement with the collaborative including use of the SSKIN care bundle. Dublin RCSI; 2015.


NMV B12

1. Embracing change and provision of individualized person-centered care are the commitments clearly evident in the inclusion of fathers in the ante-natal education sessions. As roles in parenthood are changing to include fathers as primary caregivers a commitment to the provision of relevant information, role models and guidelines to help in the transition to parenthood and the fathering role is essential. The development of educational preparation for antenatal educators in the role of the father, including group facilitation skills, adult learning theory, and evidence based information on childbirth practices and practical demonstrations are powerful enablers in the development and advancement of childbirth education for the healthcare professional and fathers alike.

2. Compassion is what compels nurses and midwives to support people by their presence, encouragement, and intervention. The antenatal education of fathers engages compassion by specifically understanding the father’s perspective in the transition to parenthood. The education in the role is inclusive and non-judgmental, prioritising the person’s needs and interests for the ultimate benefit of the father, child, family and wider community.

3. Connecting with fathers on their level through genuine open communication demonstrates the caring aspect of antenatal education for fathers. It encourages personal choice in decision making incorporating a holistic approach in the promotion of health and wellbeing. Collaborative practice based on need and evidence, and performed competently are core elements in quality and safe nursing practise and are fully endorsed in the transition to fatherhood initiative. Why the initiative was carried out “Taking the fear out of the transition to fatherhood” initiative was inspired by the fact that the traditional roles in parenthood in Ireland are changing to include fathers as primary caregivers. Transitions are shifts in lifestyle from one stage to another; the transition to fatherhood is one of the most profound developmental stages in a man’s life.[1] Fathers often lack the relevant information, role models or guidelines to help them in their transition to parenthood and the fathering role. First time fathers in particular report avoidance behaviours towards parenting which inhibit the man’s ability to support his partner, prepare psychologically for fatherhood and bond with their child. There is a discrepancy between what fathers are learning from childbirth education classes and the presumed intent of paternal childbirth education.[2] Engagement with fathers through antenatal education can help identify such reactions, thus decreasing anxiety and increasing confidence. Educating fathers in simple attachment strategies during pregnancy, and immediately after birth, promote and enhance essential bonding between father and infant. Antenatal educators are in the ideal position to engage with and support fathers in their transition to parenthood, and in doing so demonstrate the core principals of compassion, care and commitment in professional practice.[3] [1] Deave T. & Johnson D. The transition to parenthood: what does it mean for fathers? Journal of Advanced Nursing 63(6), 626-633[2] Sponsler W., Weatherspoon C., Weatherspoon D. & Campbell D. (2015) Fear of Fatherhood. International Journal of Childbirth Education 30(1), 33-37 [3] Schott J. & Priest J. (2002) Leading Antenatal Classes A practical guide (2nd Ed). Butterworth-Heinemann, Oxford, UK. How the initiative was carried out Within the current ante-natal education program a new session for fathers was negotiated with the facilitation team. The environment for each session is set up to include fathers, by displaying inspiring posters of fathers and their babies, motivational quotations/poems and video.[4] To prepare fathers for fatherhood the aim of an antenatal session should reflect the needs of the fathers as adult learners.[5] There are three learning outcomes included in the antenatal presentation for fathers:

Title of the initiative Taking the Fear out of the Transition to Fatherhood

Names: Mary O Regan-Hyde

Organisation: Primary Care Team, Macroom, Co. Cork


1. Fathers identify through a team approach their individual fears of transition to fatherhood.2. Fathers understand that the transition to fatherhood is a normal and valid reaction3. Fathers learn ways to overcome their fears of fatherhood through group work and discussion particularly in relation to bonding and attachment As a group introduction technique a “Toolkit for Dads” was compiled with various items in relation to birth and bonding, inspiring thoughts, fears and questions for the session. [6] The fathers are subsequently asked to identify their fears in relation to the transition to fatherhood, and to place themselves on a chart in the form of a football pitch subject to where they see themselves in relation to the mother and baby in centre field. As part of the tactile learning the fathers are given a baby doll to hold throughout the presentation. [7]The fathers were then asked to come up with ways of overcoming their fears in a group brainstorm and to write on a wheel diagram their solutions in relation to the identified fears of the pregnancy, birth, premature baby and postnatal period. The presentation concludes with a motivational video on fatherhood with quotations, pictures and music. [4] Robertson A. (1999) The Power of the Group. Midwife 2(4), 16-19[5] Nolan M (2009) Information Giving and Education in Pregnancy: A Review of Qualitative Studies. The Journal of Perinatal Education 18(4), 21-30.[6] Prashnig B. (1998). The Power of Diversity. Network Education Press, Stafford. [7] Small H. (1995) Icebreakers and warm-ups. Wellington Parents Centre, Wellington, New Zealand.

What is the impact for patients and service usersThe mission of the health system hasn’t changed but the context within which we organise and deliver health services continues to evolve. A new way of thinking, that has the basic value of health at its heart is important in driving our decisions and the way we behave, as individuals, members of communities and professional organisations. Initiatives should be designed to reconnect and continuously affirm compassion, care, and commitment as their unique contribution to safe quality patient care. [8] “Taking the fear out of the transition to fatherhood” initiative encompasses the infinity and eternity of compassion, care and commitment as core values underpinning professional practice, and is characterised by an appreciation, sensitivity, gentleness and awareness that demonstrates an understanding of the person. The transition to parenthood involves both women and men therefore healthcare professionals and policymakers should make efforts to include fathers when providing care during pregnancy and childbirth. Current research into antenatal education suggests that parent’s needs and education are not being met. It recommends that a parent-centred approach taking the principles of adult learning into account is the most effective method in antenatal education. [9]Transition to fatherhood should include preparation for relationship and role changes, positive mental health and training in the effective supporting role of their partner. It should also promote the development of strong attachment in fathers and infants, infant crying patterns and, parenting teamwork. Core values such as empathy and understanding towards fathers that address their concerns should be developed, ensuring the transition to fatherhood is smoother, and benefits not only the fathers themselves, but also their relationships with their partners and infants, and the wider community. [10] [8] Department of Health (2016) Position Paper One Values for Nurses and Midwives in Ireland, https://www.hse.ie/eng/about/Who/ONMSD/Nursing%20 and%20Midwifery%20Values/Nursing-Values-Position-Paper.pdf[9] Davidson M., Cooper K., Brough A. & Allen K. (2011) Dads2b Resource: A resource for professionals providing antenatal education and support to fathers. Children in Scotland, NHS Lothian, National Childbirth Trust, West Lothian Sure Start, & Fathers Network, Scotland.[10]Poh H.,Koh S.,& He H.(2014) An integrative review of fathers experiences during pregnancy and childbirth. International Nursing Review 61(4), 543-554

What is the impact for nursing and midwifery practice The father’s role in pregnancy, birth and early postnatal period is challenging but should also be an enjoyable and memorable experience.[11] Nurses and midwives need to constantly review and assess that they are doing the right thing for their patients all of the time. Each nurse and midwife is asked to reconnect and balance compassion, care, and commitment as their unique contribution to safe quality patient care. The unique needs of fathers and in particular first time fathers during antenatal classes should not be ignored but acknowledged and catered for exclusively. The introduction of fathers-only focus groups would allow nursing and midwifery practitioners to direct all their attention and resources to identifying fathers’ needs and concerns in a safe forum. By providing this informational and emotional support for fathers, healthcare professionals can positively influence fathers’ experiences during this transition.[12]The concept of antenatal classes being perceived by parents as a coping strategy for the changes and challenges of pregnancy and the advent of a new beginning makes it imperative that antenatal educators have formal educational preparation including various teaching and learning strategies, to ensure that the learning is relevant and comprehensive.[13]The development of educational preparation for antenatal educators in the role of the father, including group facilitation skills, adult learning theory, and evidence based information on childbirth practices and practical demonstrations are powerful enablers in the development and advancement of childbirth education for the healthcare professional and fathers alike.[14] [11] Folden- Palmer L. (2009) The Baby Bond: The New Science Behind What’s Really Important When Caring for Your Baby. Sourcebooks Inc, Illinois.[12] May C. & Fletcher R. (2013) Preparing fathers for the transition to parenthood: Recommendations for the content of antenatal education. Midwifery 29(1), 474-478[13] O Sullivan C., O Connell R. & Devane D. (2014). A descriptive survey of the educational preparation and practices of Irish antenatal educators. Journal of Perninatal Education. 23(1), 33-40[14] Mongon M. (2005) Hypnobirthing: The Mongan Method (3rdEd). Health Communications, Florida.


NMV B13

1. To reduce the stillbirth rate

2. Aligning practice with national guidelines

3. To increase public confidence and staff pride Why the initiative was carried out UK Research has shown that the earlier recognition and detection of Intra Uterine Growth Restriction (IUGR) has resulted in a reduction in the stillbirth rate (Gardosi et al 2013a; Clifford et al 2013). This earlier recognition and detection has been as a direct result of the introduction of The Growth Assessment Protocol (Clifford et al 2013).

This protocol, first launched in the UK in 2013, includes comprehensive staff training, monitoring of fetal growth restriction referral/detection rates and regular audit of fetal growth restriction not detected antenatally. Fetal Growth Restriction (FGR) or Intrauterine Growth Restriction (IUGR), suggests a fetus failing to reach its full growth potential because of placental dysfunction (Groom et al 2007) and is associated with stillbirth, neonatal death and perinatal morbidity (Corcoran et al 2016), which has a devastating effect on the mother, the partner, the family and the wider community. A recent population-based study on maternal and fetal risk factors for stillbirth (Gardosi et al 2014) highlighted the need for preventive strategies to focus on antenatal detection which improves the chance that growth restricted babies are delivered in good condition. Customised assessment of birthweight and fetal growth is recommended by the RCOG (2013) and is also recommended in the Clinical Practice Guideline “Fetal Growth Restriction – Recognition, Diagnosis and Management” (RCPI 2014) and by the National Perinatal Epidemiology Centre (NPEC) (2014).

The team in the maternity unit reviewed the results of the UK evidence in relation to the reduction of stillbirths. This evidence, coupled with concerns re our stillbirth rate, lead to the introduction of the Growth Assessment Protocol. It is anticipated that when introduced, the protocol will have the same impact on the stillbirth rate as seen in the UK. How the initiative was carried out Growth potential for each pregnancy is defined using the Gestation Related Optimal Weight (GROW) software which includes customised antenatal charts for plotting fundal height in centimeters and estimated fetal weight and calculation of customised birthweight centiles (Gardosi et al 2013b). Funding for the GROW licence from the UK Perinatal Institute was received from the NMPDU North East. Four “train the trainers” travelled to Birmingham where they received comprehensive training and returned to rollout sessions to 95 staff over a four week period. A local guideline, based on the UK guideline, was developed as was a Risk Assessment Referral Pathway. Go live date was 3rd January 2017 and customised growth charts have been generated for all women booked since that date. These charts are customised to each woman based on age, height, weight, parity and ethnic origin. From 26 weeks gestation, low-risk women have fundal height plotted on the growth charts and high risk women have serial scans plotted. A comprehensive care package for women who plot below the 10th centile, above the 90th centile or have static or no growth is in place. Following birth, a birth-weight centile will be completed to audit practice and to review our recognition rates.

Title of the initiative The Introduction of the Growth Assessment Protocol for the first time in an Irish Maternity Unit

Names: Gráinne Milne, Mary Rowland, Bernadette Daly, Seosamh O’Coigligh

Organisation: Our Lady of Lourdes Hospital, Drogheda, Co. Louth


What is the impact for patients and service usersThe introduction of a Growth Assessment Protocol will result in a more standardised approach to identifying growth restricted babies so that they can receive appropriate monitoring, surveillance and early delivery where indicated. The expected impact for the service users will be that all women booked from January 2017 will have a Customised Growth Chart in their hospital records and that they will be completed accurately by appropriately trained staff. This will facilitate earlier recognition of babies that are experiencing fetal growth restriction. In turn, babies not growth restricted will not require unnecessary monitoring, which will result in a more streamlined scanning service. The expected overall outcome would be a reduction in the stillbirth rate. This will increase public confidence with the organisation. Data for the financial costs of stillbirth are not routinely recorded. However, a study by Mistry et al (2013), found the total cost of comprehensive care was on average €2,080 per death. With 230 stillbirths in Ireland 2014 (Corcoran et al 2016), that total rises to €478,400 for direct costs only. However, stillbirth is associated with substantial indirect, psychological, and social costs to women, and to their families (Heazell et al 2016). These include: medical care and investigations in subsequent pregnancies; funeral costs; grief and negative psychological effects; reduced social functioning; family and relationship disruption and breakdown; and negative effects on employment. If we can even reduce one stillbirth, this will have an enormous effect on all concerned. As can be seen, the introduction of the Growth Assessment Protocol will be consistent with the values of care, compassion and commitment.

What is the impact for nursing and midwifery practice The introduction of the Growth Assessment Protocol will result in a more focused and standardised approach to the identification and management of IUGR. There will be a more focused approached to scanning services, resulting in a more efficient use of resources. Staff will be in compliance with national guidelines and recommendations from the RCPI, NPEC and RCOG. As the first maternity unit in the Republic of Ireland to introduce the protocol, there is a renewed sense of pride for staff working within the organisation. This pride will be further enhanced when we show an increase in our recognition rates from our baseline data and there is evidence of a reduction in our stillbirth rate. The personal and professional cost of stillbirth on staff is also substantial (Heazell et al 2016) therefore, evidence suggesting a reduction in in our stillbirth rate will have a significant impact for staff also.


NMV B14

Compassion In recognition of the significant impact of physical separation on parents and families following admission of their newborn babies to the NICU, the Neonatal Web Camera System, consisting of a real-time, live connection between mothers separated from their babies in the NICU, by way of android tablet and web camera, was installed in the National Maternity Hospital in 2016. Care Family-Centered Practitioners “recognise the vital role that families play in ensuring the health and well-being of infants… promote the health and well-being of individuals and families and restore dignity and control to them” (Institute for Patient- and Family- Centered Care, 2010). The Neonatal Web Camera System enables mothers and fathers to be parents in times of physical separation, returning to them an important sense of control in the oftentimes unexpected, stressful, and indeed traumatic situations in which they find themselves post delivery.

Commitment This initiative was first proposed by the team back in 2012. Some four years later, the initiative is up and running. Despite the obstacles, despite the setbacks, the commitment of the team remained strong. This was due to the team’s commitment to the cause, and belief in the neonatal web camera solution. Why the initiative was carried out The admission of a newborn baby to the Neonatal Intensive Care Unit (NICU) results in the physical separation of a mother from her baby. This separation has been shown to have a significant impact on maternal anxiety (Mizrak et al., 2015), mother and infant bonding (Tooten et al., 2012), maternal ability to breastfeed, and susceptibility to postnatal depression (Rhoads et al., 2015). Strikingly, disruption in the parent-baby bonding process is associated with adverse parenting behaviours, with a high prevalence of abuse and neglect found in children with a history of neonatal health problems (Tooten et al., 2012). How the initiative was carried out A multidisciplinary team at the National Maternity Hospital (NMH) formed to investigate and explore the possibility of a virtual solution to the physical problem. The Hospital’s 35-bed Level 3 NICU is a recognised centre of excellence. Caring for approximately 1,300 babies per annum, referrals are made to the unit for sick babies from across the country (NMH, 2017).

Funding for a pilot project was received from the Nursing and Midwifery Planning and Development Unit (NMPDU) and, in early 2016, Angeleye® Camera Systems based in Arkansas, USA, was selected as the appropriate provider for the NMH. The system was installed in the NMH in May 2016. The initiative has started small, consisting of one web camera in the NICU and one android tablet for use by mothers across a variety of internal hospital settings (between NICU and the Recovery Ward; between NICU and the Postnatal Wards; between NICU and the Gynaecological Ward). To date approximately 20 mothers/families have used the system. External family-baby connectedness between babies in the NICU and families at home via smartphone, personal computer, or tablet is the ultimate end goal.

Title of the initiative NMH Neonatal Web Camera System

Names: Kim Ryan, Denise McGuinness, Dara Keeley, Martin Keane

Organisation: Our Lady of Lourdes Hospital, Drogheda, Co. Louth


What is the impact for patients and service users

• Reduced mother-baby separation following admission of a newborn baby to the NICU

• Reduced fear, distress and anxiety in times of physical separation post delivery

• Enhanced mother-baby bonding despite physical separation • Enhanced maternal recovery in clinical diagnoses’, such as Pre-Eclampsia (PET) – aids blood pressure stabilisation

• Enhanced breast milk production despite physical separation

• Enhanced family relationships (parents, grandparents, siblings)

What is the impact for nursing and midwifery practice • Enhanced staff relationships with patients and their families

• Enhanced provision of compassionate, Family-Centered Care


NMV B15

1. The Caring Behaviours Assurance System-Ireland ( CBAS-I)is an accountability system designed to engage individuals, teams and executive boards in achieving the national agenda for assuring the quality and safety of the care experience for patients, their families and for staff.

2. It is a system for enabling and assuring the delivery of person centred care.

3. It addresses caring for patients and caring for staff in equal measure supporting the belief that when staff are looked after effectively, their ability to care for their patients in a caring and compassionate manner is enhanced( CBAS-I 2016) Why the initiative was carried out Patients right to dignity, kindness, compassion, courtesy, respect, understanding and honesty are internationally recognised as essential features of a Person-Centred healthcare service. These values are endorsed in the HSE Corporate plan (2015-2017), the National Standards for Safer Better Healthcare (HIQA 2012), and the Values in Nursing and Midwifery (2016).

However over the last number of years there have been high profile reports both internationally and nationally that have highlighted a lack of dignity, kindness, compassion & courtesy. The Quality & Safety division within the Saolta group recognised an increase in complaints regarding the human aspects of care i.e. that is the interaction between the staff and the patient / family.

The Saolta Group Chief Director of Nursing & Midwifery and her team recognised that there was a need for a programme that focused on practical strategies to assist staff in recognising and developing a more person centred approach while also developing their skills in relation to resilience and caring for self.

Working in health care carries an increased risk of burnout, this can result in a decrease in compassion and empathy compromising the ability to provide high quality care to patients (Goodrich 2012).CBAS-I offered a better way to engage staff, because it offered caring for patients and caring for staff in equal measure.

CBAS-I presented a platform for staff to celebrate good practice and also identify areas for improvement. Experience has shown us that while staff may recognise areas for improvement they did not always have the skills to change the associated behaviours, CBAS-I made the tools available to develop these skills.

CBAS-I offered a culture change for the whole organisation by engaging with senior management and frontline staff, allowing the executive board & management team to gain an understanding of care at the frontline for both patients and staff. How the initiative was carried out The Office of Nursing and Midwifery Services Director commissioned a new national programme for healthcare called Caring Behaviours Assurance System-Ireland following feedback from senior healthcare staff. This was first developed by Choice Dynamic. “This was a positive experience of hospital care. The medical team and social worker were excellent in their care”

“Nurses and support staff were very helpful and supportive at all times during my stay”

Title of the initiative Caring Behaviours Assurance System –Ireland, The Journey so far

Names: Olive Gallagher, Jean Kelly, James Geoghegan, Eavan Higgins

Organisation: Galway University Hospital, Saolta University Healthcare Group


The National Patient Experience Programme survey planned for May 2107 will also give further feedback on patient experience and the areas involved in the CBAS-I programme will be of particular interest to the Saolta Group. Information about the CBAS-I programme is displayed prominently in all areas that took part, allowing them to celebrate their good practice and achievements.

What is the impact for patients and service users Measuring the effect of the CBAS-I programme on patients and staff was something we were conscious of from the very beginning. We realised in order to measure the effects of CBAS-I we would need at least a year to embed the programme. However small changes became evident very quickly, anecdotally the following changes were evident:

• A truly multidisciplinary approach on to how to improve the quality of care in the CBAS-I wards e.g. catering attendant had equal input into CBAS-I action plan• A renewed focus on person centred care• Patients were asked their opinion through patient family interviews about the care they received and their feedback was valued• Staff introduced themselves

Examples of Actions Agreed by CBAS-I teams:• All patients requiring assistance with meals identified • Family areas identified at ward level and furnished• Monthly ward MDT Quality meetings scheduled• Staff tea room refurbished• End of life room identified and re-designed• All staff members would introduce themselves to patients

While there was anecdotal evidence of an improvement in person centred care, we conducted a patient experience survey on three CBAS-I wards. 82% of respondents rated their overall hospital experience as excellent and 87% reported that staff always introduced themselves.

What is the impact for nursing and midwifery practice Following the implementation of the CBAS-I programme, an evaluation was undertaken in autumn 2015 by the Nursing and Midwifery Planning and Development Unit. The overall aim of the evaluation was to assess the impact of the introduction of the programme as perceived by staff and the organisation within Saolta. Overall it evaluated very positively and was deemed to have a positive impact on the quality of care provided to patients and families, and contributed towards a change in behaviour (HSE 2016).

Simultaneously an employee engagement survey was undertaken by Saolta .The following question was asked “Caring behaviour is recognised and celebrated within my work unit’: 51% of employees Agreed/Strongly agreed with this statement.

Anecdotally there was:• Renewed momentum & energy amongst staff• A sense of ownership and pride at ward level• Increased resilience

St Marys ward (a CBAS-I team) were finalists in the Exceptional patient experience category for the Saolta staff recognition awards in 2015 for their work on the CBAS-I programme. ‘ This bought me, heart & soul, it brought up all those things from those early enthusiastic days of being a manager & really thinking I could make a difference’

The CBAS-I programme allowed us to support, sustain and renew our nursing values. It created an energy and momentum and environment for compassion to flourish.( 220)

References: Department of Health (2016) Values in Nursing and Midwifery, www.doh.ie/publicationsGoodrich J, Levenson R, 2012. Supporting hospital staff to provide compassionate care: Do Schwartz Center Rounds work in English hospitals? Journal of the Royal Society of Medicine, 2012: 105: 117 –122. Health Service Executive (2015) Building a high quality health service for a healthier Ireland-HSE Corporate Plan 2015-2017 Dublin: Health Service Executivewww.hse.ieHealth Service Executive (2016) Caring Behaviours Assurance System-Ireland, Information Booklet.Health Service Executive (2016) Evaluation Report of the Implementation of caring Behaviours Assurance System Ireland into the Saolta University Health Care Group, Nursing and Midwifery Planning and Development Unit ISBN978-1-898098-69-0Health Information and Quality Authority (HIQA) (2012)National Standards for Safer Better Healthcare Dublin: Health Information and Quality Authority. www.hiqa.ie/publications


NMV B16

Compassion The creation of the INFORMED-DECIDER Shared Decision-Making framework represents a quality improvement which leads to a consideration of patients’ values, needs & preferences. It creates a reality for patients that their care has been designed in a way that acknowledges their ‘lived experience’ and recognises patients as vital participants in their healthcare decisions. Prioritising the person’s interest (Position paper one)

Care A transparent way of providing care, giving confidence to the practitioner, the patient & their family. By being patient-focused rather than task oriented, practitioners can find themselves re-awakened to the needs of their patients. Encouraging personal choice in decision-making (Position paper one)

Commitment Shared Decision-Making through the INFORMED-DECIDER reflects a commitment to two parallel aspects of healthcare:

Care ‘transactions’ – (how care is delivered), a commitment to maximise patient self-determination, patient autonomy & brings practitioner expertise to healthcare decisions in the form of evidenced based practice which implies a shared responsibility between practitioner and patient. Engaging in effective communication & evidenced based practice (Position paper one)

The ‘relational’ aspects of care within the therapeutic relationship (the human interactions between practitioners & patients), facilitated by a clear intent to align patient and practitioner decisions to maximise health outcomes. Encouraging personal choice in decision-making (Position paper one) Why the initiative was carried out Respect for the patient’s agenda has become increasingly important when considering how best to develop structures and processes that deliver patient centred care (PCC) (HIQA, 2012, HSE, 2012, HSE, 2013). Key to the actualisation of this patient centred approach is a partnership which requires the contribution of both practitioners and patients alike. It is a partnership that is orientated to the needs of the patient and implies a shared responsibility between practitioner and patient (Alikari and Zyga, 2014; Fraser, 2010). Recent guidance produced by HIQA (2016) identifies the importance of respecting personal autonomy which is noted to be central to person centred care.

At times, however, health choices made by patients may conflict with the recommended interventions within their evidenced based care plan and as a consequence, respecting the patient’s right to self-determination expressed through informed decision-making can create challenges for nurses working in the community. In such circumstances, nurses may lack the confidence to document such patient decisions resulting in the submission of unnecessary risk assessments or incident reports out of fear of adverse outcomes as a result of patient’s decisions (Delaney, 2015). This research arises from preliminary discussions with nurses working in a Community Nursing Team who perceived some patient decisions to be akin to, non-compliance’. A review of the literature highlighted the complexity of this area of perceived ‘non-compliance’ and identified transitions in the use of terminology from ‘non-compliance’ (intentional & unintentional) & ‘non-adherence’ to the more recent term ‘concordance’. While ‘non-compliance’ or ‘non-adherence’ are measures of a patient’s behaviour, ‘concordance’ is a measure of the interaction between the patient & practitioner (National Heart Foundation of Australia (NHFA), 2011).

Shared Decision Making (SDM) is described as a concordant approach which appreciates shared values through a process of collaboration rather than the assiduous pursuit of practitioner orientated outcomes and punitive approaches (via completion of risk assessments and incident forms) causing mistrust and decisional conflict. Embedding SDM into systems, processes and workforce attitudes, skills and behaviours is a challenge (Munthe et al. 2012). Yet, it is viewed as an ethical imperative by our professional and regulatory bodies which expect professionals to work in partnership with patients

Title of the initiative Partners in Care: Bringing Compassion, Care and Commitment To Life Within a Shared Decision-Making Framework

Names: Yvonne Delaney

Organisation: Health Service Executive, CHO 8


(HIQA, 2012; HSE, 2013; NMBI, 2014). Simply put, SDM is the principal process for ensuring that patients get ‘the care they need and no less, the care they want, and no more’ (The King’s Fund, 2011, p.vii). Thus, the need for a standardised approach to patient decision-making and documentation of same was identified. The development of an SDM framework to support this forms the basis for the study.

How the initiative was carried out The aim of the study was to develop an evidenced-based Shared Decision-Making (SDM) framework for use by the Community Nursing Team to facilitate informed decision-making through patient-centred learning for the purpose of optimising concordance. This study drew on an organisational development approach and was underpinned by the Health Service Executive change management model (HSE, 2008).

Primary data collection included a focus group interview with Public Health Nurses, Community Registered General Nurses, Clinical Nurse Specialists and management (n=7) and a pre and post pilot questionnaire (n=7) which explored the nurses’ experiences of the promotion of concordance and the management of non-concordance. While the number of individuals involved in this development was low, the iterative nature of the research process underpinned by a change management process facilitated the development of this preliminary framework.

What is the impact for patients and service users While not every patient desires an active role in decision-making, most findings suggest that a majority do (Flynn et al. 2006). There is also compelling evidence that patients who are active partners in managing their healthcare have better outcomes than those who are passive recipients of care (Schuerman and Neely, 2013; TKF, 2011). To disregard the lived experience equates to a failure to explore the subjective meaning and to fully understand and respond to patients’ preferences and has indeed been termed ‘the silent misdiagnosis’ (Mulley et al. 2012). The INFORMED-DECIDER framework is a clear statement of commitment to this decision-making partnership. The values guiding the facilitation of client centred learning which forms the basis of informed decision-making include consideration of patient lived experience; patient choice; respect for life and truthfulness (RNAO, 2012) in line with compassionate care. The National Consent Policy (HSE, 2013), reflects these parallel principles by explicitly exemplifying that informed consent is key to respecting the right to self-determination and so the practitioner is charged with the responsibility of ensuring that information is imparted in a manner that is understood. The RNAO (2012) suggests that a patient’s learning is mediated and influenced by interactions between the patient and the professional. When nurses clarify information for patients and their families, they are promoting a greater understanding of their illness and ensuring patients are empowered to make informed decisions about their care. Integrating the INFORMED-DECIDER Framework into practice aims to improve patient centeredness by enhancing flow of information between patients and practitioners which honours patients’ values and preferences in making choices amongst evidence based options. This initiative will evolve and aims to build in the patient’s involvement in the subsequent evaluation process as regards the impact of the INFORMED-DECIDER SDM framework.

What is the impact for nursing and midwifery practice The INFORMED-DECIDER framework serves as a script for practitioners to navigate the process of SDM and is underpinned by the values of Compassion, Commitment & Care. In keeping with the content of Position Paper One; titled Values for Nurses and Midwives in Ireland, behaviours are determined by what one values’, so to search out patient values and question our own internal value system as individual practitioners, will go a long way to embedding patient centred care. Taking concordant approaches characterised by partnership, intentional, informed consent and SDM can in fact reduce the likelihood of non-concordance, non-adherence and noncompliance (The King’s Fund, 2011). The information that both patient and practitioner bring to this SDM interaction represents a merging of the dyad of expertise as reflected by (Coulter and Collins, 2011). There are many assertions as to what constitutes SDM. It is presented as a set of behaviours that must be achieved by both members of the patient professional dyad (LeBlanc, 2009). Figure 3 represents the dual elements of this care interaction. This interpersonal approach claims to nurture the therapeutic relationship, enhance patients’ knowledge, skill and confidence as a partner in their health journey which reaffirms compassion in healthcare.

Figure 3: Dual Elements of Shared Decision-Making (Coulter and Collins, 2011)

The plan is to enhance this approach to decision-making by integrating decision-making tools to further augment this patient centred process of SDM. The creation of this framework provides a new reality that will need to be mainstreamed with the support of a theoretical and practical training programme. The INFORMED-DECIDER SDM approach provides a framework for practically supporting nurses and midwives to sustain and renew the values of Compassion, commitment & Care and is very much in keeping with the symbol which denotes the interconnection between the three values and the interdependence between patient and practitioner decision-making.

Dual Elements of Shared Decision-Making

Clinician’s expertise Patient’s expertise

Diagnosis Experience of illness

Disease aetiology Social circumstances

Prognosis Attitude to risk

Treatment Options Values

Outcome probability Preference


NMV B17

1. A multidisciplinary care pathway has been developed for the care of parents following the diagnosis of a life limiting condition during pregnancy.

2. Parents are provided with expert medical care, information and support from a team of experienced health professionals.

3. Parents are support through the journey from diagnosis to delivery and beyond by the multidisciplinary team. Why the initiative was carried out The National Maternity Hospital is a tertiary referral center for Fetal Medicine. Each month approximately 30 families have a diagnosis of a fetal anomaly, and in 2016, 40 families had a life limiting diagnosis for their child.

Pregnancy and child birth is generally a joyful experience for parents. However, when a diagnosis of life limiting condition is made during pregnancy, parents embark on a different journey. Hearing their baby is likely to die during pregnancy or soon after birth is devastating for parents and their families. Parents need supportive, compassionate care from experienced health professionals. Parents need care that is individualised to their needs and provides continuity of care. With this in mind a care pathway for parents who’s baby has been diagnosed with a life limiting condition has been developed. This care pathway adopts a multi-disciplinary specialist approach with direct access to a dedicated specialist midwife for the family during the perinatal period.

The aims of care for families with diagnosis a life limiting condition is to provide compassionate supportive care from a team of experienced health professionals. At diagnosis parents are linked with Prenatal diagnosis midwife, Fetal medicine consultant and the Bereavement midwives.

How the initiative was carried out Care is provided using a multi-disciplinary team approach. The team consist of two prenatal diagnosis midwives, two bereavement midwives and consultant obstetricians specialising in fetal medicine. The team is supported by other disciplines including paediatricians, social workers and chaplains. Parents are provided with individualised information regarding their baby’s condition and prognosis. Information is provided in a private space and parents are offered the opportunity to ask questions and to arrange further meetings with members of the team. Parents are given timely appointments with direct access to prenatal diagnosis midwife by phone or email. The bereavement midwives are available to families for practical and emotional support. The bereavement midwife will meet with the parents and discuss memory making, the grieving process and practical information regarding the death of a baby. They will also meet the parents when the baby is born and provide practical and emotional support. Families are supported in memory making both during the fetal lifetime and the short neonatal period. Parents are offered a follow up appointment with their consultant and the bereavement midwives following the delivery to allow for further discussions and provide ongoing support.

What is the impact for patients and service users The journey is led with effective management from experienced midwifery staff. The National Standards for Bereavement Care Following Pregnancy Loss and Perinatal Death advocate a compassionate, multidisciplinary approach to care for parents whose baby has a life limiting condition. Family are empowered and protected to continue their pregnancy within a supportive sensitive environment. Through this multidisciplinary approach parent’s needs during a very difficult journey are met in a supportive and compassionate manner. Parents whose baby has been given a diagnosis of a life limiting condition embark on a very different journey to other parents expecting a baby. Parents are provided with individualised multi-disciplinary care from a team of experienced professionals and are guided through the journey from diagnosis to delivery and beyond.

Title of the initiative Perinatal Hospice Care; A Different Journey

Names: Sarah Cullen, Heather Hughes, Brenda Casey, Barbara Cathcart

Organisation: National Maternity Hospital


What is the impact for nursing and midwifery practice Midwives and nurses who care for patients with an antenatal diagnosis of a life limiting condition have the support of the prenatal diagnosis midwives and the bereavement midwives. This allows for effective care for parents. Education regarding caring for families with a diagnosis of a life limiting condition is provided to midwives and nurses on a regular basis.


NMV B18

Aims :• To reduce anxiety of Bereaved parents

• To reduce number of inaccurate or incorrect test results • To increase staff knowledge and awareness of importance of these tests both for clinical practice and service users Why the initiative was carried out Following feedback from the Perinatal Pathologists carrying out post-mortem examinations and histological examinations on placentas, it was noted that large wedges of placental tissue were being sent for cytogenetic testing instead of the nationally recommended 1x1cm sample. Inaccurate sampling results in :

• Incorrect cytogenetic results

• Incomplete Placental histology reporting

• Increased anxiety for parents awaiting definitive answers as to why their child has died who at times rely solely on these tests results • Increased number of laboratory discards • Increased cost implications as these are External tests which are transported to the UK for testing.

How the initiative was carried out We carried out a staff audit assessing their knowledge of the process of sample taking. It was established that a Knowledge –Practice gap existed. In order to enhance clinical practice we identified the need for education sessions at ward level, which was carried out by the Bereavement Support Midwife Fiona Mulligan and the CMM2 Michelle Scanlon. These were held twice weekly for 1 month and 95% of the staff working on the Antenatal ward were included in the education sessions. We are in the process of auditing the outcomes of the sessions and the changes to practice as a result. We updated the documentation for Perinatal loss to include a checklist from the gestational age of 14 weeks onwards incorporating exact size illustration and displayed posters in the sample taking areas to prompt staff on correct procedure. The Neonatal pathologist is currently working on an illustrated poster of this procedure in cooperation with the Maternity Units nationally.

What is the impact for patients and service users Decrease in the stress and anxiety involved for the parents following a traumatic experience by the correct sampling procedure, ensuring accurate results and provides a basis for future planning of subsequent pregnancies as genetic counselling referral may be indicated as a result of these tests. Increased staff awareness of the importance of these tests for the families we care for and the psychological impact of having, or not having, answers may have for them.

Title of the initiative Quality Initiative to reduce incidences of incorrect placental sampling for cytogenetic testing post pregnancy or perinatal loss

Names: Fiona Mulligan, Michelle Scanlon

Organisation: Our Lady of Lourdes Hospital Drogheda, RCSI Hospital Group


What is the impact for nursing and midwifery practice • Reduction in the number of laboratory discards. • Increased accuracy of histology and cytogenetic reports • Increasing the awareness and promoting education of staff yielding a competent and confident workforce.


NMV B19

The What Matters to You project embodies all of the Nursing and Midwifery values in practice: Compasssion, Care and Commitment. • Ask what matters: Person centred approach to care• Listen to what matters: Dignity for patients • Do what matters: Enhance positive outcomes for the patient and increasing staff satisfaction

Why the initiative was carried out The HSE Service Plan (2016) emphasises that people’s experience of the health service must be safe and of high quality, but it must also caring and compassionate. “What Matters to You” (WMTY) is an approach to care that supports that philosophy.

The WMTY pilot programme is a collaboration between the National Clinical Programme for Older People (NCPOP), the Quality Improvement Division (QID), Irish Hospice Foundation, St Vincent’s University Hospital and Midland Regional Hospital Portlaoise. It was initiated as a direct response to the QID work undertaken with Age Friendly Ireland and their joint report “Listening to older people: Experiences with health services”, in an attempt to counter-balance the sense of invisibility felt by older people admitted to the pilot wards (HSE & Age Friendly Ireland, 2015).

Two national pilot sites were chosen for the project: Our Lady’s Ward (Care of the Older Person and Stroke Care), St Vincent’s University Hospital and Medical ward, Midland Regional Hospital Portlaoise. Being in hospital can be a stressful experience for patients and we want to reduce this stress as much as possible. “What Matters to You” is a patient-centred approach to patient care aimed at improving the patients experience while they are in hospital. The idea is very simple; we want to get to know the person behind the illness. The patients’ experience of hospital care should be measured by the level of dignity, compassion and respect, with which they are treated. The project was created to help the multidisciplinary team see the patient and not just the disease. It also aims to improve communication at all levels.

How the initiative was carried out The project started in February 2016. Training was provided by The Irish Hospice Foundation for 107 members of the multidisciplinary team across the two pilot sites to build capacity and understanding of person centred care. A collaborative committee was set up with all the key stakeholders. Documents required for the project were created:

• Patient Information leaflets• Frequently Asked Questions leaflets• A project logo• “What Matters to You” boards• Non participation board

Information leaflets were given to patients and their relatives to explain what the project entails. Patients were given the option to participate or to opt out of the pilot. The “What Matters to You” initiative involves asking the patient to tell us what matters to them and capturing some of that information at their bedside on the “What Matters to You” board. The information on the board should help to give members of staff the opportunity to start a conversation with the patient.

Title of the initiative What Matters to You

Names: Lisa Murphy, Angela Smyth, Hepsy John, Martina Higgins, Carolyn Donohoe, Olivia Laffert, Maura Rice, Geraldine Britton, Lorraine Cuddy

Organisation: St Vincents University Hospital (SVUH) and Midland Regional Hospital Portlaoise (MRHP)


Interviews were conducted by NCPOP and QID with the patients and staff in both pilot sites at the beginning of the project and have been repeated 6 months into the project. The data is currently being analysed.

What is the impact for patients and service users • Stop seeing the patient• Start to see the person

The biggest impact for patients taking part in the pilot programme is they feel like a person and not just an ailment in a bed. Starting the WMTY conversation with the patient helps the healthcare professional to understand what matters to them and their families/carers. The patient should feel they are receiving a unique patient experience as the multidisciplinary team provides patient centred care. We aim to deliver patient-centred care that allows the patient to have a positive experience in hospital. The personalised “What Matters to You” boards signify the dignity and respect the staff have for each individual patient to get to know them beyond the medical condition that has brought them to hospital. Open communication with patients helps them to articulate their wishes, goals, and concerns, and allows healthcare professionals to hear them, so an appropriate care plan can be created around the patient’s priorities. Each of the WMTY boards have a “Hello my Name is…..” bubble which encourages the patient to let staff know what name they prefer to be addressed by and reminds all staff to introduce themselves to the patient. The information on the boards has been used by the ward staff to reduce patients’ anxiety, by ensuring their specified wishes are carried out. It can also give peace of mind to patients’ relatives that all staff are aware of the patients’ likes and dislikes who use the information documented on the WMTY boards. Engaging with patients in all aspects of their care can greatly improve the patient experience. Examples of some of the information provided by patients and their relatives:

What is the impact for nursing and midwifery practice The project has had a positive impact on nursing practice across the two pilot sites. Communication is a vital element of nursing care. This project has given nursing staff the opportunity to develop deeper connections with patients, strengthened MDT relationships and created stronger connections within the ward team. From completed boards to date it is obvious that staff get a better “sense of the person” from the information obtained in this manner. The staff have been able to use the information provided by patients and relatives in certain cases to help to reduce a patient’s anxiety and agitation by ensuring their wishes or concerns were addressed. It allows staff to have more meaningful conversations and engage with patients on a more personal level. The boards’ visibility at the bedside allows for continuity in patient care. Improved staff satisfaction is based on the knowledge that this method of care provision has been tried and tested in the NHS Scotland and nurses understanding that getting the basics right is so important to patients. “What Matters to You” reaffirms the values of nursing care: compassion for our patients and their relatives/carers, care being the cornerstone of nursing practice and commitment to deliver nursing care that is tailored to the patients’ needs.

References HSE (2016). Service Plan. Health Service Executive.HSE & Age Friendly Ireland (2015). Listening to older people: Experiences of health services. Health Service Executive.


NMV B20

Demonstrates the Care value by providing quality and safe care.Demonstrates the Commitment value by engaging in evidence based care.Demonstrates Commitment value by taking responsibility and by intellectual engagement in the need for a quality improvement initiative to ensure timely care for patients with sepsis on the ward. Why the initiative was carried out “Sepsis is a life threatening condition that arises when the body’s response to an infection injures its own tissues and organs. Sepsis leads to shock, multiple organ failure and death especially if not recognised early and treated promptly.” ( Merinoff Symposium - Czura, 2011)

Staff on this busy 35 bedded surgical ward acknowledged that they had concerns with patients deteriorating due to sepsis and the processes around the current management of this cohort of patients. The staff on this ward recognized that the number of patients deteriorating needing escalation of care that were managed at ward level due to lack of intensive care bed capacity had increased. Data was collected to identify if the “hunch” that ward staff thought was a problem was in fact reality.

We commenced with a baseline audit of 8 patient charts from November 2015 which identified that the response time by a doctor once contacted by ward staff to review a patient deteriorating from sepsis was 53 minutes. Patients should be reviewed by the Senior House Officer (SHO) within 30 minutes of triggering with a score of 4-6. Other methods we used during our project were brainstorming workshops, process mapping of current state and open discussion with frontline staff about identifying improvements that could benefit patient outcomes.

Why was this project be done?

• Ensure timely quality patient centred care and better patient outcomes • Ensure that all patients are given an equal opportunity to survive sepsis • Concerns by all disciplines working on the ward that there were delays in the response time and treatment time of patients. • The current economic climate, pressure on targets, patient flow and activity based funding places the onus on all staff to create efficiencies and eliminate waste. • HSE corporate goal to improve staff wellbeing, job satisfaction and reduce stress levels. • Reduction in need for ICU beds for deteriorating patients by early identification and timely treatment. • Reduction in Average Length of Stay (ALOS) for patients.

Title of the initiative Pathway Granularity and solutions to Barriers to Sepsis diagnosis and treatment on a Surgical Ward

Names: Sinéad Horgan & Grace Reidy

Organisation: South/Southwest Hospital Group


How the initiative was carried out This involved multiple PDSA cycles within each of the above areas. Our aim was to reduce this time by 50% to 26 minutes by May 2015. The use of methodology such as current state mapping allowed the group to identify the many steps in place in the current process , explore what they felt the problems were analyse and get to the root cause of the problems. This was done by 2 workshops where the simple post-it practice of mapping the process was captured. This involved brainstorming sessions with multidisciplinary team. This project was nurse led yet involved pharmacist, medical staff, laboratory staff and Healthcare Assistants in an effort to ensure better patient outcomes by having a multidisciplinary approach.Using the model for improvement Plan, Do Study, Act (PDSA), the ideas identified were tested to develop workable solutions that would promote and change the culture around sepsis management. Our project consisted of a three tiered intervention:

1. Education sessions for multidisciplinary staff2. Introduction of a dedicated trolley for sepsis management3. Process pathway improvement for biochemistry samples4. Sepsis Wallet sized Guide to diagnosis and treatment given to all staff

This involved multiple PDSA cycles within each of the above areas.

What is the impact for patients and service users

Results: After a five month intervention period working with the team a further 25 charts were audited. Our results identified the doctor’s response time to review the patient had decreased from 53 minutes to 30.91 minutes.

Discussion: Financial and business planning will hopefully allow us to expand this project across all surgical specialties. This model is transferable to other hospitals.

Financial Implication:Currently in the acute hospital setting there is a bed capacity crisis with an increasing demand for Intensive Care / High dependency beds. The national average length of stay for patients with severe sepsis is 26 days. The hospital cost per 24 hours for a bed on ward X is €1316 and an Intensive Care Bed is €1722. The daily demands from waiting lists, patient flow and budget constraints optimizing patient centered care and outcomes is vital.

Conclusions:Our project has proved successful in improving the prompt management of the patient with sepsis. It has allowed interdisciplinary staff to come together with a common problem and agree a mutual goal. It has empowered staff to engage in and take ownership of their own quality improvement process, generate their ideas, and initiate tests of change, measure and monitor these test to develop workable solutions and improve patient outcomes. Through using the trolley system it promotes the use of the Sepsis form and use of the form will greatly increase the likelihood of correct recognition of severity of disease and timely administration of antimicrobials.

What is the impact for nursing and midwifery practice The impact for Nursing practice has been identifying a problem on the ward, coming together brainstorming for solutions and implementation of small tests of change to improve the quality of their care delivery. It allowed the team to ensure that the patient was central to this improvement. It empowered nursing staff to engage in their own quality improvement process and to engage with other disciplines to implement a workable sustainable solution. It emphasized to the nursing staff the that they are central to always looking at new ways of improving the quality of care they provide and that working together and believing in their core values as nurses small improvements can have a vital role in improving patient outcomes.


NMV B21

-The initiative aims to establish the first Chapter of Sigma Theta Tau International (STTI) Nursing Society. -It is a collaboration between three Higher Education Institutions (University College Cork, Institute of Technology Tralee, Waterford Institute of Technology) and the Nursing and Midwifery Planning and Development Unit Cork/Kerry. -The primary goals of the initiative were to recognise and celebrate the scholarship, innovation and achievements of nurses and midwives, and undergraduate students of the profession; establish links between nurses and midwives working in practice and those working in academia; and give nursing and midwifery in Ireland a voice in the global community of nurses. Why the initiative was carried out The founding members identified the need for a nursing and midwifery specific forum outside of trade union representation that recognizes and celebrates the scholarship, innovation and achievements of members. Sigma Theta Tau International is a society that aims to advance world health and celebrate nursing excellence in scholarship, leadership and service. Several benefits of developing an Honor Society of Nursing and Midwifery in Ireland as a prelude to a Chapter of Sigma Theta Tau International were identified: • Enhanced collaboration between nurses and midwives across all disciplines and work settings;• Provision of an internationally revered platform for celebrating and recognizing excellence in Irish clinical practice, leadership and academia;• Increased accessibility and engagement in continuing professional development workshops and activities;• Provision of mentorship programs for members e.g. established nurse leaders acting as mentors for early career nurses and midwives, member engagement in executive boards and committees;• Increased Irish nursing and midwifery participation in global nursing forums; • Increased number of nurses and midwives engaging in scholarship and translational research;• More nurses and midwives undertaking postgraduate studies and being supported to do so. It was also evident that this initiative would support the Health Service Executive development plans by contributing to: • Workforce development, by providing opportunities for professional/career development for nurses and midwives;• Preservation of staff morale, by creating a peer support network for nurses and midwives in Ireland, Europe and internationally;• Leadership and governance development, by implementing mentorship programmes for nurses and midwives;• Health research and policy development, by creating links between those most closely involved in the delivery of services and academics with the skills necessary to conduct high quality research. This will ultimately ensure that health research is coordinated, prioritized and clinically focused as well as creating greater opportunities for nurses and midwives to influence policy development and implementation.

Title of the initiative Development of the first Irish Chapter of Sigma Theta Tau International Honor Society of Nursing and Midwifery

Names: Elizabeth Weathers, Dawn Farrell, Nicola Cornally, Alice Coffey, Suzanne Denieffe, Catherine Buckley, Gerardina Harnett, Patrick Cotter, Agnes Walsh, Claire O’Gorman, Lisa Herrity, Ruth Lernihan and Fiona Willis

Organisation: SIA Honor Society of Nursing and Midwifery Ireland


How the initiative was carried out To achieve chapter status, the SIA Society have operated independently as an Irish Honor Society. Two professional development/educational events for members are held each year and over 50 members have been inducted. To date the following actions have been carried out: • Jan 2014, Steering Committee established;• Oct 2014, Pre-application submitted to STTI including institutional letters of support from UCC, WIT, ITT;• Feb 2015, Pre-chapter status granted;• Feb 2015, Board of Directors appointed;• March 2015, Seed funding sought and granted from UCC, WIT, ITT and NMPDU Cork/Kerry;• Nov 2016, 1st Induction Ceremony of 50 members;

Future actions include:

• 22nd May 2017, 2nd Induction Ceremony, Masterclass and launch of Strategic Plan;• Nov 2017, 3rd Induction Ceremony, Masterclass;• Feb 2018, submission of application for Chapter status.

The Board of Directors have worked tirelessly since 2014 to lay firm foundations for the Society. The commitment of the Board is evident in the achievements to date. The Board continue to be committed to nurturing a culture of support and solidarity amongst the nursing and midwifery profession, consequently enabling the values of care, compassion and commitment, outlined in the DoH Chief Nursing Officer Position Paper, to flourish across the profession.

What is the impact for patients and service usersThe Board of Directors consists of nurses and midwives from academia, administration, and practice, who are committed to promoting solidarity and collaboration among all nurses and midwives in every type of work setting. The Society events and workshops, along with the network established, will result in a large pool of highly educated, self-motivated, empowered and celebrated nurses equipped to lead the development of future health services. Society events will be focused on priorities in clinical practice such as topics related to improving patient outcomes and quality of care. The Society will communicate regularly with members to ensure activities are member-focused. Furthermore, collectively as a Society, there will be opportunities to publish position papers and contribute to national health service development plans. For example, one strategic objective of the Department of Health Statement of Strategy 2016-2019 is the delivery of high-quality safe health and social care. There are many actions under this objective including the establishment of a National Advisory Council for Patient Safety and developing patient experience indicators to be included in the existing national healthcare quality reporting system. The SIA Society could contribute collectively to these actions by nominating members to sit on the Advisory Council. Furthermore, the membership of the Society will include both clinicians and academic-researchers who could work together to conduct clinically focused research to support the development of indicators of patient experience and quality of care. This initiative is longitudinal and is expandable. The activities and focus of the Society will adapt to meet the evolving needs of patients and service users. The initiative is committed to the advancement of the nursing and midwifery profession, ultimately resulting in better outcomes for patients and better quality of care.

What is the impact for nursing and midwifery practice This initiative will support nursing-midwifery health initiatives that are aimed at improving quality in our health services – leaders of these initiatives will be sought out and invited to become honorary members of the society, with their work showcased in an effort to build interest and capacity for future quality driven service developments. Once Chapter status is achieved, members of the Chapter will have full access to the member’s area of the STTI website and members of the Board of Directors will have voting rights in all STTI matters and the opportunity to sit on the International Board and Committees. Furthermore, there will be many opportunities for networking with other Chapters across the world and engaging in mentorship programmes with world-renowned nurse leaders. Additionally, there is a European branch of STTI that includes Chapters in Wales, England, The Netherlands, Sweden and Portugal. The SIA Society has already engaged with members of the European Region who are supportive and keen to see the Society achieve Chapter status. Thus, this initiative is not a short-term one; rather it is a national initiative that is linked to an international programme of nursing and midwifery excellence spanning five decades and is therefore sustainable and expandable.


NMV B22

Compassion: Doing the right thing for all patients despite geographical location prioritising our patient’s best interests through the establishment of a therapeutic relationship not only between patients but between two organisations.

Care: Delivering evidenced based collaborative nursing care in a timely manner. Explaining procedures and what to expect. Every patient contact is an opportunity to promote future health.

Commitment: Professional courage is a core advanced nursing practice values, without which, this initiative would not have happened. Why the initiative was carried out Cardiology Registered Advanced Nurse Practitioners’ (RANP) in Tallaght (TH) and Naas Hospitals (NGH) provide collaborative clinical care by recognition of Acute Coronary Syndromes (ACS) and instigating early percutaneous intervention (PCI). The RANPs discharge lower risk chest pain patients with symptoms of stable coronary artery disease (SCAD) for follow up in local nurse-led chest pain clinics. During the chest pain clinic consultation a differential diagnosis is formulated which may necessitate further cardiac investigations.

Computerised tomography coronary angiography (CTCA) and Coronary angiography (CA) are gold standard investigations for detection of coronary heart disease (CHD). Within the hospital group, service inequity exists for some patients, as NGH does not have access to CTCA or CA. The potential SCAD patient in NGH is often admitted and medically transferred to Tallaght hospital for further testing, utilising 1,960 beds days in 2014 at an average age cost of €981 /day (Groake et al, 2013).

The context within which we organise and deliver health services is evolving. The RANP is a competent instigator of service development to improve pathways of patient care and fosters new ways of thinking. Recognising the unequal access to further cardiac investigations and bed days wasted, collaboration occurred between RANPs in the two separate organisations establishing a direct RANP to RANP referral service. This innovation offers expert assessment and accelerated access to the most appropriate cardiac investigations in a timely manner, providing equitable patient care despite geographical address.

This unique method of advanced nurse referral and expertise utilises the group resource to expedite access to a final diagnosis, avoiding admission and reducing hospital costs. The core value of ‘heart health’ underpins this new service development and the leadership ability of both RANPs drives our commitment to care.

How the initiative was carried out A collaborative proposal was prepared by the RANPs and approved by both hospitals’ Medical Directors and Consultants, resulting in formally established referral arrangements. Realistic demands for the service were outlined i.e. that the NGH demand would not impede TH patient care or place undue demand current resources. The ‘New Norm’ ‘Going the extra mile’ is a core nursing value of the RANP and the Tallaght RANP was happy to incorporate the extra patients into the chest pain clinic workload.

Title of the initiative Connecting Cardiology services through Advanced Nursing Practice - Nursing Values in Action

Names: Shirley Ingram, Jacqueline O’Toole, Niamh Kelly

Organisation: Tallaght Hospital & Naas General Hospital


Change management however; is difficult. A potential obstacle was the perceived increase in workload for certain stakeholders. A passion to advocate the best service possible for patients was demonstrated by the RANPs over 12 months of discussion. Kotter (Webster 2012) suggests that change is achieved through certain practices until the change becomes the new norm. Initial resistance was met due to the perception of increased workload; however perseverance and problem solving on the part of the RANPs negated this. This process was lengthy, however the RANPs maintained professional resilience, reinforcing the vision for improved patient centered care at the forefront of all negotiations until buy in was achieved. The joint RANP service has now become ‘the new norm’.

What is the impact for patients and service usersProviding quality and safe care is a paramount. Audit was undertaken to analyse outcomes of the patients referred. Twenty patients were referred, with an average time frame from RANP to RANP of 3 days. Further investigations were instigated and expedited on 18 patients by the TH RANP, negating hospital admission. The diagnostic yield of 15% confirmed CHD, was comparable to other chest pain services here in Tallaght hospital (15%), (Ingram et al, 2017) and in the UK (Robson 2012).

Subsequently, two year analysis of 73 referred patients reveals similar referral times with an increased diagnostic rate of 21% CHD, with 7% requiring PCI. Mortality outcomes to date indicate no deaths or readmissions at 30days. This suggests correct patient selection and safe, person-centred care.Whilst admission avoidance, patient safety and diagnosis are the key objectives, each patient encounter is an opportunity for health promotion and education by the RANPs, thereby reducing the potential future burden of CHD.

Collaborative research is currently underway with the School of Nursing and Midwifery, Trinity College Dublin, to ascertain the patients’ experiences of this new service initiative. This evaluation study will examine patient satisfaction/experience with the service and clinical outcomes. To date, subjective feedback is excellent.

It is envisioned that this referral service will assist other hospitals within the Hospital group that do not have RANP chest pain assessment services, in the form of RANP outreach clinics. The future vision includes the development of RANP led community chest pain clinics. The nursing aim is to streamline the services directly to the right person in the right place at the right time.

What is the impact for nursing and midwifery practice RANPs are pioneers and clinical leaders, implementing and initiating change in response to patient need. Professional leadership is a core competency of the RANP (NMNM 2008:7) and is embedded in the role. Utilising the expertise of highly trained RANPs in service expansion demonstrates effective use of the RANP as a driver of change and a clinical resource. This service development has been presented to senior nursing management within the group, recognising the determination and the commitment to care by nurses advancing their practice with patients at the forefront.

The service is now in its 4th year, it is the first of its kind and utilises the expertise of Cardiology RANPs within the hospital group without the need of extra funding/resources. The research project will add to the body of work on advanced nursing practice in Ireland. Pearson (2011) acknowledges the ‘entrepreneurial spirit’ of advanced nursing practice. As Cardiology Nurse Practitioners we embrace the core values of nursing in an effort to provide safe, quality care. The initiative provides a model of advanced nursing care, within the current environment of reduced NCHDs, and interdisciplinary care within the fledgling hospital group and demonstrates a commitment to the development of patient care.


NMV B23

This initiative allows enhancement of the lives of individuals with intellectual disabilities & behaviours that challenge to experience a better quality of life and a more seamless integration into society. The initiative supports staff and families to be educated and informed of how best to support and care for individuals with an intellectual disability and behaviours that challenge.

The initiative provides a pivotal role in the multidisciplinary team that support the development of supported self-directed community living. It aims to ensure that a compassionate approach is taken to the difficulties experienced by individuals with intellectual disabilities when making this transition to community life.

This overall initiative shows the ongoing commitment of the Brothers of Charity Services to the professional development of it’s nursing service and to the service users whom it supports. Why the initiative was carried out The initiative was to ensure that the RANP would be an integral part of the multidisciplinary team including direct care nursing staff and care assistants. The RANP will be liaising with the psychology department, the occupational therapy department, physiotherapists, social work departments and speech and language therapy department. A referral in and out process between the RANP and the multidisciplinary team was agreed and this allowed for the core nursing values of Care, Compassion and Commitment to be further enhanced in the services. The RANP will also be responsible for training in relation to behaviours that challenge and a lead professional clinical holding.

The purpose of this initiative was to:• Meet the needs of the service users presenting with intellectual disabilities and behaviours that challenge.• Ensuring early intervention to prevent escalation of behaviours.• Provide continuity of care as an expert practitioner with the specific skills and competencies to manage a range of behavioural presentations.• Improving service user outcomes through health promotion and education opportunities while engaging with service users, their families and/or carers. • Act as a resource for nursing and healthcare professional colleagues within the Brothers of Charity Services Galway.• To ensure that medical procedures such as phlebotomy, administration of medication and other necessary medical interventions are conducted in a manner which protects the rights and dignity of the individuals supported by the service• Liaising with families is an essential component of the role, to support people within the family home and within their own community school or day placement. It is also to ensure continuity of care across all aspects of the person’s life. • To ensure the implementation of HSE National Policies including New Directions, Time to Move On and develop practice to be compliant with HIQA standards for social care services

How the initiative was carried out The Brothers Of Charity provide a wide range of services with an emphasis on community based services provided mainly through four community-oriented teams, our Early Childhood Services, our School Age Team, our Aftercare team and Supported Employment, and our Ballinasloe-based multidisciplinary team. This work is supported by a range of multidisciplinary specialists and there is a network of respite care and a family support system. The service recognised the need for advanced skills that an Advanced Nurse Practitioner would bring to the service in providing supports to individuals with an intellectual disability and their families..

Title of the initiative The development of the Advanced Nurse Practitioner (Intellectual Disabilities) Services Galway

Names: Aoife O’Donohue, Maurice Healy, Ann Loughney, Tony Gallagher

Organisation: Brothers of Charity, John Paul Services Galway


In 2015 the Sector Manager in discussion with the Manager of Human Resources and the Nurse/Midwifery Practice Development Officer CNME Castlebar identified the Brothers of Charity as a prime location for the establishment of a site for development of an Advanced Nurse Practitioner.An Intellectual Disability cANP Stakeholders Group was established comprising Ann Loughney Sector Manager, Anthony Gallagher Area Manager, Aoife O’ Donohue Director of Nursing, Carmel Hoey NMPD Officer, Mary Davis Head of Psychology & Maurice Healy Candidate ANP. The role of the stakeholder group was to

• Identify Service User Caseload and establish consensus to proceed with service development • Establish Referral Pathways • Develop supporting documentation • Agree Clinical Supervision

Site visit was carried out on the 12th April and The Vice President of the NMBI and the Education officer visited the Brothers of charity services in Galway. A Board decision will be made on the 9th May 2017.

What is the impact for patients and service usersThe Brothers of Charity Galway operate services from Ballinasloe in the East to Carna in the West and from Clifden in the North of the county to Gort in the South. In County Galway the Brothers offer a service to 1,032 people who have an intellectual disability and their families. Those who use our services are divided about equally between children (48%) and adults (52%).

• The role of the cANP has facilitated and coordinated the development of a multidisciplinary approach to service user care and this has benefited the service user and accelerated the appropriate care pathways. • cANP has identified health promotion priorities and implements health promotion strategies for service users within the RANP Scope of Practice.• The cANP is responsible and accountable for independently coordinating effective referral processes to other health care professional colleagues.• The cANP is initiating timely and appropriate consultations to healthcare professional colleagues according to collaboratively agreed referral pathways.• The cANP possess a highly developed knowledge of behavioral situations requiring focused interventions and an in-depth understanding of specific interventions deemed as best practice in the management of such situations. This allows for the delivery of best practice to individual service users.• cANP has examined methods of improving practice through exploration of clinical practice issues within intellectual disability services and collaboratively develop clinical practice guidelines and research/audit initiatives.• cANP has improved primary care links with General Practitioners (GP’s) ensuring that relevant personnel receive written information regarding the service users’ management and follow-up care. • cANP has developed documentation to support a complete episode of care in an accurate, timely and comprehensive manner according to BOC Records Management Policy. This is in keeping with the nursing process of Assessing, Planning, Implementing and Evaluating using the Roper, Logan, and Tierney Nursing Model. • The overall initiative supports a services response to service user need and service demand in a proactive manner. What is the impact for nursing and midwifery practice It is of vital importance that the nurse in intellectual disability practice is recognised as a vital cog in the wheel of future services for people with intellectual disability. It is clear from the establishment of the RANP site that the Brothers of Charity services are committed to nursing and advancing the clinical pathways for RNIDs within their service. The establishment of an RANP post is a clear indication that such pathways exist for those nurses and their career progression. It allows for the establishment of educational links to be made between the Brothers of Charity Services and the educational institutes of National University Of Ireland Galway (NUIG) and with St Angela’s College Sligo. Other links are also established between Athlone Institute Of Technology & Limerick Institute of Technology.

Overall this initiative has enhanced the role of the RNID as a clinical expert in their service areas allowing vision to become reality. The nursing values of Care, Compassion and Commitment have become a living component in the life of each individual supported by the Brothers Of Charity Services and has become an integral part of the professional service delivered by each nurse on a daily basis.


NMV B24

The adoption of the Careful Nursing Philosophy and Professional Practice Model that embodies the nursing values of Compassion, Care and Commitment.

The adoption of a standardised nursing language that reflects the unique contribution that nursing care makes to patient outcomes in an episode of care.

The preparation of nursing documentation for the Electronic Health Record by using a standardised nursing language i.e. the North American Nursing Diagnosis Association International (NANDA-I), Nursing Interventions Classification (NIC) and the Nursing Outcomes Classification (NOC). Why the initiative was carried out The Nursing Documentation project commenced on January 1 2016 in response to the identification of nursing documentation as a key priority for improvement by the Directors of Nursing and Midwifery in the South/South West Hospital Group (SSWHG).

The purpose of the project was the review of current nursing documentation in the medical and surgical services of the SSWHG, with a view to recommending an evidence-based, standardised system of nursing documentation that meets the clinical needs of patient’s as well as fulfilling the professional requirements of registered nurses.

Furthermore, to facilitate and contribute to the eHealth strategy for Ireland and the planned introduction of an Electronic Health Record (EHR), nursing documentation must be ready to transition from paper to an electronic format. In order that the distinctive nursing component of care to patients is accurately represented and readily identifiable in the EHR, standardised nursing languages that can also promote better communication and support decision making across healthcare settings and disciplines have been reviewed.

Best practice in the use of nursing assessment tools, nursing assessment frameworks and nursing models of care has been considered and presented to the SSWHG DONs. Extensive investigation into nursing documentation, nursing practice models and the standardised nursing languages in use nationally and internationally has been carried out and presented to the Nurse Practice Development Steering Group (NPDSG) and the SSWHG DONs. This has facilitated the SSWHG DONs in reaching consensus on the selection of the preferred model of nursing and standardised nursing language to be used in the SSWHG. The Careful Nursing Philosophy and Professional Practice Model and the standardised nursing language that is implicit in the model the North American Nursing Diagnosis Association (NANDA), Nursing Interventions Classification (NIC} and the Nursing Outcomes Classification (NOC) is currently being piloted in the acute medical ward of one of the SSWHG hospital sites. How the initiative was carried out A Project Officer for Nursing Documentation was, appointed in January 2016. The Nurse Practice Development Steering Group’ (NPDSG) with agreed terms of reference and with representation from all of the hospitals in the SSWHG as well as the School of Nursing and Midwifery, University College Cork was established.

The current nursing assessment frameworks in use across the SSWHG were reviewed and to ensure that a robust, person centred and standardised approach to nursing assessment was enabled, it was redesigned using a combination of Roper, Tierney and Logan’s Activities of Daily Living and Gordon’s Functional Health’Patterns.

Title of the initiative The introduction of the Careful Nursing Philosophy and ·Professional Practice Model to a number of

hospitals in the South/South West Hospital Group as part of a nursing documentation project

Names: Catherine (Kay) O’Mahony

Organisation: South/South West Hospital Group


The nursing assessment tools were studied and it was agreed that the following six assessment tools will be used:

• A Nutritional Screening Tool• A Falls Risk Assessment Tool• A Moving and Handling Risk Assessment Tool• A Pressure Ulcer Risk Assessment Tool• A Bed rail Risk Assessment Tool• An Infection Prevention and Control Assessment Tool

Care plans using the NANDA-I, NOC and NIC standardised language were developed. The concept of nursing diagnosis was introduced as a further step in the nursing process i.e.

• Assessment• Diagnosis• Planning• Implementing• Evaluating

A two day training programme was developed and delivered to the staff on the selected pilot sites. An audit tool and a documentation policy is currently being developed.

What is the impact for patients and service usersThe adoption of the CarefLI Nursing Model and the concomitant revised documentation will result in safer, better nursing care for patients. The three philosophical underpinnings in the Careful Nursing Model i.e. Infinite Transcendent Reality in Life Processes, Nature and Inherent Dignity of the Human Person and Health as Human Flourishing encourages nurses to adopt a truly person centred approach when caring for patients. The revised assessment framework allows nurses to gain a comprehensive overview of the patient incorporating the physical, psychological, spiritual and social domains. The importance of the nurse patient relationship and the embodiment of some of the models concepts such as ‘great tenderness in all things’, ‘therapeutic milieu’ and ‘contagious calmness’ fosters a restorative environment where patients can heal. Already, the implementation of the pilot in an acute medical ward has resulted in a hospital wide initiative that encourages visitors to the hospital to adhere to the hospital visiting times so that patients are given adequate time to rest. The concepts of ‘patient engagement in self care’ and ‘family, friends, community supportive participation’ remind nurses to involve and engage the patient and his/her family/carers in the plan of care. The patient’s progress over time is captured by use of a rating scale to measure outcome indicators in the plan of care. What is the impact for nursing and midwifery practice The standardisation of the nursing documentation and the use of the standardised language, NANDA-I, NOC and NIC facilitates optimum communication within the nursing team and gives nurses the language to articulate the unique nursing interventions within the multidisciplinary team. The revised documentation is designed to promote compliance with the NMBI ‘Recording Clinical Practice Guidelines’ as well as HIQA standards. It will also result in improvements in the Quality Care Metrics.

The adoption of NANDA-I, NOC and NIC ensures that the nursing documentation is moving towards being prepared for the Electronic Health Record and that nursing interventions are easily identifiable within a health care record.

The use of nursing diagnosis augments nurse’s ability to use their clinical reasoning, problem solving and decision making skills thus ensuring safe, high quality care for patients in their care


NMV B25

3 Key points about the values initiative Care - Family Centered Care: Promoting inclusion in decision making and partnership between clinicians and adolescent patients, rather than the traditional paternalistic approach.

Compassion – Web-based health information is becoming a pivotal aspect of healthcare provision. It enhances adolescent patients’ ability to communicate with healthcare professionals reduces stress and assists them in becoming more involved in shared decision making.

Commitment - Quality: Adolescents are a unique group with specific requirements as to the method of information dissemination. The provision of high quality information, verbal and web-based and written, prior to procedures increases their knowledge, notably reducing their distress. Why the initiative was carried out Recent emphasis on children and young peoples’ inclusion in decision making about their health and well - being has seen the development of a number of Government strategy and policy documents. Provision of information is recognised as a pre-requisite to the child’s/adolescents’ effective participation in healthcare decision-making (Committee on the Rights of the Child, 2010:25), and so is essential to promote the child’s rights in healthcare. Better Outcomes, Brighter Futures 2014- 2020 was published and its main aim is to promote a culture that listens to and involves children and young people. The National Strategy on Children and Young People’s Participation in Decision-Making 2015-2020, was launched to ensure that children and young people have a voice in decisions. Providing a child with appropriate information about a forthcoming hospitalization is recognized to be an important factor in minimizing distress and helping him/her generate accurate expectations (Jaaniste et al. 2007).

The author was aware that although the Paediatric Unit in her organisation had a number of information leaflets for younger children and their parents, there wasn’t any adolescent specific printed or web based information, available for adolescents to access prior to or during their visit to hospital. Coyne & Kirwan (2013) identified in their research that dissatisfaction among adolescents was caused by insufficient information, lack of involvement, and inadequate play facilities. Their wishes were mainly concerned with the need for more information and more involvement in communication interactions with doctors and nurses. Although, health information is more readily available to adolescents and their families, adolescents as a unique group have specific requirements as to the method of information dissemination. Web-based health information is becoming a pivotal aspect of healthcare provision and adolescents are the defining users of technology therefore a web based information site was deemed to be the most appropriate.

ReferencesCoyne, I. & Kirwan, L. (2012), Ascertaining children’s wishes and feelings about hospital life. Journal of Child Health Care. vol. 16 no. 3 293-304.Department of Health and Children (2014) Better Outcomes, Brighter Futures: A government national framework, 2014- 2020Department of Health and Children(2015) The National Strategy on Children and Young People’s Participation in Decision-Making 2015-2020,

How the initiative was carried out Following an extensive literature review on the information needs of adolescents a number of themes emerged; international/national adolescent policy developments, stress/ fear of unknown, shared decision making, communication with healthcare staff; adolescent multimedia usage. The emergent theme of adolescent anxiety as a causal effect due to lack of information was also highlighted.

The HSE change model was used to guide the change process, including strategic and stakeholder analysis, initiating, planning and implementation.

Title of the initiative Development and implementation of Adolescent section “Your Visit to Us” in hospital website

Names: Bebhinn O’Sullivan

Organisation: Cork University Hospital, HSE


1. Consultation with relevant CNM’s & CNS, ADON Children’s Services and Clinical Director Women and Children’s Directorate2. Consultation with hospital IT web developer4. Consultation with relevant MDT members including Speech & Language, Dietician, Play Specialist, Medical Social Workers5. Paediatric Quality & Safety Steering Group6. Hospital Web Governance group chaired by hospital CEO7. Information needs analysis survey distributed via CNM2 8. 80% of adolescent said they would access the CUH website if online information was available9. Website content developed in consultation with relevant stakeholders and worked closely with of hospital IT web developer to develop the site10. Reviewed by relevant stakeholders and suggested changes made11. Trialled for 2 weeks and satisfaction survey performed12. Website went live

What is the impact for patients and service usersThe overall aim of the development and implementation of the adolescent website section in the organisations’ website was successfully achieved • The information delivered on the website proved to have significant benefits to adolescents and their reduction of anxiety about being admitted to hospital

The CIPP Model was employed to guide the evaluation The project was evaluated against a number of objectives using analytical tools, information needs survey, organisational statistics and informal feedback

• Post implementation surveys were conducted to measure satisfaction with the website and adolescent anxiety levels:1. The provision of information, verbal and written, prior to procedures has increased their knowledge, notably reducing their distress 2. It enhanced their ability to communicate with healthcare professionals to assist them in becoming more involved in decision makinga) 78% of adolescents were satisfied with the level of information on the siteb) 56% of adolescents reported to be less anxiousc)67% felt they were more involved in their cared) 56% reported that they felt more at ease speaking to their healthcare team after reading the information on the website

What is the impact for nursing and midwifery practice 1. Nurse Led initiative2. Staff feedback was excellent regarding how this initiative has contributed to patient care. 3. Nurses inform all adolescent admissions of the children’s services website4. CUH nurses are proud of this nurse led initiative – which demonstrates care, compassion and commitment , reflecting the child and family centred philosophy of care within the unit.5. Enhances communication resources for nursing staff to complement their nursing care6. Provides further information resources for our patients and their families7. Led to the development of nurse/student led child/parent guardian information leaflets8. Further development of additional sections on the Children’s Services website. See: http://www.cuh.hse.ie/Children-s-Services

This initiative has very positive impact for not only nursing practice but the paediatric multidisciplinary team in CUH.

Sustainability: Nurse Representative on CUH Web Governance committee ensures sustainability and further evolving of the initiative.


NMV B26

Improved patient care through the adoption of international best clinical practice in the management of patients with sepsis which required collaboration across the disciplines of Emergency and Critical Care.

A multidisciplinary approach to embracing change and engaging in implementation of international guidelines while continuously considering changes in the clinical evidence base.

Development of a sepsis management template to record and account for the patients’ pathway in the effective management of their condition. Why the initiative was carried out “Sepsis is now defined as life threatening organ dysfunction cause by a dysregulated host response to infection” (SSC, 2016). International sepsis campaigns advocate early sepsis care, resuscitation bundles and timely referral to critical care demonstrate 20-30% reductions in mortality from severe sepsis/septic shock.

Our aims initially, as a team in Cork University Hospital (CUH), were to align our goals with the international Surviving Sepsis Campaign (SSC) standards and subsequently with the goals of the Sepsis Management-National Clinical Guideline No. 6. Surviving Sepsis Campaign 2002, Barcelona Declaration, aims to reduce severe sepsis & septic shock mortality worldwide by 25% in 5 years. Hospitals who have participated in the surviving sepsis campaign have demonstrated a year on year improvement in survival rates therefore it was intuitive that CUH would embrace the change.

In 2012 results of clinical audit in ED CUH demonstrated scope for improvement in our care of patients with sepsis. Seeing in in excess of 65,000 patients annually, patients with sepsis constitute a significant proportion of our patient cohort. While data collection surrounding the number of patient presentations with sepsis was lacking, it was anecdotally noted as needing significant clinical resources. As reported by the CDC, 80% of sepsis cases begin in the pre hospital environment (Centre for Disease Control and Prevention, 2016).

The initiative was commenced with the aim to increase and sustain the sepsis survival rate by up to 25%. The project commencement in the ED was intended to be the beginning of the process of formal sepsis screening, in conjunction with the NEWS programme, within the entire hospital.

How the initiative was carried out Commitment to this effort was paramount. A team ethos across disciplines and departments was fostered by the inclusion of all stakeholders.

To achieve the quality care target, an active multidisciplinary working group took responsibly for planning, documentation development, education, and evaluation of activities using the LEARN SSC framework. Formalisation of work processes was integral.

A sepsis education package was devised and delivered to broaden health care professionals’ knowledge and understanding of sepsis and to garner them with information to highlight the scale of the sepsis problem internationally. The education was largely based on table top simulated cases where problem solving and scenario based learning was fundamental to the process. It was formulated to work cohesively with the National Early Warning Score National Clinical Guideline No.1.

Title of the initiative Team Sepsis - The Leadership Journey, Lean, Reflect, Apply

Names: Elaine O’Farrell, Eileen Kelly, Claire Costigan

Organisation: Cork University Hospital, HSE


2011 CUH Governance Committee established September 2012 Local ED discussion regarding SSC GuidelinesJanuary 2013 Audit and Survey in ED CUHApril 2013 Sepsis Seminar in CUHNovember 2013 Collaborative documentation development commenced March 2014 Education package delivery and continued inclusion of the programme at induction May2014 NEWS protocols and Sepsis pathways commenced in ED October 2014 CUH Data Entry to the SSC Database commenced November 2014 Sepsis Management-National Clinical Guideline No.6 launched December 2014 Review and edit of sepsis pathway documentation February 2015 Appointment of CNM2 Sepsis Management March 2015 ED Clinical Risk Meetings regularly review Sepsis Cases August 2015 ED CRMs formally table Sepsis as a monthly agenda item September 2015 After action reviews with Emergency Nursing staff commenced November 2015 National Sepsis Documentation merged with CUH documentation March 2016 International Health Institute for Healthcare Improvement Reliably Reducing Sepsis Mortality 9 month Programme-MDT presence April 2016 Engagement in National Sepsis Documentation Audit June 2016 Antimicrobial Prescribing Audit & presentation of results to ED CRM January 2017 Increased clinical bedside support and teaching in the ED with the Sepsis CNM2 February 2017 CUH deteriorating patient governance committee structure re launched April 2017 Current pilot in CUH of National Sepsis Documentation which incorporates SSC 2016 recommendations

What is the impact for patients and service usersExcellence in care through use of specific evidence based pathways and practice ensures that patients have received the care appropriate to their condition. Through striving to achieve best outcomes for patients, service users have experienced a greater level of compassion, engagement and empathy.

Patients benefit from enhanced patient advocacy now that specific sepsis training is provided to all staff who care for them. When healthcare professionals are equipped with enhanced knowledge and communication tools the resulting improvement in confidence and empowerment has meant that clinical escalation of patient deterioration is more effective.

Improved patient outcomes are the ultimate impact for service users from this initiative. October 2014 to May 2016 data collection in CUH has demonstrated a quarter on quarter improvement in survival from severe sepsis. The aim of the SSC 2002 was to reduce mortality worldwide from severe sepsis and septic shock by 25% within 5 years. From commencement of the project in CUH to present we have achieved and exceeded this aim. Sepsis management is a continual improvement cycle.

What is the impact for nursing and midwifery practice This initiative has demonstrated that nursing staff have been open to change and have taken responsibility for embracing new evidence promoted based confidence practice in amongst the nursing pursuit of staff in lifelong their learning. provision of Engagement safe in quality this care quality to care patients. improvement Promotion of journey learning, confidence and critical thinking through education has served to improve professional judgement, open interdisciplinary communication and patient advocacy.

While receptive, there the was cultural an acceptance challenges in and terms recognition of change of to the need practice to has improve required our a practice number in of this additional element of initiatives, care and some staff of which are ongoing, These initiatives included ongoing clinical supervision, support and bedside teaching, visits from the national project lead to the hospital as well as clinical audit and reviews at clinical risk meetings as detailed below.

Measurement of quality care indicators through use of clinical audit and subsequent feedback to nursing staff has fostered bidirectional respect and learning. Ownership of the patient pathways and care delivery lies with frontline clinical staff, hence ensuring professional responsibility and accountability. The inclusion of sepsis as an agenda item at departmental clinical risk meetings and completion of after action reviews enables case presentations to be openly discussed and reviewed, Involvement of all healthcare professionals including nurses at these forums allows for constructive professional development through review of practice, Recommendations arising from these individual forums focus performances. on In this improvements way our of care hospital for this creates group an of open patients, culture The for focus learning, is on the change and systems and leadership.


NMV B27

At the heart of our paediatric renal/endocrine ward is our healthcare professional’s passionate drive to consistently deliver care that coincides with their values of compassion, care and commitment. In light of same, our ward has undertaken a new initiative “What Matters to Me?” in an endeavour to re-affirm these values and further prosper patient-centred-care. “What Matters to Me” is a method of giving children the opportunity to voice what matters to them individually; thus facilitating healthcare professionals to gain a greater understanding of their patients and enable the optimum delivery of patient-centred-care. Each patient designs their own poster with colourful arts and crafts to communicate what matters to them; such matters are as simple as “liking mammy to stay the night with me, I like my blood pressure to be taken on my left arm” etc. and these posters are then displayed at the bedside and retained in patient’s nursing folders. Our ward was inspired from previous work in Scotland by Jennifer Rodgers who has proven that such an initiative has had extremely positive outcomes for both patients and staff. Therefore, we strived to initiate such a change in our ward to achieve excellence in positive patient outcomes during hospitalisation.

Compassion: Building a trusting rapport with patients is fundamental to delivering high quality care. In this initiative we wanted to delve into the everyday matters which not only are important to our patients, but also define our patient’s personalities. Truly knowing one’s patient and acting upon their individualised wishes is the very essence of providing compassionate care, thus creating a more pleasant hospital experience for our patients.Care: Whilst we consistently practice holistic assessments of patients, we felt the call to further this assessment and provide children with a real opportunity to voice their own individual matters. We want to practise open communication, encourage personal choice and highlight the importance of thoughtfully listening to our patients. We strive to focus on understanding our patients as individuals and advocate for them respectively, therefore delivery nursing care in an individualised manner.

Commitment: In an ever changing nursing environment, our staff is committed to being resilient and providing patient- centred- care at all times. We were open to initiating a reform in practice towards ensuring positive patient outcomes and hence What Matters to Me was implemented. We wanted to dedicate ourselves as healthcare professionals to effectively engage with our patients to intensify the delivery of quality patient-centred-nursing nursing care. It was acknowledged that such change takes dedication, commitment, enthusiasm and perseverance. Hence, leaflets pertaining to What Matters to Me were rolled out, a launch day was advertised via posters/verbal communication and then the launch day itself was held on the ward, highlighted to families by What Matters to Me banners, balloons, photographs etc. Furthermore, a run chart was developed to track our day to day progress in implementing our new initiative, enabling evaluation and consequent amendments where necessary. Why the initiative was carried out This initiative was carried out following inspiration from previous work on this topic in Scotland by Jennifer Rodgers. Such work proved to be extremely beneficial for positive patient outcomes and additionally benefited staff in that they felt more equipped to deliver patient-centred-care following the open declaration of patient’s matters. As our ward is a renal/endocrine ward we often care for chronic patients and understand the importance of genuinely knowing our patients and their wishes, in order to deliver quality care. We develop trusting rapports with our patients and in turn experience great fulfilment in understanding and responding to each patient’s individual needs.

We wanted to provide all children admitted to the ward both acute and chronic with a real opportunity to voice their own needs and wishes in a child-friendly manner. Furthermore, we acknowledged that whilst patients with chronic illnesses are nursed by us over a period of time, they too are developing and evolving their personalities and so as healthcare professionals we must keep up with this change and deliver care accordingly. Caring is accredited as the very essence of nursing, and so in order to practice quality care healthcare professionals must really gain an insight into their patients on an individual basis. To ascertain what really matters to children, we must consistently encourage open communication, personal choice and effective listening- which are the key components underpinning the “What Matters to Me” initiative.

Title of the initiative What Matters to Me

Names: Aoife Ryan, Karen Cunningham, Lauren Clarke

Organisation: St.Michael’s C Ward, Temple Street Children’s University Hospital, Dublin


How the initiative was carried out The initiative was carried out by firstly appointing two healthcare professionals as leaders which would advocate the initiative and begin to roll it out throughout the ward. Meetings were held by the ward CNM and leaders, where plans were devised on how best to implement and sustain “What Matters to Me” , what resources would be required and what factors may hinder the sustainability of such a positive change in practice. It was identified that advertising the initiative was fundamental to informing other staff, parents and children of the forthcoming implementation. We distributed leaflets explaining “What Matters to Me”, and designed a large poster advertising a launch date for the initiative on the ward in a high visibility area. We then held the launch day, which highlighted the initiative to children, parents and staff via banners, balloons, pictures etc. Resources were obtained as we decided it was best to have a pre-made colourful box at hand to give to patients which consisted of arts and crafts and an information leaflet. These boxes were then categorised into the age groups of 0-3 years, 3-11 years and teenagers, as we recognised that different age groups had different interests and so we pre -made these packs age appropriately. The idea of pre making these packs was to overcome the pre-empted obstacle that staff may face due to time constraints during their shifts to roll out this initiative. Finally, a run chart was developed to track the wards progress on the implementation of “What Matters to Me”.

*Images: Left image, our working progress in pre- making the “What Matters to Me” boxes. Right image , our launch day of “What Matter to Me”

What is the impact for patients and service users“What Matters to Me” has already proven to have an extremely beneficial impact for our patients and their families. Patients happily smile on receiving a colourful box full of crafts that they can work with to highlight their wishes, needs and personal choices. They take their time in formulating their own personal poster and take great pride in their finished product which is displayed over their bedside. Moreover, healthcare professionals can now respond accordingly to their individual preferences, which in turn results in a happier patient and a pleasant hospital experience. Patient- centred-care is intensified throughout the ward, as there is now an increased awareness of gaining a more in depth insight into each patient which significantly improves communication between patients and healthcare professionals. Additionally, family centred care has also prospered as many patients will complete the poster with their siblings during visits and their parents. For patients who wished to be photographed with their posters, we obtained written consent from their parents and the hospital photographer took photos of these smiling children with their own personal poster. Patients who previously displayed fear/anxiety to certain nursing equipment which was voiced in their “What Matter to Me” are now more at ease due to certain simple changes by healthcare staff, for example one child’s poster stipulated that they did not like the “yellow tray”, this was relating to the yellow clinical tray and so a simple switch to a white tray proved very effective. Overall, simple changes by healthcare professionals have made a big difference to our patients. *Image: Our run chart utilised to track our progress in implementing the “What Matters to Me” initiative

What is the impact for nursing and midwifery practice The initiative “What Matters to Me” has had a very significant impact for nursing practice. Such a scheme enables us as healthcare professionals to consistently practice our values of care, compassion and commitment. We are passionately dedicated to understanding our patients as individuals and delivering safe, quality care. “What Matters to Me” has heightened our ability to engage more thoroughly with our patients in an endeavour to understand their personalities and choices. The feedback from parents/family members has already been very positive; having voiced such statements as “you know us well” etc. when we deliver care in accordance with their children’s posters and when we communicate about the child’s interests which are displayed on the poster. When healthcare professionals respond to each patient’s individual needs, the patient begins to display a more trusting rapport, enabling the patient and healthcare professional to work together in harmony with the mutual goal of a positive hospital experience and patient outcome. Whilst children are in hospital many different members of the multidisciplinary team are involved in their care. As a result, it is of prime importance that all members of the multidisciplinary team have a patient basis to work with and “What Matters to Me” is the perfect tool to enable same. It is recognised that truly knowing ones patient is indispensable in the effective delivery of high quality patient care and we believe that this initiative is positively conducive to achieving clinical excellence.


NMV B28

Compassion, care and commitment are at the core of the community midwifery team based in the NMH. Through collective leadership, the author, namely the CMM3, drove this project to success by enacting these values to all team members. This project was named “Back to Basics” demonstrates how the utilization of these simple core values provides a mutually beneficial opportunity to both service users and service providers. One key outcome of the “Back to Basics” project was midwives reporting greater work satisfaction as they feel they are returning to the roots of “being with women”. In addition, women have positively evaluated each component of this project positively. A summary of this project is depicted in figures 1 and 2. Figure 1 – Demonstrating the three complimenting parts to the “Back to Basic Project”

2.The author believes there is a collective obligation on leaders in addressing the shortage of midwives and the case complexity within the maternity services presently through the enactment of core values. The ability of midwifery leaders supporting midwives to support women leads to obtaining a sustainable workforce which provides excellent health care. This initiative aimed to influence society, public policy and culture beliefs around safety and benefits in midwifery led care.

3.Aligned with the recent publication of the Maternity strategy this project aims to offer an accountable service and bring to life the better safe maternity care guidelines through normal risk pathways. These policy documents were published following high level multidisciplinary team discussions which included service user involvement. Interestingly, during the development of these policy documents the Directors of Midwifery called for innovative measures to support women to have physiological birth within this hospital. The community midwifery team set about creating a project that would share the team’s vision and philosophy of promoting physiological birth. The philosophy can be seen in figure 3 which the author believes depicts the three values compassion, care and commitment.

Why the initiative was carried out TOn a micro level this project was brought about by two main stimuli. In addition to the call from our Director of Midwifery to develop a change project as previously stated, the backdrop of this project was a research paper. The results from the cross sectional quantitative and qualitative research project entitled ’An Evaluation of Midwife-led Domino & Homebirth Services’ where women stated they wanted clearer, consistent, accessible information on natural birth in addition access to simple tools to support normal birth.

Title of the initiative Back to Basics

Names: Teresa Mc Creery

Organisation: National Maternity Hospital


The “Back to Basics” initiative consists of three complimenting parts namely pregnancy and birthing booklets; a hopscotch birthing tool and the introduction of mobile monitoring in the labour ward. The aim of this project was to empower midwives and women in the promotion of physiological birth through highlighting the importance of remaining upright and mobile in labour. On a macro level this project was initiated in response to the notable national and international increase in interventions within maternity services and sadly a decreased service user satisfaction. Irish maternity service delivery is currently in a setting that is over exposed to volume with increasing case complexity. The shortage of midwives has also left a major challenge nationally to create a mechanism to meet the needs of the maternity health system. The community team was set up at The National Maternity Hospital in 1999 and the service has been recognized by the maternity care strategy as a template for the ideal care pathway for low risk women. It is a highly popular scheme with women but unfortunately has a strict geographical limit. This project allowed the philosophy of the team to reach more women with the aim to provide women with more choice within their birthing environment.

How the initiative was carried out This project was largely successfully through the deep commitment and passion for women centred midwifery care by the team. A collective leadership style was adopted whereby each team member is driven by a mutual purpose and shared vision namely to provide our service users with support tools to assist in obtaining a normal birth. The core values of the team were a source of motivation also. A physiological contract of a ‘win-win agreement’ was present and team morale was raised during the process. Much of this project was undertaken on the discretionary time by the team, which further highlights the team’s passion to improve women’s maternity experience. This was an enriching experience for the multi-disciplinary team at large. The process used to achieve the aims of this initiative was as follows: A cross sectional quantitative and qualitative research project entitled ’An Evaluation of Midwife-led Domino & Homebirth Services’ reported women wanted clearer, consistent, accessible information and tools to assist achieving a normal birth. HSE change model was used to initiate, plan, develop and implement the projects to meet women’s needs. Drafts sent to small focus group and staff, and comments taken on board. The feedback was taken seriously and many drafts were resubmitted for review and discussion.Qualitative and quantitate data was obtained on all the initiatives with exceptional results.

What is the impact for patients and service usersProviding women with knowledge through the booklets and a simple tool for labour, namely labour hopscotch, promoted normal birth. Firstly, the Pregnancy Information Booklet and the Labour and Birth Information Booklet were one of the innovations as seen below. The design and content of both booklets in keeping with the philosophy and values of the team, focused on keeping healthy, mentally, emotionally and physically with an emphasis on optimal fetal positioning. The birthing Information booklet further emphasised the importance of keeping mobile in labour with the added objective to empower women through positive reinforcement of their innate ability to birth. Careful consideration was employed in the production of the booklets, which are visually appealing, containing easy to remember mind maps, practical tips and positive affirmations. In essence, they are training manuals for labour and birth. In addition to the training manuals the team sough funding and purchase of a large amount of birthing equipment including 3 mobile monitors to assist women to remain upright and mobile in labour. The fundamental principle of the labour hopscotch is also to remain upright and mobile during labour and in this way possibly reduce interventions such as epidurals. A key benefit of the framework is its transferability as women can undertake the steps in their home environment and thus are provided with an opportunity to avoid early admission to a hospital setting. This is important as the setting for early labour is immensely powerful and can be the difference between a fulfilling or a traumatic childbirth experience (Walsh 2012) . A notable benefit is the opportunity it provides for partners to become involved during the birth experience. Briefly the labour hopscotch frameworks include the use of mobilisation, positioning, water-therapy and non-pharmacological methods of pain relief. as demonstrated in figure 4. Women start at the bottom of the hopscotch as they are more active and mobile. As labour progresses, they advance towards the baby’s footprints. This is a motivational image for them to visualize and facilitates women and their birth partners to maintain focus during labour. What is the impact for nursing and midwifery practice The focus group discussion held with the midwifery-led team reported an improvement in their ability to provide compassionate care which the author believes is one of the greatest successes of this project. The literature reports compassionate care leads to greater patient satisfaction (NHS 2014) and also a positive virtuous cycle of good leadership leads to empowered midwives and on to empowered women. Another implication of having an engaged staff as reported by the Kings Fund (2015) is the overwhelming body of evidence to support that engaged staff tend to make better use of resources and deliver stronger financial performance (West and Dawson 2012). Kirkham (1999) postulates if midwifery practice is to empower women then the midwives must experience empowerment themselves. Byrom and Downe (2010) allude to how an honourable circle becomes evident as the midwifery leader, in this instance the author, listened authentically to staff and developed a strategic plan which holds the same values as the team; staff then feel ‘empowered’ and subsequently, they empower the women. The confidence of staff is built upon and so the positive virtuous cycle continues to be reinforced. This was demonstrated to the author when one staff member evaluated the mobile monitors by stating “I now feel we practice what we preach offering choice and most of all the importance of mobility which we instil in women’s minds. I also feel proud we can offer mobile monitoring”. These supports evidently offer women greater choice, which will give the organisation recognition for adhering to and adapting their maternity services to align with this strategy. This project also supports the three additional priorities of the National Maternity Strategy namely women centred care, governance and workforce and health and wellbeing.


NMV B29

• The project is patient centered. • Empowering Nursing staff in early identification of the need for HSCP in the patient plan of care and direct referral. • Multidisciplinary involvement. Why the initiative was carried out This initiative was carried out to improve the patient journey from admission to discharge and to improve relationships between all care providers through multidisciplinary involvement.

We also wanted to improve communication between patients/relatives and ensure individualisation of the patient’s plan of care. This conversation is assisted by the introduction of a discharge leaflet which is now given to the patient on admission to a bed in OLH.

This project was also carried out to assist Our Lady’s Hospital with quality improvement, patient engagement and risk mitigation along the continuum of care. How the initiative was carried out A project team was convened and the project was undertaken in the format of a Rapid Improvement Event (RIE) with external facilitation from the IEHG. This RIE project supported and assisted a collaborative approach by engaging with patients,relatives and colleagues and listening and learning from what they say. Reports were delivered at 1 week, 30 days, 60 days and the final report at 90 days post event. The project involved looking at the current pathway from admission to discharge and identifying areas that could be improved to enhance the patient experience. As a result the following initiatives were introduced:

1. A discharge information leaflet.

2. Direct HSCP referral from CNM/ Senior RGN .

3. Updated admission sheet to include PDD – to be completed at Clinician at admission in ED or on day 1.

4. A system to fast track bloods on day of discharge.

5. An ISBAR handover tool for all admissions into the hospital.

6. White boards PSAG on all wards (including a space for PDD).

7. MDT Huddles on one ward.

Title of the initiative The Patient Journey – Improving Quality, Safety and Satisfaction

Names: Caroline Carpenter, Agnes Connolly, Merica Dempsey

Organisation: Our Lady’s Hospital, Navan


What is the impact for patients and service usersPatients now receive discharge information at the time of admission. This encourages dialogue between patient/next of kin and care givers regarding discharge plans and predicted date of discharge.

Timely and appropriate referral to HSCP has resulted in reduced length of stay as referrals are now made earlier in the patient journey. The new ISBAR communication tool for handover has received positive feedback. Ward staff are more prepared for the patients arrival on the ward (special equipment or other patient needs). The rapid turnaround for day of discharge bloods is facilitating earlier time of day discharges.

What is the impact for nursing and midwifery practice Empowerment of CNM/CNS who can now refer patients directly to HSCP.

Improved communication via the introduction of MDT Huddles

The introduction of an ISBAR communication tool for handover has standardised communication between staff for all patients being admitted to Our Lady’s Hospital. Nursing staff are now focusing on efficiencies to streamline the patient journey and improve the patient experience in Our Lady’s Hospital.


NMV B30

A partnership approach is taken to create a holistic patient and family/carer orientated care pathway and an environment conducive to their needs

Nursing skills and knowledge are utilised, enhanced and challenged to provide quality and safe evidence based care

It enhances quality of life for the patient and their family/carer Why the initiative was carried out In early 2014 a gap in the provision of dental services to adults with special needs was identified. The reconfiguration of services in Cork/Kerry at that time also led to the availability of a theatre session in Mallow General Hospital(MGH). Following stakeholder involvement and commitment from management and staff in MGH it was agreed to establish one session per week with the specific aim of reducing the waiting list that then stood at five years. It wasn’t until patients from this cohort started to come into the hospital for their treatment that the focus switched to a multi-modal quality improvement initiative with the core values of nursing and midwifery as the underpinning principles. As nurses, we recognised that we needed to adapt and evolve from the day surgery model of care to which we were accustomed in order to holistically care for these patients and their families/carers. This included changes to the nursing process, specifically taking a more continual approach with respect to the variability of physical, sensory and intellectual disabilities encountered. The anaesthetist and anaesthetic nurse visit the patient in the Dayward setting, introduce themselves and take time to get to know the patient there. This allows for the commencement of anaesthesia as soon as the patient arrives in the anaesthetic room, lessening the fear and stress of an unfamiliar clinical environment for the patient and their family/carer. The family/carer involvement is also much more inclusive with this cohort of patients in relation to the majority of the patient groups that use Day Surgical Services in MGH. As a result, the day surgical services in MGH have adapted to become more compassionate and individualised to the needs of the patient.

How the initiative was carried out Creating a multidisciplinary Dental User Group was the first formal step in the process. Governance issues were identified and addressed in a comprehensive Standard Operating Procedure. Documentation was tailored specific to this service and it was recognized that a robust pre-admission process was essential to gain as much information as possible about the patient prior to admission in order to provide the best individualised care. The service started with one patient per session to familiarise staff and evaluate performance before increasing to two patients. The Dental User Group met formally after two months to review the service and identified issues to be addressed such as staggering admission times more appropriately, manual handling education needed and clearer identification of blood tests requested by General Practitioners. Much of the quality improvement planning though has been done by nurses in alignment with the Institute for Healthcare Improvement(IHI) model for improvement using reflective Plan Do See Act (PDSA) cycles. Suggestions and ideas to improve the service and better care for the patient and their family/carers are welcomed from all nurses working within the departments. These are discussed, trialled and implemented/modified depending on the outcomes. Therefore the nursing approach for this service is continually evolving.

What is the impact for patients and service usersWith the pre-admission process any special requests/likes/dislikes can be noted in advance and accommodated as much as possible. The patients notes are reviewed by Dayward and Theatre Clinical Nurse Managers(CNM’s) in advance of the list and appropriate steps are subsequently taken to reduce the anxiety of the patient and their family/carer. Such measures include wearing casual clothes instead of uniforms, use of music/singing, keeping the environment quiet and non-stimulating and having only one patient in the department where possible. On arrival in the day unit an inclusive approach is adopted by taking time to engage with the patient and their family/carer to create a therapeutic, trusting and caring relationship.

Title of the initiative Providing holistic person centered care for adult patients with intellectual, physical and sensory disabilities requiring dental treatment under general anaesthetic in Mallow General Hospital

Names: Catherine McCarthy, Denise Kearney

Organisation: Mallow General Hospital


This helps make proceedings less threatening while also incorporating the nursing process and policies/guidelines ensuring all essential information is obtained to provide safe and quality patient care. There is constant open communication about the patients treatment and progress for the duration of their stay and families/carers are very much empowered to care for their relative/client. Family members/carers are also encouraged to accompany the patient into the anaesthetic room for reassurance and support and to be with them until they are anaesthetised. Nursing staff also provide extra support for families/carers during the patients time in theatre as this can be a particularly stressful and anxious period for them. Quality of life and oral health has also significantly improved for this patient group as the waiting list for treatment now stands at just three months.

What is the impact for nursing and midwifery practice Initially this service presented quite a challenge for us as nurses and there was much apprehension about how it would work out. Three nurses from MGH Theatre Department visited Cork University Hospital in advance to observe a special needs adult dental list to assist in preparing for the service. This helped from a practical viewpoint but also aided in getting a better understanding of how the service should work. Consequently, we have committed and striven to provide the best quality,safe care for the patients we treat, and this encompasses the values of nursing in their truest sense. The nursing staff from Pre-assessment, Dayward and Theatre departments have built up a very open, trusting, collaborative working relationship with excellent communication which extends beyond this particular service. We rely on and have enhanced our skills and instincts and have actively extended our knowledge base particularly in relation to medical and nursing considerations specific to this patient cohort . As nurses, we have developed not only professionally but personally also. This has resulted in a huge sense of achievement and job satisfaction for all nurses. We feel we make a difference and contribute most positively to patient care and their experience within the acute hospital setting.


NMV B31

Compassion arises out of an internalised sense of what is essentially the right thing to do according to Larkin (2011). In palliative care, this can be driven by the intentions of the RNP to alleviate suffering, to display interest, kindness, patience and empathy in response to the patient’s anxiety or distressing symptoms.

The basic principles of caring are being there, being present, listening and the willingness of the RNP to provide an holistic assessment of the patient’s needs, agreeing a plan of care in conjunction with the patient, followed by an evaluation to assess the outcome of the treatment.

A commitment by the Clinical Nurse Specialist (CNSp)/RNP to provide a rapid response to patients experiencing a myriad of symptoms by extending access to optimal prescribing fits with the philosophical construct of palliative care as a practice to relieve suffering in whatever way possible. Why the initiative was carried out Nurse Prescribing (NP) within community specialist palliative care was implemented to improve the quality of care to patients by providing a more flexible and streamlined service (Dawson, 2013). Nurse prescriber’s have been identified as safe and effective practitioners whose work results in increased patient satisfaction and a more cost effective, equitable service (Courtenay, 2016: Creedon et al 2015, Drennan et al 2009: Haider, 2008). A review of patients’ experiences of nurse prescribing reported that the therapeutic relationship with the nurse, provided reassurance, continuity of care and being approachable as the most positive aspects (Creedon et al, 2015). In addition, Creedon et al (2015) stated that the convenience, flexibility, accessibility and timeliness of safe holistic care was acknowledged as beneficial to patients. Therefore, the RNP is ideally placed to deliver a more effective patient centred episode of care, interacting with the patient and family in the comfort and dignity of their own home.

Due to the small cohort of nurses in post (288) working in specialist palliative care in the primary care setting as per data from the analysis of the current palliative care workforce (HSE, 2016), recruiting candidates has been challenging due to increased responsibility and workload associated with nurse prescribing. A resistance to change and fears around the impact on roles and relationships has been noted (HSE, 2014). The uptake of RNP is driven by an individual practitioner’s choice which is facilitated by the goodwill and interest of the department head and surrounding medical colleagues.

Evaluation of nurse prescribing in this environment is required if practice is to be informed and advanced. However, the low uptake of RNPs’ in Palliative Care, Primary Care, in Ireland, (5 RNP’s out of a total of 288 nurses) together with a paucity of empirical data from an Irish perspective, warranted further investigation and was the fundamental basis of this enquiry.

This study was undertaken as part of an MSc in Palliative Care at UCD, Dublin which commenced September 2016 and is due for submission 2nd May 2017.

How the initiative was carried out Ethical approval for this study was granted by The Ethics Committee at NMPDU, Tullamore, Co Offaly and UCD Ethics committee. A qualitative, phenomenological, Heidegger (interpretative) approach was used. Semi-structured interviews were chosen as the method of data collection. The population of interest was RNP’s in Palliative Care, Primary Care in Ireland plus key informants with an interest, who are well informed and accessible to provide leads in Nurse Prescribing.

Title of the initiative Registered Nurse Prescribers’ (RNPs’) experiences of the benefits and challenges to Nurse Prescribing in Palliative Care, Primary Care in Ireland

Names: Phyllis Howin

Organisation: HSE, CHO Area 8. Laois/Offaly Specialist Palliative Care Team


This purposeful sample was drawn from the Midlands and Leinster areas consisting of four practicing RNPs’ working in SPC in a rural Primary Care setting in Ireland, together with 6 key informants to include, two palliative medicine consultants, one national nurse lead, one prescribing site coordinator, one Public Health Nurse and one patient who was in receipt of specialist palliative care services. Following a literature review, a topic guide was developed to inform the questions for the RNP interviews. The interview guide in relation to the key informant interviews was informed following the analysis of the RNP interviews. A final critical comparison of themes was presented based on all data obtained. Colaizzis’ method of analysis was performed through a process of 7 steps.

What is the impact for patients and service usersThe importance of building a therapeutic relationship is the cornerstone in facilitating patients and their families to make informed decisions about their treatment and preferred place of care at end of life. The patient’s relationship with the RNP enhances the richness of the consultation in terms of convenience, comfort and relaxed conversation.

Providing patient centred care is at the root of nurse prescribing by channelling the nurse prescribers’ knowledge, skills and experience to provide a more efficient and holistic episode of care. NP in a palliative care context may be one of the mechanisms through which patients can be supported to remain at home with well controlled symptoms at end of life as symptoms may rapidly change requiring highly specialist and timely interventions. NP in palliative care has improved patient access to care and medication without the disruption to the consultation by reliance on GP’s for a prescription.

Safe, rapid and effective symptom control for patients is a component of the CNSp role with emphasis on advance planning and pre-emptive prescribing to ensure appropriate drugs are available for end of life care in the home environment, thus averting a potential crisis and minimising symptoms. The CNSp as an expert clinician is arguably better positioned to respond quickly to the needs of these patients due to their considerable expertise and close contact with them, therefore effective collaborative interdisciplinary working is fundamental to the successful implementation of NP in palliative care in the primary care setting. Nurse prescribing as a practice aspires to support and assist patients on their journey in the comfort of their home in one seamless encounter. This resource if fully utilised has the potential to optimise positive outcomes for patients whose wish it is, to remain at home for end of life care.

What is the impact for nursing and midwifery practice The challenge for nurses and midwives undertaking prescriptive authority is to use their skills, knowledge and experiences to meet the goals of the national health policy by delivering quality care in an ever-changing environment (NMBI, 2016). The vision of the Irish government in its health policies is to create an equitable, accessible, people centred, quality health system for its citizens (HSE, 2016). As such, where the CNSp is deemed expert and skilled, a question is posed as to why that nurse should rely on others when working in a clinical situation to take responsibility for prescribing, if this is a necessary part of treatment (Kinley, 2007). In a climate of increasing demand, nurses are expected to become more autonomous in their practice (HSE, 2016), given that multi-professional collaborative practice is a prerequisite of the CNSp role (Palliative Care Competence Framework, 2014). Ultimately, it is the patient who benefits from the nurse prescriber’s enhanced skills through this extended role thus improving the quality of care as a result. Sustainability and growth of nurse prescribing into the future will require strategic and innovative nursing leadership.

Future Plans:• Collaboration with policymakers at national level, educationalists, leaders of nursing, DPHN, DON Hospices/CNM3 to disseminate the findings of this study to show benefits of NP.• To assist with the vision to create a workforce that is flexible and adaptable in terms of geographical boundaries and innovative in service delivery.• To assist in shaping the development of future health policy.


The Epilepsy Nurse Service at St James’s Hospital (SJH) is the regional epilepsy centre for Dublin Mid Leinster providing expert care under the direction of the Epilepsy Clinical Care Programme (CCP) from the Directorate of Clinical Strategy and Programmes at the Health Service Executive (HSE)

1. Our nursing values initiatives encompass the following and are in line with key aims and objectives of the CCP. 2. Patient advocacy3. Expert timely advice and support for epilepsy patients 4. Improved integration of care, and a collaborative patient centred approach in the management and delivery of services for patients with chronic disease (HSE, 2012). Why the initiative was carried out Epilepsy is a chronic disease characterized by unpredictable, sometimes lifelong, often dangerous seizures which result in involuntary alterations in behaviour and consciousness. Of the 40,000 sufferers in Ireland only about 70% are well controlled on medication, leaving about 12-15,000 people who have breakthrough seizures, and are in regular contact with secondary and tertiary hospital services. The condition kills about 130 people per year. Many patients with epilepsy suffer from mental health problems, and the condition has significant implications for social, vocational and occupational aspirations.

The thrust of the Clinical Programme in Epilepsy Care is to use international evidence and expert consensus to create a programme of improvement in quality of access to and value of epilepsy care in Ireland. The long-term vision for the programme is to provide the best value care for all people with epilepsy in the right place, at the right time, sharing the best available information. The core of the plan to deliver these objectives is to address each aspect of care with a specified care pathway, delivered by specified experts. The kernel of the project was to create a cohort of Advanced Nurse Practitioners (ANPs) to complement the current medical expertise that can take over the chronic disease- management of epilepsy from more general services and integrate it with their care in the community. Regular prospective audit was central to the programme in order to justify funding and demonstrate improved outcomes in quality and access. These nurse led key performance indicators (KPIs) demonstrate our commitment to the above mentioned values. The Advanced Nurse Practitioner candidate team (n=3) was recruited to St James Hospital in 2012 with professional commitment to the core concepts of the ANP role as defined by the National Council are autonomy in clinical practice, expert practice, leadership and researcher.

How the initiative was carried out 1. The implementation of a rapid access seizure clinic we aimed to provide a structured nurse phone call to 80% of all new patients referred to the service following first seizure or with a suspected diagnosis of epilepsy or established diagnosis (KPI 2) 2. Following the telephone triage processes patients are seen in the Rapid Access Seizure Clinics where a full assessment is carried out and a plan of care developed. Patients are triaged and offered a clinical review in the Rapid Access Seizure Clinic (RAC) within four weeks (KPI 3) 3. The Epilepsy Nurse Telephone and Email Nurse Advice Line provided expert advice and support to patients. This service provides timely access to patients who are having particular difficulty with their condition and can offer urgent clinical review when needed. Over the 5 year implementation period we aimed to increase the number of patient encounters delivered by an epilepsy specialist nurse (KPI 1).

4. The electronic Epilepsy Patient Record is promoting a service that is more responsive to the needs of the patients. Information is available in a more timely fashion and more clinicians have access to the same information thus promoting a model of shared epilepsy care. (KPI 1)

Title of the initiative Providing expert care and commitment to nursing in advanced practice- the experience of a nursing team in a five year implementation of the Clinical Care Programme in Epilepsy

Names: Cara Synnott, Claire Behan, Denise Cunningham, Sinead Hynes, Sinead Wilson

Organisation: Dublin Mid Leinster Epilepsy Service/ St James Hospital

NMV B32


What is the impact for patients and service usersPatients frequently attend first appointments without a witness account of their event and without the results of previous investigations rendering their first visit to the seizure clinic of little value. A diagnosis of epilepsy can be made in the majority of cases on the basis of information provided from the individual and witness histories and examination of the individual (NICE 2012). Driving regulations need to be addressed as soon as the patient has had a confirmed seizure. Lifestyle and safety issues may need to be urgently addressed while the patient awaits first appointment. The patient may well be very anxious having experienced a seizure event. A structured nurse telephone within ten days of referral to the service addressed the above.

Our target with KPI no 3 is to see 70% of new referrals in clinic in less than four weeks. All patients with a suspected new onset seizure disorder should be seen by an epilepsy specialist in a timely manner according to clinical need. This is to ensure precise and early diagnosis and initiation of therapy as appropriate to their indiviudal needs. We continued to increase our nurse led clinical patient interactions providing timely access to clinical expertise- virtually through the use of the electronic patient record and face to face outpatient department visits.

The EEPR is having a positive effect on how care and clinical research is delivered. It is improving quality, safety and value in epilepsy services. Information is available in a more timely fashion and more clinicians have access to the same information thus promoting a model of shared epilepsy care. To date more than 1000 individual patients have a validated electronic record, and these records have been populated using nursing personnel.

Increased nurse activity in the use of an epilepsy electronic record to capture nurse patient telephone/ email advisory line

What is the impact for nursing and midwifery practice Our vision of expert nursing care that values patient advocacy, access to expert timely advice and support for epilepsy patients and improved integration of care, and a collaborative patient centred approach in the management and delivery of services to our patients is five years since implementation. We have shown professional commitment to the core concepts of the ANP role and in site preparation for Advanced Practice and NMBI registration as a team.

Expertise in Clinical Practice: Successfully completing the relevant post graduate nurse academic programmes. Autonomy in Clinical Practice: Managed an agreed caseload of patients supported by evidence case protocols and within scope of practice. Nurse prescribing facilitates autonomy in practice and advanced clinical decision-making. Professional and Clinical Leadership: Our leadership role in the implementation of the KPIs allowed for the collection of data and reporting of KPIs quarterly allowing for examination of current practice, applying new ideas and work force planning. Embracing new technologies such as the epilepsy electronic record and utilisation of efficient systems to manage client care. Researcher: Dissemination of our audit and project work in poster and platform at local, national and international conferences and liaising with nursing researchers to identify future research and collaboration opportunities

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