Bringing Patient Experience Closer to Home
The Introduction of Using Entonox in the Community for Children Facing Distressing and /or Painful Procedures
When children experience pain or discomfort, during nursing interventions, cause distress for all involved. This may lead to fear, anxiety and potential long term problems. We sought to reduce these issues by introducing the use of 50% Nitrous Oxide 50% Oxygen (Entonox) when undertaking invasive nursing procedures in children in the community. On investigation we found that this is not done by any other children’s community nursing team in the country.
The initiatives objectives were therefore clearly identified from the start: Our aim was to find a solution which could be utilised in all invasive treatments, preventing pain, discomfort and distress for patients, families and team members. The outcome would be person centred, subjective and qualitative, with the experience of the child, family and team members determining if the initiative had been a success or not. It is envisioned that the initiative would make a sustainable difference as Entonox could be used for many children with varying nursing requirements on a long term basis. All competencies, and guidelines developed are easily transferable to other teams and organisations and can be easily disseminated.
The ‘Eureka’ moment in regards to the use of Entonox in the community was during the insertion of a nasogastric tube (NG) to one child known as Joe. Joe has undergone dialysis, he required twice weekly injections and found that the NG experience was one procedure too many. Joe is 5 years old. Joe became so upset and distressed, he was inconsolable. This caused mistrust towards the professional, breaking down an established relationship.
Following a staff supervision session we analysed the situation and sought potential solutions. We considered sedation but felt this was too risky within the community. We acknowledged we have the use of Entonox in the hospital therefore our initial plan was to meet Joe and his Mum in hospital. He self-administered Entonox and was given distraction whilst the tube was inserted much more easily. Joe was given 10 minutes to play following the procedure and was then allowed to go home. His mum commented she wished that could be done at home where he could watch his TV and feel more comfortable. Hospitals still scare Joe. This became the challenge for our team.
Planning & Delivery
The process began by consulting the expertise of the pain control specialist nurse within the Trust. Through joint working and training we (the two teams) decided to look into the pros and cons of using Entonox on children in their own homes for any distressing procedure.
The use of Entonox is a universally established practice within community midwifery services and within our trust has been used for over 30 years. It has been found to be a safe and effective method of pain relief with a low incidence of adverse effects and a quick recovery time (Kanagasundaram S, Lane L, Cavalletto B, Keneally J and Cooper M 2001).
We carried out a risk analysis and the team underwent training and completed competencies, whilst being supervised and supported by our specialist colleagues. We contacted, by post, the entire directory of Community children’s nurses in the United Kingdom to ask of their experiences, in this regard. 98% of respondents stated they did not routinely use Entonox in the Community, but were greatly interested to learn from our experiences.
Practical problems we envisaged included:
- The cost of equipment
- Storage of equipment
- Car insurance & transportation
- Prescribing, patient group directives and consent
- Staff training
- On-going costs
The cost of the equipment was £400 which included 2 cylinders, the release valve, a carry bag and a box of disposable masks. The child keeps their own mask and this can be reused, for on-going painful dressings or procedures. The cylinders are stored in our clean utility storage cupboard which is locked and accessed by the CCN team only.
All staff have business use for work on their car insurance and as long we notified our insurers of the potential of carriage of medical gases, no one incurred any additional cost. We were asked to display a sign in our cars when carrying medical gases.
The senior nurses within the team can all prescribe so this is prescribed as either a ‘once only’ or ‘as required’ dose; however, a Patient Group Directives (PGD) was also developed in collaboration with the pharmacy department to enable Staff Nurses to still use entonox on the rare occasion a nurse prescriber is unavailable. Staff training was completed through multiagency working with the pain nurse specialists and the use of the medical representative. Hand-outs, written materials and competency sheets were undertaken by all staff. Consent of the family and\ or child is documented within the nursing notes.
On-going costs will be monitored, but are felt to be minimal and cost effective in regards to patient comfort, compliance, prevention of re-admission/re-attendance at hospital and long term outcomes of trust for the child. On-going audit will be more of a comparison of the child’s previous experience and patient satisfaction is gauged both formally and informally. We observe comments made by the child and family and also issue patient satisfaction questionnaires on a rotational sequence. Since we have started this process we have discussed this with the tissue viability team and they are considering introducing this method of pain relief throughout their clinics and home calls for painful procedures. The population of CCN’s are interested in using our experiences to inform their practice. Our aim is for children not to ever experience pain, or distress!
The types of nursing action which will require consideration for the use of Entonox include but not exclusively limited to:
- The insertion of nasogastric tubes or gastrostomy button
- The insertion of a port-a-cath needle
- Painful burns, or dressing changes
- Injections or Venepuncture for a terrified child
- Removal of clips or sutures
If the child has a good experience they are less likely to develop phobias or anxieties which can be carried through to adulthood.
Children do not have to experience any painful procedures without adequate pain relief and distraction. This should make the parents more relaxed and in turn the children may not have preconceived fears when faced with a nursing intervention in the future. The results are monitored formally by the use of patient and family satisfaction questionnaires and informally in verbal feedback from children and their families. So far, families have been very positive about the use of Entonox and children seen to be a lot less anxious about nurses visiting them at home.
Key Learning Points
- Collaborative working
- Reflecting upon experiences and identifying areas for improvement within our practice
- Identifying drawbacks
- Risk assessment
- Seeking solutions
- Sharing experiences
- Identifying a good practice
- Problem solving
About the Organisation
Frimley Health NHS Foundation Trust was created on 1st October 2014 by the acquisition of Heatherwood and Wexham Park Hospitals NHS Foundation Trust by Frimley Park Hospital NHS Foundation Trust, the first ever merger of two Foundation Trusts. It runs Heatherwood Hospital in Ascot, Wexham Park Hospital near Slough, Berkshire, England, and Frimley Park Hospital in Frimley, Surrey. It has 4,948 full time equivalent staff. The Patient Trust was launched in 2014 by Howard Kennedy with the purpose of supporting a consistent, quality experience for patients facing serious illness by raising awareness, providing practical support and working in partnership with doctors and patients.
In June 2013, Howard Kennedy received a terminal cancer diagnosis. Reflecting on his experiences as a patient and on a career as a leader of public service system reform, he determined that he would commit the rest of his life to improving the quality and consistency of patient experience. Howard knew that a culture of engagement starts at the top. He knew that leaders shaped culture, where managers responded to it. He set out to develop approaches that would support leaders to strengthen and further enhance the quality of their engagement with patients and the collective support teams offered to patients. This approach was to be about potential and growth, solution focused, not a deficit model. As he worked to develop networks and shape an innovative leadership programme, Howard was told that engaging with consultants was an impossible dream, they were too busy, too focused, too senior to embrace development. Finding, in Frimley Health Trust, an organisation committed to delivering excellent patient experience, he worked in partnership with them to challenge these assumptions. The Patient Encounter Leadership Programme launched in December 2014 with an initial cohort of six senior clinicians, feedback from 359 patients and 102 colleagues and impact beyond.
Rationale & Context
The drive behind the Patient Encounter Leadership Programme (PEL), was Howard’s determination to strengthen the consistency and quality of patient experience. In Claire Marshall, Head of Patient Experience at Frimley Health, Howard found a champion of patient engagement committed to making the biggest positive difference in the hospital trust. This partnership enabled Howard to engage with the hospital board and addressed a number of professional meetings, the first patient in the history of the Trust to do so. Howard’s address was heard by over 200 doctors in total, ranging from newly qualified doctors to consultants. His message was simple, ‘Leadership matters and as leaders you have the power to shape not only the experience of the patients you treat but the experience of all patients throughout the Trust.’ In further developing this theme, Howard outlined three critical factors he had identified during his time leading system reform. That effective leaders demonstrated three common characteristics: 1)Effective leaders never stop learning2)Effective leaders are humble, they walk with care 3)Effective leaders understand the gap between intention and impact and they work to narrow this. In describing these characteristics in greater detail, Howard set out a compelling vision for consistent, quality patient engagement. Supporting this vision was the offer to those who heard his address of the potential to participate in the PEL programme, focused on supporting effective leadership through innovative development.
Planning & Delivery
As Howard engaged with the Hospital Trust it became clear that there was a willingness to embrace new approaches to the development of senior clinicians. In building support for the programme, Howard and Claire Marshall enrolled senior colleagues from within the Trust and outside. One early morning meeting with Kath Evans stands out in the memory, strengthening both the support network and bringing real confidence that the approach was right. In seeking a partner to design and deliver the programme, Howard co-opted former colleagues from system reform days, who were only too happy to contribute time and experience to the cause. Over the course of several months, the design of the PEL programme took shape, with Gareth Cornwall, from the decision point, developing a leadership programme embedding the principles Howard had set out in his address and shaping them into an experiential learning process where consultants could step back and explore their leadership of the patient encounter. In the Autumn of 2014, senior clinicians were invited to apply for the PEL programme, a development programme comprising four days of off-site development, one to one coaching sessions and action learning sets. Within a week, 23 senior clinicians had applied for the 6 places on offer. Following the acquisition of Wexham and Heatherwood Trust by Frimley Park Trust in December 2014, the newly formed Trust, Frimley Health NHS Foundation Trust, endorsed the programme with support and engagement from the Medical Director, Tim Ho and the head of learning and development, Claire Quinn. In Spring 2015, the final cohort was confirmed and the initial cohort embarked on the process of collecting patient and colleague feedback.
Impact & Results Achieved
Applying the principles of effective leadership that Howard set out in his address to senior clinicians, the PEL programme is built on three metrics; 1) patient feedback 2) colleague feedback 3) self assessment. At the heart of this is the recognition that feedback drives performance improvement. For the patient feedback measure, the participants undertook the CARE measure, in the process gathering feedback from a total of 359 patients. For the colleague feedback, participants gathered feedback from over 100 colleagues through Hay Group’s 360 Emotional and Social Competence Inventory. For their own self assessment, participants were asked to reflect on their performance, informed by insights from 16PF psychometric profiling. In combination, these measures were selected to provide a robust measure of impact, applying established tools to give participants a real richness of data. At the time of writing this submission, we are in the process of re-running the patient and colleague feedback processes and evidence of impact from these measures will be available in early 2016. Already though, we have evidence of impact from the senior clinicians themselves:
- “The off-site gave me the opportunity to reflect on my work and attitudes towards my patients in comparison to what my colleagues do. I learned from their experiences of patients care and management. I was able to draw inspirations from my colleagues on how best to improve the doctor patient encounter considering our very different specialities.”
- “Following the PEL programme I have been able to take a greater understanding of alternative drivers and behaviours to my interactions with patients and colleagues.”
- “Believing in my own capabilities gives me the power to focus more positively on the challenges that present with very sick angry patients and relatives – who have just been diagnosed – and the challenges from non-co-operating colleagues and cultural differences. I am now more able to control my initial responses and give a more balanced reflection which allows for sustained communication channels which in turn is more likely to impact positively on my working day”
- “I will concentrate on making the patient feel at ease and including the patient in the decision process and wrap up at the end. I will be more open with colleagues to gain their confidence.”
- “I was enlightened by all that we learned and aim to put it into daily practice.”
- “I felt privileged to have been given the opportunity to join the group and gained invaluable experience. Programmes such as this provide dramatic insights into everybody’s working practices and provide a fantastic opportunity to tackle difficult cultural changes that are required within an organisation to allow it to flourish. I do hope that other colleagues of mine are given this opportunity in the future.”
- “Since the sessions I have already seen a vast change in my working and personal life. as the 2 are inter-dependant – I feel empowered to make sensible and positive changes which impact widely – like the ripples on a pond”
- “This programme lifted my mood and made me realise that I am working at suboptimal performance. Gave me an insight into behaviours which I had not noticed. Howard Kennedy’s very sincere efforts of making a difference through this programme made the experience very special. Thanks for a great programme.”
The initial PEL Programme was a pilot programme, an opportunity to learn and develop approaches which will enhance the leadership of the patient experience. In October 2015, based on the success of the initial pilot programme, Frimley Health NHS Foundation Trust commissioned a further programme, due to launch in Spring 2016. This re-commissioning was personally supported by the Chief Executive, Sir Andrew Morris, who recognised the important space the programme provides for senior clinical leaders to reflect on their practice and ‘sharpen the saw’. Howard’s charity, the Patient Trust, is committed to promoting all approaches that support a consistent quality of patient experience. The PEL programme is one element of this approach and in 2016 the Patient Trust will seek to bring in other Hospital Trust partners, alongside Frimley Health. The PEL programme generates significant learning and insight, through the participants themselves and the data that is gathered through the process. In 2016, Frimley Health and the Patient Trust intend to promote lessons learned, supporting a focus on patient experience not only across the host Trust but also through Trusts across the country. The PEN network is an important partner in this.
Awareness building has taken place through the network that has formed as the programme has developed. Interaction and the promotion of consistent, quality patient experience has been highlighted through Howard’s addresses to doctors, through the dissemination of information to Frimley Health Trust’s Health Education Board (HEB) and through the Patient Trust website.
Relevance to Other Groups
As the programme develops and learning emerges, we believe opportunities will emerge to share approaches and learning with other groups focused on patient experience. We believe the PEN network will be a valuable disseminator of this learning.
What Makes This Initiative Stand Out?
The PEL Programme stands out for a number of reasons. Firstly, at the very heart of the programme is the inspiration provided by Howard Kennedy in choosing to respond to the greatest adversity with such positive intentions and actions. The programme is inspired and shaped by a patient working closely in conjunction with a hospital trust to deliver innovation and sustainable change. Secondly, the programme is aimed at consultants, recognising the influence they have beyond their immediate group of patients. By promoting consistency and quality of patient experience with this senior group we aim to shape a broader culture of engagement across the service. Thirdly, the programme seeks to build long term mastery. The programme takes a holistic approach to development, supporting participants to reflect and be mindful of mastering the balance of patient care, professional interaction and self. It is when this balance is managed that the senior clinicians themselves say that they can deliver the most consistent quality of patient care. By focusing on potential and grounding this in reflection, dialogue and feedback the programme seeks to embed performance in capability and behaviour, overcoming the common failings of ‘quick fix’ approaches.
Key Learning Points
- We’re all human and recognising our weaknesses allows us to better understand our strengths
- Feedback is critical to development and performance enhancement
- Adopting a solutions focus approach allows people to move away from blame and look towards positive shared outcomes
- Partnership between patients and professionals can deliver real benefits
- Nothing is written – one person can make a difference and leadership is about being that person At the core of the programme is the promotion of a quality conversation with patients and about patient care.