1. Nursing and Midwifery: A futurist lens
A global and national perspective
Wednesday 2nd August 2017
Professor Jill Maben, OBE
Florence Nightingale Faculty of Nursing and Midwifery
King's College, London
Welcome and introduction – Name and role.
How might the students come into contact with that speaker when they study at King’s

2. Overview Global healthcare challenges Increased demand for healthcare
Increased need for nursing care
How is care best delivered and by whom?
What can we learn from international models of care / the past?

3. Ageing population

5. Australia life expectancy 82.45;
UK 81.60;
USA years

7. Long term conditions……..

8. How to meet patient need / increasing healthcare demand? Technology…..
Baymax, Big Hero 6

9. Pepper, UK/EU
Riba Japan
Dexter and Monty USA
Taizo, Japan

11. What do patients want?

12. What matters to patients?
What matters to patients is of course very context dependent and if patients are experiencing a life threatening situation an efficient, effective and safe service that gets treatment to them quickly is what matters. The evidence shows that patients want to feel better. This is often as much about HOW they feel about the service they received (the emotional experience) as the clinical outcome they were seeking. In 2010 the Department of Health and the NHS Institute commissioned King's College London and The King's Fund to undertake research into: What Matters To Patients? Developing the Evidence Base for Measuring and Improving Patient Experience. We found that the 'relational' aspects of care (such as dignity, empathy, emotional support) are very significant in terms of overall patient experience. I am drawing data from several recent or ongoing NIHR studies and focusing on the care of older people.
Skilled / high quality care
Feeling informed and being given options
Staff who listen and spend time with the patients
Being treated as a person, not a number
Patient involvement in care and being able to ask questions
The value of support services, such as voluntary organisations, support groups etc.
Efficient processes that provide the patient with a sense of continuity of care
Robert G. et al (2011) Measuring patient experience: evidence base

13. What do patients want?
Patients and their carers wanted to be looked after by staff
who show they care . Patients and carers expressed that
‘showing they care’ was about nurses and other staff
demonstrating a person and relational centred approach,
and being looked after by staff who are trustworthy, and inspire
confidence. Patients and carers shared that nurses and
other staff demonstrated this care via their communication,
by connecting with them. In our current NIHR CHAT study we spoke to older people and their carers in a focus group :
READ QUOTE 1
Conversely, in another NIHR post doc study Caroline Nicholson
interviewed patients and carers on two older people's wards– this man said:
READ QUOTE 2
“Make me feel comfortable and make me feel valued. Make me feel like I’m in good hands.” (Older People’s Focus Group)
I like (nurses name) … she allows me to try, I know I am old and slow but she does not treat me like that- she is kind and helps me to help myself when you have not much left that’s really important ..
( Patient 1 site 2- Nicholson )

14. Being human - seeing the person....
Joanna Goodrich and Jocelyn Cornwell wrote in 2008 about the importance of seeing the person in the patient.
If we are serious about wanting and needing to humanise health care we need to connect as human beings – George 92 Said – READ QUOTE 1
A very simple way of beginning a connection with older people is to ask what they did. When asked this patient shared aspects of his life- his time in the Air force as a bomber navigator during the 2nd world war, Following discharge had read law. Two people –patient and nurse were connecting and making the person in the patient more visible, humanising the experience for both.
Nurses efforts are appreciated by patients.
READ QUOTE 2
But how easy is it to give this attention to patients?... NEXT SLIDE
“Nobody asked me what I did, no. In fact, I had no conversation in X hospital) at all. They would come in and say ‘good morning’ and I’d ask what it was like outside and they’d tell me and then they’d go out“ (George 92, Nicholson data)
“One nurse got to know my father the day after admission. My father knew she was in her 30’s had children and he asked her about Romania under Ceausescu. I watched her relate to other patients and a guy pulled her over and thanked her for her care. She was allowing herself to be herself, not afraid to be human” (Ian, Carer) 14

15. We need human care as well as technology
Communication and relationships – with patients,
with carers and with each other
are at the heart of nursing

16. But……..

19. A radical rethink required?
Increasingly ageing population
Increasing chronic disease / demand for healthcare
Care can become unrewarding to offer and unacceptable quality to receive
How care is currently organised may need a radical rethink ….

20. Increased patient demand increased throughput and LOS
READ LEFT SLIDE
BOOK: Valerie Iles investigates how we can understand how at times good people offer bad care. The book is the result of a Learning set of 18 individuals who worked in the NHS – they moved beyond the management literature to the field of anthropology, sociology, political philosophy, history and psychology and suggest that a number of forces outside our control are at work and it is our responses to these that lead us collectively to squander the resources of the NHS while engaging in care that is unrewarding to offer and unacceptable to receive.
Factors that affect the
nature of care- the 5 winds:
The digital revolution
A culture of audit
The triumph of managerialism
A change in the nature of politics
The role of anxiety
Increased patient demand increased throughput and LOS
= Production line
Professionalising project RN less hands on care HCAs
= fragmented routinised tasks
Dissatisfying for staff and patients....

21. A culture of audit
A reduction in creativity - as a result of performance being measured against predefined objectives that are then given priority over addressing creatively all the issues that emerge after the objectives were defined…
Only activities that can be turned into code are valued - only activities that can be measured are measured - privileges the use of explicit knowledge over tacit knowledge, and activity at the expense of thinking /caring …
We don’t measure what is actually happening, only how we are managing what is happening - difficulties in capturing the nature of ‘first order activities’ (the interactions between professionals and patients) it is not these that are monitored but second order processes or ‘proxy measures’ (things like boxes being ticked)…
Litigation increases - because public understanding of professional decision making processes becomes distorted by league tables and other forms of news based on ‘performance’ data. Lowest risk option being privileged in any decision even where there are sound arguments for other options…
Policy makers set targets - for easily measurable aspects of care and local leaders deliver on those narrow targets rather than achieving them by improving the system …
Valerie Iles What is Happening to Leadership in Healthcare November 2013

22. READ SLIDE
“Much of what we do as nurses cannot easily be measured. For instance, how many other healthcare professionals know what it is like to sit at 3am with a patient who is afraid to switch off the light and close their eyes in case they never open them again? Although all the nurses I spoke to were able to describe the skills they used in their work they all believed that their real value lay in their ability to care. And how do you begin to measure the value of a nurse who takes time to listen to a worried patients concerns?” (Nursing Times 2002).

23. The Triumph of Managerialism
Managerialism tends to equate care with tasks, this allows us, as technology develops, to delegate it to people costing less and less….
Many aspects of nursing for example are delegated to health care assistants.
Receptionists in GP surgeries are being replaced by touch pad entry systems and flashing light notice boards.
Care is more than what carers do, it should involve who they are and the judgements they make and the relationship they develop with the people they care for.
It may be cheaper overall as well as better to retain the involvement of more expert carers ….
Valerie Iles 2009 Working in health care could be one of the most satisfying jobs in the world – why doesn’t it feel like that?

24. Bureaucratisation….Soulless factories?
In our times cutting edge medicine has been practised in purpose built hospitals served by an army of paramedics technicians, ancillary staff, managers, accountants, fundraisers and other white collar workers, all held in place by rigid professional hierarchies and codes of conduct. In the light of this massive bureaucratisation, it is a small wonder that critiques once again emerged. The hospital was no longer primarily denounced, however, as a gateway to death but as a soulless, anonymous, wasteful and inefficient medical factory, performing medicine as medicine demanded it, not as the patient needed it.

25. Soulless factories?
In our times cutting edge medicine has been practised in purpose built hospitals served by an army of paramedics technicians, ancillary staff, managers, accountants, fundraisers and other white collar workers, all held in place by rigid professional hierarchies and codes of conduct. In the light of this massive bureaucratisation, it is a small wonder that critiques once again emerged. The hospital was no longer primarily denounced, however, as a gateway to death but as a soulless, anonymous, wasteful and inefficient medical factory, performing medicine as medicine demanded it, not as the patient needed it.

26. And to be provocative and to paraphrase Porter I suggest to you that we have an inefficient nursing factory in hospitals, performing nursing not as the patient needs it, but as the system as currently organised requires.
Yes we now have a population living longer and we have eradicated many diseases that previously killed in the UK. But as a result we have a significantly ageing population living longer with multiple co-morbidities and multiple chronic diseases in need of skilled nursing care, yet what we now have in the UK are the least educated staff, the least qualified in terms of nursing skills spending the most time with our patients and much of the care that matters to patients is invisible to the system and therefore not valued and invested in and as professionals nurses are not trusted and valued.
Lets start with what we know is important to patients
Soulless factories?
In our times cutting edge medicine has been practised in purpose built hospitals served by an army of paramedics technicians, ancillary staff, managers, accountants, fundraisers and other white collar workers, all held in place by rigid professional hierarchies and codes of conduct. In the light of this massive bureaucratisation, it is a small wonder that critiques once again emerged. The hospital was no longer primarily denounced, however, as a gateway to death but as a soulless, anonymous, wasteful and inefficient medical factory, performing medicine as medicine demanded it, not as the patient needed it.
..soulless, anonymous, wasteful and inefficient medical factory, performing medicine
as medicine demanded it, not as the patient needed it.

27. So you’re constantly watching, watching, watching
So you’re constantly watching, watching, watching. Your focus isn’t completely on that person. […] It can’t be, because you’re constantly thinking you’ve got 11 more – six of them need feeding; two or three or four of them still haven’t had a wash and probably laying a soiled pad, because you have not had that time to go get to them yet because there’s too many other things going on […] you can try as hard as you like, but if you ask anyone, they’ll probably tell you, if they’re honest, that they don’t come away feeling that they’ve done everything they could have done because time restraints don’t allow it [....] staff are running around like headless chickens [..] ’cause you can’t slow down, because if you did, someone would suffer because of it. [...] You’ve got to try and do everything you can do, the best you can do it at the fastest speed possible. And that is rubbish, really, when you look at it like that. ’Cause these aren’t loaves of bread that – it’s like you’re pushing through a machine , is it? […] This is people. And that does upset you a lot .” (Site 1: HCA S08)

28. In our recent NIHR study examining links between staff experiences of work and patients experiences of care we drew on the unpopular patient lit (Felicity Stockwell) to understand how staff made work more meaningful by selectively offering good care to some patients(those they felt were Poppets) enhancing staff satisfaction in an otherwise unsatisfying work environment. We observed how on one of these wards staff tended to negotiate their work tasks with reference to bed numbers rather than patient names; patients on this ward were also less likely to be greeted by nurses who cared for them and there was frequently little personalisation of care. Our observations indicate that these dehumanising aspects of care were not lost on the majority of patients:
READ QUOTE 1
‘in the end, I feel like I’m being moved around like a parcel, I’m being moved like a parcel from chair to commode to bed. I feel like a parcel and not a person anymore’ (Patient 3).

29. So how might we manage / organise care so that it is more satisfying for those receiving care and for those giving care?

30. Buurtzorg (meaning Neighbourhood care) is a nurse-led, nurse-run organization of self-managed teams that provide home care to patients in their neighborhoods. Championing humanity over bureaucracy, autonomous teams work with primary care providers and support from the family and community to bring patients to optimal functioning as quickly as possible… and it costs less than the model of care it replaced. The model is being replicated worldwide, with teams starting in Minnesota, Sweden, Japan, and hopefully in the UK. The Queens nursing Institute are very interested as are a number of community trusts in London….

31. This is Jos de Blok founder and leader, who is both an RN and economist. I was lucky enough to meet him in November last year when he received the 2014 RSA Albert Medal for his work as founder of Buurtzorg, a transformational new model of community health care.

32. Buurtzorg overview Buurtzorg translates as “neighbourhood care”
READ SLIDE
Buurtzorg translates as “neighbourhood care”
New model of organizing and providing Community Care
2007: 1 team/4 nurses
2014: 800 teams /9000 nurses
Back office: 45 staff
15 coaches, 0 managers, 2 directors
70,000 patients a year
Turnover 2014: €

33. What was the problem with homecare?
READ SLIDE
• Fragmentation of cure, care, prevention
• Standardization of care-activities
• Low quality / high costs
• Big capacity problems – high turnover of staff (shortage of nurses within 10 years)
• Poor continuity -clients confronted with many caregivers
• Information on costs per client/outcomes: none!
Policy Review 2006

34. Buurtzorg started 2007
READ SLIDE
Independent teams of max 12 nurses clients
Working in a neighborhood of people
who organize and are responsible for the complete process and episode of care in self organising teams
Nurse acts as a “health coach” for individual and family, emphasising preventive health measures
Golden rule is that nurses must spend 61% of their time in direct contact with the people they support.

35. Self organisation • Optimal autonomy and no hierarchy
One of the keys to the program’s success is that Buurtzorg’s home care nurses organize their work themselves.
Rather than executing fixed tasks and leaving, they use their professional expertise to solve the patient’s problem by making the most of their clients’ existing capabilities, resources and environment to help the patient become more self-sufficient.
Put Simply, Buurtzorg professionals’ aim is to make themselves superfluous as soon as possible, versus other providers who tend to execute the subtasks without truly focusing on the patient’s overall situation.
• Optimal autonomy and no hierarchy
• Complexity reduction (also with the use of ICT)
• Sophisticated IT systems so that data is collected and analysed easily – Buurtzorgweb
• Assessment and taking care of all types of clients:
generalists!
• 70% registered nurses (average 10%)
• Their own education budget
• Informal networks in the neighbourhood and close collaboration with GP’s

36. Improving productivity
READ SLIDE
Compared with traditional nursing organizations in the Netherlands, according a study conducted by Ernst & Young, Buurtzorg’s patients heal faster, require only half the amount of care, experience one-third fewer emergency hospital admissions and have shorter average stays when they are hospitalized.
Staff are asked to focus on prevention of future problems
Give staff permission to solve problems
Train staff in improvement
Measure whether patients needs are met
Develop self managing teams
Care costlier per hour than traditional approach
Care higher quality and better appreciated by patients
Only half as much care was typically required.
KPMG 2012: Netherlands:Buurtzorg empowered nurses focus on patient value

37. High client satisfaction- by 2009 Buurtzorg had the highest client satisfaction scores compared to 307 community care organizations (NIVEL 2009)
From 2010 Buurtzorg has the highest client satisfaction rates in the country with scores of 9/10… and it is not only satisfying for patients ……

38. Staff satisfaction
READ SLIDE
Nurses monitor their own performance based on competency models the teams devise for themselves, and they take corrective action together if productivity drops. Coaches are available when specific problems arise but they have no power to impose solutions.
nurses are encouraged to build expertise in areas that most interest them
patients are able to develop a relationship with one nurse over time. It’s a more intimate, satisfying and humane experience for both parties — and, it turns out, a far more effective and efficient approach to nursing.
Thousands of nurses left traditional organizations to work for Buurtzorg:
• They appreciate:
  – Working in small teams
– Working autonomously
– Independence
– Strong team spirit
– User-friendly ICT (iPads)
• Prize for best employer of the year 2011/2012
Sickness rate: 3% (average 7%)

39. There are now around 900 teams in the Netherlands supported by no more than 50 administrators and 20 trainers.

40. Buurtzorg is being trialled in the UK and Sweden
Has 26 case studies including Buurtzorg.... Trust, Mr. Laloux found that TRUST is perhaps the most powerful common denominator in the companies he studied. “If you view people with mistrust and subject them to all sorts of controls, rules and punishments,” he writes, “they will try to game the system, and you will feel your thinking is validated. Meet people with practices based on trust, and they will return your trust with responsible behavior.”
Buurtzorg is being trialled in the UK and Sweden
Germany, Austria, US, Japan, China, Taiwan and South Korea soon to follow

41. In Hospitals - Primary Nursing?....
READ SLIDE then Pearson book....
I experienced Primary nursing in the early 1990s in Oxford in the John Radcliffe on a number of wards where there was a flat hierarchy, Registered nurses leading managing and supervising the care of patients form admission to discourage with an associate nurse and care assistant, creating continuity for patients and staff and autonomy and empowerment for nurses..... NEXT SLIDE
In Hospitals - Primary Nursing?....
Primary Nursing:
is a relationship-based, autonomous, evidence-based, and collaborative delivery care model
supports professional nursing practice via a therapeutic relationship between a registered nurse and individual patient /family with the authority to develop and implement an individualized plan of care for the patient
focuses on the nurse-patient relationship, strengthening accountability for care and facilitating patient and family involvement in the planning of care.
“facilitates professional nursing practice despite the bureaucratic nature of hospitals [..] services in bureaucracies are usually delivered according to routine pre-established procedures without sensitivity to variations in needs.”Marie Manthey 2002

42. CREAMIC BOWL
Thinking back to the ceramic bowl and wabi-sabi
In one sense wabi-sabi is a training whereby the student of wabi-sabi learns to find the most basic, natural objects interesting, fascinating and beautiful".
BRING IN QUOTE
This statement is no different from Jos de Blok's expression of the Buurtzorg model
"What we want to show is that if you have the autonomy, if you develop your skills and craftsmanship, then it's the most beautiful job you can find." Jos de Blok, Buurtzorg Founder

43. Thank you for your attention