Care Home Journey

John understands that despite the increasing care he is having at home his memory loss is impacting on his quality of life and safety.

John's respiratory specialist nurse recently examined him and has explained he will now need oxygen therapy. The community nurse Melanie meets with Sue at one of her regular visits to the home to talk through John's nursing needs.

The registered nurse has a lead role in supporting this event and can make the difference between a smooth transition or a move which is distressing. Where possible joining a care home should be carefully planned. Ideally a new resident would have seen the home and perhaps had opportunity to stay overnight, visit for lunch or take part in the activities in order to become familiar with their new home.

Many of us experience concerns when moving home and we frequently have time to prepare for the change. It is possible to imagine how the combination of ill health, sensory loss and cognitive impairment will make such moves more unnerving and the nurse's skill in supporting someone through a change is essential. Nurses draw on professional education and demonstrate high level interpersonal skills. They have the ability to adapt and modify their interactions whilst interpreting the physical and psychological needs of the person they are working alongside.

John is an 86 year old man, a retired mechanic who loves the physical act of fixing things, improving machines, fiddling with clocks and household objects to make them run more smoothly.

John is living with chronic respiratory disease and dementia and this has restricted his life outside his home. His memory difficulties mean he sometimes forgets to switch things off or eat properly.

John also has an arterial leg ulcer and frequently experiences tremendous pain - recently he has not been able to take analgesia safely.

His neighbours have become aware of his difficulties as he has stopped taking his dog Graham out for walks and now they can see Graham has destroyed John's garden.

John is a realistic man and understands that despite the increasing care he is having at home his memory loss is impacting on his quality of life and safety. John's respiratory specialist nurse recently examined him and has explained he will now need oxygen.

Following a discussion with a social worker, the district nurse, who has worked with John for a number of years, has asked John if they might all meet together to discuss the options available.

Whilst John is sad about leaving his home his overwhelming concern is what will happen to Graham. Fortunately Dave, John's neighbour, is prepared to look after Graham.

It is increasingly likely that nursing colleagues may be caring for a family member themselves and the senior nurse will have a role in providing access to support in the workplace.

Sue is one of the senior nurses in the team, she is grandmother to Veronica who has recently started school. Sue's daughter, who is also a nurse, has found it hard to collect Veronica from school in time on the three days a week she goes to work, as her shifts are so busy. This has become particularly difficult since her daughter's partner has been working away in Hong Kong.

Sue knows her employers have been very flexible with other staff's hours at the home and she would like to be able to help her daughter on at least one day a week. Sue is keen to understand her rights and responsibilities in relation to a caring role and flexible working so she can negotiate a workable solution with her employer.

Sue contacts the RCN for advice by ringing RCN Direct.

When Seema was admitted to the care home she was disorientated in place and time and understandably frightened. She was welcomed to the home by Sue and shown to her room.

As Seema moved towards the door she started to back away and stumbled. Sue was able to safely steady Seema, to gain eye contact, smile and encourage Seema's family to explain what was happening. Sue also knew Rachel was available, observing the situation but not overwhelming Seema.

Sue was aware of Seema's past history and her current confusion. Sue was alerted to the possibility that Seema is experiencing a delirium in addition to her mental health issues. Sue has recently become a delirium champion through the RCN's delirium champion campaign.

We can see that Sue had prepared for Seema's admission, was well informed and empathetic and had experience in managing situations which are emotionally sensitive.

The RCN has previously set out many aspects of the role of a registered nurse working in a care home which reflect the diverse nature of nursing. Sue's actions clearly fall into the supportive category which includes psychosocial and emotional support, assisting with easing transition, enhancing lifestyles and relationships ensuring cultural sensitivity.

The scenario may have been very different in unskilled hands, had Seema been guided in a different way without understanding her communication and perceptual needs. Seema might have displayed distress, perhaps by being physically or verbally protective. Distressed reactions can be disturbing to the person, their families, staff and other residents.

The RCN has prepared some guidance for those staff managing difficult situations, these are really useful for staff like Rachel who was unfamiliar with the situation and relatively new to her role.

Sue, as a senior member of the team, has responsibility for managing staff.

As RCN publications have previously explained the registered nurse in a care home undertakes a wide range of administrative and supervisory responsibilities that call for the exercise of managerial skills. Such responsibilities include the supervision of care delivered by other staff and the overall management of the home environment. This includes clinical supervision and the debriefing of staff who have experienced difficult or emotive situations.

It is Jane and Eileen's anniversary. Eileen tells Sue she would like to take Jane out for some supper and then go to listen to a local operatic evening. Tentatively she also suggests Jane might stay the night at Eileen's. Sue is delighted that Eileen would like to do something special on their anniversary and says she will do everything she can to help. She sets time aside to talk with Jane and Eileen and they are both very keen to go out. Eileen recognises that there needs to be extra preparation for the evening out and they agree a plan, including transport, medication, a short clinical summary in case Jane experiences a seizure and contact numbers should they need help. Sue arranges for Eileen to come in one evening before their anniversary to ensure Eileen is able to support Jane's mobility and manage her medication.

Providing information and advice as well as ensuring family members have the skills to keep a resident safe are an essential part of good nursing care.

Sue then speaks with Jane and Eileen about them staying at Eileen's together. Sue's concerns relate to Jane's mental capacity and she is aware of the legislation around consent to sexual relations, having recently read the RCN's document. Eileen is also concerned about her small home and Jane's safety overnight and they agree that Eileen will come back with Jane and spend the night with Jane at Red Cedars.

Seema has recently moved into a care home that is covered by the integrated healthcare team. The home manager has contacted the team coordinator with concerns regarding Seema as her decreased mobility has led to a high risk to her pressure ulcers, and her recent falls have also led to wounds to Seema's arms and a wound to her right leg. The care home manager points out that Seema speaks only a small amount of English. 

The community physiotherapist visited to assess Seema's needs with Seema's daughter present to enable translation. An attempt to access the local translation service did not help as they did not have anyone who spoke Seema's particular dialect.

Staff nurse Danilo provides an initial assessment which also includes establishing if others involved are covering key areas of Seema's healthcare needs. Danilo establishes that a mental health nurse is monitoring Seema's acute mental health and in particular how the new medication is helping Seema with her distress.

The following issues are listed as needing investigation or intervention:

• wound care
• risk of pressure ulcers
• urinary incontinence
• falls
• mobility problems
• social situation.

Danilo prioritises Seema's healthcare needs with concerns for pressure ulcers being highest. Pressure area equipment is provided and advice given to Seema and the care staff on how to prevent pressure ulcers, including a helpful leaflet written in Seema's own language.

The wounds are superficial but the nurse ensures that a suitable wound dressing is applied to promote wound healing in a warm moist environment. Cleaning of the wounds was not necessary as they were visibly clean and she knows that unnecessary washing of wounds can damage the healing process. Once the wound has improved and requires less frequent reassessment, Danilo delegates this dressing to Rachel the care assistant. Danilo makes this decision in line with the home's policy, his professional code and guidance from the RCN about accountability and delegation.

A continence assessment is started with thought towards reversible conditions such as infections and pelvic floor weakness. Danilo uses a continence pathway tool which enables him to methodically consider all the potential causes of urinary incontinence and assures Seema that urinary incontinence is not a normal part of ageing.

Danilo also considers if any of Seema's medication may be affecting the urinary incontinence or her falls. Although he is not a nurse prescriber, Danilo has ensured he understands the side effects of medication which is essential for all nurses that administer medication. He also starts a falls assessment although this will take a few days and includes a multi-professional assessment looking at physical, environmental and medical reasons for Seema's falls. Danilo will ensure that the falls assessment is co-ordinated and any possible causes for Seema's falls are removed to make Seema safe and improve her mobility.

Danilo has completed additional training on assessing for the use of walking aids and he has brought a walking frame to the care home: he adjusts this to the correct height for Seema and demonstrates safe use of the frame. The walking frame will help to keep Seema safe while the falls investigation is being competed.

When Danilo returns to the team office, a call is made to the social worker involved to discuss Seema's ongoing needs and to start to consider what will happen when she returns to her usual home address. A review is planned for Seema for the following week.

Sue was keen to understand what the experience of respite care had been like for Seema and her family and sought direct feedback. As the senior nurse, evaluation of the stay and the clinical outcomes were part of Sue's role.

Feedback can be sought in a variety of ways:

- direct conversations
- follow-up questionnaires
- follow-up phone calls
- feedback via other professionals
- feedback through independent agencies

As part of our professional revalidation requirements, feedback from residents and families is essential.

Seema returned home to live with her family with ongoing care from community nursing and the community mental health team as well as visits by formal carers to help with her personal care.

Sue was responsible for Seema's transfer home and worked closely with her family and community teams to meet Seema's needs and ensure a smooth transition. Sue's experience made her consider if Seema was entitled to further funding and started the assessment process. This assessment was done in conjunction with Seema's family, GP and the community teams. Sue also referred Seema's family to the local authority for a new carer's assessment.

The RCN has a number of resources to help staff identify and support people's mental health needs.

When Seema returned home she was taking different medicines to the ones she was admitted to Red Cedars. Her dosage of medication had been changed a number of times and she was now on a maintenance dose which would need to be reviewed by the CMHT.

Seema found it hard to remember her dose of new medication but her previous regular medication she remember the time for administration and the reasons why she was taking them. 

Good medicines management, or optimisation of medicines, is an integral part of most nursing and midwifery practice and includes the administration of medicines, prescribing and supporting people to take their medicines correctly.

The term medicines optimisation is now more generally used to encompass a more people centred approach to the use of medicine as part of a person's care. The Royal Pharmaceutical Society (RPS) good practice states that medicines optimisation is vital to health care and that the evidence base clearly demonstrates that health care professionals and patients need to work together to improve the quality of medicines use.

There is good evidence that medicines management supports better and more cost effective care.

The video below gives an example of a colleague's career pathway and like him, advanced practice would be a further development Danilo might wish to undertake.

John has started to enjoy life at Red Cedars and sees Graham on a regular basis. Rachel provides a lot of care for John and has started to understand a lot more about dementia. Rachel is keen to develop her knowledge and wants to put this to good effect within the care home. She recognises the number of people with dementia is increasing and represents a significant number of residents in care homes. She knows it is vital that all nurses who support people living with dementia have a sound understanding of dementia and the impact the condition has on the individual and their families. For example, staff can deliver public health messages that can minimise or prevent vascular dementia through a healthy lifestyle.

Nurses can lead the development of dementia friendly environments and ensure care is tailored to meet residents' needs. 

The RCN has supported a range of care homes across the UK to implement its SPACE dementia principles to improve care.

Eileen has been undertaking a caring role for Jane for some years now, Eileen would never describe herself as a carer but provides significant personal care and prompting for Jane. Eileen has also helped Jane manage her diabetes and takes urgent action if Jane becomes hypoglycaemic.

Since Jane has joined Red Cedars, Eileen has remained engaged in Jane's care. To assist staff in promoting partnership in caring, the RCN has published the Triangle of Care in conjunction with The Carers Trust.

The Triangle of Care is a guide to improve the relationship between the patient, staff member and carer by promoting safety, supporting communication and sustained wellbeing. The original document is designed for hospital wards but the principles are highly relevant to a care home.

The staff were aware that Eileen is living with frailty but remains in her own home in the village visiting every day to see Jane. Rachel is keen to understand more about frailty and knows Danilo has completed some online learning. She asks Danilo if he is able to offer a brief teaching session in the afternoon and suggests that some of the residents' relatives might like to come. Danilo explains that;

People often have an image of someone who is "frail", perhaps a stooped thin shuffling older lady, but this is often inaccurate. Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves both physical and psychological. It is often described as not having the ability to "bounce back" from such things as infections or a physical trauma. However, frailty is not an inevitable part of ageing: it is a long-term condition, like diabetes or Alzheimer's disease.

Older people living with frailty are at risk of poor health and social outcomes such as dramatic changes in their physical and mental wellbeing after an apparently minor event which challenges their health. Frailty varies in its severity and individuals should not be labelled as being frail or not frail but simply that they have frailty. The degree of frailty of an individual changes, it naturally varies over time and can be made better and worse. Our role as nurses is to optimise the wellbeing of people who are living with frailty and to educate and support the person and their families so that they plan for the future.

Inadequate verbal and written communication is recognised as being the most common causes of errors and poor resident experience, this being particularly true during periods of transition. Communication is more effective in teams and between teams where there are standard communication structures in place.

"SBAR" is a way of standardising handovers. SBAR stands for Situation, Background, Assessment and Recommendation. It is used frequently in care homes, particularly when speaking with external health professionals. SBAR is particularly useful if staff are trying to get complex needs across such as care at end of life. SBAR is easy to remember and encourages staff to think and prepare before communicating.

An example of how SBAR might be used is:

Situation

Background

Assessment

Recommendation