Reviewing Medication Regimens

The video is an interesting way to look at the topic you covered in class last time. Just play the video and sing along!

In this blog we are going to look at the topic of reviewing medications. As we have done before this presentation is done on Microsoft Sway. It should just play when you put your mouse in the box a scroll bar will appear and you can just scroll through it. You can click active links and play any video content as you go. You can also launch it using the full screen icon which should appear on the top right of the panel below when you click on it If you do this you adjust how it plays to suit the device you are using.

Hope its useful and remember to stay safe during this Covid-19 lockdown.


Coaching an Education Classroom Session on 11th March 2020

UWS Ayr Campus

Attached is the PowerPoint used for the Coaching & Education Session that took place on the 11th March 2020 at Ayr Campus.

To download the file click the link given below

At the session Scott said he would edit his slides and send them over to Janetta and Constantina. When we have received them we will pass them on to you from the blog.

Note that the next Coaching and Education Sessions are due to take place on the 13th May 2020 between 10am – 4pm and then on the 4th June 2020 again from 10am – 4pm.

Realistic Medicine

Realistic Medicine was a concept first proposed by Scotland’s Chief Medical Officer Cath Calderwood in her annual report for 2014-15 which was published in 2016. Realistic Medicine puts the person receiving care at the centre of decision-making and creates a supported, personalised approach. It aims to reduce harm, waste and unwarranted variation, whilst acknowledging and managing the inherent risks associated with all healthcare. It also champions innovation and improvement. To achieve this, people using healthcare services and their families must feel empowered to discuss their treatment fully with healthcare professionals, in language that they will understand. This should include any possibility that a suggested treatment might come with side effects – or even negative outcomes. Realistic Medicine is an attempt to move away from the “Doctor knows best” approach to shared decision making and the co-production of care.

Realistic Medicine has a particular ethos which involves;

  • Listening to understand patients problems and preferences;
  • Sharing decision making between healthcare professionals and their patients;
  • Ensuring that patients have all the understandable information they need to make an informed choice;
  • Supporting healthcare professionals to be innovative, to pursue continuous quality improvement and to manage risk better;
  • Reducing the harm and waste caused by both over-provision and under-provision of care;
  • Identifying and reducing unwarranted variation in clinical practices.

Realistic Medicine is not about rationing healthcare or saving money. It’s aim is to improve patient care; ensuring that people receive appropriate and beneficial care that is evidence-based and in tune with their personal preferences.

To deliver Realistic Medicine everyone should feel able to ask their healthcare professional why they’ve suggested a test, treatment or procedure, and all decisions about a person’s care should be made jointly between the individual and their healthcare team. One of the early initiatives from Realistic Medicine was to encourage everyone to ask 5 questions

  • Is this test, treatment or procedure really needed?
  • What are the potential benefits and risks?
  • What are the possible side effects?
  • Are there simpler, safer or alternative treatment options?
  • What would happen if I did nothing?

Every healthcare professional should be able to answer these questions for all treatments and procedures they suggest. When people ask these questions they are more likely to receive healthcare suited to their needs that they also be more likely to comply with.

Since its adoption in 2016 the CMO for Scotland has continued to write about Realsitic Medicine and what it involves. Her 2017 report was called Realising Realistic Medicine, the 2018 report was called Practising Realistic Medicine and the most recent 2019 report was called Personalising Realistic Medicine. Last year also saw the introduction of a new comprehensive Realistic Medicine website which you can explore HERE

This video made by Healthcare Improvement Scotland talks to members of the public about realistic medicine and asked them what mattered most to them.

With regards to Fraily

In relation to Realistic Medicine and Frailty, the Director of Public Health for NHS Highland in his Annual Report in 2017 highlighted the following key points:

  • To reduce frailty we need to promote interventions that improve physical functioning by increasing muscle mass and strength, particularly progressive resistance strength training, exercise involving gait, balance, co-ordination, and encourage walking on a daily basis.
  • The effectiveness of dietary interventions are subject to more uncertainty but a healthy diet is important in preventing and addressing frailty.
  • A life-course approach to optimising peak muscle mass and strength in early life, maintaining this in adulthood, and reducing the rate of loss in older adulthood would be a useful strategy for reducing the rate of frailty across our population.
  • For hospitalised patients, better outcomes are associated with care delivered by older people’s multi-disciplinary teams, particularly when these are delivered in designated units or wards.
  • Interventions that reduce hospitalisation include certain types of nurse-led units, tele-health care for long-term conditions, discharge planning from hospital to home, case management in heart failure and integration where more generic case management is utilised would help keep more people in their own homes, where they want to be .
  • We need to maximise the network of support around every frail person so that they have the right support to improve their health, manage their condition and maintain their independence.

Dementia: Some Guidance

Caring for people with dementia in the community is one area which is currently expanding. Recently the Alzheimer Europe calculated that with an increasing, and increasingly ageing, UK population the overall numbers of people with dementia; estimated in 2018 to be 1,031,396 will by 2050 be 1,977,399. A rise from 1.56% of the overall population to 2 .67% in 2050. There is pressure therefore to get this right now ahead of this expansion.

There is no clear way to provide all the people and their carers who require support with what they will need, so new ways to provide effective care need to be considered. This blog will look at 3 existing resources that are already being used in Scotland.

The first resource we suggest that you consider using is the winner of the Scottish Digital Health and Care Award 2020; which was NHS Lanarkshire’s Online Post Diagnostic Support Website which you can access from HERE

Two things to be aware of before you go to the site. It might have been designed for people receiving post diagnostic support but the information and advice is far more extensive than this. It has been tailored to suit Lanarkshire, so some sections discuss services and processes available in Lanarkshire which may or may not be available within the NHS Ayshire and Arran area.

The advantage of using this resource is that the information that it provides is validated and conforms to NHS Scotland standards (the information sources and hwere to get more information are all ij the links given within the site). There is 24/7 access to information which you can return to easily. People living with dementia and their carers can all access it when desired. It can be used to enhance staff knowledge of dementia, post diagnostic support and the services which might be available to improve people’s support and experience.

Topics the resource covers include understanding the illness, Power of Attorney, Driving, Anticipatory Care Planning, support for carers and lots more. Please explore this resource and use as you see fit. Note that the easiest way to find the site is to type “Dementia NHS Lanarkshire” into Google.

The second resource you should consider using is the Social Care Institute for Excellence (SCIE) Dementia Gateway. The Dementia Gateway provides access to information, guidance, resources and training for anyone supporting people with dementia. It is a very extensive resource and worth taking a bit of time to explore. There is so much on it designed to be utilised by health and social care staff in the community both as a resource and as education that you will find something your team can utilise very quickly. A note of caution though. It has been designed for England and Wales which is particularly important when the information given refer to English legislation. You can access the Gateway HERE.

The third resource we suggest that you look at is work done by the “Focus on Dementia” Group who are part of Health Care Improvement Scotland. They are currently working on improving care co-ordination for people with dementia and their carers so that this becomes more integrated.

Their work can be found at https://ihub.scot/improvement-programmes/focus-on-dementia/integrated-care/ They have set about trying to identify the critical success factors for integrated care co-ordination of people with dementia in the community. The focus of their work has been Midlothian. Their overview of the Dementia Care Co-ordination Critical Success Factors is available on the site and is discussed in the video that you will find there. A more detailed report on the critical success factors is due to be published but the list of factors is something you might already be able to use. There is also other work done by Focus on Dementia that you can access from this site.

Delirium in the Community

Delirium is a common and serious medical condition that results in a person experiencing a sudden change in their behaviour. The onset of delirium always indicates the presence of a physical disorder or acute illness.
Any person can get delirium but it is more common when a person is older, has a cognitive or sensory impairment, is very ill, or requires complex treatments.
Of those aged 80 and older living at home, one in 10 people could have delirium at any time. In care home residents, six in 10 could have delirium at any time.
Nurses and nursing assistants working in these settings are well placed to recognise delirium in the people they care for.
It is important to remember that delirium is particularly common in people with dementia – if you see sudden changes in the physical or mental health of a person living with dementia don’t discount delirium. The types of changes to look out for a listed HERE. Early recognition of delirium could help prevent the person falling over, becoming even more unwell and/or being admitted to hospital. In some cases, early recognition of delirium might even prevent their death.

Delirium can be difficult to recognise and sometimes the signs are subtle. That is why any change in a person should trigger the question “Could this person have delirium?” A useful tool to consider using here is called SQiD (the Single Question in Delirium). The single question: ‘Do you think [name of patient] has been more confused lately?’ is usually put to a member of the family or a friend but if you know the person well you may be able to answer the question yourself. Although this seems simple SQiD is almost as good at delirium detection as psychiatric interview and other more sophisticated identification tools. See Sands et al (2010) for example.

It is always better to rule out delirium than miss it completely. Remember, if you identify delirium, it is very likely that the patient has a medical condition that requires assessment and treatment urgently.

Nationally, Scotland has recently adopted its own set of Guidelines regarding the Risk Reduction and Management of Delirium called SIGN Guidleine 157.

Health Improvement Scotland published a patient information booklet to complement Scotland’s first clinical guideline for delirium. These can be used alongside resources produced by @ihubscot to improve delirium care across Scotland: http://bit.ly/37M5vcu

SIGN Guideline 157 asks that health professionals in Scotland adopt a standard assessment tool called the 4AT tool and this should be used for identifying patients with probable delirium in emergency department and acute hospital settings. They go on to suggest that the 4AT tool should also be used in community or other settings for identifying patients with probable delirium. If you are unfamiliar with the 4AT then now would be a good time to adopt it and get your team used to using it.

Identifying delirium is however only part of the issue. It is really important that you and your team create, develop and follow a local escalation plan which provides you and your team with instructions regarding what to do if delirium is suspected. It is worth checking if your organisation has an existing delirium escalation plan in place. If not, you might find the template and the information on this RCN site very useful. https://www.rcn.org.uk/clinical-topics/older-people/delirium/delirium-champion

Anticipatory Care Planning

Throughout this series of blogs, you will hear repeatedly that our population is ageing and that is really good news.  However, we are also aware that the likelihood of having long-term, multiple chronic or complex conditions increases with age.  So, as healthcare professionals need to have models of care that are designed to meet the many needs of individuals.

Anticipatory Care Planning (ACP) is part of that support. So, what is Anticipatory Care Planning?  It’s about ‘thinking ahead’ and planning action or taking action before something happens.

It involves having detailed collaborative conversations between the person, their family and their care team about future care and preferred options. The process can also be used to explore how individuals can participate in their own care as an extension of self-management.

Anticipatory care planning conversations can be uncomfortable to initiate however with practice it becomes easier and as your experience develops you will become more confident in your approach.  Some people may wish to start the conversation themselves which is great, however others may experience anxiety when considering their future and may wish to avoid having such discussions until they are ready.  This is when your coaching skills will be of great value.

There will be many opportunities to start the process during care interactions and these conversations should focus on the person’s health, well-being and their actual clinical conditions in an attempt to reduce possible crises.  ACP’s also identify where  the person wishes to be  cared for and though collaborative discussion,  it helps identify their own personal outcomes.

Anticipatory Care Planning conversations are completely voluntary and are in no way  legally binding. We know people often change their wishes as circumstances change, so it is vitally important that care preferences are recorded in an ACP with any changes highlighted, dated and communicated to the wider care team.   Example ACP’s can be found at  https://ihub.scot/project-toolkits/anticipatory-care-planning-toolkit/anticipatory-care-planning-toolkit/

Anticipatory Care Planning conversations should be:

  • Collaborative: Individuals and carers are at the centre of their ACP conversations
  • Ethical:  Respect for the person’s values, beliefs and preferences for care, by including what matters to them
  • Comprehensive: Clear communication of key information (e.g. individuals or care providers involved in care or support requirements)
  • Informative communication: Establishes a robust pathway of communication sharing (including e-sharing), which can be helpful to other colleagues, care providers or agencies involved in care. Improving individuals understanding of their health and well-being (health literacy) is essential to person-centred care models which incorporate effective communication, self-management and essentially patient safety
  • Self management approach:
    • Demonstrates the unique symptoms the person may experience and simple actions they can take to address them
    • Enables early identification of health change or health needs, and relevant interventions required to support recovery or reduce crisis
  • Personal:  Information that is important to the individual or carer
  • Relevant: Highly important matters e.g. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) status and  Power of Attorney
  • Realistic: Recovery goals that reflect the individual’s hopes, aspirations and preferences e.g. “Things that I must do to keep well” or “What is important to me and why?” Such measures may help to facilitate hope and encourage active participation in the ACP process.
  • Carer considerate: Enabling alternative arrangements or contingency plans in the event of the carer becoming unwell, thereby reducing the need for acute admission to hospital.

(Barrie, Steel & Loughlin 2019, in Essentials of Nursing Adults, Eds: Elcock, Wright, Newcombe & Everett, Sage, London)

Please take some time to watch some of the personal experiences of those who have undertaken developing an ACP before and hear how important this was to them. 

https://ihub.scot/project-toolkits/anticipatory-care-planning-toolkit/anticipatory-care-planning-toolkit/videos/

Promoting Independence and Self Management

Almost half the population of Scotland have at least one long term condition (Scottish Health Survey 2014) and we know that the older people become, the more long term conditions they will develop.

It has been suggested that on average, the length of time someone with a long term condition spends with a healthcare professional is roughly 4 hours per year (NHS England 2006). For the rest of the time, they or their families are managing the condition and their circumstances at home.

For a more detailed background and more information check out the IFIC Scotland Webinar Integrated Care Matters, Series 4: Self Management and Co production https://vimeo.com/368784654

There are a number of techniques nurses can use to help people to self manage. By embedding these skills in our practice we can support people at every interaction to engage in the behaviours necessary to facilitate self management to the point where it becomes second nature.

These include:

1. Health promoting behaviours

2. Signposting to easy to read information and educational materials

3. Facilitate the person to set small achievable goals and plan actions to achieve these.

4. Peer Support

5. Provide a coaching role

6. Support unpaid carers and recognise the very important role they have.

As nurses we have a vital role to play in ensuring people have the right knowledge, skills and support when they need it. This will enable people to develop the skills and confidence to live as independently as possible and to live well despite their long term conditions. During the development of Scotland’s Self Management Strategy, the Health and Social Care Alliance (THE ALLIANCE), together with people living with long term conditions identified key stages when people said they needed more support to continue to self manage. The key stages are:

1. On diagnosis of a long term condition

2. Living for today

3. Progression

4. Transitions

5. End of Life

Please go and take a look at the Scotland’s Self Management Strategy entitled ‘Gaun Yersel’ which can be found at www.alliance-scotland.org.uk/wp-content/uploads/2017/11/ALLIANCE-SM-Gaun-Yersel-Strategy-2008.pdf

Most people will say they self manage to varying degrees. For some this may be in the form of managing complex medication regimens, for others this may involve using highly technical skills and equipment. As a result people need different levels of support at different times to help them to self-manage their own conditions.

There are some excellent resources on Self Management and Co Production available at: https://www.alliance-scotland.org.uk/self-management-and-co-production-hub/ Take a look and watch some of the very helpful videos.

In 2011, The Health Foundation published “Helping People help themselves” which looks at the evidence around self management.

The Key Points from this document are:

Evidence suggests that supporting self-management works. Supporting people to look after themselves can improve their motivation, the extent to which they eat well and exercise, as well as improving their symptoms and clinical outcomes.

Although many initiatives and different types of support are available, some are more useful than others. To encourage people to engage in self management activities the provision of information alone is unlikely to be enough to motivate behaviour change – more self-management approaches are necessary.

So, how do we know that people understand the health related information or instruction of techniques we provide to facilitate self management? There is an approach called Teach-Back. Its very simple and quick. After providing information about their condition or demonstrating a technique, all you have to do is ask the person to explain back in their own words what they have just heard or seen in order to demonstrate their understanding. If the person is unable to explain or describe the technique or information, then we should re-educate the person using different words until the person can show they understand. This is not a test for the patient, so asking the person to explain back what they have just heard should be done in a relaxed and friendly manner, avoiding technical jargon. Teach-Back has been shown to be a very useful technique to promote understanding and facilitate self management. It is a technique related to health literacy – for more about health literacy, look at the previous post on this blog site on Sensory Changes and Frailty.

For more information about teach-back go to http://teachbacktraining.org/home

Sensory Changes and Frailty

As we age, our sensory systems gradually start to decline. For more information about the ways in which our senses are affected by age the following article from MedlinePlus Medical Encyclopaedia, called Ageing Changes in the Senses is a useful summary which you can access HERE

To understand the scale of the problem consider firstly the number of older people who wear glasses or contacts who are over 55. It’s also worth noting that it is estimated that 945,000 people in Scotland are deaf or have hearing loss and that more than 500,000 people in Scotland have a form of tinnitus.

Sensory impairment has been shown to have psychological, psychosocial,
and functional effects that may lead to social isolation, anxiety, depression, paranoia, and decreased self-esteem.

Dual sensory loss (DSL), the presence of both hearing loss and vision loss is particularly prevalent among ageing populations across the world with studies showing that more than 20% of adults older than 70 years are affected with that percentage increasing with advancing age. The interaction between the variety of visual losses and the variation in types of hearing loss means that there is a wide variation in each individuals needs. This makes it difficult for community staff who have very little cross disciplinary training to meet every need they encounter even though they are meeting older people with multiple sensory impairments every day.

However DSL also affects the ability of older people to perform Instrumental Activities of Daily Living (IADL’s). So although problems with dressing and bathing may occur using a ‘phone or grocery shopping, preparing meals, managing housework and money are far more likely problems and will limit the ability of frail older people to remain at home. The likelihood of identifying and intervening when such problems exist is not helped by older adults themselves, who tend to overestimate their capabilities. Not only are AIDL’s affected, frail older people with sensory impairments also experience poorer overall mobility and the more severe the loss the more likely functional and cognitive decline will occur.

What Can You Do?

The Importance of Hearing Aids. One of the most important things you can do is encourage the use of hearing aids. Kochkin and Rogin (2000) in a study conducted for the US National Council on Aging showed that individuals with hearing impairment who did not use hearing aids participated in statistically significantly fewer social activities and reported statistically significantly more anxiety, depression, emotional instability, and paranoia than individuals who used hearing aids.

However there is a huge stigma surrounding hearing impairment that generally manifests as a reluctance to acquire hearing aids or to participate in any other types of aural rehabilitation.

Consider the Persons Manual Dexterity? With advancing age comes diminished manual dexterity. This has direct effects on several aspects of
hearing aid use and aural rehabilitation, with the most obvious being hearing aid insertion, manipulation of the hearing aid controls, and handling of the battery. There is a strong association between poor manual dexterity and poorer hearing aid outcomes, like less daily use, and lower satisfaction with hearing aids. A study by Parving and Philip (1991) reported that 40% of hearing aid users by the time they were 90 could not use the
volume control wheel, 36% could not change the hearing aid battery, and 34% could not clean the hearing aid ear mould.

Consider the Person’s Health Literacy. DSL is also known to limit a person’s ability to understand and recall the information provided and to successfully integrate self-care into their daily life. It has
been shown that generally older people have the lowest health literacy and
related adverse health outcomes than younger people. Therefore, communication needs to be optimized to accommodate the sensory needs of older individuals to the extent possible.

  • To ensure this the environment needs to be optimized.
  • You need to speak clearly and make efforts to clearly enunciate and to increase the time between spoken words, decreasing your rate of speech.
  • Provide clear written materials. Remember literacy level and pitch to a reading age around 12. Written material should be 14 points and have wide spaces between the lines. A sans serif font should be used and multiple columns on a page should be avoided.

A more extensive guide with videos on how to communicate with someone with hearing loss can be found HERE

Provide/Use Assistive Devices. Like hearing loops, magnifiers with lights, video magnifiers, tactile devices (like vibrating alarm clocks, door bells etc). Whatever you think might help the person. See: https://www.hearinglink.org/living/loops-equipment/ and https://shop.rnib.org.uk/

Provide Redundancy. When delivering information use multiple perceptual channels (visual, auditory, and tactile). This increases the person’s opportunity to all information provided. Supplement anything you say with written materials which can be verbally repeated by carers, relatives etc. If you use low or high technology always buy/use technology with built in redundancy. The reason for doing this is that the circumstances of the person the assistive technology/device will change. As a result, you never know when you might need more functions/capabilities to be switched on.

Use Patient Teach-back. A useful method for verifying that the information you want the person to understand is understood to get the person to repeat back in his or her own words what was said or demonstrate the procedure you are trying to get them to learn/understand indicated by the provider. This way you can check the communication is understood and correct any misunderstandings. See http://scottishhealthcouncil.org/patient__public_participation/participation_toolkit/teach-back.aspx#.Xhu9_sj7TIU

Further Information

See: Royal National Institute for the Blind Services page https://www.rnib.org.uk/services-we-offer-advice-professionals-health-professionals/services-patients

and Action on Hearing Loss’s Guidance for Nurses. https://www.actiononhearingloss.org.uk/how-we-help/health-and-social-care-professionals/guidance-for-nurses/