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Helping older people access the best acute hospital care

The first feature in a series looking at career pathways in caring for older people looks at two advanced nurse practitioners working in acute hospital settings

The first feature in a series looking at career pathways in caring for older people looks at two advanced nurse practitioners working in acute hospital settings


Wendy Mashlan (right) with a patient. Picture: Stephen Shepherd

‘We are no longer in a world where it is rare to live past 65’
Wendy Mashlan 

Even in her early days as a nursing student Wendy Mashlan recognised that working with older people was rewarding and challenging. 

She says: 'I started to realise that older people might not come into hospital with just one problem; they could have other complex clinical or psychological needs. I knew it was about looking at the older patient as a whole and from a different perspective - that was what interested me.'

Ms Mashlan, who is lead advanced nurse practitioner (ANP) in care of elderly medicine at Princess of Wales Hospital in Bridgend, Wales, says that many of her peers wanted to move into intensive care, respiratory and cardiac care. 

‘But I was far more interested in the ageing population and the complexities of working with that group of people,' she says. 'I realised years ago the growing older population in the UK would need to be understood and cared for.'

After qualifying in 1994 Ms Mashlan worked on an elderly care ward at Bridgend General Hospital as a D grade staff nurse; a couple of years later she moved to an F grade sister post at another community hospital in Wales for patients with complex needs. 


Wendy Mashlan.
Picture: Stephen Shepherd

'The hospital I worked at was challenging,’ she says. ‘There was an antiquated system in place and I tried to work with the staff to show them that working with older people is positive and rewarding and that it is possible to work towards good outcomes for older patients.'

In 2002 Ms Mashlan moved to the larger general district hospital where she still works. She says: 'There are three wards in the hospital that deal specifically with care of the elderly: the acute frailty ward, shared care, which also covers mental health, and the general care of the elderly ward, which has complex discharge planning. 

‘Being in an advanced practice role means that I can provide holistic assessment, diagnostics, treatment plans and comprehensive discharge planning in an autonomous fashion.

'My role can be in any of these areas and my team are mainly ANPs and consultants.'

She explains that a crucial factor in working with older people is to never take things at 'face value’. 

'If an older person comes into hospital with a urinary tract infection (UTI), there is no point in just treating the UTI and then sending them home,’ she says. ‘You need to think about why the infection is there. Is it a fear of drinking and then going to the toilet too much? Older patients do not present typically and it is important to dig below the surface to assess what is going on.'

Ms Mashlan also leads frailty training for staff across departments at her health board. She says: ’It's not just for nurses but for all staff, including doctors, physiotherapists, occupational therapists, pharmacists and ward clerks. People are enthusiastic about the training because they are starting to recognise that we have an ageing population. This group is having an impact right across the hospital and we need to understand them.

'I worked with my team on the fact that the care process needs to start as soon as an older person enters the front door of a hospital, which can often be the emergency department.'


Ms Mashlan leads frailty training. Picture: Stephen Shepherd 

Ms Mashlan is studying for a PhD exploring the first point of contact a hospital has with an older patient and is also looking at discharge planning for older people with cognitive impairment. 

She believes that working with community colleagues is essential to achieving safe and effective discharge from hospital and admits there is still a lot of disparity between health boards in Wales in the way older patients are treated. 

'Nurses are able to highlight this issue and bring it to the forefront among managers and other staff,’ she says.

'There are so many resources available for nurses to help them in their care of older people. We need to realise that we are no longer in a world where it is rare to live beyond 65 and that the needs of older people must be met.'


Jason Cross with colleagues on the ward. Picture: Tim George

‘Older people are the most complex patients nurses care for’
Jason Cross

Jason Cross insists that the needs of older patients across all healthcare settings are similar and suggests that post-surgical complications are more likely to be related to their underlying health issues rather than the surgery itself. 

He says: 'Many of our surgical pathways are not tailored to the older, more complex patient, with many assessments not sensitive enough to tease out the complex, often hidden disease that can negatively impact surgical recovery.’

Mr Cross is the lead nurse in the proactive care of older people undergoing surgery (POPS) service at Guy's and St Thomas' NHS Foundation Trust in London. When it started in 2003 the POPS service was one of the first of its kind in the UK. Mr Cross says it is now seen as an example of gold-standard care in the management of older, more complex surgical patients.

The POPS service cares for older patients undergoing elective and emergency surgery. The team assesses patients preoperatively and treats any medical, functional, psychological and social issues, with the aim of reducing postoperative problems and ensuring a safe and effective discharge from hospital. The POPS team is involved throughout a patient's admission working closely with their surgical multidisciplinary team.

Mr Cross is an advanced nurse practitioner (ANP), a prescriber, and manages a team of six clinical nurse specialists (CNSs) and allied health professionals. 

'We provide comprehensive geriatric assessment and liaison for older surgical patients,' he says. 'I have a background in surgery and preoperative assessment. I started with POPS in a newly created CNS role in 2008 and became an ANP a couple of years ago. 


Jason Cross. Picture: Tim George

‘I always felt I needed to stretch my clinical skills and knowledge and when I looked at some of the work POPS was doing I felt it was my calling to work with the service. As my practice has evolved I have developed a greater understanding of how a holistic assessment, with an individualised perioperative plan, can be an effective way of working to reduce complications, enhance overall health and improve patient satisfaction.

‘My work is split between the outpatient setting and ward, with 80% of my time spent providing direct patient care. I work independently and have my own caseload of preoperative patients, while my ward liaison work involves supporting the multidisciplinary team on the surgical unit.

'All the POPS nursing team have a specific surgical unit and I am based in the gastrointestinal unit at St Thomas’ Hospital. Most mornings I will be on the ward for nursing handover, working directly with the nursing team to help identify patients who need assessment and support.’

Once a week the POPS team runs a ward meeting to discuss all the patients in the unit. This is consultant geriatrician or ANP-led. Mr Cross says: ‘These meetings are a valuable way of pulling the whole multidisciplinary team together. They help direct patient care while also providing interdisciplinary sharing of knowledge.'

Mr Cross, who has presented the work of the POPS team at national and international conferences, says he has experienced no negative comments from nursing students about working with older patients. But he adds: 'There are certainly other health professionals who still see geriatric care as a Cinderella service but there is a lot of respect for care of the elderly nursing. 

‘I always try to explain it as some of the hardest work you will ever do as a nurse. Older people are the most medically complex patients you will get a chance to look after. Nurses are already trained to understand the benefits of holistic assessments, similar to comprehensive geriatric assessments, in supporting the patient not only during their hospital stay but also for discharge and care back at home.

'I recognise I work in a somewhat privileged environment in a well-established service. Evidence and national reports highlight the benefits of POPS-type interventions but I know money is tight across the NHS. Developing new services from scratch is difficult and we will have to look at different ways to improve care for older patients with less money. People will have to be innovative.'

He says that his team provides advice to similar teams nationally about how to design a service with an emphasis on tailoring it for patient needs.

'A one-size-fits-all solution to these issues is unlikely and unworkable,’ he says. ‘While there is a focus on geriatrician-led services, nurses and other allied health professionals all have a part to play in developing and evolving services to meet the needs of the complex older surgical patient.'


Mr Cross examining a patient. Picture: Tim George

Jason Cross's top tips on developing surgical liaison services

  • Before you start, ask yourself if what you want to do is needed 
  • Start with a scoping project. Many do this work in their own time. Your project should look at specific outcomes that save money. A potential quick win is clinical coding. Can you prove that by improving discharge coding you can generate more income for the hospital?
  • Ask your surgical colleagues what is important to them and try to integrate this into what you are doing
  • If you can help with a specific target or initiative this will shape your service and garner support when you want to ask for money to help pay for your role/service 
  • Start your business plan early
  • If you’ve proved you are cost neutral, or can even make money from your scoping project, the business plan should be easy. Ask for one someone else has done and use that as a guide 
  • Don’t give up if it doesn’t work first time. It rarely works first time. Pick yourself up and start again

 


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