Nurse Awards

2016 winner's prehabilitation programme dramatically improves outcomes

Venetia Wynter-Blyth's innovation has achieved better outcomes for patients undergoing cancer surgery

Venetia Wynter-Blyth: an outstanding programme

Picture credit: Nathan Clarke

A holistic, tailored programme of prehabilitation is dramatically improving outcomes for people with cancer who require surgery, by encouraging them to participate in their care.

Venetia Wynter-Blyth and her team in the oesophagogastric cancer service at Imperial College Healthcare NHS Trust in London felt the sometimes ad hoc, traditional perioperative approach was directed at comorbidities, was paternalistic and missed an opportunity for a more effective approach.

RCN Nurse of the Year winner Venetia, who also won the RCNi Innovations in your Specialty award, believes a tailored, rather than one-size-fits-all approach, has long-term benefits.

So the clinical nurse specialist devised the PREPARE programme, which stands for physical activity; remove bad habits; eat well; psychological wellbeing; ask about medications; respiratory exercises; enhanced recovery. She then secured funding from the Imperial

Venetia Wynter-Blyth: ‘an outstanding programme’

Picture credit: Nathan Clarke

 

A holistic, tailored programme of ‘prehabilitation’ is dramatically improving outcomes for people with cancer who require surgery, by encouraging them to participate in their care.

Venetia Wynter-Blyth and her team in the oesophagogastric cancer service at Imperial College Healthcare NHS Trust in London felt the sometimes ad hoc, traditional perioperative approach was directed at comorbidities, was paternalistic and missed an opportunity for a more effective approach.

RCN Nurse of the Year winner Venetia, who also won the RCNi Innovations in your Specialty award, believes a tailored, rather than one-size-fits-all approach, has long-term benefits.

So the clinical nurse specialist devised the PREPARE programme, which stands for physical activity; remove bad habits; eat well; psychological wellbeing; ask about medications; respiratory exercises; enhanced recovery. She then secured funding from the Imperial College Healthcare Charity.

‘Before this programme, patients would be diagnosed with cancer and told they needed major surgery,’ says Venetia. ‘There was little or no structured support to help them prepare for the experience. This left a lot of patients feeling anxious and like they had no control over what was happening to them.

‘By working alongside patients, developing goals with them, and supporting them to reach these goals, it’s like we’re on a journey together and patients now have a deciding role over their own health outcome.’

Once a patient has been told they need surgery, they are invited to the Prepare clinic. Baseline assessments are taken to give a benchmark to gauge improvements over the four to six-week programme.

The team creates a plan with patients, setting personal daily or weekly goals, such as the frequency and duration of a set of gym or respiratory exercises. New goals are set depending on the patient’s improvement.

There is an exercise therapist on hand to assist and all patients see a dietitian to help them maintain weight before surgery and learn to manage nutrition post-operatively.

Patients are empowered to ask about medication and encouraged to drop any bad habits. ‘It is about using the teachable moment,’ says Venetia. ‘And 100% of our smoking patients have stopped.’

The psychological wellbeing aspect of the programme is central, and sets it apart from traditional prehabilitation programmes.

She explains: ‘Cancer affects the whole person, not just the physical. Effects of psychological ‘unrest’ can be wide-ranging and may have a subtle impact on the multiple domains of post-operative recovery. There is a domino effect – for example pre-operative anxiety impacts on post-operative pain, which impacts on post-operative recovery and so on.’

Patients taking part in Prepare are screened using validated tools and are offered a structured programme of support through Venetia and, if needed, a clinical psychologist.

Information about the surgical procedure manages expectations.

The psychological component enhances and reinforces patients’ motivation and engagement, as does a strong element of peer support. ‘Patients buddy up at the gym, support and compete with each other,’ says Venetia. ‘They become part of a community of people who have struggled with the same disease and challenges, and are working together to beat it.’

Mr G is an 81-year-old man diagnosed with an oesophageal malignancy.

He did no formal physical activity, and is his wife’s main carer. He was devastated by the diagnosis and primarily concerned about his wife and the need to ‘get through the surgery’ to continue to look after her.

Although he had no formal comorbidities, the initial Prepare screenings indicated he was functionally deconditioned and potentially at high risk of post-operative complications. He was anxious, with a low self-efficacy.

A tailored four-week programme of support was prescribed for exercise and nutrition. Goals were set and modified according to progress. He was advised to stop smoking, which he did immediately.

He was given information on the surgery and what to expect in the post-operative recovery period, as well as a post-operative timeline and strategies for anxiety management.

Clinical nurse specialist Venetia Wynter-Blyth drew diagrams for him, to complement standardised written information.

Mr G attended the hospital gym – with increasing frequency as he approached the date for surgery. He would often meet other patients in the gym and took great pride in charting his progress and development.

Immediately before surgery his MET score had improved. His increased confidence was illustrated by his self-efficacy score. He had maintained his weight.

‘Mr G agreed that he had never felt fitter and had overcome the anxieties he initially felt when we first informed him of his diagnosis and planned treatment,’ says Venetia.

‘Much of this can be attributed to a structured optimisation programme, tailored goal setting and peer-to-peer support by colleagues in the gym.’

Mr G had the surgery and went home on day 11.

‘He had no doubt the preparation pre-operatively had had a positive impact on his post-operative recovery,’ Venetia says.

‘In particular he remembered the diagrams and had even brought these into hospital as a reference source and a reminder of how far he had come.’

Since its launch two years ago, 80 patients have gone through the programme. An analysis of 50 patients’ data shows a dramatic improvement in outcomes. The number of patients experiencing surgical complications has decreased, as has the severity of complications. Hospital stays have become shorter as patients recover more quickly. The evaluation process includes a focus group for the development of the supported self-management programme, semi-structured interviews and a patient engagement event.

I loved the engagement at the gym with the exercise therapist and other patients. I became ‘addicted’ to the training Mr F

Venetia says, despite its success, her initial suggestion was met with some scepticism. ‘Nobody believed we’d get people in their seventies or eighties to the gym,’ she says. ‘But we’ve had the opposite experience. The majority of patients enjoy the challenge and feel like they are actively participating in their overall outcome, and it’s great to see.’

The whole team approach was particularly good Mr C

It is certainly true for patient Dominic, who says: ‘I have a wife and two children and I want to live and help myself as much as I can. By going through the exercises, you’re giving yourself the best possible chance. It’s a no-brainer.’

The programme was really good and even over the first three days I felt fitter and stronger Mr K

The team enjoys complete support from surgical colleagues, who make sure procedures are scheduled with enough time for patients to benefit fully from Prepare.

Consultant in upper gastrointestinal cancer and bariatric surgery Krishna Moorthy says: ‘All of us are extremely proud to be part of this initiative, which we can see is having a tremendous impact.

‘Patients are better informed, motivated and completely engaged in their post-operative recovery. There has been a significant reduction in complications, especially post-operative pneumonia, which is a considerable problem in our specialty. The feedback from the patients and their carers has also been fantastic.’

 

 

 

 

 

 

Consultant anaesthetist Helgi Johannsson agrees. ‘Getting patients psychologically and physically fit before surgery makes complete sense,’ she says. ‘We have seen a dramatic change in them: they are fitter, they know what to expect, they take pride in their own progress and, most importantly, there is a determination not only to get through their surgery but to sail through. I am so proud of this programme and the hard work of the people involved in it.’

 

 

 

The RCNi Nurse Awards’ judges are extremely impressed with Venetia’s idea and its execution. Specialist judge Amanda Burston, Nurse of the Year 2015, says: ‘This outstanding programme is really powerful. It gives great outcomes and is so transferable. It gives patients responsibility and ensures they are big stakeholders.’ Judging panel colleague Jan Baptiste-Grant agrees. ‘This programme has patients at its heart and they are empowered by it,’ he says.

 

 

 

 

Being able to control this aspect of my illness has enabled me to manage my mood and I have shared tips with other people around me. I feel in control as a result Mr M

 

 

 

 

 

 

 

Venetia is quick to stress that Prepare is a team effort, but colleagues say the clinical nurse specialist is the linchpin. ‘Venetia has overcome considerable resistance, jumped through hoops and organised the rest of us to get this programme off the ground and keep the momentum going,’ says Dr Johannsson.

 

 

 

 

The support was overwhelming and I cannot thank them enough. I wish that this programme may continue to help others as it has helped me Ms P

 

 

 

 

 

 

 

‘I know Venetia is not in this for glory; her motivation is the same that made her go into nursing in the first place. She cares passionately about her patients and is determined to give them the best possible care.’

 

 

 

The team is starting to expand Prepare to urological and lung cancer patients who require major surgery and intensive recovery. National targets dictate these patients should undergo surgery within two weeks where possible, so the team is adapting the existing programme.

 

 

 

‘We believe even two weeks of intensive preparation can positively affect outcomes,’ says Venetia.

 

 

 

 

Clinical nurse specialist Venetia Wynter-Blyth has secured funding to take her holistic pre-surgical programme to the next level using a personalised and interactive online e-health platform.

 

 

 

 

 

 

‘Patients are facing a huge operation and there is no way we can convey the enormity of that operation on a piece of paper,’ she says.

 

 

 

The team will prescribe individual goals and patients will be given an iPad to track their progress – so healthcare professionals can monitor them remotely and get feedback from the platform.

 

 

 

There are weighing scales, fitness tracking devices and a phone spirometer that can measure lung function. ‘Patients using it feel like they are actively participating in their own care,’ says Venetia.

 

 

 

Focus groups were held before the e-platform was launched to see if there would be any difficulties using the technology. ‘Even if patients have not used a tablet before, they know someone who does,’ Venetia says. ‘Technophobe patients have their families supporting them through the process. They don’t have to use the e-health platform but if they decide to, we will run group training sessions. We make sure it is user friendly and it works. We are not trying to make their care more complicated but to empower them.’

 

 

 

The platform also acts as an information portal, she adds: ‘If a patient goes to see their GP, they can show them their platform, which includes their treatment plan. The one constant is the patient and carers. If they know how to navigate through their recovery that is the key to success.’

 

 

 

 

 

 

 

‘Clinicians may come and go, but patients are effectively on a journey with their condition for their whole lives, so it is important they have the tools and support to drive their care right from the outset’.

 

 

 

PREPARE for Surgery video can be viewed at tinyurl.com/prepare-video

 

 

 

 

 

 

 

 

 

 

 

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