Wednesday, 29 June 2016

GuestPost & NurseSpeak: Amy Bowen on MS Clinical Nurse Specialist Education

The clinical microsystem is where workplace motivators reside #MSTrust #MSBlog #NurseSpeak

The larger organization can be no better than the sum of its frontline units #MSTrust #MSBlog #NurseSpeak

Prof G got in touch with me last week after having received an anonymous email from an MS nurse who was really disappointed that the blog might be stopping. The nurse was pleading with Prof G not to stop because of how reliant this nurse is on the blog for an independent perspective on all things MS, especially the research data. All very positive and encouraging to the Barts team, I hear you say, and of course we know that the blog lives on, so no problem apparently.



Amy Bowen, Director of Service Development, MS Trust

But the nurse also revealed a deeper and much more worrying reason for relying on the blog. The nurse revealed that there was very little support for ongoing learning coming from either the neurologist in the team or from the NHS organisation the nurse works for. (I don’t know if this nurse is male or female but to make this easier to write and just to mess with the stereotype, let’s assume the nurse is a male. I will refer to the nurse as ’he’ from now on.)

Like multi-story carpark crime, this is wrong on so many levels (ref Tim Vine). He felt that the neurologist that he works with had no real interest in cascading the learning that she (still messing with stereotypes, so the neurologist is a woman) gains from the many educational opportunities available to medics. She keeps them essentially to herself or amongst her neurology peers and doesn’t treat that as learning that is for the benefit of the whole MS team and so should be shared widely and generously.
The NHS organisation severely restricts the nurse’s access to educational events targeted at him. He does attend the occasional pharma industry funded events, often in his own time, but with a healthy caution about the data that is being presented (the nurses’ own words). He is also struggling to get time and support to attend the MS Trust’s annual conference, the largest event of its kind in the UK.

The MS Trust has always led MS nurse education and professional development. Alongside our conference, which is regularly attended by around 300 MS health professionals we also oversee the training for all new in post MS nurses and we fully fund virtually all of the NHS nurse places. We also offer bursaries for allied health professionals. We produce competency frameworks for MS nurses and for MS AHPs. We run a user survey service free to any MS team in the UK. We run our GEMSS programme, to help teams collect evidence about the value and impact of what they do and embed an improvement mindset into the whole team. We know all the teams and will come running whenever they have a problem securing their service. All of this from a Health Professionals Programme team of six and a shoestring budget. People think it’s the NHS making MS education happen, but I can assure you it is not. There is no money, it has no priority and they don’t know enough about MS specialist practice to deliver it as well.

Why do we do it? Is it really the work of a charity? Absolutely. We believe that everyone with MS should have a skilled and supported MS specialist team because they understand the complexities and variability of MS best and they are best placed to make care better. We can make a greatest difference for the greatest number of people with MS if we work with services to make them skilled, accessible and equitable.

Recently, one of my colleagues heard Chris Ham, Chief Executive of the Kings Fund, speak at the NHS Scotland conference on quality improvement. He apparently gave a really energising talk about, amongst other things, the concept of a clinical microsystem. So much emphasis is put on whole system redesign in the NHS – shifting resources around, integrating services that have historically had discrete boundaries (like between health and social care), moving decision making power nearer to or further from clinicians. Pulling the big levers that can theoretically have the greatest structural effect. Clinical microsystems are the complete opposite.

The concept is that the closely knit front line team, with a shared mission, is actually a really powerful unit of care that can make a massive change in patient experience, safety and outcomes. If they have scope to move beyond bureaucracy, they are able to define and pursue their common objectives, work collaboratively and make changes in their culture and their processes that they know will make a difference. They know this because they are living and breathing the delivery of the service every day and are right up close to the needs of the patients they serve. The textbook on clinical microsystems Quality by Design makes this point:

The clinical microsystem is the basic building block of any health care delivery system. It is where professional identity is formed and is transformed. It is the unit in which espoused clinical policy is put into practice (clinical-policy-in-use). It is the place where good value and safe care are made. Most variables relevant to patient satisfaction are controlled here, and this is where most health professional formation occurs after initial professional preparation. The microsystem is where workplace motivators reside. The larger organization can be no better than the sum of its frontline units, or microsystems.

The point is that MS teams need to find the strength that comes from shared learning, data-driven dialogue about service improvement and a humble determination to hear what their service users are telling them about how best to deliver care. They need to take ownership of that knowledge and be prepared to work together to change their practice and their services. Knowledge is a shared asset, not a tribal secret. Neurologists need to value their nursing and allied health professional colleagues enough to make their specialist competence as important as the medics. People with MS rely on their MS nurse from information, clinical expertise and skilled management. They are the health professional they see more than anyone else. And, as for NHS Trusts, if they don’t invest in their staff, they will lose them and everyone will suffer.




1. Nelson E, Batalden P, Godfrey M. Quality by Design: A Clinical Microsystems Approach San Francisco; Wiley 2007. p.235.
2. Evidence for MS specialist services: findings from the GEMSS MSSN evaluation project. MS Trust 2015. p.36.

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