My Legacy Year

In 1979, five weeks after my 18^th birthday, I started my integrated RGN/RSCN nurse training at Great Ormond Street & Hammersmith hospitals.

In 2021, I was planning to retire. I had always worked in the NHS, mostly in community settings. A return to nursing course completed in Leicester in 1993, after a 7-year break, led me to a Norfolk paediatric ward, then 6 years as a community staff nurse, before training and working as a Health Visitor, then a GPN, later community matron, COPD team lead, finally to an hospital-based Urgent Care Centre; upgrading my academic and professional qualifications along the way through diploma, degree, MSc (ANP) and Queen’s Nurse title (2014).

My association with the QNI began in 2006 when I was one of the development practice award project leaders, under Anne Pearson, for a project called ‘Quality Zone’ about GP surgery-based exercise and Long Term Conditions. The project was cited as an example of good practice in the ‘National Service Framework for Diabetes 5 years on’ publication.

My last post was hospital/community hybrid in a GP unit attached to a busy Emergency Department and, in all honesty, I felt worn out, feeling that hospital target times compromised quality and an holistic approach, and didn’t feel like taking on all the upheaval that another change of post would entail.

Creating a Legacy Nurse Team

‘A pilot role, recruiting a nurse at, or near retirement, interested in spending a ‘legacy’ period supervising, supporting, and handing over career insights to future students in primary care/Acute/Community Trusts*, using a coaching-based model (Collaborative Learning in Practice – CLiP); supporting the workforce across the Strategic Transformation Platform area (Norfolk and Waveney CCG), clinically teaching learners, pre and post-registration, working collaboratively with education leads and universities across the system to increase placement capacity.’

(*Subsequently expanded to include Social Care).

I was surprised by my level of enthusiasm when I spotted the advert above for a ‘Legacy Nurse’, just after submitting all my retirement paperwork. My reaction was immediate, partly reflecting that the Legacy Nurse role played to my skills and interests, was a development role/pilot, and based across the CCG in its transition year to ICS. It enabled me to continue as an active QN: I updated my CV within hours, had an informal conversation with my line manager-to-be, and the rest followed on.

The role was created with Health Education England (HEE) funding, following a bid to create a role to encourage retention of experienced staff, support all levels of learners including newly qualified, across all settings, looking towards the new integrated approach for Health and Social Care (H&SC), acknowledging the impact Covid had on learning opportunities, newly qualified staff, and those responsible for assessing and supervising them.

Funding was used to employ 1.9 whole-time equivalent (WTE) nurses at band 6 and fund an evaluation study, to evidence impact of the role. A team of 5 was recruited, working 15-17.5hrs per week, over 2 days with staggered start dates (February-July), depending on availability/planned retirement dates. Initially this had an impact on team building, but so did the ongoing impact of Covid. None of us anticipated being so dependent on a virtual-working environment (and the IT skills required) for so much of our time in post, but we learned a lot. Given the large geographical area covered by the CCG, this may have enabled a wider sphere of influence than might otherwise have been possible during the pilot period.

In the end, we became a team of four with broad skill-base and experience: Teresa, paediatric nurse, HV & LeDeR reviewer; Bridgitte, community LD nurse and CHC LD advisor; Eileen, Community Heart Failure Nurse Specialist & educator and me, a generalist, with experience in community, GP and hospital settings.

We spread our working days Tuesday to Thursday, working Wednesdays in common to facilitate communication, plan and jointly deliver educational sessions and meetings, but often worked more flexibly as need arose. Meetings with HEE retention/workforce representatives, wanting to know more about us and our plans were part of this. They led into the ‘Legacy: Community of Practice’ (LCoP) sessions, which became a forum bringing together teams implementing or considering a similar approach country-wide. Now, these LCoP are scheduled as monthly sessions, reflecting the Legacy Nurse role being adapted by ICS systems and individual organisations more widely, to allow sharing of ideas and learning from implementation.

Norfolk and Waveney map shows a wide and diverse, largely rural, geographical CCG patch (made up of five former CCGs) with 5 NHS provider trusts and 1 CIC, 4 HEI and 383 CQC registered homes. Over 400 students were in training between RND, RNDA, and Trainee Nurse Associates (TNA) between these and other settings, including forensic or GP placements. Accordingly, the job description was broad and allowed for creative use of skills, experience, and contacts. Being based within the Workforce Team enabled us to work across organisations, and between placement settings and we worked closely with the clinical educators in the team and those in provider organisations.

What did we do, and how did we do it?

We worked with individuals, mainly TNAs, in GP and forensic settings;

• We worked with groups;
• We worked face to face and virtually;
• We planned and delivered ‘spoke’ sessions for TNAs that proved so popular that the recordings were shared more widely via a closed YouTube channel (accessed by link, on request – NB this was created by more IT-competent colleagues);
• We drew on our own specialist practice areas to create these sessions;
• We worked closely with the Care Provider Nurses team (working at the Health & Social Care interface) to deliver interactive, blended-learning sessions, in agreed priority areas, to registered and unregistered care and nursing home staff which, attended by 50+ devices with multiple users per device, reaching far more people than would have been possible if we had visited individual homes;
• We always aimed to identify and build on existing knowledge;
• Working with the Physical Health lead at the local Mental Health (MH) trust, we engaged with topic-based learning for MH students. This was evaluated as immensely helpful in improving their understanding of the impact of physical ill-health on MH presentations and diagnostic overshadowing.

In terms of integrating learning with practice development, we contributed to preceptorship sessions hosted by a local hospital trust as they restarted, initially for international nurses; and I worked with nursing cadet apprentices at another hospital trust, providing interactive sessions for learners, building on what they were seeing and experiencing on their ward placements. They also received support to obtain functional skill qualifications before entering next stage learning and their nursing career. Both groups called for a responsive, pastoral approach to maximise their learning.

Preliminary work to set up sessions with other providers did not always bear fruit, despite advanced planning and a warm appreciation of the value that the Legacy perspective could offer. Sometimes this was due to a lead contact changing role (e.g., we were requested to offer support to Physician Associates in training), redeployment within a team or where existing Clinical Education teams were relatively small and there was uncertainty about how much oversight the Legacy Nurse role required. As part-time practitioners our time was limited, and sometimes we had to accept that and move on; there was plenty of work elsewhere to keep us more than occupied!

Evaluation

A structured evaluation ran alongside the role implementation, and qualitative and quantitative feedback was gathered regarding our activities and effectiveness. Activities were sorted into 6 categories or ‘buckets’:

• Preceptorship,
• Transferring skills and knowledge of Legacy Nurses,
• Improving learner experience
• Support for assessors and supervisors
• Increasing placements and
• Working with Higher Education Institutions (HEIs).

Feedback forms were circulated after each contact and to individuals attending online events to elicit both qualitative and quantitative measures. A 5-point Likert scale, ranging from ‘Disagree to Strongly Agree’ responses, asked participants to evaluate the sessions’ usefulness to them, and score them perceived impact on confidence in role and value in application to role, feeling valued by employer and, longer term, whether they improved intention regarding retention. These questions reflected the objectives of the original funding bid.

Additionally, participants were invited to identify further topics they wanted as learning foci, suggestions for improving the sessions and making them even more relevant to their field of practice. An excellent return rate was noted for most sessions. In a summary of initial results (n=183) we presented these results to the board:

• > 80% had greater confidence in their role afterwards
• Three-quarters reported increased job satisfaction
• Critically, over a half “strongly agreed” they were more likely to continue working in the NHS (56%)
• Following a later amendment, for specific audiences, it specified intention to:
  • continue working in Social Care 59% (n=32)
  • Primary Care 61% (n=18).

The quantitative element was used to review the cost benefit of the pilot and to support a bid for onward funding for the Legacy approach, including expanding it into other professional areas including Social Worker and Midwife; a Legacy Allied Health Professional was also recently appointed.

Feedback was also gathered through feedback from professionals we worked alongside in devising and delivering sessions, as well as the supervisors and assessors in general practice and forensics, whose students we saw on a sessional basis. Where we did individual input for career advice or mentorship, an anonymised record was made and shared with the advisee and, with permission, included in the evaluation.

Positive feedback on Legacy Nurses from learners and educators

“The feedback I’ve received from students so far has been amazing…  your personal experiences have had a profound impact upon them.  In the words of one student, sharing real-life experiences made this ‘more real’ and she felt she could ‘better remember and relate’ to actual experiences rather than learning from a ‘textbook.’… Many of the students commented on the importance of knowing the patient as a person, not just someone with a mental health diagnosis… It was clear …your contribution heightened the students’ awareness of being ‘clinically curious.’ They made links between your professional and personal experiences, and their own need to be more curious within their placements. Your insights have undoubtedly helped the students but have also helped me to see that this initiative could have wider-reaching impacts.”

“An enormous thank you to both of you for delivering such a fantastic session on Pro-Active Skincare at today’s Student Nurse Physical Health Forum. This topic is relevant to all clinicians and I thought you both pitched it perfectly for the audience (2^nd year MSc RMN Nursing Students).  You stressed the importance of accurate, comprehensive documentation when it comes to describing a wound to ensure care is delivered in a safe, effective and joined-up manner. This also links to your emphasis on using the correct terminology to describe wounds. Usually, several clinicians will provide wound care… You enhanced the students’ understanding that using correct words and phrases helps minimise confusion and ensures seamless care is delivered to maximise wound healing.”             

As a Queen’s Nurse, I continually directed attention to the wealth of resources available on the QNI website, spoke passionately about the variety of roles and opportunities for autonomous practice in the community setting, and highlighted the role played by Dr Crystal Oldman and the QNI leadership programmes team in promoting the importance of the community nursing response throughout the pandemic. This was valued by many, especially the Nursing Cadets undertaking apprenticeship training to gain their care certificate and functional skills qualifications, whose next step would be a career in nursing. These and many others were keen to know what their longer-term options might be across different fields of practice, matching their interests and passion for quality in care.

I also encouraged those exhibiting potential to develop as future Queen’s Nurses to explore relevant materials regarding the application process, offering myself as a sounding board to them. I increased my social media activity via Twitter to harness and share resources, connect people and highlight the Legacy Nurse role #legacynurses, identifying other QNs and nurses in the Twittersphere carrying out Legacy-type roles to link up knowledge and expertise.

The evaluation paper is almost complete, the Legacy Community of Practice is live and meets monthly via Zoom for the East of England region with continued HEE support. Those interested in tapping into this resourceful, regional discussion forum should contact nursingandmidwifery.eoe@hee.nhs.uk. I shared the slide set created for that group to present the evaluation to the East of England Regional QN group in March, which generated a lot of interest, and included feedback from others undertaking bespoke Legacy roles in the region.

Meanwhile, the Legacy project continues in Norfolk and Waveney CCG, formally extended until October 2022, with a current vacancy as I’m having my first whole summer off for 43 years!

Judy Miller, Queen’s Nurse

Follow Judy on Twitter.