Dementia UK provides support for families living with dementia through their Admiral Nurse Service. Admiral Nurses are specialist dementia nurses in the United Kingdom who generally work with people on a long-term basis with no fixed discharge time. They work independently and often sit outside of mental health or social care teams but may work for a variety of host organizations in different care settings. The work of Admiral Nurses is complex, and they have to be experienced practitioners functioning at an advanced level of practice. Consequently, they require a broad range of clinical, practical, and psychological skills, as well as a high level of emotional intelligence and resilience.
The Admiral Nurse Competency Framework (ANCF; Traynor & Dewing, 2003) was created early in the development of the Admiral Nurse Service to provide guidance for the Admiral Nurses, with a review taking place in 2011 (Hibberd, 2012). Dementia UK also has practice development processes in place to further support the Admiral Nurses in their role, helping them to maintain and enhance their expertise and knowledge.
In 2015, The Association for Dementia Studies was commissioned by Dementia UK to undertake a second review of the ANCF and refresh it in recognition of the increasingly wide variety of practice contexts of Admiral Nurses and the progressive complexity of their role. The desired outcome was a succinct framework that would enable Admiral Nurses to articulate and critically reflect on their own practice progression.
The Association for Dementia Studies is committed to the person-centered ethos of the Admiral Nurse Service (Brooker & Latham, 2015; Kitwood, 1997) and its focus on working with the entire family. Consequently, when refreshing the ANCF it was key to involve the Admiral Nurses themselves in the process to ensure that the refreshed framework was an accurate representation of the complexities of the role and could be embedded in their work and specifically in their practice development processes. Therefore, the aim was to develop the new ANCF with the Admiral Nurses, rather than for them. This was reflected in the methodology of the development process, which ensured that all Admiral Nurses were aware that the refresh was taking place and were able to contribute their views and feedback in an iterative fashion. Different combinations of Admiral Nurses were drawn in at specific points in the process using a range of methodologies, including focus groups and telephone interviews. This engagement with the Admiral Nurses was vital in terms of enabling them to influence the content and style of the refreshed ANCF, as well as ensuring that it was both evidence based and practice based.
The outcome of this process was the production of the ANCF–Resource for Practice (ANCF-RFP; Carter, Read, Bray, Dutton, & Brooker, 2016), which contains six overarching competencies, each with six associated elements that capture the complexity and uniqueness of the Admiral Nurse role. Within the competencies there are three levels of progression—specialist, enhanced specialist, and advanced specialist—designed in conjunction with the Admiral Nurses to provide clarity around the skills required to be classed as practicing at a particular level. These levels enable the Admiral Nurses to measure their current practice and support their ongoing professional development.
The ANCF-RFP was made available to the Admiral Nurses as a printed document and also as an online PebblePad Workbook. PebblePad is a live online tool that can be easily updated and was chosen because it was already being used within Dementia UK and by Admiral Nurses attending a Master's-level module at the University of Worcester. The ANCF-RFP was implemented in PebblePad in a simple but clearly defined structure to ensure consistency between the portfolios of different Admiral Nurses. PebblePad enables supporting evidence of practice to be captured in one central location but linked to multiple competencies in a simple way that does not require additional effort from the user.
Findings from the Development Phase
Although the ANCF-RFP development process is described elsewhere (Carter et al., 2018), it was found that there was a lot of variation in terms of how well Admiral Nurses engaged with the previous ANCF, with part of the reason for this being due to the way that it was introduced and promoted to the Admiral Nurses. There was a lot of inconsistency in this area, with some Admiral Nurses saying that when they started in their role they were “encouraged to start using it on day one,” whereas others felt like they were “supposed to know what it was” but were not actually told about it.
When Admiral Nurses have engaged with the ANCF, some found it useful to have support from someone else and “work through things together rather than by yourself.” In particular, Admiral Nurses who have been supported to use the ANCF at a more in-depth level on the Master's-level module feel “much more confident” with it.
Therefore, it became clear that in addition to involving Admiral Nurses during the refresh process, further work was required to improve engagement with the ANCF-RFP and maximize its chances of becoming fully embedded in practice. Three key areas would need to be addressed:
- There should be an overarching process relating to the introduction and promotion of the ANCF-RFP, which is consistent and involves all Admiral Nurses to ensure sign-up and a shared understanding.
- Admiral Nurses need an appreciation of the benefits of using the ANCF-RFP as a vehicle to both support and develop their practice and to gather evidence for their Nursing and Midwifery Council revalidation and appraisals. This requires the ANCF-RFP to be seen as a living entity that is regularly updated.
- Admiral Nurses need a process to support regular engagement with the ANCF-RFP to enhance their practice through critical reflection. This ongoing support requires dedicated time to consider evidence collected from practice and the opportunity to do this collaboratively rather than in isolation.
If the ANCF-RFP was truly to guide reflections on practice and progression, the processes by which this would be achieved would need to be developed alongside the framework itself. This article describes the process implemented by The Association for Dementia Studies to address how the Admiral Nurses engaged with the ANCF-RFP and promote its use in daily practice.
Method for Improving Engagement with the ANCF-RFP in Practice
Early in the process for refreshing the ANCF, the remit for The Association for Dementia Studies was extended to work with Dementia UK and the Admiral Nurses to promote and roll out the ANCF-RFP into practice and address the points identified previously. Consequently, two main activities were undertaken to support the roll-out phase.
Launching the ANCF-RFP at the Annual Admiral Nurse Forum
Dementia UK facilitates and funds the attendance of all Admiral Nurses at an annual Admiral Nurses forum. The comprehensive attendance of Admiral Nurses and senior Dementia UK staff made this the ideal event to launch the ANCF-RFP. A keynote presentation by The Association for Dementia Studies ensured that all attendees received the highlights of the ANCF-RFP simultaneously and directly and appreciated that it was a priority for Dementia UK.
The Association for Dementia Studies also facilitated a more in-depth workshop at the forum, which was repeated throughout the day to enable all Admiral Nurses to attend. For the first part of each workshop, The Association for Dementia Studies team created a number of case studies and associated examples of evidence that Admiral Nurses might collect from practice. The workshop generated an opportunity for groups of Admiral Nurses to use the case studies and simulated evidence to engage with the elements within an overarching competency, and also to introduce them to the concept of levels of progression using a structured but exploratory approach.
The second part of each workshop provided the Admiral Nurses with an introduction to PebblePad and demonstrated the online version of the ANCF-RFP. It highlighted the clear, intuitive structure and the simplicity of uploading evidence on PebblePad. It also aimed to provide encouragement to any Admiral Nurses who were less confident with technology. Feedback from the Admiral Nurses indicated that having the ANCF-RFP as an electronic PebblePad workbook was appreciated, as it provided an easy way of recording evidence in a structured format, making it more user friendly.
Working With the ANCF-RFP at Practice development days
As part of its support to Admiral Nurses, Dementia UK facilitates monthly practice development days for groups in every region. Every Admiral Nurse is aligned with a group and attends for supervision and group development. Following the launch of the ANCF-RFP, The Association for Dementia Studies embarked on a series of roll-out sessions attending a practice development day for each of the groups across the country. In theory, this process should have reached all Admiral Nurses, including any who were unable to attend the annual Admiral Nurse forum.
The intention of the roll-out sessions was to build on the workshop activities from the annual Admiral Nurse forum: promoting engagement with the ANCF-RFP competencies, elements, and levels, but also to introduce the concepts of peer support with critical reflection as an integral part of the process. Feedback from the Admiral Nurses captured during the ANCF-RFP refresh phase made it clear that, from their perspective, measuring progression depends on having an underlying peer process of critical review in order to be truly objective. This led The Association for Dementia Studies to explore the concept of peer support as a mechanism to foster fuller engagement with the ANCF-RFP.
The peer support process is used in other professional groups, such as general practitioners and primary care (Royal College of General Practitioners, 2014), and it was proposed by The Association for Dementia Studies that it would provide a more structured way of incorporating the ANCF-RFP into practice development days. Peer support refers to initiatives where colleagues meet in person or online as equals to give each other support on a reciprocal basis. It commonly refers to an initiative consisting of trained supporters and involves colleagues providing knowledge, experience, and emotional, social, or practical help and advice to each other. Effective peer support requires participants to have the ability and willingness to learn from others in order to enable the development of a structured approach to learning (Kelsey & Hayes, 2015). Within the Admiral Nurses context, The Association for Dementia Studies recommended that the support would create opportunities for critically reflective conversations and discussions of the evidence gathered by individual Admiral Nurses. This nonhierarchical, supportive process aims to capitalize on skills that are apparent within Admiral Nursing as a profession, such as the high level of communication skills, collaborative working, and the ability to be open, reflective, and discursive.
The roll-out session delivered to each practice development group therefore was structured to promote understanding of the ANCF-RFP, but also to begin the process of helping the Admiral Nurses to deepen each other's engagement through supportive shared critical reflection. When developing the roll-out session, The Association for Dementia Studies therefore was mindful of the role of reflective practice in continuing professional development to enable the Admiral Nurses to make improvements and tried to incorporate appreciative reflection into the approach (Ghaye & Lillyman, 2014).
The Association for Dementia Studies planned and delivered a session that lasted approximately 2 hours to fit into the existing practice development structure and followed a similar format for each group to ensure consistency. Following a short introduction and information recap to ensure all Admiral Nurses understood the broad outline of the ANCF-RFP and its structure, the core of the session was divided into three interactive exercises.
Exercise 1: Sharing Perspectives. Given the real expectations that Admiral Nurses have of themselves as specialist reflective practitioners, it was judged to be important that the first exercise freed up thinking around critical reflection in an engaging and nonthreatening way. There is evidence within education that art,—specifically, visual art—is effective in developing creative and critical thinking (Kisida, Bowen, & Greene, 2016), so an arts-based exercise was devised for the Admiral Nurses.
It was set up as an exercise for pairs of Admiral Nurses, using elements of art appreciation as a neutral medium to enable the Admiral Nurses to experience how it felt to be asked to justify their opinions, extend their ideas, and have their interpretation questioned, but also how it felt to support, challenge, and offer alternative opinions to colleagues. Working in pairs was a key part of the process as establishing a partnership to facilitate the sharing of understanding and perceptions, even within a confidential forum, has previously been demonstrated to be an important factor for participants in a peer support process (Purnell & Monk, 2012).
Each pair was given a preprepared image of a painting, and one Admiral Nurse was asked to give their interpretation of the painting. Their partner was responsible for encouraging them to justify and expand on what they were saying and offered an alternative perspective that challenged each other's thinking. The Admiral Nurses then swapped roles and repeated the process using a second image.
After both Admiral Nurses had discussed their image, a debrief of the exercise was facilitated by The Association for Dementia Studies. This debrief explored how the Admiral Nurses had felt in each role and expanded the concept to see whether the Admiral Nurses would find it more difficult to critique or defend an image in the same way if the topic under discussion was a piece of their own work. This was designed to get the Admiral Nurses to start thinking about how a similar process could be applied to their own evidence, which led to a second, more practice-orientated exercise.
Exercise 2: Starting Critically Reflective Conversations. In this exercise, the Admiral Nurses were encouraged to become more familiar with the ANCF-RFP and use the skills developed in the first exercise in a more realistic situation. In small groups of up to four, the Admiral Nurses were given one of the case studies developed for the workshop at the annual Admiral Nurse forum, and a specific competency to which it related. Based on the outcomes from the forum, The Association for Dementia Studies had identified where diametrically opposing views had been expressed in terms of the level to which specific pieces of evidence were felt to be best related. Different members within each small group were then asked to justify or explain the case for the evidence being assigned to a particular level, with other group members challenging the points raised.
Exercise 3: Exploring the ANCF-RFP Levels. This final exercise again used the outcomes from the forum workshops and presented each small group of Admiral Nurses with a case study and a piece of evidence where there had been consensus regarding the level of practice it related to. The Admiral Nurses were asked to discuss what additional evidence or information would need to be captured to reflect a higher level of practice. The aim of this exercise therefore was to encourage the Admiral Nurses to consider progression through the levels and potential ways of enhancing their own practice, while at the same time sharing examples from practice which could inspire their peers.
Findings from the Roll-Out Activities
Reaction to the ANCF-RFP Launch at the Admiral Nurse Forum
The forum enabled all Admiral Nurses to gain a common understanding of the ANCF-RFP and appreciate how it related directly to their practice through the case study exercise. It provided a solid foundation for the roll-out sessions by ensuring that the Admiral Nurses were familiar with the structure and format of the ANCF-RFP. Additionally, the case study work undertaken during the workshops provided evidence-based examples to use during the roll-out exercises.
Reaction to the Practice Development Day Activities
Response From the Admiral Nurses. Apprehension was initially voiced by some of the Admiral Nurses to the art exercise, feeling that they did not know anything about art, and they were reluctant to take part, possibly inwardly questioning the relevance of the exercise to them. However, after the exercise and its purpose had been explained, and also having been reassured that prior knowledge of art was not necessary, all of the Admiral Nurses engaged. The art exercise was used as a way of getting the Admiral Nurses to begin to think about critical reflection and self-reflection outside of their usual clinical experience. Although they found the exercise enjoyable, many of the Admiral Nurses also voiced surprise at how difficult the exercise had been and the feelings it initiated while undertaking it.
There is an expectation that Admiral Nurses have a high level of communication skills that are required within their clinical role working with complex family situations. Of note, the roll-out sessions revealed that applying those communication skills to themselves and their colleagues or peers proved to be more difficult and at times more uncomfortable to do than expected. Undertaking the initial art exercise therefore was beneficial because it helped to address this issue in a neutral, safe situation. It also began to build relevant communication and reflection skills within the session, helped the Admiral Nurses to feel relaxed, and provided a good opening to build a rapport quickly with peers.
As the membership of the practice development groups was unknown to The Association for Dementia Studies, so were the group dynamics. It was found that the groups could be varied, with mixed levels of Admiral Nurses, all with different levels of experience both academically and clinically. Therefore, the art exercise acted as both a warm-up exercise and a means of setting the scene by providing an equal footing that did not focus on each other's clinical work and skills. This made it less personal and avoided a defensiveness that may have emerged if the first exercise around critical reflection had gone straight into using clinical case studies.
Several studies have indicated that using case studies promotes active learning, facilitates problem solving, and develops critical thinking skills (Popil, 2011). However, case studies can also create other challenges in teaching; if students disagree with the case studies and feel that they do not reflect what they would have done in that situation or that not enough information is provided, it can deflect from the intended purpose of being a method of facilitating critical reflective discussion. This potential problem was acknowledged and anticipated by The Association for Dementia Studies, and where this was raised by the Admiral Nurses it was possible to refer back to the art exercise as a way of getting them to focus on the skills and communication they had used previously. This avoided the possibility of getting sidetracked by discussions about the accuracy of the case studies.
The exercises encouraged working in small groups, as well as whole group discussions, and these helped some of the Admiral Nurses to explore their practice more widely. They were able to share ideas, explore different ways of working, and think about other types of evidence they could capture to demonstrate their practice. They took inspiration from what their peers were doing, as well as being more able to appreciate the value of their own practice rather than just seeing it as “what we do.” Some Admiral Nurses had a tendency to underrate their own skills or assume that everyone worked in a similar way, so being given time to reflect on their practice and get a peer perspective could be a positive and reaffirming experience.
Educator Perspective. As facilitators of the sessions, the challenges for The Association for Dementia Studies included having limited time to engage with a group with which they had no prior relationship. Therefore, it was important to break down initial barriers quickly, instill trust, and develop a level of engagement that would produce meaningful critical self-reflective discussions. The opening art exercise changed the mood in the room from one of apprehension and a level of formality to a more relaxed mood, creating a lighter atmosphere that is more conducive with learning and discussion.
The facilitators were aware that some Admiral Nurses had previous experience with earlier versions of the ANCF, and the reluctance by some to use it, either through lack of explanation or understanding of it, may affect how they felt about the roll-out session. There was also the pressure of running a session within the wider context of a practice development day, which was out of the control of The Association for Dementia Studies. To a certain extent, the facilitators were going in blind and having to adapt quickly, but the art exercise and case studies were flexible enough to work in this context. By requiring the Admiral Nurses to work in small groups of two or three, the exercises were suitable for groups of any size, and by adopting a practical, hands-on, interactive approach, they fit well with a post-lunch slot following a morning session that may have focused more on listening to a lot of information.
Involving the Admiral Nurses in the development of their ANCF-RFP was previously found to work well, creating an evidence-based and practice-based resource about which Admiral Nurses have a sense of ownership (Carter et al., 2018). However, this is only part of the wider engagement process. To promote the ANCF-RFP and embed it into practice, the Admiral Nurses also need to be engaged in a roll-out phase. The development and promotion were two parts of a connected process for fully engaging with the ANCF-RFP.
The roll-out phase undertaken by The Association for Dementia Studies was well-received, enabling the Admiral Nurses to expand their communication skills. The combination of the art exercise followed by more detailed clinical case study analysis worked well because it allowed the Admiral Nurses to develop a critical reflective dialogue with each other as peers, regardless of grade or experience. Their engagement and feedback were good, especially the discussions around their feelings of the exercises. The interactive nature and neutrality of these exercises provided a platform with which to create rapport quickly with groups and enabled the Admiral Nurses to explore critical reflection in a safe and meaningful way that was flexible enough to allow creative and in-depth discussions.
To be meaningful and improve the likelihood of embedding change into practice, proactive engagement of professionals should not be limited to the initial development of a resource such as the ANCF-RFP. It should instead incorporate a roll-out aspect to enable professionals to appreciate how the resource relates to and supports their practice. The flexibility provided by the approach used during the roll-out phase could be of benefit in a wide range of work-based learning and clinical teaching opportunities, especially when time is limited and facilitating critical reflection within practice is the aim. Although the focus of this work related to specialist dementia nursing, the underlying principles of the engagement approach and the neutrality of the art exercise make it applicable to a wide range of audiences in different professional disciplines.
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