REPORT ON THE DEVELOPMENT OF A PROTOTYPE TOOL FOR MEASUREING THE CONTEXT OF CARE DELIVERY IN LEARNING DISABILITY SETTINGS
REPORT ON THE DEVELOPMENT OF A PROTOTYPE TOOL FOR MEASURING THE CONTEXT OF CARE DELIVERY IN LEARNING DISABILITY SETTINGS AND; A BUSINESS CASE AND HIGH LEVEL TECHNICAL SPECIFICATION FOR AN ONLINE SECURE PLATFORM FOR FUTURE LOCAL, REGIONAL AND NATIONAL REVIEW [The TCOC-LDS: Version1.]
Professor Bob Gates, The Institute for Practice, Interdisciplinary Research and Enterprise (INSPIRE) and, Dr Kay Mafuba, Associate Professor of Learning Disabilities, London College of Nursing, Midwifery and Healthcare, and Dr Stephen Roberts, Associate Professor (Information Management), and Christian Sauer, Doctoral Researcher, and Dr Nasser Matoorianpour, Senior Lecturer, School of Computing and Technology (SOCT), all from the University of West London.
December 2014
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INDEX Page Introduction to the report
4
1.
Background and context
4
2.
The origins, development and testing of the tool
7
3.
Issues of reliability and validity
11
4.
The development of a demonstrator prototype
12
4.1.
Feasibility and prototyping
13
4.2.
The business case
16
5.
Delivery systems
17
5.1.
Design considerations and potential
18
5.2.
Technologies
18
5.3.
Performance and outcomes
18
6.0.
Deliverables
19
7.0.
Conclusions and next steps
19
Appendix 1 - Tool for measuring the context of care delivery in learning disability settings [The TCOC-LDS: Version1.]
22
Appendix 2 - Covering letter for testing 8th August 2014
39
Appendix 3 - Covering letter for testing 18th August 2014
41
Appendix 4 - Technical specification
42
References
43
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Introduction to the report This report details the background and context to the development of a prototype tool to measure compliance with factors thought to be necessary for the delivery of safe and compassionate learning disability nursing care to people with learning disabilities in inpatient and community settings. It also details the origins, development, and testing of this tool, along with reporting on its initial psychometric properties. Next, the report details the development of the demonstrator prototype; and explores the feasibility of further developing this prototype through a business case; this includes an outline of a range of factors related to the delivery system itself. Finally the report concludes on the success of the work so far undertaken, and points to some of the limitations, as well as articulating possible next steps to take this important work forward in contributing to the delivery of safe and compassionate learning disability nursing care to people with learning disabilities. 1. Background and context The learning disability nursing community has for some time been concerned about declining numbers of learning disability nurses, along with reducing numbers of education commissions from HEIs by Local Education and Training Boards (LETBs) (Gates, 2010; U.K. Chief Nursing Officers, 2012; Glover and Emerson, 2012; CfWFI, 2012). This is especially relevant in a complex landscape of service provision with a multiplicity of service providers. The location of service providers in different agencies make it difficult to locate strategic responsibility for ‘sensible’ workforce planning, and yet all epidemiological evidence concerning people with learning disabilities points to a need for increasing the numbers of this part of the nursing workforce (Gates, 2010). This prompted the Professional Advisory Board for Nursing and Midwifery, DH, England in 2010 to commission a task and finish group to explore this issue. Subsequently a report was submitted to, and accepted by, the DH that made a number of important recommendations (Gates, 2011), and subsequently submitted as written evidence to the House of Commons Health Committee (DH, 2012). This report prompted a UK review of learning disability nursing with support from the four Chief Nursing Officers. Subsequently ‘Strengthening the Commitment: The Report of the UK Modernising Learning 5|Page
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Disabilities Nursing Review’ was published (U.K. Chief Nursing Officers, 2012). This report contained 17 recommendations, two of which specifically related to workforce planning. 1. The four UK health departments and the independent/voluntary sector should establish a national collaborative to enable better understanding of, and planning for, a high-quality and sustainable-registered learning disabilities nursing workforce across all sectors. 2. Systems to collect workforce data are required in each country, with links across the UK, for workforce planning for future provision of learning disabilities nursing. These should be able to capture information on service provision, educational and research requirements and should cover the independent/voluntary sector (U.K. Chief Nursing Officers, 2012, 55). Following this report a number of work streams, and actions have commenced across the UK to influence workforce planning and education commissioning decisions in relation to the learning disability field of nursing, all work streams report to the UK steering group Chaired by Dr Ben Thomas. The more recent report Strengthening the Commitment: One year on (DH, 2014) has provided an update on progress regarding the recommendations from the original Learning Disability Nursing Review. In relation to commissioned places the report notes that Health Education England (HEE) has made a modest increase in the number of learning disabilities nurse education and training places by 4.5% for 2014/15 (DH, 2014). In 2012 the Centre for Workforce Intelligence (CfWFI) undertook a strategic review of the learning disability nursing workforce; they claimed that 35% of these nurses worked in the NHS; that the supply of these nurses had decreased since 2006; and that the education commissioning of these nurses has been reducing since 2002/3 (CfWFI, 2012). Although illuminating it should be noted that its conclusions are equivocal, and simply rehearse much of what has already been said, and what is already known. A later paper by Glover and Emerson (2012) continued to corroborate an existing and predicted shortfall in workforce by Gates (2010), although the CfWFI did not corroborate this. Ensuring adequate numbers of education commissions, and learning disability nurses does not of itself address the context of national concern regarding the 6|Page
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ability of nursing to deliver safe and compassionate care. The Francis Report (2013, 1.14) identified ‘poor leadership and staffing policies, [and that] a completely inadequate standard of nursing was offered on some wards in Stafford. The complaints heard at both the first inquiry and this one testified not only to inadequate staffing levels, but poor leadership, recruitment and training. This led, in turn, to declining professionalism, and a tolerance of poor standards. Staff did report many incidents which occurred because of short staffing, they exhibited poor morale in their responses to staff surveys, and received only ineffective representation of concerns from the RCN’. Also the RCN, specifically the RCN learning disability forum have been proactive in this respect by developing learning disability nursing in the United Kingdom, and establishing an RCN position statement on the role of the learning disability nurse (RCN,2011; 2014). Nonetheless similar concerns regarding inadequate staffing, leadership, training, and recruitment were found in the serious case review into Winterbourne, which followed the appalling lack of care, and abuse inflicted on people with learning disabilities (Flynn, 2012). Principally the report found there ‘was no overall leadership amongst commissioners’, who continued to place individuals at this facility regardless of service failures and the concerns of relatives and that the volume of safeguarding referrals ‘were not treated as a body of significant concerns’; and that patients had limited access to advocacy services. And of central relevance to this review was the apparent exclusivity of learning disability nursing and psychiatry as the only disciplines employed in ‘multi-disciplinary’ teams. The report identified that the structure of the service and staffing relied heavily on support workers. Concern was noted that were no occupational therapists employed, and this has relevance when exploring safe staffing levels. Also noted were high staff turnover and high sickness rates among staff. Long 12-hour shifts were routinely worked, and there was lack of detail regarding daytime activities, and timetables for those who lived at Winterbourne View (Flynn, 2012). In response to these very public concerns a nursing strategy was launched late 2012 that set out the purpose of nurses, midwives and care staff in delivering high quality, compassionate care, and their role to achieve excellent health and wellbeing outcomes (DH, 2012b). As part of the implementation of the 7|Page
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national Compassion into Practice Programme (2012b), further work was planned, and specifically for task area 5; ‘ensuring we have the right staff with the right skills in the right place: learning disabilities’. So whereas much time and attention over the last three years has concentrated on investigating the issue of declining numbers of learning disability nurses, and the numbers of education commissions by the LETBs, for the future workforce, the lens of inquiry has now firmly focused on exploring the numbers of learning disability nurses needed in a range of health care settings to ensure the delivery of safe and compassionate nursing care. This is being explored through two major work streams that are being monitored by the learning disabilities task and finish group. The first is the development of a staffing tool, this is being undertaken by Dr Keith Hurst, and comprises tested software that will establish the numbers of nurses needed to be on duty at any one time in order to safely and compassionately meet the needs of patients. This work is on going with workshops, benchmarking and testing currently being undertaken. The second work stream itself comprised two elements. The first was the development of a prototype tool that can be used to measure compliance with factors likely to impact, based upon best available evidence, on the delivery of safe and compassionate learning disability nursing care to people with learning disabilities in residential and community settings. The second element presents the development of a business case along with a high level technical specification to further develop this prototype tool; this element has been undertaken by SOCAT; and it is these elements of the second work stream that this report exclusively deals with from hereon in. 2. The origins, development and testing of the tool On the 7th February 2014 a presentation was made of the systematic review of literature on learning disability nursing staffing levels, and its relationship to the safety, quality and the delivery of compassionate nursing care to the task and finish group (Mafuba et al. 2014). This review organised the literature into eight themes, which included; •
Level of client need,
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•
Staff attributes,
•
Staff perception of challenging behaviour,
•
Job satisfaction,
•
Working as a team,
•
Stress, burnout and work overload,
•
Organisational support that includes staff feedback.
Working in the community1.
Subsequent to this meeting UWL were commissioned to develop a valid and reliable tool to measure the ‘context of care’ for the delivery of safe and compassionate learning disability nursing care to people with learning disabilities in a range of settings. First, a range of factors, collectively referred to as the ‘context of care’, were developed into a prototype tool to measure compliance the factors from the review of literature thought to be necessary for the delivery of safe and compassionate learning disability nursing care to people with learning disabilities in a range of settings. Fundamental to the development of this tool was a belief that focussing purely on numbers of nurses alone would not address shortcomings in practice or services. It was thought it was important to develop a tool that could support the capability and capacity of nurses in their context of practice to deliver safe and compassionate nursing care. Context is a relatively new concept in the field of learning disabilities, and it relates to; ‘a concept that integrates the totality of circumstances that comprise the milieu of human life and human functioning. Context can be viewed as an independent and intervening variable. As an independent variable, context includes personal and environment al characteristics that are not usually manipulated such as age, language, culture and ethnicity, gender and family. As an intervening variable, context includes organisations, systems and societal policies and practices that can be manipulated to enhance functioning’ (Shogren, et al., 2014, 110) 1
The final theme ‘working in the community’ was added as a consequence of UWL being commissioned to further extend this review of literature to include community.
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The first stage in developing the tool was to operationalise ‘context’ into a number of trial statements for a number of the themes from the review of literature. These initial ideas were presented to the task and finish group in Birmingham on the 23rd June 2014, and a mandate was sought, and given to further develop, and test the tool within the parameters of the presentation given. This led to the construction of agreed aims to govern the scope of, and the deliverables for the next stage, which were to; •
Develop and deliver, in parallel with the staffing tool, a ‘paper based’ tool to measure the context of care delivery in learning disability settings and,
•
Construct a business case to extend this work, and finally,
•
Construct a high level technical specification for a secure online audit tool that can be developed for use locally, regionally and nationally.
The formal development of the prototype tool commenced in June 2014, and comprised the development of carefully crafted statements for each of the themes. In all, 7 statements for each of the 8 themes were developed; some 56 separate statements in total. The tool was designed with clinicians in mind who would have to rate each statement, drawing on a range of evidence to support their clinical judgment, as the extent of compliance with the statements. It was originally envisaged that each statement would be RAG rated; drawing on specified evidence (the proposal of RAG ratting was subsequently dismissed following advice, and direction from the expert reference group meeting in July 2014). It was proposed that a senior clinician should undertake the rating. The tool was developed with instructions on how it should be used, and completed, and was designed so as it would take no longer than 60 minutes to complete. Initially we advocated that it should be repeated every four months; this was subsequently changed to six months on the advice of clinicians. Each statement comprising the tool required the completing clinician to identify corroborating evidence authenticating their response. At this stage the volume of the corroborating evidence was to be the subject of further advice from clinicians. The tool was developed so as the scoring process would provide an immediate pictorial radar representation of compliance factors, this has yet to be further developed. The tool was 10 | P a g e
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advocated, and designed for self, and peer audit use. Finally, the tool was designed for use at unit/ward level, as well as Directorate level across an organisation for Board reporting (NHSE, 2014, 5 - 7). Next an expert reference group was then convened and then met on July 24th at the UWL. The draft paper version of the tool was extensively evaluated, and the meeting was also used to discuss user requirements for further information system development. It was agreed that the comments made by colleagues would contribute to an amended tool. It was agreed that the revised tool would be sent out to organisations to test for reliability. It was also agreed that a prototype for a demonstrator of the tool would also be developed. Consequently based on the comments gathered from the expert reference group the tool was extensively amended. This amended tool was then sent electronically with a covering letter (see appendix 2) to N = 22 individuals and organisations, who had expressed an interest in helping the research team undertake some initial psychometric calculations for the tool. We have until to date received N = 8 completed forms returned from 22 organisations/individuals this represents a 36 % return. Also, attached to this letter was an evaluation form with a series of questions related to the tool that respondents were asked to complete. Of the N = 8 completers, N = 4 (50%) completed and returned the evaluation form. Of these 3 strongly agreed with questions 1 - 3; 1 strongly agreed with questions 4 - 6; and 2 strongly agreed with question 7; 2 agreed with question 1; 1 agreed with questions 2 - 3; 2 agreed with questions 4 - 6; 1 agreed with question 7; 1 was not sure for question 5 and finally 1 disagreed with questions 6 - 7. The overall evaluation was almost universally positive. Notwithstanding, attention needs to be given to how long it takes to collate required evidence, and how an action plans should be constructed. The tool was again sent electronically with another covering letter (see appendix 3) to the N = 8 completers of the tool in order for us to calculate a test - retest coefficient for the temporal reliability of the tool [to date we have not received any returned completed forms to calculate this aspect of reliability for the tool]. A consistent point of discussion at a number of task and finish meetings, and throughout the development of the tool was whether it could be amended to incorporate ‘community’, as well as residential settings subsequently a 11 | P a g e
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workshop event took place on 19th August in Birmingham that was attended by 21 practitioners, and a commissioner to provide insights and discuss this. The workshop was oversubscribed, and those who could not be offered a place on the day were offered the opportunity to respond to a range of questions. The workshop concluded with broad agreement of a need for a further review of literature, followed by making amends to the tool to incorporate a community element. 3. Issues of reliability and validity The reliability of a tool as a scale is of critical importance in statistical measurement. There are predominantly two broad types of reliability; internal consistency reliability, and temporal reliability (DeVellis, 2012; Pallant, 2013). Internal consistency reliability is important in assessing the reliability of a scale (DeVellis, 2012). Our focus at this stage has been on establishing internal consistency reliability, in order to ensure that all the items on the scale ‘hang together’ (Pallant, 2013). Due to time constraints of this project it has not been feasible at this stage to establish the temporal; or test-re-test reliability of the tool. This will need to be developed over time as more data emerges. Assessing temporal reliability of the tool is important to ensure that items on the scale are answered easily, and consistently (DeVellis, 2012). According to Pallant (2013), the most commonly used indicator of internal consistency reliability is Cronbach’s Alpha coefficient. Pallant (2013) has recommended that for scales with 10 items or less, a Cronbach’s Alpha coefficient value of .5 or more is acceptable, and .7 is desirable, and values above .8 are desirable for scales with more than 10 items. The Cronbach’s Alpha coefficient for the [The TCOC-LDS: Version1.] tool is .921 and based on standardized items, is .912. Using a confidence level of 95%, with a data set from different participants, a reliability coefficient of between .89 and .97 would be expected; therefore we can state with a significant degree of confidence that the tool has very good internal consistency reliability. It is however prudent to note that this is a new tool and no comparisons of this coefficient can be made at this stage. It should also be noted that this testing was undertaken before adding the section on ‘Working in Community’. Subsequently claims made to the internal consistency reliability of this tool 12 | P a g e
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cannot be extended to the section on community; further testing is required and advocated. Our approach to validity has been driven by the need to ensure that data collected by the tool would represent the underlying context of safe and compassionate care (DeVellis, 2012). In addition, we also wanted to ensure that practitioners would be able to answer all the items on the tool as intended. Because the item measures on the scale were based on literature (Mafuba et al., 2014), construct validity rather than content validity was considered more important. To ensure construct validity the tool has been subjected to critical review by an expert reference group of professionals drawn from services from across England. There has been unanimous support for construct validity both at the expert reference group, and the subsequent evaluation form accompanying the tool when it was sent out for testing. 4. The development of a demonstrator prototype The use of digital technologies in health care is now a professional norm. Technologies and applications have followed the development trends since the 1970s. Organisational and personal computing power have developed in parallel and increasingly are becoming convergent so as to offer powerful, timely and usable access to supports management, evaluation and decision making. The Internet and the WWW are now part of both technical and social infrastructure. These innovations have yielded great benefits in terms of speed of access, scope for sharing and the use of varied sources of data. However, these innovations have brought new challenges not only in terms of maintenance and upgrading, but also in the areas of data and device security, privacy and confidentiality. This is the context in which the safe staffing tool is being developed and can be applied to future uses. The need to measure factors which impact on safe staffing, and to be able to do this widely across all the areas of the health service can now be achieved through the use of the widely available digital technologies. The proposal in this business case is to develop the demonstrator prototype, discussed here, to fully operational capability within a 12-month period in order that it can be implemented in practice for use in learning disability
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settings, both in the health service, as well as a range of private, and independent providers of health services. Thus the proposed final application will embody the following key features; A standard tool (with a robust conceptual basis, compliant with all health service norms), A secure web platform (to provide access to the tool under typical operational environments), and Tool software available on a range of hardware platforms within institutional systems or downloadable to portable devices, A suitable interface resembling the paper version to provide access to the tool, self-completion, presentation of results, facilities for analysis and archiving, and scope for combining results with other data files, An enhanced technical specification for development, A schema for incorporating the tool into a wider system of hardware and information architectures so as to increase its value for health service management, quality audit and compliance. 4.1 Feasibility and prototyping Development work on a prototype was carried out during August 2014, and has shown that the current paper based tool can be successfully implemented as a computer based application. This section briefly outlines the main features of the prototype. Real survey data has now been successfully uploaded, and simple reports have been generated. For the demonstrator Java Server Pages were chosen to implement the webbased questionnaire, and subsequently the necessary software elements of the demonstrator were implemented in Java. The database format used in the demonstrator is MySQL. However, for a later development of the full online audit tool we can also choose different approaches, such as a PHP based website, and different database formats. The final choice of the tools will depend on the user requirements elicited, to best match these. The main components of the demonstrator are at the current time as follows; A web server, providing the webpages and script/java functionalities to serve the questionnaire pages,
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A MySQL database to store basic ward information and the answers from the wards/institutions, and A basic data mining, data evaluation interface to inspect the data provided The basic outline of the demonstrator is currently configured as shown in figure 1.
Figure 1 Basic layout of the demonstrator The following screenshots figures 2 - 5 are taken from the demonstrator, showing a selection of the webpages in a Windows7/Firefox 31.0 context, however the prototype is also compatible with IE, Chrome and other browsers.
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Figure 2 - Welcome page
Figure 3, Section 5 - Working as a team page from the tool
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Figure 4 - A simple data overview for a single ward/unit
Figure 5 - A selection of tabs from the demonstrator2 4.2 Developing a delivery system - the business case Having created a prototype, and carried out testing this provides a firm foundation from which to proceed to a new proposed stage of work to be undertaken over a 12-month period. UWL are in a position to implement the further development of this prototype, which can be further constructed and
2
It should be noted that the final layout of the electronic version will appear differently to this screen shot as we have incorporated many changes since this element of the work was originally undertaken.
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refined through a combination of development and trial. This will move the prototype to a new operational level comprising; A standardised tool (with a robust conceptual basis, compliant with contemporary health service values), A secure web platform (to provide access to the tool under typical operational environments), Tool software available for use on a range of hardware platforms within institutional systems or downloadable to portable devices), A suitable interface to provide access to the tool, self-completion, presentation of results, facilities for analysis and archiving, and scope for combining results with other data files, An enhanced technical specification for further development (see appendix 4). A schema for incorporating the tool into a wider system of hardware and information architectures, so as to increase its value for health service management, quality audit and compliance, An easy to use user interface to perform data analysis and data mining on the data hold in the systems database, and the ability to provide Clear visualisation of data analysis and results for report generation. 5. Delivery systems 5.1. Design considerations and potential The model will be developed with further reasoning potential (for example, using recommender systems, staff planning modelling and similar) to enhance the initial evaluation of functionality. There will be ‘hard to quantify’ dimensions, for example, ‘work satisfaction’ which will need to be further explored within the emerging design brief. It will be possible to break down a number of (now) composite-attributes of staff into further sub attributes? An example would be, ‘staff are encouraged and supported in developing their career’ breaking this down into, ‘staff are encouraged to develop their career’, and ‘staff are supported in developing their career’. For a number of attributes we think there will be a need to explore the resolution of possible scale values in order to keep them concise but so as not to lose information through over abstraction. 18 | P a g e
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5.2. Delivery systems - technologies There are likely to be specific functional requirements for the technologies in use. The exact requirements can only be specified after the completion of the non-functional requirements specification. For the time being we estimate some of the core functional requirements to be response time of the system, scale of the database and access limits, such as maximum simultaneous user actions. In the context of the vision for a large-scale deployment of the system we assume the available technologies as sufficient to provide a service that will meet the estimated values for the above-mentioned key performance requirements. 5.3. Performance and outcomes SOCT will address questions of internal performance, and seek solutions. To do so meaningfully will require this next stage of proposed development, which will; Address general stakeholder and specific user performance expectations from the system, Observe how the system is likely to be used in practice, and Determine how the system be incorporated into work practices? The next proposed stage will combine iterative technical development of the system (the tool and the digital platform) with use / user evaluations and rigorous analysis of the feedback from users. The system can also be evaluated by a conventional usability trial (which can be contracted out to another group within SOCT to conduct independently, and in parallel with the project team). The answers to these wider outcome questions will help shape later development of the three main ‘system architectures’ (information, technical systems, communications). 6. Deliverables All work from the original proposal was delivered electronically, initially as a draft, on the 19 September 2014 to the Chair (Professor Oliver Shanley) of the task and finish group, and the project manager (Lindsey Holman). This report 19 | P a g e
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was considered, and approved by the task and finish group on the 2 October 2014. Included with this report were;
A tested prototype paper based tool to measure the context of care delivery in learning disability settings, A business case to extend this work, and A high level technical specification for a secure online audit tool that can be developed for use locally, regionally and nationally.
In addition, and not in our original proposal, has been the development by Dr Stephen Roberts, Associate Professor (Information Management), and Christian Sauer, Doctoral Researcher, and Dr Nasser Matoorianpour, Senior Lecturer, all from the School of Computing and Technology (SOCT) of an electronic version of the paper based tool as a demonstrator prototype. 7. Conclusions and next steps UWL were commissioned to develop, and submit a tested prototype paper based tool to measure the context of care delivery in learning disability settings, a business case to extend this work, and a high level technical specification for a secure online audit tool that can be developed for use locally, regionally and nationally. This report provides all three of these deliverables, along with an account of how they have been developed, and in the case of the tool, tested. Following the workshop that took place on 19 August 2014 in Birmingham we have shown that it has been possible to amend the tool to accommodate ‘working in the community’ subsequently a further review of the literature has been undertaken, and this has led to further development and modification of the tool to incorporate this as a further theme. We would offer a cautionary note concerning the extent to which this tool might be thought of as reliable, at present as we have only tested internal consistency reliability, and the tool has yet to be subjected to temporal reliability, or inter-rater reliability testing, and we also caution that testing was undertaken before adding the theme ‘working in community’. Subsequently, we repeat claims made to the internal consistency reliability of this tool cannot
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be extended to the section on community; further testing is required and advocated. We would like to conclude by proposing that we move beyond the pilot work as at December 2014, given the demonstrable need for the tool already expressed. We believe that the system proposals can be significantly scaled up from the prototype. The project uses well-tried and tested components. As the intelligence and knowledge and management area is developed there is useful scope for innovation, which can be supported by SOCT. We would like to explore, in the longer term, the real possibility of integrating and aligning the safer staffing toolkit to other sets of data, platforms and systems. We would also advocate, if further work were commissioned, that testing would take place at each stage of the system development, as the ‘safer staffing tool’ evolves. We envisage that variations can be easily accommodated into future planning, taking the scope of development beyond the initial focus on learning disabilities nursing. User evaluation and evaluation in use will be a requirement. We will build on experiences in this area from other projects that we have taken place in health informatics. Finally, risk factors in information systems development project are of critical importance. We recognise that this is a high profile area in the field and the NHS has been a laboratory for design and field-testing. Information systems project management is a speciality within SOCT. We will use standard inventories to carry out risk analysis and management. A risk analysis will be undertaken during the review of the business case proposal if general agreement to proceed to a formal project proposal is given. We also believe, assuming UWL are asked to further develop the tool’s capabilities, that we have the expertise, capacity and infrastructure to host the co-ordination, and management of a national peer review system for this important work. Briefly, this would include the management of a server, and database capable of producing bespoke reports. Organising, training and managing the peer review process. We would advocate that all NHS and private providers of health services for people with learning disabilities subscribe to this initiative, and that its use should be a ‘Key Performance Indicator’ required by commissioners in all future contracts.
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Finally, we would like to thank the task and finish group for their confidence in UWL to undertake this work and being afforded the opportunity to contribute to the national agenda of the ‘Compassion into Practice Programme’ for task area 5. We would also like to record our sincere and heartfelt thanks to all those clinical colleagues who have given up their valuable time in very busy work schedules to assist us in developing this tool.
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Appendix 1 TOOL FOR MEASURING THE CONTEXT OF CARE DELIVERY IN LEARNING DISABILITY SETTINGS [The TCOC-LDS: Version1.]
December 2014 University of West London.
INDEX Page Introduction and background 3 23 | P a g e
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The tool and Instructions for use
5
Section 1
Staff attributes
8
Section 2
Level of client need
9
Section 3
Staff perception of challenging behaviour
10
Section 4
Job satisfaction
11
Section 5
Working as a team
12
Section 6
Stress, burnout and work overload
13
Section 7
Organisational support and staff feedback
14
Section 8
Working in community
15
Summary Report
16
Action Plans
17
Evidence - Embedded Files
17
References
18
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INTRODUCTION AND BACKGROUND This valid and reliable tool has been developed to measure the ‘context of care’ for the delivery of safe and compassionate learning disability nursing care to people with learning disabilities in residential and community settings. The need for such a tool has arisen as a consequence of continuing concern about declining numbers of learning disability nurses (Gates, 2010; U.K. Chief Nursing Officers, 2012; Glover and Emerson, 2012; CfWFI, 2012), and the capacity to deliver safe and compassionate learning disability nursing care. For example, in the serious case review into Winterbourne, that followed the appalling lack of care, and abuse inflicted on people with learning disabilities, a wide range of issues such as; inadequate staffing, leadership, training, recruitment, single discipline issues, long shifts were all found to be problematic (Flynn, 2012). Also noted were high levels of staff turnover and sickness rates among staff. In addition to long 12 hour shifts, which were routinely worked, there was lack of detail regarding day time activities, and timetables for those who lived at Winterbourne View. Parallel to this the imperative to achieve safer staffing levels for nursing, along with the capacity to deliver compassionate nursing care, was to be found in other fields of nursing (Francis Report, 2013). This Report, amongst many other things identified; ‘poor leadership and staffing policies, [and that] a completely inadequate standard of nursing was offered on some wards in Stafford. The complaints heard at both the first inquiry and this one testified not only to inadequate staffing levels, but poor leadership, recruitment and training. This led in turn to a declining professionalism and a tolerance of poor standards. Staff did report many incidents, which occurred because of short staffing, exhibited poor morale in their responses to staff surveys’ (Francis Report, 2013). Subsequently, and in response to growing public and political concern about nursing the CNO for England in 2012 launched a nursing strategy that set out the purpose of nurses, midwives and care staff in delivering high quality, compassionate care, and their role to achieve excellent health and wellbeing outcomes (DH, 2012). Also the RCN, specifically the RCN learning disability forum have been proactive in this respect by developing learning disability nursing in the United Kingdom, and establishing an RCN position statement on the role of the learning disability nurse (RCN,2011; 2014). As part of the implementation of this national Compassion into Practice Programme, work is now underway to address task area 5; ‘ensuring we have the right staff with the right skills in the right place: learning disabilities’. A task and finish sub group chaired by Dr Oliver Shanley, Deputy Chief Executive, Executive Director Quality and Safety, Hertfordshire Partnership University NHS Foundation Trust, are overseeing this work. In 2013 this group commissioned a systematic review of literature to summarise the best evidence available on safe staffing levels for learning disability nurses to inform the future work of the learning disability sub group. This review identified a range of factors, collectively referred to as the context of care, which are believed to impact on the delivery of safe and compassionate 27 | P a g e
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care (Mafuba et al. 2014). These factors have been used to develop a framework for a prototype tool to measure compliance with these factors, which are necessary for the delivery of safe and compassionate learning disability nursing care to people with learning disabilities in residential and community settings. Fundamental to this tool is a belief that focussing purely on numbers of nurses alone will not address short comings in practice or services, rather in addition to addressing the numbers of staff the capability and capacity of nurses must be empowered in their context of practice to deliver safe and compassionate nursing care. Context is a relatively new concept in the field of learning disabilities, and it relates to; ‘a concept that integrates the totality of circumstances that comprise the milieu of human life and human functioning. Context can be viewed as an independent and intervening variable. As an independent variable, context includes personal and environment al characteristics that are not usually manipulated such as age, language, culture and ethnicity, gender and family. As an intervening variable, context includes organisations, systems and societal policies and practices that can be manipulated to enhance functioning’ (Shogren, et al., 2014, 110) We have operationalised context into 8 themes, and then articulated 7 statements for each of the themes; some 56 separate statements in total. Clinicians must rate each statement, drawing on a range of evidence to support their clinical judgment, to measure compliance with them, thus proving a valid and reliable measure for the delivery of safe and compassionate learning disability nursing care to people with learning disabilities in residential and community settings. The tool has been designed for self, and peer audit use. The tool can be used in a range of services, and can be used at Directorate level across an organisation for Board reporting (NHSE, 2014, 5 - 7).
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THE TOOL AND INSTRUCTIONS FOR USE 1. This tool is an evidenced based tool for measuring factors impacting on the delivery of safe and compassionate learning disability nursing care to people with learning disabilities in residential and community settings. 2. By using this tool practitioners, services and organisations are able to proactively focus their attention on issues that will improve the ‘context’ of care delivery, providing a basis from which to develop, if needed, remedial action plans to address unsatisfactory areas of practice, and, or, organisational support. 3. This tool comprises 56 statements grounded in, and integral to 7 themes elicited from a recent systematic review of literature (Mafuba et al., 2014). These themes include; staff attributes, level of client need, staff perception of challenging behaviour, job satisfaction, working as a team, stress, burnout and work overload, and finally organisational support and staff feedback. 4. A rating for each statement in each theme has to be undertaken internally by a senior clinician, band 6 or above, or if preferred the rating can be completed by a small team of clinicians, or externally by peer review. 5. The tool should take no longer than 60 minutes to complete 6. Each statement in each section should be rated as 3, 2, 1 or 0; the score will be determined by the volume of evidence available to support the statement. 7. All of the responses to statements will require the clinician to identify corroborating evidence that authenticates their response. 8. As the clinician records their rating of 3, 2, 1 or 0 an immediate pictorial radar representation of compliance with factors likely to impact on the delivery of safe and compassionate learning disability nursing care to people with learning disabilities in settings will emerge in the summary report page 14. 9. The volume of corroborating evidence has been set following advice and guidance from clinicians, and this evidence should be ‘scanned’, and then embedded into this document on page 17 as PDF file/s.
10. The tool should be used and repeated every six months.
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SCORING For each statement a clinician is required to make a clinical judgement in relation to their unit/ward/service by inserting a score of 3, 2, 1 or 0 in the corresponding box, as shown in the example on page 6. To score 3, there must be a minimum of 3 separate up-to-date documented pieces of evidence relevant to the organisation as shown in the examples given. Highlight all the evidence that is available. To score 2, there must be a minimum of 2 separate up-to-date documented pieces of evidence relevant to the organisation as shown in the examples given. Highlight all the evidence that is available. To score 1, there must either be none or 1 up-to-date documented piece of evidence relevant to the organisation as shown in the examples given. Highlight all the evidence that is available. To score 0, the statement must not be applicable to the setting. SECTION TOTALS Add all of the scores for each statement; the maximum possible sub score for each section is 21. SUMMARY TOTAL FOR ALL SECTIONS To obtain a summary total add all of the section totals in the summary report section; the maximum possible total score is 168. EXAMPLES OF EVIDENCE These have been highlighted for each statement and are for guidance. Local requirements and practices also need to be considered, and additional evidence may need to be added to the examples given. ACTION PLAN An action plan is required for each item in each section with a score of less than 3. The action plan must clearly specify what actions are to be taken, by whom, and by when, in order bring about an improvement in rating, as shown in the example on page 6.
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Example
Does your unit/ward/service ensure that;
3
1.1 there is representation of the age range (18-29; 30-49; 50+) of staff available on duty.
3
2
1
0
Evidence: Duty rosters (3 months); staff profiles; staff personal records.
1.2 there is representation of staff from ‘novice’ (less than 2 years’ experience) to ‘experienced’ (more than 2 years’ experience) of staff available on duty.
1
Evidence: Duty rosters (3 months); staff personal records; staff profiles.
1.3 there is representation from both genders from staff available on duty at any one time to meet the gender needs of patients/ service users.
3
Evidence: Duty rosters (3 months); staff personal records; staff profiles.
TOTAL (An action plan is required for any Total Score less than 21)
7
Action Plan Section 1
Staff attributes
1.2 - Need to ensure that a more balanced profile of staff from ‘novice’ to ‘experienced’ are available on duty at any one time. This could be evidenced, for example, by a series of duty rosters over the next six months. Ward Manager Gerry Smith to ensure this is done when making up the duty rosters, as from 1 September 2014, and this should be rated again in six months’ time.
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THE CONTEXT OF CARE TOOL Section 1
Staff attributes
Does your unit/ward/service ensure that; 1.1 there is representation of the age range (18-29; 30-49; 50+) of staff available on duty. Evidence: Duty rosters (3 months); staff profiles; staff records. 1.2 there is representation of staff from ‘novice’ (less than 2 years’ experience) to ‘experienced’ (more than 2 years’ experience) of staff available on duty. Evidence: Duty rosters (3 months); staff records; staff profiles. 1.3 there is representation from both genders, and ethnic groups of staff available on duty at any one time to meet the gender and ethic needs of patients/ service users. Evidence: Duty rosters (3 months); staff records; staff profiles. 1.4 staff have received up to date training required for the activities / function of the service. Evidence: Staff mandatory training records; service user / patient condition specific training records; training schedule / planner / calendar; training matrices. 1.5 staff have received up to date training on Positive Behaviour Support [PBS]. Evidence: Staff training records; training schedule / planner / calendar; training matrices. 1.6 staff have received up to date appropriate / accredited / approved training to meet physical intervention/s necessary for the service. Evidence: Staff training records; training schedule / planner / calendar; training matrices. 1.7 staff have received up to date training on safeguarding vulnerable people. Evidence: Staff training records; training schedule / training planner/s / calendar; training matrices. TOTAL (An action plan is required for any Total Score less than 21)
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Section 2
Level of client need
Does your unit/ward/service ensure that; 2.1 people with learning disabilities with very different care needs, and levels of dependency are supported in appropriate environments. Evidence: Patient / service user profiles; care / support plans; patient / service user risk assessments; treatment plans; observation level records; CPA records; health action plans, CQC Reports. 2.2 all staff understand the levels of needs of people with learning disabilities they work with appropriate to their role. Evidence: Patient / service user need specific staff training records; staff supervision records. 2.3 the health and social care needs, and risk faced by people with learning disabilities are regularly assessed using evidence-based methods. Evidence: Patient / service user profiles; care / support plans; patient / service user risk assessments; treatment plans; observation level records; CPA records; health action plans; clinical notes. 2.4 people with learning disabilities are engaged in social and occupational activities which are appropriate to their abilities. Evidence: Occupational therapy assessments; activity plans; activity records; daily patient / service user records; minutes of service user / patient meetings; nursing notes. 2.5 staff skill mix and working practices are appropriate to the level of needs and abilities of people with learning disabilities. Evidence: Therapeutic intervention plans; activity plans; activity records; daily patient / service user records. 2.6 people with learning disabilities receive age / needs appropriate care and support. Evidence: Therapeutic intervention plans; activity plans; activity records; daily patient / service user records. 2.7 processes are in place to safeguard people with learning disabilities. Evidence: Staff training records; training schedule / planner / calendar; training matrices; safeguarding policies and procedures; whistleblowing policies. TOTAL (An action plan is required for any Total Score less than 21)
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Section 3
Staff perception of challenging behaviour
Does your unit/ward/service ensure that; 3.1 staff are debriefed, and if necessary counselled following any verbal or physical incident. Evidence: Incident reports; incident management action plans; notes / reports of staff de-briefing sessions; staff supervision records. 3.2 staff are supported individually and collectively to work in challenging services. Evidence: Staff supervision records; incident management action plans; notes / reports of staff de-briefing sessions; resilience training records. 3.3 staff practice within a value-based and safeguarding framework. Evidence: Anti-discrimination policy; whistleblowing policy and procedures; safeguarding training records. 3.4 staff are familiar with, and base their practice on latest evidence-based guidance in managing challenging behaviour. Evidence: Risk management plans; patient / service user care / support plans; training records (management of aggression); incident reports. 3.5 there is a ‘whistle blowing’ policy, and that all staff are made aware of this, and how to access it. Evidence: Whistleblowing policy and procedures (accessible to all staff); staff induction records; staff training records; staff personal development plans. 3.6 staff are developed to demonstrate confidence in reporting poor practice. Evidence: Staff induction records; staff training records; staff development plans. 3.7 that all clients are engaged in meaningful occupational and leisure activities, and that staff are engaged with them. Evidence: Activity records; daily patient / service user records; nursing notes. TOTAL (An action plan is required for any Total Score less than 21)
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Section 4
Job satisfaction
Does your unit/ward/service ensure that; 4.1 staff are assessed as to their perception of life satisfaction [relevant scales for work]. Evidence: Staff satisfaction surveys; staff supervision records; staff appraisal records. 4.2 staff are clear as to their status of job security. Evidence: Staff newsletters; organisational communications; staff briefings; staff surveys, staff supervision records; clear organisational development goals; staff recognition schemes. 4.3 the importance of staff, and their contributions are promoted within the service on a regular basis. Evidence: Staff newsletters; organisational communications; staff briefings; staff surveys; clear organisational development goals; management compliments of staff / staff teams. 4.4 all staff have a clear and unambiguous job description that details their role. Evidence: Up-to-date (reviewed annually) job descriptions; staff supervision records; staff appraisal records. 4.5 staff are regularly engaged / consulted in decision making that affects them in the delivery of services. Evidence: Staff team meetings; staff team meetings with managers; staff surveys; staff consultations; nominated roles within team / ward / service / unit. 4.6 staff who leave the service are debriefed. Evidence: Staff exit interview records; management action plans on any issues raised in exit interviews. 4.7 staff are encouraged and supported to develop their careers Evidence: Staff personal development plans; staff supervision records; staff appraisal records; individual staff training / education records; secondments; NVQ / Registered Nurse specialist courses / organisational training portfolio of courses; clear internal promotion processes. TOTAL (An action plan is required for any Total Score less than 21)
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Section 5
Working as a team
Does your unit/ward/service ensure that; 5.1 staff have opportunity to attend regular team development, training and supervision events. Evidence: Team meeting records; group / team supervision records; teamworking training records / plans. 5.2 there is representation of the multidisciplinary team available to implement intervention plans. Evidence: Staff profiles; patient / service user activity / intervention records. 5.3 it has a clearly articulated vision and mission as to its function and purpose. Evidence: Mission statement; service goals (reviewed annually); service strategic / action plans. 5.4 there is representation of an appropriate ethnic mix of staff available to meet the ethnic needs of patients / service users. Evidence: Staff profiles; duty rosters. 5.5 staff teams are de-briefed following adverse events. Evidence: Notes / reports of staff de-briefing sessions; group staff supervision records; incident management action plans. 5.6 there is an appropriate range of clinical grades available at any one time to meet the needs of patients / service users. Evidence: Duty rosters; on-call rosters for clinicians. 5.7 staff teams are given autonomy and support to make team and clinical intervention decisions. Evidence: Minutes of clinical team meetings; CPA meeting minutes; care plan review minutes. TOTAL (An action plan is required for any Total Score less than 21)
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Section 6
Stress, burnout and work overload
Does your unit/ward/service ensure that; 6.1 staff are regularly monitored for signs of stress and work overload. Evidence: Staff supervision records; staff records; occupational health records; staff sickness records; staff turnover records; exit interviews records (where appropriate); occupational health referrals. 6.2 vacancies are monitored and there are process in place to fill positions when they become vacant. Evidence: Recruitment and retention strategy; monthly vacancy returns; monthly bank / agency staff use returns. 6.3 sickness and absenteeism is regularly monitored, and that managers are timely alerted and supplied with data and acted upon if above staff exceed local targets. Evidence: Sickness and absence policy and procedures; sickness and absence records; staff records; occupational health records; occupational health referrals; return to work interviews. 6.4 levels, and the use of bank / agency staff are regularly monitored. Evidence: Monthly bank / agency staff use returns; monthly bank / agency staff expenditure returns; duty rosters. 6.5 cancelled study leave is monitored. Evidence: Duty rosters; monthly staff time-sheets; training planner/s / schedule. 6.6 unfilled shifts are monitored. Evidence: Duty rosters; monthly management reports. 6.7 senior posts for clinicians and managers are not left as vacancies. Evidence: Recruitment and retention strategy; clear recruitment processes. TOTAL (An action plan is required for any Total Score less than 21)
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Section 7
Organisational support and staff feedback
Does your unit/ward/service ensure that; 7.1 clinical supervision is provided on a monthly/weekly basis. Evidence: Staff supervision records; clinical supervision records. 7.2 all staff are in receipt of an annual performance and development plan. Evidence: Staff appraisal records; staff development plans; staff performance reviews. 7.3 staff working hours are regularly audited. Evidence: Duty rosters; Process for monitoring working time directive (48 – hour week); working time directive disclaimers; audit reports. 7.4 staff who work in challenging environments are given access to personal and professional counselling services. Evidence: Referral process for occupational health and professional counselling; referral records to occupational health and / or professional counselling services. 7.5 staff turnover is monitored. Evidence: Exit interview records; exit questionnaires; resignation letters / records; unit / ward / service staff compliment statistics / records. 7.6 long 12 hour shifts are avoided, but if used, are monitored. Evidence: Clear local policy on working patterns; duty rosters; working time directive guidance, policy, and procedures. 7.7 staff are regularly informed of strategic organisational developments. Evidence: Staff newsletters; organisational communications; staff briefings / meetings; intranet. TOTAL (An action plan is required for any Total Score less than 21)
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Section 8
Working in community
Does your unit/ward/service ensure that; 8.1 all staff have a clear and unambiguous job description that details their community nursing roles. Evidence: Staff supervision records; clinical supervision records. 8.2 all staff have their caseload, ‘level of client support’, and visiting patterns regularly reviewed Evidence: Staff supervision records; clinical supervision records, staff appraisal records; staff development plans; staff performance reviews. 8.3 administrative work and travel is monitored Evidence: Mileage claim forms, audit reports, staff supervision records; clinical supervision records, staff appraisal records. 8.4 staff have opportunities to develop specialist skills in order to practice autonomously Evidence: Training records, staff profiles, personal development plans, staff supervision records, clinical supervision records, staff appraisal records. 8.5 staff are involved in identifying and diagnosing the health needs of people with learning disabilities in the community Evidence: Referral records, staff supervision records, clinical supervision records, staff appraisal records. 8.6 communication with primary care is formalised Evidence: Clear local policy on working arrangements, communication records. 8.7 staff receive support with legal matters (e.g. best interests / safeguarding etc) Evidence: Correspondence records, policies and procedures, best interest meeting records, safeguarding meeting records. TOTAL (An action plan is required for any Total Score less than 21)
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SUMMARY REPORT Sections
Themes
Section 1
Staff attributes
Section 2
Level of client need
Section 3
Staff perception of challenging behaviour
Section 4
Job satisfaction
Section 5
Working as a team
Section 6
Stress, burnout and work overload
Section 7
Organisational support and staff feedback
Section 8
Working in community
TOTAL (An action plan is required for any Total Score less than 168)
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Summary Action Plan
ACTION PLANS Section 1
Staff attributes
Section 2
Level of client need
Section 3
Staff perception of challenging behaviour
Section 4
Job satisfactions
Section 5
Working as a team
Section 6
Stress, burnout and work overload
Section 7
Organisational support and staff feedback
Section 8
Working in community
Evidence - Embedded Files
Date…………………………………………………. Signature …………………………………… Review Date………………………… Date of next review:………………………………….
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Appendix 2 Institute for Practice, Interdisciplinary Research and Enterprise St Mary’s Road Ealing London W5 5RF
[email protected] Tel: 0208 231 2209
[email protected] Tel: 0208 2094217
8 August 2014 Dear Colleague, TOOL FOR MEASURING THE CONTEXT OF CARE DELIVERY IN LEARNING DISABILITY SETTINGS [The TCOC-LDSLDS: Version1.] I hope that this letter finds you well. Kay, Stephen, Christian and I remain grateful for your continuing involvement in assisting us in developing this tool for measuring the context of care delivery in learning disability settings [The TCOC-LDSLDS: Version1]. As has already been outlined this is an important part of the implementation strategy of the national Compassion into Practice Programme for Task Area 5: Learning Disabilities. Along with this letter, and attached to this e-mail you will find a copy of the latest iteration of the above tool. This has been amended extensively based on the comments gathered from an expert reference group that you may have attended recently in London. We would now like you complete this tool as soon as you are able, and return the completed document to either Kay or myself, our e-mails are at the top of this page. Please return this no later than 12 August 2014 by 16.00. Also, attached to this letter is an evaluation form with a series of questions related to the tool that we would also ask you to complete, this will only take a few minutes of your time, but your responses will be invaluable to us in documenting your collective views on the tool as we continue to develop it. Please return this along with the completed tool no later than 12 August 2014 by 16.00. Please note we will be sending you another copy of this tool by e-mail in about one weeks’ time, and we would ask you to complete this again, and once you have completed it return this to us just as soon as you are able, you will be given a further date at this time. The purpose of sending the tool for the second time is for us to compare if scores change over time. Should you have questions and, or, suggestions then please do not hesitate to contact us. Yours sincerely,
Bob Gates, Professor of Learning Disabilities, University of West London, Editor of the British Journal of Learning Disabilities, Emeritus Professor, the Centre for Learning Disability Studies, University of Hertfordshire, and Honorary Professor of Learning Disabilities, Hertfordshire Partnership University NHS Foundation Trust.
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Please complete the statements below by placing a √ in the columns below that best describes your view.
I found that the tool ….
Strongly Agree
Agree
Not Sure
Disagree
Strongly Disagree
provided clear instructions for use took me 60 minutes or less to complete, excluding collating and embedding evidence was relevant to my organisation in measuring the context of care used a scoring system that was clear and easy to understand made It easy for me to embed the evidence required required evidence that did not take long to collate made it clear how to make an action plan
Finally please use the space below to make any other additional comments relating to the completion of the tool.
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Appendix 3 Institute for Practice, Interdisciplinary Research and Enterprise St Mary’s Road Ealing London W5 5RF
[email protected] Tel: 0208 231 2209
[email protected] Tel: 0208 2094217
18 August 2014 Dear Colleague, TOOL FOR MEASURING THE CONTEXT OF CARE DELIVERY IN LEARNING DISABILITY SETTINGS [The TCOC-LDSLDS: Version1.] I do hope that this letter finds you well. Firstly, thank you so much for recently completing the above tool, your involvement and support is much appreciated. Attached to the last letter was an evaluation form with a series of questions related to the tool that you completed these will be used to further refine the tool as a consequence of your observations. The purpose of sending this tool for the second time is for us to see if the tool is reliable and also compare if scores change over time. We would ask you to complete the tool again, there is no need to collate evidence and or construct action th plans. Please send the completed form to us by 17.00 on the 26 August.
Please note we will not be sending you any further copies of this tool for testing, but if you know of a colleague in a similar service to your own either in the NHS, or the private and independent sector, and who would be willing to get involved in this project then do please pass their details on to us by email, and we will make contact with them. We are endeavouring to establish a cumulative data bank for testing purposes, and the more people we have involved in testing the more confident we will be as to adopting the tool for wide use. Once again sincere thanks for all your help and support and should you have questions and, or, suggestions then please do not hesitate to contact us.
Yours sincerely,
Bob Gates, Professor of Learning Disabilities, University of West London, Editor of the British Journal of Learning Disabilities, Emeritus Professor, the Centre for Learning Disability Studies, University of Hertfordshire, and Honorary Professor of Learning Disabilities, Hertfordshire Partnership University NHS Foundation Trust.
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Appendix 4 High-level technical specification A demonstrator prototype, see pages 12 - 15 has been developed illustrating initial concepts. However, the proposed application will be an enterprise grade system with the following features and attributes;
The system will be a multi-tier component-based enterprise system with both vertical and horizontal tiers. Private cloud-based virtual servers will provide scalability to server interoperability across internal and external components. The vertical tiers will provide a clear separation of concerns in terms of componentbased business rules and constraints. Extensibility will be provided by loosely coupling self-contained components via webservices. Pluggable User Interface layer will be based on Web 2.0 and HTML 5 specification transparently running on mobile, Tablet and Laptop computers. In addition to data encryption for security, authorisation and authentication will be based on hierarchical role based permissions. The data-centric layer of the system will provide data persistence and connectivity via pluggable data persistence services.
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References Centre for Workforce Intelligence (2012) Workforce risks and opportunities. Learning disability nurse. Education and Commissioning Risks. Summary from 2012. Surrey. Centre for Workforce Intelligence. DeVellis, R.F. (2012). Scale development: Theory and applications. 3rd edn. Thousand Oaks, California: Sage. DH (2012a) Annex A: Nursing and Midwifery Professional Advisory Board Evidence. (ETWP 01).http://www.publications.parliament.uk/pa/cm201213/cmselect/cmhealth/6/6we02.ht m. Accessed 14/09/2014. DH (2012b) Compassion in Practice, Nursing, Midwifery and Care staff: Our Vision and Strategy. Leeds. DH. DH (2014) Strengthening the Commitment: One year on Progress report on the UK Modernising Learning Disabilities Nursing Review. London. DH. Flynn, M (2012) Winterbourne View Hospital: A Serious Case Review. Gloucestershire Safeguarding Adults Board.
Gloucester.
Gates, B., (2010) When a workforce strategy won't work: critique on current policy direction in England, UK. Journal of Intellectual Disabilities. 14. (4). 251 - 258. Gates, B., (2011) Learning Disability Nursing: Task and Finish Group: Report for the Professional and Advisory Board for Nursing and Midwifery - Department of Health, England. Hertfordshire University, Hatfield, Hertfordshire. Glover, Emerson, E., (2012) Patterns of decline in numbers of learning disability nurses employed by the English National Health Service. Tizard Learning Disability Review. 4. (17). 194 - 198. Mafuba, K Gates, B and Shanley, O (2014) Final report of a systematic review of literature in the public domain on learning disability nursing staffing levels, and its relation to the safety, quality and the delivery of compassionate nursing care. London. University of West London. NHSE (2014) How to ensure the right people, with the right skills, are in the right place at the right time: A guide to nursing, midwifery and care staffing capacity and capability. London. NHSE. 5 - 7. Pallant, J. (2013) SPSS survival manual. 5th edn. Maidenhead: Open University Press. Royal College of Nursing, UK (2011) Learning from the past- setting out the future: developing learning disability nursing in the United Kingdom. London, RCN.
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REPORT ON THE DEVELOPMENT OF A PROTOTYPE TOOL FOR MEASUREING THE CONTEXT OF CARE DELIVERY IN LEARNING DISABILITY SETTINGS
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