The Essence of Care programme was designed to help practitioners take a structured and patient-focused approach to developing best practice in areas of care that have the most significance for patient

Re-launched in 2003 by the Modernisation Agency (MA), Essence of Care is now an interdisciplinary initiative. A tool has been developed and published, that supports patients, carers and professionals in working together to describe and develop good quality care.

There are currently nine essential aspects of care, together with a six-stage audit cycle that describes the process of making continuous improvements in the quality of care (Diagram 1).

In 2001, Barts and The London Trust undertook to develop all of the essential aspects of care that had been described at that time, and the initiative was incorporated into the Practice Development Strategy under Strategic Aim 1, objective 4 - improving the patient's experience and outcomes. A Trust resource group supported each aspect of care. Each resource group had an identified lead member who had both an interest and expertise in the specific aspect of care. The role of the resource groups was to support, guide and provide links for those undertaking the benchmarking process in clinical areas. The groups also gained an overall picture of how the Essence of Care initiative was progressing in the Trust by receiving action plans from clinical areas and posting them on the intranet site.

At that time, the Essence of Care programme was linked to the Clinical Practice Nursing Team, within the nursing shared governance framework, and the Clinical Practice Nursing Team had overall responsibility for implementing the initiative.

Initially, clinical areas chose which aspect of care to develop and there have been a number of successes in areas undertaking benchmarking in one or more of the aspects of care. Some examples of these are:

• Improved continence resources, staff knowledge and patient information
• A patient/family questionnaire incorporating all aspects of personal and oral hygiene care, which led to identification of areas of care that were a priority for development and the development of patient-centred information leaflets
• The development of a universal nutrition screening tool, redesigned food charts and renovated day rooms to enable patients to eat away from the bedside.
• Improvements in the assessment, care planning and documentation of care for pressure ulcer prevention; increases in pressure-relieving aids in A&E and better use of patient information leaflets for pressure ulcer prevention

An Essence of Care celebration day was held at the end of the 2001 chaired by the Medical Director Charles Gutteridge. Over 40 members of staff attended the day, and work on each aspect of care was presented.

Since April 2004, each clinical area has had a target of undertaking benchmarking in two new essential aspects of care annually. Priorities for benchmarking in the Trust this year have been identified from the results of the PEAT audit, as privacy and dignity and nutrition.

In order to facilitate this objective, an Essence of Care workshop was held on 24 August 2004. Thirty staff attended. The group was made up of both nurses and AHPs. The aims of the workshop were:

• To provide an overview of the background and provide the context for the Essence of Care initiative.
• To hear from a wide group of staff, their views about Essence of Care in practice.
• To give examples of Essence of Care in practice.
• To provide an opportunity to gain practical experience in the benchmarking process.
• For each participant to take away two priorities or next steps for developing Essence of Care in their departments.
• To gain feedback that will inform the development of a new internal support and data reporting structure

The workshop participants used a method called 'Claims, Concerns, Issues' (see below) to express their ideas and thoughts about the Essence of Care initiative. This method was developed by Guba and Lincoln (1989) as a means of gaining stakeholder input, reflecting their experience, circumstances and values.

Claims, concerns and issues of Practice Development in Nursing (McCormack et al, 2004)

Claims
A claim is any favourable assertion about the initiative and its implementation.

Feedback from staff involved in Essence of Care, across the Trust, has identified a number of challenges to the success of the project. These include lack of resource group membership and leadership, lack of clarity regarding roles and responsibilities within the project and unclear reporting structures.

These challenges were reflected in the concerns identified by participants at the workshop who identified that:

• AHPs needed more encouragement to be involved at ward level;
• staff have difficulty with the process;
• that improvements are unsustainable owing to staff turnover;
• roles and responsibilities are unclear;
• the project may be no more than at trend; and
• that the structure to support people in implementing the project should be strengthened.

With reference to these concerns participants identified the issues as: 

• How are we going to ensure that good practice as a result of Essence of Care is implemented throughout the Trust?
• How do you get other members of the Interprofessional team apart from nurses, on board?
• What do people think about Essence of Care?
• How do you motivate people to be involved and see it as a good thing?
• How do we know if it is really making a difference? (patient stories/observation of care, data collection and website)
• Why does it take so long to come up with the smallest changes?
• How do we get people to see it as part of their everyday practice rather than something separate?
• How can we make it a joint activity between clinical areas so that we can share more effectively the changes that have been made?

These questions reflect staff concerns and the challenges to the project. In order to meet these challenges and answer the questions, the following proposal has been developed by the practice development facilitators and essence of care leads.

One Essence of Care resource group will form to replace the current structure of nine resource groups. The Interprofessional group will be self-organising and undertake the following roles:

• Facilitation of sharing good practice e.g. through networking and posting examples on the intranet site
• Advising on standard setting and the steps/changes needed to move towards meeting the standards
• Advising on development of Trust protocols and guidelines in any of the nine aspects of care

Ownership and organisation of a web page on the practice development section of the Trust intranet site, ensuring essential information is available; this will include accounts of the impact of Essence of Care in clinical areas, interactive Essence of Care paperwork, a chat room for Essence of Care discussions, search facilities, teaching resources, presentations, and a direct link to the resource group e-mail.

Each clinical team will have an identified link/lead person for each aspect of care (staff members may be the link for more than one aspect of care). The link person will be responsible for communication between the resource group and the team.

The benchmarking process and action planning will be a clinical team activity The link person will be responsible for facilitating and co-ordinating activity in clinical areas, in conjunction with the clinical leaders.

Essence of Care data will be collected and analysed in local areas, the process incorporated into established audit activity

Aspects of clinical practice that are identified for development, following the benchmarking process, are incorporated into local objectives and reported on through existing structures, i.e. to ward sisters/charge nurses, senior nurses and heads of nursing.

Data on activity undertaken to develop aspects of care, together with the identified key factors for development in each area, will be reported to and collected at directorate level (Appendix 1).

Identified key factors for development will inform directorate objective setting.

Directorate data will be incorporated into the clinical governance-reporting template and reported to the clinical governance committee, facilitated by the directorate clinical governance lead (Appendix 2).

This proposal has been circulated widely for feedback and comment to heads of nursing, senior nurses and AHPs and to the Interprofessional practice development steering and planning group. The first meeting of the Trust Essence of Care resource group will be held in February 2005 in order to refine and plan the next steps.

The Essence of Care work undertaken in some clinical areas in the Trust has resulted in genuine improvements to patients' experience. However, these benefits are often difficult to develop and build on. Some clinical areas are finding getting started on the benchmarking process daunting, as they are unclear about the process of benchmarking, what support is available, who is responsible for it and where the data should go.

It is proposed that Essence of Care should not sit outside the annual audit programme, but be integrated into it and reported on through existing structures where the usual lines of responsibility and accountability apply. The resource group will provide support, guidance and facilitate sharing of good practice throughout the Trust. Development of the Essence of Care initiative should become a standing agenda item on clinical team and directorate meetings and incorporated into local clinical governance agendas.

The key messages from those directly involved in implementing the initiative, and the participants in the recent workshop are that Essence of Care must be integrated into and sustainable in every day clinical practice.