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Nurse of the Month: Frazer Underwood

Consultant nurse and associate director of nursing at Royal Cornwall Hospitals NHS Trust, Frazer Underwood helps shape improvements in hospitals for people living with dementia and their carers. Frazer believes that knowing the dementia patient, their life story and their goals is key to providing optimal care as it puts their everyday reality into a context.

Jenny Chou: Please describe your role. Why did you choose to go into the field you're in?

Frazer Underwood: My work at Royal Cornwall Hospitals NHS Trust is varied and sometimes quite complex as I hold many different roles and responsibilities. The part I most enjoy is my consultant nurse role, which I have been doing for the last 12 years. This brings me into contact with older people living with frailty and the frontline care teams working with them on our acute wards. Recently, I have taken on the role of clinical lead for dementia care for the trust; this leadership role shapes the improvements in our hospitals for people living with dementia and their carers. Under my role as associate director of nursing, I am the lead for the trust's non-medical prescribing, so I look after a number of corporate portfolios that include continence care, patient experience and academic partnerships. I also have an honorary clinical fellowship with Plymouth University, where alongside lecturing, I am involved in academic research developments with our clinical teams. I am passionate about nursing and care of older people living with frailty. I started off practicing as a rehabilitation nurse in intermediate care, and our increasing ageing population has meant I have had a very non-traditional career trajectory. 

JC: What are some interesting initiatives around diagnosing and supporting older people with dementia?

FU: The national agenda to increase the diagnosis of people living with dementia is very important. Acute hospitals for the last three years have been challenged to contribute to the agenda through the national CQUIN framework (Commissioning of Quality and Innovation incentive scheme). Incrementally, we have been required to develop screening and reporting systems to delivery this target. Locally, we developed a module with software supplier IMS MAXIMS to do this that sits on our evolving electronic patient record. Improving diagnosis is just one element of the initiatives in acute care we are undertaking. 

Not only are we working hard to ensure we offer a very personalised care response to people in hospital with dementia, we have recently completed investing a Department of Health grant to improve the care environments in our hospitals. Ambitiously we chose to deliver a standardised ward enhancement package to all of our inpatient wards (and those in all of Cornwall's community hospitals). This county-wide standardisation of colour use and signage in every ward will provide better orientation and familiarisation through consistency for people living with dementia and many others.

JC: Can you talk a little about the software IMS MAXIMS to improve dementia diagnosis rates?

FU: The software module development we undertook with IMS MAXIMS was in response to finding a long-term solution of meeting the quality improvement target (CQUIN target) we were initially set three years ago from now. 

The challenge of the CQUIN required a target patient group to be identified (those aged 75 years and over, admitted as an emergency) and for a dementia /delirium screening to be recorded. Then depending on the outcome, a cognitive assessment recording would be required, and the patient placed on an appropriate pathway of care, which includes specific tests and investigations being undertaken and medications being reviewed. The final requirement of the target requires patients identified to have potential risks or signs of dementia be referred on - locally this is back to their General Practitioner (GP). This is a very complex process and has to be completed within 72 hours. 

The IMS MAXIMS module supports our dementia work by ensuring the screening outcome is entered into our IT system, (and, if prompted, an abbreviated mental test score created) the remainder of the process is completed automatically - reporting and referral being made into the patient electronic discharge summary for the GP. This module has helped us refer on over 600 patients back to their GPs for further investigation into their memory concerns and impairments. I am planning to look into studying the longer-term outcomes of these referrals. With the module, we can now reduce unnecessary duplication of data input and access the information we need all in one place which helps us coordinate our dementia patients more efficiently. 

JC: What initiatives are in place to raise awareness about dementia?

FU: Alongside having mandatory dementia awareness information booklets and video clips on our induction and annual clinical and non-clinical staff updates, a range of additional training opportunities for staff exist. We have a network of around seventy dementia champions in all of our clinical areas who promote to their clinical teams the importance of using life stories to support providing personal care. Finally, alongside the programme of environmental enhancements we have undertaken, we used the opportunity to promote further key messages about dementia alongside the reason of why we were changing our environments.

JC: What's key to the management of dementia and other long-term conditions?

FU: I strongly believe that knowing the person and their personal goals is key to supporting them. By putting these front and centre in all of our interactions enables us together to achieve an optimal well-being. Knowledge about their life story is vital to care for people with memory problems as it helps put their reality into the context for us to best respond to their needs - it is as simple as that; very easy to say, but ultimately requires skill and expertise to do well.

JC: What do you find most inspiring about your job? What do you find most challenging?

FU: The most challenging aspect of my job is juggling the diverse roles and responsibilities it contains, although I would not want it any other way. I thoroughly enjoy this mix too as it brings me into contact with a great range of people across the hospital and outside in the community.

I am inspired every day by the patients I meet and the frontline care staff I work with providing great care. This is why I came into nursing twenty-five years ago and that is why as a consultant nurse - I am able to retain such an important and very grounding aspect of my complex nursing role.