Leading change

A Matron at the David Lewis National Epilepsy Centre, a health foundation based in Cheshire, led a programme of work to embed Vagus Nerve Simulation (VNS) mentorship into clinical practice. This has supported staff to develop their skills, knowledge and roles which is impacting outcomes, experience and use of resources locally.

Where to look

Vagus nerve stimulation (VNS) refers to any technique that stimulates the vagus nerve, including manual or electrical stimulation. Vagus nerve stimulation therapy can be a treatment for epilepsy, depression, inflammation, metabolic syndrome, and heart disease with varying effectiveness (Howard 2014). Due to the speciality and complexity of this treatment it should be carried out by staff with specialist training.

As part of a wider service review, the Matron identified that there were very few individuals within the team with the correct skills and competencies to undertake VNS which meant when the doctors suggested changes in dosing parameters there may be a delay in the VNS being reviewed and re-programmed. This was unwarranted variation in practice. The matron identified the opportunity to develop the clinical team’s skills and competence to address this.

What to change

The David Lewis National Epilepsy Centre is a health foundation which cares for people with epilepsy, learning disabilities and associated disorders. The centre supports individuals to gain independence, positive identity, self-esteem and personal control over their lives via specialised support packages delivered in a variety of community locations.

Having recognised variation in practice, the Matron developed a programme to enhance the service provision for service users who need VNS clinic appointments. Prior to the change and additional staff training, these appointments were limited to matron availability due to the specialised care needed. This was also increasingly complex given the service users had varying physical and behavioural needs that resulted in cancelled or missed appointments which could not always be accommodated with increased waiting times ensuing.

The centre recognised they needed to have increased flexibility in the appointments offered, but this required additional staff training. Vagus Nerve Stimulation is a skilled, technical process and there were only two nurses at the centre who were fully trained.

The ‘VNS Therapy Magnet guidance’ leaflet and ‘an introduction to VNS Therapy’ leaflet (produced by Livanova) provided information on the benefits of the correct magnet use technique and understanding the device. After observing that care staff and families did not always use the magnet in an effective way, the need for additional training was clear. This would support staff to understand the device and the benefits of effective use. The guidance leaflets were provided to everyone responsible for the use of the magnet. This small change has started to show improvements in the clinical effectiveness of the therapy. It was also apparent to the matron that for effective therapy, specialist mentoring was required for the clinical team, to support them to develop and hone the skills and competencies in providing this service at the centre.

How to change

The Matron supported two colleagues to attend a training conference on VNS, to support them to better understand the devices used and the responsibilities of the clinicians undertaking procedures. This would support the successful implementation of the project as they could share this learning across staff at the centre.

A programme of learning was devised to support the nurses in developing their knowledge and skills. This included developing a training package and presentation. A meeting was arranged with the Livanova representative to provide opportunity to ask questions and gain further practical experience. This included:

• Establishing VNS clinic appointments, with mentorship and clinical oversight;
• Care and management of VNS equipment;
• Training and support when carrying out diagnostic procedures;
• Documentation requirements;
• Service user follow up assessments.

Regular nurse led clinics were developed, with supervision from the matron. This included the use of equipment and assessment of staff competency as well as feedback and support to enable further development. These clinics provided technical support to the doctors and increased the confidence and competence of the clinical team. The clinics aimed to engage the care teams in capturing information on how seizure severity and duration were reduced with more effective management. The nurses with this additional training and development opportunity were better equipped to liaise closely with consultants and specialist epilepsy nurses at the centre to deliver high-quality, evidence-based treatment.

Adding value

Better outcomes – This development programme has supported the nurses to provide increasingly effective monitoring and guidance on day to day usage of VNS devices, including supporting service users undergoing the procedure. This is demonstrating decreased waiting times for diagnostics and re-programming. The team can now provide the service at any time of day or night to suit the needs of the service user. The nurses have been supported to develop their skills which is demonstrating increased confidence in practice and they are able to actively respond to service user need. There has anecdotally been increased engagement with families and carers in this nurse-led approach which is proving effective and has been well-received. It is anticipated that the increased capacity to complete procedures at the centre is resulting in less need for service users to attend hospital and supports provision of care closer to home.

Better experience – Feedback from service users, their families and carers has reflected the increased responsiveness this programme has advocated. Carers at the centre have reported feeling better informed and trained in the correct use of the device. Feedback includes:

‘Many thanks for the comprehensive information. I feel more informed and much appreciate being kept in the loop’.

‘I am happy that the nurses know what to do to help my seizures, I like being able to come and see them in the clinic’.

Better use of resources – VNS procedures can now be carried out by a wider range of staff members which has resulted in better use of time across the team, including the matron who can now focus on other aspects of service provision. Continued professional development has improved which is already improving engagement and empowerment. Battery life of the devices through closer monitoring has increased. This has improved device efficacy which is associated with the observed reduced seizure rate.

Challenges and lessons learnt for implementation

It is important to remember that everyone has the capacity to learn new skills and undertake new roles.

Empowering staff to take ownership of a role or process under mentorship is key to success and proved invaluable in this programme of work. This will promote their ability to learn a new skill and gain more knowledge of the process and expand their professionalism and confidence.

For more information contact

Jackie Lamb
Matron
David Lewis National Epilepsy Centre, Cheshire
Jackie.Lamb@davidlewis.org.uk