Working as a nurse for the past 15 years has been rewarding – it has provided me with the opportunity to support the healthcare needs of individuals from different backgrounds. There is a common theme running through the variety of roles I have had both in the UK and internationally, demonstrated through the projects I have been a part of, and this is that equality should cut across all areas of care and that everyone has a right to health care even in often challenging settings, to meet complex organisational and patient needs.
At the start of 2023 I took on the role of the Chief Nurse Fellow with Birmingham Community Healthcare NHS Foundation Trust. This provided me with a platform to support the development of Black, Asian and Minority Ethnic (BAME) staff aspiring to be senior leaders. The role also encourages the exploration and development of new ways of working to promote the delivery of culturally sensitive services.
Within this role, I undertook and led on a health improvement project at His Majesty's Prison (HMP) Birmingham, focusing on inclusive hypertensive care provision, the aim being to provide a standardised hypertensive care pathway at HMP Birmingham.
Hypertension at HMP Birmingham
Hypertension is known to be a significant risk factor for cardiovascular disease, which is the major cause of death in the UK. In Birmingham, around 12% of the population are estimated to be affected, compared with 13.9% nationally (Birmingham City Council, 2019; 2021). Stress, being of Black African or Black Caribbean heritage, and living in a deprived area are some of the known causes and associated risk factors for hypertension (Lane and Lip, 2001; NHS website, 2024).
Studies have shown that incarceration has an impact on cardiovascular disease risk factors such as hypertension (Anon, 2009).
HMP Birmingham is a category B men's prison with a diverse population and, over the past 3 years, 35–40% of prisoners have been from a BAME background. Hypertension is the fourth most common chronic health issue at the prison, with about 50% of those diagnosed with the condition having a BAME background.
HMP Birmingham strives to provide an equitable safe environment to rehabilitate prisoners to return to society, and this includes the delivery of high-quality health care. Doing so in a high-security prison has its challenges: for example, the use of ambulatory blood pressure monitoring that supports the diagnosis of hypertension is not approved by the prison due to associated security risks. Consequently, healthcare practitioners are adept at exploring and developing tailored pathways to enable the delivery of high-quality care within the constraints of a secure environment (Bennett, 2014).
Hypertension service evaluation
Alongside other health professionals at HMP Birmingham – nurses, pharmacists, general practitioners, data analyst, healthcare assistants and trainee nurse associates and others – I undertook a hypertensive service evaluation with the aid of a range of quality improvement tools.
Gap analysis
This process entailed mapping current hypertensive care provision against guidance on hypertension in adults from the National Institute for Health and Care Excellence (NICE) (2023), and identifying gaps in practices and standards of care.
Stakeholder analysis and engagement
This step involved the identification of stakeholders according to the role they play in enabling project delivery. Stakeholders were grouped into four categories: satisfy, manage, inform and monitor. The methods used for communication and the frequency of communication with stakeholders were also considered.
Shadowing
A number of clinics and activities involved in delivering hypertensive care within HMP Birmingham were attended and analysed. These included reception and release clinics, secondary assessment clinics, nurse clinics, Wellman clinics, multidisciplinary handover meetings and clinical governance meetings.
Patient data audit
Ten patient records were reviewed at the start of the service evaluation to identify whether the current hypertensive care process was being followed and whether this was in line with the NICE (2023) guidance, with a particular focus on the hypertension process initiation time.
Post project delivery, 15 patient records were reviewed to identify the impact and benefits of implementing the hypertension pathway and the guidance on hypertension in adults in prison, both of which were developed as part of the project.
Staff survey
An initial staff survey was conducted at the start of the project to ascertain the level of knowledge and education on hypertension in adults among the healthcare staff and to identify the support required to improve their skills. A second staff survey was conducted at the conclusion of the project to review the impact and benefits for staff following the delivery of training and the implementation of the pathway and guidance for HMP Birmingham.
Research and literature review
There was engagement in research and a literature review was undertaken on the currently available evidence for best practices on the prevention, diagnosis and management of hypertension in adults.
Brainstorming
In addition, brainstorming sessions were held to provide clarity on the aims, objectives and the primary and secondary drivers, as well as to identify the change ideas most suitable to achieve the intended outcomes.
All of the above identified inconsistencies and variations in the care practices that had been leading to delays in initiating the hypertensive care process. Health prevention strategies and staff lack of confidence and clarity about the hypertensive care process also needed to be taken into account.
The findings of the evaluation highlighted the issues that impeded early diagnosis and treatment, which could lead prisoners to develop cardiovascular disease. It was evident that there was a need to put in place a clear, accessible hypertensive care pathway that would include prevention strategies for prisoners at high risk of developing the condition.
Resources developed to facilitate inclusive care provision
Hypertension in Adults guidance for HMP Birmingham
Hypertension in Adults: a guidance document for His Majesty's Prison Birmingham (HMP) was developed to support healthcare staff in delivering standardised high-quality hypertensive care. It details the hypertension pathway and provides information on the resources on hypertension available for healthcare staff and the prisoners in their care. It also covers a range of topics pertaining to hypertension and the delivery of hypertensive care within HMP Birmingham.
This draft document went through consultation with committees, groups and individuals, and was launched in November 2023 following approval by the clinical governance committee for HMP Birmingham.
Hypertension pathway for adult prisoners in HMP Birmingham
The pathway was developed to support healthcare staff consistently deliver standardised hypertensive care to prisoners. It aligns with NICE (2023) guidance, and focuses on the following areas: diagnosis, investigation, treatment, prevention and monitoring (review), specialist referral and advice.
A visual summary of the pathway was devised for ease of access by clinicians, with copies laminated in poster format and available in all clinics. The use of the care pathway facilitates timely initiation of treatment, which is critical for preventing morbidity and mortality in such a restrictive environment, enabling clinicians to deliver best practice and high-quality care.
Patient hypertension leaflets
I ensured that patient leaflets on hypertension were made available and accessible for prisoners. Patient leaflets on hypertension published by the charity Blood Pressure UK (https://tinyurl.com/bpukhypotension) are now in use at HMP Birmingham. These explain hypertension, its causes, how to manage and prevent it, and how to check blood pressure. They include contacts for support that prisoners can access when released from prison, enabling continuity of care.
Staff training on hypertension in adults
Training sessions on hypertension in adults were held to bring awareness of and education about hypertension to the primary care staff within HMP Birmingham. The Hypertension in Adults guidance also details the availability of and access to training on hypertension, which is now an essential component of induction for primary care staff at HMP Birmingham.
Clinics
Hypertension-and-release clinics were reestablished and made accessible to all prisoners who require monitoring. The clinics include provision for healthcare staff to monitor prisoners at high risk of hypertension and those already diagnosed with the condition, and to signpost individuals to ongoing support and continuity of care when released from prison.
Positive changes
The benefits ensuing from the development and implementation of the pathway and the associated resources have included:
There were also benefits in terms of service improvement, with the implemented changes facilitating the efficient delivery of high-quality, safe hypertensive care, and the prevention of patient harm.
Sustainability and recommendations
The hypertensive care pathway was embedded into business as usual to aid the sustainability of the project work. It involved implementing processes to support compliance and monitoring through monthly key performance indicators audits for chronic diseases, and an annual review of the guidance. In addition, there is now a hypertension lead/champion in the service to support staff as required.
The key takeaway messages arising from this project were as follows:
Winning the BJN Awards 2024 Nurse of the Year in recognition of this project gives me great pride in my work and practice as a nurse. It encourages me to continue to advocate for the delivery of high-quality services that are accessible and equitable.