ESSENCE: amalgamating marginal gains in ESSEntial Nursing Care

ESSENCE: amalgamating marginal gains in ESSEntial Nursing CarE


The ESSENCE team was awarded almost £100,000 as a Programme Development Grant from the National Institute for Health Research (NIHR) Programme Grants for Applied Research. The Development Grant started in February 2016 and finishes end of July 2017. Completion of the developmental work should place the team in a competitive position to submit a NIHR Programme Grant. NIHR Programme Grants aim to produce independent research findings that will have practical application for the benefit of patients and the NHS in the relatively near future.

Essential nursing care aims to meet or help patients to improve, maintain or recover health and achieve the best possible quality of life. Where it is not delivered well it leads to poor outcomes and negative experience for patients. Initiatives to improve nursing care are not supported by research and evidence is required for nursing interventions that improve care quality and improves outcomes for patients and residents of care homes.


The aim of the ESSENCE programme is to develop and test a nursing intervention that focuses on the ‘essentials of nursing care’, focusing on communication, eating and drinking, elimination, mobility and hygiene for hospital patients. In our intervention nurses will deliver care within a successful model used in elite sport and health services organisational change that tries to achieve a small margin of improvement in all possible areas that could lead to better outcomes, then amalgamating these ‘Marginal Gains’.

Richards DA (2015). Complex interventions and the amalgamation of marginal gains: a way forward for understanding and researching essential nursing care?International Journal of Nursing Studies, 52(7), 1143-1145.

The ESSENCE developmental work

The Programme Development stage addressed critical uncertainties that needed to be answered before progressing to apply for the Programme Grant. The uncertainties we addressed were:
1. Understanding how to translate successful performance innovation in the form of ‘Amalgamation of Marginal Gains’ into nursing care.
2. Synthesizing the existing evidence for essential nursing care behaviours.
3. Strengthening the Patient and Public Involvement, clinical, methodological and stakeholder elements of the future Programme Grant.

The three research activities deliverables related to these questions are:

  • Activity 1. Interviews to understand improved performance from experienced AMG practitioners in sport and healthcare. 
  • Activity 2. A systematic review of the evidence for nursing behaviours.
  • Activity 3. Development and strengthening the team.

Activity 3 involved several activities with our ESSENCE patient and public involvement group, were they worked together to produce ESSENCE patient stories. This enabled essential stakeholder engagement.

More information about activities 1, 2 and 3 can be found in our ESSENCE Poster

For update information about ESSENCE see our newsletters: ESSENCE Newsletter July 2016 and ESSENCE Newsletter April 2017

The ESSENCE Programme of research

If successful in the Programme Grant stage we will evaluate existing evidence, and work with hospital patients and nurses to develop a feasible and effective intervention. This will then be tested in hospitals in a definitive randomised trial, large enough to determine the effectiveness and cost-effectiveness of the intervention. We will investigate the feasibility of transferring the ESSENCE intervention to nursing/care homes, and provide a series of recommendations outlining the ‘work to be done’ in translating our ESSENCE intervention into the care home context using Normalisation Process Theory as the theoretical structure for subsequent implementation work.

The ESSENCE team

Led by Professor David Richards, we are working with lay advisors, senior clinical and nurse managers, and are collaborating with experienced health service researchers and academics from NIHR CLAHRC colleagues from the Universities of Exeter, Plymouth and Southampton. We are also consulting with stakeholders from NHS nursing organisations, nursing/care homes, charities and Non-Government Organisations (NGOs) such as Age UK, Heathwatch and other interested parties.

For more information please contact: Dr Claire, ESSENCE Project Manager and Researcher.


Pentecost C, Richards DA, Frost J (2017). Amalgamation of Marginal Gains (AMG) as a potential system to deliver high quality fundamental nursing care: a qualitative analysis of interviews from high performance AMG sports and healthcare practitioners. Journal of Clinical Nursing, DOI: 10.1111/jocn.14186 (In Press)

Richards DA, Hilli A, Pentecost C, Goodwin VA, Frost J (2017). Fundamental nursing care: a systematic review of the evidence on the effect of nursing care interventions for nutrition, elimination, mobility and hygiene.Journal of Clinical Nursing. DOI