Jill Hoyle, Lead Nurse, Education and Mandatory Training, Division of Medicine, Bradford Teaching Hospitals NHS Foundation Trust

Background

To improve the experience for patients with dementia when they attend a district general hospital for a physical illness. It is well recorded that most patients with dementia stay in hospital longer and experience high levels of anxiety and poor levels of understanding about their dementia from all staff disciplines. I wanted to look at care from the patient’s perspective and ask staff to reflect on those experiences to see how it could be improved, by observing care in areas that have high levels of older people with dementia.

Aim

To look at the quality of interactions between all staff and patients with dementia.
To look at whether staff were delivering person-centred care.
To look at the care environment from the perspective of the patient.
To use a method of observation with a tool specifically designed for use in acute care settings (PIE- Person, Interactions and Environment tool).
To feedback to staff the observations and ask them to devise an action plan.

What did you do?

Two members of staff attended a one day workshop to learn about the tool and person-centred care.
Two wards were identified to carry out the observations: one elderly care and one orthopaedic.
Mutually agreed date and time set to carry out observations on both wards.
Meetings held to inform staff what was happening and why.
Information leaflets and posters put out for staff, patients and carers.
On the day, consent gained from ward manager and identified patients for observation to go ahead.
Two staff sat in different areas of the ward and observed for a total of four hours: two hours in the morning and two hours over lunchtime.
Information reviewed by observers and key themes identified.
Observations were fed back to all members of staff involved in the observation.
Discussion between ward manager and team to develop an action plan to disseminate good practice and develop areas for improvement.

What changed?

Not all patients had their ‘This is me’ document completed and this was reflected in the quality of the interactions between staff and patients. A focus to be put on ensuring every patient gets their document completed and all staff to use the information when interacting with the individual.
Conversations with patients were very care orientated. Little interactions based on the persons areas of interest probably as a result of not having background information on the patient. Staff to utilise the information gathered to stimulate conversations that are not care orientated.
Lots of missed opportunities where other members of the MDT entered a room but there was no acknowledgement of the people in the room. They came in, did what they needed to do and left. Every staff member to say ‘good morning’ or something appropriate when entering the room, and talk to the person in the bed even if they are dealing with paperwork.
Meals were delivered to patients, but those requiring help were given their meals at the same time as everyone else. A staff member would then return to assist them to eat. Those identified as requiring help now have their meals given out last and staff delivering them stay to assist.
To make sure the ward temperature suits the patients. Windows were often left open when patients were cold whilst staff wrapped patients in blankets.
Domestic staff to converse with patients as they cleaned around their bed area. They had previously been instructed not to do this to save time.
Staff only to put the TV or radio on when requested to do so by the patient and for the programme to reflect the patients taste not those of the staff.
Previously, staff naturally migrated to rooms with higher functioning patients when care was not required. Staff need to spread any spare time equally across all care areas.
Longer term - to review the environment within which the care takes place as there is no art work or similar in the rooms. Art work is concentrated on the ward corridor. The rooms are very un-stimulating and patients tend to nod off to sleep with boredom.

Advice for others

Observation is a very powerful tool. It allows the staff to see things from the patients perspective, things that have previously been missed or overlooked. After initial training this tool should be used as a practice development tool to review the wards on a regular basis and see whether the action plan has been implemented or needs re-visiting. Not all changes are resource intensive. Quite subtle changes can be made with no resources.

For further information please contact Jill Hoyle at Jill.Hoyle@bthft.nhs.uk

See other examples at Dementia - best practice examples.