Journal of Advanced Nursing, 1 9 7 6 , 1 , 391-398
Encouraging innovations in iiospitai care David Towell M.A. Ph.D. Lecturer, Nuffield Centre for Health Services Studies, University of Leeds
Tim Dartington B.A. Social Scientist, Tavistock Institute of Human Relations Accepted for publication 2 April 1976
TOWELL D . & DARTINGTON T . {1976) Journal of Advanced Nursing i , 391-398
Encouraging innovations in hospital care There is currently widespread concem in the British National Health Service with the problems of improving hospital care, particularly in the long-stay sector, at a time of economic constraint. In the light of two recent reports providing guidance on good practices of patient care, an analysis is presented of how change in existing attitudes and practices can be encouraged. The real diificulties of this process are recognized but a case study of one hospital over several years, when combined with insights from other social scientific research, suggests a set of principles which may be of assistance to hospital staff with potential leadership roles in innovation. Attention is directed to the variety of channels through which patient care may be influenced, the importance of harnessing the motivation of care staff, the need to provide support in working through emotional barriers to change, the complementary roles of staff at different levels and in different professions, and the scope for mutual exchanges of experience between different units. Finally some ways in which these principles might be apphed in particvilar initiatives are suggested in outline.
INTRODUCTION There is currently widespread concem in the British National Health Service about the problems of improving hospital care, particularly in the more deprived sectors ofthe service, at a time when because ofthe economic crisis there is litde likelihood of extra resources being allocated. In this situation, improvements in care have to rely heavily on the transformation of existing attitudes and practices, and the more effective use of such resources as are available. Perhaps with this in mind two reports have been published recently which provide detailed guidance on good practices of patient care and make suggestions for the wider implementation of these practices. A joint working party of the Royal College of Nursing 391
392
D. Towell and T. Dartington
(RCN) and the British Geriatrics Society (BGS) (1975) has produced a useful report Improving Geriatric Care in Hospital which contains guidelines for staff in geriatric wards. The King Edward's Hospital Fund has prepared a booklet Living in Hospital which deals with the care of long-stay patients more generally. No doubt through discussion of these reports and more independently, many health service staff, both directly involved in patient care and in various leadership positions, will be trying to make improvements in the care for which they are responsible. Many staff members will also be encountering the real difficulties which can arise in trying to foster innovation in tbe complex and often anxietyridden social situations which are common in hospitals. While recognizing these difficulties, the purpose of this article is first to indicate the possibility of change and then to identify some principles, drawn from our own experience and other social scientific research in hospitals, which might assist staff at various levels in their efforts to encourage improvements in existing practices. We believe that all staff and indeed other patients and relatives can contribute to this process but, in writing tbis article, we have had in mind particularly staff in the key roles of ward sister, nursing officer, medical consultant and tutor. In addition, we believe these ideas should also be relevant to the district management team in their efforts to fecilitate innovation and to other service development staff, for example training officers, who are in a position to provide support for staff direcdy engaged in change activities. Following the BGS/RCN report we concentrate here on the care of old people in hospitals, although the points made are generally relevant to the problems of innovation in the Health Service. We begin with an illustrative case study (based on work previously reported by Savage 1974, Savage & Widdowson 1974, Towell 1975) of one hospital where substantial changes in. the care of old people have been achieved in recent years. A CASE S T U D Y The hospital in question is a 700-bed psychiatric hospital serving a largely rural catchment area. Six years ago the nine wards in the psychogeriatric unit of the hospital together housed 300 old people, who formed a largely static but slowly increasing population among whom death was more common than discharge. These patients were allocated to different wards according to their sex and degree of dependence, and of those placed in wards with the more dependent patients, many showed evidence of confusion, required help in eating and dressing and were also incontinent. In comparison with other parts of the hospital there were on these wards a relatively high proportion of untrained and older nursing staff, and medical staff had minimal influence (one part-time consultant psychiatrist having responsibility for all these patients). In this situation, particularly given the widespread view that there were too few staff available even to accomplish adequately the more fundamental aspects of patient care, the main activities of nurses and their dominant concerns centred
Encouraging innovations in hospital care
393
around the routinized daily administration of the basic necessities of physical existence for these old people. On these wards there was very little attention to treatment, and little time devoted to the social and psychological needs of patients. Indeed there was some tendency for the patients to become the partially depersonalized objects of the task-centred routines, a tendency encouraged where the influence of organic deterioration of tbe brain on patient behaviour was emphasized and patients came to be viewed as less than fully human. All this was an important source of dissatisfaction to many ofthe nursing staff working on these wards, particularly tbe trainee nurses who experienced a considerable misfit between established practices and the more ideal conceptions of the nurse's role derived from the influence of tutors and the lay expectations they brought to the hospital. This contributed to a high rate of withdrawal from training. Over the succeeding four years (and continuing into the present) this traditional pattem has been considerably altered. Substantial changes have occurred, pardy forced by circumstances but certainly encouraged by new leadership, both at senior and ward level, taking advantage of new opportunities. The growing demands for the admission of old people to hospital bave meant that a policy of just allowing long-stay patients to accumulate has become increasingly untenable. Short-stay admissions originally introduced under extemal pressure have led subsequently to more sustained efforts to increase patient turnover, requiring fresh attention to the possibilities of treatment and rehabilitation for patients. Similarly, the overload on the part-time consultant psychiatrist has required several other consultants to take responsibility for admissions from different parts ofthe catchment area. Both these changes have encouraged the development of better links between the hospital and community services. Capital expenditure on the hospital has permitted tbe upgrading of some wards and a reduction in size ofthe larger wards, while new facilities (for example, a geriatric day centre) have also been provided. Under the improved conditions, more ofthe staff recruited have been retained, and the overall staffing ratios have increased. The implementation of 'Salmon' (Ministry of Health 1966) in the hospital has led to decentralization of control in the nursing hierarchy and encouraged nursing officers to assume a more supportive and facilitative role in relation to the staff in their units. Tbis in tum bas permitted nursing and medical staff together to provide fresh leadership, open to new ideas from their own staff and from other institutions in which progressive practices were being developed. Within wards, these developments have implied significant changes in tbe roles of nurses with increasing variety in their work as more attention has been given to maintaining the independence of patients in hospital and providing domiciliary support for those who can manage outside. These trends have been reinforced where staff in key roles have sought to encourage tbe full participation of other staff in these changes, provided relevant ward teaching and a supportive climate in wliich the difficulties involved could be worked through. The net effect, although there is sdll much to be done, bas been the provision of an active
394
D. Towell and T. Dartington
treatment setting and, probably, an improvement in the quality of life for many patients. The sustained effort required of staff and tbe processes involved in bringing about these changes bave been highlighted in one of these wards where a particularly innovative approach bas been developed. The appointment of a new charge nurse to this ward provided an important stimulus to fresh thinking about the care of its patients. In the more supportive climate provided by wider changes in the hospital this charge nurse set out to involve his staff in examining what improvements could be made. Wldle always experiencing some pressure to demand extra staff, they decided to begin by examining what use they made of their existing staff allocation. Through a systematic study of their own activities, they discovered for themselves bow their concentration on completing rigidly scheduled routines (such that all staff were engaged on the same tasks at the same time each day) meant that much the same work was done irrespective of tbe number of staff on duty during any shift. Tbis discovery enabled them to break out of these routines into a more flexible and patient-centred pattern of care, as they sought to deploy variable staff resources on activities which related to more than tbe physical aspects of patient care. In turn this led to the reappraisal of patients' capacities and needs (for which the staff together devised an original assessment technique) which provided the basis for the clarification of objectives in relation to different patients, and the grouping of patients according to tbeir needs for different therapeutic activities. The experience of some success in these initiatives over a period of a year or more, and tbe more active treatment regime which was established, subsequently encouraged further innovation as ward nursing staff became involved in tbe domiciliary assessment of patients referred for admission, and closer collaboration was achieved witb the relevant social work team (to the extent that a current experiment entails nursing and social work staff in joint management of bed use on the ward). These changes together have done much to improve the care of patients, particularly through creating tbe conditions in which the individual needs of old people could be more fully recognized, while also increasing the job satisfaction of staff on this ward. Sustaining these developments and extending them throughout the geriatric wards of tbe hospital has become a continuing task for the staff concerned. COMMENTARY Three main points may be inferred from this case study. First, the progress made at tbis hospital certainly shows the possibility of staff bringing about improvements in patient care. Second, however, achieving change can be a complex, lengthy and difficult process. Third, such changes can be encouraged both intemally and extemally by the appropriate leadership, poHcies and support. Drawing on this case and other experiences of facilitating social change, a fuller analysis of the processes involved can be summarized:
Encouraging innovations in hospital care
395
1 Changing practices in order to improve patient care can entail or be assisted by changes in a range of contributory elements. These include the numbers and skill ofthe staff available; tbe physical environment and associated facilities; tbe equipment and techniques employed; the pattern of management and collaboration between the professions and others involved in care; the training and ongoing support provided for staff; tbe professional attitudes and roles adopted. 2 Perception of the need to change existing practices can arise from a wide variety of influences both extemal and internal to the hospital. From outside tbe hospital may be confronted by new demands and expectations from the community it serves. Policy developments in tbe wider health service, the recommendations of bodies like the Hospital Advisory Service, and the influence of new thinking witliin particular professions also impinge on hospitals. Moreover, staff may become aware, either directly or through professional journals, of progressive practices being adopted in other institutions. Inside the hospital new leadership, the arrival of fresh personnel and the impact of education and training may also generate a felt need for change. 3 The translation of this felt need into changed actions by those providing patient care typically involves groups of staff in fashioning altemative practices out of the available influences, opportunities and constraints in a way dependent on the mobilization of their own skills. Tbis process entails the adoption or invention of new solutions to their problems, tbe decision to adopt a particular option, and the generation of authoritative sanction for this change. 4 The implementation of new practices, especially to the extent that improving patient care requires changes in professional roles and attitudes, commonly provokes considerable resistance among staff. This is because of tbe disruption of established ways of working and social relationships entailed, the guilt that may derive from the unfavourable reflection on past activities which innovation often implies, and the challenge which change constitutes to existing systems of defence against anxiety embodied in traditional practices. (See for example the work of our colleagues, Menzies i960. Miller & Gwynne 1972.) These difficulties are particularly likely to arise in efforts to improve geriatric care because of the way in which hospital staff in their work have to cope with the ambivalence about old people in tbe wider society and the conflicts between the various parties involved in tbe total system of care to which attempts to deal with the 'geriatric problem' give rise. It follows that groups of staff engaged in innovation often require considerable support if they are to overcome these resistances to change and successfully work through the emotional issues involved, particularly if this is to be achieved without the innovating group being psychologically 'split off' from other groups of staff in their hospital. 5 Such changes are further encouraged where staff in key roles are able to provide appropriate leadership and support, and where the hospital organization as a whole provides conditions facilitating innovation. This is likely to imply a situation in which different professions cooperate together in treatment teams in which tbe interdependence of their contributions is recognized, and in whicb a
396
D. Towell and T. Dartington
participative mode of working seeks to ensure that the skills and experience of all staff are positively mobilized in patient care. Change is also fostered where there is sufficient decentralization in the management ofthe hospital's treatment services to permit effective collaboration with extemal agencies and staff initiative in responding to problems which arise. Change is further supported where the leadership and authority structure ofthe hospital as a whole are such that openness and experiment are widely valued. GENERAL PRINCIPLES This analysis provides tbe basis for suggesting a set of general principles to guide the planning of efforts to encourage improvements in hospital care perhaps in conjunction with the guidance provided by tbe reports referred to earlier: 1 As a number of elements are involved in changing practices of patient care and these are subject to a wide variety of influences, it is desirable to employ multiple strategies of change whicb seek to mobilize action through administrative, professional, educational and otber channels. At each level the tactics adopted within these strategies need to be sufficiendy flexible to take advantage of the particular opportunities and problems whicb arise in different situations. 2 While the publication and availability of the guidance provided by these reports should be a valuable stimulus for change, past experience suggests that such documents by themselves are likely to have only a diffuse and limited impact in many settings where improvement might be desirable. Accordingly efforts should be made where possible to reinforce their impact through the activation of those in the local key positions to influence the adoption of new practices and the provision of more extensive advice and support to groups of concemed staff seeking to make changes. 3 In this context it is useful to recognize that the main asset available to tbe Health Service is the commitment and contribution of the staff involved in providing care and their motivation is essential to bring about improvements. To the extent that dissemination of these reports can be regarded as a 'top down' approach, it needs to be combined witb a 'bottom up' approach which starts from how care staff define their situation, and helps them to discover for themselves their capacity to bring about change. If opportunities can be provided for groups of staff themselves to initiate better methods of care and ways of working, the guidance in these reports can become a valued stimulus to thought and hence a resource to be used, rather than a set of injunctions to be obeyed. Here it will often be most appropriate, because of the interdependence of their contributions, if the multidisciplinary team providing patient care are together the prime movers in considering possible changes. 4 If changes in practice are to be achieved in the face ofthe considerable resistance that such changes are likely to provoke, it is important that the staff involved be provided with support and the opportunities in a protected forum to review their own activities, consider problems and altemative solutions, experiment witb new
Encouraging innovations in hospital care
•
397
practices, monitor these experiments and implement decisions reached. This process is likely to raise emotional issues which require careful working through in order that staff needs are met and tbe difficulties involved in reordering past experiences and changing attitudes overcome. 5 While staff at all levels and in each profession have a part to play in fostering innovation in hospital care, three particular roles can be identified in geriatric hospitals with considerable leadership potential. Tbe ward sister, wbo is responsible for managing the nursing team and coordinating the activities of patient care, has a crucial influence. Tbe consultant geriatrician is likely to carry much ofthe responsibility and be a key figure in supporting change. The nursing officer, especially where the 'clinical/managerial role' envisaged in Salmon is fully developed, can be a very positive catalyst. Staff in leading roles are themselves likely to derive help in encouraging change not just from the ready availability of information about progressive practices, but also from access to expertise in the social and psychological aspects of innovation, such as might be provided by some experienced managers and training officers. 6 Senior managers at hospital, district and area levels, in addition to their direct responsibilities for services, can do much to help create the organizational conditions required to facilitate informed innovation by more junior staff, particularly through the model provided by tbeir own leadership and exercise of authority. 7 Another significant resource is the experience of staff in other hospitals, sometimes not far away, who may be facing similar problems. If, for example, the staff of many geriatric hospitals are going to make efforts to improve patient care, there may clearly be much to be gained through fostering a greater sharing of experience and mutual support among the staff so engaged. 8 Finally, since the hospital is only one part of the total system of patient care, it follows that what is done in the hospital will be affected by and will affect what is done in other parts of this system, to tbe extent that changes in the relationships between all these parts, for example, as represented in tbe process of admission, may often be a necessary condition for other changes within tbe hospital. It is important therefore that efforts to produce change focused on the hospital should keep in mind the relationship between this and tbe contribution of the social services, the family, etc., to patient care, so that improvements in one area are not gained at tbe expense of deterioration elsewhere. APPLICATION These broad principles can be applied through a variety of initiatives at different levels. A ward sister for example with support from her unit nursing officer, consultant and a tutor, might seek to involve her staff in reviewing existing practices of care in her ward as in the example given in the case study—aiming particularly perhaps to provide some protected opportunities for staff as a wbole to examine the BGS/RCN guidelines in tbe light of their own experiences of giving care. At area or regional level, conferences might be organized at which
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multidisciplinary teams from a number of hospitals involved in the care of old people would explore together the possibihties for change in their own situation, and establish mechanisms for the cross-fertihzation of experience and mutual support as efforts to bring about improvements got underway. And at national level, the various bodies concemed about the care of old people might get together to coordinate their own efforts to foster change, monitor more widely what is happening to geriatric services, and perhaps establish an advice centre equipped to provide information and support to groups of staff taking more local initiatives. In conclusion it should be emphasized, however, that as with the guidance on what changes may be desirable, these principles about how improvements might be encouraged can only be of assistance if used creatively by staff at all levels in the hght of their own experience and the particular problems faced in different situations. Fundamental to this process is the critical examination of existing practices as the basis for informed innovation in the services to be provided.
References BRITISH GERIATMCS SOCIETY AND ROYAL COLLEGE OF NURSING (1975) Improving Geriatric Care in
Hospital. RoyaJ College of Nursing, London. KING EDWARD'S HOSPITAL FUND (1975) Living in Hospital. King's Fund Centre, London. MENZIES I. E. P. (i960) A case study in the functioning of social systems as a defence against anxiety. Human Relations 13, 95-121. MILLER E. & GWYNNE G. (1972) A Life Apart. Tavistock, London. MINISTRY OF HEALTH (1966) Report of the Committee on Senior Nursing Staff Structure (The 'Salmon' Report), H.M.S.O., London. SAVAGE B . (1974) Rethinking psychogeriatric nursing care. Nursing Times 70, 282-284. SAVAGE B . & WIDDOWSON T . (1974) Revising the use of nursing resources in the care of the elderly. Nursing Times jo, 1372-1374, 1424-1427. TOWELL D . (1975) Understanding Psychiatric Nursing. Royal College of Nursing, London.
Encouraging innovations in iiospitai care David Towell M.A. Ph.D. Lecturer, Nuffield Centre for Health Services Studies, University of Leeds
Tim Dartington B.A. Social Scientist, Tavistock Institute of Human Relations Accepted for publication 2 April 1976
TOWELL D . & DARTINGTON T . {1976) Journal of Advanced Nursing i , 391-398
Encouraging innovations in hospital care There is currently widespread concem in the British National Health Service with the problems of improving hospital care, particularly in the long-stay sector, at a time of economic constraint. In the light of two recent reports providing guidance on good practices of patient care, an analysis is presented of how change in existing attitudes and practices can be encouraged. The real diificulties of this process are recognized but a case study of one hospital over several years, when combined with insights from other social scientific research, suggests a set of principles which may be of assistance to hospital staff with potential leadership roles in innovation. Attention is directed to the variety of channels through which patient care may be influenced, the importance of harnessing the motivation of care staff, the need to provide support in working through emotional barriers to change, the complementary roles of staff at different levels and in different professions, and the scope for mutual exchanges of experience between different units. Finally some ways in which these principles might be apphed in particvilar initiatives are suggested in outline.
INTRODUCTION There is currently widespread concem in the British National Health Service about the problems of improving hospital care, particularly in the more deprived sectors ofthe service, at a time when because ofthe economic crisis there is litde likelihood of extra resources being allocated. In this situation, improvements in care have to rely heavily on the transformation of existing attitudes and practices, and the more effective use of such resources as are available. Perhaps with this in mind two reports have been published recently which provide detailed guidance on good practices of patient care and make suggestions for the wider implementation of these practices. A joint working party of the Royal College of Nursing 391
392
D. Towell and T. Dartington
(RCN) and the British Geriatrics Society (BGS) (1975) has produced a useful report Improving Geriatric Care in Hospital which contains guidelines for staff in geriatric wards. The King Edward's Hospital Fund has prepared a booklet Living in Hospital which deals with the care of long-stay patients more generally. No doubt through discussion of these reports and more independently, many health service staff, both directly involved in patient care and in various leadership positions, will be trying to make improvements in the care for which they are responsible. Many staff members will also be encountering the real difficulties which can arise in trying to foster innovation in tbe complex and often anxietyridden social situations which are common in hospitals. While recognizing these difficulties, the purpose of this article is first to indicate the possibility of change and then to identify some principles, drawn from our own experience and other social scientific research in hospitals, which might assist staff at various levels in their efforts to encourage improvements in existing practices. We believe that all staff and indeed other patients and relatives can contribute to this process but, in writing tbis article, we have had in mind particularly staff in the key roles of ward sister, nursing officer, medical consultant and tutor. In addition, we believe these ideas should also be relevant to the district management team in their efforts to fecilitate innovation and to other service development staff, for example training officers, who are in a position to provide support for staff direcdy engaged in change activities. Following the BGS/RCN report we concentrate here on the care of old people in hospitals, although the points made are generally relevant to the problems of innovation in the Health Service. We begin with an illustrative case study (based on work previously reported by Savage 1974, Savage & Widdowson 1974, Towell 1975) of one hospital where substantial changes in. the care of old people have been achieved in recent years. A CASE S T U D Y The hospital in question is a 700-bed psychiatric hospital serving a largely rural catchment area. Six years ago the nine wards in the psychogeriatric unit of the hospital together housed 300 old people, who formed a largely static but slowly increasing population among whom death was more common than discharge. These patients were allocated to different wards according to their sex and degree of dependence, and of those placed in wards with the more dependent patients, many showed evidence of confusion, required help in eating and dressing and were also incontinent. In comparison with other parts of the hospital there were on these wards a relatively high proportion of untrained and older nursing staff, and medical staff had minimal influence (one part-time consultant psychiatrist having responsibility for all these patients). In this situation, particularly given the widespread view that there were too few staff available even to accomplish adequately the more fundamental aspects of patient care, the main activities of nurses and their dominant concerns centred
Encouraging innovations in hospital care
393
around the routinized daily administration of the basic necessities of physical existence for these old people. On these wards there was very little attention to treatment, and little time devoted to the social and psychological needs of patients. Indeed there was some tendency for the patients to become the partially depersonalized objects of the task-centred routines, a tendency encouraged where the influence of organic deterioration of tbe brain on patient behaviour was emphasized and patients came to be viewed as less than fully human. All this was an important source of dissatisfaction to many ofthe nursing staff working on these wards, particularly tbe trainee nurses who experienced a considerable misfit between established practices and the more ideal conceptions of the nurse's role derived from the influence of tutors and the lay expectations they brought to the hospital. This contributed to a high rate of withdrawal from training. Over the succeeding four years (and continuing into the present) this traditional pattem has been considerably altered. Substantial changes have occurred, pardy forced by circumstances but certainly encouraged by new leadership, both at senior and ward level, taking advantage of new opportunities. The growing demands for the admission of old people to hospital bave meant that a policy of just allowing long-stay patients to accumulate has become increasingly untenable. Short-stay admissions originally introduced under extemal pressure have led subsequently to more sustained efforts to increase patient turnover, requiring fresh attention to the possibilities of treatment and rehabilitation for patients. Similarly, the overload on the part-time consultant psychiatrist has required several other consultants to take responsibility for admissions from different parts ofthe catchment area. Both these changes have encouraged the development of better links between the hospital and community services. Capital expenditure on the hospital has permitted tbe upgrading of some wards and a reduction in size ofthe larger wards, while new facilities (for example, a geriatric day centre) have also been provided. Under the improved conditions, more ofthe staff recruited have been retained, and the overall staffing ratios have increased. The implementation of 'Salmon' (Ministry of Health 1966) in the hospital has led to decentralization of control in the nursing hierarchy and encouraged nursing officers to assume a more supportive and facilitative role in relation to the staff in their units. Tbis in tum bas permitted nursing and medical staff together to provide fresh leadership, open to new ideas from their own staff and from other institutions in which progressive practices were being developed. Within wards, these developments have implied significant changes in tbe roles of nurses with increasing variety in their work as more attention has been given to maintaining the independence of patients in hospital and providing domiciliary support for those who can manage outside. These trends have been reinforced where staff in key roles have sought to encourage tbe full participation of other staff in these changes, provided relevant ward teaching and a supportive climate in wliich the difficulties involved could be worked through. The net effect, although there is sdll much to be done, bas been the provision of an active
394
D. Towell and T. Dartington
treatment setting and, probably, an improvement in the quality of life for many patients. The sustained effort required of staff and tbe processes involved in bringing about these changes bave been highlighted in one of these wards where a particularly innovative approach bas been developed. The appointment of a new charge nurse to this ward provided an important stimulus to fresh thinking about the care of its patients. In the more supportive climate provided by wider changes in the hospital this charge nurse set out to involve his staff in examining what improvements could be made. Wldle always experiencing some pressure to demand extra staff, they decided to begin by examining what use they made of their existing staff allocation. Through a systematic study of their own activities, they discovered for themselves bow their concentration on completing rigidly scheduled routines (such that all staff were engaged on the same tasks at the same time each day) meant that much the same work was done irrespective of tbe number of staff on duty during any shift. Tbis discovery enabled them to break out of these routines into a more flexible and patient-centred pattern of care, as they sought to deploy variable staff resources on activities which related to more than tbe physical aspects of patient care. In turn this led to the reappraisal of patients' capacities and needs (for which the staff together devised an original assessment technique) which provided the basis for the clarification of objectives in relation to different patients, and the grouping of patients according to tbeir needs for different therapeutic activities. The experience of some success in these initiatives over a period of a year or more, and tbe more active treatment regime which was established, subsequently encouraged further innovation as ward nursing staff became involved in tbe domiciliary assessment of patients referred for admission, and closer collaboration was achieved witb the relevant social work team (to the extent that a current experiment entails nursing and social work staff in joint management of bed use on the ward). These changes together have done much to improve the care of patients, particularly through creating tbe conditions in which the individual needs of old people could be more fully recognized, while also increasing the job satisfaction of staff on this ward. Sustaining these developments and extending them throughout the geriatric wards of tbe hospital has become a continuing task for the staff concerned. COMMENTARY Three main points may be inferred from this case study. First, the progress made at tbis hospital certainly shows the possibility of staff bringing about improvements in patient care. Second, however, achieving change can be a complex, lengthy and difficult process. Third, such changes can be encouraged both intemally and extemally by the appropriate leadership, poHcies and support. Drawing on this case and other experiences of facilitating social change, a fuller analysis of the processes involved can be summarized:
Encouraging innovations in hospital care
395
1 Changing practices in order to improve patient care can entail or be assisted by changes in a range of contributory elements. These include the numbers and skill ofthe staff available; tbe physical environment and associated facilities; tbe equipment and techniques employed; the pattern of management and collaboration between the professions and others involved in care; the training and ongoing support provided for staff; tbe professional attitudes and roles adopted. 2 Perception of the need to change existing practices can arise from a wide variety of influences both extemal and internal to the hospital. From outside tbe hospital may be confronted by new demands and expectations from the community it serves. Policy developments in tbe wider health service, the recommendations of bodies like the Hospital Advisory Service, and the influence of new thinking witliin particular professions also impinge on hospitals. Moreover, staff may become aware, either directly or through professional journals, of progressive practices being adopted in other institutions. Inside the hospital new leadership, the arrival of fresh personnel and the impact of education and training may also generate a felt need for change. 3 The translation of this felt need into changed actions by those providing patient care typically involves groups of staff in fashioning altemative practices out of the available influences, opportunities and constraints in a way dependent on the mobilization of their own skills. Tbis process entails the adoption or invention of new solutions to their problems, tbe decision to adopt a particular option, and the generation of authoritative sanction for this change. 4 The implementation of new practices, especially to the extent that improving patient care requires changes in professional roles and attitudes, commonly provokes considerable resistance among staff. This is because of tbe disruption of established ways of working and social relationships entailed, the guilt that may derive from the unfavourable reflection on past activities which innovation often implies, and the challenge which change constitutes to existing systems of defence against anxiety embodied in traditional practices. (See for example the work of our colleagues, Menzies i960. Miller & Gwynne 1972.) These difficulties are particularly likely to arise in efforts to improve geriatric care because of the way in which hospital staff in their work have to cope with the ambivalence about old people in tbe wider society and the conflicts between the various parties involved in tbe total system of care to which attempts to deal with the 'geriatric problem' give rise. It follows that groups of staff engaged in innovation often require considerable support if they are to overcome these resistances to change and successfully work through the emotional issues involved, particularly if this is to be achieved without the innovating group being psychologically 'split off' from other groups of staff in their hospital. 5 Such changes are further encouraged where staff in key roles are able to provide appropriate leadership and support, and where the hospital organization as a whole provides conditions facilitating innovation. This is likely to imply a situation in which different professions cooperate together in treatment teams in which tbe interdependence of their contributions is recognized, and in whicb a
396
D. Towell and T. Dartington
participative mode of working seeks to ensure that the skills and experience of all staff are positively mobilized in patient care. Change is also fostered where there is sufficient decentralization in the management ofthe hospital's treatment services to permit effective collaboration with extemal agencies and staff initiative in responding to problems which arise. Change is further supported where the leadership and authority structure ofthe hospital as a whole are such that openness and experiment are widely valued. GENERAL PRINCIPLES This analysis provides tbe basis for suggesting a set of general principles to guide the planning of efforts to encourage improvements in hospital care perhaps in conjunction with the guidance provided by tbe reports referred to earlier: 1 As a number of elements are involved in changing practices of patient care and these are subject to a wide variety of influences, it is desirable to employ multiple strategies of change whicb seek to mobilize action through administrative, professional, educational and otber channels. At each level the tactics adopted within these strategies need to be sufficiendy flexible to take advantage of the particular opportunities and problems whicb arise in different situations. 2 While the publication and availability of the guidance provided by these reports should be a valuable stimulus for change, past experience suggests that such documents by themselves are likely to have only a diffuse and limited impact in many settings where improvement might be desirable. Accordingly efforts should be made where possible to reinforce their impact through the activation of those in the local key positions to influence the adoption of new practices and the provision of more extensive advice and support to groups of concemed staff seeking to make changes. 3 In this context it is useful to recognize that the main asset available to tbe Health Service is the commitment and contribution of the staff involved in providing care and their motivation is essential to bring about improvements. To the extent that dissemination of these reports can be regarded as a 'top down' approach, it needs to be combined witb a 'bottom up' approach which starts from how care staff define their situation, and helps them to discover for themselves their capacity to bring about change. If opportunities can be provided for groups of staff themselves to initiate better methods of care and ways of working, the guidance in these reports can become a valued stimulus to thought and hence a resource to be used, rather than a set of injunctions to be obeyed. Here it will often be most appropriate, because of the interdependence of their contributions, if the multidisciplinary team providing patient care are together the prime movers in considering possible changes. 4 If changes in practice are to be achieved in the face ofthe considerable resistance that such changes are likely to provoke, it is important that the staff involved be provided with support and the opportunities in a protected forum to review their own activities, consider problems and altemative solutions, experiment witb new
Encouraging innovations in hospital care
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practices, monitor these experiments and implement decisions reached. This process is likely to raise emotional issues which require careful working through in order that staff needs are met and tbe difficulties involved in reordering past experiences and changing attitudes overcome. 5 While staff at all levels and in each profession have a part to play in fostering innovation in hospital care, three particular roles can be identified in geriatric hospitals with considerable leadership potential. Tbe ward sister, wbo is responsible for managing the nursing team and coordinating the activities of patient care, has a crucial influence. Tbe consultant geriatrician is likely to carry much ofthe responsibility and be a key figure in supporting change. The nursing officer, especially where the 'clinical/managerial role' envisaged in Salmon is fully developed, can be a very positive catalyst. Staff in leading roles are themselves likely to derive help in encouraging change not just from the ready availability of information about progressive practices, but also from access to expertise in the social and psychological aspects of innovation, such as might be provided by some experienced managers and training officers. 6 Senior managers at hospital, district and area levels, in addition to their direct responsibilities for services, can do much to help create the organizational conditions required to facilitate informed innovation by more junior staff, particularly through the model provided by tbeir own leadership and exercise of authority. 7 Another significant resource is the experience of staff in other hospitals, sometimes not far away, who may be facing similar problems. If, for example, the staff of many geriatric hospitals are going to make efforts to improve patient care, there may clearly be much to be gained through fostering a greater sharing of experience and mutual support among the staff so engaged. 8 Finally, since the hospital is only one part of the total system of patient care, it follows that what is done in the hospital will be affected by and will affect what is done in other parts of this system, to tbe extent that changes in the relationships between all these parts, for example, as represented in tbe process of admission, may often be a necessary condition for other changes within tbe hospital. It is important therefore that efforts to produce change focused on the hospital should keep in mind the relationship between this and tbe contribution of the social services, the family, etc., to patient care, so that improvements in one area are not gained at tbe expense of deterioration elsewhere. APPLICATION These broad principles can be applied through a variety of initiatives at different levels. A ward sister for example with support from her unit nursing officer, consultant and a tutor, might seek to involve her staff in reviewing existing practices of care in her ward as in the example given in the case study—aiming particularly perhaps to provide some protected opportunities for staff as a wbole to examine the BGS/RCN guidelines in tbe light of their own experiences of giving care. At area or regional level, conferences might be organized at which
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multidisciplinary teams from a number of hospitals involved in the care of old people would explore together the possibihties for change in their own situation, and establish mechanisms for the cross-fertihzation of experience and mutual support as efforts to bring about improvements got underway. And at national level, the various bodies concemed about the care of old people might get together to coordinate their own efforts to foster change, monitor more widely what is happening to geriatric services, and perhaps establish an advice centre equipped to provide information and support to groups of staff taking more local initiatives. In conclusion it should be emphasized, however, that as with the guidance on what changes may be desirable, these principles about how improvements might be encouraged can only be of assistance if used creatively by staff at all levels in the hght of their own experience and the particular problems faced in different situations. Fundamental to this process is the critical examination of existing practices as the basis for informed innovation in the services to be provided.
References BRITISH GERIATMCS SOCIETY AND ROYAL COLLEGE OF NURSING (1975) Improving Geriatric Care in
Hospital. RoyaJ College of Nursing, London. KING EDWARD'S HOSPITAL FUND (1975) Living in Hospital. King's Fund Centre, London. MENZIES I. E. P. (i960) A case study in the functioning of social systems as a defence against anxiety. Human Relations 13, 95-121. MILLER E. & GWYNNE G. (1972) A Life Apart. Tavistock, London. MINISTRY OF HEALTH (1966) Report of the Committee on Senior Nursing Staff Structure (The 'Salmon' Report), H.M.S.O., London. SAVAGE B . (1974) Rethinking psychogeriatric nursing care. Nursing Times 70, 282-284. SAVAGE B . & WIDDOWSON T . (1974) Revising the use of nursing resources in the care of the elderly. Nursing Times jo, 1372-1374, 1424-1427. TOWELL D . (1975) Understanding Psychiatric Nursing. Royal College of Nursing, London.
