Patientcentredness
Learning about the Patient: an innovative interprofessional dementia and delirium education programme Andrew Teodorczuk, School for Medical Education, Newcastle University, Newcastle upon Tyne, UK Elizabeta Mukaetova-Ladinska, Institute for Ageing and Health, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK Sally Corbett and Mark Welfare, Education Centre, North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust, UK SUMMARY Background: Patients with confusion (delirium and dementia) in the general hospital environment are more likely to have negative health outcomes compared with other patients. Poor team and individual practice is partly responsible for this, and a training gap has been described. We report an innovative interprofessional teaching intervention that is founded on robust medical education research findings, and has the potential to improve staff practice. Innovation: A 2–day programme is described that seeks to address previously identified learning needs in relation to
managing the confused older patient. The programme is underpinned theoretically by learning from patients and carers, action learning and matching of teaching methods to aims (e.g. by the use of mindmaps to differentiate between dementia, delirium and depression). The programme has been implemented in Northumbria, England. Results: In total 48 health care professionals, representing 12 different professional groups, attended three courses. Findings suggest that the programme significantly increases confidence across six core domains towards managing the confused older patient
(p < 0.001, Mann–Whitney U–test). Furthermore, the course addresses negative attitudes and empowers staff to introduce relevant practice change. Implications: These results are pertinent given the findings of the Francis Inquiry, which identified significant care deficits within a culture of failing to practice in a patient-centred manner. As the core material focuses on learning about the patient, rather than the disease process, this programme may help address these gaps. Arguably our findings are of relevance to other innovators seeking to teach effectively in the hospital setting and improve patient care.
Patients with confusion in the general hospital environment are more likely to have negative health outcomes
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502 497
tct_12203.indd 497
11/11/2014 4:04:14 PM
These vulnerable patients challenge the professionalism of staff and have worse outcomes
INTRODUCTION
C
onfusion amongst older hospitalised patients is highly prevalent. In a typical hospital one in three beds are occupied by confused people aged over 65 years, with the most common causes of confusion being delirium and dementia.1 Converging evidence suggests that these vulnerable patients challenge the professionalism of staff and have worse outcomes in terms of length of stay, quality of life, institutionalisation and mortality.2,3
In part the negative outcomes have been attributed to a training gap. In the UK there is a policy consensus that staff working within the acute (i.e. non-psychiatric) setting lack the necessary skills and knowledge to effectively manage patients with confusion.4,5 Reports call for greater education; however, little is reported as to what training is effective.
CONTEXT By means of a grounded theory study, we have previously identified eight specific areas of learning need.6 They concern: (1) clinical ownership of the confused older patient; (2) negative attitude; (3) lack of understanding of how frightened the patient is in hospital; (4) carer partnerships; (5) person-centred care; (6) communication; (7) recognition of cognitive impairment; and (8) specific clinical needs (e.g. capacity assessments). Underpinning the learning needs were the sociocultural barriers, and knowledge and interprofessional hierarchies, that undermine good practice.7 Based on this new understanding of the learning needs of staff, an innovative interprofessional programme was developed to drive learning at individual, team and organisational levels.
Furthermore, we found a need to base such an educational programme in active teaching approaches.7 Unlike previous interventions in the field, which were predominantly underpinned theoretically by Kolb’s experiential or Knowles’ adult learning theory, we selected Biggs’ constructive alignment as the dominant model.8 Consequently, objectives and teaching methods were aligned with identified learning needs. The key objective was to facilitate learning about the patient. The benefit of adopting constructive alignment is that it is congruent with the social constructivist theoretical stance adopted by our original grounded theory study.7
INNOVATION A 2–day course, Learning about the Patient, was developed (Table 1). Day 1 challenged beliefs and attitudes (the core learning needs) about the confused older patient that undermined good care. Day 2 focused more on managing complex cases and practice change. The educational strategies incorporated within the programme are described in Table 2. The innovative teaching processes are as follows. 1. Learning directly from patients and carers. Patients taught sections of the course, and staff therefore had an opportunity to hear in-depth narratives as well as question their own attitudes. Learning by patient experience was further promoted by the production of two patient videos (‘Two stories of dementia’ and ‘Delirium patient experience’, http:// europeandeliriumassociation. com/delirium-information/ health-professionals/ patient-experience-ofdelirium-teaching-video). 2. Using an interprofessional teaching approach to develop
a deeper understanding of the contributions of all members of the multidisciplinary team in managing complexity. 3. A clear focus on action learning. For example, working in teams, learners were asked to produce a poster to demonstrate their increased understanding of delirium and dementia. The course was originally implemented three times over 18 months within Northumbria Healthcare NHS Foundation Trust, an Acute Trust in the North East of England. For each course 16 participants were invited to attend from across the health care spectrum. Hence a total of 48 participants attended the course in total over three cohorts. The staff groups working within the hospital included nurses, health care assistants, domestic staff, ward clerks, modern matrons, physiotherapists, occupational therapists, doctors, pharmacists, and porters (Table 3).
EVALUATION We evaluated outcomes in two areas of learning. • The course participants’ confidence in certain aspects of professionalism related to the care of confused elderly patients, using a pre-course and post-course questionnaire facilitated by means of handheld devices for electronic feedback. This was based on a five-point Likert scale. Change was assessed using the Mann–Whitney U–test for non-parametric data. • Changes in attitudes and knowledge, as suggested by a review of posters produced by the participants and by examining free-text comments from their evaluations (Box 1).
498 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502
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relevance of the course to clinical practice, and allude to a shift in the learner’s view of the work and feelings of empowerement.
Table 1. Broad outline of the course content Day 1
Day 2
The three Ds (dementia, delirium and depression)
Recognising confusion
Person-centred care
Treating delirium
Developing champions
Environmental factors
Learning from patients and carers
Practice change
RESULTS There has been a significant improvement in the learners’ confidence in managing issues relevant to this patient group, as demonstrated by the improving Likert scores demonstrated in Table 4. Mann–Whitney U–test scores were significant at the level of p < 0.001 for all questions. The course evaluation and posters also suggested positive changes in knowledge and attitudes. The themes touched on
IMPLICATIONS
in the poster (Figure 1) are typical of the posters produced by participants. They reveal a deeper understanding of the experience of the confused patient (references to time and being terrified, to visual hallucinations, and the need for food and water), and an understanding of a need to change attitudes and to engage with the individuality of the patient. Lastly, in line with the other findings, examples of post-course feedback (Box 1) highlight the
We report an innovative interprofessional educational programme that succeeds in changing confidence and attitudes towards caring for patients with dementia and delirium. Arguably this may lead to improved practice towards this traditionally challenging patient group.
[The posters] reveal a deeper understanding of the experience of the confused patient
The principal results are a highly significant change from pre- to post-intervention responses to the set questions (that aligned with the objectives of the course). The significant change in confidence has limitations concerning what we can infer as it only demonstrates initial learning being at Kirkpatrick level 2, at best.9 This evaluation
Table 2. Educational approaches that were incorporated within the programme to address the identified learning needs Learning need
Educational approach
Negative attitudes and understanding patients’ fears Learn from patients’ experiences, either by directly involving patients in the teaching process or by means of a patient video. Activate tacit knowledge (e.g. encourage staff learners to reflect on possible family members who have had experience of delirium or dementia). Active learning by means of producing a poster amongst teams to demonstrate new understanding. Ownership
Develop delirium and dementia champions. Actively target higher management levels to help promote organisational learning in relation to the core business of the hospital.
Carer learning need
Actively hear carer stories of marginalisation and plan practice change based on it. Recognise, celebrate and value the expertise a carer can bring.
Recognise delirium and dementia
Use mind maps to teach complexity in terms of differentiating between dementia, depression and delirium.
Communication
Interprofessional education to promote an understanding of the different roles that team members can bring, and which are needed to overcome patient complexity.
Person-centred care
Learn from successful episodes of good practice when a deeper understanding of patient values led to improved care. © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502 499
tct_12203.indd 499
11/11/2014 4:04:15 PM
Arguably, the format of the teaching is reproducible across specialties
study,7 which identified core learning needs concerning health care professional’s attitudes, ownership and understanding towards cases involving confused older people. It follows that the programme that evolved from our study will equally help address the findings and shortcomings identified by the Francis report. Arguably, the format of the teaching is reproducible across specialties and has the potential to help educators who seek innovative methods to facilitate learning about the individuality of the patient.
has proven useful in showcasing the success of the course to managers, however, and has led the trust to adopt the programme and roll-out a further 20 courses. Our findings are particularly timely and relevant given the publication of the Francis report within the UK.10 The report highlighted a negative culture that was characterised by a lack of compassion towards the patients, and was pervasive across all levels within one individual UK hospital. By means of analysis of the stories of both patients and carers, Francis identified a clear lack of ‘putting the patient first’. Furthermore, he argues that this systems failure was pertinent to the confused older patient lacking an advocate in the hospital setting. There is much overlap between this report and the findings of our grounded theory
We propose that the success might be because it is underpinned by robust research findings, relevant theory and a novel reconceptualisation of the learning needs of hospital staff.6 Consequently, an innovative programme has been
Table 3. Staff attended and profession (n = 48) Staff group
Number attended
Nurse
15
Health care assistant
8
Physiotherapist
5
Modern matron
5
Doctor
3
Physiotherapy assistant
3
Ward clerk
2
Occupational therapist
2
Domestic
2
Pharmacy assistant
1
Porter
1
Pharmacist
1
Box 1. Post-course comments Very informative, update in relation to best practice. Empowering to make a difference to patient experience. Respondent A Share findings with other Health Care Assistants and demonstrate to domestics how important their input could be. Respondent B The course has given me a better understanding of dementia, delirium and depression. It has changed the way I think that I can help patients by showing them respect, warmth, acknowledge them and not avoiding the patient. Respondent C
developed that has patients and carers at the heart of the teaching process, and empowers staff who may not necessarily receive other formal education. Furthermore, the collaborative team approach between professional groups as diverse as porters and doctors creates a learning space where a dialogical pedagogical approach can flourish, so that staff members who feel threatened in a ward setting can freely question their knowledge and understanding. A weakness of the course is that there were relatively few doctors represented; however, it was apparent that the doctors who did attend learned from the experience, having entered an interprofessional learning arena often with misplaced views that they had little to learn. Interestingly, within all three courses undertaken there appeared to be a ‘tipping point’ for staff after the session led by patients and carers (day 1), when they realised that they had much to contribute, although in different ways. At times this was emotional. For example, on one course a ward clerk shared with the group how guilty she felt that she did not realise the crucial role she played in relaying information to other staff. She learned that this was even more pertinent given the fact that patients with confusion could not communicate themselves. A further study limitation is that we did not evaluate practice change. Although there were informal reports of practice development on the wards following the course (such as improved dementia-specific signage, a reduction in noise levels and more regular use of screening tools for cognitive problems), we did not formally collect these data. Despite the fact that practice behaviour is highly complex and context specific, there would have been
500 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502
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Table 4. Evaluation of programme on participant’s confidence Strongly agree Q1
Q2
Q3
Q4
Q5
Q6
Agree
Neutral
Disagree
Pre-training
1 (2.3%)
5 (11.4%) 14 (31.8%) 23 (52.3%)
Post-training
10 (21.3%) 31 (66.0%) 6 (12.8%)
0 (0%)
Pre-training
4 (8.7%)
10 (21.7%)
Post-training
23 (51.1%) 22 (48.5%) 0 (0%)
0 (0%)
Pre-training
0 (0%)
26 (56.5%)
Post-training
4 (8.5%)
36 (76.6%) 7 (14.9%)
Pre-training
2 (4.2%)
16 (33.3%) 19 (39.6%) 9 (18.8%)
Post-training
23 (48.9%) 19 (40.4%) 5 (10.6%)
Pre-training
1 (2.2%)
Post-training
26 (55.3%) 19 (40.4%) 2 (4.3%)
Pre-training
3 (6.4%)
Post-training
23 (50.0%) 21 (45.7%) 2 (4.3%)
21 (45.7%) 9 (19.6%)
7 (15.2%) 9 (19.6%)
0 (0%)
0 (0%)
14 (31.1%) 16 (35.6%) 12 (26.7%) 0 (0%)
26 (55.3%) 13 (27.7%) 4 (8.5%) 0 (0%)
Strongly disagree
Mean (SD)
Median
1 (2.3%)
2.59 (0.82)
2.0
0 (0%)
4.09 (0.58)
4.0
2 (4.3%)
3.33 (1.06)
4.0
0 (0%)
4.51 (0.51)
5.0
4 (8.7%)
2.41 (0.86)
2.0
0 (0%)
3.94 (0.48)
4.0
2 (4.2%)
3.15 (0.92)
3.0
0 (0%)
4.38 (0.68)
4.0
2 (4.4%)
3.00 (0.93)
3.0
0 (0%)
4.51 (0.59)
5.0
1 (2.1%)
3.55 (0.83)
4.0
0 (0%)
4.46 (0.59)
4.5
Delivery at prequalifying level would open up the opportunity to shape professional identity formation
Mann–Whitney U–tests for significant differences between pre- and post-training scores. Q1 Practice with the confused older patient: Udf = 89 = 191.5; Z = 7.0; p < 0.001 (two-tailed). Q2 Understanding of patient-centred care: Udf = 89 = 365.0; Z = 5.7; p < 0.001 (two-tailed). Q3 Ability to manage difficult cases: Udf = 91 = 206.5; Z = 7.2; p < 0.001 (two-tailed). Q4 Understanding roles: Udf = 93 = 350.5; Z = 6.1; p < 0.001 (two-tailed). Q5 Working with carers: Udf = 90 = 211.0; Z = 6.9; p < 0.001 (two-tailed). Q6 Attitude to the confused older person: Udf = 91 = 441.5; Z = 5.3; p < 0.001 (two-tailed). NB Percentages calculated according to available data which differed according to number of responses for each question.
value in evaluating these outcomes by means of more formal approaches. An additional benefit concerns the degree of organisational learning that has
occurred as a result of implementing the programme. Recognising the changing nature of the hospital with the ageing population, Northumbria Healthcare NHS Foundation Trust now places delirium and
dementia at the centre of its induction process, and all staff are shown the relevant patient experience videos. The next step is to translate the innovation from a postgraduate to an undergraduate level. Delivery at prequalifying level would open up the opportunity to shape professional identity formation at an earlier stage. Development of an active identity more aligned with the current health care needs of the hospital population ultimately might promote greater accountability and lead to better patient care for the confused older patient. REFERENCES 1. Holmes J, Bentley K, Cameron I. Between two stools: Psychiatric services for older people in hospitals. Leeds: University of Leeds; 2002.
Figure 1. Example of a poster produced by a ward team attending the course
2. Marshall M. “They should not really be here” – people with dementia in the acute sector. Age Ageing 1999;28:9–11. © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502 501
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Ultimately might promote greater accountability and lead to better patient care for the confused older patient
3. Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010;304:443–451.
6. Teodorczuk A, Corbett S, Welfare M, Mukaetova Ladinska E. Reconceptualising models of delirium education: Findings of a Grounded Theory study. Int Psychogeriatr 2013;25: 645–655.
4. National Audit Office. Improving Dementia services – an Interim Report. London: National Audit Office; 2010.
7. Teodorczuk A. Developing Educational Approaches for Liaison teams: A Grounded Theory study of the learning needs of hospital staff in relation to managing the confused older patient. Doctoral Thesis, Newcastle University: Newcastle upon Tyne; 2011.
5. Alzheimer’s Society. Counting the cost. London: Alzheimer’s Society; 2009.
8. Biggs J, Tang C. Teaching for Quality Learning at University. (3rd edn). Maidenhead: Open University Press; 2007. 9. Kirkpatrick D. Evaluating training programs: the four levels. San Francisco: Berrett-Koehler; 1994. 10. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Department of Health: London; 2013.
Corresponding author’s contact details: Andrew Teodorczuk, School for Medical Education Development, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK. E-mail: [email protected]
Funding: Delivery of the course was supported through a NHS North East SHA Workforce Development Innovation Fund. Conflict of interest: None. Ethical approval: Ethical advice was sought from the National Research Ethics Service (NRES) North East Committee. We have been advised that research ethics comittee approval is not required for the study. doi: 10.1111/tct.12203
502 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502
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Learning about the Patient: an innovative interprofessional dementia and delirium education programme Andrew Teodorczuk, School for Medical Education, Newcastle University, Newcastle upon Tyne, UK Elizabeta Mukaetova-Ladinska, Institute for Ageing and Health, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK Sally Corbett and Mark Welfare, Education Centre, North Tyneside General Hospital, Northumbria Healthcare NHS Foundation Trust, UK SUMMARY Background: Patients with confusion (delirium and dementia) in the general hospital environment are more likely to have negative health outcomes compared with other patients. Poor team and individual practice is partly responsible for this, and a training gap has been described. We report an innovative interprofessional teaching intervention that is founded on robust medical education research findings, and has the potential to improve staff practice. Innovation: A 2–day programme is described that seeks to address previously identified learning needs in relation to
managing the confused older patient. The programme is underpinned theoretically by learning from patients and carers, action learning and matching of teaching methods to aims (e.g. by the use of mindmaps to differentiate between dementia, delirium and depression). The programme has been implemented in Northumbria, England. Results: In total 48 health care professionals, representing 12 different professional groups, attended three courses. Findings suggest that the programme significantly increases confidence across six core domains towards managing the confused older patient
(p < 0.001, Mann–Whitney U–test). Furthermore, the course addresses negative attitudes and empowers staff to introduce relevant practice change. Implications: These results are pertinent given the findings of the Francis Inquiry, which identified significant care deficits within a culture of failing to practice in a patient-centred manner. As the core material focuses on learning about the patient, rather than the disease process, this programme may help address these gaps. Arguably our findings are of relevance to other innovators seeking to teach effectively in the hospital setting and improve patient care.
Patients with confusion in the general hospital environment are more likely to have negative health outcomes
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502 497
tct_12203.indd 497
11/11/2014 4:04:14 PM
These vulnerable patients challenge the professionalism of staff and have worse outcomes
INTRODUCTION
C
onfusion amongst older hospitalised patients is highly prevalent. In a typical hospital one in three beds are occupied by confused people aged over 65 years, with the most common causes of confusion being delirium and dementia.1 Converging evidence suggests that these vulnerable patients challenge the professionalism of staff and have worse outcomes in terms of length of stay, quality of life, institutionalisation and mortality.2,3
In part the negative outcomes have been attributed to a training gap. In the UK there is a policy consensus that staff working within the acute (i.e. non-psychiatric) setting lack the necessary skills and knowledge to effectively manage patients with confusion.4,5 Reports call for greater education; however, little is reported as to what training is effective.
CONTEXT By means of a grounded theory study, we have previously identified eight specific areas of learning need.6 They concern: (1) clinical ownership of the confused older patient; (2) negative attitude; (3) lack of understanding of how frightened the patient is in hospital; (4) carer partnerships; (5) person-centred care; (6) communication; (7) recognition of cognitive impairment; and (8) specific clinical needs (e.g. capacity assessments). Underpinning the learning needs were the sociocultural barriers, and knowledge and interprofessional hierarchies, that undermine good practice.7 Based on this new understanding of the learning needs of staff, an innovative interprofessional programme was developed to drive learning at individual, team and organisational levels.
Furthermore, we found a need to base such an educational programme in active teaching approaches.7 Unlike previous interventions in the field, which were predominantly underpinned theoretically by Kolb’s experiential or Knowles’ adult learning theory, we selected Biggs’ constructive alignment as the dominant model.8 Consequently, objectives and teaching methods were aligned with identified learning needs. The key objective was to facilitate learning about the patient. The benefit of adopting constructive alignment is that it is congruent with the social constructivist theoretical stance adopted by our original grounded theory study.7
INNOVATION A 2–day course, Learning about the Patient, was developed (Table 1). Day 1 challenged beliefs and attitudes (the core learning needs) about the confused older patient that undermined good care. Day 2 focused more on managing complex cases and practice change. The educational strategies incorporated within the programme are described in Table 2. The innovative teaching processes are as follows. 1. Learning directly from patients and carers. Patients taught sections of the course, and staff therefore had an opportunity to hear in-depth narratives as well as question their own attitudes. Learning by patient experience was further promoted by the production of two patient videos (‘Two stories of dementia’ and ‘Delirium patient experience’, http:// europeandeliriumassociation. com/delirium-information/ health-professionals/ patient-experience-ofdelirium-teaching-video). 2. Using an interprofessional teaching approach to develop
a deeper understanding of the contributions of all members of the multidisciplinary team in managing complexity. 3. A clear focus on action learning. For example, working in teams, learners were asked to produce a poster to demonstrate their increased understanding of delirium and dementia. The course was originally implemented three times over 18 months within Northumbria Healthcare NHS Foundation Trust, an Acute Trust in the North East of England. For each course 16 participants were invited to attend from across the health care spectrum. Hence a total of 48 participants attended the course in total over three cohorts. The staff groups working within the hospital included nurses, health care assistants, domestic staff, ward clerks, modern matrons, physiotherapists, occupational therapists, doctors, pharmacists, and porters (Table 3).
EVALUATION We evaluated outcomes in two areas of learning. • The course participants’ confidence in certain aspects of professionalism related to the care of confused elderly patients, using a pre-course and post-course questionnaire facilitated by means of handheld devices for electronic feedback. This was based on a five-point Likert scale. Change was assessed using the Mann–Whitney U–test for non-parametric data. • Changes in attitudes and knowledge, as suggested by a review of posters produced by the participants and by examining free-text comments from their evaluations (Box 1).
498 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502
tct_12203.indd 498
11/11/2014 4:04:15 PM
relevance of the course to clinical practice, and allude to a shift in the learner’s view of the work and feelings of empowerement.
Table 1. Broad outline of the course content Day 1
Day 2
The three Ds (dementia, delirium and depression)
Recognising confusion
Person-centred care
Treating delirium
Developing champions
Environmental factors
Learning from patients and carers
Practice change
RESULTS There has been a significant improvement in the learners’ confidence in managing issues relevant to this patient group, as demonstrated by the improving Likert scores demonstrated in Table 4. Mann–Whitney U–test scores were significant at the level of p < 0.001 for all questions. The course evaluation and posters also suggested positive changes in knowledge and attitudes. The themes touched on
IMPLICATIONS
in the poster (Figure 1) are typical of the posters produced by participants. They reveal a deeper understanding of the experience of the confused patient (references to time and being terrified, to visual hallucinations, and the need for food and water), and an understanding of a need to change attitudes and to engage with the individuality of the patient. Lastly, in line with the other findings, examples of post-course feedback (Box 1) highlight the
We report an innovative interprofessional educational programme that succeeds in changing confidence and attitudes towards caring for patients with dementia and delirium. Arguably this may lead to improved practice towards this traditionally challenging patient group.
[The posters] reveal a deeper understanding of the experience of the confused patient
The principal results are a highly significant change from pre- to post-intervention responses to the set questions (that aligned with the objectives of the course). The significant change in confidence has limitations concerning what we can infer as it only demonstrates initial learning being at Kirkpatrick level 2, at best.9 This evaluation
Table 2. Educational approaches that were incorporated within the programme to address the identified learning needs Learning need
Educational approach
Negative attitudes and understanding patients’ fears Learn from patients’ experiences, either by directly involving patients in the teaching process or by means of a patient video. Activate tacit knowledge (e.g. encourage staff learners to reflect on possible family members who have had experience of delirium or dementia). Active learning by means of producing a poster amongst teams to demonstrate new understanding. Ownership
Develop delirium and dementia champions. Actively target higher management levels to help promote organisational learning in relation to the core business of the hospital.
Carer learning need
Actively hear carer stories of marginalisation and plan practice change based on it. Recognise, celebrate and value the expertise a carer can bring.
Recognise delirium and dementia
Use mind maps to teach complexity in terms of differentiating between dementia, depression and delirium.
Communication
Interprofessional education to promote an understanding of the different roles that team members can bring, and which are needed to overcome patient complexity.
Person-centred care
Learn from successful episodes of good practice when a deeper understanding of patient values led to improved care. © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502 499
tct_12203.indd 499
11/11/2014 4:04:15 PM
Arguably, the format of the teaching is reproducible across specialties
study,7 which identified core learning needs concerning health care professional’s attitudes, ownership and understanding towards cases involving confused older people. It follows that the programme that evolved from our study will equally help address the findings and shortcomings identified by the Francis report. Arguably, the format of the teaching is reproducible across specialties and has the potential to help educators who seek innovative methods to facilitate learning about the individuality of the patient.
has proven useful in showcasing the success of the course to managers, however, and has led the trust to adopt the programme and roll-out a further 20 courses. Our findings are particularly timely and relevant given the publication of the Francis report within the UK.10 The report highlighted a negative culture that was characterised by a lack of compassion towards the patients, and was pervasive across all levels within one individual UK hospital. By means of analysis of the stories of both patients and carers, Francis identified a clear lack of ‘putting the patient first’. Furthermore, he argues that this systems failure was pertinent to the confused older patient lacking an advocate in the hospital setting. There is much overlap between this report and the findings of our grounded theory
We propose that the success might be because it is underpinned by robust research findings, relevant theory and a novel reconceptualisation of the learning needs of hospital staff.6 Consequently, an innovative programme has been
Table 3. Staff attended and profession (n = 48) Staff group
Number attended
Nurse
15
Health care assistant
8
Physiotherapist
5
Modern matron
5
Doctor
3
Physiotherapy assistant
3
Ward clerk
2
Occupational therapist
2
Domestic
2
Pharmacy assistant
1
Porter
1
Pharmacist
1
Box 1. Post-course comments Very informative, update in relation to best practice. Empowering to make a difference to patient experience. Respondent A Share findings with other Health Care Assistants and demonstrate to domestics how important their input could be. Respondent B The course has given me a better understanding of dementia, delirium and depression. It has changed the way I think that I can help patients by showing them respect, warmth, acknowledge them and not avoiding the patient. Respondent C
developed that has patients and carers at the heart of the teaching process, and empowers staff who may not necessarily receive other formal education. Furthermore, the collaborative team approach between professional groups as diverse as porters and doctors creates a learning space where a dialogical pedagogical approach can flourish, so that staff members who feel threatened in a ward setting can freely question their knowledge and understanding. A weakness of the course is that there were relatively few doctors represented; however, it was apparent that the doctors who did attend learned from the experience, having entered an interprofessional learning arena often with misplaced views that they had little to learn. Interestingly, within all three courses undertaken there appeared to be a ‘tipping point’ for staff after the session led by patients and carers (day 1), when they realised that they had much to contribute, although in different ways. At times this was emotional. For example, on one course a ward clerk shared with the group how guilty she felt that she did not realise the crucial role she played in relaying information to other staff. She learned that this was even more pertinent given the fact that patients with confusion could not communicate themselves. A further study limitation is that we did not evaluate practice change. Although there were informal reports of practice development on the wards following the course (such as improved dementia-specific signage, a reduction in noise levels and more regular use of screening tools for cognitive problems), we did not formally collect these data. Despite the fact that practice behaviour is highly complex and context specific, there would have been
500 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502
tct_12203.indd 500
11/11/2014 4:04:15 PM
Table 4. Evaluation of programme on participant’s confidence Strongly agree Q1
Q2
Q3
Q4
Q5
Q6
Agree
Neutral
Disagree
Pre-training
1 (2.3%)
5 (11.4%) 14 (31.8%) 23 (52.3%)
Post-training
10 (21.3%) 31 (66.0%) 6 (12.8%)
0 (0%)
Pre-training
4 (8.7%)
10 (21.7%)
Post-training
23 (51.1%) 22 (48.5%) 0 (0%)
0 (0%)
Pre-training
0 (0%)
26 (56.5%)
Post-training
4 (8.5%)
36 (76.6%) 7 (14.9%)
Pre-training
2 (4.2%)
16 (33.3%) 19 (39.6%) 9 (18.8%)
Post-training
23 (48.9%) 19 (40.4%) 5 (10.6%)
Pre-training
1 (2.2%)
Post-training
26 (55.3%) 19 (40.4%) 2 (4.3%)
Pre-training
3 (6.4%)
Post-training
23 (50.0%) 21 (45.7%) 2 (4.3%)
21 (45.7%) 9 (19.6%)
7 (15.2%) 9 (19.6%)
0 (0%)
0 (0%)
14 (31.1%) 16 (35.6%) 12 (26.7%) 0 (0%)
26 (55.3%) 13 (27.7%) 4 (8.5%) 0 (0%)
Strongly disagree
Mean (SD)
Median
1 (2.3%)
2.59 (0.82)
2.0
0 (0%)
4.09 (0.58)
4.0
2 (4.3%)
3.33 (1.06)
4.0
0 (0%)
4.51 (0.51)
5.0
4 (8.7%)
2.41 (0.86)
2.0
0 (0%)
3.94 (0.48)
4.0
2 (4.2%)
3.15 (0.92)
3.0
0 (0%)
4.38 (0.68)
4.0
2 (4.4%)
3.00 (0.93)
3.0
0 (0%)
4.51 (0.59)
5.0
1 (2.1%)
3.55 (0.83)
4.0
0 (0%)
4.46 (0.59)
4.5
Delivery at prequalifying level would open up the opportunity to shape professional identity formation
Mann–Whitney U–tests for significant differences between pre- and post-training scores. Q1 Practice with the confused older patient: Udf = 89 = 191.5; Z = 7.0; p < 0.001 (two-tailed). Q2 Understanding of patient-centred care: Udf = 89 = 365.0; Z = 5.7; p < 0.001 (two-tailed). Q3 Ability to manage difficult cases: Udf = 91 = 206.5; Z = 7.2; p < 0.001 (two-tailed). Q4 Understanding roles: Udf = 93 = 350.5; Z = 6.1; p < 0.001 (two-tailed). Q5 Working with carers: Udf = 90 = 211.0; Z = 6.9; p < 0.001 (two-tailed). Q6 Attitude to the confused older person: Udf = 91 = 441.5; Z = 5.3; p < 0.001 (two-tailed). NB Percentages calculated according to available data which differed according to number of responses for each question.
value in evaluating these outcomes by means of more formal approaches. An additional benefit concerns the degree of organisational learning that has
occurred as a result of implementing the programme. Recognising the changing nature of the hospital with the ageing population, Northumbria Healthcare NHS Foundation Trust now places delirium and
dementia at the centre of its induction process, and all staff are shown the relevant patient experience videos. The next step is to translate the innovation from a postgraduate to an undergraduate level. Delivery at prequalifying level would open up the opportunity to shape professional identity formation at an earlier stage. Development of an active identity more aligned with the current health care needs of the hospital population ultimately might promote greater accountability and lead to better patient care for the confused older patient. REFERENCES 1. Holmes J, Bentley K, Cameron I. Between two stools: Psychiatric services for older people in hospitals. Leeds: University of Leeds; 2002.
Figure 1. Example of a poster produced by a ward team attending the course
2. Marshall M. “They should not really be here” – people with dementia in the acute sector. Age Ageing 1999;28:9–11. © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502 501
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Ultimately might promote greater accountability and lead to better patient care for the confused older patient
3. Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010;304:443–451.
6. Teodorczuk A, Corbett S, Welfare M, Mukaetova Ladinska E. Reconceptualising models of delirium education: Findings of a Grounded Theory study. Int Psychogeriatr 2013;25: 645–655.
4. National Audit Office. Improving Dementia services – an Interim Report. London: National Audit Office; 2010.
7. Teodorczuk A. Developing Educational Approaches for Liaison teams: A Grounded Theory study of the learning needs of hospital staff in relation to managing the confused older patient. Doctoral Thesis, Newcastle University: Newcastle upon Tyne; 2011.
5. Alzheimer’s Society. Counting the cost. London: Alzheimer’s Society; 2009.
8. Biggs J, Tang C. Teaching for Quality Learning at University. (3rd edn). Maidenhead: Open University Press; 2007. 9. Kirkpatrick D. Evaluating training programs: the four levels. San Francisco: Berrett-Koehler; 1994. 10. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. Department of Health: London; 2013.
Corresponding author’s contact details: Andrew Teodorczuk, School for Medical Education Development, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK. E-mail: [email protected]
Funding: Delivery of the course was supported through a NHS North East SHA Workforce Development Innovation Fund. Conflict of interest: None. Ethical approval: Ethical advice was sought from the National Research Ethics Service (NRES) North East Committee. We have been advised that research ethics comittee approval is not required for the study. doi: 10.1111/tct.12203
502 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 497–502
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