synthesis of art and science is lived by the nurse in the nursing act Art & science || The acute settings care
JOSEPHINE G PATERSON
TRANSFORMING DEMENTIA CARE IN AN NHS TRUST Jennifer Robinson and colleagues found that education had a positive effect on the culture of one hospital as well as the knowledge and skills of the workforce Correspondence jennifer.robinson@ walsallhealthcare.nhs.uk Jennifer Robinson is lead nurse older people and vulnerable adults Jane Longden is interim associate director of facilities Jayne Murphy is dementia project lead All at Walsall Healthcare NHS Trust, Walsall, West Midlands Date of submission August 28 2014 Date of acceptance October 29 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ nop-author-guidelines
Lead author Jennifer Robinson shares a cup of tea with Joyce Butler. The wards now use orange crockery because research has shown the colour stimulates patients to eat and drink
Abstract Walsall Healthcare NHS Trust was one of nine trusts selected to take part in the RCN development programme transforming dementia care in hospitals during 2013. The programme aimed to improve the experience of care for people with dementia and their carers in hospital. This article outlines a two-day training programme delivered to staff on two pilot wards with a larger cohort of adults with dementia than other wards in Manor Hospital. A range of staff were trained including nurses, clinical support workers and allied health professionals and also, in a bespoke format, housekeepers, porters and security staff. The programme has led to a noticeable cultural change and significantly improved care and management of patients with cognitive impairment and/or dementia on the two pilot wards. As a result, the training programme has been implemented more widely across the hospital. Keywords Carers, cognitive impairment, dementia, development programme, education, hospitals A FOCUS of Walsall Healthcare NHS Trust’s quality and safety strategy is to improve dementia care. In addition, the trust’s dementia strategy articulates its vision in more detail (Walsall Healthcare NHS Trust 2013). The trust recognises the need for a skilled and competent workforce to ensure any
18 February 2015 | Volume 27 | Number 1
improvement in patient care and outcomes, and the importance of an appropriate training and development programme. National policy has directed attention towards improving acute care for adults with dementia. The National Dementia Strategy (Department of Health 2009, 2010), National Institute for Health and Care Excellence (2010) dementia quality standard and the National Audit of Dementia (Royal College of Psychiatrists 2014) all focus on developing the skills of the workforce. In 2012 the RCN announced its development programme for improving dementia care in general hospital settings. The programme was aligned to the National Dementia Strategy and intended to use the RCN (2010) Principles of Nursing Practice, along with other measures, to demonstrate and evaluate outcomes for patients, carers and staff. Resources to support learning included the RCN (2011) SPACE principles (Box 1, page 20) and the Triangle of Care (Carers Trust 2013).
Pilot wards The programme aimed to support staff working in general hospitals to: ■ Develop skills and knowledge to support implementation of good practice in the care of people with dementia and their families in an acute setting. ■ Develop a strategic approach to partnership working that shows understanding of the NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Tim George
NURSING OLDER PEOPLE
February 2015 | Volume 27 | Number 1 19
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | acute settings care The programme was used to develop and promote the ethos of person-centred care planning and implement care bundles role of carers, families and friends and principles of involvement. ■ Understand the national context and guidance supporting improvements in dementia care in hospitals and how this informs and relates to local developments. ■ Develop local action plans to identify important changes, involving interested parties. ■ Apply quality improvement initiative approaches to support, deliver and evaluate local action plans. ■ Build on clinical leadership skills to develop practice. ■ Evaluate the effect of improvements in their wards/settings using an outcomes-based approach focusing on patient/carer experience. The programme ran from March to December 2013 and included attendance at three facilitated development days and a site visit by RCN staff and expert carers to support progress. The Association for Dementia Studies at the University of Worcester was commissioned to undertake an external evaluation of the effectiveness of the programme in developing practice and supporting improved outcomes for people with dementia, family carers and staff (Brooker et al 2014). After presentation to a shortlisting panel comprising representatives from the RCN Foundation, RCN Learning and Development Institute, Uniting Carers, Dementia UK and RCN dementia project lead, the trust was selected to be one of nine offered a place on the programme. A prerequisite of the programme was for each organisation to have an executive lead who would be a member of the project team. The trust dementia steering group chaired by the executive lead endorsed the action plan that was developed around the RCN (2011) SPACE principles. Data collected for dementia diagnosis in the trust identified a care of the older adult ward and a trauma and orthopaedic ward as providing care for Box 1 SPACE principles to support good dementia care 1. 2. 3. 4. 5.
Staff who are skilled and have time to care. Partnership working with carers. Assessment and early identification of dementia. Care plans that are person centred and individualised. Environments that are dementia friendly.
(Royal College of Nursing 2011)
20 February 2015 | Volume 27 | Number 1
a larger cohort of adults with dementia compared with other wards. The project team thought that these two ward teams, including allied health professionals, required foundation knowledge of dementia to improve care and support for adults with dementia and their carers. This led to a comprehensive programme of education and training being devised, which covered patients at all stages of dementia up to and including end of life care. The programme was used as an opportunity to develop and promote the ethos of person-centred care planning and helped introduce and implement care bundles for the environment, nutrition and communication.
Training Ward managers on the two pilot wards – one medical and one trauma and orthopaedic – were asked to encourage support workers, registered nurses, allied health professionals and housekeepers to answer questions about caring for patients with dementia by means of a graffiti board over one week. Comments were sought under four headings: What are your challenges? What education and training do you require? Any concerns? How can we improve dementia care? Challenges included caring for patients who were physically and verbally abusive, aggressive, agitated, disorientated and confused. Staff requested education and training on dementia awareness, delirium, mental capacity, advocacy, communication and managing patients with challenging behaviour. These requests reflected the thoughts of the project team on what the programme would comprise. In addition, they supported the literature on staff skills and competence, for example, the Alzheimer’s Society (2009) recommended an informed and effective acute care workforce for people with dementia. Concerns included poor communication, ensuring patients with cognitive impairment and dementia were receiving adequate nutrition and fluids, patients who were already confused and disorientated being moved around the hospital because of bed management issues and inconsistent completion of documents such as the Alzheimer’s Society’s (2013a) tool This is Me. This document is designed to support people with dementia receiving care in a variety of settings and promotes the concept of person-centred care and seeing the person. The project manager developed a training programme in response to the graffiti board requests that consisted of: NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
■ Dementia awareness. ■ Recognition and management of behaviour that challenges. ■ Recognition and management of delirium. ■ Advance care planning. ■ End of life care. ■ Mental Capacity Act and Deprivation of Liberty Safeguards. Training was run over two days and staff were required to attend both sessions. Participation was sought from qualified nursing staff at all levels, clinical support workers, allied health professionals, discharge co-ordinators and ward clerks. An additional short bespoke session was offered and delivered to housekeepers, porters and security staff. The training programme was delivered over a six-month period in six cohorts and trust board level support was gained to enable a number of registered and non-registered staff to attend each cohort. It was delivered by the trust’s dementia project lead, palliative care education co-ordinator, lead nurse for older people and the older people’s mental health liaison team. A total of 44 staff from the two pilot wards completed the training, comprising nurses, therapists, discharge co-ordinators and ward clerks, and representing 74% of the total number of staff. A further ten support staff completed the short bespoke session. All attendees also received The Dementia Guide (Alzheimer’s Society 2013b) and the pocket-sized Dementia Care Survival Guide (Brooker and Lillyman 2013), which they could use as a quick reference. Each attendee was also introduced to the Alzheimer’s Society’s Dementia Friends initiative, which aims to provide an understanding of the disease and the small things that can make a difference to people living in the community. Attendees received a session explaining what the initiative is about and were presented with a Dementia Friends badge on completion of day one.
Feedback Attendees completed a pre- and post-training questionnaire to determine their confidence in aspects of dementia care and whether learning had been successful. Overall, questionnaire responses indicated that attendees’ knowledge, confidence and awareness of all aspects of dementia care had increased as a result of their participation in the training. Feedback was obtained after each day as part of an overall evaluation. It was positive and attendees indicated that they had enjoyed and valued the NURSING OLDER PEOPLE
programme. It enabled peer support and sharing of knowledge between the two wards and in a safe environment. Attendees felt able to express opinions about dementia care in the acute setting. This ability to express opinions enabled them to undertake a form of clinical supervision that was valued and added to the overall satisfaction rate. Ward teams could attend collectively, which allowed them to share their learning and develop their vision together. In addition, attending with another ward team allowed them time to appreciate that improving dementia care was being considered from an organisational perspective and would improve patient care across the organisation. Attendees were asked to indicate which aspects of the course they particularly liked. Responses included: ■ Participation and discussion. ■ Ability to express opinions. ■ Theory behind practice. ■ Knowing the previously unknown. ■ Improved awareness. ■ Speakers’ knowledge. Attendees were also asked to identify three areas where they had improved their knowledge. Responses included: ■ Recognising early dementia. ■ How to manage patients with dementia in their delirium phase. ■ Behaviour that challenges. ■ How to complete the six-item Cognitive Impairment Test (6-CIT) (Brooke and Bullock 1999). ■ Support for carers. ■ Mental Capacity Act and Deprivation of Liberty Safeguards. ■ Triggers that can exacerbate behaviour for a patient with dementia, for example, environment. ■ Problem solving. ■ Use of available resources. Comparison of the pre- and post-training questionnaires and the evaluation forms demonstrated that learning had taken place and that the training had had a positive effect on attendees. The two-hour session provided for support staff aimed to share essential information about dementia awareness and how to communicate with patients with a cognitive impairment. The dementia project lead and the older people’s mental health liaison team delivered this. The feedback requested on the session was more informal than for the two-day programme, via a form asking for comments. Some examples of the comments received were: ■ ‘I feel more in control of caring.’ ■ ‘It made me think about being more patient.’ February 2015 | Volume 27 | Number 1 21
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | acute settings ■ ‘There were some excellent communication tips.’ ■ ‘I thought the session was informative.’ ■ ‘I have a much better understanding of dementia.’ ■ ‘It made me aware that we can all make a difference.’ ■ ‘Every little thing helps and we don’t have to be experts to make a difference.’ The session was so well received that it will continue to be offered to support staff as part of the overall workforce plan.
Evaluation The RCN completed a site visit in September 2013 and the University of Worcester in January 2014. Both site visits involved the teams visiting the wards and speaking to staff. Informal feedback from both visits included praise for the enthusiasm of staff and positive interactions with patients and carers. Staff interviewed gave positive reports about the training programme.
Benefits to the organisation The training programme has led to significantly improved care and management of patients with cognitive impairment or dementia on the two pilot wards. The training has affected the culture on these wards. There have been reports of more positive engagement with patients with dementia, staff satisfaction in the care they deliver and increased morale and team cohesion. Benefits from the patients’ perspective have been difficult to assess. However, the older people’s mental health liaison team has reported receiving more appropriate referrals as clinical staff have a greater understanding of symptoms such as confusion and disorientation. While referrals are still received by this team and by dementia support workers for specialist advice, they are timelier and staff are more likely to have implemented interventions without being prompted to do so. Carer questionnaires have indicated that carers and loved ones think that staff have a greater understanding of dementia and are not just treating patients’ medical or surgical conditions. Staff have become much more aware of the effect of the environment on patients with cognitive impairment and dementia, including signs, colour and noise. As a result of the involvement of the
Porters and security staff are now much more empowered to question staff about whether a patient should be moved 22 February 2015 | Volume 27 | Number 1
interim associate director of facilities in dementia training, all new work schemes at the trust are now reviewed from a dementia-friendly standpoint. In addition, a number of environmental initiatives have been piloted on the two wards. These have included the introduction of orange crockery in response to evidence that patients with dementia are more likely to eat food that is presented in this way, which was learned from the King’s Fund Enhancing the Healing Environment programme. An internal audit identified a subsequent 15% reduction in food waste. As a result, implementation of orange crockery is planned across all wards. The use of aromatherapy to encourage patients to eat their meals and to enjoy a good night’s sleep is also being piloted. Two aromas have been chosen specifically to assess the effect on nutrition and sleep patterns, the outcomes of which have yet to be assessed. Housekeepers are now able to use This is Me (Alzheimer’s Society 2013a) to ensure patients are given their preferred drink at meal and refreshment times. They are asked to consider whether patients require a beaker or whether a mug would be more appropriate. When patients displayed aggressive or challenging behaviour ward staff called security teams. As a result of the training, clinical staff report being much more knowledgeable and confident in managing patients expressing such behaviours on the ward, without the need for external support. An approach to minimise ward moves for patients with dementia has been initiated and if a patient needs to be transferred to another ward, this is done during the day. A formal list of patients recommended for no ward moves is generated in preparation for the weekend, as it was recognised that patients were moved between wards out of hours. The list is sent to all the executive teams and heads of nursing, and a patient on the list can only be moved with the approval of the mental health liaison team or executive director if out of hours. A reduction in ward moves is built into the trust’s key performance indicators, and if a patient on the list is moved staff are advised to complete a clinical incident report. Implementation of the list has reduced patient moves considerably. The list is also given to the security manager so that porters and security staff are aware. Porters and security staff have reported that the programme has integrated them into the clinical team, and they have a greater understanding of dementia and its effect on patients in a hospital environment. They are now much more empowered NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
to question staff about whether a patient should be moved. It has been observed that they engage with patients in a much more meaningful way, whereas previously they may have seen their role as just moving a patient from A to B.
Next steps The training programme will continue to run on a regular basis. Staff from two further wards – one elderly care and one general medical ward – underwent training in September 2014, along with new starters from the two pilot wards. The trust dementia steering group is supporting implementation of the training programme across the organisation and offering it as an option among a variety of dementia education opportunities available to meet the needs of the workforce. Staff who have received the training will be encouraged to help improve response rates to the
carer questionnaire so that their feedback can be reflected in the care given to their loved ones.
Conclusion The training programme has met its aim of developing the knowledge and skills of the workforce and supporting them to deliver improved care for patients with cognitive impairment and dementia in the ward environment. Observational tools will be used to show the culture change as the programme is rolled out across the organisation. Given the competing priorities of the organisation, a learning point from the project team is that a six-month gap between cohorts makes it more difficult to maintain momentum; a shorter gap would be better. However, ensuring best practice in the care of adults with dementia and their carers is a priority across the trust and will continue to be so.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References Alzheimer’s Society (2009) Counting the Cost: Caring for People with Dementia on Hospital Wards. Alzheimer’s Society, London. Alzheimer’s Society (2013a) This is Me. Alzheimer’s Society, London. Alzheimer’s Society (2013b) The Dementia Guide — Living Well after Diagnosis. Alzheimer’s Society, London. Brooke P, Bullock R (1999) Validation of a 6 item cognitive impairment test with a view to primary care usage. International Journal of Geriatric Psychiatry. 14, 11, 936-940.
NURSING OLDER PEOPLE
Brooker D, Lillyman S (2013) Dementia Care Survival Guide. Routledge, Abingdon. Brooker D, Milosevic S, Evans S et al (2014) RCN Development Programme: Transforming Dementia Care in Hospitals Evaluation Report. University of Worcester, Worcester. Carers Trust (2013) The Triangle of Care – Carers Included: A Guide to Best Practice For Dementia Care. Carers Trust, London. Department of Health (2009) Living Well With Dementia: A National Dementia Strategy. DH, London.
Department of Health (2010) Quality Outcomes for People with Dementia: Building on the Work of the National Dementia Strategy. DH, London.
Royal College of Nursing (2011) Commitment to the Care of People with Dementia in Hospital Settings (SPACE Principles). RCN, London.
National Institute for Health and Care Excellence (2010) Dementia Quality Standard. NICE, London.
Royal College of Psychiatrists (2014) National Audit of Dementia. tinyurl.com/kjt5roa (Last accessed: December 3 2014.)
Royal College of Nursing (2010) Principles of Nursing Practice: Principles and Measures Consultation. RCN, London.
Walsall Healthcare NHS Trust (2013) Provider Dementia Care Strategy. tinyurl.com/p6gvjhk (Last accessed: December 3 2014.)
February 2015 | Volume 27 | Number 1 23
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
JOSEPHINE G PATERSON
TRANSFORMING DEMENTIA CARE IN AN NHS TRUST Jennifer Robinson and colleagues found that education had a positive effect on the culture of one hospital as well as the knowledge and skills of the workforce Correspondence jennifer.robinson@ walsallhealthcare.nhs.uk Jennifer Robinson is lead nurse older people and vulnerable adults Jane Longden is interim associate director of facilities Jayne Murphy is dementia project lead All at Walsall Healthcare NHS Trust, Walsall, West Midlands Date of submission August 28 2014 Date of acceptance October 29 2014 Peer review This article has been subject to double-blind review and has been checked using antiplagiarism software Author guidelines rcnpublishing.com/r/ nop-author-guidelines
Lead author Jennifer Robinson shares a cup of tea with Joyce Butler. The wards now use orange crockery because research has shown the colour stimulates patients to eat and drink
Abstract Walsall Healthcare NHS Trust was one of nine trusts selected to take part in the RCN development programme transforming dementia care in hospitals during 2013. The programme aimed to improve the experience of care for people with dementia and their carers in hospital. This article outlines a two-day training programme delivered to staff on two pilot wards with a larger cohort of adults with dementia than other wards in Manor Hospital. A range of staff were trained including nurses, clinical support workers and allied health professionals and also, in a bespoke format, housekeepers, porters and security staff. The programme has led to a noticeable cultural change and significantly improved care and management of patients with cognitive impairment and/or dementia on the two pilot wards. As a result, the training programme has been implemented more widely across the hospital. Keywords Carers, cognitive impairment, dementia, development programme, education, hospitals A FOCUS of Walsall Healthcare NHS Trust’s quality and safety strategy is to improve dementia care. In addition, the trust’s dementia strategy articulates its vision in more detail (Walsall Healthcare NHS Trust 2013). The trust recognises the need for a skilled and competent workforce to ensure any
18 February 2015 | Volume 27 | Number 1
improvement in patient care and outcomes, and the importance of an appropriate training and development programme. National policy has directed attention towards improving acute care for adults with dementia. The National Dementia Strategy (Department of Health 2009, 2010), National Institute for Health and Care Excellence (2010) dementia quality standard and the National Audit of Dementia (Royal College of Psychiatrists 2014) all focus on developing the skills of the workforce. In 2012 the RCN announced its development programme for improving dementia care in general hospital settings. The programme was aligned to the National Dementia Strategy and intended to use the RCN (2010) Principles of Nursing Practice, along with other measures, to demonstrate and evaluate outcomes for patients, carers and staff. Resources to support learning included the RCN (2011) SPACE principles (Box 1, page 20) and the Triangle of Care (Carers Trust 2013).
Pilot wards The programme aimed to support staff working in general hospitals to: ■ Develop skills and knowledge to support implementation of good practice in the care of people with dementia and their families in an acute setting. ■ Develop a strategic approach to partnership working that shows understanding of the NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Tim George
NURSING OLDER PEOPLE
February 2015 | Volume 27 | Number 1 19
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | acute settings care The programme was used to develop and promote the ethos of person-centred care planning and implement care bundles role of carers, families and friends and principles of involvement. ■ Understand the national context and guidance supporting improvements in dementia care in hospitals and how this informs and relates to local developments. ■ Develop local action plans to identify important changes, involving interested parties. ■ Apply quality improvement initiative approaches to support, deliver and evaluate local action plans. ■ Build on clinical leadership skills to develop practice. ■ Evaluate the effect of improvements in their wards/settings using an outcomes-based approach focusing on patient/carer experience. The programme ran from March to December 2013 and included attendance at three facilitated development days and a site visit by RCN staff and expert carers to support progress. The Association for Dementia Studies at the University of Worcester was commissioned to undertake an external evaluation of the effectiveness of the programme in developing practice and supporting improved outcomes for people with dementia, family carers and staff (Brooker et al 2014). After presentation to a shortlisting panel comprising representatives from the RCN Foundation, RCN Learning and Development Institute, Uniting Carers, Dementia UK and RCN dementia project lead, the trust was selected to be one of nine offered a place on the programme. A prerequisite of the programme was for each organisation to have an executive lead who would be a member of the project team. The trust dementia steering group chaired by the executive lead endorsed the action plan that was developed around the RCN (2011) SPACE principles. Data collected for dementia diagnosis in the trust identified a care of the older adult ward and a trauma and orthopaedic ward as providing care for Box 1 SPACE principles to support good dementia care 1. 2. 3. 4. 5.
Staff who are skilled and have time to care. Partnership working with carers. Assessment and early identification of dementia. Care plans that are person centred and individualised. Environments that are dementia friendly.
(Royal College of Nursing 2011)
20 February 2015 | Volume 27 | Number 1
a larger cohort of adults with dementia compared with other wards. The project team thought that these two ward teams, including allied health professionals, required foundation knowledge of dementia to improve care and support for adults with dementia and their carers. This led to a comprehensive programme of education and training being devised, which covered patients at all stages of dementia up to and including end of life care. The programme was used as an opportunity to develop and promote the ethos of person-centred care planning and helped introduce and implement care bundles for the environment, nutrition and communication.
Training Ward managers on the two pilot wards – one medical and one trauma and orthopaedic – were asked to encourage support workers, registered nurses, allied health professionals and housekeepers to answer questions about caring for patients with dementia by means of a graffiti board over one week. Comments were sought under four headings: What are your challenges? What education and training do you require? Any concerns? How can we improve dementia care? Challenges included caring for patients who were physically and verbally abusive, aggressive, agitated, disorientated and confused. Staff requested education and training on dementia awareness, delirium, mental capacity, advocacy, communication and managing patients with challenging behaviour. These requests reflected the thoughts of the project team on what the programme would comprise. In addition, they supported the literature on staff skills and competence, for example, the Alzheimer’s Society (2009) recommended an informed and effective acute care workforce for people with dementia. Concerns included poor communication, ensuring patients with cognitive impairment and dementia were receiving adequate nutrition and fluids, patients who were already confused and disorientated being moved around the hospital because of bed management issues and inconsistent completion of documents such as the Alzheimer’s Society’s (2013a) tool This is Me. This document is designed to support people with dementia receiving care in a variety of settings and promotes the concept of person-centred care and seeing the person. The project manager developed a training programme in response to the graffiti board requests that consisted of: NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
■ Dementia awareness. ■ Recognition and management of behaviour that challenges. ■ Recognition and management of delirium. ■ Advance care planning. ■ End of life care. ■ Mental Capacity Act and Deprivation of Liberty Safeguards. Training was run over two days and staff were required to attend both sessions. Participation was sought from qualified nursing staff at all levels, clinical support workers, allied health professionals, discharge co-ordinators and ward clerks. An additional short bespoke session was offered and delivered to housekeepers, porters and security staff. The training programme was delivered over a six-month period in six cohorts and trust board level support was gained to enable a number of registered and non-registered staff to attend each cohort. It was delivered by the trust’s dementia project lead, palliative care education co-ordinator, lead nurse for older people and the older people’s mental health liaison team. A total of 44 staff from the two pilot wards completed the training, comprising nurses, therapists, discharge co-ordinators and ward clerks, and representing 74% of the total number of staff. A further ten support staff completed the short bespoke session. All attendees also received The Dementia Guide (Alzheimer’s Society 2013b) and the pocket-sized Dementia Care Survival Guide (Brooker and Lillyman 2013), which they could use as a quick reference. Each attendee was also introduced to the Alzheimer’s Society’s Dementia Friends initiative, which aims to provide an understanding of the disease and the small things that can make a difference to people living in the community. Attendees received a session explaining what the initiative is about and were presented with a Dementia Friends badge on completion of day one.
Feedback Attendees completed a pre- and post-training questionnaire to determine their confidence in aspects of dementia care and whether learning had been successful. Overall, questionnaire responses indicated that attendees’ knowledge, confidence and awareness of all aspects of dementia care had increased as a result of their participation in the training. Feedback was obtained after each day as part of an overall evaluation. It was positive and attendees indicated that they had enjoyed and valued the NURSING OLDER PEOPLE
programme. It enabled peer support and sharing of knowledge between the two wards and in a safe environment. Attendees felt able to express opinions about dementia care in the acute setting. This ability to express opinions enabled them to undertake a form of clinical supervision that was valued and added to the overall satisfaction rate. Ward teams could attend collectively, which allowed them to share their learning and develop their vision together. In addition, attending with another ward team allowed them time to appreciate that improving dementia care was being considered from an organisational perspective and would improve patient care across the organisation. Attendees were asked to indicate which aspects of the course they particularly liked. Responses included: ■ Participation and discussion. ■ Ability to express opinions. ■ Theory behind practice. ■ Knowing the previously unknown. ■ Improved awareness. ■ Speakers’ knowledge. Attendees were also asked to identify three areas where they had improved their knowledge. Responses included: ■ Recognising early dementia. ■ How to manage patients with dementia in their delirium phase. ■ Behaviour that challenges. ■ How to complete the six-item Cognitive Impairment Test (6-CIT) (Brooke and Bullock 1999). ■ Support for carers. ■ Mental Capacity Act and Deprivation of Liberty Safeguards. ■ Triggers that can exacerbate behaviour for a patient with dementia, for example, environment. ■ Problem solving. ■ Use of available resources. Comparison of the pre- and post-training questionnaires and the evaluation forms demonstrated that learning had taken place and that the training had had a positive effect on attendees. The two-hour session provided for support staff aimed to share essential information about dementia awareness and how to communicate with patients with a cognitive impairment. The dementia project lead and the older people’s mental health liaison team delivered this. The feedback requested on the session was more informal than for the two-day programme, via a form asking for comments. Some examples of the comments received were: ■ ‘I feel more in control of caring.’ ■ ‘It made me think about being more patient.’ February 2015 | Volume 27 | Number 1 21
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | acute settings ■ ‘There were some excellent communication tips.’ ■ ‘I thought the session was informative.’ ■ ‘I have a much better understanding of dementia.’ ■ ‘It made me aware that we can all make a difference.’ ■ ‘Every little thing helps and we don’t have to be experts to make a difference.’ The session was so well received that it will continue to be offered to support staff as part of the overall workforce plan.
Evaluation The RCN completed a site visit in September 2013 and the University of Worcester in January 2014. Both site visits involved the teams visiting the wards and speaking to staff. Informal feedback from both visits included praise for the enthusiasm of staff and positive interactions with patients and carers. Staff interviewed gave positive reports about the training programme.
Benefits to the organisation The training programme has led to significantly improved care and management of patients with cognitive impairment or dementia on the two pilot wards. The training has affected the culture on these wards. There have been reports of more positive engagement with patients with dementia, staff satisfaction in the care they deliver and increased morale and team cohesion. Benefits from the patients’ perspective have been difficult to assess. However, the older people’s mental health liaison team has reported receiving more appropriate referrals as clinical staff have a greater understanding of symptoms such as confusion and disorientation. While referrals are still received by this team and by dementia support workers for specialist advice, they are timelier and staff are more likely to have implemented interventions without being prompted to do so. Carer questionnaires have indicated that carers and loved ones think that staff have a greater understanding of dementia and are not just treating patients’ medical or surgical conditions. Staff have become much more aware of the effect of the environment on patients with cognitive impairment and dementia, including signs, colour and noise. As a result of the involvement of the
Porters and security staff are now much more empowered to question staff about whether a patient should be moved 22 February 2015 | Volume 27 | Number 1
interim associate director of facilities in dementia training, all new work schemes at the trust are now reviewed from a dementia-friendly standpoint. In addition, a number of environmental initiatives have been piloted on the two wards. These have included the introduction of orange crockery in response to evidence that patients with dementia are more likely to eat food that is presented in this way, which was learned from the King’s Fund Enhancing the Healing Environment programme. An internal audit identified a subsequent 15% reduction in food waste. As a result, implementation of orange crockery is planned across all wards. The use of aromatherapy to encourage patients to eat their meals and to enjoy a good night’s sleep is also being piloted. Two aromas have been chosen specifically to assess the effect on nutrition and sleep patterns, the outcomes of which have yet to be assessed. Housekeepers are now able to use This is Me (Alzheimer’s Society 2013a) to ensure patients are given their preferred drink at meal and refreshment times. They are asked to consider whether patients require a beaker or whether a mug would be more appropriate. When patients displayed aggressive or challenging behaviour ward staff called security teams. As a result of the training, clinical staff report being much more knowledgeable and confident in managing patients expressing such behaviours on the ward, without the need for external support. An approach to minimise ward moves for patients with dementia has been initiated and if a patient needs to be transferred to another ward, this is done during the day. A formal list of patients recommended for no ward moves is generated in preparation for the weekend, as it was recognised that patients were moved between wards out of hours. The list is sent to all the executive teams and heads of nursing, and a patient on the list can only be moved with the approval of the mental health liaison team or executive director if out of hours. A reduction in ward moves is built into the trust’s key performance indicators, and if a patient on the list is moved staff are advised to complete a clinical incident report. Implementation of the list has reduced patient moves considerably. The list is also given to the security manager so that porters and security staff are aware. Porters and security staff have reported that the programme has integrated them into the clinical team, and they have a greater understanding of dementia and its effect on patients in a hospital environment. They are now much more empowered NURSING OLDER PEOPLE
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
to question staff about whether a patient should be moved. It has been observed that they engage with patients in a much more meaningful way, whereas previously they may have seen their role as just moving a patient from A to B.
Next steps The training programme will continue to run on a regular basis. Staff from two further wards – one elderly care and one general medical ward – underwent training in September 2014, along with new starters from the two pilot wards. The trust dementia steering group is supporting implementation of the training programme across the organisation and offering it as an option among a variety of dementia education opportunities available to meet the needs of the workforce. Staff who have received the training will be encouraged to help improve response rates to the
carer questionnaire so that their feedback can be reflected in the care given to their loved ones.
Conclusion The training programme has met its aim of developing the knowledge and skills of the workforce and supporting them to deliver improved care for patients with cognitive impairment and dementia in the ward environment. Observational tools will be used to show the culture change as the programme is rolled out across the organisation. Given the competing priorities of the organisation, a learning point from the project team is that a six-month gap between cohorts makes it more difficult to maintain momentum; a shorter gap would be better. However, ensuring best practice in the care of adults with dementia and their carers is a priority across the trust and will continue to be so.
Online archive For related information, visit our online archive and search using the keywords
Conflict of interest None declared
References Alzheimer’s Society (2009) Counting the Cost: Caring for People with Dementia on Hospital Wards. Alzheimer’s Society, London. Alzheimer’s Society (2013a) This is Me. Alzheimer’s Society, London. Alzheimer’s Society (2013b) The Dementia Guide — Living Well after Diagnosis. Alzheimer’s Society, London. Brooke P, Bullock R (1999) Validation of a 6 item cognitive impairment test with a view to primary care usage. International Journal of Geriatric Psychiatry. 14, 11, 936-940.
NURSING OLDER PEOPLE
Brooker D, Lillyman S (2013) Dementia Care Survival Guide. Routledge, Abingdon. Brooker D, Milosevic S, Evans S et al (2014) RCN Development Programme: Transforming Dementia Care in Hospitals Evaluation Report. University of Worcester, Worcester. Carers Trust (2013) The Triangle of Care – Carers Included: A Guide to Best Practice For Dementia Care. Carers Trust, London. Department of Health (2009) Living Well With Dementia: A National Dementia Strategy. DH, London.
Department of Health (2010) Quality Outcomes for People with Dementia: Building on the Work of the National Dementia Strategy. DH, London.
Royal College of Nursing (2011) Commitment to the Care of People with Dementia in Hospital Settings (SPACE Principles). RCN, London.
National Institute for Health and Care Excellence (2010) Dementia Quality Standard. NICE, London.
Royal College of Psychiatrists (2014) National Audit of Dementia. tinyurl.com/kjt5roa (Last accessed: December 3 2014.)
Royal College of Nursing (2010) Principles of Nursing Practice: Principles and Measures Consultation. RCN, London.
Walsall Healthcare NHS Trust (2013) Provider Dementia Care Strategy. tinyurl.com/p6gvjhk (Last accessed: December 3 2014.)
February 2015 | Volume 27 | Number 1 23
Downloaded from RCNi.com by ${individualUser.displayName} on Nov 16, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
