On Poplar, ‘mealtime as a social event’ had by the conclusion of the study not only been extended to all bays but was incorporated as part of ward routine. There were aspects of the initiative that required ongoing work based on experience: men appeared more reluctant to engage than women; and staff needed to consider which patients would get on with each other.
PIE observations continued periodically throughout the research. New issues identified and which resulted in immediate action plans to pursue included: ensuring that patients did not feel isolated, ignored or disconnected (e.g. leaving curtains closed around patients post-care delivery, being mindful not to exclude patients from discussions when within earshot, and regular checking that the clocks in the bays were accurate to time and date).
A persistent focus of action planning was provision of stimulating activities for patients who were well enough to take part but insufficiently recovered to be discharged, including puzzles,
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newspapers, games and reminiscence resources (REM Pods). Plans required identifying staff time and sources of funding to purchase materials. By the end of the third improvement cycle, reviews indicated some positive change: staff sitting with, and encouraging patients to read and using pictures as prompts for conversation. Overall, these action plans were evaluated as ‘partially met’. Engagement was constrained by staff availability which waxed and waned depending on demand, patient flow and level of patient acuity, which was unpredictable.
Over time, the composition of the PIE team changed as some members moved on and were replaced by new staff. Although never a formal member of the team, the ward manager continued to play a crucial enabling role; in supporting and encouraging staff to get involved in PIE and in facilitating communication of action plans to the wider staff group. Her commitment to PIE, the authority and legitimacy this gave to implementation work and the support provided to enable staff to take time out to do observations, were critical to the process. Her inclusive management style was a factor in involving HCAs directly in the PIE team. One HCA, when asked by the researcher why she felt able to take the initiative with PIE, commented: “the ward manager treats all her staff as equals” and
“there is no hierarchy here.” Another HCA, who took special interest in nutrition (which dovetailed
with PIE action plans) also reported that her enthusiasm was due to the ward manager’s encouragement. Apart from a period of absence (as a result of injury), she was present throughout the research but retired just as it came to a close.
On Crane, alongside ‘music as stimulating activity’ which expanded in form and content over time, new action plans identified and pursued included: encouraging patients who were well enough and near to discharge to dress in their own clothes during the day, not usual on this ward. This was viewed as supporting normalisation of the transition from hospital to home and encouraging independence. It was also aimed at nursing, care and therapy staff to increase person-focused interaction while they helped the person choose their clothes and assisting them to get dressed. Making this happen involved negotiating with relatives to bring in clothing and ensuring staff went about the work with individual patients.
Four PIE cycles were completed on Crane by the end of the study. Subsequent observations were shorter – around 30 minutes duration – to make the process manageable given the demands on staff time. Ward staff, not part of the PIE team, conducted some observations, extending its reach. An explicit objective of the manager, integrated into action plans, was to engage the wider staff team in discussion about change and provide opportunities for them to put forward ideas through team meetings and handovers. Inclusivity was valued as a principle of team working and a strategy to ensure staff ‘buy-in’ to change. For example, use of food charts was systematised through flagging up on handover sheets which patients needed them.
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Trying out different ideas around activities to increase stimulation for patients was an ongoing topic of action plans, including encouraging use of reminiscence materials secured for the ward via the dementia team and creating themed ‘memory boxes’ to add to them. This work tended to proceed in fits and starts. Initially, it was very successful with support of the dementia visitor, a volunteer who came to the ward once weekly, and two nurses who were keen to take part. As on Poplar, success depended on demands, investment of time and staff was an ongoing issue particularly during winter pressures when the team helped to cover an additional six beds. The cramped nature of the environment and lack of separate space for patients outside of the bays, was an additional constraint. On this ward also, engagement in activities was assessed as being ‘partially’ implemented. The long term plan, advocated by the specialist dementia team, through the Dementia Strategy, was recruitment of an activities organiser to work with a number of wards, including Crane, to enhance activities for patients.
The composition of the PIE team for a long time did not extend beyond senior nurses, occupational therapists and therapy assistant. As therapists rotated between wards, this meant that individuals changed, although ongoing therapy involvement was maintained. More than 12 months into implementation, a staff nurse was ‘recruited’ to the PIE team. Even so, success in accomplishing specific action plans required active engagement of frontline staff, including nurses and HCAs (for example, music at lunchtimes, observational monitoring of nutrition intake and encouraging patients to dress in their own clothes). Strategies to enable ‘buy-in’ of the changes were both essential and contributed to translating plans into action on the ward.
Joint action between PIE teams
A cross site workshop and a significant event for members of both PIE teams, was held in spring 2015, just under a year following PIE introduction. This was instigated by the Poplar team. Ten staff from both wards took part, including the dementia specialist nurse from a third Trust hospital; the researcher was also invited. Networking between wards initiated through the meeting was important in facilitating a shift from PIE adoption to programme innovation.
The meeting provided opportunity for reflection on what needed to be done, using the claims, concerns and issues framework. There was considerable enthusiasm about being part of a process that actively involved staff on the front line in collaborative action to effect change, which in turn encouraged them to use their initiative to try out new ideas. They perceived a change in practice: increased use of the patient biographical tool, ‘This is me’ booklet; greater involvement with patients’ families; and heightened awareness of patient experience as being at the centre of what they did. Concerns centred on time constraints; how to sustain PIE after the research ended; and
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how to embed changes in routine practice. Ideas on joint action to pursue included: incorporating information on PIE into a general induction pack for staff; and involving all new staff in undertaking a short PIE observation with a link PIE team member.
Throughout the day, there were explicit linkages made between the PIE objective of enhancing person centred care and the Trust’s Shared Purpose Framework; the criticality of the role played by the Dementia specialist team in championing PIE, which was also perceived as a vehicle through which aspects of the dementia strategy could be pursued. Both were viewed as operating in synergy one with the other.