Two Ironbridge wards initially expressed interest in participating in PIE: a trauma orthopaedic ward and an acute dementia ward. Both met our‘readiness’criteria. Before fieldwork commenced in January 2014, the trauma ward withdrew, citing staffing difficulties. Efforts to engage another ward were unsuccessful.
Netherton: structure and organisation of care delivery
Netherton was an acute medical ward for those aged≥70 years with comorbid dementia or delirium/acute confusion. It was not a specialist dementia ward:59it did not employ specialist mental health staff, therapy
input was similar to that in other care of older people wards, and it had no additional staff providing activities. During baseline, Netherton comprised 28 beds (including one bed for‘winter pressures’, which was consistently in use during fieldwork).
Physical environment
Netherton was organised in four six-bedded bays and four single rooms: one male and three female bays. The bays were colour-coded (purple, yellow, blue or green). Each had a small table near a window at which staff sometimes sat to write. The single rooms were relatively spacious and pleasant with natural daylight.
The ward presented as a bright, airy, clean and open environment. Each bay was separated by a low divider (work surface, no doors), opening on to a wide corridor with a large skylight, exuding a sense of spaciousness and allowing ample daylight. There was a very small workstation down the entrance corridor with space for a single computer. There was a table in the corridor around which there was space for 4–6 people to sit (which patients and staff did, interchangeably).
Off the bays (opposite the work station) was a large L-shaped day room with a separate door and half-height windows overlooking the hospital grounds. Painted in neutral colours, it had three tables with ample seating for dining and socialising. At the far end was a lounge space with chairs and a television (there were no televisions in the bays). Various reminiscence/household objects were laid on side tables (an old-style radio, an alarm clock and games); on the walls were old brand adverts and pictures of the locality. A small, enclosed room off this served as a private space, and had a settee, chair, lamp and bookshelf. It was slightly shabby, but homely, in appearance.
Off the corridors to the left and right of the central ward space, and opposite the bays, were the patient toilets, shower room and single rooms. The toilets had visible signage, and toilet seats and rails that were dark blue, contrasting with the otherwise white suites. The location of the toilets allowed patients who
were mobile the opportunity to walk between their bed in the bay and the toilet. Further along from these rooms was a designated staff space (a toilet with key access and a small room). There was an atmosphere of calmness and quiet efficiency, with staff and patients sharing communal spaces.
Patient profile
There were 75 people admitted during baseline (an average of eight per week), and no readmissions. Most patients came directly from A&E or the assessment unit (70%; 52/75); just under one-third had been admitted from other hospital wards. The median length of stay was 41 days (range 1–126 days); extended lengths of stay were attributed to changes in the system for financially assessing patients, resulting in delays to some patients being discharged.Table 5summarises the patients’sociodemographic profile. Just under two-thirds of patients were in advanced older age, a slightly older profile than in other participating wards, and women dominated. Most had been admitted from their own home.
Most patients (n=70, 93%) had dementia (the remaining patients had delirium but not dementia). Nearly two-thirds (60%; 31/52) of new acute admissions had delirium. Overall, 70% (54/75) had delirium during their stay, of whom nine (13%) were in delirium for≥30 days. The median number of days in delirium was 16 (range 1–57 days). The reasons for admission are shown inFigure 10.
Discharge destination data were available for 44 patients (the remaining 25 still being in the ward at the end of data collection). These are presented inFigure 11.
Of those for whom information was available, 25 (57%) were discharged to their own home; one-fifth involved new admissions to long-term, mainly nursing home, care.
TABLE 5 Netherton patient profile: sociodemographic characteristics
Characteristic n(%)
Age range (years)
60–64 1 (1) 65–69 0 (0) 70–74 3 (4) 75–79 9 (12) 80–84 14 (19) 85–89 30 (40) 90–94 16 (21) ≥95 2 (2) Gender Men 18 (23) Women 57 (76)
Residence prior to acute admission
Own home (including sheltered housing) 66 (88) Residential care home 3 (4)
Nursing home 5 (6)
Assisted living 1 (1)
CASE STUDY PROFILES
NIHR Journals Library www.journalslibrary.nihr.ac.uk 36
Staff profile
The ward team comprised 35 staff. The typical staffing complement was five nurses and three HCAs (early shift); four nurses and three HCAs (late shift); and two nurses and two HCAs (night shift). The ratio of registered nurses to patients on the day shift was 1 : 5.6. The staffing complement was generally maintained during baseline, although, as elsewhere, staff shortages on a shift involved the substitution of a HCA for a nurse.
Netherton: care culture
An established, stable team, half of them had worked together for at least the 8 years in which the current ward model had operated (acute, dementia care). This included senior staff (ward manager, senior sister and charge nurse) who had a wealth of knowledge and skill in caring for people with dementia, acquired through formal self-directed learning, personal and professional experience. They conveyed, through formal and informal mechanisms, a consistent and coherent team ethos and a commitment to the ongoing appraisal of work practices. Twice-yearly away days were held for staff to examine practice and identify problem areas to work on. Everyone was expected to attend (the away days were organised as two separate
Reduced mobility (8%) Fall/fracture (24%) Other (13%) General decline/unwell (3%) UTI, urinary retention (3%) Confusion (38%) Failed discharge (4%) Behaviour (4%) Chest pain (3%)
FIGURE 10 Netherton: reasons for admission. UTI, urinary tract infection.
Died (8%) Returned to own home (34%) Own home to residential care (5%) Own home to nursing home (15%) Own home to psychiatric unit (1%) No information on discharge (discharged post fieldwork) (37%)
days to facilitate participation). Through these various mechanisms, new staff were enculturated into a style of team working that emphasised continuous improvement as‘how we do things on this ward’. The ethos of person-focused care was reflected in the responses to the Culture of Care questionnaire, completed by just over half of the team (n=18).
Consensus existed among respondents that the team shared an explicit philosophy of care; the psychological needs of patients were considered; involving patients and their carers was an important part of the work; and these values and expectations were communicated to new staff. There was agreement that patients were treated with dignity and respect; they experienced individualised care, and patients’and families’care needs were met (reflected in research observations).
Most respondents agreed that there were sufficient ward resources to deliver good care, including staff with the requisite knowledge and skills to provide it. Just under half regarded staffing levels as insufficient to allow them to spend enough time with patients.
They felt supported as a team, could rely on each other, were relatively comfortable about bringing up problems with colleagues and felt that they could influence ward decision-making. In agreement with staff on other study wards, there was too much work to do in too little time, but they particularly valued the learning and development opportunities available.
Strong, positive feedback was received about the ward’s leadership and management style, especially the support provided and clarity of expectations around achieving care excellence. Perceptions of the wider hospital were mixed, although views were more neutral to positive about the availability of training opportunities and access to resources.