On both Poplar and Crane wards, where full PIE adoption occurred, there were discernible changes to ward practice, directly attributable to the intervention. The experience of doing observation reinforced its value as a means to‘see’action and interaction in a different way:
It’s allowed us to step back and look at what we’re doing.‘Cause when we’re right in the middle of it it’s all quite difficult, seeing what’s going on and what you should be doing.
Staff nurse, Poplar Ward
Senior staff also saw new ways of‘seeing’, as indicated in the discussion with the dementia specialist team: Dementia nurse:And it’s the good stuff that you don’t pick up unless you’re doing the observations and you realise–because you don’t have the time to see it.
Lead dementia nurse:Because you’re in the middle of it.
Dementia nurse:And you do see much more when you just step back and watch.
Dementia specialist nurses, PIE meeting December 2015
The observations heightened staff’s perceptions of what it was like to be a patient:‘I didn’t realise the levels of noise and stuff around patients . . . or what an effect that has . . .’. At the heart of work initiated through PIE was an increasing awareness that patient experience should be at the centre of how staff worked. It reinforced the necessity for additional work by staff to facilitate a‘connection’with the person so as to pursue the work of‘recovery’. Creating opportunities for communication between staff and patients in a
‘normal’setting contributed to the collection of meaningful knowledge about the person. For example, on Poplar the practice of patients sitting around tables for lunch was a significant change resulting from PIE action plans. Observation and staff reports indicated that the broader objectives of the activity–to improve nutrition and to enhance social interaction and communication–were achieved. Staff reported that patients had better appetites and were socialising with others at the table, as well as benefiting from being mobilised more often by way of walking to the table. Social interchange in an informal environment enabled staff to discover new things about the person and pick up more information about individuals’dietary likes and dislikes. On Crane, similarly, the focus on nutrition led to regular‘lunch-club-style’events in the middle of bays, against the odds, given the restricted space. This resulted in improved communication between staff and patients; and more interaction between patients, albeit their exchanges were often largely
incomprehensible to outsiders. Events such as the dementia cafés, held off-ward, provided opportunities for patients who were well enough to socialise in a convivial environment. Although not initiated through PIE, the provision of support to attend was integrated into PIE action plans.
The PIE process, observation and space to reflect collectively on practice, along with the observable changes that were set in train, gave staff confidence that they could make a difference, including those who were not directly involved in PIE teams.
I think it’s just made us more aware of what we can achieve . . . as the word has spread, there’s been more of an understanding.
HCA, follow-up, Poplar Ward
On both wards, staff felt able to challenge aspects of established practice, including those that involved other services, for example negotiating with external caterers to serve smaller portions and a wider selection of finger-food to support the nutritional intake of frail patients.
These practice changes represented steps forward, contributing to an enhanced patient experience. They had a positive impact on ward care culture in myriad ways even if not fully transformative of the care culture. Respectful, warm, task-focused communication practices still dominated in routine staff–patient encounters, particularly during busy periods, although staff’s responsiveness to patients’emotional needs during tasks was also observed:
HCA returns to patient in bed 1 and pulls the curtains round.‘Can you wash your face?’she asks. Then‘you’re a bit down in the dumps today, Ron. What are you thinking about?’He says his wife. The HCA provides reassurance, reminds him his wife phoned yesterday and said she is coming in today . . . that she wanted a rest yesterday so couldn’t come. She asks the patient to stand up as she
continues to help him wash. She encourages him to walk a few steps– ‘it will do you good’.
Field note, Crane Ward, interim, February 2015
Staff perceptions of Person, Interactions and Environment
Interviews with staff at the conclusion of the study showed that PIE had harnessed enthusiasm and
engendered confidence, collaboration, a sense of empowerment and agency, including among unqualified staff, in trying out new ways of working. They also talked about the time pressures on them from increased throughput and higher patient dependency, both of which affected the time that they were able to spend with individual patients, thereby reinforcing the criticality of staff outside the ward in driving change. Given the timing (winter 2015), this probably reflected seasonal variation in demand, although the lengthening period during which‘winter pressures’beds remained open on most sites suggested ongoing high demand:
Because we’ve been really busy, we’ve had a lot more patients with higher needs and I think we’ve struggled . . . to achieve what we had been achieving . . . We come up with the ideas, but it needs someone [to say]‘yes that’s OK let’s do that’. . . Whereas if you’ve not got that support I think some of it might flounder.
HCA, Poplar Ward
Some staff were impatient at what they regarded as the slow speed of change. The lack of involvement of front-line staff in the Crane PIE team was a disappointment to some senior staff. Yet without the engagement of nurses and HCAs in pursuing action plans, PIE adoption would not have occurred and nor would its reach have gone beyond the PIE team. The Crane manager considered that PIE had stimulated reflection and action across the team as a whole, but that sustaining the process would necessitate renewal through the involvement of new staff in PIE. One proposal being considered at the conclusion of the study was to initiate new staff through the use of the observation tool alongside an experienced‘observer’. On both wards, plans were in train to continue PIE beyond the study conclusion. A further year on, PIE had been sustained in Crane, with the increased participation of front-line staff. The merger of Poplar with another ward encompassed plans to extend PIE to the joint ward.
OUTCOMES OF PERSON, INTERACTIONS AND ENVIRONMENT
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