Dr Sophie Edwards is a consultant geriatrician, older persons’ advocate, and dementia trainer.
Dr Sophie Edwards is a consultant geriatrician, older persons’ advocate, and dementia trainer with a passion for instilling the values of high quality, person centred care for all @docofagesSophie. Here she describes some of the challenges she faces embedding quality improvement in an organisation.
I work on an acute geriatric ward in a busy district general hospital, where we serve a diverse ethnic and socioeconomic area – we have one of the busiest accident and emergency departments in London. Recruitment and retention of staff is difficult; morale is low, and fatigue is high. I’m not dismissing our service but I am keen to be honest and realistic about the challenges we face.
I’m sure many of you will recognise this picture. So, how on earth do we maintain a safe, high quality service when we are effectively working with one hand behind our backs?
I reflected on what I would expect from a high quality service as a client or customer. Competency in knowledge and skills is taken as a given. So what makes the difference between timely, correct treatment and high quality, memorable treatment?
Much of my workload includes caring for people with dementia or delirium. A person with dementia or delirium needs focused and flexible care. They need to know what is happening and when. They need to be reassured that their needs are being met. They need the involvement of their family and carers and they need staff to know who they were and who is important to them now.
Much of this can be achieved through good communication. It’s more than introducing ourselves properly, although this is absolutely vital; it’s about standing back and listening. It’s about watching the subtleties in body language and facial expression. It’s about picking up the little clues from the midsts of a patient’s delirious mutterings (many of my patients provide some superb insights while in the throws of their delirium). Ultimately, it’s about really knowing what makes each patient tick.
I would suggest that high quality care needs connectivity. It needs staff to be connected to each other and with the reasons that they went into health care in the first place. It needs staff to be connecting with patients and not shying away from the emotional investment that caring for people needs. It also needs staff to have the opportunity and space to reflect when things are overwhelming.
I wanted staff to really know the person behind the patient, so we introduced “Ten important things you need to know about me” based on “The important things you need to know about me” from The Alzheimer’s Society. It was originally for use with people with dementia so that staff would know what to say or do when someone was distressed or agitated. I think everyone should be able to tell us their story, who they need when things are tough, and what their likes and dislikes are. I’m keen that we use it for all inpatients if they wish.
Embedding this initiative has not been easy. I’ve personally filled up trays of it around the hospital, but it is yet to be part of our standard care. If it really works once and provides a key piece of information that calms a patient, or provides an insight that allows staff and patient to connect in a way they hadn’t done before, then the benefits will be seen and staff will want to use it again.
No one intervention will work in isolation, and the importance of supporting our staff to care cannot be underestimated. A chance meeting with a sports masseur led me to applying to our local training board for some funding to train some staff in hand massage. The trainers provide a course which includes massage techniques but also teaching around dignity and person-centred care. It gives staff a bit of much needed breathing space away from the ward that isn’t just mandatory training or e-learning.
Back on the wards, it allows them to sit down and spend time connecting with the people they wash, dress, and provide medication to. In the rush of the hospital that talking time is lost. This was about connecting staff back to their role as a carer and a provider of comfort. We use if for people with dementia, for end of life care, overwrought carers, and anyone who might be in need of the contact.
Again, encouraging staff to keep using these skills has been hard. Time is scarce, and it needs good support from the development nurses to ensure that the skills are used regularly.
It is frustrating that many of these small, quality interventions often save time in the long run. Calmer, informed patients can translate to less behavioural problems reducing the need for one to one nursing, less incidents, and less complaints. Staff that are motivated, connected, and supported are more likely to care about the quality of care they provide.
The prospect of trying to change or improve can feel overwhelming and daunting, but I’m a great believer that sometimes small, simple ideas can have a local impact that can ripple through an organisation and before long can establish a culture of improving and quality improvement. We may only be at the starting blocks of this journey on our ward, but at least we are out of the changing rooms!