Within Witham Court, an acute mental health hospital for older adults, Langworth Ward is an assessment unit for people with a diagnosis of dementia. Early last year we embarked on an Innovation Project. The aim of our Innovation Project was to engage people with severe dementia in personalised, sensory interventions to assist in managing the behavioural and psychological symptoms of dementia (BPSD). It was envisaged that this would reduce the levels of pharmacological and restrictive interventions (RI), improve care and quality of life; what we have actually achieved is a change in culture on our Ward. Although we already utilised person centred care approaches such as Life Story work, it was evident that some of our patients displaying severe symptoms of BPSD were not able to communicate their identity or preferences to us and therefore were not benefiting from this type of intervention.
Co-Production
From start: No
During process: Yes
In evaluation: No
Evaluation
Peer: Yes
Academic: No
PP Collaborative: Yes
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Jacqueline Tyson - OT Technical instructor, Lincolnshire Partnership NHS Foundation Trust
Within Witham Court, an acute mental health hospital for older adults, Langworth Ward is an assessment unit for people with a diagnosis of dementia. Early last year we embarked on an Innovation Project. The aim of our Innovation Project was to engage people with severe dementia in personalised, sensory interventions to assist in managing the behavioural and psychological symptoms of dementia (BPSD). It was envisaged that this would reduce the levels of pharmacological and restrictive interventions (RI), improve care and quality of life; what we have actually achieved is a change in culture on our Ward. Although we already utilised person centred care approaches such as Life Story work, it was evident that some of our patients displaying severe symptoms of BPSD were not able to communicate their identity or preferences to us and therefore were not benefiting from this type of intervention.
Incrementally we introduced a varied ‘trial and error’ range of sensory activities. We created themed rummage boxes, introduced animal therapy including Ben and Gerry, our therapy rabbits and Flora, the PAT dog. We facilitated a range of themed events such as a 1940’s Tea Dance, street parties, gardening activities, pamper sessions and Going Places – a virtual trip to a different location each week that included food, music and dress. From our observations and feedback from such activities, we have been able to ascertain what each patient connected with and develop their own sensory toolkit. As an example: when Graham was admitted he was presenting as extremely agitated, constantly exit seeking; he would approach other patients, picking up their belongings and invading their personal space. This would lead to confrontation and a volatile Ward. He became a high falls risk as he lacked sleep and would attempt to rearrange furniture. Graham routinely entered a spiral of escalating distress and hostility that resulted in use of medication and RI. Staff became increasingly stressed by the end of their shift in their attempts to maintain safety and general wellbeing on the Ward and were frustrated in their efforts to help Graham as he could not explain why he was so agitated and had no family to provide background information. Through trial and error with various activities, we established that Graham was more relaxed when he was ‘working’. With some detective work and by entering his world, we were able to understand his intrinsic values and beliefs. We created a personalised, sensory toolkit for staff to utilise; for Graham, this meant providing the tools of his trade: a butcher’s apron, an order form and fake meat products that he could deliver each day. Staff found that Graham was easily diverted, he was content and fulfilled, in his mind going to work each day and consequently the whole atmosphere was calmer and safer for all patients and staff. His daily record illustrated that this approach reduced the need for medication and RI. This was a ‘light bulb’ moment for many staff.
Before the project, we were reactionary; when a patient became verbally or physically hostile, was exit seeking etc. it was then that the intervention started and due to the dementia, our knowledge of how to support the person was limited. We might use existing de-escalation techniques but ultimately most situations resulted in moving the person away from communal areas, medication and restraint. Now, we anticipate. We learn how our patients may react to different stimuli, what situations may cause them distress so can avoid or intervene early. When a situation does arise, our staff have a toolkit of sensory interventions that they can use to de-escalate before it reaches boiling point. We are proactive, creating an environment that meets the needs of the person and communicating with our patients in a way that is meaningful to them. Communication has been the key, underpinning all that we do. Finding ways to talk with someone who has lost the ability to convey what they are feeling requires using all the senses, everything at your disposal.
The changes have had a huge impact on staff. It can be stressful, emotionally and physical draining working on a dementia Ward but our staff will tell you they also have fun! Many of the ideas we have implemented are transferable for staff to use, such as the benefits of a pamper session, taking time to smell the flowers or feel the sunshine. Staff now have shared experiences with patients, positive connections, not just doing tasks. They have learnt from our patients what a sensory world we live in. Importantly they stop and ask “Why? Why is this person behaving in this way?” Despite the environment being limited by its nature as an acute Ward, we have made some dramatic changes, most recently a 1950’s Ladies Lounge and Gentleman’s Snug. There have been some unexpected, positive outcomes such as discovering some of our gentlemen wishing to actively participate in decorating and now have a designated ‘working wall’ so they can have a go!
Wider Support
Throughout the project we have been keen to learn and share new ways of working. We have formed new partnerships with Linkage, a charity who usually working in learning disabilities, piloting their new Sensory Bus which led us to re-develop an area to include sensory equipment such as lighting effects. We have been working with Green Synergy, a dementia friendly gardening charity, who facilitated activities on the Ward and provided training for staff. Green Synergy have also drawn up plans to re-design our courtyard area to incorporate sensory ideas following feedback sessions with patients, carers and staff. We are working with Playlist For Life, a charity who focus on harnessing musical memories and commissioned a training session with them for inpatient and community staff.
Co-Production
From the outset, we endeavored to canvas opinion from all stakeholders to encapsulate their opinions, reactions, needs and wishes. For example, we brought in wallpaper and paint samples for staff and patients to choose from, held garden activities to stimulate discussion about plant choices. We have routinely encouraged staff to give feedback at meetings and adhoc opportunities to write ‘feedback bubbles’. We have included community staff and volunteers in training opportunities and sought feedback from community staff where Ward- based interventions have been tried by them with their client group. Although the project team have initiated, by encouraging staff to bring their own ideas has enabled them to take ownership of the project and this has helped build their confidence in adopting the approach and embed the changes into everyday working practices. We actively encourage carers/relatives to attend group events, provide life history, items for memory boxes and support them to use the sensory toolkit during visits – the rabbits are particularly popular!
Looking Back/Challenges Overcome
We quickly realised that one of the main barriers was staff engagement – morale was low and staff were task orientated, focusing on nursing tasks and regarding ‘activities’ as the domain of Occupational Therapy and Activity Co-ordinators. They did not always appreciate the long term connection between the impact of therapeutic interventions and context of environment on BPSD. To combat this, we have led by example, demonstrating the approach and its benefits. There is an ongoing process of engagement with staff, valuing their opinion, facilitating fun events they can join in with, access to training, recognition of their input and visibly acting on their feedback. Consequently staff have adopted the project, spontaneously initiating activities and confidently suggesting new ideas, giving feedback without prompting. This has also been improved cohesiveness of the team and breakdown of hierarchical barriers and prejudice. Lack of time has been the biggest barrier as success has led to more opportunities and invites from across the county; there are not enough hours in the day!
We have also been a victim of our success in that many relatives are often reluctant to seek alternative placements when their loved one is ready for discharge; we are often told ” I wish he/she could stay here”. This is why we are expanding the project to work alongside care homes and outside agencies that that our ethos can be continued outside the Ward environment.
Sustainability
The project has resulted in a change in culture on the Ward with techniques fully embedded in working practices and within our care pathways. The project no longer relies on the project team as all staff are using the toolkit on a daily basis, new staff simply follow suit. Numerous students from various disciplines spend time on our Ward and we have lectured at Lincoln University to nursing students as we recognise they are our future professionals and hope they will continue to develop our ethos. We are developing links with local care homes and have facilitated some group activities such as sing-alongs to demonstrate how our approach can be transferred to their setting. We also support patients through the transition from hospital to care home or home, educating carers how to use the techniques. We are currently exploring research opportunities with our research team and Lincoln University as we have found a gap in research covering this area.
Evaluation (Peer or Academic)
We have been gathering statistical data to evidence the impact of our project on the patient experience, especially patient safety. To date, the project has shown a huge reduction in the use of RI comparing Datix Risk Incident Reporting from Jan 2016 – Jan 2017; this showed Langworth Ward’s use of RI was 57% lower than its comparable sister Ward (without the project). We have also recorded a 20% reduction in falls. We are hoping to conduct a research project in this area and are continuing to collect statistical data and intend to complete a full service review.
Outcomes
1) Reduction in the use of RI 2) Reduction of falls 3) Shortlisted for HSJ National Patient Safety Award, attending award ceremony in July 4) Acknowledgement from Management Team of achievements resulting in further support to extend project to sister Ward. 5) Increasing staff engagement and positive feedback 6) Positive engagement with carers and reduction in complaints. 7) Positive feedback and interest from community staff, care homes and outside agencies
Sharing
Our ideas are transferable to other settings and we have also gained new ideas when visiting other locations. We are supporting our Community teams to transfer working practices to their client group and have liaised with adult and children’s services to explore how aspects of the project can be adapted to suit their client groups. We have been asked to support our sister Ward in Grantham to implement the project, spending time with staff to demonstrate our approaches. Our reputation is growing countywide and we have been invited to present our project at a wide range of events such as ENRICH (Enabling Research in Care Homes) at Nursing conferences, student workshops, Cognitive Stimulation Therapy groups, Recovery College Courses and Alzheimer Dementia Cafes. The request list is growing! Throughout the project we have generated interest within the local community; we have recruited an army of volunteers and local businesses who support the project by providing various resources and have also visited the Ward to engage with patients such as for Knit and Natter groups. We are now supporting a campaign to make North Hykeham, where we are based, a dementia friendly town as part of the Dementia Action Alliance. We have generated interest in the local press and this supports an underlying aim at the heart of everything we do which is to raise awareness about dementia.
Is there any other information you would like to add?
It has been a joy to watch the staff team embrace this project and go that extra mile for their patients; whether it’s dressing up, helping to paint walls. coming in on days off to support us, we have numerous photographs to illustrate the fun we have had during this project that we would be happy to share. This project continues to evolve and we are excited to see where this journey takes us. It has shown us that with the right approach, someone experiencing the symptoms of dementia can continue to enjoy their life.
Nothing I can write sums up our achievement better than this quote from a relative; “You have given us our dad back, we have even heard him laugh again“.
