DIGNITY IN HOSPITALS Win Tadd National Network for Older People’s Advocacy in Wales 20 March 2013, Maesmawr Hall Hotel, Caersws, Nr Newtown.

DIGNITY IN HOSPITALS

Win Tadd

National Network for Older People’s Advocacy in Wales 20 March 2013, Maesmawr Hall Hotel, Caersws, Nr Newtown

Campaigns, investigations and reports on the care of older people

1962 An Investigation of Geriatric Nursing Problems in Hospital Norton et al.

1967 Sans Everything: A case to answer Barbara Robb

1997  ‘Dignity on the ward’. Observer newspaper campaign

1998  Not Because They Are Old. Health Advisory Service inquiry report

1999  ‘Dignity on the wards’. Help the Aged report and campaign

2001 Caring for Older People: a nursing priority. Standing Nursing and Midwifery Advisory Committee report

2001 National Service Framework for Older People. Department of Health

2006  ‘Hungry to be heard’. Age Concern campaign

2006 A New Ambition for Old Age: Next steps in implementing the NSF for older people. Department of Health

2006 ‘Dignity in care’ campaign. Department of Health

2006 Dignity in Practice. SCIE guide 2

2006 ‘Behind closed doors’. British Geriatrics Society campaign

Campaigns, investigations and reports on the care of older people

2006 Commission For Social Care Inspection. (2006) Handled with care?: managing medication for residents of care homes and children's homes: a follow up study. London: Commission for Social Care Inspection.

2006 Commission For Social Care Inspection (2006) Highlight of the day?: improving meals for older people in care homes. London: Commission for Social Care Inspection.

2007  The Challenge of Dignity in Care - Upholding the rights of the individual. Help the Aged report

2007 Caring for Dignity. A national report on dignity in care of older people while in hospital, Healthcare Commission

2007 Joint Committee on Human Rights, (JCHR), (2007). The Human Rights of Older People in Healthcare, Eighteenth Report of Session 2006-07. HL Paper 156-I HC 378-1. London: The Stationery Office.

2007  Investigation into outbreaks of Clostridium difficile at Maidstone and Tunbridge Wells NHS Trust. Healthcare Commission

Campaigns, investigations and reports on the care of older people

2007 Commission For Social Care Inspection (2007) Rights, risks and restraints: an exploration into the use of restraint in the care of older people. London: Commission for Social Care Inspection.

2008 Commission For Social Care Inspection. (2008) See me, not just the dementia: understanding people's experiences of living in a care home. London: Commission for Social Care Inspection.

2008  Spotlight on Complaints. Healthcare Commission report

2008  ‘Defending dignity: at the heart of everything we do’. RCN campaign

2009  Guidance for the Care of Older People. Nursing & Midwifery Council report

2009 Patients not Numbers, People not Statistics. Patients Association report

2009  Counting the Cost: Caring for people with dementia on hospital wards. Alzheimer’s Society report

2010  Listen to Patients, Speak up for Change. Patients Association report

Campaigns, investigations and reports on the care of older people

2010 ‘Still hungry to be heard’ campaign. Age UK

2010 An Age Old Problem: A review of the care received by elderly patients undergoing surgery. National Confidential Patient Enquiry into Outcome and Death report

2010 National Audit of Dementia. Royal College of Psychiatrists

2010  Independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 - March 2009. Chaired by Sir Robert Francis (ongoing new Public Inquiry)

2010 Acute Awareness: improving hospital care for people with dementia. NHS Confederation

2011 Dignified Care? Care of older people in acute hospitals in Wales. Older People’s Commissioner Wales

2011 We have been listening, have you been learning? The Patients Association, and associated CARE Campaign (with Nursing Standard) November 2011

Campaigns, investigations and reports on the care of older people

2011  Care and compassion? Report of the Health Service Ombudsman on ten investigations into NHS care of older people

2011 Dignity and nutrition for older people. Series of reports from CQC

2011 Living Well at Home Inquiry. All Party Parliamentary Group on Housing and Care for Older People. Chaired by Lord Best

2011 Report of the National Audit of Dementia Care in General Hospitals 2011. Royal College of Psychiatrists

2011  Close to home: An inquiry into older people and human rights in home care. Equality and Human Rights Commission

2011 Which (2011) Care home investigation. London: Which Magazine

2011 Quest for Quality British Geriatrics Society Joint Working Party Inquiry into the Quality of Healthcare Support for Older People in Care Homes:A Call for Leadership, Partnership and Quality Improvement

Campaigns, investigations and reports on the care of older people

2011  Close to home: An inquiry into older people and human rights in home care. Equality and Human Rights Commission

2012 Northern Ireland Human Rights Commission (2012) In Defence of Dignity: The Human Rights of Older People in Nursing Homes Belfat: NIHRC.

2012  Commission on Dignity in Care (2012) Delivering Dignity: securing dignity in care for older people in hospitals and care homes. A report for consultation. (Age UK, NHS Confederation and Local Government Group)

2012 Care Quality Commission (2012) Health care in care homes: A special review of the provision of health care to those in care homes London: CQC

(2013) Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Robert Francis QC

The study report: http:/www.netscc.ac.uk/hsdr/projdetails.php?ref=08-1819-218May 2008 – June 2011Ethnography of 4 Acute NHS Trusts.176 in-depth interviews: older people; relatives; front line staff & senior Trust managers.617 hours non-participant observation in 4 wards in each Trust.http://www.cardiff.ac.uk/socsi/dignity/index.html © W Tadd 2012

Dignity in Practice: Policy & practice themes

‘Whose interests matter?’ Tensions between priorities of Trusts, staff and patients

‘Right place, wrong patient’ Refers to the unanimous view expressed by staff at all levels in the Trusts we visited, that the acute ward is not the ‘right place’ for older people

‘Seeing the person’ Meeting the needs of older people as people as well as patients

‘Influences on dignified care’ A wide range of barriers to, and facilitators of dignified care

© W Tadd 2012

Dignity in Practice

Failure to act on the fact that In-patients are very likely to be oldUp to 70% bed days in acute hospitals are occupied by older people

Many are likely to have mental health problems

Up to 40% of older people in acute hospital will have some form of dementia confusion, delirium or depression. Most in-patients are likely to have more than one

chronic condition complicating their acute illness Has resulted in

Variability in acute service provision - often not fit for purpose

Inadequate physical environments Deficiencies in the knowledge and experience of ward staff© W Tadd 2012

Whose interests matter?

What matters is what is measured. The problem of risk and unintended

consequences. Working the system and unintended

consequences. Bed occupancy rates, targets, incentives. Protocols of care. Trust, blame and the culture of defensiveness. Caring roles and the division of labour. Seeing the task. Staffing levels and continuity of care.

© W Tadd 2012

Are some risks worth taking?

Annie calls out again and Amy goes to her. ‘Can I go to the toilet please?’ ‘You’ve got a pad on.’ ‘Can I have help to the toilet please?’ ‘If you...(she sighs with frustration) you’ve

got low pressure, when you stand up your blood pressure drops and you’ll be falling.’

(Observation Fieldnote: Rapid Rehabilitation Ward, Westway Trust Night Duty)

© W Tadd 2012

Quality measures, audit and protocols

William says he doesn’t want any [food]. The HCA tries to persuade him to have some soup and the domestic shouts out that he didn’t eat anything the night before nor for breakfast. The HCA says, ‘I think he needs to be referred to the dietician and

we need to set up a food chart.’ 

(Observation Fieldnote: Acute Medicine Older People, Uphill Trust, Lunchtime)

© W Tadd 2012

Pressures on staff and organisations “It’s just the case of beds. I would honestly say that the pressures of …. we need to get this patient out to get this patient in, but you may have people sat in wet beds. You know but that isn’t a priority anymore. If you’ve got people that are breaching down in A&E, … they’re on the phone constantly to us, then we’ve got to, but then the patient care, where does that.., you know?” (Interview with Staff Nurse, Female Surgical Ward, Meadowfield Trust)

© W Tadd 2012

Defensiveness & Self-protection

‘I mean, there was one time I spoke, I tried to speak to one of them, and she – she said, “Yes?” and leant against the wall and looked at me and I said, “I’m sorry, I’m not going to speak to anybody like that, leaning against the wall and so on, I’d prefer to go somewhere private, can we go to…” and she said – she said – I don’t know what she thought I was going to say, she said, “Well, yes, but I suppose so, but I’ll have to have a witness”. And she went off and got someone else and fair enough and we’re sitting, you know, like this, now I don’t know whether she thought I was going to hit her, verbally abuse her or what, but it – it um – I think, I suppose I felt they were on the defensive um, which is a shame. (Relative interview) © W Tadd 2012

Perpetual motion

Impact on staff

‘I didn’t come into nursing care to ship patients to different wards, I came into nursing to care you know and all the nurses are the same.’

(Interview with a Staff Nurse, Female Surgical Ward, Meadowfield Trust)

© W Tadd 2012

Right place – wrong patient

Environmental influences

Deficiencies in the knowledge and experience of ward staff

© W Tadd 2012

Environmental influences

The disempowering nature of many acute wards can add to the disorientation experienced by many older people.

The anxiety engendered in many older people by being in close proximity to patients of the opposite gender.

The boredom and dejection resulting from the loss of communal spaces and activities.

The environmental hazards that the acute ward presents especially for older people whose acute illness is compounded by dementia, confusion and/or delirium.

The lack of information about the personnel, ward routines and layout, or treatment/care plans.

© W Tadd 2012

Environment

Two porters arrive with Mr D from bed 10. They ask him if he knows his bed number which he doesn’t – no-one seems to be able to help and they say ‘They’ve given us the wrong ward again haven’t they’ Mr D starts to say it’s the wrong ward too. Then the SN comes out from behind the Supper trolley and says ‘Oh yes he’s mine – bed 10’ and they wheel him in.(Observation: Respiratory Medicine, Evening)

© W Tadd 2012

Staff skills

Professional training does not prepare staff to meet the needs of current in-patients that is frail older people.

There are few programmes of specialist education or post-qualifying courses relating to ageing or care of older people with complex needs.

Skill deficits relating to the care of people with dementia, confusion and delirium are widespread.

Few opportunities exist for staff to consider what dignified care consists of or how it might impact on outcomes.

Because staff are not trained for the realities of everyday practice they become disillusioned, burnt-out and dissatisfied.

© W Tadd 2012

Staff experience mirrors patient experience

‘If employees are abandoned and abused, probably clients will be too. If employees are supported and encouraged they will take their sense of well-being into their day-to-day work’.

(Kitwood 1997)

‘The degree to which staff are treated with dignity and respect by their colleagues, managers, patients and carers is also variable and the role of the ward manager in providing a respectful working environment is critical’ (Tadd et al 2011)

© W Tadd 2012

Is it the right place for the wrong patient?

‘It’s just not the right place for them’(Interview with a Staff Nurse, Vascular &

General Surgical Ward, Uphill Trust)

‘….in a busy acute hospital because with the best will in the world it... they do need to be

somewhere where the staff have some awareness of the needs of people.’

(Interview with Safeguarding Co-ordinator, Downlands Trust) © W Tadd 2012

Common issues

Complexity Failure to acknowledge that many older people have complex,

high support needs and reorganise services to meet them Failure to acknowledge that ‘the lack of dignity’ constitutes a

complex problem Complex interface between the many agencies and stakeholders

Resource issues and competing interests of organisations, staff & ‘users’ Reactive, task based approaches to care rather than proactive,

person-centred approaches Leadership issues at organisation and unit levels

Lack of clear and shared goals/vision Failure of senior management to engage with the issues Fragmentation of team leader/ward manager role

Deficiencies in education/training Demoralised staff © W Tadd 2012

40 minute DVD drawn from evidence around theme of Seeing the Person

Suitable for a wide range of staff from new recruits to Board members

Suitable for multi-professional audiences

Raises awareness of the impact of individual actions and of organisational factors on patients, staff and their practices

Comes with detailed reference notes for facilitators

© W Tadd 2012

Dignity: A tale of two wards

Thank you

This study was commissioned and funded by the NIHR-SDO programme and managed by the Department of Health and Comic Relief under the PANICOA initiative. The views expressed are those of the author and not necessarily those of the NIHR, the Department of Health or Comic Relief.Further information: [email protected]: http:/www.netscc.ac.uk/hsdr/projdetails.php?ref=08-1819-218

Other resources: http://www.cardiff.ac.uk/socsi/dignity/index.html