Win Tadd: Transforming patients' experience - Why it matters to staff

TRANSFORMING PATIENTS' EXPERIENCE: WHY IT MATTERS TO STAFF

Win Tadd, Cardiff University

Data sources

Wrong patients?

What is important to staff?

Learning to care Teamwork Leadership

Learning to care

Professional training doesn’t prepare staff to meet the needs of current in-patients who are frail older people.

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

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

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.

What the staff said: Older people’s care

“They’re new…you know, completely new, they come in, they do the basic Trust induction, which is nothing to do with being an HCA. They’ll then come to a ward and we’ll try to allocate them to a nurse to look after them. They’re supernumerary for a week, eight days….And then they’re out there. They then do an HCA induction but that happens very often about eight weeks or more after they’ve been in the job.”

(Interview with a ward manager, Care of Older People Ward, Downlands Trust)

What the staff said: Older people’s care

“Obviously when you train to be a nurse you go through so many different placements every year and they normally do throw in a healthcare of the elderly placement. So that’s all the real training you get is whether you pick it up while you’re training as a nurse.”

Interview with a staff nurse, Acute Medicine for Older People, Uphill Trust)

What the staff said: Dementia skills But, in terms of dealing with say dementia

patients you only sort of cover that if you’re in mental health, it’s sort of missed in adult nursing. So…you know, really unless you were lucky enough to go on the ward as a student with dementia, you don’t really, cover it at university because it’s classed as mental health . I think it should be incorporated at university and studying to like deal with people with dementia because you don’t know the best way to deal with them.”

(Interview with a staff nurse, Acute Stroke Ward, Westway Trust)

What the staff said: Dignified care Respondent: ‘I trained in 1970-73 so it was very

much old school then. I mean you learnt on the wards. You didn’t have as much…well certainly no university training. You just had general, you know, training about diseases and medications and general nursing type…medical stuff’

Interviewer: ‘Yeah. And have you had anything since then? Have there been any sort of in-service training sessions on dignity?’

Respondent: ‘Not on dignity. No.’ (Interview with senior staff nurse, Nelson Ward,

Westway Trust)

What the staff said: Dignified care

“It’s [dignity] covered all the way through, you don’t just learn it and it stops, every – Yeah, if I write an assignment, it’s got to be in there, it’s like key things you’ve got to include, dignity and respect, in everything we do. It’s taught in everything and they taught us to do examinations, they’ll say, ‘Don’t forget your dignified care, remember to introduce yourself to the patient, ask them if it’s alright, give consent, pull your curtains round, privacy.’ So, it’s not just – we’re not just taught it once, it’s everything you do, we’re taught it over and over and over. It’s like it’s drummed into us a lot [laugh] and then when you come to the wards, well it’s all different.”

(Interview with a nursing student, Beech Ward, Meadowfield Trust)

Team work – the difficulties

Inability to control who is part of the team

Inability to spend time with the team as a whole

Impact of staff numbers and skill levels on team work and continuity of care

Little opportunity to engage in the more positive aspects of team work

Difficulties in managing performance

Team work?

From conversations between the nurse in charge (the deputy ward manager) and the doctor and other nurses, there seems to be some animosity between her and the ward manager. I also got the impression from others on the ward that they did not always agree with the decisions that the ward manager makes or asks them to make.

(Observation: Care of Older PeopleWard, Westway Trust, Night Duty)

Team work?

I meet up with the two HCAs who are checking backs at the other end of the ward. One in particular gives me a long moan about the morale of the HCAs, ‘We are the ones who do all the work – we do everything, since the nurses have had their pay rise they think they are above it – even the ones that were good aren’t anymore…’ The other HCA seems to agree but doesn’t say much.

(Observation: Acute Medicine for Older People Ward, Uphill Trust, Night Duty)

Team work?

A staff nurse who I have met on the ward before a few times was working and when the first 4 bed male bay had been ‘made comfortable’ she noticed that one of the catheter bags had not been emptied and mentioned this to Rhiannon an HCA, who later told Sam, another HCA ‘You didn’t empty John’s, I’ve done it now, it was 500’. This seemed a bit accusatory to me – rather than simply saying ‘We forgot’ for example.

(Observation, Stroke Ward, Westway trust, Night duty)

Team work?

A buzzer has been going for some time on the North side. It is coming from the male toilet. The ward sister has been standing in the corridor during all this time with the medication trolley. After about 10 minutes an HCA comes past and shouts, ‘I’m coming Gerry’ – she goes and does something in the day room. She then comes back and goes and gets Gerald from the WC.

(Observation: Acute Medical Ward, Uphill Trust, Morning)

Team work?

When I arrive on the ward, the deputy ward manager is doing the medications. She is in the female nine-bed bay. She makes a point of lowering her voice to ask, ‘Anything for your bowels?’ When she arrives at one bed the patient says, ‘I need the toilet’. Sister stops doing the medications and helps take the woman to the toilet. She looks at me as she passes and says, ‘You can never do one thing at a time.’

(Observation: Wellington Ward, Westway Trust, Morning)

Leadership

“I think that that [leadership] is best dealt with by 3 things. One is example, example, example. That’s what ward sisters and matrons are for. That’s what people like me are for and we must never forget that part of our job is to reinforce the dignity of every individual and the rights of every individual.”

(Interview with the Chief Executive Uphill Trust)

Leadership

“No, it’s about leadership and it’s about culture and it’s equally about everybody owning that and we’re running a programme which we’ve developed, called ‘Valuing Patients, Valuing Staff’ and we’re taking frontline staff and their supervisors because what you find is for whatever reason the staff are feeling slightly disempowered, so they know what needs to be done, and quite often that takes no money, it doesn’t actually take any time, just takes a bit of thought and a little bit of effort, but they – they would argue they can’t do it because nobody’s told them they can or because it doesn’t fit the Trust policy or, because they want to do something and the supervisor comes along and says, “Well actually you can’t do that”.

Leadership

So, we’re trying to instil a culture where service improvement belongs to everybody and it isn’t about a central team jettisoned in, it’s about you understanding your service, your ward, your department and the needs of your patients and making a difference. The smallest difference can make a huge difference to the patients. So, it’s very much about the culture and that comes from leadership. Leadership sets the culture, it’s okay to do, it’s okay to take a risk, it’s okay to have a try and if it doesn’t go well, then we’ll learn from that and we’ll try something else.”

(Interview with Director of Learning and Development, Meadowfield Trust

Leadership

Interviewer: ‘So did you get a sense of leadership on the ward you were on?’

Respondent: ‘No. There seemed to be a culture of fear there. Staff would immediately defend themselves and each other’

(Interview with a 66 year old man, General Medical Ward, Westway Trust)

Why it matters to staff

A staff nurse came in to write up the patients’ notes. She looked upset and said it had been a terrible few days and staff morale was very low. They had been told by the matron not to discuss issues on the ward as patients were ‘picking up’ on staff conversations. Matron had also told Sister to accept responsibility for the recent ward changes and not let staff think they had been imposed on her. She said a lot of staff were looking for new jobs.

The staff nurse returned and said she hadn’t left the ward until 10.30 the previous evening – she went off-duty crying as it had been a dreadful shift and when she had got home she was too upset to eat. She was going to document the state of affairs with the sister before going off on her half day.

Why it matters to staff

Lunches have arrived and there is a furore as the domestic staff have said if they are not given out immediately they will be taken away, but with 41 patients and 6 staff who are all busy with other tasks, it is difficult. The senior staff nurse bursts into tears and leaves the room.

Chatting to Angela (a staff nurse) at the nurses’ station she also tells me that she didn’t sleep the previous evening as it was a very busy and distressing shift and she worried that she had forgotten something for the patients.

(Observation: Orthopaedic Ward, Meadowfield Trust)

Why it matters to staff

Thank you

This study was commissioned and funded by the NIHR-SDO and managed by the Department of Health and Comic Relief under the PANICOA initiative. The research team wish to gratefully acknowledge this support. The views expressed are those of the author and not necessarily those of the SDO programme, the NIHR, the NHS, the Department of Health or Comic Relief.Further information: [email protected]: http://www.sdo.nihr.ac.uk/projdetails.phpref=08-1819-218