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Caring for all to reduce harms in care homes
Peter Jeffries – Patient Safety Programme Manager
An artificial divide?
Effective, person
centred care
Safety Staff well-being and resilience
Safety Culture
A story:
PROSPERPromoting Safer Provision of care for Elderly Residents
ProsperPromoting Safer Provision of Care for Elderly Residents
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• Funded by The Health Foundation - Closing the Gap in Patient Safety
• Essex County Council & UCLPartners working in partnership with Essex Residential Care & Nursing homes
• Focus on Prevention - reducing the prevalence of falls, pressure ulcers and Urinary Tract infections across care homes.
Prosper Methodology
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• Building staff capability through education in quality improvement methodologies – PDSA cycles (plan do study act) of small tests of change for continuous improvement
• Using data measurement over time to inform improvement cycles –moving homes away from feeling that data is only used for negative reasons
• Changing staff culture & behaviour on safety from being reactive to proactive & preventative
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Outcome/Aim Primary Driver Secondary Driver
To achieve a 50% reduction in falls rate by
December 2015
To reduce the number of days between falls to 45
days or greater by December 2015
Recognition & Assessment of Risk
Plan to address risk of falls
Act to reduce risk of falls
Review and monitor
Education/Training
• Pre assessment prior to admission • Resident specific falls risk assessment within 24
hours of admission • Understand local falls risk – where, when etc. • Log falls in incident book/falls register/Safety cross
for analysis
• Identification of risk for resident in their care plan • Agree plan with resident and /or family or carers • Agree timescales and review date • Provide information about falls prevention • Appropriate referrals for specialist assessments • Identify mobility aids, equipment, correct footwear
• Communication • Intention rounding : SAFETY Walks
S – Surface A – Availability of Aids F – Falls Risk E – Evaluation T – Tell Y – Your initials
• Environment • Resident, family and carer involvement • Review falls risk assessment/care plan • Review compliance with care plan • Continue to record and review falls register
• Falls prevention training • Falls champion
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Getting Hydration correct…….. Could see a reduction in the above 3 areas.
Remember HYDRATION IS KEY!
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Check for Urine Infection
If concerned call the Community Matron:
Check urine colour
Good
Good
Dark
Dark
If urine is dark – give extra fluids. Check for bowels open
Are any of these symptoms present?
Urgent need to pass
urine/ incontinent when not usually
Confused
more than usual when not usually
Feeling feverish and unwell
Low tummy or
suprapubic pain
Prolonged contact with urine can encourage urine infection. Therefore, it is important to ensure that Incontinence Pads are changed in a timely way
Clients with urinary catheters are likely to have bacteria in their urine – encourage fluids
If symptoms present
Safety Cross
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Implementation
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• Prosper Champions• Safety Cross• Falls checklists• Medication Reviews• Good Slipper guides at
pre-assessment• On spot debriefs• SBAR
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• Doily’s• Hydration stations• Training for
staff/residents/relatives• Fluid content of foods• Involving Chefs• Fluid intake monitoring on
admission
Focus on Hydration
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Jelly!
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Pressure Ulcers
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Falls
Challenges
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• Difficulties in collecting consistent data.
• Retention of Managers
• Safeguarding pressures
• Maintaining momentum
• Varying offers of support across Essex
Outcomes
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• A change in staff culture across two thirds of homes participating (96 homes in total)
• Downward trend in Falls and Pressure Ulcers, 5% reduction in falls, 20% reduction in pressure ulcers
• Improved data recording, capturing information previously not recorded – Falls, UTI’s, pressure ulcers, hospital admissions
• Homes are using data to inform proactive approaches to prevention
• Homes sharing and working together
© The Association for Dementia Studies
Creating positive organisational cultures for person-centred care in
care homes
Isabelle Latham, Senior Lecturer Association for Dementia Studies, University of Worcester
CHOICE research project Care Home Organisations Implementing Cultures of
Excellence
© The Association for Dementia Studies
What is organisational culture? The values, assumptions and norms of behaviour
that influence how members of an organisation behave and interact.
These help provide working solutions to everyday problem-solving and decision-making.
This includes formal rules and overt values but also subconscious or unofficial practices
Passed on to new members as correct: ‘the way we do things here’. (Schien, 1990)
© The Association for Dementia Studies
“Culture is the all-pervasive substance in which we grow. It is where we have our roots and from where we
absorb our nourishment. Whether it is the culture of our workplace, community, organisation or society, we
take up and use what is available to us from our cultural soil, good or bad. Crucially, we cannot help but soak it up…. What is in the soil affects how well we can grow, regardless of how much pruning or attention we
receive from outside,” Brooker & Latham, 2016
The influence of culture
© The Association for Dementia Studies
Thinking change? Think culture… “Leaders and managers are very often surprised at what does, (or does not) emerge as a result of their
efforts to change practice. To achieve a person-centred approach…they need to be able to recognise the
features and impact of culture on actions and behaviours in care delivery. Without such
understanding there is a risk that efforts to improve care will fail to have maximum impact and create only temporary enthusiasm rather than long term change,”
Brooker & Latham, 2016
© The Association for Dementia Studies
Providing person-centred care
experiences depends on a positive care
culture
There are seven features of positive
care cultures
Without good soil, strong stems, and
healthy leaves, the flower won’t thrive
© The Association for Dementia Studies
Beliefs, values lead to actions that create
conditions for person-centred care to happen
Frontline staff are enabled to make day to
day decisions so that care is person-centred
Norms of care practice reinforce beliefs, values
and actions
Person-centred care is seen to ‘work’ for people’s
well-being
© The Association for Dementia Studies
Our plant’s root #1We all work together to deliver best care
• Everyone had the same understanding of what person-centred care means in their home
• This understanding was based on practical, everyday actions and their impact on residents
When different staff at one home were asked what advice
they would give to a new member of staff, all of them
independently answered:
“get to know your residents”
© The Association for Dementia Studies
Our plant’s root #2:
We all matter to each other • All residents, staff and
visitors have opportunities to be involved in home life
• Residents are known throughout the home and enjoy everyday experiences
• Friendship-like interactions with and between residents
“When G’s niece was visiting I saw her chatting and welcomed
by staff. Smiles and ‘how are you?’ She belongs here, she is not just “next of kin” , she is a
friend to us,” (Researcher Observations)
© The Association for Dementia Studies
Our plant’s root #3 Leadership protects frontline care
• Managers protected the daily work of staff from the impact of external factors by absorbing it or translating it into resident-focussed action
• External factors included: regulatory & organisational requirements, family requests and financial pressures.
“Making sure the T’s are crossed and the I’s are dotted, that’s what the job is mostly about now. The amount of
time staff have to sit down and spend on care plans,” (Manager)
this led to a typical observation of care practice:
“Carer asks about dietary records for residents who haven’t eaten yet.
Another carer replies ‘just record a spoonful’.
Care plans are a care task here rather than a product, to the extent
that we record something even when it hasn’t been done,”
© The Association for Dementia Studies
Our plant’s stem Empowering and supporting frontline staff
• Staff were both willing and able to make decisions and take action for resident well-being
• Management & leadership practices either encouraged or discouraged this
Fred’s key worker was highly responsible and had good insight
into why he often reacted physically to staff. However,
management were seen to exclude care staff from discussions about
Fred’s care.
When the manager was asked about the key worker’s relationship
with Fred she replied: “I haven’t really thought about why she’s so
good with him.”
© The Association for Dementia Studies
Our plant’s 3 leaves
The norms of care
We constantly look to make life better
Openness to change for the benefit of residents. When it directly benefits a resident
change happens daily.
We help people enjoy places The environment is used
flexibly and changed daily to meet residents needs.
We help people to enjoy life We enable meaningful
occupation and engagement for residents all of the time
© The Association for Dementia Studies
Old Culture New Cultureorganisational culture creates the conditions for
person-centred care
‘Malignant Social Psychology’ needed to be transformed into ‘Positive Person Work’
(Kitwood, 1997)
These practices are habitual and passed on from one worker to another and normalised in day to day work
© The Association for Dementia Studies
Organisational culture has to allow solutions to everyday problems to be positivePerson’s psychological need: Comfort
Behaviour (MSP) that detracts from need: “WITHHOLDING”
Refusing to give asked for attention, or to meet an evident need for contact
Behaviour (PPW) that meets the need: “HOLDING”
Providing safety, security and comfort to a person
In a busy care home Mr Martin cries out: “help me, help me, please help me.” Staff are very busy providing care and support for other residents
A care worker turns to her colleague and says, “He’ll just have to wait his
turn. We have to do Room 4 next as the GP is coming soon.”
The care worker asks her colleague to go to the next resident. She visits Mr
Martin and holds his hand. “it’s okay, I’m sorry we’re so slow today,” she soothes
him for a few minutes and then says,“Here’s your paper to read, we will be
with you by half past 9.” She then rejoins her colleague.
© The Association for Dementia Studies
For positive person work to exist in this scenario:
• Everyone in the home needs to agree that soothing Mr Martin is important, even though its busy.
• Everyone in the home has a role to play in meeting Mr Martin’s needs.
• The manager has to explain to the GP that ‘room 4’ might be delayed and why this is necessary
• The care workers need to be skilled, encouraged and rewarded to take this type of action for Mr Martin.
We all work together
We all matter
Leadership protects frontline
care
Empower and support frontline
staff
© The Association for Dementia Studies
For positive person work to exist in this scenario:
• All staff need to be observant, willing and able to change what they’re doing to meet Mr Martin’s need today
• The routine and physical set up of home needs to change to accommodate Mr Martin’s need today.
• All staff need to know that having something to do is important, and Mr Martin’s newspaper needs to be readily available to give him.
We constantly look to make life
better
We help people to enjoy places
We help people to enjoy life
© The Association for Dementia Studies
Without good soil, strong stems, and
healthy leaves, the flower won’t thrive
Whatever you do, you have to ensure
it waters your plant!
© The Association for Dementia Studies
Thank you for listening Isabelle Latham
[email protected]/dementia
KILLETT, A et al., “Digging deep: how organisational culture affects care home residents' experiences” Ageing and Society, available on CJO2014. doi:10.1017/S0144686X14001111.
© The Association for Dementia Studies
Acknowledgements CHOICE PROJECT
This research is funded through the PANICOA programme by the Department of Health and Comic Relief. The views expressed in this presentation are those of the authors and do not reflect those of the Department of Health or Comic Relief.
With special thanks to: • The care homes (including residents, relatives, visitors and staff)
who volunteered to take part the project • Our research team colleagues at University of East Anglia,
University of Stirling and Cardiff University
Caring for carers- putting on your own oxygen mask first…
29 November 2016. Care Homes ConferenceYvonne Sawbridge. Health Services Management Centre.
“KINDNESS AND COMPASSION COST NOTHING”
CQC 2011
(Available at: http://www.birmingham.ac.uk/Documents/college-social-sciences/social-policy/HSMC/publications/PolicyPapers/policy-paper-twelve-time-to-care.pdf
Key stakeholders Literature search Nursing think tank 3 main themes: -Environment of care -Education &
Development (“too posh to wash?”)
-Emotional Labour of Nursing
What are we here for?
Emotional labour (1)
Hochshild (1983) work on flight attendants “Induction or suppression of feeling in order
to sustain an outward appearance that produces in others a sense of being cared for.”
“requires workers to suppress their private feelings in order to show desirable work-related emotions’”Mastracci et al, 2012 p4).
Emotional labour (2)
1950’s-Menzies. Nursing as a series of “....disgusting, distasteful and frightening tasks....” Menzies IEP. (1960) A Case-Study in the Functioning of Social Systems as a Defence against Anxiety: a Report on a Study of the Nursing Service of a General Hospital. Human Relations 13(2): 95-121.
If anxiety not managed then burn-out can result and unhealthy detachment.
Emotional bank accounts need topping up- or become overdrawn.
Emotional Labour (3) “In the case of
health service, reading the emotions of patients and their loved ones, responding to them and managing them becomes as important as drawing blood with syringes or performing mastectomies”.
Compassion is?
“- a sensitivity to distress… with a commitment to try to do something about it and prevent it. Awareness, attention and motivation are involved.” p 3 Cole-King and Gilbert.
Potential Solutions
Restorative supervision (Wallbank 2010)
High stress levels of HVs
Reduced effectively AND means clearer
thinking and ability to function/make difficult decisions
Schwartz CenterRounds (Goodrich 2011)
supporting staff to improve care
Improving organisational culture
Reducing isolation The value of a multi-
disciplinary approach to problem solving, especially one involving senior staff”
Potential solutions
Samaritans “buddy up” Debrief post shift Follow up if thought necessary Turn off ‘phones-volunteers needs are
priority.
Invisibility of emotional labour• Organisations
understand legal responsibilities to staff well being in general terms. (Boorman Report 2009)
• Physical safety well understood- hoists provided; manual handling training mandated etc.
• Caring seen as easy-for those individuals who are “that way inclined”
• Emotion work is a poorly understood role requirement.
Role of leaders?
What does the evidence tell us?
“In summary, the findings make it clear that cultures of engagement, positivity, caring, compassion and respect for all – staff, patients and the public –provide the ideal environment within which to care for the health of the nation.
When we care for staff, they can fulfil their calling of providing outstanding professional care for patients.”
Continuing work...The challenges for the delivery of healthcare in the future are well documented and understood. This book will help to ensure that the focus on the importance of compassion to patients, their families and of course all those who deliver care, is not lost on the journey.(Foreword, Sir Stephen Moss Former Turnaround Chairman, Mid Staffordshire NHS Foundation Trust)
Additional info
TEDx on Emotional Labour https://www.youtube.com/watch?feature=youtu.be&v=VC4FajTFpRU&app=desktop
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