Improving Dignity for Older People in Hospital Christine Norton PhD MA RN Florence Nightingale Professor of Nursing Imperial Healthcare & King s College London Team: Marcelle Tauber-Gilmore, Sue Procter, Corina Naughton, Zainab Zahran, Gulen Addis + students
Aim of the study To improve the delivery of dignity in the care to older adults during acute hospital admission through a staff led intervention Research Questions 1) Can a supported dignity programme impact on the quality of interaction between staff and older patients and improve patient experience? 2) Can improvement be sustained once support is withdrawn?
Background Dignity a particular issue in acute care (Francis and others) Pace of modern hospitals is challenging to dignity and person centred care We obtained 2 year funding from Burdett Trust for Nursing 3 phases: Systematic review Interviews, survey and observations Dignity intervention
Dignity definition The Steering Group s agreed definition of dignity: Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. Dignity in care means the kind of care, which supports and promotes, and does not undermine or erode, a person s self-respect regardless of any difference. [Patient] 'Being treated like I was somebody'. Incorporated: -The Royal College of Nursing's dignity definition (2008) and -Social Care Institute for Excellence (SCIE) Dignity in Care Research Overview Guide using Policy Research Institute on Ageing and Ethnicity (PRIAE) and Help the Aged, (2001) -Opinions of the Steering Group (2014)
Review and interviews Systematic review: interventions for dignity in acute care: none!! (Lots of descriptions and recommendations but never tested). Plus no outcome measures tested. (Zahran et al, J Clin Nursing 2016) Views of older people and staff about dignity. Agreed about what dignity is. Care inconsistent and continence a challenge. Staffing levels and organisational culture central. Lack of training. (Tauber et al, J Clin Nursing 2017).
maybe its more recognisable when its not there (doctor) he [nurse] spoke, he held me, he cuddled me, and encouraged me to scream it out, to let it out. And I did. And the panic passed. (Patient 6) when you are in hospital you forget about privacy, you re here as a patient (Patient 1) I asked for a bed pan because I was so exhausted. A girl (HCA) came in, turned off the buzzer and said: we are doing handover, no-one can help you now (Patient 5)
Pre-post control group design 17 units 3 sites Intervention N=12 Control N=5 Intervention engaged N=3 Min engagement N=9 N=5
Data Collection August 2014 September 2015. Non-participatory observations Only staff interactions with consented patients recorded 45-60mins and recorded by trained observers Interaction labelled as Positive, Negative or Neutral Verbal and/or non-verbal communication -48 patients -125 hours of observation -651 interactions Observer s reflection & contextual comments Interviews Two questions strands; Self and Organisation Similar questions for staff and patients -51 interviews overall -13 patients (aged 68-91yrs) -38 staff (13 RGNs, 9 Drs, 4 OTs, 3 Physio, 3 Pharm, 3 ST/N, 2 HCAs &1 Ward Admin) Patient Dignity Survey Six questions and opportunity to leave a free text comment Ideally completed by any ward patient aged 65 yrs & over Collected monthly (Friends & family test) -5693 responses Pre, during & post intervention
Quality of Interaction (QUIS) Observation Tool: Observer s Name: Observer s Signature Ward: Time Observation Period Started: Date: Time Observation Period Finished: Time : Total Number of Interactions: Positive: Neutral: Negative: Interaction Description: 0956 Care task (bed bath) Categorised: Between: Positive: Code: warm, Verbal/N respectful, Length of sensitive on- Interaction Neutral: Verbal: basic care functional Negative: cold, insensitive, unhelpful, disrespectful Nurse & Patient Some fluidity positive to neutral Reflections + V Long Behind curtain. Lovely explanation & instruction from nurse, encouragement pt. Pt expressed preference for shave, nurse agreed. Pt thanked nurses, acknowledged by nurse. Friendly. Warm. Social conversation 1001 Pharmacist & Patient - NV Brief Pharmacist stood at the end of patient bed, looking at bed side folder. Patient trying to ask a question about a medication. Pharmacist ignores patient, leaves folder on the bed and walks away
Electronic Survey Were the healthcare staff caring and compassionate? At any point during your stay did you feel ignored by staff? Did you feel the staff treated you as an individual person? Were you given privacy when discussing your condition, treatment or care? Where possible, did staff give you choices? Where possible, were your preferences respected? Response options: Never, Sometimes, Often, Always.
Intervention Monthly feedback on Dignity Survey & observation data to ward manger (face-to-face/ email) (8 wards) Sustaining strengths Care Concerns Bespoke teaching sessions as requested Communication training (1 ward 1hr*4 weeks), continence and dementia, Discussion and debrief of specific patient experiences (1 ward -5 sessions) VERY LIMITED ENGAGEMENT (too busy, even when supported)?? No MDT- delivered to nurse only
Bespoke dignity feedback by ward Staff Reaction to feedback: Shock, dismay More doom and gloom But Can try harder Did not realise that is how we came across
Observation data ward clerk enters a side room and passes a message on to the nurse and leaves. The ward clerk did not knock on the door before entering or acknowledge the patient A nurse was at the patient s bedside inserting a new cannula. The clinical task was done in silence. When the nurse spoke to the patient, they said I need to flush it. Overall % (n=651) 20 38 42 Positive Neutral Negative Discharge nurse and a patient discussing the patient s discharge. Clear explanation from the nurse about options. Patient asking questions; the nurse was listening and responding to questions. Nurse and patient both at ease, open and friendly.
Outcomes: Dignity Survey 100 90 80 70 60 50 40 30 20 10 0 Caring & Compassion Ignored by Staff Treated as individual Pre: Always (n=3611) Privacy Given Choice Preferences Respected Post:Always (n=2082)
Dignity improvement sustained 23.2 Mean Score 23 23 22.8 22.6 22.4 22.6 p=0.04 22.2 22 22 21.8 21.6 21.4 Pre Post Six-months Followup Max potential score 24
Comments Strengths I was always treated with dignity. The staff made me feel safe and valued Very caring nurses, but they need to speak to patients more. Concerns Depending on the staff that were on shift you either had a pleasant experience or an appalling one. [made to wait for bedpan] Incontinent of urine for the first time in my life. I m 68 years old and a retired teacher. This is not supposed to be the way someone in genuine need is treated.
Trust feedback event Dramatised: entrenched poor behaviour, stealth and robotic care- based on observation data i) Role-modelling and leadership i) Support (from individual line manager, senior management or the organisation) i) Culture (locally and organisationally) i) Education, training and development i) Communication
Learning & Next Steps Monthly dignity survey & observation feedback valuable but time consuming to sustain Potential for quarterly Wards had limited capacity to actively engage in quality improvement interventions Specific project e.g. continence more traction Trust developed leadership programme for different nursing bands Film illustrating impact poor quality interactions (10mins)- reflection tool to aid the revalidation process
Dignity in acute care Very difficult to implement interventions Feasible to influence by simple feedback? Students really enjoyed observations Simple scores (high) maybe hide actual experiences? Dedicated strategies- MDT Training? Actors really engaged staff Time & staffing Talk & Listen whole team Continence