The project aimed to explore and improve aspects of dignity in care for older people using discover interviews.

Using discovery interviews to improve dignity in acute care for older people University College London Hospitals NHS Trust Keywords: Dignity, privacy, discover interviews, active learning Duration of project: May 2008 March 2010 Project team: Jonathan Webster, previously Consultant Nurse Older People (initial project leader) National Neurological Hospital: Gillan Johnson, previously Clinical Practice Facilitator Lead (subsequent project leader) Sue Humblestone, Occupational Therapist Vicky Dunne, Ward Manager University College Hospital: Jacob Aspinall, Clinical Practice Facilitator Jingo Paras, Staff Nurse Introduction At University College London Hospitals NHS Foundation Trust (UCLH) there was a Dignity in Care Work Stream group that had been in place for two years and reported to the Older Person s Strategic Steering Group. Work that this group carried out had highlighted the need to ensure robust patient feedback on experiences of dignity in care was embedded and owned in practice by clinical teams. Patient stories had been used as part of practice development programmes, but it was anticipated that discovery interviews would enable a deeper level of understanding locally (leading to change and development) which would complement other methods of feedback within the trust. A successful funded programme of practice development had already been run in the Trust (Webster, Noble and Coats, 2008) along with local work based programmes of development aimed at improving older people s experience of care through transformational change. More broadly there was a clear trust wide commitment to embed and make explicit the importance of the dignity agenda. In early 2008, support from the Chief Nurse was sought along with commitment from the Dignity in Care Work Stream group to progress a project to use discovery interviews to focus on improving dignity in care. The project was part of a larger two centre project (also involving Brighton and Sussex University Hospitals NHS Trust), that was supported by the Foundation of Nursing Studies (FoNS) and City University. The project aimed to explore and improve aspects of dignity in care for older people using discover interviews. Setting up the project at UCLH A number of clinical areas that provided services for older people were contacted through Work Stream group members to see if they would be prepared to take part. One divisional site expressed an interested along with a member of staff who worked within integrated medicine for older people. An initial overview presentation was given in which staff were able to discuss both the process and potential outcomes of using discovery interviews. From this meeting five staff identified that they would be keen to participate along with four clinical areas. At the same time a meeting was held with the wider project team (City University, FoNS, National NHS Improvement Lead) to explore how discovery interviews had been used 1

as part of other programmes of work along with agreeing the training that would be provided for participants. The project leader (JW) recognised the importance of work based culture and context as part of any programme of practice development aimed at improving care for patients through transformational change and that applying a standardised technical approach to implementation would lead to limited outcomes. For this reason it was identified as being of importance to help prepare project team members to work with and understand their work based cultures along with being able to reflect, share and learn through active learning. Three sessions were run for project team members that focussed upon: Work based culture (a wider group of staff joined this session) Using discovery interviews Gaining consent from people with a cognitive impairment An additional training session was also run for two project team members who would evaluate the discovery interview process. Following the preparation sessions the UCLH project team met with the Lead Nurse for Nursing Research in the Trust to discuss their learning and reflections. It was identified at this stage that the team found the standardised spine of questions too restrictive, a technical approach also felt at odds with an approach to transformational change and development. For this reason a new spine of questions was developed that were more sensitive to the subject matter. A plan was also agreed for taking forward practice interviews and validation locally. Full ethical approval for undertaking the project was granted in June 2008 from MREC Wales. This process was facilitated by City University. Discovery interviews During the period of the project, it was anticipated that all the project team members (with the exception of JW) would undertake discover interviews with patients. However, staff changes, illness, difficulty with identifying suitable patients and other contextual factors meant that in the end, only two members of the project team actually interviewed patients. In total, four discovery interviews were undertaken with patients; these were transcribed verbatim. Active learning groups Active learning is an approach or method for learning that takes place in the workplace (Dewing, 2008) that involves thinking critically and creatively about practice to develop new understanding and learning that can inform the development of practice and improvement of care. The development of an active learning group was therefore proposed by Jonathan Webster to enable the project team to experience a variety of learning opportunities in relation to enhancing dignity in care and consider how they could take them back to the clinical areas to help practitioners to be aware of and understand the ways that they are currently working, what needed to be changed and be actively involved in exploring how these changes could be achieved and evaluated. The group met six times for two-three hours between November 2008 and January 2010 and was facilitated by Kate Sanders, Practice Development Facilitator from FoNS. Initially the group involved Jonathan, Gillan, Sue, Vicky and Jacob, but due to staff changes, fewer members were able to attend. Over time, the staff changes and other contextual factors impacted on the project and the functioning of the group to the extent that only the first three sessions used active learning approaches. Subsequent groups focused more on critical reflection and action planning. A brief summary of the first three groups is provided below with further details in the appendices. A summary of the action points and achievements to date identified in the fourth and fifth group is also included in the appendices. 2

1 st Active Learning Group November 2008 Five project team members attended the first group. A number of approaches were used to enable participants to discuss and agree the purpose of the group; ways of working; and to consider their involvement in DI project. Claims, concerns and issues (Guba and Lincoln, 1989) was also used to identify and plan individual actions and future support and development needs. 2 nd Active Learning Group January 2009 Four participants attended the second group. Following an initial discussion to catch up on the progress of the project, the group agreed that it would be useful to consider what a successful outcome for the project would look like to provide/create a shared focus. They then participated in activities to explore the concept of dignity from the perspective of staff and patients. 3 rd Active Learning Group March 2009 Five participants attended the third group. As all of the group members were finding the organisational context difficult when trying to move forward with the project, the group agreed that it would be helpful to revisit the claims, concerns and issues to gain a sense of their progress. A number of actions were identified to help the group move forward e.g. keeping in more regular contact. Facilitating developments in practice Two of the project team (GJ and SH) were able to facilitate some learning and development opportunities in their practice areas; and one of the team (GJ) was able to share some of the discovery interviews with staff. These activities will be outlined below. Initial staff workshop on neuropsychiatry ward Sue ran a workshop for several members of nursing staff in August 2009 which involved: A discussion to define dignity Use of the RCN DVD on dignity in care Exploring issues around dignity from the perspective of patients and staff The workshop promoted discussion which raised staff awareness about a particular issue relating to caring for patients with challenging behaviour. Sue planned to run a second workshop that would involve other stakeholders to encourage the sharing of perspectives, but unfortunately due to competing work priorities, staff changes leading to a lack of support, this was not possible. Initial staff workshops on stroke and neurology ward Using some of the activities and approaches utilised in the active learning groups, Gillan facilitated two workshops involving staff from two wards (stroke ward, neurology ward). Four staff attended each workshop and included the dignity champions and nurses who expressed and interest. Gillan used the activity to enable staff to explore the concept of dignity from the perspective of patients and staff using the senses. Through the discussion that was stimulated by this activity, staff identified key issues in work areas relating to dignity and a small working group was formed who decided to explore these on their wards using informal observation and meet again to discuss and plan actions. Identifying areas for development Informal observation identified the following areas of concern in relation to dignity in care: Curtains not closed Staff walking through curtains Patient not fully clothed Poor practices at mealtimes e.g. food too far away for patients to reach 3

The group considered the following action points: Use of pictorial prompts Review use of curtain clips and messages Review food delivery with domestic staff/managers Taking action Progress was made towards introducing the use of curtain clips and messages to prevent patients dignity being compromised. Members of the working group met with the catering manager to discuss issues with the serving of food. It was identified that many agency staff were being used to serve food on the wards and therefore this created difficulties with training and consistency. As a consequence, information on how to present food were created for catering staff e.g. table is laid, encourage patients to go to table and displayed in all kitchen areas. One of the members of the working group was also keen to explore staff views of their own dignity at work. She therefore developed a questionnaire which was distributed to all staff on one ward. At the time of reporting, there had been a 46% response rate. The responses were going to be themed and fed back to staff at away days. Wider dignity agenda This development work was not happening in isolation as Gillan and others were involved in wider trust dignity initiatives. All staff were involved in staff away days and governance days where the RCN dignity campaign resources were being used to raise discussion. The trust was also in the process of introducing the Dr Foster questions using a hand held pod. Gillan was hoping to explore the possibility of including some questions directly relating to patients experiences of dignity in care. Follow up staff workshops Two workshops were facilitated by Gillan (4 th and 5 th March 2010) involving five and eight staff from two wards. The workshops were held in the evening to enable staff to attend and lasted approximately one and a half hours. Gillan fed back two of the stories from the discover interviews and discussions to explore the meaning for staff followed. The first story highlighted positive aspects of care, whereas the second story identified some elements of care that could be improved. When reflecting on the first story with staff, Gillan identified the following themes from the discussions: The staff felt proud in response to positive feedback about care from patient The staff have a strong sense that they are trying to work as a team even though ward is busy The staff recognised that they had come a long way compared themselves to how care was given on neighbouring ward Good management was recognised as being important and something that they (the staff) had e.g. meetings to air problems The staff experiences a sense of being appreciated In response to the less favourable story, Gillan noted the following themes: The staff expressed feeling ashamed The staff stated that this was not a good image for the ward The staff felt that the nurse in the story should have been more patient and shown more respect and understanding for the patient The staff identified that communication could have been improved 4

The discussions enabled staff perceptions of dignity to be challenged. For example, one of the stories described how a patient felt that their dignity had been compromised due to a problem with one of the showers which had caused water to run onto the ward. Some of the nurses could not see why the patient should be concerned as they just viewed this in very practical terms as an issue that the nursing staff would sort out with the estates department. The discussions also enabled staff to realise that apparently small things can make a big difference to patients e.g. knowing a patient s name. When reflecting on the stories, Gillan reported that staff seemed to be measuring themselves against the stories. This enabled Gillan to consider how far the staff had developed since the first workshop, made sense of all the development activities and brought them together to gain a sense if the whole. The staff identified the following as key learning from the workshops: The need to keep talking as a team including recognising the importance of regular meetings to provide an opportunity to air concerns and identify how to put things right The need to support each other Recognition of the role of good ward management Gillan reported that the experience of feeding back the discovery interviews was more positive than she had anticipated. The stories seemed to have a greater impact and staff really engaged. Gillan had not been expecting this, probably she thinks because this was her first experience of using discovery interviews. Gillan believes that the timing of feeding back the stories was right. Staff had been involved in a variety of dignity related activities which had enabled them to reflect on their journey as a team. They had gone through a period of turbulence, including time without a manager. Although it had taken some time for the new manager to settle and work with the team, there was a sense that the new ways of working introduced by the manager e.g. regular team meetings had enabled the staff to develop and become more receptive to the messages in the stories. Shortly after these workshops, Gillan left the trust and therefore the discovery interview transcripts along with the decisions about continued development was handed over to the ward managers. The clinical governance department were also interested in using the discovery interviews for learning and development opportunities across the wider trust. Conclusion Several clinical areas within UCLH were initially interested in undertaking discovery interviews to enhance dignity in care; however, complex and changing contextual factors ultimately made it difficult for some team members to participate fully in the project. The initial project leader left the trust during the project and the project came to a conclusion when the second project leader also left the trust. These changes meant that the project was not able to achieve all that had initially been anticipated. Despite this, the active learning groups provided an opportunity for the project team members to explore the concept of dignity and consider ways of enabling learning and development for staff in clinical areas in relation to enhancing dignity in care. Two of the project team were able to work with clinical teams, and one in particular, was able to undertake some development work, culminating in the sharing of two of the discovery interviews. Staff from two wards were involved in a working group that identified areas of care that could be enhanced and set actions in place to achieve this. Subsequent workshops with these staff suggested a raised awareness about issues relating to dignity but also further areas for improvement. 5

References Dewing, J. (2008) Becoming and being active learners and creating active learning workplaces: the value of active learning in practice development. Chp 14 in Manley, K., McCormack, B. and Wilson, V. (Eds) (2008) International Practice Development in Nursing and Healthcare. Oxford: Blackwell Publishing. pp 273-294. Guba, E. and Lincoln, Y. (1989) Fourth Generation Evaluation. CA, USA: Sage Publishing Inc. Webster, J., Noble, G. and Coats, E. (2009) Enabling privacy and dignity in care: using creative arts to develop practice with older people. In Foundation of Nursing Studies Dissemination Series. Vol. 5. No. 3. Retrieved from: http://www.fons.org/resources/documents/dissemination%20series/dissseriesvol5no3.pdf. (Last accessed 9 th September 2011). 6

Appendix 1 First Active Learning Group - 13 th November 2008 (Attended by Jonathan, Gillan, Sue, Vicky, Jacob and Kate) Establishing the group The group was established using discussion to agree: the purpose of group ways of working The agreed purpose of the group was to ensure that the discovery interviews (DI) make a difference in practice by providing the project team with: Support Problem solving Resources Help to resolve issues The following ways of working within the group were agreed: Commitment Contribution all, openness, valuing contributions, listening Provide feedback Commitment to support each other outside of the group Confidentiality Exploring involvement in project The group were then invited to have a short period of contemplation to consider: how they feel about their involvement in the project what success would look like for them A selection of images were offered to the participants to stimulate thoughts, feelings and ideas. Each group member was invited to feedback to the group. The following themes were collected from the feedback: Feelings about involvement in DI project Optimism/excitement/interest Isolation/being alone Frustration Tough workplace cultures o We know best o Conflicting messages o Contradictions Lack of support from above and below Barriers o Time o Apathy Doubt about knowledge and skills Claims, concerns and issues Claims, concerns and issues (CCIs) (taken from Fourth Generation Evaluation, Guba and Lincoln, 1989) were then used to explore the participants perspectives on using discovery interviews to improve dignity 7

in care. The concerns and issues were then used to identify and plan individual actions and future support and development needs. The CCIs are outlined below. Claims (+ve statements about DIs) I feel they can make change I feel they will improve/can improve the patient experience They can change my practice for the better I believe it can be an ongoing process I feel excited about undertaking the DIs I believe the DIs will promote ownership of change I believe that DIs listen to the voice of the patient I believe that DIs enable transformational learning Concerns (-ve statements about DIs) I feel that there is a lack of support in the areas where I am doing the DIs I find it difficult to fit the DIs into my workload I am concerned how I am going to engage with staff so that they see the value of DIs I did not know where people were in the DI process Issues The issues below were used to inform the development of actions. Issues o How can I find out where people are in the DI process? o How can Jonathan best support individuals/groups? o How can we support each other? o How can we spread the word about the DIs? o How can I fit my workload around the DIs? o How will I get people on board with the DIs? Actions o Jonathan to arrange to meet with individuals in the workplace o Individuals to contact Jonathan in between visits and group meetings if he can offer support o Group to meet 2 weekly for support o Individuals/group to use existing meetings/opportunities e.g. end of ward rounds to raise awareness of DI work o Once clinical areas have been identified, more targeted awareness raising can be planned o Management support to enable staff to have time for the work was secured before the project o A small amount of backfill funding is available o Jonathan happy to discuss time issues with managers if that would be helpful o This issue has been noted and will be given greater consideration in future AL groups once clinical areas have been identified and issues are starting to be identified from DIs 8

Appendix 2 Second Active Learning Group 15 th January 2009 (Attended by Jonathan, Gillan, Sue, Vicky and Kate) Creating a shared focus Following an initial discussion to catch up on the progress of the project, the group agreed that it would be useful to consider what a successful outcome for the project would look like to provide/create a shared focus. The participants offered the following responses: Shared vision of success Changing practice o active interest o active reflection Self innovation Raising awareness and questioning Dignity o more often spoken about o feedback from patients The group were then invited to participate in activities to explore the concept of dignity. Exploring the concept of dignity from the perspective of patients and staff using the senses Activity 1 Working in two small groups - one from the perspective of staff and the other from the perspective of patients, the participants were first asked to work individually and using a variety of approaches e.g. words, drawings, pictures/postcards, to describe: What dignity would look like? (see) What dignity would sound like? (hear) What dignity would smell like? (smell) What dignity would taste like? (taste) What dignity would feel like? (touch) They were then asked to share their perspectives within their small groups and then there was a large group discussion to explore the differences between the views of patients and staff and what this might mean in practice. The following perspectives were shared: 9

Sense Patients Staff See Calm environment Safe and comforted Organised Staff happy in work build on sense of belonging Nothing unpleasant very practical Hear Staff engaging in conversations with patients Empathetic tone Including patients in care/plans according to agreed times Listening to patients and acting Nurses asking questions e.g. what patient wants to be called Don t want to hear confidential information e.g. phone calls, ward rounds Introduce to who is around Be able to communicate with others Honesty, openess Inappropriate physical exposure Routinised care be specific Two way conversations Listening being heard Patient involvement Smell Biscuits Nice cleaning fresh Nice food smells Care of offensive smells Own/familiar smells Flowers Non-smelling staff Feel (physical and psychological) Warmth comfort, at ease Appropriate touch Taste Comfort/safety Catering meet patients needs What patient wants Clean mouth Fresh water/ice Bread comfort Fresh linen Protected Gentle with confidence Feel that you are in the right place belonging Comfort/nurturing Purity Freshness A discussion followed this activity around the expressed views and perspectives, the approach and how the group could use this with staff in practice. The following points to consider were also identified: Staff and patients may hold different perspectives There may be assumptions that we should challenge The meanings of words and expressions should be explored e.g. what does appropriate mean? Values clarification of maintaining patient dignity - Activity 2 A values clarification exercise (Manley, 1992) can be used for developing a common shared vision and purpose as the starting point for cultural change in the workplace, as our values and beliefs influence 10

our behaviour. The participants were first invited to complete this exercise individually and then all responses were collated. What is the ultimate purpose of maintaining patient dignity? Patient s hospital stay to be as least traumatic as possible Individual needs respected and delivered To keep our jobs For patients to have a positive experience of care Because we want to It is how we would want ourselves and others to be treated It is a key value in our practice So people experience feelings of being cared for and are safe It can contribute to patient recovery I believe the purpose can be achieved by Everyone sharing same values common understanding of dignity Treating everyone with respect and as an individual Visible leadership Demonstrating that it is an important priority Effective work based cultures Care being given in the right environment Raising awareness and maintaining work being undertaken Not being fearful to challenge and question I believe the factors that help us to achieve this are. Staff morale and motivation Leadership o Acting as a role model Dignity a priority Valuing staff Provide effective support and challenge Opportunities for working alongside o Feedback o Reflective discussion set o Open to/welcoming support of new ideas Commitment What factors would hinder? Low staffing levels Poor performing staff Lack of access to education o Low levels of knowledge o Lack of opportunity Poor staff morale Environmental factors 11

Lack of managerial support No positive leader Other values and beliefs Difficulty/limitations with scope of influence Hierarchy may dominate culture in a negative way Action planning Following the activities, the participants identified some short term actions. These included meeting the following week to explore: Running senses workshops across three wards Facilitating the values clarification exercise with staff on individual units 12

Appendix 3 Third Active Learning Group 12 th March 2009 (Attended by Jonathan, Gillan, Sue, Vicky, Jacob and Kate) As all of the group members were finding the organisational context difficult when trying to move forward with the project, the group agreed that it would be helpful to revisit the claims, concerns and issues to gain a sense of their progress. Claims (+ve statements about the project) There is increased communication better networking between team members We have a request for presentation at PIC UCLH Nursing conference (October) We are maintaining enthusiasm There have been positive outcomes from group workshop positive action. Points moving forward: o e.g. audit of dignity issues o enthusiasm from ward staff We have the wards working towards change Concerns (-ve statements about the project) We remain concerned about engaging staff (especially from HJW) in workshops due to ward pressures Concern that individuals have not completed interviews Individual time constraints Issues How can we involve more staff? o Benchmarking o Multi media techniques o Graffiti board o Questionnaires o Values/beliefs analysis o Observation of care develop protocols How do we help people challenge? o Empowering people to challenge o Setting examples How do we maintain momentum with project in context of other agendas? o What resources do we need? o Potential for paying for extra time From this process the following actions were identified: Renegotiating regular contact Clarification of approaches and tools to be used, e.g. value clarifications 13

Appendix 4 Fourth Active Learning Group 21 st May 2009 Agreed action points: Vicky: to pilot the observation of care tool make amendments as necessary feedback to Sue and Gillan so that they can start to use the tool Sue: liaise with Lesley to explore the way in which the exploratory workshops and the observation of care can be achieved Gillan: continue working with group and arising activities All: continue with DIs try to complete at least one interview before we next meet 14

Appendix 5 Fifth Active Learning Group Sue Review of progress to date: Has completed one interview Has talked with staff Has run a workshop with staff (Aug 09) which involved: o Defining dignity o RCN video o Exploring issues from the perspective of patients and staff There is currently a particular issue on the ward which relates to caring for patients with challenging behaviour. Plans: Run a second workshop aim to do within next 3 weeks.?involve other stakeholders to gain multiple perspectives Gillan Review of progress to date: Has run two workshops involving two wards o What dignity means to patients o What dignity means to nurses Working group developed from workshops using senses approach to consider back on the wards what dignity looked like. Identified: o Curtains not closed o Staff walking through curtains o Patient not fully clothed o Poor practices at mealtimes e.g. food too far away to reach Considered action points: o Use of pictorial prompts o Review use of curtain clips and messages o Review food delivery with domestic staff/managers Consider Dr Fosters questions and how they could inform project Staff have completed a survey 46% response rate still to be themed General points: Consider who else can help and/or should be involved Consider other approaches to involving staff e.g. graffiti boards in office etc. 15