Transcript 'Dignified care for frail older people: Can we deliver?

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
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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
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1998 Not Because They Are Old.
Health Advisory Service inquiry
report
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1999 ‘Dignity on the wards’. Help
the Aged report and campaign
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2001 Caring for Older People: a
nursing priority. Standing Nursing
and Midwifery Advisory Committee
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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
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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
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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 156I 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
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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
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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
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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)
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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
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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
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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
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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)
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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/pr
ojdetails.php?ref=08-1819-218
May 2008 – June 2011
Ethnography 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
© W Tadd 2012
‘Influences on dignified
care’ A wide range of
barriers to, and facilitators
of dignified care
Dignity in Practice
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Failure to act on the fact that
 In-patients are very likely to be old
Up 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.
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Most in-patients are likely to have more than one chronic
condition complicating their acute illness
Has resulted in
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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?
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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)
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© 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
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Environmental influences
Deficiencies in the knowledge and experience of
ward staff
© W Tadd 2012
Environmental influences
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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 – noone 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
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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
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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, personcentred 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
© W Tadd 2012
Demoralised staff
Dignity: A tale of two wards
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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
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]
Report: http:/www.netscc.ac.uk/hsdr/projdetails.php?ref=08-1819218
Other resources: http://www.cardiff.ac.uk/socsi/dignity/index.html