National policy context: dementia

When the study began, in early 2013, the timing seemed propitious. National policy on improving the care of people with dementia had been given impetus with publication of the Prime Minister’s Challenge on Dementia 2015.⁹ This coalesced with other policy drivers: the report of the Francis inquiry, published in March 2013,¹⁰⁸ on the failings in Mid Staffordshire NHS Foundation Trust, particularly around the care of frail, older patients; and the findings of the first National Audit of Dementia Care on acute wards.²⁵

Interest in improving hospital care for patients with dementia was reflected across the five trusts. All had in place, or were in the process of developing, dementia strategies, although the content of these varied.

Organisation

City Trust is a long-established foundation trust, being among the first wave to achieve foundation status. It provides services to a core population of around 500,000, and employs > 5000 staff. Acute services are mainly located within a 900-bed hospital, with an 80-bed facility providing rehabilitation and outpatient provision from a separate site. It is a large, busy trust, with > 120,000 accident and emergency (A&E) department attendances annually. Situated in a region with a post-industrial heritage and a diverse culture, its diversity has contributed to an increased demand on health and social care provision at both ends of the age spectrum.

Since attaining foundation status, City Trust had generated an annual surplus. However, annual reports noted the challenge of securing improvements in quality and performance, managing reduced income growth, identifying efficiency savings and responding to the demands of a multiethnic population within one of the most deprived English local authorities.

Up until 2011, the trust was assessed as meeting the performance targets set by the national regulator, Monitor. During 2012 and 2013, performance targets on waiting times for treatment were breached, resulting in a review by the NHS Support Team, the launch of a comprehensive turnaround programme, and a return to compliance in April 2013. In January 2014, the Care Quality Commission (CQC) issued a report on an unannounced inspection the previous October on the main hospital site and assessed that action was needed in several areas, including respecting and involving people who use services and assessing and monitoring the quality of provision. A warning notice was issued on staffing because of staff vacancies carried. Strategic action centred on making improvements in problem areas, including the recruitment of staff, for implementation during 2014. A CQC inspection in October 2014 assessed the trust as ‘requiring improvement’; medical care was ‘good’ at both hospital sites. A change in leadership at board and senior management level at this time created some organisational instability. This was the context in which the strategic priorities around the care of people with dementia were established.

Care of people with dementia

A strategic trust priority from 2011 to 2012 was improving the physical environment for patients with dementia. City Trust was successful in securing external funding for this purpose, augmented by investment through its capital improvement programme. The design and execution of the changes on several older people’s wards was described as ‘exemplary’ in the CQC’s 2014 inspection report. The 2013/14 annual report announced the extension of the improvement programme to the second hospital.

Since 2012, a rolling programme of ‘dementia awareness’ training tailored to different staff groups had been delivered jointly by the dementia lead within the elderly services directorate and the trust’s practice development lead. Both subsequently launched an initiative to recruit ‘dementia champions’. The appointment of a lead nurse for dementia in 2014 instigated a dementia strategy through the formation of a multidisciplinary dementia steering group.

Rivermead: structure and organisation of care delivery

Rivermead is a ‘step-down’ ward for rehabilitation. The hospital in which it is located previously had more inpatient wards but now mainly comprises outpatient services and rehabilitation beds, acute services being centralised in the main hospital. Bed numbers fluctuate according to bed management demands: usually 27 during ‘winter pressures’ and 23 at other times.

Patient profile

There were 123 admissions over 7 weeks at baseline, eight of which were readmissions (approximately 18 admissions per week). All of those admitted had come from the main hospital following an acute episode. The median length of stay was 14 days (range 1–48 days). Table 1 provides a summary of the patients’ sociodemographic characteristics.

TABLE 1

Rivermead patient profile: sociodemographic characteristics

More than half of the patients were in advanced older age (i.e. aged ≥ 85 years), and women dominated. Most patients had been living in their own home before the event that had precipitated their acute admission.

Over one-third (n = 44) of patients had an ongoing cognitive impairment: 36 had a diagnosed dementia and eight had been assessed as having probable dementia. Almost one-fifth had delirium (n = 24), of whom 12 had both delirium and dementia. Thus, just under half of patients (n = 56) on this ward had a cognitive impairment on admission. Just over half of patients had delirium during their stay (n = 64), although for most of them the mean number of days in delirium was 3 (range 1–27 days). Only one-quarter (n = 32) of patients were identified as having no cognitive impairment either on or during admission.

The reasons for admission are shown in Figure 2, although for most patients multiple factors (medical, functional and cognitive) were implicated.

FIGURE 2

Rivermead: reasons for admission. COPD, chronic obstructive pulmonary disease; SOB, shortness of breath.

A further indication of a patient’s degree of frailty is their discharge destination (Figure 3). Ten per cent of patient discharges involved a new long-term care admission; a further 10% of patients were discharged to intermediate care for additional rehabilitation; and 2% died in hospital.

FIGURE 3

Rivermead: discharge destination.

Rivermead: care culture

At the start of fieldwork (February 2014), Rivermead had a stable ward leadership and purpose. The staff group had worked together for a long time (median 4 years and 3 months, and up to 25 years among those completing the Climate of Care questionnaire; n = 15), reflecting the broader profile of a stable team.

The responses to the Climate of Care questionnaire indicated that staff shared an explicit philosophy of care and culture of caring, were respectful of each other’s skills and knowledge, and valued patient involvement in decision-making. The ward manager was viewed as someone who inspired confidence, consulted the team about daily problems, acted in a caring manner towards the team, was explicit about the care standards expected and set an example in hands-on care, actively coaching individuals. At ward level, staff felt supported and engaged, a picture reinforced from observation and interviews. The ward manager was a key driver in shaping the care culture: an experienced nurse and manager, she perceived her role in priority order as ‘looking after my patients’; ‘looking after my staff’ (emotionally, developing knowledge and skills, and encouraging them to participate and further their careers); and ‘as a manager’, ensuring compliance with trust policies and procedures. She had undertaken advanced training in dementia, and conveyed, in values and practice, a commitment to providing individualised care to patients.

There were mixed views regarding staff relationship vis-à-vis the trust. The downside of being located at a distance from the main hospital site was poor communication and links with senior or specialist colleagues. There was a sense that colleagues in the main hospital lacked understanding of the ward’s purpose (rehabilitation), and had little appreciation of their particular skills and the complexity of the patients with whom they worked. Positively, they valued the sense of camaraderie engendered among staff in the smaller site and the greater autonomy and predictability of the work. External pressures on day-to-day-work were viewed as constraining their ability to deliver the quality of care they aspired to provide. Among some staff, a source of stress was the lack of time to reflect on ways to improve care delivery. As the bridge between the hospital and ward, senior staff, particularly the manager, sought to contain the tension between the priorities and requirements of the trust and their espoused values on providing individualised care and supporting staff. This, along with their physical separation from the main hospital, meant that the ‘troubles’ of the trust around meeting performance targets, and the changes at trust and senior management team level, were less salient for the ward team. Furthermore, the stability of the staff team meant that although there was recourse to Bank and agency staff to cover some shifts, hospital staff vacancy levels had less of an impact on Rivermead than on other wards with an unstable staff group.

Cedar: structure and organisation of care delivery

This orthopaedic trauma ward had moved to a temporary location at the end of 2013 and there was uncertainty surrounding its future purpose. Subsequently, following bed closures and ward remodelling, a new ward was created, involving half of the beds on a former older people’s ward and half for older trauma patients. This ward came into existence in August 2014 and agreed to participate in the study, with fieldwork commencing in September 2014. Given the late entry of this ward into the research, it was agreed that PIE implementation would occur over 9 months rather than the 18 months originally envisaged.

Of the 28 beds on this ward, 14 were for patients aged ≥ 60 years with fractured neck of femur; the remainder were for older, medical patients.

Patient profile

During baseline, there were 190 admissions to Cedar over 7 weeks, four of which were readmissions (approximately 27 per week). The median length of stay was 7 days (range 1–47 days), facilitated by access to ‘step-down’ beds (Rivermead or similar). Table 2 provides a summary of the patients’ sociodemographic characteristics.

TABLE 2

Cedar patient profile: sociodemographic characteristics

Just under half of patients were in advanced older age (44% were aged ≥ 85 years). The majority for whom data were available had lived in their own homes before being admitted to hospital.

On admission, at least one-third (n = 62; missing data, n = 96) of patients had an ongoing cognitive impairment: 41 with a diagnosed dementia and 21 assessed with probable dementia. Eight patients were identified with delirium, of whom seven also had dementia (missing data, n = 120). For those patients for whom data were available (approximately half, n = 94), just over half (n = 50) had a cognitive impairment on admission. Of the data collected on delirium during admission (missing data, n = 157), 18 patients had delirium (median of 3 days in delirium; range 1–12 days).

The reasons for admission to Cedar are shown in Figure 4. The pattern reveals a more acute profile than in Rivermead, suggested also by the relatively high proportion of patients who died during their admission (15%).

FIGURE 4

Cedar: reasons for admission. COPD, chronic obstructive pulmonary disease; SOB, shortness of breath; UTI, urinary tract infection.

The data on discharge destination (Figure 5) reflected the fact that a significant minority of patients on this ward were discharged to the ‘step-down’ ward when they were medically stable but still insufficiently recovered to return to their usual residence. The symbiotic relationship between the acute older people’s wards and rehabilitation wards such as Rivermead contributed to the very short length of stay on Cedar, the ‘step-down’ wards providing additional therapy for patients deemed not safe to be discharged.

FIGURE 5

Cedar: discharge destination.

Cedar: care culture

The ward manager had spent most of her working life nursing older people and, like her colleague on Rivermead, was an experienced ward manager. Although a number of team members had come with her from a care of older people’s ward, melding a staff group into a team with a dual focus on complex medical conditions and orthopaedic trauma was still a work in progress when fieldwork commenced. The level of patient dependency was regarded as high, and the physical demands of providing care weighed heavily on staff, as many patients required two people to assist them with personal care.

In interviews, the ward manager conveyed a strong ethos of individualised care, tempered with an acknowledgement of the reality of the multiple and simultaneous demands on staff. The work of a ward manager was presented as balancing different and competing interests: meeting hospital targets regarding flow and spending time with patients, reducing falls risk and undertaking rehabilitation work towards functional improvement.

From their responses to the Culture of Care questionnaire (n = 14), staff echoed the priority that their manager attached to individualised care, treating patients with dignity, putting effort into providing good-quality care, meeting patients’ care needs, and involving patients and caregivers in decision-making. They valued the skills, competence and support of colleagues; had trust and confidence in each other; communicated and worked well as part of the MDT; and felt able to bring up issues and challenge practice. The manager was perceived as inspiring confidence, consulting with the team about daily problems, acting in a caring manner towards staff, being explicit about the care standards expected and setting an example in hands-on care.

Similar to colleagues on Rivermead, staff on Cedar perceived a gap between their aspiration to provide individualised care and the inadequate support and resources for spending time with patients and developing new skills. In comparison with Rivermead staff, they were less critical of the resources available to them at the hospital level, particularly valuing the access they had to expertise on aspects of care. This probably reflected their physical proximity on the main hospital site, being closer to decision-making structures. For senior ward staff, particularly the manager, hospital priorities on patient flow, reducing length of stay and cutting beds imposed a heavy burden, as they were closer to the everyday impact of these pressures.

Organisation

Valley NHS Foundation Trust provides acute, rehabilitation and community services in hospital and community settings for a geographically dispersed rural and urban population of > 200,000. It covers an area of > 700 square miles in north-west England and acquired foundation status in 2010.

When the study began, the main hospital had 395 beds for acute, elective and specialist care, and some 55,000 A&E department attendances annually. It had a strong local presence and community connection, reflected in its large volunteer base, with around 400 volunteers carrying out over 30 different roles across wards and departments. The trust also managed three community hospitals in different locations across its wide area.

Annual reports between 2010/11 and 2013/14 revealed an organisation consistently meeting national targets on finance and governance, clinical safety and effectiveness and which had been operating with a relatively stable trust leadership. Similar to City Trust, Valley had invested heavily in the modernisation of its built environment, including improving the ward’s physical environment.

As in other study trusts, NHS reorganisation posed considerable uncertainty for forward planning. Simultaneously with organisational upheaval, the following challenges were noted: delivering safe and quality care, and managing a 3–5% year-on-year increase in volume demand on services alongside the requirement on providers to find efficiencies of 4–5% per annum to absorb the growth within a fixed overall real-term budget. The dual strategy pursued in meeting these competing demands was to cut costs and develop new services to grow income.

Care of people with dementia

Local strategic priorities included reducing ‘slips, trips and falls’, which were viewed as a particular risk for people with dementia. Initiatives included the development of a system to more accurately monitor falls; the introduction of screening, assessment and evaluation tools to improve risk management processes; the purchase of monitoring equipment to reduce falls incidence; the provision of floor-level beds for patients at high risk of falling out of bed; and the inclusion of falls prevention and bed rail use in mandatory training.

For people with dementia, priorities were improving nutritional care and implementing the ‘Butterfly Scheme’. The former involved the expansion of an established ‘feeding buddy’ system with trained volunteers to assist vulnerable patients to eat and drink. The ‘Butterfly Scheme’, introduced in 2011, used a butterfly symbol to highlight the needs of patients with a dementia diagnosis; provided staff with practical guidance to meet the needs of these patients; and alerted staff to the collection and use of information from relatives to better engage with these patients and to inform care planning. The scheme was supported through mandatory training for the clinical and support staff who directly provided care.

Increasing staff awareness of dementia was prioritised through a programme of ‘dementia champions’, and the creation of more ‘dementia-friendly’ environments was pursued through ward refurbishment in 2013/14, supported by external funding.

Oak: structure and organisation of care delivery

Oak ward was a 28-bed, acute orthopaedic trauma ward. Around 30 months before the study, there had been a change in medical leadership: orthogeriatric consultants had been introduced alongside orthopaedic surgeons to provide comprehensive geriatric assessment and care planning for older patients. This involved separate MDT meetings on a twice-weekly basis.

Patient profile

There were 174 people admitted during baseline, of whom one was a readmission. This was a mixed-age profile (range 16–101 years). There were two distinct admission patterns: younger people with limb fractures typically sustained in motoring accidents, and people in advanced older age with fractured neck of femur and comorbid chronic health problems. The median length of stay was 9 days (range 1–78 days). Table 3 provides a summary of patients’ sociodemographic characteristics.

TABLE 3

Oak patient profile: sociodemographic characteristics

Whereas around one-quarter of patients overall had a diagnosis of dementia or were assessed as having probable dementia on admission, this applied to 40% of those ≥ 80 years. Furthermore, 9% had a delirium on admission, the majority of whom (11/15) had delirium on dementia. Most people had been admitted from their own home; 13% were residents in a nursing or residential care home. Just over one-third of older people (aged ≥ 65 years) had delirium during their inpatient stay (36%), and the median number of days in delirium was 4 (range 1–28 days).

The reasons for admission to Oak ward are shown in Figure 6. Given the nature of the ward, admissions were dominated by orthopaedic trauma; among older people, the largest single reason was a fractured hip.

FIGURE 6

Oak: reasons for admission.

Patient destinations on discharge are shown in Figure 7; 5% died in hospital and, of the rest, 9% went to a new permanent nursing or residential care home (although this applied to just under one-fifth of older patients).

FIGURE 7

Oak: discharge destination.

Oak: care culture

During baseline (end of November 2013 to early February 2014), the ward team was undergoing change. Until then, it had been relatively stable, with a strong, supportive team ethos. The manager had been in post for 6 years, first as a junior sister and then as manager, and many of the nursing and care staff had worked together for ≥ 5 years. However, several nurses had left or were in the process of leaving when fieldwork commenced; difficulties and delays in recruiting new staff resulted in the use of temporary staff, which had an impact on workload and ward morale.

The manager placed high value on supporting her staff, considering that a ‘stressed’ staff member affected everyone, both colleagues and patients. Observation revealed a leader who was a visible and cheerful presence on the ward and who conveyed to staff that their work was appreciated. Delivering ‘quality care’ was seen to require attention to patients’ emotional as well as physical and care needs; furthermore, spending time with patients was conveyed as a necessary and valued part of nursing and care work. The current staffing difficulties were regarded as compromising the realisation of this vision. In her interview, the manager envisaged that an aspect of her role was to absorb pressures from senior management so as to sustain a calm and ‘happy’ care environment. This conception of the ward leader as ‘buffer’ between the demands of senior management and the day-to-day work of providing direct patient care was felt as isolating and stressful.

The change in the staff team was evident among those completing the Climate for Care questionnaire (n = 14). Respondents were equally divided between those who had worked on the ward for between 1 and 6 months and those who had been there for ≥ 5 years. Staff reported that they shared an explicit philosophy of care, that there existed a culture of caring for patients and that the psychological aspects of care were highly valued, as was the involvement of patients and their caregivers. Staff were generally negative about the adequacy of support services to enable them to spend time with patients and also considered that there were insufficient numbers of staff who had the knowledge and skills to provide quality patient care. This was felt across the board: among both long-standing staff members and those who had been in post for ≤ 6 months.

Respondents considered that the quality of care provided by the MDT met patients’ individualised needs and was responsive to the needs of caregivers; staff were viewed as treating patients with dignity and respect; there was good communication between team members; and people worked well together and were supportive of each other. The general view was that there was insufficient time to reflect on performance and ways of improving care delivery. This view was supported by observation: staff members were in continuous motion, a combination of the physical demands of patients who were immobile and staff shortages. External pressures acted as a constraint on delivering the quality of care that they aspired to provide. The team viewed the ward manager as supportive, a visible presence and a role model in delivering hands-on care. In contrast, their perception of the hospital management was negative: they considered that staff views were not listened or responded to, and that support for staff at ward level, when needed, was not forthcoming.

Ambridge: structure and organisation of care delivery

Ambridge was a 30-bed care of older people ward, although bed numbers were reduced to 29 during baseline because of staffing shortages. The ward was designated for patients with ‘acute and complex needs’.

Patient profile

There were 171 people admitted to Ambridge over 9 weeks (around 17 per week), of whom two were readmissions. (Baseline fieldwork extended a further 2 weeks here, compared with other sites, to take account of the disruption caused by the move to the new space.) The median length of stay was 11 days (range 1–89 days). Table 4 shows the patient profile.

TABLE 4

Ambridge patient profile: sociodemographic characteristics

Over half of the patients were in advanced older age (56% were aged ≥ 85 years). One-quarter had a diagnosis of, or probable, dementia. From fieldwork (handover, MDT meetings and observation), this appeared an underestimate and inconsistent with findings from other care of older people study wards. Just under one-fifth of patients (n = 30) had delirium on admission, of whom most (21/30) had a delirium on dementia. Data on delirium incidence were not collected.

The reasons for admission to Ambridge ward are shown in Figure 8.

FIGURE 8

Ambridge: reasons for admission. AF, atrial fibrillation; COPD, chronic obstructive pulmonary disease; SOB, shortness of breath; TIA, transient ischaemic attack; UTI, urinary tract infection.

Discharge destinations are shown in Figure 9. Two-thirds of patients returned to their own homes on discharge, a smaller proportion than in Oak, reflecting a higher number who died during admission (9%) and a higher proportion of new admissions to long-term care (13%) or to hospice/palliative care (2%).

FIGURE 9

Ambridge: discharge destination.

Ambridge: care culture

Similar to Oak, Ambridge was a ward in transition. This had a spatial dimension (being parked in a temporary location while awaiting the move to its permanent, refurbished home) and a staff dimension (change in ward leadership and departure of experienced staff). Both contributed to disruption.

During most of baseline, the junior sister managed the ward. An experienced nurse, this was her first management post. She expressed strong commitment to providing care that treated ‘people as individuals’ and therefore placed store on finding out their concerns and wishes, including people unable to communicate through language. The combination of few experienced staff on the team, others in post only a short time, and reliance on temporary staff to cover shortages, exacerbated the difficulty in creating and sustaining a coherent ward culture. Whereas some on the ward had chosen to work with older people, and had knowledge and understanding of dementia, others had not.

There were only four respondents to the Culture of Care questionnaire: two had worked on the ward for 12 and 10 years, and the others had done so for 5 and 6 months. Their responses echoed the views of staff from informant conversations during observations and formal interviews. They conveyed common values: placing emphasis on caring for and supporting patients, and seeing the involvement of patients and caregivers as important. Yet they considered that there was an absence of resources and support to allow them to spend time with patients, and insufficient staff to provide quality care; and as a team, they did not review how to improve care delivery. Although supportive of each other, they reported an inability to challenge poor practice or to raise difficult issues with colleagues. They were most negative about the hospital, perceiving that their concerns and opinions were neither listened to nor responded to, and that assistance was not available when needed.

Organisation

Ironbridge Trust, similar to City, is a long-established foundation trust. It provides acute, elective, specialist and some community services to a core population of around 650,000. The location of a major trauma centre, it has > 150,000 A&E attendances annually. With around 2000 inpatient beds and employing some 16,000 staff, it is one of the largest trusts in the country and one of the biggest local employers.

Annual trust reports between 2010/11 and 2013/14 presented an organisation that, in leadership, efficiency, safety and caring, was successful and consistently meeting national and local targets. Similar to other study trusts, it presented as being challenged by the multiple and competing political, organisational, performance, financial and regulatory demands.

A major transformation in service delivery was initiated by the integration of adult community and acute services from spring 2011. A further integrative step from autumn 2014 involved combining the Directorate of Geriatric and Stroke Medicine and the Primary and Community Services Care Group, a union with a direct impact on our study ward.

Care of people with dementia

From 2011/12, the trust’s strategic priorities included improving the care of people with dementia and creating ‘dementia-friendly’ physical environments on care of older people wards.

In 2011, a new ward was established that was dedicated for older patients with dementia undergoing hip fracture surgery; and, in 2012, an integrated multiprofessional care pathway for patients with both dementia and delirium was implemented, supported by training. A discreet symbol was developed (as in Valley wards) to enable staff to recognise people with dementia; this was aligned with a personal information booklet, ‘All About Me’, launched in spring 2014, for use by patients with confusion/dementia and their caregivers.

Netherton: structure and organisation of care delivery

Netherton was an acute medical ward for those aged ≥ 70 years with comorbid dementia or delirium/acute confusion. It was not a specialist dementia ward:⁵⁹ it did not employ specialist mental health staff, therapy input was similar to that in other care of older people wards, and it had no additional staff providing activities. During baseline, Netherton comprised 28 beds (including one bed for ‘winter pressures’, which was consistently in use during fieldwork).

Patient profile

There were 75 people admitted during baseline (an average of eight per week), and no readmissions. Most patients came directly from A&E or the assessment unit (70%; 52/75); just under one-third had been admitted from other hospital wards. The median length of stay was 41 days (range 1–126 days); extended lengths of stay were attributed to changes in the system for financially assessing patients, resulting in delays to some patients being discharged. Table 5 summarises the patients’ sociodemographic profile.

TABLE 5

Netherton patient profile: sociodemographic characteristics

Just under two-thirds of patients were in advanced older age, a slightly older profile than in other participating wards, and women dominated. Most had been admitted from their own home.

Most patients (n = 70, 93%) had dementia (the remaining patients had delirium but not dementia). Nearly two-thirds (60%; 31/52) of new acute admissions had delirium. Overall, 70% (54/75) had delirium during their stay, of whom nine (13%) were in delirium for ≥ 30 days. The median number of days in delirium was 16 (range 1–57 days). The reasons for admission are shown in Figure 10.

FIGURE 10

Netherton: reasons for admission. UTI, urinary tract infection.

Discharge destination data were available for 44 patients (the remaining 25 still being in the ward at the end of data collection). These are presented in Figure 11.

FIGURE 11

Netherton: discharge destination.

Of those for whom information was available, 25 (57%) were discharged to their own home; one-fifth involved new admissions to long-term, mainly nursing home, care.

Netherton: care culture

An established, stable team, half of them had worked together for at least the 8 years in which the current ward model had operated (acute, dementia care). This included senior staff (ward manager, senior sister and charge nurse) who had a wealth of knowledge and skill in caring for people with dementia, acquired through formal self-directed learning, personal and professional experience. They conveyed, through formal and informal mechanisms, a consistent and coherent team ethos and a commitment to the ongoing appraisal of work practices. Twice-yearly away days were held for staff to examine practice and identify problem areas to work on. Everyone was expected to attend (the away days were organised as two separate days to facilitate participation). Through these various mechanisms, new staff were enculturated into a style of team working that emphasised continuous improvement as ‘how we do things on this ward’. The ethos of person-focused care was reflected in the responses to the Culture of Care questionnaire, completed by just over half of the team (n = 18).

Consensus existed among respondents that the team shared an explicit philosophy of care; the psychological needs of patients were considered; involving patients and their carers was an important part of the work; and these values and expectations were communicated to new staff. There was agreement that patients were treated with dignity and respect; they experienced individualised care, and patients’ and families’ care needs were met (reflected in research observations).

Most respondents agreed that there were sufficient ward resources to deliver good care, including staff with the requisite knowledge and skills to provide it. Just under half regarded staffing levels as insufficient to allow them to spend enough time with patients.

They felt supported as a team, could rely on each other, were relatively comfortable about bringing up problems with colleagues and felt that they could influence ward decision-making. In agreement with staff on other study wards, there was too much work to do in too little time, but they particularly valued the learning and development opportunities available.

Strong, positive feedback was received about the ward’s leadership and management style, especially the support provided and clarity of expectations around achieving care excellence. Perceptions of the wider hospital were mixed, although views were more neutral to positive about the availability of training opportunities and access to resources.

Organisation

This foundation trust is one of the largest in England, employing around 11,000 staff (one of the top five employers in the region). It treats more than 1.2 million people and has 250,000 A&E attendances annually. Acute services are primarily located in one main hospital, with additional beds in two smaller hospitals. The study wards were located in one of these, comprising around 229 beds and providing a range of community, outpatient, inpatient and emergency care services. This hospital was situated approximately 6 miles from the main hospital, within a self-defined, organisational community (it has its own local authority) of 250,000 people.

Trust board annual reports from 2011/12 reveal an organisation in which balancing finances was a persistent and significant challenge. In 2013, the trust’s contingency fund was under pressure; the research site hospital was in overspend by 15% and had not delivered on its cost improvement programme. A plan to reduce costs by closing flexi beds was set in train; and the financial position of the hospital was in focus, including weekly rectification update meetings. The trust was also reviewing staffing models as a cost-saving measure.

By November 2013, the A&E waiting time performance target had been missed for five consecutive quarters, creating concern that Monitor would intervene and prompting micro-management to regain control. All elective inpatient surgery was temporarily suspended, which resulted in failure to meet the 18-week referral-to-treatment target and the creation of a backlog in excess of 1000. The research site hospital met A&E waiting time targets, but, with significant pressure on the trust affecting all sites, work was conducted to review capacity and demand.

A CQC inspection in autumn 2013, the results of which were published in January 2014, deemed the trust as requiring improvement on all criteria apart from ‘effective’. The trust board and senior management were under considerable pressure to balance development and redesign against significant challenges, including winter pressures, increased activity and securing financial recovery.

Care of people with dementia

Local strategic priorities during 2011–14 included a programme to deliver improvements to the care of people with dementia and delirium, including policy, ward environment and drug treatment. The dementia strategy and steering group selected key areas to monitor, including education, improved pathways, metrics, and the embedding of personalised ‘all about me’ documentation into practice. A supported integrated discharge team was established to facilitate the timely discharge of frail elders, and joint old-age medical and old-age psychiatry were to be available on every site. The trust dementia steering group placed emphasis on improving dementia screening rates, which were well below target. Of the trust hospitals, the research site had best compliance with screening: from 3% in September 2013 to 33% in December 2013 (the target was 90%).

A trust-wide ongoing programme of ‘dementia awareness’ training had been delivered before the start of the research, tailored to different staff groups, with the intention of utilising a group of ‘dementia champions.’ In recognition of the increasing number of patients with dementia, 30 mental health nurses were recruited to Bank staff, and some volunteers received specialist training in dementia in the main hospital, with a rollout plan to other sites.

Denton: structure and organisation of care delivery

Denton comprised 13 beds. A designated ‘enhanced recovery ward’, it was intended to provide dedicated support to people with dementia who were medically fit and mobile and would benefit from the expertise and calmer environment offered there. It was also part of the trust’s winter initiatives to manage patient flow. When fieldwork began, the ward was relatively new, having opened in January 2013. Early in the data collection phase, it emerged that long-term funding to the ward was insecure and that bed numbers were not included in the hospital total. The ward underwent waves of imminent closure threats. The impetus for keeping the ward open came from clinicians who were passionate about having access to a resource for people with dementia and from positive feedback from patients and relatives.

Patient profile

During baseline, there were 39 people admitted over 9 weeks (approximately four per week), of whom one was a readmission. Patients were admitted from other wards in this hospital, following an acute stay. The median length of stay was 25 days (range 4–79 days). Table 6 summarises the patients’ sociodemographic characteristics.

TABLE 6

Denton patient profile: sociodemographic characteristics

More than half of patients were in advanced older age (median 88 years), and the majority were women. Most had lived at home before their acute admission. All (n = 39) had dementia; one-quarter (n = 10) had delirium (of whom seven had delirium on dementia). During their admission, most patients had delirium (n = 33); the median number of days in delirium was 11 (range 1–36 days). The reasons for admission are shown in Figure 12.

FIGURE 12

Denton: reasons for admission. UTI, urinary tract infection.

A further indicator of the frailty of the patient profile is the discharge destination pattern (Figure 13), which shows that 16% of patients died and 38% went to long-term care.

FIGURE 13

Denton: discharge destination.

Denton: care culture

Most staff had worked together since the ward opened, some 7 months prior to baseline. All had chosen to work there because they had an interest in dementia. Many of the resources on the ward – for example games and reminiscence materials – had been purchased through fundraising initiatives by ward staff. There was heightened goodwill among staff, patients and relatives in joint working towards such initiatives.

Ten Culture of Care questionnaires were completed: eight by nursing and care staff, and one each by a doctor and a housekeeper.

There was consensus that the team had a caring approach, shared an explicit philosophy of care, placed high value on the psychological care of patients and the provision of enabling support, and regarded the involvement of patients and caregivers as very important. There was agreement that the team had access to adequate resources and that they routinely engaged in reflection and discussion aimed at improving care delivery.

The perceptions of the MDT were almost unanimously positive, with good working relationships. There was a consensus that patients were treated with dignity and respect, that they experienced good individualised care and that patients’ and families’ care needs were usually met. Observation supported this picture, attesting to a style of collaborative work with families that embraced sensitivity and responsiveness to their anxieties and concerns. There was very positive feedback about the emotional and practical support offered within the team, with respondents unanimous about the trust, competence and confidence they shared, and that they felt comfortable about discussing difficult issues together.

There was a slightly mixed response with regard to balancing resources and demands. Although some considered that there was too much work to do in too little time, most agreed that they could follow best practice within existing resources. They were generally very positive about ward learning and development opportunities.

Universal, strong, positive support about all aspects of ward leadership and management was conveyed: the ward manager was reported to consult daily with the team and to be an ongoing presence who was involved in hands-on patient care.

The most variable responses were provided to questions about the hospital, indicating mixed views about hospital resources, access to expert assistance and the responsiveness of hospital management to staff concerns. It was largely agreed that the hospital provided adequate training opportunities and treated staff with dignity, and that staff had the authority to make decisions.

Comparing all wards in the study, Denton respondents were most universally positive, summed up in the comment of a HCA:

I have worked on [Denton] since it opened . . . I have never been as happy since I started working for the trust. It is a lovely well-run ward . . . patients get great care here.

Beech: structure and organisation of care delivery

This ward provides care to a mix of older people with complex medical needs and those who suffered orthopaedic trauma, primarily fractured neck of femur. During baseline, the ward usually had 24 beds: 12 trauma and 12 medical. There was an additional bay, open as part of the hospital’s capacity-management strategy, making a total of 31 beds (over five bays and three side rooms). Historically, the ward had undergone many changes over the years (of purpose, size, patient group and physical location).

Patient profile

During baseline, admission data were recorded for approximately 5 weeks, during which there were 60 admissions (12 per week). The median length of stay was 20 days (range 4–153 days). The physical and cognitive abilities of patients varied. For example, ability to mobilise spanned those who walked around the ward independently to people who were mostly in bed. Many patients were physically frail, requiring assistance to transfer or to mobilise. Table 7 summarises the patients’ sociodemographic characteristics.

TABLE 7

Beech patient profile: sociodemographic characteristics

More than half of patients were in advanced older age (median 87 years; range 67–99 years). The majority had lived at home (including many who had caregivers) prior to the event that had brought them into hospital. Just over one-third had dementia (n = 21). Given the age profile of these patients, and based on observation, this probably underestimated the dementia prevalence (data were incomplete; data were missing for 27 patients. On admission, at least one-fifth had delirium (n = 12; missing data, n = 27). Of those who were assessed for delirium during their admission (n = 18; missing data, n = 42), almost half were identified as having a delirium (n = 8) for a median of 3 days (range 1–15 days). The reasons for admission are shown in Figure 14.

FIGURE 14

Beech: reasons for admission. AF, atrial fibrillation; TIA, transient ischaemic attack; UTI, urinary tract infection.

Data on discharge destination are presented in Figure 15. Just under three-quarters of patients returned to their usual residence on discharge; a further quarter were equally divided between those who died and those who were newly admitted to long-term care.

FIGURE 15

Beech: discharge destination.

Beech: care culture

The ward model was relatively new, and there was considerable ongoing work necessary, from the ward manager’s perspective, to construct a team and forge a common care ethos; this was made more difficult by a shortage of permanent staff and a reliance on temporary workers. This was reflected in the responses to the Culture of Care questionnaire, completed by five staff only (two nurses, one HCA, one geriatrician and one who did not provide his or her job role). Interpretations of the questionnaire data are limited, given the paucity of data; however, there are clear patterns in the responses that echo those derived from observation and interviews. Of all of the wards, the respondents here were most negative.

Generally, the respondents conveyed that among the team there was low value placed on involving patients and caregivers, insufficient basic ward equipment, inadequate support to allow time to be spent with patients, and no routine mechanism for improving care delivery. Regarding multidisciplinary working, there were mixed views: although communication was perceived as good, it was felt that patients did not experience individualised care (a view shared by the ward manager during an informant interview). With regard to decision-making, respondents considered that they had little influence in how the work was managed, and that there was too much pressure on resources and demands, such that there was insufficient time to deliver best care and pursue appropriate training. Although the manager was perceived as available and supportive, she was not visible in direct care provision. Respondents indicated that they did not feel well supported by the hospital, were not fairly rewarded for their work and were not treated with respect, and that management did not listen to their concerns.

Rose: structure and organisation of care delivery

Rose ward was for patients recovering from stroke who required medical care and rehabilitation. Non-stroke patients with medical needs were also admitted, including those with palliative care needs, particularly into the four single rooms, of which there was a shortage in this hospital. The ward had 23 beds (sometimes 24, with an additional bed in the male bay). It seemed, from the patient profile, that the ward was evolving from a specialist unit into a mixed medical ward.

Patient profile

During baseline there were 167 people admitted over 8 weeks (approximately 21 per week). The median length of stay was 5 days (range 1–91 days). Table 8 provides a summary of the patients’ sociodemographic characteristics.

TABLE 8

Rose patient profile: sociodemographic characteristics

The age (median 77 years, range 18–99 years) and physical and cognitive abilities of patients varied considerably. Given the age range and variability of recovery, there was potential for added complexity. Some patients had life-changing, newly acquired disabilities and others aimed to resume paid work following their recovery. Many of those currently on the ward required staff assistance to transfer or to mobilise.

The majority had lived at home before their acute admission. On admission, 13 patients (8%) had dementia and three had delirium. Among those assessed for delirium during their admission (n = 19; missing data, n = 148), over half were identified as having delirium (n = 11), for a median of 4 days (range 1–7 days). The reasons for admission are shown in Figure 16. Just under half of patients had suffered a stroke; the remainder had been admitted for various acute medical conditions.

FIGURE 16

Rose: reasons for admission. CVA, cerebrovascular accident; FAST, Facial drooping, Arm weakness, Speech difficulties, Time to call emergency services; SOB, shortness of breath; TIA, transient ischaemic attack; UTI, urinary tract infection.

Data on discharge destination are shown in Figure 17.

FIGURE 17

Rose: discharge destination.

The proportion of patients discharged to their usual residence was reflective of a population who, before admission, was slightly younger and healthier than that of other wards in this study. Additionally, patients here benefited from access to the Early Supported Discharge and Hospital at Home services, both of which facilitated the continuation of monitoring, nursing support and rehabilitation on acute discharge.

Rose: care culture

Based on observation and staff interviews, the manager had ward presence but limited patient contact. She was newly promoted and appeared stretched. She was supported by the sister and the charge nurse, both of whom were visible and active in providing direct patient care and had long experience of working on the ward. Several HCAs had been based on the ward for many years. The existence of a stable group of staff at different levels over time provided continuity and a strong sense of collegiate working. Morale was affected by staffing difficulties, as was working in a physical environment regarded as ‘tired’, cluttered and dark. The manager considered that her staff team were overburdened and was protective of them, for example being careful to ensure that feedback on performance and critical incidents was conveyed and reflected on constructively.

The responses to the Culture of Care questionnaire (12/30 questionnaires returned from nursing, medical and therapy staff) indicated mixed views about the care and ward working environment. Positively, it was reported that the team shared an explicit philosophy of care and that the involvement of patients and caregivers was valued. However, staff considered that there was inadequate support to allow them to spend time with patients. They conveyed a positive sense of providing good care and working as a team, for example indicating that staff worked well within the MDT, provided individualised care and treated patients with dignity and respect. Respondents were largely neutral about team support, raising difficult issues and being able to participate in ward decision-making. There was much disagreement about the extent to which resources and demands negatively affected work and care, although there was agreement on the availability of, and access to, training. Ward leadership was perceived as positive, although, in comparison with City, Ironbridge and Seaford wards, this was expressed in less enthusiastic terms. The perception of support from the hospital was mixed; respondents were generally positive about being able to obtain expert assistance when needed and being treated with dignity and respect.

Organisation

Seaford Trust is one of the largest in England, with five hospitals, spread over a wide geographical, socioeconomically diverse area and serving a population of approximately 759,000. The three acute hospitals (two of which were involved in PIE) employ > 7500 staff and serve a bed base of 1107. It was awarded foundation trust status in 2009.

Trust annual reports from 2010–11 to 2013–14 present a picture of high performance and future uncertainty that was similar to that in other participating trusts. In the recent past, it had received the accolade of Trust of the Year, was the top performing hospital in the Healthcare, Excellence and Leadership Awards and met all of Monitor’s governance and financial targets. In the 2 years from 2012 to 2013, the pattern of high performance was seen to persist, although the foreshadowed difficulties included an increasing demand on services, particularly as a result of ‘winter pressures’.

A major strategic initiative pursued was the development of a Shared Purpose Framework and set of values that would guide practice, which was launched in 2013, when the study began. This was intended as the starting point for a programme of cultural change and was aimed at engaging staff at all levels around four key purposes: person-centred care, safe care, effective care, and creating an effective workplace culture to sustain and enable quality improvement.

Care of people with dementia

Dementia per se was not identified as a key priority in trust annual reports until the 2012/13 report. This announced two key initiatives: the establishment of a dementia team and a new Enhancing Quality Programme pathway for dementia, both launched in early 2013. The dementia team comprised a matron, two experienced nurses and a consultant working closely with them to lead improvements and support the implementation of the dementia strategy. The matron and specialist nurses were attached to each of three district general hospitals in the trust, including the two study wards.

The dementia team was in post for < 1 year when the research began but had already instigated several initiatives that were quickly and widely acknowledged. In 2013, they won the trust’s Caring Award for their work, which included a trust pathway for dementia care, staff dementia training, a ‘confusion pathway’ and a pocket guide to preventing falls and managing confusion, in collaboration with the falls matron.

Poplar: structure and organisation of care delivery

The easternmost site, where Poplar ward is located, is an acute hospital with 388 beds providing a range of emergency and elective services and comprehensive trauma, orthopaedic, obstetrics, general surgery and paediatric services. The hospital dates back to the 1930s, when the original building was constructed. Between 1996 and 1998, most services were relocated and expanded into a new hospital building linked to the original facilities.

The hospital has several specialist units and new staff accommodation. Co-located on the site are mental health facilities for working-age adults and older people run by the local NHS and Social Care Partnership (mental health) trust.

Poplar is a 22-bed orthopaedic ward for older people. Most patients are admitted as emergencies following a fall and the sustaining of a fractured neck of femur.

As baseline data collection started, the ward clerk, who had agreed to assist with accessing the ward profile data, sustained a fall and was hospitalised with bilateral ankle fractures. She was off sick for the whole period, which made data collection a challenge, as the researcher did not have access to the electronic patient data.

Patient profile

At baseline there were some 90 admissions, all emergencies, having a median length of stay of 15 days (range 1–36 days). For the reasons above, there are many missing data. Table 9 presents the Poplar patient profile.

TABLE 9

Poplar patient profile: sociodemographic characteristics

Patients were mostly aged ≥ 80 years and female. The majority were admitted from home following a fall. According to documentation, approximately 50% of patients had a degree of cognitive impairment at any one time. This is supported by staff interview data, although the numbers appeared to fluctuate upwards. Data on delirium were not collected. Figure 18 reports the reasons for admission.

FIGURE 18

Poplar: reasons for admission. ‘Other’ includes dislocated hip, hip fracture, wrist fracture, displaced neck of femur, cellulitis.

Data on discharge destination are presented in Figure 19.

FIGURE 19

Poplar: discharge destination.

For more than half of patients discharged at baseline, their destination was not recorded, reflecting difficulties with data collection. Nor is there any information on discharge for those patients remaining on the ward at baseline. Of those for whom information is available, some three-quarters were discharged to their usual residence, and the rest were divided between intermediate care placements, transfers to another hospital and long-term care.

Poplar: care culture

Twelve questionnaire responses were received from the 20 distributed (mainly nurses and HCAs, with one volunteer and one student nurse). Although most had not worked for long on the ward (seven had done so for < 2 years), most had worked in the hospital for between 5 and 21 years and were experienced in the care of older people.

Responses showed strong agreement on the existence of a shared philosophy of care that valued psychological support and involving patients and caregivers. It was considered that the ward had sufficient equipment and skills among the team. The interviews further suggested a strong team who could rely on each other, as well as shared information and skills. Team members considered that they had influence on decision-making and that there was time to share task-related information. There was strong support for the leadership and management style of the ward manager in all areas. In particular, she was seen as an ongoing ward ‘presence’, supportive and protective of her staff and keen to ensure that everyone received appropriate training. She was also viewed as keen to appoint staff with a particular interest in dementia care. The dementia nurse linked to the ward was highly respected and much appreciated. She had worked on Poplar prior to her role change and was well known.

Most staff agreed that there was too much work to do in too little time and without adequate resources. They generally felt that they were not listened to by senior managers, and nor were they rewarded for their work. This is largely supported by comments from the 2014 CQC inspection regarding leadership (which included evidence of bullying and harassment). Moreover, there was some resentment about a recent ward move from an environment that staff perceived as more conducive to the well-being of patients, and a sense that other wards, less skilled in dementia care, tended to send people with dementia to their ward.

Crane: structure and organisation of care delivery

Crane is a 26-bed ward based in the westernmost hospital. Opened in 1979, the hospital was part of a plan to expand the town and surrounding area in the late 1960s by relocating people from London. It employs about 2500 people and has 476 beds. It offers a wide range of specialist facilities and services, including a shop run by Friends of the Hospital, a volunteer-run society, providing basic goods and services to patients and visitors, which raised £2.5M in donations.

Patient profile

There are a large number of days towards the end of the baseline for which there is no documentation, as the acting ward manager, who had been maintaining records, left around this time.

During baseline there were 121 admissions. The median length of stay was 8.5 days (range 1–64 days). The sociodemographic patient profile is presented in Table 10.

TABLE 10

Crane patient profile: sociodemographic characteristics

The majority of patients were in their eighties, and there were slightly more men than women. Three-quarters had been admitted from their own homes. From documentation and staff interviews, at least half of the patients had dementia, but this fluctuated upwards to over three-quarters at times.

The reasons for admission are shown in Figure 20. Many included multiple pathologies, and those categorised as ‘other’ included undifferentiated diagnoses, various cancers, and heart and autoimmune diseases, plus long-term conditions or infections.

FIGURE 20

Crane: reasons for admission. ‘Other’ includes cellulitis, heart failure, shortness of breath, cancer and urinary tract infection.

The data on destination at discharge (Figure 21) indicate that most patients returned to their usual residence, although there is considerable missing information, including in respect of those who remained on the ward at the end of baseline data collection. There were also a number of deaths on the ward during this time.

FIGURE 21

Crane: discharge destination. IC, intermediate care.

Crane: care culture

Five responses were received from the 13 Climate for Care questionnaires distributed. This is a small and unrepresentative sample, limiting interpretation of the findings. Two of the respondents were experienced, one having spent 12 years on the ward; the others had been there for < 1 year.

The questionnaire responses and interviews suggested that there was support for a shared philosophy of care; psychological aspects were highly valued, expectations were communicated and staff were knowledgeable. There was support for the effectiveness of the MDT, with occupational therapists being particularly valued as a fount of information. Staff reported trying to shift from a task-orientated approach towards supporting patients’ families. Their approach to dementia care was shaped by the lead dementia specialist nurse based at the site and considered an enormous support through the provision of education and advice. She saw her role as offering a resource for practice-based learning and modelling care. Her work was acknowledged at senior management level, including by the deputy nurse for quality and the senior consultant. As with Poplar, there was support for the leadership style of the ward manager, which, at baseline, was an ‘acting’ one. Overall, the picture depicted was of an enthusiastic, motivated and optimistic workforce.

Less positively, there was ambivalence about the availability of wider trust support. Respondents considered there to be too much work for the time available and that resources were inadequate. In particular, there was insufficient time to sit with individual patients, it was difficult to take staff from the wards for them to undergo training, and the physical environment was regarded as noisy and cramped. Similar to Poplar, ward staff complained of a lack of social space and the loss of a bathroom. They also expressed frustration at the paucity of step-down facilities, which meant that patients remained on the ward longer than was ideal for their well-being.