Full details of implementation and delivery phases for each of the six wards can be found in Report Supplementary Material 8.
Implementation planning
Critical to the engagement of ward staff and volunteers in the POD implementation planning was involvement and direction provided by those with the authority, legitimacy and resources to make change happen, specifically the trio of ward manager, VSM and either a matron or senior nurse practitioner, to assume a proactive role in leading it. The combination of commitment and participation around a common purpose was fully achieved in wards 1, 2, 3 and 6, and failed in ward 5, as a consequence of short-staffing and the preoccupation of senior ward staff in getting through day-to-day tasks, meaning delirium was not a priority. This ward withdrew without engaging in any implementation planning work. In ward 4, an implementation team was not established: a staff member was designated by the ward manager to take implementation planning forward, including working with hospital voluntary services staff to recruit volunteers.
Features of the change management process to engage implementation team members in seeing the need for change, such as the POD system of care audits/reviews of practice, were initially a concern because of the time required to complete them. They later became valued as a lens to ‘see’ current practice, identify taken-for-granted practices that required attention and reinforce what was positive that could be built on:
The observations . . . make you ‘see’ things . . . it was good that it was me looking at my ward because it’s people I know so they . . . are comfortable with you in that situation . . . as an insider.
Staff nurse, ward 1
All five wards (1–4 and 6) conducted the audits. In ward 1, senior staff with knowledge of the ward and from different disciplines undertook audits in their area of expertise (e.g. the mental health liaison practitioner carried out the audit relating to communication and a senior therapist undertook the audit relating to mobility); in wards 3 and 4, they were carried out by the designated staff member. Important in engaging the wider ward team was that a system was established for communicating audit findings to the team and for seeking their views on the implications for practice change. In wards 1, 2, 3 and 6, this occurred through handover and staff meetings; in ward 4, findings were conveyed to senior ward staff and conveyed informally to staff ‘on the ground’.
Each ward developed its own documentation for identifying delirium risk, delirium care plans, job descriptions for volunteers and systems for communication between staff and volunteers on the work that needed to be done and how to convey it. These drew on exemplars from the PODv1 manual, but were adapted to be integrated into existing assessment and planning documentation.
Delivering training to ensure inclusion of all staff, using material in the PODv1 manual, was challenging. Creative approaches were adopted: multiple short sessions during the early morning break in ‘breakfast meetings’, a ‘delirium tree’ in the staff room with notes of risk-reducing actions hanging from the ‘branches’ and reinforcement through discussion at handovers.
In wards 1 and 2, the implementation phase was conducted as envisaged and within the timescale, driven by a matron who assumed overall responsibility for the process, with functioning implementation teams overseeing the work on each ward. In wards 3 and 4, the work of planning implementation was very protracted until a staff member was given dedicated time to pursue it. This was successful in ward 3, but was unsuccessful in ward 4 in the absence of senior ward involvement and because of ongoing staffing difficulties that, in practice, meant that the demands of nursing work made inroads into project time. In ward 6, there was a hiatus following initial implementation work with a proposed change in the ward model, and then a move to a temporary space. Once the change occurred and the move to a permanent site was completed, implementation was pursued quickly within a foreshortened timescale (< 3 months), with dedicated staff nurse time.
The flexible approach to implementation adopted in the PODv1 was based on recognition that ‘my ward is different from your ward’. In wards that fully pursued implementation, this allayed fears that the PODv1 would multiply paperwork, as staff worked at ensuring that new systems and processes were integrated into existing ones. It also fostered creativity and a problem-solving approach, and facilitated active decision-making by staff in how to make change happen, thereby contributing to staff ownership of change. Critical to engagement of the wider staff team was that ward managers acted as change ‘facilitators’, legitimating ward investment and conveying the significance of the work to the wider staff group through routine and special forums. Where this did not occur (as in ward 4), the work of implementation planning was not translated into action at the level of the ward team.
Delivery phase
Adherence to protocols
Adherence to the POD protocols in the four implementing sites was generally good: care plans for patients specifying action on each of the delirium risk factors were completed, integrated into patient notes as part of the admission process and reviewed in the MDT/ward round/handover, as necessary. Several sites developed new ways of responding to needs around communication and stimulation. For example, on ward 6, the senior occupational therapist involved occupational therapist students in engaging in therapeutic activities (reminiscence work, playing games) with patients identified as being at high risk of delirium. Occupational therapists also worked with volunteers to engage with patients based on information in the care plan on what interested them and relatives were encouraged to bring in patients’ favourite music and books. In one full implementation ward (ward 1), initial high adherence to protocols, as reflected in completion of care plans, reduced towards the end of the delivery period. Contextual factors were implicated. Early in the delivery phase, senior hospital managers conveyed their intention to close the ward as part of a strategy to reduce acute beds. The proposal was subsequently revised to merge ward 1 with an adjacent ward at the conclusion of the study, thereby effecting an overall reduction in bed capacity. However, a combination of the ward manager taking on responsibility for the two wards in the interim and uncertainty engendered among staff had the consequence that several staff moved to other posts and morale was adversely affected, which affected engagement with the research.
Changing ward practice
Similar to ward staff in the project 1 sites, nursing, therapy and care staff on all participating wards reported minimal knowledge of the significance of delirium and its adverse outcomes for patients and caregivers. In addition, there was little or no awareness that delirium might be prevented among those at risk. Education sessions, observation and structured review of current practice proved helpful and facilitated empathic connection with the experience of patients with delirium, as opposed to ‘just seeing a “problem” patient’ (sister, ward 1).
Senior ward staff in wards 1, 2, 3 and 6 and observation of practice suggested that, even prior to delivery, but during the implementation planning phase, engagement in the POD system of care had resulted in practice change:
Slowly you started noticing at handovers . . . that staff . . . wouldn’t say that Mrs X was confused, the word confused went, and people talked about whether she may have a delirium . . . it became a clinical thing, not something to be dismissed . . . and delirium wasn’t just about the person walking up and down . . . they were picking up on people who were quiet. They just started associating a sudden change in behaviour of patients with possible delirium and doing something about it.
Matron, wards 1 and 2
They also reported that, whereas before nursing and care staff might have reacted impatiently if a patient was ‘behaving badly’, now they were more patient and would spend time talking to the person, seeking to ease their confusion.
The period of implementation and delivery of the PODv1 was one of considerable organisational turbulence shaped by both national policy drivers (e.g. the imperative to achieve efficiency savings) and initiatives on improving care for people with dementia, and by local contextual factors such as ward re-organisations and staffing difficulties. This affected the engagement of the sites in both the implementation planning and delivery of the POD system of care.
Volunteers
Implementation phase
Recruitment of volunteers was completed in 6 months. Roles and ‘job descriptions’ agreed during implementation were supported with volunteer training. Even so, the volunteer component of the POD system of care was implemented to a variable extent across all the sites. The training provided was diverse, comprising specific PODv1 training in wards 1, 2 and 6; the trust’s standard volunteer training (ward 3); and provision of a leaflet (ward 4). In addition, in four wards (wards 1, 2, 4 and 6), volunteers were invited to the ward to familiarise themselves with the environment and to meet with staff prior to the start date. Dedicated training and ward introduction meetings reinforced for volunteers that they were involved in a specific programme of work as part of the ward team.
Delivery phase
The volunteer component of the PODv1 was implemented to a variable extent across all sites, being most developed in wards 1, 2, 4 and 6. The core features of the role were spending time conversing with patients; providing emotional support, reassurance and stimulation; giving practical assistance at mealtimes; and, in one ward, encouraging and supporting patients to mobilise. There were numerous examples of ways in which volunteers developed creative and person-centred approaches to communicate with very frail and cognitively impaired older people, not as patients, but as individuals with a past and present and with fears and hopes for the future, to an extent that staff were unable to offer.
The number of hours contributed monthly to each ward by volunteers was modest (mean 27 hours, range 13–56 hours). This was not a result of a lack of commitment by the volunteers – some individually contributed up to 8 hours a week – but was a consequence of the limited number of volunteers available. Except for one ward (ward 6), VSMs did not continue to recruit volunteers after the initial POD system of care implementation period.
Despite attention to introducing volunteers to ward staff prior to delivery and a dedicated POD training event for volunteers, volunteers were initially anxious and unclear as to their role and lacked confidence about how best to approach patients:
Going onto a ward where there are quite a lot of really ill people . . . you can imagine it being quite daunting. It was for me . . . I’d done loads of preparation for it and I still found it daunting so, yeah. But I think once you’ve done it once or twice you kind of know what it’s like and you know what to do . . . and staff were welcoming . . . they were all quite helpful and reassuring and they showed me what to do at the time until I got the hang of it and they knew I’d got the hang of it so, so yeah.
Young volunteer, ward 6
This early period was particularly vulnerable to volunteer attrition. Approximately half the volunteers initially recruited did not sustain their involvement over the 6 months of the PODv1 delivery. Of these, around one-third never started and most of the rest left after a few sessions either for personal reasons (illness, pressure of work) or because they found working with older people too difficult. Although volunteering was established in all four hospitals, their specific deployment directly with older people, in a dedicated system of care, was new, and the need for ongoing work and time to sustain involvement was not anticipated. The VSMs considered inadequate support at ward level to be a key factor in volunteer attrition, particularly for less confident and inexperienced volunteers. They would have liked to offer them more support, but were unable to do so because of the pressure of work. Ward staff found that supporting volunteers, at least initially, required time, effort and patience, which not all wards could easily provide. The degree of support and how it was provided varied across wards. In ward 2, for example, the nutrition assistant assumed responsibility for liaison between the ward and the volunteers; in ward 6, the ward manager took this on initially, meeting with each volunteer, assigning a staff member whom they could shadow and a more experienced volunteer to act as mentor.
Factors that appear to be important to the retention and sustainability of volunteers, and that need to be put in place by wards implementing the POD programme, are:
Acceptability of the Prevention of Delirium system of care version 1
Questionnaires: patient and carer satisfaction
Patients
A total of 1360 patients were discharged during the questionnaire distribution periods; 827 questionnaires were distributed by ward staff and 134 were returned (16.2%). Return rates varied between the wards (11–38%). Satisfaction of care among patient respondents was mixed, being high for some items (e.g. choice of food, confidence and trust in doctors and nurses, enough nurses on duty to care for the patient) and low for other items (e.g. being bothered by noise at night, a number of items regarding communication) (see Appendix 3). There was a trend in a substantial number of items for less satisfaction in the delivery phase of the POD programme than in the implementation phase. This was significant for three items: item 10 – did the nurses talk in front of the patient as if they were not there?; item 12 – did a member of staff say one thing and another say something quite different?; and item 16 – did the patient find someone on the hospital staff to talk to about their worries and fears? It is possible that the focus on reviewing current practice meant that staff were more reflective on how they engaged with patients. However, the poor response rate makes it difficult to draw definitive conclusions.
Carers
Only 80 carers returned a questionnaire (of 827 questionnaires distributed). There was also a trend for less positive responses in carer questionnaires during the delivery phase than in the implementation phase across nearly all of the individual items in the questionnaire (see Appendix 3). The total score for the second subsection of the carer questionnaire was significantly lower in the delivery phase than in the implementation phase.
Sixty of the 134 patients and 51 of the 80 carers provided written comments. Across both phases of the questionnaire, the comments of the patient and carer respondents related to six common themes: staff attitude, communication, care and treatment, availability of staff, food, and environment. Overall, more patient respondents commented positively regarding staff attitude during the implementation phase than during the delivery phase. Among both patient and carer respondents, there were fewer negative comments in the delivery phase concerning staff availability than in the implementation phase. There were no other notable differences in the nature of the comments provided during each phase (see Appendix 3).
Interviews with patients and carers
For the patients and carers that were interviewed (one patient, three carers and five patient/carer dyads), it was the focus of the POD interventions that was valued: attention given to hydration and nutrition, meeting sensory needs, and help with mobilisation. Particularly valued by carers was staff spending time with their relative and getting to know what was important to them. Carers’ main criticisms related to the communication of information, such as failure of staff to actively seek or regard information about the patient, lack of involvement in discharge planning and the unavailability of nursing staff. The small sample reflects recruitment difficulties. Ethics approvals did not permit us to have direct access to patients’ personal information. It was intended that a letter inviting participation with a stamped addressed reply envelope would be given out by staff at patient discharge. This did not happen consistently. The method of recruitment was also not conducive to engaging people, many of whom were frail and living with cognitive problems.
Ward staff
Staff found some aspects of the POD system of care challenging. Of particular issue were the volume and clarity of the POD manual and the time required to implement the system of care and to support volunteers. However, staff in the majority of sites believed that the POD system of care had been beneficial and had resulted in practice change. In some wards (wards 1, 2, 3 and 6), it was considered that the ward team had developed an increased understanding and recognition of delirium and that this had enhanced practice.
Staff accepted and appreciated volunteers and considered that they brought a new and positive dimension to the ward. There were some initial concerns on the part of staff regarding the tasks that volunteers would carry out and around issues of confidentiality. In practice, they found that their fears were unfounded. Staff valued having the consistency of regular volunteers who knew what was wanted of them. The general assessment by staff of the volunteers who sustained their involvement with the ward was that they were ‘very good’ or ‘excellent’. On only one ward (ward 3) were there concerns expressed about the calibre of volunteers, specifically of some student volunteers. In ward 6, by contrast, a collaborative initiative involving sixth-form colleges was very successful in engaging volunteers interested in pursuing careers in medicine, nursing and allied professions. Although slow to establish, this was pursued beyond the POD programme, recruiting a large volunteer team of young people, which was sustained through reciprocal support of ward staff and volunteers.
Volunteers
When interviewed about their experiences, volunteers reported that they had generally found staff to be friendly and welcoming, but were not always sure that they were valued by them. Most volunteers were initially anxious about their role and lacked confidence about how best to approach patients and had sometimes felt uncertain about what they should be doing. As noted previously, the early period was particularly vulnerable to volunteer attrition. In wards where support was perceived to be inadequate, those volunteers who continued often had previous experience of volunteering or working in a care environment. Volunteers who remained reported considerable pleasure and enjoyment in their work, even if it was regarded as emotionally difficult at times.