It’s January 2024 and the pressures on our acute sites are causing serious concerns … patients are queuing at our accident and emergency departments for never heard of before, prolonged periods of time. With not enough beds to cope with the demand for admission, patient care is not at the usual level we strive to achieve. Staff are struggling to provide safe, effective care whilst recovering themselves from unprecedented times, and agency use is at an all-time high.
With concerns about the cost and nature of the care being delivered when using agency staff and enhanced observations, firefighting is becoming a common term. Staff wellbeing related to distressed behaviour is worrying, and the impact on the wider system, complicating the delivery of acute care and delayed discharges, more evident. With the loss of so many of our workforce to changes and retirement, are staff really feeling confident in their level of knowledge and skills to deliver quality care to one of our most vulnerable populations?
As a group of national Dementia Consultants, how we support staff to achieve the appropriate level of knowledge and skills required in their role to care for people with dementia, their families and carers, is always high on our agenda. The effects the pandemic had on social contact, community supports and access to training is well known, but the time has come now to recover and reconfigure … access to online learning resources is simply not enough.
With many approaches since 2012 when Scotland committed to moving away from the use of challenging behaviour, using mostly NES materials to train staff in knowledge and skills, to introduce assessment and intervention paperwork, and to support implementation, this was going to be a very different approach. Grounded in the theory of the evidence-based Newcastle Clinical Model, and with a human approach to understanding the reason for the person’s distress rather than focusing on the perceived challenge of the behaviours, we wanted staff to start at the point of admission, from a place of curiosity about the person themselves. We wanted staff to consider personalities and situations … think about physical and mental health and consider level of cognition. Like detectives, we wanted staff to try to find out as much as possible about the person, which so often enables person centred care that simply prevents distress getting to a level that requires more specialist assessment and intervention. But when needed, we wanted staff to feel able to consider functional analysis of the distressed behaviour to identify both the triggers and reinforcement cycles, and also the underlying unmet needs driving the distress and therefore behaviour. This in turn would enable care plans to proactively prevent distress, or use a targeted intervention when required, reducing the all too familiar reinforcement cycle that so often escalates things.
So, how were we going to do this … Let me introduce you to two of the most amazing colleagues I know, Su and Kim. Dr Su Ross is a Consultant Clinical Psychologist in NHS Lanarkshire and Kim Brown, at the time, our interim Chief of Nursing at University Hospital Wishaw. A powerful partnership who knew staff were struggling and patients were distressed … and more importantly wanted change. And if one of the primary changes we were aiming to support is in staff behaviour, why not use the exact same approach as we’re teaching them about distressed patients? What are the staff underlying needs, and what conditions do they need to enable them to bring human curiosity and compassion to their care, to tolerate the risks that come with positive person-centred care plans? How can we ensure they feel valued, supported, and importantly have the tools, systems and supports to feel personally and professionally safe and therefore able to deliver the highest quality of person-centred care?
Right, the first step … we had to get the buy in from other disciplines at the same level, get them on board and bring them into our way of thinking. With dementia affecting so many of us in one way or another, it wasn’t difficult to do this. The passion and the drive was there, colleagues wanted to be involved, they wanted staff to feel supported and patients to receive the right care.
With representation from Acute, Mental Health, Psychology, Practice Development, Health Improvement, AHP’s and Organisational Development, a collaborative core group was established to lead, plan and coordinate. We embraced the complexity, knowing education isn’t just about knowledge and skill acquisition but supporting staff to form attributions that enable them to understanding the lived experience of someone living with dementia, we had a plan for the first steps. With guidance from our Organisational Development team, and following in the successful footsteps of the Essentials in Leadership and Management programme, we developed an 8-week programme, with up to two hours self-directed learning using Promoting Excellence online learning resources followed by a one hour facilitated reflective coaching session on Teams each week. With the aim to shift attributions about distressed behaviour, and maximise influence and change, we hand selected Care Support Workers and Charge Nurses from the older adult wards across our three acute sites and community cottage hospitals.
In week 1 and 2 we wanted to focus on what distress is, and recognition, encouraging staff to connect with the patient experience, consider their perspective and think about causes. At this stage we also wanted staff to feel valued, and know they were chosen because of their knowledge and skills, to develop and shape the programme. This began with them choosing their own name: Comfort Champions … as opposed to Distress Champions and really aligning with the ethos of the approach. Week 3 and 4 looked at proactive approaches to prevention, thinking about dementia focused person-centred care and considering staff stress. In weeks 5 and 6, our attention turned to responsive care, when prevention hasn’t been enough … looking at the unmet needs model and functional analysis. Finally, week 7 and 8 took us to support and escalation … the point at which both proactive and responsive measures haven’t worked and we need that specialist advice, along with space to think about terminal agitation and some complex ethical issues. We had some initial attrition, as expected, but engagement from those who attended was outstanding, discussions during the sessions were rich and reflective, with staff reporting significant changes in practice as we progressed through the programme. They spoke of less reactivity and slowing down to tune into what lies behind the behaviour they see. They shared their experiences of getting to know their patients and putting little nuggets of information together in realistic and high impact careplans … such as finding jobs within the ward for patients to meet identity and occupation needs, or reducing visual noise around mealtimes to support independent eating before moving to finger food. They reported a reduction in reliance on enhanced observations, an intervention that had previously been seen as ‘gold standard’ and highly reassuring, and shared positive feedback from families via Care Opinion. This significant change in practice was also spontaneously captured by our Older Adult Psychiatry Acute Liaison team, who praised staff for using proactive and responsive care interventions before looking for specialist input.
Well what can I say … to say we’re proud doesn’t even touch the sides of the pride we have in our first cohort of Comfort Champions. With the commitment and collaboration to implement and rollout, everyone is a leader. On the 11th October 2024 we celebrated this achievement when our first cohort of 19 Comfort Champions from 14 wards across 3 acute and community sites in NHS Lanarkshire graduated, with our Executive Director of Nursing in attendance to recognise and celebrate their achievement.
This however is just the start … with the support of the Champions we plan now to develop a clinical care pathway, look at an escalation and support matrix and consider day to day guidance to support staff. We also intend to work with our Interface Division to maximise information flowing into acute and assist with discharge planning, and not to forget of course, we want to scale up our 8 session training package in a sustainable way. And who’s to say we haven’t just only gone and developed an NHS education programme for Scotland right here in Lanarkshire.
Contributor
Jane Mimnaugh, Dementia Nurse Consultant (Older Adult Mental Health) NHS Lanarkshire, written in collaboration with Su Ross and Kim Brown, Our Story.