practice changing practice by dfsiopmhy6


									practice changing practice
Keywords digNiTy | AcuTe cAre | digNified cAre

Everybody matters 1: how getting to know
your patients helps to promote dignified care
This project revealed ‘see who I am’ as a main theme for patients. Guidance is
offered on how nurses can make small changes to their practice to address this

Authors Caroline Nicholson, PhD, Msc,              INtroDuCtIoN                                                  the centrality of relationships in delivering
Bsc, hV/DNCerts, rGN, is dignity                   Within the demands of acute work in                           high quality, dignified care.
development nurse; Mary Flatley, PhD, Bsc,         hospital, the multifaceted nature of dignity                    Nolan et al (2006) argued that the
rGN, is lead research and development              often remains invisible and difficult to                      experiences of staff, patients and relatives are
nurse; both at royal Free hampstead trust          translate into a set of behaviours or                         central to developing good care
and City university; Charlotte Wilkinson,          procedures. Health and social policy has                      environments. Cummings et al’s (2010)
Dh, MA, Msc, rGN, is lead research and             recently stressed the importance of this                      recent work on nursing leadership notes “by
development nurse, Barnet and Chase Farm           concept (Department of Health, 2008).                         investing energy into relationships with
hospitals trust and City university; Julienne        Dignity and privacy have been identified as                 nurses, relational leaders positively affect the
Meyer, PhD, Msc, Bsc, CertEd (FE), rNt,            a core standard by which all healthcare                       health and wellbeing of their nurses, and,
rN, is professor of nursing/project lead,          organisations are measured. However, Help                     ultimately, the outcomes for patients”.
school of Community and health sciences,           the Aged, in Davies et al (2007), described                     Thus the project works in partnership with
City university; Patricia Dale, rGN, is            dignity as a “hurrah” word − a term of                        staff to think about practice and possible
dignity development nurse, royal Free              general approval often loosely cited as an                    changes, with a focus on the positive aspects
hampstead trust and City university;               essential ingredient but frequently without                   of care. Using a combined approach of action
Lucinda Wessel, rGN, is dignity                    consensus over its meaning.                                   learning and appreciative enquiry we have
development nurse, Barnet and Chase Farm             Furthermore, there is little evidence on                    worked alongside nurses to change practice.
hospitals trust and City university.               how to put dignified care into practice or on                   We began by appreciating what it is like to
ABstrACt Nicholson C et al (2010)                  how the competing demands of the                              work in an acute hospital. By doing shifts,
Everybody matters 1: how getting to know           healthcare system affect its delivery.                        observing practice and collecting the views
your patients helps to promote dignified             The Dignity in Care Project (DCP) is                        of nurses, patients and families, we
care. Nursing times; 106: 20, 12-14.               underpinned by an appreciation of the                         developed an understanding of what helps
the Dignity in Care Project aims to develop        realities of delivering dignified care in the                 and hinders dignified care.
practical interventions to promote dignified       modern NHS. This is exemplified by the                          This understanding was gained through a
care in hospitals, embedded in the project         story in Box 1, taken from practice.                          combination of feedback from nurses on the
slogan: “Everybody matters: sustaining                                                                           wards and monthly action learning sets
dignity in care.” It is a nurse led research       DIGNIty IN CArE                                               (meetings in which groups meet to support
collaboration with royal Free hampstead            The project uses a systems approach,                          each other in their learning) off the ward
and Barnet and Chase Farm hospitals trusts         working with ward nurses, patients and their                  with ward mangers, junior matrons and
and City university.                               carers and hospital managers. It is guided by                 nurses particularly interested in dignity.
  Practical interventions devised by the
project are presented around three main
themes that emerged from the views of older         box 1. practice example
people and their relatives (Bridges et al,
2010; 2009). the first theme of “maintaining        It is 11am. Edith,* a healthcare assistant, and I           “will have to wait”. Molly grumbles and asks why
identity – see who I am” focuses on                 have already washed three patients, changed two             she is last.
knowing about people, while the second              who were doubly incontinent and we are in the                 I go over to her and start to explain the morning
of “creating community – connect with               middle of getting a woman ready for discharge               we have had, and the fact that we need to get
me” recognises that in the act of caring,           home. The place is frantic. There are two planned           people ready for transport. I stop. Molly is crying.
nurses receive as well as give. the last            procedures, three discharges and a ward round to              As I hold her hand I begin to think about why she
theme of “shared decision making – involve          be done, and we are one staff member down.                  might be so disturbed. Molly’s companion for these
me” looks at how decisions about care                  Molly* shouts across from the opposite bed in            past weeks is leaving but she is staying. Molly has
are made.                                           the bay: “Can I have my wash now?” I look at                no family and will be placed in a care home when
  this first article in a three part series         Edith; she rolls her eyes and notes that if one of us       the formalities are agreed. She wipes her eyes and
summarises the project and focuses on the           does not go on break soon we will mess up the               says she will wait.
first theme. It reports on practical initiatives    whole rota with lunchtime. She says something
to enhance dignity in hospitals by enabling         about needing to keep things moving and she                 * Names have been changed.
nurses and patients/carers to know and              looks tired. Edith calls back to Molly that she             source: extract from project field notes
value each other as people.

12                                                                                                          Nursing Times 25 May 2010 Vol 106 No 20
                                                                                                                 This ArTicle hAs beeN double-bliNd peer-reViewed

These dignity leaders helped to collect
evidence and then consider with the project                    table 1. Ways to change everyday practice
team what interventions might help.                            Creating dignity              Nursing handover: does your handover include information about patients
  A main issue was that interventions needed                   conversations throughout      whose dignity may be at particular risk that shift?
to be feasible for nurses in a busy                            the shift
                                                                                             Time to talk? does your shift have times that allow staff to share patient care
environment and relevant to their everyday                                                   issues? for example, during “huddling”, when nurses group together naturally;
work. We came to see these as small
processes that occur over time. Bigger                                                       Are nurses supported by the team to give dignified care in difficult
projects with more obvious impact have a                                                     situations? for example, by buddying up, checking out, time out.
corresponding need for substantial effort                      Seeing the person: getting    Routine morning conversations between nurses and patients at the
and rarely available time. However, it                         to know the people you are    beginning of the shift;
became clear that small things often had the                   caring for by…
power to make a real difference, both to staff                                               Rounding with dignity: using routine care practices such as observations/
                                                                                             medication rounds as an opportunity to connect with people.
and to patients and relatives.
  Supporting ward nurses to implement                          Promoting awareness of        Being curious about everyday practice: helping staff to “stop, look and
interventions is essential and sustaining                      dignity throughout the ward   listen” through observation. for example, do we call patients by their name or
change in practice is both exciting and                        environment                   their bed numbers when conversing with colleagues?
challenging.                                                                                 Thinking about dignity for yourself, your colleagues and those you care
  During this project we worked intensively                                                  for: examples are dignity workshops, a dignity noticeboard, values exercise.
with a select number of wards (dignity
development units) and, more widely,
through action learning sets with clinical                 l Creating dignity conversations                           due to the circumstances surrounding the
leaders across the hospitals. These sets have              throughout the shift;                                      patient/family or because of our own
proved a powerful place for colleagues, often              l Seeing the person: getting to know the                   humanity. Working as a team and helping
“siloed” in their clinical areas, to learn and             people you are caring for;                                 each other is important dignity work.
share knowledge with each other and                        l Promoting awareness of dignity                           Intentional times to stop and talk about the
formulate ideas before returning to                        throughout the ward environment.                           shift can allow staff to feel valued and
implement them in practice.                                                                                           supported in their caring work.
  We have attempted to mirror this cycle of                Creating dignity conversations
reflection and action on the wards by taking               Although nurses may agree that dignity is                  seeing the person
a short time to stop, look and listen to each              central to nursing, delivering dignified care is           The average length of stay in one of our
other about a possible change.                             getting lost (Royal College of Nursing, 2008).             trusts is three days for an elective procedure
                                                           Promoting dignity requires intentional and                 and four days for non-scheduled admissions.
‘sEE Who I AM’                                             practical ways to embed it into everyday work.             With 12 hour shifts, this may mean nurses
Being in hospital can affect people’s sense of             l Nursing handover: The Health                             see a person only once.
individuality; with a unique life history, likes           Foundation’s (2009) Safer Patients Initiative                 This means it cannot be assumed that
and dislikes are part of who they are.                     asserted that effective communication is a                 getting to know patients will just happen
  Although formal ward assessments may                     vital factor in improving clinical practice                over time. Below are some practical tips to
ask some personal questions, the                           and patient outcome. Linking this into                     get to know people in the moment.
information gathered does not always                       dignity may mean adding a specific question                l Routine morning conversations: in this
influence the care received.                               to the safety briefing which asks staff to                 project, nurses are supported to introduce
  This carer sums up the need to see beyond                identify people at particular risk of their                themselves to their allocated patients at
the immediate problem to the person when                   dignity being diminished that shift, such as a             the beginning of each shift. They are
giving dignified care:                                     planned procedure which may mean lunch                     encouraged to ask how patients are and, if a
                                                           is missed.                                                 person is new to the ward, how they would
 “Some staff, they did not seem to treat my                l Time to talk? Long working days and                      like to be addressed and if they have any
 wife as an overall patient, that is, they                 reduced staff overlap between shifts can                   concerns for that day. This “simple”
 only gave information about specific                      mean nurses do not informally get together                 connection can be challenging as it may
 problems, the immediate, no                               to talk about caring. The Compassionate                    stimulate discussions around priorities and
 understanding of the bigger picture, and                  Care Project (2009) in Scotland identified                 time pressures.
 also what I was going through.”                           the need for caring conversations, that is,                   Ongoing support is important to facilitate
                                                           points in the shift when staff get together to             working in this way and to allow space for
   Below are some practical suggestions on                 talk about emerging issues around care. In                 such conversations and the possible
how nurses can both reflect on and change                  this project, we talk about “huddling” –                   implications that replies may bring. On one
their everyday practice to see beyond “the                 using times when nurses naturally group                    occasion, a patient told the nurse that the
immediate task” to the “person behind the                  together, perhaps waiting for the meal                     name by which she had been known all her
patient” – a phrase used by the King’s Fund                trolley, and intentionally focusing this time              life was not the “proper” name on her
(Goodrich and Cornwell, 2008) to help                      to reflect and talk about care.                            medical notes which all care staff had been
illuminate the meaning of dignity. For ease                  Recognising and valuing these huddles can                automatically using. This “proper” name
these are considered under the following                   be used to support fellow staff in the practice            was one the patient associated with being
headings and summarised in Table 1:                        of caring. Caring can be difficult, whether                naughty as a child.

Nursing Times 25 May 2010 Vol 106 No 20                                                                                                                   13
practice changing practice
                                                             l Draw a line down the page. On the left                          handbooks. This has its challenges but also
 box 2. the soler communication                              hand side write what you saw and on the                           creates exciting possibilities.
 tool                                                        right hand write what you thought and felt                          It brings to the fore the personhood of
                                                             about what you saw;                                               professionals, patients and family members.
 S    Squarely face the person; “I am with you”              l Bring your notes to a meeting to share                          It also challenges each of us to think about
 O    Open posture                                           with colleagues.                                                  where and how we work.
 L    Lean towards the other; be responsive                    Two widely reported themes are:                                   Dignity is about drawing on the capacity
 E    Eye contact. Direct, appropriate.                      l The high degree of background noise in                          and leadership of all nurses. The following
 R    Relaxed. Being comfortable in using your               which people work and are cared for, such as                      field note captures the importance of the
      body as a vehicle of communication and                 pumps left on after an infusion or a bleeping                     small things by which every nurse can
      expression                                             bed mattress. This is much more noticeable                        promote dignity. Small things change people
                                                             to people who are confined to bed or a chair.                     and practice and can have far larger
 source: egan (1990)                                         One nurse found it so unbearable during                           consequences than we might know.
                                                             this exercise that he had to stop observing                         Dora*, a healthcare assistant, smiles at
                                                             and turn off a pump that had been left on.                        Mr Smith*: “Can I take your blood
l Rounding with dignity: routine care                        This background noise is exacerbated by                           pressure?” He holds out his arm, somewhat
practices, such as “doing the obs” or “doing                 staff shouting requests for assistance or                         mechanically. Dora unfastens his watch,
drugs” can be reframed as opportunities to                   queries about drug keys;                                          commenting on its shape and how grand it
see the person you are “doing” things to.                    l The almost universal practice of calling                        is. Mr Smith’s face breaks into a smile, “My
Communication tools such as SOLER                            people by bed numbers rather than names.                          dad gave that to me [after a pause]… can
(Egan, 1990, Box 2) can help staff to think                  Clearly, there are occasions when it is                           you imagine me having a dad, long gone
about how they present themselves to                         important to locate a patient quickly and a                       now?” Dora bends over to put the cuff on
patients when carrying out activities. This                  bed number is appropriate. However, in                            and gently pats his arm: “Yes, I can, gone but
“small” change requires courage and                          most conversations between professionals,                         not forgotten eh….” It is a fleeting moment
support to put into practice. Clearly, some                  people were referred to as beds, for example:                     but I remember it as I write up my notes; I
encounters need to be more task oriented                     “Bed 19’s daughter is on the phone” (clerk                        imagine Mr Smith does too. l
but they can still be carried out with an                    to nurse). Giving people names is an
appreciation of the person’s individuality.                  essential part of acknowledging their                             *Names have been changed.
                                                             personhood; this does not apply only to
Promoting awareness of dignity                               patients and relatives. You may wish to                           Part 2 of this series, to be published in
l Being curious: hospitals are busy places                   reflect on how many staff members,                                next week’s issue, focuses on values and
and, as part of the project, we have been                    including support staff, are referred to by                       expectations and ward culture
encouraging staff to have curiosity about                    name. How might you want to raise the
what they do and the effect this may have                    profile of naming both staff and patients in                        box 3. useful resources
on dignity.                                                  your ward area?
  Various team staff used the following short                l Thinking about dignity for yourself,                              Leadership in Compassionate Care programme:
observation exercise to help them to stop,                   your colleagues and those you care for:                   
look and listen to their everyday                            promoting awareness of the issues around
surroundings and routines.                                   dignity and looking at values and attitudes is                      DH Care Networks – Dignity in Care:
  Top tips for observing your own                            an important part of changing practice.                   
surroundings:                                                Dignity workshops, feedback to the team on
l Stay in your own clothes;                                  some of the exercises and ideas and a                               The Point of Care: Improving Patients’
l Try to think of yourself as a stranger;                    noticeboard can all keep dignity in people’s                        Experience:
l Observe for 10-20 minutes;                                 minds (see Box 3 for useful resources).                   
l Try not to intervene;
l Do not take notes at the time;                             CoNCLusIoN                                                          RCN Dignity campaign:
l Write up your notes immediately after                      Dignity, unlike some aspects of care, cannot              
you have finished;                                           be reduced to a set of procedures or
Bridges J et al (2010) older people’s and relatives’         Cummings GG et al (2010) leadership styles and                    Goodrich J, Cornwell J (2008) Seeing the Person in
experiences in acute care settings: systematic review and    outcome patterns for the nursing workforce and work               the Patient: the Point of Care Review Paper. london: The
synthesis of qualitative studies. International Journal of   environment: a systematic review. International Journal of        King’s fund.
Nursing Studies; 47: 1, 89-107.                              Nursing Studies; 47: 3, 363-385.                                  Nolan M et al (2006) The Senses Framework: Improving
Bridges J et al (2009) Best Practice for Older People in     Davies S et al (2007) Dignity on the Ward. Promoting              Care For Older People Through a Relationship-Centred
Acute Care Settings (BPOP): Guidance for Nurses.             Dignity in Hospital: A Guide for Hospital Staff. london:          Approach. sheffield: school of Nursing and Midwifery,
london: rcN publishing/city university.         help the Aged, in association with rcN.                           university of sheffield.
best-practice-older                                          Department of Health (2008) High Quality Care For All.            Royal College of Nursing (2008) Defending Dignity:
Compassionate Care Project (2009) ‘Caring                    NHS Next Stage Review Final Report. london: dh. tinyurl.          Challenges and Opportunities for Nursing. london: rcN.
Conversations’: Little Things Make a Big Difference.         com/darzi-final-report                                  
conference organised by Nhs Quality improvement              Egan G (1990) The Skilled Helper: a Systematic                    The Health foundation (2009) Making Our Hospitals
scotland, Nhs education scotland and the public service      Approach to Effective Helping. london: chapman                    Safer: Journeys on the Safer Patients Initiative. tinyurl.
ombudsman, at Murrayfield stadium, edinburgh, 20 March.      and hall.                                                         com/hospitals-safer

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