Maximising Positive Lunchtimes on Marchburn Ward

What do you get when you combine a Speech and Language Therapist, an improvement project and a very accommodating charge nurse?  Thankfully, a positive outcome!

Why did we bother?

As food is fundamental to health and wellbeing, mealtimes are extremely important.  They also offer the opportunity to promote social interaction and the potential for enjoying one of the remaining pleasures for many people with significant cognitive impairment.  Clinical research supports the use of relaxing music played during mealtimes to exert a calming effect and decrease stress and distress.  As a speech and language therapist, I regularly require to undertake assessments during lunchtimes.  I also have a personal interest in music.    Having the opportunity to undertake Quality Improvement training allowed me, after a fair bit of background reading around the subject, to use these skills to seriously develop my initial project idea.  Combine all of the above ingredients plus approachable Charge Nurse Lainey McLeod and I was good to go.

The setting

Marchburn Ward, in the local community of East Ayrshire, provides care to people living with dementia with who have complex care needs.   Stress and distress symptoms of dementia are a significant problem that impacts on clinical care and overall life quality.  The sensory stimulation and increased demand for social interaction required when dining can create uncertainty and anxiety which is often expressed in various forms of disruptive behaviour.  Mealtimes, particularly the midday meal, were identified to be stressful for both patients and staff resulting in increased stress and distress behaviours. 

What we aimed for

It was hoped that through introducing specific changes to the usual lunchtime there would be a 10% reduction in symptoms of stress and distress exhibited.  10% improvement in staff perception of the lunchtime environment was an additional goal. 

How did we do it?

By adopting a quality improvement approach, change ideas were explored and undertaken.

  • Introducing relaxing classical music during lunchtime.
  • Increasing staff awareness of the current evidence regarding achieving an optimal mealtime experience.
  • Ensuring staff consistently initiated appropriate interaction with patients, providing information/comments on their meal e.g. taste, smell.
  • Minimising noise and conversation unrelated to the dining experience.
  • Establishing a consistent lunchtime routine.

Following months’ of planning and paperwork, staff training and burning of CDs with classical music of a particular style and speed, we started making changes.  This required tallying various behaviours observed at lunchtime, noting staff experiences and much gnashing of teeth over excel spread sheets and run charts………. The results however indicated it was worth it.

What did we achieve?

  • Stress and Distress – Classical music reduced overall stress and distress behaviours. Positive interactions adopted by the staff helped stabilise stress and distress behaviours at a lower level. 
  • Lunchtime Environment- Staff were asked ‘How relaxed and harmonious did lunchtime feel? 1(not at all)-7(very) scale. There was 20% perceived improvement. Even better than was hoped- result!

Staff feedback

‘One patient sat for the longest spell I have ever witnessed her doing during lunch’

‘Calm today, patients’ content’

‘Music helping, less behaviour’

What did we learn?

  • Levels of stress and distress behaviour were higher at lunchtime than dinner time.  We tested this out and at the evening meal the levels of behaviour were much lower overall and no significant change was made.
  • Optimum staffing levels directly impacted on level of patient stress and distress.  Fewer staff led to increased negative behaviours.
  •  Continuity of staff was important.  Stable/predictable staffing ensured appropriate use of positive interaction training and knowledgeable management of individual patient needs.
  • Changes within the typical lunchtime routine negatively affected behaviour.  The timing of music to the arrival of the meal was vital.  One day when the trolley was delayed by ten minutes stress/distress behaviours reduced when the music began and then increased above the usual levels.
  • Patient stress/distress affected other patients and staff, influencing their behaviour.
  • On a personal note, the project improved my skills and confidence in quality improvement, providing an opportunity to lead a project. I also developed knowledge in producing a poster including the importance of presenting the information in an accessible format.

NB. Specific pieces of music with contrasting dynamics are not a good idea unless someone stands beside the volume control……….

Learning summary

The addition of classical music and intentional positive interaction between staff and patients created a calming lunchtime environment with positive benefits for both staff and patients.

Contributor

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Jennifer Beck

Speech and Language Therapist

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The right to physiotherapy rehabilitation for people living with dementia following a hip fracture.

Introduction  

As a physiotherapist working in Medicine of the Elderly rehabilitation, I am also currently a part time student undertaking the MSc in Advancing Physiotherapy Practice at Queen Margaret University (QMU), Edinburgh.  As part of my MSc degree, I opted to study the module, *‘Developing rights-based practice for Allied Health Professionals (AHP) working with people living with dementia, their families and carers’.  This module is delivered by the Division of Occupational Therapy & Arts Therapies at QMU, in partnership with Alzheimer Scotland, and is available to all AHP’s.  One advantage therefore of undertaking my MSc at QMU has been the flexibility of choosing modules across disciplines which has allowed me to study subject topics most relevant to my existing practice.

A key policy informing the module content of the rights-based AHP MSc module is ‘Connecting People, Connecting Support Transforming the allied health professionals’ contribution to supporting people living with dementia in Scotland, 2017-2020’.  The development and publication of this first policy in Scotland guiding the work of AHPs with people living with dementia, was funded by the Scottish Government, led by the National Alzheimer Scotland AHP Consultant.  The work undertaken to support the publication of Connecting People, Connecting Support, reflects a new synergy between the practice of AHPs and the lives of people living with dementia.  Consequently, in part, one aspiration of this policy is about AHP’s in Scotland maximising their contribution to supporting people living with dementia, their families, partners and carers to live positive, fulfilling and independent lives, for longer.

Central to this is the AHP approach which focuses on 5 key elements (diagram 1).  In relation to physiotherapy, one important element of this approach is ‘maximising [the] physical wellbeing’ of people living with dementia.  In turn, this supports our professional ambition to enhance access to services to allow people with dementia to continue to live a good quality of life, at home, for as long as possible.  Consequently, this perspective underpinned the development of my assessed presentation related to the MSc module, entitled,

‘A person living with dementia has the right to physiotherapy rehabilitation following a hip fracture’.

Diagram 1: The Allied Health Professional (AHP) Approach (Connecting People, Connecting Support, 2017).

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A person living with dementia has the right to physiotherapy rehabilitation following a hip fracture.

As a physiotherapist one aim is to restore the function and independence that people had prior to injury, to discharge back to their own homes if possible.   Many obstacles can stand in the way of this happening especially to a person living with dementia, for example, acute confusion, pain, noise and an unfamiliar environment and people.  We as healthcare professionals are therefore making judgements and decisions about people’s future in the unfamiliar environment of a hospital ward, often using terms such as “no rehab potential”.  It prompts a question; how do we determine if a person does or does not have the potential to rehabilitate and what evidence do we have to support this?

 A rights-based approach

A rights-based approach ensures that a person’s human rights are put at the very centre of policies and practice (Scottish Commission for Human Rights Act, 2006).  It is widely recognised that people living with dementia are frequently denied their rights (WHO, 2015).  As such, the PANEL approach (Alzheimer Scotland, 2017) provides a framework from which we can help protect people’s rights.  People living with dementia have the right to be as independent as possible, be part of their community and access rehabilitation.

Over 40% of people with a hip fracture have dementia or a cognitive impairment (Resnick et al. 2016) and it has been suggested this population of patients have poorer functional outcomes and a more uncertain rehabilitation journey (Huusko et al. 2000).  Only 40-60% of people regain their pre-admission level of mobility following a hip fracture leading to an increased likelihood of admission to 24-hour care (Hall et al. 2017).  Consequently, there is an indication that people living with dementia receive less rehabilitation as it is assumed to be more challenging to manage this group of patients.

Reasons have been suggested as to why rehabilitation with people living with dementia can be poorer, for example:

  • Cognitive, emotional and motor issues related to dementia.
  • Lack of staff understanding, knowledge and experience in how to encourage engagement and participation, resulting in patients deemed to have no rehabilitation potential. Hall et al (2017) in a qualitative study reported that less experienced physiotherapists feel fear and panic treating this population of patients and this may lead to under treatment.
  • Barriers exist in accessing rehabilitation services due to a perceived lack of potential to improve.
  • Lack of treatment time and resources, including staff.

(Buddingh et al. 2013; Killington et al. 2016; Hall et al. 2017)

Dementia and Rehabilitation

There are a small number of studies that have shown with enhanced rehabilitation there is an increased likelihood of gaining pre-admission mobility, decreased length of stay in hospital, reducing the likelihood of long-term placement for people living with dementia (Smith et al. 2015).   However, these studies have been deemed to be of low quality evidence.  There have also been studies looking at the treatment strategies we can employ to engage participation in rehabilitation of people living with dementia (Buddingh et al. 2013; Fjellman-Wiklund et al. 2016; Hall et al. 2017).  These strategies include family involvement, simple instructions, adjusting the environment, short sessions, consistent physiotherapist, a familiar environment, knowing the persons’ life story, interpreting body language.  Again, there is insufficient evidence to guide physiotherapy treatment interventions and strategies for people living with dementia, with little evidence to show how engaged people are with physiotherapy.  There is a need to develop evidence using specific interventions and strategies to investigate innovative ways to rehabilitate people living with dementia to enable us to improve quality of life.

 How did the module influence my practice?

Through studying the AHP rights-based practice module, I developed a focus which helped to highlight strategies that could positively influence a change in my practice, leading to enhancement, for example:

  • Family and carer involvement.
  • Incorporate increased assessments in patients’ own environment.
  • Adapt communication.
  • Using knowledge of a persons’ life to adapt treatment e.g. hobbies, work, music.
  • Focus on strengths with positive feedback, adopting an assets-based approach.
  • Consistent therapist.

In addition, there have been qualitative changes in how I practice since completing the module.  Specifically, my confidence has grown allowing me to embrace conversations with other members of the multi-disciplinary team when discussing a person’s potential for rehabilitation and the importance of home visits.  As a result, the module has provided the opportunity to share and discuss more widely with colleagues across the multi-disciplinary team evidence to influence incremental change to existing practice.

In summary, this has emphasised our insight and understanding of the possibility and importance of valuing the rights of people living with dementia to ensure equal access to physiotherapy-led rehabilitation, in our case, following a hip fracture.

Questions:

How do you determine a persons’ rehabilitation potential?

What strategies do you use to ensure that you have given someone the best possible chance to rehabilitate?

Contributor:

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Vicki Salisbury

Twitter: https://twitter.com/vicki_salisbury

Email: Vicki.Salisbury@nhslothian.scot.nhs.uk

Vicki Salisbury, Team Lead Physiotherapist, Assessment and Rehabilitation Centre, Western General Hospital, NHS Lothian.

I work in Medicine of the Elderly rehabilitation previously working on ortho-geriatric rehab wards as a Band 6 for 4 and a half years before getting a Band 7 post in a day hospital setting.

*To find out more about the MSc module co-delivered by Alzheimer Scotland and Queen Margaret University, Edinburgh, ‘Developing rights-based practice for Allied Health Professionals (AHP) working with people living with dementia, their families and carers’, refer to an earlier blog post, dated 18th April 2019, here: https://letstalkaboutdementia.wordpress.com/ 

The module will start again this year on the 19th September.

Journeying through the Fellowship

Beginning a Clinical Fellow

“How was your training?” I was asked by a colleague, having returned to the department following two days attending the NES AHP Careers Fellowship workshops; “It was really good” was my response but in hindsight this doesn’t seem to quite cover everything I had gained.  How did I communicate how incredibly supportive and encouraging it was being and learning with people who, like me, were there because of their drive to improve services and learn from that experience. How did I put into words how thought provoking and motivating it was to hear speakers, clearly so knowledgeable and passionate within their own areas of expertise.  Also, and importantly, how did I bring this learning back and use this to guide and support me in my project, but also to support me and my team in my day to day clinical work?

I have a few ideas but in the meantime applications have opened for the next cohort of the fellowship.  I have taken this opportunity to share more information with my team regarding the fellowship, including how supportive it has been learning with different people, from different professions and working in different clinical areas.  I have encouraged all the staff in my department, including the support workers, to consider applying as the fellowship is a great opportunity.  Click on the link below for further information:

https://www.nes.scot.nhs.uk/education-and-training/by-discipline/allied-health-professions/the-ahp-careers-fellowship-scheme.aspx

Journeying Through Dementia #Scotland

The project I am involved in aims to support two demonstrator sites in Fife and Aberdeen, to evaluate an occupational approach in self-management in dementia called Journeying through Dementia.

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Journeying though dementia is an evidence-based programme that has been created by occupational therapists and people living with dementia. It aims to promote continued engagement in meaningful activity through equipping individuals at an early point of their dementia journey with the knowledge, skills and understanding of ways to continue to do the things they enjoy for as long as possible.

These skills are developed in weekly groups supported by occupational therapists where participants have the opportunity to build understanding, share techniques and experiences and engage in activities to put these into practice. Further information regarding the development of the intervention was the focus of a previous blog post by Dr Claire Craig which you can access here: https://wordpress.com/read/blogs/67936544/posts/3554

Over the next six months, as part of the Connecting People, Connecting Support (Alzheimer Scotland 2017) AHP dementia policy document, Journeying through Dementia will be implemented in Aberdeen and Fife underpinned by integrating an improvement approach to capture the impact of this work for people living with dementia and the occupational therapists facilitating the groups. It is hoped that this will be the beginning of a much longer journey, one that will be shaped and crafted by people with dementia and therapists across Scotland.

A poster outlining the work so far was displayed at the Alzheimer Scotland Annual Conference 2019 and the team involved were on hand to answer any questions or queries people had – please use the link below to see a copy of our poster https://bit.ly/2VUPc77

I am very pleased to be a part of this project, working with a great group of people including Dr Claire Craig and Helen Fisher at Lab4Living, Elaine Hunter, National AHP Consultant, Alzheimer Scotland, and a group of Occupational Therapists who will be supporting the implementation of the intervention.

Please look out for more information as we will be sharing the work on social media with further blog posts in future!

Contributor:

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Ashleigh Gray

Occupational Therapist

AHP Career Fellow 2019

Contact me @ashleigh_gray1

NHS Lanarkshire Occupational Therapy and Connecting People, Connecting Support

National AHP Dementia Webex Series

The Allied Health Professionals (AHPs) in Dementia webex series was launched in December 2018.  It had been identified that the AHPs would like the opportunity to hear more from their AHP colleagues about areas of good practice and quality improvement in dementia.  It was agreed to trial the use of webex in order to make this as accessible as possible.  We also wanted to support the delivery of Connecting People, Connecting Support (Alzheimer Scotland, 2017) Ambition 3: AHP workforce skilled in dementia care where an action for change included:

“The Alzheimer Scotland AHP dementia forum will work collaboratively to ensure a national approach to…..sharing best practice…..”(2017:42)

Wendy Chambers @wendyAHPDem facilitates the bi-monthly webex on behalf of the AHP Dementia Forum and the presentation in June 2019 was on the topic:

NHS Lanarkshire Occupational Therapy and Connecting People, Connecting Support      

An overview of work around self-supported memory management, Home Based Memory Rehabilitation, Tailored Activity Programme, What do you want for Tea?, Lanarkshire AHP Dementia Forum, Link work with Emergency Service partners and Primary Care developments.

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The Webex was hosted by:

Lesley Bodin (Locality Lead Occupational Therapist), Gillian Gowran @MHOTGill (Advanced Specialist Occupational Therapy Practitioner), Lynsey Dow (Specialist Occupational Therapist) and Sarah Jane Donald (Specialist Occupational Therapist), NHS Lanarkshire.

The presentation can be found here:  bit.ly/2Zmy8sX

Following the webex, the participants are asked to complete a short evaluation with the following 3 questions, which will guide future webex sessions:

  • Something you liked about the Webex?
  • Something that would have made the Webex even better?
  • Future topics?

A large number of people joined the webex, linking in from across 13 Board Areas as well as national organisations.  Participants fed back that it was beneficial being sent the presentation prior to the webex.  It was highlighted that it was useful to hear about the various projects the team are involved in, with lots of interest in finding out more.  This was evident from the many questions posed, which were answered by the team with the offer for people to get in touch for more information.

We will continue to Blog about the AHP Dementia Webex and will share information from these – look out for this throughout 2019.  Further information and previous presentations can be found on the AHP Dementia Community of Practice (National AHP Dementia Webex): bit.ly/2XoMlYY

A big Thank You to Lesley, Gill, Lynsey, Sarah Jane and Wendy!

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Supporting post diagnostic support in NHS Lanarkshire

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NHS Lanarkshire were keen to make post diagnostic support (PDS) information more accessible to people living with dementia and their families and carers.

It was agreed an online resource, that was primarily for use by the person with dementia, but open to everyone would be designed.  Maureen Cossar who had worked as a community psychiatric nurse (CPN) in the East Kilbride and has an MSc in dementia studies was seconded into the post of Project Manager to collate the relevant information, create the resource design and write in an easy reading format.

Maureen sought the views of what should be contained in the resource from people with dementia and carers across Lanarkshire by attending various dementia and carer groups. She also formed a working party including staff from Nursing, the carers sector, Occupational Therapy, Medics, Alzheimer Scotland as well as a person with dementia and their carer; who all assisted in collating the relevant information. In addition she regularly liaised with Amanda Minns, Head of Evidence regarding the computer software package to be used and how it could be adapted to include the relevant material.

It was agreed to follow the principles of the 5 pillar model with the information being added that was relevant, including links where possible.  It was agreed duplication between some sections was inevitable and that it was better to repeat information than for it to only sit under one pillar.

Prior to its launch the package was trialled with people with dementia and their carers, with their feedback being used to inform the final package.

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The online resource has been positively received by people with dementia, their carers and those delivering PDS since it’s launch in March 2019.  It can be accessed via the Clinical Knowledge portal:

http://www.clinicalknowledgepublisher.scot.nhs.uk/Published/PathwayViewer.aspx?fileId=2598

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The plan is for the resource to be the responsibility of the Practice Improvement and Development Team with Maureen reviewing it 6 monthly and the working party reviewing yearly to ensure information is relevant and up to date.

Contributors

Gill Gowran

Advanced Practioner Occupational Therapist

@MHOTGill

 

Maureen Cossar

Practice Improvement and Development nurse

@CossarMaureen