Leading Better Care
Sharing Good Practice
NHS Board: NHS Tayside
Ward / department / team: Ward 4 (Rehabilitation) Royal Victoria Hospital
Details of Improvement:
The ward aimed to distribute the fundamental nursing care needs of their patients throughout the day and to work with AHPs to ensure rehabilitation therapy times better met with the needs and preferences of patients. The previous routine meant that the ward staff concentrated on ensuring all patients were out of bed, washed and dressed in the morning and that they all were supported to eat in the dining room at specific times throughout the day and all ready for therapy prior to 0930, regardless of their therapy time.
How was this identified?
The patient population has changed in recent years with the introduction of early supported discharge schemes. This has meant that most patients have a number of co-morbidities; many are PEG/NG fed and need to be hoisted to transfer. Observations indicated that this aspect of care was normally rushed and not delivered at a pace consistent with the patients’ abilities. The ward were routinely collecting feedback from patients and a common complaint was the long days with early rises. Additionally staff were expressing and seen to be physically exhausted by 11.30 am each day as all of the labour intensive work was forced into the hours of 0700 and 1130.
What were the implemented improvements (what tools/techniques did you use)?
The team through the RTC programme worked on their ward visionand had a number of meetings to identify a new ward routine that would better match their patients’ needs and preferences. The SCN met with the AHPs to generate a collective understanding of the need for change and the following was implemented:
- Agreement with AHPs that patients who required hoisted would not have therapy first thing in the morning
- Patient therapy schedule is posted in the ward the night before therapy is due in order that nurses can plan with patients as to when the patient needs to be up out of bed the following day
- Patients are asked by staff each morning if they would prefer to get up for breakfast or have breakfast in bed and have a longer lie
- Staff breaks were limited to one member of staff on break at any time to ensure maximum staff on the ward throughout the day
What is the situation now?
Patients are provided with a choice each day as to when they get up and where they prefer to have their breakfast (bed or in dining area). They can choose when they wish to wash and dress and can opt to have a long lie. Because patients opt to get out of their bed at different times throughout the morning and are not all needing to be up prior to breakfast arriving staff have more available time to deliver breakfasts to patients as soon as it arrives on the ward and have been able to commence their 8 o’clock drug round on time.
How is the change sustainable?
The ward tested this new way of working for 2 weeks and because of the positive impact it has had on staff and patients and the strong leadership in the ward; with a SCN who is dedicated to ensuring care is person centred this way of working has become the norm.
Measurable outcomes
The ward no longer receives comments on their routine feedback forms relating to early rises and long days. Patients are routinely opting for longer lies in the morning. Care is now being observed to take place at a pace that is more suitable to the patients rather than more suitable to the workforce.
What are the staff benefits?
Staff workload is better distributed across the working day leading to less physical exhaustion.
What are the organisational benefits?
Improved patient experience
How did staff feel before the improvement/during theimprovement and after the improvement?
Staff were reluctant to consider changing routines they had engaged with over many years. The SCN worked with them , developing a poster of how the face of their specialty was changing , the quality strategy and how that had led to different expectations of the service. After agreeing to change the way they worked they were anxious in the first few days as to how to do things differently but now are content with the different way of working , recognising the benefits it has brought to patients.
What are the lessons learnt and what would you dodifferently next time?
Changing the whole ward routine is challenging and needs to be taken as a whole system approach. Involvement of AHPs was crucial to the success of the programme and including them within the observations undertaken for RTC may have helped them appreciate the need to change their routines quicker than they did.
What plans are there to spread the improvement?
There are no plans as yet to spread this specific approach however the organisation is about to embark on testing interventions aimed at enhancing care routines and approaches such that they are more person centred
Contact information for case study
SCN Linda Barnett : 01382 26286 /