Try observing and recording care from the patient’s viewpoint. You will find it an extremely emotional and enlightening experience, according to older people’s champions at Dewsbury and District Hospital.
The 12 champions, including ward nurses, porters and care staff, were surprised and deeply moved by their training in dementia care mapping - a systematic process for identifying patients’ experiences that has been developed at Bradford University. All the participants have gone on to apply the principles in their everyday routine.
‘Dementia care mapping is a very thought-provoking experience,’ says Fay McKalroy, modern matron in older people’s services.’It means looking through someone else’s eyes, which is an easy thing to say but very striking when you actually do it.’
Although care mapping is a tool that could be transferred to many clinical areas, it was developed specifically for people with dementia and dementia-like illnesses. It involves sitting at the side of the care area, usually for six hours, observing a patient’s behaviour, well-being or ill-being and any positive or negative events. Mappers may notice how busy nurses inadvertently upset patients by failing to greet them properly or by talking over their heads.
After analysis, the observations are fed back to the teams, and used to improve the processes of patient care. Ms McKalroy says: ‘You begin to realise how small deeds and words have a profound impact on people.’
Her first experience of care mapping was in a dining room on an old people’s ward, where she and a colleague observed a woman’s experience of the lunchtime routine. ‘We sat quietly in the corner. People were aware of us at first but they forgot we were there within about 10 to 15 minutes.
‘First of all, I was amazed by the level of noise in the room. There was no shortage of staff, and they all came in en masse - very noisily. And they tended to talk over the patients. No one was unkind or unpleasant, but they were all focused on the job they had to do, not on the patients’ experiences.’
It was clear the woman they were observing, who had dementia, was not enjoying the mealtime. ‘She had fleeting periods of ill-being throughout. She looked particularly distressed at one point because the nurses accidentally forgot to give her her lunch - although they quickly noticed and apologised, and gave her a meal.’
The observations also took in the broader environment. They noticed that the staff gave no thought to who sat where, and whether patients had any choice in the matter. ‘We listened to the clients talking about the hospital - which wards they liked and disliked, which staff they liked and disliked. It was extremely enlightening. And it has made me think carefully about every aspect of how I approach every patient. For example, whenever I enter a room or a bed space I try very hard to put all my focus on the person first and the clinical task second.’
Ms McKalroy and her fellow champions were trained by a visiting team from the Bradford Dementia Group, supported by staff from the trust’s team for implementing standard 4 of the National Service Framework for Older People.
Kath Williams, the nurse who leads the standard 4 team, trained in dementia care mapping in 2002 and underwent an advanced course a few years later. She is now working towards gaining trainer status. She says the experience of the sessions has made her reflect on everything she has done since she first started working with older people. ‘You look back and think - how could I have done that?’
She describes the six-hour mapping sessions as ‘exhausting’ and ‘an emotional wrangle’. But the rewards of feeding back the information to the care team, and motivating staff to take a more patient-focused approach, make it all worthwhile.
‘One day two of us were mapping in a bay with four elderly clients who were clearly bored. A member of staff walked in and walked out again without speaking to any of them. Then a nursing auxiliary came in and said a cheery ‘Good morning. How is everyone?’ You could see the difference she made immediately - it brought the clients into a state of positive well-being.’
Ms Williams has been fascinated by dementia since she was a young girl, when she saw how it affected some people in her own family. ‘That’s what made me decide to go into mental health nursing,’ she explains.
She found out about her present post in the general hospital, with dementia care mapping as one of the components. ‘It is a role that requires sensitivity,’ she explains. ‘There is always a danger that care mappers will be seen as management spies, but we alleviate those sorts of fears through working to prepare the staff. We explain what we are doing and why.’
Feedback is given to the whole team at the same time, usually at handover periods, rather than being cascaded via managers. And even though she sometimes has to point out negative aspects of staff behaviour, Ms Williams has always experienced a positive reception. ‘I prepared myself for handling people who might be upset, but it hasn’t happened at all so far. It’s wonderful how welcome we are made to feel.’
She is adamant that there are real benefits for everyone involved in care mapping - staff as well as patients. She says it empowers staff to argue for changes to patients’ care. And, personally, she feels she is a much better nurse since her care mapping training. ‘It has made me 100 per cent better. I am more understanding and I have more conviction in my ideals for the care of older people.’
WHAT IS DEMENTIA CARE MAPPING?
Dementia care mapping is an observation tool designed at Bradford University to examine the quality of care from the perspective of the person with dementia, with the aim of promoting patient-focused holistic practices. Ideally, mappers work outside their own departments to avoid distractions. Mappers typically work in pairs, and begin by briefing staff on the process and obtaining consent from patients and carers.
They spend six hours observing events in a given care area. Every five minutes the mappers note down codings for the patient’s behaviour, score episodes of well-being and ill-being from +5 to -5, noting whether they are brief or sustained, and document any positive events or personal detractions.
A mapper will intervene only in extreme cases, for example if a patient is in danger or in cases of abuse. Afterwards, the mappers analyse the data and provide feedback for staff as a means of changing and improving the patients’ care.
For further information contact the Bradford Dementia Group, School of Health Studies, University of Bradford: phone 01274 235726; e-mail email@example.com; or visit the www.bradford.ac.uk/acad/health/bdg/index.php website.