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Promoting excellence in the care of older people: case report 3

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VOL: 96, ISSUE: 36, PAGE NO: 41

Sue Davies, MSc, BSc, RGN, RHV, lecturer at nursing at University of Sheffield

Jayne Brown, MMedSci, RGN, lecturer at nursing at University of Sheffield;Fiona Wilson, MSc, BSc, RGN, is research fellow at the Sheffield Institute for Studies on Ageing;Mike Nolan, PhD, MSc, MA, RGN, RMN, is professor of gerontological nursing at the University of Sheffield

In 1999, the charity Help the Aged commissioned research to examine good practice in acute hospital care for older people. It focused on two wards providing services for older people as part of a community NHS trust in Portsmouth. Their particular strengths appeared to be strong democratic leadership at all levels in the organisation, coupled with an emphasis on evidence-based practice.

In 1999, the charity Help the Aged commissioned research to examine good practice in acute hospital care for older people. It focused on two wards providing services for older people as part of a community NHS trust in Portsmouth. Their particular strengths appeared to be strong democratic leadership at all levels in the organisation, coupled with an emphasis on evidence-based practice.

An imaginative ward upgrade has resulted in a bright, pleasant ward environment and these developments, together with a number of practice innovations, appear to have contributed to high levels of patient satisfaction with the care provided.

Two wards - Mary Ward and Victory Ward at Queen Alexandra Hospital, Portsmouth - were studied in detail. Both provide acute medical care for men and women who are generally over 65 years of age, although there is no rigid age criterion.

One ward includes six stroke-assessment beds as part of a streamed stroke rehabilitation service. The wards are tastefully decorated with bright colours, vivid fabrics and colourful prints, reducing the sense of 'being in an institution'.

Partitions midway along the Nightingale wards have been designed to make an architectural statement and include nautical features alluding to the seafaring history of the local population. A central station is incorporated into the central partition, ensuring that nurses are highly visible.

These wards are extremely well equipped, particularly in relation to pressure-relieving devices, and moving and handling equipment. Infusion pumps are available for all patients requiring intravenous infusion, representing best practice. Staff were seen to be busy and under pressure, but the open-plan layout of the wards seemed to make patients feel secure.

Day rooms are beautifully decorated with TV, stereo and comfortable chairs and sofas, which are particularly valued by patients who want to sit close to their visitors. Tea and coffee-making facilities are kept well-stocked. A smaller room is available for visitors who wanted to speak more privately and there are facilities for relatives to spend the night if they wish. A comfortable discharge lounge for patients awaiting transfer helps to avoid long waits for admission.

The two wards provide a contrast in terms of leadership style, yet the contribution of effective ward leadership is acknowledged in both areas. Regular and effective communication between the different disciplines appears to be another important factor ensuring high standards of care.

Structured systems for communication, such as formal ward meetings and written communication records, are supplemented by regular informal discussions. Recognition and respect for each other's expertise also seems to be a key feature.

In an unconventional attempt to break down the traditional ward hierarchy, qualified nursing staff (except for ward managers) and health care assistants in the directorate wear the same uniform. However, some staff feel it is difficult for patients and relatives to identify staff by grade. Others feel that it encourages nurses to introduce themselves and explain their role. Nevertheless, the initiative is one example of the democratic approach to change management in the unit.

Partnership in care
The willingness of senior managers in the trust to seek the views of user groups and confront problem areas has resulted in strong links with the local community, with benefits for both staff and service users.

Local people feel they are able to influence service developments, and managers can be more confident that services are responsive to the views of service users. Local charities raise funds to allow the purchase of 'extras', but also to support relatively major service developments, such as the refurbishing of a ward devoted to palliative care.

The benefits of collaboration were illustrated by the following example, described by a consultant: 'There was a major change about three years ago in relation to single-sex ward areas.

'The local pensioners' action group campaigned stoically and there were months of ongoing discussions. We felt we always considered what patients wanted. But they did some background work and we were faced with evidence that said elderly people do not like mixed sex wards.

'We then got funding to re-adapt the wards and decorate them. We increased the number of toilet facilities and included a shower area, which we didn't have before. Local people were involved every step of the way. We had a lot of help from the League of Friends, particularly in relation to equipping the day rooms.'

In addition to the wider involvement of the local community, family members are seen as making an important contribution to patient care and encouraged to participate in multidisciplinary discussions. Staff also suggested it was important to adopt an individual approach and not put too much pressure on relatives to make decisions.

Bedside handover
Patients' needs on both wards are complex and ample time is allocated to handover reports. On one of the two wards, a system of handover at the patient's bedside had been introduced, which seemed to work well for staff and was highly appreciated by patients. Nursing staff demonstrated an obvious willingness to negotiate care with patients and goals of care and treatment plans are openly discussed (Box 1).

Medication review programme
A further innovation at ward level includes a move towards a system of patient self-medication where patients bring in and, where appropriate, use their own medicines during their stay. This has the combined advantages of facilitating a review of each patient's medication and identifying any need for further education and cutting down costs.

Following admission, the pharmacist reviews the medication with the patient and provides educational input as necessary. Patients are given a seven-day supply of medication on discharge, after which they are encouraged to consult their own GP (Box 2).

Transition between hospital and home
The interface between primary and acute care is facilitated by an admissions unit. During daytime hours GPs can arrange for patients to be admitted directly to the ward rather than via A&E. Consequently, patients can experience a smooth transition from home to the unit without a distressing wait. Ward staff can negotiate the time of admission with patients so they are ready to welcome them on arrival.

Maintaining dignity
Full, heavy curtains helped ensure that patients were screened during intimate procedures, together with a mindset that 'treats curtains as if they are doors'. These were important in helping patients maintain their dignity, especially on a mixed-sex ward. Several members of staff insisted that having men and women on the same ward made them more aware of the need to ensure patients were adequately covered and comfortable with their appearance.

Developing practice
The appointment of a projects manager is just one innovation that has contributed to the swift and planned approach to identifying problems and implementing solutions. One project consisted of an environmental audit involving patient representatives.

A number of specialist nursing roles aimed at supporting evidence-based practice have also been introduced (Box 3). The importance of developing staff was mentioned repeatedly during our visit and there is a rolling programme of in-house education. Staff can claim a voucher for undertaking training and education in their own time. They can then take time in lieu or be paid overtime.

Resources are also invested in creating 'experts' by sending small groups of staff on external courses. Information packs are then developed for distribution to every ward and staff who have undertaken the training work with the clinical practice development manager to develop in-house training packages, often in distance-learning format.

Fact-finding visits to centres of excellence are encouraged, together with the borrowing and implementation of ideas.

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