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INNOVATION

A wellbeing tool to help plan care for older people

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An NHS trust has developed a tool to assess wellbeing in older people with mental health issues, enabling staff to detect and record individual needs

Abstract

After recognising that care for older people could be more person-centred and have a broader focus on the person’s holistic wellbeing, a mental health unit for older people introduced individual wellbeing reviews in which staff discuss a different resident each week. The aim is to collate information on individual needs and preferences in order to strengthen the care-planning process and help staff provide holistic, person-centred care. This article reports on how the wellbeing reviews work and how a dynamic tool supporting the sharing of information was developed. The wellbeing reviews and tool not only benefit residents, but also empower staff and give them opportunities to develop their skills and knowledge.

Citation: Wheeler NL, Gardner RL (2016) A wellbeing tool to help plan care for older people. Nursing Times; 112: 39/40, 21-24.

Authors: Nicola L Wheeler is a trainee clinical psychologist at Plymouth University, and formerly an assistant clinical and research psychologist at Birmingham and Solihull Mental Health NHS Foundation Trust; Rachael L Gardner is a senior occupational therapist in mental health services for older people at Birmingham and Solihull Mental Health NHS Foundation Trust.

Introduction

In old age, dementia can challenge wellbeing by reducing the personal and social resources individuals need to manage difficult situations. Care providers looking after older people, especially those with dementia, therefore need to focus on wellbeing (Bradford Dementia Group, 2008). This article discusses the approach taken to improve the wellbeing of residents in a continuing care mental health unit at Birmingham and Solihull Mental Health NHS Foundation Trust, and describes the development of a person-centred care-planning tool to help staff meet residents’ holistic wellbeing needs. A case study illustrates how the tool is used to tailor care to individuals.

Residents with complex needs

The Bradford Dementia Group (2008) defines ‘wellbeing’ as how a person is managing in their everyday life – what is happening to and around them, and considering the natural ups and downs they may experience (Diener and Larson, 1993).  It advises that dementia can challenge a person’s wellbeing, impacting on the resources (personal and social) they need to manage and overcome difficult situations.

Carers of people with dementia need to offer support to maximise their wellbeing. As multidisciplinary healthcare professionals, we appreciate wellbeing is affected by numerous factors including an individual’s mental and physical health, his/her context and circumstances, the environment (physical and social), and opportunities and resources to engage in meaningful occupations (Bradford Dementia Group, 2008).

Our unit provides residential care for up to 19 older people with a range of long-term mental health difficulties, both organic and functional, including psychotic episodes, severe depression, complex trauma and dementia. Our residents have complex needs and sometimes display behaviours that can be challenging for staff. Many have come to live on the unit because local nursing homes have been unable to manage their care and meet their needs.

Staff working on our unit traditionally addressed residents’ wellbeing from a medical perspective, with limited input from psychology and occupational therapy. In 2008, the unit started offering psychology and occupational therapy input to its residents. In 2009, we embarked on a culture shift to start thinking about wellbeing holistically and raise staff’s awareness of its importance in promoting good mental health (Department of Health, 2009).

National dementia guidance emphasises the importance of person-centred care (National Institute for Health and Care Excellence, 2006), so we wanted to ensure this was happening on our unit. We particularly wanted to consider residents’ relationships with staff and others, recognising how these can affect wellbeing (NICE, 2006). We therefore decided to introduce resident wellbeing reviews (Wheeler and Johnson, 2010).

Introducing wellbeing reviews

The wellbeing reviews, facilitated by psychology and occupational therapy, ensure unit staff (nurses, healthcare assistants, management, housekeeper, activities coordinator) have a dedicated, one-hour weekly time slot to focus on a resident’s wellbeing. The number of staff and mix of professions vary for each review (Wheeler and Johnson, 2010); healthcare assistants and nurses are always present alongside the facilitators; other members of staff attend according to availability and whether they have information to share about the resident.

The aims are to:

  • Embed person-centred care into the unit’s culture by increasing staff understanding of the approach and how they can use it in their practice;
  • Empower staff to learn more about indicators of wellbeing and ill-being;
  • Prompt staff to reflect on a resident’s behaviours that they might find challenging by considering the resident’s personhood, life history (including cultural and religious identities), physical health (including undetected pain), mental health, psychosocial factors and physical environment;
  • Generate actions or solutions to improve care and promote residents’ wellbeing, including reducing behaviours perceived as challenging.

After one full review cycle (that is, after each of the 19 residents have been reviewed once), a new cycle starts. In subsequent reviews, in addition to thinking about the resident’s current wellbeing, the team also discusses actions from the previous reviews.

Improving the reviews

When we analysed the first reports, we noted that discussions frequently focused on aspects of care that staff struggled with; for example, managing behaviours perceived as challenging, or managing personal care at times of conflict or when a resident was in distress. Staff appreciated thinking about these issues together and generating actions to tackle them. They found that review discussions enhanced their personal knowledge, perspectives and practice (Wheeler and Johnson, 2010).

With each review cycle we sought to improve their usefulness. We felt that the initial cycles had major drawbacks: while the discussions yielded a wealth of information and empowered staff to think about how to promote wellbeing, the emphasis was on us as facilitators to ensure discussions were accurately recorded and actioned. Immediately after the review, we completed a report summarising discussions and agreed actions. We would also communicate information gleaned in the discussions to the wider team – by documenting it in residents’ notes and the staff communication book, and by amending care plans. This took up a considerable amount of our time.

To introduce the concepts of person-centred care and wellbeing, we had used Kitwood’s (1997) mindsets and Brooker’s (2004) VIPS model. We felt that an evidence-based wellbeing measure would help staff identify indicators of well/ill-being for each resident, and tried incorporating the Bradford Well-being Profile (Bradford Dementia Group, 2008) into the reviews, which involved summarising pertinent issues discussed by the team under the profile’s indicators of ill-being and wellbeing. After a trial period of one cycle, reflecting on the use of the profile, we felt discussions had been more stilted. Staff seemed reticent to use the profile and were unsure how to interpret its indicators, especially for residents with advanced dementia in whom some social behaviours can be wrongly attributed to ill-being.

Completing the Bradford Well-being Profile involved one of the facilitators observing a resident alongside a member of staff and using these observations to supplement the review discussion; when possible, we spoke directly with residents about their wellbeing, empowering them to think about possible solutions for themselves. However, this placed emphasis on the indicators we identified, creating a power imbalance between us and the staff. Our aim was to take a reflective practice stance, enabling staff to openly discuss issues and concerns; however, creating the profile before the review seemed to disempower them and negatively affect their understanding and subsequent actions. As a result, we decided the Bradford Well-being Profile was not the right tool.

Developing a new tool

We researched a number of wellbeing measures – generic, older people-focused, dementia-specific – but found nothing suitable. We sought advice from a psychology colleague, Andrew Papadopoulos, who is particularly interested in the wellbeing of older people; he helped us identify what we wanted from a wellbeing measure.

We were aware that we, as multidisciplinary professionals, contributed to the reviews we facilitated, and recognised that our unique contribution lay in:

  • Our understanding of biopsychosocial factors and how these affect residents;
  • Our use of person-centred, more positive language;
  • The way we formulated residents’ behaviours and distress as expressions of unmet needs.

After concluding that no existing measure met our requirements, we set about devising our own tool, which would:

  • Meet NICE (2006) dementia guidance and apply the principles of person-centred care by paying particular attention to respect, dignity and people’s life history; individualising activities; be sensitive to religious, spiritual and cultural identity; and understand behaviours that challenge as a way of expressing unmet need;
  • Respect residents’ individuality and diversity by documenting individual preferences;
  • Maximise clinical utility for staff and improve their knowledge and skills;
  • Reduce facilitators’ administrative burden.

Our Person-centred Wellbeing Care Planning Tool (PWCPT) does all the above. It can be downloaded from the attached Files section. The category questions, taken mainly from DEMQOL and DEMQOL proxy (Parker et al, 2007), encourage staff to think about the relevance of each category for the resident and help them identify priorities for improvement. In the ‘formulation’ column, staff document how they understand residents’ behaviours and what unmet needs (arising, for example, from discomfort, pain, fear or distress) these behaviours might reflect.

When devising the tool and determining its terminology, we drew on a range of existing evidence-based wellbeing measures and models, including those of Papadopoulos et al (2011), Bradford Dementia Group (2008), Parker et al (2007), Tennant et al (2007), Logsdon et al (1999), Kitwood (1997) and Kitwood and Bredin (1992). Staff at the residential unit, and other professionals and carers who have used the PWCPT, particularly like its categories, especially Kitwood’s (1997) hope, comfort and identity. They feel these categories allow them to obtain a detailed biopsychosocial understanding of individual residents and their needs, unlike other care planning tools, which focus mainly on care tasks.

Using the tool in practice

During wellbeing reviews, one facilitator leads the discussion while the other completes the PWCPT. Staff are asked to identify the wellbeing categories they think are the most pertinent for the resident, and these are considered first. The discussion then goes on to cover the remaining categories. All suggestions of how to improve wellbeing are documented in the ‘possible ways to enhance wellbeing’ column of the tool, and discussed in order to reach a collective decision about which ones seem most relevant or practical to try first; these are then recorded in the ‘actions’ column. The other suggestions remain in the ‘possible ways to enhance wellbeing’ column so they can be revisited at future reviews.

Specific staff members are tasked with implementing the actions that have been collectively agreed upon. In the weeks between reviews, staff add comments and observations to the tool in preparation for the next review. This can include new information, feedback about action points and hypotheses about what might be happening to the resident. The PWCPT therefore becomes an evolving document, as everyone is encouraged to contribute.

The case study in Box 1 summarises a review discussion for a fictional resident, Gwen Parker (this is a clinical case example, which has been devised for illustrative purposes and does not contain any confidential information about any of our residents). A completed tool for Mrs Parker can be found attached in the Files section. It shows how information is documented and how the PWCPT can be amended as new information is obtained and further discussions take place. It also shows how staff were able to develop a shared understanding of Mrs Parker and her preferences from their observations and discussions with the resident and her family. The tool allowed staff to document a wealth of information under broad categories (many of which are not routinely covered in care plans), as well as to identify what additional information would help them to better understand Mrs Parker.

Box 1. Case study

Gwen Parker, a 78-year-old woman with vascular dementia, was admitted to the residential unit when her husband’s declining health meant he could no longer care for her at home.

Focus of the wellbeing review:

  • How staff could help Mrs Parker feel more settled in her new home
  • Staff’s difficulties in facilitating her personal care

Main points highlighted during review discussions:

  • Two members of staff were needed to provide Mrs Parker’s personal care, as she would hit and shout. During the discussions, one staff member reported finding out that Mrs Parker preferred pink flannels and having her baths in the evening, which settled her for bedtime. The fact that she had been given her baths in the morning was thought to explain why she would often be unsettled, and had been observed trying to get into the bath, around bedtime. This information was shared with all present and documented in the ‘actions’
  • Staff acknowledged that Mrs Parker had always been a housewife and liked to have a sense of purpose. She appeared to enjoy helping with tasks around the unit, such as laying the table. This was to be encouraged
  • Mrs Parker liked talking about her family and flowers. Her family had told staff that she had always been a keen gardener. These topics could be used by staff to engage with her
  • Mrs Parker did not appear to interact with other residents, and staff were concerned about her isolation outside family visits. They suggested asking her family about her hobbies/interests, so they could help her engage in group activities and talk to residents with similar interests
  • Staff shared Mrs Parker’s food and drink preferences and her related routines, so these could be respected by all
  • Mrs Parker had hearing difficulties. Staff acknowledged they must speak clearly, gain her attention before speaking and ensure she was wearing her hearing aids

The discussion and completed tool (available in the Files section of this article) ensured all staff had access to important information about Mrs Parker and her preferences. Areas where staff needed more information were highlighted. Actions were agreed to improve her wellbeing and ensure she received individualised, person-centred care.

Advantages of the tool

We collected feedback from staff informally during the review discussions and in conversations about care planning, as well as formally via an anonymous questionnaire. We found that staff appreciated the tool’s “ease of use”, stating its categories and accompanying descriptions helped them “understand more about wellbeing in a broader sense”. The PWCPT offers an in-depth biopsychosocial understanding of the resident while “still addressing all important aspects of care tasks/duties”. Staff liked its “very practical” focus, feeling it made care planning “much easier”, as the category descriptions give guidance on what information to record, while the multidisciplinary discussions generate ideas and actions.

Previously, staff had perceived care-planning duties and paperwork as onerous; these were usually the responsibility of a nurse, while other staff members had no opportunity to contribute. All staff need an in-depth understanding of each resident. The review process and tool help them appreciate the importance of incidental pieces of information in building a holistic picture of residents, as well as the importance of sharing this information with all involved. They highlight areas where staff need more information, training or co-working opportunities. The PWCPT enables staff to capture all information in a clear and clinically useful format, therefore being “empowering” for all. The tool’s categories highlight gaps in understanding about individual residents, enabling staff to discuss how they might glean this information, for example, by requesting multidisciplinary assessments from colleagues or talking to residents’ families and friends.

Following the review, the completed tool is placed at the front of residents’ notes, where it is “readily accessible” and can be “easily referred to”, which eliminates the need for additional notes or care plan actions. It provides a “good overview/summary” of information about each resident. DEMQOL questions enable staff to give a quantitative judgement about wellbeing so this can be monitored over time.

During reviews, our multidisciplinary perspective helps staff to better understand challenging behaviours and reframe them as expressions of unmet needs. The team discusses how different staff members manage challenging situations, sharing expertise and best practice. For example, in Mrs Parker’s case (see Box 1), finding out and sharing that she prefers to take a bath in the evening made a significant difference: morning baths, which had been creating stressful situations for her and the staff, no longer took place.

Other ways of using the tool

The PWCPT was originally created to facilitate wellbeing reviews, but the way staff have used it to document information suggests that it may have other uses. Having spoken to NHS and care professionals, we are aware that existing care plans are often limited – none being really fit for purpose, holistic and person-centred. We have begun to discuss how the PWCPT – a readily accessible, evolving document – could be used in other settings.

In more permanent settings, such as care or nursing homes, we anticipate the tool could be used as originally intended; that is, completed through facilitated multidisciplinary discussions, with the completed tool becoming the care plan. This avoids one staff member being responsible for reviewing and updating information for all residents.

Relatives and home-based care staff could use the tool for care planning in the home. It could become an important resource, held by the family and/or home-care staff, to be shared with other health professionals, such as staff in hospitals or respite settings  when required.

Recently, we have been considering the use of the tool in assessment units and inpatient settings. Its usefulness lies in its ability to record information from different sources. All staff, regardless of level or professional background, can record their observations and thoughts, which is essential for a high-quality, in-depth assessment.

Improved access to information technology within healthcare means the tool can be accessed on tablets and uploaded to electronic records, therefore preventing information from being ‘missed’, ‘lost in progress’ or stored on inaccessible electronic care plans. We suggest that an individualised tool is created for each patient or resident, and saved on a tablet or computer accessible on the ward in a practical location (for example, the desktop), so that it is easily accessible for staff to check or add information. At the end of a shift, the tool can be uploaded to electronic care records, for example, care notes or Rio, so that there is an up-to-date version stored in the patient/resident’s notes. Thus, the tool is a dynamic, constantly changing document that helps ensure care planning is timely and meets the person’s changing needs.

Information collected through the tool can then be reviewed in care meetings or in wellbeing or care reviews; as part of team formulations, meetings or discussions; and when thinking about or finalising the next steps in a patient’s care. It can also be shared with appropriate services/organisations at discharge, ensuring appropriate support is put in place.

Conclusion

We are delighted by the positive feedback about the PWCPT and are keen to share it. The tool can be modified to reflect the needs of a specific care environment, and we are happy to help with this. We hope it helps other services and settings improve care planning, generate richer assessments and care plans for patients, and increase staff’s job satisfaction.

  • The authors welcome comments about the Person-centred Wellbeing Care Planning Tool and any suggestions regarding its future development. Organisations or services interested in using it are welcome to contact the authors via email (nwheeler@nhs.net), explaining who they are and for what purpose(s) they intend to use the tool.
  • The authors would like to thank Dr Andrew Papadopoulos for his guidance and encouragement in developing the tool.

Key points

  • Focusing on patients’ wellbeing is important to promote good mental health
  • Using wellbeing reviews for older people with mental health issues can create a space for staff development  
  • A patient-centred care planning tool can provide a structure for team discussions of individual patients’ behaviours and needs
  • A care planning tool needs to be an evolving document that staff can easily access and update
  • Such a tool could be used in different settings to improve care and increase staff’s job satisfaction
  • 1 Comment

Readers' comments (1)

  • There is no file section where you can look at the document discussed - very difficult when talking about something in the abstract - would have been beneficial to give at least a brief description of the 'care plan' Tried various shortcuts and searches, downloaded pdf and clicked on link - doesn't work!!!! Article is quite meaningless, also quite a few of the references are listed twice! !

    Unsuitable or offensive? Report this comment

  • Hi Anonymous,<br/><br/>The 'Related files' section is below the references, or you can access the full PDF here: https://www.nursingtimes.net/download?ac=3018403<br/><br/>The same author appears in the reference list where two different articles by the same author have been cited.<br/><br/>Hope this helps!<br/><br/>Kind regards,<br/>Nursing Times

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