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Improving the hospital experience for older people

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While older people may receive good care for the ailment that took them into hospital, other needs are often neglected (Health Advisory Service, 1998). The Department of Health has therefore funded 30 hospital trusts to develop projects to raise the standard of care in general hospitals. This article outlines the innovative project set up by Portsmouth Hospitals NHS Trust.


VOL: 102, ISSUE: 02, PAGE NO: 23

Joanne Odell, BSc, RGN, is project lead, care of older people, Portsmouth Hospitals NHS Trust

Joy Holbrook, RN, is project nurse, care of older people, Portsmouth Hospitals NHS Trust;Ruth Sander, MSc, PGCE-A, BA, RN, is senior lecturer, University of Portsmouth

While older people may receive good care for the ailment that took them into hospital, other needs are often neglected (Health Advisory Service, 1998). The Department of Health has therefore funded 30 hospital trusts to develop projects to raise the standard of care in general hospitals. This article outlines the innovative project set up by Portsmouth Hospitals NHS Trust.



Most hospital wards have a high proportion of older people among their patients. Admission rates for people over 65 are three times higher than for those aged 16-64, and people over 65 remain in hospital significantly longer (DoH, 2004), often due to complex needs caused by pre-existing disease or disability. The NSF for older people is clear in its intention to improve care for older people whatever their setting and circumstances (DoH, 2001). Standard four considers the skills and knowledge of staff caring for older people in hospital, including those in acute medical and surgical wards.



Cheek and Gibson (2003) found that in many cases nurses did not have the knowledge and skills needed to achieve the best possible outcome for older people in acute settings. Caring for older people requires special expertise for several reasons: physiological ageing alters the presentation of disease and effects of medication; incidence of depression, dementia and delirium become increasingly common; pre-existing conditions can make self-care more difficult and social support for successful discharge requires complex organisational skills.



Emotional care is also especially important for older people when they are ill because they are often more dependent on others than most adults. This can lead to infantilisation, loss of self-esteem and self-image as ‘less of a person and more of an object’ (McCormack, 2001).



Improving general hospital care
This project encompasses acute ward areas managed by Portsmouth Hospitals NHS Trust and is being carried out in close collaboration with major stakeholders from all the primary care trusts, social services and voluntary agencies. Close links have been forged with the department of medicine for older people, which has representation on the project management and steering groups. Box 1, p24, illustrates the project’s key features.



Developing champions in clinical areas
Six pilot clinical areas were recruited and asked for two senior nurses to act as representatives on the six-month project. These nurses agreed to become ‘older persons’ champions’ and facilitators of change in their own areas. The programme launched with a two-day introduction that focused on exploring attitudes to and beliefs about old age, including participants being challenged by a professional theatre group to look at common attitudes and language used in care. They were also introduced to the concepts of action learning and critical companionship (Titchen, 2003).



A strong feature of the programme is three assessments of care including taking an older person’s narrative and observation in the project clinical areas. These will form the basis for an action plan to inform change, which will be repeated at the end of the project as a measure of success.



The champions will relate ideas to their clinical areas in monthly study days. The detail of the study days is flexible so issues raised by stakeholders and committees can be included, ensuring their involvement is genuine and not just rhetorical.



Using action learning and critical companionship to develop care
Action learning is a method of management and organisational development (Neubauer, 1996) characterised as a continuous process of learning and reflection, supported by colleagues, with the intention of getting things done. Individuals learn with and from each other by working on real problems and reflecting on their experiences so enabling the linking of academic theory to clinical practice (McGill and Beaty, 1992).



The champions’ development programme will feature action learning sets for the development of critical companionship skills so they are better able to challenge existing practices in their clinical areas. They will set up and facilitate action learning groups to include as wide as possible a representation of staff in their clinical area. These groups will identify manageable projects for development and it is hoped will lead to measurable improvements.



Engaging senior management
A project management group meets once a month and oversees the operation of the project. It reports to the project steering group that meets quarterly and is chaired by the deputy chairperson of the trust - and thus directly to the trust board. The groups represent all stakeholders from within and outside the organisation including service users and voluntary agencies.



To ensure two-way communication and active engagement of all members, each committee has been asked to discuss the project using a system based on the fourth-generation evaluation (Guba and Lincoln, 1989) or stakeholder analysis. Working in groups of four, members express which elements of the project they like and any concerns. These are then shared with the whole group and recorded by the project leaders.



Involving older people
There is much discussion of service user involvement in recent DoH communications (Aldgate and Dimmock, 2003). The voice of the older person needs to be heard at all levels. The project supports this in several ways. Representatives from service user groups are included at management level but there is also an effort to give older people a voice at contact level. An experienced oral historian, who has documented the life stories of older volunteers, has been asked to discuss her skills with the champions to help them develop techniques of obtaining and recording the views of the older people in their care. The project team has also presented the project proposal to a local older people’s day centre, and gathered information along the fourth-generation evaluation process. The participants were keen that the project team return at the end of the project and present the findings.



Maintaining good care
Arguably the greatest test will be what happens when the formal project ends. Its continuation in the initial areas should be ensured by the commitment of both senior management and frontline staff. Engagement of organisational leaders has begun with the inception of the project and it is hoped that this shift in organisational culture will be sufficient to maintain their support. The development of individual projects by frontline staff will ensure they are relevant and workable in the clinical area for which they were designed and so will be relatively easy to maintain. Adoption of new practices in other areas depends on the effective dissemination of information. Completion of the project will be marked by a celebration. This will honour the work of the people involved and provide an opportunity to broadcast details of progress to a wider audience.



To support evaluation and enable dissemination of the project outcomes, a collaborative action research project has been commissioned with the University of Portsmouth. A senior lecturer in gerontological nursing is acting as researcher and forms part of the project team.



- This article has been double-blind peer-reviewed.



For related articles on this subject and links to relevant websites see

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